Introduction

The use of psychopharmaceuticals has raised a debate on the effects of these substances on persons. We do not mean the medical risks and side-effects, such as the risk of suicide assumed to be related to certain antidepressants. Neither do we mean the debate about the disappointing effects of some psychopharmaceuticals compared to placebo. We focus on the discussion about the claim that using psychopharmaceuticals may change a person’s personal identity. Peter Kramer, the author of the famous book ‘Listening to Prozac’ claims that some people using Prozac feel as though their ‘real self’ finally emerges [1]. These people claim that using Prozac changes their personality in a way that makes them more truly themselves. In opposition to this claim, some authors, most notably Carl Elliott, have argued that the use of psychopharmaceuticals may be a threat to personal identity and authenticity: it may seriously threaten “a way of living that is uniquely our own and not that of someone else” … “that it threatens to separate us from who we really are and how the world really is” [2–3]. Our true, real self is at stake.

Such allegations are raised specifically with respect to psychopharmaceuticals, i.e. drugs for mental conditions, and much less or not at all for drugs for physical diseases such as heart diseases, cancer or diabetes. Therefore, it is not surprising that the debate between critics and proponents of the development and use of psychopharmaceutical enhancers also involves the specific nature of mental conditions. For example, Kramer argues that depression should be seen as a disease in the same way as tuberculosis, asthma or heart diseases, while Elliott wants to show the unique nature of mental conditions. What makes these conditions unique is that consciousness and subjectivity are inherent in them—that they cannot be understood solely in physiological terms.

Elliott also points out the danger of medicalization which entails that more and more normal character traits and behaviours, such as shyness or gloominess, are being medicalized. He considers this a bad thing not just because therapies may be risky and have side-effects and may turn out to be more harmful than beneficial, but also because of the expansion of diagnostic categories: “Should I really feel better about having my native gloominess classified as a psychiatric disorder for which I will be encouraged (or even compelled) to seek treatment?” [4: 170].

Although Elliott explicitly states that he does not adhere to the view of an essentialist self (i.e. a self with fixed and essential characteristics), he unfortunately remains rather vague about what it means to be authentic or really yourself. Elliott contrasts authenticity with alienation while alienation seems to involve two phenomena: 1) the phenomena of political quietism, societal pressure, medicalization and disease mongeringFootnote 1, and 2) the loss of touch with the real world and real experiences. Elliott uses the example of Sisyphus to illustrate that psychiatry has difficulty in dealing with the concept of alienation and to question whether psychological well-being is the sole measure of a successful life. “Is a medicated Sisyphus obviously better off than an unmedicated Sisyphus?” [2: 171].

The proponents argue differently. They claim that psychopharmaceutical enhancers may in fact help us to become who we really are, to help us to a way of living that is uniquely ours. Personal identity, according to this view, is not a stable, static ‘thing’ and, although it is not malleable in every conceivable way either, we are capable of changing our ways while staying ourselves. According to DeGrazia for example, Elliott’s’ view on self and personal identity is mistaken. The self is not “given”, it is not “a pre-existing reality” [6: 37]. He argues that whether personal characteristics are definitive of someone depends on “whether she identifies with them—whether she owns them (pun intended!) autonomously” [6: 37].

In light of this debate, we were interested to know how persons who actually have experience with the use of psychopharmaceutical medication would view their ‘self’ or their authentic personal identity in relation to the use of medication. Because we believed that these experiences would add to the theoretical discussion, we have interviewed a number of adults diagnosed with ADHD and discussed their experiences with medication use in relation to their conceptions of self and identity.Footnote 2 In the first part of this paper we illustrate that the concepts of identity and authenticity play an important and sometimes problematic role in the experiences of ADHD adults. This shows that the question about identity and psychopharmacology is not merely an ‘academic’ issue, but one that influences everyday lives of real people [7–10].

Empirical research alone, however, cannot answer the question whether psychopharmaceuticals threaten personal identity and authenticity. We also need to analyse the concepts of personal identity, authenticity and self: what do we mean when we use statements such as: ‘a way of living that is uniquely our own’, ‘our true self’, or ‘who we really are’? In the second part of this paper we discuss two important philosophical views on personal identity, authenticity and self: the self-control view as elaborated by Frankfurt, and the self-expression view as proposed by Schechtman. We compare these with the experiences of our respondents to see which view can help us to understand the diverse and often conflicting experiences that people have with medication for ADHD. This will contribute to a better understanding of whether, and in which cases, personal identity and authenticity are threatened by psychopharmacology.

