Consuming an edge: ADHD,stimulant use,and psy culture at the corporate university

Abstract

We examine “psy” on the college campus. Psy refers to ways of knowing and acting on ourselves that shape everyday life psychologically. We suggest that there is an “elective affinity” between psy and the neoliberal management strategies that now dominate the “corporate university.” We describe ways that psy organizes college life by drawing on the history of college health services; interviews about mental health and services at a university in Canada; and historical, social, and media accounts of student mental health and pharmaceutical drug use—both prescribed and not—on campus in the US and Canada. By the 1990s, for the first time, many students were arriving at college as already experienced consumers of psy with diagnoses and prescriptions. We approach this and the increased use of medication as an aspect of the psy-campus. We focus on stimulants, using ADHD to illustrate the blurring line between treatment and enhancement. Students who use stimulants—with or without prescription—do so in the same way: instrumentally in relation to academic demands. The blurred line between academic stress and psychiatric distress is further illustrated by “clinic notes,” an institutionalized practice that enables all students to act on academic pressure as a matter of mental health. We describe the links between psy and institutional branding and marketing to illustrate the role of mental health and wellness services in the corporate university.

Keywords

ADHD college mental health corporate university neuroenhancement pharmaceutical stimulants psy

Introduction

Psy culture organizes everyday life as an ethical problem of the self (Rose, 1996a, 2003, 2007). The term “psy” captures the encompassing ways of knowing and acting on ourselves psychologically that extend well beyond professional practice (Donzelot, 1979; Rose 1996a). In this paper, we are interested in some of the ways psy has permeated the college campus in Canada and the United States.¹

The 1980s witnessed an expansion of mental health and wellness practices including the substantial increase in psychiatric prescribing, beginning in that decade, which included for the first time growing numbers of children and adolescents. This normalization of pharmacotherapy (in both mental health practice and popular culture) has transformed ideas about personal identity and the pathologies and potential of human experience (Martin, 2006; Rose, 2003, 2007). By the 1990s, larger numbers of students began arriving at college with psychiatric diagnoses and prescriptions (Carter & Winseman, 2003) and with “psychopharmaceuticalized” assumptions about how routine experience is ever amenable to pharmacological modification (Caplan & Elliott, 2004; Hyman, 2006; Rose, 2003, 2007).

In this paper, we examine how the changing role of college mental health services since the 1980s has both reflected and reinforced the expansion of psy and the way students experience ordinary difficulties as matters of mental health. College health professionals have declared a mental health crisis on campus related, in part, to the idea that college has become a high-stakes, high-pressure environment. Whether or not this perception is true, popular media amplify these claims, especially in coverage of unusual events such as campus homicides and suicides, while also routinely reinforcing the central assumption that mental health services are relevant not only to dramatic events and mental illness but also to the routine distress and well-being of all students.

We also examine the role of psy in the corporate university (Aronowitz, 2000; Giroux, 2002; Hyslop-Margison & Sears, 2007; Jancius, 2008; Strickland, 2002). Corporatization is the organizational trend toward adopting neoliberal management strategies in higher education, emphasizing efficiency and outcomes as well as the expansion of special initiatives and services over teaching. The emphasis on accountability and individual responsibility dovetails with campus efforts to increase awareness of the stresses of college life and to promote self-care for the prevention or management of mental health problems, through professional activities (e.g., psychotherapy or medication) or community ones (e.g., yoga classes). Moreover, psy and corporate cultures converge in the now common practice of institutional branding and marketing in education: student services, including mental health and wellness, are important in the competition for applicants (Duenwald, 2004; Gately, 2005; Prescott, 2007).

We discuss prescribed stimulant medications on campus and then three interviews with students who have a diagnosis of ADHD and take medication. The interviews illustrate the blurry line between academic and psychiatric distress and between treatment (of disorders) and enhancement (of ordinary performance). ADHD is integral to how these students understand and organize their relationships to their schoolwork which, we suggest, is now a way all students potentially can organize their academic stress as a matter of mental health. Students who use these drugs—with and without prescription—do so to manage academic demand. Our cultural and qualitative approach offers a contribution to the study of psy practice on campus in relation to the ongoing transformations in higher education. We suggest an affinity between psy and the corporate university.

Methods

We draw on different kinds of empirical data. The three interviews we discuss are drawn from a larger study conducted at an elite, urban research university in eastern Canada (which we will refer to as “The University”). This research underwent ethics review by The University and was supported with a grant from the Social Sciences and Humanities Research Council (SSHRC). The study’s initial aim was to understand the experiences of students who take prescribed psychiatric medication but, during the research, we became particularly interested in prescription stimulants and ADHD. We interviewed 22 young people in 2007–2008 using the semistructured interview schedule, Teen Subjective Experiences of Medication or TeenSEMI (Floersch et al., 2009), which we modified to reflect the college-aged participants and their new experiences of independence. The participants were 19–24 year old current and recent students (10 men and 12 women) who volunteered in response to flyers or campus classified ads. In the sample, 15 participants were White and seven were of African, Asian, or Middle Eastern descent. In our self-selected sample, 18 participants were from middle and upper middle class families with parents in the professions and business. Most accounts—both popular and professional—of psy culture and practice on campus are about similarly elite institutions. Though all colleges have had to adapt to the expansion of psy and the psychopharmaceuticalization of campus life, wealthier institutions have witnessed greater increases in mental health and wellness services.

The three interviews were with students who had a diagnosis of ADHD (two women, one man; all were White and from middle and upper middle class families). Although these students are not representative, their experiences of ADHD reflect broader ways in which academic stress and psychiatric distress are linked. For data on nonmedical stimulant use, we draw on research about college students in the US and Canada. There appear few relevant differences between countries. Jerry Floersh (personal communication, June 17, 2011) and his colleagues are currently analyzing data from a study of psychiatric medication use at different kinds of colleges in Canada and the US, and their preliminary findings affirm that there is little difference in psychiatric treatment, college services, attitudes toward psychiatric illness and medication use, and institutional transformations in higher education.

