TCM Patient

Understanding
the
Difficult Patient
A GUIDE FOR
PRACTITIONERS OF
O R I E N TAL ME DI C IN E
NANCY BILELLO RN, L.Ac.
Blue Poppy Press

Published by:
BLUE POPPY PRESS
A Division of Blue Poppy Enterprises, Inc.
5441 Western Ave. #2
BOULDER, CO 80301
First Edition October 2005
ISBN 1-891845-32-2
Library of Congress LCCN # 2005933171
COPYRIGHT 2005 © BLUE POPPY PRESS
All rights reserved. No part of this book may be reproduced, stored in a retrieval
system, transcribed in any form or by any means, electronic, mechanical, photocopy,
recording, or any other means, or translated into any language without the prior
written permission of the publisher.
Disclaimer: The information in this book is given in good faith. However, the transla-
tors and the publishers cannot be held responsible for any error or omission. Nor can
they be held in any way responsible for treatment given on the basis of information
contained in this book. The publishers make this information available to English
language readers for scholarly and research purposes only.
The publishers do not advocate nor endorse self-medication by laypersons. Chinese

medicine is a professional medicine. Laypersons interested in availing themselves of
the treatments described in this book should seek out a qualified professional practi-
tioner of Chinese medicine.
COMP Designation: Original work using a standard translational terminology
Printed at C & M Press, Denver, Colorado on acid-free paper and soy inks.
10 9 8 7 6 5 4 3 2 1
■ Table of Contents ■
Dedication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1. An Ounce of Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2. Who Are You?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
3. The Noncompliant Patient . . . . . . . . . . . . . . . . . . . . . . . . . . 35
4. The Angry Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
5. The Patient with High Utilization of Health Care . . . . . . 75
6. The Needy/Dependent Patient . . . . . . . . . . . . . . . . . . . . . . 99
7. The Manipulative Patient . . . . . . . . . . . . . . . . . . . . . . . . . . 117
8. The Patient with Communication Problems . . . . . . . . . . 131
9. The Seductive Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
10. The Chronically Late/No-show Patient. . . . . . . . . . . . . . 161
11. The Nonpaying Patient. . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
12. Terminating the Therapeutic Relationship. . . . . . . . . . . . 183
Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
This book is dedicated to every patient
I have had the privilege to serve.
You are my greatest teachers.
■ Acknowledgments ■
I would like to thank Bob Flaws, L.Ac., Bruce Staff, and Blue
Poppy Press for the opportunity to write this book. Your guid-
ance and support are greatly appreciated.
I would also like to acknowledge Fred Jennes, L.Ac. for the orig-
inal idea for this book. I hope I have done it justice.
I would also like to thank my partner, Mark Newmaster for his

patience, support, encouragement, and enthusiasm during the
writing of this book.
It is of the utmost importance not to take
what a patient says or does personally
but rather to view behavior as another clue
in the therapeutic puzzle before us.
Preface
Receptionist: Mrs. S. is here early for her appointment.
Practitioner: Oh no, not “Needy Nelly” again! Wasn’t she just

here a few days ago? She drives me crazy. I just don’t know what
to do with her anymore!
The above dialogue and variations thereof occur every day in

countless health care settings. While most medical training
schools focus heavily on theory and application, very few direct
attention to the actual relationship that develops between a
practitioner and his or her patients. Yet this therapeutic rela-
tionship is just as important as any academic knowledge is to
the patient’s healing.
As practitioners of acupuncture and Oriental medicine, we

believe our medicine is holistic. We are very aware that the body
does not function as a bunch of individual parts working inde-
pendently but as a complex entity of interconnecting factors that
must all be taken into consideration in both diagnosis and treat-
ment. However, how often do we include patient behavior, and
vii
viii Understanding the Difficult Patient
especially problem behavior, in this model of holism? We are

all very complex beings and are propelled to certain behaviors
by forces we generally are not aware of. Childhood experiences
and family dynamics certainly play a big role in defining our
adult behavior. Many physically challenging conditions also
shape our moods and personalities. Culture and finances are
powerful forces in all of our lives that cannot be ignored. The
health care setting seems to be a magnet for attracting problem
behavior. Sickness, fear, anxiety, and discomfort induce people
to different types of behavior. Asense of entitlement may move
someone to act out in a clinic in a way they might not in any
other place. Prior negative experiences with health care may
carry over into present situations.
Problem behavior can manifest in a number of ways. Some

patients will demonstrate inappropriate anger. Others may be
very demanding or needy, while still others will be completely
noncompliant with practitioner advice and instruction. It is a
common human reaction when faced with these types of behav-
ior to become defensive and to lash out or “get back” at the per-
son. Health care providers are not afforded this luxury. Even
though we are not always taught this in school, a patient’s behav-
ior is very much a part of their overall make-up and is often a
result of whatever condition they are seeking help for. Instead
of having “knee-jerk” reactions to negative behavior, practition-
ers must become detectives of sorts and try to figure out what is
driving the particular actions. It is of the utmost importance not
to take what a patient says or does personally but rather to view
behavior as another clue in the therapeutic puzzle before us. It
is also our responsibility to find ways to assist the client through
their crisis and towards more positive behavior. In school we are
taught the fundamentals of theory, advanced practice techniques,
clinical “hands-on” experience, and point location, but rarely are
we taught how to deal with the actual personality, the spirit of
the person who has come to seek our aid.
Preface ix
Over the past 20 years, I have had the distinct honor and privi-
lege of being a health care provider, first, as an RN and, for the
past six years, as a practitioner of acupuncture and Oriental med-
icine. In spite of all the technical training I have received over
the years, my greatest joys and challenges have been in the day-
to-day and face-to-face dealings with patients. The many diver-
gent courses of my career so far have put me into contact with
an enormous number of people from a wide variety of back-
grounds and experience. My patients are a never-ending source
of hope, wisdom, and teaching for me.
One of the aspects of health care that has always bothered me is

the somewhat adversarial attitude that some health care providers
take toward their patients. I have known providers who make
up nicknames for difficult patients, who give such patients infe-
rior treatment “just to keep them happy,” or who make deroga-
tory comments about problem patients. It would be wonderful
if every person who came for treatment were cooperative, com-
pliant, and participated in their own healing with a positive atti-
tude. Certainly, our jobs would be much easier. But the truth is
that we are dealing with the world of human suffering in all its
various stages and ramifications. Human beings are complex
entities, and there is much we do not know about ourselves as
individuals and as a species.
It is distressing that there is so little instruction in our schools

regarding the interaction and relationship between practitioner
and patient. Learning how to deal with difficult behavior is a
skill that cannot come without direct experience. Although this
skill cannot really be taught as such, nor measured in test scores
and grades, a certain basic foundation in patient relations would
be of enormous benefit to aspiring students.
While we may not like or be comfortable with all the conduct

patients may exhibit, we must take a detached view and learn
to view behavior as another diagnostic tool that can help us
x Understanding the Difficult Patient
understand the human being before us. Our job description does
not include liking every single person we treat. It does include
meeting each and every patient on his or her own level and an
obligation to understand them as best we can. It also includes
the duty to help them in their journey towards wellness.
This book was written largely based on my own experiences as

well as those of colleagues in both Western and Oriental medi-
cine. There are numerous books written for Western medical
providers regarding problem patients, but none so far written
expressly for the practitioner of Oriental medicine. In this book,
you will find scenarios and situations unique to the practice
of acupuncture and Oriental medicine and the most common
problem behaviors that are seen in these clinics. It is my sincere
hope that it may be useful to students as well as to experienced
practitioners in helping to formulate a better basic understand-
ing of how to provide quality health care to every single patient
they meet.
. . . we must constantly look within to find
our own truth and, therefore, be able to bring
healing to a greater number of people.
Introduction
THE PURPOSE OF THIS BOOK

This book is intended as a guide for practitioners of acupunc-
ture and Oriental medicine. It is only a guide. Acupuncture and
Oriental medicine are gaining status as viable forms of treatment
in the U.S. and are now legal (under the heading of acupuncture)
in almost every state, although the scope of practice varies widely
from state to state. As this medicine becomes even more widely
accepted, new and challenging clinical situations will arise. It is
up to each individual practitioner to decide how he or she will
deal with problem patients. Policies will vary depending on loca-
tion and size of clinic, practitioner personality, patient popula-
tion, and economic realities. Practitioners will also vary in their
views of what constitutes problem behavior. The information
contained herein is meant to provide a starting place or a focus
for those struggling with difficult patients. I have selected 12 dis-
tinct problem behaviors to outline and explore, but this is by no
means all-inclusive. Likewise, there are situations presented in
1
2 Understanding the Difficult Patient
this book that may not have an actual bearing on every clinical
situation. It is up to you as the reader to take what can benefit
you and leave the rest. The personality profiles and situations in
this book are in no way intended to be stereotypes. I have labeled
them only for convenience. Within each personality type, myr-
iad forms of behavior may manifest. It is absolutely crucial to
view each and every client as if they were your first and only
client and to see them within the unique paradigm of their indi-
viduality. The information presented here may be used very well
in a classroom setting. There are questions for discussion at the
end of each chapter, and the “scenarios for discussion” can eas-
ily be turned into role-play models.
This book may also be used by any individual to help with a spe-
cific type of clinical problem. You may choose to read the book
from front to back in its entirety or simply refer to the chapters
that best suit your needs. I hope every reader will give due con-
sideration to Chapter One, since it is my firm belief that we must
constantly look within to find our own truth and, therefore, be
able to bring healing to a greater number of people. It is my hope
that everyone who picks up this book will find something use-
ful in it and, even more so, that it may foster more excellent and
compassionate care for all of our clients.
CH APT ER SET-UP
The first two chapters in this book outline the “groundwork” of
the topic. Chapter One explores how a practitioner might look
at his or her own personality, personal issues, and practice style
and set-up to determine if there are any elements therein that
may contribute to difficult situations in the clinic. In fact, this is
a theme throughout the book. It is my firm belief that we cannot
fully assist another person without first looking at ourselves.
Indeed, we may even be responsible for causing difficulty in our
own clinics by the way we have the office set up, the way we
carry ourselves, our body language, and our interactions with
clients. This chapter will be particularly useful to beginning
Introduction 3
practitioners. It is always easier to start off on the right foot

than to have to change established patterns or routines.
Chapter Two goes on to define and identify what comprises a

difficult patient. You will soon discover that difficult behavior
often arises from emotions such as fear, anxiety, feelings of inad-
equacy, etc. and is not really intended to make the practitioner’s
life miserable, no matter how much it may seem so. Factors such
as culture, finances, and psychosocial issues are also explored to
see how they might contribute to difficult interactions in a health
care setting.
Chapters Three through Eleven go on to discuss specific types

of problem patients and include suggestions for how to handle
these situations effectively. Each of these chapters deals with one
particular type of problem behavior, except for Chapter Ten in
which I combined two types for convenience. Each of these chap-
ters, as well as the first two chapters, includes at least one case
history provided as an example to help illustrate the point of the
chapter and bring the theoretical into the real world of clinical
practice. The case studies are all unique to acupuncture and
Oriental medicine. The case studies are presented followed by a
“what went wrong” synopsis and suggestions as to how it could
have been better managed. Lest the reader think I see myself as
a solver of all problems, let me state here that most of these case
studies come from my own mistakes and the “what went wrong”
part is what I learned as a result of not handling a situation as
well as I could have. Of course, names and other identifying
details have been changed to protect patient privacy and confi-
dentiality. The suggestions and opinions regarding how any sit-
uation could be better handled are just that, suggestions. Only
you as a practitioner can really determine how your patient inter-
actions will proceed.
Chapters Three through Eleven also include sections titled “clin-

ical presentation,” “contributing factors,” and “the inside story”
as well as “questions for discussion.”
C L I N I C A L P R E S E N TAT I O N :
This section describes how the particular patient of that chapter
might manifest initially in the clinical setting. Sometimes a prob-
lem patient will be readily identifiable from the first minute, but
at other times, the problem behavior may be hidden or may man-
ifest later in the therapeutic relationship. Again, these descrip-
tions are not meant as stereotypes, only as helpful descriptions
of what might be expected and what to be alert to in order to
help fend off problems before they start.
C O N T R I B U T I N G FA C T O R S :
This section is the meat of the chapter. It always begins with a sub-
title called “home base” in keeping with my opinion that we must
look to ourselves for causation before blaming patients or exten-
uating circumstances for the problem behavior. In some chapters,
“home base” is the only heading under contributing factors. In
other chapters, more in-depth detail is given about patient situa-
tions and experiences that may adversely color behavior.
THE INSIDE STORY:

This section serves as a kind of summary of the chapter as a
whole and outlines underlying and often hidden factors that may
contribute to undesirable patient conduct. Such factors include
cognitive deficits, psychological problems, and psychiatric dis-
orders to name just a few. I want to be clear that I am not a psy-
chologist and have no training in this field. However, after many
years of interaction with clients in many different settings, I have
become a student of human nature, and certain truths about
human nature have revealed themselves to me enough times to
allow me a certain degree of comfort in offering my opinions.
QUESTIONS FOR DISCUSSION:

Each chapter is followed by four questions and one scenario for
discussion. The questions may be used as fodder for individual
contemplation or may be discussed in a group or classroom
Introduction 5
setting. I believe that exchange of ideas between like-minded

people with a similar goal is beneficial in broadening everyone’s
horizons and providing different perspectives on each issue. The
scenarios for discussion attempt to draw most of the key
elements of the chapter into a cohesive and, hopefully, realistic
situation that will allow the reader to challenge him or herself
in problem-solving.
I sincerely hope that this book will be of use to all its readers. I
wish you all the best of luck and success in practice!
Physician, heal thyself!
CHAPTER ONE
An Ounce of Prevention
THE DI FFICULT PRAC TITIO NER

Before we start looking at and defining the difficult patient, we
should first make sure that we are not being difficult practition-
ers. Our own behavior and appearance can very definitely impact
our relationships with our patients. It is essential that we take a
good, long look at ourselves, our own life situation, tempera-
ment, philosophy, and mental health. Healing is hard work and
can be very draining. If a practitioner is not experienced in deal-
ing with problem personalities, he/she may have an even harder
time establishing healthy rapport with such individuals. It is
paramount to keep in mind that there are two parties in the ther-
apeutic relationship—the patient does not embark on this voy-
age entirely alone. And yes, we as practitioners can be a source
of difficulty.
So, you ask, just how are we to know exactly what our part is
in this dynamic relationship? I believe it is essential for any
health care provider to heed the old adage, “Know thyself.”
7
In any situation in which personality or behavior becomes a

problem, the practitioner should first ask him or herself some
searching questions:
1. Am I doing anything to contribute to or foster

this problem?
2. Did I already have a negative impression of this

person from a phone conversation or a report of such
from my staff?
3. Is this situation bringing up any personal problems for

me or reminding me of a situation in the past that was
uncomfortable?
4. Is my office set-up or my staff posing some kind of

barrier to this patient encounter?
The above are all fairly basic questions which most of us could
probably answer if we are willing to be honest with ourselves.
However, there may be deeper issues affecting us. If you have
never experienced any kind of psychotherapy yourself and you
feel there are emotional blocks you have yet to explore and purge,
it would be of great value to delve into these areas at the begin-
ning of your practice. You need not envision yourself on the couch
facing away from a bearded professor who is asking you about
your childhood. Today, there are dozens of therapy modalities
to choose from, including movement, voice, dance, music, and
12-step programs, in addition to the more traditional talk ses-
sions. And don’t forget to look in our own backyards. Another
wonderful avenue of self-exploration might be a series of five
phase treatments from a properly trained practitioner. With all
these options, you are bound to find one that suits you. By sug-
gesting therapy, I am not suggesting that you are crazy (although,
by the time you are finished with school, you may very well feel
that you are). I am merely suggesting that we all take a good,
hard, and honest look at ourselves before we presume to do the same
to others.
An Ounce of Prevention 9
It is crucial for every practitioner to constantly be aware of his/her

attitudes towards the patient. We are all human, and we all have
our foibles. It is entirely possible that you may find yourself
resenting or resisting a patient through no action of the patient’s
but rather because he/she reminds you of someone or of an
unpleasant situation or memory.
During the course of your practice, you will find yourself advis-
ing your patients on diet and lifestyle choices. It is not uncom-
mon for an acupuncturist or Oriental medicine practitioner to
suggest relaxation techniques, meditation, qigong, or yoga to our
patients. What a great idea! So often I hear myself giving such
advice to a client and I think to myself, “Hey, that sounds like
great advice!” The next step, of course, is to ask myself whether
or not I am following it. Working with sick people all day, as
stated earlier, can be very draining and, at times, frustrating.
Keep yourself in balance with some good, regular disciplines
such as those mentioned above. Practices such as qigong or tai
ji chuan will help keep your own qi strong and freely flowing,
will help you keep a healthy detachment from your clients, clear
negative energy, and generally hone your concentration skills.
Also make sure your own diet is healthy and that you get your
fair share of exercise and rest. In order to care for others effec-
tively, you must first make sure that you are in the best shape
possible. In other words: “Physician, heal thyself!”
A place of one’s own

Of course, the best case scenario is to prevent a difficult situa-
tion before it starts or to diffuse a situation which has the poten-
tial to become difficult. Once you have taken inventory of your
own internal issues, it is time to take a look at the external heal-
ing environment you are creating. The ambience of your office,
your own demeanor, and that of your staff have a tremendous
impact on anyone who walks through your door, from the mail-
carrier to the most difficult of your patients. It is well worth some
extra time and, yes, money to create an atmosphere that will put
almost anyone at ease. Needless to say, your choice of decor will

and should reflect your own tastes and desires, but remember
that the office is a service area for clients, not an advertisement
for your political, religious, or social views. Many of us in this
profession have strong spiritual convictions and often wish to
have mementos of these convictions in our office to provide us
with inspiration for our work. However, not all of your patients
will share or appreciate your views, and some may even be
offended by them. It is easy to try to stereotype the “type” of client
who would most likely come for Oriental medical treatment, but
you might be surprised at some of the folks who will walk through
your door. I believe you want to attract as broad a clientele as pos-
sible. So keep the decor of your office relaxing but neutral. Any
religious objects are best kept in your private office or workspace
where the general public is not likely to see them. Likewise, any
political or social literature should be kept out of sight. You can
always have these items on hand in case there is someone appro-
priate with whom you would like to share them.
Your office should feel welcoming and calming. You may wish
to offer tea or juice to clients. Light, healthy refreshments can
add charm and a feeling of hospitality to your office space. If you
do offer these, be sure to provide a variety of flavors as well as
spoons and convenient trash receptacles.
It is certainly appropriate to keep magazines, journals or reprints

of articles in your reception area, but again, these should appeal
to a broad audience. Don’t feel embarrassed to include the lat-
est issue of a popular magazine about celebrities or decorat-
ing among other journals about health or healthy living. While
your office should provide some edifying reading material,
some people are just too nervous or harried to want to deal
with that. Many people will go for that easy reading to help
distract them from their problems. (I, personally, am disap-
pointed if I am waiting for an appointment about which I am
apprehensive and find no mindless reading material at hand.)
So give your clients a break and let them choose whether they
want education or entertainment.
Slow, soothing background music is a nice addition to any office

and has the effect of immediately putting people at ease. There
is no shortage of “easy listening” or “new age” discs, and they
are often fairly inexpensive. (As an aside to this, I might add that
I often invite clients to bring in their own music for the treatment
rooms as long as it is calm and relaxing. The heavy metal can be
saved for another time.) Speaking of the treatment room, do give
your patients the choice of music or silence. During a difficult
time or at the end of a long workday, some folks just want to
doze off or to enjoy a rare opportunity to experience some peace
and quiet.
Why is it so important to give people choices? One of the surest

ways to feel like you are losing control over your life is to incur
a serious health condition. Sure, you will treat a large number of
people who are seeing you for a transient attack of wind heat or
a mild case of disquietude of the spirit, but a larger number will
be coming for serious issues that have had a negative impact on
their independence and well-being. In such cases, allowing even
a simple choice of what magazine to read or what flavor of tea
to have can offer these patients a sense of control.
If you do have an office staff, choose them carefully. They should

be people with whom you feel comfortable and can get along
with easily. Before they ever take their first seat at your recep-
tion desk, educate them to your expectations and how you wish
your patients to be greeted. Your front desk staff should be organ-
ized, pleasant, efficient, and professional. (Resist the urge to
please your mother by hiring her best friend’s bored teenager
for the summer.) It is in everyone’s best interest to have a plan
in place in case a truly difficult situation arises. It is prudent to
have ready access to emergency numbers for police, suicide
hotlines, or domestic violence hotlines. Most of us will never
need these numbers, but, in a challenging situation, you do not

want to be fumbling through the phone book for assistance.
Looks aren’t everything, but . . .

How you present yourself is every bit as important as how you
present your office and your staff. We would all love to roll out
of bed and slide off to work in our favorite pair of jeans, but per-
haps they should be saved for the weekend. I know Oriental
medicine practitioners who do wear jeans and more casual attire
to work. Your choice of apparel is entirely up to you, of course,
but make your wardrobe decisions carefully. If you know for sure
that your clientele will feel comfortable with a practitioner wear-
ing jeans, then there is no harm done. However, your choice of
attire may not be acceptable to all people. After even a short time
in practice, you will realize that seemingly insignificant events
can have a profound affect on people’s behavior. If someone is
skeptical or hostile, being greeted by a sloppily dressed or very
casually attired practitioner may be just what is needed to pro-
voke undesirable conduct. A professional appearance is more
likely to put a new or nervous client at ease and automatically
instill a preliminary sense of trust, thereby helping to avert a
potential problem situation. Traditional white lab coats are some-
times required in student clinics and do add an air of profes-
sionalism. Once outside of school, however, these lab coats are
usually optional. In any case, whatever mode of attire you choose,
it is never, ever appropriate to wear skimpy or sexually sugges-
tive clothing.
Hair length is also a personal choice. Long hair should be tied

back when working directly with the patient. It is both unsightly
and non-hygienic to have hair hanging down over your patient
when you are inserting needles or doing palpation. Ayoung child
or extremely agitated client may find it irresistible to tug on a
lock of accessible hair. Needless to say, hair of any length should
be kept clean.
Whether you are male or female, it is wise to keep your hands

well manicured. Think of how many things you will be doing
with your hands, from pulse-taking to needle insertion and
removal to abdominal palpation. Some clients may just shut
their eyes tight and ask never to be shown a needle. Others,
however, will inspect every move you make, especially when it
concerns their body. People notice more than you think they do,
and your fingernails will be center stage for a good part of the
appointment.
Make-up and jewelry are also factors to think about. Make-up

should be tasteful and not overdone. Jewelry is best limited to
smaller items. Some acupuncturists feel that jewelry on the arms
and fingers interferes with the transmittal of qi. Whether or not
you adhere to this theory, jewelry should not pose any kind of
distraction. Beware of excessively long dangling earrings. A con-
fused, irrational or frightened patient may not be able to resist
the temptation to give a tug on one of them. This is especially
true if you treat infants or very young children.
Colognes and perfumes are best avoided. ■

Not all aromas affect every person the Remember that
same way, and some people may be put many of your
off by certain smells. Also bear in mind patients will be
that some of your clients may be experi-
coming to you
encing digestive disorders, including nau-
for their first
sea and/or vomiting. A whiff of cologne
or perfume may not be the most thera- acupuncture
peutic balm for these maladies. treatment. They
may feel nervous,
Any and all of the suggestions above apply frightened, and
to your office staff as well as to you. leery of
Presenting that professional image will do the unknown.
wonders to allay many patients’ misgiv-
ings or fears and will benefit your prac- ■
tice in many other ways as well.
Meeting & greeting

Feeling at ease with your patients and in turn making them feel
at ease with you will go a long way to fostering a healthy ther-
apeutic relationship. Your words should always be chosen care-
fully. It is important to convey friendliness. Remember that many
of your patients will be coming to you for their first acupuncture
treatment. They may feel nervous, frightened, and leery of the
unknown. Greeting your patients with a warm smile and a
friendly handshake will make a good first impression and will
be something your returning patients will look forward and come
to expect from you.
Although the public is becoming more educated and more aware

of the benefits of acupuncture, there are still many misconcep-
tions and fears surrounding our medicine. For many patients,
acupuncture and Oriental medicine may be a last resort in a long
and tiresome journey to find relief from a baffling condition. Some
may be coming out of a sense of adventure or curiosity. Still oth-
ers may have heard good things about acupuncture and Chinese
herbal medicine from friends or family and are willing to give it
a try. Whatever the case may be, it is beneficial to determine the
patient’s acupuncture experience at the time the appointment is
made or, at the very latest, as a question on the intake form.
Even if you are the only person in your office and you feel it is
obvious that you are the practitioner, always introduce yourself
to a new patient. Glance at your appointment book in advance
so you know who your next patient is. At first, your practice may
be slow, and you may have no trouble knowing who is coming
in next, but, as your practice grows, it may become easier to lose
track of appointments. When greeting a new patient, if you are
unsure as to how they prefer to be addressed, use Mr., Ms., or
Mrs. with their last name. This is especially true of patients who
are somewhat older than you. This form of address may seem
overly formal, but it is professional and polite, and most people
will readily let you know how they prefer to be addressed. Unless
you are addressing a child, avoid using words like “sweetie,”
“dear,” or “honey.” They are diminutive terms that may sound
condescending, especially if you are younger than the person to
whom you are speaking. Do not assume that Deborah likes to be
called Debbie or that Robert likes to be called Bob. I have found
that some people are very particular about their name. So it is
always good policy to ask. If you are unsure how to pronounce
someone’s name, ask instead of attempting a potentially offen-
sive mispronunciation. Asking denotes respect for the client, and
it is always best to ask rather than to risk offense or to sound
foolish by mangling someone’s name.
If the patient has never had acupuncture or herbal treatment,

leave a little extra time to let him or her feel comfortable with
you as well as to ask any questions about the procedure. Your
explanation should be concise and clear and definitely not couched
in Oriental medicine jargon. By the time you are done with your
schooling, words like yin vacuity or external contraction of wind
heat may be all that is running through your head. Using such
terminology will not impress your clients and may alienate them.
Remember how strange these terms seemed to you at the begin-
ning of your studies. Then imagine how much stranger they
sound to the new client. No one wants to be treated for some-
thing they cannot understand and have never heard of. Since it
may be out of our scope of practice to use Western medical ter-
minology (depending on your state laws), you may at times have
to use some terms specific to Oriental medicine. This is a perfect
opportunity to educate your clients and help demystify our med-
icine. The use of any terms should be accompanied by a clear but
brief explanation. Keep a reference book or illustrated posters
handy so you can show your clients the channel pathways and
some pertinent points. You may want to order or create your own
pamphlets written for the layperson for patients to read and take
home with them. You may also want to keep a list of books about
Oriental medicine handy to recommend to ambitious clients who

wish to know more about their treatment than an appointment
time will allow. I like to recommend Between Heaven and Earth by
Harriet Beinfield or, for more ambitious people, The Web that Has
No Weaver by Ted Kaptchuk. There are also several others from
Blue Poppy Press that may be relevant for your specific patient.
Actions speak louder than words

We hear and read an awful lot about body language these days
and for a good reason. Our body language may serve to enhance
or illustrate our message, but it may also belie the words we are
POSITIVE BODY LANGUAGE AND PATIENT INTERPRETAT I O N

POSITIVE BODY LANGUA GE PAT IENT TRAN SLAT I O N
Sitting up, comfortably, with slight “I’m bringing my full energy,

forward leaning of your upper interest, and attention to this
torso toward the patient. meeting, as well as my efforts on
your behalf.”
Maintaining appropriate eye con- “You and I have an important

tact, being particularly attentive professional relationship. I will work
when the patient is divulging with you and you can trust me
something that is emotionally with your physical and emotional
troubling. concerns.”
Shoulders and upper torso facing “You are the primary focus of my
or angled toward the patient. attention. Not your chart, not my
computer. You have my fullest
attention while we are together.”
Nodding the head occasionally “I’m listening, I’m interested in

at key points in the patient’s con- what you are saying.”
versation.
A smile, or other facial expressions, “I’m really happy to see you, and
as seems appropriate. I look forward to working with you.
I hope you feel comfortable
telling me about your concerns.”
Upper torso not closed off by “I am available to give you my

arms, charts, or medical equip- fullest professional attention. I am
ment as much as possible. always approachable.”
N E G ATIVE BODY LANGUAGE AND PATIENT INTERPRETAT I O N

N E G ATIVE BODY LANGUAGE PATIE NT TRANSLAT I O N
Examining test results, intake “I’m going to ignore your emo-

forms, or case research as the tional silliness. Only the clinical
patient is speaking about their information here is important to
most deep-seated fears. me.”
Responding to the patient’s “I can’t get personally involved

description of their condition with in your pain. This is purely clinical.
an occasional “OK” or “I see” You are just a bunch of parts and
without looking up from their pieces to me.”
chart.
“Don’t even think about getting
Arms folded over the chest or on any closer to my personal space.”
the desk while talking with the
patient.
“This is top secret information and
Holding the chart against the you can’t see it. You wouldn’t
front of the chest, arms folded understand anyway because this
over it, while talking with patient. requires my superior intelligence.”
“OK. OK. Cut to the chase,

Rapid and frequent head nod- because I haven’t got all day.”
ding while the patient is talking.
“You’re taking up my valuable
Tapping your pen rapidly on the time here. Can you just get to the
desk, note pad, or file. facts, please?”
“Do you really think I care about

Listening with no facial expression, this? I’m just enduring this con-
no movement of your hands, versation until I can write a pre-
head, or eyes. scription and move on.”
“This is really boring. Maybe I can

Leaning back on your chair, rest- sleep through it.”
ing comfortably on your lower
spine; rocking your reclining office
chair. “Oh, are you still here? I thought
I was finally alone and could get
Silently and diligently entering some work done.”
data into the computer with your
back toward the patient. “Of course I’m looking down at
you. I’m vastly more intelligent
Looking at the patient through and powerful than you are.”
the bottom of your bifocals with
your head tilted up. “You’d better have the right
answer to this. Have I thoroughly
Looking over the top rim of your intimidated you yet?”
speaking. It can also convey unintended messages. As a health

care practitioner, your words carry more power than you can
imagine. An offhand remark that you forget almost as soon as
you utter it may be something the patient takes home and remem-
bers for a long time. Therefore, it is important not to sabotage
our verbal messages with body language. However, we are often
not as aware of our body language as we are our words. Take
some time to observe the body language of others in everyday
situations. Do you have an upcoming doctor’s appointment? Are
you planning to go to a store where you will need to ask some-
one for information? Is your car (using body language as only a
car can) telling you to get to the mechanic’s? If so, be observant
of the way the doctor, clerk, or mechanic holds his/her body and
make a mental note of how it positively or negatively affects you.
Then take some time to note your own body language.
When you are with patients, be conscious of the way you behave
with them, just as you are analyzing their behavior with you. As
stated above, greet your patients warmly and with a firm hand-
shake or even a light hug if that seems appropriate. As you usher
them into the treatment room, hold the door open for them and
let them enter the room first. With a new patient, indicate whether
they should have a seat in a chair or sit up on the table. If you
and your patient are both seated in chairs, have the chairs at a
slight angle, rather than facing each other straight on. You don’t
want your patients to feel as though they’re at an interrogation.
Try not to cross your arms when talking with them. This con-
veys a message of impatience and being closed off. Keep hands
loosely in your lap. Assume a relaxed position—but not too
relaxed. An arm casually draped over the back of your chair may
make the patient feel that you are too casual and not taking them
seriously enough. Leaning a little forward indicates interest and
encourages the speaker to continue and to give further details. If
you are addressing a patient who is already lying on the table,
again keep your arms uncrossed and do not place hands on hips
as this may be reminiscent of an angry parent about to scold an

unruly child. Eye contact is crucial nonverbal communication. This
may sometimes be more difficult than you think. If a patient is
describing an especially personal physical or emotional problem,
you, as the practitioner, may feel embarrassed or at a loss as to
how to react. Even so, try to maintain eye contact. Looking away
may make the person feel awkward or may make him or her feel
that you are uncomfortable and/or unwilling to deal with their
problem. On the other hand, don’t just stare at the person either.
A little eye movement is required. While we should generally
maintain eye contact when the other person is speaking, it is per-
fectly all right for our eyes to wander when we are speaking.
Touching is an integral part of our practice, and we cannot avoid

it. In fact, we are actually licensed to touch! In the strictly pro-
fessional sense of the word, we touch patients when palpating,
taking pulses, and inserting and removing needles. Touch can
also convey sympathy from the practitioner. If a patient is in
pain, is anxious or overwhelmed, a gentle hand on the shoul-
der can provide comfort and solace. Likewise, a light pat on the
back can be reassuring to a patient. These are all acceptable forms
of touch. Of course, there are also very inappropriate forms of
touch and these will be dealt with in more depth in the chapter
on the seductive patient.
Listen carefully when a patient gives you details about his/her

personal life. Some practitioners even make small notes in the
patient’s chart to help them remember the names of the client’s
children, an important upcoming trip or anniversary, or other
significant events. Do not ignore such details but rather make
some comment to show you acknowledge that these details are
also important to you. Making reference to these points tells the
patient that you are listening to them and that you have an inter-
est in them as a whole person, not just as a medical problem. It
will help put them more at ease.
Being a healer means being a teacher. You will have lots of advice
and instruction to give to your patients on a variety of topics,
from diet to posture to herbal therapy. You will most assuredly
have patients who do not take your advice to heart or who do
not follow your instructions (for more advise on this, see Chapter
Three). Try not to assume the old schoolmarm position of point-
ing or shaking a finger at the patient. This action can easily be
perceived as being critical and authoritative and is an instant
turn-off for most people.
Sign on the dotted line

Paperwork is a necessary evil in these times, and even we who
practice an ancient system of healing are not exempt from hav-
ing to deal with it. It is especially frustrating to many of our
patients because so many of them will have been to so many
other practitioners before they reach our doors and have filled
out their health history countless times. Nonetheless, we do need
to keep accurate records for legal purposes as well as to have a
good, ongoing chart of patient problems and progress. The
acupuncture/Oriental medicine intake form should be detailed
enough to give the practitioner a truly holistic overview of the
patient but easy enough for the patient to fill out without becom-
ing frustrated. Many practitioners use forms in which the patient
mostly just has to check boxes to indicate details of the history
without having to enter an essay contest. This is a very reason-
able way of presenting your forms. In this case, you might want
to leave space for yourself to fill in details during the interview
process. A thorough intake form will typically prove to be a valu-
able asset to you if the patient does end up displaying difficult
conduct. You can go back over that initial intake to see if you
missed any details that might give clues to the patterns under-
lying the patient’s behavior. The intake form should include infor-
mation about the patient’s physical as well as emotional state of
being. Even if the patient is coming with the sole complaint of a
sore shoulder or sprained muscle, a holistic history is beneficial
in uncovering possible related factors as well as conditions the
client has not even mentioned that might also be well treated
with acupuncture or Oriental medicine.
Many states require that practitioners of acupuncture and Oriental

medicine also give patients a disclosure form that outlines the
practitioner’s educational and professional background, fee sched-
ule, hours of operation, cancellation policy, and numbers to call
in case of grievance. These forms also include any potential
adverse effects of the treatments and, therefore, serve as consent
forms. For legal purposes, every practitioner should be diligent
about having every patient read and sign these forms. If prob-
lems should arise in the future, these records could prove very
useful as protection for you and your clinic.
After reading this chapter, you may feel ■

as though you have just been lectured The main idea
by Miss Manners. It is by no means the here is to create
intention of this book to dictate to any-
a nurturing and
one what should be worn or said or what
safe environment
image to present. However, as Oriental
medicine is welcomed more and more that will minimize
into the mainstream, practitioners will difficulty and
be exposed to a larger patient popula- maximize benefits
tion. Generally speaking, most Oriental to you, your
medicine practitioners do not wish to practice, and
be cast in the same mold as the stereo- most of all,
typical old doctor who is polite but dis- your patients.
tant, caring yet conservative. Rules
■
dictating traditional dress and behavior
may seem somewhat prim and even outdated. Of course, there
is plenty of room for personal choice and freedom. After all, our
medicine is unique and most of us want the freedom to express
the uniqueness of our practice and of ourselves as we see fit.
Certainly different states, cultural climates, and patient popula-
tions will help dictate how you present yourself. The main idea
here is to create a nurturing and safe environment, one that will
minimize difficulty and maximize benefits to you, your practice,

and, most of all, your patients. Many of your patients will be
experiencing pain, discomfort, and/or a high degree of stress. It
is your job to help make them feel comfortable, less stressed, and
to offer solace, healing, and compassion.
Cases in point:
Case 1. Mrs. H.is a 90 year-old woman with arthritic knees who

is coming for acupuncture at the suggestion of her family. She
is very nervous about the treatment. When she enters the wait-
ing area, she is told to have a seat while she fills out her intake
fo rm . The practitioner had brought in a few old chairs for the
reception area.Mrs. H. found these quite uncomfortable.When
the practitioner greeted her, he was dressed in a pair of old jeans
and a casual sports shirt .M rs. H. appeared nervous and uncom-
fo rt able during her tre at m e n t , even though the practitioner
allowed extra time for her appointment given her age and frail
condition.She received a good treatment but did not resched-
ule. As she was leaving, the practitioner overheard her say to her
daughter,“I wouldn’t come back here.I can hardly stand those
old chairs, and he didn’t look like much of a doctor to me.”
■ What went wrong?

