“It is no measure of health to be well adjusted to a profoundly sick society.” —Jiddu Krishnamurti
For those of us who are aware of our privilege, it’s our role to expose where dominant institutions and narratives make power invisible. In the field of mental health and wellbeing we have not been doing a great job. Statements like ‘one in four people will experience a mental health problem’, the current mantra of the Time to Change campaign and mainstream mental health promotion, imply that poor mental health is distributed equally among us and rather randomly according to the fate of our brain chemistry or levels of personal ‘resilience’.
These campaigns invite us to celebrate that people in the UK are finally talking about mental health and if they are not, then they certainly should be. Talking, seeking help from your GP, engaging in mindfulness, or participating in mental health first aid training in the workplace are the solutions that are prioritised in mental ill-health. Yet, by focusing solely on the individual, these ‘solutions’ obscure the impact of our current economic and social systems on our psychological health, essentially suggesting that we can all talk or think our way out of this mess. Should we be teaching people mindfulness to cope with an impossibly demanding workload or should we be addressing the workload demanded of us?
In this article, we’ll counter this focus on the individual by bringing together some of the evidence of the impact of our economy and society on psychological distress, and make suggestions for what is needed to create a psychologically healthier arrangement of our current economic, social, and political systems. I (Sally) was lucky enough to be trained by the NHS as a clinical psychologist, working in a variety of NHS settings with a broad range of populations, from secure inpatient hospitals to children’s social care. During this time I learnt that the role of psychologists in children’s social care often boils down to providing parenting classes for single mothers living in inadequate housing. As a middle class, non-parent, professional living in comfortable housing with multiple other privileges, I felt uncomfortable to say the least, and so too did the mothers, who often expressed this by not turning up. Within the children’s social care system, poverty can be conflated with neglect, a lack of participation with ‘not taking responsibility’, working two jobs with ‘absent parenting’, and family breakdown with a skills deficiency. Funding cuts to social care and family support services have meant an increase in children from the most deprived wards in the UK going into care. Indeed, the number of children going into care is steadily rising. It is hard to describe how much suffering is wrapped up in that statement.
In all my professional and activist work, I’ve witnessed the hard end of inequality, poverty, austerity, and the impact these have on people’s lives and behaviour. Yet often these contextual issues are rendered invisible. Writing in my clinical assessment reports, "Jake is suffering from the effects of neoliberalism or the closure of youth centres" doesn’t go down well. What is the point of individual prescriptions, talking therapy or medication, if those are not the causes?
As the sociologist CJ Wright Mills once wrote, the work of sociology is to translate “how public issues become ‘private troubles’”. It’s easy to understand how this works with more extreme public issues, such as war or living under a military regime, but in the UK where many of us, though far from all of us, live in relative peace, it is less intuitive to see how social problems are internalised. Yet the evidence of the political, social, economic, and community determinants on mental and physical health is robust. Approximately 40% of our health outcomes are connected to the quality of our housing, the quality and security of our employment, the quality of our social relationships, our education, transportation options, and socioeconomic status. Children and adults from the lowest 20% of household incomes are three times more likely to have common mental health problems than those in the richest 20%, and nine times as likely to have what have been called ‘psychotic disorders’. There are other mental health inequalities, too, that cut across structural inequalities linked to ethnicity, gender, sexuality, disability, and intersectional marginalisation. These stories are much less present in our public narratives of mental health.
‘You are worth so much more than your productivity’
Anti-capitalist love note
Survivor activist groups have been bringing to life these links for decades yet their voices remain marginalised in the mental health system. The Mental Health Resistance Network (MHRN) have been painstakingly campaigning to shine a light on how damaging recent welfare reforms have been, like the introduction of universal credit, and how it’s led to a rise in suicides. People are feeling pressured, mistrusted, and coerced, not to mention worried about losing their homes. MHRN are also challenging the inclusion of employment as a health outcome in the recent NHS Long Term plan, arguing that evidence that ‘work is good for your mental health’ is being misused to put pressure on people to get into work. The proffered solutions to mental distress are rejected by survivor activists who argue that, “positive psychology is not a substitute for proper housing, a secure income, free healthcare, and a more equal society.”
‘Equality is the Best Therapy’
In 2014, inspired by the survivor activist groups and a collective sense of despair, myself and a group of psychologists, academics, students, therapists, and survivors joined together to campaign on the impact of austerity on our nation’s psychological health and ever-widening mental health inequalities. We became Psychologists Against Austerity (PAA) and, in the run up to the 2015 General Election campaign, released a briefing paper outlining the mechanisms through which community, economic, and social policies affect people’s psychological health. The briefing paper, The Psychological Impact of Austerity, describes five psychological ‘ailments’ which have been worsened by austerity policies and which act as pathways to distress (see www.psychchange.org). They were:
1. Humiliation and shame
2. Fear and distrust
3. Instability and insecurity
4. Isolation and loneliness
5. Being/feeling trapped and powerless
In one instance, cuts to domestic abuse services are leading to more women being trapped in abusive relationships, the use of foodbanks is fuelling family shame and humiliation, and welfare reform is creating more insecurity. We don’t claim these are the only five psychological processes through which economic and social factors affect our psychological health, nor that these are the only contributing factors to mental ill-health, just that they are useful indicators.
