Should You Leave? - Peter D. Kramer, MD

[Auspicious]

Should You Leave?

Peter D. Kramer,

First published on September 01, 1997 - last reviewed on October 02, 2009

You are in a difficult relationship, one that feels painful to stick with or to leave. You imagine there is something particular a psychiatrist can offer--perhaps the fresh perspective of a neutral observer. You want to know how your relationship looks from the outside. Is your partner impossible, or do you bring out the worst in others? Are you too tolerant, or too demanding? If you could decide which view to accept, you would know just how to behave. You have had it with the slow, self-directed process of psychotherapy; you want a frank and immediate response, an expert opinion.

I am sympathetic toward your wish for immediacy and plain talk. But often people who ask for advice in such matters are really looking for someone to blow up at when the rules indicate they should leave, but they dearly want to stay. Or perhaps you want permission. Sometimes a child can skate only when a parent is on the ice right beside; the parent becomes the child's nerve or guts, even the stiffness in the child's ankles. You may need what the child skater needs: additional self. If this is what you require of me, you will tell me what you already know you should do, and I will confirm your conclusions. But if you have a good supply of self, then the choice you are confronting must be a difficult one, or else you would have already made a decision.

I take it that you are in love, or have been, or think you might be in time. Love, not operatic passion: Those who are swept off their feet rarely ask questions. And since you go to the trouble to seek an expert opinion, you must value the investment of emotion and the creative effort you have put into your relationship. Intimacy matters to you, shared experiences, time together. And you imagine that people should and can exercise control in affairs of the heart.

To this picture I might add that you already know the conventional wisdom. Television, romance novels, late-night radio call-in shows, and self-help books all provide exposure to the tenets of psychotherapy. Characters advise one another continually: Walk away from abuse. Don't bet on actively reforming an alcoholic. Communicate. Compromise on practical matters. Hold fast to your sense of self. Take emotional crises to be opportunities for growth. Expect and accept imperfection. No one is a stranger to these commonplaces.

But you hope to be an exception. You feel different enough to ask whether the conventional bromides illuminate your special predicament. Perhaps you fear that you are inept at judging partners, so that when it is time for others to leave, you should stay, because you will do no better next time. Or you are more vulnerable than others, less able to bear transitions. You have been telling yourself as much, and you hope that a neutral observer will agree.


IRIS'S STORY

Here is how I imagine we come to meet. The bell rings, and you are at my office door. "Iris," I say, not concealing my surprise. My daughter used to play on the same soccer team as your nephew, and I remember admiring your spirit while your marriage and publishing career were unraveling. You assure me that you are not here for psychotherapy. You want help with a predicament.

You have not done well with men, you say. Your large-boned and angular stature, and what they call your fierceness, scares them off. Those few who are attracted to tough women don't give support when you need it, hate any sign of vulnerability--or are outright sadists. Randall seemed the sole exception. He is a man with enough confidence to enjoy forthright women and enough awareness of his own wounds to allow for frailty.

Randall courted you vigorously, tried to sweep you off your feet. He has given you the happiest two years of your life. He is sweetly handsome, separated, en route to divorce. Having grown up in a difficult family in a neighborhood that chews up its children, he now works with wayward youth. Best of all, unlike your ex-husband, who publicly humiliated you with a younger woman, Randall loves you alone.

At least that's what you thought until two weeks ago, when you went to download your e-mail. You received an extraordinary bundle of messages, all forwarded from bunny@univ.edu. You knew who this Bunny was: a touchy-feely social worker who runs a clinic Randall consults to. She had sent you the modern equivalent of the stack of letters, tied in a ribbon, deposited on the wife's dressing table. Although there was no evidence in the e-mail that Randall had slept with Bunny, he had revealed a few of your intimate secrets--enough to make you physically sick. And in his postings, Randall kept referring to you as Prickly Pear--barbed on the outside, tender within--the same term he had once used for an ex-girlfriend. You suddenly understood his m.o.: commit to one woman, then denigrate her to another.