We also conducted formal open-ended interviews with three senior clinicians from The University mental health clinic (two psychiatrists and one psychologist) and with two disability services counselors about their perceptions of mental health problems on campus, the nature and role of their services, and about college life in general. In addition, we had informal conversations with a number of other clinic staff and informal interviews with 10 faculty members about their perceptions of student mental health issues and academic life.²

The 22 student participants reported having “mild” or “moderate” problems (those with psychotic disorders were not eligible). All involved conditions often considered treatable also or in combination with nonpharmacological techniques such as psychotherapy or cognitive behavioral therapy (and all were, or at one time had, engaged in some form of talk therapy or counseling). Most participants described themselves in terms of diagnostic categories (depression or anxiety) and most used more than one to do so (depression and anxiety). One student described herself in terms of a symptom (“cutting”) rather than a disorder. Two women reported both depression and an eating disorder.

Almost half the participants (10) described themselves as academic high-achievers but all 22 described the academic demands of college as “heavy” or “intense,” identified their emotional difficulties as a potential obstacle to academic performance, and regarded their medication as helping them to function in college. For the 18 participants who did not have ADHD, however, academic performance was merely one of a number of personal issues, and these students focused largely on their experiences coming to terms with their personal difficulties, wanting to feel better overall, and maintaining primary relationships and friendships. By contrast, the three students who had ADHD focused extensively on the relationship between their diagnosis, their medication, and their ongoing academic activity and performance.

What was also striking was that they described in detail how and when they took their stimulant medication: it was always in relation to academic demands. (The handful of other participants who described how and when they took medications referred to prescribed medications for anxiety or sleep.) We use excerpts from the interviews that address student self-understanding, medicine use, the diagnosis, and academic performance.

Psy culture at the “college of the overwhelmed”

There was consensus among clinic staff about the mental health crisis on campus and the marked increase “over the past several years” both in visits by students and in the severity of problems. Increased academic pressure was one explanation and reflected the assumption, widely held in college health, of the consequences of what Kadison and DiGeronimo, in their best-selling book, call the “college of the overwhelmed” (2004).

Prescott (2007), in her history of college health in the US argues that, through the 20th century, services changed with changing student bodies, and in response to broader social problems. College health services have been integral to the promotion of access to higher education for historically excluded groups. They were first established, largely at elite colleges, in the decade following WWI because of the psychiatric recognition of shellshock. Though integrating former military was the impetus, the argument for establishing campus services was broader: the stresses of modern life, even in peacetime, required the expertise of mental hygiene to help all college students in their transition from home and in their preparation as citizens. The idea that problems with “growth and transition” were common to all students and not just “the more obvious misfits” led colleges to assume responsibility for the “emotional health” of their students (as quoted in Prescott, 2007, p. 127). After WWII, mental health services expanded along with higher education which brought greater campus diversity by class, sex, and, over time, race. The field of college health continues to see as crucial its role in access to higher education. Gone, however, is the explicit early 20th-century notion that college is a parental surrogate, defined now by its responsibility to “foster a bridge toward independence” (2007, p. 168).

College health services have not only helped define the responsibility of institutions to their student bodies but, we argue, have also contributed substantially to the dissemination of psy knowledge and practice on campuses. Well beyond the bounds of college life, the 1980s witnessed massive growth in psychiatric diagnostic categories and prescribing as well as an explosion of popular psy knowledge in 12-Step and other mutual support movements, television talk shows, and so forth. The turnaround in student attitudes toward professional mental health at this time is a telling measure of the normalization of professional psy expertise on campus. In the 1960s, when illegal drug use, changing sexual mores, and birth control emerged as issues, students began avoiding campus services because of their paternalistic, conservative character and concern about confidentiality. As a result, well into the 1970s, college mental health services expanded through the creation of alternative settings and approaches—such as peer counseling and drug drop-in centers—to address student suspicion of both medical and campus authorities (Kraft, 2009; Prescott, 2007). By the end of the 1980s, students had again come to prefer professional mental health practitioners and still do (Kraft, 2009).

Another change in the 1980s was the growth of community prevention and education campaigns, now a defining activity of campus mental health services (Kraft, 2009). These activities contribute to the growth and normalization of psy by continually offering students new psy problems and solutions. The dramatic increase in education and prevention campaigns was a response to AIDS, which galvanized an expansion of campus services as did the identification, at the same time, of “another epidemic: the growing mental health crisis on college campuses” (Prescott, 2007, p. 166). A major response to both were prevention and awareness campaigns that aimed to reduce stigma and prejudice, often with the participation of student activists and volunteers (Prescott, 2007). Over the years, these campaigns, which have always aimed to identify students in need of services, have involved increasingly sophisticated strategies (Kraft, 2009). The continuous growth in campus education and prevention has also been sustained by the concern about institutional liability, heightened occasionally by widely publicized student suicides and homicides (Davenport, 2009; Kraft, 2009; Shuchman, 2007).

