Two un-answerable questions

Even after almost 12 years in practice, I still can’t answer the two most common questions about acupuncture: “Does it hurt?” And “Will it help?”

The short answer to those questions is the same: “Maybe.” Which, on its own, is not satisfying or helpful. But it’s also a really important place to start, and a critical trail marker to establish at the beginning of a patient relationship. That’s because safety is not about eliminating risk, it’s about a collaborative balancing act between me and my patient about the risks (like hurt) and the benefits (like help).

When people are asking about hurt and help, they are essentially interviewing me for the job of their acupuncturist. It’s a critical moment in defining the job itself and the structure of our relationship, and I want to slow this moment down a bit and look closely at the power dynamics at play. These initial questions are a very positive sign for the potential to establish a good therapeutic connection with a patient. People asking these questions are being curious and pro-active and are taking care of themselves, all while being in touch with their needs and their boundaries. This is great stuff! Depending on my responses, I can use the opportunity to support that dynamic, or I can screw it up and establish an unhealthy pattern of authority and power. It’s a key moment to maintain a focused intention, and it happens not only in the clinic waiting room or on the clinic phone, but often enough in the grocery aisle or at a kid’s birthday party.

Taking this in slow motion, then, someone asks if acupuncture can help or if it hurts, and basically, they are seeking information. But, implicitly, there’s more than that going on. Because of the cultural context we’re operating in, having information confers authority, and authority confers power. All of this matters because the locus of power relates to safety. Power can get confused with control, and bodies don’t respond to control. Thinking they do creates unsafe conditions for treatment.

Reversing the information flow contributes to a safer clinical environment by establishing a continuous feedback loop as the norm.

So, I always answer “Maybe” to those two questions, not because I don’t have some ideas or information I’m willing to share, but because it is not safe to tell people what will happen with their own bodies.

The locus of power is not with me, neither of us is in control, and true consent depends on a mutual understanding of that.

The issues of information and consent are of interest to an invisible third party to this conversation, as well: my professional liability insurance carrier. Most policies require that I have the patient sign an “informed consent.” These documents usually lay out the potential harms like bruising or bleeding, so the patient can sign that they are aware of these possibilities and want to get treated anyway. I’ve always found these artifacts of a litigious society kind of sad and discordant with the culture of safety and continuous consent I aim for in my clinic. They seem like the red tape version of “good fences make good neighbors.” I prefer swapping cookies and stories as my way of being neighborly. To support a safer environment at the clinic, what I’m talking about goes way beyond a hurried signature; it’s more like “informed consent deluxe.”

A safer clinic environment requires that, together, we are really clear about what could go right and what could go wrong, and that the decision to move ahead with a treatment is a distinct and affirmative moment. As the acupuncturist, asking for - and waiting for - a solid “yes” is one skill. As the patient, clearly communicating a “yes” - while securely feeling the absolute right to say “no” - is another skill. These are the very same skills that are taught to teens and others who are learning consent-based touch, and they are not as common in our culture as they could be. If we were more skilled at these two sides of asking for and delivering consent, our culture would be a much safer place to be; in fact there are sub-cultures where these practices are much more common. Like in the polyamory and kink communities.

The moment where a patient’s consent is being established for the first time, it’s my job to fill out that “Maybe” answer. I have found that some people verbalize these questions and some don’t, but I approach every new patient encounter assuming they are wondering, and boy do I have things to say. I have an agenda. That agenda includes bringing everything I’ve learned from 11 years of experience to add color and texture to that “Maybe” answer.

When I was a new practitioner, I really dreaded these questions about whether it hurts and whether it will help. I hoped people wouldn’t ask, because I didn’t want to say “I don’t know.” I thought they might leave, or stay but think poorly of me. I wanted them to have more confidence in me than I had in myself. Now, as I said, I’m gonna answer these two questions whether you ask me or not. And if you do ask, I get downright excited. My eyes will light up and I’ll roll closer on my little stool and I’ll lean in for this conversation.

Part of the reason I love this conversation now is that it helps me orient towards the patient’s unique situation. I can learn so much about what symptoms the patient is having, how intensely, for how long, what else they’ve tried, how it all started, and what it would mean for them if it could end. That’s because, a lot of the time, before a person walks into an acupuncture clinic, they have tried a lot of other things first. They’re intimate with the fluctuations in their symptoms, and they’ve known other failed treatment modalities.

