It changes you very profoundly to be even modestly successful in
America. You almost forget certain insecurities. I don't know if the
changes are very profound, but there certainly have been some changes. I
find myself, for example, a little tougher with patients, a little bit
freer to be demanding of patients.
I'm drifting into some other area that interests me, which is the
life of the American doctor under the very unusual circumstances that
we're under. I was head of the private practice committee of the American
Psychiatric Association for a couple of years, so I heard lots of
private- practice stories.
I feel it's very important for doctors to be needed, wanted, in
demand--so busy that they're never tempted to prolong a treatment that
can be done more parsimoniously, so busy that it makes sense for them to
triage in terms of match between patient sand their skills.
PT: How do you become demanding with patients in therapy?
PK: I have always been very demanding with my patients and I hope I
have always appreciated them. But I think it's the question of whether
you let the silence linger a little longer and let them get a bit more
anxious, or whether you're a little more direct in saying, sounds like
you're thinking about suicide or whatever it is. It's subtle.
PT: So it's been a therapeutic experience for you?
PK: I don't know whether this is good or bad. That other hesitant,
ambivalent, uncertain, insecure part of myself may be very good
therapeutically also.
PT: What are you going to do next?
PK: I've always wanted to write fiction. Some would say I've been
doing it already. It turns out that even when you've written this book,
there isn't a tremendous audience for your fiction. So I have a contract
for a new nonfiction book and an informal agreement from an editor to
shepherd along my novel.
PT: What about the nonfiction?
PK: The non fiction book in my mind has a tentative title of Advice
or A Word of Advice, although one of the editors feels that the working
title ought to be Should I Leave Him ? And it's sort of a rift on
self-help. When you write a best-selling book as a psychiatrist, the next
question is should you write a self-help book. What do we really know? If
I were to give advice, what is it that I know, what is it that we have to
say that has any basis, that I would sign my name to?
Also, why is it so hard to give advice? Why do psychiatrists do so
badly at it? Why was Freud so disastrous in those instances where he
stepped outside of the psychoanalytic frame and told people whether to
marry one another or not and broke up marriages? Why are we who sit with
people and see how life goes, hour after hour, so bad at helping people
take the next step?
The book is really an epistemology of social relations. What do we
actually know about social relations? How would we actually approach
someone who said, I've had enough of psychotherapy, what I want is to
come in for a few hours and talk to you about a matter of the heart and
have you tell me where to place my bets. And to think through the
assumptions with which I would approach such a problem.
There also will be some reference to biological psychiatry in the
book because a lot of where people go wrong in matters of choice of mates
or decisions whether to end relationships is in missing their own or the
other's mood disorder. Mood disorder plays a big role in relationships,
issues of temperament and in personality as well.
PT: The idea that somebody who writes at the level you do would
write a self-help book is cheerful.
PK: I really have tried in each of my books to allow people to see
what people who deal with the mind everyday really think as they deal
with these issues: Why should I give the pill or not?
What are all the hundreds of things that inform that moment where
we decide to say: I really would recommend that you do take the medicine,
or I would or would not accede to your request for a medicine?
"It's very hard to surprise a psychiatrist. We see dozens of people
like O.J. Simpson] who look from the outside to be squeaky clean and who
on the inside have all kinds of urges and impulses, or who look very
different in different contexts."
PHOTO: Peter Kramer, M.D.
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