Liberation Acupuncture and Integrative Medicine
The oppressors – who oppress, exploit and rape by virtue of their power – cannot find in this power the strength to liberate either the oppressed or themselves. Only power that springs from the weakness of the oppressed will be sufficiently strong to free both. Paolo Freire, Pedagogy of the Oppressed
Acupuncturists have a difficult relationship with the healthcare system. Almost all of us chose acupuncture because it provided us with an alternative to conventional biomedicine. Some acupuncturists want to stay outside the system entirely, inhabiting “alternative medicine” as if it were an alternate universe, while others want to carry what they see as the strengths of alternative medicine into the mainstream, transforming conventional biomedicine into something kinder, gentler, and more holistic. This latter group typically describes their approach as “integrative medicine”.
That’s the ideological perspective; the economics are something else entirely. The question about whether to practice inside or outside of the healthcare system generally translates into whether or not to bill insurance. Some acupuncturists see billing insurance as a straightforward way to increase their cash flow and diversify their patient base; many patients who are unwilling to pay out-of-pocket market rates for acupuncture are happy to use the “acupuncture benefit” their health insurance plan provides. The process of billing insurance, however, is much more complex than just submitting claims. It imposes many aspects of the healthcare system – not only on the business side of acupuncture but on its clinical practices, including both patients’ and practitioners’ concepts of what acupuncture does and how it does it.
Given how difficult it is for most acupuncturists to earn a living, the question about whether to practice inside or outside of the system isn’t just about how much money you might earn, it’s also about the opportunity to work and about what relationships it’s possible to have with both individual patients and society as a whole. The alternate universe of alternative medicine can be too small and too lonely for many acupuncturists to sustain.
My own relationship to the healthcare system is complicated for a number of reasons, not least that one of my formative experiences was having an acupuncture job in an “integrative” public health clinic and subsequently losing it due to budget cuts. I’m acutely aware that there are millions of people who can’t afford to pay out of pocket for acupuncture, even when – as in my own clinic – the cost of acupuncture is $15 a treatment and no insurance premiums are involved. However, once third parties are participating, everything changes -- and those changes can include the possibility of an acupuncturist’s job disappearing overnight. For this reason among others, I have always been wary of practicing “integrative medicine”.
Over the last few years, however, a series of events has shifted my perspective.
In 2012, my clinic began a collaboration with one of the “coordinated care organizations” created to serve Medicaid recipients. The WellBeing Program (not its real name) represents an approach to health care reform that is sometimes described as “hot spotting”, or focusing attention on “high utilizers” of the health care system. The “high utilizers” are the 20% of the patients who access 80% of the resources, with recent hospital admissions or frequent emergency room visits, often because they suffer from multiple chronic conditions that are poorly managed. Because they are Medicaid recipients, they are also experiencing poverty and intersecting forms of oppression such as racism, sexism, disablism, etc. Clients of the WellBeing program are assigned caseworkers to help them navigate the healthcare system, to coordinate care, and to advocate with them.
The WellBeing Program (WP) caseworkers approached my clinic to get access to acupuncture for their clients. Because these clients are all already taking multiple medications, many of them are interested in trying a non-pharmaceutical therapy (like acupuncture) to better manage problems like pain, mood issues, stress, and addiction. Because we thought that only a relatively small proportion of the WP clients would want to try acupuncture, we agreed to provide unlimited treatments at no charge just to see what would happen.
In Oregon, Medicaid does “cover” acupuncture for a limited range of conditions and a limited number of treatments. Patients must have a referral from a primary care provider in order to receive three treatments. It is rare for patients to be approved for more than ten treatments. Unfortunately, acupuncture works best at managing chronic conditions and chronic pain when it is available frequently and regularly – meaning multiple visits a week for long periods of time. It seemed to us that Oregon's Medicaid acupuncture benefit would not be of much use to the WP clients, since the structure of limits and gatekeeping around treatments did not match either their level of need or the reality of their lives.
Whatever their feelings about alternative vs. integrative medicine, most acupuncturists would agree that the WP clients at our clinic represent the way that acupuncture can be most useful to 21st century America. Our healthcare system has a lot of problems. Many people don’t get what they need from it, even when they are “over-using” it. Too many people are taking too many medications. Chronic conditions are hard to manage.
