Holding Space in Community Acupuncture
For a community acupuncturist ("punk"), maintaining a patient base is a lot like being the nucleus at the center of a little electron cloud of patients. An atom is the basic unit of matter, and a punk with a patient base is the basic unit of community acupuncture.
(A diagram with an image of a person sitting on a rolling stool at the center of a group of people relaxing in recliners)
This diagram represents similar dynamics in three major areas: clinical practice, safety and ethics, and practice management. Let’s break down each of the elements in detail: the electrons/patients, the nucleus/punk, and the bonds between them, then look at what the diagram as a whole represents.
An early adopter of community acupuncture, Nora Madden, once commented memorably that an acupuncturist without patients is just some weirdo stabbing needles in the air. You can’t work as a punk unless you can attract patients who want you to treat them. Without a patient base, you can’t develop as a clinician, you’ve got no cash flow, and you can’t make a living. Without patients, there’s no praxis of community acupuncture, just a bunch of theories.
At WCA, we say that our goal is to offer people as much acupuncture as they want, in support of whatever goals they have, so that they can use it in whatever way works best for them. As a result, within the electron cloud you’ll find categories of patients who use acupuncture in different ways: regulars, semi-regulars, sporadic regulars, and tourists. These categories show the role of routine and habit in building a patient base that’s big enough to be sustainable for the punk. (Note: in real life these are not perfectly neat categories, there’s blurring and overlap.)
Acupuncture is important to these people. Receiving treatments provides a kind of rhythm and ritual for them; acupuncture keeps them going. Whether they’re managing a chronic condition, navigating a terminal illness, or they’re just really serious about self-care, these are the patients who show up every week or every other week like clockwork, sometimes for decades. They are the foundation of a sustainable clinic; they’re the reason the community acupuncture model can be financially self-supporting. They establish a deep connection with their practitioner, though they may not express it in words.
Acupuncture is important to these people for periods of time and under certain circumstances, but not as consistently and broadly as the regulars. A sporadic regular might come in three times a week for a month for a sprained ankle, then you won’t see them again until they pull a muscle in their back a year later, or get a divorce, or start a stressful job, at which point you’ll see them regularly for another month or two or six, and then they drop away again. They don’t need acupuncture all the time, but when they do need it, they’re serious.
These people tend to not establish a rhythm around acupuncture like the regulars and semi-regulars; in fact they might not be able to follow a treatment plan, no matter how clearly the punk explains it. They drop in and out. They want acupuncture when they want it, and the punk might not be able to figure out exactly why. A relationship is established, but it’s not a close one.
These are the one-and-dones, people who show up because they want to try acupuncture but decide it’s not really their cup of tea and so they don’t come back. Sometimes they’re literally visiting from out of town, and I suppose miraculous, one-treatment cures would also fall into this category. There isn’t an ongoing relationship between this person and the punk. Which is not to say that they’re not a valuable part of the patient base, because they are; they might introduce the clinic to members of their social circle who then become regulars, or they might someday become regulars themselves.
A punk needs to do the work to make it possible for any patient to become a regular if they want to, which involves giving them the right information (doing a good intake and appropriate treatment planning) and also providing the energy, intention, and consistency to establish a relationship. A punk who doesn’t learn how to do this work will have so many one-and-dones that their practice won’t be financially sustainable. The presence of regulars in a punk’s patient base is a kind of measure of the strength of the punk’s relationship-building skills. If, after a reasonable amount of time has elapsed, a punk doesn’t have a healthy share of regulars, something’s off.
The atomic bonds in the diagram represent the connection between the punk and their patients. It’s a very specific kind of connection with very specific boundaries, but each individual punk has to figure out how to create and maintain these bonds in their own way; nobody does it exactly like anybody else. Essentially, the bonds are made out of a kind of nonjudgemental, accepting, empathic, focused attention that the punk directs toward the patient and the patient reaches out and holds on to. For some patients, it’s a literal lifeline. This attention is how the punk provides accompaniment to their patients in whatever they’re going through. It has a quality of being simultaneously personal and impersonal, and it’s mostly non-verbal.
Directing this kind of attention isn’t an accessory to the treatment process, it’s a foundational part of it. It’s an art. It’s probably impossible to understand by reading about -- you have to watch somebody doing it, and know what to look for.
