Should You Leave?

THE OPEN MIND
Guest: Dr. Peter D. Kramer
Title: “Should You Leave?”
VTR: 9/10/97

I’m Richard Heffner, your host on The Open Mind. And when, in 1993, the brilliant young psychiatrist, Peter Kramer, wrote Listening to Prozac, his still unmatched landmark book about antidepressant drugs and what he characterized as the “remaking of the self,” Dr. Kramer joined me here for two of the most stunning possible Open Minds about what we called the “medicalization of personality.”

Psychiatrist Kramer has now written a quite compelling afterward to this seminal study of Prozac for a new, Penguin soft-cover edition. And on next week’s Open Mind we’ll again listen to Prozac with him. But today I want Dr. Kramer, who is Clinical Professor of Psychiatry at Brown University, and has a private practice in Providence, to turn with me to his new Scribner’s volume, Should You Leave, subtitled A Psychiatrist Explores Intimacy and Autonomy and the Nature of Advice. Of course, I hope Dr. Kramer won’t consider me out of line, or inappropriate, or a wiseguy if I first ask him to share with me just why he wrote this book. I’m not often moved to ask that question quite so abruptly, but today I must. Why did you do it?

KRAMER: I think it’s like other phenomena psychiatrists look at: very over determined. At one level, there was just the blank request, sort of a balloon floated, after I had written a bestseller, that I think about writing a book on advice. And I thought, “What can I do that would be truly interesting? What do we care about? What do we know?” And I thought part of what would be fascinating to me would be to step back and say, “Why don’t psychiatrists advise? Where does communal advice, where does self-help come from? What values does it hide? Do we all know its values?” So I think that’s one strand.

The other strand is the same kinds of patients who interested me in Listening to Prozac, who were people who were maybe too loyal, sentimental, melancholic, artistic for the ordinary social norms, were also the people who would come in and say, “You know, I understand that everyone things I should leave this relationship, but I think I’m an exception.” And I often had to ask myself, “Well, are they right? Is it possible to buck consensual advice and stay with a relationship that other people think has failed?” So I think that was another aspect to it.

I think there was sort of a perverse challenge in this as well. I think that, although Listening to Prozac was terrifically well received, the caveats or criticisms had to do with it being a little undoctorally, a little too public. And I thought I would try to do something yet more public and take it to a serious level to see whether one could take the form of self-help and do something interesting with it, and , in particular, to take the breathless, intimate, second-person quality of self-help and transform it by using second-person techniques that are more common in fiction.

HEFFNER: And it worked how well, in your own estimation?

KRAMER: I like this book. In other words, an early Kurkiss review that said, “Not only is this a tour de force, but it’s a neat literary trick.” And I thought, “Thank goodness, you know, someone said it. That was sort of what I was aiming for, which was to do something which is seriously helpful but also is sort of fun or daring.” I think that I didn’t want to do that next book, you know, Attending to Ritalin, or whatever it is that, you know, the next book in the series that would be safe. I thought, “I want to do something that is challenging in a writerly way, but that also continues to get at a core cultural question, which is: How does psychiatry express or question our most important values?”

HEFFNER: Before looking at the values involved in the question “Should you leave?” let me ask you about the question of advice. And why is it you grapple with the question of what advice you do give?

KRAMER: I think that I have a strong foot in the practical. I’ve tried to train as a psychiatrist really along psychoanalytic lines. And there the premise, at least, is that the therapist works with the material in the room and is only working with what comes out of the patient’s consciousness. And, of course, my tendency is to say, “Yeah, all right. But I can see in advance this isn’t going to work out. Why should I let the patient suffer through it?” There’s a sort of a, oh, a meddler’s sense with an interest in the practical.

And I had noticed throughout my training that there were other theorists, particularly American psychotherapists in the last 50 years, who have struggled with this question of: Can we use what we know? To what extent can we bring into psychotherapy our awareness of societal norms and probabilities? So I think that question has interested me.