Our data is neither complete nor fully analyzed, but a preliminary analysis shows that about 100 WP clients have tried acupuncture at our clinic over the last two years. 19% of them chose to receive 10 or more treatments. 39% came only once. The remaining 58% fell somewhere in between. The WP clients, compared to other people who get acupuncture at our clinic, are more likely to have transportation challenges (the cost of bus fare can be prohibitive) and also to be juggling numerous medical appointments. Even so, the proportion of people who became “regulars” and the proportion who got acupuncture only once are fairly similar to our general patient base.
Over the last two years, we have also observed that the WP clients, as individuals receiving acupuncture at our clinic, do not in any way stand out from the rest of our patients. They are not more demanding or more difficult to serve. They fit right in.
The WP caseworker who initiated the collaboration noted that the impact of WP clients having access to community acupuncture was positive because, in her words:
People feel welcomed at this community acupuncture clinic. This is not always the case in the larger medical system where they may be labeled as problem patients, malingerers, drug seekers, or someone with a personality disorder. At this community acupuncture clinic there is a predictable structure, minimal talking, and a lot of reliability which allows for relaxed and non-pressured healing relationships.
Unlimited resource sharing is rare for people living in poverty. Having a community acupuncture clinic say that you can come as much as you want is the antithesis of almost all current social resource allocation practices. Everything is limited: money, medical, counseling, food, housing, etc. By having an open door, judgments about self-care do not get in the way of treatment and, in fact, are not a part of the dialogue and culture of this clinic. This cuts down on feelings of guilt which trauma survivors so commonly battle.
This clinic asks little of patients. They don’t have to fill out forms or questionnaires every time they visit. They don’t have to share an awkward amount of personal information. I think this cuts down on self-care guilt.
For clients with trauma histories, acupuncture provides: relaxation, relaxation while with other people, and access without expectation. It seems to heal the nervous system although I am not sure how. What I see with clients is not that all of their symptoms go away, but they are able to handle things in their lives better. They are able to pause; their viewpoint becomes larger. They are triggered less often and have less anxiety. Being in an environment where you are not alienated or seen as different allows peoples’ hyper-vigilance to relax. There is a major component of isolation when it comes to trauma. Community Acupuncture has the potential to heal that part of trauma.
Access to community acupuncture is important from a trauma informed perspective because it offers restoration of dignity. By being welcomed and given unlimited access the message becomes “you know yourself…you know what you need…and the community is here to support you in that effort”. This is an important message for someone who is feeling overwhelmed and alienated in society –especially feeling that way when trying to get medical treatment.
People are also getting pain management needs met. For survivors of trauma there is often a long history of being labeled as having psychosomatic symptoms, being hysterical, being drug seeking, or having interpersonal deficits which re-traumatizes people, makes people hopeless, which then increases symptoms of pain. I think of my own situation in which I was told my 3 years of chronic pain was a “stress response” without any direction given, the main message being, “you need to manage your stress better”. In general the message in conventional biomedicine is you are doing something wrong which is causing your poor health/pain and if you would just do xyz then you would be better/get better/be a better person.
At the same time we were developing our WP collaboration, we were working on opening our own acupuncture school. From the moment we began the collaboration, I knew that the relationship was just as positive for us as it was for the clients and caseworkers of the WP. It wasn’t until we began to describe the foundation of our school as Liberation Acupuncture, however, that I was able to understand exactly why.
I first heard the phrase, “trauma-informed” from an WP caseworker. I didn’t know exactly what it meant, but it got my attention. During the same period, I was having discussions with other acupuncturists with trauma histories to both provide peer support for each other and to figure out best practices for working with patients with trauma histories. It wasn’t long before we connected the dots and discovered the new universe of trauma informed care.
Observing how the WP clients used acupuncture at our clinic made me think about how everyone else uses it and how we as acupuncturists understand what we do. At the same time, because of the new school, I was reading Paolo Freire’s Pedagogy of the Oppressed. I felt that I understood some things in a new way, in the context of trauma-informed acupuncture, integrative medicine, Liberation Acupuncture, and above all, our relationships with the individual clients and caseworkers of the WP.
1) Paolo Freire writes that it is everyone’s vocation to become more fully human. The process of liberation is about becoming a new person: “no longer oppressor nor longer oppressed, but human in the process of achieving freedom.” Freire’s ideas about education have great relevance to the practice of healthcare. Healing is always humanizing. If it’s dehumanizing, it isn’t healing. Unfortunately, as noted above, many aspects of our healthcare system can be dehumanizing. Many people seek out acupuncture because conventional medical systems left them feeling disempowered, overwhelmed, and feeling like an object. Acupuncture can’t do everything for everyone, but trauma informed acupuncture can be a tool to help restore people’s dignity.
