As social epidemiologists, Wilkinson and Pickett studied the connection between society and health in the broad sense of the word. Stress proves to be a key factor here. Research has revealed its impact, both on our immune systems and our cardiovascular systems. Tracing the causes of stress is difficult, though, especially given that we live in the prosperous and peaceful West. If we take a somewhat broader view, most academics agree on the five factors that determine our health: early childhood; the fears and cares we experience; the quality of our social relationships; the extent to which we have control over our lives; and, finally, our social status. The worse you score in these areas, the worse your health and the shorter your life expectancy are likely to be.
In his first book, The Impact of Inequality: how to make sick societies healthier, Wilkinson scrutinises the various factors involved, rapidly coming to what would be the central theme of his second book — that is, income inequality. A very striking conclusion is that in a country, or even a city, with high income inequality, the quality of social relationships is noticeably diminished: there is more aggression, less trust, more fear, and less participation in the life of the community. As a psychoanalyst, I was particularly interested in his quest for the factors that play a role at individual level. Low social status proves to have a determining effect on health. Lack of control over one’s work is a prominent stress factor. A low sense of control is associated with poor relationships with colleagues and greater anger and hostility — a phenomenon that Richard Sennett had already described (the infantilisation of adult workers). Wilkinson discovered that this all has a clear impact on health, and even on life expectancy. Which in turn ties in with a classic finding of clinical psychology: powerlessness and helplessness are among the most toxic emotions.
Too much inequality is bad for your health
A number of conclusions are forced upon us. In a prosperous part of the world like Western Europe, it isn’t the quality of health care (the number of doctors and hospitals) that determines the health of the population, but the nature of social and economic life. The better social relationships are, the better the level of health. Excessive inequality is more injurious to health than any other factor, though this is not simply a question of differences between social classes. If anything, it seems to be more of a problem within groups that are presumed to be equal (for example, civil servants and academics). This finding conflicts with the general assumption that income inequality only hurts the underclass — the losers — while those higher up the social ladder invariably benefit. That’s not the case: its negative effects are statistically visible in all sectors of the population, hence the subtitle of Wilkinson’s second work: why more equal societies almost always do better.
In that book, Wilkinson and Pickett adopt a fairly simple approach. Using official statistics, they analyse the connection between income inequality and a host of other criteria. The conclusions are astounding, almost leaping off the page in table after table: the greater the level of inequality in a country or even region, the more mental disorders, teenage pregnancies, child mortality, domestic and street violence, crime, drug abuse, and medication. And the greater the inequality is, the worse physical health and educational performance are, the more social mobility declines, along with feelings of security, and the unhappier people are.
Both books, especially the latter, provoked quite a response in the Anglo-Saxon world. Many saw in them proof of what they already suspected. Many others were more negative, questioning everything from the collation of data to the statistical methods used to reach conclusions. Both authors refuted the bulk of the criticism — which, given the quality of their work, was not a very difficult task. Much of it targeted what was not in the books: the authors were not urging a return to some kind of ‘all animals are equal’ Eastern-bloc state. What critics tended to forget was that their analysis was of relative differences in income, with negative effects becoming most manifest in the case of extreme inequality. Moreover, it is not income inequality itself that produces these effects, but the stress factors associated with it.
Roughly the same inferences can be drawn from Sennett’s study, though it is more theoretical and less underpinned with figures. His conclusion is fairly simple, and can be summed up in the title of what I regard as his best book: Respect in a World of Inequality. Too much inequality leads to a loss of respect, including self-respect — and, in psychosocial terms, this is about the worst thing that can happen to anyone.
This emerges very powerfully from a single study of the social determinants of health, which is still in progress. Nineteen eighty-six saw the start of the second ‘Whitehall Study’ that systematically monitored over 10,000 British civil servants, to establish whether there was a link between their health and their work situations. At first sight, this would seem to be a relatively homogenous group, and one that definitely did not fall in the lowest social class. The study’s most striking finding is that the lower the rank and status of someone within that group, the lower their life expectancy, even when taking account of such factors as smoking, diet, and physical exercise. The most obvious explanation is that the lowest-ranked people experienced the most stress. Medical studies confirm this: individuals in this category have higher cortisol levels (increased stress) and more coagulation-factor deficiencies (and thus are at greater risk of heart attacks).
My initial question was, ‘Is there a demonstrable connection between today’s society and the huge rise in mental disorders?’ As all these studies show, the answer is yes. Even more important is the finding that this link goes beyond mental health. The same studies show highly negative effects on other health parameters. As so often is the case, a parallel can be found in fiction — in this instance, in Alan Lightman’s novel The Diagnosis. During an interview, the author posed the following rhetorical question: ‘Who, experiencing for years the daily toll of intense corporate pressure, could truly escape severe anxiety?’* (I think it may justifiably be called rhetorical, when you think how many have had to find out its answer for themselves.)
