Anatomy of a Safety Incident #4, Part 2

OK, let’s unpack! If you haven’t already done so, first please read this post about why and how we unpack safety incidents.

We’ll begin at the end and describe the “Orlando Policy” that Phoebe and I drafted. After that, we’ll retrace our steps through the incident itself -- now with 20/20 hindsight! -- and examine all the safety issues.

WCA’s Orlando Policy, a work in progess

Safety Priority #1: Do NOT Call the Police/911 on Orlando
We have no reason to believe that Orlando is a danger to any WCA staff, volunteers, or patients. However, HE is potentially in life-threatening danger from the police themselves. Anyone who thinks that we are overreacting for Political Reasons is kindly required to watch the film Alien Boy, a critically acclaimed documentary by long time Friend of WCA Brian Lindstrom (who also made the community acupuncture documentary The Calmest Revolution). Alien Boy tells the story of James Chasse, a gentle Portland artist and musician who had schizophrenia, whom the police beat to death in broad daylight in front of witnesses just because he ran from them. Things have been very bad with the Portland Police for a long time with respect to people with mental illnesses and people of color; Orlando is at risk on both counts.

Safety Priority #2: Don’t Let Orlando Disrupt Cinic Operations ...
which unfortunately means not letting him be in the clinic. He’s distracting to receptionists and punks while they’re working, and distracted receptionists and punks are a safety concern for the clinic itself. Orlando is inclined to wander everywhere (including into areas where he shouldn’t be) asking lots of questions and getting people into conversations they find it hard to get out of. He really wants acupuncture, but he’s an example of a potential patient that WCA unfortunately doesn’t have the resources to treat. We might be able to treat him if we/he had a lot of help in the form of a caseworker or a friend who could work with him one on one to navigate the clinic space and everyone else’s boundaries, but unfortunately we don’t have that -- which means he can’t be in the clinic.

Safety Priority #3: Don’t Try to Manage Orlando’s Mental Health for Him
Orlando is familiar with all the local mental health resources and what they offer. He’s not a thousand miles away from home in a strange city with no idea what to do; as far as we know he lives somewhere in Cully. He may present as confused or altered but he appears to be able to take care of himself; he may be having strong feelings (fear about powerful people who are “after” him, sadness about addiction) but we have no indication he’s a danger to himself or others and/or incapacitated. He’s living his life just like the rest of us and also, he isn’t our patient (see #2). Engaging with him for the purpose of accessing mental health services on his behalf is a safety risk because it sucks up time and energy that staff and volunteers need to keep WCA functioning. Also, spending lots of time trying to get Orlando help that he doesn’t actually want is a way of encouraging him to come into the clinic and have distracting conversations with everybody.

How to Communicate with Orlando
Use short, clear sentences and/or simple directives. Don’t use lots of words, and don’t argue with him! For example: “I’m sorry, you can’t be in here, you need to leave. Please follow me.” “No, I’m sorry, unfortunately we can’t treat you and you need to leave.”

If Orlando shows up at the clinic again, please call both Phoebe and Lisa so that there is an extra person to talk to him. Stay calm, don’t get into long conversations with him, don’t try to “help” him, and above all DON’T CALL THE POLICE/911.

So how did we get to that policy? We rehashed what happened with various participants and here’s how we view the incident now.

In hindsight, Celia realized that she should have asked for help as soon as it became clear that she was getting stressed by trying to both respond to Orlando AND do all the normal multi-tasking of a busy shift. It was simply too much to do, and there weren’t enough humans present to manage everything, even if Celia hadn’t been triggered by Orlando’s behavior -- which she was.

In hindsight, Phoebe realized that in addition to coming in to the clinic and talking to Celia, she should have dashed off an incident report and emailed it to everybody at WCA. One of the most notable aspects of this incident is the way that Orlando was transformed from “neighborhood guy that we have history with/not a problem” to “scary random stranger/mental health patient in crisis that we need to manage”. And that transformation created safety risks for everyone, but for Orlando most of all.

Phoebe wrote afterwards, “I realized this was a person in the neighborhood (not a patient) that I had had previous contact with and had had to "move along" a number of times which was never hard to do. He just really likes the energy of the clinic. (Celia and I) discussed this history and my experience of him being non-aggressive, mostly soft spoken but never more than occasionally annoying to deal with. I had a lot of compassion for him as he is in and out of jail, mentally ill and a meth user. We discussed boundaries and how to handle getting him out/away if he was to come back and we both agreed it was OK for me to leave as he had not come back and Celia was feeling better...I wish I had recorded this narrative with Celia at the front desk when I was there sitting with her right after the first episode -- and then sent it out to everybody.” (This episode demonstrates the value of incident reports better than anything else I can think of.)

Because what didn’t happen next was important: Rosalind didn’t get the backstory about Orlando, and neither did Robin or Antonia when they came on for the next shift.