In this case, the practitioner’s skill was not in question. In fa c t ,h e
gave the client an excellent initial treatment. Unfortunately, how-
ever, in an attempt to save some money early in his practice, he
placed older,uncomfortable furnishings in his office.An older client
like Mrs. H. needs and looks for comfort and a sense of newness
to her surroundings in a health care setting. This alone may not
have been enough to dissuade her from returning, but the prac-
titioner’s mode of dress left her feeling she was not in the hands
of a professional.Even though the skill level was there, the patient’s
first impression left a negative enough imprint on her that she did
not feel comfortable in making another appointment.
Case 2. Mr. S. scheduled an acupuncture appointment for a

long-standing problem of infertility and impotence. The acupunc-
turist was young and fairly new at her practice. The client was
eager for help and described his history and present condition
in detail. The acupuncturist was uncomfortable with the sexual
and personal nature of his case and kept shifting in her seat and
avoiding eye contact with the patient.The treatment itself went
well, but the patient did not return for any follow-up appoint-
ments.

Although this practitioner had adequate training to treat this
client, her age and inexperience left her uncomfortable with the
client’s frankness and the details of his condition. Her discomfort
was evident in her body language and left the client feeling he
could not communicate openly with her. No matter how nervous
a practitioner might feel with personal problems such as this one,
these are valuable learning experiences. A practitioner should
always be aware of his/her body language and the effect it
might have on a client as well as on their practice.
QUE STI ONS FOR CHA PT ER ON E:
1. What kinds of personal practices/disciplines are you or

could you be practicing to help keep yourself focused
and clear?
2. Think of a positive and a negative experience you have
had in a health care setting. What made it positive?
Negative?
3. Design your future office, bearing in mind the con-
cepts from Chapter One. If you are already in practice,
what areas of improvement can you identify in your
current office?
4. Can you recall any instances in which body language

hindered or enhanced a speaker’s intent?
5. Scenario for discussion:
Mrs. J. has been to many doctors and other health care
providers trying to find relief from symptoms of
fibromyalgia. She is tired and more than a little anxious
about getting acupuncture treatments. She is afraid they
will hurt and maybe make her pain worse. When she
enters the office for the first time, the receptionist is on
the phone and takes several minutes to complete her call
but does not look up or acknowledge the client. When
the receptionist finishes the phone, she greets the client,
saying, “Hello, Mrs. D.” The client indicates to the recep-
tionist that she is very nervous, but the receptionist only
responds, “You’ll have to talk to the acupuncturist about
that.” She is asked to have a seat in the waiting area and
rustles through some old magazines on the table. When
the practitioner comes out to greet her, she notices that
his shirt has stains on it and he does not shake her hand.
What changes could be made to this scenario to help the
client feel more at ease? How could the receptionist have
been better trained? What effect do you think this initial
encounter might have on this client?
Most difficult behavior hides fear, anxiety, or
some other negative reality the patient is either
unaware of or does not want to face.
CHAPTER TWO
Who Are You?
So, who is this book about anyway? It is about human beings

who are in discomfort and who are seeking relief from this dis-
comfort. Because of past or present events—or a combination of
both—they may exhibit certain behaviors which interfere with
the efficacy of treatment. Oriental medicine is truly a holistic dis-
cipline based on the uniqueness of each individual. In my expe-
rience, most of us in this profession cringe at defining or
pigeon-holing people. For the purpose of this book, however, a
brief definition may be helpful. Asurvey of existing literature on
the subject reveals a surprising lack of definition. Because
providers, too, are individuals, there may be conflicting ideas
regarding what constitutes a difficult patient. Hooberman and
Hooberman offer a concise, broad definition: “A difficult patient
is a person who presents to the caregiver behaviors and emo-
tional difficulties of a severity significant enough to impact
adversely on the treatment or the provider.”1
25
Some of the most common patients you will see who fit this def-
inition are those who are noncompliant, angry, overuse the health
care system, are needy, rambling, vague, chronically late, seduc-
tive, nonpaying, and/or manipulative. That covers a lot of ter-
ritory! Each of these particular types will be discussed in their
own chapter, and, after some time in practice, you may well be
able to add to the list.
In Chapter One, we looked at the practitioner as a potential

source of difficulty in the therapeutic relationship. It is essen-
tial to keep in mind that when we are dealing with a patient, we
are indeed in a relationship with them. As with any relation-
ship, consideration of the other person will allow us to see a dif-
ferent point of view and not take things so personally. Problematic
behavior rarely manifests for its own sake. It generally is an out-
let of some sort for a deeper issue of which the individual is not
fully aware or is unable to cope with. It is helpful for providers
to understand the reasons behind troubling behavior. The term
“secondary gains” is often used to describe benefits an indi-
vidual may receive from an illness. This is often the reality in
patients who are noncompliant, for example. Secondary gain
can be defined as
the use of illness to meet a variety of other needs. This

may be the receipt of money for pain and suffering . . . or
the sick role may relieve one of professional and family
obligations and may be used to obtain attention and
sympathy from others.2
Relief from the illness may force the person to face realities
he/she does not necessarily want to face or to assume respon-
sibilities he/she does not want to assume. In addition, some
patients may feel they have lost control or independence in their
lives, and the resulting frustration can leak out in their behav-
ior. Sometimes, it is just plain old fear that holds someone back
from true healing. There may also be personal conflicts, about
Who Are You? 27
which the patient is reluctant to talk and which can affect behav-
ior. Financial woes, a divorce or relationship crisis, problems
with children or aging parents, and substance abuse are all exam-
ples of existing conditions that a patient may not feel are rele-
vant enough to mention to the practitioner but that, nonetheless,
affect the therapeutic relationship and treatment outcomes.
Consider the following situations:
Case 1. E. S. is a 19 year-old man with a long history of depres-

sion, indigestion and fatigue. Before seeking acupuncture treat-
ments, he had been to numerous doctors and therapists but had
found little relief for his symptoms. After treating him for sev-
eral sessions without results, the acupuncturist suspected that
he was resisting getting well. When questioned about this pos-
sibility, he at first denied it. On his next visit, though, he opened
up, expressing a fear of getting well. He felt that if he did get
well, he would have to function in society. Having been out of
high school only a short while, he realized he did not know what
direction he wanted to go in. His parents had quite high expec-
tations of him and were already disappointed that he was not
pursuing a college career. They were very alarmed at his state of
health, however, and urged him to seek help before entering col-
lege. The acupuncturist allowed this patient to vent his fears and
referred him to a psychologist with the understanding that he
would work on some of the underlying issues preventing his
improvement.
Case 2. R. S. is a woman in her mid-30s who came for help in

losing weight. She had initial success in shedding about 20
pounds, was very compliant with diet and exercise instructions,
and had a positive attitude. The practitioner was quite surprised
when she suddenly did not book her usual weekly appointments,
then returned in about a month, having gained most of the weight
back. Upon discussing the situation, she revealed that, while she
was overweight, she used her weight as an explanation as to why
she was unable to find a meaningful relationship. She had
convinced herself that if she could lose weight, men would find
her attractive and her dating problems would be over. At her
lower weight, however, she was still not meeting anyone, and
she felt it was easier to gain the weight back and have her old
excuse rather than look at some tougher underlying issues.
Case 3. B.W. is a 60 year-old woman who had recently started

chemotherapy treatments for cancer. She was hoping acupunc-
ture would alleviate the side effects of her treatment. Each time
she came in, she found fault with something the practitioner
was doing. The room was too cold, he was talking too fast, the
table was uncomfortable, the needles hurt too much, etc. On one
or two occasions, she became angry and irritable for no appar-
ent reason, although she was getting satisfactory results from
the treatments. The practitioner realized there had to be some-
thing else going on, and the next time she came in, he took a few
extra minutes to ask how she was doing and what she was feel-
ing. She began to cry and expressed a high level of fear of the
unknown and of the initial diagnosis. It was obvious then that
her behavior reflected a valid fear that she had not been able to
properly express.
Case 4. T. A. is a middle-aged mother of three teenagers who

was suffering from severe allergies. She had tried acupuncture
before with good results and was anticipating a good outcome
this time as well. Her first two sessions went well, but thereafter
she cancelled two consecutive visits on very short notice. She did
come in again but started asking about fee structure. She told her
acupuncturist she was unable to pay the full fee for that visit
because she was short on cash and had no checks with her. The
acupuncturist also noted at this time that there was an increase
in her anxiety level. She took the liberty of asking the patient if
she was experiencing any financial difficulties. At that point, the
patient revealed a harrowing tale: One of her teenaged sons had
been involved in a drunk driving incident which had caused
Who Are You? 29
severe injuries to an innocent party, and the family was now

involved in a long and very expensive legal battle. When asked
why she had not brought any of this up before, she replied, “I
didn’t want to unload on you, and I didn’t think this had any-
thing to do with my health or my treatments.” Working together,
the practitioner and patient were able to come up with a treat-
ment plan as well as a payment plan that allowed her to con-
tinue treatment and devote the energy she needed to her personal
situation.
Admittedly, not all covert issues will be so easily revealed by

simple discussion. Very often, the patient may not be able to iden-
tify or express the depth of the truth. The practitioner needs to
hone his/her listening skills because, quite often, a casual remark
made during the treatment by the patient may hold clues to their
behavior problems.
From the above cases, it is clear to see that most difficult behav-
ior hides fear, anxiety, or some other negative reality the patient
is either unaware of or does not want to face. We do not have to
be psychologists to help these patients. A little detective work, a
sympathetic ear, and a safe place to receive treatment is enough
to correct most behavior and improve the patient’s chances for
healing. In other cases, the problem may be beyond our scope of
practice. If attempts at discussion do not yield positive results
or if the patient is just plain unwilling to talk with you, it is most
likely time to refer to a psychologist or therapist. It is important
from a legal as well as a practical point of view that we as prac-
titioners understand our scope of practice and do not try to be
what we are not. Specific situations and suggestions for handling
such situations will be dealt with in the following chapters. We
would all like to think we can help every single person who
comes to us with every single need they have, but this is not the
case. So, when in doubt, refer out!
As a final word on attempting to define the problem patient, I

would also like to note who is not considered a problem patient.
For example, cultural differences do not constitute personality
problems. When treating a client who is from a different culture,
bear in mind that their behavior may be a reflection of the cul-
ture and not an indication of difficulty for the practitioner (other
than trying to understand the other culture). For example, in
many Asian societies, it is unacceptable to complain about pain;
stoicism, especially in males, is seen as an asset. It may be diffi-
cult to obtain a good history or to ascertain what is wrong with
the patient. This type of patient may also not be expressive in
telling you when he is experiencing relief.
In many Hispanic cultures, the family unit is placed higher than

the individual. It is not unusual for a Hispanic patient to show
up in the clinic with two or more family members. Treatment
options may be a decision for the whole family to make and not
just the patient. There is usually a kind of hierarchy in the fam-
ily system, with the final decision typically resting with an old-
est son or other dominant male figure. There may be much debate
and even hesitation during the family discussion.
Traditional Arabic cultures often have very strict rules regard-

ing the treatment of female patients. A traditional female Arab
patient will most likely not be comfortable or even permitted to
be in a room alone with a man. She may have to be accompanied
by a male relative. She may not be able or willing to remove cloth-
ing to the degree necessary for treatment.
Diet is a huge issue when considering cultural influences. So

much of our teaching in Oriental medicine focuses on diet, but
our teaching may not cross cultural boundaries. No matter how
high her cholesterol was, my Italian grandmother was not going
to give up the fat in her diet for anything and, furthermore, would
not have understood the rationale for doing so. I would not want
to be the one to tell a Buddhist that she would be better off adding
Who Are You? 31
a little red meat to her diet to nourish the blood. Nor would I rel-
ish telling my older Greek gentleman that coffee should be elim-
inated from his diet.
If there is a language barrier as well, things may get truly com-

plicated. In this case, it is always best to have the client bring
along a companion who can translate.
These are just a very few examples of how culture can dictate
behavior and, perhaps, hold a challenge for the practitioner. But
these patients are not being difficult. They are merely acting as
their culture dictates. The difficulty here lies simply in the prac-
titioner’s ability to broaden his/her horizons and reach beyond
what is known and familiar in order to accept the client in the
exact place he/she is in.
As professional health care providers, we must also be able to

differentiate between a patient with diffi- ■
cult or challenging behavior and the In the course of
patient who suffers from a true psychi- your practice, you
atric disorder, such as schizophrenia or will meet many
bipolar disorder. Although these patients
people who have
do pose problems for us, I do not consider
diseases that are
them problem patients. They are operat-
very hard to treat
ing under the influence of an actual dis-
ease. Of course, Oriental medicine can or even those that
treat many psychological and psychiatric are refractory to
disorders, but be sure you are capable and Oriental medicine.
comfortable in treating these cases. Again, These cases,
there is no shame in referring out if nec- too, should not
essary. If you do not have much experi- be confused with
ence in dealing with these types of the patient
disorders, it may be difficult to identify
being difficult.
the true psychiatric patient from one who
It is the disease
is merely exhibiting difficult behavior. Of
course, if the psychological diagnosis is that is difficult.
■
what they are coming to see you for, that will make things fairly
obvious. But if they are coming for a different problem, the psy-
chological issue may not be so obvious. Areview of the medica-
tions the patient is taking is very helpful. (You should always
have a Physician’s Desk Reference handy for quick research.) You
may want to include some questions on your intake that specif-
ically ask whether the person has experienced or is experienc-
ing any psychological problems, including suicidal ideation.
Consulting with a professional in the field of mental diseases is
also an option if you feel you need further information on some-
one’s behavior.
Psychiatric or psychological disorders are only one category of

diseases that are difficult to treat. In the course of your practice,
you will meet many people who have diseases that are very hard
to treat or even those that are refractory to Oriental medicine.
These cases, too, should not be confused with the patient being
difficult. It is the disease that is difficult. Frustration, fear of inad-
equacy, pride, and stubbornness are all pitfalls for the practi-
tioner to be aware of. They can lead you to transfer your own
feelings onto the patient, when it is really the condition that is
vexing you. In cases like these, honest self-appraisal is the only
way out. Consulting with senior acupuncturists or herbalists,
doing extensive research, and reviewing the case thoroughly are
the tools available to help you deal with the situation and not
transfer wrongful traits onto the patient.
A major concept to keep in mind is that the patient is not there

for the practitioner. The practitioner is there for the patient.
Patients come in all shapes, sizes, and colors. It is your job to
understand what makes a person tick, what drives their actions,
and what place in life they are coming from. The patient physi-
cally comes to you, but otherwise, it is you who must really come
to the patient. You are expected to do your best to meet them
where they are and to interact with them at their level without
compromising the quality of treatment.
Who Are You? 33
QUEST IO NS FOR C HAPTER TW O:
1. Think of a situation in your own life where you or some-

one else exhibited behavior that was masking a deeper
issue. Were you or they able to resolve the issue? What
were the consequences of the behavior?
2. What does the term “secondary gains” mean? Give an
example.
3. What are some common underlying issues that may lead
to problematic behavior in a patient?
4. Think about the area where you are or plan to be
practicing. What are some of the predominant cultures
in this area? How might they pose difficulty in a thera-
peutic setting?
An elderly Japanese gentleman comes to your clinic seek-
ing relief from chronic constipation. He is accompanied
by his daughter-in-law. The patient gives very vague
answers to questions on the intake form and seems
unduly anxious about the treatments but asks very few
questions. His daughter-in-law takes the liberty of ask-
ing questions as well as answering questions directed at
the patient. On subsequent visits, although objectively
he appears more comfortable, he insists that the treat-
ments are not helping him. Use your imagination to con-
strue some possible blocks to this patient’s healing. How
would you handle the situation?
Endnotes:
1 Hooberman, R. Ph.D. and Hooberman, B. MD, 1998, Managing the Difficult Patient,
Madison, CT, Psychosocial Press, p. 8
2 Sohr, Eric MD, 1996, The Difficult Patient, Miami, Medmaster Inc., p. 47
In treating the noncompliant patient,
the practitioner needs to let go of the feeling
that he/she is the authority in the
relationship and must allow the patient
to become a willing participant.
CHAPTER THREE
The Noncompliant Patient
By far, the most commonly experienced difficult behavior in any

clinic, Western or Eastern, is noncompliance. Ask any provider
who has been in practice for even just a few months and he or
she will be able to relate more than one instance of noncompli-
ance. It is the perennial plague of doctors, nurses, physical and
occupational therapists, and now practitioners of acupuncture
and Oriental medicine. Noncompliance is a complex topic with
a very simple definition: “Noncompliance can be defined as the
patient’s refusal to follow prescribed treatment recommenda-
tions, large and small.”1
It is easy to become frustrated with a client’s seeming unwill-

ingness to participate in their own care. We cannot understand
why they would spend so much time and money on treatments
and neglect the important follow-through instructions that hold
the key to their well-being. What’s going on in this case? Is it
wrong to assume that someone coming to us for treatment really
wants to get better? Why else would they be coming? Why would
35
they waste time and money seeking help if they don’t want to
follow the advice of the practitioner?
■ Not following practitioner recommendations and
prescriptions
■ High utilization of health care system
■ Chronic complaints that have gone unresolved for a
long period of time
■ Discovery of past noncompliant behavior
Home base
There are countless factors that contribute to a client’s noncom-
pliance. Let us again begin with ourselves. As discussed in Chapter
One, your dress and demeanor, the words and actions of your
staff, and the ambience of your office influence the way a per-
son will react to you. If something offensive or confusing was
said, however unintentionally, the patient may feel guarded and
may want or need more time to form a good impression. Most
patients will not actually tell you that something you or your
staff did or said had a negative impact.
■
Most people maintain a level of social
If the office is not politeness and do not wish to offend or
comfortable or risk any kind of confrontation or unpleas-
does not have a antness. However, their feelings may be
professional feel, expressed in future actions and attitudes.
that might also It is important to remember the effect your
affect the words have on your patients. They are
client’s attitude. coming to you for health care, and that
implies an inherent level of trust. Your
■ words hold an enormous amount of
power. Even an offhand comment can stick in someone’s mind
for better or worse. Always be aware of your speech and choose
The Noncompliant Patient 37
your words carefully lest you inadvertently give someone the

wrong impression.
If the office is not comfortable or does not have a professional

feel, that might also affect the client’s attitude. People will tend
to be more compliant if they feel they are being treated by a pro-
fessional. If they do not have this impression, they may not hold
the practitioner’s advice in as high regard as it deserves.
Another good policy is to be a role model for your patients. It is

up to each practitioner to decide how much of his/her personal
life to reveal to patients. It does not hurt, however, to let patients
know in some way that you exercise regularly, take herbs your-
self, go for acupuncture treatments, etc. It puts you on a more
equal level with the patient and also provides some guidance
and motivation for them.
As acupuncture’s popularity increases, practitioners will be see-

ing a wider and wider variety of people in their offices. Keep in
mind that your values and those of your patients may not be the
same. As always, individuality plays a crucial role in the thera-
peutic relationship. Your idea of optimal quality of life may actu-
ally differ quite drastically from your patients’. A surprising
number of people will put up with a surprising amount of dis-
comfort and still feel they have a good quality of life. They have
a right to feel this way, even if you think their quality of life is
not ideal and could be improved. Any further improvement may
not seem worth it to the patient if it involves actions or changes
in lifestyle or diet that are unpalatable. Discomfort is a valid
option, and one that patients have a right to choose, however
difficult that may be for practitioners to comprehend or accept.
Case in point:
G. D. had been suffering from severe heartburn for years. She also
had accompanying symptoms of bloating,borborygmus, and
constipation.After about three months of weekly acupuncture
treatments, the heartburn was largely resolved, but some of the

other symptoms remained and were slow to resolve with acupunc-
ture alone.The patient had already changed some dietary habits,
and the practitioner next suggested a course of herbal treat-
ment to augment the acupuncture.The patient was agreeable
and was sent home with an appropriate formula in powder form.
When she returned the following week,she told the practitioner
that the taste was awful and she could not tolerate it.The prac-
titioner explained that the formula was custom-made for her
symptoms and patterns and he was not able to provide it in pill
or tincture form. The patient then decided against the herbs and
stated,“That’s OK. I feel so much better than when I first started
coming that a little bloating now and then isn’t that big a deal.”
The practitioner also explained that the remaining symptoms
indicated that the root of the problem had not been sufficiently
eradicated and that the symptoms might worsen. The patient
responded that,“Oh, I’ll just come back for more acupuncture
if that happens.”

As conscientious providers, most of us can sense how this par-
ticular practitioner might have felt frustrated. He knew that the
patient could have had an even better quality of life and longer
lasting effects, but the patient’s point of view was that she was
satisfied with her present level of health and it was not worth the
trouble or the taste of the herbs for her to continue with that
course. Although nothing technically went wrong here, the prac-
titioner’s fru st r ation could be mitigated by realizing that this
patient’s view of health was different from his and that each
patient must be given the respect to decide what type of treat-
ment they want.
It’s all Chinese to me

Another area to examine is how you are presenting the infor-
mation you wish the patient to heed. Acommon mistake of both
Western and Oriental medicine providers is using language that

patients do not understand or giving instructions that do not
make sense to them. Even though the complex language of
Oriental medicine may have sounded strange to you at first, after
years of schooling, reading, and engaging in discussion with col-
leagues, the language has become a natural part of your vocab-
ulary and you feel comfortable hearing someone lecture about
“damp heat in the liver-gallbladder” or telling someone you think
the “heart and kidneys are not interacting.” Your patients, how-
ever, have not gone to Oriental medical school and such termi-
nology sounds even more incomprehensive to them than does
Western medi-speak!
Cases in point:
Case 1. B. J. started acupuncture treatments after suffering an

attack of Bell’s palsy. Her most troubling symptom was facial
drooping and an inability to close one eye completely. In addi-
tion to needles and herbs, the acupuncturist made some rec-
ommendations. She told the patient that her symptoms were
caused by wind in the channels and instructed the patient to
keep her head and ears covered when it was windy out and not
to stand directly near any air-conditioning units or indoor fans.
The patient left the office bewildered. She thought to herself,“What
does wind have to do with anything? It’s summertime and I just
woke up with these symptoms one day. That sounds like the
strangest bunch of malarkey I’ve ever heard.I am not going to
sweat to death this summer by avoiding air-conditioning or fans!”

The acupuncturi st ’s explanation was obviously not thorough
enough. She made the incorrect assumption that the patient
could understand the theories of Oriental medicine without hav-
ing been through the training. A few extra minutes explaining
that channels are often portals to the elements and that envi-
ronmental elements can actually enter and become trapped
in the body via the channels might have been helpful. The client
could have been told that some types of neurological symp-
toms are often thought to be the result of wind lodged in the
channels and vessels. Although the concept might still have
seemed strange to the client,the extended
■
explanation might at least have made some
Respect
sense whereas the first explanation was sim-
your clients’ ply too arcane to grasp.
intelligence
while also Case 2. Mr. G. was seeking treatment for
recognizing sinus congestion that was severe and had
their persisted since his childhood. His pulses were
limitations. very slippery and he complained of large
amounts of nasal drainage and a produc-
■
tive cough. The practitioner made some
dietary recommendations, including cutting out salads and
uncooked vegetables. Mr. G. left the clinic confused,thinking,“I
thought acupuncture was ‘natural healing.’ Salads and vegeta-
bles are good for you. I don’t know if this guy knows what he’s
doing! I’m not going to stop eating healthy food just because
of a sinus problem!”

Again, the explanation did not satisfy or even make sense to the
client.There are so many perceptions regarding health. The pub-
lic is inundated with all kinds of conflicting messages, but many,
if not most,people assume that salads and vegetables cannot
possibly be harmful. A simple explanation of the role of the
“Chinese” spleen in the process of digestion and the engen-
derment of phlegm, the fact that digestion is likened to a process
of cooking, and the spleen’s aversion to dampness according
to Oriental medicine might all have helped the patient under-
stand that the spleen benefits from warmth and the predigestion
of cooking in order to properly transform food and fluids and
prevent them from stagnating in the body.
Come again?
Sometimes the practitioner does give a good and complete expla-
nation to the patient, the patient appears to understand, but non-
compliance occurs nonetheless. In this type of case, the patient’s
understanding may be faulty. This may be especially true if
English is not the patient’s primary language. Even if he/she
seems to understand what you are saying, it is worth having
them repeat it back to you to make sure. If it is a true language
barrier, a translator or interpreter is absolutely necessary in order
to avoid confusion. In all cases, keep your wording simple but
not patronizing. Respect your patients’ intelligence while also
recognizing their limitations. In other cases, the patient may have
misconstrued your meaning.
Written instructions
Giving written instructions is always a good idea. Nowadays,
we are all so busy and preoccupied with myriad issues that ver-
bal instructions are easily and often forgotten. Having something
written down on paper also lends it more validity and serves as
a reminder to the client (unless, of course, they have forgotten
where they put it!). Writing out instructions leaves less room for
misunderstanding or misconstruction of the provider’s intent.
When giving written material to clients, it is best to use your let-
terhead or paper printed with your name, address, and phone
number. This serves two purposes. First, it looks professional
and is more likely to make an impression. Secondly, it is yet
another way to get your name out of your office and into the
world. Make sure your written instructions are easy to read and
understand. You can use a variety of methods to get your point
across. There are several companies that sell various types of
instructional brochures already printed. Just stamp your name
and information and give them out to the patient. You can also
easily create your own pamphlets, brochures, or instruction sheets
on a computer and have them printed yourself. Of course, you
can always handwrite instructions as well, but be sure you do
not have typical “doctor’s handwriting” that no one can read. If

writing out instructions by hand, print legibly. Do not use script.
Black ink on white or light-colored paper is easiest for most peo-
ple to read. A larger piece of paper, for example an 8 x 10” sheet
rather than a memo-sized sheet, is less likely to get misplaced.
Written instructions are especially important when prescribing

herbs. Many of your patients will be totally unfamiliar with herbs.
Whether you choose to prescribe bulk herbs, powders, or pills,
people want clear instructions . They want to know exactly how
to prepare the herbs, how and when to take them, if they will
interfere with any of their other medications, if there are any side
effects, and if they can add anything to make them taste better.
Patients will appreciate having something to look over when
they get home or to share with their family and friends.
Case in point:
D. C. is a middle-aged woman who is interested in Chinese herbal

therapy for persistent dizziness and fatigue. She had had good
results at other times in her life with herbal therapy, but this prac-
titioner was new to her. The herbalist prescribed an appropriate
formula and verbally instructed the patient that the powdered
herbal formula was to be taken with hot water in tea form twice
a day. On follow-up visits, the client told the herbalist she was tak-
ing the herbs every day, but, after a month or so, no change in
symptoms was noticed. On further questioning, the patient
revealed that she was taking the formula as a “tea.” To her, that
meant she could add a little sugar to the formula, had poured
herself a full cup, and sipped it slowly while eating her meals.

Although the herbalist was diligent in telling the patient how to
take the formula, he made the mistake of assuming she knew
how to take Chinese herbs from her previous experiences. He,
therefore, did not give her written instructions and also did not
make his instructions as detailed as they should have been.No
matter what the patient tells you about past experiences, never
assume they know what your particular expectations are. It is
always wise to view each patient as if they have never had an
Oriental medicine experience befo re . That way, misunder-
standings are less likely.
Money makes the world go round

Depending on where you live and practice and your own per-
sonal philosophy, you may or may not accept insurance. The
truth is that most acupuncture practices are still largely cash-
based. Even in cases where insurance is accepted, most policies
do not cover herbs, including liniments, ointments, and other
external applications. Your clients may already be paying out
cash for the acupuncture treatments. Having to purchase herbs
or other products recommended by you might be a financial bur-
den. Many people will already be taking vitamins or supple-
ments that can be quite steep in price. They may be reluctant to
let go of these therapies, especially if their bottles are not yet
empty. This is also true of referrals to other disciplines, such as
chiropractic, massage therapy, energy work, etc. Finances are an
extremely personal subject. Some people have no qualms telling
you up-front what they can or cannot afford, but others may be
reluctant or even embarrassed to admit they cannot afford a sug-
gested therapy or remedy. Of course, if you dispense products
from your office with payment due at the time, the patient will
have to either pay or not. However, some practitioners may send
their patients to pick up a prescription at an herbal pharmacy.
The patient may decide to wait until he/she can afford it to pick
it up or may not pick it up at all. When making recommenda-
tions that will be an added cost to the patient, do not be afraid
to broach the subject in a tactful way. If the patient indicates that
they cannot, in fact, afford your suggestion, you need to respect
that and not show anger or frustration to them. In these cases,
you may have to forego that particular avenue, offer reduced

rates, or just administer acupuncture to the extent that the client
can afford.
Case in point:
P. M. has been suffering from upper-and mid-back pain for many

years. The patient works at a computer for most of her workday
and, generally, has experienced quite a bit of stress in her life.
After several acupuncture treatments, the pain was improving
and the acupuncturist recommended some ergonomically cor-
rect furniture to use while at the computer. The client stated she
would approach her employer with the suggestions. The practi-
tioner also suggested that the client step away from the com-
puter at least once an hour and do some neck and shoulder
rolls to help alleviate st a g n at i o n . The patient stopped her
acupuncture treatments a short time later, stating that her pain
was “so much better.” A few weeks later she returned, stating that
the pain was “creeping back again and is getting pretty bad.”

