Let's Rethink the Relationship Between Mental Health Healers and Those They Serve

Dr. Shauna Springer -- known as "Doc Springer" in the military community -- is a leading expert on trauma, military transition and close relationships. Her work has been featured on CNN, Business Insider, The Washington Post and NPR. As chief psychologist at STELLA, she works to advance a new model for the treatment of trauma that fuses biological and psychological interventions. Her most recent book is "WARRIOR: How to Support Those Who Protect Us."

2020. The Year of Trauma. A year of events that reads like a sci-fi/horror script.

There have been nearly 30 million confirmed COVID-19 cases in the U.S. alone. Studies show that between 18% and 36% of people in the post-illness phase of COVID-19 experience symptoms of post-traumatic stress.

Record-setting wildfires have swept across California and other states in 2020. The prevalence of PTSD is between 30% and 40% among direct victims of disasters.

Roughly 314,976,000 U.S. citizens were forced to socially isolate during 2020. Between 25% and 29% of people in isolation or quarantine for a period of 10 days or longer met the criteria for PTSD.

A city-by-city report found that calls to police regarding domestic violence increased by 10% to 27% between March and April 2020, when most shelter-in-place orders took effect.

During this time of unprecedented trauma, before we collectively slide back into the regular distractions of modern life, we have a window of opportunity to reimagine the existing contract between our nation's healers and those they support, including those who risk it all to protect us.

For the past year, along with my co-host Duane France, I have listened to, and commented on, interviews with 50 health care thought leaders -- all with different perspectives on the national tragedy of military and veteran suicide.

Our Military Times podcast "Seeking the Military Suicide Solution," has brought weekly episodes from those leading our national suicide prevention efforts, former Navy SEALs, Special Forces operators, guests with high military rank, corporate leaders, and those with the wisdom of lived experience.

This bird's-eye view has brought clarity for me around how we need to reimagine the contract between healers and those they serve. That includes:

Meaningful Collaboration, Rather Than Territorial Thinking

Despite the commonly observed rhetoric around the value of team-based care, meaningful, active collaboration between health care providers is often the exception to the rule. In many systems, patient care is fragmented between providers who never connect or consult with one another about how to align their expertise.

The hidden cost of expertise is an insidious form of professional stagnation: the belief that we know what is best for our patients. This takes form in a private (or public) feeling that the treatment we worked so hard to learn -- the one we are licensed to offer -- is the optimal one for all of our patients.

True healers do not own their patients. Instead, they set the conditions for healing, and this requires deep, mutually respectful relationships with other types of care providers.

Over the past two years, I have seen the potential for a new model of care, through deep collaboration with field-leading medical doctors specializing in treatments for PTSD. This is the new model we need -- Medicine as a Team Sport.

Along with colleagues in the Special Forces community, I wrote an article to describe this model and its many advantages: better outcomes, overcoming barriers to care, reduced dropout rates, advancement of the field, and more professional fulfillment.

In the single most downloaded episode in our podcast series, Rear Adm. Matt Kleiman, the former director of psychological health for the chief of the National Guard Bureau and now the assistant U.S. surgeon general, picked up on this theme. As Kleiman reflects, "The [National] Guard has these silos of excellence. ... It became really evident to me pretty quickly that we didn't have a great way to align this and leverage our best practices to inform our broader strategic effort across the National Guard."

Reimagining the contract between healers and those they serve means integrating this understanding: Health care is one mission.

A Communal Response to Our National Mental Health Crisis

As I wrote in my recently published book, "WARRIOR," we have long deployed a "get thee to a doctor" approach to mental health crises. This has severe limitations. As a society, for several decades now, we have been using a "professional defender" model of suicide prevention. The professional defender model says that suicidal thoughts and feelings are experts-only issues. By virtue of our training, licensed professional therapists are seen as having the required skills to help people effectively wage war against hopelessness.

To be fair, licensed professionals do have substantial assets to bring to this fight. Seasoned professionals are relatively comfortable asking questions about suicide risk. We may also have heightened skill in reading body language. In addition, experienced professionals have internalized an understanding of how people move through pain to post-traumatic growth. Based on this, we can authentically communicate hope for recovery because we know that effective treatments can, and do, save lives.

At the same time, mental health professionals have serious limitations when it comes to assessing and treating high-stakes health care problems -- for example, suicide risk.

Therapeutic relationships, particularly with certain populations, often start as low-trust relationships. In fact, according to recent data collected by the Department of Defense, in a list of 12 potential categories of people that an active-duty service member would talk to when feeling stressed or overwhelmed, mental health providers came in 10th, just slightly above attorneys.

Developing trust can take a long time. Until trust is earned, therapists often fail to hear the true story of their patients' hidden pain.

Even when trust has developed, the bonds of attachment in therapeutic relationships are typically not the active ingredient in saving lives. If this sounds odd, ask yourself: Do patients who are in crisis fight through despair because of their relationships with their therapists? Or are people in crisis more likely to stay in the fight for their tribe of loved ones -- their battle buddies, parents, partners, children, respected mentors and trusted friends? If the latter, then why do we continue to place the therapeutic relationship at the center of crisis interventions?

