Dual Relationships in Community Acupuncture

A dual relationship means that, in addition to having a practitioner-patient relationship with a person, you also have another type of relationship with them. Here’s an excellent article about dual relationships from the perspective of psychotherapy. Types of dual relationships include:

social -- you’re friends with one or more of your patients;

business -- you’re in a business relationship with one or more of your patients (for example, you’re treating your landlord and/or their family members, or you and your business partner treat each other);

communal -- you go to the same church as one or more of your patients, or you’re part of the same LGBTQ+ community, or you live in the same small town/neighborhood and go to the same coffeeshop, hardware store, etc.;

digital -- you’re friends, followers, or otherwise connected online with one or more of your patients.

Non-sexual dual relationships are not necessarily unethical. Only sexual dual relationships with current patients are always unethical and, for licensed acupuncturists, illegal.

For a community acupuncturist, dual relationships with patients are unavoidable. Remember this diagram:

If you build a big enough patient base to support your practice, some of the people in it are going to be people that you have dual relationships with. That’s just how community acupuncture clinics grow. Eventually, you’ll probably be treating your hairdresser, your barista, your neighbors, and any number of other people you have relationships with outside the clinic, along with their friends and extended family. If your clinic is structured as a nonprofit, your patients will be your volunteers and your board members. You’ll need your patients to show up for you in various ways in addition to showing up to be treated. The point is not to try to avoid dual relationships with patients (it’s impossible) but to figure out how to have good boundaries within them.

The community acupuncturist job is inherently demanding; it doesn’t mix well with interpersonal drama and conflict with patients. That combination is a recipe for burnout. Dual relationships become a problem if they’re a source of stress for you, particularly if they generate interpersonal drama that interferes with you being able to treat someone or with them being able to access the clinic.

Here’s an example from WCA (and I’ve heard similar experiences from other clinics) of a relationship with a patient that was simple, straightforward and helpful when it was restricted to the treatment room, but turned into something convoluted and unpleasant when it moved outside those boundaries.

A patient, let’s call her Camille, found WCA during a stressful time in her life. She had recently graduated from a professional program in which she trained to be, let’s say, a project manager. It turned out that the career wasn’t a good fit for her so she quit her job and was living off her savings while trying to figure out what to do next. She started getting acupuncture for anxiety (the second most common reason that people come to WCA) and got great results. She didn’t have any income, though, so she quickly gravitated to volunteering so that she could get free treatments as a perk. She loved WCA’s community-service vibe and since she had a lot of time on her hands, she was soon filling more and more volunteer shifts, as well as asking to help with any projects which might benefit from her various professional skills -- in addition to getting acupuncture three or four times a week. She was always around WCA, very much a part of our community, and for awhile it was fine -- but somewhere in there, the relationship between Camille and the clinic (including all the practitioners who had been treating her) began to slowly and inexorably deteriorate. None of us could figure out precisely why, what the problem was or how it started, but we could see that Camille was increasingly unhappy with WCA and everyone who worked there (though she continued to get frequent treatments). She would occasionally drop hints about how she’d like to reorganize various aspects of WCA’s business operations, which wasn’t something we were interested in having her do. When nobody took her up on these indirect offers, she became more and more critical, frustrated, and negative. Efforts to communicate about what was bothering her went nowhere; she wasn’t willing to tell us directly. Maybe she thought it was our responsibility to figure it out? During Camille’s shifts at the front desk, she snapped at the punks she was working with and generally made their lives unpleasant, until finally a member of the management collective sat down with her and told her as gently as possible that her attitude would have to change. At which point she got up and left, and we never saw her again.

In hindsight (20/20 hindsight is such a beautiful thing) WCA should have restricted Camille’s volunteering to one reception shift a week and not allowed her to get more involved in the clinic -- even though she had time, she wanted to, and we needed volunteers. She benefited from getting acupuncture at WCA but as it turned out, she really didn’t like working with us -- any of us. Eventually the expanded relationship that Camille had with the clinic, as a volunteer, cost her the relationship she had with the clinic as a patient. I don’t think anybody in this story did anything wrong, but it’s an example of a dual relationship that went awry.

That can happen with any dual relationship of any kind. Unfortunately there’s no foolproof formula that I know of to identify which relationships might develop problems and how to redirect them before it happens - before the clinic loses a patient, and a patient loses the clinic (and possibly their access to acupuncture). That risk is inherent in dual relationships.

I’ve learned to keep an eye on patients’ level of investment in the clinic, because their investment can be a double-edged sword. People who love the clinic so much they want to remake it in their own image need to be kept at arm’s length, whether they’re volunteers, landlords, vendors, or community members who aren’t shy about sharing their ideas and suggestions. People who have an appetite for drama in their relationships also need to be kept at a safe distance; they’re generally able to use the clinic as patients because the clinic systems are sturdy and structured enough, but any dual relationship is almost certainly a mistake -- eventually it’ll blow up.

(And if you as a practitioner have an appetite for drama in your personal relationships, you should probably work on changing that, and meanwhile be extra careful with your dual relationships. You’re also going to need a rock-solid practitioner persona to protect you in the clinic.)

The inevitability of dual relationships for community acupuncturists is a good example of the way in which boundaries in community acupuncture require more intention, thoughtfulness, and planning than boundaries in conventional private-room acupuncture do. Because a community acupuncture clinic is in a sense more open, fluid and accessible than a conventional practice, the acupuncturist needs to be even clearer about the difference between who they are when they’re at work and who they are in any other setting. It’s one more area in which safety-making has to be active and creative, because a list of “don’ts” just isn’t going to help. There are too many variables and too many nuances in navigating dual relationships to rely on rules; what you need most is a safety-positive, boundary-positive attitude toward yourself and everyone else.