Inequalities in society are major causes of stress, they get under your skin, causing long-term physical and mental health problems. And modern rich societies with the greatest income inequalities have the highest psychosocial fallout.

The all pervasive damage of inequalities on a personal level can be difficult to acknowledge sometimes, but as more and more we value wellbeing as the fundamental aim in life rather than economic growth at all costs, it is time to challenge structural inequities and look for solutions.

Professor Emeritus of the University of Nottingham Medical School, Richard Wilkinson, and Kate Pickett, Senior Lecturer at the University of York, estimate that they have clocked up 50 person-years between them to research the material in their book, The Spirit Level.¹ ‘The role of this book,’ they say, ‘is to point out that greater equality is the material foundation on which better social relations are built.’ They started out looking at what caused the discrepancy in life expectancy of individuals at different levels of the social hierarchy in modern societies. However, their breakthrough came when they did what no one else had done before, put together the health figures with data that showed income inequalities in a society. The figures show economic growth is no longer a useful driver for developed rich countries. It doesn’t make us happier or healthier. In the face of recession and the human misery caused by job losses and insecurity, stating that economic growth – so long the mantra of politicians on left and right – has come to the end of its useful life, is a brave assertion. However the figures bear this out. As a country develops, increases in average living standards do improve the quality of people’s lives. But once the majority of the population no longer has to worry about food, clean water and keeping warm, increases in wealth do not increase life expectancy, happiness or wellbeing.

Instead, what does increase, are the psychosocial problems. Over and over, those countries with the greatest inequalities of income came out worst: higher levels of mental illness and addiction, higher homicide levels and prison populations, lower life expectancy and higher infant mortality, poorer educational performance, lower levels of trust, higher levels of obesity, more teenage births and lower social mobility. ‘Modern societies, despite their affluence, are social failures.’

The authors collected internationally comparable data from ‘reputable sources’ including the World Bank, the World Health Organisation, the United Nations and the Organisation for Economic Co-operation and Development on health and social problems. They then combined this with data on income differences of 23 of the richest countries (and each of the American States). That is the income differences between the top 20 per cent and the bottom 20 per cent of the population. The UK is amongst the most unequal, with the top 20 per cent having over seven times that of the bottom 20 per cent. At the other end of the scale, Japan and some of the Scandinavian countries, the gap is less than four times.

How inequality gets under our skin
There’s an interesting chapter where the authors pull together research to explain what it is about income inequalities and a person’s position in society that makes such a difference. It is an individual’s sensitivity to the social structure that makes unequal societies so devastating. Understanding the relationship between the two will unlock the door to wellbeing.  It’s not the individual who must change, but society: ‘Rather than requiring anti-anxiety drugs in the water supply or mass psychotherapy,’ say the authors, ‘what is most exciting about the picture we present is that it shows reducing inequality would increase wellbeing and quality of life for us all.’

To show how inequality gets under our skin, trends over the past 50 years are examined. Firstly, stress levels have gone up. Being mindful of the possibility that more awareness might result in increased reporting, research shows that people in developed countries have experienced substantial rises in anxiety and depression. This is a trend that started before the inequalities of the past 30 years of the 20th century, and so inequalities cannot be said to have caused the increase, but may have exacerbated it.

And secondly, there has also been an upward, seemingly contradictory trend in self-esteem. This is not necessarily a rise in healthy self-esteem, however. ‘What we have seen is a rise of an insecure narcissism – particularly among young people – rather than a rise of genuine self-esteem,’ the authors say. The rise can be seen as a defence mechanism in the face of a threat to self-esteem manifested in denying personal weaknesses and talking oneself up. ‘Rises in anxiety have been accompanied by rising narcissism and the two have common roots. Both are caused by an increase in what has been called “social evaluative threat”,’ say the authors. Individuals are sensitive to their perceived position in society.

Threats to your social position and self-esteem are great stressors. Reviewing research into stress it becomes clear that cortisol levels, the central stress hormone, are highest when people undertake a task that is going to be judged by others, where there is the possibility of humiliation. And what stresses us out most is where we have no control and failure cannot be avoided.

More research adds to the picture, showing that psychological stress has a major impact on health in rich countries. Feeling worthwhile and valued are important factors for wellbeing. Obviously there are those at the bottom who have healthy self-esteem and those at the top who don’t, but the higher up the social ladder you are, it may be easier to deal with the self-doubt. A lack of friends, low social status and stress in early life come up as markers for stress, all of which are intensely social and about how at ease we feel about ourselves in relation to others.

Shopping is about social evaluation, also: ‘Too much consumerism is regarded as if it reflected a fundamental material self-interest and possessiveness,’ say the authors. ‘That, however, could hardly be further from the truth. Our almost neurotic need to shop and consume is instead a reflection of how deeply social we are. Living in unequal societies we use possessions to show ourselves in a good light, to make a positive impression, and to avoid appearing incompetent or inadequate in the eyes of others.’

