Critical Values Based Practice Network

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Inequality and Mental Health

Written by Steven Coles on . Posted in Clinical Psychology Bite-Size

Inequality and Mental Health

Issue 45 – September 2015

Author: Steven Coles (steven.coles@nottshc.nhs.uk)

Key points

  • Inequality has been increasing in the UK for over 3 decades
  • Greater inequality is related to increases in mental health and community problems
  • There are concerns that austerity policies have increased: humiliation and shame; fear and distrust; instability and insecurity ; isolation and loneliness; and powerlessness

 Implications for practice

  • People with mental health problems will need support with practical and social issues, and help to access resources
  • Mental health models can hide the importance of social factors such as inequality, instead they should be central to our understanding of people’s problems
  “Britain’s divided decade: rich are 64% richer, poor are 57% poorer” The Independent, 10 March 2015.  Rising financial inequality is a global issue. Oxfam (2015)1 highlight that “The combined wealth of the richest 1 per cent will overtake that of the other 99 per cent of people next year unless the current trend of rising inequality is checked”. Differences in wealth are differences in power and influence. Inequality has been increasing in the UK since the late 1970’s / 80’s and wages in relative terms have decreased significantly during the recent economic crisis, particularly for younger people2. Oxfam (2014)3 reported that within the UK, the five richest families were wealthier than the bottom 20% of the population. Mental health is directly related to levels of inequality and therefore central to mental health practice.  

Inequality, Mental Health and Well-being

Read (2010)4 points to evidence that poverty and inequality is a clear causal factor in mental health, including people who hear voices and have unusual beliefs. Poverty works through others factors, such as working conditions, stress on families and so forth. The Marmot Review (2010)5 and the work of social epidemiologists Richard Wilkinson and Kate Pickett (2010)6 detail extensive research evidence that social inequality impacts on a wide range of personal and community measures of well-being. A WHO (2009)7 report concluded that there is “overwhelming evidence that inequality is a key cause of stress in itself and also exacerbates the stress of coping with material deprivation”.  

Psychological Impact of Austerity

A briefing paper on the impact of austerity policies since 2010 describes several psychological mechanisms by which cuts in public services and welfare have negatively impacted upon people (Psychological Impact of Austerity)8. The five mechanisms are:
  • Humiliation and shame
  • Fear and distrust
  • Instability and insecurity
  • Isolation and loneliness
  • Being trapped and powerless
  Inequality can be felt through the practical and everyday stresses of living with limited resources. Furthermore, we are all affected by inequality, directly and indirectly. Our culture’s focus on materialism and consumption creates unhealthy expectations and hyper-competitiveness that leaves many feeling ashamed and damages social relationships 6, 9.  

What can I do as an individual practitioner?

If we are to take inequality seriously we must emphasise issues such as money, housing, access to education when attempting to understand people’s problems. If people are to have any chance of sustaining reasonable mental well-being, they will need support with practical and social issues, such as housing, access to education, seeking legal advice around benefits. An individual with limited resources has limited power and influence over their life. However, this might be improved by forming links with other people in similar situations or by connecting people with organisations and groups that can help them. Overtime mental health services could develop a community public health approach by working with communities as well as with individuals.   As well as trying to find ways to help, we also need to consider our own practice. Mental health professionals have been criticised for models that locate problems in the person, and for not focusing on the importance of people’s social world and life experiences 9,10, 11. For example, influential advocates of the Improving Access to Psychological Therapy programme, Layard and Clarke (2014) minimise the importance of the external world, such as income, education and housing whilst emphasising the internal world. Their claims appear to overestimate the effectiveness of approaches such as CBT and to underestimate the significance of research on how the external world shapes people’s mental well-being.   We need to ensure clients understand the effects of inequality and oppression on their well-being and to support and encourage in whatever ways we can. Services can try to help people practically and we could develop new ways of working with communities, however, even then there are limits to what we can do. For example, it is not in our power to build new and decent housing, design neighbourhoods and spaces that are conducive to positive well-being, to create supportive and positive job opportunities. Addressing these issues are all necessary, so to decrease the rates of mental health problems and aid people in recovering from difficulties in their lives. We need to speak up on such topics. As individuals our voice is quiet when speaking out on the importance of equality, decent housing, good working conditions, and safe neighbourhoods, however, we can increase this volume if we join with others who share the same concerns.   As mental health practitioners we witness the end result of inequality: shame, humiliation and entrapment. Taking inequality seriously is a daunting challenge, but also an ethical imperative requiring us to acknowledge its central importance in our practice and whenever possible, in solidarity with others, we should challenge those who oppress those with least.  

REFERENCES

  1. Oxfam (2015). Inequality and poverty. Retrieved 23 January 2015 from https://www.oxfam.org.uk/media-centre/press-releases/2015/01/richest-1-per-cent-will-own-more-than-all-the-rest-by-2016
  2. Blanchflower, D. & Machin, S. (2014). Falling real wages. Centrepiece (Spring 2014), 19 – 21. http://cep.lse.ac.uk/pubs/download/cp422.pdf
  3. Oxfam (2014). A tale of two Britains: Inequality in UK. Oxford: Oxfam, http://policy-actice.oxfam.org.uk/publications/a-tale-of-two-britains-inequality-in-the-uk-314152
  4. Read, J. (2010). Can poverty drive you mad? New Zealand Journal of Psychology, 39, 7-19
  5. Marmot Review (2010). Fair Society, Healthy Lives. Marmot Review
  6. Wilkinson, R. & Pickett, K (2010). The spirit level. London: Penguin.
  7. WHO (2009). Mental health, resilience and inequalities. Denmark: WHO
  8. Psychologists Against Austerity (2009). Psychological Impact of Austerity: A briefing paper. Retrieved 2nd March 2015 https://psychagainstausterity.wordpress.com/
  9. Smail, D. (2001). The Nature of Unhappiness. London: Constable – Robinson.
  10. Moloney, P. (2013). The Therapy Industry. London: Pluto Press.
  11. Midlands Psychology Group (2012). Draft manifesto for a social-materialist psychology. Journal of Critical Psychology, Counselling and Psychotherapy, 12, 93-107
  12. Layard, R. & Clark, D.M. (2014a). Thrive: The power of evidence-based psychological therapies. London: Allen Lane.

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