The Inner Level

by Richard Wilkinson

  There are so many life events or situations that can trigger this ‘deactivation’ strategy – defeats and setbacks, being dominated, bullied or rejected. While initially protective, such a response involves feeling less (or nothing), turning off our positive as well as negative emotions, and some of us get stuck, unable to turn off this ‘coping’ strategy when it is no longer helpful. Feeling cut off from other people, we can get stuck in a self-reinforcing cycle of rumination, trying to work out why we feel such a failure and driving ourselves further into depression. This chain of events, from rejection and defeat to depression, seems to be activated on the scale of an epidemic in the modern world: as mentioned earlier, according to the World Health Organization, depression is the major cause of disability globally.77 We might be trapped in a situation, at school or work or at home where we are bullied, put down or made to feel inferior. We might hate our job but need the money, so continue in a situation where we feel stressed every day. We are often trapped, and it is this entrapment in a submissive or subordinate response that is at the root of depression. The following were all posted on an internet chat site, I Just Want To Be Left Alone:

  I don’t think I have always been someone who hides … I do believe it is because I am somehow ashamed. I take on every fault that is turned my way as my own. I think if an injustice is done to me that I must have caused it somehow. (Posted 2009)

  Too much concern about what other people think. I hide away not only because I think others will think poorly of me, but because I care a lot about their opinions. (Posted 2008)

  The real person in my head, whom I’m trying to let out [is] not … quiet, boring, always thinking and having anxiety from every little aspect of his life. Being shy is destroying my life. I love people but I have no clue how I could interact with them to the extent that they will be my friends. (Posted 2009)

  Psychologists have developed a measure of our sensitivity to subordination called the ‘striving to avoid inferiority scale’.78 This measures fear of rejection or criticism for ‘not keeping up’ with others; the pressure to compete to avoid inferiority. Researchers have found that some people exhibit what they call insecure striving, a fear of rejection, of being overlooked and losing out, linked to a tendency to seek validation from others, feel inferior, shame and submissive behaviour – and increased stress, depression, anxiety and self-harm.79

  Self-harm is perhaps the most shocking example of how low self-esteem and perceived lack of control can manifest as a health problem. The numbers are staggering. Representative surveys of health behaviour in England, carried out in schools under exam conditions, suggest that 22 per cent of children aged fifteen have self-harmed at least once, and 43 per cent of those said they harmed themselves once a month.24, 80 Figures from an Australian study, based on telephone interviews, suggest that one in twelve (2 million people) self-harm sometime during their lives.81 This figure is likely to be an underestimate resulting from a low response rate (38 per cent) caused mainly by parents refusing to give permission for children under eighteen to be interviewed. The USA and Canada consistently report that somewhere between 13 and 24 per cent of school children self-harm.82 Young people, some as young as seven years old, are cutting, scratching and burning themselves, pulling out their hair, bruising themselves and deliberately breaking their own bones.

  It’s hard to imagine the mental anguish that makes life seem so painful that inflicting bodily pain comes as a release, and provides a (very temporary) sense of control, but those feelings are what many young people and adults consistently report. Self-harm is more common in people who are very self-critical and have feelings of shame; early experiences of abuse, trauma or neglect can, unsurprisingly, play a part, but the recent epidemic rise of self-harm suggests that something has changed in our societies to make this problem worse.83

  It may be that for those unable to reach ‘socially desirable goals or self-images’, the ensuing sense of shame turns into anger and harm towards oneself. Self-harm as a response to social pain may also reflect the very close connection between physical and social pain. Brain scans show that the pain of feeling excluded by others activates the same areas of the brain as physical pain.84 The connection between the two is so deep that doses of common pain-killing drugs like acetaminophen / paracetamol (marketed as Tylenol and Panadol) have been found to reduce not only the physical aches and pains we normally use them for, but also the emotional upsets and anxieties that come, for instance, from the experience of rejection.85

  Looking back at Figure 2.3, at the gradient in depression from rich to poor, it is hard to avoid the conclusion that this is partly a reflection of a gradient in the freedom of action to escape from entrapment in a stressful situation; and then, looking at the pattern in Figure 2.1, that more unequal societies increase this kind of threat for all of us. We need to link our understanding of individual vulnerability to what might be damaging characteristics of whole societies or cultures to gain an understanding of the modern epidemic of depression and anxiety.

  Depression and anxiety are so much a part of our human development, so much a part of our evolutionary heritage, that they feel like programmed responses we can’t shake off. Understanding the Dominance Behavioural System helps to explain why we are so sensitive to the way that others see us, why we are attuned to rank and status, and why some of our individual experiences – such as poor attachment in infancy, rejection and bullying in adolescence or not feeling valued by people round us – might trigger submission and subordination in some people.

