Re: "Going Beyond 'Do No Harm'"

11/5/16

To the editor

Haider Javed Warraich (Going beyond 'do no harm') rightly encourages the medical profession to rethink its attitude towards assisted suicide for the terminally ill.  He notes that the often evoked worries around this intervention (encouraging 'eugenic sterilization', harming the vulnerable and uninsured, avoiding palliative care) have not been borne out based on all evidence.  However, he leaves out the most important clinical consideration: the presence of a major depression that exists alongside a terminal medical illness.  A careful clinical assessment by a psychiatrist is crucial to make sure the patient's wish to die is not part of a treatable psychiatric illness.

Respectfully,

Larry S. Sandberg MD

Re: "Intimacy for the Avoidant"

10/7/16

To the editor:

Donald Winnicott, a Britiish pediatrician and psychoanalyst, spoke of the endearing objects young children often have a special attachment to - raggedy stuffed animals or dolls, blankets held onto on their last thread - as 'transitional objects.'  These things soothe children by creating a bridge or link to the most important person in a child's life during periods of separation - typically one's mother.  Over time, these objects are given up having outlived their usefulness.  The child's secure attachment to her mother is internalized and forms the basis for building healthy intimate relationships.

David Brooks (NYT, 'Intimacy for the avoidant', 10/7/16) describes a perverse form of this phenomenon for individuals with a 'phone addiction.'  Perverse because the 'security blanket' of the smartphone is not a link to a deeply loved other; rather it is a poor, superficial substitute.  Perverse because it is not transitional; it cannot be relinquished as there is no deeper attachment to replace it. 

Technology, as David Brooks notes, can be a valuable tool to build relationships . But for some the seductive appeal of distance, relative invulnerability and, sometimes anonymity, can inadvertently convert the tool into an impediment to intimacy. I think we are all vulnerable to this addictive behavior.  Caution is warranted in the use of these devices especially with young people whose brains, minds, and social capacities are being actively developed.

Respectfully,

Larry S. Sandberg MD

Re: "Trump's Latest Birther Lie"

9/17/16

To the editor:

As Trump continues to be Trump (NYT, 9/17/16, 'Trumps latest birther lie'), Hillary Clinton repeatedly gets attacked for being such a weak candidate asserting that any other reasonable opponent would have buried Trump in the polls by now.  But it should be remembered that it was Trump who buried a field of over ten other Republicans some of whom possessed the character and potential competence to be President.  

Hillary Clinton's description of many of Trump's supporters being the the 'basket of deplorables' was insulting to a large part of the electorate. But his popularity begs the question: how can someone whose comments are, by and large, deplorable be acceptable to so many people? How can he be so appealing to so many people? 

I am sure the answers are complex but I think it is naive to believe that people support Trump in spite of his duplicity and hostility towards so many sectors of the population.  It is even more naive to believe that 'if only' there were a less flawed candidate running against him Trump's popularity would dwindle. 

Respectfully submitted,

Larry S. Sandberg

Re:

9/16/16

To the editor:

Buried in the today's paper (NYT, 9/16/16) Trump is said to be in 'excellent' health in new doctor's note while noting his calcium score was 98 in 2013 and his blood sugar level is 99.  The previous day we learned (albeit absent in his 'doctor's note') that based on his BMI he is obese.  The calcium score measures plague build up in the coronary arteries and, if it has risen minimally since 2013, would put him at risk for a cardiovascular event.  Per the Mayo Clinic: 'A score of 100 to 300 — moderate plaque deposition — is associated with a relatively high risk of heart attack or other heart disease over the next three to five years.' Why was the test done in the first place?  Has it been repeated?  Has he had a stress test?

The article also points out that Trump's glucose is teetering on being considered 'pre-diabetic'.  A measurement of hemoglobin A1C is a more sensitive marker but none is reported.

Donald Trump may be in good health or even very good health.  But the judgment that he is in excellent health is contradicted by the few objective facts that have been released. All politicians running for the highest office should be held to the same standard of disclosure about their underlying health.  And we should not take at face value the judgment of a personal physician when that judgment is at odds with much of the sparse data that judgment seems to be based upon.

Respectfully,

Larry S. Sandberg MD

Re: "A Fatality Forces Tesla to Confront its Limits"

To the editor:



While the cause of the accident that killed a driver in a self-driving car (A fatality forces Tesla to confront its limits, 7/2/16) remains to be determined, the assertion by Tesla that data is 'unequivocal' supporting the enhanced safety of self-driving should be strongly challenged. 

Driving conditions in the real world are incredibly complex. When is the benefit of 'decreased workload' offset by inattention? When does the relative passivity encouraged by Autopilot decrease reaction time? In what ways might the driver non-consciously become a 'back seat driver'? 

As a psychiatrist who appreciates how sophisticated the brain is I would argue that safe driving is no doubt enhanced by some technology. However, we risk losing ourselves - literally and figuratively- in becoming overly reliant on technology. Energy, time and money would be better spent teaching our youth the dangers of using technology while driving rather than chasing a grandiose dream.



