Mental illness and economic inequality: A compassionate case for an egalitarian society.

There are many contributing factors leading to a deterioration of one’s mental health; environmental, genetic components, ethnicity and of course abuse in all its varying forms. Each of these elements can have a profound effect on someone’s psychological wellbeing. However, there is one particular aspect that is linked to practically all mental health conditions and that is poverty. More specifically we are talking about economic inequality or what can otherwise be termed as relative poverty.

In a paper published by the Lancet Psychiatry, Dr Wagner Ribiero investigated the correlation between income inequality, mental health problems, the use of services and resilience. This inquiry was conducted via a systematic review and meta analysis. What Ribeiro found was that widening economic inequality is associated with higher rates of mental health incidents, particularly with regards to depression and anxiety. However, additional studies suggest that schizophrenia, narcissism and psychotic symptoms are also more common in unequal societies.

Furthermore, this proposed link appears to be much more prevalent in English speaking countries, particularly in the US and the UK. Which incidentally are two of the most unequal countries in the developed world. As an example, Sweden is also considered a rich country, but with markedly less economic inequality than the UK. Similarly to the UK it boasts a comprehensive health system, but in contrast Sweden has substantially lower levels of social and mental health problems. Findings by Wilkinson and Pickett which were published in their book ‘The Spirit Level’ similarly highlighted a disparity between the ‘anglosphere’ and mainland Europe with regards to mental health issues and economic inequality.

mental health and inequality

With all this in mind, if we truly care about society as a whole and how our species can flourish, it makes sense to investigate this pathway in a little more detail. As previously mentioned, a key driver that is persistent throughout the research is one of economic inequality as opposed to absolute poverty. In a nutshell, impaired health and in this case mental health is less about being poor and more about but feeling poor. It is proposed that relative poverty is related to feelings of social failure and inferiority, in addition to social isolation, alienation and loneliness.

Perceptions such as these are exacerbated when we live in societies that encourage us to incessantly compare ourselves to much richer individuals. A practice which by no means is healthy, possessing all the qualities of a sadistic form of motivation and self-punishment. Without doubt we have all been on the receiving end of this regularly in the form of advertisements, TV, magazines and social media.

One theory used to explain the correlation between mental illness and relative poverty centres around the brain’s dominance behavioural system. This processes information around subordination and social dominance, a system which is likely connected to a broad range of mental illnesses and personality disorders. It is purported that externalising disorders, mania proneness and narcissistic traits are related to heightened dominance motivation. On the flip side, anxiety and depression are linked to subordination and submissiveness. However, as we will see this isn’t the only suggestion on offer.

Dr Robert Sapolsky neuroendocrinologist and Professor at Stanford University proposes a further explanation. Dr Sapolsky suggests that relative poverty generates stress, which in turn produces an overactivity of hormones and neural responses, including the secretion of cortisol. Surviving at the lower end of the socio-economic scale is associated with raised levels of stress. It is also well documented that elevated cortisol levels is a risk factor for depression, with relatively poor kids displaying higher levels than richer kids. While it is surmised that this constant battle to return the body to a normal non-stressed state predisposes people to premature ageing.

High levels of glucocorticoids (of which cortisol is one) affects a part of the brain called the hippocampus, which is critical for memory and learning. Regular exposure to excessive glucocorticoids via stress impairs memory and learning by reducing the excitability in this area. In a part of the brain called the amygdala, which is central to fear and anxiety, glucocorticoids increase the excitability and expands neuronal connections contributing to a heightened response.

Together this can offer one explanation as to why a condition such as Post Traumatic Stress Disorder shrinks the size of the hippocampus, while expanding the amygdala. Glucocorticoids can also impact the mesolimbic dopamine system, responsible for reward, anticipation and motivation. This disruption predisposes individuals to the anhedonia component of depression and a vulnerability to addiction. Anhedonia is described as a reduced ability to experience pleasure.

Brain, skull and meninges

The pre-frontal cortex (PFC) is a region of the brain pivotal for long term planning, executive function and impulse control. An excess of glucocorticoids in the PFC results in poor decision making, primarily focusing on short-term gains. As mentioned, stress leads to raised levels of glucocorticoids, making it more difficult to choose long-term health over instant gratification. This is one explanation as to why people with substantial stress increase in weight, smoke and drink more than people with less stressors. Unsurprisingly, this is also a reason why a lower socio-economic standing can effect long-term decision making. When day to day living is proving difficult and life seemingly so precarious, the future can appear to be a place of much less importance.

Lower socio-economic status creates chronic financial concerns, that exhausts and distracts the individual. Although people may on the whole have more money than individuals from developing countries, being poor in relation to the rest of society contributes to being despised, shamed and humiliated. Economic inequality automatically emphasises the importance placed on social status. In unequal societies, the dramatic disparities in income can make the rich appear as superior beings. There is also a tendency among capitalist countries to equate an individual’s wealth with their internal worth, thus compounding any negative self-perceptions for the people who find themselves battling to make ends meet.