[* Cited in Lane, p. 185. The Diagnosis tells the story of Bill Chalmers, who suddenly becomes unwell on the way to his job at a multinational. He seeks help from the medical world, expecting a clear diagnosis and treatment. Neither is forthcoming, and he gradually sinks into a social and psychological swamp. One of the strengths of the book is the way it shows how reassuring a diagnosis is (‘They know what it is!’) and, conversely, how worrying it is when none is forthcoming. The book’s twin themes are the capacity of corporate pressure to make people ill and the inadequacy of a diagnostic system that only takes account of purely physical factors.]
A study by a research group at Heidelberg University very recently came to similar conclusions, finding that people’s brains respond differently to stress according to whether they have had an urban or rural upbringing.3 What’s more, people in the former category prove more susceptible to phobias and even schizophrenia. So our brains are differently shaped by the environment in which we grow up, making us potentially more susceptible to mental disorders. Another interesting finding emerged from the way the researchers elicited stress. While the subjects of the experiment were wrestling with the complex calculations they had been asked to solve, some of them were told (falsely) that their scores were lagging behind those of the others, and asked to hurry up because the experiments were expensive. All the neo-liberal factors were in place: emphasis on productivity, evaluation, competition, and cost reduction.
Mental disorders as moral disorders
The vast majority of mental disorders are not illnesses, but biopsychosocial manifestations in individuals of broader social problems. This social aspect is also expressed in diagnoses: the characteristics leading to someone being labelled with a disorder always concern that person’s failure to comply with social norms. I described today’s normal identity, with its associated norms and values, in the previous chapter. The current health norm is ‘success’, and it mus
t be financially and materially visible into the bargain. The possibility that a high-flying young male professional who gets bonus after bonus might be spending his evenings miserably alone in his loft — pepping himself up with pills, alcohol, and online sex — doesn’t fit the picture.
Success as a yardstick fosters certain characteristics: flexibility, speed, efficiency, results-orientedness, and articulateness in the sense of being able to sell yourself. Modesty may once have been a virtue; these days, it’s an aberration. Strikingly, every single one of today’s ‘right’ characteristics has to do with contemporary professional identity, and the same applies to the interpersonal characteristics we are expected to possess. Two of them recur time and again: competitiveness (needed for the modern war of all–against–all) and social skills (in the sense of being able to network and promote yourself).
If we look at what is expected at an individual level, the answer is ‘to enjoy life to the full’. The person who best meets the norm is the one who enjoys the most, enjoyment being explicitly linked with consumption and products. You must holiday in the right place, and have the right bike, the right mobile, the right laptop, and the right clothes. Up to a point, it has ever been thus, the difference being that hypes these days are much harder to escape, much more ephemeral, and invariably extremely expensive. It would be terrible to wear the wrong jacket or be seen with the wrong mobile phone (unless it’s amusingly retro).
If success is the criterion for a normal identity, failure is the symptom of a disturbed one. Current psychodiagnostics presents a picture of the various forms of failure, and the diagnostic business is increasingly coming to resemble a pseudo-scientific Rank and Yank system. I have already discussed its most distressing application, to children. Nearly all juvenile disorders these days have to do with failure at school. That stands to reason in the case of learning disorders, but it also applies to ADHD, CD (conduct disorder), ASD (autism-spectrum disorders), ODD (oppositional defiant disorder), and performance anxiety. These diagnoses form the other side of the coin to high-pitched social expectations, with the result that there are now only two kinds of pupils in schools: gifted children, and children with disorders. ‘Ordinary’ children are becoming an endangered species, and the old notion of average being normal is now taboo.
Note that in this form of diagnosis, little if any attention is paid to the problems experienced by the children themselves — the diagnostic criteria almost always highlight the problems that the environment has with the child. As a result, such criteria are never value-free, as I noted earlier, when discussing the scientistic model as the dominant paradigm. Fortunately, there are still teachers and social workers who focus on the children themselves, but this doesn’t fit in well with the official approach — a DSM diagnosis followed by protocol-based treatment selected for efficiency, scientific objectivity, and measurability. The lack of attention to the difficulties that the children themselves experience is also clear from the fact that as soon as they conform once again, therapy is dispensed with. And you can see it in the reactions of youngsters who have been referred to social services. They increasingly opt out, rejecting psychiatric help because they intuitively feel that counsellors and care professionals do not have their interests at heart.
It’s worth taking a brief etymological excursion here. We speak of diagnostic categories, which we use to reach a classification. The word ‘category’ goes back to ancient Greek kategorein, which, rather surprisingly, means ‘publicly accuse’. This chimes with the underlying intention of all classification systems, as Ian Johnston reveals in a wonderful article on the importance of Darwin. Johnston writes that we need classification systems in order ‘to make moral distinctions, to establish the hierarchy of goods and goals for our lives’. Revolutionary thinkers are revolutionary precisely because they introduce a new classification system and with it a new way of looking at reality, along with new goals — this applies to Plato as well as to Darwin, Marx, and Freud. The conclusion is that classification systems can never be ideologically neutral. Any ordering in categories implies a political or moral significance, or makes it explicit. Darwin’s great achievement in this field was to replace an earlier ‘natural order’ — that is, a Scala Naturae thought to be divinely imposed — with an order based on evolution, in which the notion of goals and progress is lacking. The emphasis is on chance, and the direction is random. The moral and political implications of his theory are denied to this day, and social Darwinism is a regression to a pre-Darwinian hierarchical order that can be used to justify a polity.
