Psychological Anthropology in Research on College

Journal of the Society for Psychological Anthropology

COLLEGE PSYCHIATRIC EXPERIENCE 501

“I’m Not Your Typical ‘Homework Stresses Me Out’ Kind of Girl”: Psychological Anthropology in Research on College Student Usage of Psychiatric Medications and Mental Health Services Eileen P. Anderson-Fye Jerry Floersch

Abstract

Research has established that a large minority of college students today are taking psychiatric

medications and that college mental health services are overwhelmed by this relatively recent trend. Little is known about the subjective experience of these college students in regard to their medications and utilizations of services as they transition from home to a peer-based environment during a key developmental moment in the transition to adulthood. In this article we argue that theory and methods from psychological anthropology are ripe to guide data collection in this area. We provide data from a longitudinal mixed-methods pilot study with residential college students to argue that policy and practice regarding college mental health and psychiatric medication can benefit substantially from insights gained through psychological anthropology. In particular, college administrators, counseling and health centers, and their professional organizations can benefit from research examining student experience and meaning making in particular institutional and community settings. [college, psychiatric medication, mental health services, adolescence, psychological anthropology]

Forty percent of U.S. college students meet the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association 2000) requirements for classification of mental illness (Blanco et al. 2008). Half of these students are estimated to be taking prescription psychiatric medications (Benton et al. 2003; Kadison 2005). Although the statistics are stunning, little is actually known about these students’ subjective experiences, medication management practices, or help-seeking behaviors (Floersch et al. 2009; Locke et al. 2009). We argue that psychological anthropology is well-poised to contribute theory and method with which to think about what is now called “the Mental Health Crisis” (Kadison 2004) on college campuses and present evidence from a pilot study with late adolescent college students taking psychiatric medications. The dramatic uptick of late adolescents taking psychiatric medications for mental illnesses in college settings is both quantitative and qualitative in nature. That is, not only are there more students taking medications but also the severity of the problems has increased. In prior generations, many of these students would have been precluded from postsecondary educational pathways, particularly college admission. However, with an increase of

C 2011 by the American Anthropological ETHOS, Vol. 39, Issue 4, pp. 501–521, ISSN 0091-2131 online ISSN 1548-1352. Association. All rights reserved. DOI: 10.1111/j.1548-1352.2011.01209.x

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efficacious treatments, including a surge in psychotropic medication prescriptions, many more students with psychiatric diagnoses are attaining postsecondary academic success (Fromm 2007; Kessler et al. 1995). Since 1997, between 62 and 69 percent of high school graduates in the United States have gone on directly to college (National Center for Education Statistics 2009). Presumably a portion of this historically high percentage is because of better treatment and management of mental illness. Not surprisingly, with increased admission of students with mental health issues, college counseling centers have been overwhelmed with the rising mental health demands of students. In a recent international study of college mental health services centers, 83 percent of centers reported dealing with an increase of students taking psychiatric medications (Rando and Barr 2008). Additionally, in a U.S. study, 95 percent of college counseling directors reported an increase in the number of students entering college counseling centers who are already on prescription medications (Gallagher 2008). Surveys taken by North American college and university health services indicate that 20–25 percent of students served by these clinics are taking psychiatric medications, especially antidepressants, with the number even higher at private elite U.S. colleges (Fromm 2007; Gallagher 2008; Young 2003). In addition to the steady rise in the numbers of medicated students visiting college mental health centers, counseling centers also note an alarming increase in the severity of student psychopathology. Changes in both prevalence and severity of mental health concerns are pushing college counseling centers far beyond their capacity to meet student need (Benton et al. 2003; Hoover 2003; Kadison and DiGeronimo 2003; Locke et al. 2009). Increased worry centering around suicide and violence has gathered on campuses (Hoover 2003). Colleges are struggling with how to provide enough high quality services at a time of simultaneously unprecedented demand and fiscal restriction (Locke et al. 2009). Tragedies such as the 2007 Virginia Tech shooting highlight the precipitously high stakes in trying to get support and services to all students, and especially those in the most need (Yorgason et al. 2008). The pilot study described here is a step toward addressing this critical gap in knowledge about the experiences and practices of late adolescents who are taking psychiatric medications in the context of a college setting. Such data have important implications for policy and practice in an in loco parentis context designed prior to the current surge in adolescent mental health concerns. Although the trends and data discussed in this article are domestic, they are indicative of global dynamics. In the study of global health, psychiatric disorders (esp. depressive disorders) are projected to move from the current rank of the third-largest burden of disease in the world to first by 2030, thus overtaking illness such as heart disease and infectious disease (WHO 2004). Twenty percent of adolescents worldwide are thought to have a diagnosable mental disorder, with psychiatric medications being increasingly prescribed to young people around the globe (Saraceno 2003). A global health and medical anthropology perspective reminds us that the issues and trends we see in the United States are not isolated but, rather, are part of worldwide flows of people, information, images, and products such as prescription drugs (Appadurai 1996; Floersch 2002). Particularly when we consider that


20 percent of our school age children in the United States are from immigrant families, and that number is increasing (Rong and Preissle 1998), we cannot underestimate the impact of global processes, even in specific domestic college settings. Internationally, trends regarding psychiatric medication and mental health concerns among college students parallel the quantitative and qualitative concerns seen in the United States (e.g., WHO 2005).

