The Inner Level

Citation

Caan, W. (2019), "The Inner Level", Journal of Public Mental Health, Vol. 18 No. 3, pp. 207-208. https://doi.org/10.1108/JPMH-09-2019-085

This book carries the subtitle “How more equal societies reduce stress, restore sanity and improve everyone’s well-being”, so I eagerly awaited practical tips for the reader on mental health promotion. The authors’ previous book had been full of interesting, international observations on various impacts of inequality (Caan, 2011). Four years ago, the Institute of Health Equity at University College London prepared a very helpful report on the social determinants of mental health (World Health Organization and Calouste Gulbenkian Foundation, 2014) including recommendations for action across the lifecourse, at both local and national levels.

The new book by Wilkinson and Pickett has 325 pages with 512 references, but after page 110 and “Myths of human nature, meritocracy and class” began, I found little of interest for mental health professionals. Most of the evidence relates to income inequalities across American states or OECD member countries. The underlying theory seems to be that social anxiety related to “status” leads to illness in individuals and societies, and that may well be reasonable in relation to the pathogenesis of some clinical disorders. The essence of the whole book is summarized in one sentence in a chapter on “Self-doubt”: “The reality is that inequality causes real suffering, regardless of how we choose to label such distress”.

The authors have many elegant turns of phrase, for example “in a society of strangers, outward appearances and first impressions become more important”. However, as a mental health educator, I became exasperated by their conflation of everyday distress, isolated symptoms, survey ratings and psychiatric diagnoses into one “huge burden of unhappiness and mental illness”. Having researched the diverse antecedents of both clinical depression and alcohol dependence, the shallow views given here on the roots of “depression” or “addiction” really grated. This book reaches a nadir in a section “Narcissism Trumps good leadership” in which the authors, whom I assume are neither authorities on personality disorder nor closely acquainted with the US President, speculate wildly on his mental functioning.

For all its 512 references, there seems to be only one point where the book considers any evidence that is contradictory to its claims. My old colleague Derek Summerfield (2011) is disparaged for doubting the validity of the reported prevalence measures the book plots against International income data. Dr Summerfield worked as a Psychiatrist across diverse cultures, nationalities and languages, so perhaps his concerns do merit serious consideration? One of the blind spots in the book is its failure to see a possible reverse relationship between inequalities and mental illness. Perhaps improved mental health care might improve income, housing, social relationships and even “status” as opposed to stigma. Improved prevention of mental illness through better antenatal care, child protection, parenting programmes, community development linked to education or community safety, and better workplace environments, all appear likely to impact on “well-being” – what would that do to inequality in the population? That sounds like a case for evidence-based mental health promotion!

The authors have highlighted that income inequality is growing in many societies, today. Social injustice undermines all that “Public Health” is founded on, such as good citizenship, solidarity and collaboration for health. Whatever your background, I hope all readers will work towards “more equal societies”.