In this case, the acupuncturist was surprised that the patient had
stopped her treatments, since she had been experiencing quite
a bit of improvement but the pain was not completely gone. She
was even more surprised when the client returned, stating the
back pain was worse.The acupuncturist did not realize that the
patient’s company would not pay for new furniture and that any
adjustment would have to be paid for by the patient herself.
Furthermore,the patient was afraid to step away from her desk,
even for short periods of time, because her boss was very strict
and did not like to see his employees not working during pre-
scribed workday hours. The patient felt too embarrassed to reveal
these facts to the practitioner, but the practitioner could have
discovered the truth with some compassionate and well-directed
questions about how the patient was doing with her suggestions.
When is a door not a door?

Sometimes, noncompliance is not really noncompliance. Chronic
fatigue syndrome (CFS), anxiety, severe stress, brain injury, and
senile dementia are all examples of symptom manifestation. These
symptoms are directly related to the patient’s disease and must
be considered when giving recommendations, even in writing.
Those who suffer from CFS are often so exhausted from simply
trying to get through the day that they may literally not have the
energy to devote to follow-up suggestions or self-care. Anxiety
narrows a person’s field of awareness so that, at times, all they
can comprehend is the anxiety itself. Or they may become pre-
occupied with the thought or event causing the anxiety and be
unable to focus attention on anything else. The practitioner’s rec-
ommendations may themselves be a source of anxiety for the
patient, which he or she may then choose to avoid in order to
avoid becoming overwhelmed.
It is certainly no secret that we live in a fast-paced, high-stress

world. Many of your patients may be coming to you solely for
the purpose of stress reduction. The young mother with a sick
child, the salesman working on commission to provide for his
family, and the working mother juggling home and office respon-
sibilities are all examples of people whose stress level is so high
they may not be able to devote their energy to self-care.
In this automobile-crazed society, there is no shortage of car acci-

dent victims, and you will see your fair share of them in your prac-
tice. Brain injury is more common than you may realize and need
not be severe in order to affect a person’s cognitive functioning.
Many people who have suffered brain trauma can hold jobs and
may not appear to have any deficits, but there is often a low level
of compromised functioning going on. Concentration may not be
as sharp as it once was. There may be evidence of increased for-
getfulness or the patient may become easily fatigued. Sleep dis-
turbances are not uncommon in such cases. All of these factors
serve to distract the patient from full attention to compliance.
More and more senior citizens are seeking out alternative med-
icine, tired of taking too many pills and feeling ignored by the
existing health care system. Like brain injury, dementia need not
be severe or even obvious but may certainly affect the client’s
ability to adhere to advice. Forgetfulness is another unfortunate
reality of aging in some people and may not even be apparent
to anyone but the person experiencing it. This type of patient
may be having difficulty accepting these realities in themselves
and so may be unwilling or unable to share with the practitioner
that this is happening. If a family member accompanies this client,
it is worthwhile to review the instructions with them as well to
insure greater understanding and compliance. The main point
here is to differentiate between a patient who is truly noncom-
pliant and one whose noncompliance is a result of their baseline
health status.
Case in point:
Mr. J., an 85 year-old gentleman, is coming for acupuncture

because of an old case of “shingles” which still causes him a lot
of pain even though the lesions have resolved. This client is quite
mentally alert, still drives, and is very active in his local civic asso-
ciation. His Chinese herbalist gives him a formula in pill form,
instructing him to take four capsules three times a day. The herbal-
ist also gives written instructions. The client appears to under-
stand the instructions and states he should have no problem
taking the pills. He seems excited that the herbs might provide
him some long-sought relief. When he returns two weeks later for
a follow-up herbal consult, he tells the herbalist that his symp-
toms are still bothering him quite a bit. When asked about the
pills, the client states he has been taking them every day. The
herbalist is somewhat confused because the formula he pre-
scribed seems to fit the client’s pattern differentiation exactly. He
urges the patient to come again in two weeks. However, the
p atient did not re t u rn for that scheduled ap p o i n t m e n t . T h e
herbalist called the patient’s home to see what had happened.

The patient’s wife answered the phone. After a brief conversa-
tion, the wife started laughing and said,“Oh, you mean that bag
of capsules you gave him? He’s lucky if he remembers to take
them once a day!”After a little more discussion, the wife explained
t h at , while her husband generally functioned quite well, he
needed constant reminders about pills, medicines, and appoint-
ments, and that she was the one who often helped him out with
such matters.

In this case, the patient intended to take the herbs and did not
intend to miss his appointment. Because of the patient’s initial
presentation, the herbalist did not suspect any cognitive dys-
function.While it is extremely important not to stereotype and to
realize that many senior citizens have no memory loss at all,
memory loss may be a covert aspect of someone’s life. In this
case,the herbalist could have recruited the wife’s help in ensur-
ing patient compliance. For example, she could have placed
the herbal capsules in the patient’s regular pillbox so that he
would remember to take them. The herbalist could also have
agreed to give the patient a reminder call the night before his
appointments to help keep him on track.
T HE INSI DE STO RY:

One of the most devastating effects of illness that an individual
can experience is the loss of independence and control. A once-
healthy woman who maintained an active lifestyle and is now
limited by the symptoms of fibromyalgia is a good example of
such a situation. Likewise, the elderly gentleman who has just
had his car keys taken by his family because of poor eyesight
and failing memory also experiences a debilitating loss of con-
trol. It is human nature to want some kind of control over our
lives and our health. Adults generally do not want to feel like
helpless children who cannot care for themselves. Most people

abhor the thought, let alone the reality, of having to depend on
others, of feeling like a burden. When faced with such a loss of
control, it is instinctual to look to the areas that we can control,
however small they may seem. Patients want to do what they
can to get well, but also don’t want to feel like they’re just at the
mercy of the health care system. The decision to follow or not to
follow health care instructions may give the patient a sense of
control, even if it is not conducive to healing. The need for inde-
pendence and control may sometimes take precedence over the
need for optimal health. Recognizing this need to express, regain
or establish a sense of control and independence will assist the
practitioner in understanding patient behavior, especially when
it comes to failure to adhere to instructions.
Case in point:
Mrs. R. J.,a bright 80 year-old, was brought into the clinic by her
son who was hoping that acupuncture would help decrease her
knee pain from arthritis. She had been living in her own apart-
ment but had moved to an assisted living facility two years ago
at the insistence of her family who were concerned about her
safety. The assisted living facility provided meals and assistance
with bathing as well as house-cleaning and laundry services.
Although the patient had had to rely heavily on her family when
she was living on her own, the move to assisted living really made
her feel helpless. She had not wanted to move in the first place,
was in unfamiliar territory, surrounded by unfamiliar people.She
especially resented having to have a stranger help her with her
bath. She also did not want to come for acupuncture treatments,
but her son had insisted after he saw a TV special about the ben-
efits of acupuncture in treating arthritis. So she had reluctantly
agreed to go. The acupuncturist gave her a treatment with nee-
dles and also recommended she buy some Zheng Gu Shui
Orthopedic Water, (a commonly used Chinese ready-made
herbal liniment) to apply at home between treatments. The patient

was taught how to apply the liniment with instructions for twice
daily applications. When she came back for her second visit,
the acupuncturist asked how she was doing with the liniment.
She stated that she had not used the Zheng Gu Shui at all, say-
i n g ,“ T h ey can make me come here, but they can’t make me
use this smelly stuff!”

There may have been some clues during the initial intake inter-
view regarding the patient’s feelings. She may have been hesi-
tant to say anything directly in front of her son, but just the facts
of her age and her living situation could have alerted the
acupuncturist to a potential problem. In this case, presenting the
instructions as a choice for the patient rather than as an instruc-
tion may have helped:
Acupuncturist: Mrs. J., some of my patients with arthritis

have used this special liniment and have found it relieves
their pain.
Mrs. J.: Well, I don’t want it. I take too many things as it is.
Acupuncturist: You don’t have to try it. It’s just a suggestion.

Some people choose to use this because it helps them feel bet-
ter and they don’t have to come to the office as frequently.
Mrs. J.: You mean they won’t have to drag me here as much?
Acupuncturist: Maybe not! But it’s up to you. I can give you

a small sample to try. If you like it, you can buy a bottle, but
if you don’t like it, you don’t have to keep using it.
Mrs. J.: Well, if it means I might be able to cut down on my

visits here, maybe I can try it for a while. But if I don’t like it,
I’m not going to use it.
Acupuncturist: That’s fine. But please let me know how it

works for you. That’ll help me know if it’s effective for oth-
ers in your situation.
Mrs. J.: Well, I can do that, especially if it might help some-

one else.
In the above scenario, the acupuncturist’s approach did two

things: It gave the patient a choice and therefore some control
over whether or not to use the oliniment. It also gave her the
opportunity to feel like she might be able to be helpful, which
further lessened her feelings of powerlessness.
In treating the noncompliant patient, the practitioner needs to

let go of the feeling that he/she is the authority in the relation-
ship and must allow the patient to become a willing participant.
Understanding the client’s situation and the effect of illness on
their lifestyle will help the practitioner find more healthy and
empowering avenues for follow-up teaching.Helping the client
to achieve as much independence as possible and to leave
behind the “sick role” will be a healing in and of itself!
QUEST IONS FOR C HAPT ER T HR EE:
1. Why do you think noncompliance is such a big problem

in the clinic? Have you ever been noncompliant with a
health care provider’s instructions? If so, what were the
reasons behind your behavior?
2. How might a practitioner unwittingly contribute to
noncompliant behavior?
3. Name three other factors that may contribute to
noncompliance.
4. Think of a situation that made you feel helpless and
out of control. How did powerlessness make you feel?
What were some actions you took to regain your sense
of control?

A middle-aged man who is supporting a wife and three
teenagers comes to your clinic seeking relief from long-
standing back pain. The patient had been going to a gym
regularly and lifting weights. Part of your teaching
includes telling the patient he should refrain from weight-
lifting until his back is stronger and the pain is resolved.
The patient acknowledges that his activities at the gym
might be aggravating the back pain and agrees to “lay
off” for a while. When he returns to the clinic, his back
pain is worse than ever, and he admits he “just had to
lift some weights the other night.” What are some under-
lying causes that might be instrumental in the man’s
decision to continue harmful actions? How would you
handle this situation?
Endnote:
1 Hooberman, R. Ph.D. and Hooberman, B. MD, 1998, Managing the Difficult Patient,
Madison, CT, Psychosocial Press, p. 57
There is a lot of repressed anger out in the world
today and that poses a danger to each individual’s
health as well as to the therapeutic relationship.
C H A P T E R FO U R
The Angry Patient
It’s my perception that anger is becoming a more and more com-

monly expressed emotion in modern society. Most practitioners
of Oriental medicine in the Western world are all too familiar
with the irritability (literally “easy anger”) that goes along with
liver depression qi stagnation. The bowstring pulse is probably
the first one you learned to identify and the one that you will
feel most comfortable identifying. We live in a world and create
lifestyles for ourselves that often end up in denial of our own
needs. Our fast pace of living contributes to such phenomena as
road rage. Lack of feeling like part of a community, spiritual dis-
enfranchisement, and disintegration of the family may contribute
to a sense of rage and anger, as do histories of physical, sexual,
or verbal abuse.
The current state of the health care system in this country leaves
many people feeling like they have been neglected, treated like
a number or a statistic, or just plain inconvenienced. Political
climates may also foment anger in certain populations. Overall,
53
we as a society are not taught how to express our anger. Women

in particular are taught from an early age that they should not
display anger or even feel it, let alone give vent to it or recog-
nize it as a healthy emotion. There is a lot of repressed anger out
in the world today and that poses a danger to each individual’s
health as well as to the therapeutic relationship. In other words,
anger is a force to be reckoned with in ourselves as well as in
our patients.
Pent up feelings need to be let out somewhere—and that some-

where is often a health care setting! You may well find yourself
the innocent target of a patient’s anger. It is important to under-
stand the source of the anger and that, in most cases, although
you may be the target, you are not the source. Although it is a
natural reaction to lash out if we are attacked, health care providers
are really not afforded this luxury. Keep in mind that helping a
patient through their anger is part of helping them heal. If you
can separate yourself and not take it personally, you will go a
long way to achieving the goal of ultimate and deep healing.
■ Frequent complaints about other people, work, the world,
life in general
■ Chinese medical diagnosis of a liver-wood pattern, a
bowstring pulse, tongue with red or purple tip and edges
■ Relatives or friends reporting bursts of anger or irritation
■ Difficulty holding a job
■ Body language: fidgeting,“huffing and puffing,” constantly
looking at watch, shaking head, rolling eyes
Home base
You have set up your office to accommodate anyone who would
come to you. Your staff are pleasant and efficient, and your office
The Angry Patient 55
space is quiet, welcoming, well lit, and calm. You welcome all
your patients with a pleasant smile, a handshake, and some
friendly words. Your manner is gracious and even-toned. What
on earth could possibly anger one of your patients? Keep in mind
that a truly angry person does not just become angry overnight.
More often than not, he/she has had anger brewing inside for
quite some time and is subconsciously looking for a place to
“blow off some steam.” It sometimes does not take much to set
someone off.
Always be conscious of your time. Many of your patients may

be coming to you on their lunch break or between other appoint-
ments and have to be somewhere at a certain time. People gen-
erally do not like to be kept waiting more than five or ten minutes.
They may have had previous experience at a health care provider’s
office in which they were kept waiting up to an hour just to be
given a quick, ten minute examination. Try to be at your office
well before your first patient arrives and to have the treatment
rooms and paperwork neat, organized, and ready to go. If you
are running late and have a staff, call ahead so they can alert the
patient that you are on your way. If you do not have a staff, keep
a list of your patients’ phone numbers (for example in your cell
phone memory or in a palm pilot; those gadgets really do come
in handy sometimes) and call them as soon as possible to let them
know you will be delayed. It helps to give a reason so the per-
son can understand that you are not slacking off. If you cannot
reach them in time and they are already waiting at your door
when you arrive, there is not much you can do except to express
your regret. Apologize to them for your lateness and tell them
you recognize how valuable their time is. You may even want to
give them a discount if you are considerably late.
Keep your initial intake short and convenient for your patients.
Many people who come to see you will have already visited sev-
eral providers and, therefore, have filled out many history forms.
They are probably really sick of it. A form that uses check marks
instead of lines is more convenient for most people. Keep all

intake questions simple. Any further details can be gathered dur-
ing your discussion time with the patient. If possible, keep an
eye on the patient as they are filling out the form. If they seem
to be getting aggravated or generally having trouble, you might
want to suggest that you just go into the room together and go
over the questions with them, filling in the answers yourself as
you go along. It is helpful to get an idea from a first-time patient
■ as to what they are coming to see you for.
If it seems like a complicated problem, you
I have often been
will be duly alerted to the fact that the per-
surprised at how son may be experiencing frustration or
many people do may have a large amount of information
not ask about to share with you and you may be able to
fees up-front. ease them into that first visit more gently
I would rather with this foreknowledge.
have this
Make sure your disclosure form is up-to-
understood at
date and that you have clearly stated your
the beginning of
fees and cancellation policy. Most people
the treatment only give the disclosure form a cursory
rather than to look. So you might want to have these
have the patient items in bold print or italicized, or you
express dismay might want to verbally point out these
at the cost after items to the patient. I have often been sur-
a full treatment prised at how many people do not ask
has been about fees up-front. I would rather have
administered. this understood at the beginning of the
treatment rather than to have the patient
■ express dismay at the cost after a full
treatment has been administered. Likewise, it is best not to have
a surprised patient when you explain you have to charge them
for a missed appointment. If they have insurance, do be sure you
can accept their insurance and that they understand any co-
payments that are required. If problems with insurance do arise,
try to address them as quickly as possible and do everything you
can to keep the patient informed of the claim status. If it is an

injury situation and the patient’s lawyer requests records from
you, try to expedite the sending of such records (with the patient’s
written consent, of course).
Bear in mind to whom you are speaking. As discussed in Chapter

One, do not use words like “honey” or “sweetie” unless you feel
they are appropriate. Do not use diminutive terms when speak-
ing to seniors. Likewise, do not use a patronizing tone either.
This standard applies to your staff as well. Instruct your employ-
ees to be professional and courteous at all times, even in the face
of someone who is angry. If they feel uncomfortable, have them
refer the situation to you. Angry retorts or expressions of exas-
peration with a patient are unacceptable behaviors from staff
members and should never be tolerated. You may want to set
scheduled times to meet with your staff, i.e., monthly or bimonthly,
to discuss office procedures and issues. At these meetings, employ-
ees should also be encouraged to verbalize any problems they
may be having with patients. Employees must be made to feel
that their comments will be taken seriously, will not hinder their
job, and will be kept confidential.
Explain as much as you can about what you are doing, especially
if it is the person’s first visit to an acupuncturist. Be honest about
how much relief they can realistically expect from Oriental med-
icine as well as the time they can be expected to wait for results.
In this day and age, we have become so accustomed to instant
gratification that many of our patients have a difficult time under-
standing why our treatments do not provide immediate relief all
the time.
Case in point:
Mrs. K. came to an acupuncturist for her first appointment. She

had called and spoken to the practitioner first, explaining that
she wanted to be treated for high blood pressure,and that her
pressure had risen dramatically after her husband had died

recently. While she was filling out the intake form, the practitioner
noticed she was fidgeting and sighing a lot and was writing quite
a lot of information but allowed her to continue on with the form.
At one point,the practitioner came out to the waiting room and
said,“Take your time filling out that form.It seems like you’ve got
a lot going on.” At that point, the patient slammed the clipboard
down on the table and said,“You bet I do. I am so fed up with
all this writing! I don’t even know where to start or if this will even
help me!” The practitioner told the patient to do the best she
could filling out the form and then they would go over it together.
The patient agreed, but continued to sigh and fidget until it was
done.It took a few more visits until this patient felt more at ease
in the clinic.

In this case, there were several clues that the practitioner ignored.
Just the fact that someone has high blood pressure can often
indicate that they have some stress in their lives. In addition,this
woman had told the practitioner that she had recently been wid-
owed. Such a life-changing event often causes anger in a per-
son. We can all experience anger at a sudden loss, at the
unfairness of the situation, or even at the deceased for having
left the bereaved behind. When the practitioner noticed the
patient’s body language, it should have been a clear indica-
tion that the patient was having difficulty with the questionnaire.
If the practitioner had acknowledged and recognized these
signs earlier, she could have just taken the patient into the room
and conducted the initial interview, filling out the form as they
went along.It would probably have been beneficial to give the
patient a little time to vent or to talk a bit about her recent loss.
A little sympathy can go a long way. If the situation had been
better addressed at the first visit, it may not have taken a long
time for the patient to feel comfortable.
Sick and tired of being sick and tired

It is a fact that many of your patients will have been grappling
with a particular health issue long before they come to see you.
Although acupuncture and Oriental medicine are entering the
mainstream, they are still often thought ■
of as a last resort. You can never under-
You can never
estimate the effect that a long-term illness
underestimate
or chronic pain has on the sufferer. If you
yourself have enjoyed relatively good the effect that
health, you may not understand all the a long-term
ramifications of a severe or prolonged ill- illness or chronic
ness. It is human nature to crave inde- pain has
pendence and to abhor becoming helpless on the sufferer.
or a burden to others. This is true at any
■
age, but younger people with compro-
mised health may have an especially difficult time accepting lim-
itations on activity, diet, and freedom that their peers are
unencumbered by. Physical compromise affects thought and emo-
tion. It is hard to concentrate, difficult to think clearly, and not
easy to communicate clearly when one’s body is not cooperat-
ing. Socializing becomes awkward and, at times, downright
impossible. Even simple tasks such as preparing a meal or brew-
ing a pot of tea take on immense proportions. Independence
decreases and frustration mounts as the condition progresses or
simply does not improve. Long searches for answers on the
Internet, at doctors’ offices, and in alternative health care clinics
can lead to exhaustion and despair if a solution does not seem
forthcoming.
Illness has a profound affect on family life as well. It can inter-

fere with the ability to interact with and enjoy children and
grandchildren. Younger parents may not be able to be as active
as they’d like at their children’s school activities, and older peo-
ple may feel deprived of quality time with their grandchildren.
Marriages often go through drastic changes when one partner
is sick. Roles within the family may change. If it is the bread-

winner who is ill, he/she may experience a crisis in self-image
and self-worth. If it is the primary care-taking parent who is ill,
children may feel ill at ease with the other parent taking over.
Security is threatened. Finances are almost always an issue in
cases of illness, especially when it has been going on for some
time. And the longer a condition persists, the greater the nega-
tive impact is likely to be.
Even someone whose complaint is relatively new will still expe-

rience many of the above problems, even without the added fac-
tor of chronicity. People are impatient to get better and feel they
want a cure or at least some relief as soon as possible.
All the above situations can lead to anger. Most people do not
realize just how much anger is building up inside them. They
may want to appear and feel strong for themselves as well as for
their friends and family. Anger may be perceived as a sign of
weakness or an indication that they “can’t handle” the situation,
even though anger, in this case, is a perfectly valid emotion.
Repressed anger is bound to seep out at some point.
Case in point:
S. V. is a 35 year-old mother of five children who was diagnosed

with a rare form of cancer about two years ago. Her prognosis
is not very positive.Her husband,in addition to bearing the bur-
den of being the main breadwinner, has also had to take over
most of the child-rearing tasks. She has sought acupuncture for
relief from severe and debilitating pain in her legs and hips as
a result of some of the chemotherapy she has been receiving.
The acupuncturist had been doing home visits for her because
her condition prevented her from easily getting out of the house.
On all of the previous visits, the patient and her family had been
very pleasant and extremely appreciative that someone would
come to the house to administer treatments. On one occasion,
however, as the acupuncturist was helping the patient attain a

comfortable position in bed, the patient suddenly became quite
agitated and lashed out at the acupuncturist,saying,“Why don’t
you just get the hell out of here! You’re not helping at all, and
you don’t understand anything. I don’t even think you know what
you’re doing.”Caught off guard, the acupuncturist replied,“Well,
I was just trying to help. I don’t know what else to do. Maybe we
should just forget it and continue next week.”
The patient agreed and the acupuncturist left without doing a

treatment.

In this case, the acupuncturist had an inappropriate response
to what she perceived as inappropriate anger on the patient’s
part. Her competency had been questioned and she felt help-
less to assist the patient. A better solution would have been to
allow the patient to vent a little more. She might have even asked
some pointed questions such as,“Has anything new been both-
ering you lately?”or,“You seem really upset today. Would it help
to talk about it before starting the treatment?” By denying the
patient’s need and failing to recognize that there was an under-
lying issue,the acupuncturist actually made the situation worse
by 1) not assuaging the patient’s anger and 2) by not giving a
treatment which would have alleviated some of the patient’s
pain.Further conversation would have revealed that the patient’s
six year-old daughter was having a class party and had asked
her mother to bake cookies for the event, not understanding that
her mother was not able to fulfill this basic request. The patient
was then overcome by her powerlessness and frustration and
lashed out at the first person she could. The patient and acupunc-
turist were able to talk about the event the next day. She con-
fided to the acupuncturist that she was afraid to express anger
to her husband because “he’s so good and helpful all the time
and I feel like I’m always dumping on him.”
It’s all their fault

Sometimes a patient will express anger that has nothing to do
with you. In fact, they may even be somewhat conspiratorial,
trying to gain you as an ally against someone or something they
are upset with. This is often the case when a patient is angry with
another health care practitioner or with the existing health care
system in general. We all take a great deal of pride in our work
and sincerely want the best for our patients. When we hear a
patient complain about another health care provider, it is tempt-
ing to want to know the details, and it is easy to make a snap
judgment and end up siding with the patient. In such cases, it is
imperative to remember that you are hearing only one side of
the story, and the patient’s view of the situation may very well
be colored by their own feelings and/or past experiences.
Hearing this type of complaint becomes an even more emotional

issue if the complaint is against another acupuncturist. Before
plunging in and “siding” with the patient, it is again important
for you to examine your own feelings and motives. Sometimes
■ a lack of confidence or a feeling of inse-
curity, especially at the beginning of your
It is important to
practice, can lure you into saying some-
understand the
thing negative about another health care
source of the provider. There is an inherent sense of
anger and that, superiority in such a case, a tendency to
in most cases, think, “Well, I may not be the best practi-
although you tioner in the world, but at least I’m not as
may be the bad as that guy.”
target, you are
If the patient’s complaint is against a
not the source.
Western MD, there may be an even greater
■ sense of righteous indignation and a feel-
ing that, “Western medicine is bad and alternative medicine is
good.” As Oriental medicine practitioners become more accepted
in the medical world, keep in mind that these same physicians
are your colleagues. You do not want to become guilty of the same
criticism that has plagued our medicine. Likewise, a comment
against a fellow acupuncturist does nothing except destroy the

unity of our profession. So proceed with extreme caution when
a patient complains about another practitioner. As stated above,
you do not usually have the benefit of knowing both sides of the
story. Always keep an open mind, supporting the patient while
remaining neutral. Granted, not an easy trick!
Sometimes the patient’s complaint might be absolutely valid.

Perhaps they really were mistreated, misdiagnosed, their care
badly managed. As we all know, the current health care system
in this country is far from perfect and fraught with myriad prob-
lems. Most of us have had our own experiences with this sys-
tem. In fact, that may be the very reason you decided to study
Oriental medicine. Even so, be careful about bad-mouthing. Find
tactful ways to recognize the patient’s frustration and anger
while refraining from your own criticism of the situation. So
often, people just want someone to listen to them, and that is all
you need to do. Other times, however, the patient may be actively
trying to solicit a response from you. Again, my best advice is
to remain neutral.
Case in point:
Acupuncturist: Well, Mary, have you ever had acupuncture

before?
Patient: Yes, I did, last year, but he was absolutely horrible. I

didn’t even want to come again, but my friend referred me
to you and said you were a miracle-worker. So I thought I’d
try one more time.
Acupuncturist: Well, I don’t know that I’m a miracle-worker,

but tell me, why didn’t you like acupuncture the last time
you had it?
Patient: Oh, I went to some guy down on Main Street and, right
off the bat, I didn’t like the office. There wasn’t enough privacy.
Then he told me he could fix my back in three treatments.
Well, after the third treatment, my pain was worse than ever.
I don’t think he had a very good bedside manner either.
Acupuncturist: Your pain actually got worse? What kind of

treatments did he do?
Patient: Oh, he just stuck a bunch of needles in me and burned

some stuff on them, too. I thought it was kind of weird, and
I was afraid he might even burn me.
Acupuncturist: Well, that doesn’t sound like you got the results
you wanted. Don’t worry, I won’t use any of that burning
stuff, and I’m sure your pain won’t get worse with me!

In the above situation, the acupuncturist was a fairly new prac-
titioner who did not want to be seen in the same light as the
patient’s previous acupuncturi st .T h e re fo re , he tried to disasso-
ciate himself as much as possible from his colleague and to try
to prove to the patient that his services would be superior. What
may not have occurred to him was that the patient had done
some very heavy lifting between the second and third treatments,
and it was the burden of activity that made the pain worse,not
the acupuncture treatments. A good health care provider must
always be cognizant of all possible angles of a story. Another
possibility might have been that the patient had gone to a chi-
ropractor or massage therapist, which may have temporarily
exacerbated the pain.
Experienced practitioners know that sometimes a condition gets

worse initially after treatment due to long stagnation of qi but
that, once the stagnation is successfully resolved, the desired
relief will be felt. Indeed, this acupuncturist may even run the risk
of embarrassing himself if his treatments did not produce satis-
factory results.
Mea culpa, mea culpa

And now for the hard part. You may at times find yourself as the
direct target of a patient’s anger. What’s worse, the patient may
have a valid reason for being angry with you. This is probably
one of the most difficult situations for any health care provider
to deal with. Pride, self-esteem, and integrity all come into play
and are all threatened. We are all human. We do make mistakes.
We certainly do not intend to cause harm. In fact, we are ethically
bound to adhere to the Hippocratic Oath: “First, do no harm.”
But, sometimes, our best efforts are thwarted. Oriental medicine
is an art and a science that takes years to master. In the United
States, we do not have the benefit of intensive clinical training
such as would be received in a Chinese medical school in China.
Most of us do not even have the benefit of a good postgraduate
internship. We are faced with the pressures ■
of entering a new profession, having to Your internal
pay back loans, make a living, market our-
struggle with such
selves, and provide optimal care.
a scenario is
As if all that weren’t enough, we are gen- your problem, not
erally faced with treating patients who the patient’s!
have what the Chinese call “knotty dis- So put the ego
eases.” These are complicated conditions aside and
with multiple patterns and, often, con- just say,
flicting signs and symptoms. Given all “I’m sorry.”
this, it is not unforgivable that you may
err in your diagnostic skills. Most unfor- ■
tunately, sometimes this type of error will cause further hard-
ship to the patient. No one wants that, but it does happen. In
such a case, there is a very simple remedy. However, simple does
not necessarily mean easy. The simple solution is: apologize.
I have had so many conversations with patients who were upset

with previous care they received. Time and time again, I hear
comments such as, “I’m not even mad that she made a mistake.
What really bothered me is that she didn’t even apologize.” For

most of us, ego gets in the way of true humility. Apologizing is
difficult. It forces us to admit we are not perfect, that we do make
mistakes and that, on occasion, these mistakes may injure or
inconvenience the very person we are trying to help. The effects
of finding yourself in this situation can be very uncomfortable,
causing you to question your competency and your worth.
However, none of that matters to the patient. He/she simply
wants to be acknowledged and made to feel that, even though
an error was made, it was not intentional. They have a right to
be angry and to expect reparation of some kind.
These are simply the things that any of us would want. Your
internal struggle with such a scenario is your problem, not the
patient’s. A simple apology along with a solution to correct the
problem is all they want, and certainly the least they deserve.
You will be surprised at how a simple apology will actually ele-
vate you in the patient’s eyes. It will, in fact, help and not hin-
der your practice. So put the ego aside and just say, “I’m sorry.”
Another related situation is one in which the patient asks you a

question to which you do not know the answer. When this occurs,
you may internally feel stupid. You may also feel frustrated that
you do not know the answer. Again, you may question your com-
petency and your worth. But similarly, I have found that most
patients don’t really care if you don’t know. They care that you
can admit it and make an effort to find the answer. Society has
so long accepted the word of physicians and other health care
providers as the final word that people are actually sick of the
“doctor as God.” It is, in fact, refreshing for a lot of people to
know that you are just as human as they are. Anger brews when
the patient feels that the provider is making up answers, avoid-
ing the question, or just dismissing it as not important.
The best way to handle such a situation is simply to admit that

you do not know and then offer to follow up with some research
and get back to the patient. But, if you take this route, be sure
you really do get back to them. A phone call to their home with
the information is exceptional service and will make the patient
feel very cared for. However, even providing the information at
the next visit will be welcomed. Most patients will be pleasantly
surprised that you cared enough to have taken the time and
energy to pursue their requests. A little humility will actually
boost your image and your practice.
Cases in point:
Case 1. B .K . made an appointment for acupuncture to help her

through chemotherapy for breast cancer. While going over her
history, she becomes increasingly agitated as she reveals to the
practitioner that her diagnosis and subsequent treatment were
delayed because her physician failed to read her ultrasound
report in a timely manner. She was understandably upset that
her prognosis would be adversely affected by this oversight.The
practitioner found herself taking on the patient’s emotion, imag-
ining herself in that same situation and the conversation went
like this:
Acupuncturist: That is horrible! I can’t believe that happened

to you. If I were you, I would consider some legal action.
Patient: I thought about that, but wasn’t sure if that’s some-

thing I really want to pursue.
Acupuncturist: Well, I would give it serious consideration if I

were you. These doctors think they can get away with any-
thing. I’m glad you are coming for acupuncture. You can be
sure nothing like that will happen in my clinic.
Patient: Now that you mention it, I think you’re right. I am

not going to just let this slide by.

In this case, the practitioner was a little too empathetic. She accen-
tuated and furthered the patient’s anger with her response. In
addition, real harm was caused—not to the patient, but to the
initial physician. Without knowing the full circumstances, the
acupuncturist not only fueled the patient’s anger but also cre-
ated a potentially volatile legal situation for a doctor she didn’t
even know. A better way to handle this situation would be to
empathize with the patient without bad-mouthing the other physi-
cian. For example:
Acupuncturist: Wow, I guess that must have really made you

mad. I would certainly be angry if that happened to me.
Patient: It sure did! I should just call and give that doctor a
piece of my mind.
Acupuncturist: I can understand how you might feel, but doc-

tors are human, too. Maybe you should give yourself a day
or two to process all this and then call the doctor to discuss
the situation when you are a little calmer. I’m sure she did
not intend to hurt you. Doctors are so busy these days, it’s a
wonder they can do their job at all.
Patient: Yeah, I guess you’re right. I’ve always liked this doc-
tor and I think she’d be open to talking to me.
In this case, the acupuncturist helped diffuse the patient’s anger

while avoiding negative commentary about another provider
and also offered a viable plan of action for the patient to follow.
Case 2. Mrs. M. came for acupuncture for chronic sinusitis. The

acupuncturist needled Si Liao (St 2) as part of the treatment.The
next day, the patient called and was extremely upset. She had
developed a quite obvious bruising just below her right eye .S h e
was livid and called to let the acupuncturist know how she felt
as well as to cancel her next appointment.
Patient: Do you know what you did to me? I thought acupunc-

ture was supposed to be harmless. Now I look like I’ve been
in a fight. I wish I had never come to see you. I feel worse
than ever!
Acupuncturist: Well, these things happen. I’m sorry, but you

did sign a consent form that states clearly that bruising is a
potential danger. Anyway, it’s no big deal. It’ll go away in a
few days.
Patient: What am I supposed to do in the meantime? Tell

everyone I walked into a door? Yeah, right! You people
shouldn’t be allowed to practice. I think this is all really just
a bunch of quackery. I’m going to tell all my friends never
to get acupuncture!
Acupuncturist: Well, you can do that if you want to, but I think
you’re making a big deal out of nothing.