When you felt able to stand, you left work, stopped for a moment at a florist, and drove to Randall's condo. Once there you shoved your purchase, a small cactus, into the open lips of the disk drive on his PC. For good measure, you erased his hard drive and threw his modem in the oven and set it to self-clean. You packed your clothes and bathroom paraphernalia. Then you pulled a jar of gravy from the fridge. You spread the contents onto Randall's favorite rug and left his dog Shatzi to do her worst.

As you drove home, you were overcome with the awareness that you love Randall as you have never loved another person. And indeed, since then Randall has done all of the right things. He's broken off contact with Bunny, plied you with flowers, called the lawyer and directed that his divorce be set in motion, resumed treatment with his therapist and invited you in for joint sessions. But you realize that you are in one of the classic bad arrangements between lovers. Randall is behaving like a naughty boy who buries himself in the skirts of the mother he has injured and sobs apologies. Looking back, you see that even your tornado-like attack on his apartment was only an enactment of his basic fantasy: woman as avenger. How can you stay with a man who sees you this way?

And yet you are tempted to. That there is something flawed about Randall makes him seem more accessible, less puzzling. Now that his flaws are laid out, you feel peculiarly well-matched with him. After the fall, he seems more truly yours. You feel alive when you are with Randall. You still trust and admire him. Besides, you want to sustain this complex, intimate liaison you have done so much to nurture. Are you mad? Do these things ever work?

To say the obvious--that you must leave a man who has been dishonest, contemptuous, and incapable of commitment--doesn't seem to suffice. I know too little about you to answer the question you are asking, which is not whether most people should leave in these circumstances (they should) but whether you and Randall form an exception. I am taken with the odd detail that you feel more comfortable with Randall after the fall; to you, it is a relief to know that for all his kindness he is as crazy as you. I like your argument that even after the betrayal, there remains in your ledger a balance of trust in Randall's column. And since you are indicating that you have every intention of letting the relationship proceed, I feel unmotivated to throw myself in your path. You're making a bad bet, but I have seen worse bets succeed.

"To go ahead with the relationship will require all of your skills," I say. Business skills, people management skills, negotiation skills, every skill you possess. But you can risk continuing the relationship if you make that risk an occasion for your own maturation, for attaining something you can bring with you if the relationship fails, as it likely will. If you can be single-minded about what you need, and if you can let him be who he is--in that delicate combination of self-assertion and caring and disengagement, there will be hope that you will grow and that he will then grow to meet you.

WHY STAY?

As a therapist, I lean in the direction of reconciliation. I lean that way in part because of my experience that simple interventions sometimes suffice to hold together couples who seem on the verge of separation, and that those repaired relationships proceed ordinarily well. Moreover, second marriages do not seem gloriously better than first marriages, or if they do, it is often because the second marriage benefits from efforts or compromises that might as readily have been applied to the first.

People tend to choose partners who operate at an emotional level similar to their own. To stay with a flawed relationship thus may entail tacit acknowledgment of your own limitations. And coming to grips with your limitations, and those of your relationships, is an important form of personal development. If you are loyal and slow to say goodbye, I might say leave, because leaving would represent facing your fears. But if your tendency is to cut and run, I lean towards staying and altering perspective. If you leave, will you find greater satisfaction elsewhere? Most relationships, after all, are practice. That's why, in a culture that allows dating, people have more relationships than they have marriages. Not only because they're finding the right person, but because they're learning how to do it.

SANDY AND MARK

Perhaps you have little in common with Iris. Your story is simpler, quieter. As you enter my office, I am aware of a critical sensibility. You approve, I think, of the framed photographs on the walls, though you squint at one and judge it prosaic. In your soft voice, you say that you have known almost from the start that there were problems in your marriage. Now that you have the chance, you are determined to get a little help about whether to stay on.

