Boundaries in Community Acupuncture, Part 3

Recently the universe gave me another writing prompt about boundaries: a few days after the episode of the sketchy guy, I taught a POCA Tech class, Patient Education Deconstructed. That class was originally designed to check the box for the ACAOM requirement about patient education (Standard 7.04, "the student must demonstrate the ability to educate patients about behaviors and lifestyle choices that create a balanced life and promote health and wellness") but over time it’s gotten more useful than just box-checking. Anyway, we were having a good discussion; somehow the topic of my long-ago internet fight with Peter Deadman came up. Later on I went back and re-read all the relevant materials (more about those in a minute) and I thought, wow, it's striking that I tried so hard to be polite to the sketchy guy, the would-be thief who was casing my clinic -- meanwhile look how rude I was to Peter Deadman. In print, no less.

What’s up with all that?

In late 2011, I received an invitation to write an article about community acupuncture for the Journal of Chinese Medicine (yes, that one, “the foremost English language journal on all aspects of Chinese medicine including acupuncture, Chinese herbal medicine, dietary medicine and Chinese medical history and philosophy”). At that point I’d been writing about community acupuncture since 2004 or so. Acupuncturists in the UK were interested in the model, and Peter Deadman, JCM’s founder, was sympathetic.

I didn’t want to do it. But I didn’t feel like I could say no, for a variety of reasons. (Note to self: this is how SO many safety/boundary issues --that later require extensive unpacking -- start out.)

Before I started writing about community acupuncture, I talked about community acupuncture. Beginning in 2003, I talked about community acupuncture with any acupuncturist who seemed even slightly interested, because I was so excited about the model and its potential. I vividly remember one acupuncturist who sought me out; I happily spent about four hours with her, one on one, over the course of a couple of weeks as we talked through her plans to set up a community clinic in her town. I remember I was sitting at the front desk of my clinic about a month later when she called. “I just wanted to let you know,” she said, “that I’ve decided to follow your model. In my clinic, though, I’m going to make it... nice. Not like yours.”

She went on to describe how she was taking out a loan to buy new, heated, leather-covered recliners and individual music headsets for each patient; she was going to splurge on satin eye pillows so that none of her patients would have to hear or see each other, so it would be just like a private treatment! She went on cheerfully for quite awhile, apparently without any awareness that she was insulting me and my shabby, beloved clinic that had given her the idea (not to mention hours of free consulting). I guess she thought I’d want to know all the ways my work could be improved if I had more money? (The point of the whole exercise was that I didn’t have more money.)

That was the beginning of a certain repeating pattern with other acupuncturists, the “what a great idea, now let me upgrade it so that it’s actually acceptable” conversation (the culmination of course is Modern Acupuncture). Along with it, sometimes occurring simultaneously, was the “what a noble humanitarian you must be to spend so much energy helping those people” conversation -- because only a noble humanitarian would set up shop in my neighborhood, right?

After a few years of this, the only response I could muster was some variation on “fuck you, leave me alone”. I was sick of acupuncturists who thought they were being nice to me while reminding me that I’m white trash. Okay, fine, I’ll act like white trash; I’ll act like what I am until you go away. I preferred the haters who knew they were haters, the ones who came out swinging with their litanies of how I was degrading, devaluing, and debasing the acupuncture profession. (What else would you expect a white trash girl to do?)

I figured an article about community acupuncture published in JCM, the JCM, would bring my least favorite acupuncturists out of the woodwork, the upgraders and the humanitarians, all the acupuncturists who loved the idea of the community acupuncture model while pointedly turning up their noses at the people I’d made it for. And they would all want to talk to me. So I did write the article, because I didn’t think it was an option to say, “Thank you for the kind invitation, but no”. What I wrote was a pre-emptive fuck you, a pre-emptive go away. I wrote for the haters.

You can read that article, and also Peter Deadman’s response, here (only if you want to, you don’t have to for the purposes of this post).

Some of that exchange is an argument about tone (understandably -- I was rude); underneath it, though, is a substantive disagreement that I didn’t know how to have, back in 2011, without being rude. This was years before I could quote Tyler Phan Ph.D. about horizontal epistemology in the acupuncture profession, before I could write “there is no one right way to practice acupuncture and there never has been” and know without any doubt it’s true. There were a lot of resources I didn’t have back in 2011, and the most important one was Liberation Acupuncture.

Bear with me while I explain.