Good punks use their presence the way they use their needles, and doing this consistently is how they establish relationships with their patients. Being good at needling, providing clinically effective treatments, and being a nice person all help in establishing relationships with patients, but none of those is a substitute for providing nonjudgemental, accepting, empathic, focused attention with the intention of forming a therapeutic bond.
Being a technically proficient punk and a nice person is, unfortunately, no guarantee of being able to have a sustainable practice. Building a patient base, by intentionally forming enough of these bonds to have a practice, is something a punk has to choose to do. A patient base doesn’t just happen to a punk because they want it to, they have to make it happen. It requires intention, focus, and effort sustained over time.
Both the patient and the punk contribute the energy necessary to form a therapeutic relationship (see above: regulars really want a relationship with the punk, tourists really don’t, and the semi-regulars might just not have enough energy to sustain much of one). There is an element of mutuality to the relationship (more about that in a minute). However, in all the important ways, the punk has to go first in extending themselves. The punk has to contribute the majority of the stability and the intention in forming the relationship -- because that’s the punk’s job.
To understand more about the relationships that establish a patient base and create a sustainable practice, we have to look harder at the nucleus, the punk at the center of it all.
The punk’s job is to be the calm center of an energetic web of patient relationships, to hold the space for healing for a wide variety of people. Having thought about it for a long time, I’m convinced there are two key aspects to successfully being a nucleus: first, the need to do it and then, the ability to step into the practitioner role.
Let’s talk about the need first, in somewhat painful detail.
As noted above, there’s a necessary element of mutuality to the punk-patient relationship; both parties have to be invested to a certain degree. However, there’s an extra dimension that makes some punks magnetic, and I believe that’s because they have a deep, driving, personal need to build and maintain a patient base. This is the foundation for attracting patients, and it can’t be faked. It’s either there or it’s not, and punks should be as honest with themselves as they can about that.
For myself I recognize the need that made me a magnetic punk was rooted in the pain of being helpless, as a child, specifically in relationship to my family’s suffering. People in my family were in chronic mental and physical pain, they often took it out on me, and there was nothing at all I could do about it. Their pain was inseparable from the toxic stress of being working-class in this society. Becoming a punk was my way of redeeming that experience. As a punk, I could meet suffering people and relieve their pain, more often than not. I could be there for them in a way that felt safe to me; I could be intensely, lovingly present with them. I could help them and not get hurt in the process. I was rewriting my history. It was magic.
I needed to treat a lot of people, and the people who became my patients felt that from me -- the magic -- whether they recognized it consciously or not. I wasn’t being altruistic; the relationship was mutually healing. My patient base represented the family I wished I could have done something for. When I stopped being a punk, it wasn’t because I was burned out, it was because punking WORKED for me. After a couple of decades of doing it, I was okay in a way that I hadn't been before. The need was fulfilled and the urgency was gone. And once the urgency was gone, I didn't attract patients like I used to.
My guess is that there’s often a similar redemption dynamic at work with some other successful punks, because a lot of us grew up around suffering people. A lot of us loved people who didn’t get what they needed. Being in the punk role is a way to heal that.
There are other possible dynamics for magnetic punks -- and practitioners in general.
An urgent need to redeem and repair can also emerge from an acute, painful consciousness of the state of the world. Some punks find the “prefigurative intervention” aspect of the community acupuncture model to be deeply healing. Though we might live in a society where people seem unwilling to share important resources and treat vulnerable humans with care, nonetheless a punk can make a space in which those things happen anyway: resources are shared and care is extended, and every treatment given to someone who needs acupuncture but otherwise couldn’t afford it feels like a personal victory. Building a patient base feels like restoring something that’s broken on a vast scale. Maybe it’s just a tiny, fractal gesture, but it’s real and potent nonetheless.
From another perspective, I’ve known punks who were driven by a deep need to be liked and/or to be the center of attention; for them, building a patient base who adored them was a way to get that need met. The praxis of punking asks us to level power dynamics as much as we can, but outside of the punking context, you can see practitioners who establish themselves as gurus in the center of a web of devoted acolytes. I think that’s because the gurus need a whole crowd of people focused on them in that way, and their acolytes need somebody to worship. It’s not wrong, it’s just what’s happening -- and it’s definitely a successful strategy for establishing cash flow. But “the magic” can’t be faked. A punk who just wants to make more money is not necessarily a candidate for becoming a guru. Gurus are driven by internal guru-needs, just like punks are driven by internal punk-needs.
