The Inner Level

by Richard Wilkinson

  Just as risks of heart disease can be increased by many different causes, including lack of exercise, poor diet, smoking, stress, diabetes, obesity and high blood pressure, so numerous different factors can contribute to each kind of mental illness. However, not only are most physical and mental illnesses multi-causal, but most causes contribute to many different diseases – you could say these ‘broad spectrum’ causes are ‘multi-diseasal’. For example, a list of diseases to which smoking contributes would include emphysema, chronic bronchitis, asthma attacks, lung cancer and cancers in at least ten other parts of the body, stroke, diabetes, heart disease, and a good many others.

  Evidence that almost two-thirds of the population with social anxiety disorder suffer from other comorbid disorders, ranging from bipolar disorder to eating disorders and drug dependence, serves as a caution against thinking that shyness, rises in anxiety and increases in a wide range of mental illnesses are independent of each other. Feeling overly self-conscious, stressed and ill-at-ease when with other people, sometimes combined with almost overwhelming doubts about your self-worth, is a mix which strikes at the heart of our social existence. It would be hard to devise anything as psychologically damaging as circumstances that simultaneously undermine how we get on with other people and how we feel about ourselves.

  Given that economic growth has brought us unprecedented luxury and comfort, it seems paradoxical that levels of anxiety have tended to increase rather than decrease over time. Being better off than previous generations should surely mean we have less to worry about compared either to our predecessors or to people in countries which have not yet enjoyed the same increases in living standards. However, the survey figures compiled by the World Health Organization (WHO) to provide a basis for international comparisons suggest that richer countries have substantially higher rates of mental illness than poorer countries.13 WHO surveys conducted in the early years of this century found that the lifetime prevalence of any mental disorder was 55% in the USA, 49% in New Zealand, 33% in Germany, 43% in the Netherlands, but only 20% in Nigeria and 18% in China.

  If anxiety has increased despite rising living standards, then that should shift the focus of any attempt to identify causes from material difficulties to social life. The greater prominence of the self-conscious emotions, including shyness and social anxiety, may be an important contributor to the rises in anxiety as a whole. But because material standards tend to play such an important role in our presentation of ourselves, they are not absolved from being a focus of anxiety. Instead of worrying primarily about keeping body and soul together, the balance has changed. Having (for the most part) reached a standard of living unthinkable a couple of centuries ago, we now worry much more about maintaining standards in relation to others – where we are in relation to the norms of our society and position within it. Our concern with living standards is closely related to the anxieties round self-worth and social comparisons mentioned earlier. There is, for example, a substantial body of research showing how well-being and satisfaction with our own pay depends substantially on how it compares with other people’s pay, rather than whether it provides us with what we need.17, 18 Our argument is not that there was a time when people did not make social comparisons, but that they have become more important to our sense of ourselves than they once were.

  Worries about what others think of us often interact powerfully with judgements of and insecurities about social status. That means they may appear to depend on many factors that influence social status – everything from anxieties about exams, jobs, money and promotion, to worries about how your children behave in public.

  APART TOGETHER

  The press has greeted research reports about rises in anxiety and mental illness with a succession of alarming headlines: ‘The Epidemic of Worry’,19 ‘The Maddening of America’,20 ‘The Anxiety Epidemic Sweeping Britain’.21 In the words of commentators, ‘The United States has transformed into the planet’s undisputed worry champion’,22 and ‘Severe, disabling mental illness has dramatically increased in the United States’.23 The data quoted from research on the scale of the increase in mental illness have been hardly less dramatic than the headlines: ‘In 1980, 4% of Americans suffered a mental disorder associated with anxiety. Today half do.’24 ‘Anxiety epidemic affects 8.2 million in the UK’.21 ‘The tally of those who are so disabled by mental disorders that they qualify for Supplemental Security Income or Social Security Disability Insurance increased nearly two and a half times between 1987 and 2007. Among children there was a 35-fold increase during the same period.’25

  There is no clear dividing line between people whose lives are drastically restricted by how stressful they find almost any social contact and those who experience levels of shyness more typical of the majority of the population. Those sharing experiences of incapacitating levels of social anxiety online, such as those quoted earlier, include women and men, young people, parents, soldiers and even people who find themselves struggling to do jobs which involve more than a minimal degree of social exposure and performance. No section of society is unscathed by social anxiety. We quoted at the beginning of this chapter Martha Beck’s account of her ‘party anxiety’, which would have been recognized by many of her readers.7 Famous for his outdoor survival skills, toughness and ability to deal with any eventuality, Bear Grylls’ lifestyle could hardly differ more from that of a style coach. Yet in a TV programme on climate change with former US President Barack Obama, he admitted that what he most fears are not snakes or poisonous spiders, but cocktail parties.

