The High Priest of Prozac

Psychiatrist Peter Kramer, M.D., wrote Listening to Prozac in hopes ofgetting us to understand the personality types our culture is breeding in us--and to decide whether we like ourselves. In the process, he has become something of a celebrity and admits to being changed by the experience.

PT: There has been a fire storm and you have become the lightning rod for reactions for and against Prozac. How do you explain people's reactions?

PK: There are some interesting issues that relate to Prozac. I like to think that most of them are taken up in the book. I think that much of the reaction in the press, unfortunately, is standard journalistic story telling in which heroes are made and unmade, which has actually very little relationship to the facts.

PT: You said in your book that Prozac is a whole gamut of opinion. It's become that, hasn't it?

PK: I underestimated the publicity capabilities of the American media to take something and run with it. I felt Prozac had already achieved a level of celebrity that was astonishing. To think it could increase by another order of magnitude was more than I anticipated.

PT: Were you really surprised?

PK: Yeah. I actually thought the publisher would have trouble earning back the advance.

PT: How do you explain the enormous commercial success of the book? Is this American enthusiasm for feeling good--all the things that you deal with in the book itself?

PK: I have thought about this so long that I have 10 responses to this. The first is that every summer leading up to this book, there's a serious book that makes it onto the nonfiction best-seller list that "oughtn't be there." The David McCollough book about Truman is a terrific book, but it's thick enough that it's an aberration on the best-seller list. Or In the Name of the Rose by Umberto Eco, or Steven Hawking's book, A Brief History of Time.

PT: You would include your book as one of the ones that shouldn't have been on the list?

PK: It's a difficult book, and a serious book. Best-seller lists don't have books that try to explain what neurotransmission is and why we're working with failed theories and try to pull together amine theory, cellular biology, pharmacology, and medical ethics. Anyone who predicts a book with that content will be a best-seller is taking a very long shot.

PT: So your book was a weird event when it became a best-seller.

PK: I have some ideas about how the weird event happened. I had a very committed editor who had enough connections to get the book thoughtful consideration.

And the other thing, which I didn't think of sufficiently, was that people who were on Prozac and were hungry for some explanation would pick up a book that had Prozac in the title. The book was a best-seller on both coasts before the publication date and before any reviews.

PT: It wasn't just that the book was read. People have opinions about Prozac and the use of Prozac independent of whether they've used it or are candidates.

PK: The book put the right question on the table, which was not does this work for depression or does this cause suicide, but what are these nonstandard uses and what do they tell us about what we demand of people as a society.

What do they tell us about the types of solutions we look for? How do they fit in with a whole American tradition of ameliorism or optimism about man's perfectability? The book gave people the framework to discuss something that they had wanted to discuss but that had not been crystallized.

PT: You talk about why we continue to discuss failed theories. Specifically, which failed theories?

PK: First of all there's the amine hypothesis, the idea that depression is related to or caused by or equivalent to depletion of serotonin or norepinephrine. There's lots of evidence that that can't be the whole answer and even some evidence that contradicts that theory entirely.

One is that you can deplete people of these chemicals and most don't get depressed. Another, that there are drugs that don't seem to have any direct effect on these systems that act as antidepressants. Plus there are contradictions within the literature as to whether you're up-regulating or down-regulating pathways that use these chemicals.

Then there's the whole Cartesian dichotomy between mind and brain. It's imperfect but convenient to use as a manner of expression or analysis.

The last thing is not so much something that's wrong as exaggerated, which is that our evidence regarding biological underpinnings of personality is very limited. It's weak even in the areas where it has been best researched. When we talk about the biology of personality, which is really what the book is all about, we are riding on the back of three very weakly supported concepts or concepts that have even been outmoded.

This is a book that underlines the weakness of our understanding of depression and personality and gives a sense of societal shift in our beliefs about ourselves that is "in advance of the evidence." Which really means lacking evidence.

PT: With Prozac, aren't the people who come in asking for it being whipsawed by the ambient society and its thinking? How realistic or unrealistic is the expectation of an introvert becoming an extrovert? And should you reward it?

