By guest blogger Peter Kinderman
“I’ve been rich and I’ve been poor. Believe me, rich is better” (Mae West).
Critiques of the rather discredited “disease-model” of mental illness are commonplace, but we also need to articulate the alternative. New research by Sophie Wickham and colleagues helps do that, by providing support for the idea that we learn, as a consequence of our experiences in life, a framework of appraising, understanding and responding to new challenges. This psychological schema then shapes our emotional and behavioural responses to future events.
Wickham and her colleagues used data from over 7000 people and, based on a composite measure of each person’s neighbourhood (including data on income, health, education, and crime), they found that participants living in more deprived neighbourhoods had much higher levels of both depression and paranoia.
But the researchers did not merely correlate social deprivation with mental health. They also looked at a range of psychological mediators. They found that, if people reported low levels of stress, high levels of trust in others and high levels of social support, then social deprivation was no longer associated with more depression. The same was partially true in the case of paranoia – when people reported low levels of stress and high levels of trust, social deprivation had a greatly reduced association with levels of paranoia.
In one sense this is a relatively conventional correlational study using secondary data (the Adult Psychiatric Morbidity Survey) to look at a rather well-established link between social factors and mental health. But I think there’s more to it than that.
There are many ways to be overly simplistic about mental health issues. A simple “disease-model” of mental health problems doesn’t really help us much, but an equally simplistic model of social causation is equally reductionist – reducing people to mechanistic pawns, pushed around by social pressures. Instead, a more elegant psychosocial model might suggest that the emotional (and behavioural) impact of life events is at least in part a consequence of how we appraise and respond to those events… and in turn that our appraisals and responses have been learned over time as a consequence of the events to which we have been exposed.
Wickham and colleagues have gone some way in exploring that hypothesis. Their data suggest that people’s appraisals of their circumstances – their perceived stress, perceived trust and perceived social support – mediate the impact of social deprivation on depression and paranoia. It is also interesting to note that these relationships appeared specific to depression and paranoia; they did not apply to auditory hallucinations or hypomania, the rates of which were not associated with poverty in this study.
If these kinds of findings are replicated in future research, the implications could be important and far-reaching. But first, it seems important to replicate this work, exploring the specific combinations of social circumstances, and mediating psychological processes, that lead to different emotional and behavioural outcomes. Wickham and colleagues speculate about what some of these may be – for example, whereas the combination of deprivation and a person’s appraisal of their situation was associated with more depression and paranoia, perhaps a combination of childhood trauma and a perceptual source monitoring problem (e.g. misattributing one’s own thoughts to a third party) might be associated with auditory hallucinations.
The researchers also speculate about the implications of their findings – how we might intervene at a population level, with social and psychological interventions targeted at specific risk factors and psychological mechanisms. Long term political and social policies could address issues of population-level social disadvantage, deprivation and inequity. Similarly, social interventions and targeted welfare packages might be effective in addressing social risk factors at an individual or family level. And, unsurprisingly given that they are psychologists, Wickham and her colleagues also point out that psychological interventions such as cognitive-behaviour therapy (CBT) and interpersonal psychotherapy could help individuals develop more effective psychological responses to the inevitable social stressors that accompany social deprivation.
One study cannot possibly explore all these issues. But, by examining both the social deprivation that is known to contribute to mental health problems and the psychological mechanisms that mediate the impact of this social stress on the individual, Wickham and colleagues offer a model for an elegant approach to understanding and, ultimately, intervening to improve psychological health and well-being. These ideas are important, and new, but are also evidence of the growing maturity and power of psychosocial explanations in mental health. I discuss these ideas further in my book, A Prescription for Psychiatry: Why We Need a Whole New Approach to Mental Health and Wellbeing
and in my new, free, online course.