College Student Mental Health Services The primary research on college student mental health services comes from quantitative studies surveying college mental health service providers. Such large survey studies are invaluable to identify trends such as the recent surge in service-seeking, psychiatric medication usage, and severity of problems (Locke et al. 2009; Rando and Barr 2008; Stone et al. 2000; Vespia 2007). They can also identify which types of disorders are being treated among college students (Benton et al. 2003; Locke et al. 2009). Most of these studies historically have been conducted through professional organizations of college mental health center staff and directors such as the Association of University and College Counseling Center Directors (www.aucccd.org). A newer body of literature attempts to understand individual differences in help seeking (Eisenberg et al. 2007; Salzer et al. 2008; Rosenthal and Wilson 2008). Rarely do quantitative studies integrate qualitative or ethnographic approaches that might reveal more about how students themselves experience college mental health services, what they see as barriers, and what may help them on their own terms (M. Becker et al. 2002; Fromm 2007).

Why Late Adolescent College Students’ Mental Health Matters The transition to college is known to be both a stressful time (Gore et al. 1997) and an important step in the transition from adolescence to adulthood (Cooke et al. 2006). In addition to the sociocultural factors underpinning this developmental transition (e.g., increased time with peers, additional legal rights, and living without daily parental supervision), a relatively new body of work in developmental neuroscience highlights the importance of adolescence as a crucial time period to study medical management. Developmental neuroscience has shown dramatic brain changes during this time of late adolescence (Giedd et al. 1999; Sowell et al. 2003), with18–25 years of age representing the final phase of neural plasticity in the human life cycle. Such dynamic change in brain physiology sets up a unique opportunity for examining developmental assets and risks because they can have long-lasting impact on multiple levels (i.e., biological, psychological, social, and behavioral). Some biobehavioral researchers have posited that late adolescence is a time when the brain’s ability to self-regulate changes from needing external scaffolding in the form of parents, communities, and institutions toward internal monitoring (Dahl 2003). If we consider this finding in light of the high rates of psychiatric medication usage during this developmental time frame, then understanding how individual youth experience, understand, and make decisions about medication and how they do or do not use available resources found at college become increasingly important.

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The college setting may be the scaffolding that sets a student’s meanings and practices in the direction of a particular trajectory. Not only do particular experiences and practices related to mental health have the capacity to become “hard wired” during this time (Pynoos 2003) but also researchers have found that by the end of this period, most young adults have made life choices with “enduring ramifications” and that “when adults later consider the most important events in their lives, they most often name events that took place during this period” (Arnett 2000:469; Birth 2006). The college setting, therefore, holds lasting impact in the lives of young people with mental disorders, a fact of which college counseling centers tend to be more or less aware (Fromm 2007; Locke et al. 2009), and a fact that makes colleges’ policies around these issues critical to the well-being of the next generation. In contemporary U.S. culture, this dynamic time of life of late adolescence houses the modal ages of onset for a number of psychiatric disorders. These include those thought to have greater sociocultural influence (e.g., eating disorders; A. Becker et al. 2002) and those considered to be more heavily genetically influenced (e.g., schizophrenia; Craddock et al. 2005). The identity issues salient at this life stage (Arnett 2001; Erikson 1968; Kroger 2007) may be further heightened for those taking psychiatric medication in terms of both meaning and management practices (Karp 2006; Floersch 2003). The study of adult medication narratives has shown that fundamental aspects of self, identity, and sense of embodiment are affected by taking psychiatric medications (hence, the title of David Karp’s 2006 book, Is it Me or My Meds?). As Karp’s data with adults demonstrate, “the experience of taking antidepressant medications involves a complex and emotionally charged interpretive process in which nothing less than one’s view of self is at stake” (2006:102). What happens when typical U.S. ethnopsychological developmental changes in identity development and autonomy (Arnett 2001; Kroger 2007) are juxtaposed with these heightened issues raised by mental illness diagnosis and medication? Related to these developmental concerns is the question of what happens when adolescents transition from a mother-centered medication management program, the most typical pattern among adolescents, to the in loco parentis setting of college (e.g., Kranke et al. in press)? A New England Journal of Medicine editorial reflecting on the Virginia Tech massacre notes that college freshman may stop taking medications or receiving mental health services because they want to assert autonomy; they feel leaving home is a time for a new beginning and stopping medication becomes a marker of independence (Shuchman 2007). Similarly, in our pilot study, the vast majority of students made medication changes including stopping without consultation (Anderson-Fye and Floersch 2009). Students and clinicians alike report that connecting to local mental health services, either within the university or the community, tends to be difficult (Kadison and DiGeronimo 2003). Additionally, standard clinical-trial psychopharmacology research does not correlate findings to the sociocultural conditions influencing medication experience, nor have researchers in this field investigated the myriad ways users, parents, friends, professors, school staff, and clinicians constitute a grid of social relations that shape medication treatment (Longhofer and Floersch in press;


Longhofer et al. 2003a, 2003b). Psychological anthropology, with its long history of investigating culture and human development and its often mixed-methods, person-centered, experience-near approach offers many of the tools necessary to more fully investigate these important issues.

