Boundaries in Community Acupuncture, Part 2

Many times in clinic I’ve reaffirmed a boundary with a patient by saying silently to myself, “I’m just your acupuncturist.”

I’m not your doctor, I’m not your mental health therapist, I’m not your physical therapist, I’m not your friend, I’m not your prospective date, I’m not your mom, I’m not your life coach. I’m just your acupuncturist.

That last one, life coach, took me awhile to get clear about because, in my own acupuncture training, I was encouraged to think of myself as a something very much like a life coach. The Chinese proverb “the superior doctor prevents sickness; the mediocre doctor attends to impending sickness; the inferior doctor treats actual sickness” is often interpreted by acupuncturists to mean that any illness can be prevented by maintaining mental, emotional, and spiritual harmony, and so a “sage healer” or “scholar-physician” is primarily a teacher or a guide for ordinary people in how to live so that they don't get sick -- the assumption of course is that if you do get sick, you could have prevented it.

An irony of being an acupuncture student in my particular TCM school was that a number of my teachers didn’t seem to have much use for acupuncture itself; they seemed to view it as a minor adjunct to Chinese herbs, tui na, qi gong, and of course lifestyle counseling. As holistic healers practicing “a complete system of medicine”, acupuncturists were supposed to transform people, not “just stick needles” in them. At worst, acupuncture was presented as a distraction from a patient’s primary work of cleaning up their diet, their habits, and their attitudes.

As noted elsewhere, I was also taught to approach access to acupuncture as a reward for good behavior; for example, if I had a patient who was smoking cigarettes or ate what I perceived as unhealthy food, at some point I was supposed to confront them and tell them that I wouldn’t continue to treat them unless they changed their habits. If I didn’t do this, I was “enabling” them.

What do you call an acupuncturist who doesn’t really want to give their patients acupuncture? I couldn’t spend too much time being confused about that while I was in school, because I needed to get busy becoming an authority on how other people should live their lives. In other words, a guru.

One prominent acupuncture teacher, Lonny Jarrett, described the job like this:

"One of our primary directives must be to break (patients’) cycle of self-indulgence. We as clinicians must become relatively less concerned with the patient's internal experience and relatively more concerned with the evolution of the patient's values and integrity as evidenced by his or her behavior...It's interesting to note that when we practitioners put our attention on a patient's highest potential and encourage it as a living possibility "right now", we often encounter an enormous degree of resistance from the patient. It becomes evident rather quickly that patients come to us for comfort and not to be held accountable to any higher potential...We in Chinese medicine pride ourselves on our holistic value system, but the truth is, we tend to ignore a patient's ethical development in favor of improved physical functioning and emotional "wellbeing". Materialism and narcissism are endemic in our culture, and are central forces at the root of the problems we face. Our willingness and ability to face these forces in our patients will reflect the degree to which we have taken them on in ourselves."

Um. OK, so that’s...ambitious? I responded to the article where this description appears, soon after it came out in 2011. Lots of things have changed since then; my main reaction to re-reading Lonny Jarrett’s take on the acupuncturist role is, wow -- where are the boundaries?

Seriously, where are the boundaries when you see yourself as being a scholar-physician tasked by the universe with managing your patient’s values, integrity, and ethical development, all under the auspices of healing? For that matter, where are the boundaries when you see yourself as primarily a holistic healer whose goal is to transform your patients into healthier (and possibly more spiritual) versions of themselves?

I’m sorry -- the role of enlightened transformer of lives just seems, well, sketchy.

And the thing is, when I was an acupuncture student trying to learn how to be a guru, nobody addressed boundaries related to that role at all. Certainly I was informed about the boundaries enforced by acupuncture licensing boards, such as not dating patients. But nobody explained to me that if you’re counseling patients on their lifestyle, on some level that makes you a counselor. If you’re providing spiritual direction, you’re a spiritual director. I wasn’t actually trained in how to be a counselor or spiritual director, I was just sort of expected to know how to do it based on a desire for enlightenment, which presumably all my patients would share with me, and if they didn’t, I guess I was supposed to fire them rather than “enable” them?

Lifestyle counseling is not a risk-free activity. Besides the obvious risks related to Trauma Informed Care, consider the risks associated with attempting to transform people by improving their lifestyles. Without even realizing it, you could: trigger or participate in a patient’s eating disorder, particularly orthorexia; interfere with a patient’s religious or cultural practices; or undermine their ability to manage their own chronic conditions by presenting yourself as an authority and dismissing their lived experience. In other words, you could make them worse.

I’m sure there are ways to manage these risks -- but the point is, 1) I didn’t learn what they were and I’m pretty sure a lot of other acupuncturists didn’t either and 2) these risks are substantially different from the risks associated with just providing acupuncture. They’re a whole nother ball of wax, as my grandfather used to say (my grandfather was known for eating moldy baloney -- he would scrape off the worst bits and then fry it up -- and he lived to be 96, just sayin’). With acupuncture, we provide an informed consent that explains the possible risks of receiving it, generally based on the information in the Clean Needle Technique manual. If you’re providing lifestyle counseling in addition to acupuncture but using an informed consent that only gives information about the risks of acupuncture, your patients aren’t actually giving consent for lifestyle counseling. And in my experience, many patients who are trying acupuncture for the first time wouldn’t guess that it implicitly involves a requirement that they transform themselves to match their acupuncturist’s ideals.

I’m not saying that lifestyle counseling isn’t helpful to some people under some circumstances. (Maybe my grandfather would have lived to be 97 if someone had talked him out of his fondness for greenish lunchmeat.) But the assumption that every patient who comes to you needs it whether they ask for it or not isn’t a good foundation for building healthy patient-practitioner boundaries. I think if you want to provide lifestyle counseling, you should figure out a trauma-informed way to do it, with clear consent -- and also, it would be safer to separate your lifestyle counseling from your acupuncture practice (at the very least, with separate appointments).

Because being just an acupuncturist is actually pretty great.