GK2

Status anxiety increases in relation to the inequality of a nation. We live in a world where many people worry about how others view us and how we are judged. Whether we are seen as capable and successful or as a failure, all adds to our stress levels and has a profound influence on our mental health. More unequal societies are also likely to feel less trust towards one another, falling from 60-65% in the most egalitarian of nations to about 20% in the most unequal. All this can contribute to a reduction in participation within society, for instance being less likely to volunteer and partake in local activities. This is often displayed through an increase of violence, combined with a lack of willingness to help one another out.

All of the above contributes to more stressful social lives and social anxiety, as we worry about how we appear and perform in the world. Responses to this threat can be exhibited as defensive narcissism or alternatively through low self esteem and a lack of confidence. There is a strong implication that mental health and neoliberalism are interconnected, even exploited. Raised social anxiety and narcissism feeds consumerism, using purchases and possessions as a method to give off a good impression, while attempting to create a sense of self worth. In sum money becomes essential as a means for many of us to communicate our self-worth.

People in unequal societies not only work longer hours, but save less and borrow more. In these nations debt rises in a desperate attempt to maintain appearances. Our collective emotional vulnerabilities are seized upon by corporations and advertisers callously using our fears for profit, confirming that status anxiety sells. Meanwhile, economic inequality negatively impacts our mental health, friendships, societal bonds and community life, all of which is integral for our general wellbeing. If somebody does not possess a sufficient income, full participation in society becomes virtually impossible. Particularly in a world that prioritises GDP, while celebrating personal wealth and corporate gains over the wellbeing of our fellow human beings.

There are a variety of compelling arguments suggesting why we should reject neoliberalism, of which mental health is just one element when considering if our current system is really the best we can do. We have well and truly reached a fork in the political and moral road. Simply put, we could persist with our current dominant political ideology, whereby, a tiny group of people will continue to accrue the bulk of money and power, forever loading the dice in their favour. Or we can challenge the status quo, constructing a society that works for most people. Furthermore, neoliberalism does not work in harmony with our beleaguered planet or the vast majority of people who inhabit it.

Effective change must involve questioning all that is used to support the present doctrine; politics, media, education, the law and in particular how we do business. No area of society should be off limits when trying to imagine and construct a better world for us all and future generations. I wrote this article predominantly to highlight the extent to which economic inequality can contribute to mental distress and to ensure this too is added to the list of reasons why we should fight for a serious paradigm shift towards a more compassionate and fairer world.

Equity versus equality; why it really isn’t so simple.

Equity and equality are often terms that are confused or melded together, but are they the same? Lets start with equality, the goal is to make sure everyone has the same things to be successful. It’s premise is to seek fairness, but in many cases this intervention can be implemented on the false assumption that people start off on a equal footing. In contrast equity attempts to understand what is needed so people can prosper. Good, is that’s it, problem solved? Unfortunately not, to expand, equity demands justice and fairness in all situations good or bad. Therefore, the onus is on treating people differently but fairly as individual circumstances dictate. In effect this is about providing the resources for the person to achieve their maximum potential.

As equality focuses on treating everyone equally, an individual is afforded the same rights and responsibilities, regardless of any personal differences. The whole tenet of equality is to prevent discrimination on the basis of; sex, race, caste, nationality, disability age and so on. This is to ensure everybody gets equal treatment in society, which is considered paramount in a democratic society, particularly in the eyes of the law. One huge problem that jumps out, while equality is simple to measure, meaning simply the same, equity is much trickier as it relates to fairness. This steers us into the choppy waters of subjectivity, as clearly not everybody agrees on what’s fair.

A debate around this often rages between left/right and the many points in between. Now we’ve defined both equity and equality and some potential issues, the problems do not stop there. Many political tribes from centrists to libertarians, talk about providing equality of opportunity, as opposed to equality of outcome. The argument often runs on the lines of; the state must treat individuals unequally in order to enforce equality of outcome and this is considered unfair in many circles.

People on the left often campaign for equal outcomes, for example the use of all-women shortlists by the Labour Party (UK) in an attempt to attain 50/50 men and women MP’s. This hasn’t exactly been a success, between 1997 and 2016 out of the 170 candidates selected from all-women shortlist, just 49% have manage to reach the house of commons. During this time the number of female Labour MP’s have fallen from 101 to 99. With all this in mind, I’m going to argue for a huge dose of nuance. I will propose that the optimal route depends entirely on what society is trying achieve. Some issues should favour equity, while others would more likely benefit from equality.

