Written by Shauna Springer, Ph.D., James Lynch, M.D., and John Okiishi, Ph.D.
Let’s define the problem. Despite the commonly observed rhetoric around the value of team-based care, meaningful, active collaboration between healthcare providers is the exception to the rule in some areas. In many systems, patient care is fragmented between providers who never connect or consult with each other about how to align their expertise.
In some systems, virtual referrals are sent for co-occurring care, and this is accepted as a substitute for meaningful collaboration between providers. In the worst cases, providers feel a sense of “ownership” over their patients and fail to refer them for treatments that may be helpful. My co-authors and I have served our patients through a fusion of expertise that is intentional, collaborative, and highly effective. A strong focus for each of us has been to support patients exposed to trauma.
In this article, we will propose a new model for addressing trauma that fuses expertise and strategically sequences the skills of allied providers. To illustrate the value of this model, we will highlight a potentially game-changing treatment that pairs a biological intervention called Stellate Ganglion Block (SGB) with high quality psychological care.
By way of brief introductions, my name is Dr. Shauna Springer. Known as “Doc Springer” to our nation’s warriors and their families, I am the Chief Psychologist for Stella Center and one of the nation’s leading experts on trauma. To make the argument that our model of trauma care needs a fundamentally different approach, I am joined by two highly esteemed colleagues.
Dr. Jim Lynch is a trusted Army physician to many of our nation’s most elite warriors. A combat veteran of five deployments throughout his 31-year career, Dr. Lynch is a highly skilled Family and Sports Medicine Physician who has also served as a Team Physician for the US Olympic Team since 2011. For the past ten years, Dr. Lynch has been a pioneer in the advancement of stellate ganglion block to treat post traumatic stress symptoms.
Dr. John Okiishi is a fellow Psychologist who has worked with Doc Lynch for many years as a trusted, insightful, sought-after provider to warriors in the Special Operations community. As part of a team of therapists who develop and implement wellness and resilience programs in this community, Dr. Okiishi provides clinical care to active duty Soldiers and their families, many of whom have completed 10+ deployments in combat specific roles.
As collaborating authors, we divided who took lead on various portions of the content to follow as indicated.
Why does the problem of fragmented care exist?
Springer: Instead of blaming health professionals for being ego-driven and “unwilling to collaborate with others,” let’s consider how systems shape and maintain this behavior. Professionals who spend several years of their adult lives in graduate schools in the health field are socialized into holding “expertise.” Expertise implies that one has a well-developed, uniquely valuable set of skills that can only be gained through dedicated study in one’s field. Several years of committed effort socializes us to develop an internal sense of self as “an expert” who has much to offer. We may be encouraged in subtle – and overt ways – to protect our image as an “expert” as we navigate our professional careers. This is the hidden cost of expertise that Harvard’s Francesca Gino talked about on NPR’s Hidden Brain: Rebel with a Cause. As she puts it, “Expertise, while wonderful, creates potential problems if we use it as a way of saying, I know the answer; I’m the expert.” Additionally, on a practical level, many systems of care are set up in ways that simply impede collaboration. For example, by overloading providers and moving patients from service to service by computerized systems, there is little time and perceived need for live doc-to-doc consults over the phone or even email.
What new model do we propose?
Lynch: The solution to fragmented care lies in one of my favorite expressions–the adage that Medicine is a team sport. None of us has all the answers. As a family physician, I know the value of collaborating with multiple specialists to synchronize the optimal care for my patients–that is what primary care managers do. While expected to be an expert in many areas of health, effective primary care providers must know how best to augment their care with the skills and expertise of colleagues from physical therapists, neurosurgeons, and psychologists to social workers, nurse case managers, and audiologists.
What are the advantages of coming out of our individual foxholes, and treating medicine as a team sport? Many of these lessons can be attributed to other fields of medicine who have harnessed the individual powers of different specialties for the collective benefit of their patients.
There are at least 5 advantages when medicine is seen as a team sport for treating mental illness.
1. Better Outcomes
Springer: As healers, we do our best within our scope of expertise, but part of the responsibility we hold is to recognize the boundaries of this expertise. In light of these boundaries, when medicine is a team sport, our role as healers involves being advocates that facilitate collaborations with other professionals whose expertise compliments our own.