  Public appearances of course heighten these anxieties. In a Saturday column in the Guardian newspaper called ‘How I Get Ready’, celebrities described how they prepare to be seen – a process which usually takes several hours and sometimes starts a day before an appearance. Despite careful attention to hair, nails, make-up and clothes, both women and men mention their nervousness, and regard having a few drinks to steady their nerves as part of the preparation. Some also admit to cancelling a booking if they ‘don’t feel up to it’.

  But even without having to appear in public, a great many of us show signs of feeling that in some way we are just not good enough. When people are expecting visitors to their home, most (though perhaps fewer of those who employ someone else to do their housework) do extra vacuuming, cleaning and tidying before guests arrive. We prefer to hide how we really live – even from friends. Occasional exceptions are of course made for people who know us too well for pretences: we just hope that as they already know how we live they will accept us, warts and all. But with most other people – typically including our in-laws and relations – we try to present ourselves as having higher standards than we really do.

  Although a large majority of the population probably clean and tidy before visitors come, we tend to do it rather secretively. We don’t tell our guests that we only just managed to finish clearing up as they arrived at the door, even though most people admit that this is true of them too. It is such a widespread pattern that websites give advice on the quickest ways to clear up before guests arrive: tips on what makes most difference in the shortest time. According to one survey, people take an average of 28 minutes to tidy up in preparation for visitors.26 Just how embarrassed people feel about their housekeeping is shown by the quarter of those surveyed who admitted to trying to prevent guests from entering their home and seeing their untidiness. In their hurry to clear up, people say they hide things away in the washing machine, tumble dryer or laundry basket. Fifteen per cent admit to hiding dirty dishes in the oven.26

  People often disguise their motives for doing this even from themselves, saying things like ‘I just think it’s nice to have your home all pretty for your guests to make them feel comfortable during their time with you.’ But the reality of feeling the need to hide a guilty secret shows through when the same person went on to say: ‘No one needs to know what a slob I can really be; I’m certainly not proud of it. But … part of me does wish that I could let people
into a normal day’s mess without feeling anxiety or judgement.’ She adds that that would feel ‘quite freeing’.27

  Signs of our concern for social appearance are everywhere. It is as if most of us fear being seen for what we are, as if acceptance depended on hiding some awful truth about ourselves: what we really look like, our ignorance, signs of ageing, unemployment, low pay, incipient alcohol dependence, humourlessness, inability to make small talk – in fact anything which might make others view us less positively.

  For most people these feelings are not usually serious, but they are nevertheless a mild source of additional stress in a great many spheres of life. As such, they increase our vulnerability to other difficulties. For example, to stiffen your nerve, you might get used to drinking more than you should, or become oversensitive to what people say, or start to be seen as ‘touchy’. Nervousness can make you more inhibited. Some become depressed by a sense of failure. In the absence of easy and enjoyable interaction with people, you become more prone to having slight paranoia about others. When these difficulties seem to be piling up it would be tempting – for example – to start feigning sickness, and taking extra days off work. You might comfort eat, or find it harder to stop smoking. These behaviours could themselves become additional things to hide from others, or reasons to avoid them altogether, so making you more socially isolated.

  FRIENDSHIP AND HEALTH

  Being cut off from each other by high levels of social anxiety is very damaging. Over the last thirty or forty years, a large number of studies have shown that having a network of close friends, good relationships and involvement with others is extraordinarily beneficial to health. As well as its direct effects on health, anxiety also makes a powerful additional contribution to illness and reduced life expectancy because it reduces friendship, weakens community life and increases social isolation.

  The best summary of evidence on the health benefits of friendship comes from a 2010 research report combining data from almost 150 different peer-reviewed studies, which together included individual data on more than 300,000 people.28 The report concluded that having lots of friends, enjoying good relationships and being involved with others is not just an attractive idea: it is at least as important to health and longevity as not smoking. Although the long-term sick may lose friends, the studies found that having fewer friends led to poorer health.

  Many of the studies of friendship and health were observational: they asked initially healthy people about their friendship patterns and followed them over time while taking differences in education, income or class into account to ensure that they compared like with like. But there have also been experimental studies. One involved making blister wounds on the arms of volunteers. It found that they healed more slowly among people who had more hostile relationships.29 Another, in which volunteers were given nasal drops containing cold viruses, found that after the same measured exposure to infection, people with fewer friends were four times as likely to develop colds, even after taking account of prior antibody levels and a number of other factors.30

  Causes of health and illness which stand out most clearly in population data are likely to be those which at least some people have too much or too little of. For example, the effects of vitamin deficiency were most obvious when many people were short of nutrients. Scurvy couldn’t be ignored on long sea voyages when people were short of fresh fruit and vegetables, but in well-nourished populations the evidence that particular nutrients are important for health is much less obvious. It is the same with friendship. Because studies depend on comparisons, what makes it possible for so many studies of large random samples of the population to provide evidence that friendship and social networks are so protective of health, is that each sample contains not only people with good social networks but also a large number whose networks fall below some level of adequacy. It is an odd paradox that in our modern, densely populated urban societies, there is a shortage of friendship and good relationships; people are together, but separate. Recognizing the importance of social bonds to health, people in Germany sometimes refer to them as ‘vitamin B’ – for Beziehungen, meaning ‘relationships’. To remember the health benefits of friendship, English speakers would do well to remember the importance of vitamin F.