The assumption in college health is that, since the late 1990s, the mental health crisis on campus has pushed services far beyond their capacity with the steady rise in the numbers seeking services and the increasing severity and complexity of student psychopathology (Hoover, 2003; Kadison & DiGeronimo, 2004; Kitrow, 2003). College health professionals, including the clinic staff, consider the campus mental health crisis to be related to enormous college pressures that begin in high school and escalate once they arrive. In addition to the way such claims shape professional practice on campus, they are also notable as an index of psy culture, especially in the relationship between psychiatric and personal distress on campus.³

Critics regard psy practices on campus as undermining the value of autonomy during a crucial period of transition to adulthood and as an extension of “helicopter parenting” (e.g., Marano, 2008). We are interested in how the development of services involves the production of new needs in the medicalization of academic distress. Increasingly, mental health counselors and “wellness-resource tutors” are available in dorms to “help students deal with issues from procrastination and stress to depression” (Gately, 2005), and dog therapy programs, late night yoga, and oxygen bars are available to manage stress and promote “wellness” (The Associated Press, 2010; Williams, 2011). Public awareness campaigns routinely include depression-screening days, such as at Harvard, where students who participated were rewarded with a new iPod (Gately, 2005). Such a practice adopts on campus a main technique of pharmaceutical marketing through so-called value-added programs: a combination of material incentive, education, assessment, and the “advertising” of a disorder (and its pharmacological treatments).

Psy and the corporate university

The diffusion of psy has occurred at the same time as the corporatization of the university in which neoliberal institutional structures and management strategies have altered traditional professional values of teaching and scholarship (Aronowitz, 2000; Giroux, 2002; Hyslop-Margison & Sears, 2007; Jancius, 2008; Strickland, 2002). The corporate university, focused on efficiency and the standardization of outcomes, has shifted powers of governance away from faculty toward administration. This involves more than the management rhetoric of efficiency, assessment, and, accountability. Academic institutions are changing to reduce costs and to generate revenue in new ways. Universities have closer relationships with private and commercial sectors and cultivate grant-generating fields, especially those of interest to foundations. In the US, at all institutions of higher learning, from 1998 to 2008 spending on administration well outpaced spending on teaching (Dillon, 2010). Critics argue that corporatization has devalued the humanities and shifted curricula toward applied, technical, and occupational “skills” training, including new revenue-generating “professional” graduate programs. This has redefined the historic role of universities in the cultivation of engaged citizens and has created consumers out of students and their families (Hyslop-Margison & Sears, 2007).

Psy and corporatization come together in two ways. First, they share an emphasis on individual responsibility and accountability. Second, and more directly, the “psy campus,” so to speak, has become a marketing strategy. Institutional branding is now standard in higher education and the quality and nature of mental health and wellness services are increasingly important in a competitive “corporate university system” (Strickland, 2002). Institutions compete for private and public resources as well as for students. At the same time, government mandates to accommodate disabled students are also opportunities for new markets. As college health has always seen itself as crucial to the incorporation of excluded groups, on the psy-campus health professionals and administrators regard mental health services and medications as enabling many to pursue a college education who, in the past, would have found it impossible (Prescott, 2007; Young, 2003).

Pharmaceuticals on campus

The use of prescribed psychiatric medications by students increased fivefold from 1992 to 2002 (Schwartz, 2006a) and the growing role of medication treatment in mental health raised questions for college health professionals about their own practice. The very title of one of the first conferences on this issue in 2002 indicates how psy-experienced students were changing the clinical landscape of college mental health: “The Escalating Use of Medications by College Students: What Are They Telling Us, What Are We Telling Them?”⁴ At The University, clinic staff were concerned enough by 2003 to conduct a survey of first-year dormitory students, finding that 12 to 16% reported taking a prescribed psychotropic in the past 6 months. In the US, an average of 20% of students served by campus clinics take psychiatric medication, frequently antidepressants, with the number even higher at elite private colleges; more than half of the 2,000 students who sought counseling at Harvard’s clinic in 2002 received a prescription for an antidepressant medication (Young, 2003).

The number of students with prescriptions is associated with another problem on campus: an increase in the use of psychoactive pharmaceuticals without prescription (Barrow, 2010; McCabe & Boyd, 2005; Yan, 2009). During the 2000s, this issue received growing attention as a problem of drug abuse (McCabe & Boyd, 2005; Wilens et al., 2008), and students with prescriptions do form the main source for the illegal circulation of opiates, benzodiazepines, stimulants, and other drugs (McCabe, Knight, Teter, & Wechsler, 2005; Spurgeon, 2001; Wilens et al., 2008).

Stimulants on campus

Unlike opiates and benzodiazepines, stimulants without prescription are not used mainly as pleasure drugs but to facilitate academic work as “cognitive enhancers,” “brain steroids,” or “study drugs.” The rates of nonmedical use vary greatly by institution, sample, and region. A review of studies from Canada and the USA determined that between 5% and 35% of college students had taken stimulants for nonmedical purposes in the last year (Wilens et al., 2008). In a special report about Adderall use at U.S. colleges, the National Survey on Drug Use and Health (NSDUH) reported that 6.4% of students had used the drug without a prescription at least once in the past year (Substance Abuse and Mental Health Services Administration [SAMHSA], 2009).

Nonmedical stimulant use on campus illustrates the blurring line between treatment and enhancement in psy culture. Drug abuse researchers, however, do not consider this cultural dimension, presuming that drug use without prescription is per se abuse and, therefore, a danger to health.⁵ Nonetheless, the studies that do make distinctions between patterns of stimulant use show, overall, that the vast majority of students who take stimulants without prescription do so to enhance academic performance, for “concentration” and “alertness” (Advokat, Guidry, & Martino, 2008; DeSantis, Webb, & Noar, 2008; DuPont, Coleman, Bucher, & Wilford, 2008; Hall, Irwin, Bowman, Frankenberger, & Jewett, 2005; McCabe, 2008; McCabe & Boyd, 2005; McCabe et al., 2005; McCabe, Teter, & Boyd, 2006; Teter, McCabe, Cranford, Boyd, & Guthrie, 2005; Wilens et al., 2008). Interestingly, in one large university sample, nonmedical use of prescription pain relievers was the highest (9.3%) followed by stimulants (5.4%), yet college students with prescriptions for stimulants were far more likely to be approached to sell, give, or barter their medication (54%) than were students with prescriptions for other psychoactive drugs: pain medications (26%), anxiolytics (19%), and sleeping pills (14%; McCabe & Boyd, 2005; McCabe et al., 2006). Some students with these other prescriptions use their medicines to barter for “study drugs” (McCabe et al., 2005).

