More about Sketchy Guys (and Related Topics)

Last weekend I had a great conversation with some POCA Tech students about boundaries. We unpacked the incident with my sketchy prospective patient, and that got us to issues of bias, inclusion, and (my favorite!) organization.

First, though, some observations about boundaries in general. As I mentioned previously: I wish my own acupuncture school had been a lot more explicit about how to build professional boundaries, and I especially wish that the topic had been uncoupled from shame. I wish that I had known to approach building boundaries as a task, not unlike setting up a system for charting or bookkeeping or any other task under the heading of “practice management”. I wish I hadn’t absorbed a sense that the state of my boundaries was somehow indicative of my value as a person.

It’s something of a relief to confirm that I’m not the only one. Here are some unscientific conclusions based on a few weeks of talking about this topic with both students and other acupuncturists:

More people than I expected feel shame about boundaries because of times in the past when they had trouble holding on to their own;

More people than I expected feel shame about boundaries because of times in the past when they crossed other people’s boundaries;

More people than I expected feel shame about boundaries because of BOTH; and

The few people who seem to have no shame whatsoever related to talking honestly about boundaries have either done a LOT of therapy/personal work -- or appear to be clueless about the topic in general.

Acknowledging that many people have shame related to boundaries, and consequently have a hard time talking about them, is an important prelude to actually talking about them, particularly with practitioners in training. All this shame is making none of us any safer. We also need to recognize that working on boundaries takes time, effort, and often, some kind of external support. People don’t build good boundaries overnight; we shouldn’t expect them to.

Getting back to our class discussion last weekend, the intern who set up an appointment for our sketchy prospective patient asked, “Should I have not let him in? Should I have turned him away at the door?” She noted that she had gotten a weird vibe from him immediately.

“Did he ask for an appointment?” I asked. “Or did he just sort of wander in without a clear idea of what was happening inside, and you offered him an appointment?”

“No, he definitely asked.”

“In that case,” I said, “yeah, you needed to give him an appointment. At that point there wasn’t much you could do to deter him without crossing the line into stereotyping -- as in, this guy looks like a drug user so we don’t want to treat him. It took me ten minutes at least of sitting with him in the waiting room before I got the sense that he was actually casing the joint, I don’t see how you could have picked up on that in the seconds between him walking in and requesting an appointment -- unless he was wearing a t-shirt that said ‘hello I’m here to rob you’ which he wasn’t. So I think you did the right thing by giving him an appointment.”

Later I remembered a story I wish I’d told in class, about how a community acupuncturist I knew developed fears that affected their practice. This person was a new practitioner, and in the early days of their clinic, they had a disturbing experience with a sketchy patient. After that, they required all new patients to show their drivers’ licenses at the front desk so that they could make a copy, in case the new patient turned out to be up to no good and the police needed to be contacted.

I think of this as an unfortunate response to sketchiness, for any number of reasons. There are many different people for whom producing a drivers’ license for inspection and copying would be a barrier to receiving care: undocumented people; people whose gender doesn’t match what’s on their drivers’ license; people who don’t drive because they can’t afford a car; people who don’t drive because they’re not able to, etc. In WCA’s experience, these people are likely to be lovely humans who become perfectly fine community acupuncture patients. They’re not sketchy. Causing discomfort and stress for them at the front desk is bad for business, and it makes the clinic less accessible to marginalized people.

Another student brought up the question of what to do in light of the fact that her personal response to sketchy guys, in general, is fear. She knew that if she got a weird vibe from a masculine-identified prospective patient, she would have a hard time responding appropriately in the moment because her fight/flight/freeze response would kick in.

The book The Gift of Fear: Survival Signals That Protect Us from Violence, by Gavin de Becker, emphasizes the idea that everyone has gut instincts about other people, and we can get into trouble when we ignore what our gut is telling us. In my experience as a practitioner, this is true (though the stakes in the clinic are much lower than in the situations de Becker is describing). Many clinic safety incidents, before they actually happen, include some kind of quiet internal warning for the practitioner -- a sense that something about the situation is “off” or some misgiving or hesitation about a choice that in hindsight, turns out to be a mistake.

When it comes to paying attention to our intuition about patients, this is one reason why we as practitioners need to work on identifying our biases: so we can tell the difference between our bias and our gut. As noted above, your biases can create an unwelcoming, even unsafe, environment for patients -- but they can also set up an unsafe environment for you, in which you make wrong decisions about who is trustworthy based on bias. In WCA’s experience, many many many people who are on the wrong side of society’s biases (and who suffer as a result) are admirable humans and perfectly fine to work with, while some people who benefit from society’s biases are, well, not -- and are fully capable of creating safety problems in the clinic. Treating everyone equitably is an important aspect of creating safety, in part because it helps you focus on boundaries and behavior as opposed to what someone looks like or sounds like.

The student’s question about fear also highlighted yet another important aspect of boundaries and safety, which is the value of creating buffers, which in turn involves organization and planning. Let me explain.

One of the most important strategies I learned to manage my PTSD -- and thus to make myself and other people safer -- was to build buffers between myself and stressful situations. Any scenario in which I feel I’m under pressure to make quick decisions or process certain kinds of information (particularly in settings where I feel like I can’t leave) is fertile ground for a PTSD meltdown. For example, I hesitated before signing up for a vaccine appointment at the local convention center because I worried that the scene there had all the ingredients for a panic attack: crowds, bureaucracy, complicated instructions, and my personal nemesis, noise that I can’t escape. I needed my partner to get his vaccine first, then come back and walk me through exactly what was going to happen so that there would be no surprises -- and it helped enormously to hear from him that the environment was amazingly well-organized, friendly, and above all, quiet. (Despite hundreds of people moving through long lines, it was actually quiet.) My vaccinations both went off without a hitch - but for that to happen I needed a buffer of time, planning (including knowing what to expect), and support.

I suggested to the student that her awareness that she might not respond well in the moment to a trigger was, all by itself, an important safety measure that she could build on by making a plan. She would need to think through what to do if a prospective patient with a sketchy vibe walked into her future clinic (particularly if she was a solo practitioner). In her case, it might mean that she didn’t offer him a treatment -- because she had reason to believe that she couldn’t do it safely. Instead, she could let him know that she couldn’t take a walk-in at that moment (true) and would take his number and call him back. She could create a support relationship with a volunteer who would be available to be present in case she needed to treat a patient she didn’t feel safe being alone with. There are many potential options for creating a safety buffer, but they all require her to believe that she deserves to put time and energy into safety planning for herself. It doesn’t mean she’s weak or defective and should just put more pressure on herself to perform -- on the contrary, to create safety she needs to identify ways to reduce pressure.

I learned the hard way that the more I beat myself up for my PTSD symptoms, the more symptomatic I got. Conversely, the more I resolved to work with them instead of insisting they should just disappear, the more manageable they became. I believe this to be true of all safety problems and potential safety problems. And “working with them” always requires organization and planning. Also, talking about them openly. Thanks for reading.