We have all observed that when patients are in the wrong mind state, when they are over-run with adrenaline, and unable to calm down, they are not prepared to receive and integrate psychological insights. Patients with trauma may or may not meet criteria for a diagnosis of PTSD. What unifies them is that they exist in a state of what Doc Lynch calls “dysfunctional sympathetic tone” (Mulvaney et al., 2014) – the same thing that I call “chronic threat response.” In essence, they are chronically existing in a state of “survival mode” where decisions are made in a “fight or flight” context.
Lynch: As many experienced therapists know from clinical practice, a finding which is reinforced by research, exaggerated hyperarousal is an independent predictor of nonresponse to standard PTSD treatment (Averill et al, 2020; Zayfert & DeViva, 2004). There are certainly many approaches to address hyperarousal, but some, especially medications such as benzodiazepines (e.g. alprazolam, clonazepam, diazepam) have undesired side-effects such as dependency on these medications to escape the very things patients need to face in order to overcome their trauma symptoms (Guina et al., 2015).
Advances in neurobiological models of PTSD can allow us to deploy more effective treatments for addressing PTSD. New insights about the role of the cervical sympathetic chain and the amygdala and hippocampus now allow us to directly address some of the most debilitating symptoms experienced in post traumatic stress. Key to this new understanding is a cluster of nerves in the autonomic nervous system called the stellate ganglion that lies along the cervical sympathetic chain in the neck, just above the collarbone. By administering an ultrasound-guided injection of local anesthetic, a successful Stellate Ganglion Block procedure precisely targets elevated sympathetic tone and re-sets the body’s sympathetic response system.
For all of us, SGB has been an invaluable adjunct to trauma-focused therapy. But it is not a new procedure. SGB has been used successfully for over ten years on thousands of patients to treat post traumatic stress symptoms with a success rate of approximately 70%-80% (Navaie et al., 2014). The effects of a successful block are immediate and can last from six months to many years when paired with effective psychological interventions.
Research has shown consistently that SGB can reduce PTSD symptoms by 50% and is particularly helpful in improving symptoms of irritability, surges of anger, difficulty concentrating, and trouble falling or staying asleep (Lynch et al., 2016). A level one randomized clinical trial published in JAMA Psychiatry this year demonstrated twice the effect of SGB as compared to sham (placebo) injection. (Rae Olmsted et al., 2020). The magnitude of effect and high success rates of SGB are simply too compelling to ignore.
Okiishi: As mentioned above, a chronically altered physiological state can prevent patients from experiencing therapy in a way that is truly healing. While many are able to logically explain why they “shouldn’t” feel or react a certain way, their body does not cooperate. This can be frustrating for the therapist and patient alike.
In some contexts, a sensitive fight or flight reaction can be adaptive. For example, this may be true for military service members while they are on dangerous missions, where they do very grizzly work in highly kinetic environments. It is not a good idea to go headlong into a fortified Taliban bunker in a relaxed frame of mind. However, these soldiers then come home and find themselves jittery and unable to sit still at a kids’ soccer game. They stand in line at the Golden Corral and feel like someone in a suicide vest is going to burst through the door. They know it is not rational to feel this way. The system that allowed them to excel at their dangerous profession while deployed undermines daily functioning at home.
The basis of most trauma-focused psychotherapies is the idea that the client needs to repeatedly learn that the fear and concern brought on by trauma triggers are not going to play out in the relatively safe situation they live in day-to-day. I have found these approaches work great with people who have had a single traumatic event.
But with those who have had hundreds of traumas over decades of war, their bodies can be too stuck for these treatments to be as effective as we would like them to be. Yet, despite years of trauma exposure, and perhaps especially after years of trauma, SGB can be a game-changing treatment. After SGB, soldiers who would sweat profusely when they even considered talking about their experiences are able to tell their stories in a way that brings healing. The procedure provides enough emotional and physiological headroom to look at, and process, traumatic experiences differently.
I had one client who has had the block say recently:
“I am now able to choose how much I want to talk about and how much feeling I will allow to come through as I do so. Before the block, talking about [traumatic events] was overwhelming. I would try to use the tools I have learned in therapy, but my body would take over and I was done. It is nice to remember difficult things, cry a bit, figure out what it means to me, feel some resolution about it and move on after my appointment. Before, if I could talk about it at all, there was a good chance it was going to mess up my day, maybe even my week.”