In this case, the acupuncturist was caught off guard by the phone
call and was also immediately horrified by what had happened
to the patient. Instead of admitting and claiming responsibility
for the error, he became defensive and tried to dismiss the com-
plaint. In fact,he even tried to transfer the blame to the patient
for not reading the consent form more carefully. A more thera-
peutic conversation might sound like this:
Patient: Do you know what you did to me? I thought acupunc-

ture was supposed to be harmless. Now I look like I’ve been
in a fight. I wish I had never come to see you. I feel worse
than ever!
Acupuncturist: Oh my word, I am so sorry! That point below

the eye is a delicate one. It’s very rare that a thing like this would
happen and I apologize for the trouble this is causing you.
Patient: That’s all very well and good, but what am I sup-
posed to do now? I think this acupuncture is a crock!
Acupuncturist: I can certainly understand how you feel. I’d

be pretty steamed if that happened to me. Unfortunately,
there’s not much I can do right now. Please know that this
will resolve in a few days. In the meantime, you might want
to try some ice over the area. Maybe a little concealer would
help to make it seem less obvious. I would be happy to refund
your money for that treatment. I really hope this does not
deter you from ever using acupuncture. I would like the oppor-
tunity to continue treating you, and I promise not to use that
point again.
Patient: Well, I appreciate your apology. I guess it’s not the

worst thing that could happen. I don’t know if I want to try
it again, but give me a few days to think about it.
Acupuncturist: Fair enough. But please do not hesitate to call

me if you have further concerns.
In this case, a prompt apology automatically took the conver-

sation down a few notches. The acupuncturist sympathized with
the patient, made a sincere apology, and also offered some
possible ways to deal with the situation as well as offering to
refund the money. In addition,she kept the door open for future
communication. The patient was still upset but not nearly as much
as she had been at the outset of the conversation.An even greater
response on the part of the acupuncturist would be to call the
patient in a few days just to check and see how she’s doing.
Boy, am I steamed!
A last word about anger: As practitioners, we create a space of
safety and freedom for our patients, in which they may express
a variety of emotions. We do not share this luxury with them.

However, our own lives are also filled with events and people
that have an effect on us and we will at times find ourselves vic-
tims of our own anger. It is essential that we not let our anger
seep out and affect the patient or the treatment. If something in
your personality or in your personal life is angering you, take
stock of that before you go to work in the morning. Use the tools
at your disposal to help check your anger: meditation, deep
breathing, qigong, tai ji chuan, yoga, or even a little Xiao Yao San
(Rambling Powder)! If necessary, take a few seconds of deep
breathing in between patients to help keep your anger at bay
during your workday. Be sure to find a therapeutic way to han-
dle the situation that is angering you so you can eradicate it before
it snowballs.
On occasion, you may find that you are angry with a patient.
This is especially likely to happen in cases of noncompliance,
violence, seduction, or anger on the part of the patient. It is never,
ever appropriate for a practitioner to lose his/her temper with
a patient. It is completely acceptable to calmly express your frus-
tration or disapproval of patient behavior and to use the occa-
sion to problem solve with the patient.
Cases in point:
Case 1. Mr. H.,an acupuncturist, was experiencing some mari-

tal difficulties. He and his wife had a fight before work one morn-
ing.On the way to the office,Mr. H. kept replaying the scene of
the fight over and over in his mind, which made him more and
more furious. By the time he got to the office,he was consumed
with the argument.While treating his first patient, the patient com-
plained that the needles were more painful than usual. The
patient’s complaint further aggravated him and he told the
patient,“You just must be more sensitive than usual today.”

Mr. H. failed to spend some time doing self-healing before going
to work that morning. He might have restored himself to calm-
ness by doing some deep rhythmic breathing while driving to
work, putting on some relaxing music, or even making a brief
telephone call to a friend to vent a little.When the patient com-
plained about the needle sensation, he should not have made
it seem like the patient was somehow at fault.It also would have
been inappropriate to start telling the patient about his own trou-
bles, but the patient’s comment should have served as a warn-
ing sign that he was allowing his personal life to hinder his
treatments.
Case 2. Mr. W. had been coming to the Oriental medical clinic

for several weeks and had been given an herbal prescription for
stomach heat. He was consistently noncompliant with the herbs,
and the practitioner was becoming fed up with this particular
case. One day when Mr. W. came to the clinic, he told the herbal-
ist he had again neglected to take his herbs and was still having
lots of heartburn and epigastric pain. The herbalist let out a heavy
sigh, shook her head in disbelief, and said,“Well, you’ve only got
yourself to blame. I don’t know what you expect me to do if you
won’t take your herbs. Of course you’re still having pain, but that’s
your fault, not mine!” The patient then became very irritated,got
up and left the clinic, stating he would not be coming back.

The herbalist had allowed a situation of noncompliance to con-
tinue for too long. She should have addressed this problem sooner
rather than letting her anger build up. Then she committed the
cardinal sin of blaming the patient, which only served to lose her
a patient and send someone away in anger, which is certainly
not therapeutic for anyone. Instead, she should have devoted
some time to discovering why the patient repeatedly neglected
his prescribed therapy. If she could not unearth the reason,

she might have considered tactfully ending the therapeutic
relationship with this patient,prescribing an alternate remedy, or
referring him to a different modality that might suit him better.
Anger is a complex emotion and can have many roots. You do

need to be aware of the harmful effects of unchecked anger. If
you are to be a true healer, you must be willing to be a healer on
every level, and sometimes helping a patient manage his/her
anger is part of a therapeutic treatment, even if the anger does
not appear to have any direct correlation to the condition for
which the patient is seeking treatment. Above and beyond all,
we must keep our own anger under control and participate in
our own healing so we can better serve our patients.
T HE INSI DE STO RY:

Anger is an emotion that most people have a difficult time deal-
ing with in an effective manner. Some people express their anger
inappropriately but see nothing wrong with that. Others tend to
submerge their anger for fear of losing control, appearing nega-
tive in front of others, or being afraid of their own anger. The
truth (or part of it, at least) is that anger is a healthy emotion, just
like any other emotion. It is when it gets out of hand or out of
balance that problems arise. Anger in its early stages can act as
a type of emotional messenger to alert us that something in life
is not going well even if we may not be consciously aware of that
fact. If ignored, anger will build up and become potentially harm-
ful. If suppressed for too long, it can turn into depression. Anger
springs from feelings of being mistreated, underappreciated,
victimized, or treated unfairly in some way, to name a few.
Realizing this should help practitioners understand the nature
of this volatile emotion and help them to not take patient
outbursts too personally. If you remember the five phase cycles,
you can direct your treatments at the liver to help soothe an
inflammatory situation.
QUEST IO NS FOR C HAPTER FO UR :
1. What are some ways in which a practitioner might con-

tribute to a patient’s anger?
2. Recall a situation in which you were angry at a health
care provider. What made you angry? Was it handled
well? If so, how? If not, how could it have been handled
better?
3. Think of a case in which your own anger at a personal
situation was taken out on someone else. How could
you have prevented that from happening? What were
the consequences?
4. What kind of patient behavior might make you angry?
How would you manage that?
Mrs. S. has been coming to your clinic for assistance with
weight loss. Every time she comes, you have the sense
that there is anger brewing just below the surface, though
she has never expressed it. One time when she comes
for her appointment, she embarks on a vehement (and
potentially lengthy) tirade about some coworkers. She
then also makes an offhand remark that your office
“smells funny” that day and demands you do something
about it. How would you handle this situation?
If we can safely determine that this patient
truly has need of all of his/her providers
and modalities, our job becomes that of
supporting the patient to the best of our abilities
within the scope of our own practice.
CHAPTER FIVE
The Patient with High

Utilization of Health Care
“An apple a day keeps the doctor away,” but, is there a similar
anecdote for keeping the patient away? That may sound cynical
and counterproductive. Of course we want patients, and lots of
them, to keep our practices full and thriving! But we must be dis-
criminating and realistic at all times. Patients who are “frequent
flyers,” those who overutilize the health care system, can become
problem patients for us. There is often an underlying need for
attention or an underlying anxiety that drives this type of patient
to seek frequent treatment from health care providers. Very often,
such patients will not discriminate between alternative and con-
ventional practitioners but may very well seek help from a vari-
ety of sources. One of the difficulties in dealing with this type of
patient is to differentiate between the person whose problems
are so varied and complex that they truly do need to be seen quite
often, and may even legitimately require several modalities and
75
providers for optimal health, and the person who is simply

habituated to the patient role.
We never want to be in the position of dismissing a patient’s com-

plaints, thereby risking missing a serious problem. All complaints
and histories need to be taken seriously. It is a sad fact that many
people in our society suffer from a number of maladies simul-
taneously. It is not uncommon to meet people who are under the
care of several providers at once: the cardiologist, the pulmo-
nologist, the primary care physician, and perhaps an endocri-
nologist as well. Unfortunately (or fortunately, depending on
your point of view), health care in the United States has become
incredibly specialized. There are “foot doctors” who will not look
at an ankle, “hand doctors” who will not look at a forearm, etc.
Therefore, sometimes a multitude of specialists may be neces-
sary to completely cover the full range of a patient’s needs.
However, if there is suspicion that high utilization of the health
care system is not as necessary to full healing as the patient per-
ceives it to be, we can run into problems. In these cases, our abil-
ity to set boundaries and clarify options for our patient will come
to the forefront.
■ Seeking care from multiple practitioners and modalities
■ Long history of various illnesses and/or complaints with
questionable outcomes from previous therapies
■ Questioning other providers’ knowledge or
recommendations
■ Taking multiple medications and/or medicinals/
supplements at once
■ Bringing in long narrative files or many test results for the
practitioner to read
■ Difficulty making appointments because of other health
care appointments
The Patient with High Utilization of Health Care 77
Home base
There are basically two types of patients who make frequent use
of health care systems: 1) those who truly have a need for mul-
tiple providers and 2) those who do not have such a need but
perhaps have a deeper underlying need or anxiety which com-
pels them to seek frequent treatment. Both of these types of
patients pose a challenge to the Oriental medicine provider but
in differing ways. They will each be discussed in this chapter.
Usually, someone who frequently utilizes the health care system

has a long history of doing so. It is fairly safe to assume that the
acupuncturist or Chinese herbalist is not the first practitioner
this type of patient will see. More typically, he/she will have
been to many conventional doctors for several years. Following
that, there may be some ventures into alternative health care
while still maintaining contact with previous providers.
If we can safely determine that this patient truly has need of all
of his/her providers and modalities, our job becomes that of sup-
porting the patient to the best of our abilities within the scope of
our own practice while at the same time
■
tailoring our treatments and recommen-
dations so as not to interfere with any Likewise, you must
coexisting treatments. In this way, we truly constantly be
become holistic practitioners. As we con- aware, for legal
tinue our examination of ourselves as prac- and ethical
titioners, in this case we probably have reasons, of your
not done much to contribute to the origi- scope of practice
nal problem. and what you can
and cannot do to
However, we may unwittingly contribute
to the problem by not analyzing whether help someone.
our services will be really useful to this ■
patient. It is necessary to be on guard against becoming an enabler

for this type of patient. If they really do need your services, that’s
fine, but, if they are simply seeking attention and going in sev-
eral different directions to attain it, it might be more prudent for
you to help them determine their best course of treatment, whether
it is Oriental medicine or something else.
The case of the patient who displays a legitimate case for high
utilization of health care poses more of an intellectual and per-
haps even academic challenge for the practitioner of Oriental
medicine. From our cubbyhole of Asian thought and treatment
principles, we are now forced to look at what else the patient is
using to assist with healing. A thorough intake is one of the keys
to successful treatment and, in this case, is the number one tool
we can use to discern the best course of treatment for the patient.
The difficulty here lies not in patient personality or behavior,
but in our ability to understand the coexisting treatments the patient
is undergoing. Most schools of Oriental medicine in this country
are incorporating classes in Western pathophysiology and phar-
macology as well as in the interpretation of various test results.
In California and New Mexico, this training has been so elevated
that practitioners in these states have achieved the status of pri-
mary care physician, and their extensive academic and clinical
training leads to that degree of expertise. In other states, the edu-
cation may not be quite as extensive, but it can fulfill a basic
level of knowledge needed to operate within the current health
care system.
The Oriental medicine practitioner must be constantly on guard

regarding his/her knowledge, comfort level, and ability to deci-
pher what the patient’s experience has been. Likewise, you must
constantly be aware, for legal and ethical reasons, of your scope
of practice and what you can and cannot do to help someone.
Your intake form should include a line for the patient to list the
primary care physician. Easy enough, right? Over the years, I
have added more lines for “other health care providers” which
can be anyone from a chiropractor to an MD to a psychologist. I
have often been surprised at how many people really do need
that extra space. You may also find it necessary, as I have, to pro-
vide several lines for the patient to list the chief complaint they
are wanting you to address as well as for other existing medical
problems, even if the patient is not seeking acupuncture for those
complaints. As tedious as these forms can be, a thorough and
accurate history is essential for providing the best care possible.
Even if the patient is coming in for a simple case of tendonitis,

do get a complete history. This can be beneficial on several lev-
els. It may uncover another problem that could be simultane-
ously treated (e.g., insomnia), and it will also alert you to possible
factors that may not be obvious contrib- ■
utors to the patient’s condition but may
The first step,
be playing a part nonetheless. Lastly,
as always,
knowledge of the patient’s medications is
absolutely necessary if you are prescrib- is to put ego
ing herbs. Though herb/drug interactions and personal
are rare, it is always an issue and should opinion aside and
not be taken lightly. act in the best
interests of
Let’s consider the case of the patient who
the patient.
has a legitimate need for multiple care-
givers, medications, etc. After interview- ■
ing the patient, you come to the conclusion that the patient is
indeed in need of multiple care-givers and medications. You also
determine that you feel you can help her with her chief com-
plaint. But what about all that other information filling up your
intake form? What to do about that? The first step, as always, is
to put ego and personal opinion aside and act in the best inter-
ests of the patient.
Your first thought might be something like, “What does he need

all these doctors for? Too many cooks spoil the broth. All he really
needs is some good Oriental medicine.” Or, “Doctors prescribe

too many pills for people these days. She doesn’t need all this
when a basic herbal formula could cover all her problems.”
Again, these are only your opinions, no matter how true they
may be. Unless you really do have a degree in Western medicine,
you are not legally allowed to make suggestions to the patient
regarding any care that is prescribed by a Western medical doc-
tor. Keep in mind, also, that your patient may not share your
opinions. Sure, some people will come to your office, stating
they’ve had it with their doctors and medicine and want to pur-
sue an entirely different route of treatment. On the other hand,
many people have a great deal of trust in their physicians and
in the drugs they’ve been prescribed. They may be quite content
to utilize different health care systems simultaneously, and the
beauty of Oriental medicine is that this is often a very plausible
route. Still other patients may be very reluctant to contemplate
changing a medication they feel has helped them for a long time.
Your job in this situation is to keep yourself well informed and
well educated.
If there is something on the form you do not understand or are

not familiar with, ask the patient. There are countless Western
diagnoses out there and some of them are rare or confusing. Do
not be afraid to ask the patient to explain a diagnosis you are
unfamiliar with. They will appreciate your honesty and will be
happy to provide you with what you need to know. This also
furthers the patient’s role as an active participant in their own
care and in the therapeutic relationship. Take a careful look at
the patient’s medications. If you have had course work in Western
pharmacology, you will most likely be familiar with most drugs
the patient is taking, but again, if you are not, do ask them.
However, do not be surprised if the patient doesn’t know. It is

alarming how many people take pills that they really do not
understand or even know the name of. If neither you nor the
patient can figure out a particular medication question, it is time

to refer to your PDR or other drug reference. Pharmacists are an
often-ignored source of information and are usually more than
happy to answer questions over the phone. You can call the
patient’s pharmacy directly or any pharmacy in the area and you
will more than likely get a great response. (Be sure to mention
that you are an acupuncturist. It is just one more little way to get
acupuncture into the mainstream awareness and, who knows,
that pharmacist just might be wondering how to get hold of a
good acupuncturist.)
Once you have established a good working knowledge and

understanding of your patient’s history and present condition,
consider all the facts carefully. I suggest you ask yourself the
following questions:
1. What can you help with and what is best left to another
provider?
2. Will your treatment interfere with other treatments the

patient is receiving?
3. Are there any potential herb/drug interactions you need

to be aware of?
It might at times be helpful to consult with the other health care

providers the patient is seeing. This can sometimes be a little
tricky. Some Western MDs will be quite open to speaking with
you, while others will not give you the time of day. Sometimes
going through the “back door” is a more productive option.
Speaking with a nurse or an office manager first may facilitate
your getting through to the physician.
I have found that most physicians will not respond to a letter or

other type of written communication, but a fax sent directly to
the office may get you the attention you need. Send a simple fax
with a patient Release for Information Form already filled out
and a few pertinent questions for the doctor. Make sure your
request is professional and polite. It is best sent on your own let-
terhead. It will probably be much easier to contact another alter-
native medicine provider such as a homeopath or a nutritionist.
They are much more likely to return a simple phone call and are
usually very happy to confer on a case with you. As always, get
the patient’s written permission for any such consultations.
Quite often in complex cases your best course of action will be

to prioritize. We would all love to be able to cure all of our patients
of all of their ailments in one fell swoop, but this is not realistic.
You and the patient need to decide which problems will best be
helped by Oriental medicine and which are best left to another
provider. In all cases, even when you disagree with another
provider ’s course of action, be respectful, do not badmouth
another provider, and honor the patient’s wishes and feelings.
Case in point:
G. L. is a 45 year-old woman who made her first acupuncture

appointment due to chronic pain in the neck and shoulders. She
stated that she has had this pain for about 10 years and believes
it was the result of a skiing accident. The acupuncturist’s specialty
was musculoskeletal problems. He did notice on the intake form
that the patient had been to an acupuncturist several years ago
for the same problem and had also visited a chiropractor, had
some Reiki work done, and had undergone some physical ther-
apy. In addition, she had seen her primary care physician for
the same problem. Nothing much had seemed to help her. In
the space provided, the patient had also marked off some other
conditions that were bothering her, but her chief complaint was
the neck and shoulder pain. Since it seemed to be a pretty
clearcut case, the acupuncturist did not spend much time on
the history and proceeded to treat the chief complaint. After
about eight sessions, both the acupuncturist and the patient were
frustrated and bewildered by her lack of progress. The pain just
wasn’t budging. At this point, the acupuncturist went back and

reviewed the history and started asking the patient questions
about her chiropractic care and what that practitioner had done
for her. She smiled and grimaced a little and said,“He thought I
had a Candida infection and put me on that ‘yeast diet.’ I hate
to admit it, but that’s the only thing that ever helped this pain.”

There were a few oversights made in this case.The acupunctur-
ist did not carefully read the history. Even though he noted the
presence of a long history as well as several attempts at seek-
ing relief, he did not adequately delve into this information, nor
did he carefully go over the intake form.Therefore, he failed to
notice that one of the other conditions the patient had listed was
trouble with digestion.While the diet connection may not have
been very strong or obvious in this case, a little more question-
ing at the outset of the treatments might very well have revealed
this piece. The patient and acupuncturist could have been spared
some wasted hours, and the patient could have been spared
some cost as well.Also, the acupuncturist may have been a lit-
tle too confident in his own abilities and not thought it necessary
to inquire why others had also not been successful. He felt cer-
tain his skills were superior and that he would be able to get to
the bottom of the problem. In this case, the patient had had a
legitimate reason for frequent use of the health care system since
several therapists had failed to correct her problem.
The other side of the coin

The second type of patient in this category is more problematic.
This is the patient who demonstrates high utilization of the health
care system and may not truly require all the attention he or she
is seeking. Oftentimes, this patient will have only one or two
diagnoses, but there may be a type of fixation on his/her health
in general or on the particular diagnosis itself that compels the
patient to continually seek care for this problem. Very often, in
spite of such a long history of journeying into the health care

field, the patient will report that nothing ever really helps, yet
continues to seek treatment. Often they will show reluctance to
part from a practitioner or practitioners even though they do not
appear to be benefiting from those particular services. Likewise,
they may also be reluctant to give up a medication, herb, or sup-
plement that does not seem to be providing relief. (This type of
patient is frequently also a “needy patient,” and you will notice
several overlapping qualities in these two chapters.)
This type of patient will often have gathered quite a healthy col-
lection of literature which may have been culled from the Internet,
magazine articles, books, or handouts from various classes he/she
may have attended. In addition, he/she may also have accu-
mulated several months (or even years!) of printed test results
from a variety of other health care providers. These may or may
not be relevant to their present complaint. Sometimes it is help-
ful for you to read an MRI or lab result. Utilize this information
if it is within your scope of experience, but do not agonize over
information that is not pertinent to the present case or that may
take you out of your legal scope of practice.
This type of patient may also have a tendency to self-diagnose

and to self-medicate whether or not such actions are compatible
with other prescribed therapies. They often have a fairly stub-
born outlook in that they are convinced their course of action is
necessary, that the doctors are helpful, but don’t know every-
thing. In some instances, in fact, they may not be forthcoming
with their providers in disclosing everything they are doing. This
is often the result of a mistrust or fear that their provider will not
approve of what they are doing and may criticize their choices.
These can indeed be quite difficult cases for Oriental medicine

practitioners. In these cases, it is your job to efficiently (and as
quickly as possible) wade through the history as well as any lit-
erature the patient may want to share. No matter what your
opinion of your patient’s literature is or whether or not you agree

with what they have been doing, you must show respect and
dedicate an appropriate but reasonable amount of time to what
they are showing you. It is important not to alienate the patient
by dismissing their materials or telling them you don’t have the
time to read through everything (even if this is true—which it
usually is).
You can simply let them know that you would like to focus on
the interview or conversation with them and that you will read
what they have brought later in the day when you have more
time to concentrate on it. Do give at least a cursory glance at the
material and do comment on it the next time they come, even if
it is only to say something like, “That article on aliens practicing
Oriental medicine was really interesting. I’d never heard of that
before. Thank you for sharing that with me. May I make a copy?”
These actions indicate to the patient that you have paid atten-
tion to what is important to them, even if it never results in a
direct action on your part.
The practitioner’s job here is to cut to the chase and figure out
what the patient’s chief complaint is, what they are currently tak-
ing, what other practitioners they are currently seeing, and, most
importantly, whether or not you can help them. Again, your
intake form will be your greatest ally here. Sometimes these
patients may waver off track and divert the conversation to
include stories about their forays into health care that are not
particularly relevant to what you need to know. Allow a few
moments of this at most but then redirect the conversation as
soon as possible, using the questions you have in front of you.
D i fficulties may arise when you notice that something the

patient is doing or taking may not be compatible with what
you would like to prescribe. You should help the patient pri-
oritize since he/she will most likely want to address multiple
problems at once. It is helpful to point out to the patient that
Oriental medicine involves the balancing of the patient’s energy

and doing too much or treating too many diagnoses at once will
be counterproductive and perhaps even harmful. Try not to let
your sincere desire to help this person get in the way of reality.
Be honest with them as well as with yourself regarding what you
can and cannot do to help them. Do not disparage anything they
are currently doing, but help them to figure out their own best
direction. This course of action is often not possible to accom-
plish in one visit, so your first treatment may be a simple bal-
ancing protocol. Subsequent visits, should you decide to proceed
with offering care to this patient, can be dedicated to uncover-
ing more of the patient’s history and delving a little deeper into
their Oriental medical diagnosis.
Cases in point:
Case 1. D. S., a 54 year-old insurance salesman, comes for

acupuncture treatments as a last resort for his asthma. He is tired
of taking his inhalers and hopes that acupuncture will offer him
a viable alternative.However, he has several other medical prob-
lems including eczema, diabetes, obesity, and depression. He
appears somewhat depressed at his initial visit but has filled out
the health history questionnaire very thoroughly. In fact,he has
even written some in the margins. Because of his presentation,
the acupuncturist started interviewing him before looking care-
fully at the health history. The depression was forefront during
their conversation,and the acupuncturist thought this was actu-
ally the chief complaint. She did a treatment to rectify the qi,
resolve depression, and quiet the spirit. She also gave him a
Chinese herbal formula in pill form,which he agreed to take.At
the end of this first treatment, the patient stated he felt much bet-
ter and made a second appointment. While talking to him at
the follow up appointment, the acupuncturist asked how he had
been feeling since the last appointment. The man replied that
he wasn’t feeling quite so depressed but was still having a lot of
trouble breathing and that his asthma had not seemed to improve
at all.The acupuncturist was surprised to hear him mention the
asthma, but when she glanced at the intake form,she realized
he had indeed listed that as his chief complaint! He also men-
tioned that his blood sugar had been somewhat higher than
usual the past few days. The acupuncturist was also surprised to
hear him mention his blood sugar but,after looking at the form
again, saw that diabetes was listed as part of his past medical
history.

This acupuncturist was fairly new at her practice and was imme-
diately caught up with the patient’s presentation and neglected
to carefully peruse the entire form before deciding on a treat-
ment strategy. She lost her own focus and treated the patient
only for what was obvious at the time of the intake,thereby actu-
ally neglecting the patient’s chief complaint, which was, in fact,
strongly contributing to his feelings of depression. More dan-
gerously, however, she also overlooked the fact that he was dia-
betic, and she prescribed pills that contained some sugar as an
additive. The pills may very well have raised his blood sugar. Had
she focused more carefully on the whole picture, she would have
prioritized correctly, treated the asthma, and avoided giving the
patient a formula that was contraindicated for his diabetes.
Case 2. Mr. M. made his first acupuncture appointment for

persistent digestive problems. He had seen his primary care
physician, a chiropractor, a medical intuitive, and a gastroen-
terologist for this problem. He tells the practitioner that all these
things have helped him a little, but he still has gas, bloating,and
diarrhea. He becomes very involved in relating his history and
goes into great detail about his experiences with each of the
above providers. The acupuncturist, noticing his long history and
multiple providers, earnestly wants to understand the big picture
and wants to make sure that whatever he prescribes will not be
duplicated or contraindicated with his other treatments. So he

allows the patient to describe these things in detail. The interview
takes quite a long time, and there is barely enough time left for
the actual treatment before the next patient arrives. The acupunc-
turist becomes a little flustered but gives the patient a peremp-
tory treatment that is shorter than it should be.

The practitioner can be commended for his earnest desire to
understand the complete patient history, but he neglected to
sort out all the details. When he saw so many practitioners listed
on the patient’s form, the first question should have been, “Are
you currently seeing all of these practitioners?”The patient would
have divulged that he rarely sees his chiropractor, that the gas-
troenterologist was a one-time referral from his primary care
physician (PCP), and that he mostly goes with what the medical
intuitive tells him. This information would have greatly reduced
the interview time, leaving more time for a good treatment. It
would have also given the acupuncturist a clearer idea of what
types of treatments are important to the patient and which are
secondary as well as who the patient is currently seeing.
Desperate times call for desperate measures

We are a society that clamors for instant gratification. When peo-
ple are plagued with discomfort, they do not want to know the
cause, they just want relief, and fast! When one treatment modal-
ity fails to alleviate symptoms in a week or so, people become
impatient and then want to seek another modality they hope will
lead to a faster cure. Often they turn in desperation to a practi-
tioner or therapy that advertises relief from their specific prob-
lem. They may be reluctant to let go of previous practitioners,
however, fearing that the first modality might work eventually
and not wanting to give up on that possibility. In this manner,
they may easily end up with several providers and several treat-
ments at once. The end result, of course, is that their own energy
ends up getting scattered from too much information being

thrown at them.
One of your tasks in this situation is to assist the patient in find-

ing his/her best course of action, realizing that the best course
of action may or may not be Oriental medicine. At all times, the
patient’s best interests should be your absolute primary concern,
even if it means that a different type of practitioner might serve
them better at the time. When you are faced with this type of
patient, carefully go over the intake form with them, taking note
of all they are doing. Make use of your teaching skills to help the
patient understand that utilizing too many types of therapy all
at once can be counterproductive and that, especially in energy
work, patience is a virtue and the longer a condition has been
present, the longer it is likely to take to heal. Ask the patient
which current therapy seems to be helping the most. If he/she
is dissatisfied with most of them, then suggest they put those
modalities aside for a time while they try Oriental medicine.
Reassure the patient that they can always
resume the other therapies if acupuncture ■
doesn’t work well for them. At all times, the
client’s best
Also point out that when employing sev- interests should
eral treatment types simultaneously, it is be your absolute
almost impossible to determine which
primary concern,
therapy is the one that is actually pro-
even if it means
ducing results. Instruct the patient to
that a different
choose one modality and stick with it for
a certain amount of time, for instance, 4- type of practitioner
8 weeks, and only then move on if there might serve them
are no results. There may also be some better at the time.
kind of treatment that the patient has not ■
tried that you might feel is beneficial to
them and you can make a suggestion to that effect as well. It is
not uncommon for a patient (as well as ourselves) to confuse the
tip or branch of the problem with the root.
It is quite common for patients to see the branch as the main

problem and seek treatment only for that manifestation. A little
guidance can go a long way.
Cases in point:
Case 1. J. L. is a 60 year-old with late-stage lymphoma. His

chemotherapy treatments are having a good effect at slowing
down the cancer’s growth, but the treatments have left him weak
and he also has chronic back pain as a result of some of the
tumors. He and his wife have sought multiple avenues of relief
to improve his quality of life while he undergoes his chemother-
apy. They arrive at the acupuncturist’s office with a box filled with
herbs and supplements as well as several articles on various ther-
apies they have used to help him.They wonder what acupunc-
ture can do for him.The practitioner takes the literature without
commenting on it and sets it aside, telling them that she’ll look
at it later. She then looks at the box of remedies they have brought
along and says, “I really don’t know what any of this is. I guess
you can keep taking it and I’ll see what I can do with acupunc-
ture.” The patient comes for several treatments, but eventually
stops, saying,“I’m feeling better, but I think it’s the supplements
that are really working.My sister recommended them and they
worked for her friend who had cancer. So I’ll just take them for
now.”

In this case, the acupuncturist did not create a feeling of trust
between herself and the patient.She should have at least com-
mented briefly on the literature the patient showed her which
would have made the patient feel she was interested in him per-
sonally. She also dismissed the supplements the patient was tak-
ing.Even if she did not know what they were, it is her responsibility
to understand everything that the patient is doing that affects his
health care.
The real problem, however, is that the patient’s body-mind was

experiencing too many things at once,and it was impossible to
tell what was really working.A better course of action would have
been to explain to the patient that if he continued to pursue so
many modalities at once, it would be impossible to determine
which of his remedies was most therapeutic for him.She should
have helped the patient sort through all his supplements and
decide if he might be willing to put them aside while trying
acupuncture. Alternatively, she could have suggested he con-
tinue with the supplements for a while and if he still did not expe-
rience relief in a few weeks, to stop them and revisit acupuncture
as a possibility.
Case 2. Ms. W. is a pleasant 40 year-old with multiple medical

problems. She has a urostomy as a result of bladder cancer, has
fibromyalgia,arthritis, general weakness, and fatigue. She is cur-
rently seeing a psychic healer, a Reiki practitioner, her PCP, and
a massage therapist, and wants acupuncture to help with the
fibromyalgia. The acupuncturist agrees to work with her, but finds
that the patient’s reactions to the treatments vary from week to
week. Sometimes she gets relief, at other times she feels worse,
and still other weeks she reports no change.The acupuncturist
does not note an overall improvement and also notices that the
patient is losing more and more weight.On the initial intake,the
patient had listed what appeared to be a fairly healthy diet.
Therefore, the acupuncturist continued to treat her, but eventu-
ally the patient stopped the acupuncture treatments without any
significant improvement.