But there also is a quite ghastly history of advice in psychotherapy, where psychiatrists focused on what was obvious to them, demanded that patients act in ways that they thought would succeed, and, of course, the result was utter disaster. So I think those two poles, my being drawn toward practical solutions, and my being aware that those solutions are both taboo and, in reality, quite dangerous as elements in psychotherapy.

HEFFNER: You say “taboo.” I understand when you say “quite dangerous,” because in certain hands they could well be dangerous. But you approach that taboo with considerable willingness to recognize the involvement you must have personally. And when you write, as you do, “As a therapist, I lean in the direction of reconciliation,” mustn’t every person who practices in your field lean in some direction?

KRAMER: Yes, I think the tabula rasa notion that one is coming to an analyst who has no opinion, is only reflecting back to you your own prejudices, is clearly wrong. And I think classical psychoanalysis in its more sophisticated forms has recognized it. But I don’t think the recognition has gone as far as it could.

HEFFNER: What do you mean?

KRAMER: Well, I think that there is a sense in modern psychoanalysis that reality is negotiated between the patient and the therapist in some way, that the therapist takes a fictive attitude and renegotiates the patient’s story with him or her. But I don’t think there is a sense of how much the therapist’s attitude is grounded in the ambient culture, in ordinary opinion, in ordinary prejudice. That really it’s not that we bring a little bit of our own self into the therapy, but that we’re very much present. And I start the book with an almost joking reference to the way that opinion bleeds through into therapy. I talk about supervising someone who has been working with a patient, doesn’t have to high an opinion of the patient’s boyfriend, and the patient points out at the end of the hour that although the resident hadn’t expressed an opinion, she started referring to the boyfriend in the past tense. And I think, in a subtler way, that happens in any human communication.
I also had another opinion about advice that’s related to a quirky, little-known psychoanalyst named Helmut Kaiser, who insists that the best therapy is grounded in ordinary speech, that a lot of resistance is expressed by patients, and maybe by analysts as well, in their speaking in special ways as if this were a real conversation but not having an ordinary conversation. And I think because advice is part of ordinary speech, we make therapy very odd and, to some extent, hamstring the effort if we don’t let ordinary advice enter the conversation. Now, of course, leaving the patient free to disregard advice, as most people disregard most advice anyway.

HEFFNER: But is the technique that you use, the way in which you formularize your thoughts, isn’t that a way of avoiding being told by your colleagues and associates, “Kramer, you have been giving advice, and that’s a no-no.”

KRAMER: Yes. I think I’m at least putting that issue on the table and saying, “Look, we’re all giving advice. I’m giving advice sometimes. And it is not a question just of crossing a line; it’s a question of what has to be done in ordinary work.”
When I presented part of this book as a paper at a psychiatric conference, one of the discussants said, “Look, if you teach a man to fish, you know, he eats for life; if you give a man a fish, he just eats for a day.” And I thought, “That’s not right. Because advice is a form of teaching a man to fish.” Advice says, “Here’s an alternate perspective. Now you have your perspective. This can be seen many ways.” And advice does part of what the central cast of psychotherapy is. You know, assuming one isn’t insistent and demanding, but just careful about it, using a particular rhetoric of advice, that advice gives someone an impression of their alternate perspective.

HEFFNER: We hear about hanging judges. Do you suggest then we should have reconciling psychiatrists, divorcing psychiatrists, so that you pick the one, the direction in which you wish to go? Or do we do that anyway as patients?

KRAMER: I think we do it anyway. I talk in the book about a patient coming in to me as a Jewish, sort of iconoclastic psychiatrist and asking whether she should divorce her Jewish iconoclastic husband. And I think, you know, “What kind of a question is that?” I felt, in a certain sense, that I’d been chosen to give a certain sort of answer. And I realized that, if I was to be effective at all, I had to go against the grain, that there needed to be a rhetoric of advice. Not that I wanted to impose my opinion on this woman, but I needed, in a way, to disappoint her expectations if I was to reach her at all as a human being.

