Boundaries in Community Acupuncture, Part 1

Let’s take another look at the nucleus diagram:

(A diagram with an image of a person sitting on a rolling stool at the center of a group of people relaxing in recliners)

The energetic bonds between practitioner and patients are made out of a kind of nonjudgemental, accepting, empathic, focused attention that the practitioner directs toward the patient and the patient reaches out and holds on to. These bonds are the core of the patient-practitioner relationship in community acupuncture.

What’s implicit in the diagram of the practitioner “holding space” for all these patients is a quality of sameness in all those relationships. That’s what makes it a diagram of a nucleus and electrons, as opposed to just a list of dissimilar elements: the practitioner at the center of it all shows up in the same way for hundreds of people, day in and day out -- which requires a particular kind of stability, consistency, and commitment.

Maintaining this sameness is an aspect of creating healthy boundaries in clinic. Although your relationships with patients will vary based on a number of factors, not least how invested they are in receiving acupuncture, there should be a core consistency in how YOU approach them. If someone were observing you in clinic, ideally they wouldn’t be able to see significant differences in how you interact with a patient that you like on a personal level versus a patient you don’t like on a personal level, or even actively dislike. Your preferences should be firmly held in check, which is one way to describe what’s commonly known as “professionalism” -- and it’s also a boundary that protects both you and your patients.

The foundation of that boundary is a set of decisions you make about who you are as a practitioner. And you enact this boundary, in part, by means of clear, structured, intentional communications with patients. To put it another way, your interactions with patients are based primarily on decisions you’ve made (long before you walked into the clinic that day) about how you want to show up for them, as opposed to reactions you have in the moment about how they’re showing up with you.

Being present for patients in a stable, consistent, accepting, and unconditionally positive way makes high volume practice both sustainable and sustaining. Busy community acupuncturists love their jobs in part because they get into a flow state of relating to people (and an unusually diverse group of people at that). Flow states are rewarding experiences in their own right, but flow states in relating to people are especially valuable if, say, you’re a socially awkward, introverted nerd in the rest of your life. (I’m speaking hypothetically of course.)

The quality of your presence is what makes all those brief, largely nonverbal interactions feel good to everyone involved. The quality of your presence, your stable seat at the center of that little electron cloud of patients, is what allows you to treat six patients an hour and feel genuinely connected to all of them. Each relationship reinforces and reaffirms every other relationship; getting it “right” with one patient makes it easier to get it right with every other patient.

You need certain boundaries to get into this flow state, and being in the flow state, in turn, shores up your boundaries.

If you have a relationship with a patient that varies a lot from the baseline of all your other relationships with patients, it will affect the vibe of the clinic, and not in a good way. You need consistency in a community acupuncture clinic, it’s not optional. A problematic wobble in your consistency is likely to show up in how you communicate with the patient in question, which gets us back to the risk continuum of talking to patients. Risk increases as communication gets less clear, less structured, less intentional, and more focused on topics outside of how the patient wants to use acupuncture to meet their own goals, and outside of the boundaries of the clinic itself. This doesn’t mean that you drone the same words to every patient like a robot -- it just means that everything you say fits into the boundaries and matches the vibe that you’ve established for yourself as a community acupuncture clinician.

And establishing that boundary really is a form of self-care. Psychologists describe two necessary sets of boundaries: the ones that protect us from other people, and the ones that protect other people from us. (Here's a good article.) A deep consistency of relationships in the clinic is a way of supporting both kinds. Also, it can be fun; I’ve enjoyed private, stubborn satisfaction in being just as friendly and accepting to a patient who’s cranky, rude, and hard to deal with, as to the rest of my patients who are reliably sweet and easy. The effort of being the same with patients gets me to a clear, sane, impersonal place within myself that I like.

The converse, of course, is that me being different with different kinds of patients (particularly based on how much I like or don’t like them) will impact my ability to maintain a stable, consistent, trustworthy, accepting quality of presence in ALL my clinical relationships. Being different with different patients invites the more personal, reactive part of me to get involved -- and that person doesn’t actually belong at work. She’s not equipped to deal with the challenges.

In some settings, more likely private acupuncture settings, acupuncturists use hierarchy and the symbols of hierarchy -- white coats, impressive titles, an all-knowing manner -- as a kind of short cut to establishing boundaries. In community acupuncture (and Trauma Informed Care) we aim for non-hierarchical relationships as much as possible. Which means you have to be MORE intentional and do MORE critical thinking about your boundaries and how to enact them, not less. Showing up to work in jeans and a t-shirt doesn’t mean you don’t have professional boundaries; it does mean you’re not relying on your clothes to do your work for you. Hierarchies are necessary sometimes but in a clinical setting, they can contribute to their own boundary problems. (See also: gurus and lifestyle counseling.)

As a community acupuncturist, you need to create boundaries that fit you and your practice while doing their job of protecting you, your patients, and the clinic space itself -- which requires time, intention, and some degree of trial and error. It’s a subset of making imperfect, homemade safety. The more intention you put into this process, the better your boundaries will fit and the more you can relax into them and enjoy your work.