Reading Group Guide

INTRODUCTION
Prozac Diary

Lauren Slater wakes up one morning to find "the world as I had known it my whole life did not seem to exist."The commonplace things in her scruffy, barely furnished basement apartment and the familiar scene outside her kitchen window have been transformed, smoothed out, slowed down. The "nattering need to touch, count, check, and tap, over and over again"—a manifestation of the obsessive-compulsive disorder that has controlled her life—has disappeared. For Slater, each transformation represents a small miracle. At the age of twenty-six, after five incarcerations in mental hospitals "pursuing and pursued by one illness after another,"she is experiencing the world from a healthy perspective for the first time in years. A pioneer patient in an era of cutting-edge psychopharmacology, Slater owes her miraculous awakening to Prozac. Released on the market by Eli Lilly in 1988, Prozac promised to revolutionize the treatment of everything from chronic depression to anorexia to OCD. As Slater's doctor proudly put it, it "was a drug with the precision of a Scud missile, launched miles away from its target only to land, with a proud flare, right on the enemy's roof."

In Prozac Diary, a rich and beautifully written memoir, Slater describes what it is like to experience the heady high of Prozac's bright flare, to spend most of your life feeling crazy and then to find yourself in the strange state of feeling well. Interweaving the chronicle of her cure with glimpses of the events and emotional turmoil that led her to embrace comforts of "being ill"even as a young girl, she recounts the difficulty and compromise that accompany her return to health, the grief she feels for the passing of the symptoms that once defined her and for the final silencing of the eight inner voices which had been her constant companions for as long as she could remember. She re-creates in vivid detail the terrors of "Prozac poop-out,"when, without warning, the medication fails and symptoms of OCD return, and the small but vital victory she wrests during her frightening relapse with the emergence of "bits of self that manage to rise above the chemicals of illness, the chemicals of cure, and . . . for a moment take in the world."

Slater's first packet of Prozac works its wonders in only five days, less time than even her doctor, a staunch advocate of its powers, predicted. Liberated from the debilitating anxiety and pain that had circumscribed her life, Slater ventures into the world with the innocence and enthusiasm of a child. She wanders joyfully through Boston's Faneuil Hall, captivated by its irresistible array of foods, its extraordinary street performers, and the crowds of ordinary people pursuing ordinary pleasures. She allows herself the luxury of sleeping late for the first time in her life, attends her first rock concert, spends long, languid afternoons drinking lattes at outdoor cafés with newly acquired friends. Her body confirms the transformation: "I was the picture of health, as though I had finally come into the body meant for me."Armed with new found confidence, she sends out her résumé ("to date, one of my finest pieces of fiction") and gets her first real job, as a teacher in a literacy center. After almost a year on Prozac, she is accepted at Harvard, where as a student in psychology she eventually earns a doctorate in record time. She falls in love with Bennett, a chemist who is willing to accept her simultaneous "love affair"with Prozac.

Like all love affairs, however, Slater's infatuation with the small green-and-cream pills demands sacrifices. There are practical repercussions: her creativity ebbs, her sex drive dwindles, and she learns that Prozac is an inconstant lover when she suddenly experiences a horrifying descent into "crazy,"obsessive behavior. The emotional toll is at once more elusive and more profound. In the early months of her treatment, Slater is torn between her enthusiasm for the rewards and possibilities of health and a deep-seated fear of abandoning her "illness identity.""There was no more depression, which had felt like the stifling yet oddly comforting weight of a woolen blanket, or anxiety, which lent a certain fluorescence to things, or voices, which had always been there, sometimes louder, sometimes softer, some North Star of sound in the night."As time passes, she adjusts to Prozac's cool and calming effects and to the sporadic imperfections in its chemistry that allow odd bits of illness to break through. Now, after a decade on Prozac, she is resigned to her dependency on Eli Lilly and at the same time determined to exercise her freedom to reenvision the past and the present, to choose who she is and wants to be. "Prozac is not my lover any longer,"she writes, "but over the long haul has become a close friend, a slightly anemic, well-meaning buddy whose presence can considerably ease pain but cannot erase it."

Today, Prozac has become the legal drug of choice of a whole generation, used by millions of people all over the world. It's been hailed as a wonder drug and condemned as a drug that triggers violence. While 40 to 50 percent of patients on Prozac experience sexual dysfunction, a group of Prozac-taking British women reported a rather more stimulating side effect: whenever they sneeze, they have orgasms. As one of the first people to take the drug and among the few who have stayed on it for ten years, and as a psychologist who has also been a psychiatric patient, Lauren Slater is in a unique position to shed light on both Prozac's immediate impact and its long-term effects. Her book supports neither the generally positive position found in Dr. Peter Kramer's widely acclaimed Listening to Prozac nor the backlash against it expressed in Peter Breggin's Talking Back to Prozac. Her territory lies outside and beyond the noisy controversy. With elegance and humor, she takes us directly inside the strange new world Prozac has created, and using the language and images of poetry, reveals its gifts and its burdens.

Much has been written about Prozac, from both negative and positive points of view. What does Prozac Diary add to this ongoing dialogue?

