Re: "Santa on the Brain"

To the editor:



Kelly Lambert (12/22/13, Santa on the Brain)  discusses the value of fostering 'mental time travel memories' in childhood so as to create enduring visceral and emotional links to our past that are evoked by stimuli in our present life. This phenomenon, no doubt universal, is at the heart of insight oriented psychotherapies where such excursions into the past are encouraged in interaction with the therapist. But what makes the mental time travel in psychotherapy different?

Unlike other relationships where such experiences occur implicitly and automatically, the ability to explore such memories in a therapeutic setting can change or deepen the emotional meaning of one's past. This is because memories are not stored as unmodifiable files in the brain - remembering helps to re-memorialize the past!
 Since past is prologue, the consequences can be life changing. 



Respectfully submitted,

Larry S. Sandberg

Re: "Rich People Just Care Less"

To the editor:



Daniel Goleman (Rich people just care less, 10/6/13) speaks of an 'empathy gap' borne of differences in social status whereby powerful (including wealthy) individuals are less likely to experience compassion for those less fortunate.  He speaks of the policy implications being played out in the current political morass in Washington adding 'elected officials don't even have to encounter many voters from the rival party (due to gerrymandering), much less empathize with them'.  But this observation fails to take into an important consideration.

There is not only a lack of empathy, but a willful effort on the part of Tea Party Republicans to frighten their own constituents into feeling threatened by the very programs intended to help them.  Perversely, the most vulnerable sector of the population is being disempowered by being made to feel overpowered by a government with sinister intentions. How is this being done?  With an all out campaign, funded by wealthy Republicans like the Koch brothers, to derail Obamacare in any way possible - even if this means shutting down government (A crisis months in the making, 10/6/13). 





Respectfully submitted,


Larry S. Sandberg

Re: "Diagnosis: Human"

To the editor:



Ted Gup (Diagnosis: Human; 4/3/13) poignantly highlights the potentially fatal consequences of colluding with 'a system that devalues talk therapy'. Evidence abounds to support his view about therapy: A recent study found that 1.2% of the general U.S. population receives antidepressant medication despite displaying symptoms of only mild severity for which drugs are not indicated. Another study found that less than 11% of psychiatrists in the U.S. are providing psychotherapy. Furthermore, insurance companies continue to aggressively move to control costs by preferentially reimbursing and supporting drug therapy over talk therapy, 

These trends have not evolved overnight and will take time and effort to reverse.  Medication, when correctly prescribed, can be lifesaving for many individuals.  Psychotherapy, while more labor intensive and costly in the short run, can also have profound and enduring therapeutic effects. Clearly we are living at a time where cost control is a major and legitimate consideration for the delivery of health care.  Gup highlights the less conspicuous but heartbreaking cost of a system that devalues talk therapy.




Respectfully,



Larry S. Sandberg MD

Re: "Psychiatric Diagnoses"

To the editor,

As a psychiatrist and psychoanalyst, I applaud Ronald Pies' highlighting underlying societal and psychological determinants that contribute to negative attitudes about psychiatric diagnoses (3/20/13 NYT, 'Psychiatric Diagnoses).  But the fact that some medical diagnoses are made on a similar phenomenological basis as psychiatric diagnoses conceals the fact that psychiatry, as a branch of medicine, remains at a very primitive level with regard to understanding etiology and pathophysiology. This is not reason to abandon diagnoses or to embrace therapeutic nihilism. The brain is a complex organ. But it is reason to exercise caution precisely because diagnosis does inform treatment, as Pies notes, and there can be a risk of over-diagnosing and over-treating. In my experience, young adults who come to see me have often come with diagnoses of 'bipolar spectrum illness' or 'borderline personality' with multiple unsuccessful medication trials when what is indicated is psychotherapy. Baumeister, in a study published last year, estimated that 1.2% of the American population was receiving antidepressant treatment for either mild or subsyndromal Major Depression; i.e., conditions that are not believed to be responsive or in need of medication. These findings do not make psychiatric diagnoses inherently problematic, but the public should be aware of the unintended consequences being given diagnoses in addition to the problems noted by Pies.

