The State of Psychiatric Care in the U.S.

To the editor:

Kelli Maria Korducki (It's not just a chemical imbalance, 7.27.19) rightly laments the state of psychiatric care with its overemphasis on drug treatment for what are, inevitably, complex psychological problems.  As a psychiatrist and psychoanalyst, I am unaware of any acute psychiatric condition for which drugs alone are adequate.  Excellent research now exists establishing the effectiveness of psychotherapy - alone or in combination with drugs - for most major psychiatric illnesses including personality disorders.  Other studies have shown distinct brain changes with talk therapy; i.e., psychotherapy is a biological treatment.

A major impediment, alluded to by the author, is an insurance industry governed by profits and a perverse misuse of 'medical necessity' criteria to deny patients needed psychotherapy - as evidenced by a finding in a recent class action suit against United Healthcare. Those of us who can work out-of-network do so in an effort to preserve the integrity of our work.  But that does not prevent insurers from aggressively auditing treatments, withholding payments or denying care once a patient is no longer in 'crisis.'  I would say, without exception, this euphemistic  'quality control' always pertains to talk therapy, not medication management.

As the 2020 Presidential election cycle is upon us, I hope candidates will address the for-profit insurance industry's role in intentionally under-insuring those in need of psychotherapy.

Respectfully submitted

Larry S. Sandberg

Clinical Associate Professor of Psychiatry at Weill Cornell Medical College

Re: "Key evidence solidifies CIA assessment that Saudi Prince ordered Khashoggi killing"

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: "Breaking With U.S. Intelligence, Appears to Accept Saudi Explanation of Journalist’s Death"

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"

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: "For Once I'm Grateful to Trump"

To the editor:

I read with dismay Bret Stephens (10.4.18, For once I'm grateful to Trump) lauding President Trump's unconscionable behavior mocking a victim of assault because 'he's one big bully willing to stand up to another.'  Since when do two wrongs make a right? And why does Stephens focus his attention on everyone but the victim?  He does not own or even recognize his implicit bias in his thinking.

Yes, Blassey Ford and Brett Kavanaugh cannot both be telling the truth.  As a psychiatrist and psychoanalyst, the most likely explanation based on brain science and knowledge of how the mind works is that the episode became a memory for Blassey Ford because it was traumatic and a non-memory for Kavanaugh because he was drunk.  On this basis alone, the risk to the functioning and integrity of the Supreme Court is far greater if Kavanaugh is seated rather than replaced by another nominee. Erring on the side of caution is in the best interest of the country given the stakes.

There has also been much justification of Kavanaugh's conduct at the hearing; an angry man unfairly attacked fighting for his name and honor.  No doubt this has been a trying time for Kavanaugh and the hearing a difficult stress test.  For many of us, including legal scholars, he failed the test.  His strategy was using rage to show innocence -  Republicans were gleeful because they could embrace that narrative.  But for the rest of us it showed an ugly side of him that he will carry into the Supreme Court to the detriment of all Americans.

Respectfully

Larry S Sandberg

Re: "Cardiologists Should Care about our Love Lives"

To the editor:

Sandeep Jauhar (NYT, 9.16.18, Cardiologists should care about our love lives) powerfully illustrates the way negative emotions can damage heart functioning in the case of  'broken heart' syndrome and how stress reduction can improve cardiac health.  But he too quickly dismisses the heart as a 'source' for emotions and adopts a dualistic way of thinking when distinguishing our 'hearts' from our 'emotional system.'

The seminal research by affective neuroscientists like Antonio Damasio and others supports the view that our metaphoric use of language to describe our emotions (heart break, gut wrenching, pain in the neck, pissed off  - among others) has a literal, concrete basis. We rely on our bodies, not only our hearts, to 'tell us' how we feel. This takes place automatically and largely unconsciously in the way we carry ourselves and the state of our viscera. An anxious patient with a racing heart feels his tachycardia as his anxiety regardless of the mental trigger.  In other words, our emotions are embodied.

The takotsubo cardiomyopathy is an extraordinary example of a coming together of the concrete and metaphoric broken heart.  But the healthy heart, however silently, is itself, expressing a state of emotion whether it be peace, calm or love.  I applaud Dr. Jauhar for emphasizing the critical importance of taking emotional factors into consideration when treating the physical body.

Respectfully submitted

Larry S. Sandberg

Re: "The Big Myth About Teenage Anxiety"

To the editor

Richard Friedman (NYT, 9.9.18 The big myth about teenage anxiety) is right to point out that there is no available research to prove - or disprove - the notion that an epidemic of anxiety exists among teenagers and that some academic research - correlating brain regions that are active in individuals who are 'addicted' to technology - is uninformative in this regard.  I believe, though, that it is highly problematic to argue that some parents,teens and young adults simply worry too much and should recognize that our brains are 'resilient and more resistant to change than we think.'

