LABELS AND CUT-OFFS
Before we consider how inequality might create depression and anxiety, we do need to be sure that the statistics we’re relying on are valid and appropriate for comparing levels of mental illness in different populations. Few countries have the kinds of health-care systems and data storage that would let us compare hospital admissions or outpatient treatment rates for mental illness. In any case, these measures would be skewed by the variance in access to medical care, and the degree to which mental illness is stigmatized in different cultures and societies. For the same reasons, we can’t simply ask people in a survey whether or not they have ever been treated for mental illness, or told by a doctor that they have a mental illness.
If we want to know whether a particular individual has a mental illness, we can refer them to a psychiatrist for a careful (also lengthy and expensive) diagnostic interview. The psychiatrist will consider his or her assessment of the patient against a system for classifying different types of mental illness. But if we want to know about the level of depression in the whole population, rather than in a particular individual, or examine trends in depression over time, or compare different countries, then we obviously need a method that is quicker and cheaper than the gold-standard psychiatric interview, but which nevertheless remains accurate and reliable. For these purposes, researchers use ‘diagnostic interview schedules’, developed in the United States in the late 1970s for large-scale surveys of mental illness in the population. They are highly structured interviews that lay out very precisely the questions that the interviewer must ask, with a substantial number of questions related to symptoms of each mental illness. Once someone has answered all the questions, their answers can be scored to decide whether or not they meet the criteria for one or more disorders. The reason these interviews can be used in large-scale surveys, despite being rather lengthy, is that they can be carried out cheaply by non-clinician interviewers with minimal training.
There have been a huge number of studies that evaluate how these interviews compare to the gold-standard psychiatric assessment, and the interviews have been refined and improved over time. The general feeling in the academic psychiatric literature is that, while they may slightly overestimate ‘clinical’ levels of mental illness, they allow us to reliably compare levels of mental illness over time and across different societies. The main criticism of the technique comes from those concerned about thresholds: are we labelling too many people as ‘ill’, when all mental health conditions exist along a continuum?68 Some people are severely depressed, some are moderately depressed, some are mildly depressed, some have been depressed for long periods of time, others for short episodes – where should the cut-offs fall?
WHY ARE SOME GROUPS SO VULNERABLE?
To some extent, these questions about cut-offs and labels are red herrings. If we accept the consensus of experts that the surveys are reliable and reasonably accurate, then the question is not whether it is 23 per cent of British adults suffering from mental illness, as opposed to, say, 20 per cent, or whether a particular score should put you into the category of severe depression versus moderate depression, but rather: why do some societies have much higher levels of mental illness, particularly depression and anxiety, than others? And why do those levels change over time? In some countries around a quarter of the population suffers mental distress each year. If almost one in four of us feels sad, unhappy, fatigued, suicidal, traumatized, guilty, lonely, anxious, nervous, unconfident, etc., what is it about those environments or societies that produces such feelings, and why are we so vulnerable to feelings that can cause us to withdraw from our family, be incapable of work, and unable to involve ourselves with friends and community?
When faced with such questions, we should look for a pattern. We can begin to move towards some answers by looking at the relationship between mental illness and where people fall on the social ladder. As with so many other health and social problems, people at the bottom are more affected than those at the top: mental illness is a socially graded issue. A 2007 national survey of mental illness in England showed that people whose incomes put them into the lowest 20 per cent of household incomes were more likely to have a ‘common mental disorder’ than those with incomes in the top 20 per cent, and that this pattern was particularly striking for men.69 Men in the lowest income group were three times more likely to have a mental health problem compared to men in the highest income group, after taking age into account. Specifically, depression showed the most extreme gradient: men at the bottom were thirty-five times more likely to have depression as men at the top (Figure 2.3). But as with so many other health and social problems, mental illness isn’t restricted to the least well off; even men in the second richest income group were substantially more likely to have depression than those in the richest group.
DOMINANCE AND SUBMISSION
Psychologists are now uncovering the role of both evolution and experience in creating regular responses to and interactions with features of our day-to-day environments. Some systems of behavioural responses can be recognized in animals as well as in humans. One such system that casts an important light on our understanding of mental illness is the Dominance Behavioural System, or DBS.70 Because issues of dominance and subordination are key to the conduct of social life in all animal species with ranking systems, the brain has evolved systems for understanding them, making judgements of rank and producing appropriate behavioural responses.