Stimulants have long been known to enhance certain kinds of task performance in healthy subjects. The origin of the connection between these drugs and academic work is thought to date back to 1937 when, during a study of the effects of amphetamine on mental tests at the University of Minnesota, the student subjects were apparently so impressed by their elevated mood, wakefulness, and focus that they spread the word about the drug (Grinspoon & Hedblom, 1975; Iverson, 2008; Rasmussen, 2008). Today, the idea of using drugs to improve normal cognitive function probably seems reasonable to many students given that “neuroenhancement” and “cosmetic pharmacology” are taken seriously by some neuroscientists and ethicists as both a current practice and future possibility (Chatterjee, 2007; Greely, 2008), Although we do not address the ethics of enhancement, it is worth noting that the debate itself, as well as its prominence, seems possible only in a pervasively psy and psychopharmaceuticalized culture.⁶

Yet it is the drug abuse agenda of researchers and college health professionals that is most often amplified in popular media. For example, 60 Minutes, the long-running U.S. television magazine show, aired a segment called “Boosting Brain Power” (CBS, 2010) about the prevalence of pharmaceutical stimulant use on college campuses. Portions of a discussion with a group of eight students at the University of Kentucky were interspersed throughout to demonstrate the degree to which the practice is normalized. Only one student took issue, calling it a form of cheating; and only one admitted that she had used stimulants herself to study, cram for exams, or finish papers. But all the students in the group agreed not only that many do it but also that the campus consensus is that it is okay. As one put it: “Everybody’s trying to get an edge. And I mean, and if you can take a pill that will help you study all night to get that grade you need, I mean, a lotta people don’t see why they wouldn’t do it.”⁷

ADHD

As the lines blur between treatment and enhancement, between psychiatric and routine distress, and between legal and illegal drug use, ADHD highlights the expansion of psy culture on campus. The diagnosis is controversial among some professionals and popular writers precisely because it medicalizes ordinary stress in a demanding multitasking world and, at least, indicates that pharmacological treatment is seen as the only option (Breggin, 1994, 2001).⁸

Stimulant drugs have been used since the late 1930s to treat children for problems of attention and focus (variously called, among other things, hyperkinesis and minimal brain dysfunction). The current diagnostic category ADHD appeared only in 1980 (initially as ADD) in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) and, since then, the number of diagnoses and prescriptions for Adderall, Ritalin, and related drugs has continued to climb. Around 1980, roughly 150,000 children in the US were receiving medication for ADHD; by 1990 the number was near 1 million and, just 10 years later, the number was estimated to be between 3 to 4 million (Greydanus, Pratt, & Patel, 2007; Rasmussen, 2008).

At The University clinic, staff were concerned about the number of students on campus with prescriptions for stimulants. The clinicians knew that stimulants are effective performance enhancers regardless of ADHD symptoms or diagnosis (Lampert, 2006; Loe, 2006). Given the perception of ever-burdensome academic pressure at The University, clinic staff regarded students generally as vulnerable to the greater campus presence of the drugs. While we were conducting this research, concern about nonmedical stimulant use at The University led to a task force and the campus paper described a drug problem related to academic pressure. One article quoted the clinic director and campus chaplain describing their worries about “our achievement oriented society” and about how students arrive with “tremendous pressure on them about what they have to get out of this [their college] experience.”

Clinic staff were suspicious of students inappropriately seeking these drugs even though they reported only a few such instances. Elsewhere, campus services report that students come in with self-diagnosed ADHD to obtain prescriptions (Kadison, 2005), and attempt to manipulate counselors by describing a history or symptoms of ADHD (Staufer & Greydanus, 2005). Although Sollman, Ranseen, and Berry (2010) are concerned with the detection of feigned diagnoses, they affirm our claims about psy knowledge by emphasizing that students have the ability to seek stimulants fraudulently: they are “symptom educated” and understand the reasons to do so.

The illegal campus market though is furnished primarily by students with prescriptions who give away, sell, or barter their drugs (McCabe & Boyd, 2005; McCabe et al., 2006). One study suggests that the majority of students who use prescription stimulants nonmedically receive them from friends for free (Dupont et al., 2008). The standard stimulant treatments for ADHD can be taken irregularly (unlike antidepressants, for example). People with ADHD often do not take them as prescribed precisely because when and how much they take is situational: tied to particular tasks or events. College students with ADHD often have a reserve of pills because they take them in relation to academic demand and may skip weekends and vacations, and some are even strategic about their use in order to provide a supply for others (DeSantis et al., 2008).

The interviews we discuss below show how a diagnosis of ADHD can serve as a resource: as access to medication and services, and as an aspect of how students understand themselves. There is an integral connection between stimulant use and academic performance and, in the context of college, this helps makes sense of why students without an ADHD diagnosis also may consume an otherwise sanctioned therapeutic product to enhance performance.

Jenny

Jenny, a 20-year-old junior, said she “was put on medication [Ritalin] and seeing psychologists and psychiatrists from the age of 3” because she was “a very anxious and aggressive child” and “had ADHD.” At age 14, Jenny decided to stop taking the drug though she was aware of how much it had helped, that it “made school possible.” As a teenager, she worried about whether it “was something that I’m going to have to do for the rest of my life, you know?” Her mother was opposed and told her about an uncle with ADHD in an attempt to change Jenny’s negative idea of long-time medication use. This attempt backfired. “I don’t want to be 40 and 50 taking drugs, you know.”