It concerns me when I see a young mother strolling down the street with her infant while looking down at her phone rather than engaged with her newborn.  The technology has co-opted a deeply biological and psychologically driven motivation to attach and engage the newborn. It concerns me when people walk down the street glued to their phones rather than engaged with their environment - one that can include a visually impaired individual on a collision course.  It concerns me when teachers lament their inability to get their students to pay attention in the classroom. The list goes on.  I do not see this as an epidemic of anxiety - rather an incursion of technology in the relational realm in ways that are (objectively in my mind) deeply problematic. 

People develop powerful relationships with their cellphones and the technology it provides. Like any transformative tool, it has its risks.  I think we do well to realize that the technology industry is fueled by for profit businesses invested not in the emotional or intellectual well-being of the public but in maximizing profits by getting people to stay connected to their devices.  For this reason alone, a healthy skepticism is warranted in evaluating the impact of technology on mental health.

Respectfully submitted

Larry S. Sandberg MD

Re:

To the editor:

I did not realize that job security was a consideration in deciding whether to publish the name of an opinion piece contributor.  It is one thing to grant anonymity in the service of protecting a contributor's safety; quite another to protect his/her job.  However well intended, I believe the NY Times has allowed itself to be played and used as a pawn by the author to destabilize an already unstable President.  I do not think President Trump is mentally fit and believe it would be in the best interest of our country for him to step down or be removed.  But I do not think it is the NY Times proper role to publish a piece that knowingly, by virtue of the anonymous authorship, would feed a paranoid man's paranoia. Given the President's repeated attacks on reality the public has a right to know the contributor's name. Ultimately our President and country are best served by taking a courageous stand and speaking truth to power.

Respectfully submitted,

Larry S. Sandberg MD

Re: "Donald Trump, Mesmerist"

To the editor:

 Emily Ogden (Donald Trump, Mesmerist; NYT 8.5.18) likens President Trump’s appeal to that of the mesmerists who used hypnotic suggestion to lull their subjects into ‘credulous obedience’ and further argues that efforts to expose his lies backfire because he is ‘selling anti-mesmerism’ turning accusations against him into strengths. But President Trump’s popularity exists only because of a deeply engrained mistrust, borne of marginalization among his supporters, that he has masterfully stoked with the blunt force of lies rather than sleight of hand.

I attended a magic show last night where I was mesmerized when my wedding band was put in a locked box on a stage next to me and ended up on the stem of a wine glass where I had been seated. I have no idea how that happened and not knowing and not needing to know made it entertaining. It was a great performance.

There is no subtlety, no effort of orchestrated illusion, in President Trump’s conduct. He is a manipulator whose dangerous skill is to get a large part of the electorate to believe demonstrable falsehoods; to collectively close their eyes to rational thought and to stoke fear and hatred. If the mesmerist seduces his audience by encouraging them to trust their own perceptions, President Trump, using demagoguery, reinforces his supporters’ mistrust of our most basic democratic institutions.

Respectfully submitted

Larry S. Sandberg MD

Re: "GOP Faces Another Midterm Threat as Trump Plays Shutdown Card"

To the editor:

While it may make for laughs among his loyal supporters, President Trump's texting about the media's being driven insane by their  'Trump Derangement Syndrome' (GOP faces another midterm threat as Trump plays shutdown card, 7/30/18) is yet another example of his disturbed mind as he attempts to manipulate and deceive by perpetuating the use of a pseudo-condition that creates an impression that such a psychological condition is real and can be given a name; one that labels as pathological journalists who are committed to the truth.

As a practicing psychiatrist and psychoanalyst I can attest to the fact that many of my patients are suffering with heightened anxiety, insomnia and feelings of powerlessness in response to President Trump's relentless attack on reality. And some worry they are losing their minds - not because of Trump's policies - but due to his relentless attack on facts themselves.

It is undeniable, yes a fact, that President Trump uses deception as a major mode of relating to world; it is hard to know the degree to which he engages in self-deception though some of his lies (the size of the inaugural crowd, for example) beg the question.  Regardless, I applaud the media for their arduous work in being committed to the truth and helping to keep American citizens sane during this difficult time.