HEFFNER: Yes, but in so doing what did you have to do by way of sacrificing what you say here, write here, as a therapist, “I lean in the direction of reconciliation.” You’re talking about personal conviction.

KRAMER: Well, I think I probably did nudge her in the direction of reconciliation, but not by recommending that she reconcile. I actually said she ought to be free to go down a different path, and invited her to look down that path. It’s like what Harry Stack Sullivan says in the case of emergencies — this is a man who claims to be against advice, but he talks in a famous footnote of saying, stopping a patient by saying, “My God,” you know, “What will be the consequence of that?” And asking the patient, “Isn’t it the case that such, such, and such will result?” Well, if that’s not advice, you know, it’s very close to advice, asking the person to consider what the consensual societal view of things is.

I think, of course, that is very dangerous in psychoanalysis, because one of the purposes of psychoanalysis is for people to be able to be different. I think that is another theme of this book, which is: To what extent can one be an exception?

HEFFNER: Explain that.

KRAMER: I think that we have in every culture a sense of the obvious and a sense of what ordinary advice is. For instance, 20 or 30 years ago, a woman who was having trouble in a marriage would be advice to be more enticing or seductive, or educate herself in matters of interest to her husband; and that same woman nowadays would be advised to be assertive, and go her own route, and seek self-fulfillment, and see if her husband follows along. And both of those are value-laden, and I think they are good advice. I think it’s hard to beat the odds. You know, it’s hard to do better than the advice that’s encoded into all the sitcoms and television shows and comic books that we have in this culture.

HEFFNER: Now, that’s a surprising thing to hear. Does that mean you’re not critical about the nature of our culture and its message?

KRAMER: I am critical, but I think it’s hard to beat the odds. I think it is true that in a society in which women didn’t have jobs, enticing your husband probably had its virtues as a good solution and in a culture in which women have their own careers and really have to be able to stand on their own two feet and risk divorce, since divorce is so frequent, that the right solution often is in the direction of assertiveness or autonomy. But even if that is true in general, isn’t the focus of consultation with an expert, or, in particular, of psychotherapy, to find a solution that’s exactly right for you, that’s hand-tailored, and in some case ignores the values of the culture in favor of your own values?

HEFFNER: But that’s why you puzzle me a bit in what you just said, because I was thinking of the op-ed piece you wrote in The Times at the end of August 1997. When I came to the end of, to the last paragraph of that piece, Dr. Kramer, I was puzzled as hell, because I kept thinking about this point of yours, “As a therapist, I lean in the direction of reconciliation.” And you write her, “Though we profess abhorrence of divorce, I suspect that the divorce rate reflects our national values,” which, in a sense, is what you’re saying now, “with great exactness, and that conventional modern marriage and eternal commitment with loopholes galore expresses precisely the degree of loss of autonomy that we are able to tolerate.” What you don’t add, because that’s the last sentence, is, “So we better go with the flow.” It seemed to me that that’s what you were saying. It seems to me that that’s what you’re saying now.

KRAMER: I think it is dangerous to advise people to go against the flow. My concern about the Louisiana law, which is not a very grave concern — I think that lawyers will get people out of covenant marriages as easily almost as they have got them out of what oddly are called “no-fault” marriages.

HEFFNER: You’re right.

KRAMER: I’d like to be in one of those. My concern is that people are being asked to make a commitment that’s very hard to sustain in this culture, because the traditional values, the strong American values are really not collaboration, compromise, mutuality, connection. The real traditional values, in my opinion, are autonomy. And I wonder whether what disturbs the salons of Baton Rouge is not so much autonomy as autonomy being extended to women. I see people being invited to enter into contracts that are very hard to sustain. And if you look at studies, at research of people entering marriage — this is not, despite my having written this book, my field of expertise — but apparently they show that if you ask people what their attitudes are toward divorce, the people who say that they’re very much opposed to divorce are as likely to end up divorced as people who are more neutral on the subject. People are very bad at predicting whether they’re likely to get divorced. And we are a culture where, I think, very often the right answer for people who are being exploited in marriage is to walk away.