You and Mark married just after high school and then moved from your hometown. It has always been Mark-and-Sandy: People run the words together, like warm and sunny or, lately, cool and cloudy. You shared fine taste, an appreciation of the arts and of the art in daily life. Having seen enough fighting and drinking in your own families as you grew up, you promised implicitly to protect each other from any more indignities.

Then you panicked when Mark leaned on you in his childish way. He resented the stress of competition on the job and the pressures associated with being a breadwinner, and would come home feeling unappreciated. In childhood, you had the responsibility for the care of your brothers, and you never felt you could do right by them. You lacked confidence that you could make another person feel better. So merely to think of Mark heading home worn out and hungry for affection made your day seem black. When he walked through the door and saw you already drained, he would shrink away. You felt his withdrawal as another sign of your inability to give or elicit nurturance. You became hopeless and more needy than Mark could bear. I hope you will not feel diminished when I say yours has been a marriage between melancholies.

But you maintained the marriage in its early years by carrying on affairs with married men. To you, an adoring man is solace from the isolation Mark imposes. Although you felt dirty, in your bluest states you were buoyed by these dalliances. You felt that you had no choice, that life is too bleak without at least the pretense of admiration. As a result of these affairs, you were more emotionally available for Mark, and your support allowed Mark to do better at the office. And what surprised you through the course of these events is how much tenderness you continued to feel for Mark. He tries hard in a world he is not made for, and sometimes he succeeds.

Over the past couple of years, your odd jobs--making up gift packages in pharmacies and florist shops, designing window displays for boutiques--have fumed into a career. Your work in a fabric shop led to requests that you consult on interior design. A former lover has begun small-scale commercial production of your decorated mirrors, boxes, and picture frames. This good luck has allowed you to feel secure month in, month out. There are no more lovers, though with your patron the door is open, especially now that his own marriage is headed for divorce.

For a while Mark seemed to disapprove of your commercial success, as if you had gone over to the enemy, the movers and shakers, in a way that were disloyal to your joint view of the world. Now Mark has told you he has a platonic girlfriend. He needed you to know of his near-peccadillo, because for him it throws the marriage into question. You know he does not really want a lover. He is asking for reassurance that you, despite your success, still want him. Lately, however, you have found yourself thinking that here is an opportune moment for you to leave.

I recognize this crisis--change in a member of a depressive couple. Marriages between emotionally sensitive people can be models of the best human beings are capable of. But the result can also be a stifling sort of peas-in-a-pod marriage such as yours, one made overtly stable by an implicit promise never to change, never to move toward the wider world. Although the stalemate is often broken when a patient is "transformed" by medication, career success such as yours can have this function too. Now you are over your depression, and the question is whether you should stay.

This is a moment for remarriage or separation. Since you care so deeply for Mark and admire so many of his qualities, and since you have come so far with him, you may choose to let the marriage play itself out further. You could suggest to Mark that he seek treatment for depression, although what seems to be at issue is personality style rather than illness. If you stay put, you may next find Mark turning angry, which I would consider progress. Or you may find instead that he will move forward to join you, and you will be able to judge, after these many years together, whether a period of real marriage is possible.

Are you thinking of divorce and marriage to your patron entrepreneur? How could you not be? This is a frequent response to recovery from prolonged depression--entry into a highly "normal" marriage, one focused on pleasure rather than ideals, on the future rather than the past. This solution has its dangers. The patron may be someone who enjoys and demands dependency in a wife, while you take pride in your hard-earned autonomy your quiet toughness and firm balance. And yet I have seen such relationships work. Perhaps your entrepreneur will treasure you and challenge you and rejoice with you in the bounty of life, and you will hold on to what is precious in your sadness without having sadness possess you.

The only apt advice is to say that you will need to fiddle with this problem as you have with others, quietly, from around the edges, at your own pace. You will need to be an artisan, here as elsewhere, and to rely on your unerring sense of the fitting. You seem someone who would prefer to find just the right time for leaving and to craft your exit in a way that pleases you--if you are to leave at all.