Jenny laughingly acknowledged that part of her insistence on stopping was partly adolescent defiance. However, she really “hated” it and thought at the time that she had learned to “deal with” her ADHD herself. “I didn’t do too well in school at first. I definitely had trouble paying attention and whatever it was that I was taking Ritalin for.” That didn’t last, however, and, Jenny did well enough, she emphasized, without the Ritalin to be accepted at The University. ADHD during high school was “not an issue,” something she “didn’t think about.” She was academically successful and worked hard to get into a “really good school.” At 17, Jenny “discovered on the Internet” that she had a “typical case” of depression and began taking a selective serotonin re-uptake inhibitor (SSRI) and a benzodiazepine. (At the time of the interview, Jenny was still taking these and had resumed taking Ritalin.)

Once Jenny arrived at The University, her “anxiety resurfaced” in relation to academic work, especially exams: “I would just freak out and sweat and think I was going to pass out.” Jenny realized almost immediately that the greater academic demands at The University changed her expectations of herself. She started to “think about myself again in terms of ADHD.” On an early visit home, Jenny went to her psychiatrist who agreed that she resume ADHD treatment.

Jenny took Ritalin but “as needed” to “get work done” which, she acknowledged sheepishly, was different from the prescribed daily administration. On the one hand, Jenny said that, as a college student, the drug made the difference between barely managing and doing well. On the other hand, she was ambivalent because it symbolized a failure of personal control. This reflects a common form of psy reasoning that presumes an opposition between the biophysiological power of medicine and the power of the self, that is, between a narrow biomedical assumption that reduces all explanation to the chemistry of drugs and a sense of personal responsibility for how one feels that reflects the strong cultural identification of the self with self-efficacy (Karp, 2006). Jenny was an experienced patient and did not regard taking psychiatric medication as a moral problem. However, she was burdened by a sense of responsibility and wondered, for example, why the doctor didn’t suggest exercise and, ultimately, why she can’t make herself feel better: “I can figure out ways, and I have been exercising … figuring out ways to deal with it on my own.”

While discussing her ambivalence, Jenny emphasized that she knows Ritalin works, acknowledging that this is why students take it without prescription as a study drug. At the same time, such nonmedical use was also a failure of personal responsibility. She equivocated when asked if the way she used Ritalin was “any different than how students [here] take [it] as a study aid?”

I know I have ADHD, I’ve always had ADHD, but I worked on it on my own. And I figured it out without the Ritalin. So now if I have Ritalin I think I would be taking it not because I think I can’t do it on my own and not because like I’m messing around … Like if the psychiatrist says I should take it, and I took it when I was younger and it helped, then I’m different than someone who’s just popping pills because like it will help them study. I don’t know if that’s a rationalization … I’m not really sure if I should be taking Ritalin. You know the psychiatrist says so, but I don’t know, I don’t know.

Jenny’s explanation incorporated psychiatric discourse: she accounted for her problems in the idiom of a naturalized disorder that she has and that makes her use of medication different from those who use it without prescription as a study drug.

Jenny’s psy narrative of self provided meaning and coherence to her personal struggles. Her ethical dilemma about medication is common because it symbolizes a practice of responsible self-management and, at the same time, an inability to manage oneself. Peter Kramer (1994) uses Gerald Klerman’s phrase, “pharmacological Calvinism,” to describe this contradiction and the complex meaning of medication in contemporary wealthy societies: a fear of psychoactive drugs borne of a medicalized culture that both idealizes the “quick-fix” and sees it somehow as cheating, a kind of short-cut. Psychiatric pill-taking is portrayed often as a straightforward solution but one that violates broad ideals of fairness and above all, self-responsibility, even in health. Moreover, the notion that psychiatric medication might be considered not only as treatment but also as enhancement undermines values of personal discipline and effort. Jenny expressed a sense of moral integrity, even pride, for having been able to manage the ADHD without medication in high school, for “figuring [it] out without Ritalin.” Paradoxically it is precisely the sense of accomplished self-management that enabled her to function without Ritalin that justified taking Ritalin again. The hard work Jenny had done on herself before makes it acceptable for her to take the drug now.

Steve

Steve was also diagnosed in childhood but he was ambivalent about ADHD and whether he actually “had” it. He conceded:

Like I probably do have ADHD. Like I totally go off in different directions. You know, I’m an extreme person … I’m ADHD probably because I don’t know how to be moderate about things. I’m either really doing this or really not doing anything or—you know?

However, as he was discussing the experience of being diagnosed, he said:

I have no idea. To this day I don’t even understand what ADHD is entirely. No one told me … Just some doctor said, you’re ADHD, take these [pills] … No one made an effort to educate me or explain to me what I was.

For Steve, ADHD was a potential resource that could be activated, so to speak, to procure a prescription when he needed help with academic pressure. For both Steve and Jenny, the newfound autonomy and academic demands at The University resulted in a reorientation to the diagnosis and to the medication. At the time of his interview, Steve, 22, had just graduated and described himself as having been an “emotionally troubled child,” and “very isolated and angry” in his family. His parents—an academic and a professional—were eager for him to see a psychiatrist. Steve was having behavioral problems in school and at age 8 his parents took him for psychiatric evaluation but objected to the recommendation that Steve take medication for his ADHD.

Steve described a contradiction for his parents that is typical in psy culture: invested in the psychiatric expertise they sought but then uncomfortable with pharmacological treatment. “They weren’t cool with that” but it seemed to him that his parents felt they had little choice. He had to change schools because of his behavior and the new school accepted him on the condition that he take the prescribed Ritalin: “basically the deal was I had to go on medication or else they wouldn’t take me.” Like Jenny, Steve decided to stop taking it in high school (at age 15) but, by then, his parents pressed him to continue.