2) Freire believed that the problem with most education is that it follows a “banking” model, which mirrors oppressive society as a whole. Students memorize mechanically, which “turns them into “containers” or “receptacles” to be “filled” by the teacher. Education becomes “an act of depositing, in which the students are the depositories and the teacher is the depositor.” Substitute here "the problem with healthcare" for "the problem of education", using the image of patients instead of students as depositories to be filled and the image of practitioners instead of teachers as depositors doing the filling, and you’ll get a good idea of why healthcare can be a disempowering experience.
For the acupuncturists who value the idea of integrative medicine, a key to getting acupuncture established in the mainstream has been defining the process of seeing an acupuncturist as analogous to seeing a physician. When acupuncturists bill insurance, they bill the treatment as an “office visit”: there’s a diagnosis and a diagnosis code, a treatment and a treatment code. Making an individualized diagnosis is key to being able to make the right treatment, the right deposit, into the patient.
However, both the “office visit” model and the banking model fail to reflect both the reality and the potential of what acupuncture can do. Studies suggest that 1) acupuncture’s effectiveness increases with the number of treatments provided, and 2) up to 60% of acupuncture’s effectiveness is due to non-specific factors. No medical treatment works 100% of the time, but in the case of acupuncture, it’s vital to recognize that acupuncture only works if people use it. The most important part of the equation is not a perfect diagnosis by the practitioner but the active participation and engagement of the patient. When people have virtually unlimited access to acupuncture, not all of them will choose to use it. The ones who get the best results are the ones who get a lot of it -- in other words, the ones who really like it.
3) “Indeed, the interests of the oppressors lie in ‘changing the consciousness of the oppressed, not the situation which oppresses them’; for the more the oppressed can be led to adapt to that situation, the more easily they can be dominated. To achieve this end, the oppressors use the banking concept of education in conjunction with a paternalistic social action apparatus, within which the oppressed receive the euphemistic title of ‘welfare recipients’. They are treated as individual cases, as marginal persons who deviate from the general configuration of a ‘good, organized and just’ society. The oppressed are regarded as the pathology of the healthy society...(t)hese marginals need to be ‘integrated,’ ‘incorporated’ into the healthy society that they have ‘forsaken’. The truth is, however, that the oppressed are not ‘marginals’, are not people living outside society. They have always been ‘inside’ -- inside the structure which made them ‘beings for others’. The solution is not to ‘integrate’ them into the structure of oppression, but to transform that structure so that they can become ‘beings for themselves’.” (p.74)
Paolo Freire’s description of ‘welfare recipients’ fits the situation of the WP clients exactly. From the perspective of healthcare reform, “high utilizers” rather than capitalism itself are frequently blamed for the skyrocketing costs of healthcare. A lot of integrative medicine is focused on getting individuals to change their diet and lifestyle so that they can stop being sick. The idea is that their ignorance about health must be corrected so that they stop being a drain on the system, and this can be accomplished only by depositing knowledge into them.
What we learned from offering high utilizers as much of our services as they wanted was that they are not a problem: neither as individuals, nor as a group. They are not a drain on our clinic. In contrast, they use acupuncture exactly like people who are theoretically less marginal than they are. Furthermore, because of the clinic's structure people who become regulars require less energy to treat than people who are new. They know what to do and they inhabit the clinic space as if it belongs to them, as if they are at home in it. Because treatment is provided in a communal space, regular users help establish the atmosphere of relaxation for new people. If we believe that an important dynamic of Liberation Acupuncture is the process of entrainment, or the synchronization of different people into a state of harmony, then regular users are contributing as much as they are receiving. No one is depositing or being a depository; everyone is simply sharing.
People who use acupuncture as self-care are, in a sense, using acupuncture to try to be “beings for themselves”. Observing how the most marginalized people use acupuncture, and why it is beneficial for them, helps us understand why it is beneficial for everyone else. It's clear that trying to prescribe herbs for patients who are already taking a long list of medications is not a good idea; it's clear that offering lifestyle advice to people who have to worry about being evicted is unhelpful. Articulating why acupuncture at our clinic met the particular needs of the WP clients helped us articulate in general the parameters of Liberation Acupuncture as a distinct school of thought, intended to serve a much wider range of people than other types of acupuncture.