Identity, Self and ADHD Adults

Methodology

We have interviewed 19 people (10 men and 9 women, ages ranging from 21–59 years) living in different regions in the Netherlands, and from different socio-economic backgrounds. They had been diagnosed with ADHD between 3 years and 10 years previously and all had been diagnosed when they were adults (i.e. not in their childhood). The respondents were recruited by posting a request on the website for the patient group of ADHD adults, as well as in their newsletter. After the first series of about 11 interviews, we also intentionally included a number of people who deliberately decided not to take medication for their ADHD condition.

We used a semi-structured design, with a list of open questions, touching first on the diagnosis and their ideas concerning the disorder itself and then turning to their experiences with medication, and their reasons to use medication or to refrain from using it. Interviews lasted for 1 to 1½ hour and were audiotaped and later transcribed.

We analysed the interviews in a qualitative way, by assigning codes (keywords) to interview fragments and ordering them accordingly. We took a hermeneutical perspective, meaning that we aim to grasp the subjective reality of living with ADHD and with (or without) medication.

Results

For most respondents it appeared difficult to separate their personality or character from their disorder.Footnote 3 ADHD was perceived either to have an impact on their personality, or to have contributed to the development of their personality, or it was said to be intertwined with their personality. For many it was a confusing and puzzling issue. “I believe that besides having ADHD I’m also an active and lively person. But well, it’s not easy to separate these things now.” Another respondent put it this way: “… it is intertwined in such a way that you can’t tell where the personality disorder ends and the lack of or the disposal of dopamine, or however you want to put it, starts.” And yet another person said: “You don’t have ADHD, you are ADHD”.

Apart from the difficulty in distinguishing their ‘real self’ from their disorder, many respondents experienced that the use of medication changed their personality or their self to some degree.Footnote 4 They felt less themselves on medication, less authentic. Some character traits that they liked have changed because of the medication. They felt less creative, spontaneous, happy, funny or sociable; almost all qualified this as a loss. Some stated explicitly that this was the reverse side of the choice to be on medication: medication brings advantages and if you want these, you just have to bear the disadvantages that come with it. As one respondent said: “Now I can keep my job for more than half a year, and I can complete my schooling. People seem to be more pleased with me.”

For others, however, feeling less themselves was the main reason for their choice to abstain from medication. One respondent told us that on medication there seemed to be no challenges anymore and no fun: “… in former days I used to sing a lot at home and now I was quiet. And well, I guess that at a certain moment I missed myself. And I thought: well let’s see if I can do without [the medication]”.

Another respondent told us that on medication he appeared to be indifferent and more cynical and he did not like that. He decided to use medication only when necessary for certain job activities but to abstain from medication in his private life. Although there were disadvantages, he said: “I prefer to be myself in my private life. Just being myself is like I was as a teenager without medication.” He called this “my first self”. Medication is just an aid to do his job: “I accept that the working man in me needs this kind of backing”. This respondent described himself as “a switchable personality”. According to him, being on medication also influenced what kind of people he chooses as his friends. “I think that, depending on whether you are timid and shy or energetic and very lively, you will assemble other kinds of friends.”

Two other respondents also mentioned the influence on friends. One of them told us that a member of his ADHD adult group had changed in such a way, due to the medication, that his friends did not want to be friends anymore. “A member of my ADHD group found out he had ADHD at the age of 38. And then he began to use Ritalin, and he changed in such a way that his friends said: ‘… you’re still a nice guy but you’re not the person we want to associate with’. That’s how much he had changed.” This story clearly frightened our respondent and he was of the opinion that this person should not have changed himself. “I think you keep fighting against yourself your whole life, if you don’t accept the way you are.” According to him, one should look for a job that is suitable for you, and choose friends that accept you the way you are. “And I think that this is possible. I think that to do that is better than to stuff oneself with medication in order to have a job at the office because that’s what you’re supposed to do.”

Societal pressure to conform to an ideal was also mentioned by other respondents. One said that she valued diversity and was afraid of pressure to conform to a uniform ideal of personality; she compared this to the pressures exerted with respect to cosmetic surgery nowadays.