After he arrived at The University, Steve “needed to talk to someone” and went to the mental health clinic. He emphasized that this was the first time he had decided himself to seek professional help. A clinical psychologist soon referred him to a psychiatrist because he had depression and “[the doctor] could prescribe medication.” Steve really liked the psychiatrist who not only prescribed but also did psychotherapy which, for Steve, made the doctor the “real deal.” In Steve’s assessment of the psychiatrist, psychopharmacology was valued less than talk therapy. An antidepressant, venlafaxine (Effexor), and a benzodiazepine, alprazolam (Xanax), helped but did not improve his ability to keep up with his schoolwork and he requested Ritalin based on his history. Steve used it to manage his schoolwork—for “concentration problems,” to “focus”—though, like Jenny, remained ambivalent about its effects. Both described the medicine as effective but also expressed apprehension about it and even dislike. At first, Steve took it daily as prescribed but not for long.

[After a while] if I really needed to get something done, I’d take a pill … I don’t believe it helps very much, as I never continue using the drug for very long, it makes me feel even more tense and uptight than I do normally and the withdrawal side effects afterwards are somewhat unpleasant.

Steve thinks about his medicines in different ways. The Effexor was simply therapeutic, a medicine, and he took it according to the prescribed instructions. Xanax and Ritalin however were both medicines and techniques to enhance or enable his routine activities. He took them when he felt he needed to and often at higher doses than indicated because he, rather than the doctor, could best determine how and when he needed the medications. His understanding of the drugs combined conventional medical assumptions about the specificity of effects and popular assumptions about how they enhance normal functioning. Steve valued the psychotherapy—he described it as the “real deal”—but recognized that while he used the medications for the reasons discussed in session, how he actually used them was different from the doctor’s orders. This made the doctor both “a healer and a dealer,” and as much as Steve liked and trusted him, Steve recognized the potential problems with being honest about how he actually used his drugs: “you don’t want to tell the doctor who is giving you your drug that you’re abusing it, you know? He was kind of my supplier.” In psychiatric discourse, the line between symptoms and routine life problems is often and unavoidably ambiguous. Using Ritalin to “get something done” as opposed to treating a problem is a situated and practical distinction and illustrates how psychiatry unwittingly medicalizes personal and social problems. Moreover, because different drugs have different meanings to patients they can perceive psychiatrists at once as healers and dealers.

That he viewed his drugs, psychiatrists, and psychiatry in multiple ways suggests that the increasingly dominant discourse of biology in psychiatry and the greater reliance on medication treatment has not produced passive patients but new forms of agency. Steve was not merely a passive consumer either of psychiatric discourse and, as many would have it, of its pharmaceutical products. While he claimed not to know what exactly ADHD really is, Steve knowingly departed from doctor’s orders and used the Ritalin instrumentally to do schoolwork. Psychiatric medications, as value-laden molecules, change meanings as they change the nature of authority and agency between experts and users (Greenslit, 2005; McKinney & Greenfield, 2010; van der Geest, Whyte, & Hardon, 1996).

Steve and Jenny expressed a form of psy-citizenship in which identity is shaped by the cultivation of the self through consumption practices that often blur the line between treatment, prevention, and enhancement (Rose, 1996a, 1996b, 2003, 2007). For both, coming to college forced them to think differently about how they should manage themselves actively in relation to greater academic demands. This meant seeking out those resources—therapeutic and/or performance enhancing—that would maximize their own capacities, or at least enable them to feel they were fulfilling the obligation to try. In the psychiatric discourse of therapeutic interaction between doctors and patients, perhaps especially when problems are task-specific academic ones, there may be little distinction for patients between medication treatment and performance enhancement. This gives meanings to drug treatments that psychiatrists may not intend but that some student-patients understand. These practices also illustrate what Rose (2003, p. 28; 2007) calls the “neurochemical self” which is “flexible” and can be shaped through practices that cross “boundaries between cure, normalization, and the enhancement of capacities” such as psychiatric medications which “offer the promise of the calculated modification and augmentation of specific aspects of selfhood through acts of choice.”

Caitlin

Caitlin was unequivocal about having ADHD and about the medication. However, Caitlin also discussed her medicine both as a treatment and as a resource to manage academic demands. As with Jenny and Steve, she pursued other activities to feel and function better: psychotherapy, listening to music, a therapeutic practice called “conscious-focusing,” exercising, and using organizational tools (such as lists and notebooks). These techniques of the self reflect the ethic of work one should do on oneself in addition to taking medicine, and at the same time, these techniques of self-work further justify taking medication.

Caitlin was diagnosed at 16. Before entering high school, she had been a “wonderful student” if somewhat “disorganized and stuff.” Caitlin had always loved school and was extremely distressed when, in high school, she began “failing badly.” She went to a psychologist and “did three days of testing that were hell [laughs] and then … and got put on Ritalin.” The diagnosis and medication were a relief: what she thought had been “just her” became “something else.” Caitlin was emphatic about what the medication does:

School, it lets me be in school. That’s why when people are like, maybe you shouldn’t be on it, maybe it’s not good for your health. Not till I graduate. Not a chance. I’d steal it if they wouldn’t prescribe it for me anymore. Like, it’s way too important, and I’ve failed without it.

Despite the effectiveness of medication, Caitlin sought other support. When she arrived at The University, she went to the clinic. Though she was in the care of her psychiatrist from home, she was eager to “have someone [at The University].” Caitlin liked the psychotherapist and, as a result of this regular contact with the clinic, she registered with disability services. Caitlin described the individualized support (including, for example, access to tutors, proofreaders, a counselor, and untimed testing) as essential to her success at college.