Respectfully submitted

Larry Sandberg MD

Re: "Successful and Schizophrenic"

To the editor: 

Elyn Saks (Successful and Schizophrenic, 1/27/13) does the public a great service by highlighting her capacity to live a full life with a severe psychiatric illness rather than be defined by it.  Her story is familiar to those of us who treat this and other serious illnesses like schizoaffective illness or bipolar illness. Of particular relevance is her unabashed acknowledgement that 'excellent psychoanalytic treatment' has been critically important. An examination of national trends in office-based psychotherapy by psychiatrists (2004 - 2005)  found that only 10.8% of psychiatrists provide psychotherapy and the number is probably lower now. As pressures grow on the practicing psychiatrist to limit cost and to document 'medical necessity' (no doubt more easily done with medication than psychotherapy) there is a real danger that the talking cure will be lost as part of the psychiatrist's armamentarium.

Respectfully,

Larry S Sandberg MD

Re:

To the editor:

Republican Representative Mike Rogers, in rejecting tighter gun control measures, is quoted as saying ' ... the more realistic discussion is, how do we target people with mental illness who use firearms?'  I disagree. News reports suggest the shooter's mother,  herself a victim, owned the guns used in this tragic event. It appears that restricting the sale of guns to the mentally ill, however wise and appropriate, would not have prevented this horrific act.

As a country we have moved to protect the rights of same sex couples to marry.  How can we not have the same resolve to protect the innocent against acts of terror? The right to bear arms, as currently legislated in this country, infringes on the right to life of our most vulnerable citizenry. We must make our voices heard to our elected officials to compel them, as Mayor Bloomberg exhorts, to immediate action.  It is the least we can do to honor the lives of those lost. 

Respectfully,

Larry S. Sandberg

Re:

11/25/12

To the editor:

As a psychiatrist and psychoanalyst interested in neuroscience, I applaud Alissa Quart's highlighting the manner in which brain science findings are often conveyed in a misleading, reductionistic, pseudo-authoritative manner by the media.  This is especially relevant for people with mental illness who may, inadvertently, be encouraged to view their suffering as devoid of context or meaning outside of a 'biological' explanation.  While this may serve a valuable de-stigmatizing role, there is a real risk that modalities of treatment that are not typically considered 'biological' (i.e., talk therapy) though, of course they are, become devalued and underutilized.

Respectfully submitted,

Larry S. Sandberg MD

Re: "Moderate Mitt Returns"

To the editor:



David Brooks hails the unveiling of a 'more authentic version' of Mitt Romney during the debate being the 'man (I think) he truly is' (Moderate Mitt Returns, 10/5/12).  Hope springs eternal for Mr. Brooks.  Are we really to believe that Governor Romney's attitude towards those in need was more truthfully conveyed in his televised performance than in his spontaneous comments to a group of his supporters? While I appreciate Mr. Brooks owning his view as his own, I regret that he is doing with his readership precisely what Governor Romney did in the debate - engaging in spin. I hope the American public can look at these contrasting images of Governor Romney and consider what is says about a man who can harbor such contradictory views.



Respectfully,



Larry Sandberg

Re: "Don't Show Me The Money"

To the editors:

It may be that our interest in money is, as James Atlas suggests, a form of pornographic pleasure (Don't Show Me The Money, 9/16/12) with a perverse interest in the very rich.  But I would emphasize, as he notes only in passing, the potential value and necessity of being informed about the practices of a world most of us know very little about and have tended to trust, however naively, with money put aside for retirement, our children's education or a rainy day. This is not pornographic indulgence, but essential reading. The current inundation of financial news may serve as a corrective for those blindsided by the financial meltdown.  Most important, if it keeps pressure on our elected officials for true financial reform perhaps it will be less likely that millions of innocent people, through no fault of their own, will have their lives destroyed by the actions of those who were trusted to take care of them.  But, of course, that may be naiveté kicking in.

Respectfully,

Larry S. Sandberg

Re:

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: "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