Some respondents described positive effects of medication on their personality or stated they felt more themselves on medication. One respondent said that the medication allowed her to explore more sides of herself and to see a different I. “It’s not that you’re not yourself anymore. I believe I have always been myself, but because the medication makes you more tranquil you start to look differently at yourself. You take more time for yourself. And you discover things that you did not expect of yourself.” In fact, she discovered that she was a good painter and enjoyed painting a lot. Another respondent also said that he felt more ‘himself’ on medication. He was more able to control his impulses and his life moved more smoothly. He also felt calmer on medication and this gave him more ‘time for himself’: “I haven’t read a book in years because I couldn’t concentrate. But now I’m reading again. I used to read a lot when I was younger”. However, when he went to a party he chose to abstain from medication in order to be more sociable; off medication he felt more involved in the things around him.

Finally, some respondents stated that medication did not influence their self or personality at all. One of them, however, did not use ADHD medication but an antidepressant. Another respondent said she could not imagine any medication that would change the way she was leading her life. “Am I a different person when I have fever? No. I behave differently, but I’m not a different person.” She describes medication as a mechanical process: “… in case of a creaky door I put oil on the hinges”. However, if medication were to change certain traits like spontaneity or creativity, she would decide to abstain from medication.

Another respondent also declared medication did not change his identity: “No, I remain who I am because there are still times that I have no control over myself. At other moments I do have control—that is because I want it myself. I do think I am changing. But that is me. Also because I want it.”

A respondent, who claimed that medication did not change her self, told us that she never went to a party without taking her medication: “Am I myself in that case or not? I don’t know. But I do know that if I went to the party off medication I would become very vivacious and I notice that people think that I have crossed the line. And that makes me insecure and not happy.”

To summarize, most respondents experience that medication influences their emotion and behaviour in the sense that they lose part of their creativity, spontaneity, and sociability. This fact forces them to make a trade-off: how important is it to be funny, lively and impulsive, how important is it to be able to study, keep one’s job, etc. For some of them the disadvantages of medication outweigh the advantages: on medication they feel less themselves and therefore they choose to be off medication. For others, however, medication gives them the opportunity to complete their training and schooling, or to keep their jobs, or to have fulfilling relationships. Put differently, it enables them to do things they value deeply but were unable to do because of their lack of concentration and inability to control their impulses.

Two respondents described the influence of medication in positive terms because it gave them opportunity to change and to discover new aspects of themselves.

While some respondents seem to succeed in accepting their situation (either by accepting that they need medication to achieve the things they value, or by accepting the way they are off medication), others experience ambivalence: on the one hand they want to be able to achieve some things and on the other they like the way they are and do not want to change their self in order to be more agreeable for others or for a more successful life. Some experiment with medication in order to find a balance, for example by being off medication in their private life and on medication during work.

Philosophical Views on Self, Personal Identity and Authenticity

Among the ADHD adults that we interviewed, do the changes caused by psychopharmaceutical medication make them somehow less authentic, less true to their real selves? This depends not only on the empirical data, but also on the conceptions of self, personal identity and authenticity that one adopts. Here, we discuss two different views and assess how the experiences of the respondents can be related to these views. Following Schechtman, we distinguish between a ‘self-control’ view and a ‘self-expression’ view of the self [11].

Self-Control View

Schechtman uses the work of Frankfurt to represent the self-control view. Other authors who take a similar position are Gerald Dworkin [12] and, more recently, [13]. Of central importance to Frankfurt’s account of the self is the notion of freedom of will [14–15]. What is distinctive of human beings is that they do not only have desires and motives that move them to do things, but that they want to have certain desires and motives. In case of conflicting desires they are not simply led by the strongest desire, but they have the capacity to ‘take sides’. To illustrate his view Frankfurt uses the example of the unwilling addict who repudiates his desire for drugs and is struggling hard to resist his desire but in the end slides back in his craving for drugs. The action in this case does not belong to the addict; it is not the agent’s real desire leading to the action but the addiction. The addict has conflicting first-order desires: the desire to give in to his addiction and a desire to resist his craving for drugs. He may also have a second-order desire: he desires that his desire to give in does not lead him to action. In that case he identifies with his desire to resist his craving for drugs. If nevertheless he loses ground and is moved by his desire for drugs, the addict’s action is not an action of free willFootnote 5. The act is, in other words, not really his own.