Culture and Human Development, Psychological Anthropology, and Adolescence The field of culture and human development, closely related to psychological anthropology, has a long history of looking at adolescence and mental health. From its antecedents in Mead’s early work in Samoa (LeVine 2007; Mead 1928) to the Whitings’ and their students’ multiculture study of adolescents 50 years later (Burbank 1988; Condon 1987; Leis and Hollos 1995; Whiting et al. 1986; Worthman 1987) to contemporary work (BluebondLangner and Korbin 2007; Weisner and Lowe 2005), scholars at the cusp of anthropology and human development have studied adolescents as part of their familial, community, institutional, and cultural settings for nearly a century. Perhaps because the life stage of adolescence is so newly described relative to others and was from its inception described in relation to contemporary society of the day (Hall 1904), adolescence has long been understood to be carried out in particular historical and cultural contexts. Even Erikson, arguably the greatest theorist of adolescence, was trained in cross-cultural methods and was highly aware of the dependence of the meaning of this life stage on a particular cultural and world setting (Erikson 1950, 1968; LeVine 2007). Whiting’s definition of adolescence, drawn from rigorous empirical and comparative research incorporating these understandings; that is, the “time between puberty and the assumption of full adult roles” (Whiting et al. 1986), is still the best definition of this flexible life stage. Recent advances in developmental neuroscience have also shown this life period of late adolescence and emerging adulthood to be a dynamic one in terms of brain development with particular consequences for mental health outcomes (Spear 2000; Walker 2002; Dahl 2003). During development from early to late adolescence, the brain shows considerable plasticity, including nonlinear changes in cortical gray matter, linear increases of cortical white matter, pruning of neurons and connections, new connections among nerve cells and a remodeling of neural pathways, particularly in the frontal cortex (Giedd et al. 1999; Huttenlocher 1990; Sowell et al. 2002). The hormonal effects of puberty are thought to affect gene expression of neural structures in both typical and psychopathological development (Walker 2002). These considerable brain changes during adolescence impact developmental psychopathology and help explain why adolescence is considered a “high risk” period for mental health problems generally (Walker 2002) and for disorders related to self-regulation (Ladouceur et al. 2004; Spear 2000) and affect (Dahl 2003) in particular. Some disorders tend to worsen in adolescence such as depression (Yorbik et al. 2004). Others have modal onset in adolescence, such as the aforementioned eating disorders (A. Becker et al. 2002) and schizophrenia (Walker and Bollini 2002). For still others, such as post-traumatic stress disorder, adolescent experience and intervention predict adult outcomes (Pynoos 2003).

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Therefore, it is less surprising that estimates of psychiatric medication usage are high in this population and more surprising how little is known about this usage across levels of analysis, including how to support college students. In both biological and sociocultural terms, this transitional time period is critical with respect to mental health and illness, education, and life pathway choices. Adolescents ages 18–25 enter transitions to adulthood that unfold in a setting specific way in college, with the task of medication management important to their development particularly in relation to autonomy and identity. Student health behavior choices are often formidable when making the transition from home to the university. Students’ style of psychiatric medication management is a likely indicator of their willingness to treat psychological problems pharmaceutically not only for themselves individually but also in the coming adult generation. Hence, these choices and practices are an indicator of ongoing and future cultural and social change, and a direction increasingly important to college campus planning. LeVine (this issue) has pointed out how adolescents are also collectively at the forefront of historical cohort-level change in most societies, and we take this to be an important theoretical backdrop as today’s college students are the first mass medicated cohort. Estimations of students entering college counseling services taking psychiatric medications rose from nine percent just 20 years ago to 25 percent today (Kadison and DiGeronimo 2003), with additional students prescribed medication during the course of college. The dropout rates among students with diagnosed mental illness remain high in the United States at a time when a college education is more important than ever (Kessler et al. 1995). Understanding this vulnerable group is critical to providing the best supports and services possible through postsecondary educational settings, and may even represent a new pathway along transitions to adulthood (Anderson-Fye 2011).