First, the patient had had so many health problems in her life
that she was starting to lose sight of what her complaints and
goals really were.The practitioner should have spent some time
helping the patient prioritize what she wanted treated first and
what was bothering her the most. Secondly, the acupuncturist

failed to adequately assess the patient’s diet. It is a fact that many
patients will tell you they have a good diet but will omit the fact
that they eat junk food 2-3 times a week or skip breakfast every
day. There is not much we can do about that, but, having noticed
a gradual weight loss in this patient, the acupuncturist should
have revisited the patient’s nutritional needs. Further assessment
would have revealed that the patient had an eating disorder,
which was, in fact, a crucial factor in exacerbating symptoms of
her existing conditions. In this case, the eating disorder turned
out to be fairly severe and was probably beyond the acupunc-
turist’s scope of practice to deal with.A referral to a psychiatrist,
psychologist, nutritionist, or eating disorder clinic would have
been appropriate.The acupuncturist could have let the patient
know that once her nutrition was more balanced,acupuncture
would then be an appropriate path for her.
The patient who cried wolf

Almost all of us know or have known someone who suffers from
hypochondriasis. A hypochondriac can be defined as a “patient
who has a physical disorder but who, in actuality, suffers only
from worry and not from any organic pathology.”1 It can be exas-
perating to deal with such a person as a friend or family mem-
ber. They seem to always be in pain but not always with the same
complaint. Simple physical sensations are seen as disastrous
health problems. A common cold is leukemia, a headache is an
inoperable brain tumor, a case of night sweats is HIV/AIDS.
Knowing such a person on a personal level is one thing. We may

have known this person for a long time and are aware that he/she
is a hypochondriac. As practitioners, though, we are not always
privy to this knowledge and are obligated to take all complaints
seriously until we can prove that they are unbiased. The saying in
the medical world is, “Sick until proven otherwise.” The first mis-
take a practitioner must avoid is misdiagnosing a patient or nul-
lifying a complaint that is actually serious. However, it usually
does not take too long to identify a hypochondriac because, quite

often, there are identifying characteristics that become readily
apparent after only a short time. Often, the complaints will change.
Something that bothered the patient last week is of no conse-
quence the following week, but a new problem has arisen. There
may also be a fixation on the complaint and an insistence that
something is dreadfully wrong, even though countless medical
tests have proven otherwise. Logical explanations do little to
assuage these patients, and they may bring up the same com-
plaint, concerns, and questions over and over again.
As practitioners, we must recognize the underlying need or needs

that spur hypochondriasis. Psychologists point out many roots
of this problem, including childhood neglect, feelings of insecu-
rity, need for attention, and anxiety or panic disorders to name
a few. It is pointless to try to convince this patient that they are
not sick or to try to explain to them that their frequent complaints
are due to unresolved psychological issues. They will often not
respond well to such an explanation. Rather, the practitioner
should take the complaint seriously and even try to treat the
physical symptom in some way, but can also do some points to
help quiet the spirit or soothe the flow of the depressed liver at
the same time.
It is worthwhile to also mention two related syndromes that are

not commonly seen but are also not that rare. They are
Munchausen’s disease and Munchausen’s by proxy. In primary
Munchausen’s, the person actually creates a physical problem
that must be treated or deliberately causes an exacerbation of an
existing problem. The subconscious issue here is a need for atten-
tion that is so severe the person will cause harm to themselves.
Some examples of this:
1. Awoman with leg ulcers who picks at the ulcers with

dirty implements such as toothpicks to infect the wounds
and worsen the condition.
2. A man whose diabetes is well-managed with medications

but who eats a large amount of candy to elevate his blood
sugar to a dangerous level.
3. A young woman with allergies who spends time around

animals she knows will amplify her symptoms.
An even more insidious and difficult disease to understand is

Munchausen’s by proxy in which a person, usually a parent,
deliberately causes a health problem in another person, usually
their own child, in order to seek frequent medical attention. The
likelihood of an Oriental medicine practitioner encountering such
a case in a private practice is extremely low. However, as our pro-
fession becomes more mainstream and integrated, our contact
with this syndrome will also grow, and it is useful to at least be
aware of its existence. If you do encounter such patients as these,
realize that you may be in dangerous waters. Refer this patient
for psychological help or consult a psychologist yourself for
advice on how to proceed.
Case in point:
A .S . is a 47 year-old woman with chronic sinus congestion.When

she arrives at the acupuncturist’s office for her first visit,she is vis-
ibly anxious and stressed. She has a hard time concentrating on
the history form and only fills out the bare essentials. She tells the
acupuncturist she would rather talk than write about her problems
and proceeds to outline a long history of visiting doctors for her
sinus problems. She says that antibiotics help sometimes but not
all the time, so she is certain there is something else going on.She
tells the practitioner she knew someone once who had leukemia
that was misdiagnosed as a recurring cold, and she is convinced
that is what is happening to her. She is very upset that no one has
discovered this yet. The acupuncturist finds her demeanor and
story somewhat comical and cannot help smiling a little as the
patient talks. The patient is already hypersensitive and picks up
on the acupuncturist’s facial expression, which upsets her even

more. The acupuncturist then says,“Well, I can certainly treat you
for your sinuses, but I can’t treat you for something you don’t
have.” The woman becomes indignant and leaves without her
treatment—and without paying.

In this case, it is fairly obvious that the cardinal error made by
the practitioner was not taking the patient seriously. Admittedly,
some people’s interpretations of their health problems can some-
times be comical to us, but we must remember it is not funny to
the patient. At all times, the patient deserves our attention and
respect, no matter how crazy we think their complaint is. In this
instance, the acupuncturist could have explained that he was
not qualified to diagnose leukemia but that a routine blood test
will often show this illness.
■
He could have recommended that the At all times, the
patient request blood work from her PCP patient deserves
(not an unreasonable request) and wait our attention
until the test results were back before and respect,
jumping to conclusions. He could have no matter how
also told the patient that sinus conges- crazy we think
tion can be so severe at times, it may their complaint is.
seem like something more serious and
■
that acupuncture can often allev i at e
these symptoms quite dramatically. A little extra sympathy might
have been enough to reassure this patient, at least for the dura-
tion of that visit.
THE INSIDE STORY:

Most people abhor going to the doctor and shudder at the thought
of going to more than one medical provider for their needs. The
health care system is so complex and can be so difficult to navi-
gate, that most of us avoid it as much as possible. Why, then, are
there so many people whose lives seem to revolve around get-

ting attention for their health? Aside from the obvious case of
someone who really does require multiple medical avenues for
their care, there are those who are lonely, who feel deprived of
attention, or ignored by family, friends, or society in general.
There is a certain comfort in seeking medical attention and know-
ing that you will at least get someone to pay attention to you for
some period of time. Recognizing loneliness or even a feeling of
neglect in a patient can help us to understand the motives for
such behavior. Some people simply need someone to lend an ear
and hear their story.
In our “high tech,” fast-paced, compartmentalized society, there

is often no room left over for plain old human contact, and some
people may be driven to find attention where they can, even at
a doctor’s office. If you have been able to successfully treat a “fre-
quent flyer” patient in your clinic, he/she may let you in enough
to tell you they are lonesome or have no one to talk to. This can
open the door for you to help them solve this condition by sug-
gesting social activities at a local recreation center, adult educa-
tion classes, or joining a club. Once again, healing does not have
to be limited to just the complaint the patient originally came in
with. True healing takes place on many levels, and helping some-
one to help themselves can be the greatest healing gift of all.
QUEST I ONS FOR C HA PTE R F IV E:
1. What are some of the various reasons a person might

have to be a high utilizer of the health care system?
2. What dangers does this pose for the patient? What dan-
gers does it pose for the provider?
3. What are some of the problems inherent in treating this
type of patient?
4. What are some tools that the Oriental medicine practi-
tioner can use to help treat this patient?

Mr. B., a 30 year-old shop owner, comes to your office
because of long-standing irratible bowel syndrome (IBS).
He brings in several medical reports from his PCP, his
gastroenterologist, and his nutritionist, along with three
articles on IBS, including one that talks about a “rice
only” diet for this condition. He also lists about seven
different supplements he is taking and says, “I think
there are more, but I can’t remember right now.” Under
his chief complaint, he also states that he suffers from
low back pain and frequent headaches, but that noth-
ing he has tried has helped either of these problems.
Because he runs his own business, he is often pressed
for time and wants to know how long it might take for
you to treat all his complaints. How would you handle
this situation?
Endnote:
1 Hooberman & Hooberman, op. cit., p. 235.
Successfully managing this patient will require
an equal measure of empathy and detachment as
well as an ability to set boundaries.
CHAPTER SIX
The Needy/
Dependent Patient
In the previous chapter, we discussed patients who frequent

the health care system to a fault. Many of these patients dis-
play characteristics of neediness, though not all needy patients
over-utilize the health care system. In fact, some patients who
are needy will latch on to one practitioner and expend a lot of
energy trying to get help and attention from that one person.
The patient/practitioner relationship can sometimes be like a
parent/child relationship, with the practitioner in the role of
comforter, adviser, and caregiver and the patient in the role of
a dependent receiver. Whether or not the practitioner is a par-
ent, this type of patient can evoke maternal or paternal feel-
ings, and this role can at times be detrimental. A needy patient
may also bring out the “rescuer” in the practitioner, and he/she
may find him or herself desperately wanting to help this patient.
In a case like this, it is easy for the provider to lose sight of the
focus or diagnosis for the treatment and a kind of emotional
tango can result.
99
It is especially important to have a good grasp of your own emo-

tional agenda when treating a needy patient in order not to
become entangled in an emotional web yourself. In fact, part of
the healing of this patient is to assist him/her to become more
confident and independent over a period of time. Needy patients
may also frustrate a practitioner since they are prone to asking
countless questions, requiring repetition of follow-up instruc-
tions, or making frequent phone calls to the office.
These patients can also bring their personal problems to the clinic,
and the practitioner must avoid the temptation to give advice on
these matters or, indeed, on any matters not directly connected
to the treatment itself. Always keep in mind that you are hear-
ing only one side of the story, and very likely a skewed version
at that. Also remember that your words carry an incredible
amount of power; any advice you give is bound to be taken more
seriously than you may think and may
■
even result in worsening the patient’s
Always keep in
problems. In this instance also, you need
mind that you are to be able to attain a certain level of detach-
hearing only ment to avoid becoming angry or irritated
one side of the with patient behavior.
story, and very
likely a skewed Your staff may also have difficulty with
this patient. The patient may foster a rela-
version at that.
tionship with the front desk staff as well
■ as yourself and expect certain “favors,”
such as “squeezing them in” for appointments or forgiving last-
minute cancellations. Successfully managing this patient will
require an equal measure of empathy and detachment as well as
an ability to set boundaries, a delicate balance to be sure!
■ Disclosing personal information not related to the diagnosis
■ Seeking advice on personal matters not related to the
treatment
The Needy/Dependent Patient 101
■ Frequently complimenting the practitioner and/or staff

■ Bringing gifts for the practitioner and/or staff
■ Frequent calls to the office for a variety of reasons
■ In some cases, calling the practitioner at home
■ Inviting the practitioner and/or staff to social functions
with them
Home base
Compassion, empathy, and a sincere desire to help people are
the fundamental requirements necessary to becoming a good
healer. However, sometimes these very qualities, along with
your own unmet needs, may contribute to or enhance neediness
in your patients. Some practitioners may also have a need to be
controlling or to rescue. Either of these characteristics can come
into play in the therapeutic relationship. When confronted with
neediness in a patient, you must be willing to make an honest
self-appraisal as to your own motives and actions in the situa-
tion. As mentioned in the introduction to this chapter, the ther-
apeutic relationship can often mimic that of the parent/child
relationship. Aneedy patient may move you to want to do any -
thing to help them, just as you would want to help a child in
need. This patient may also move you to indulgent actions just
so you can placate them and get them “off your back” (just as
you might a persistent child). Like a real parent, though, you
must maintain an air of confidence and caring, while at the same
time setting limits.
Unlike some of the other patient types in this book, the needy
patient will often show him/herself to be so from the start. It is
likely that this patient will be very thorough in filling out the
intake form and may well include information that is not neces-
sarily pertinent to the chief complaint. During the interview,
he/she may start talking about their personal problems, or ask
a lot of questions, or try to solicit your opinion about actions they

have taken in the past, especially those related to health issues
(but not limited to such). This is tricky ground indeed, and care
must be taken not to offend the patient or dismiss their conver-
sation as unimportant while at the same time proceeding with
the interview in an efficient manner.
The focus should always be kept on the chief complaint. When

or if the patient diverges from the topic, allow a short amount of
time for them to talk, make a comment on what they’ve said to
show your interest. Then, gently steer the interview back to the
problem most concerning the patient. If the patient starts asking
you questions about information, tests, or diagnoses given to
them by other practitioners, be aware that this may be a sub-
conscious tactic to try to win your favor, and you may find your-
self wanting to provide the answers to them. This is especially
so if the question is presented in such a way as to make you feel
that other practitioners are incompetent and you are the one who
can solve all the problems. Be honest when you do not know the
answers and encourage them to consult the original practitioner
with their questions. If it is simply a matter of explaining what
a certain word means or what a certain medication is used for
and you do indeed know the answer, there is usually no harm
in providing that information, but be sure you do not linger on
the subject. Remain in your own territory and you will stand on
solid ground.
After what would seem a normal course of treatment, if the patient

is not getting better but still wants to come for treatments, it is
time to re-evaluate with them what you can do for them. This,
too, is a delicate matter. He/she has placed trust in you and you
have developed a good rapport. For any number of reasons, the
patient may be afraid or reluctant to end the therapeutic rela-
tionship and may want to cling to the attention they are getting.
It is important not to be too curt with the patient or to tell them
that there is nothing further you can do for them so you cannot
see them anymore. Rather, help them to see the progress they
have made, congratulate them for their perseverance, and sug-
gest other practitioners who you think may be able to help them.
You can ease them into detaching from you by starting to sched-
ule visits further and further apart. If they were coming weekly,
tell them it is time to cut back to every other week or even once
a month. On these visits, try to accentuate whatever positive
aspect of their situation you see to help them have a more inde-
pendent outlook. Also reassure them that
■
you will always be there if another prob-
lem arises. If they do agree to seek other It is an unfortunate
treatments, ask them to give you a call and reality that you
let you know how it worked out for them. will not be able to
Do not offer to call them, however, as this help everyone
will only foster the neediness. who comes to you.
You will recognize
Conversely, you need to be aware your-
yourself maturing
self when the treatments are no longer
as a practitioner
therapeutic. Especially in the beginning
of your practice, you will be searching for when you can
patients and your appointment book may really embrace
seem a little thin. It is never all right to this truth and
continue treating a patient who you feel accept your own
you are not helping just in order to keep limitations.
them on the books. You may also find
■
yourself feeling frustrated or that you have
let the patient down. But it is not all right to continue treating
this type of patient because of your own need to help them and
your own fear or frustration in disappointing them. It is an unfor-
tunate reality that you will not be able to help everyone who
comes to you. You will recognize yourself maturing as a practi-
tioner when you can really embrace this truth and accept your
own limitations.
Oriental medicine is a holistic and deeply personal field. As an

Oriental medicine practitioner, you want and need to get to

know your patient and their history as thoroughly as possible.
As the therapeutic relationship develops, you may also find
yourself sharing personal information with the patient. This is
a fairly gray area, and different practitioners have varying lev-
els of comfort regarding how much of their personal lives to
share with their patients. Of course, this is an intensely personal
decision, but keep in mind that you are there to help them and
not vice versa.
Giving out your personal phone number and/or address may

serve to invite the needy patient to call you or to even stop by
your house. (While this is uncommon, it is not unheard of.) It is
best to let the patient have only your business phone number. If
your private number is listed in the phone book and the patient
looks it up and calls you at home, be very clear with them that
you do not accept business calls at home and that you will be
more than happy to speak with them during regular business
hours. If your office is in your home, the patient will of course
know where you live. Try to keep your treatment/office area sep-
arate from the rest of your home and try not to allow the needy
patient to explore too much of your private area. If they start ask-
ing questions about your home, lifestyle, etc., short, simple, and
polite answers are the best.
You are a healer, but you are also human and have your own
needs. Be alert to any factor in your own life that may lead you
to become a “needy practitioner.” You may have just ended a
relationship or experienced some other difficulty and have a
need to share your feelings with someone. Apatient who is needy
may try to engage you into divulging personal information to
them. This actually strengthens their position because now not
only do they need you, but you need them as well. If you have
developed a good rapport with the patient, you may well be
tempted to unload, but resist this temptation. Of course, there
is no harm in sharing some minor details, but, for the big issues,
rely on family, friends, and support groups. The therapeutic

relationship should not be a forum for the practitioner’s needs.
It is the patient’s space in which to heal.
Also, needy patients often try to develop some kind of relation-

ship with office staff. If your staff answer phones, make appoint-
ments, handle insurance information, and process paperwork,
the patient will most likely have a fair degree of contact with
them. Advise your staff to maintain a professional demeanor at
all times. Instruct them not to accept invitations to lunch, shows,
or other social functions so as not to get too personally involved
with the needy patient and to avoid the patient becoming depen-
dent on them. This is especially true of patients who live alone
or feel isolated for whatever reason. Though you and/or your
staff may sympathize with the patient, a better solution is to assist
them to find activities in the community that can facilitate meet-
ing other people in their peer group.
Cases in point:
Case 1. Ms. B. is a 45 year-old woman recently diagnosed with

breast cancer. Someone had recommended acupuncture as
a support therapy while she underwent chemotherapy. Ms. B.
was a licensed social worker (LSW) and was also working on a
Ph.D. She initially presented as very self-assured, but,on the sec-
ond visit,she became quite tearful and shared her fears about
her diagnosis with the acupuncturist.She had also done quite a
bit of research on her illness and, on subsequent visits, started
discussing the results of her searches with the acupuncturist.Her
recent divorce and financial difficulties started coming into the
conversation and taking up appointment time. In addition,the
chemotherapy treatments had made her skin very sensitive ,a n d
she often verbally expressed discomfort during the needling,
sometimes whining a bit about the whole pro c e d u re . The
acupuncturist gave the patient her home phone number and
told her to call her any time she needed to vent or talk things
over. The patient took her up on this suggestion and even invited
the acupuncturist out to lunch. As things progressed,the practi-
tioner felt she was losing her place in the therapeutic relation-
ship and found herself asking the patient what she thought she
needed at every visit.The patient also began asking advice on
matters other than her health,many of which the acupuncturist
did not feel qualified in answering. Eventually, the acupunctur-
ist ended the relationship when the patient finished her chemother-
apy treatments.

In this case, the acupuncturist saw the patient as her professional
equal.Furthermore,she was impressed by the patient’s obvious
intelligence and professional achievements. Subconsciously, the
practitioner wanted to impress the patient with her own knowl-
edge and degree of professionalism. As the patient displayed
a greater neediness, the practitioner felt even more pressed to
help her and found herself entering a type of codependent rela-
tionship. In the end,her treatments, though helpful, were not as
e ff e c t i ve as they could have been and her confidence was
somewhat shaken. No matter what patients’backgrounds or cre-
dentials are, it is important for practitioners to maintain a healthy
degree of confidence in themselves to be able to represent the
profession and serve patients to the highest degree possible.
Case 2. Mrs. S. was receiving acupuncture treatments for urinary

stress incontinence. She was an older woman living alone with-
out any close family nearby. The acupuncture treatments had
been extremely helpful for her, and she continually praised the
acupuncturist and his staff. They initially felt sorry for her because
of her social situation. During the course of her treatments, she
made frequent calls to the office between appointments, often
telling the staff she needed “the doctor” to call her right away,
that something was terribly wrong. When the acupuncturist
returned the calls, there was never a very real problem, but the
patient kept him talking on the phone for a long time.
In addition,she often brought treats for the staff when she came
for her visits. After her visits, she would sometimes linger in the
office and ask the acupuncturist and his staff about their per-
sonal lives and even about other patients she would see in the
office.Eventually, the acupuncturist and his staff became impa-
tient with her, started answering her questions rather abruptly,
and even cutting her visits a little short. The patient soon became
offended by the lack of attention and tearfully told the staff and
practitioner that she felt very let down and disappointed. Of
course,they all felt somewhat guilty about this attitude and had
a very hard time ending this therapeutic relationship.

The acupuncturist and his staff failed to recognize and act on
the patient’s neediness fast enough and the situation was allowed
to get somewhat out of hand. When the acupuncturist and his
staff finally realized that the patient was becoming something of
a burden, it was too late to handle the situation in an optimal
way. It is important not to confuse sympathy with wanting to cor-
rect what is wrong in a given patient’s life. The practitioner and
staff had no control over the patient’s social situation, but their
innate sympathy led them to want to soothe the patient’s feel-
ings of loneliness and isolation which only led to greater depen-
dence on the patient’s part.
The acupuncturist should have instructed his staff to ask the patient
the specifics when she placed her “emergency calls” and for
them to inform the patient that the practitioner would get back
to her as soon as possible. It was the acupuncturist’s responsi-
bility to curtail his phone conversations with the patient when he
did return her calls. The office staff should have given only very
short answers to personal questions or even could have stated
that they do not discuss their personal lives in the office. Of course,
the patient should have been immediately informed of HIPAA
requirements and that no information about other patients could
be divulged.Short, final, but polite answers would have helped
stem the needy behavior of Mrs. S.
The devil made me do it

Sometimes the devil really is the culprit; in this case, the devil
being the person’s illness itself. Long illness creates dependency
out of necessity. The patient may very well have become depen-
dent on friends, family members, and/or health care providers
because of limiting symptoms such as chronic pain, debilitating
weakness and fatigue, or plain old age. Even if the patient was
previously independent, their illness has forced them into a
dependent position. They may have lost their driving privileges,
may need others to do shopping or household chores for them,
or may need help getting dressed.
Further complicating matters are family members or friends who

become overly solicitous in trying to help the patient and end
up promoting neediness unwittingly. In these cases, a vicious
cycle can easily develop in which the caregivers soon become
resentful of the very neediness they helped to create. The patient
is now fully ensconced in the “sick role” and often relinquishes
more and more responsibility and independence to others. By
the time they reach your office, they may be fully engaged in this
type of dependency. Family dynamics and role hierarchy in the
patient’s social and family circumstances may fuel problem behav-
ior. The lines between what the patient can actually do for them-
selves and what they cannot do become blurred and they become
committed to a dependent lifestyle.
In other cases, it is the symptoms of the illness that may create

neediness. This is especially evident in emotional/spiritual dis-
eases, which can dictate behavior the patient might otherwise
not display. A depressed patient may find it difficult to complete
tasks that they were once efficient at and, at the same time, crave
attention for their depression. A bipolar patient in the manic
phase may be beyond distinguishing what is and is not socially
acceptable behavior, and their compulsions may lead them to
frequent visits, phone calls, or other contact with practitioners.
Medications may also contribute to unhealthy behavior. Prolonged

steroid use, especially at high doses as prescribed for people with
respiratory or rheumatoid conditions, may make a patient prone
to emotional lability, which may lead them to needy behavior.
And let’s not forget good old hormones. If you treat women in
menopause, you will most likely run into your fair share of tears
and even hysteria. In all these cases, the patient’s illness and not
his/her intentions dictate needy behavior, but the behavior must
still be efficiently managed.
Case in point:
H .L . is a 36 year-old woman who recently underwent a complete

hy st e re c t o my due to endometriosis. ( U n fo rt u n at e l y, she was
unaware that Oriental medicine can be effective in tre at i n g
endometriosis.) The sudden drop in her hormone levels had
caused a severe emotional depression characterized by fre-
quent crying jags and,on some days, an inability to go to work
because of her depression.She was also prone to some hyster-
ical behavior, which caused her to make mountains out of mole-
hills. Her gynecologist had prescribed an antidepressant but that
had done little to curb the emotional storms, and she desper-
ately wanted to try some “natural”treatments to help restore her
to stability.
Before the surgery, she had been quite competent in the busi-
ness world, running her own clothing store and generally being
quite socially active. She told the herbalist that she had never
experienced this type of behavior in herself and did not know
what to do. She was also having some marital problems that she
found herself incapable of getting a rational perspective on.

Because the herbalist was the same age and sex as the patient
and had just come out of a difficult phase in her own relation-
ship, she identified with the patient very strongly. On the first visit,
she allowed the patient to cry for quite a while and to vent about
her problems. The herbalist even found herself giving the patient
some advice on how to speak to her husband and related sim-
ilar problems that had occurred in her own relationship. The
patient bonded very strongly with the herbalist and started call-
ing between visits to give her a blow-by-blow description of her
latest encounters with her husband.The herbalist soon became
frustrated with these frequent calls and also noticed that the visit
time for this particular patient was becoming longer than the
allotted time and was interfering with the timeliness of her other
scheduled visits.

The herbalist made the common mistake of identifying too closely
with the patient and losing sight of her therapeutic role. She also
failed to fully recognize that the patient’s emotions were a by-
product of her physical condition and that this physical condi-
tion was itself partly responsible for the problems the patient was
having at home. Of course, she needed to allow the patient some
venting time. A patient who is tearful in the office needs to be
allowed a few moments to compose herself. The practitioner
should have offered her a tissue,some tea, or even just a glass
of water as a comfort measure, allowed a few minutes of vent-
ing, but then proceeded with the treatment without dwelling on
trying to find solutions to the patient’s personal problems. The
herbalist would have been correct in teaching the patient that
her hormonal situation was making her unduly emotional and
that realization of this fact should help the patient refrain from
rash actions or decisions for the time being. She could have also
suggested that the patient and her husband seek counseling
for their issues.
Part of her treatments should have also included reassurance

that the treatments were the best way to restore balance to the
patient and that such treatment would be far more effective than
talking endlessly about her problems.The treatment room should
have provided as relaxing an atmosphere as possible and the
practitioner could have also worked with the patient on relax-
ation breathing, guided imagery, or other methods to help calm
the mind and quiet the spirit.
High anxiety
There is an awful lot of free-floating anxiety in our society, and
any kind of illness or compromised lifestyle is likely to create or
exacerbate that anxiety. Many people you will see have an under-
lying anxiety or even panic disorder for which they may or may
not be receiving treatment. In some cases, the anxiety disorder
is itself the reason they come to you. In other cases, the patient’s
health issues create the anxiety or intensify the existing anxiety
disorder. Practitioners must not underestimate how anxiety affects
a person. It often actually reduces the person’s field of percep-
tion to their immediate surroundings. In advanced cases, they
may not be able to “see the forest for the trees,” may not be able
to see rational angles to their situation, or may not be able to per-
ceive simple and reasonable solutions which would otherwise
be obvious.
Anxious patients can frequently become fixated on a certain sub-

ject, especially their health, and may need a great deal of reassur-
ance that they are not deathly ill or in immediate danger of a dire
health crisis. Panic disorders are an advanced form of anxiety and
can interfere with a person’s ability to perform their daily duties.
People who suffer from panic disorders often say they have a feel-
ing of impending doom, that the world is going to end, or that
they are going to die. These feelings may be accompanied by phys-
ical manifestations such as shortness of breath, heart palpitations,
or headaches. Patients with this presentation often ask frequent
and repetitive questions about the practitioner’s instructions in a
desire to do everything just right and avoid aggravating their sit-

uation. For example, they may be fearful that missing one dose of
herbs will have a devastating effect on their health or, conversely,
that the herbs will somehow cause a new health problem. It is the
practitioner’s job again to provide reassurance and extremely accu-
rate information to assist the patient in relaxing and in complying
with the treatment. In fact, I believe that points such as Shen Men
(Ht 7), Nei Guan (Per 6), Shen Ting (GV 24), and Yin Tang (M-HN-
3) should be part of their treatment to help mitigate the effects of
the anxiety.
Case in point:
B. C. is a 26 year-old male with an underlying anxiety disorder.

He had also just finished treatment for Hodgkin’s lymphoma.
Fortunately, his prognosis was excellent, and his oncologists were
quite optimistic that he would make a full and lasting recovery.
B.C.decided to get some acupuncture treatments to help him
fortify his immune system, which had been devastated by his
lymphoma as well as by the chemotherapy. Like many cancer
survivors, he had an abject fear of the cancer returning,and his
anxiety led him to believe that any new physical manifestation
was a sign of the cancer’s return.He was also anxious that if he
did not do everything exactly right, the cancer would recur. He
voraciously collected info rm ation on the Internet and often
printed out articles about anything and everything that would
possibly harm him.He also started bringing these articles to the
acupuncture office.At every visit,he found new concerns to dis-
cuss and would often ask the acupuncturist if a certain feeling
was indeed a sign that the cancer had returned.
The practitioner was at first patient with this patient,understand-

ing how his recent bout with cancer could exacerbate his anx-
iety, but, as this pattern continued over the course of several
treatments without signs of abating,the acupuncturist became

weary of the constant questions and worrying to the point that
he started dreading this patient’s visits. The patient’s attitude was
especially exasperating to the practitioner because the patient
could not see the excellent progress he was making with his
acupuncture treatments. The practitioner soon adapted a rather
curt manner with this patient that eventually led the patient to
believe that the acupuncturist was aware of some problem with
his health that he was not sharing with the patient.

This is a very difficult situation. The acupuncturist here should
not have underestimated the power of this patient’s anxiety.
As mentioned earlier, it would have been very ap p ro p ri at e
and even essential for the practitioner to treat the anxiety con-
currently with the supplementing treatment for the immune
system. A pre-existing anxiety disorder should always alert the
perceptive practitioner to its effects on the whole person and
should be addressed along with the chief complaint.
The practitioner must also be extremely cautious about falsely

reassuring the patient. Since the acupuncturist was not an oncol-
ogist,he should have advised the patient to consult his oncolo-
gist with any concerning symptoms. It is possible that this patient
could have had a symptom of clinical significance, one that the
acupuncturist may have simply attributed to his anxiety level.
Again, it is paramount for practitioners to remain within their
scope of practice. The practitioner might have also found occa-
sion to recommend counseling of some sort for this patient.The
practitioner could have pointed out to the patient that the health-
iest attitude he could take would be one of positive thinking and
that dwelling on negative outcomes could actually create unfa-
vorable results.
■ THE INSIDE STORY:

Recognizing fear Patients who are needy and dependent
and powerlessness can easily become a source of vexation
as the primary and frustration for any practitioner.
issues underlying Childlike behavior, repetitive questions,
most needy and entangled conversations can cer-
behavior can give tainly sabotage a treatment. Neediness
does not exist in a vacuum. It is borne
us an insight into
of life situations over which we may
the patient’s state
have no control. It may even stem from
of mind, and we
childhood experiences, both positive
can use this and negative. We are generally never so
information to secure as when we are young children,
help the client dependent yet having all of our needs
heal on many met. When, as adults, we become fright-
different levels. ened or anxious, it is understandable
how some people may revert to this
■
childhood behavior in hopes of finding
a safe haven. Recognizing fear and powerlessness as the primary
issues underlying most needy behavior can give us an insight
into the patient’s state of mind, and we can use this information
to help the patient heal on many different levels.
QUES TI ONS FOR C HA PT ER SI X:
1. Can you think of a situation in your life in which you

felt needy or dependent? Can you identify the underly-
ing cause of your feelings? How were your expectations
of yourself and others affected?
2. How might a practitioner actually foster or encourage
neediness in a patient?
3. What are some examples of setting limits for a needy
patient?
4. How can a person’s illness create or contribute to
dependency?

Mr. T. reluctantly sought acupuncture for chronic back
pain resulting from an automobile accident. He had tried
narcotic therapy, hypnotherapy, and over-the-counter
medications for relief, all to no avail. His wife suggested
acupuncture since her sister had found relief from pain
using Oriental medicine. She accompanied her husband
to the office and answered many of the practitioner ’s
questions instead of letting the patient answer for him-
self. The patient was sweaty and nervous and told the
practitioner that he was deathly afraid of needles stem-
ming from a traumatic childhood incident at a doctor’s
office. At each visit, he required an unusual amount of
time in which to get relaxed enough to “endure the treat-
ments,” thought up some “rituals” to help him relax
(which were time-consuming), and asked the practitioner
countless questions about the safety of acupuncture.
How would you handle this situation?
The danger here lies in you losing control over the
effectiveness of the treatments and having your
own thoughts and energy become scattered as you
try to accommodate the patient’s wishes.
CHAPTER SEVEN
The Manipulative Patient
As practitioners of Oriental medicine, we do not always want

our practitioner/patient relationships to resemble those of a
Western MD’s office. We would like to think of our therapeutic
relationships as true partnerships in which both parties exchange
information and ideas and strive to reach a treatment plan that
is acceptable to both. Although it may be a partnership, that does
not mean both parties have access to the same information. There
are two different roles in this special relationship. The practi-
tioner has the knowledge of his/her field backed by years of
study and training. The patient has knowledge of his/her body,
illness, and wants and needs backed by years of experience. Both
sides of this relationship carry equal importance, but the parties
involved cannot cross the boundaries of their respective roles
within the relationship.
It is not the practitioner’s job to dictate to the patient what he/she

needs or to determine what is the best course of action without
taking the patient’s opinions into consideration. Likewise, it is
117
not the patient’s role to direct the course of treatment or to pre-

sume to have enough knowledge of Oriental medicine to feel
that he/she is capable of making professional decisions about
the treatment. Both parties need to understand and abide by these
differing roles in order for the relationship and treatment to be
successful.
It is not uncommon to encounter patients who will be manipu-

lative and will try to either outsmart the practitioner or to direct
the course of their treatment by telling the practitioner what to
do. Manipulation can also occur when the patient feels entitled
to special treatment, attempting to get treatments at a lower cost,
or to arrange appointment times that may not be compatible with
the clinic’s schedule. At times, the patient may even try to make
the practitioner feel guilty and thus give in to the patient’s wishes.
When faced with this type of patient, the practitioner must rely
on his/her training, knowledge, and, above all, self-confidence
in order for everything to proceed smoothly.
■ Comparing the current practitioner or treatments with past
practitioners or treatments
■ Suggesting specific points or herbs that the practitioner
“should” use
■ Asking the practitioner to incorporate ideas from fields other
than Oriental medicine
■ Bargaining with the practitioner about fees or appointment
times
■ Wanting to continue treatments even after no improvement
is being noted
Home again
Lack of self-confidence is probably the biggest obstacle standing
The Manipulative Patient 119
in a practitioner’s way when faced with a manipulative patient.