How does a person whose faith in his or her partner has been breached decide whether to stay? Hungarian psychiatrist Ivan Boszormenyi-Nagy refers to what he calls "residual trust." Loss of trustworthiness, he observes, is rarely absolute. Each relationship contains an invisible slate or ledger of give and take, what I might call a "trust fund." Partners deposit trustworthy acts, earn merited entitlement, and owe due obligations. Strong balance sheets make stable marriages. But if one partner continually overdraws the account, the other will feel justified in retaliating or leaving--though other factors, such as good sex, excessive guilt, or power arrangements, might complicate the decision.

An additional complication is that people are poor bookkeepers. They attribute credits and debts to the wrong accounts. In Nagy's view, ethical relations are intergenerational. A child is due reliable care by his parents and is owed restitution if he doesn't get it, but once he reaches adulthood there is no one appropriate from whom to seek it. So the deprived child will enter adulthood with a destructive sense of entitlement. In marriage, this creates further injustice, since it is not the spouse who created the imbalance in the books. Perhaps you demand excessive loyalty because you have been treated disloyally elsewhere, just as your wife demands support that she has been denied elsewhere. If you treat the other unjustly, however, the relationship will be further depleted of resources of trust.

NORA

What made you ask for a consultation is something that will sound trivial. Philip gave you a public tongue-lashing at a recent party, and the hostess took you aside. Nora, she said, if you will not stay here with me tonight and tell Philip goodbye, you must at least promise that you will see someone else.

You want me to understand how decent Philip can be. Often you wonder what's wrong with you that you cannot bring that Philip back. What you loved was his self-assurance, his calm in the face of turmoil. Back then, you were attractive, and--you wonder whether I can believe this--accustomed to avid responses from men. In Philip, you met a man who made you want to earn his admiration. You gladly merged your consulting business into his, and moved from a business relationship to courtship.

When you discovered you were pregnant by Philip, you were secretly thrilled. You had believed you were infertile, because in years of unprotected sex with an old boyfriend, you had never conceived. But Philip turned icy cold--how could you do this to him? He would marry you, but on the condition that you abort the pregnancy. You aborted, which was more horrible for you than Philip could know, or that you would let him know, since you wanted to enter the marriage as the sort of woman he demanded, a happy one. What was funny was that you loved him all the more, loved his little boy squeamishness about intimacy.

After the marriage you started falling apart, failing him in small but important ways. At the office, you might fail to pass on a phone message, or in the middle of a meeting make a comment that infuriated him. He began to demand--with every reason--that you stay in the office and do grunt work.

When Philip was finally ready to have children, you failed to give him any. There has been unspoken resentment about that, you suspect. And now you sometimes wonder if he is turning his attention elsewhere. You came across a document that seems to show he co-owns a condominium with a woman. He yells at you so much over little things, you can't imagine what would happen if you asked him about the condo.

What put you up to asking for advice was a world in Philip's diatribe at the party--he called you a dried-up prune. You know what he meant: infertile. That one epithet seemed to step over the line. You realized, in a confused moment, that some of what has kept you in the marriage is loyalty to your lost pregnancy--your lost unborn child. After what you sacrificed, the marriage has to work. You feel foolish asking whether you leave a man you love and who has put up with so much from you.

If I thought I could get away with it, if you were not too skittish, I would advise you to leave. But I am afraid that if I give you advice in full measure you will bolt. My first goal is not to lose you; my second is to make you less isolated within your fearful perspective. The only rhetoric at my service is the look on my face when you say "prune." Not horror or astonishment, just your expression plus a little extra. I want to underline what you have said.

Sometimes I think of enslavement in relationships as a hypnotic phenomenon: The enslavers induce a substitution of their will for the subject's. They are vampires, gaining strength as their victim wastes away; the commanding and decisive executive by day flourishes on the blood of the wife he drains by night. Lesser degrees of possession are the root of many ordinary relationship troubles. The demanding impose expectations, while the loyal are exploited for their loyalty.