Cultivating self-awareness is obviously important. It really helps to be honest with yourself, without judgement, about what drives you, what you’re working out in your life, and how that shows up in your relationship with other people. Building all the relationships contained in the web of a patient base is a lot of work; if there’s nothing deep-seated driving you to do it, you might not be able to. Even if a thriving community acupuncture clinic with a big, stable patient base is something that has an abstract, altruistic appeal for you, you might not have the capacity to make it happen without the magic of deep, unmet personal needs.
T/F I’m fine, I don’t have any deep unmet personal needs that would cause me to embark on all the emotional labor of building a patient base.
If your answer was “F”, fill in the blank: I think I might need to build a patient base because _______________________________________________________.
Creating the Basic Unit of Community Acupuncture
Let’s look at the next aspect of being a nucleus: stepping into the practitioner role, which leads to what might get in the way of building a patient base.
For those of us who grew up in troubled families where we filled a caregiver role in some form, it’s just a hop, skip and a jump to taking on the role of helper. We have plenty of lived experience being a person who is supporting other people through hard things. We got lots of practice and socialization in how to inhabit this role, possibly long before we were adults. People who didn’t grow up with this family dynamic may need more practice and more role models. For everyone, boundaries and intentionality are crucial -- for clinical practice, for safety and ethics, and for financial sustainability.
Becoming a punk requires defining who you are as a practitioner, primarily to yourself. If you’re clear on that, you can’t help but communicate it to your patients. And the clearer you are, the easier it will be to do the work of building all the relationships you need to have a patient base, because you know who you are and what you’re about. The topic of building a “punk persona” is too big to address here, but suffice it to say that who you are as a practitioner, at work, can’t be exactly the same as who you are as a human, on your own time. There has to be a boundary marker to protect you and your patients. But when the boundary is clear, it becomes easier to be a nucleus holding space for other people.
As noted above, the presence of regulars in a punk’s patient base is a kind of measure of the strength of the punk’s relationship-building skills. If, after a reasonable amount of time has elapsed, a punk doesn’t have a healthy share of regulars, something is probably getting in the way. Possibly the punk doesn’t have a driving need to build these relationships, or there’s a problem with the punk inhabiting the practitioner role.
Some questions that are worth asking yourself:
Do you have enough self esteem to see yourself as a reliable, positive influence on a few thousand other people? Do you see yourself as capable and a good person? If your life has caused you to have doubts in this area, those doubts could present an obstacle.
Are you able to focus? Are you able to be consistent? Do you like and need routine? In other words, are you prepared to become the source of somebody else’s (thousands of somebody elses’) self-care habit? Is that role a good fit for you? Are you enough of a grown-up to fill it?
Do you have enough space in your life to make room for an energetic structure that represents hundreds or thousands of (specific, boundaried) relationships with other people, most of whom are going to be in pain? Do you have enough headspace and enough literal energy to hold up your part of this?
And will your life outside of work support this task? If your life outside of work is too chaotic, there simply might not be enough YOU available to be a nucleus that can hold energetic bonds. This question might require you to investigate your relationship with chaos, period. Building a patient base demands a certain amount of order, structure, and self-discipline; how do you really feel about those things? And how do you really feel about chaos -- do you create it because it appeals to you or because it’s familiar, and will you undermine any structures you create, even though you claim to want them, because chaos is your expertise?
Finally, since the process of building this energetic structure requires decision, commitment, and intention, do you have any issues with those outside of punking? If it’s hard for you to make decisions, it might be hard for you to effectively announce to the universe that you are a practitioner now and you are available to your future patient base. (So let the phone begin to ring!) If commitment is something that you struggle with, you will probably have trouble attracting the committed regulars that are the basis of a financially sustainable practice – because you have to commit first. And if you aren’t sure that you deserve to shape your life with your intentions, it will be hard to summon, guide, and sustain the intention required to be a nucleus. On a certain level, being a nucleus is selfish (in a good way) -- so are you able to be selfish enough to channel your energy in a direction that you choose, even if other people try to redirect you?