To this dialogue Prozac Diary adds the voice of the consumer—myself—telling the story of pharmacological "cure"from an intimate, and, I hope, authentic stance. Writing about Prozac, as so many people have done, is really not at all the same as writing through Prozac, as I have done, and the portrait that emerges, although no more or less honest than the more distant, "objective"portraits, is a singular story with singular details that no amount of detached research could have uncovered.

In addition, Prozac Diary is meant to address directly the issues involved in long-term Prozac use, which are in many ways different from the issues and ethical dilemmas involved in relatively short-term Prozac use. I wrote my book with the partial intention of portraying what this drug is like when taken over a lifetime, the difficulties, the dangers, and the blessings; and my hope is that it will speak to other people considering, or already embarking on, long-term usage.

Your first book, Welcome to My Country, was primarily about patients you worked with, while Prozac Diary is a much more personal book. Which book did you find easier to write? How did the writing processes differ?

At some essential level, the writing process is always the same for me, no matter how different the project is. Writing, whether about myself or others, demands a rigorous imaginative stretch, a reach for lyricism that conveys emotion, as opposed to covering it. This is always my struggle.

That commonality aside, the two books did present different artistic problems. I think I found it easier to write about other people, about patients, because I could portray the enormity and dignity of their suffering without risking self-absorption, or blatant narcissism. In writing about myself, I feel much more constricted. I worry about solipsism, shortsightedness, self-aggrandizement, self-denigration, and all the other treacherous territories that come with the fascinating pursuit of autobiography.

You offer readers glimpses of your childhood in passages interspersed within the running narrative. Why did you choose this method, rather than presenting a straight chronology from the onset of your illnesses through your experiences with Prozac?

There is a fairly simple answer to this. I intended for Prozac Diary to be a book about cure, not illness. Thus, I self-consciously set out to avoid a linear illness narrative, a structure that would have placed as much weight on sickness as on health. Instead, I chose to give quick glimpses of the illness—enough, I hope, to convey its essential character, but not so much that it obscures my main purpose: to write about an emergence, not a descent.

In retrospect, what was the hardest part of crossing into "the landscape of health"?

The hardest part for me was, and continues to be, my concern that I have lost some of the honesty and intensity that illness, which by its nature places one at the periphery of society, brought to my life. In Freud's famous essay "Mourning and Melancholia"he articulates this conflict extremely clearly. "The depressive has a keener eye for the truth than people who are not melancholic . . . we only wonder why a man has to be ill before he can come to truth of this kind."

Memories of your mother play a large role in your descriptions of your childhood. What was your relationship to your father like? How did your two sisters react to the atmosphere at home?

My relationship with my father was placid but fairly distant. His way of coping with the crises on the homefront was to absent himself, physically and emotionally. I don't remember him around a lot. As for my two sisters, they were treated quite differently than I. My mother adored my younger sister and treated my older sister with respect. However, they did not escape the trauma that comes from witnessing the cruelty she inflicted on myself and others. Their scars are different, but, I'm sure, deep.

One of the "side effects"of Prozac you experienced was a new interest in religion and spirituality. Did this help you adjust to the changes you were undergoing? Can you describe the spiritual aspects of mental illness—and of mental health?

My own belief is that spirituality, the idea, the feeling of a greater moral coherence to our world, is essential for people, in illness and in health. Health was a crisis for me, a new world, and I partially relied on my sense of spirituality to guide me through. This "sense"for me is rooted in moral conviction. We are, I believe, morally obligated to navigate the complexities of living with as much grace and courage as we can muster. So yes, my spiritual leanings certainly helped me adjust to the adventure that was, and is, Prozac.

As for the spiritual aspects of mental illness and health, that's a big question, one which would be answered differently by every person to whom the question was posed. For me, the spiritual aspects are the same whether in the sanguine or pathological state. Spirituality transcends illness and health. It is, for me, a fixed yet oddly fluid set of beliefs that serve as a guide. However, in illness I am less capable, in some ways, of responding to the moral challenge that spirituality is, while in health, I have more stamina and, perhaps, more courage. On the other hand, in health, in the pastel glow of good days, I often catch myself becoming slack, letting myself loose from the discipline that a spiritual life requires. Illness represents, in many senses, a reminder, a calling back to attend to all I've let slide.

In what ways have your own experiences as a psychiatric patient helped you as a psychologist?

I don't think my experiences as a psychiatric patient have been much help to me as a psychologist. I don't believe the suffering induced by mental illness necessarily makes a person more empathic to others. In fact, it may be just the opposite. Mental illness, for me, can be a painfully self-absorbed state that shuts out the world, and one's ability to connect to it.

Memoirs, particularly by women with dysfunctional or difficult family histories, have become quite popular today. Why do you think this is true? Did any of them influence your own memoir, and if so, in what way?

I have always been an autobiographical/biographical writer long before the "memoir"craze. I have had a powerful urge to document "real lives,"as a means of directly communicating with other people. I love fiction, but it can feel like a veil to me, like a slanted way of saying something. Because, perhaps, I grew up in a home of lies and denial, I consistently crave art that is balder and somehow more stripped. So I actually don't think my own autobiographical writing was influenced by other memoirs, as I've been charting my life and the lives of others since I was a child. However, I do think the publication of my books, and any measure of publicity they have received, is probably entirely dependent on the popularity of the memoir in general.