Dr. Harold Kudler, the former assistant deputy undersecretary for patient care services at the Department of Veterans Affairs, emphasizes a similar belief: "We need to do something that was done at the end of World War I. We need the entire nation to develop a national suicide prevention strategy."

I share this perspective and, as I wrote in a 2016 article in Psychology Today, crisis response models are not sufficient. What we need is a radical redistribution of responsibility for preserving life -- a communal response to crisis.

Elimination of the Mental Health Stigma

Suicidal struggles may not be commonly discussed, but they are commonly experienced. In fact, if any among us believes that suicidal thinking is rare, or that suicide is an act of weakness, we should alter our thinking: Even the strongest of us -- the fierce tribe of warriors who fight our wars -- sometimes die by suicide. A man or woman can be a hero to many, noted for his or her uncommon bravery and unconquerable fighting spirit, and still be at risk.

Michael Sugrue, a warrior who served in the Air Force and then as a sergeant in the police force, is a good example of this. Sugrue is a highly respected leader within these communities whose insightful posts reach more than 30,000 LinkedIn followers. He was once bent on organizing a hero's death for himself, when he became suicidal after being involved in a series of highly traumatic incidents. The deterrent to carrying out his plan was the suicide attempt of his best friend John, a reserve police officer. John had compartmentalized his hidden pain, in the way that warriors often do. No one saw it coming.

The trauma of nearly losing his friend moved Sugrue to persist through his own valley. Now, he shares this message: "You're not crazy. You have an injury to your brain, and you need to get help. It's no different than if a police officer injures their shoulder, their back or their knee."

Former Navy SEAL Mark Divine said this during his podcast interview: "Trauma doesn't discriminate. [SEALs have] a culture of 'we're a bunch of bad asses. That stuff doesn't affect us. ...' Until it does."

Sometimes, the tragedy of suicide gets marginalized as a "veterans' issue" or a "first-responder occupational risk." Mental warfare is an unaddressed American problem. People who appear to "have everything," who inspire us with their artistry and dazzle us with their personalities -- Kate Spade, Anthony Bourdain and Robin Williams, for example -- may find themselves at the end of this dark tunnel.

Mental warfare is not unusual. Pain is a universal human experience. We need to reimagine our health care system with this guiding understanding.

Healers as Guides, not Saviors

Contrary to some people's perceptions, psychologists are not all-knowing, and we do not have unlimited power to save people's lives. To tell the truth, we don't even do a great job of predicting when some of our patients may be at risk for suicide. For too long, we have allowed ourselves to be positioned as "saviors."

Dr. Matt Miller, director of Suicide Prevention Programs for the VA, said, "I think what's not working is an overreliance on clinically based interventions to the exclusion of community-based interventions and, conversely, an overreliance on community-based interventions to the exclusion of continuing to attend to that which we can do in furthering clinically based intervention."

Healers should not replace a functional tribe of those we love and trust. We may benefit from the skills of a trusted doctor when navigating challenges in our lives, but all of us also need our tribe, regardless.

Interestingly, two of the most clarion calls for this perspective were shared by researchers who do complex, high-level research in the field of suicide prevention.

Dr. Craig Bryan, a suicide prevention researcher and director of Ohio State University's trauma and suicide prevention programs, promotes a critical humanistic perspective. As he explains, "Think of the friends that you have that you care about the most. They typically express appreciation to you. They thank you for the little things. They back you up; they support you. They reach out to you in times of need. And even when you're not in need, they just send you a text message every once in a while and say, 'Hey, I was thinking about you. Hope you're doing OK.' Or 'Hey, I read this funny article online; it reminded me of you.' These are the little things that we can actually do on a day-to-day basis that influence and reduce the probability of a person tipping over the edge when they find themselves in that momentary moment of despair."

Dr. Rajeev Ramchand, a senior behavioral scientist at Rand Corp., has similar clarity on this issue. "I think that if we were in a society where people just genuinely cared for one another, that might turn the tide on suicide more than mental health treatment or a lot of things," he said.

Culturally Adapted Approaches

What works for one group does not work for another. Full stop.

For too long, we have tried to apply strategies that address the needs of one population to other populations without considering fundamental differences in psychological and cultural factors.

Take warfighters, for example. As I explain in my book "WARRIOR," warfighters are capable of tolerating a massive amount of pain and suffering. Many of the Vietnam veterans I've worked with have suffered without relief for several decades from a combination of ongoing physical pain, chronic insomnia, untreated trauma, an immense burden of unaddressed grief and loss, and a thousand pounds of survivor guilt, but they have still stayed in the fight.

In many cases, the Achilles' heel of our warriors is not their own suffering. Their weakness is different. To understand the greatest vulnerability of the strongest and bravest citizens in our society, we need to understand the following five factors.