Ecocultural Theory and the Adolescent in College Settings Culture and human development and psychological anthropology have long provided rich theory and methods with which to conceptualize human development in the context of local and cultural settings. Some of the best of these include the Whitings’ theoretical commitment to unpacking categories of culture into specific practices through careful spot observational methods (LeVine 2007; Whiting et al. 1986), Rogoff and colleagues’ understanding of child socialization through guided participation theory (1993), activity theories (Gonc ¨ u¨ 1999), developmental niche theory (Super and Harkness 1986), and ecocultural theory (Weisner 1997). Ecocultural theory, particularly as articulated by Weisner (cf. this issue), as a combination of ecological adaptation theory and cultural activity theory, is a potent perspective and well suited to the study of college student use of psychiatric medication. Ecocultural theory posits that “families seek to make meaningful accommodations to their ecological niches through sustainable routines of daily living” (Cooper and Denner 1998) and goes beyond the individual to include her immediate social and cultural contexts and interactions. Such a conceptualization is particularly interesting to adolescent experience of psychiatric medications because management is considered to take place in a “social


grid” (Longhofer et al. 2003a, 2003b). In the case of postsecondary education, not only are there developmental issues at stake but also colleges assume in loco parentis roles to differing extents in students’ mental health and medication management (Stone et al. 2000). Ecocultural theory helps parse out how experiences of medication and help seeking occur between the two “families” of home and school. In other ecocultural studies on residential college campuses, roommate pairing had an effect on nonprescription drug use for some students. For example, Duncan et al. 2005 found that males who reported binge drinking in high school drank much more in college if assigned a roommate who also binge drank in high school than if assigned a non–binge drinking roommate. In our pilot work, we have found a wide range in how students procure their medication from mothers sending weekly prepackaged pill packs to students who forget to refill their prescriptions on campus. The ecocultural emphasis on sustainability of routines in context (Weisner et al. 2005) may be a particularly powerful concept for college student psychiatric medication usage to explain some of students’ educational successes or drop outs while taking psychiatric medications. Might students who craft sustainable medication and care routines—whether on campus or in a combination of on campus and at home—do better over time (with respect to mental health outcomes, subjective experience of well-being and educational achievement, most notably attrition) than those who struggle with establishing new routines? Which aspects of daily routines lend themselves toward help-seeking behavior? Moreover, might the conceptualization, provision, and communication about college mental health services on the part of the particular campus make it easier for students to engage services in their daily routines? And, which aspects of the campus setting do students engage in their routine practices? Ecocultural theory guides us not only to powerful explanatory models but also to specific aspects of college settings that may be enhanced or changed for intervention. For example, in the pilot study discussed below using modified ecocultural methods, we learned that students would skip scheduled counseling sessions at an on-campus counseling center if there was even a remote chance a peer or classmate would see them entering the counseling services wing, regardless of their desire for services or the severity of their problem. The sustainability and consistency of support services could be improved by modifications in the physical setting of counseling services.

Bringing Psychological Anthropology to College Mental Health Research: The TIME Study Recognizing aforementioned limitations of research on college student psychiatric medication and mental health services usage, in consultation with the focal university’s counseling center director, Jes Sellers, we developed the Transitions in Medication Experience (TIME) study. The TIME study was collaboratively designed as a multidisciplinary, multimethod exploratory examination of late adolescent mental health in the college setting foregrounding students’ reports of their subjective experiences. Set at a competitive, urban, private Midwestern college from 2008 to 2010, the TIME study included an online component of a battery of detailed surveys as well as the option to be contacted about participating

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in a qualitative interview component. The qualitative interview component included four longitudinal interviews over the course of two years (one interview per semester). Inclusion criteria for both student sections of the study included: college student of any year, ages 18–25, taking a prescribed psychiatric medication. Because of the exploratory nature of the work, all psychiatric diagnoses were included. All undergraduate students were emailed a link to the study, and students who both met inclusion criteria and self-selected participated. Eighty-six students completed the entire online battery of measures (taking approximately 30 minutes), and 17 of those 86 total students opted in for the in-depth qualitative longitudinal interviews (lasting 60–90 minutes each) adapted from the Subjective Experience of Medication Interview (Jenkins 1997). Students were offered $20 gift cards at the end of each interview. The study also investigated attitudes and experiences of campus faculty, staff, administrators, and clinicians to provide additional ethnographic data about student medication use on campus. All research was approved by an IRB. Data discussed below are drawn from preliminary analysis of the qualitative interview portion of the study. Interviews were transcribed, deidentified, and input into Atlas.ti (ver. 6) for coding (Muhr 1993). Relevant to the extant college mental health services data, interviews were read and thematically coded for data regarding students’ direct experiences with educational policies and mental health services, and their perceived barriers to help seeking. These pieces of interview text were coded by theme and grouped into higher-level categories, the main four of which are discussed below. One of the categories dovetails well with the college mental health services literature, albeit from the other vantage point, that is “overwhelmed mental health services.” The next three categories were only touched on in that literature. They are, “stigma management,” “convenience and options in services,” and “general environment.” The aggregate data from each of the categories were consistent with the ecocultural theory prediction of the importance of sustainability of daily routines. That is, factors that created inconvenience or confusion were perceived as barriers to care while choice and convenience were perceived as helpful. The longitudinal data support the prediction that the students who successfully created pathways to care and procurement of medication had greater success in terms of college completion or continuation than those who struggled to manage their medication and help-seeking routines.