Where these factors do feature in our public narratives they are decontextualised and depoliticised. Loneliness, as one example, has been conceived of as a public health problem and an economic one in terms of its cost to employers. However, the government’s strategy document unsurprisingly has nothing to say about the impact of austerity or neoliberal policies on loneliness.Similarly, the adverse childhood experiences movement, which raises awareness of the links between early adverse experiences (such as abuse, neglect, domestic violence, bereavement, poverty, parental drug abuse) and psychological health, remains quite often a ‘safe’, depoliticised movement. It frequently connects people to the hope of ‘trauma-informed’ practice and brain plasticity, rather than social and economic justice.
So if talking therapies and narratives about the brain only serve to obscure the underlying problem, what is the solution? How can we both reduce an individual’s distress and improve the health of our society? In terms of what experiences contribute to good psychological health, the PAA briefing paper also pulls out five key psychological processes which social and economic systems need to enhance:
These processes can be strengthened at a relational and collective level, as well as at an individual level. For example, improving a marginalised community’s sense of agency and self-determination can lead to collective health gains, as can a sense of security through material gain. The briefing paper highlighted these five community determinants above because they are ways of trying to fill a ‘cognitive gap’ in terms of people’s understanding of how structural issues can become psychological. Other community level factors important to psychological health include a sense of safety, access to resources, and social cohesion. A follow-up briefing paper by our campaign group (now writing under the banner of Psychologists for Social Change), used the five processes above to assess the potential psychological impact of a universal basic income, arguing the policy has the potential to generate more of all of these experiences at a collective level, but with some caveats that it is not inevitable and more trials are needed.
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Community health building?
Community Wealth Building (CWB) is a set of principles designed to increase the overall wealth of a local community over time and prevent value from being extracted from that community. In the Demos-PwC Good Growth for Cities Index 2018, Preston, the UK's leading example of CWB, was named as the UK’s most improved city, with unemployment having fallen from 6.5% in 2014 to 3.1% and above- average improvements for health, transport, work-life balance, and youth and adult skills. The ‘good growth’ index maps onto several of the key social determinants of health outlined in a famous report by Professor Marmot and team at the Institute of Health Equity called Fair Society, Healthy Lives, which is crucial. But as yet there doesn’t seem to be enough discussion about the impact on psychological health or the psychological processes of community building within Preston local authority’s outputs, such as whether people are trusting each other more, or developing a stronger sense of individual or collective meaning through the principles, and which of the principles are having the biggest impact on these.
At the other end of the spectrum, the Bevendean housing estate is a 10 minute drive from the centre of Brighton, but light years away in terms of wealth and opportunity. Officially ranked among the most deprived 3% in England, the residents suffer from some of the worst health and education statistics in the country. Physically removed from the city centre by distance, a lack of public transport and extremely steep hills, the estate lacks most of the amenities taken for granted elsewhere – a GP surgery, for instance, or shops. And until recently it would have been a four mile walk to get to the nearest pub. The original pub had problems with anti-social behaviour and crime, leading to the withdrawal of its licence and subsequent closure. Local community organisers saw the importance to the community of having a place to gather and wanted to return the building to being the asset it had once been. Over two years, volunteers raised funds and sold shares to hundreds of local people using a community share issue. The Bevy is now a sustainable community business, governed by a committee of volunteers, and answerable to it’s community shareholders.
The Chair's annual report makes it clear how, as a community business, they're much more than just a pub. “You know you’re onto something when the doctor recommends you go to the pub. But with a loneliness epidemic that advice might not be as unusual as it sounds. So meeting up with the Friday Friends every week for some food, company, bingo, and a laugh is literally just what the doctor ordered – and a lot more fun than antidepressants.” But again to what extent has this sort of impact been more formally captured?
Standing on the shoulders of giants
As these new institutional, community, and neighbourhood structures and innovations develop and spread, we must ensure we are understanding their impact on the psychological processes outlined above and how these connect to the material benefits. Different social groups begin with varied amounts of trust, meaning, connections, agency, and security in the first place, so the effects of these innovations will be different. Psychologists, and those with a health and wellbeing interest, need to be more engaged with this work, bringing knowledge from social, clinical, and community psychological research and methodologies to help measure and understand the full range of potential impact, and guard against all too common human errors. Like how to avoid creating more ‘outgroups’ who are unwelcome and mistrusted, and prevent groups of people from losing the sense of meaning in their lives as old institutions are swept away, or how to reach out effectively to those who are often most marginalised and include them, like those living with learning disabilities. These new economies have so much potential for creating a psychologically-healthier society and community, let’s make sure they are building on what we already know. ∞
Sally is a clinical & community psychologist, Co-founder of Psychologists for Social Change, Chair of The Community Psychology Section of the British Psychological Society, and Director of Public Health & Prevention at MAC-UK.
Jenni is a programme manager working on the ShareLab Fund. Prior to Nesta, Jenni founded PurposeLab, an experimental consultancy designed to explore purposeful work.
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