4) The collaboration between our clinic and the WP clients and caseworkers led to conversations with other people within Oregon's Medicaid program about what we were trying to do, why, and how to do it better. As a result, we began to try to frame the relationship in a way that made sense in the context of third party payers and integrative medicine. Or, as one medical doctor put it, “How would you describe this relationship if you were thinking like a health plan?”
Setting aside for the moment the question of economics and payment, the answer to that question is that Liberation Acupuncture can and should be translated into the context of integrative medicine; it simply requires a different model.
The closest equivalent in the conventional healthcare system to Liberation Acupuncture would be a psychiatric day program where patients can come as often as they want in order to share in a healing community environment that is dependent on the participation of their peers. You could describe Liberation Acupuncture as a day treatment program for certain physical and psychological effects of trauma, including those inflicted by capitalism itself, that is open to, and supported by, the public at large.
5) To borrow Freire’s words: the solution is not to integrate acupuncture into the structure of oppression, but to use it to transform the structure wherever possible.
Returning to the question of economics and payment – from the time I lost my public health job in an integrative clinic, I have struggled with how to both relate to the healthcare system (especially its public health aspect) and how to work with patients who have no choice other than to engage with it and cannot afford the low end of our sliding scale. Thinking through the relationship with the WP clients and with the larger coordinated care organization itself helped me see a different – and liberating – possibility.
If our model is a day treatment program to be accessed freely and at will, rather than a limited series of individual visits prescribed by an authority, this has economic as well as philosophical implications. The goal does not have to be how to figure out how to reimburse for individual visits: the goal can be to make the program itself available to as many people as possible. The question becomes: how big would our clinic have to grow in order to be able to provide acupuncture to people receiving Medicaid in our geographic area at a price they could genuinely afford? We know that if you offer people unlimited acupuncture, most of them will not take you up on it. The ones who do are the ones who get the best results and who contribute the most to the clinic itself by offering their presence. If people are allowed to decide how much acupuncture they want and need, they will choose appropriately. It does not seem to be possible to abuse the offer of affordable acupuncture, as long as the systems of the clinic work properly. We also know that many members of the general public will gladly pay for acupuncture at $15 to $35 a visit. We don’t yet have the data required to fill in values for all of the variables within this equation, but we do know that the equation can be solved without compromising the principles of Liberation Acupuncture.
There is another economic model for acupuncture as integrative medicine that does not require billing third-party payers.
In conclusion – during our two year collaboration with WP, it has been difficult to explain why we were so enthusiastic about providing services that we refused to bill for. The framework of Liberation Acupuncture has given me a clear understanding. It still might not make sense to anyone else, but here goes:
It often feels to me that the only power that our society offers us is the power to buy and sell -- including human relationships, including ourselves. Acupuncturists often seem to be obsessed with asserting their worth in relation to the healthcare system: are we being valued or devalued? You can only answer that question with a dollar amount, and whatever it is, it never seems to be enough for the acupuncturists asking the question. The perspective that comes out of this obsession is that acupuncturists will not have a meaningful role in society until we are appropriately compensated or “valued” by third party payers. Our relationships with patients are dependent on the market. It seems to me that much of the effort that acupuncturists put into integrative medicine is really about whether the market will recognize our worth, our value, our right to exist.
Freire and others have written that the system that oppresses you will never willingly give you any power: you have to take it. Our collaboration with the WP clients and caseworkers is important to me because through it, we are able to say -- with actions, not just with words -- that we refuse to be bought and sold. We refuse to have our relationships defined by the system and the market, by what anyone wants to pay or can pay for our services. In this instance, the power that we take is the power to create relationships, the power to be human beings with other human beings, in the face of a society that is constantly trying to dehumanize all of us.
However, the only reason we are able to create relationships, to have this power, is because the WP clients are willing to give us a chance. As people who are often marginalized by the medical system, they are taking a much greater personal risk in trying acupuncture at our clinic than we are taking in offering it to them. By giving us their presence in the clinic, they are giving us something precious and irreplaceable.
Through our relationship with them, we have come to understand both Liberation Acupuncture and ourselves at a deeper level. We have been able to imagine a different model for integrative medicine, a different relationship to the healthcare system. The WP clients, as people who are arguably most oppressed by the system, showed us how to be in relationship to the system so that we could be free. As Freire said, they liberate us.