As they say, “Alittle knowledge is a dangerous thing.” Some of
your patients will have had previous experience with Oriental
medicine or may have done some reading on the subject. Others
will have heard or read about a certain treatment or cure that
they may tell you they want you to incorporate into the treat-
ment. Especially at the beginning of your practice, you will be
eager to please and even impress your patients. You will lack
experience, the great teacher upon which you will eventually
build your treatment strategies, and this lack of experience may
induce you to yield some of your control over to the patient. The
danger here lies in you losing control over the effectiveness of
the treatments and having your own thoughts and energy become
scattered as you try to accommodate the patient’s wishes. It is
important not to be intimidated—even on your first day as an
acupuncturist or herbalist.
There is no shame in not knowing a fact or not being sure of what

to do or how to proceed. However, the patient need not be aware
of your doubts. It is not necessary and certainly not desirable to
let the patient know you feel unsure of yourself, but, at the same
time, you also do not need to feel intimidated by the patient. If
you truly do not know how to proceed, you can simply tell the
patient that there are several treatment options for them and you
will research each one and present this information at the next
visit. Meanwhile, for the present treatment, you can always treat
based on what is before you: the history, the pulse, and the tongue
signs. In my experience, these will give you enough preliminary
clues to begin a good initial treatment.
When faced with a manipulative patient, it is easy for practi-

tioners to feel challenged and even “put upon.” These patients
do not always react well when their suggestions or demands are
not heeded. At times, the patient may use tactics such as guilt or
ingratiating behavior to try to manipulate the practitioner ’s
actions. If they do not get their way, you may even lose the patient
■ completely, but it is still better to lose a

As always, you patient than to lose control of your prac-
need to find that tice! Fortunately, it is often the case that
middle ground the patient will remain with you even if
you cannot comply with their suggestions.
on which you can
In many cases, you will increase your
show respect for
patients’ respect for you by standing your
your client’s ground, especially when they experience
opinions, yet the positive results of your work.
retain your
place as the As stated throughout this book, it is not
practitioner. okay to get angry with the patient or to
a rgue with them. In fact, arguing will
■
only aggravate the situation. As always,
you need to find that middle ground on which you can show
respect for your patient’s opinions, yet retain your place as
the practitioner.
One of the dangers of acquiescing to a manipulative patient is

that it makes it even easier for them to manipulate in the future.
Dealing with manipulative patients does require establishing
boundaries and setting limits. It also involves the great tool of
education. You must find a way to educate your patients as to
why their suggestions will not fit into your treatment plan. If pos-
sible, you might try to find some common ground whereby the
patient will be satisfied, even if their original wishes are not met.
Case in point:
M. D. is a 50 year-old woman with a long history of insomnia that

started during the illness and eventual death of her eight year-
old daughter. She also suffers from an anxiety disorder that at
times borders on panic. She is a chiropractor who often uses
Applied Kinesiology (AK) in her practice. She contacted an
Oriental medical practitioner in hopes of finally finding a solu-
tion for her insomnia and anxiety. When she initially called for
the appointment, the acupuncturist’s staff was put off because

she insisted on being seen the next day, even though the prac-
titioner’s schedule was full. The staff scheduled her for the day
after that. When she came for her appointment, she informed
the practitioner that she was disappointed she could not have
taken her the day before, especially since her problem was quite
pressing. She told the practitioner, “I have a friend who is an
acupuncturist,and she would never make someone wait to see
her.”The practitioner took this comment as something of an affront
but continued with the appointment.
The practitioner prescribed an herbal formula based on the

patient’s presentation, but the patient insisted that she “test”the
formula with kinesiology before taking it.The practitioner reluc-
tantly agreed, but the patient then stated that she could not take
the formula because it did not “test right”and asked for another
formula. The practitioner then prescribed a second, though in
her opinion less appropriate, formula. This second formula “tested”
to the patient’s satisfaction.However, on the return visit, the patient
was again dissatisfied because the formula she was given was
not having the desired effect.

This relationship started off on the wrong foot with the staff being
challenged to find an appointment time that would suit the patient
even though it was not in keeping with the office schedule.Things
went from bad to worse when the patient made a comparison
in which the present practitioner did not appear fa vo r ab l e .
Although the practitioner was somewhat insulted by the remark,
she also could not help taking it to heart and feeling that she
would like to prove to the patient that she, too, was a caring
healer. This herbalist was a believer in AK but had misgivings
about the way the patient was using it. In the end,she chose to
try to please and appease the patient but with less than satis-
factory results. She should have stuck to her guns and given an
explanation to the patient as to why the first formula was her pri-
mary choice and why the second formula would probably not
be effective.If the patient still refused to try the first formula, the
herbalist might have had to suggest another practitioner or
another type of discipline.
The upper hand

Sometimes patients will try to manipulate things other than the
treatment itself. In fact, they may have nothing to say about the
treatment but plenty to say about time or money. Time and money,
as we all know, carry tremendous power and can be used as tools
of manipulation by patients trying to get reduced fees or special
time considerations. Again, as the practitioner, you must be will-
ing and able to set limits and stand your ground.
The person who truly does not have the funds to pay for their
treatments will usually find a fairly forthright way of request-
ing a payment schedule, or they simply will decide to put off
treatment until they can afford it. In a manipulative situation,
however, the patient may very well be able to afford the treat-
ment. Money or lack thereof is not the actual issue. It is more a
kind of bargaining chip, and what they are bargaining for is “the
upper hand,” a chance to feel they have “gotten their way,” or
even that they have “pulled one over” on someone.
Time can also be a bargaining chip. Some patients will try to

maneuver their way into a busy schedule or try to talk the prac-
titioner into staying late or coming in early just for them. They
may also try to linger or prolong their treatment time. If there
are other patients waiting in the office, the manipulative patient
may even try to use their presence as a means to their ends. This
is often done by complimenting the practitioner in front of these
patients or trying to engage them in the situation. When this hap-
pens, the pressure on the practitioner is doubled, and it is usu-
ally then necessary to draw the patient into a private area to
discuss the matter away from the influence of others.
Cases in point:
Case 1. An acupuncturist had been treating a terminally ill man

for some time at a reduced rate because the gentleman’s
finances were a problem. The acupuncturist had had no trouble
working out a payment schedule that was acceptable to all con-
cerned.During the course of the treatments, the practitioner had
been introduced to several of the man’s family members.
Unfortunately, the man passed away but,a few months later, his
daughter called for an appointment for a case of tendonitis.
When she showed up for the appointment, the first thing she
asked was how much the treatment would cost. The acupunc-
turist quoted her his usual fees. The patient balked a little and
stated that she thought she should be treated at a reduced rate
like her father had been. The acupuncturist told her that that had
been a special consideration and reiterated his usual fees.
The patient was quite persistent, however, and started compli-

menting the practitioner profusely, saying how his treatments
had prolonged her father’s life and enhanced his quality of life.
She stated that, since she was a close relative and was still griev-
ing, she should also be given “a break” on the fee. When the
acupuncturist held firm, the patient actually started a kind of bar-
gaining process. The acupuncturist had become quite fond of
the patient’s father when he was treating him, and the daugh-
ter’s insistence started wearing on him. Because time was being
wasted on this topic, the acupuncturist finally gave into the
patient’s wishes and did agree to treat her at a lower rate.

This patient was quite skilled at emotional manipulation and
knew what would tug at the acupuncturist’s heartstrings. She
actually was able to afford the treatments but felt that she wanted
the upper hand for some reason and so persisted until she was
able to get her way. Even though the acupuncturist had an
emotional attachment in this situation, he would have been

wiser not to argue with the daughter. The fact that they already
knew each other did not help since he wanted to maintain the
same professional and caring image he had created when
treating the father.
He should have clearly and firmly explained that the father had
received a reduced rate because of extenuating circumstances
that did not apply across the board. He could have asked the
daughter if she was having any financial problems that would
interfere with her paying for the treatments or could have sim-
ply stated the fee and let the patient decide if she wanted to
continue or not.
Case 2. After a treatment,a patient approached the front desk

to make her next appointment.There were two other patients in
the reception area at the time.
Patient: I’d like to make an appointment for next Friday at

6:00 PM.
Receptionist: You know that [the practitioner’s] last appoint-

ment on Fridays is at 5:00. I could get you in at 4:30 or 5:00.
Patient: Oh no, that won’t work. I have to come in next week,

but it has to be Friday after 5:00. I’ve been coming here so
long. Don’t you think she could make an exception just this
once?
Receptionist: I’m sorry. She won’t be able to do that. Is there

any other time you can make it next week?
Patient: (turning to the others in the waiting room) I just can’t

believe it. She is usually so great, isn’t she? I mean, she has
done so much to help me. Don’t you think I deserve a
little slack here?
Receptionist: Well, I don’t know. Let me get [the practitioner]

for you.
The receptionist then called the acupuncturist to the front desk

and explained the problem.The acupuncturist relented slightly
and told the patient she could come in at 5:30 if she wanted to.

Several errors were made in this scenario. First, the receptionist
had perhaps not been fully instructed by the acupuncturist on
how to handle this type of patient.Second, the receptionist should
have spoken to the acupuncturist privately in order to allow her
the time to assess the situation and make a decision about how
to handle it.When the acupuncturist came to the front desk,she
was immediately thrown into a situation in which the patient had
tried to gain support from the other patients and the situation
could have escalated had the acupuncturist not compromised.
However, this type of action only paves the way for further future
manipulation. If the patient had not been willing to schedule
during normal hours of operation, she should have been told
that she could have the first available appointment after Friday.
Driving with the brakes on

Other forms of manipulation may not always be so obvious.
Sometimes a patient will use his or her lack of progress as a form
of control. These are the patients who come to you week after
week with the same complaint that does not seem to improve,
yet they do not show discouragement with the treatments.
Instead, they continue to make their appointments and are vis-
ibly shaken if the practitioner indicates that the treatments are
not working and that it might be best to pursue another plan.
Patients who demonstrate this type of behavior are often afraid
to end the relationship with the practitioner. The fact that they
are not getting better is not their fault; so they are absolved of
that responsibility.
In addition, the relationship with the practitioner gives them

a much-needed sense of being cared for. The attention they
receive is important to them and may also be filling a void in
their lives. Nonetheless, you as the prac-
■
titioner must realize that that is not your
Manipulative
role. These cases can be emotionally very
clients will challenging and difficult for a practi-
embrace your tioner. You see a hurting individual and
suggestions and s i n c e rely want to help them. You do
even try to prove everything in your power towards that
to you how end, yet you see no pro g ress and you
they’ve tried become frustrated.
to follow up on
Most of these patients do not express anger
your advice, but
or any type of blame towards the practi-
somehow it just tioner. In fact, in most cases, they may be
did not work out overly grateful and try to reassure you
in spite of their that they think you are doing all you can
best efforts. to help. They may even blame their lack
■ of progress on themselves with comments
such as “I know you’re doing all you can
to help me. It’s just me. I’m so messed up that no one can help
me.” The self-pitying attitude is hard to brush off and will often
make a practitioner feel that he/she wants to do even more to
assist the patient.
Manipulative patients will embrace your suggestions and even

try to prove to you how they’ve tried to follow up on your advice,
but somehow it just did not work out in spite of their best efforts.
When dealing with these patients, there is bound to come a time
when you need to end the relationship. When this time comes, it
is paramount to offer the patient some choices for what they can
do next. Sending them away with no hope is extremely detri-
mental. However, it must also be made clear that the ultimate
decision lies with them and that, if they do not like what you have
offered as follow up advice, there is not much more you can do.
Case in point:
N.K.sought acupuncture treatment for a case of long-standing,

severe depression at the suggestion of a friend. The initial inter-
view went well with the patient expressing a sincere desire to
get well. The acupuncturist noticed that she was already tak-
ing some prescription antidepressants, but the patient st at e d
they really were not helping. When asked how long she had
been on the medication, she gave vague answers. When asked
why she continued on the medication even though she did
not feel it was helping, she gave even more vague answers.
The acupuncturist proceeded to administer twice-weekly treat-
ments for depression and was encouraged by the patient’s
optimistic attitude towards acupuncture. After about four weeks
of treatment, the patient demonstrated no noticeable improve-
ment and, at times, told the acupuncturist that she thought the
depression was getting wo rs e .
The acupuncturist was becoming frustrated and referred the

patient to a Five Elements practitioner. The patient took the infor-
mation, but never called. When asked why, she put on a sad face
and said,“What could she do that you can’t? You already know
me and I feel comfortable here.” The acupuncturist also referred
this patient to a local support group and suggested she also try
Trauma Touch therapy. Again the patient seemed eager to try
these avenues but came back stating she so far had not had
time to go to the support group. She also stated she had done
some research on Trauma Touch massage and felt that it would
not help her.
The practitioner eventually became exasperated and told the

patient there was not much more she could do for her and that
the patient would have to try to find other sources of help. The
patient left the office rather tearfully but did not return.

The patient gave a hint early on in the treatments that she might
be somewhat manipulative when she gave vague answers
regarding her antidepressants. It might have been worthwhile
for the acupuncturist to pursue this information in a little more
detail and perhaps to consult with the doctor who prescribed
the antidepressants if the patient would have agreed to that.As
the treatments continued with no progress, the acupuncturist
should have tried to gently taper off the frequency to once a
week, then twice a month, etc. instead of abruptly ending the
relationship.
When it became clear to the practitioner that the patient needed

another means of treatment, the acupuncturist should have reit-
erated her original suggestions and given them to the patient
in writing. In the gentlest way possible, she needed to let the
patient know that, just because acupuncture was not working
for her, there was still hope and the patient had not exhausted
all her options. She needed to acknowledge the patient’s tear-
fulness and express sympathy but still hold firm to her own advice.
T HE I NSI DE ST ORY:
Manipulative patients can often prove to be frustrating and even
annoying at times. Their desire to control the treatments can be
a real challenge to any practitioner. It is helpful to understand
that underneath this behavior is a person who has likely been
manipulated themselves, either in a present situation or in a past
instance from childhood. In more serious cases, there may be a
history of sexual, physical, or emotional abuse. They feel out of
control, yet also have a need to exert control. In so many cases,
the only way they know how to do this is by mimicking the way
they have been or are being treated.
Many of these patients may also have been somewhat neglected

as children. Their behavior can often seem quite childlike, and
they may be seeking a kind of surrogate ■

parent or caregiver role from their health It is helpful to
care providers. However, even though understand that
they seek to exert control, there is also a underneath this
feeling that they have a deep need to be
behavior is
cared for and taken care of. If they have
a person who has
not been able to find this in their personal
relationships, the health care provider is likely been
a logical choice to pursue. manipulated
themselves, either
Of course, these motives are usually quite in a present
subconscious, and it is not the job of the situation or in a
Oriental medicine practitioner to analyze past instance from
the patient or find answers to deep-rooted
childhood.
problems, but just being armed with a basic
understanding of this type of patient can ■
help the practitioner develop an effective treatment strategy that
will benefit both the patient and the therapeutic relationship.
QUEST I ONS FOR C HAPTE R SEVEN :
1. Can you think of an instance in which you yourself used

manipulative behavior? If so, what were your motives?
What did you hope to achieve and were you successful?
2. Have you ever been in a situation in which someone
manipulated you (or tried to)? How did it make you feel?
How did you handle that situation?
3. What are some clinical presentations of a manipulative
patient?
4. What are some of the underlying issues that may cause
a person to be manipulative?
J. W. is a 25 year-old woman with a history of irritable
bowel syndrome (IBS). She is very squeamish about
acupuncture needles, but has a large number of tattoos
and body piercings. She often complains and even whines

about how much the acupuncture needles hurt and that,
when she had her piercings and tattoos, she did not feel
much pain. She also mentions that she had had acupunc-
ture “a long time ago” and that the needles did not hurt
then. She often tells the practitioner which points not to
needle and also requests the practitioner needle other
points that she says “don’t hurt so much.” How would
you deal with this patient?
It is important not to show impatience with either
the “Rambler” or the “Vague Complainer.” This
behavior is difficult to change since it is often part
of the person’s basic personality and diagnosis.
CHAPTER EIGHT
The Patient with

Communication Problems
(The Rambler & the Vague Complainer)
Effective communication is critical in a healthy therapeutic rela-

tionship. It is the only way the practitioner can attain the knowl-
edge that he/she needs to be an effective healer. Patients need
to be able to convey their symptoms succinctly and as accurately
as possible. It is important for them to be able to give an accu-
rate medical history as well and it is helpful if they have a fair
working knowledge of their medications. They also need to be
able to convey their comfort level with the treatment and to
inform the practitioner of any true discomfort. Practitioners on
the other hand, must be able to explain their treatments in ver-
nacular terms. They need to be able to offer timely and coherent
explanations about a medicine not native to the culture they prac-
tice in and incomprehensible to much of the general public. The
practitioner also must develop skillful interviewing techniques
131
and learn how to ask critical questions from the history the patient
gives. In this way, both parties can proceed in a positive and ther-
apeutic manner.
However, not everyone is an effective communicator, and there

will be some patients who make their way to your office who
will pose problems in this area. I have divided these patients into
two basic types for the purposes of this book, but you will prob-
ably be able to identify other types of communication problems
not mentioned here. In my experience, the two most problem-
atic patients regarding communication are the “rambler” and the
“vague complainer.”
The Rambler is familiar to almost anyone in or out of a health care

situation. This is a person who loves to talk, especially if they are
the focus of the conversation! Conversations with such people
are often one-sided. The listener is hard-pressed to get a word in
edgewise and finds him or herself looking for an escape. Ramblers
relish telling others personal anecdotes about themselves, at times
in excruciating detail. They rarely let the listener express an opin-
ion, nor do they ask for one. This type of person usually does not
seem to mind whether they are talking to a stranger or to some-
one they know well. Everyone is a potential audience.
The Vague Complainer is more likely to be seen more often in

a health care setting. He or she knows something is wrong but
cannot define what it is. Even when asked specific questions,
they are often unable to come up with clear answers. Common
responses from these people are statements such as, “I don’t
know,” “I’m not sure,” “I can’t really describe it,” and “I guess
so.” In this case, the listener has no trouble getting into the con-
versation. In fact, the listener often finds him or herself trying
to draw the patient into the conversation with varying degrees
of success. Such a patient can prove difficult because of their
diminished participation in the therapeutic relationship.
Fortunately, Oriental medicine affords us tools such as pulse
The Patient with Communication Problems 133
and tongue signs that become absolutely critical when dealing

with a Vague Complainer.
■ “Stream of consciousness” talking with little or no opportu-
nity for the listener to talk
■ Giving long-winded descriptions or explanations
■ Frequently changing the subject or an inability to stay on
one subject for any length of time
■ Inability to give accurate descriptions of what is bothering
them
■ Insufficient answers to practitioners’ questions
■ An intake form that is either overly detailed or not filled out
enough
■ Lack of eye contact
■ Hyperactivity or hypoactivity
Home again
There is not much in the office setting that will enhance or deter
someone with a communication problem, but there are always
some areas to explore. A Rambler can sometimes pose problems
for the front desk staff when the practitioner is busy with another
patient. They will often try to engage the staff or other patients
in conversation. This is an area in which having some good read-
ing material can be helpful. If a talkative patient in the waiting
room is disturbing the staff or other patients, the staff can try
pointing out an interesting magazine or article for them to read
while they wait. (Of course, this can also be an effective strategy
for any other unwitting audience members to use as a distrac-
tion and deterrent.) If the Rambler persists in conversation with
the staff, the staff can simply but politely state that they need to
attend to their work. Of course they should honor the patient
with all the normal courtesies but, beyond that, should discour-
age long-winded conversation.
It is usually the practitioner who bears the brunt of dealing with

this patient, however. You may sometimes feel that you are
trapped in the room with no way out. The intake form may be
your greatest ally in this situation. It is important to allow the
person a little leeway to express themselves, but this needs to be
limited to just a minute or two. You need to be alert to the
inevitable but fleeting break in the conversation, which will allow
you to ask a crucial question or to redirect the conversation to
the subject at hand.
You must also check yourself to make sure you are not unwit-
tingly engaging the patient. Although some Ramblers are bor-
ing and monotonous, others are interesting and have stories to
tell that may pique your interest. Resist the urge to pursue the
topic because it is certain you will get what you asked for.
Remember, your primary purpose is professional, not personal.
ARambler will often fill out the intake form in painstaking detail.
It is the practitioner’s job to sort through the information and
distill only what is pertinent.
The Vague Complainer will rarely pose a problem in the recep-

tion area. They will often be quiet and keep to themselves. They
may pose a problem to the staff in that they may not be able to
be decisive about when they want their next appointment. They
may even want the staff or the practitioner to help them decide
when a good time to come in would be. Their intake form may
look pretty sparse. They may tell you that, “I just didn’t know
how to answer the question.” Your challenge here is to elicit more
detailed responses from them. In some cases, you may not be as
successful as you’d like in this area and may need to rely on data
such as pulse and tongue examination, facial color, voice timbre,
and complexion to assist you in your treatment plan.
It is important not to show impatience with either of these types

of patients. This behavior is difficult to change since it is often

tied up in the person’s basic personality. Instead, you need to
find ways to allow just enough time to get the information you
need without having the appointment time be devoted solely to
that end.
Cases in point:
Case 1. Ms. W. made an appointment with an herbalist because

of a persistent rash on her upper torso that had been refractory
to Western dermatological treatment.When she called to make
her initial appointment, she went into considerable detail on the
phone and the herbalist found herself spending quite a bit of
phone time fielding questions she could not possibly answer
without examining the patient in person.When Ms. W. came in
for her appointment, she asked for an extra sheet of paper to
supplement her responses on the intake form.When asked how
long she had had the rash, the patient gave details dating back
20-30 years, including the names of various doctors she had
been to and the years she had received treatment from them.
She also diverged from the main question and started telling the
practitioner how her mother had had similar problems and then
delved into stories about her dysfunctional relationship with her
mother. At one point she became quite emotional and started
crying.After 45 minutes, the herbalist realized they were still only
about halfway through the interview! By the end of the interview,
the herbalist felt that she had too much information but did not
have a good grasp on the chief complaint.

Needless to say, the original phone conversation was the star t-
ing point of the trouble. It was easy to see that this patient had
a lot to say, but the practitioner should have obtained the basic
information and then quickly but politely told the patient that
there would be plenty of time at the first appointment to discuss

her issues. When the patient showed up for her appointment,she
should not have been given extra paper to write on.The practi-
tioner could have told her that whatever would not fit on the form
could be discussed afterwards. When the herbalist realized the
patient was diving back several decades, she needed to wait
for that opportune opening in the conversation to insert a state-
ment like,“How long have you had the rash this time?”When the
patient started discussing her mother, the practitioner should
have immediately interjected, stating something like ,“ W h at I
really want to hear about is you.” This type of statement serves
the purpose of keeping the focus on the patient while at the
same time keeping the interview on track.
Case 2. A .K . is a 60 year-old man who had recently been diag-

nosed with cancer. He called the acupuncturist to see if Oriental
medicine could help him. The patient was not sure of his exact
diagnosis or even what type of cancer he had. He was also unable
to name any of the chemotherapy agents he would be receiv-
ing and was very unsure of his chemotherapy schedule. He was
also unable to fully describe his symptoms. His responses were
statements such as, “Sometimes my neck hurts, but not always.
Well, it really doesn’t hurt. I think it’s the headaches that bother
me the most.” The acupuncturist was incredulous at the patient’s
lack of knowledge and found it hard to hide his disbelief. At one
point he said, “How can you not know what kind of cancer you
have or when you start your chemo?” The patient became intim-
idated and clammed up even more. The acupuncturist felt frus-
trated and at a loss as to how to help this gentleman.

This patient is a man who is quiet by nature and unaccustomed
to talking about himself. The fear he had over his cancer diag-
nosis made him even less willing to talk. He did not fully under-
stand what chemotherapy could do for him, but he also had
never had acupuncture and did not know what to expect or

even what to ask for. The acupuncturist would have found it help-
ful to briefly broach the subject of how the cancer diagnosis was
affecting this man.When questioning him about specific symp-
toms, he could have used broad questions such as,“What is both-
ering you the most right now?”or “How do you feel now that is
different from the way you normally feel?”These questions may
have helped the man pinpoint his objectives as well as helped
the acupuncturist to divine the information he required.In addi-
tion, the acupuncturist should have paid even closer attention
than normal to the pulse and tongue signs to help him under-
stand where this patient was experiencing imbalances.
It’s a cultural thing

Culture can be a huge factor in communication difficulties. Earlier
in Chapter One, we discussed situations in which the patient and
practitioner do not share the same primary language. Even when
both parties are speaking the same language and have a good
working knowledge of that language, culture can still affect com-
munication. In some cultures, it is common for a person to talk
a lot and share their difficulties, even to the point of being overly
dramatic. This type of communication is sometimes a feature in
some Mediterranean cultures.
It can be frustrating to deal with this type of person if the prac-

titioner is not familiar with this culture or is from a culture that
does not promote expressive dialogue. Other cultures such as
Asian cultures encourage people to be taciturn. It is seen as a
sign of selfishness or even shame to talk much about oneself.
People from these backgrounds may only give one-word answers
to questions and may deliberately leave out very personal infor-
mation such as the emotional or sexual history.
If the communication difficulty is indeed due to cultural influ-

ences, it is even more important for the practitioner to try to
understand the patient. Hopefully there will be some obvious
sign that the person is from a different culture. They may speak
with an accent, have different colored skin, or even wear cloth-
ing that identifies their cultural background. Noticing these signs
is important on so many different levels. Of course we do not
want to stereotype anyone, but a healthy recognition of differ-
ences is vital to successful communication.
Cases in point:
Case 1. J. D. is a 38 year-old man with Crohn’s disease who

wants acupuncture treatments to help decrease abdominal
spasms. When he came for his first treatment, he was accom-
panied by two family members. He had no trouble revealing
personal details; in fact he did so to the point that the acupunc-
turist was somewhat embarrassed. The family members did not
share this discomfo rt . In fa c t ,t h ey chimed in quite often, some-
times disagreeing with the patient or with each other. Before the
acupuncturist could realize what was happening, the conver-
sation had strayed to an entirely different topic. The acupunc-
turist became frustrated and annoyed with the patient and his
family. He requested that the family step into the waiting room
for a while, but the patient explained that,“There are no secrets
in my family.” The family members were offended that they were
being requested to leave and the feeling in the room became
rather uncomfortable.

This patient was indeed from a Mediterranean culture in which
family input was expected, even in very personal situations. The
acupuncturist failed to recognize this as a cultural factor and
merely thought the patient and his family members were overly
demonstrative and talkative. The patient’s family name as well
as several comments made by him and his family members
should have tipped off the acupuncturist to the culture of origin.
Even if he could not identify the exact culture, he could have
determined that culture was a factor. Whenever this is suspected,

all angles of patient behavior must be held up to that light and
benefit of the doubt given. The acupuncturist should not have
discouraged family participation but should have set bound-
aries so that only one person at a time was talking. When the
topic changed,he should have indicated an interest in the new
topic very briefly but brought the conversation back around to
the patient’s health as soon as possible. He could have said
something like,“I wish we had more time to talk about that, but
right now I need to know what I can do to help.”
Case 2. K. M. is a 48 year-old Asian woman referred to an

acupuncturist for menopausal symptoms. Although the patient
spoke with a slight accent, she spoke English fluently. The patient
was extremely polite,friendly, and cooperative until the acupunc-
turist started asking questions about her menstrual cycle. The
woman became very quiet and gave only vague answers. She
did not make any eye contact at all.For some questions, all she
would say was,“Oh, I can’t answer that.”The acupuncturist began
to suspect that the patient was malingering and became upset
when further questioning was met with further evasiveness. Finally,
the acupuncturist told the woman she did not know if she could
help her since she was unable to give her the information she
needed. The patient smiled and quietly left the office.

This is a similar situation to the preceding one, only instead of
being too talkative, this patient was not talkative enough. Although
it was obvious she was from a different culture,she had lived in
this country quite a while and spoke very good English.Therefore,
the practitioner did not immediately recognize the woman’s hes-
itation as a cultural factor. In fact, the woman was unprepared
to be asked questions of a personal nature. Although she had
lived in this country for quite some time,her ties to her own cul-
ture were quite strong and she adhered to mores she had learned
as a child,including not discussing personal matters, even with

an acupuncturist.In fact,she expected the acupuncturist to be
able to determine her needs just from her pulse and tongue.
In this case, the acupuncturist’s options were very limited. She

could have suggested that the woman come again with a close
friend or family member if that would have made the patient
feel more comfortable.The other person could have assisted in
giving answers. Ultimately, the acupuncturist might have had to
rely on pulse or tongue diagnosis, or she might have had to refer
the patient to a practitioner who was of the same background
or at least more familiar with that culture.
A case of nerves
Anxiety and fear can also impede effective communication. Many
times this is seen when someone has been given a frightening
diagnosis. It may also just be a way of dealing with an unfamil-
iar setting. Even though Oriental medicine is gaining popular-
ity, there are still scores of people who have never tried it. They
may be victims of misconceptions or misunderstanding. They
may also be at the appointment under duress. Perhaps a well-
meaning wife or husband pushed them to come.
Anxiety may make them “run off at the mouth” as a way to

express their nervousness. On the other hand, these same emo-
tions can also make someone “clam up.” Anxiety can cause short-
ness of breath. Fear can be paralyzing. The patient may truly not
know what to say. In these cases, you must use your skills to help
alleviate the patient’s distress. Allow them some time to discuss
what may be making them nervous. Reassure them with simple
explanations. Assure them that they can ask questions at any
time and that they should tell you if they are uncomfortable with
any aspect of the treatment. If you suspect that their health con-
cern is the source of their inability to communicate, it might be
worthwhile to allow them a little time to discuss how they are
feeling about their condition.
Cases in point:
Case 1. W. S. is a 32 year-old who had been in perfect health

until he started having numbness and tingling in his limbs as well
as some double vision. Although tests were inconclusive, his
Western doctor had indicated that the diagnosis might be mul-
tiple sclerosis (MS). When asked about his symptoms, the patient
began talking very rapidly in a “stream of consciousness” fash-
ion. Whenever the practitioner tried to steer the conversation
back to the topic, the patient had trouble focusing and would
start talking about something else.This situation continued until
the acupuncturist asked the patient exactly why he was there
since he would not stay on the subject. This made the patient
more nervous and he felt that the acupuncturist did not want to
help him.

The acupuncturist in this case was not as sensitive as he should
have been to the overwhelming impact the patient’s symptoms
and possible diagnosis were having. Working in health care can
sometimes make us a little hardened to what a patient may be
feeling. We know that there are thousands of people with debil-
itating illness, and we see them on a regular basis. However, a
person diagnosed with such a condition cannot help but be
upset and feel as if their whole world is crashing in. They may
have heard dire things about the condition. They may know
someone with a similar diagnosis who did not do so well.There
are countless thoughts rushing around inside their heads and
they may have insufficient information to develop a clear under-
standing of what is happening to them. Talking quickly and
changing the subject can be methods of avoiding a topic that
is too frightening to discuss outright.
Noticing the chief complaint, the acupuncturist should have

been more sensitive to the patient’s emotional state and devoted
some time to asking the patient how this new development was
affecting him. That in itself might have been enough to soothe
the patient and help slow him down a little.
Case 2. P. C. is a 62 year-old woman who comes to the acupunc-

turist for relief from indigestion and bloating after meals. While
reviewing the patient’s medical history, the acupuncturist noted
that the patient had had breast cancer several years ago. When
questioned about this, the patient stated she was in complete
remission and was not currently receiving any cancer treatment.
She also said,“Once you have had cancer, nothing is ever the
same.” When the acupuncturist started asking the patient about
her digestive symptoms, the woman gave only brief, one-word
answers and was not able to provide details about her symp-
toms. She was also unable to maintain eye contact and contin-
ually looked out the window instead of at the practitioner. The
acupuncturist gave up trying to elicit responses from her and
relied on her pulse and tongue diagnoses. She was able to pro-
vide the woman with some relief from her symptoms, though
they did not resolve completely. The woman continued to have
problems communicating on all her subsequent visits.

In this case, the acupuncturist was not so put off by the patient’s
reluctance to talk, but her treatments were not as effective as they
should have been. The acupuncturist should have taken the
patient’s statement about cancer as more than just a passing
remark.Further discussion would have revealed that, even though
she was in remission, she was terrified of a recurrence and sus-
pected that her current symptoms were, in fact,indicative of the
cancer’s return. She was so afraid of this possibility, however, that
she could not bring herself to say it out loud. Her fear made her
turn to silence. In her silence, she found a place where she did
not have to reveal or acknowledge her fears. If she had been
given a chance to express her true inner feelings, she might have
actually felt relief in being able to talk about them.
It’s not all in your mind

Physical or emotional illness often has a profound impact on
behavior. When faced with a communication problem patient,
the practitioner should also be alert to any disease process that
might affect the patient’s communication. A bipolar patient in
the manic stage might have a tendency to talk nonstop and have
trouble staying on one subject. Someone who is very depressed
may find it difficult to engage in a conversation. More and more
adults are being diagnosed with a type of attention deficit
disorder (ADD). Attention deficit disorder may manifest as hyper-
activity, including “hyperactive speech.”
Stroke victims may have expressive or receptive aphasia. In

expressive aphasia, the patient knows what he/she wants to say
but cannot make the correct words come out. In receptive apha-
sia, the patient recognizes the words being spoken to him/her
but cannot make sense of them. Someone afflicted with Bell’s
palsy or any kind of facial deformity may also have trouble con-
veying their ideas. These types of patients require extra atten-
tion. In many such cases, the reason for the communication
problem may also be the reason the patient is seeking help. The
origin of the problem will be very obvious, but sometimes it may
be difficult for a practitioner to know how to deal with it. It is
always helpful if a friend or family member can accompany the
patient and help facilitate communication.
Cases in point:
Case 1. R. B. is a 65 year-old gentleman who suffered a mild

stroke several months ago. His daughter had heard that acupunc-
ture can be effective in treating the sequelae of st ro ke and
brought him in for an appointment.After she helped the patient
fill out his paperwork, she stated that she had to leave and run
some errands but would be back to pick the patient up in an
hour. Although the patient did appear to have some difficulty
conveying his thoughts, he also appeared to manage fairly well.
After the daughter left,however, the acupuncturist had difficulty
trying to get some further information from the patient. The patient
appeared to want to participate very much, but, every time he
opened his mouth, the words that formed did not make sense.
The acupuncturist was able to proceed with the tre at m e n t
nonetheless, but both he and the patient felt frustrated.