Figure 2.3: There is a social gradient in depression.69
In the words of Sheri Johnson, a psychologist at the University of California at Berkeley, and her colleagues, the DBS can be ‘conceptualized as a biologically based system which guides dominance motivation, dominant and subordinate behavior, and responsivity to perceptions of power and subordination’.70 The DBS affects how we react to superiors and inferiors and ensures that we know our own position. Crucial in social interactions, it helps us learn the best social strategies for meeting our own needs while avoiding unwinnable conflict and defeat. If competition leads to misjudged aggression, there can be huge costs, both for individuals and for the group, so we have evolved a capacity for judging rank, deciding when to play dominant or subordinate roles.
Although the DBS is a system with a long evolutionary history, it is shaped by our environment and experience. As children, we learn from experiences of power and powerlessness, and develop a working model which shapes our thoughts, emotions and actions related to power. We learn, for example, that if we are aggressive towards other children, maybe we can snatch a desired toy, but that doing so often leads to conflict and consequently we have nobody to play with; if we share a toy, sometimes others might share with us. We learn from past success and failure. Some people develop a strong motivation for dominance; others try to avoid it. People who have a high motivation for dominance might act more aggressively than others, they might assert their authority, display over-confidence in their abilities or opinions, or they might try to gain dominance by aligning themselves with others, ingratiating themselves with those who have authority or power. Psychological researchers have tried to capture some of this complexity in the model we draw below (Figure 2.4): we all act somewhere along a continuum from dominant to submissive behaviour, but in addition we can act in social (warm) or antisocial (hostile) ways to achieve our goals.
Figure 2.4: Humans act along two dimensions of behaviour: dominance/submissiveness and warmth/hostility.
In our modern world, most of us are not seeking access to scarce food or shelter (although we still, of course, seek access to sexual partners); we’re trying to access esteem, praise, attention, respect and power, whether cultural, political or economic. When we have powerfn1 our emotions are more positive, we are more confident, we think faster and are less behaviourally inhibited, which means that sometimes we’re less sensitive to others than we could be.70 On the other hand, when we’re powerless, we feel vulnerable and inhibited, we are sensitive to threats and fearful of
being disliked or rejected.
The Dominance Behavioural System relates to our emotions, specifically the self-conscious ones: feelings of pride on the one hand and shame on the other. We feel pride when we’re doing well in the eyes of others, when we have their respect and attention. We feel shame when we feel devalued by others, when we feel inferior and unattractive, when our confidence is low. The experience of loss of face and humiliation is often a trigger to violence when people try to defend themselves against being shamed.
We can measure different aspects of the human Dominance Behavioural System – dominance motivation, dominance behaviour, power, pride and shame – which means we can see how it relates to mental illness and to inequality. We can measure it in children as young as pre-school age, rating how they interact with others, whether they are aggressive or submissive in a conflict and so on. In addition, biological measures, such as levels of testosterone in the saliva or blood, can be usefully correlated with other measures of dominance motivation and behaviour. For example, in a study of almost seven hundred men in prison, those with a history of violence had higher levels of testosterone than those with a history of property crime.71 This link between testosterone levels and dominance is reinforced by studies which show that people with low levels of testosterone show signs of distress when they are temporarily placed in a high-status position in psychological experiments. Other hormones, such as dopamine, serotonin and cortisol, all intimately related to our emotional reward system and stress responses, are also linked to power and the kind of social defeat – losing in any kind of confrontation – that invokes shame.
STUCK IN SUBORDINATION
In what ways is our Dominance Behaviour System linked to mental illness? In a remarkable review of many hundreds of psychological research papers on experimental, observational, biological and self-reported aspects of mental illness, Sheri Johnson and two colleagues found evidence that a number of different kinds of mental illness and personality disorders were related to the DBS.70 They report:
Extensive research suggests that externalizing disorders, mania proneness, and narcissistic traits are related to heightened dominance motivation and behaviors. Mania and narcissistic traits also appear related to inflated self-perceptions of power. Anxiety and depression are related to subordination and submissiveness, as well as a desire to avoid subordination.
Externalizing disorders include disorders characterized by disruptive behaviour. Mania includes conditions with heightened arousal and mood and is part of bipolar disorders and depression, as well as psychotic mood disorders and schizophrenia.
When this paper was written in 2012, the authors had assumed that the scale of the social class pyramid which would raise issues of dominance and subordination involving the DBS was much the same in most societies. But it is now clear that most of the conditions to which the authors drew attention are actually more common in more unequal countries. We shall see in the course of this chapter and the next that depression, psychotic symptoms, schizophrenia and narcissistic traits are all significantly more common in more unequal societies. Given that people with these disorders are at one end of a continuum of much more widespread but less severe problems, the evidence points to the very serious costs of greater inequality across entire populations, in terms of the personal anguish which so many suffer. The conclusion that these forms of psychopathology involve the DBS, and that greater inequality strengthens issues to do with dominance and subordination which trigger the DBS more strongly is hard to avoid.