If your standard of “best practice” for acupuncture equals “acupuncture + lifestyle counseling/spiritual direction”, that will have profound implications for your practice. Peter Deadman put it this way in his response, “To understand a patient's condition, mirror back to them the behaviours that they (as all of us) are often blind to, offer information and sensitively explain it, discuss options for changed behaviour, all these take time as well as great skill but are to my mind a vital part of medicine.”

If that’s your standard for what “good treatment” or “best practice” is, what does it mean for all of the patients who can’t or won’t participate in that kind of conversation with you? That list is a long one and it includes: patients who don’t trust you enough (for any number of excellent reasons); patients who don’t speak your language or whose language you don’t speak well enough to have a “sensitive” conversation about their lifestyles; patients who don’t have the resources to change their behavior; patients who have more pressing priorities than changing their behavior; and particularly, patients to whom you are in no position to be giving advice because you have no clue what it’s like to live their lives. (And if you somehow had to switch places, you probably wouldn’t handle their challenges nearly as well as they do.)

Sorry, I asked a rhetorical question there -- I’m going to tell you what it means to set your standards in that way. The kind of treatment that would actually work for all those people who can’t or won’t engage with lifestyle counseling/spiritual direction becomes, by definition, substandard. It means that in your practice, those patients will be at best second-class citizens and on some level, they’ll constantly be failing -- because they’re not in a position to participate in your efforts to improve them. Are you really going to want to treat them at all, since treating them requires you to lower your standards?

There are a lot more people, SO MANY PEOPLE, so many otherwise marginalized people, who can successfully receive “just acupuncture” and get great results, than there are people who can participate in lifestyle counseling/spiritual direction as delivered by an acupuncturist (who most likely got no training in how to be -- safely -- in the counselor/spiritual director role, but never mind). Why should the standards not be set for the people who need, and can benefit greatly from, “just acupuncture”? Why should there not be multiple best practices, instead of only one, that only works for relatively privileged people?

It was a few more years before I remembered there’s a term for how it works when standards are set with vulnerable and marginalized people in mind, and it comes from Liberation Theology: the preferential option for the poor. From there it was just a hop, skip and a jump (okay, some of those hops were labor-intensive) to the work of Ignacio Martin-Baro and the development of the concept of Liberation Acupuncture.

At one point in his response, Peter Deadman described the article he wanted me to write for JCM when he extended the invitation: “If Lisa Rohleder's argument were as simple as, ‘here's how we community acupuncturists practise; it works for us and our patients; these are its strengths, these are its weaknesses’, my honouring of her work would be wholehearted, for she has clearly worked tirelessly on behalf of financially challenged patients and practitioners.” But I couldn’t have written that article without accepting his standards for acupuncture best practice, in order to then describe the community acupuncture model’s strengths and weaknesses according to them. Which I absolutely didn’t want to do. I didn’t have the language or the concepts to write an article that would have politely laid out an alternative set of best practices based on a foundation of a preferential option for the poor. I couldn’t accept Peter Deadman’s paradigm, and I didn’t yet have the resources to gently pick it up and set it beside a different paradigm in order to politely discuss the contrasts -- so I picked up his paradigm and threw it at him, basically.

My choices in 2011 were 1) to describe the community acupuncture model, which had saved my life, in terms that defined most of my patients as second-class citizens of the acupuncture world or 2) to say, fuck you, acupuncture profession, leave me alone. I’m sorry now that I was rude to Peter Deadman, but I’m not sorry I was loyal to my patients and myself. The only way for me to be neither uncivil nor dishonest and disloyal, at that point in time, would have been to not write the article at all. (Which in hindsight is what I wish I had done.)

Which gets us back to boundaries. Psychologists describe two necessary sets of boundaries: the ones that protect us from other people, and the ones that protect other people from us. For a long time, I didn’t have those boundaries in relationship to the rest of the acupuncture profession. It took over a decade before I could say “no” without also saying “fuck you, go away”. In fact, I didn’t have the boundaries I needed until I had Liberation Acupuncture (a distinct and complete philosophy of practice) which allows me to describe what I do without insulting anybody or being insulted. The boundaries I needed were a tall order.

I think about that a lot when I’m talking to POCA Tech students about boundaries. I think about how the boundaries we need most aren’t necessarily easy to get; about how people don’t magically have boundaries instantly as a result of being told to have them; about how boundaries are often painstakingly (and painfully) constructed over time.

The best boundaries, in my experience, are made out of love and intention. Nobody acquires those as a result of somebody else scolding them to have better boundaries. Creating boundaries has quite a bit in common with setting standards; it involves saying “no” to some things because you are saying “yes” to others. Liberation Acupuncture was, and still is, my “yes”.