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in the USA (Bruce et al., 1991), which found that adults living in poverty with no histories of de-pression were at twice the risk of experiencing depression than those not living in poverty.
The second is Brown and Moran’s study in 1997 that followed up 404 mothers over two years and found that the risk of the onset of depression was almost double for those women in financial hardship. Single mothers were twice as likely to experience humiliating or entrapping life events as the married women, and were more likely to experience depression if they worked full time rather than part time. Brown and Moran point out that those women experiencing a painful event rarely developed depression in the absence of risk factors such as a poor relationship in their household or a negative self-evaluation.
They also argue that poverty affects the quality of relationships and ‘is probably capable of in-fluencing every factor in the model’ (p.32).
Other indicators of poverty that have been found to affect mental health are self-reported financial strain (Kessler et al., 1988; Weich &
Lewis, 1998), length of time on income support (Graham & Blackburn, 1998) and mortgage in-debtedness (Nettleton & Burrows, 1998).
Reading and Reynolds (2001) conclude from a review of research on depression in lone mothers that financial hardship is the most important underlying feature of the range of explanations for depression. In their study with mothers of young families, worry about debt was found to be most strongly associated with maternal depres-sion, and owing money and being in receipt of benefits was also significantly linked. Although being in debt was not an independent prospec-tive predictor of depression, they argue from their results that it is central to understanding the association between socio-economic hard-ship and depression.
The extent of debt has been linked with stress and poor physical health (Drentea & Lavrakas, 2000); anxiety (Drentea, 2000) and attempted suicide in men (Hatcher, 1994). People who use mental health services face particular hard-ships and have been found to attribute their problems to debt (Grant, 1995) which is more likely to affect them for example with rent, credit card and utility bill arrears (Morgan et al., 2001).
Explanations of mental health inequalities
Wilkinson’s contributions (1999) to the under-standing of the interplay between relative in-come, wealth and health are useful in illustrating the pathways through which physical and psy-chological survival are economically influenced.
He suggests that the pathways between living standards and health experience are psychoso-cial and involve the following three risk factors for chronic stress: low social status, weak social affiliations and stress in early life. While these are clearly influential on the experience of chronic stress, they do not offer a full enough explanation of people’s mental health experiences.
Wilkinson’s emphasis on psychosocial relation-ships need not underestimate the overwhelm-ing challenge of actually managoverwhelm-ing poverty and material deprivation, and the further susceptibil-ity to oppression that this can entail. Historical factors like childhood trauma and poor attach-ment are not independent of adverse socio-eco-nomic conditions. While people in constrained financial circumstances may use ingenious means to deal with their situations, financial status is crucial for the exertion of power over the inevitable demands that they encounter.
Money influences the quality of relationships and the capacity to reciprocate practical help and support.
In appraising the links between people’s situa-tions and experiences and their mental health we need to give consideration to three elements:
■ exposure to life events, demands and diffi-cult situations;
■ people’s social position and identities (e.g.
social class, race, employment status, mental health service user);
■ access to resources (including educational, physical, health, financial and social).
These elements draw on the work of Smail (1996) and particularly on Hagan and Smail’s mapping of the terrain of proximal powers and resources (1997). They are pertinent to people in the present and the past, and financial security impinges on all of them.
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Financial insecurity means that people are more likely to have to deal with crises and unpredicted issues like debt collectors or alarming demands for repayments through the post. Wilkinson is right to highlight the potent impact of relative social positions, and the psychologically damag-ing effects of coercive, unequal relationships.
Financial status, and the gaining or losing of it, affects people’s social position, and how they regard themselves with respect to others. This can generate competition and financial over-commitment that are psychologically and prac-tically difficult to sustain.
Finally, finances are an important resource among others such as education, physical health, good nutrition, decent housing and social capital, that are essential in order to negotiate day-to-day life with some ease. Having sufficient money to deal with crises if they arise, and to ensure some comforts in day-to-day living, has a palpable in-fluence on well-being. Social capital and relation-ships of trust, mutuality and equality may facilitate access to a wide range of material and social re-sources, but lack of resources also impinge on social capital.
There are methodological limitations to many of the studies that have been outlined.