After 20-odd years in the field, the only distinctive thing I know about ending enslavement is that sometimes you get a gift--an act by your partner that crystalizes what you should do--and if you receive such a gift you had better recognize and accept it. Usually I hear about these gifts in retrospect. A woman who is now doing well tells me about an incredible act of overstepping by her former possessor: He knocked up a single mother with four kids and wanted to move them in. Or the act may seem indistinguishable from the person's habitual behavior, as with Philip's shockingly unreasonable diatribe at the party.

I take your response to the gift Philip offers as an important part of our transaction because it is your own. If you have filled your life with authoritative others who tell you what to do, I will not want to validate that behavior. In highlighting this gift, I hope to instead what remains of your perspective. I offer the self-help bromide "listen to your own voice," with this difference: I point to one of your voices and say this one, and not the others. The voice that says: No human being should be asked to give what that man demands nor accept what he imposes.

MY MISGIVINGS ABOUT GIVING ADVICE

Despite the psych jockies on the radio, despite the widespread acceptance under managed care of therapies that entail little more than the quick proffering of an opinion, despite my own enduring curiosity about advice, I find the prospect of advising slightly illicit. I am suspicious of books of advice: When I read a self-help precept, I think that the opposite advice might be equally apt, for someone. The advice that I have valued in my own life has never turned on fixed maxims or canned metaphors. More crucially, lists of precepts don't work like targeted advice because lists contain inherently constraining messages. They seem to say that complex matters are knowable, that a given process leads to foreseeable results. It implies a thin and predictable world, whereas the sort of advice that has mattered to me bespeaks a quite tentative optimism, the optimism of the quest whose outcome is finally unknowable.

Thus, even after an extended interview, as we have had, you might remain unknown to me in important ways. This, then, is the advisor's dilemma: Like a partner in a troubled relationship, an advisor faces an other who is at once transparent and opaque. I will offer a perspective, you will add it to those you already entertain, and you will stay, or leave, or remain in limbo.

HEADS I STAY, TAILS I LEAVE... .

For most of human history, the question of whether to leave a long-term relationship was almost irrelevant. Marriage was seen as an unbreakable contract, and the economic perils of a solo existence made abandoning one's partner difficult, particularly for women. Throw in legal and religious restrictions against divorce and leaving simply wasn't an option. As late as 1930 famed psychiatrist Karl Menninger refused to advise women to leave their husbands--even in cases of repeated philandering or abuse.

Today, most of the social and practical impediments to leaving have fallen, but the decision to do so remains psychologically daunting. "There's no litmus test you can give a partner that determines whether you should leave, or whether this person is good partner material," notes family therapist Diane Sollee, M.S.W. So figuring out whether to leave remains a complex and intensely personal calculation incorporating issues ranging from the philosophical--How happy am I?--to the profoundly practical: Can I find somebody better?

The upshot: Nobody can give you a definitive formula for when to try to salvage a relationship and when to move on. But here are some issues to keep in mind:

THAT'S MY STORY AND I'M STICKING TO IT

When pondering whether to leave, most people retrace the history of their relationship, taking a mental inventory of the good times and the bad. But there's a hidden pitfall in this technique, notes University of Minnesota psychologist William J. Doherty, Ph.D., author of Soul Searching: Why Psychotherapy Must Promote Moral Responsibility. The problem: Our memories tend to be biased by how we're feeling at the moment. So when people are feeling pessimistic about their relationship, says Doherty, they "unconsciously put a negative spin on everything--how they met, why they got married." And they're more likely to overlook happier times.

Let's say you and your spouse eloped right after high school. If you're feeling hopeless about the relationship at the moment, you're especially likely to describe the elopement as the act of two impulsive, foolish kids. "But two years earlier, when you were feeling better about the relationship, you would have told the story in a whole different way," says Doherty. Instead of viewing your teenage marriage as impulsive, you might have fondly remembered it as an exceedingly romantic act by two people passionately in love.