One of the problems with this view of identification is that it leads to an infinite regress problem: second-order desires can also be in conflict with each other, in which case an appeal to third-order desires is needed to resolve it, these third-order desires can also be in conflict and so on, resulting in the infinite regress problem.

Frankfurt attempts to solve this problem by introducing the concept of ‘wholeheartedness’ [14]. A self-constituting identification must be ‘wholehearted’; this means that we must make a decision without reservation, that we want a certain desire to be our will. In later texts Frankfurt defines wholeheartedness as a certain kind of stability or equilibrium with respect to our higher-order attitudes. According to Schechtman both interpretations of wholeheartedness come down to the same idea: “What is required to identify with–or repudiate–a desire, is to achieve a certain sort of stability or equilibrium with respect to one’s attitude towards it” [11: 412]. Schechtman characterizes Frankfurt’s view as ‘the self-control view’ because it implies that control over one’s desires is central. We can not be our true selves if our self-control is compromised. If we do not succeed in resisting a powerful desire, a desire that is wholeheartedly repudiated, and we act on it, we have failed to be ourselves [11: 413].

In the account of DeGrazia, someone is authentic, or truly himself, if and when his choices are autonomous. DeGrazia follows Dworkin’s account of autonomy, which is similar to Frankfurt’s account of free will. Also here, the notion of identification is important and this identification should be formed in the absence of illegitimate, alienating influences. “A autonomously performs intentional action X if and only if (1) A does X because she prefers to do X, (2) A has this preference because she (at least dispositionally) identifies with and prefers to have it, and (3) this identification has not resulted primarily from influences that A would, on careful reflection, consider alienating” [13: 102]

ADHD, Medication, and Self-Control

If we look at the experiences of our respondents we can recognize this self-control view in some of their accounts. Some clearly identified with their desire to use medication in order to complete schooling, to finalize a PhD thesis, to be able to do a job successfully, or to be pleasant company and to have good relationships. One could, following Dworkin and DeGrazia, characterize their decision as autonomous.

The idea of self-control can also be noticed in the experience of one of the respondents who claims (somewhat cryptically) that his personality has not been changed by medication because he still has moments of loss of control, and when he is in control it is because he wants it. Medication might even result in more control if it results in more insight in aspects of oneself: see, for example, one of the respondents who said she became aware of new aspects of herself and who found a new desire she could identify with, i.e. to paint. Moreover, the self-control view can also be discerned in the experiences of respondents who decided to abstain from medication because off medication they felt more authentic. They identified with the desire to be spontaneous, creative, funny, and so on, and acted accordingly by not taking medication that would diminish these traits.

However, it seems as if some other experiences cannot be fully captured by Frankfurt’s self-control view. First, his view fails to make explicit that, although one might make an autonomous choice to use medication in order to complete for example, one’s schooling, you have to pay a (significant) price for this: the loss of characteristics that you feel are important for your identity, like spontaneity, having up and down sides, being energetic and creative or funny. For our respondents this often meant that the choice for a certain degree of well-being and functioning implied a significant loss of self. They literally felt less themselves. Second, some respondents chose to use medication but seemed to do so to conform themselves to the expectations of others. “I often think that it [the medication] is more for the benefit of the outside world that I’m more adjusted, than for my own benefit. I wonder. On the other hand, however, I do notice that I’m functioning better.” Some stressed the need to accept yourself as you are: “I think you keep fighting against yourself your whole life, if you don’t accept the way you are”. Third, respondents seem to experiment with medication, to find out what works for them (e.g. medication in order to function properly during work) but also to find out who they are off medication. The same experience can be seen in adults suffering from depression. Karp describes in his book ‘Is it me or my meds?’ that the interviewees wanted to know how they would be off medication: “For many the urge to know one’s true self prompted ongoing experimentation with medications” [16]: 117.