Afterwards, Rosalind commented that there was a huge difference between the relationship between Orlando and WCA that Phoebe described, and how the atmosphere in the reception area felt when she observed Orlando and Celia interacting.

Pardon me as I interrupt this blog post for a public service announcement: as a person who has PTSD, the hardest thing for me to explain to people who don’t, is how completely my experience of reality changes when I’m triggered. It’s disorienting and terrifying. Once I realize I’m triggered, I can start to observe the difference between what I’m experiencing and what everybody else is experiencing. But just registering that I’m triggered, and realizing my brain is not working properly, takes time and effort, let alone actually managing the situation that triggered me in the first place. Usually I can’t manage it and I need to just remove myself, but sometimes it’s hard to even do that. As Jersey commented recently, “It strikes me as super important for us to have a solid inventory of our own triggers” -- because otherwise we can get ourselves into dangerous situations, and sometimes we bring other people along with us.

In hindsight, we all need to be clear that when someone like Orlando shows up in the clinic, there isn’t a binary choice between “calling the cops” (which thank God nobody did) and “engaging mental health services”. Our various efforts to get Orlando help that he didn’t actually want were likely a big factor in changing how Orlando interacted with WCA. Meaning, Orlando went from somebody who occasionally wanted to do something we couldn’t let him do -- like join a staff meeting -- but who would then politely leave, to somebody who refused to leave the clinic and its staff alone when we asked him to. Trying to get Orlando help that he didn’t want created charged, adversarial interactions between him and clinic staff that somebody (for example, Robin in Episode 2) then had to de-escalate. We were more responsible for the original escalation than Orlando was.

Note to self: assume that those of us who are attracted to the healing arts need to do a lot of work on our boundaries. It’s not appropriate for us to try to help every person in every circumstance; for safety’s sake, we sometimes need to not try.

In hindsight, we also need to be clear about who we can treat, who we can’t, and why. A side note to the safety drama is that after one episode, when Orlando had just left, Phoebe happened to cross paths with a WCA patient coming into the clinic, let’s call her Lady Macbeth for oh, no reason. Lady Macbeth probably warrants her own post at some point, but let’s just say most other community acupuncture clinics would have parted ways with her a long time ago, and one reason why we haven’t is that she provides POCA Tech interns with a kind of one-person bootcamp in trauma informed care. Lady Macbeth regularly walks the line of what kind of behavior WCA can accommodate, and as Phoebe passed by and Lady Macbeth scowled at her, Phoebe reflected that Lady Macbeth is barely on one side of a certain boundary, and Orlando is just over that boundary on the other side. But they’re not actually that far apart, and as multiple people have commented when pondering their differences, Orlando is a lot nicer. However, he is actually over the line in terms of being disruptive to clinic operations.

In hindsight, there are also things to learn from what went well in this incident.

First, it’s vitally important to have enough humans present, which means calling for help when things get difficult. WCA, like most community acupuncture clinics, runs on a shoestring; we need to keep our overhead low in order to keep our prices low. The role that POCA Tech observers played in this safety incident showed how important it is to have additional hands on deck sometimes. Leander and Beatrice created safety by helping meet patients’ needs (de-needling patients when they want, as opposed to making them wait, is a crucial aspect of managing stray needles) and generally providing back up and communication. Most people who come through WCA’s doors can navigate our systems just fine, which is crucial to our business model, but occasionally somebody like Orlando can’t, and that’s when we need more humans involved.

Second, Hero demonstrated the importance of setting boundaries simply, clearly, calmly, and kindly. WCA staff tried all sorts of things to interrupt Orlando’s behavior -- helping him, arguing with him, scolding him, appeasing him -- but the only thing that worked consistently was just telling him, in simple language, and with no emotional charge, what we needed him to do. The “no emotional charge” was only possible because Hero wasn’t triggered by him (Beatrice and Phoebe weren't either, when they followed her lead in episode six). Hero also acknowledges that over many years in the healthcare field, she’s done a lot of work on her own boundaries.

Finally, I used a lot of character names from Shakespeare’s As You Like It because that play had a longer list of characters than All’s Well That Ends Well, but that was the play I was thinking of. It’s considered one of Shakespeare's "problem plays", a play that poses complex ethical dilemmas that require more than typically simple solutions -- which I think is true about safety, as well. I’m so, so glad nobody called the police at any point during this drama, and also, I’m disappointed that we couldn’t treat a prospective patient who wanted acupuncture so much that he came back to the clinic six times to try to get an appointment. Maybe if we or Orlando had more and better resources, he’d be a happy WCA regular. This incident clearly demonstrates the dynamic tension between safety and access, and I kind of hate that. I wish we only had to think about access. But at least nobody was injured -- that’s something -- and we all learned a lot.

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