Don't Get Punched in the Face

Published in on Dec 6, 2021

A POCA Tech student asked, “How would you describe Trauma Informed Care to an acupuncturist who went to a conventional acupuncture school and didn’t learn anything about it there, but wants to catch up? P.S. I appreciate how much time we spend on this topic at POCA Tech.”

These days when I introduce TIC to a new cohort of students, I usually say something like: People sometimes have misconceptions about what TIC is and why we teach it here. I think it’s a common mistake to imagine people with trauma histories as cute fluffy sad things, and TIC as some noble humanitarian philosophical orientation. Actually, TIC is about how to not get punched in the face. We teach it at POCA Tech because it’s a basic, pragmatic safety measure; sometimes people with trauma histories might be cute fluffy sad things, but a lot of the time they’re... not.

At WCA, we learned about TIC through our relationship with the caseworkers of Care Oregon’s Health Resilience Program, a hot-spotting program for “high utilizers” of healthcare ( people who end up in the hospital and/or the emergency room a lot). At a TIC workshop I went to, the presenter Laurie Lockhart told this story about an experience that caseworker Lisa Achilles had (Lisa is also a longtime member of WCA’s Board of Directors):

She was working on getting one of her clients, a young man with a trauma history who was houseless, into stable housing. After significant effort, she’d gotten him to the point where he was actually sitting in the waiting room of a housing organization, filling out his application, which was a big step. But there was a lot of paperwork, and that kind of bureaucracy is a trauma trigger for many people who have had bad experiences with “the system” -- and her client had a panic attack which was so severe that he ended up in the ER. In the ER, a healthcare provider came up behind him and touched him on the shoulder -- and he spun around and punched the person in the face. At which point he went to jail, and lost his place in line for housing. He and Lisa had to start the process over from the beginning. Growing up, he had an alcoholic stepfather who beat him.

This story is important for understanding why life can be so difficult, in general, for people with trauma histories, but also for illustrating how implementing TIC is about physical safety for everyone.

Pre-pandemic, a friend of mine who isn’t an acupuncturist told me, “I had this weird experience with a person I met on the train. We were sitting next to each other, I had a headache, so I closed my eyes and started massaging my temples. She said what’s wrong, I said I have a headache, she said oh I’m an acupuncturist, I can help you with that -- and she just reached over with no warning and started rubbing my shoulders really hard. I said ow, please stop. I didn’t even know her name.”

“Oh my God,” I said, “She’s lucky she didn’t get punched in the face!”

TIC recognizes the prevalence of trauma, which means you have no way of knowing whether any given person has a history that might result in hair-trigger reactions if you touch them. So before you touch anybody, you should have some idea about how trauma affects people.

Recently Jersey and I were talking about the acupuncture profession’s ambivalence about patient access, and Jersey said: It relates to needle exchanges and harm reduction in that some people who say they want to help only want to help the "worthy & deserving" - with overtones of moral virtue. So, no help for drug injectors who don't practice abstinence, the same way there was no help for AIDS patients whose disease could be tied to voluntary & "deviant" behavior. And also, people being very cold and cruel about COVID illness and death among the unvaccinated. So the acupuncture profession as it developed into providing an elitist service had no interest in broad access, because that wouldn't allow for the careful selection of the "worthy" patients - which happens via an extensive intake interview about behaviors and beliefs, in which the patient's commitment to making changes via sheer willpower is the gauge of their worthiness. So they've narrowed down the field of potential patients to just those who will submit to this particular exercise of power... and then when they've got a really small subset of the population defined, there's a scarcity of patients (even outside of price accessibility) and so they need to limit practitioner access to those patients via licensing... The ideal patient is suppliant, compliant, and wealthy, and there aren't enough of those to go around.

I think Jersey’s point about access goes a long way towards explaining why conventional schools don’t seem interested in teaching their students to practice TIC (and also, why POCA Tech approaches intakes so differently). For one thing, TIC wasn’t actually designed for cute fluffy sad victims, it was designed for difficult people, for people who do bad things (which is why I love it). Remember the TIC maxim, don’t ask what’s wrong with someone, ask what happened to them? TIC offers a great perspective why you can’t expect patients to be compliant, and why compliance isn’t a good goal to have in the first place.

If your goal as an acupuncturist is to only treat the worthy and compliant, by definition you’re not going to treat a lot of people. The more people you treat, the more traumatized people you treat, and the more likely it is that you’ll discover an acute need for TIC because people’s triggers will show up in your clinic. You’ll have to not only learn to manage those triggers -- you’re going to become very motivated to learn how to avoid them if you can. Most of the time people being triggered doesn’t lead to anyone being punched (at least not in community acupuncture -- ERs are a different story) but it can be very disruptive, for both the patient and you.

TIC is about having systems that make your clinic easier for traumatized people to use, though you’ll never be accessible to every traumatized person. As Jersey says, trauma triggers are “cruelly specific and wickedly unpredictable”. You're aiming for safer rather than safe.

I imagine that at least some conventional acupuncture schools will start teaching TIC in the classroom at some point, if only because it’s become such a core aspect of behavioral healthcare. Where I expect they’ll have trouble, though, is applying it to their school clinics. POCA Tech is different in that respect, in that we didn’t intentionally apply TIC to our clinic. TIC was built into the community acupuncture model because I needed to create a clinic that I could stand to practice in while I was busy surviving my own trauma history. (Back then, sometimes I was a fluffy sad thing but more often I was a dissociated, disregulated, explosively angry thing.) It was only later that we learned, thanks to the caseworkers of Care Oregon, that there was a technical term for why many of their traumatized clients loved WCA and the term was TIC. We’ve always worked backwards from the concrete to the abstract, and most acupuncture schools are the other way around.

So for an acupuncturist coming out of a very heady, abstract, academic environment it could be easy to mistake TIC for a philosophy as opposed to a pragmatic strategy to create more safety and more access. If I were talking to someone in that situation, I’d want to help them remember to keep it simple, and try not to get punched in the face.