Overwhelmed Mental Health Services Well established in the mental health services literature is the fact that counseling centers across the United States are overwhelmed by both quantity and quality of student concerns (Locke et al. 2009; Rando and Barr 2008; Stone et al. 2000). These studies cite reports by counseling centers about their load. Our data reflect this overwhelmed situation from the student point of view. Several students mentioned long wait times when calling psychological services, or not being able to get in at the time or frequency desired. As one student who had waited on hold for up to 30 minutes put it: You know just in general, you know just getting set there on hold for a half an hour is a little frustrating, and it’s not the first time that’s happened to me, and a lot of times if


I’ve called Counseling Services I just get a mailbox. And it’s a frustrating mailbox, ‘cause you’ll hear someone say their name and you’re like, “Oh, hi,” and then they’re like, “Oh, this is my mailbox,” and it’s like a trick call, and it’s not cool if you’re depressed. You know people are supposed to be helping you and they’re kind of playing with you. [Participant 9, Interview 1, 2008]

This student, frustrated by long wait times, was equally frustrated by not getting through to a human being during business hours, particularly when seeking help for a problem like depression. Similarly, several students described what it was like to attend a counseling session with someone they felt did not understand the complexity of their needs, a mirroring of providers who say they feel incompetent to meet the increasing severity of student problems (Kadison 2006). For example, one student who had a complex history of substance abuse and a variety of neuropsychiatric diagnoses described her experience with counseling services: I felt like I was talking to someone that was not experienced at all and I was really uncomfortable with that, because I’m, as someone that’s really been involved in like the psychological community, I was just like, “Oh, I do not want to talk to you. You’re just gonna go home and look at your psych textbook and try to figure me out, like what? No way.” . . . It wasn’t unprofessional. I can’t find the word for it. Like I love the way they have things set up. I love how comfortable I felt being there. I did not love how I felt like the shrinks they had working there were like fresh out of school. Like I was like, like going to them, I felt like I was intimidating this lady because I was like “Sorry, I’m really messed up. I have a lot on my plate. Like I’m not your typical like homework stresses me out kind of girl. Like I’m coming to you like these are my problems. This is what’s wrong. What do you want to do about it?” And like she gave me her response and I was like, “No, that doesn’t work for me.” And I felt really, I felt intimidating going in there, because I was like “I think I have too many problems for [the local college counseling center] to help with,” like “I have too much going on for these people that don’t have a lot of experience to be able to handle my brain,” like I felt like I was gonna have them up at the library all night like “What the heck is wrong with this girl?! She’s over-calm, and then yet she’s really, really crazy at the same time!” Like “Is she manic? Is she borderline? What’s wrong with this girl?” So I really like the general atmosphere of [the local college counseling center], but I don’t dislike the people there. I just think that they need more experience before I personally want to talk to them. [Participant 7, Interview 1, 2008]

This young woman had enough history with psychological services to feel that she needed a very experienced clinician. Feeling she was not “your typical homework stresses me out kind of girl,” she recognized the complexity of her concerns, felt she intimidated her clinician, and believed her concerns were beyond the capacity of counseling services even though she felt comfortable in the physical space. In a case like this, hearing the experience of the frustrated student is a helpful pairing to hearing the report of the frustrated clinician. Both parties agree these are critical problems that must be addressed both for individual students but for the new generation of college students growing up with much more access to psychiatric medication.

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In contrast to the above examples, several students were quite pleased with the help they received. One student who saw a psychiatry resident and the director of counseling services for depression reported:

[The psychiatrist and psychologist] you know were always regular with me, always scheduled another appointment, always did their best to work with my schedule as a student. I was always able to see both of them. I always was able to make time. As far as the university goes, I haven’t really had an issue . . . As far as [the local on-campus counseling services] go, I haven’t really had a problem. [Participant 5, Interview 1, 2008]

This student was pleased with his care at counseling services, and felt the practitioners were competent and accommodating. His problem was wanting more on-campus services than were provided: “The big issue this year is that technically it’s not supposed to be a long-term service” when this student wanted additional care. In the category of “overwhelmed mental health services,” hearing the students’ perspectives gives another dimension to clinician and director reports. Understanding the experience of a student with depression waiting 30 minutes for help on the phone only to get a recording, or of the student who believes she intimidates her clinician because of her plethora of problems contributes to the urgency of better staffing college mental health services in terms of sheer number of clinicians as well as matching levels of experience.

Stigma Management Although quite a bit is known about the stigma faced by individuals with a mental illness diagnosis and taking medication (Kranke 2009), less is known about how this stigma mediates their everyday routines and choices. Even though college students have been found to have lower stigma regarding psychiatric medication usage than younger adolescents on average in survey research (Kranke et al. n.d.), our data were replete with examples of how stigma could dominate help-seeking behaviors on campus. For example, as mentioned above, some students were terrified to be seen in or around counseling services by classmates and other peers. One fourth-year student, seeking treatment for bipolar disorder, described her meticulous surveying of the area before entering:

There was one time that I was at the [university counseling center] and that was for group therapy. You know and I walked into the lounge and I saw someone there who was in my class, and I actually freaked out. I freaked out so much that I literally ran to the back , so I hope that you know he didn’t see me or anything. Like that’s how desperate I am to make sure that no one knows anything about it. I like, you know like I always pick times when I know no one else is going to be around, like as far as I know, in the area, like in any of the classrooms. I’ll walk in. I look around, make sure no one’s in the hallway. Then I’ll sneak right in. You know I try and sneak out. I just make sure that in any of these situations no one knows anything. [Participant 2, Interview 1, 2008]