2–Overcoming Barriers to Care
Lynch: Stigma is a substantial obstacle to many who suffer from trauma symptoms. Of course, the nature of trauma itself involves fear and avoidance, which are additional barriers to care. We have all worked with many patients who are initially unwilling to seek traditional mental health support due to fear of such stigma.
However, many of these same patients are open to interventions that use a biological approach, although many are resistant to taking a pill for a variety of reasons. I have normalized this biologic approach with my patients by describing SGB as a neurologic procedure for a neurologic problem in the autonomic nervous system. In the same way that I address hypothyroidism or Type 1 diabetes, there is no blame, shame, or guilt. It’s just biology. Many have not considered the overlap between neurology, psychology, and endocrinology, but our brains are not uncoupled from our bodies.
My patients understand this, appreciate the biologic nature of their challenges, and welcome the biologic solution. Many times this opens the door for a visit to a mental health professional- where the real healing begins. SGB has enabled many of my patients who would have never spoken to a therapist to step forward and make that first appointment. These patients would otherwise go on suffering if not for SGB.
A case report on the use of SGB for PTSD (Lebovits et al 1990) tells this story. The case involved a 15 y/o girl who was struggling with trauma symptoms after being shot. According to Lebovits and colleagues, “relief of the first stellate ganglion block was very encouraging for her and enabled her to overcome her initial hesitance in seeing the psychologist.” We have all seen the same effect in many of our patients, who have typically been battle-hardened combat warfighters.
Further, when medicine is undertaken as a team sport, the development of trust can be accelerated through something that Doc Springer refers to as “the transfer of trust.” That is, one can gain immediate trust and make quantum leaps in therapy when a patient is referred by a co-treating provider that has already earned the trust of that patient. This transfer of trust accelerates the timeline for therapeutic gains, thus preventing weeks – or months of additional struggle in patients’ lives.
Okiishi: I came up, like many psychologists do, in a way of practice that did not involve a multidisciplinary approach. I occasionally had a practicum where a psychiatrist would visit for an afternoon a week, but that was about it. On my internship we had in house psychiatry and more interaction, but functionally psychiatrists operated like additional therapists who also had prescription privileges.
For the past 10 years I have been fortunate to work on a team that includes physicians, physician assistants, social workers, psychological technicians, and combat medics. We talk about our shared patients regularly and this provides the opportunity for me to learn and develop a much more robust understanding of physiology, biology and how it is impacted by trauma. I have also been able to help my colleagues understand the psychology of trauma and the impact relationships with providers can have on motivation, belief, hope and trust with our patients.
By the time one of my patients gets an SGB they have usually spent a significant amount of time discussing it with me, and a variety of other providers. They have a clear understanding of what the procedure is, what it might do for them and how they can leverage the headroom created by the SGB to improve habits, repair relationships, and better achieve therapy goals. Their trust in their medical team is likewise heightened when they see that there is a network of people who know and trust each other who are working together for their betterment.
3–Reduced Dropout
Springer: In the fields of medicine and psychology, the mythology of the solitary healer is strong. In medicine, this takes the form of the town doctor who addresses all ailments, fictionalized in television programs and novels. In psychology, the image of Freud with a single suffering patient laid out on a couch is iconic.
Yet the change in this model to a team approach has many advantages for our patients. When patients are received – and treated – by a team of collaborating professionals, they may experience a feeling of wrap-around care – a feeling of being held and supported by a “unit” rather than an individual. This becomes especially helpful when our patients are current or former military service members, who are accustomed to unit-based support. Patients benefit from the input of multiple lines of expertise. When their care is supported by a team of people investing in their healing, they may feel more accountable to their role in the healing process. In other words, they drop out of care less frequently.
There is an overlooked cost to less effective and more protracted treatments for trauma. Patients who have struggled with trauma for many years often struggle with hopelessness. Understandably, some patients may also experience suicidal thoughts and urges when they cannot visualize hope of relief for their symptoms. They may feel a burst of hope that propels them to enter treatment, but when relief does not come for many weeks or months, their hope can take a lethal hit. SGB turns this dynamic on its head. Instead of waiting to “habituate” to repeated re-telling of one’s trauma story or waiting 6-12 weeks for a medication to take effect, SGB can immediately restore a feeling of hope.