  KEEPING UP WITH THE JONESES, LOOKING DOWN ON THE SMITHS

  In more competitive, unequal and materialistic societies, where hierarchy matters more and people are more prone to compare themselves with others, doing well in others’ eyes and having all the trappings and characteristics of success becomes the main meaning of achievement. The Dominance Behaviour System helps us understand how we have evolved to be sensitive to situations of social threat. From this, we can hypothesize that situations in which our social status is higher, where we feel in control of our lives and more appreciated by people round us, will lead to less depression and anxiety, and situations where we are at greater risk of low social status and feel less in control will lead to more.

  There is a common belief that as people ascend to positions of leadership and face increasing demands and responsibilities, they will experience higher levels of stress. If, however, leaders also have an increased sense of control as a result of their higher status, leadership should actually be linked to lower levels of stress.

  Researchers studying people enrolled in an executive education programme at Harvard University compared leaders (defined as people who managed others) with non-leaders.86 After taking into account age, sex, education, income and mood, they found that the leaders had lower levels of the stress hormone cortisol, and reported lower levels of anxiety than the non-leaders. Then, looking only at the leaders, the researchers studied the interplay between leadership, a sense of control, and stress. Higher leadership (managing more people, having more people directly reporting to them and more authority) was linked to lower cortisol levels and lower levels of anxiety. Higher leadership predicted a greater sense of control, and this in turn predicted lower cortisol and lower anxiety. The higher the rank that people held and the more power and control they had, the less stressed they were.

  An additional insight into the importance of rank comes from psychologist Alex Wood, from the University of Stirling, and his colleagues.87 They argue that if social rank is important for mental well-being, then income should be related to mental health through the way it acts as a proxy or marker for rank: the amount of income you have should matter primarily for where it places you in the social hierarchy.

  Taking a very large sample of 30,000 people in the UK, they used a statistical model that allowed them to compare the effect of absolute level of income to income rank. They found that in terms of predicting mental distress, rank trumped absolute incom
e, even when accounting for age, gender, education, marital status, house ownership and other factors. The researchers were also able to show that a person’s income rank at a given time was related to changes in mental distress over the next year – whatever their mental state to begin with. The same was true for people thinking about or attempting suicide: where people ranked in the income distribution was more important than how much money they had.88 The same pattern was confirmed by research in the United States, which showed that, over time, a person’s income within a social comparison group, rather than their income itself, predicted the development of depressive symptoms.89

  The effects of rank go beyond distress, depressive symptoms and even suicidal thoughts; income rank leaves a physical mark on our bodies as well. Woods’s research team has shown that income rank trumps absolute income for predicting biological markers of disease such as levels of cholesterol, blood pressure, body fat and blood sugar control.90

  A similar study used data on psychological (e.g., feeling low or nervous) and physical (e.g., headache) symptoms in more than 48,000 adolescents in 8 countries. It looked to see whether the frequency of symptoms among children was most affected by actual family income or by how their income compared with families of other children attending the same school or living in the same area. Once again, income rank compared to other families was related to the adolescents’ symptoms more strongly than absolute levels of affluence or deprivation.91 These findings are reinforced by a study of eleven-year-olds in the UK, which found that, as expected, children had higher self-esteem and life satisfaction if family incomes were higher. In addition, young people who viewed their family as poorer than those of their friends were more likely to have worse well-being, even when actual family incomes were the same.92

  As we have seen, people in positions of leadership tend to suffer less stress, and where we stand on the social ladder seems to matter more for both mental and physical health than the actual amount of money we have. If income is important mainly because of where it locates you in the social hierarchy, it doesn’t mean that differences in the level of inequality wouldn’t matter. In any given society income differences could be made either bigger or smaller without moving anyone up or down the rank order of incomes. But if the differences between people’s income become very small indeed, we would be almost unaware of the differences – we would all appear and feel much the same in status. If, however, the income differences were huge, we would be unable to ignore them. Everyone’s position in relation to others would be immediately apparent and the status differences would be obvious. So the size of income differences makes income rank, social position or status either much more or much less important.

  THE EVIDENCE GROWS

  We started this chapter by showing the strong link between income inequality and levels of status anxiety and mental illness in different societies. With a clearer understanding of how inequality increases the importance of the social evaluative threat, and how this activates the Dominance Behavioural System, we can begin to understand the consequences of greater inequality for mental illness. There are now several studies showing that some of the disorders that Sheri Johnson and her colleagues found to be related to the DBS are indeed more common in more unequal societies.