This memory bias colors the relationship history you present to friends, family, counselors, and other confidants. So these individuals may wind up advising you to pull the plug on a relationship that isn't as bad as you've portrayed. (The same bias, of course, gives you an unrealistically rosy view of your relationship during good times.) And even if you don't consult others, your own ruminations on whether to leave will be similarly slanted. None of this means that your relationship history is irrelevant to the decision to leave--only that the evidence may not be as clear-cut as you initially think.

Assessing whether you should leave may require assessing whether you have tried to stay.  What he means is that relationships take work, and that couples often abandon relationships that would be successful with a little more effort. Sollee says, it's ironic that couples who are expecting a baby "will take months of classes to get ready for that one hour in which the mother pushes out the baby, but they don't take the time to [get counseling] on how to keep the marriage alive."

Given that every relationship requires effort, the fact that a relationship is somewhat rocky is not in itself a sign that a couple should split. What's more important, says Peter Frankl, M.D., a psychiatrist at New York University School of Medicine, is how motivated the partners are to give each other a chance and to work out viable solutions to their particular problems. This motivation, says Frankl, is the best predictor of whether a troubled relationship will succeed. "I've fumed around some marriages that were on the brink of divorce," he says. But if your partner isn't motivated to put some work into the relationship, the odds of success fall--and leaving may make more sense.

ADVICE DEPENDS ON THE ADVISOR

Visit three different doctors for your sore throat and you're likely to get similar diagnoses and treatments. Ask three different therapists whether you should leave your ailing relationship, however, and the advice you get may differ dramatically. The reason: a therapist's specialty--marriage counseling, individual therapy, groups--is linked to his or her feelings about commitment.

Marriage and family therapists are, by nature, inclined to keep people together. "I would never advise a couple to divorce," says Atlanta psychiatrist Frank Pittman, M.D., who feels that telling people to end a marriage is akin to advising a parent to put a child up for adoption. "You don't do it, especially when there are kids involved." (Pittman did, feel comfortable, however, advising a pair of newlyweds to break up when he learned that the wife had cheated on her husband during the honeymoon.)

On the other hand, individual therapists, whose training in treating troubled relationships may range from extensive experience to a single seminar in graduate school, are more likely to see a relationship as something that should be sacrificed if it interferes with a client's happiness. "I read a case study of a woman who stayed with the same analyst through five marriages," says Sollee. "And that analyst helped end all five marriages." Minnesota's Bill Doherty calls such cases "therapist-assisted marital suicide," noting that by repeatedly asking their clients whether they are happy, "the therapist is basically saying, `Why do you stay?'"

Because therapists typically maintain a neutral stance with regard to what a client does--the better to appear objective--these philosophical differences on the importance of saving relationships may not be immediately apparent. But they're always present, warns Doherty. The lesson for those who seek counsel from therapists: Keep in mind that the advice you get may be more of a reflection of your therapist's personal values than a scientifically valid assessment of the "correct" thing to do.




CHATTING WITH PETER KRAMER

PT: Reading Should You Leave?, one gets the impression that you believe people should try to stay together. [/b]

Kramer: I do lean in that direction. When people come into the office and say they've tried to make their marriage work, and I hear what the effort was, it seems to me that there's some lack of understanding of what effort is. Also, people in this business of mental health care--myself among them--tend to have a vision of how people might be able to get along better. They have a sort of interior decorator's sense of how things might fit, if only this chair were moved and that lamp were a different color.

Listening to Prozac, to the extent that it was about Prozac, was about how Prozac affects [cases] of depression that are on the border of wellness--close calls. And I think Should You Leave? is also about the close calls. It's not about should someone leave an abusive marriage, or a marriage that is clearly dead. It's really about marginal cases, where you almost don't understand why it's falling apart.