  Much of the effect of friendship on health is likely to be rooted in reduced stress and increased social ease which means that people are less likely to ‘keep themselves to themselves’. The health differences between people who are more and less sociable will partly reflect differences in the stresses and anxieties that make us either welcome or avoid social contact in the first place. Even people who experience only mild levels of shyness or self-consciousness will sometimes feel social contact involves too much of an effort and would prefer to stay at home than go out. Those more susceptible to social anxiety will often find social gatherings so stressful that they regard them as an ordeal to be avoided whenever possible.

  Sustained over long periods, stress is damaging to health. It interferes with many different physiological processes, including the immune and cardiovascular systems. When prolonged, its effects are similar to more rapid ageing: people become vulnerable to the effects of old age – including the risks of degenerative diseases and death – earlier than they otherwise would. And if even fairly low levels of stress continue for months and years, the evidence shows (Figure 1.1) that death rates are raised and lives shortened.31

  But although the number of friends people have is sometimes an indication of how stressful they find social contact, that is not the only reason friendship and health are related. At its heart it is about whether people feel liked or disliked, valued or devalued, by others. Having friends who value you makes you feel better about yourself and increases confidence, just as feeling excluded and unwanted has the opposite effect. It’s a two-way relationship: whether or not you have friends is partly a reflection of how easy or difficult you find social contact, but having friends increases feelings of self-efficacy and confidence.32, 33 It is, after all, almost impossible to remain self-confident if you feel excluded by others.

  Figure 1.1: The more stress people experience, the higher their death rates. Data include 8,365 deaths among 75,936 people (aged 35 years and older living in England) whose levels of distress were surveyed using measures of anxiety, depression, social dysfunction and loss of confidence.31

  There are few sources of pleasure as important as time spent chatting and joking with friends, and it would be surprising if having friends and good social contacts was not also a key to happiness. In his book Happiness: Lessons From a New Science, the economist Richard Layard outlined the evidence showing how marriage, friendship, involvement in community life and voluntary work are all powerful contributors to happiness.34 A more recent 2014 study, using data on almost 50,000 people in 25 European countries, confirmed that social interaction and feeling you can trust others makes an important contribution to happiness.35 Human beings are more fundamentally social animals than is often recognized, and our enjoyment of relaxed social contact is a pleasure that is too often overlooked. If you had to choose between more money and more contact with other people, the data suggest that becoming more involved with other people brings as much additional happiness as an increase in income of £85,000 a year.36 On that basis, if happiness was for sale, it looks as if rather few would be able to afford it.

  THE CHALLENGE

  The high levels of social anxiety in modern developed countries mean we are faced with an important conundrum. Friendship and good social contact are essential for health and happiness, and yet people so often shrink from meeting each other.

  Resolving this problem would improve the quality of life not merely of those who experience it most acutely, but probably for a substantial majority of the population who are less inhibited by it. Fortunately, a vital clue both to the root of the problem and to its solution is becoming increasingly clear. A number of studies show that community life is weaker in societies with bigger income
differences between rich and poor. Societies with smaller income gaps have repeatedly been shown to be more cohesive. People in more equal societies are more likely to be involved in local groups, voluntary organizations and civic associations.37 They are more likely to feel they can trust each other, are more willing to help one another, and rates of violence (as measured by homicide rates) are consistently lower.38-40 People get along with each other better in more equal societies.

  Since before the French Revolution, the idea that inequality is divisive and socially corrosive has been widespread.41 Now that we have sufficient data to compare inequality – as measured by income differences between rich and poor – in each country, it has become clear that this intuition is emphatically correct, perhaps more so than we ever imagined. Rather than a private hunch, it has – as hundreds of studies now show – become an objectively demonstrable truth.2, 3 Figure 2.7 in the next chapter shows the international association between income inequality and participation in local organizations and groups. In The Spirit Level we showed similar relationships between inequality and measures of trust.

  We thought that the most likely explanation for why community life is stronger in more equal societies might be that people are more at ease with each other in those societies; greater equality might make mixing easier if it meant there were smaller differences in perceptions of personal worth. Most people do, after all, tend to choose their friends from among their near equals. Although that is certainly true, the causal processes are not quite so simple: social anxiety does not just affect people when in the company of those who are better off than them. People worry about failing to create a good impression even among near equals.