Re: "When Truisms Are True"

To the editors:

In 'When truisms are true' (NY Times, 2/26/12) Kim and Sanchez-Burks discuss the important advances in 'embodied cognition' that elucidate the ways in which the mind and body are inextricably linked.  Their research focuses on the implications of such a connection for creativity - thinking outside the box.  Embodied cognition has relevance for treating patients as well.

Many individuals suffering significant histories of trauma in addition to anxiety and depression benefit from the use of more conventional talk therapy in conjunction with dance movement psychotherapy. It is a way of more effectively mobilizing - literally and metaphorically - all of the patient's internal resources for healing. 

Respectfully,

Larry Sandberg

Re: "Not Diseases, but Categories of Suffering"

To the editor:

Gary Greenberg (1/30/12, Not diseases, but categories of suffering) notes that the DSM-III was introduced in 1980 having adopted a strategy 'mostly by leaving out meaning of our suffering' in favor of a descriptive approach of syndromes. This was in part an important corrective to the over reliance on psychodynamic explanations of mental illness at a time when biological psychiatry was in its infancy. But he perpetuates a myth that psychoanalysis has been largely discredited. 

The brain is a social construction where the environment interacts with one's genes to create the person we become. Insofar as biochemical markers advance our ability to heal, it will likely be due to studying them in relation to environmental factors. Contemporary psychoanalysis explores meaning as a critical vehicle to healing.  For some patients, this may include the meaning of having a 'biological' illness requiring medication or the way in which an apparent genetic vulnerability has been unmasked by certain life experiences.  While few patients pursue intensive psychoanalytic treatment, psychodynamic approaches  (which adopt basic psychoanalytic principles) have a growing evidence base for treating depression, anxiety and personality disorders. 

Respectfully submitted,

Larry Sandberg MD

Re: "The Limits of Empathy"

9/30/11

To the editor:

David Brooks (The Limits of Empathy, 9/30/11) selectively references scientific literature and anecdotes to support his view that empathy is a shortcut that 'has become a way to experience the illusion of moral progress without having to do the nasty work of making moral judgments'.  I disagree.  Of course, the self-satisfaction of feeling another's pain can be used as an excuse to not act to relieve suffering.  However, one cannot act in a moral way towards others without feeling empathy for them. Conversely, those without feeling (like the cold blooded sociopath) will act in unfathomable ways. Codes of moral conduct, rather than overshadowing empathy in importance as Brooks suggests, are based on empathy. It is a necessary, though admittedly insufficient, basis for moral action and is an essential ingredient of the mother infant relationship where the mother's ongoing effort to know the internal experience of her child is the basis for her loving behavior.

Respectfully,

Larry S. Sandberg MD

Re: "The Tea Party Take Two"

8/6/11

To the editor:

While Joe Nocera ("The Tea Party Take Two", 8/6/11) rightly apologizes for likening the Tea Party Republicans to terrorists, he accurately expresses the impotent anger many Americans of both parties feel towards members of Congress who acted coercively to compel a debt ceiling/reduction deal that creates more pain for middle America. Senator Reid's plan, unacceptable to the far right, would have been considered a coup for Republicans in the past.  Perhaps impotent anger will change to constructive change in the next election cycle.

Respectfully submitted,

Larry Sandberg

Re:

7/13/11

To the editors:

The public benefits from Warren Procci's balanced assessment of challenges around treating depression (7/13/11).  The impact of direct to consumer advertising (DTCA) on discourse (and patient preference) about this condition cannot be overestimated.  Since the mid-1990's, when the FDA loosened its regulations on such advertising, there has been a massive escalation in money spent for drug advertising.  The cultural zeitgeist has shifted in worrisome ways.  Psychotherapy, alone or in combination with medication, is a legitimate and evidence based treatment for depression.  The public will see no advertisement selling the benefits of psychotherapy.  Given the distortions inherent in DTCA where the goal is to sell a brand, I believe such advertising should be restricted to facilitate balanced information being obtained from impartial sources.

