How Does Social Inequality Affect Mental Health?

April 2012

“Are there many things more important than understanding why people stay healthy or get sick?” asks Richard U’Ren, MDCM’64. “To understand that, you can’t just look at an individual patient, which is what medical training has always stressed. The way society is organized and our positions in it greatly affect our health and wellbeing.” The professor emeritus at Oregon Health and Science University has practised and taught psychiatry for four decades and is the author of the new book, Social Perspective: The Missing Element in Mental Health Practice, published by the University of Toronto Press.

U’Ren makes a compelling argument for a broader approach to mental health. He points out that the least affluent members of society have the poorest mental health, while the rich typically fare much better. However, a gradient exists between the two extremes, such that individuals in the middle of the social class hierarchy experience better health than the poor, but worse than the rich. In essence, social disparities become also health disparities.

U’Ren believes that a more complete picture of a patient’s mental health depends on understanding the nature and distribution of resources such as income, wealth, education, and social ties and connections. He also points out that American society has become increasingly unequal in recent decades. There is evidence that this increasing inequality is resulting in poorer mental (and physical) health for a large number of people.

One of the most intriguing chapters of the book discusses the Diagnostic and Statistical Manual of Mental Health Disorders – the DSM. Drawing extensively on the work of Allan V. Horowitz and Jerome C. Wakefield, U’Ren argues that the DSM encourages the diagnosis of specific disorders as “internal dysfunctions” in individuals. This exclusive focus on the individual is, in U’Ren’s view, too limited, and is one of the factors responsible for the neglect of a social perspective in mental health work. “A lot of symptoms that we see in clinical practice, anxiety and depression being the major ones, are not necessarily disorders but rather non-specific responses to difficult life circumstances,” he says. The DSM “pays lip service to social factors.”

Richard U'Ren, MDCM'64

U’Ren’s book gets to the very heart of what is even considered “medical” at all. In chapter 7, he describes the work of sociologist and internist Howard Waitzkin, who studied the transcripts of conversations between family practitioners and patients over several years. “Waitzkin found that practitioners systematically excluded social issues from their dialogue with patients.” Sidelining social issues led to the reinterpretation of social difficulties “into the language of individual symptoms.” Waitzkin borrowed a term from Karl Marx to describe what was happening: reification, “a process in which social relations and social processes become transformed into other things – symptoms and diagnoses in this case.”

To take just one real-life example cited by the book, a 55-year old man, a radial drill operator, goes to the doctor. Suffering from coronary artery disease, he recently had a heart attack and has also been diagnosed with severe depression. Returning to work worries him because his union is expected to go on strike. The doctor turns to the man’s wife and says, “I tell you if this guy stays home, he’s going to curl in a ball… he’s going to be unreachable.” The doctor makes it clear that he believes in the restorative power of work. His patient, though, is ambivalent.

In discussing this case, U’Ren says things are not as straight forward as the doctor claims. “While employment is indeed generally good for health, distinctions must be made,” he writes. “The doctor either ignores or is oblivious to the financial problems his patient will face… The doctor transmits the message that work is beneficial to the patient’s health.” Missing from the conversation is an acknowledgement that returning to work means dealing with certain stresses. U’Ren believes health professionals often fail to engage in such conversations because their training has encouraged a focus on the individual. “I think an informed discussion about the context of these problems represents a mode of approach that may be more useful than just medication.”

If reification occurs frequently among physicians and to a lesser though still substantial degree among psychologists and psychiatrists, the implications go well beyond the medical field. Far from being “internal dysfunctions,” many common psychological problems are in fact exactly what a professional should expect to see in a society where large numbers of people struggle to make ends meet and lack a sense of control over their lives.

“Many of the things I write about in this book are things that people know about intuitively,” says U’Ren. He describes how most parents attempt to provide the best for their children – essentially to try and secure them a place in society where they are more likely to succeed materially, and by consequence, be healthier, happier, and less vulnerable to the stressors that a lack of resources entails. “This is naturally easier to do if parents have more resources in the first place,” he says.

Is there anything that can be done about the social inequalities that underlie resource inequalities? “The natural conclusion of this book is that social action is necessary in order to reduce the degree of inequality that makes our glaring mental and physical health differences possible,” says U’Ren.

[Laurence Miall]

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