On 12th December 2016 preliminary reports appeared of the Origins of Happiness , an upcoming book by Andrew Clark, Sarah Fleche, Richard Layard, Nattavudh Powdthavee and George Ward. This has caused some controversy due to the apparent claim that Governments should abandon attempts to alleviate poverty, and turn their attention to ‘mental illness’ instead.
There are many aspects of the Origins of Happiness preliminary report that should be celebrated. We are pleased to see mental health being given such prominence, and a public mental health agenda being promoted. Furthermore, the presentation of the social determinants of mental well-being in the report alongside preventative strategies to tackle mental health problems in society is something psychologists have long been promoting (see Albee 1999 & Harper, 2016). The focus on specific policies that aim to reduce fear and misery is definitely to be welcomed, as is a recommendation to invest more money in mental health services.
Much of the media coverage has focussed on the dichotomy presented in the report between ‘income’ and ‘mental illness’ as predictors of life satisfaction. The authors of the preliminary report conclude that, a) income has a lesser impact on life satisfaction than ‘mental illness’ and b) poverty is more expensive to address than ‘treating mental illness’. They, therefore, conclude that policies should focus on treating mental health, rather than addressing income inequality or other factors such as unemployment. Some media reports have gone further, apparently taking the results to imply that there is no causal relationship between poverty and mental illness.
This report minimises the social context of mental health too readily. It presents ‘poverty’ and ‘mental illness’ as independent variables, even though they are related in a complex variety of ways, with both causally influencing the other (Elliott, 2016). For instance, there is substantial evidence that social factors, especially adverse experiences in childhood, social disadvantage, poverty and inequity, are related to mental health issues (Cromby, Harper & Reavey; Friedli, 2009; McGrath, Walker & Jones, 2016; Pickett & Wilkinson, 2010; Rogers & Pilgrim, 2003; Rogers & Pilgrim, 2013; Smail, 1993; Smail, 2005; Wilkinson & Pickett, 2009). However, the link between poverty and mental distress is not due to a singular variable of ‘income’ (see Elliott, 2016). Living in poverty is more stressful, with fewer buffers, so challenges are more likely to be catastrophic. People living in poverty have less agency and control over their lives, and live with lower status, often accompanied by stigma, powerlessness and shame (Marmot, 2004). In fact, shame and powerlessness are common features of many mental health presentations (Cromby & Harper, 2009; Gilbert, 2010). Simple regression modelling, as presented in the Origins of Happiness report, fails to capture these interrelationships because is not based on a psychologically plausible account of people’s lived experiences.
The report is right to point out that as our average incomes have increased we have not got happier as a nation, at least as measured by ‘Life Satisfaction’. However in addition to incomes rising overall, we have become a more unequal society, particularly since the early 1980s (Atkinson, 2015; Piketty, 2014). As the authors of this summary note in their conclusions, relative poverty is more important than absolute poverty in mental health terms (Wilkinson & Pickett, 2009). In our society, income is often taken as a proxy for status. Awareness of people’s income relative to our own can therefore profoundly influence how we feel about ourselves. Status determines how much control people can exercise over their lives and the extent to which they are recognised as a member of society (Marmot, 2004), and not being able to meet this fundamental human need can cause stress, low self-esteem and anxiety (Marmot 2004; Wilkinson & Pickett, 2009). Coburn (2015) has recently argued that status anxiety, the anxiety involving our perception that we are of low social status in relation to others, may affect upper income groups, but that lower income groups may be more affected by the material constraints that living in poverty entails. We are concerned about the absence of this research in the report’s discussion of mental health and poverty. This may be an omission due to the brevity of the publication, and we would expect the authors’ forthcoming book-length analysis to include a more rigorous review of the relevant literature. These decisions need to be critically assessed to determine whose interests are being served. Discussions of mental health that leave out a thorough analysis of poverty and income inequality may be used uphold policies that maintain disadvantage and oppression in society.
Not only does the research take some of these elements out of context, but the resulting models are tautological. For instance, the authors say, “Misery [is] caused by mental illness: When we ask what distinguishes Les Misérables from the rest, the biggest distinguishing feature (other things equal) is neither poverty nor unemployment but mental illness.” Another term we could use for ‘mental illness’ here is suffering; people suffer when bad things happen to them. Sometimes, enough bad things happen, or a sufficiently severe thing happens, which tips people beyond emotional turmoil and into more extreme experiences that are labelled mental health problems. Framed in this way it becomes obvious that ‘mental illness’ will predict ‘misery’ (here defined as the lowest 10% of people on life satisfaction). These two terms relate to the same experiences. There are rich literatures dealing with these issues in philosophy, psychology and sociology, yet the report – written, it seems, by economists without reference to other disciplinary perspectives – takes a conceptually naive approach to ‘misery’. A genuinely interdisciplinary approach to public health will require collaborative research between researchers from different backgrounds. There are very real challenges to working across disciplines, but also opportunities for a revitalised approach to articulating a vision of how we might organise society to take more account of the social determination of mental health.
To conclude, the call for increased investment in mental health services and consideration of wellbeing in governmental policy-making is welcomed. However, the assumption in this report that ‘mental illness’ is something that occurs in individuals, divorced from their physical and social contexts, has narrow implications for policy. All treatment proposed is on the individual level with psychological therapies delivered in adulthood, or individualised resilience training for children. There is a place for both of these interventions. As psychologists, we work therapeutically with people experiencing distress on a daily basis. We know the benefits of these approaches, and how they can help support people through times of difficulty and onto a path of recovery. However, we also know what their limitations are because, whilst they may be effective, they will never be available to all those who need them and they do not proactively address the fact that the causes of distress are not only individual – they are also social, relational and material. Without action to minimise poverty and social inequalities which cause and worsen distress, the effects of psychological treatments are at best short-lived.
What can I do?
- Get people talking; ask whether your colleagues have heard about the preliminary report on Monday. What do they think about distress and mental illness being separated in this way? What about the role of poverty and unemployment in mental distress? What needs to change on the basis of this? Our second briefing paper might help you prepare for this!
- Read about the relationship between poverty and mental health status (Drentea & Reynolds, 2012; Rai et al., 2013; Reading & Reynolds, 2001; Rogers & Pilgrim, 2003), and the experiences of those seeking to claim benefits (Cromby & Willis, 2013; Friedli & Stearn, 2015).
- This is a preliminary report, so let’s alert policy-makers to its limitations and contradictions in preparation for the upcoming report. Write to your local councillors, MP or health and wellbeing board to highlight your concerns about the report and ask what their response will be to the actual report when it is announced.
- Share your concerns through the media; letters to local papers, blogs, tweets, articles and podcasts will all help to inform public debate on allocation of funds within the public sector. Use this statement as a basis for your own commentary, or refer back to the first briefing paper for a wider range of research relating austerity policies to mental health.
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