It is sometimes suggested that the lower burden of mental illness in more equal societies may not result from the psychological effects of inequality, but could instead reflect higher public expenditure on services which could help prevent or treat illness.72 A study was specifically designed to test this using data on over 35,000 people from 30 European countries. It found no support for explanations involving public spending, but did find support for what the author called the ‘psychosocial hypothesis’72: more equal countries seemed to have better mental health at least partly because their populations are less anxious about status and are more involved in social networks that involve reciprocity, trust and co-operation. A similar study that sought to see if lower public expenditure contributed to the relationship between higher inequality and higher levels of violence reached the same negative conclusions.73
Inequality, then, damages mental health because it affects how we feel and the nature of our social relationships, not because of the amount a country chooses to spend on its health system. We should therefore continue to follow up the issues to do with dominance and subordination related to inequality. First we’ll concentrate in this chapter on the pathways involving submission and subordination running from inequality to status anxiety, to depression and anxiety. In the next chapter, we’ll consider what happens when inequality heightens dominance behaviours.
Researchers increasingly consider involuntary subordination and submission to be a pathway into depression. Submission involves signs of defeat. In our evolutionary past, this would be how we avoided physical injuries, even death: submissive behaviour served to end fights with superiors and avoid future conflict. Even when competition and aggression is rarely physical, submissive behaviours can still make sense; they may help us to avoid ongoing conflict or trigger assistance from others.
That our stress responses to subordination still reflect the fear of physical conflict is shown by studies of levels of a blood clotting factor called fibrinogen. Fibrinogen levels rise in response to stress so that blood clots faster in the event of injury. In a study of almost 3,300 middle-aged men and women working in the British civil service, fibrinogen levels were found to be higher in both sexes at each step down the office hierarchy.74 The blood of subordinate civil servants appeared to be prepared for the kind of attacks which, for example, a subordinate baboon might risk from dominants.
The theory linking depression to submission and subordination suggests that it results from an inability to stop, or escape from, a submissive situation or defeat. A growing body of research supports this idea. Across more than twenty research studies, it has been found that people with depression were more likely to report feeling inferior, or experiencing shame.70 Twenty-three studies have found that low testosterone levels are related to depression and depressive symptoms, and in an experiment where men were given testosterone-lowering drugs, 10 per cent developed depressive symptoms, compared to none in the group receiving a placebo drug. In another study, people without depression who were given antidepressant medication became less submissive, when assessed by the people they lived with, and more dominant when interacting with strangers in a psychological laboratory.
Anxiety and depression often coincide, and anxiety is also closely related to powerlessness, lack of control, subordination and social defeat. People seem to be particularly susceptible to social anxiety as a result of rejection and childhood experiences of insecure attachment, which lead to a heightened sensitivity to social comparisons and attempts to avoid ostracism and harmful attention. Anxious individuals are constantly monitoring social rank, fearful of humiliation, and perceive themselves as lacking power. As with depression, studies of anxiety show that it is correlated with feelings of shame and submission, and people with anxiety are prone to comparing themselves unfavourably to others. Some studies suggest that anxiety is most common in individuals with high levels of dominance motivation who experience threats to social power – a situation slightly different from depression, where people are more motivated to avoid conflict. But, overall, the desire to avoid inferiority seems to be stronger in those with anxiety disorders than among those trying to achieve dominance. When shown images of angry faces, which psychologists consider a potent social signal of hostility or dominance, people with social anxiety disorder react more strongly than others.75
This large body of research evidence linking the Dominance Behaviour System to the self-conscious emotions (including sensitivity to social t
hreats and low self-esteem, as well as to symptoms or clinical diagnoses of depression and anxiety), makes the links between inequality, worries about how we are judged and mental illness very clear. We have built-in strategies – not necessarily conscious ones – for dealing with situations that might require us to adopt either a dominant or submissive tactic, or a balance of both.
Paul Gilbert, a pioneering clinical and research psychologist at the University of Derby, who has extensively studied these patterns of behaviour, their evolutionary basis and links to mental illness, describes in his book, The Compassionate Mind,76 the human need to be cared for in infancy and childhood. Through our long evolutionary history, maternal caring protected us from predators, provided food and comfort and calmed us when we were upset or anxious. When an infant or child is cut off from this care, it protests through crying and communicating distress, trying to elicit help, protection and support. But if help or the return of the mother doesn’t happen quickly, these signals could quickly become dangerous – noise can attract danger, it’s better to be silent. Gilbert describes despair as ‘a form of behavioural deactivation when protest does not work. Positive emotions and feelings of confidence and the desire to explore, search and seek out must be toned down.’
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