This area of research suffers from the absence of longitudinal studies, limited and diverse con-ceptualisations of psychological well-being and inconsistency in the defining of poverty. How-ever, there is enough evidence to make a strong case for the inclusion of material as well as social relationship issues in the addressing of psycho-logical distress.
So what do psychologists need to do?
Delineate the structural and social influences on well-being
Interestingly, there is very little evidence of psychologists being active in the surveys and studies that I have reported (note the exception of Reading and Reynolds, 2001). There is the potential to develop research that further ex-plains how material, social and ideological influ-ences, both proximal and distal (Smail, 1996), enable psychological functioning or threaten well-being. We also need to communicate how organisations and social systems perpetuate in-equalities via practices that undermine people’s
capacity to control aspects of their lives. These delineations are relevant for individual psy-chological therapy and for the development of socially valid research in psychology.
Research into inequalities and health needs to include measures of financial status that account for the number of years on benefits or particular incomes, estimate the proportion of debt to income and measure actual income and wealth.
Debt needs to be included as an indicator of poverty. Research and individual clinical work also need to include people’s subjective reports about their current financial situations, and how they perceive their financial security.
Collaborate with others to reduce poverty There is a strong public health argument for ad-dressing the socio-economic determinants of health inequalities. In Northumberland a small group of people from Welfare Rights, Debt Advice, a mental health service user group, a psychologist and a funding facilitator devised the Action Against Poverty project. This received funding from the Community Fund and Northern Rock Foundation to promote the increased awareness of debt and its effects in order to prevent associated crises. Four development staff work with voluntary groups and health and local authority staff to highlight the extent and impact of debt and help to develop credit unions.
These staff also work with volunteers who have experience of debt to run ‘Money Matters’
workshops. These lively evens using role play and discussion have been successful with vari-ous groups, such as a mental health drop-in and people using Sure Start. They consider how money or the lack of it affects health, calculate how much lending actually costs, give clues about misleading advertising, illustrate how sales people operate, suggest how to deal with aggres-sive demands for payments, clarify people’s legal rights and provide information on alternative sources of borrowing such as credit unions.
The workshops are highly participative and supportive, and they also generate more volun-teers for further workshops, and ideas and people to train staff. They engender a strong affiliation between people, based on a perspective of debt-related problems as externally generated by
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poverty, and the credit industry’s intimidating and opportunistic practices, rather than due to indi-viduals’ foibles. They argue that there is a strong case for lobbying against the unfairness of bene-fits that are insufficient to live on, and against the exploitative practice of predatory lending.
While this work is largely ameliorative, it has raised the profile of debt as a specific issue.
This, of course, does also raise the danger of identifying groups of people with debt concerns and exposing them to further stigma. However, the energy and creativity which these workshops have generated appear to have moved people from being isolated individuals or mental health service users to being active and vocal volun-teers with a clear cause.
Influence social policy
This final challenge is controversial, and I am mindful of David Smail’s warning that ‘politics is, of course, all about power and interest, and psy-chologists cannot possibly become so detached from their own interests as to become the ob-jective arbiters of other people’s interests’
(Smail, 1994, p.6). My view is that we need to articulate how our interests are bound up in our representation of others’ interests and the risks of well-meaning misrepresentation and oppression, while also being explicit about issues of social justice. Taking up these issues will not necessar-ily be in our professional interest and may be un-comfortable and contentious.
There is currently scope within and between the organisations with whom we work to con-tribute to local and national policies. For instance, in Northumberland there is the opportunity to make suggestions to the county council about their social inclusion policy, and we have been involved in some local strategic partnership dis-cussions about priorities for improving health.
Recently, a group of mental health service users, staff and advice providers in Northumberland fed back comments to the Social Exclusion Unit’s questionnaire about social exclusion. We recommended:
■ simplifying the benefits system – it is not just a ‘perception’ but an actuality that the route between benefits and employment is complex, confusing and intimidating;
■ adjusting the conditions of work and re-entry to work to suit the needs and resources of individuals;
■ opportunities for trying out employment need to be non-coercive, and not jeopardise or reduce existing financial status – eligibility for housing and council tax benefits needs to be retained for three or six months;
■ therapeutic earnings need to be increased;
■ debt is a major stressor, and legislation is re-quired to regulate lending and to prevent the promotion of high-interest loans to people on low incomes.