So concerned about possibly being seen in counseling services by an acquaintance, this student preferred to miss appointments if there was risk of being seen. She reported trying to schedule appointments at times no one was likely to be around, and she arrived early to scope out the entire floor before entering the reception area. Although as a group, college students may report lower stigma than other age groups, there is likely significant variation and individual concerns may still be staggering. Counseling centers that provide wider access to wellness services may be one way to reduce stigma for students like this one. Centers designed with private entry, waiting, and exit areas also may mitigate stigma concerns. Particularly when so many centers are aging or makeshift, the physical plant of a generation ago is not enough to support the demand of today. In seeing other clinicians at student health services, students taking psychiatric medications report feeling judged—particularly by nurses—for taking “too many meds.” A sophomore student taking five medications reported:

I’ve been to the [university health services] a few times for like say infections, whatever, and I’ll give them a list of my medications, and I get looked at horribly every time and they yell at me for taking so many medications actually, telling me that there’s probably you know medicines that are interacting and that my doctor probably doesn’t know. You know I get judged a lot because of it. So I feel that there’s a disrespect within just medical fields in general . . . they’re assuming that I don’t know what I’m doing, that I’m just like an irresponsible child that’s just kind of you know getting as much candy as I can get, I guess. [Participant 9, Interview 1, 2008]

Feeling that she knew exactly what she was on and why, she felt frustrated that the nurse second-guessed her doctors and her regarding her medications; students who saw doctors both at home and at school were more likely to report this “judgmental,” “humiliating,” or “disrespecting” experience, as several students called it. Students also reported some fear of speaking with their professors about their mental illnesses because of stigma concerns, leading us to believe that better education on student mental health and illness has to be conducted for all college personnel. Other students reported stigma concerns in their residential living situations. Although some students had roommates and friends who knew about their medications, others wanted total privacy, which can be a challenge when sharing a room. A number of students commented on roommate protocol for opening and closing the dorm room door. One student described her gratefulness that the dorm lock system was upgraded to a key card swipe, allowing her to take medication in private without raising suspicion by having to actively bolt the door.

Like the way the locks work on our door is it’s a swipe lock. It’s like a hotel, so the only way you can get in is with a key. So like if we’re going to sleep or like you know need serious privacy like to take a personal phone call or something, like that’s when you shut the door all the way. So with these locks it’s easier for me to like discreetly take my meds . . . [Participant 5, Interview 2, 2009]

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Like this student, others enjoyed having roommates, suitemates, or living in sorority or fraternity houses, but they wanted to maintain personal privacy for taking psychotropic medications. On-campus, student orientation sessions and professor knowledge of mental health services was another way students felt stigma of mental illness was mitigated. For example, first-year students commented that they liked it when their professors or coaches showed them where the counseling center was, described the resources there, or brought the director in to speak with them. Similarly, residential education programs aimed at the general population helped these students feel like they were not alone. Students spoke about how they felt better about their academic futures after sharing their concerns with faculty or staff, and having their needs taken seriously.

Convenience and Options in Services A key challenge among the students from first through fourth year was managing services and prescriptions between home and school. Some students had better insurance coverage at school and therefore had to stop services when they went home for the summer. Others reported better care at home and had difficulty finding trusted professionals at school. Still others described the difficulty of out-of-state prescriptions with Schedule II drugs (which need to be filled in the state in which they were prescribed) as they moved between home and school. Ecocultural theory would predict that those students who were able to navigate successful routines of care and prescriptions would fare better. Indeed, this hypothesis was borne out in the self-report data over time. Students who had a harder time finding trusted providers at either location were more likely to leave the university over time; four out of 17 total participants had a difficult time finding providers and left the university over the two-year duration of the study. Students who had a harder time filling prescriptions were more likely to let those prescriptions lapse; five out of 17 total participants both had difficulty filling prescriptions and therefore let them lapse. For example, one second-year student spoke of the difficulty of transitioning her psychiatric care and prescriptions for ADD between home and college. Her pediatrician initially prescribed her medication. I’m currently like changing doctors ‘cause my pediatrician, so you know he can no longer see me since I’m in college now and I’m 19, and so I’ve been you know kind of going through doctor changes, and so I talk to my parents about that too . . . ‘Cause the next, I got like a normal physician and she refuses to prescribe like psychiatric medications, so then I have to go through another ordeal, find like a psychiatrist to prescribe medication for me . . . I have one back at home, but she’s like a pediatric psychiatrist. So I mean she’s willing to follow me, but she’s been telling me that I should probably go to the [university health services] and talk to them and see if they can prescribe me medication, because you know she says I should have someone who’s you know there that I can easily talk to and go to if I have concerns. So probably I’ll do that soon . . . [Participant 3, Interview 1, 2008]