Self-Expression View

In order to understand these kinds of experiences we need a different view of the self, and we think Schechtman’s self-expression view might be of help here. According to Schechtman the self-control view provides a legitimate view on what it means for a person to be herself, but it fails to fully capture what it means to be oneself, since being oneself also involves expressing one’s nature and, interestingly, self-control can sometimes prevent this. Schechtman uses Friedman’s example of the 50’s wife to explain this. The 50’s wife is a housewife living in the 1950s in a traditional American town. She is raised in a family and environment holding traditional views on the duties of women as wives and mothers. Although she conforms to those views, she is often troubled by desires to have a job, take schooling, spend time with her friends, and to become politically active. She repudiates these desires, sees them as unfeminine and selfish and is struggling to resist them. The 50’s wife might even decide to use Valium in order not to give in. She may avoid friends who might support her in exploring her own interests. Moreover, the 50’s wife wholeheartedly conforms to the traditional views: she is not in conflict about her non-traditional desires, she never wonders whether the duties of a good woman and mother are worthy or not. She is steadfast in her decision to conform.

Schechtman argues that the self-control view is not able to put to rest the intuition that the 50’s woman is not leading a life of her own.Footnote 6 Her situation is in a way similar to that of the unwilling addict: if she gives in to her desire for a different life, she is acting against what she most wants to do. For Schechtman, however, she is herself in one sense (the self-control sense), but she is not herself in another: her desire to conform to tradition prevents her from expressing herself. “At the same time, it also seems right that being oneself involves expressing one’s nature. There is a clear sense in which the 50’s wife, when she is in command of her will, is using it to keep her from being herself” [11: 420].

Moreover, Schechtman argues that the self-control view implies an active role: “The self-control view insists that we must be active with respect to any inclination which can be considered our own” [11: 425]. Interestingly, however, we also believe that a person can be herself in cases where self-control is absent: “people are often most truly themselves when inhibition fails” [11: 413].

Schechtman thus introduces an alternative view on the self, the self-expression view: “we are most ourselves when our acts express our nature” [11: 409]. At first sight, this view entails that any spontaneous desire can be characterized as one’s own, but that is not the case. The self consists of ‘a set of natural inclinations and traits’. Inclinations and traits can be considered natural if they satisfy a few basic conditions:

  • “inclinations must be relatively stable, coherent and powerful”;

  • “inclinations must not originate in obvious physical or psychological diseases”;

  • “self-defining inclinations are desires for a way of being or a type of life” [11: 415].

Her view of a self boils down to “a self” that exists in “a person’s robust inclinations” that subsequently are part of “a person’s nature”. We are not being ourselves or our desires are not truly our own, “…when we fail to express some part of our nature”.

Schechtman states that the two views on self are both legitimate, but capture different senses of what it means to be ourselves: “The self-control view expresses the fact that we are alienated from our actions when we cannot control or direct them; the self-expression view that we are alienated when our lives do not express our natures” [11: 424]. These two views are linked in a certain way because in both cases being oneself is an essential part of living a meaningful or fulfilling life. The views show two different ways in which the capacity to lead a meaningful and fulfilling life can be threatened, two ways in which alienation can occur. Schechtman argues for an integrated view which implies finding the appropriate balance between them. “To be ourselves we must govern our lives in a way that avoids this alienation - carefully balancing the demands of self-expression and self-control” [11: 427].

While the self-control view demands activity and unity, the self-expression view implies a certain amount of passivity, and a certain toleration of ambivalence. As we more often than not lack perfect insight in our inclinations and do not know in advance which actions are meaningful for us, a certain amount of experimentation is needed: to explore different possibilities, to change our ways to see whether alternative ways might work better. In some cases this might involve a passive attitude or a ‘letting go’ rather than an active and controlling stance.

We believe the self-expression view is helpful in capturing those experiences of ADHD adults that could not be adequately understood from a self-control view. It can account for the unease of some respondents who felt less themselves, and who identified more with their personalities off medication than they did with their medicated selves, even when they acknowledged and appreciated the benefits. Schechtman’s account is also able to acknowledge the concerns of Elliott regarding the alienation which can occur if people conform to cultural patterns or social expectations to such an extent that they ‘lose themselves’. The self-expression view also shows the need for experimentation.