The authors argue that the relationship between inequalities in society and psychosocial problems is so strong that it cannot be put down to chance. How unequal a country is will be a predictor of how prevalent a problem will be. The differences between the more equal and the most unequal societies are large – the problem can be between three and 10 times as common. And the problem is prevalent within the whole of the society, not just within a high-risk group. The authors found one glaring exception – suicide tends to be more common in equal societies. ‘Violence tends to be directed towards other people or yourself,’ says Wilkinson, ‘and it is our guess that in societies with a higher sense  of community responsibility, people tend to blame themselves rather than other people when things go wrong.’² A joint report published by the Mental Health Foundation and the World Health Organisation Europe, Mental Health, Resilience and Inequalities,3 in March concurs with Wilkinson and Pickett’s findings. ‘It is abundantly clear that the chronic stress of struggling with material disadvantage is intensified to a very considerable degree by doing so in more unequal societies,’ says author Dr Lynne Friedli. ‘An extensive body of research confirms the relationship between inequality and poorer outcomes, a relationship which is evident at every position on the social hierarchy and is not confined to developed nations.’

Do we acknowledge inequalities on a micro level?
Wilkinson and Pickett’s book gives us the evidence at a macro level that is needed to take a stand against inequalities. On a micro level, inequalities permeate every part of our lives. We are aware of where we stand in the pecking order and who is in our league. However it is something we don’t readily acknowledge and often feel powerless to do anything about. On a micro level do practitioners feel that Wilkinson and Pickett’s work resonates for them? Paul Kelly is a clinical psychologist working in the student counselling services at Dublin University, having trained and worked in the UK: ‘There is little attention paid to macro socio-economic factors and how they impact on people’s mental health. This is an area that I am particularly interested in. It is an area that is very neglected in psychology and therapy training. ‘I worked in the community before the university setting and I’ve been to some extent surprised by the level of distress I’ve seen in the student population,’ says Kelly. ‘People rarely present or say that inequalities are a problem, but when you explore underneath it is often a factor. People are reluctant to acknowledge it openly. If you ask them how they feel in relation to other students in the university, there will be a lot of talk about not feeling the same. There are a lot of cliques, well-off students who drive to the university – they don’t feel part of that – and they feel inadequate in different ways, academically or socially.’

Children and young people are particularly vulnerable to social evaluative threat. University is a big adjustment, in terms of scale and finding your place in it, just at an age when you might be unsure who you are. Students have often been uprooted from families and lives where they have been known and find themselves in an unfamiliar community of thousands. ‘People feel powerless if you start talking about structures in society,’ says Kelly, ‘and their links with something like eating disorders and advertising, how that might link with how people feel about themselves. They find that difficult. They can see it intellectually, but emotionally they are concerned with the immediacy of their lives, the relationship with their mother or their partner. They feel that they cannot do anything about the wider social issues.’

Gerard Reissmann has been a GP in the North East for 25 years, working in a number of practices with patient lists from very different socio-economic backgrounds. ‘I see this drive to better oneself at every level. At a certain level it’s just called greed. I see doctors coming in at a weekend to do out of hours work driving a brand new sports car and they tell me how stressed they are and how hard it is to manage on the money.’

Reissmann believes that the authors are spot on when you look at society on a macro level, but that it is hard to translate it on the ground. ‘The main mechanism I see is that we live in an individualistic society and it pushes you to take individual action to do something that’s seen as bettering yourself. People are much more likely to do some overtime and get some money rather than say, “I’m going to start a community garden on that land across the way and see how many people I can get to join in”. The evidence shows that the latter will make us happier and healthier, but we don’t do it because that hasn’t been the culture of the past 30 years.’

Wilkinson and Pickett suggest that the breakdown of communities is one factor that exacerbates our sensitivity to social evaluative threat. Finding ourselves surrounded by strangers, with no links to our childhood and family histories, we become overly concerned about how people see us. ‘A lot of the social networks are much stronger for working class communities where people are around their families,’ says Reissmann. ‘In a way they are much more resilient. When I worked in a very poor area they had a stoical approach. They appreciate what they’ve got despite having less and actually value the fact that they have people around.’ What is to be done? Wilkinson and Pickett’s book adds more weight to the argument for radical change. Change that will address global warming, a broken financial system and the distress caused by an unequal world. However there are palpable feelings of powerlessness and frustration in the air.

Disillusionment with party politics means that millions don’t even vote. Political stalwarts can still write letters and take to the streets to demonstrate, but does that really work? Global society being in disarray was debated by Peter Morrall in his article ‘The Trouble with Therapy’ (Therapy Today, February 2009). Counsellors and therapists were criticised for navel gazing and urged to shift their focus from the individual to working dynamically in the production and implementation of radical social policies. Morrall suggests that ‘impossiblism’ – the notion that nothing can be done about global suffering – should be tackled. BACP members who have replied to his challenges have done so with a resounding chorus: the therapy room is not the place for political activism. ‘When a client walks into my counselling room, my concern is immediately focused on their world and the interpretations they make of that place,’ says Geoff Boutle, BACP accredited counsellor. ‘I may be personally convinced that our present social and political structures are leading towards some form of political Armageddon... The place however, for me to take that incandescent rage is to groupings such as Liberty, but not the counselling room.’