Jenny, Steve, and Caitlin discussed their experiences with diagnoses and treatment almost exclusively in relation to their academic problems or performance. By contrast, the non-ADHD students in our sample discussed multiple experiences and contexts. This probably reflects the way in which most students use stimulants instrumentally, prescribed or not, to manage academic demands. The other difference for Jenny and Steve, which seems to reflect the common moral dimensions of being a psychiatric patient, is their recognition of the drug’s effectiveness along with assertions that it “doesn’t really work” or about side-effects, negative qualifications that were not offered among the non-ADHD sample. Caitlin also did not offer any negative qualifications of her drug experience but, unlike Jenny and Steve she embraced without conflict a psy narrative of self.

“Dear Professor”: The use of clinic notes

Jenny, Steve, and Caitlin’s stories illustrate how taking medication and managing academic work can be experienced as inseparable. Because of their ADHD diagnoses and legitimate access to psychostimulants, they perceived themselves in more or less medicalized ways. However, their stories shed light on how other students can and do treat academic demand as a problem of psy. Many students seek assistance from the clinic and receive diagnoses of standard common disorders (such as depression) as well as newer ones, such as “exam anxiety,” which illustrate the conflation of academic stress and psychiatric distress.

The practice of “clinic notes” enables any student to medicalize academic distress without having ongoing mental health issues. Any student may request a clinic note informing a professor that the student has complained of emotional distress and accommodation is appropriately considered or, rarely, that accommodation is necessary. In most cases, accommodation involves granting deadline extensions or scheduling make-up examinations without penalty or undue pressure. In large lecture classes, there are often enough students with notes that the teaching assistant will schedule a make-up exam for all of them.

Many students requesting notes are “walk-ins” who are seen briefly by a clinician who makes an assessment. If a student is known to the clinic, the note indicates that the student is being followed there and has “personal issues” or “problems with anxiety” that can interfere with academic performance and would the professor take this into consideration. For those with severe ongoing problems, the note does not ask the professor’s consideration but states that the student “needs” an extension or an examination rescheduled. For students registered with disability services, like Caitlin, accommodations are in place and clinic notes are not necessary. A significant number of clinic notes, however, are not issued to students who are known to the clinic apart from the requests for notes. Those in obvious crisis, of course, are likely to receive a note asking the professor’s consideration or, rarely, stating the need for accommodation, and these students are scheduled for a follow-up visit. Such crises are however seen infrequently.

The clinic notes issued most merely document the request, informing that the student “came into the clinic today” or “came in with anxiety” and “any decision about exams or assignments should be made between the student and professor.” These clinic notes then can be seen as a routine technique available to students that gives their requests for extensions or make-up exams an institutional legitimacy. The clinic’s authority further legitimizes a student’s difficulty and the note itself implies that the difficulty warrants accommodation. It is the simple fact of the clinic note far more than its content. They offer quite generic characterizations of a student’s distress and effectively leave the question of accommodation to the professor’s discretion.⁹

Some of the clinicians were ambivalent about issuing these notes, which is a routine part of the clinic’s work. On the one hand, the clinicians believed that it is important to recognize how mental health issues can affect academic work. On the other, they were uneasy with the volume of notes requested especially by students who have no relationship with the clinic. They suspected that some do not have unmanageable stress or genuine mental health problems and use the clinic to change deadlines and exams simply because they can. The clinicians erred on the side of caution, however, because they could never be entirely sure. The work of issuing notes seemed less important than their crucial work: “in the trenches” with students who really are “freaking out,” “falling apart,” “not coping well,” or otherwise “suffering.” Their authority to issue notes made them central participants in an economy of academic and psychiatric distress that they saw as out of balance, participating in a system that runs on manipulation (at worst) and dependency (at best).

One long-time clinic psychiatrist said that because of the increasing concern about access (to services and to education), mental health practice on campus has both shaped and reflects changing ideas of fairness and competition. The option of having a mental health problem, if only temporarily, and one legitimated by the clinic, now enables students to experience and express their distress psychiatrically.

Before, everyone was in the same boat, … you have to write three exams in two days but all the other people in the same class are doing the same thing and they’re not getting out of it either. Then, the whole atmosphere was different … I think when they have the option of freaking out, when they have the option of getting out of— so now there are these options, they have the option. There’s more competition. There’s the sense that if you don’t get the good mark … Well [this has] been happening for years. [But] it’s been increasing … It kind of goes along with this whole issue about diagnosis. You know, there’s something wrong with me, you know, and the whole issue, the disability issue which, you know, now people with disabilities have certain rights according to the United Nations and then, you know, disability has become an industry. Exam anxiety—20 years ago we didn’t write notes for exam anxiety. But there wasn’t an office for students with disabilities then. So the whole thing kind of goes with this package. And [The University] promotes it. Makes sure you’re aware that you have rights.

According to clinic staff, professors almost always accommodate students with notes. The professors we interviewed described feeling “obliged” even though they were sometimes suspicious about most students’ claims. Two professors regarded the procedure as an appropriate institutional recognition that mental health issues, even occasional ones, can affect academic performance. The others saw the effort to request a note as an indication that “something really must be going on” with the student even if it did not necessarily seem to merit an extension or make-up exam. All acknowledged what they perceive to be the potential legal function of the notes. “I try to bend over backwards,” one said, “if I get one of these notes, I mean, what can I do?”

Practices such as clinic notes that are meant to increase access and inclusion also differentiate and individualize. What Epstein (2007) calls the “paradigm of inclusion and difference” shapes these efforts because equality in principle requires attention to the specific features of individuals that limit their participation. If anxiety or difficulty focusing, for example, prevents a student from realizing their potential, then there should be a basic technique available that permits them to adjust the schedules of deadlines and exams. Our conversations about clinic notes—with clinic staff, students, and faculty—revealed in various ways the idea that clinic notes were assumed to be an entitlement at The University.