When we have specifically used Stellate Ganglion Block in combination with psychological care, patients often report an immediate and sustained burst of hope within a single day as they feel significant symptom relief from SGB. This relief gives some of them the edge they need to fully engage in therapy. In multiple cases, I’ve seen how this burst of hope can propel them forward in therapy, creating increased openness – and ability – to invest in furthering the gains they can make with a psychologist or other co-treating mental health provider. With a team approach, the whole is truly greater than the sum of its parts.
4–Advancement of the Field
Lynch: Again, Medicine is a team sport. In treating mental illness, I’ve learned valuable lessons not just from psychologists and psychiatrists but also from neurologists, internists, pediatricians, and pain management/anesthesia physicians. And of course, the most helpful instruction I’ve received in treating mental illness such as PTSD has come from my patients, many of whom I know well, serve alongside, and have had the privilege to care for their families as well.
When the concept of using a nerve block to help treat mental illness was first introduced to me by a fellow Army physician, Dr. Sean Mulvaney, in 2011, I was skeptical. After seeing firsthand the dramatic improvements from receiving Stellate Ganglion Block, I was intrigued and have spent the past nine years studying PTSD pathophysiology and tracking the results of my patients to whom I have administered hundreds of stellate ganglion blocks. These patients are men and women whom I know well, not nameless, faceless “subjects” in a research study. Their successes with SGB over time have taught me that if it’s stupid and it works, then it’s not stupid.
Enlisting the help of a qualified pain or anesthesia physician to administer a nerve block on a patient suffering from posttraumatic stress may sound like an odd suggestion. However, our collective experiences demonstrate that this type of team sport medicine may be the single most helpful thing you can do to optimize the time you spend face-to-face with your patients suffering from posttraumatic stress.
Okiishi: Like Doc Lynch and Doc Springer, when I first heard about the SGB, I was skeptical. Correction, I was more than skeptical, I thought it was voodoo insanity. I first read about the procedure in Wired magazine in an article entitled “Obama Loves This Freaky PTSD Treatment; The Pentagon, Not So Much.” It was forwarded to me by a student who had already tried to convince me that MDMA and re-birthing therapy were a smart treatment for depression. After reading the article, I asked around the office if anyone had ever heard of the procedure. One other psychologist
had. We joked for a minute about the absurdity of biological reductionist physicians trying to invade our field. In closing, he said, “There is no way in hell they would ever let you do that at an Army hospital, even if you wanted to.”
Fast forward two years. I had just started a new job at Fort Bragg working with soldiers who had 10+ combat filled deployments under their belts. As I was getting familiar with the population, I was told by a patient, who we will call “Gordy” that a former Navy SEAL, now a sports medicine physician, came to our clinic occasionally to perform “the neck shot.” I asked what he meant and he explained that it was the SGB.
“Does it work?” I asked.
“It helps me calm down and not be so much of a dick,” Gordy responded. “Lots of guys get it. It has helped me get enough space in my head to figure out a lot of stuff. I know it sounds like a Bizarro-world version of The Manchurian Candidate, but if it helps, it helps.”
Gordy was shot in the leg in an ambush six months earlier. He had killed two enemy combatants after his injuries. It was the third time he had been seriously injured while deployed. We had done some good work in therapy and he was getting out more, connecting better with his wife and four grade school aged children, but was still struggling with being jumpy and “on edge all the time.”
A few weeks later I saw Gordy get an SGB. His wife came with him and she and I stood next to him as the procedure was performed. The visiting Doc explained to us on the ultrasound the anatomy we were seeing, stuck a six inch needle in the neck, jogged around the carotid artery and injected 8 milliliters of a local anesthetic into a core structure in Gordy’s sympathetic nervous system.
“All done” said the Doc, pulling out the needle and patting Gordy on his heavily tattooed shoulder, “How does it feel?”
Gordy was silent.
After a few beats, he said, “My body feels quiet. It’s kind of like those moments in the mornings right after we get the kids off to school. It has been nothing but noise and chaos and lost assignments and running and slamming doors and the bus driving away. Then suddenly it is gloriously still.” This is the part in the story where the bleeding-heart therapist that I am would love to say Gordy cried and held his wife and professed his love. But he didn’t. Instead, he looked at her, smiled gently and said, “Let’s go get some lunch.”