Opinions about what will work differ widely. ‘I am strongly for more equality,’ says Richard Layard. ‘But we need both equality and therapy.’ However Colin Feltham, Professor of Critical Counselling Studies at Sheffield Hallam University takes a pessimistic view. ‘I don’t think mental health problems can be significantly addressed with or without a correction of inequalities. Generic social policies do not (perhaps cannot) get at deeper causes of human dysfunction. Government imposed equality would probably make life better for some (and I am certainly in favour of higher taxes for the too rich, for example) but doesn’t at all get at the problem of widespread mendacity and greed. I also think the Layard, IAPT/CBT proposals are naïve and misguided in the extreme and will prove to be a terrible waste of public money. Generic counselling can bring temporary comfort and improved morale to some people but is also not “the answer”, the counselling profession like all other professions being unfortunately distorted by hierarchy, bureaucracy and public relations dynamics.’

Clinical psychologist and author of Affluenza, Oliver James believes the problem of selfish capitalism must be dealt with. ‘Inequality is caused in the developed nations by the kind of political economy that I’ve described as selfish capitalism... That’s what makes people mentally ill. They put too high a value on money, possessions. It means you don’t meet your fundamental psychological needs, you’re chasing socially generated wants, largely generated by advertising and marketing of which there is much more in the English speaking world than Continental Europe.’ Feltham, however, believes the distress has deeper causes. ‘I think inequality is one factor in the development of psychosocial problems but (unlike Oliver James, for example) I believe human problems are rooted in natural, genetic, evolutionary and historical conditions as much as (maybe more than) being rooted in recent socio-economic conditions. I have explored these themes in my 2007 book What’s Wrong With Us? The Anthropathology Thesis. It’s a simple, doctrinaire and attractive position that most of our problems can be traced to social injustices associated with capitalism (or runaway selfish capitalism) but I do not subscribe to it, I think it’s naïve. Human nature in my view is complex and includes many collective, deeply rooted, dark elements of violence, greed, deceit, irrationality, inter-group conflict, patriarchy and so on. I don’t believe that either socialist or capitalist regimes are ultimately effective.’

‘A focus on social justice may provide an important corrective,’ says Friedli, ‘to what has been seen as a growing over-emphasis on individual pathology. Mental health is produced socially: the presence or absence of mental health is above all a social indicator and therefore requires social, as well as individual solutions.’

How greater equality has been achieved is not universal. Japan has greater equality in market incomes – that is incomes before taxes. While in Sweden equality is a result of fiscal policy and a large welfare state set up to redistribute money. To bring about lasting change in the UK would take decades. It would require a vision that had the sustained support of the population. Rich bankers and celebrities would not be envied or a source of inspiration. Greed, conspicuous consumption and damaging the planet would be seen as something socially unacceptable, such as drink driving. Wilkinson and Pickett suggest practical answers may lie in technology and a rethink of the way that business enterprises are owned and run. The digital economy means that products that were once expensive to make in terms of resources, can now be acquired in a digital format for very little manufacturing cost and so could be cheap or free, for example music, entertainment, books, newspapers, software and free communication such as emails or Skype. A revision of patent and copyright laws could enable those who research and produce valuable products to be paid without it restricting access to them.

Democratic employee ownership avoids the problems of state ownership and the concentration of power in executives who are answerable to shareholders who may have no other interest in the company than a return on their capital investment. Employee share ownership would be combined with a more participatory management method. People thrive when they have more control over their work. The workplace is more of a community.

If Britain became as equal as the four most equal of the rich countries (Japan, Norway, Sweden and Finland), say the authors, ‘levels of trust might be expected to be two-thirds as high again as they are now, mental illness might be more than halved, everyone would get an extra year of life, teenage birth rates could fall to one-third of what they are now, homicide rates could fall by 75 per cent, everyone could get the equivalent of almost seven weeks extra holiday a year and the Government could be closing prisons all over the country.’

Is such a seismic shift in attitudes and behaviour possible? To move away from a more individualistic society to a community focused one. To build trust in each other and in our political and business systems. To make a commitment to living in a sustainable way. Wilkinson and Pickett give us the evidence of what is wrong. Who will have the courage to lead the way ahead?

The Equality Trust is a not-for-profits trust set up by Wilkinson and Pickett to campaign for a healthier, happier, sustainable society. For further information visit www.equalitytrust.org.uk

1. Wilkinson R, Pickett K. The spirit level: why more equal societies almost always do better. London: Allen Lane; 2009. 2. Crace J. The theory of everything. The Guardian. www.guardian.co.uk/society/2009/mar/12/equality-british-society 3. Friedli L, Mental health, resilience and inequalities. Mental Health Foundation and the World Health Organisation Europe; 2009.