PT: What do you see as the principal themes of Should You Leave?

Kramer: My books are not about what they might at first seem. Part of the inspiration for Listening to Prozac was how much I liked certain patients who were mildly depressed, very loyal, thoughtful, and to some extent not rewarded by the world for those qualities. What Prozac does is to lend autonomy to such people, and I thought that was a mixed blessing--in ways a great leap for them and a loss for the world.

Should You Leave? approaches that question of how we value autonomy through the lens of the psychotherapy that developed in the '50s, '60s, and '70s. That's a lens I like, because it includes [therapists who] have been largely forgotten, people like Murray Bowen, Harry Stack Sullivan, and Helmut Kaiser--I mean, no one's heard of Helmut Kaiser. And these are really among the most thoughtful, wise, brightest people we have. They interest me because their thought has filtered into common self-help and advice. Another theme of the book is, how is it that self-help books now favor a kind of muscular autonomy on the part of women as a solution to problems, whereas 30 years ago the solution was charm? How did that transformation take place?

PT: You wrote Should You Leave? in the second-person, addressing it to a shifting series of "you"s. Why?

Kramer: Self-help books are sometimes written in the second person, although it's done in a sickly sweet way, creating a sort of false intimacy. But Should You Leave? is written in the manner of second-person fiction. I like the oddness of second person, how partly you're drawn in and partly you're kept at a distance because clearly it's not you. I think that is one of the virtues of second-person fiction: doubleness of perspective. The book is for me a move toward writing fiction.

PT: We're watching you metamorphose into a novelist.

Kramer: My next book will be a novel, but the following might be nonfiction again. I hope readers will recognize that there is something new about Should You Leave? in terms of its writing. It is a writerly book and consciously so.

PT: And you think that contributes to the arguments presented the book.

Kramer: It helps set the level of the argument. And I hope it gives it some of the grand ambiguity of fiction. Whether or not I come down in a certain way on a certain issue, there is something disturbingly ambiguous about the vignettes so that you are left realizing that life is complicated, that people make choices and have regrets and can't know in advance how things turn out.

I will be interested in the reviews. I'm not one of these writers who can say, I don't care what the reviews are--

PT: Did you see Publishers Weekly?

Kramer: Publishers Weekly [said] that this book has some of the qualities of successful fiction writing. But there will be reviews in the other direction.

If Listening to Prozac had been a failure--let's say it had gotten good reviews and no sales--I would have written a novel as my next book, figuring it was my destiny to have no sales, so I might as well try something different and not make money at that either. Because [Prozac] was successful, it was clear to me that I ought to write another work of nonfiction, but I wanted it to be brave. I didn't want to write Attending to Ritalin, which was the obvious next book.

PT: You could do the drug of the year.

Kramer: Right. You could write a series of these books and never stop doing it.

PT: Four years after Listening to Prozac was published, what can we say about the influence of the culture on use of medication, and vice versa?

Kramer: The book's about a number of things, certainly about how we as a culture see the world through what you might call psychological reductionism, the notion that people are just biological entities, largely the product of genetics. The book predicted a future in which that view will predominate, and four years later that seems not like a prediction but a description. There seems to be a slot in the daily newspaper for the article that says, The amount of happiness you experience in life is determined in utero, or, The violence of inner-city youth is attributable to testosterone or genetic inheritance or whatever.

PT: Does it make you uncomfortable that so many people are taking these drugs now?

Kramer: Well, it makes me comfortable to have put the issue on the table in advance of its becoming urgent. It doesn't make me especially comfortable to have so many people on one medication.

PT: Your literary influences are pronounced. You wear your education very much on your sleeve.

Kramer: Yes. I think constantly in literary, philosophical, psychotherapeutic terms. Should You Leave? as it stands results from my throwing out 80 percent of the references that would be there if I were left to my own devices. It appears full of self-conscious literary references, but to me it is almost spare in that regard. I'll hear a conversation and think, That's dime-store Kierkegaard, that's absolutely how I hear. I hone it doesn't appear that the references were shoehorned in.