As for the first part of the question, I don't know. I can hazard a few guesses. I can say for sure that I am fascinated by the phenomenal interest in the autobiographical form. Perhaps the public interest in this form has something to do with a collective sense that we are, as a culture, becoming increasingly less direct and honest, that we are ever more image-driven, that we know the media to distort and even lie, that we know our figureheads to distort and even lie. There is, perhaps, an ever-increasing sense that our world is warped, a place of funhouse mirrors and ever-shifting ground. In response, we want something solid, we want a real glimpse into real lives, and thus we grasp these books. That "these books"happen to contain much dysfunction in them is simply because any honest account, from Saint Augustine's Confessions to The Liars Club, will, by necessity depict dysfunction. Real life is difficult, and difficulty leads to dysfunction. It's not the dysfunction we're after. It's the sense of truth, of authenticity.

What message does your book have for people who are not prescribed Prozac or other Selective Serotonin Reuptake Inhibitors?

I think, I hope, my book is about the search for and struggle with identity, about what constitutes a "real self,"and these are questions that are pertinent to any sentient human being. In addition, there is no person in the developed world today who is not a part of the "Prozac Nation."SSRIs, and Prozac in particular, have influenced the brains and souls of everyone—those who swallow the pills, those who don't. We all know someone who is on Prozac, or think about going on it ourselves, or see it seep into our communities in ways both alarming and amusing. Prozac, for these reasons alone, is a remarkable drug. It is perhaps the only drug to have seeped so far out of its plastic shell, to have been absorbed by the bloodstreams of so very many, even those who have never had any tactile relationship with it. I would go so far as to say we are all "on"Prozac, in that we all must grapple with its presence, its meaning, and its implications for our lives.

Has your relationship with Prozac changed since writing the book?

My relationship with Prozac has changed somewhat since writing the book, although the change has nothing to do with the book's publication or creation. Since that time, however, I have had more trouble with the dreaded tolerance, and have had to increase my dose to levels so high they are over what the FDA recommends. Of course, this is frightening for many reasons—side effects, toxicity, permanent cognitive damage, no one really knows. I will wait and see what the future holds.

1. For much of the book, Slater calls her doctor the "Prozac Doctor,"rather than by name. How does this reflect her feelings about and her experience with the medical profession? Does the doctor's attitude justify this depersonalization, or does she expect too much of him? What does she mean when she says, "The Prozac Doctor was biblical to me"?

2. Slater writes about her mother, "Nothing was ever enough, for there was no plug to stopper the hole in her soul, no pill."From the evidence in the book, do you think that Slater's mother had serious emotional problems? In what ways are Slater's symptoms a reaction against her mother's "manic intensity"and in what ways do they echo the very things she objects to about her mother? How much do Slater's own problems affect her descriptions of her mother, and how do they change in the course of the book?

3. What purpose do the sections called "Letter to My Doctor"serve in the narrative? Why do you think Slater decided to juxtapose the cold clinical facts about her illness and her hauntingly poetic reminiscences about childhood?

4. Why did Slater wait four or five days before taking her first pill, despite the fact that she was clearly upset about her obsessive-compulsive disorder? Why did her dream about the Prozac Doctor make it possible for her to begin her medication?

5. Slater questions the assumption that health is "natural"and "good."Do you think the Judeo-Christian tradition and the medical profession accept this point of view too readily? Can illness offer insights that a "healthy"person might never discover?

6. Slater writes about the eight people she pictures living inside her: "three men who taunted me, three nine-year-olds, a girl trapped in a glass cage, and a blue baby, sometimes dead, sometimes dying."Based on what you know about Slater's life, what do you think these figures represent?

7. How did Slater's job at the literacy center help with her own healing process? In what ways is her passage from an illness identity to one of health similar to the transition her immigrant students are facing?

8. Slater compares Prozac to the drugs used in primitive cultures as a means of accessing the gods. Do you think this is a valid comparison? Does Prozac make Slater more spiritually aware or does it undermine her spirituality?

9. Why does Slater switch from a first-person narrative to a third- person narrative when she describes the actual events of her childhood and the early signs of her illness?

10. How does Slater's diminished sexuality affect her sense of self? Is her ability to love more fully a fair "trade-off"for her lack of physical pleasure?

11. Slater cites literature from Eli Lilly and other researchers that claim that the success of serotonin-specific chemicals like Prozac show that "the patient's past, the story of self, is no longer relevant. We do not need to explain mental illness in the context of history. We can place it, and its cures, firmly in the context of chemicals."Does Slater's own story support this conclusion?

12. Some research suggests that Prozac actually improves one's personality rather than just eliminating symptoms of illness. Is it unethical or deceitful or even dangerous to use a drug in this way? Despite her acknowledgment that Prozac has changed her life, Slater reports that she feels both shame and guilt about her dependence on it. Do you sympathize with her feelings?