The Role of Ruthless Honesty, or What Are You Really Doing?
Building a patient base requires intention, focus, and effort sustained over time, which means that over time it may also require some troubleshooting. Some punks seem to get a great start on building a patient base, but then fizzle out. Some punks seem to have a good understanding of their job, but their treatment numbers, week to week, are erratic. Some punks seem to be doing fine, and then their patient numbers abruptly crater; the phone stops ringing, the online schedule stays empty, and they wonder, where has everybody gone?
Sometimes there are genuine external reasons for a drop in numbers, for example, weather. (Also: pandemics.) Sometimes there’s really nothing a punk can do about an empty schedule. But I think it’s always worth asking, no matter the circumstances, is there an internal factor? Is there something going on that maybe isn’t out of the punk’s control? Specifically, is there a way that a punk’s attention is not going into the relationships that make up the patient base, maybe because it’s going somewhere else?
Which is where ruthless honesty comes in. My experience of small business is that I’m always doing what I’m really doing, as opposed to what I claim to be doing, or wish I were doing, and that’s what determines how my business is doing. (This maxim is somewhat related to the Buddhist saying, how you do anything is how you do everything.) Let me explain.
Everyone only has so much energy to give to their work. Humans have limits. Also, we are capable of self-deception. So while I may say that all my attention and intention is going into building the relationships that make up my patient base, really my attention and intention might be going into my anxiety about NOT having enough patients. And as a result, I might direct my energy even farther away from the relationships I need to build, by scrambling to do marketing activities like putting fliers up all over town, which wears me out, leaving less energy to put into relationships. (I’m not saying there’s no role for marketing, just that if it’s driven by anxiety, what I’m doing then as a business owner is reinforcing my anxiety.) Or, alternately, booking myself a CEU class to better learn how to treat, say, neck pain, which is interesting but takes up an evening that I really needed to rest and recharge in order to have more energy to put into relationships. (I’m not saying there’s no role for CEU classes and polishing up technical skills, just if that’s driven by anxiety, what I’m doing in that class is reinforcing my anxiety -- in the name of learning.) If I lose my focus on the relationships, I can’t direct my energy toward them and they won’t grow. If what I’m really doing, in general, is being anxious and scattered, how my business is doing will reflect that; “anxious and scattered” doesn't help with being a nucleus, the center of a healing space. Conversely, putting energy into marketing and brushing up my skills can actually cause the phone to ring, IF I’m doing those things as part of a genuine effort to channel my energy into my patient base. Only I’m close enough to myself to be honest about what I’m really doing in any given moment.
I’ve seen punks struggle to build a patient base because what they were doing in their practice mostly was not building a patient base, but something else, for instance: trying to become an expert in some technical aspect of acupuncture treatment; trying to please everyone who walked through their doors; trying to fix/improve everyone who walked through their doors; trying to be the perfect small business owner who did every task correctly; having an amazing social media presence; making the most beautiful, aesthetically pleasing space; or (regrettably) generating drama with their coworkers. In all of these instances, they succeeded to some degree at those other things (except pleasing and fixing everyone they met, that’s a tall order) but they failed at building a patient base -- because relationships made out of empathic attention simply weren’t their focus. You could tell where their energy was really going, by the results.
It might be easier (and more socially acceptable) to focus on marketing, or social media, or technical skills, or the decor in your clinic -- but these things won’t solve the problems that result from a punk not doing the demanding internal work to build a patient base.
As a side note, this is why student acupuncture clinics lose money. The main thing that student interns have to focus their attention on -- they don’t have a choice -- is being students. The work of getting through school is nothing like the work of building a patient base, and even if it were, students don’t have the energy and headspace to be nuclei. The best case scenario for a student clinic is that it catches the overflow from the patient base of a working punk.
This is not to say that you need to have all your problems sorted out and all your rough edges sanded off before you embark on the project of building a patient base -- otherwise the process wouldn’t be redemptive. The point is that building a patient base is, in part, an inside job that demands self-awareness. And developing that self-awareness can actually be a valuable benefit of becoming a punk.