As soon as you begin to do an internet search on equity and equality millions of results based predominantly around gender and race are vomited onto the screen. For this piece I’m going to attempt to stay away from this region the best I can, primarily because I’ve written enough in that area recently. In this piece I want to chiefly explore socio-economic inequality and how it could be best addressed. I will use ‘Maslow’s Hierarchy of Needs’ to slightly and crudely suggest that the lower we sit on pyramid regarding needs, the more we require our focus to be on equity. However, as we work our way up through the levels, utilising equality may prove to be more beneficial. For those of you who are not familiar with Maslow’s hierarchy, check out the diagram below.

8 stage maslows

For this exploration, I have decided to use the more updated 8 stage format. Initially this was a 5 stage theory, the new hierarchy was adopted in 1970. Maslow’s original intentions was for this to be a form of motivational theory, but I’m primarily going to utilise this as a depiction of how these needs are organised and where other factors such as personal responsibility may fit in.

Firstly, you will have most likely recognised that the pyramid is split between 4 ‘deficiency needs’ (D-needs) and 4 ‘growth needs’ (G-needs). D-needs arise primarily through deprivation, according to Maslow this motivates the person to fulfil these needs if they are unmet. For example the longer someone goes without food, the hungrier they will become. Note that to progress up the pyramid, one must in general meet the requirements of one level before moving to the next.

Towards the upper reaches of the pyramid are G-needs, in comparison these are not a deficit of anything as such, but more a desire to grow as a human being. As explained with the D-needs, an individual must work their way through the levels, eventually reaching the top level of transcendence. Progression through the ranks is rather like a game of snakes and ladders, moving up during the good times, but slipping back during difficult experiences such as; a loss of job or a divorce. It is also worth pointing out that most behaviour is multi-motivated, meaning an individual is simultaneously motivated by more than one basic need.

If we observe these needs in relation to a capitalist system in which we live in, some people will struggle to gain access to the very basic needs (dwelling in what I call Maslow’s cellar), while others will inhabit the ‘penthouse of  transcendence’. Following the advent of neoliberalism in the late 70’s (UK) and the early 80’s (NZ, US, Aus and Can) many entities that were once considered universal are now in the hands of private corporations and are often more expensive, such as healthcare in the US. Furthermore, some people will have the resources, connections, luck and perseverance to move up through the levels, while others may have varying struggles that make life more difficult to acquire even the most rudimentary of needs.

It makes moral and economic sense to ensure that everybody has their basic physiological needs met, whether this is via their own volition, through assistance in some way or a combination of the two. These physiological needs would include; food, water, shelter and warmth. Looking at this in terms of the equity/equality conundrum, some people for a myriad of reasons often require more help than others.

161223_homeless_uk

Maslow proposed that the first tier contains the most important set of needs and are essential for the human body to function at an optimal level. I look at it as the foundations of human flourishing. If we have empathy for our fellow human beings, if we want to create conditions so people can thrive, therefore, contribute to society, equity at this level should be a simple decision. Vital requirements such as; food, water and shelter should be provided to those in need, not to everybody. This can be justified by stating that not everyone in society are dealt the same hand and many people do not need this level of support.

Moving one rung up we encounter ‘safety needs‘, described as; protection from the elements, security, the provision of healthcare, stability, freedom from fear and a functioning legal system. Even at this second stage, we start to approach what could be considered grey areas for some people, who would offer that some of these factors are chiefly the responsibility of the individual.

It seems perfectly logical that each human being is seen equally under the eyes of the law, which is of course is equality. Furthermore, all people should have access to adequate legal representation when required, such as legal aid if required. This is an obvious example of equity, by providing what is needed an individual can adequately partake in society. Here we have an example of equity in an effort to promote equality.

Another area is healthcare, in the US in particular the quality of healthcare is based on your insurance plan. In other words your social status, employment situation or your bank balance decides upon the care you receive. Surely, in a humane society suitable health provision is a basic human right and the best healthcare available should be afforded to all human beings.

This for me is non-negotiable, it is difficult for a society to claim civility while employing a multi tier health system. This highlights a glaring problem with capitalism, if “all people are considered equal”, as is claimed in most western societies, then care shouldn’t be based on economic status, overwise we are contradicting the initial statement. The original statement should, therefore, be amended to read, “all social status is proportional to the wealth of the individual”.

If we take the stairs to the next floor we arrive at the level of ‘love and belongingness’ needs. This refers to emotional needs such as family, friends and intimacy. It is proposed that the need for interpersonal relationships motivates our behaviour. This is where we learn about trust, intimacy, love and being part of a group. These needs are particularly strong in childhood, as we require a stable platform to flourish as an adult. Emotional and psychological needs in childhood are often protected by law to enforce a certain level of acceptable care, broadly speaking we could call this equality. However, kids are unique and have differing requirements for them to develop. This could be given as an example of equity.

The 4th floor is the last of the deficiency needs and where ‘esteem’ hangs out. Maslow classified these needs into two categories.