1. Being protectors is core to their identity. They are protectors of their family, their military tribe and their country.
2. In their military training, warriors repeatedly learn to take decisive action to eliminate threats. This response to threat becomes ingrained in their muscle memory.
3. They are firearms experts who view a weapon as a tool for eliminating threats to those they are protecting.
4. They suffer from injuries that are not well understood by most clinicians -- injuries that are even more invisible and insidious than post-traumatic stress. Survivor's guilt, moral injuries, shame and grief are like silent cancers that can put them at risk for suicide. These are the topics I focus on in my book "WARRIOR."
5. When they see themselves as a threat to the safety, well-being and hopeful future of those they love, veterans are at heightened risk of moving decisively to eliminate the perceived threat: themselves.

In their most desperate moments, when they feel like a burden, they become profoundly detached from the people they love. They put themselves in the crosshairs, and they drop into a tactical threat elimination mode. Of course, this doesn't explain all veteran suicides, but it explains a lot of tragic outcomes.

My friend and a trusted partner in my work, Marine Corps veteran David Bachmann, was asked why he thinks warriors are dying in higher numbers than civilians. David was part of 2nd Battalion, 7th Marines, the unit that was profiled in The New York Times as having the highest suicide rate in the Marine Corps. He comes to the table with the wisdom of lived experience, having suffered the loss of many of his brothers. He has seen what works in the trenches of mental warfare.

As he explains, "I think it's more of the perfect storm scenario. I think most people have this grief in them, and this works up to create this perfect storm. And then, Marines aren't scared to pull the trigger. And a lot of times with veterans, I think it's more of them thinking of themselves as a threat and not being scared to take out that threat."

Failing to understand the different psychology and cultural influences of various groups guarantees that our interventions will miss the mark. We need to reimagine our healing approaches in a way that integrates key cultural insights.

Innovate, Despite Our Fears and Our Tendency Toward Risk Aversion

We must innovate like our lives depend on it -- because the lives of people we love do depend on it. One of the most promising interventions for trauma is a treatment that has long been used for pain -- for conditions such as shingles and phantom limb pain. It has been used in military hospitals, Special Forces units and select VA treatment facilities. Thousands of warfighters have gotten relief from their worst symptoms of trauma with this procedure, usually within a single session. And very few people have even heard of it.

Dr. Eugene Lipov, a world-renowned anesthesiologist, first made the link that stellate ganglion block, or SGB, injections have promise for the treatment of trauma symptoms. For more than a decade, since he published a case study on the use of SGB for PTSD in 2008, he has been refining its use for trauma.

The treatment involves injecting a widely available, commonly used anesthesia into a bundle of nerves in the neck, just above the collarbone. The injected medication has the short-term effect of soothing and "resetting" the overactive nerves. Since it does not involve psychoactive medications, there is no danger of getting a "positive" drug test that can impact one's employment situation, and it works in 70% to 90% of cases. My patients have consistently reported successful outcomes with SGB.

SGB, as an intervention for trauma symptoms, arose from a line of thought that views PTSD as a largely biological condition, with psychological and emotional components that are maintained by a shift in normal biological functions. In other words, after trauma exposure, our baseline functioning may change in dramatic ways. In some cases, we become stuck in "fight or flight" mode, which can be observed in certain types of brain scans.

Common indicators of this altered biological state -- what I call "chronic threat response" in my work -- include symptoms such as disrupted sleep, anger attacks, overwhelming panic, difficulties concentrating, a feeling of constantly being on "high alert," and a strong startle response. In other words, the "hyper-arousal" cluster of trauma symptoms.

So why don't people know about this treatment option?

A major reason is that research and practice have mainly occurred within active-duty military contexts. For example, Dr. Brian McLean, one of the most productive SGB providers in the country, has done hundreds of procedures to address trauma-related symptoms in active-duty soldiers at Tripler Army Medical Center in Honolulu, Hawaii.

Other SGB providers have included physicians who have also spent much of their career within active-duty settings, including Drs. Sean Mulvaney and Jim Lynch, and other teams of physicians at Fort Bragg, North Carolina; Walter Reed Medical Center in Bethesda, Maryland; the U.S. military base in Landstuhl, Germany; and Madigan Army Base at Fort Lewis, Washington. Physicians operating within the Department of Veterans Affairs have also helped to advance the practice of SGB, and a group of providers are leading efforts at the Long Beach VA.

Due to the efforts of these pioneering physicians, SGB is considered a "go-to" intervention within several units within Special Forces, as well as at select military hospitals and a handful of VA hospitals.

Conclusion

Seismic shifts in our paradigms happen in the context of crises. 2020 was a continual crisis. To fix what is broken in our health care system, we need to boldly move in a new direction, based on new insights and the power of innovative thought. Innovation in trauma care is especially critical 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 a responsibility for our patients, but responsibility is not the same as "ownership." We are responsible to offer them the best of what we can deliver and, equally, to recognize the boundaries of our expertise. Getting the best outcomes requires us to resituate ourselves not as a solitary expert but as team members who work to get the best outcomes for those we serve.

2020 was a year of trauma. But if we team up, continue to advance innovation, and offer treatments that are grounded in the values, language and culture of those we serve, 2021 can be a year of healing.

-- The opinions expressed in this op-ed are those of the author and do not necessarily reflect the views of Military.com. If you would like to submit your own commentary, please send your article to opinions@military.com for consideration.