Dr. Umar Toseeb Hello, welcome to the Papers Podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I am Umar Toseeb, Professor of Psychology. My research focuses on special educational needs and mental health in childhood and adolescence. In this series, we speak to authors of papers published in one of ACAMH’s three journals. These are the Journal of Child Psychology and Psychiatry, commonly known as JCPP, the Child and Adolescent Mental Health, known as CAMH and JCPP Advances. All listeners to this and indeed, any of ACAMH’s podcasts, are eligible for a free CPD certificate. Do please visit acamhlearn.org for details of this, together with information on how you can access hundreds of hours of free talks, lectures, interviews, all of which you can also get free CPD certificates for. The web address is acamhlearn.org. That’s a-c-a-m-h-l-e-a-r-n.org. If you’re a fan of our Papers Podcast series, please subscribe on your preferred streaming platform, let us know how we did, with a rating or review, and do share with your friends and colleagues. Today, I’ll be speaking to Professor Kate Pickett, Professor of Epidemiology, University of York, and Richard Wilkinson, Visiting Professor, University of York. Professors Pickett and Wilkinson are authors of the bestselling book, “The Spirit Level Why Equality is Better for Everyone.” The focus of today’s podcast will be the issues raised in the book and more specifically, a recent editorial in Child and Adolescent Mental Health Journal called “Socioeconomic Inequality and Child and Adolescent Mental Health.” Kate and Richard, thank you so much for joining me. Can you begin…? Professor Kate Pickett Thanks for having us. Dr. Umar Toseeb Can we begin by you telling us a bit about your research interests? Professor Kate Pickett Sure, I’ll start. We’re both Social Epidemiologists, so that means we study the social determinants of health. I focus these days is on children and families more than on the general population, but we’re interested in how the wider determinants of health create poor health, but also, poor social outcomes in different societies. And we very much focus on the impact of income inequality in recent years. Professor Richard Wilkinson Yes, I’ve worked for, well, getting on for 50 years, on the social determinants of health, starting off on health inequalities, which were almost unknown when I started. People were blind to them. They thought that businessman’s stress at the top of society meant death rates might be higher than. Now we know it’s all the other way round. And I worked on income and health and then on income inequality and health and finding psychosocial links, suggesting that maybe not just health would be affected, but all sorts of other social problems, as well. Dr. Umar Toseeb Excellent, thank you both. Let’s just get into it. So, let’s talk about the relationship between socioeconomic inequality and child and adolescent mental health. What is the relationship between the two? Professor Kate Pickett Well, as countries become more unequal, so that means the gap between rich and poor gets larger, those societies have worse child and adolescent mental health. Now we know that from looking at rich developed countries, comparing outcomes between them, and we know from looking at the 50 US states, as well. So, when societies become more unequal, we have more child and adolescent mental health problems. Dr. Umar Toseeb Are we talking income inequality or wealth inequality at the individual level, but also at the country level? Professor Richard Wilkinson Well, we’ve used income inequality because that’s the data that’s available, internationally comparable data. But I think probably wealth inequality is also pretty important. I’ve seen one study which uses the little bit of data there is available internationally comparably, and it shows similar relationships to health that we’re used to seeing with income inequality. So, I suspect we should be looking at a, sort of, total of material or economic inequality. Dr. Umar Toseeb And would you expect the relationship to be different at different levels of country wealth? So, as in if you have countries that are particularly poor in general, if the gap between rich and poor there, would the effect of that on child and adolescent mental be – health be the same as it would be the same as it would be in a rich country and the gap – if it was a similar gap there, for example? Professor Kate Pickett Well, we’ll have to guess there from what we know about, sort of, health in general. In poorer countries, in general, they have worse health at lower levels of development, but they also have worse health at higher levels of inequality. So, both of those things matter and in fact, inequality might matter more in those countries than it does in developed countries for certain outcomes. So, it’s a worldwide problem, but we don’t have good data on child and adolescent mental health from the Global South, for example. So, it’s very hard to be very specific about that. Professor Richard Wilkinson And the main problem, as Kate says, is there’s just less data available, but the little that there is suggests the effects of income inequality are quite similar. And as