Scientific work looking at SGB is in the early phases of development, but our experience suggests that SGB may hold real promise. I have had over 100 patients get the block and the majority of them have had significant improvements in symptoms following the procedure. The average drop in PCL-M scores of the patients I have data on was 24 points. This is the equivalent of five of their PTS symptoms going from “Extremely” bothersome to “Not at all.” With their biology slowed down to normal levels, they make much more progress in therapy and at home. If the SGB is placebo, it is a darn fine one that helps a lot of people.
Trauma of any sort can be complicated, but we are serving a population that has lived years of time in combat zones, seen death and destruction in close quarters, and lost friends to enemy fire, substance abuse, suicide and mental illness. They are world class at pushing down pain and emotion and driving on in the face of abject suffering. This is what allows them to keep doing their dangerous and difficult jobs. We need every tool we can access to help them sort out their experiences and lead as normal a life as possible when they step off the line. SGB is one such tool and as it gains traction in the military world, I am hopeful that it will have a broader acceptance and impact on combat veterans.
5–More Professional Fulfillment
Lynch: In the current environment of healthcare in the US, many clinicians struggle to maintain professional satisfaction and avoid the many contributors to burnout. Many of us are not afraid of hard work, long hours, or even thankless patients. However, what has driven me and provided lasting fulfillment is making meaningful, substantial improvements in the quality of my patients’ lives. There comes great satisfaction from treating an elite athlete’s musculoskeletal injury so that he or she can return to the sport they love. But there is even greater satisfaction in helping heal a wounded mind and assisting a suffering soul to regain control of his or her life.
Following administration of SGB for many of my patients, I have heard comments such as “Doc, you saved my marriage” or “Doc, you have no idea what a huge help that was.” But, what I really value are statements like: “Doc, thanks so much. My son dropped the plate and I would’ve normally flown off the handle at him, but I didn’t. Thank you so much (with tears in his eyes).” I have had no greater level of professional gratification than hearing from a wife of a career Soldier and hardened combat veteran, “Thank you for giving me my husband back.”
My colleagues have also experienced these transformative moments with patients. Doc Springer says that she often hears from her patients statements like, “It feels like someone just lifted a thousand pound weight off my chest,” “I am actually happy – I can’t remember the last time I felt joy,” and “I feel like myself again – maybe not the same as I was before the military, but that’s OK – I have a good life to look forward to now.” Doc Okiishi adds that he has heard patients say, “It is nice to be able to feel fully again. I think I was stuck for years feeling nothing but amped up, angry or nothing. I thought I had become tougher or hardened, but really I was not living a full life” or “Now that my symptoms are under control, I think we can actually start doing some real therapy.”
Conclusion
Springer/Lynch/Okiishi: Innovation in trauma care is critical, especially right now, when trauma due to COVID-19 – or secondary to our global health crisis – is rampant. Those who suffer from trauma deserve the best care we can provide – care that is practical, effective, and informed by modern neuroscience.
As healers, we have responsibility for our patients, but responsibility is not the same as “ownership.” That is, we are responsible to offer them the best of what we can deliver, and equally, to recognize the boundaries of our expertise. We do not however have “ownership of a patient.”
Getting the best outcomes requires us to re-situate ourselves not as a solitary expert but as team members who work to get the best outcomes for those we serve. Care that fuses the expertise of those providing biological and psychological interventions like Stellate Ganglion Block hold game-changing promise for relief from suffering. This is the new model we need in medicine – Medicine as a Team Sport.
Resources
American Psychiatric Association. Posttraumatic stress disorder (PTSD). (2020). Retrieved from https://www.psychiatry.org/patients-families/ptsd/what-is-ptsd.
American Psychological Association: PTSD
Resource produced by the Department of Veterans Affairs about the use of Benzodiazepines for PTSD – https://www.ptsd.va.gov/understand_tx/benzos_ptsd.asp
National Institute of Mental Health:
NPR: Hidden Brain: Rebel with a Cause (interview with Dr. Francesca Gino about the hidden cost of expertise, referenced above)
National Alliance on Mental Illness:
SGB for PTSD: https://sgb4ptsd.com/
www.giveanhour.org
References
Averill, C. L., Averill, L. A., Fan, S., & Abdallah, C. G. (2020). Of Forests and Trees: Bridging the Gap Between Neurobiology and Behavior in Posttraumatic Stress Disorder. Biological psychiatry. Cognitive neuroscience and neuroimaging, 5(2), 135.