After I say “Maybe,” to the “Will it help?” question, I usually say something related to the chief complaint, along the lines of “Some people get great results with that” or “That’s a tough one, but sometimes it responds.” The focus of these replies are the patient and the condition. Not me. “I” don’t get great results sometimes, nor do “I” get conditions to respond. I am not in control.

I have experience with other bodies and with acupuncture;
They have experience with their body and other treatments.

Together, these circumstances can create a fantastic feedback loop for us to communicate about expectations, with information flowing in a cycle between us. Along with the information circulating, so does the authority and the power.

What I didn’t know as a new punk, that I know now, is that when I say “I don’t know,” people relax. More often than not, that honesty is the beginning of trust. And then the other thing is, it’s rare any more that someone comes in with something I haven’t treated before. So after my “Maybe” and a little bit of context, I immediately switch to some reconnaissance questions. This does two things: first, it establishes the circulation of information, and second, it helps narrow down my answer so that I can share stories about what kinds of results have happened for people with varying severity, duration, etc. And if the condition is something I haven’t seen before, somewhere in my 50,000 or so treatments, then by definition it’s rare, and “I don’t know” is the right answer.

As far as the “Does it hurt?” question, this is where my “Maybe” answer gets filled in with a description of the treatment itself, and helping the patient understand how it’s going to go, with consent as an ongoing process. What follows “Maybe” is: “It doesn’t have to hurt to work… and if it does, you’ll let me know and we’ll fix it. I’ll adjust or remove the needle. I’ll change the number and/or location of the pins I’m planning to place. I’ll use a different needling technique. Or we’ll stop altogether if we can’t get you comfortable.” And that is how consent becomes an ongoing, collaborative process. As I needle, there’s a call and response happening. I am continuously asking (through touch, eye contact, or verbally) about the point I’m about to place a pin into. I am checking in for all the cues at each location I am about to needle. I’m paying attention to non-verbals, like tightening muscles, changes in skin temperature or moisture, breathing becoming more shallow or stopping altogether, or unconscious flinching or pulling away as I prepare a new point for needling. This is where I can get a lot of information by the pre-poke cleaning of each point. By using an alcohol wipe to touch each point in advance of placing a needle, I can give the patient a little preview of the planned treatment, and this a great time to notice any sensitivities or aversions. And if I have done my job in establishing a culture of safety, people do communicate a lot during this time, either verbally or nonverbally. They are engaged and sharing the power of the treatment equally with me. As the treatment progresses, I adjust my treatment plan based on this revised, in-process consent.

Once the pins have been placed, the patient and I together will experience how, even though we both had power over the treatment, neither of us has control of the results. Bodies don’t respond to control. They do what they will. If I’ve done a decent job taking the initial questions and establishing a good circulation of information, we will have encountered together, and normalized, the otherwise somewhat frightening, utter lack of control we have over the body and its processes of disease and healing. Normalizing that also contributes to a sense of safety while being treated, because surprises happen, and when our bodies surprise us, it can feel very unsafe.

Some of the things bodies can do during treatment include: crying, fainting, having a nightmare, talking in their sleep, experiencing a trauma trigger, burping, sneezing, vomiting, leaking urine, snoring, fainting, or even having a grand mal seizure. Neither the patient nor I is in control of any of this.

Some of the things bodies can do after treatment include: pain gets worse, develops a new pain, gets hives from needle allergy, symptoms stay the same, gets a bruise, develops headache, fatigue, or fogginess. Neither the patient nor I is in control of any of this. But I am responsible for it, which means it’s my job to respond: by listening and offering help with any distress the patient is having.

Other, happier things that we hope bodies will do after treatment include: sleeping well, feeling better after one treatment, feeling better after the recommended course of treatment, feeling better after a whole lot of treatments, resolving symptoms we weren’t even working on, feeling better sleep, mood, and energy. Neither the patient nor I is in control of any of this, either.

The beautiful thing about acupuncture, at its best, is that even though we need to face the frightening truth about how not-in-control we are when it comes to our bodies, if we do it well and safely, it can help us center into our actual power. To me, this feels like a deeper and more stable safety. I like acupuncture. Many patients have had great results with it. Life is a tough one. But some patients have felt well enough to get a divorce, get a therapist, get a new job, get to a meeting, get to the gym, or call a friend. Some patients have been able to take less meds, avoid surgery, get back to water aerobics, pick up grandkid, or play their instrument again.

Was it the acupuncture? Maybe? Also, who cares? Together, let’s take the wins, even though we weren’t in control. Let’s celebrate the power of helping what we can, when we can.