This student had not yet gone to find a new prescribing psychiatrist because her mother sent prepackaged pill packs for her at weekly intervals and remained active in her medication and services management. However, over the course of this study, the student began to struggle with finding providers and procuring medication on her own, preferring when her parents did it because, “if they’re willing to do it, it kind of takes all the stress off of me.” Although this student had not yet had lapses in medication, she was concerned about it because of her perceived difficulty in finding a prescribing psychiatrist. It was not clear to her who at the university should do the prescribing, nor did she remember her “normal physician” referring her to a psychiatrist. Several other students who had less active parental monitoring did have lapses in prescriptions and therefore in taking their medications regularly. Students also wanted flexibility in choosing which providers were a good fit for them. For example, one sophomore student who ended up leaving the university reported having difficulty finding a good fit at counseling services and not feeling like there were easy options to switch to someone she liked better. I mean I’ve talked to counselors, but one counselor I had kind of made me feel like I’m a small child and that I was kind of playing around, and I’m kind of frustrated ‘cause I want to schedule a weekly counseling appointment, but I can’t. I had to talk to them today and it was really stupid, like I couldn’t ask for a new counselor, even though I didn’t like the one I’d seen. I didn’t like her at all. I just didn’t like the way she did stuff. But I had to go see her or otherwise I’d be counted as a new client and there are just stupid policies like that. It’s just “I didn’t like her as a counselor. I don’t want to see her again. Could I see someone else?” you know, but . . . [Interviewer:] And then a new client would mean? I guess a new client would mean that I’d have to go through the whole process and I wouldn’t get you know a weekly appointment or something. [Participant 9, Interview 1, 2008]

This student would rather stay with someone she did not like at all, rather than risk losing her weekly appointment. Rather than going through what she perceived as a lengthy intake process again, and having a lag time in setting up appointments, she continued with a counseling routine she felt was less effective than it could have been if she had more options. Even when a university has multiple pathways and options for management of mental illness, it does not mean students know about it. During an interview, one fourth-year student diagnosed with bipolar disorder was surprised to learn she could have accessed Disability Services for help managing her condition. I didn’t realize that this could potentially follow under Disability Services. Had I known that, maybe it would’ve helped as far as times like when I was having issues with my classes. I didn’t want to tell them why I was having issues with my classes, but I feel like maybe they would have been more lenient, at least, or more understanding. Like maybe they would’ve have given me extra time on an assignment, or maybe they would’ve let me redo a test because of a particular situation. Thinking back on it now, had I known, yeah, I would’ve done that; but as of now, I don’t use any other services than [university health services] and [university counseling services]. [Participant 2, Interview 1, 2008]

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Not aware that she had other options to manage her academics, this student struggled throughout her undergraduate career with medication and services management, with a particular concern about stigma including unwillingness to disclose to professors when she was having difficulty because of her disorder. Disability services may have provided her a less stigmatized way to access support services regarding her academics. This student is like the majority in our sample who both wanted more options in care and were not always aware of the structural options that were already available to them.

General Environment The final category of general environment suggests to us differences among campuses for future research. In this category fall a number of reports about the particular competitive environment of the target campus. Multiple students used phrases such as “stressful, competitive pre-professional environment” and complained that the campus was not “nurturing” like they imagined a smaller liberal arts campus to be. Such competitive factors have been implicated in the abuse of prescription drugs such as psychostimulants on college campuses (Kadison 2005). One student described her process of debating whether to transfer schools to a less competitive environment, a choice made by several students in the larger ethnographic study. There’s a possibility I will not be coming back to [the university] next semester. That’s a very large possibility. Just I don’t feel like the amount of work that I have to put in, you know, is worth the fact that I’m you know sitting in my room alone reading all the time so I want to go somewhere where I can enjoy myself a little bit more . . . [Participant 9, Interview 2, 2009]

Indeed that student did leave the university to attend a less competitive liberal arts school in the same state the following semester. Our interview data cause us to wonder about the variation among campuses in actual service provision but also about a school’s identity, tone, and perceived stress level and workload. Ongoing analyses of the qualitative data are showing additional issues at stake for students in medication adherence and service utilization (Anderson-Fye 2011). These may include developmental (e.g., transitions to adulthood, identity) and contextual (e.g., matching the daily, weekly, and semester cycles of other college students) concerns as well as a deep desire to appear “normal” in the perceived eyes of other college students (Anderson-Fye and Floersch 2009). These data provide a sample of the type of rich findings that person-centered data offer for a topic such as this one that is both pressing and has been predominantly investigated through quantitative analyses.