Guina, J., Rossetter, S. R., DeRhodes, B. J., Nahhas, R. W., & Welton, R. S. (2015). Benzodiazepines for PTSD: a systematic review and meta-analysis. Journal of Psychiatric Practice®, 21(4), 281-303.
Lebovits, AH, Yarmush, J, Lefkowitz, M (1990) Reflex sympathetic dystrophy and posttraumatic stress disorder. Multidisciplinary evaluation and treatment. The Clin J Pain 6(2);153-157.
Lynch, J. H., Mulvaney, S. W., Kim, E. H., de Leeuw, J. B., Schroeder, M. J., & Kane, S. F. (2016). Effect of stellate ganglion block on specific symptom clusters for treatment of post-traumatic stress disorder. Military medicine, 181(9), 1135-1141.
Mulvaney, S. W., Lynch, J. H., Hickey, M. J., Rahman-Rawlins, T., Schroeder, M., Kane, S., & Lipov, E. (2014). Stellate ganglion block used to treat symptoms associated with combat-related post-traumatic stress disorder: a case series of 166 patients. Military Medicine, 179(10), 1133-1140.
Navaie, M., Keefe, M. S., Hickey, A. H., Mclay, R. N., Ritchie, E. C., & Abdi, S. (2014). Use of stellate ganglion block for refractory post-traumatic stress disorder: a review of published cases. J Anesth Clin Res, 5(403), 2.
Rae Olmsted, K. L., Bartoszek, M., Mulvaney, S., McLean, B., Turabi, A., Young, R., … & Kane, S. (2020). Effect of stellate ganglion block treatment on posttraumatic stress disorder symptoms: a randomized clinical trial. JAMA psychiatry, 77(2), 130-138.
Summers, M. R., & Nevin, R. L. (2017). Stellate Ganglion Block in the Treatment of Post‐traumatic Stress Disorder: A Review of Historical and Recent Literature. Pain Practice, 17(4), 546-553.
Zayfert, C., & DeViva, J. C. (2004). Residual insomnia following cognitive behavioral therapy for PTSD. Journal of Traumatic Stress: Official Publication of The International Society for Traumatic Stress Studies, 17(1), 69-73.
Author Bios[12]
Dr. Shauna Springer – known as “Doc Springer” in the veteran community, is the chief psychologist for Stella Center and one of the nation’s leading experts on PTSD and trauma. Known as “Doc Springer” in the military and veterans’ communities, she has worked with hundreds of veterans over the past decade. Her work has been featured on CNN, Business Insider, THRIVE Global, Dr. Oz, US News and World Report, NPR, NBC, CBS Radio, Forbes, Washington Post, and Military Times. She is a regular contributor to Psychology Today. Her next book, “WARRIOR: How to Support Those Who Protect Us,” published on May 18.
Dr. Jim Lynch is an Army physician stationed at Fort Bragg, North Carolina with the United States Army Special Operations Command. Dr. Lynch earned a bachelor of science in Psychology from the United States Military Academy at West Point in 1989, a master of science in healthcare improvement from Dartmouth College in 2001, and his medical degree from Brown Medical School in 2003. He is board certified in Family Medicine and Sports Medicine. Dr. Lynch is a team physician with the U.S. Olympic & Paralympic Committee and has supported USA Swimming as a National Team Physician since 2011.
John Okiishi, Ph.D – Dr. John Okiishi is a Psychologist who has been working for the past nine years supporting a variety of Army Special Operations Forces units at Fort Bragg, NC and Fort Lewis, WA. He is a proud (and only male) member of his unit’s Family Readiness Council. In addition, he is a highly trusted advisor to commanders regarding organizational dynamics, difficult interpersonal conflicts and the impact of combat related stress. Has spoken nationally and internationally on tracking and improving psychotherapy outcomes and how to maximize and sustain optimal performance in high stress, demanding military environments.