Respectfully,

Larry Sandberg MD

Re: "In Defense of Antidepressants"

7/10/11

To the editors:

While Peter Kramer writes in 'defense of antidepressants' (7/10/11), I believe the public would benefit from a vigorous defense of psychotherapy for depression.  We are inundated by direct to consumer advertising about antidepressants, managed care aggressively limits coverage for psychotherapy, and psychiatrists in dwindling numbers are honing the necessary skills to treat the whole patient.  These forces contribute to an over utilization of medication and foster a non-introspective stance towards human suffering.  Individuals with significant histories of trauma or ongoing personality troubles will often require combined treatment to effectively treat depression and prevent relapse.  Psychotherapy is a legitimate evidence based treatment for depression and is in danger of being lost in the 'doctor's satchel'.

Respectfully submitted,

Larry S. Sandberg MD

Re: "Squandering Medicare's Money"

May 26, 2011

To the Editors:

Rita Redberg (Squandering Medicare’s Money, 5/26/2011) highlights the value of an evidence-based approach to medicine (EBM) – enhancing the quality of patient care and reducing unnecessary cost.  However, insurance companies can and do deny care based on a perverse misuse of an evidence based model.

Not all clinical care can be guided by rigid adherence to evidence based guidelines. Sometimes evidence involves knowing one’s patient and his particular situation – admittedly a weak source of evidence from a scientific perspective but not useless.

I have recently had insurance companies refuse to cover medications for patients with histories of severe mood disorders.  In one case, the dose of medication was 'too high'; in another 'too low'.  In both situations, the fact that both patients had histories of doing well on these doses was irrelevant.

The problem, of course, is not with evidence-based medicine per se. Difficult decisions need to be made to bring down spiraling costs in health care, insurance companies cannot be expected to support all treatments, and clinicians should strive to provide the best care possible based on the best possible evidence. Rather, it’s important that the valuable EBM paradigm within medical research not be used as a weapon to hurt the very people it was intended to help. 

Respectfully submitted,

Larry S Sandberg MD

The writer is psychiatrist and psychoanalyst.

7/10/11

Re: "The People vs. Donald Trump"

1.6.19

To the Editor:

David Leonhardt (1.6.19, The People vs. Donald Trump) writes cogently about Donald Trump's unfitness to serve as President but leaves out the blatant example of his ineptitude as evidenced by his mishandling of the government shutdown. For an individual who boasts his ability to finesse the 'art of the deal,' we have hundreds of thousands of hardworking Federal employees being hurt by a strategy that can only be characterized as bullying and coercive.  There is a complete incapacity to negotiate as this requires giving something up in return for getting something.  This is not rocket science but it is beyond Donald Trump's grasp.  Threatening that the shutdown can go on for years, oblivious to the already precarious situation of furloughed and unpaid Federal employees, illustrates that it is his ego rather than American citizens he is trying to protect. 

Leonhardt speculates that an external emergency may be the tipping point that compels the reality of Trump's unfitness to be confronted. Will this self-made internal emergency - the shutdown -  be the catalyst?  We will only know in hindsight though one thing is certain: Democrats and Republicans will need to come together in a way they rarely have in recent years if this national nightmare is going to end. How ironic it would be for Trump to have 'succeeded' in bringing the two parties together.

Respectfully submitted,

Larry S. Sandberg

Re: "Key Evidence Solidifies CIA Assessment that Saudi Prince Ordered Khashoggi Killing"

12/3/18

To the Editor:

(Key evidence solidifies CIA assessment that Saudi Prince ordered Khashoggi killing, 12.3.18): Most explanations of President Trump's refusal to accept the likely role of Mohammed bin Salman in the killing of a Washington Post journalist centers on the transactional nature of his relationships.  While this is no doubt true, I believe there is an additional and no less likely motivation - one that is not particularly subtle.

President Trump, in dismissing the CIA's findings as merely 'feeling' based, is arguing for the guilt of all those who surrounded the Saudi Prince while the Prince himself is exonerated from all wrongdoing.  As the Mueller investigation moves forward we see more and more evidence that President Trump's inner circle has been involved in various criminal activities. Depending upon the 'loyalty' of those accused, he will either attack (Michael Cohen) or defend  (Paul Manafort)  those who have been found guilty. Ultimately, inevitably I believe, President Trump will be left arguing his innocence surrounded by guilty parties just as he absurdly argues that the Saudi Prince is innocent.