Respectfully,



Larry S Sandberg

Re:

1/24/16

To the editor:

Sally Satel and Scott Lilienfel (NYT, 1/24/16) criticize American culture for promulgating the idea that shame ‘is … a damaging, useless emotion….’. They criticize efforts to ‘eradicate’ shame (by likening drug addiction to cancer) for those with addictions worrying such individuals will see their ‘habits as unalterable.’

Shame, as a universal social emotion, serves an evolutionarily adaptive function. It is also extremely painful and often dealt with by hiding. Contrary to the authors’ assertions, I believe our culture tends to stigmatize people with addictions– to wit the authors use the pejorative label ‘addicts’. Such individuals often avoid treatment because of shame and destroy themselves in the process.

The role of agency is complex in illness whether dealing with addictions or illnesses the authors categorize as ‘biological.’ For example, a patient with lung cancer who smokes is a different patient than a nonsmoker. Regardless of the condition it is critical to mobilize the healthy part of the patient to take responsibility for his or her health. This has more to do with mobilizing self-love in the setting of shame.

Diminishing the stigma attached to addictive illness may help some people more readily enter treatment and come out of hiding. Twelve step programs intuitively integrate this into their philosophy by encouraging people to accept being powerless (i.e., to not ‘lose face’) in relation to their addiction while proceeding to do a moral inventory where reparation is an essential part of recovery.

Respectfully submitted

Larry S. Sandberg MD

Re:

11/27/15

To the editor:

'Turn the volume down on drug ads' (NYT, 11/27/15) glosses over the significant shift that occurred in the mid-1990's leading to the proliferation of direct to consumer advertising (DTCA).  At that time,  the FDA came increasingly under attack in its efforts to regulate the drug industry fueled, in large part, by the Republican Party's taking control of Congress in 1994. House Speaker Newt Gringrich called the FDA the 'no. 1 job killer' and the pressure to deregulate was intense. In 1997, the FDA, under pressure, clarified that drug companies could advertise their drugs as long as consumers were referred elsewhere (a website, a toll free number, a physician) for complete product information. The result? Between 1997 and 1998 television DCTA spending more than doubled; total DCTA advertising jumped from $1.3B in 1998 to $3.3B in 2005. For the pharmaceutical industry, this was also an effort to mitigate the growing role of managed care in encouraging the use of less expensive drugs.

Respectfully

Larry S. Sandberg

Re: "Believing What You Don't Believe"

To the editor:

Jane Risen and David Nussbaum (11/1/15, Believing what you don't believe) problematically argue that intuition is at the heart of certain behaviors that are either superstitious in nature (using a lucky charm) or reflect statistically unlikely judgements in decision making (an 'ill timed' sacrifice bunt). They suggest that the 'slow system' for information processing may be able to detect errors without correcting them. 

Emotion is a critical dimension in decision making even at high levels.  It may contribute to tragic outcomes  - look at what's going on in the Middle East - or acts of heroism.  A coach making a high risk call is not making an error; he is introducing an element of surprise into his decision making in an effort to win and to fool his opponent.  As for the lucky charm this too is not an error in thinking.  It is a token that helps create an illusion of power and control (and diminishes our anxiety ) and comes in handy, especially when your team is struggling. What the authors call intuition is the emotional dimension of life from which we cannot divorce ourselves.

Respectfully,

Larry S. Sandberg

Re:

10/20/15

To the editor:

New approach advised to treat schizophrenia (NYT 10/20/15) highlights the value of combining talk therapy and medication for patients with first episode psychotic illness.  But, as the article points out, this is not a new approach; nor is it a discovery as much as it is a rediscovery.  Similar programs have been in place in other countries for decades.  In most simplistic terms, the distinction is between treating the patient as a person having an illness as opposed to being the illness.  The former approach is compassionate and humanizing while helping patients manage reality - the core problem in psychosis - while minimizing the serious side effects of anti-psychotics. The latter approach leads to massive non-adherence as the article points out.

The finding is important because it highlights, for better or worse, the place of evidence based medicine in shaping the standard of care. On a practical level it is reassuring that the authors found that such care is within reach of this most vulnerable population.

Respectfully,

Larry S. Sandberg

Re: "A New Way to Tackle Gun Deaths"

To the editor:



In an otherwise powerful piece encouraging responsible gun policy (A new way to tackle gun deaths, 10/4/15), Kristof labels America's mental health care system a 'disgrace' both devaluing the hard work and effort of those of us treating mental illness and implying that an improved system would somehow reduce or eliminate such tragedies. Meanwhile, Kleinfeld and colleagues (Mass murders fit profile, as do many others who don't kill, 10/3/15), in reviewing the available data,  illustrate just how difficult it is to predict who will act violently.  An isolated, socially withdrawn, vengeful individual who sees himself as a victim is not the kind of person who seeks out mental health services. Whatever shortcomings exist in our mental health care system, the real disgrace is that our elected officials have sold out to the powerful gun lobby and no longer represent the will of the people.



Respectfully,



Larry S. Sandberg

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