Respectfully

Larry S. Sandberg MD

Re: "Trump Says he Got Only One Word Wrong"

To the editor:

When someone is telling the truth he has only one story to keep straight in his mind. This is not  a complicated intellectual task; the story does not change over time because the events that comprise the story - remembered and part of history - have not changed.  We hope to learn from history but do not engage in revisionism - either for ourselves or others. Our well-being, our sanity, requires that we grasp reality and tolerate it especially when painful. If not, important judgements as to how to deal with reality cannot be made.

President Trump (NYT, 7.19.18, Trump says he got only one word wrong), with help from his inner circle, repeatedly changes his stories though his true sentiments often reveal themselves. He is a confabulator-in-chief who creates stories that suit his audience and his own emotional needs. In Helsinki, Vladimir Putin was his audience.  Back home, his audience became Americans and his story shifted accordingly. He constantly seeks to dismiss news stories not to his liking by creating his own story - 'fake news' - manipulating the minds of his supporters.

The multitude of confusing and contradictory statements of 'fact' are comprehensible only through a psychological lens: President Trump will say or do whatever he has to based on his internal emotional needs. Whether this is based on a purely psychological problem, a problem with past behavior he is trying to conceal, or some combination of the two is impossible to know at this point. Regardless, deception including self-deception, appears to be a frequently used coping mechanism.

When neurological patients confabulate it is poignant to see how they fill their gaps in memory with more pleasant stories than are warranted by their state of illness.  When the President of the United States repeatedly makes things up we are dealing with an emergency.  To view it otherwise is to collectively deny reality.

Respectfully submitted

Larry S. Sandberg MD

Re: "Trump, At Putin's Side, Questions U.S. Intelligence on 2016 Election"

To the editor:

The American Psychiatric Association, wedded to an outdated concept of ethical conduct, refuses to make any public statement concerning the mental health of President Trump because he has not been personally examined.  In staying silent, they do a disservice to their membership and to a population desensitized, numbed or terrifed by the current state of affairs. President Trump's conduct over the last several days - with our allies in Europe and England and today with Vladimir Putin - is a reflection of mental instability regardless of diagnosis. 

Today (Trump, At Putin's Side, Question U.S. Intelligence on 2016 Election, 7.23.18) the President of the United States, in avoiding rebuking Russia and more importantly in equivocating in his support of our intelligence agency, laid bare is unfitness to govern.  He does not trust the agency whose function is to keep us safe.

Given President Trump's ability to spin reality, hail fake news as real and real news as fake, and manipulate the minds of a vulnerable public, we need the American Psychiatric Association and other professional associations invested in the well-being of our country to step forward and make a statement - any statement - that serves as a reality check that what we are witnessing is not normal and a threat to our national security. 

Respectfully,

Larry S. Sandberg MD

Re: "Trump's Magical Fantasy World"

To the editor:

David Brooks (NYT, 5.25.18, Trump's magical fantasy world) opines we are being seduced into President Trump's fantasy world 'like puppets on a string' dominated by the Trumpian 'soap opera.'  He is misunderstanding, in my opinion, the reality of many Americans.

As a psychoanalyst I hear many of my patients describe the feeling of living in a waking nightmare in a reality that is both terrifying and terrorizing because reality itself is under constant attack.  This leads, not to seduction, but hypervigilance in an effort to manage a constant feeling of threat. My patients do not feel they are engaged in a 'soap opera;' rather they feel this is like a soap opera (albeit a bad one) and one they should be able to turn off. But they wake up in the morning and ... it is still going on!

I have urged many of my patients to respect their need to be informed without compulsively monitoring the news in a failed effort to reassure themselves they are safe. The evening news does not make for good bedtime reading. For many people some form of activism, an antidote to feeling paralyzed with fear and helplessness, is crucial.

Many mental health experts have argued that President Trump's problem staying in reality impairs his ability to make decisions and raises questions as to his fitness to serve.  We are witnessing a metaphorical train crash in slow motion.  History will not be kind to those who blindly or knowingly joined our President for the ride.

Respectfully submitted

Larry S. Sandberg

Re: "10 Dead in Shooting at High School"

5.19.18

To the editor:

As the details of yet another tragic school shooting unfold (NYT, 10 Dead in shooting at high school, 5.19.18), a predictable narrative, highlighting with '20:20 hindsight' the mentally deranged state of the shooter, Dimitrios Pagourtzis, will likely follow.  The signs are already there: wearing a 'Born to Kill' t-shirt, an apparent attraction to music adopted by neo-Nazi groups and the alt-right. He will be demonized and there will be calls for improved mental health services; an unobjectionable idea in principle that cynically shifts attention away from gun control.

