Re: "Stop Googling, Let's Talk"

To the editor:



Thank you, Sherry Turkle (9/27/15, Stop Googling, Let's Talk).  The dangers of texting and driving are well known but this piece highlights the pervasive negative impact of texting while living.  This is evident when walking down a busy street with people looking down and texting on their phones oblivious to others and the nonverbal 'conversation'  that defines consideration. More painful is the mother strolling her infant while her gaze is on her phone rather than her child.  As a psychoanalyst it is obvious that many patients use texting as a form of pseudo-intimacy and distraction from the present moment - whether it is a moment with another person or oneself.  I had one patient suggest to me that I keep talking while she responded to a text - turning off her cellphone in sessions marked the beginning process of introspection and being present.

The problem is that no one is selling, advertising, tempting the public with the 'wares' of empathy and introspection. It behooves parents to teach their children well and to have the kinds of conversations with their children that often emerge (and are remembered as special) spontaneously without distraction.



Respectfully submitted,


Larry S. Sandberg

Re:

To the editor:

Lisa Rosenbaum advises patients to 'let fear guide early breast cancer decisions' (NY Times, 8/27/15) but I think it needs to be emphasized how subjective fear is and, also, how inter-subjective it is.  The degree of fear a patient feels will be influenced by the physician's attitude and the push to intervene is often conveyed implicitly or explicitly.  Living with uncertainty can be very anxiety provoking, especially in relation to one's health.  But informed consent requires the physician to make explicit his uncertainty (based on the best available evidence) about the long term benefits of a suggested intervention. In this way, the authoritative position of the physician is tempered by humility and expresses respect for the patient's autonomy and right to be fully informed about reasonable - even opposing - options.



Respectfully


Larry S. Sandberg MD

Re:

8/3/15



To the editor:



Police detain man in death of officer in Memphis (NY Times, 8/3/15) reports the shooting death of an officer during a traffic stop in southeast Memphis.  I believe this story, at this particular moment in our public discourse on the inappropriate use of force by policemen, belonged on the front page rather than where it was placed. It is a sober reminder that policemen put themselves in harms way on a daily basis.  This does not justify or excuse the shooting of unarmed minority civilians but may heighten empathy for the majority of policemen who are decent and who put their lives on the line everday.



Respectfully,


Larry S. Sandberg

Re: "Psychiatry's Identity Crisis"

To the editor

:

One consequence of 'Psychiatry's identity crisis' (Richard Friedman, 7/19/15) is that many patients pursue treatment with a psychiatrist who prescribes medicine and a psychologist or social worker who engages in psychotherapy.  Known as 'split treatment,' this arrangement can work well if physician and therapist communicate with one another. Too often, however, communication is poor or nonexistent.  This situation can create the proverbial left hand not knowing what the right hand is doing.  As fewer psychiatrists take the time to develop skills in psychotherapy and choose drug prescribing as their area of specialty, 'split treatment' is likely to grow in popularity.  It is important for patients to feel empowered and ask, if not expect, members of his/her treatment team to speak with one another during periodic intervals and challenging or complicated phases of either treatment.



Respectfully,


Larry S. Sandberg MD

Re: "The Lost Language of Privacy"

To the editor

David Brooks (The lost language of privacy, 4/14/15) laments the ‘lost language of privacy’ but has lost the forest for the trees in seeing cop-cams as a problem that ‘strike(s) a blow against relationships’ rather than an essential way to reestablish trusting relationships between policemen and the public, especially minorities. No sector of the public should live in fear of public servants who have a duty to protect them. Cop-cams may encourage the use of language rather than bullets in dealing with possible criminal behavior. The concern that embarrassing domestic scenes will go viral can and should be dealt with by implementing restrictions on the use of this material.

Respectfully,

Larry S. Sandberg

Re: "Why Doctors Need Stories"

10/19/14



To the editor: 



Peter Kramer (Why Doctors Need Stories, 10/18/14), by focusing on the value of storytelling for patients and doctors alike, brings to our attention the limitations of a strictly evidence based medicine. The latter emphasizes how people with a certain condition are similar; narrative medicine (as the alternative is often described) emphasizes each person's unique circumstance. The integration of these approaches is not only important for compassionate and empathic care; it also serves as a corrective, especially for psychiatric illness in two respects. First, the cultural 'narrative' borne of massive advertising campaigns by drug companies has equated depression with 'biological illness' - a gross oversimplification that encourages overprescribing. Second, the co-creation of a narrative within psychotherapy is healing - no doubt affecting biology - for many patients with depression.