Discussion The recent globalization of mental illness diagnoses (Watters 2010) and of psychiatric pharmaceuticals means that college campuses are arguably key sites where culture, policy,


and practice intersect at a transformative developmental moment for students. Between their routines of households of origin and new transitory forms of living arrangements (i.e., dormitories, fraternities, and apartments), students who have mental health care needs that include medication must reconstruct daily self-care routines (i.e., medication management) in the context of campus environments. Campuses have responsibilities for providing mental health care that meets the needs of students and these policies and practices mean that campuses become contexts where students’ prior psychotropic treatment will necessarily intersect with campus psychotropic treatment. Moreover, in an environment of heightened need for campus psychiatric services in terms of both quantity and quality issues, each campus has to grapple with what it should and can provide in context of the surrounding community and resources. In the United States, the college treatment context includes biopsychiatry, the pharmaceutical industry, and Federal Drug Advisory (FDA) systems that place primary focus on monitoring symptom profiles and physical “side effects.” Monitored symptoms and side effects in psychotropic treatment rarely include those in the psychosocial domain, issues heightened anyway at this late adolescent life stage (cf. Lester, this issue). The unique college setting also includes an in loco parentis context that transitions youth from household of origin to households that the young adults organize themselves. In between, professors are handed student disability accommodation statements and administrators are allocating more and more resources to mental health services. Moreover, student nonprescription use of psychostimulants as “cognitive enhancers” blurs the line between illness treatment routines and academic study routines (e.g., Kadison 2005). The latter is the exemplar of how psychiatric medications are inevitably connected to meaning making and universities by virtue of disability accommodations, and how providing mental health services will contribute to student medication meaning making. The preliminary study findings reported here in terms of students’ experiences of services suggest that students will make meaning: of where services are located; of how services are provided; of how professors react to an accommodation request; of how dormitory rooms provide privacy; and of how students react to officials questioning their use of medication. This meaning will be embedded in everyday routines shaped by the specific college campus. For example, privacy is preserved by a self-locking dormitory door, thus precluding an obvious act of bolting a door to take medication. Walking into a university counseling center is shaped by what other services are gained there and who will observe the entrance. Elsewhere we discuss other sorts of habits such as altering medication practices to match sleep–wake cycles that establish an individual as a member of a particular college subcommunity (Anderson-Fye and Floersch 2009). Investigating the relationships between meanings and practices of psychiatric medication and help seeking can help uncover patterns unique to college campuses, or reveal particular characteristics of specific college campuses. In consultation with clinicians and administrators, psychological anthropologists can work to shape contextual factors such as physical plant, programming, and faculty, staff, and parent education to maximize patterns and habits that lead to well-being and success and minimize those that lead to unintervened distress and dropping out.

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There are additional factors beyond the scope of this particular article. How does a student taking psychiatric medication make sense of a classroom lecture that discusses the proposition that the United States overmedicates youth? Suddenly, the student must reconcile his medication consumption as either targeting “real” psychiatric concerns or as the target of a carefully constructed pharmaceutical marketing campaign. Universities, as in loco parentis, will inevitably contribute to the myriad ways students will make meaning of growing up and living life on psychiatric medication. Campus policies toward psychiatric medication use will influence how students make meaning of illness and treatment, perhaps for the rest of students’ lives (cf. Arnett 2000; Birth 2006), and therefore implementation matters.

Conclusion Person-centered and subjective data are a necessary next step in the examination of the college mental health crisis. The implications from in-depth qualitative and ethnographic data cover a myriad of topics from psychosocial risks to understanding experiential and meaningcentered issues with pressing policy implications. Psychological anthropology, with its wellhoned theories and methods linking the individual with her sociocultural and institutional contexts is well suited to take up this challenge. In particular, cultural developmental and ecocultural theories may be particularly instructive in understanding individual experience and concerns that can aid in constructing better policy and practice with students, their families, and their campus contexts. On campus, these types of data can be shared with college and university administrators, campus counseling centers, and families to help scaffold sustainable routines for students and understand affordances and barriers to help seeking. These data also supplement larger-scale survey research innovated at places like Penn State’s Center for Collegiate Mental Health (n.d.). Such mixed-methods research can show large trends (e.g., college students endorse lower stigma than other groups regarding taking psychotropic medication) and important variation (e.g., when stigma is important to a particular student, it can be an insurmountable barrier to help seeking in public spaces). They can also point to the level of variation that matters. For example, one might expect to see differences in necessary campus service provision in urban versus rural contexts. That is, rural campuses have to provide more comprehensive services because surrounding access is generally lower than in urban areas. In contrast, stigma experience varies on an individual student level and perhaps should be screened (e.g., if a student experiences high stigma, she might need added counseling about managing stigma issues), although it is conceivable that campus-level structural and climate factors might matter to stigma concerns as well. Because the campus mental health crisis is so complex and multifactorial, our approaches to understanding the multilevel dynamics must also be multifaceted. Psychological anthropology is well suited to help integrate various levels and types of knowledge as well as apply a long tradition of understanding human development and well-being in cultural and institutional contexts to some of the most pressing contemporary concerns among


adolescents and young adults both in the United States and increasingly, around the world (WHO 2005). EILEEN P. ANDERSON-FYE is Assistant Professor of Anthropology, Case Western Reserve University. JERRY FLOERSCH is Associate Professor of Social Work, Rutgers, the State University of New Jersey.

Note Acknowledgments. The authors sincerely thank Janet Dixon Keller, Derrick Kranke, Timothy Landry, Lisa Townsend, and anonymous reviewers for constructive comments on earlier versions of this article.

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