Respectfully submitted

Larry S. Sandberg

Re: "An Exit, a Leader Unbound and a Jittery Capital"

12.21.18

To the Editor:

(Re. An Exit, a Leader Unbound and a Jittery Capital, NYT, 12.21.18): Mental health experts have tried in vain to draw attention to the profound threats posed by President Trump.  Such warnings have largely fallen on deaf ears. Yet evidence continues to grow that President Trump poses an imminent danger. He displays impaired decision making marked by impulsivity and personal emotional needs rather than a dispassionate assessment of complex facts.  His decisions about troops in Syria and Afghanistan along with his inviting a government shutdown are the most recent examples of his dysfunction. His complete inability to depend upon others is a fatal flaw. The departures of John Kelly and Jim Mattis should raise alarm bells - they served as a reality check on the President and their inability to prevail is an ominous sign.

President Trump is not only unbound.  He is unhinged.  What will it take for his core supporters to realize his interest is self-interest? At what point will our elected officials in Congress - form both parties - unite and acknowledge our President in unable to carry out the functions of his office?

Respectfully,

Larry S Sandberg

Re: "Your Dreams Tell You Who You Are"

11/11/18

To the Editor:

It came as a surprise to me to read that 'conventional wisdom' supports the idea that dreams are 'silly little stories, the dandruff of the brain' that should be ignored and not reflected upon (Alice Robb, Your dreams tell you who you are, 11.11.18).  While it is true that some neuroscientists adopted an antagonist view to the idea that dreams were meaningful and motivated, I do not believe this was ever a conventional or wise perspective.  It not only defied common sense for those who reflected upon their dreams; it begged the question as to the evolutionary adaptive value of dreams.

Sigmund Freud famously said that dreams were the royal road to the unconscious.  Our dreams, whether they become conscious or not, literally and metaphorically help guide us into the future.  Many patients in psychotherapy or psychoanalysis find their lives and self-understanding enriched by reflecting upon the meaning, including the hidden meaning, of their dreams. Often times, this involves uncomfortable truths that one prefers not to confront making the therapist an important partner or vehicle in its exploration.

Respectfully submitted,

Larry S. Sandberg MD

Re: "Breaking With U.S. Intelligence"

10.20.18

To the Editor:

In what seems an eternity ago, then candidate Trump opined that he could shoot someone on Fifth Avenue and not lose a single vote. This boast will now be put to the test, figuratively if not literally, in the brutal killing of Jamal Khashoggi.

President Trump (Breaking With U.S. Intelligence, Appears to Accept Saudi Explanation of Journalist’s Death, 11.20.18), unbelievably though unsurprisingly, finds credible (or pretends to find credible) the Saudi fabrication that Khashoggi died during a fight in the consulate putting Trump on the side of a government that killed a U.S. resident, journalist and father while visiting the embassy to get papers in order for his marriage.

President Trump’s absence of a moral compass and grasp of his responsibility to our country is revealed in his bizarre comment: “This one has caught the imagination of the world, unfortunately … It’s not a positive.” He sees the problem not as the murder itself but the world’s response to it. The video of Khasshoggi entering the embassy is haunting because we know – we do not need to imagine - what ensued. We experience moral outrage and the need for justice. For President Trump, always the self-serving businessman, the problem is the imagination of others rather than the misdeed.

I hope that Republicans in Congress and his base of supporters do not let him get away with this degradation of life and denigration of moral outrage as ‘imagination.’

Respectfully submitted,

Larry S. Sandberg

Re: "When a President Believes he is Entitled to his own Facts"

To the Editors:

Maggie Haberman (Re. When a President believes he is entitled to his own facts, 10.19.18) illustrates the profound threat posed by President Trump's idiosyncratic relationship with objective reality.  Young children make up things all the time; 'pretend play' is a normal aspect of childhood and a source of great pleasure precisely because one's imagination is given free range.  Most of us outgrow this phase and are capable of discerning when we are engaging our imaginations and when we are observing the external world. Yet the most powerful man in the world is perversely engaged in the acrobatic juggling of reality and facts to suit his inner emotional needs.