PK: I think it's a social demand. Introversion is not rewarded in our society. I was on a talk show last night where someone called up saying thank you, she'd been introverted and very afraid of change and through reading the book was willing to take medication. I thought it an interesting view of the function of the book. On one hand it's very gratifying for an author to find that his or her book has opened up some potential of the self for someone.

On the other hand, the book argues that one ought to be free to be introverted. No book is strong enough to counteract the enormous social forces depriving the people who are introverted. They may be very valuable for a company, or as family members, but they have a lot of trouble getting a spouse and getting raises, and getting heard. People need to be concerned. There's an eerie confluence between what Prozac does and what society demands. Precisely, society demands a kind of muscular assertiveness.

PT: Don't we all have a right to have the best possible life within the domain of the drugs that are available? There'll always be those who take the purist approach: I'm not tainting this temple of my body.

PK: Don't fool with Mother Nature. They may be right. And it may be that in the long run they'll live healthier and be happier, more fulfilled. But there's certainly in this hypothetical case the possibility that they'll be wrong as well.

PT: There is something to be said for progress, and progress may well include these drugs that change things we thought were irreversible. Take Shakespeare. If you gave him the option of taking a drug such as Prozac when he was writing his tragedies, he probably would have said, yeah, I feel really rotten, I worry about all sorts of terrible things.

PK: We're certainly better off that Shakespeare had been just the way he was.

PT: You've raised a lot of issues and weighed them back and forth. What do you, Peter Kramer, believe about the nature of personality?

PK: I'm a member of my own culture, and I don't think that what I say is at all culture-free--the end of the millennium American culture and a professional culture. I try to take some distance from that culture and say we shouldn't buy into all of this or we should be aware that other cultures have other perspectives.

That being said, I would say I'm more aware of the role of inborn temperament than I was earlier. I am slightly more aware of and more pessimistic about changeability, malleability through psychological means. I see biological effects of trauma. People who are traumatized are not just traumatized through cognitive memory or even through the kind of wincing effect one gets along with memory; they are traumatized in terms of static biology. That may be changeable through psychotherapy and new experiences, but probably very extensive, intensive, and explosive therapy or experience. It may be most parsimonious in those cases to give medicine as a starting point for doing the psychotherapy.

I think a certain pessimism attends that point of view. For all that's said about Freud being a pessimist, he was really a tremendous optimist to believe that traits that are the result of trauma would be very responsive to awareness of the truth. The extent to which human beings respond to truth is overstated.

PT: You talked about the biological and the psychological, but nothing in the interpersonal or social realm.

PK: It goes without saying that we are very social beings, that we're probably biologically driven to be cooperative, altruistic, dominance-seeking--all the things that Darwin talked about.

And that we exist almost only in a social setting. It is very hard to meet other people in any pure sense without all the problems of the observer influencing the field and the moment, and the culture and the family and the group influencing the presentation of the person in front of us, and the unknowability about whether there is really any person independent of contacts. All those things are what makes psychotherapy or meeting a person for the first time or knowing a person very interesting and difficult.

That perspective also makes us hard to surprise. I happened to be on the air on some talk show when O.J. Simpson was being sought in Los Angeles. I didn't say very much, but my thoughts were, it's very hard to surprise a psychiatrist.

We have seen dozens and dozens of people who look from the outside to be very squeaky clean and who on the inside have all kinds of urges and impulses, or who look very different in different contexts. That is almost the norm, that people are surprising and unpredictable.

PT: Has the sort of celebrity that comes from your book changed you at all?

PK: I think it has affected me. The book tour was an exercise in maintenance of differentiation of self. I oscillate on this. A lot of what I pride myself on over the year was being the same person and not being swept up in debates that didn't interest me, and not getting a swelled head.

At the end of the year I said, maybe I should have instead made hay while the sun shines and spun off the CD and the fiction movie, maybe I should have signed on to the speaking agency. I didn't take advantage of all the things that the culture offers to a best-selling author. Maybe trying not to be swept away may not have been what I wanted.

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.