We have failed as a society to keep our children safe but the threat is not the conveniently often scapegoated, untreated mentally ill or the fringe, disenfranchised 'troubled' youth.  There will always be segments of the population who are deeply troubled who do not seek treatment.  The upsurge of nationalism and neo-Nazism in parts of Europe has not lead to the mass violence we have in the United States.

Our politicians have sold their souls with blood money from the NRA.  They have abdicated their responsibility as elected officials; shamelessly invoking God during each tragedy.  I have no faith that today's politicians can do what needs to be done.  But children across this country and across all demographics - rich and poor, Democrat and Republican, conservative and liberal, black and white - are growing up. Their courage to speak up and come together due to their shared history of trauma from gun violence may create the necessary common ground to effect change.  I hope so.

Respectfully

Larry S. Sandberg

Re: "Trump's Lizard Wisdom"

To the editor:

David Brooks (NYT, Trump's lizard wisdom, 5.11.18), in a striking display of wishful thinking, describes President Trump's actions as based on lizard wisdom. He seeks to reassure us that behind President Trump's erratic, impulsive, self-centered, paranoid, grandiose behaviors there is something of evolutionary value in his conduct.  Lizards are typically sit and wait predators that adapt to their environment through anti-predatory behaviors like camouflage, playing dead or reflex bleeding as a chemical defense. These behaviors are well suited to their environment. One can say the President can learn a thing or two from lizard wisdom.

Humans have adapted more sophisticated brains to create, survive and flourish in a more complex world.  Wisdom involves forethought; reflex gives way to introspection; impulsiveness gives way to restraint.  President Trump possesses none of these traits. Yes, some of his actions may have favorable outcomes. After all, even a stopped clock is right twice a day. 

It is a serious misunderstanding of the man - and the lizard - to equate his conduct or thinking with anything resembling wisdom.  I would suggest the more apt metaphor is that President Trump is like a bull in a china shop attempting to destroy valuable, albeit delicate, international agreements on peace relations, trade and climate change and, of course, the domestic achievements of President Obama.

Respectfully submitted,

Larry S. Sandberg MD

Re: "Trump Tells Macron the U.S. Will Withdraw from the Iran Nuclear Deal"

To the editor:

Mental health experts have been expressing concern  that President Trump's ability to make sound decisions is impaired because of his trouble staying in reality whatever the underlying cause.  Withdrawing from the Iran nuclear deal (NYT, 5.8.18, Trump tells Macron the U.S. will withdraw from the Iran nuclear deal) is the latest and perhaps most consequential illustration of this problem.  He has managed to surround himself with the few like minded radical thinkers who back him while rejecting the advice and guidance of moderates in his own party and our allies.

President Trump has a long history of failed business ventures many ending in litigation or bankruptcy.  But in today's decision he has made the world a less safe place.  We  have not only a reason but an obligation to question his motivation. His behavior must no be normalized.  And we should expect our elected officials to speak out; silence is complicity.

Respectfully submitted

Larry S. Sandberg MD

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

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: "The Antidepressant Withdrawal"

To the editor:

(Re. 'The antidepressant withdrawal', 4.17.18) Psychotherapy is a credible, evidence based treatment for mild to moderate Major Depression and a valuable adjunct to medication for severe Major Depression where suicide is a distinct risk.  There are many reasons anti-depressants have been over prescribed.  As you report drug companies have historically played an important role with aggressive lobbying efforts, direct to consumer advertising and funding academic research in ways that biased outcome.  Diminished stigma to mental illness has been a complicated factor making treatment more acceptable to people who have shunned care.  Most important, from my perspective, has been the cultural trend to value the quick fix, devalue talk therapy (really conversation in any form) and to have an insurance industry that is largely antagonistic to the legitimate role of psychotherapy to treat mental illness. 

Respectfully

Larry S. Sandberg MD

Re:

To the editor:

The murky perils of quitting antidepressants after years of use (NYT, 4.8.18) reports on the prevalence of withdrawal or discontinuation symptoms when antidepressants are stopped.  These medications can be lifesaving for people with severe depression; a condition which tends to be chronic and recurrent. When a decision is made to taper an antidepressant vigilance is required to monitor for relapse as well as withdrawal.

Not only should a patient be aware of the risks of taking any drug at the outset; she should also be aware of alternative treatments.  Psychotherapy for mild to moderate depression is an effective and evidence based approach that alters brain chemistry without side effects or withdrawal symptoms.  And, when effective, its benefits can be long lasting.  Individuals seeking treatment for depression should discuss drug treatment, psychotherapy and combined approaches with their physician before embarking on any course of treatment.

Respectfully

Larry S Sandberg