For me, constant reading is what constitutes a rich mental life. My family has these moments we call The Library Is In Session, where all the members are together but their faces are all in books.

PT: You've written about the marriage between F. Scott and Zelda Fitzgerald, and to me it's unambiguous that they both should have left. What would you say if Scott came in and said, Jeez, I'm in love with my wife, but our sex life is not working out, and now, unfortunately, she's mentally ill. What do I do? Or Zelda came in and said, My husband is a drunk, self-absorbed, jealous of me. I love him, but I had an affair, and what do I do?

Kramer: I think Scott and Zelda raise the question of what the function of marriage is and what makes a successful marriage. They actually were in an early form of marital therapy. This was after her third or fourth breakdown. He was trying to finish up Tender Is The Night, and she had written her own novel using the same material. The question was whether writing was bad for her and agitated her into mania or whether Scott was trying to squelch whatever artistic qualities his wife had. In terms of his leaving her, the issue is not of one's own happiness but how one thinks about partnership obligation. It is hard, or ought to be hard, for a spouse to leave a somewhat successful marriage when their spouse becomes ill. Psychiatrists see this issue a lot. It is very attractive to leave mentally ill spouses.

Kramer: Yes, they do. Certainly back in the days when people were actually hospitalized for mental illness it was a very convenient time [to run away]. You knew where your spouse was and the spouse couldn't do much to prevent you from doing whatever you wanted to do. Part of the function of a third party in these situations is not just to ask about happiness but to ask about how one feels about moral obligations.

PT: What would you say to Zelda?

Kramer: I'd say you'd have to be crazy to leave, that in certain times of crisis it's just hard to do better. I don't know I'd say anything strongly. She might not want advice.

PT: To what extent are your patients the source of your ideas? Do they worry they're going to appear in print as case studies? It's like James Taylor worrying about showing up in Carly Simon's songs.

Kramer: "You're So Vain"? Now there's a guy who... .no, I won't say anything. I think patient care is very invigorating and grounding. It teaches you how insoluble human problems are, how serious life is. You also get a sense of how people, even myself, can be utterly obsessed over something when there's some other danger threatening them that they're ignoring entirely. I do tell people that one of the risks of entering my practice is something of that sort [showing up in a book], and that there's--if not an explicit contract, some expectation that I will be able to write about them in some form. People do say, Why aren't you writing about me? Aren't I interesting enough?

PT: Often people say they left a relationship because they weren't having good sex, or because there were sexual problems. But none of the vignettes in Should You Leave? are about people with such problems.

Kramer: I've not found sexual incompatibility to be the kind of problem that people come to therapists about when the issue is leaving. They certainly ask how they can have more satisfying sex lives within their relationship if they're intent on continuing it. But my experience is that people who develop serious sexual incompatibilities stay together and leave over some other issue. Maybe sex could have been the glue that would otherwise have kept them together.

PT: In this book people tend to value continuity, sticking with a relationship. And yet you don't really address the question of where these values come from. Should we value continuity?

Kramer: I think that the book is largely addressed to people who value continuity. That doesn't mean that there's anything the matter with people who don't. There are people who lead perfectly fulfilling and creative lives without ever having a long-term relationship or even wanting one. Then the question "Should you leave?" is much less interesting.

PT: Do you foresee giving up your practice to write full time?

Kramer: I think about it. It's a "Should you leave?" question for me. I'm not on the verge of doing it. Before I became a doctor my vision was that I would be like Freud: I would write in the morning and see patients in the afternoon. And that is what I've ended up doing.

PT: How has your life changed since you became a celebrity of sorts?

Kramer: Not much. The only thing that varies is whether I start seeing patients at noon or start seeing them at 2 or 3 in the afternoon. I do have a little more confidence that somebody will publish books I propose down the road. That is what every writer wants--the right to write the next book.