How can he get away with this?  It is only because he has others who are willing to play along with him.  This includes members of Congress who are complicit in their silence and, as Haberman points out, a Republican base that uncritically plays along infusing Trump with the power of a charismatic leader . Robert Jay Lifton, a psychiatrist and scholar on the effects of war and political violence, speaks of the danger of 'malignant normalization' when threats to the safety and fabric of society are no longer perceived as such.  It is unfolding before our eyes.

Respectfully submitted

Larry S Sandberg

Re: "Saudis Now Plan to Say Journalist was Killed by Mistake in Inquiry

10.16.18

To the Editor:

(Saudis now plan to say journalist was killed by mistake in inquiry, 10.16.18): We are witnessing the creation of 'fake news' before our eyes between the President and Saudi Arabia. Rogue killing, seriously?  Is the world so beaten down and numbed by relentless attacks against reality that it is to be expected that we accept silently such deceit? Is this how little our 'pro-life' President values human life? How many more moral lines must President Trump cross before those who support him stand up and say no more?

Respectfully submitted

Larry S. Sandberg

Re: "The War of Words on Abortion"

1.10.19

To the Editor:

 Charles C. Camosy (The War of Words on Abortion, 1.10.19) argues that being identified as ‘anti-abortion’ rather than ‘pro-life’ is a manipulation of language that serves to obfuscate what is really at play; i.e., his concern for vulnerable populations.  But these two points of view are not contradictory.  Rather they fit logically; the flip side of the proverbial coin.  This in not the case with regard to Camosy’s own wordplay.

He laments, following Pope Francis, our  ‘throwaway culture’ and conflates racist and prejudiced attitudes towards immigrants, minorities, the disabled, the elderly, and prisoners with individuals who support a woman’s right to choose abortion.

Camosy wishes to be understood as pro-life rather than anti-abortion and cautions against dehumanizing language in the discourse around the abortion issue.  Is it not dehumanizing to categorize those who differ with his position as expressing a ‘throwaway’ mentality?  I think so.

Respectfully submitted

Larry S. Sandberg

Re: "Trump Repeats False Claims about Trade with Canada"

3.16.18

To the Editor:

President Trump is painfully transparent in exhibiting his unfitness for office and risk to our country (NYT, 3.16.18, Trump repeats false claims about trade with Canada).  He tells Republican donors in a private meeting that he was ignorant of the most basic details of the trade balance between the U.S. and Canada.  Aware of his ignorance, he asserts to Prime Minister Trudeau what he wishes to be true (i.e., that a trade imbalance exists with Canada) in an apparent effort to manipulate the Prime Minister.  He then flaunts this behavior to Republican donors in an effort to impress them and garner their financial support for a Senate candidate. His press secretary, as expected, comes to his defense by manipulating the facts.

As a psychiatrist and psychoanalyst, I am troubled not only by this undeniably pathological behavior.  I am troubled by the lack of outrage, the deafening silence of those in elected office who turn a blind eye and embrace denial putting their self-interest before country.  Moderate Republicans should be ashamed of themselves for their complicity and moral abdication of responsibility. I am troubled because this story is buried in the pages of the Times as if this is trivial news. Or so typical as to not be particularly newsworthy.

It is crucial that citizens do not become numb or see our current reality as the 'new normal.'  We must insist that our elected officials do the right thing.  If not, we will do the right thing at the ballot box next  November.

Respectfully submitted

Larry S. Sandberg

Re: "Why Trump Supporters Don't Mind Lies"

4.28.18

 To the Editor:

 Daniel Effron (4/28/18, Why Trump Supporters Don’t Mind Lies) cites research that supports the idea President Trump’s lies are tolerated by his supporters because they can be regarded as plausible and hence less unethical or immoral.

He describes as a ‘subtle psychological strategy,’ for example, Sarah Huckabee Sanders responding to Trump falsely claiming that a Muslim had committed assault by saying ‘Whether it’s a real video, the threat is real.’ 

As a psychoanalyst, I hardly find this subtle.  However effective, language has been manipulated to say, in effect, the truth does not matter.  The focus is progressively moved away from the false statement about a video to a ‘threat’ that makes the President’s lie irrelevant or, perversely, illustrative of the threat.  The truth is twisted.