HEFFNER: Let me press you a bit on this business, if I may, of spitting against the wind. What part of your obligation as a therapist, as you sense it, leads you to say, on the one hand, your own givens take you in the direction of reconciliation; on the other hand, do you not want to see your patients punished by the nature of the society around us, and therefore you’re going to go with the flow of divorce?

KRAMER: I think there are two levels of obligation. The first and larger obligation is to protect people. And I think that the group of people who need protection in the case of marriage are largely women who are being exploited or abused in a relationship, and they need an exit. They need the possibility of exit. It’s very hard to get them out.
That is not largely what I deal with in the book. I think the book deals with what I call “close calls.” That is, relationships that are interesting, they’re important enough to seek advice over, they’ve probably lasted awhile, given some satisfaction, and now, for some reason, they seem dead, inappropriate, one person claims to have outgrown the other. And I try to understand what those intimate difficulties are. I say at one point something about how marriages founder on pebbles. What is grating about the relationship? And there I think it is possible to go against the grain.
I start the book with a vignette of a woman who has been hurt in a marriage, is now in a relationship, and the man has just proved himself unreliable in some very strong way. But she seems to come in and say she’d like to continue the relationship despite the fact that this man has shown some lack of integrity. And I try to be sympathetic with that and ask what it might mean to stay with a man who’s shown a lack of integrity, and whether that is a choice that a person could legitimately and happily make.

HEFFNER: Continuing along these same lines, you say that persons hurt most in situations that are unhappy, women, because it’s harder for them to get out. I thought you would say children.

KRAMER: Yes. Well, I’ve done something difficult or odd in this book, which is I’ve tried to leave children out of it.

HEFFNER: And I’ve wondered why.

KRAMER: There are stories that involve children, because I wanted to get to what seems to me a difficult enough issue, which is: What constitutes relationship? What are the virtues of relationships? What are the dangers of relationships? And I think once you bring children into it, all sorts of other considerations apply. People stay together for the sake of the family, the marriage, the children. And we don’t get to ask the question, “What is it that ought to hold people together? What is it that we value in relationships? What is it that drives us to despair over relationships?” I think children are too much of a distraction. And the research isn’t really there, despite the fact that there’s a very interesting book by Judith Wallerstein saying that children are being hurt by divorce, no one really knows how much children are hurt by people who are angry at each other staying together. So that it’s just a question where we have strong social prejudices and no real answers. And I thought, well, let’s put that aside if we can, and ask, you know, “What do we make anyway of passion, loyalty, equity in relationships? What do we make of the different values that relationships express on their own without worrying about things like, ‘I can’t afford a divorce, it will hurt my children, you know, how are we going to split the possessions,’ and so on.?”

HEFFNER: But when you… Again coming back to your statement about reconciliation about leaning, certainly you have had to formulate that within the context of a lot of thinking about what we can afford and what our children can afford, and what our children can tolerate in this. And, in terms of your own… You say the research isn’t in. But in terms of your own practice.

KRAMER: Unless people are throwing knives, I really do, where there are children involved, lean toward reconciliation. It’s almost an uninteresting stance because I think, “Yes, let’s give it a second or a third chance.” But even where children aren’t involved I lean in that direction, because I think, even for people who search for autonomy, where that is what they want, that the place to find it, the place to grow is largely in a complex relationship. That the complexity, the frustrations, the fact that you are deeply moved by this relationship, those things make it the right place to find self, and that the people who go off and find self in the desert I think are very largely fooling themselves.