  Researchers from the Inter-American Development Bank used data from more than 80,000 people from 93 countries who responded to a 2007 Gallup Opinion Poll.93 Although this study is limited by having only a self-reported measure of depression, its findings are still thought-provoking: overall, almost 15 per cent of people reported feeling depressed the previous day. Significantly, some countries had much lower, and others much higher, rates. These differences were unrelated to average incomes but correlated closely with income inequality. The effect of inequality seems to have been felt more keenly by people living in cities, rather than in rural areas. Some studies have looked at particular population groups. Higher income inequality was linked to higher depression scores among 17,348 university students from 23 high-, middle- and low-income countries, after controlling for family wealth and other factors.94 In a 2008 study of 251,158 people, surveyed in 65 countries by the World Health Organization from 2002 to 2003, income inequality was related to depression in high-, but not middle- and low-income countries.95 In a study conducted across forty-five US states,96 there is a clear relationship between income inequality and higher rates of depression (see Figure 2.5), and this is borne out by another study by Amy Fan and her colleagues,97 and one of depression among older adults.98 Another study found that depression was more common in those European societies where people judged social status differences to be larger.99

  The questions used to identify the prevalence of depression shown in Figure 2.5 would have included most cases of bipolar disorder. Before the revised official categorization of mental illness introduced in 2013, bipolar disorder was treated as a sub-classification of depression. Bipolar disorder, in the past also called ‘manic depression’, is characterized by dramatic mood swings. Over periods that can vary from a few days to a few months, people can move from depression to a very positive, even euphoric, mood and back again. A paper by Johnson and Carver reports the results of a series of experiments which found that people in the manic phase showed numerous signs of dominance motivation, and high assessment of their own power in terms of both dominance and prestige.100 They also showed signs of hubris and pride in themselves. Other research has suggested that these characteristics tend to go with overly positive social comparisons, high self-esteem and sometimes delusions of grandeur. But bipolar disorders are also related to self-harm, substance abuse and suicide. It looks as if the growing understanding of the Dominance Behavioural System may shed light on both the depressive and manic phases of bipolar disorder.

  Figure 2.5: Income inequality and prevalence of depression across forty-five US states.96

  Several studies have shown a tendency for schizophrenia to be more common where income differences are greater. The largest collected 107 measures of the prevalence of schizophrenia from 26 countries, and found that rates were higher in more unequal countries.101 The authors suggested that an explanation for the link might lie in the loss of social cohesion and heightened comparisons of rank in more unequal societies.

  Figure 2.6: Income inequality and incidence of schizophrenia, 1975–2001.101

  Another large multinational study analysed data on psychotic symptoms collected as part of a World Health Organization dataset that used diagnostic interviews with representative samples (totalling almost 250,000 people) in 50 countries.102 These symptoms included hearing voices, having feelings that people were ‘too interested in you’ or were plotting to harm you, and that your thoughts were being controlled by another person or by strange forces. Because more repressive governments might increase these kinds of fears of persecution or of being controlled, the study took into account the number of years of democratic government in each country. It found a significant tendency for these symptoms to be more common in the more unequal of the fifty countries. An increase in the share of income going to the richest 1 per cent of the population in each country was associated with increases in people experiencing hallucinations, delusional moods, delusions of thought control and with the total number of these symptoms suffered by people.

  Feelings that other people or external forces control your thoughts could perhaps be seen as the extreme end of a continuum from what psychologists call ‘external locus of control’ to ‘internal locus of control’. People differ in how far they regard what happens to them, and how their life pans out, is down to luck, fate and other people (i.e. external factors), and how far they believe that what happens to them depends on their own actions, choices and efforts (internal factors). For over fifty years psychologists have been looking at how far people have an internal or external ‘locus of control’. Measures are based on people’s responses to twenty-three contrasting pairs of statements, such as ‘People’s misfortunes result from the
mistakes they make’ versus ‘Many of the unhappy things in people’s lives are partly due to bad luck.’ Professor Jean Twenge collected all the data she could find from measures of external versus internal loci of control among samples of children (nine to fourteen years old) and of college students over the years 1960 to 2002 in the USA.103 She assembled measures from forty-one samples of children and ninety-seven college students. When she looked at changes over time she found that there had been a large decline in how much control young people felt they had over their lives. According to Twenge, ‘the implications of increasing externality are almost uniformly negative’. People with an external locus of control are more anxious and more likely to be depressed, and in childhood they do less well at school. She says that the rise in external locus of control measures reflects a growth of cynicism, distrust and alienation.

  The rise in income differences in the USA from the later 1960s, and which continued well beyond the end of Twenge’s study period, is at least consistent with the idea that increasing inequality might have contributed to the trend towards this feeling of external locus of control. We found only one study that looked to see if there is a relationship between locus of control and inequality. Using data for forty-three countries, it found – as expected – that people in more unequal countries felt they had less control over their lives.104 The same study also showed that there was an increase in external locus of control at each step down the income scale, from the richest with most sense of control to the poorest with least.

  The reality is that inequality causes real suffering, regardless of how we choose to label such distress. Greater inequality heightens social threat and status anxiety, evoking feelings of shame which feed into our instincts for withdrawal, submission and subordination: when the social pyramid gets higher and steeper and status insecurity increases, there are widespread psychological costs. Status competition and anxiety increase, people become less friendly, less altruistic and more likely to put others down.