Entitlement has two meanings that are not easily disentangled: conventionally, as enabling access and inclusion and, also, as an entitlement simply to optimize personal capacities. That is, as an entitlement to assert some control over academic demands on the basis of mental health independently of actual ongoing mental health issues. This cannot be explained simply as a moral problem such as coddling (Marano, 2008). Clinic notes illustrate an institutional expansion and normalization of psy that changes the nature and threshold of distress and suggests that, quite independently of psychiatric issues, there is little difference generally between academic stress and psychiatric distress. Going to the clinic for a note—effectively an individual student’s ability to adjust deadlines and exams—is simply another available resource for stress management that any student may use to do as well academically as they can.

Several student interviewees described clinic notes as commonly used including by those who otherwise do not seek mental health services. Accurate or not, our interviews suggest that the practice is perceived as a resource available to all students. One was particularly pointed:

At [The University] those notes are really central and they are really important in understanding how students operate here. Like I know a lot of people … who were always planning and strategizing to get good grades, and they would like talk to their parents in the beginning of the semester, and look at their course schedule, and with their parents they would decide, oh, I will try to go to the mental health service to get an exam deferral note for that class. And, yeah, the parents were very involved in all this planning.

Conclusion: Psy-corporatization of the university

Social and economic criticisms of the corporate university point to the branding and marketing that have transformed students into consumers (Aronowitz, 2000; Giroux, 2002; Jancius, 2008; Strickland, 2002). We suggest that psy culture on campus—with its emphasis on the responsible individual and the institutional responsibility for the wellness of all students—has shaped these corporate strategies in ways that cannot be explained by structural arguments alone. There is an “elective affinity” (Weber, 1992) between psy and neoliberal corporate practice that is particularly visible in the expansion of mental health and wellness activities, institutional transformations that could be characterized as psy-corporatization. Mandates for access and accommodation have enabled new markets and, at the same time, have intensified the responsibility of colleges for their student bodies. Yet legal mandates alone do not account for the encompassing discourses of diversity and inclusion or for the way campus health, wellness, and disability services have become a factor in marketing and selecting colleges (Duenwald, 2004; Gately, 2005).

Resources at the corporate university are invested far less in teaching than in services and administration.¹⁰ Mental health and wellness are often featured aspects of a campus brand, which expands the role of psy and reinforces the college’s responsibility for student well-being. When parents and students take college tours or attend orientation events, campus mental health professionals are often present to discuss services and provide reassurance about the support available (Duenwald, 2004; Marano, 2008; Prescott, 2007). Ironically, such marketing is part of an already distorted admission process—both competing for students and heightening competition among them—that is increasingly stressful and begins more than a year before students even arrive on campus.

Historically, college health services have played a role in greater access to education and the diversification of student bodies (Prescott, 2007). Services have also contributed to the expansion of psy culture and the medicalization of personal and academic distress. The clinical landscape changed for college health professionals when students began arriving on campus already experienced with psy, professional or otherwise. Mental health services are integral to the life of college students and bear an ever-greater responsibility to the institution. The rare campus suicides or homicides throw into relief the growing expectation of services to prevent problems (Gabriel, 2010; Sulzberger & Gabriel, 2011). Campus services are “caught up within a culture of blame,” as Rose (1996b, p. 4) describes psychiatry, “in which almost any unfortunate event becomes a ‘tragedy’ which could have been avoided and for which some authority is to be held culpable.” This places “new political expectations” on mental health professionals.

Davenport (2009) argues that college counselors are increasingly obliged to act on problems before they appear and to play a greater role in concerns about institutional liability, in effect, as part of campus threat assessment and security in ways that change and potentially compromise their conventional clinical role. At college and in general, prevention has increasingly become a kind of “cure” which heightens the urgency of intervention (Greco, 1993). In the wake of campus tragedies, mental health services are held accountable and burdened by “new political expectations,” both inside and outside of their institutions. This presents yet another opportunity to demonstrate the continuous need for more and better services (e.g., Shuchman, 2007; Winerip, 2011). On the psy-campus, services are integral to the health and wellness of all students. The expansion of services is not only for the “obvious misfits” nor for the misfits who are not obvious but whose hidden danger to the community and to themselves must be identified by psy practices of prevention, assessment, and monitoring.

In this paper, we have explored psy practice on campus in a few ways. The interviews with ADHD-diagnosed students illustrate how stimulant use and academic work can be experienced as inseparable. Because of its cultural dimensions, ADHD provides a fruitful analytic link between academic and psychiatric distress that sheds light on the way any student can potentially act on routine academic stress as a matter of mental health. This link makes particular sense given that college students who take stimulants—prescribed or not—do so instrumentally in relation to academic demands. More than ADHD, clinic notes represent an institutional instance of the psy campus and the assumption that any student might manage academic stress as psychiatric distress. The elective affinity between psy and corporatization has meant the increasing individualization of psy health through practices of self-management and improvement and also, for better or worse, has intensified both the institutional responsibility of mental health services and colleges’ responsibility for students in their transition to adulthood.

Footnotes

Funding

This research was supported with a grant from the SSHRC.

Notes

Jack Levinson teaches in the Sociology Department at the City College of New York. He is the author of Making Life Work: Freedom and Disability in a Community Group Home. His research interests include the role professional knowledge plays in everyday life, which is a focus of his current research on the cultural and social aspects of both medical and nonmedical drug use in a range of areas.

Kelly A. McKinney teaches in the Humanities, Philosophy and Religion Department at John Abbott College In Ste.-Anne-de-Bellevue, QC and is a research affiliate in the Division of Social and Transcultural Psychiatry at McGill University. Her current research focuses on technologies of selfhood, youth, psychiatry, and neuroscience.

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