Respectfully submitted,


Larry S. Sandberg MD

Re: "Why Do Doctors Commit Suicide?"

September 5, 2014

To the editor:



Pranay Sinha (9/5/14, Why do doctors commit suicide?) downplays the role of stigma towards mental illness as an impediment for a physician pursuing psychiatric treatment.

The vast majority of people who die by suicide suffer from a diagnosable mental illness with clinical depression being most frequent. Reassurance, which was helpful for the author, is of limited value for most patients with clinical depression and suicidal thinking.

A resident may feel insecure about his capacities to heal due to lack of experience as he moves into a role of increased responsibility. But insecurity may also be a realistic reaction to being impaired by mental illness. Being ill while developing one’s healing capacities and identity can feel like an impossible bind. Acknowledging that one is ill - to colleagues and to oneself – can feel terrifying and dangerous.

Sensitivity to this conflict may make it easier for physicians to pursue treatment while assessing the physician's competence during a period of illness. This makes more likely a positive outcome will prevail - doing no harm to one's patients nor oneself.

Respectfully,

Larry S. Sandberg

Re: "Powerful and Coldhearted"

To the editor:



Inzlicht and Obhi (Powerful and coldhearted, 7/27/14) problematically generalize from the laboratory an inverse relationship between power and empathy.  No doubt power can have a corrupting impact on empathy - the dysfunction in Washington is an unfortunate and blatant example. But when we think about power, it is important to ask what kind of power we are talking about. The article suggests that the 'power' explored in the authors' research involved power as domination and submission. Someone who feels subordinate to others has a higher likelihood of surviving if she is attuned to the emotional states of others (i.e., empathic). On the contrary, it is more difficult to dominate someone if you are empathizing with that person's predicament.

However, empathy can be, in itself, an important expression of power.  As a psychiatrist and psychoanalyst empathy is my most important tool. Arguably the most powerful man on earth, the Pope, seems to possess deep empathy. The authors state it is hard for influential people to feel empathy. If the pope is not among the most 'influential people' in the world who is?



Respectfully submitted


Larry S.  Sandberg

Re: "Why Teenagers Act Crazy"

6/29/14



To the editor:



Richard Friedman (Why teenagers act crazy, 6/29/14) focuses our attention on anxiety problems in adolescence - an issue that often takes a back seat in the public eye given the blatant dangers of impulsivity and risky behavior during this developmental phase. It is helpful to keep in mind that fear and anxiety, though related, are different.  Fearfulness when entering a potentially threatening, novel situation (for example, a party scene with heavy drinking) is adaptive and can balance out the impulsive tendency. Anxiety, anticipating and imagining a threat, can keep a teenager home. While many models of anxiety focus on the amygdala, others (Jaak Panksepp, for example) highlight the importance of brain regions that modulate separation distress - a critical and inevitable aspect of this developmental phase. Through this perspective, we all need some blend of fearfulness and exploration to successfully navigate adolescence.



Respectfully,



Larry S. Sandberg

Re:

12/31/13

To the editor:

Most people would choose to avoid a relationship experienced as adversarial and borne of mistrust.  Such is the predicament of the psychiatrist, especially if talk therapy is involved, in relation to the insurance company.  Letters come informing us, for example, that on average patients are seen for eight visits or less.  Not a subtle message.  On the surface 'medical necessity' as a factor in determining ongoing coverage seems inoffensive and unobjectionable. But it is often used as a weapon to deny care when intensive treatment is taking place. The practicing psychiatrist must insulate himself from the background threat with which he and his patient are confronted in order to listen carefully to his patient.  

Yet insurance companies are entitled to know what they are paying for and cost containment is a legitimate concern. What reforms does Helen Farrell suggest to remedy this situation?

Respectfully,

Larry S. Sandberg

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