Where Is the Line?

This post is based on an excellent question from a POCA Tech intern, who wrote:

“At WCA Rockwood today someone walked in and started talking loudly and accusingly while another intern, M, and I were at the front desk. They weren't a patient. They wanted to know if we had their checks or something like we were maybe holding back their money? Then they went off to talk (at high volume) about sexual, racial, and other inappropriate topics and accused M of something. The supervisor was dealing with another intense situation (a patient who spoke only Somali had arrived without her translator and the supervisor was on the phone trying to find someone to help) so I asked the angry person to leave, because I didn't feel like they could receive acupuncture or that it was safe for us to be around them. (The energy of the interaction felt really, really bad.) The supervisor ended his phone call, and then gestured the person to the door and they left peacefully. It was intense! (It was a good thing that the only patient in the waiting room was the one who didn’t speak any English, given the angry person’s topics of conversation.)

I wanted to ask you - what is "the line" for providing treatment to someone? My gut feeling was nope, no way for this angry person, not ever... but is there some kind of system where someone could "come back" or calm down and then...graduate themselves to being treated? Thanks!”

I love this question because so many safety issues involve figuring out where the line is, why it’s in that particular place and not somewhere else, and what to do when somebody crosses it.

Also, it made me think of one of WCA’s beloved long term regulars, who started coming to community acupuncture after being diagnosed with bipolar disorder. He had no clue he might be dealing with that particular illness until he had a manic episode that lasted two weeks and resulted in the loss of his job, his housing, and almost all of his support system. Afterwards, most of his friends and the people in his community wanted nothing to do with him. He started psychiatric treatment and had to rebuild his entire life from the ground up. This was many years ago, and I doubt anybody who knows him now would ever guess that he had once burned pretty much every bridge that a person can burn. As a community acupuncture patient, he was never anything but delightful to treat, he supported the clinic in numerous ways, and he got fantastic results. For years.

I wonder how we would have felt about treating him if we had met him during his life-altering manic episode, if he had walked in off the street and started yelling God-knows-what at the receptionist. Could he have come back from that?

I’d say the question of whether or not to treat the angry person at WCA Rockwood is entirely theoretical at this point, in part because it doesn’t sound like they actually knew they were in a community acupuncture clinic when they wandered in and started yelling. We don’t know that they even want acupuncture. But what would we do if they returned and said that they did?

I’m going to pretend that I’m the punk on duty and try to describe the process I’d go through.

First, I would check my gut. And by that I mean, check to see if my gut is in good working order with regard to this person. I think I mentioned this is in earlier post: Part of figuring out where “the line” is, in dealing with any patient, is to make sure that you as a practitioner are not being influenced by personal biases -- and in order to do that, you need to have a sense of whether you might have any unconscious ones. This situation is a great example of how unconscious bias could create not just access problems for patients, but safety problems for practitioners. If my unconscious bias makes me assume that people from certain racial, ethnic or social backgrounds are inherently untrustworthy, I might not be able to sense when people who don’t match those characteristics are the untrustworthy ones. So I would want to check to make sure that there’s nothing in my instinctive response to this potential patient that has to do with problems with my own wiring, my history, or my frame of reference. If I suspected that there might be some bias I couldn’t see, I would ask for help from someone whose judgement I trusted.

Second, once my gut passed the bias test, I’d check it again to see what it had to say about the possibility of treating this person whose first encounter with the clinic had been, let’s just say, not great. Regardless of what they had to say about what happened (more about that in a minute), how do I feel about walking this person back into a room of sleeping patients, rolling up next to them on a stool, and inserting a bunch of needles into their body?

One of the things we believe at POCA Tech about training community acupuncturists is that it’s not only about what’s happening in a student’s left brain, though memorizing and critical thinking are very important components. There’s this other, mysterious level that’s more about instinct and flow, about the heart and the hands, not so much the head. One of the things I miss about actually being a punk in the clinic is the way that my head would shut up so that I could be mostly heart and mostly hands in relationship to other people. We joke about how weird it is that punks want to stick needles in people (seriously, what is wrong with us?) but it’s true; good community acupuncturists have a kind of itch, a kind of magnetic pull towards needling itself. Punks want to needle people the way sheepdogs want to herd sheep. You can see that affinity, that weird tactile impulse, start to take shape the very first time students open a packet of needles.

So if I encountered a patient in the clinic and I didn’t feel that itch, I didn’t feel that pull, if on some level I had no desire to treat them - or I even felt an aversion to treating them -- I would take it seriously. (If I’m a sheepdog and suddenly I don’t want to herd a particular sheep, something’s wrong!) However, if I did feel the familiar pull to sit them down and put needles in them, I would take that seriously too. I would assume my heart and my hands had information that my head didn’t, information that made them to want to do their thing, even in this situation, even with this person whose behavior had been concerning.

Part of how you find “the line” is trusting your heart and your hands and your instincts as a practitioner; it’s not just about logic and reasoning. Another part of finding “the line” is communication.

Getting back to our hypothetical situation of the formerly angry person returning to WCA Rockwood, if all of my non-rational components (heart, hands, instincts) gave me the all-clear signal, my next step would be to have a conversation with them. I’d say something like, “So last time you were here, you were pretty upset and also, you kind of upset the people at the desk with how you talked to them. What was that about?”

I would expect their response to be revealing. If the question (along with that bit of feedback I slipped in) caused them to start yelling at me AGAIN, well, they wouldn’t be getting any acupuncture at WCA that day. If they sidled around the question like, “How do you know that was me, what if I had, like, an evil twin who randomly yells at people” -- nope. If, however, they said something like, “Oh no, I’m so sorry, last week I ran out of my meds and couldn’t get in touch with my doctor -- I don’t remember it clearly but whatever I said or did, I’m sorry it happened. I’m back on track now” -- I might take a little extra time explaining our expectations of patients in the shared treatment space (“So, the yelling? That can’t happen again”) but I’d give them a chance. I’d give them the new patient paperwork, I’d go through the intake process, and if all that went okay I’d walk them back to the treatment room.

I think in the end it comes down to relationships. I would be asking myself, can this potential patient be in a relationship with the clinic and those of us who run it in a way that basically works for everybody, even though none of us are perfect? Or is there going to be disruptive conflict over and over? A community acupuncture clinic that runs on a fee for service model and a shoestring budget can’t have disruptive conflict on a regular basis. We literally can’t afford it. Which means we can only treat patients who can (mostly) manage their own relationship with the clinic and who won’t require us to do all of the managing.

This fits with our goal of establishing the clinic as a collective resource for people to use on their own terms, to manage their own health, in whatever way works best for them. But it’s very different from a typical consumer mindset in capitalism, where you expect to be able to make demands and get whatever you, as an individual, want most at any given moment. (I assume it’s clear that I’m not talking only about potential patients who are dealing with mental health issues, but everyone.) This can be a subtle and challenging point for punks, students, and prospective students to wrap their minds around. Locating “the line” that defines who we can provide services to, versus who we can’t, isn’t like using a checklist; it’s more like feeling out whether our boundaries as providers are a good enough match for our patients’ boundaries and whether we can create, together, a mutually beneficial relationship.