Psychologists may contribute in health, local and national government, and academic settings to the understanding and addressing of the psy-chological impact of social and economic in-equities. Rather than an individualistic focus on people’s styles of coping, this requires an analy-sis of injurious social and economic conditions, in order to highlight the possibilities for social changes that benefit people’s well-being.
Acknowledgements
I should like to thank the Action Against Poverty staff and volunteers, Maureen Plumpton, and col-leagues in Northumberland for their support and contributions to this work.
References
Brown, G.W. & Moran P.M. (1997). Single mothers, poverty and depression. Psychological Medicine, 27, 21–33.
Bruce, M.L., Takeuchi, D.T. & Leaf, P.J. (1991).
Poverty and psychiatric status. Longitudinal evidence from the New Haven epidemiological catchment area study. Archives of General Psychiatry, 48, 470–474.
Drentea, P. (2000). Age, debt and anxiety. Journal of Health and Social Behaviour, 41,437–450.
Drentea, P. & Lavrakas, P. J. (2000). Over the limit:
The association among health, race and debt. Social Science and Medicine, 50,517–529.
Graham, H. & Blackburn, C. (1998). The socio-economic patterning of health and smoking behaviour among mothers with young children on income support.
Sociology of Health and Illness, 20(2), 215–240.
Clinical Psychology 38 – June 2004
Grant, L. (1995). Debt and disability. Social Policy Research Report 78. York: Joseph Rowntree Foundation.
Greenhill, R. (2003). Debt is closing in on the middle classes. The Guardian, 1 September.
Hagan, T. & Smail, D. (1997). Power-mapping: 1. Back-ground and basic methodology. Journal of Community and Applied Social Psychology, 7,257–267.
Hatcher, S. (1994). Debt and deliberate self-poisoning.
British Journal of Psychiatry, 164, 111–114.
Kempson, E. (1996). Life on a low income. York:
Joseph Rowntree Foundation.
Kessler, R.C., Turner, B. & House, J.S. (1988). Effects of unemployment on health in a community survey:
Main, modifying and mediating effects. Journal of Social Issues, 44(4), 69–85.
Meltzer, H., Singleton, N., Lee, A., Bebbington, P., Brugha, T. & Jenkins, R. (2002). The social and eco-nomic circumstances of adults with mental disor-ders. London: HMSO.
Morgan, E., Bird, L., Burnard, K., Clark, B., Graham, V., Lawton-Smith, S. & Ofori, J. (2001). An uphill struggle:
A survey of people who use mental health services and are on a low income. London: Mental Health Foundation.
Nettleton, S. & Burrows, R. (1998). Mortgage debt, insecure home ownership and health: An exploratory analysis. Sociology of Health and Illness, 20(5), 731–753.
Palmer, H. & Conaty, P. (2002). Profiting from poverty. London: New Economics Foundation.
Pevalin, D.J. & Rose, D. (2003). Social capital for health: Investigating the links between social capital and health using the British Household Panel Survey. London: Health Development Agency.
Reading, R. & Reynolds S. (2001). Debt, social disad-vantage and maternal depression. Social Science and Medicine, 53,441–453.
Smail, D. (1994). Community psychology and politics.
Journal of Community and Applied Social Psychology, 42,3–10.
Smail, D. (1996). How to survive without psycho-therapy.London: Constable.
Weich, S. & Lewis, G. (1998). Poverty, unemployment and common mental health disorders: Population-based cohort study. British Medical Journal, 317, 115–119.
Wilkinson, R. (1999). Putting the picture together:
Prosperity, redistribution, health and welfare. In M.
Marmot & R. Wilkinson (Eds.) Social determinants of health(pp.256–274). Oxford: Oxford University Press.
Wilkinson, R. (2003). Presentation to Nottingham Community Psychology Conference, February.
Address
Newcastle, North Tyneside and Northumberland Mental Health NHS Trust, Directorate of Psy-chological Services, 1–2 West Farm House, West Farm Court, Station Road, Cramlington, Northumberland NE23 1AX; [email protected]