However, Schechtman seems to put aside too easily the questions that are being raised by one of her conditions for inclinations to be natural that is “inclinations must not originate in obvious physical or psychological diseases”. She mentions “brain tumours, physical addictions, obsessive-compulsive disorder, and similar sources of impulsive desires” [11: 415]. Exactly at this point, however, lies one of the controversies of the debate on the use of psychopharmaceuticals. As mentioned in the introduction, some claim that gloominess or shyness are natural traits, while others tend to call these a disease or a disorder. Our respondents also found it difficult to decide whether their inclinations and traits were natural parts of themselves, or expressions of a ‘mental disease’.

Finally, Schechtman’s self-expression view does not seem able to account for a specific kind of alienation: alienation in the sense that by using medication one might lose contact with reality. This is what Elliott aims at when he argues that experience of happiness is not all there is. A good life does not consist of a series of happy feelings or an overall feeling of self-contentment, we want to have real experiences (see Nozick’s experience machine). For example, if a man lost his wife he should feel sad; it is a proper response. Prescribing medication would not only prevent this man from understanding what the death of his wife means [17: 116], but using medication in cases like this might also be in contradiction with how a human being should respond to the loss of a significant other human being. Authenticity and alienation in this context may eventually raise questions concerning the good life and what it means to be human [18].

Conclusions

Questions regarding identity and authenticity are a central issue in the enhancement debate, especially enhancement by psychopharmacological substances. Proponents of enhancement hold that psychopharmacological substances can help users to ‘become who they really are’ and thus strengthen their identity and authenticity. Critics, however, believe that the substances will lead to inauthenticity, normalization, and socially-enforced adaptation of behaviour and personality. Our empirical research shows that the philosophical debate about personal identity, authenticity and psychopharmaceutical enhancers is not just an academic issue: authenticity and personal identity do play an important role in the experiences and narratives of ADHD adults. The use of medication in particular may confront them with questions concerning personal identity. Do I feel myself off or on medication? Does the medication obscure or reveal my true self? Should I use medication for certain reasons even though this may change who I am in a certain way? Our respondents try to work out their experiences in terms of loss of self and authenticity (‘who I really am’).

The debate on the question whether or not psychopharmaceuticals are a threat to personal identity and authenticity can not be resolved by merely referring to empirical research. In order to answer this question we need concepts of personal identity and authenticity. The self-control view and the self-expression view, as distinguished by Schechtman, can be of help to understand the experiences of ADHD adults. Whereas a self-control view is characterized by identification with first-order desires and the absence of alienating influences, the self-expression view holds that we are most ourselves when our actions express our nature.

Some of our respondents’ experiences can be understood in terms of self-control. For example, if an ADHD adult identifies with his/her desire to be more stable, calm and serene, his/her decision to be on medication can be seen as an action of free will. Or, if an ADHD adult identifies with his/her desire to be spontaneous, creative and sociable, his/her choice to be off medication can be characterized as authentic.Footnote 7 Other experiences, however, can not be fully captured by the self-control view. For some respondents the choice to be on medication, although authentic along the lines of the self-control view, implies a significant loss of self. For others, medication helped them to discover new sides of themselves they had not realized they possessed before. Moreover, a choice to be on medication may spring from a failure to express one’s personality and to conform to a lifestyle along the line of societal expectations. Some respondents were anxious about pressures to conform to a certain lifestyle, to become a kind of person that is valued in society but who they feel would not really be ‘them’. Conforming to society’s standards may come at a price if one fails to express one’s nature. Due to its emphasis on self-control, on unifying first and second-order desires, ambivalence is valued negatively in the self-control view. The self-expression view, however, pleads for a toleration of ambivalence and emphasizes the need for experimentation. We do not have perfect insight into our desires and in order to discover what kind of life is the most meaningful for us, ambivalence and experimentation may be appropriate.

Psychopharmaceutical medication, therefore, does not necessarily endanger authenticity, neither according to the self-control view nor according to the self-expression view. Authenticity, however, may be jeopardized if the focus is solely on medication, if alternative ways of dealing with one’s nature are neglected, and when social pressures are the main reason to conform. One respondent formulates it thus: “Society should make room for people who do not fit in easily”.

As Schechtman argues, the self-control and the self-expression view capture what it means to be oneself and both argue that failing to be oneself is at the expense of something important. Alienation can occur if one is not able to control one’s actions and one’s course in life, but also if our lives do not express our nature. Both views should be balanced to fully understand what it means to be really oneself.