Safety/Risk Continuum for Talking to Patients

C/W for trauma, sexual assault

Just like there’s a safety/risk continuum for styles of acupuncture, there’s a safety/risk continuum for talking with patients. And just like there’s no one right way to practice acupuncture, there’s no one right way to talk with patients -- AND certain forms of talking with patients are clearly more risky than others.

As part of encouraging a neutral, analytical, non judgmental, safety-positive relationship to risk, let’s get into the safety/risk continuum of talking, with a particular focus on intakes, since this is where patients’ expectations of communication in the clinic get established.

Community acupuncture is distinct from other styles of acupuncture in that verbal communication between the patient and the practitioner can be minimal. In my mind, a defining goal for community acupuncturists -- and what we aim to teach POCA Tech students -- is to be able to successfully treat a patient who is in a lot of pain, who has few financial resources, and who doesn’t speak your language -- in the middle of an otherwise busy clinic shift. If you can be a good acupuncturist for that person under those circumstances, you’re a good community acupuncturist; that’s our standard. Similarly, a foundational concept for community acupuncture is that you don’t need a lot of verbal information from the patient to get good clinical outcomes.

But let’s get back to the safety/risk continuum. When it comes to needling, risks include things like bruising and minor bleeding on one end, all the way to tissue damage and organ puncture on the other. In general, the more needles you use and the deeper you insert them, the more risk of needle safety issues you’ll have; it’s just math. Similarly, the more needle stimulation you do (dipping, twirling, thrusting) the more risk of tissue damage you’ll have.

How about the risks of talking with patients? Well, just like with needling, the more invasive/aggressive you are and the more territory you cover, the more risks you’ll encounter.

On the “safer” end of the continuum is clear, structured, intentional communication, designed to support the patient in using the clinic on their own terms. It’s focused on their experience IN the clinic rather than outside it. Risks increase as communication gets less clear, less structured, less intentional, and focused on topics other than how the patient wants to use acupuncture to meet their own goals. Risks increase when communication extends to topics outside of the boundaries of the clinic itself. On one end of the safety/risk continuum is the kind of minimal verbal communication that allows a patient with few resources and a lot of distress to use the clinic in a way that empowers them; on the other end is verbal communication that can lead to exploitation of the patient by the practitioner.

There’s a whole lot in the middle, and many boundaries to negotiate. A rough outline of the safety/risk continuum for talking, moving from least risky to most risky, might look like:

basic clinic communications --
treatment planning conversations --
conversations about adverse events or poor outcomes --
lifestyle counseling --
communication that involves topics outside the boundaries of the treatment relationship --
intimate relationships with patients

As noted previously, the community acupuncturist job is about being centered, and also making sure the space itself is centered. Certain kinds of energy can knock the clinic space off its axis, and so you have to intensively manage those energies in order to protect it. Too much agitation or noise or disruption in the clinic space will make it not work, and in community acupuncture, you need the space to work for you and with you to successfully treat a high volume of patients.

One of the risks of verbal communication is that you might get into a conversation that sends the clinic off its energetic rails -- which is why a lot of experienced community acupuncturists limit themselves to basic clinic communications and treatment planning conversations. These communications can absolutely include warm, friendly chitchat (and jokes) -- the kind you would exchange with your neighbor or mail carrier or favorite barista. Which is very different from probing questions about someone’s childhood, diet, exercise regime, or spiritual beliefs.

Practicing Trauma Informed Care means working to minimize instances in which people’s trauma gets triggered. Let’s review the list of common trauma triggers in healthcare settings, according to Laurie Lockhart MS:

authority figures
sensory cues of past events
lack of power/control
feeling threatened or attacked
caught by surprise
feelings of vulnerability and rejection
sensory overload

A conversation that involves any of these elements, including reminding people of past events by talking about them, represents a risk that either the patient or the practitioner or both will get triggered.

You can minimize risks related to trauma triggers in the following ways:

By practicing self-care
So that you’re able to engage in conversations from a centered place. It’s harder to be centered if you are tired, hungry, thirsty, or distracted -- or if your own needs aren’t being met in significant ways.

By being clear about exactly what information you need to get from the patient in order to give them a good treatment in that particular moment in time -- and no more.
This means not digging for, or even soliciting, extra information. From a risk perspective, it’s as simple as this: the more you talk, the more likely you are to wander into a trigger. Trauma Informed Care means “recognizing the prevalence of trauma”; which is another way of saying you should assume that any given patient’s history is a minefield of trauma triggers. Just as you would not wander cheerfully through a minefield, you should not meander through conversations about a patient’s history. Know where you’re going with everything you say. A student recently shared an example of an intake in which they asked what seemed like a benign, open-ended question about what might be causing a patient’s insomnia, to which the patient responded, “I haven’t slept well since I was raped. When I was six.” At which point both people in that conversation were having a hard time.

By being clear about exactly what information -- and no more -- you need to share with a patient in order for them to develop a relationship with acupuncture, and the clinic, that allows them to use it for their own goals.
Particularly in the context of an intake, the most pressing questions in the patient’s mind -- consciously or not -- are things like, “Will I like this? Will it help me? Will it hurt? Is this a safe thing for me to try?” Until they get those questions answered through experience, they don’t have much room to take in more information. Remember that a goal of Trauma-Informed Care is to avoid overwhelming people.

By being in touch with your intuition and paying attention to the patient’s nonverbal cues as they’re talking.
The more time you spend with patients, viewing them through a trauma-informed lens, the more sensitive you’ll get to subtle indicators that someone’s anxiety is rising and you need to either back off or redirect the interaction. These can include muscle tension, a change in facial expression, a general feeling of closing off or withdrawing -- the signs vary enormously from person to person but they all spell “trouble ahead”. It’s certainly true that triggers show up out of the blue sometimes with zero warning -- in my opinion, that’s one of the worst things about PTSD -- but it’s also true that sometimes warnings are there but a practitioner doesn’t catch them.

To sum up, a major aspect of reducing risks in talking to patients is by being organized and intentional in your communications.

A well-organized intake conveys to patients both that you know what you’re doing and that there’s no pressure or expectation for them to share more information than they’re comfortable with. Planning and preparing for intakes ahead of time, including using scripts, can help you stay on track and keep the interaction manageable for everyone. Practicing with scripts can also free you up to pay more attention to patients’ nonverbal cues, because you don’t have to think as hard about the words you’re saying. A well-organized intake makes clinic processes feel transparent to patients -- and that’s a vital part of creating safety.