This acupuncturist was new to practice and had not had much
experience with stroke victims. When he witnessed the rapport
between the patient and the daughter, he felt that the patient
was able to make himself understood. After the daughter left, the
situation became more difficult. The fact is that the daughter had
become accustomed to her father’s aphasia and had devel-
oped effective ways to understand and communicate with him.
Of course, the acupuncturist did not have this benefit.
It would have been more appropriate for the daughter to stay

for the treatment to help everyone have a more beneficial expe-
rience. The acupuncturist would have been well within reason
to request this. If the daughter were unable to stay, he could
have asked her advice on how well the patient could commu-
nicate and what he could do to assist him. If the patient had
use of his writing hand, the practitioner could also have had
him write down some information or even some questions he
might have had.
Case 2. J. S . is a 45 ye a r-old woman seeking acupuncture

treatment for chronic depression. She was rather quiet during
the interview and gave mostly one-word answers to the practi-
tioner’s queries. In addition, she had a tendency to mumble
when speaking which sometimes made her speech difficult to
understand. Her body movements were slow and even labori-
ous, and she had trouble making eye contact. She sighed often
and sometimes had a delayed response to quest i o n s. T h e
acupuncturist recognized the severity of the woman’s condition
but had trouble finding the patience to bear with her. She even
found herself wishing the patient would seek help elsewhere.

Although the acupuncturist was aware of the severity of the
patient’s depression, she had trouble understanding how deeply
the depression affected everything the patient did, including
conversation. Severe depression is an emotional disorder that
often has somatic effects, including slow movements, laconic
speech, and inability to fully engage with another person. The
acupuncturist could have facilitated this encounter by keeping
questions very simple and using “yes/no”questions for the most
part. When the patient had delayed responses, the acupunc-
turist could have used this as an assessment tool, and could have
also evaluated the patient’s body language as a diagnostic
measure as well.This would have helped the practitioner herself
to stay engaged.
THE INSIDE STORY:

We take the power of speech for granted, but it is essential to our
interactions with others. Abnormalities or difficulties in this area
have a profound effect on relationships, and the health care rela-
tionship is no exception. There are many factors that affect the
way any given individual communicates. Sometimes difficulty
in communication is a symptom of an emotional or physical syn-
drome. At other times, cultural factors weigh in. Family history
also affects the way a person interacts with others. Similar to cul-
tural considerations, some families are quite demonstrative within
the family unit, while others are more reserved. Upbringing often
dictates how we behave in the larger social arena. Social isola-
tion may also make someone overly talkative or withdrawn.
In spite of all our high-tech ways to communicate in this society,

loneliness is rampant. In fact, technology can often make people
feel isolated. E-mail instead of phone conversations, telephone
menus, answering machines, and caller ID allow us more choices

for communication but, at the same time, reduce actual human
contact. Someone who is lonely, lives alone, and has little con-
tact with other people may take the opportunity of a doctor ’s
visit to engage in conversation. Because of their social situation,
they may not be aware of boundaries and may have a tendency
to talk too much or to linger after appointments just to have some-
one to relate to.
Conversely, social isolation may also cause someone to retreat

to the point that they lose some of their social skills and become
overly withdrawn in the company of others. As practitioners of
Oriental medicine, it is part of our job to help people feel con-
nected and more complete. Understanding the underlying causes
of communication difficulties can go a long way to achieving
this goal.
QUES TI ONS FOR C HA PT ER EI GHT:
1. Has there ever been a time in your life when you felt you
talked too much or not enough? If so, what was going
on with you at the time? Were you aware of how other
people reacted to you?
2. List three factors that contribute to rambling speech. List
three factors that contribute to vague complaints.
3. What are some illnesses that can affect the way a patient
communicates?
4. What are some social factors that contribute to com-
munication difficulties?
Mr. J. arrives at your clinic for his acupuncture appoint-
ment. He is being treated for HIV/AIDS. You have seen
him twice before and never had any problems, but today
he is unusually talkative. It is hard to get the treatment
started because he starts a lively conversation with the
receptionist. Once in the treatment room, he laughs inap-

propriately and starts talking about problems he is hav-
ing with his pet dogs. He has trouble staying on the
subject, and his speech is rapid. When you ask him a
question, he is unable to give a direct answer. How would
you handle this situation?
We must always be on guard and be aware of
what is happening in our own personal lives that
may cloud our judgment and drive us to feel some
kind of attraction toward a particular patient.
CHAPTER NINE
The Seductive Patient
The American Heritage Dictionary defines seduction as “1. entic-

ing into wrong behavior; corruption. 2. The act of inducing to
have sexual intercourse.” 1 The word “seduction” is most often
associated with sexual attraction and/or exploitation. The prac-
titioner/patient relationship is definitely not exempt from this
type of seduction. In fact, it can sometimes invite seductive behav-
ior in the patient as well as in the practitioner just by the very
nature of the relationship. So many of our patients are vulnera-
ble. They need and are seeking to be cared for. Perhaps they are
lonely or feeling rejected or were not sufficiently cared for as chil-
dren. Finding a health care provider who shows them empathy
and compassion can certainly foster feelings of emotional and
physical attraction.
The therapeutic relationship, though professional, is also intensely

personal. Patients share feelings and information with us that
they may never share with another human being. The lines
between professional intimacy and personal intimacy can often
149
become blurred. Too often, the attraction in this situation is a

false type of attraction. Either party is attracted not so much to
the person but to what the person represents. If an actual involve-
ment should ensue, the relationship is often doomed to failure
because it is based on unmet needs and realizations rather than
on true attraction to the actual person.
Of course, practitioners are by no means exempt from this type

of feeling, either. We must always be on guard and be aware of
what is happening in our own personal lives that may cloud our
judgment and drive us to feel some kind of attraction toward a
particular patient.
Seduction need not only be of a sexual or romantic nature, how-

ever. Sometimes a practitioner and patient find they have a com-
mon interest, hobby, or lifestyle. What starts out as small talk or
polite conversation can quickly grow into a more intimate bond-
ing. The patient or practitioner may find themselves wanting to
take their relationship further than the clinic. The patient may
invite the practitioner to some kind of social event that has to do
with a shared interest. Gifts may also be presented to the prac-
titioner. The practitioner, on the other hand, may find him or her-
self accepting such invitations or gifts and perhaps even
reciprocating in kind. The practitioner may also find that, dur-
ing the appointment time, he/she and the patient end up dis-
cussing common interests and losing focus on the reason that
the patient is actually there. The treatment then becomes sec-
ondary and ethical issues arise.
Atoo-personal relationship with a patient may also predispose

the patient to asking for or expecting favors or special consid-
erations from the practitioner. Of course, there are times when
a true friendship or even a serious romantic relationship may
arise between a practitioner and patient. In these cases, each
party needs to seriously consider how they wish to proceed. It
is usually not advisable to bring a friendship into a therapeutic
The Seductive Patient 151
relationship as the professional relationship may lose its power

and integrity to underlying emotional issues and expectations.
It is never appropriate to continue treating a patient if sexual
attraction is a concern, whether it is mutual or not.
■ Wearing skimpy or revealing clothing
■ Inappropriate physical contact with the practitioner
■ Complimenting the practitioner on his/her looks, personal
appearance, etc.
■ Flirtatious behavior
■ Gifts or invitations to social events
■ Conversation that leads away from the patient complaint or
from the treatment in general
Home again
Although this chapter is titled “The Seductive Patient,” you as
the practitioner can also be the seducer, or you may unwittingly
invite seductive behavior by your actions. As discussed in the
first chapter, a practitioner must always be aware of how he/she
is presenting themselves to their patients. Wearing skimpy or
revealing clothing is not appropriate under any circumstances.
Not only is it highly unprofessional, but it conveys a message
you may not be intending to convey. (If the intention is there and
is conscious on your part, then a whole new discussion needs to
take place!) It is very likely that you will find yourself being phys-
ically or otherwise attracted to one or more of your patients dur-
ing the course of your practice. This is normal and can be
controlled with a modicum of self-restraint. It is when the feel-
ings of attraction lead to action that the danger occurs. Mind your
words, your dress, and even your body language at all times in
order to avoid a potential powder keg in your clinic.
Be aware of your own life situation. Practitioners can be just as

vulnerable as any one else. If you have recently ended a rela-
tionship, divorced, or are unhappy in your present relationship,
you may find yourself looking for attention outside your per-
sonal life. You have access to a wide variety of people in your
practice and may find someone attractive. Or, if you sense that
one of your patients is attracted to you, you may be flattered by
the attention and be tempted to respond in a like manner.
Likewise, if you are new in town, are feeling lonely, or are feel-
ing overburdened by starting a new practice or maintaining an
existing one, a patient’s affection may be very appealing. It is
easy to lose perspective in a situation like this. Take advantage
of a good friend or a trusted colleague to get a more realistic pic-
ture of what you are feeling. So often, an objective party can shed
light on truths that are obvious but to which we are blind when
we let our emotions take hold of us.
Be mindful of your conversations with patients when you are

treating them. Small talk is a way to break the ice and also a way
of letting your patient know you are interested in them as a whole
person. If you and your patient happen to discover a common
interest, it is very easy to get swept away in a conversation that
focuses on that interest instead of on the treatment. Always
remember that you are there for the patient and not the other
way around. Also remember that the patient is paying you for
the time you reserve for them and they deserve the best possi-
ble care during that time.
Another danger of getting too closely involved with a patient is

that it may lead to a situation whose outcome is less than desir-
able. You may find that someone with whom you seem to be
compatible in the clinic is not really the person you thought they
were. While patients confide a great deal in us, they may also
hide a great deal from us as well. Furthermore, this type of involve-
ment can lead to actions which then present a problem in the
more personal relationship and this problem may carry over into
the therapeutic relationship.
It is crucial for the practitioner to be able and willing to set bound-

aries when the therapeutic relationship involves seduction of
any kind. As they say, silence implies complicity. As with any
undesirable behavior, the longer the behavior is allowed to go
on, the more the situation intensifies. Nipping it in the bud is
always the best course of action.
Cases in point:
Case 1. W. H. went to see an acupuncturist for hip pain that he

had had for a number of years. Due to the location of the pain,
he had to remove his lower body clothing in order for the
acupuncturist, a female, to treat the affected area. The acupunc-
turist explained everything she was doing and gave the patient
a sheet with which to drape himself. The patient made some off-
hand remarks such as, “I bet you get to see lots of guys without
their clothes on.” The practitioner brushed off these remarks and
continued to keep the sessions professional.Eventually, the patient
started commenting on her wardrobe, stating,“I love those cute
dresses you always wear. They really accent your figure.” At this
point, the practitioner became a little uncomfortable, but did
not say anything to the patient. On subsequent visits , however,
he started comparing the practitioner to his wife, saying things
like, “I wish my wife could understand me like you do,” and “I
always feel so good when I leave here.” The acupuncturist and
this patient had discovered earlier in the clinical relationship that
they both shared a passion for rock climbing, and the patient
started asking the practitioner to meet him at the rock climbing
gym. At first, she tried to laugh off these invitations, but the patient
persisted until she finally had to tell him she did not socialize with
patients at all. He continued coming for treatments, but the prac-
titioner always felt uncomfo rt able with him and found herself
rushing through his appointments.

In this case, the acupuncturist did her best to maintain a pro-
fessional attitude, but the patient was persistent in his seductive
b e h a v i o r. The mist a ke here was that the behavior was not
addressed before it progressed to an uncomfo rt able place.
When the patient first started making inappropriate remarks,
the practitioner should have immediately discouraged such
remarks. When the remarks then crossed over to her personal
appearance, a serious discussion needed to take place. Failing
to set boundaries allowed this situation to get to a level in which
neither party was benefiting and the patient’s care was com-
promised.
Case 2. D. B. was a long-time patient who relied on acupunc-

ture to help her with symptoms related to rheumatoid arthritis
(RA). She and the practitioner were approximately the same age
and had a lot of things in common.Over the course of time,her
visits took progressively more time because she and the acupunc-
turist would spend about 20 minutes in social chatter. One of their
shared interests was horses. The acupuncturist was also an avid
rider and was in the market to look for a new horse.The patient
stated that she knew several people who were selling horses and
that she could help the practitioner out.They met several times,
but the practitioner never found a horse she liked. The patient
spent time seeking out horses she thought would be good for
the practitioner and soon the practitioner started feeling obli-
gated to see all these animals, even though she was becoming
discouraged with the search and also was realizing that her rid-
ing ability was not as advanced as the patient had thought.While
she at first appreciated the patient’s efforts on her behalf, she
ended up feeling resentful and a little embarrassed and had a
hard time figuring out how to tell the patient she was no longer
interested in pursuing those avenues.

The acupuncturi st was well-meaning but did not re c o g n i z e
when the therapeutic relationship started to get offtrack. She
should have checked herself when she found her appointment
times with this patient getting longer and longer, but she allowed
it to continue because she herself was benefiting from the per-
sonal conversations. She did not have many other friends who
shared her hobby. Therefore, she enjoyed the mutual interest
she shared with the patient. When the relationship spilled over
into non-clinical areas, she became aware that she and the
p atient we re really not on the same level re ga rding hors e-
manship and her discomfort eventually infiltrated her clinical
relationship with this patient.
Sexual abuse
It is an unfortunate and incomprehensible aspect of our society
that abuse of all types is rampant. You will meet many people
who are victims of physical, verbal, emotional, and/or sexual
abuse. You yourself may have experienced these types of abuse
in your life. It is certain that many of your patients will have
abuse in their histories. Some will freely admit this to you and
will even seek treatment as a means of healing from past pain.
Others may be too embarrassed to discuss the issue or they sim-
ply may not have the level of trust required to share this with a
health care provider. Still other people will have repressed their
memories of abuse so deeply that they may not be aware of it. It
lies buried deep within the subconscious. And yet others will be
able to tell stories about abuse but may not see their story as seri-
ous or as true abuse, no matter how obvious it may be to an objec-
tive observer.
Sexual abuse is especially difficult for some people to define

or discuss. Its effects may manifest in a variety of ways. Some
survivors of sexual abuse may become shy and withdrawn and

may shun social contact. They may exhibit an extreme fear of
intimacy or of relationships in general. Feelings of mistrust are
common. However, a victim of sexual abuse may also exhibit a
heightened overt sexuality, even if they are inwardly feeling
awkward or afraid. It is not uncommon for sexual abuse victims
to dress provocatively or to be flirtatious or promiscuous.
Of course, some people display this characteristic even if there

is no history of abuse. It may not always be easy to determine
if someone is simply sexually expressive or if their behavior is
stemming from a painful past. Nonetheless, in any patient who
displays overt sexual behavior, the influence of abuse must at
least be suspected. How to deal with this situation is not easy
or clear cut. On one hand, this patient has many unmet needs
and is, in many aspects, quite fragile, although they may appear
self-confident and even aggressive. They may very much need
help but may not even be aware themselves of what has hap-
pened to them. In these cases, you must be careful and use your
intuition to determine whether a discussion is possible. You may
want to include on your intake form a space about possible
abuse. Some people will be honest, others may not be able to be
that honest and may leave that space blank or openly deny any
significant history. If you do suspect a history of abuse and the
patient does not indicate this in writing, you might try to find
a way to weave the topic tactfully into the interview.
In some cases, you can ask the patient outright, if that feels com-
fortable and appropriate. In any case, it is important to realize that
the outward manifestation of their sexuality might be a cry for
help. Outright rejection can be extremely detrimental. You must
proceed with caution. If you do discover that the patient has had
an abusive encounter and has not received help, refer them to a
mental health practitioner and urge them to get counseling.
Case in point:
B. M. is a 20 year-old woman who comes to the acupuncture

clinic for digestive problems. On her first visit,she is dressed in a
flimsy and revealing dress. She is openly flirtatious with the (male)
acupuncturist. The acupuncturist does not comment on her dress
or behavior. As part of the treatment, he needles Tian Shu (St 25).
The patient immediately starts crying but, at the same time,
becomes even more flirtatious, taking the practitioner’s hand
and telling him she needs a shoulder to cry on.At this point,the
acupuncturist becomes quite distressed. He does not understand
the sudden tears and is taken aback by the patient’s apparent
need for his affection.He becomes quite stern with her and tells
her that her behavior is not appropriate for a clinical setting and
that he feels they should end the treatment and perhaps con-
tinue another time.

Obviously, the acupuncturist here was not attuned to signs of
possible abuse. Acupuncture is a gentle healing form, but to
some people, it can also seem quite invasive. It is also a very
personal form of healing. This patient had been sexually abused
by her uncle, and the needles at Tian Shu (St 25) were close
enough to the abdominal area to bring on memories of her
past trauma, but she did not know how to express this. Her tears
we re an invo l u n t a ry reaction to painful memories that had
been re s u r rected during the tre at m e n t . The acupuncturi st
needed a heightened level of sensitivity to understand that the
young woman’s behavior was masking a deeper and more
s e rious pro b l e m . When she st a rted cry i n g , he should have
stopped the treatment but attempted to discover exactly what
was upsetting her so much. Even if she had not been able to
state her feelings or history directly, she might have dropped
some clues regarding her background. The acupuncturist might

have been able to pick up on these enough to gently broach
the subject of abuse. In any case, any further treatments would
be futile until the patient could be assisted to recognize the true
problem. In most cases, a history of abuse can lead to physi-
cal symptoms such as digestive problems later in life.
Hey, look at me!

The above situations reflect some serious problems and issues.
However, sometimes seductive behavior is simply nothing more
than another means of trying to get attention. Loneliness and
social isolation are common afflictions in our society. People may
feel they are ignored or unappreciated. Pressures at work or home
may contribute to such feelings. Some people’s self-esteem is low
enough that they feel the only way any one could like or pay
attention to them is through their physical appearance. Of course,
the media is no help here, as we are inundated on a daily basis
with messages that tell us we can get what we want by being
sexy. Cars, food, movies, and television all advertise with sexual
images, and the general public is eager to respond and to take
the message to heart. Women seem to be especially vulnerable
to this type of hype.
Case in point:
L. M. is a 50 year-old woman who wanted acupuncture for her

back pain. When she showed up for her first appointment, she
was dressed quite stylishly and wore quite a bit of make-up. The
acupuncturist, a male, assumed this was her usual attire for work.
However, she acted a little coy during the intake,not openly flirt-
ing with the acupuncturist but making some generally sugges-
tive remarks. Her behavior was similar on subsequent visits, and
the acupuncturist told her, in a gentle way, that her comments
were not appropriate for the clinic.She seemed genuinely star-
tled by his comments and insisted that she was not deliberately
trying to imply anything and that she was “just trying to make
small talk.” However, she also became a little teary at the same
time and seemed as if she were holding back tears.The acupunc-
turist then became somewhat uncomfortable himself and was
a little unsure as to how to proceed from there.

In truth, nothing truly went wrong here. The acupuncturist han-
dled the situation appropriately but did have some trouble deal-
ing with the patient’s emotional response to his remarks about
her behavior. During the interview, she had revealed that she was
new in town and had relocated after getting divorced.Sometimes
practitioners have to be detectives . An astute practitioner may
have realized that this woman was simply lonely and grieving
the loss of a relationship. He may have been able to find a way
to help her find some social activities in town. He could have also
complimented her on some achievement in her life, perhaps
even giving her positive feedback regarding her ability to start
over again.He could have mentioned that starting over takes a
lot of courage and effort.Non-suggestive compliments such as
these may have helped alleviate a sense of isolation and helped
her see more positive aspects of herself.
THE I NS IDE ST ORY:

Sexual energy carries a lot of power. Most of us are not fully aware
or equipped enough to deal with the ramifications of our own
sexuality, let alone that of others. Because sexual imagery is so
prevalent in our society, we all fall prey to its messages. In addi-
tion, the darker side of society is the abuse that so many people
suffer when they are young, innocent, and vulnerable. Although
we are becoming more able to discuss sexual issues openly, there
is still a level of discomfort and misgiving among many people.
Sexual energy can also be fraught with misunderstanding and
mixed messages. So many people have a “come hither” attitude
when all they really want is a little attention, recognition, or friend-
ship. It is imperative that we, as practitioners, are comfortable
with our own sexual nature in order to 1) provide safe and effec-
tive treatment for our patients, 2) to maintain an optimal clinical
environment and, 3) above all, to do no harm. Recognizing the
underlying behavior that leads to flirtatiousness or other seduc-
tions is the first and most important step in helping patients
achieve their best and most effective healing.
QUESTIONS FOR CHAPTER NINE:
1. What kinds of patient behavior can be considered

seductive?
2. What are some of the dangers inherent in becoming too
personally involved with a patient?
3. What are some of your own attitudes towards sexual-
ity? Are you comfortable with your own sexuality? Are
there any issues in your past that you feel you might
need to explore more in depth?
4. What are some methods a practitioner can use to assess
whether or not a patient may be a victim of sexual abuse?
A patient of your same age and sex comes to you for
acupuncture treatment for abdominal cramping. You
develop a good rapport with this patient over the course
of several treatments. On about the fifth treatment, how-
ever, the patient appears reluctant to leave the office.
Finally, he/she discloses that he/she finds you very
attractive and has been thinking that he/she would like
to become more involved with you. How would you
handle this situation?
Endnote:
1 American Heritage Dictionary, Davies, Peter, editor, 2003, NYDell Publishing Co., Inc.
Remaining steadfast to your policies
and remaining true to yourself are paramount
qualities to acquire in order to maintain
as smooth a practice as possible.
CHAPTER TEN
The Chronically Late/

No-show Patient
When operating your own practice, time and money are the most
important practical issues you will face. In these last two chap-
ters, we will deal with both of these topics and how they play
into the therapeutic relationship. In this chapter, our focus is time.
In general, most patients are conscientious about showing up on
time. In fact, many patients will arrive quite early for their appoint-
ments. However, there are those who prove themselves to be
chronically late.
Then there are the most vexatious and, perhaps, most difficult
to understand; the patients who simply do not show up. They
do not call before or after the appointment to let you know what
happened. They just do not show up. You will see a good deal
of these types of problem patients, and it is a good idea to decide
from the outset what your policies should be and how you are
going to handle these situations when they arise. Remaining
161
steadfast to your policies and remaining true to yourself are

paramount qualities to acquire in order to maintain as smooth a
practice as possible.
■ Consistently arriving over 10 minutes late for appointments
■ Not calling to inform practitioner of lateness
■ No excuse or a profusion of excuses
■ Making no apologies or being overly apologetic
■ Not showing up for appointment at scheduled time
■ Not calling to explain the reason they did not show up
Home again
1. Lateness
Deciding what your policies regarding lateness and no-shows
will be will depend quite a bit on how your office is set up. If
you have only one treatment room, patient punctuality will be
a critical issue. If one patient is late, that may upset the schedule
for the entire day in a kind of domino effect. You may want to
leave 15-30 minutes or so between each appointment in order to
allow a little room for unavoidable lateness (i.e., due to traffic,
weather, etc.). In this case, you may also want to inform all of
your patients of the situation on their first visits so that they will
have a clear understanding of the office dynamics and the impor-
tance of being on time. Your policy may include having to cut
the appointment short if the patient shows up late.
This information can and should be clearly stated in your dis-

closure form. It is a good idea to verbally discuss this with each
patient, since a lot of people do not take the time to really read
through what they are signing. Even if you have more than one
treatment room and can accommodate lateness, you do not
want to give your patients the idea that lateness is all right.
The Chronically Late/No-show Patient 163
Tardiness is disruptive, even if you can accommodate it, and it

also shows a lack of respect for the practitioner as well as for
the treatment itself.
Of course, there are very legitimate reasons for a patient to be

late. They may have had an unexpected situation at home or
work that delayed them. Weather and/or traffic may be a factor.
The patient’s children or other family members may have a last-
minute need that detained the patient. Most practitioners allow
at least a 10-minute window. Tell patients that, if they are going
to be much later than 10 minutes, they should call so you know
they are on their way.
If the patient shows a tendency to be chronically late, however,

you may want to ask them why they have such a hard time show-
ing up on time for their appointments. It is possible that you may
be able to help them problem solve or find ways to better man-
age their time to prevent future problems. If this fails and the
patient continues to show up late, you may have to curtail treat-
ment time or have a more serious discussion with the patient
regarding this bad habit.
2. No-shows
A ”no-show” is just that, a patient who makes an appointment
and then simply does not show up at the designated time. There
is no phone call or other explanation. This is perhaps one of the
most exasperating experiences a practitioner can have, and you
will find that it happens fairly often. Again, it is best if you have
your policy regarding no-shows set ahead of time so you do not
feel as though you are fumbling your way through a difficult
situation. Some practitioners give patients reminder calls the day
before the treatment. This is not a bad idea. Some people are just
plain forgetful or disorganized, and a friendly reminder call may
be the boost they need to remember that they have an appoint-
ment. For others, it may present the opportunity to cancel ahead
of time. Even though this is not really an ideal situation, it is still
better to know in advance if someone is not going to be there

than to sit around waiting and wondering. Surprisingly enough,
there are more than a few people who will acknowledge the
reminder call and still not show up.
■
Unfortunately, these types of patients
The truth is that
come with the territory.
time is money.
You must learn Most practitioners have a cancellation pol-
to view your icy that specifies that the patient needs to
own time give a 24-hour notice of cancellation. If
as a valuable this is not done, there is a full or partial
commodity. Even fee required. Unfortunately, there is little
we can do to actually enforce this policy.
if the patient
Hopefully, patients will comply and that
does not show up,
will help to stem future no-shows, but if
you showed they don’t, there is not much recourse.
up and reserved Again, point out your cancellation policy
that time slot to the patient and discuss it at the first
especially visit, even if they seem to have read the
for them. disclosure form thoroughly.
■
Do not make a big issue out of it. That
might alienate or offend the patient. But it doesn’t hurt to point
it out in a gentle way. The real problem with cancellation poli-
cies is that many practitioners have a hard time adhering to them.
Most people who gravitate towards the healing professions have
little or no interest or aptitude regarding business management.
Most of us would volunteer our services if we could and if we
did not have to make a living ourselves. Some practitioners feel
guilty enforcing the cancellation policy. They feel they are tak-
ing someone’s money but haven’t done anything to earn it.
The truth is that time is money. You must learn to view your own
time as a valuable commodity. Even if the patient does not show
up, you showed up and reserved that time slot especially for
them. It is very likely that you showed up early and did some
prep work too, such as preparing the treatment room or research-

ing that patient’s particular problem. You deserve to be com-
pensated for your time and effort. Enforcing the policy is a way
of letting patients know you are serious about what you do and
that you expect them to respect you and the healing process. It
is quite acceptable to waive the policy on the first occurrence,
but to let the patient know in a gentle way that if it happens again,
you will need to charge them for a missed visit.
If a patient does not show up for an appointment, a telephone

call is in order. There are several reasons for this. First of all, it
lets the patient know you care about them. After all, an accident
or other unforeseen event may have occurred. A telephone call
will let the patient know you care and will also give them a chance
to explain what happened. The call is also another way of letting
the patient know you do take your appointments seriously and
do follow up on them. If the patient has a legitimate reason for
not showing up, express understanding and ask if they would
like to reschedule. If it is not the first time the patient has not
shown up, try to determine the reason for this. The patient them-
selves may not always understand their own actions, but it won’t
hurt to ask, and it may give the person pause to consider what
they are doing. Review the cancellation policy with them.
If the patient continues to not show up, you may have to refer
them to someone else or to a different modality and terminate
your relationship with them. Although taking a stern stance can
be difficult for someone who works from the heart, in the end it
will boost your practice, increase patients’ respect for you, and
raise your own self-esteem. Being compassionate does not mean
you need to be a martyr. In addition, we all must be representa-
tives of our profession. There are still many people who do not
view Oriental medicine as a serious discipline but rather as a
novelty or a side-kick to Western medicine. Whenever we take
ourselves seriously, we help the public to do the same and so
benefit not only ourselves, but our profession as a whole.
Cases in point:
Case 1. R. J. is a 65 year-old man who suffers from low back pain

and intermittent sciatica.He was referred for acupuncture care
by a friend of the practitioner’s.Although he experienced improve-
ment in his condition as a result of his treatments, he often showed
up about 20 minutes late for his appointments. At first,the prac-
titioner said nothing since the man was apologetic and seemed
to sincerely regret his lateness. However, he usually did not offer
an excuse for the lateness and soon he began showing up even
later for appointments and wreaking havoc with the clinic sched-
ule. On one or two occasions, other patients were kept waiting
in order for R. J. to receive his full treatment time.
Finally, the acupuncturist informed him that his lateness was keep-
ing other people waiting and that he would have to make an
effort to show up on time. He expressed understanding, but the
next time he came, he showed up a half hour late. The acupunc-
turist told him he would not be able to treat him in the remain-
ing time and he would have to reschedule. The patient then
became quite sad and upset that he could not get his treatment
and stated that,“My pain flared up last night, and I really need
some relief today.” The acupuncturist relented and gave him an
abbreviated treatment, but was upset with the man’s behavior.

The acupuncturist’s main mistake here was not addressing the
problem seriously from the start.As we have seen in previous sit-
uations, bad behavior that is allowed to continue will do just that.
And the longer it goes on,the more difficult it is to correct.When
the patient showed up a half hour late, the acupuncturist should
have remained strong in telling the patient he would have to
reschedule.Giving a shorter and less effective treatment,espe-
cially when the practitioner was feeling upset with the patient is
not good practice and does not benefit either party. In addition,
it merely reinforces to the patient that if he shows up late,he will
be seen and does not give him much incentive to arrive on time.
It is also not fair to other patients who do show up on time to be
kept waiting or to be inconvenienced in any way.
Case 2. E.S.is a 28 year-old man who has been coming to the

acupuncturist for a few years on and off for various problems.
He had recently taken a high-stress job position and called the
acupuncturist to schedule some appointments to help him deal
with his stress. He did not show up for the first appointment,and,
when the practitioner called him, he was profusely apologetic
and rescheduled for the next week. He did show up for that
appointment but then missed the next two after that.Each time
the practitioner called him to find out what happened, he again
apologized profusely but had one or two more no-shows. The
acupuncturist did not review her cancellation policies with him,
and then felt awkward confronting him with the situation.

One of the main difficulties in the above scenario is that the
patient had been coming for acupuncture for quite some time,
and the acupuncturist felt kindly toward him. They had devel-
oped a good rapport over that period of time and she was afraid
to “make waves” or to seem too harsh to the patient.When he
repeatedly failed to show up on time,she was reluctant to men-
tion the cancellation policy also and the behavior continued.
This young man needed some guidance with time manage-
ment.Although his attitude towards his treatments was sincere,
he was allowing other obligations to eclipse his responsibility to
himself and to the practitioner.
The acupuncturist could have used this situation as a teaching

opportunity to help the patient assess his new lifestyle and set
his priorities. It is understandable that she was hesitant to enforce

her cancellation policy with a loyal patient, but, when the behav-
ior started to follow a pattern, she should have sat down with the
patient to discuss the inappropriateness of his no-shows. She also
could have offered to give him a reminder call the day before
his appointments to help keep him on track.
■ THE I NSI DE ST ORY:

Chronic lateness Time management is a big problem for a
can be seen as a lot of people. Many people have so many
person’s exerting things going on in their lives that they
their will or control find it difficult to keep track of every-
over a situation thing they need to do. It is easy to see
when other how someone could be late or even for-
aspects of their get to show up for an appointment. The
pace of today’s society barely allows any
lives may seem
breathing room. Realizing that people
to be careening
may be overwhelmed by their life’s activ-
out of control. ities can be a starting place to under-
■ standing a seeming lack of re g a rd for
health care treatments. Practitioners can use their skills in teach-
ing lifestyle changes and time management to patients as part
of the treatment itself.
For other people, time is a means to gain and exercise some con-
trol over circumstances in their lives. Chronic lateness can be
seen as a person’s exerting their will or control over a situation
when other aspects of their lives may seem to be careening out
of control. People who do not show up for appointments may
be exhibiting a similar desire for some control over their lives.
If illness has forced them to curtail some activities or they are
faced with caring for an ill family member, they may also feel
that they have little freedom in their lives.
In some cases, not showing up for appointments or being

chronically late may also be a sign of mounting frustration.

As always, a good practitioner must be aware of these hidden
factors and be willing and able to assist the patient in under-
standing themselves as well as promoting respect for their health
and for the practitioner.
In other instances, it is the sad truth that patients may not be tak-
ing alternative health care appointments as seriously as other
obligations they may have. They may regard Oriental medicine
as something that is not really that important or even as a kind
of frivolous luxury that they do not have a real need for. Our job
as practitioners is to continually educate the public about the
benefits as well as the seriousness of our profession.
QUESTI ONS FOR CHA PT ER T EN:
1. Examine your own time management behavior. Do you

tend to be punctual or are you consistently late? If you
tend to be late, can you think of any reasons why this
is so?
2. How does it make you feel when other people are late
in meeting you, whether in a professional or personal
relationship?
3. How can a patient who is chronically late or a chronic
no-show disrupt a clinical practice? What are some rea-
sons patients may exhibit this type of behavior?
4. Design a policy for your practice that addresses lateness
and no-shows. What difficulties do you foresee in adher-
ing to these policies?
J. D. is a 52 year-old patient with lung cancer who started
acupuncture treatments a few weeks ago to help with
the side effects of her chemotherapy. While she gener-
ally arrived on time for her appointments, there were a
few occasions on which she was over 15 minutes late.