  1. Esteem for oneself, such as dignity, mastery, achievement and independence
  2. The desire for reputation or respect from others, such as status and prestige.

Exploring what equitable processes could be put in place to facilitate these needs, much of it points to education. Creating a system that fosters critical thinking, that recognises individual talents and abilities, that delivers excellent education, will help children to meet the deficiency needs as laid out above. Having a good start in life, with excellent education for all is one of the best ways to achieve equality or simply a fair shot at life. In this case, equity is undoubtedly the tool required to achieve this, such as putting more resources into struggling schools. This is especially poignant when considering that only 7% of the UK attend fee paying schools and yet 39% of those in position of power are privately educated. This is an example of entrenched elitism and something to be challenged.

As we leave deficiency needs (D-needs) and enter the territory of growth needs (G-needs) it becomes increasingly more difficult to find examples of when equity is valid, while providing ample justification for any actions. Many growth needs that people fight for are less of an economic or basic necessity or even a need as such, but could be more easily categorised as a want. These ‘needs’ are often found in the realm of identity politics and are much more politically driven, even though the actual requirements are less pressing. However, because these matters are pushed by often the educated, middle classes and not the powerless in our society, their demands regularly garner more attention. One of the blunt tools to gain equity is “positive discrimination” or to use the more cuddly term “affirmative action”.

female control

This is the domain where educated, relatively comfortable, middle class, centrists who proclaim to be progressives demand a 50:50 ratio in every occupation. Correction, equal representation in only the top professions including MP’s, CEO’s and worthwhile careers, such as within the upper echelons of education. Unsurprisingly, there seems little clamour to protest for equality for work on oil rigs, the front line of the military and many shitty, dangerous jobs men fill on a daily basis. We are led to believe that this discrepancy is simply due to discrimination, rather than average sex differences in career preferences and life goals. There is also very little coverage about the many professions women dominate. Here are some examples:

  • Medical and health service mangers
  • Vets
  • Psychologists
  • Teachers
  • Medical scientists
  • Financial specialists
  • Accountants/auditors
  • Veterinarians
  • HR managers

It’s also worth acknowledging that in universities approximately 60% of students who achieve degrees are women. Women can obtain female only scholarships into STEM (science, technology, engineering and maths) in an effort to address the supposed discrimination within this field. Shockingly at the University of Oxford, an extra 15 minutes was added to computer science and maths exams, as it was thought that time pressure may adversely affect female candidates. This for me highlights when positive discrimination and the quest for equity goes too far. This is effectively social engineering, surely we would live in a freer society if people were allowed to make their own decisions regarding their lives, rather than being cajoled into a profession purely to satisfy some political dogma.

Much of this positive discrimination crosses the line, shifting from needs; food, shelter, education and health, to wants; a better job, status, prestige and more money. How in any way does this type of campaign, supported by relatively privileged people, positively affect the majority of working class, poor and the homeless? These are campaigns designed by the middle class, for the middle class and are no more than self serving ventures. Often these comparatively trivial concerns are heavily supported by politicians and the mainstream media in an effort to secure middle class voters, at the expense of the hapless working class.

I am all for using equity as a tool to combat an incongruence of human rights. Nobody should go without adequate food, shelter, heat, education, health care, protection by the law and even a means of earning money, or we must consider that we have failed as a first world society to support all of it’s members. Equally we should not be duped into providing a further leg up for the bourgeois, educated, manipulative, middle classes who convince us that their requirements are of far greater importance than anybody else’s.

So where does personal responsibility fit in, you may ask. Many on the right suggest personal responsibility encompasses practically every choice we make. I would argue that the choices available are greatly reduced if your basic needs, primarily the bottom four blocks of Maslow’s hierarchy are not met. In contrast, an individual like Bill Gates for example went to a school where he could gain programming experience, at a time when less than 0.01% of his generation had access to computers. Further to this, he also had a mother with social connections to the chairman of IBM. These types of advantages experienced by the rich obviously provide a greater range of choices than the average person. Examples such as Bill Gates only serves to question the validity of the “personal responsibility” hypothesis within this context.

Bill Gates

It is relatively well documented that rich kids will likely go on to be a rich adult. It fact, a child’s basic earnings can be based off a percentile of their parents income. Additionally, people who are more affluent are more likely to marry and kids who have a stable two parent family tend to go on to having more fruitful lives. This information adds weight to the argument that if we decrease economic inequality, society as a whole will benefit.

Equity and equality both have their place, but if we want to provide everyone with an opportunity to thrive, equity is necessary to ensure that all people have their basic needs met, contributing to good foundations for life. Less inequality can increase trust and societal participation, decrease health problems, reduce crime, increase social mobility, improve education levels and even stabilise the economy. So, the question is, why wouldn’t we do what we can to raise all boats, starting with the very people who have run aground?