I suggest that President Trump’s core supporters are not expending too much energy thinking about his lies or, worse his being a ‘liar.’  They will rationalize his statements as ‘white lies’ as long as they believe his policies address their concerns.  It is deeply ironic that his biggest lie – his urge to help those truly in need – goes undetected by his core supporters.

Respectfully submitted,

Larry S. Sandberg MD

Re: "In Therapy Forever? Enough Already"

 4.22.12

To the editor:

Jonathan Alpert (4/22/12) presents a caricatured picture of long-term psychotherapies and trivializes the suffering of patients whose illnesses require more than an  'aggressive prod' to get them better.  Insight oriented therapy is not passive, but involves a kind of activity that encourages mobilization through self understanding - often by apprehending unconscious motivations. The effectiveness of this approach is supported by research (Leichsenring and Rabung).

He suggests that anxiety and depression are not severe psychological disorders compared to schizophrenia.  These mood states can be part of syndromes that are life threatening.  For example, Major Depression has a lifetime risk of suicide around 10% and Panic Disorder can be incapacitating.

While some patients may be in ineffective therapies, many more lament the inadequacy of their insurance coverage as it limits access to psychotherapy.  Others are encouraged to take medication because it is expedient rather than it necessarily being more effective.  The problem of the perennial patient pales in comparison to these contemporary problems.

Respectfully,

Larry S. Sandberg MD

Re: "The End of Intelligence"

4.29.18

To the editor:

Michael Haydn (The end of intelligence, 4.29.18) powerfully argues about the risks posed to our country when objective reality and truth are devalued, ignored or manipulated.  But it is not, as he suggests, that facts exist in opposition to emotion.  President Trump appeals to base emotions of fear, paranoia and mistrust and he provokes moral indignation in those who oppose him and his effort to render reality irrelevant. 

There is a basic reality that psychoanalysts and psychiatrists all know: decision-making requires an intact capacity to parse out reality from fantasy.  While one cannot definitively say why President Trump has this problem without a comprehensive psychiatric examination, the very presence of this symptom – regardless of diagnosis – should worry all of us. Turning a blind eye, denying this reality, is its own complicity. 

Like a malignancy that has metastasized, President Trump has mobilized Republicans in Congress, Sarah Huckabee Sanders, Fox News and, of course, his base to engage in a folie-a-deux (sharing and perpetuating of false beliefs).  This, too, should worry all of us.

It is only through a passionate embrace of the truth that the tide can be turned.  The excitement and energy amongst Democrats going into the midterm elections is a hopeful sign.  The fact that many recent special elections have been won by Democrats also suggests that the cancer may not be fatal.

Respectfully submitted,

Larry S. Sandberg MD

Re: "When Fiction is a Fact of Life"

3.18.18

 To the Editor:

 ‘When fiction is a fact of life’ (NYT, 3.18.18) highlights President Trump’s ignorance about basic details of trade with Canada, his knowingly lying to Prime Minister Trudeau and his boasting to Republican donors that he lied.  I thank the Times for deeming this newsworthy and protecting us from what Robert Jay Lifton has called malignant normalization. This must never be normalized.  What parent hearing of her child behaving like this would not be deeply concerned?  What psychiatrist or psychoanalyst would deem this behavior non-pathological?

What White House press secretary would be complicit with this dangerous behavior? Sarah Huckabee Sanders is astonishing in her straight-faced effort to normalize President Trump’s behavior. As reported, she acknowledges that President Trump fabricated a story about the Japanese dropping bowling balls on American made cars to curtail imports and then asserts how this false story illustrates ‘creative ways some countries’ block U.S. imports.  In other words, President Trump’s lie becomes truth telling.

We should be troubled by the lack of outrage, the deafening silence of those in elected office who turn a blind eye and embrace denial putting their self-interest before country.  Moderate Republicans should be ashamed of themselves for their complicity and moral abdication of responsibility.

It is crucial that citizens do not become numb or see our current reality as the 'new normal.'  We must insist that our elected officials do the right thing.  If not, we will do the right thing at the ballot box next November.

Respectfully submitted

Larry S. Sandberg