Unlike proper clinical psychodiagnostics, which centres on the problems of the individuals concerned, a DSM-style psychodiagnostic classification is a moral ranking used to accuse people and get rid of them by means of labels. They themselves are acutely aware of this fact, as witness the way children use these labels as terms of abuse (‘Autist!’). That’s also why people seize on the presumed genetic and neurobiological explanations (‘I’m ill’) to escape feelings of guilt. It’s not much use, though; the dominant mindset (individuals are perfectible as long as they make an effort) will condemn them anyway.
In his study of neo-liberalism, Hans Achterhuis notes that every quasi-utopia — and he ranks our neo-liberal society under that heading — treats deviations from the imposed social norm as psychiatric disorders. Huxley’s Brave New World and Orwell’s Nineteen Eighty-Four are increasingly becoming reality. Ironically, disorders also result from some people adapting too well to the ideal image. Taken to extremes, the obligation to enjoy can cause sex addiction, bulimia, and, of course, shopaholism. Up to a point, psychopathic characteristics prove very useful in the corporate world, but beyond a certain level they become a disorder that is hard to treat. The same applies to the ability to be your own manager — taken to extremes, this becomes narcissistic personality disorder. In all these cases, the line between being successful and being disturbed is fairly thin.
At the other end of the scale are the adult losers, in whom fear and depression predominate. Although some maintain that the welfare state has made people ‘soft’, those who fail to make it often wrestle with feelings of extreme guilt. In her study on depression, Trudy Dehue rightly observes that people are far from being the passive, irresponsible scroungers they are often made out to be; quite the contrary. In this age of the perfectible individual, the majority of us feel more than ever responsible for our own failure or success, both at work and in our relationships. The pharmaceutical industry has unerringly sensed this, and in commercials we see the workplace portrayed as a battlefield, where the right pill can save your life.* Coffee isn’t enough anymore; we need Red Bull at the very least, and in the US, Ritalin is prescribed as a performance enhancer. Healthy people are told they need to become yet healthier, and books with titles like Train Your Brain sell in vast numbers.
[* The left side of a hoarding that is advertising an antidepressant bears the following message: ‘Should have … could have … would have … can’t. I just can’t.’ In the centre: a depressed-looking young man with a tie. On the right: ‘Show them they CAN; PAXIL’ (sold as Seroxat in Europe, Aropax in Australia). These and other examples are to be found in the studies of Lane and Dehue.]
A study by the Belgian sociologist Piet Bracke confirms this: cases of depression have doubled, and sufferers often regard depression as a personal failure.4 This ties in exactly with what Sennett was amazed to discover, that people who were fired for ‘structural’ reasons blamed themselves. The image of the snivelling, self-pitying underdog is the exception, not the rule. A similar trend is revealed when it comes to anxiety disorders, the most common of which are performance anxiety and social phobia. In other words, fear of the other, who is either an evaluator or competitor, and sometimes both at once.
Something that rarely emerges from these labels, but that every clinician will have seen among their patients, is an excessive urge to control, along with hyperperfectionism and ambition. Every hitch, every unforeseen circ
umstance, increases the pressure to respond quicker and better next time. In the case of eating disorders, this combination of factors is almost always present, and sufferers also try to hide the problem. Like the successful young man who, unknown to everyone around him, is going to pieces in his loft, there are many perfectionistic women (and, increasingly, men) who combine a high-flying career with a carefully concealed eating disorder. No one is allowed to know, as every weakness can be used against the individual as manager of him- or herself.
It is in the sphere of relationships that I see the most distressing effect of this trend. The double whammy of excessively competitive individualism and the obligation to seek pleasure at all costs (replacing the old ethics of self-control) spells disaster for lasting relationships. The ubiquitousness of relationship problems reveals how lonely we are; loneliness is without doubt the most widespread ‘disorder’ of our time. This isolation, coupled with the commandment to enjoy, leads to what Mark Fisher very aptly calls ‘depressive hedonia’.5
Within a couple of decades, my professional field — psychodiagnostics and psychotherapy — has made a complete U-turn. If diagnosis amounts to little more than establishing deviations from the social norm, treatment amounts to little more than compelling patients to recomply with that norm. Changes in the way we perceive the disturbed individual tie in with this trend. Not so long ago, the notion that their difference meant they were somehow special and closer to the truth was common to almost all cultures. As recently as in the film Revolutionary Road (2008), we hear the truth from the mouth of a psychiatric patient.6 This is no longer the case, though. Today’s psychiatric patient, as represented by the Norwegian Anders Breivik, is not only disturbed, but downright dangerous.
What About Me?: The Struggle for Identity in a Market-Based Society Page 17