More upsetting than that, however, is that on a few occa-
sions she did not show up for her appointment at all.
Follow-up phone calls revealed that the patient had sim-
ply forgotten the appointment, and she always apolo-
gized and always rescheduled. How would you handle
this situation?
Examine your own views, feelings,
and relationship with money
from the outset of your practice.
C H A P T E R EL E V E N
The Nonpaying Patient
As much as most of us would like to think that money is not our

main objective in choosing a healing profession, we must admit
that we, too, have to make a living. You have spent a large amount
of time, energy, and money in serious pursuit of your training
so that you can be the best practitioner you can be. During the
course of your practice, you will have patients who are quite
wealthy as well as patients who are barely making ends meet.
In many cases, insurance may help to cover a patient’s costs, and,

if you decide to accept insurance, part of your problem is solved.
However, depending on where you live and what your views
on insurance are, this may not be an option for your practice. It
is important to remember that money lends value to things. That
is just the way our society operates, and, whether we like it or
not, we do have to operate within that paradigm at least part of
the time, especially if we want to seriously pursue and maintain
our business.
171
Most people do not want a hand-out. In fact, many people feel

uncomfortable if they think they are being treated like a “char-
ity case.” Offering free treatments reduces the value of the treat-
ment itself and may negatively, though unwittingly, affect a
patient’s self-esteem. Of course, there is definitely an appropri-
ate time and place to do pro bono work. This is one way mem-
bers of the Oriental medical profession can make a positive and
selfless contribution to our world. There is no shortage of need,
and each practitioner must decide for him or herself how much
time and service to donate and what causes to focus on. This
chapter is not about pro bono work. It is about people who, for
whatever reason, fail to pay for the service provided and how
you as a practitioner can handle such cases.
While the majority of your patients will be happy to pay for your
services, there are those who may ask for some kind of leniency
or who may not pay you at all. You will have to seriously review
your own relationship with and feelings towards money in order
to have a clear idea not only of what your fees will be, but when
you may wish to do some pro bono work and when you may
need to insist on payment.
■ Hinting that they do not have enough money to pay for
treatments
■ Telling the practitioner stories of personal financial trouble,
but not necessarily saying they cannot pay
■ Asking to be billed rather than paying up front at time of
appointment
■ Not sending payment in after receiving a bill
■ Remarking on how expensive treatments are
The Nonpaying Patient 173
Home again
In my experience, money is a bigger issue than you might imag-
ine when you first start out. When you are consumed with stud-
ies, making a living while going to school, getting used to a whole
new way of thinking and living, and memorizing more material
than you thought possible, the logistics of starting, building, and
maintaining a practice may not be foremost on your mind. Many
aspiring Oriental medical practitioners have a vague and foggy
notion that, if they practice from the heart ■
with integrity and compassion, the money
The bottom line is
will follow.
that your patients
While this may be true in some cases, the are your source of
majority of experienced practitioners will income. They are
tell you that the money does not flow where the money
effortlessly and that it requires continual comes from! When
effort to keep a good cash flow. It is wise faced with a
to seek out advice from someone who is patient who does
experienced who can guide you regard-
not pay or has
ing practice-building and marketing strate-
trouble paying,
gies. The bottom line, however, is that your
you must keep
patients are your source of income. They
are where the money comes from! When in mind that
faced with a patient who does not pay or that is money out
has trouble paying, you must keep in mind of your pocket.
that that is money out of your pocket. ■
As stated above, many people entering this profession have some

conflict with money. We are, for the most part, compassionate
humans who sincerely want to help others, and the thought of
doing this for profit may make us feel selfish or mercenary.
Examine your own views, feelings, and relationship with money
from the outset of your practice. If possible, try to identify areas
where you feel uncomfortable with money. Do you feel guilty or

ill at ease taking money from people for your service? Are you
comfortable with your fees? Do you feel you deserve to make a
good living? Sometimes views of what we perceive as our own
inadequacies make us feel we do not deserve to be paid what we
are worth.
Beginning practitioners may be especially vulnerable to such

feelings, viewing their lack of practical experience as a liability.
While you may initially want to charge a little less than a sea-
soned practitioner, do not sell yourself short either. Your time,
energy, and training are worth a lot. If you are experiencing dif-
ficulty in your own relationship with money, it might be a good
idea to seek some counseling so you can attain a reasonable level
of comfort. Conversely, if all you see are dollar signs, then you
might need to seriously consider your priorities and the reason
you chose this profession in the first place.
Setting your fees is, of course, an essential step in starting a prac-

tice. The best way to do this is to see what other practitioners are
charging. By the time you graduate, you will have a fairly good
idea of typical fees for Oriental medicine in your area. You may
want to start at the low end of this scale but do not undersell
yourself. Our society values money and charging too little may
give people the idea that your services are not quite up to par,
that you are struggling and desperate, or that you lack confi-
dence. Charging too much at the outset can also be detrimental.
You need to be honest with people about your actual level of
experience. Many people will find it hard to pay a novice the
same fees as a senior practitioner, but they also do not expect to
pay peanuts for legitimate service.
Once you determine what your fees will be, assess your comfort
level with them. If you feel your fees are reasonable but, for some
reason, you do not feel comfortable with telling people what they
are, consult with other practitioners for advice. You can also
practice with an imaginary patient in front of your mirror. Try

saying your fees out loud to this imaginary patient or practice
with a friend until the uneasiness wears off. When you do tell
people your fees, use a confident voice. Wavering will only make
you look unsure of yourself.
Part of setting your fees is deciding whether or not to treat at a

discount, to use a sliding scale payment system, or to treat some
patients for free. If you decide to set discount fees or to use a
sliding scale, decide ahead of time exactly what type of patient
would qualify for this benefit. Also look at your own overall
costs and what you need in order to make a decent living for
yourself and to cover your monthly expenses. If you are not
skilled at accounting or bookkeeping, it is a good idea to seek
the help of someone who does this for a living. Free treatments
really should be reserved for extreme cases, promotional events,
or demonstrations.
Bartering is often a good alternative to actual monetary exchange

if a patient really does not have the cash to pay. Bartering should
be an equal exchange. So be sure that what you are bartering for
has the same value as your treatments. It is a fact that, if some-
one receives something for nothing, the value of what they receive
lessens. Patients will take you and themselves more seriously if
they pay in some way for what they are getting.
Case in point:
V. B. recently graduated from Oriental medical school and has

started her own practice. She set her fees at $70.00 for initial vis-
its and $60.00 for follow-ups, which is in keeping with the standards
of her community. She gets a call from someone inquiring about
her services. She explains her practice and what she can do for
this person. Then the potential patient asks about the cost of a
treatment. She tells the person what her fees are. There is some
hesitation on the other end of the line, and the acupuncturist
quickly states, “I can offer a discount if that’s a problem.” The

person on the other end then asks what the discount is. The new
practitioner stutters a little, then says, “I can offer you the first
treatment at $60.00 and the follow-up visits for $50.00.” The new
patient takes her up on this offer. However, when she hangs up,
the practitioner feels frustrated, confused, and unhappy.

V. B.,as a new practitioner, had not yet reached a comfort level
with her own fees. Even though she initially stated her actual fees,
the caller’s hesitation threw her off. She should have allowed the
caller to indicate whether or not she could pay those fees. She
assumed that the caller’s hesitation meant that the caller was
troubled by the stated fees when it might just as well have had
nothing to do with the call itself or might have simply been the
caller reviewing her own finances to see if she could afford the
treatment.Instead, the practitioner’s insecurity led her to a hasty
decision to offer a discount she did not feel comfortable with. A
little practice with a friend or in front of a mirror might have helped
her feel more at ease with what she was charging which was, in
fact, competitive and quite reasonable to begin with.
The cupboard is bare

One of the most difficult situations you will face regarding pay-
ment of fees is the patient who sincerely wants and needs your
help but honestly cannot afford it. People’s finances can be poor
for any number of reasons. Some people work at low-paying jobs
and do not have the means or desire to do anything that would
get them better employment. There are too many families out in
the world who are struggling. The cost of raising a family can be
astronomical. Add to that unexpected medical bills or legal fees
and the situation can quickly become a crisis. When the econ-
omy is down, layoffs are rampant, and many people who had
good incomes find themselves looking at financial hardship.
In short, most people do not suffer lack of finances because of

sheer laziness. There is often some sort of misfortune or socio-
economic disability behind the money situation. The difficulty
facing the practitioner is how to accommodate these patients
while fostering respect and value for your services. Some prac-
titioners decide to maintain a fairly stalwart attitude towards
their fees and insist on payment; if a person is unable to pay, the
person will not receive the care. However, I feel that these prac-
titioners are in the minority. Most practitioners are more than
willing to find some way to get these patients good care. These
are the situations in which you might want to consider your slid-
ing scale or discount rates. Always measure the patient’s per-
ceived need and sincerity when calculating these matters. Most
practitioners would not want to turn these types of patients down.
Remembering that “something for nothing” usually is not a good

policy, you can offer some sort of trade or barter if that is an
option. You can also offer the sliding scale or discount rate
dependent on the patient’s actual income. Even a fee of $10.00
will be significant to a patient who is scraping the bottom of their
barrel. The upside of this is that these patients will often find a
way to pay the full fee if given enough time or may reimburse
you at a later date when their situation improves. Even if you
find yourself balking at the lower fee, keep in mind that this
patient may be so appreciative of your generosity that he/she
will become a good referral source for you!
Case in point:
C.V. is a 62 year-old woman with chronic fatigue syndrome (CFS).

She does not know much about acupuncture, but is desperate
to find some help for her condition.She is on Medicaid and has
a very limited budget for out-of-pocket expenses, and is dis-
mayed to find that she will need a series of at least weekly treat-
ments for at least 10 treatments. The acupuncturist quotes her his
fee of $75.00 for the first visit and $65.00 for the follow-up visits.
The patient explains her financial situation and the “vicious cycle”
she is in. Even though she is on Medicaid, she is working part-
time. She would like to work full-time, but the CFS prevents her
from doing so. This acupuncturist does not adhere to any kind
of discount policy and regretfully tells the patient he cannot treat
her unless she can pay the full fee.The patient expresses under-
standing but leaves the office feeling frustrated and disappointed.

In this case, the acupuncturist felt a necessity to not offer any
reduced rates, which is certainly his prerogative. However, in
being so rigid, he denied care to a truly needy individual who
was willing to pay what she could. A better choice in this situa-
tion would have been for the practitioner to work with the patient
within her means. Of course, he had every right to abide by his
own policies, but he could have also checked around for her
and helped her find another practitioner who would off e r
reduced fees. This would have left the patient feeling cared for
and would have sent her away with some options instead of a
heart full of discouragement. What he did not know was that
this woman did find an acupuncturist who was willing to work
with her financially, and she was able to refer three new patients
to that acupuncturi st .
The check is in the mail

Unless a particular patient is under an insurance plan, most of
your fees will or should be expected at the time of service. Most
practitioners would feel very uncomfortable asking for the fee
up-front before the treatment is given. It is much more common
and acceptable to collect your fee after the treatment is done. In
most cases, your patients will pay by check or cash. You may
have the means to collect fees from credit cards, too, which is a
convenience for your patients and can help eliminate the “for-
gotten checkbook” syndrome (unless they’ve forgotten their
credit card, too).
Generally, patients are happy to pay for the service they have
received. However, once in a while, a patient may be caught
off-guard with no means to pay. In the majority of cases, this
oversight is real and no malingering is intended. Not everyone
carries their checkbooks around all the time, and some people
only like to carry a limited amount of cash. It is entirely possible
and not uncommon for someone to forget their checkbook or
even the wallet they carry their credit cards in. In other cases,
however, it might be that the person really is trying to get away
without paying. At other times, simple forgetfulness might again
be the culprit.
You will have to assess each situation individually and decide

how to handle it. If it is a known and trusted patient, you can tell
them they can pay you at the next visit or can send the payment
in the mail. If it is a relatively new patient ■
or someone you don’t have complete The important
trust in, make sure you have their cor- thing here is not
rect address and tell them you will send
to let a missed
them a bill. It is a good idea to get that
payment slide.
bill in the mail to them as soon as pos-
It is what is due
sible. If 3-4 weeks pass and you still do
not receive payment, send a second bill you for your
or make a “friendly reminder” telephone honest work
call requesting payment as soon as pos- and effort and
sible. There are a few practitioners who patients need
do enlist the services of a collection to be held
agency if the patient persists in not pay- accountable for
ing, but many other practitioners find their part in
that this problem is so small it does not
the therapeutic
warrant this avenue. Depending on
relationship.
where you practice, your patient, and
how large a practice you are managing, ■
you will have to make that decision for yourself. If you do not
choose to use a collection agency, there is really no means to force
the patient to pay. You may end up forfeiting that fee, but, if the
same patient calls again for an appointment, remind them of their

outstanding balance and let them know you cannot treat them
again until the balance is settled. The important thing here is not
to let a missed payment slide. It is what is due you for your hon-
est work and effort and patients need to be held accountable for
their part in the therapeutic relationship.
Case in point:
D. M. is a 45 year-old woman who has been coming for acupunc-

ture treatments for migraine headaches. She has a develop-
mentally disabled son at home and has been coming to the
same practitioner for several months. She looks forward to her
treatments, but, for the last four treatments, she tells the acupunc-
turist she has forgotten her checkbook.The acupuncturist has a
lot of compassion for this patient because of her home and social
situation and decides to allow a balance to add up each week,
trusting that the next week, the patient will pay in full. However,
each week progresses without full payment and before long,
the balance is up to $300.00 and the patient states that she can-
not pay it all at once. The acupuncturist reluctantly tells the patient
she cannot treat her until the balance is paid.

This is another case in which some preventive action could have
stemmed a situation from getting out of hand.While the practi-
tioner was within reason to let the patient “off the hook” initially,
after two or three missed payments, the fee needed to be frankly
discussed with the patient. Although this patient was dealing with
a difficult home situation as well as migraine headaches, many
other people are also suffering hard times. If the practitioner
allows all of these patients the same leeway, she will find herself
very short of cash. Addressing the situation earlier would have
allowed the patient to make more reasonable payments and
would have also solidified the practitioner’s stance on payment

options. The patient’s unintentionally neglectful behavior would
not have had a chance to get out of hand, and both the prac-
titioner and patient would have felt more at ease.
THE INSIDE STORY:

It is true that, “Money makes the world go round,” no matter
how much we would like to deny this fact. Money means dif-
ferent things to different people. Some people have feelings of
guilt or resentment around money, while others simply do not
have enough. Some people who have more than enough money
may horde it and not share it with others, while some of the poor-
est folks can often be the most generous, sharing the last of what
they have to help others. You as a practitioner must find out what
your own feelings around money are and find a way to feel com-
fortable with accepting money as tender for your services.
Your patients also have their own views on money. For some,
money may represent control or a degree of comfort and secu-
rity. They may be reluctant to part with something that gives
them this sense of satisfaction. When money or lack thereof is an
issue, you must be able to determine patients’ sincerity and future
ability to pay and set realistic expectations both for yourself and
for them. It is not your responsibility to teach anyone financial
maturity, but you do need to feel confident enough in yourself
to be able to collect the payment you deserve.
QUE STI ONS FOR C HA PT ER EL EVEN :
1. Think about your own relationship with money. What

are some of your feelings about money that may affect
your practice?
2 . What are your views on the system of bartering?
A re there any limits you would set on this practice
in your clinic?
3. What are some of the underlying factors that might make

a patient miss one or more payments?
4. What are your views on pro bono work and how can
you incorporate that into your practice and still make a
living for yourself?
L. M. is a student in his mid-20s who cannot come for
acupuncture treatments but is willing to take bulk herbs
on a consistent basis for his IBS. After a few months of
taking the herbs, his symptoms are starting to resolve
very nicely, but he has missed two payments so far and,
on the last visit, states he lost his job and does not know
when he will be able to pay you again. He suggests some
bartering arrangement, but he is a little unclear as to
what he may actually be able to exchange for the herbal
therapy. How would you handle this situation?
CONCLUSION
Being part of a healing profession is not only a career goal, it is
a privilege, and one that all of us should take with the utmost
respect and due care. Illness, pain, and suffering induce people
to behavior that can be troubling for a practitioner. It is part of
the art of our medicine to see the patient as a holistic being, includ-
ing any type of behavior that is manifested. Problem behavior
can in itself help diagnose what is wrong and can point the way
to areas of need. It is the practitioner’s responsibility to see beyond
the surface of the behavior and to recognize the causes of the
problem behavior, and then to take measures to assist the patient
to grow beyond this stage. Although dealing with such patients
may not be the highlight of your day, it is still imperative to treat
them with the same respect and consideration as anyone else.
Remember that, beneath the puzzling and sometimes annoying
behavior, there is a hurting human being, exactly the kind of per-
son you went into practice to help.
Being a health care practitioner is an awesome
responsibility. The work is rewarding and, most of
the time, enjoyable, but you must never forget that
you have an ethical, moral, and legal obligation to
render the best care possible to each and every client.
C H A P T E R T W E LV E
Terminating the
Therapeutic Relationship
One of the most difficult crossroads a practitioner can come to

is the realization that a therapeutic relationship is no longer ther-
apeutic and should be terminated. There are many reasons why
this situation may manifest and, unfortunately, no easy solutions.
In most cases your relationship with a client will have a natural
beginning, middle, and end point. When the patient’s condition
improves to the satisfaction of both parties, the patient generally
does not schedule future appointments or schedules maintenance
appointments appropriate to his/her condition.
In some cases, however, the patient demonstrates a need or desire

to continue to come for treatments, even when it is apparent to
the practitioner that the patient is either not receiving benefits
from the treatment or is hanging on for some kind of dysfunc-
tional reason. I have touched briefly on this subject in some of
the individual preceding chapters, but would like to explore this
183
issue in a little more depth. It is a topic that most practitioners

would prefer to avoid because it is unpleasant and we would
rather not deal with it unless it actually occurs. However, it is
always best to be prepared for an eventuality rather than to find
oneself at a loss for action in the midst of a difficult situation.
■ Being a health care practitioner is an awe-

As Oriental some responsibility; the work is reward-
medicine ing and, most of the time, enjoyable, but
gains greater you must never forget that you have an
acceptance, ethical, moral, and legal obligation to ren-
expectations of der the best care possible to each and every
client. The majority of these clients will be
Oriental medicine
delightful to work with, and those who
practitioners will
are difficult may prove to be amenable to
increase. We must
various strategies, some of which have
hold ourselves been discussed in this book. It is not a
to the highest given that you will like all of your patients.
standards of It is, in fact, a given that there will be
patient care. patients you do not like. Simply not lik-
■ ing a patient, however, is not reason
enough to terminate your relationship
with them. Your responsibility is to help them heal, not to like
them. As Oriental medicine gains greater acceptance, expecta-
tions of Oriental medicine practitioners will increase. We must
hold ourselves to the highest standards of patient care.
REASO NS NO T TO EN D
T H E T H E R A P E U T I C R E L AT I O N S H I P
1.“I can’t stand this person!”
It would be wonderful if we could truly embrace every person
on their own terms and accept them completely. But just as we
want to acknowledge the humanity of our clients, it is important
to realize that we, too, are human! Personality differences abound
everywhere, and the clinical setting is no exception. You may
encounter clients whose basic personality grates on your nerves.
Te rm i n ating the Therapeutic Relationship 185
Perhaps you don’t like the sound of their voice, their manner-
isms or the way they dress. Nonetheless, you owe them as much
time, effort, and consideration as any other client. This is a time
when a practitioner may need to practice a healthy form of detach-
ment; in other words, to provide the necessary service but not to
become emotionally entangled in your feelings for the person.
It might be helpful to call on a colleague to vent some of your
feelings or to ask for helpful coping strategies. It is always pos-
sible to refer the client to another practitioner, but if he/she prefers
to stay with you, is compliant, pays and shows up on time, you
do not have much legal leg to stand on if you want to end your
professional relationship with them.
2. “I can’t figure out what to do!”

It is common for Western-trained practitioners of Oriental
medicine to have little or no clinical experience in dealing with
difficult diseases before graduating and going into independent
practice. Unfortunately, our Western society is a fertile ground
for complex diseases manifesting several patterns of disharmony
all at the same time. Signs and symptoms seem to pile up and
contradict each other. Pulse and tongue diagnosis do not match,
symptoms do not fit easily into patterns of differentiation, and
the practitioner feels like he/she is floundering. It is tempting to
throw one’s hands up and say, “I just don’t want to deal with
this anymore!” It is encounters such as these, though, that pro-
vide some of the best learning experiences.
If you are baffled by a client’s presentation, it is time to do research,

to hit the books, to confer with others in your field, and to deci-
pher the meaning beneath the complexity. With persistence and
honest intent, this task is possible, if not always easy. By plow-
ing through the unknown, you will shed light on areas you need
to strengthen. If you really get stuck in this type of situation and
have truly tried everything you feel is at your disposal, then a
referral to someone more experienced may be in order. Most
patients will appreciate your honesty in this matter (and so will
the other practitioner!). If it is a case of treating a condition you

do not feel drawn to or interested in, the simple answer is: do
not take the case in the first place! At the beginning of your prac-
tice, you will be eager to accept any client
■
that is willing to come to your office and
Remember,
be treated, but it is important to learn dis-
though, that cretion and to discern the kinds of cases
each situation is you really do want to attract.
unique and
each individual’s R EASO NS TO EN D THE
characteristics and T H E R A P E U T I C R E L AT I O N S H I P
personal situation There are several valid cases in which a
must be taken practitioner may ethically, legally, and
into account. morally end a relationship with a patient.
No matter how It is important to remember that this can
never be done lightly. In most cases, a sin-
negative or
gle incident is not enough to warrant ter-
unpleasant a
mination. Usually, the practitioner must
particular client demonstrate that there has been a consis-
may be, tent pattern of unacceptable behavior that
it is in everyone’s has not been amenable to suggestions
best interest for and/or attempted solutions.
the practitioner
to remain Following are some of the most common
reasons a therapeutic relationship may be
professional,
justifiably terminated:
caring and as
pleasant as Noncompliance: A patient who delib-
possible during erately and repeatedly fails or refuses to
the termination comply with practitioner advice and
process. i n s t ruction places him or herself in a
potentially dangerous situation. A prac-
■
titioner cannot reasonably be expected
to assist a person who will not comply with medical advice. If
a patient is showing a pattern of noncompliant behavior and
the practitioner begins to feel that the relationship should be
terminated, the practitioner should start documenting the spe-

cific details of the client’s noncompliance as well as all meas-
ures the practitioner has taken to address the problem. The
situation should be reviewed with the patient at intervals dur-
ing the course of the treatment. If the problem continues, the
practitioner may well have reason to end the relationship.
Anger/Abuse: As discussed in the chapter on the angry patient,

anger usually masks a variety of unexpressed emotions. With a
little compassion and a lot of patience, a compassionate practi-
tioner can often assist a client to work through feelings of anger,
uncover the source of the anger, and facilitate emotional as well
as physical healing. However, there are those people whose
anger is so deep rooted that it may not be possible for the prac-
titioner to assist them. In fact, they may require the help of a men-
tal health expert. This type of anger may involve abusive language
or behavior towards the practitioner, staff, and even other clients.
This type of behavior is not acceptable and if the strategies in

Chapter Four prove to be unsuccessful, the practitioner may have
sufficient grounds to terminate the relationship. In this case, it is
of the utmost importance to explain fully to the client the rea-
sons he/she cannot continue to be seen in your clinic. You your-
self may want to consult with someone in the mental health
profession to assist you with finding the best possible way to
deal with a dysfunctionally angry client. It is a good idea to have
someone else present when you talk to this patient to help dif-
fuse tension if the situation looks like it might escalate or if the
client has difficulty accepting what you are conveying.
Seduction: Sexual advances, physical attraction, or outright

harassment are not appropriate at any time in the health care
setting. If the attraction is mutual, the practitioner and client
must agree to end their clinical relationship in favor of the per-
sonal one, and the client can then seek health care elsewhere. If
it is a one-sided attraction initiated by the patient or experienced
by the practitioner, the clinical benefits of the relationship are

in danger and the relationship cannot continue. This can be a
touchy (no pun intended!) subject to broach with a client but
temporary embarrassment or discomfort is better than an
unhealthy clinical partnership. Your disclosure form should
include your policy about sexual relationships in the clinic, and
you can refer to this as a starting point if you find yourself in
this situation.
Nonpayment: You are providing a fee for service. This should be

clear and apparent at the outset of every client encounter. Fee
schedules must be included in your disclosure form, and it is a
good idea to discuss fees with each client in person to avoid mis-
understanding. Most practitioners expect full payment at the
time of service. If there is third party reimbursement, then pay-
ment will be made according to the insurance policy. If a client
refuses payment even after a series of bills, reminders, etc. have
been sent, the practitioner is not obligated to continue treatments
until the bill is paid in full.
There may be other cases in which a practitioner decides it is

in the best interests of all concerned to discharge a patient
from care. The above list includes the most common cases.
Unfortunately, there is no easy formula to guide a practitioner
in ending a professional relationship with a client. The individ-
ual chapters in this book provide some strategies specific to each
type of patient behavior. Remember, though, that each situation
is unique and each individual’s characteristics and personal sit-
uation must be taken into account. No matter how negative or
unpleasant a particular client may be, it is in everyone’s best
interest for the practitioner to remain professional, caring, and
as pleasant as possible during the termination process.
It is wise to check with your state’s regulatory agency regarding

policies about ending a patient/practitioner relationship. In some
cases, the practitioner may be charged with patient abandonment
Terminating the Therapeutic Relationship 189
if there is not sufficient evidence to warrant termination of a patient.

If your state’s regulatory agency does not have a clear policy, it is
best to adhere to the standards to which Western medical practi-
tioners are generally held. This usually includes the following:
1. Documenting a consistent pattern of unacceptable,

difficult, or problem behavior and all measures the
practitioner and staff have taken to resolve the problem.
2. A 30-day written notice sent to the patient’s home

outlining the problem and the reason the professional
relationship is to be terminated. It should be made clear
in this notice that you will continue to assume care of the
patient during this 30-day period while he/she seeks out
another source of health care. You should also offer to
assist the client to this end in any way feasible.
3. Alist of other practitioners to whom the patient can

be referred. This list can also include any appropriate
community resources you feel might benefit the client.
4. Offering to forward the client’s medical records (with

proper release, of course!) to the client’s new practitioner.
Hopefully, with your instinctive compassion, personal resources,

and the suggestions in this book, you will never find yourself
in the position of having to terminate a patient relationship. If
you do, keep in mind all the legal, ethical, and moral ramifica-
tions and take every necessary precaution to protect yourself
and your client.
CONCLUSION
Like everything else in life, your career as a practitioner of Oriental
medicine is a journey. This journey will take you to many thrilling
and rewarding places, and will also present you with constant
challenges along the way. I hope this book will be one of the tools
you use along this journey. Most of the patients you will see over
the course of your career will be delightful, cooperative, appre-

ciative, and responsive. There will, of course, be those who frus-
trate and confound the practitioner. Instead of regarding these
“difficult” patients as pesky problems to be avoided and dodged
at every turn, we should accept them with open arms and greet
the challenge they present. Indeed, you
■
will probably discover at some point that
The most
these difficult patients have something to
important thing teach you. In any case, you need to treat
to remember them with increased compassion and real-
is that beneath ize that the problem behaviors they pre-
the annoying sent have deeper meanings. Above all,
behavior, the practitioners should never take these chal-
confusing lenges as personal affronts. In a world as
messages, and hectic and abrasive as ours, everyone
needs understanding, and some people
the frustrating
need more than others!
presentations, the
difficult patient is Some of the problem behaviors studied
a hurting human in this book include noncompliance,
being—exactly anger, dependency, and seduction as well
the kind of patient as practical issues such as timeliness and
you went into finances. In all cases, the practitioner
practice to help! should always look first to him or herself
to see if he/she is in any way contribut-
■
ing to problem situations. In order to help
others heal, we must be willing and able to look at ourselves
and to find healing for what ails us, as well. In addition, a prac-
titioner must realize the importance of not being a martyr and
of taking care of our own well-being. Appropriate rest, diet, and
recreation are essential for the practitioner as well as for the
patients he/she counsels. Taking care of yourself will make
you better able to care for others. In most cases, with a little
understanding and some extra care, a difficult patient can be
successfully treated and can even become a treasure for you.
Your patience and attention will be rewarded when you see

this client healing, making positive lifestyle changes, and pro-
gressing towards fulfillment of their own personal goals.
There may, however, be those clients whom you cannot assist

fully, who continue to abuse your care no matter how patient
and understanding you are, who refuse to pay, do not respect
clinic hours, etc. These are probably the most difficult situations
since they often involve the painful decision on the part of the
practitioner to end the therapeutic relationship. If you find your-
self in such a situation, be sure you follow all the legal routes
outlined by your state so you avoid liability. No matter how dif-
ficult the client may be, you are still responsible for providing
care until an alternate solution can be reached.
Difficult patients are part of the territory of being in the public

arena and assuming the responsibility of being a health care
provider. There are numerous ways to assist even the most chal-
lenging patient. The most important thing to remember is that
beneath the annoying behavior, the confusing messages, and the
frustrating presentations, the difficult patient is a hurting human
being—exactly the kind of patient you went into practice to help!
■ Bibliography ■
Beinfield, Harriet, L.Ac. and Korngold, Efrem, L.Ac. OMD,

1991, Between Heaven and Earth,
NY, Ballantine Books
Davies, Peter, editor, 2003,

American Heritage Dictionary,
NY, Dell Publishing Co.
Desmond, Joanne and Copeland, Lanny R., MD, 2000,

Communicating with Today’s Patient,
San Francisco, Jossey-Bass
Hooberman, Robert E., Ph.D, and Hooberman,

Barbara M., MD, 1998, Managing the Difficult Patient,
Madison CT, Psychosocial Press
Kaptchuk, Ted J., OMD, 1983,

The Web that Has No Weaver,
NY, Congdon and Weed, Inc.
Platt, Frederic W. and Gordon, Geoffrey H., 1999,

Field Guide to the Difficult Patient Interview,
Philadelphia, Lippincott, Williams, and Wilkins
Sohr, Eric, MD, 1996, The Difficult Patient,

Miami, Medmaster
193
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Understanding

NANCY BILELLO RN, L.Ac.

Blue Poppy Press

First Edition October 2005

COPYRIGHT 2005 © BLUE POPPY PRESS

The publishers do not advocate nor endorse self-medication by laypersons. Chinese

COMP Designation: Original work using a standard translational terminology

I would also like to thank my partner, Mark Newmaster for his

Receptionist: Mrs. S. is here early for her appointment.

Practitioner: Oh no, not “Needy Nelly” again! Wasn’t she just

The above dialogue and variations thereof occur every day in

As practitioners of acupuncture and Oriental medicine, we

especially problem behavior, in this model of holism? We are

Problem behavior can manifest in a number of ways. Some

One of the aspects of health care that has always bothered me is

It is distressing that there is so little instruction in our schools

While we may not like or be comfortable with all the conduct

This book was written largely based on my own experiences as

THE PURPOSE OF THIS BOOK

practitioners. It is always easier to start off on the right foot

Chapter Two goes on to define and identify what comprises a

Chapters Three through Eleven go on to discuss specific types

Chapters Three through Eleven also include sections titled “clin-

THE INSIDE STORY:

QUESTIONS FOR DISCUSSION:

setting. I believe that exchange of ideas between like-minded

THE DI FFICULT PRAC TITIO NER

In any situation in which personality or behavior becomes a

1. Am I doing anything to contribute to or foster

2. Did I already have a negative impression of this

3. Is this situation bringing up any personal problems for

4. Is my office set-up or my staff posing some kind of

It is crucial for every practitioner to constantly be aware of his/her

A place of one’s own

almost anyone at ease. Needless to say, your choice of decor will

It is certainly appropriate to keep magazines, journals or reprints

Slow, soothing background music is a nice addition to any office

Why is it so important to give people choices? One of the surest

If you do have an office staff, choose them carefully. They should

need these numbers, but, in a challenging situation, you do not

Looks aren’t everything, but . . .

Hair length is also a personal choice. Long hair should be tied

Whether you are male or female, it is wise to keep your hands

Make-up and jewelry are also factors to think about. Make-up

Colognes and perfumes are best avoided. ■

Meeting & greeting

Although the public is becoming more educated and more aware

If the patient has never had acupuncture or herbal treatment,

Oriental medicine handy to recommend to ambitious clients who

Actions speak louder than words

POSITIVE BODY LANGUAGE AND PATIENT INTERPRETAT I O N

Sitting up, comfortably, with slight “I’m bringing my full energy,

Maintaining appropriate eye con- “You and I have an important

Nodding the head occasionally “I’m listening, I’m interested in

Upper torso not closed off by “I am available to give you my

N E G ATIVE BODY LANGUAGE AND PATIENT INTERPRETAT I O N

Examining test results, intake “I’m going to ignore your emo-

Responding to the patient’s “I can’t get personally involved

“OK. OK. Cut to the chase,

“Do you really think I care about

“This is really boring. Maybe I can

speaking. It can also convey unintended messages. As a health

as this may be reminiscent of an angry parent about to scold an