I talk about Thoreau’s Walden as the one truly great American self-help book. Maybe the defining American self-help book.

HEFFNER: But you also note that he sent his laundry back to his mother, or you assumed he did.

KRAMER: [Laughter] I think there is a lot of hidden support for these autonomous men, yes.

HEFFNER: What does “autonomy” mean?

KRAMER: “Autonomy” means many things. But I think, in this book, I start with a psychiatric concept called “differentiation of self,” which refers to the ability to hold onto one’s values and beliefs in the face of communal pressure. I think it’s a very important concept. I think you really do respect people who can do that. Just in ordinary life you probably know people who have that quality of just knowing what they believe, whatever’s going on around them. And they’re terrifically attractive people for that reason. I think they were even more attractive at a particular time in history, just after the Second World War in the light of mob psychology, with totalitarian states, in the light of McCarthy hearings, we had particular admiration, I think, for this very autonomous self, the, you know, the High-Noon cowboy who’d go up against the whole town.

HEFFNER: Why less now?

KRAMER: Well, I think that is an interesting value. I think autonomy is very important. But I think we are so rabidly capitalistic, we are so individualistic, we so much have our eyes on the main chance, that this other line of American values, which frankly I think have always been secondary, that include community, cooperation, mutuality, and so on, are being put much too much in the shadow. There are people who are happier in relationships, even relationships that aren’t so terrific. There is some joy and zest that comes from loss of self, from being able to trust and even, I think, sometimes make compromises, serious compromises, for the sake of a relationship or marriage.

HEFFNER: The communitarian movement of our time…

KRAMER: Yes.

HEFFNER: …not very much of a movement, but something. What’s your response to it?

KRAMER: Well, I think it is a little desperate, because it’s not so well supported. In other words, if you read about hippie communes 20 years later, you realize that those are people with interesting values, but they’re socially marginalized. There’s so much support in this culture for individualism, from the technology that allows you to work at home, to the promises that society makes of individual happiness, just to the general wealth of the culture, that I think there is less pressure and less teaching to cooperate. I mean, almost any article you read about Japanese schools being essentially more collaborative as far as the way students work when compared to American schools. There are just are many cultures that instill communal values better than ours does.

HEFFNER: Dr. Kramer, again taking my favorite quote from your book, about your own leanings, and then this New York Times op-ed piece and its conclusion, and spitting against the wind, the title of the book is Should You Leave? What might one say, in the minute we have left, is the answer that you give?

KRAMER: I think the answer is that struggling to stay in the relationship and grow, and particularly to grow in flexibility of perspective, seems to me the most important first move. I think people often have very little sense of what real effort is in relationships. I think effort entails letting the other person being his or herself, tolerating and enjoying that person, and doing it with enough persistence that the other person can trust you again.

HEFFNER: Your previous book, Listening to Prozac, wonderful title. Do you think we’re capable of listening to Kramer and what he just said?

KRAMER: I think it’s a tough sell, but I think that there is a general sense that something is missing in this culture, both the demand for assertiveness that creates a need for Prozac, and the demand for assertiveness that creates a high divorce rate. I think there’s going to be some sense that something is a little wrong with the limb we’ve put ourselves out on.

HEFFNER: Dr. Kramer, thank you so much for joining me here on The Open Mind to discuss this quite intriguing book, Should You Leave? I hope everyone reads it. I hope everyone stays with it until we talk about your afterward, your new afterward on Listening to Prozac. Thank you.

KRAMER: Thank you.

HEFFNER: And thanks too, to you in the audience. I hope you join us again next week. If you would like a transcript of today’s program, please send $4 in check or money order to: The Open Mind, P.O. Box 7977, FDR Station, New York, NY 10150.

Meanwhile, as another old friend used to say, “Good night, and good luck.”

N.B. Every effort has been made to ensure the accuracy of this transcript. It may not, however, be a verbatim copy of the program.

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