economic growth progresses in poorer countries, of course, as she says, death rates come down, but the more equal countries always seem to do a bit better for any level of economic development. Dr. Umar Toseeb And when we’re talking about there not being good data in low and middle-income countries, why is that? Is that resourcing, is that research infrastructure, is that a measurement tools issue? Professor Kate Pickett Well, to be honest, there’s not great data on international scale in rich, developed countries, either. You know, there’s a real paucity of good quality, sort of, robust epidemiological data on children’s and adolescents’ mental health. Some of it will be to do with infrastructure and access, but I don’t know why we have such poor data, really. I suppose it’s because it’s not been an issue for long enough for people to have put those data collection structures in place. We didn’t have good comparable data on adult mental health in different countries until fairly recently. Part of the problem is that with mental health, you don’t want subjective measures if you want to compare different countries, really, because cultures might differ on how they define mental health and illness and the likelihood that people will disclose that they have problems. And then differences in medical care, treatment, access to therapies, etc., is wildly different. So, what you really want and what has been done for adults, at some scale by the World Health Organization, is proper diagnostic interview schedules with random samples of the population. And so, that’s been done for adults in some countries, although not that many, but nobody’s yet done anything like that for children at the international level. Professor Richard Wilkinson When I was in training many years ago, people used to joke that Epidemiologists were quite good at telling whether people were dead or alive and so, in calculating death rates, but not much good at illness, particularly mental illness. Dr. Umar Toseeb Thank you, and let’s talk about mechanisms. So, what might be some of the pathways or mechanisms through which socioeconomic inequality affects child and adolescent mental health? Professor Richard Wilkinson Well, I think it’s got a lot to do with social comparisons. I often talk about income inequality as a social relationship, because it puts one person, sort of, higher than another. It puts us in a hierarchy that people see as, sort of, from best to worst. I think the feelings about being looked down on, disrespected, all those kinds of things, and the sense of shaming that comes out of that. We know, for instance, it’s a very powerful source of violence. There are a lot of studies now that show that homicide is more common in more unequal societies and that’s because it’s so often triggered by loss of face, humiliation, disrespect. But these are also chronic stressors and that’s why they affect health. Indeed, Kate and I have argued that one of the most important causes of chronic stress across the whole society is these worries about how we’re seen and judged by other people, our sensitivity to others’ judgments of us. Which, you know, you can worry that you’re boring, unattractive, not clever enough, looked down on, all those sorts of things. And when you look at this kind of thing amongst teenagers, of course, so many, and particularly young girls, are worried about what they look like and something like 90% of them are dissatisfied with what they look like. But this also feeds into bullying, which is, again, hierarchical behaviour, much more common in more unequal societies. So, it’s these kinds of things about social differentiation and the idea that it’s a differentiation between better and worse that’s so humiliating. Dr. Umar Toseeb And is it more of a problem in adolescence than it is in other life stages because of the importance of peers and friends and those kinds of relationships? Professor Richard Wilkinson I suspect from the violence data, and I think that’s relevant because I do see – we both see the causes as pretty similar, inequality is a stressor, that, you know, and violence is highest in late teens and early 20s, wondering where they are in these stakes. It’s a nasty business and I think we’re particularly sensitive to it. At my age, some of it’s gone; we’re a bit less worried about what people think of us. Dr. Umar Toseeb If inequality is the stressor, so then there’s the inequality and then there’s social comparisons, then what? As in how do we get from that to mental health difficulties, like in adolescence, like depression, anxiety, self-harm, those kinds of things that are common? Professor Kate Pickett Well, there seem to be three different ways in which people react to these increased social stresses, this hierarchy, this concern about how they’re judged. So, inequality seems to, sort of, produce three different sorts of reactions in people. One is to withdraw from that, essentially, and that’s linked to, sort of, depression, as, sort of, withdrawing from social contact. It’s almost like animals retreating from a difficult social situation. But some people react almost in the opposite way and try to, sort of, fight it out and say, “I’m okay.” So, we get more self-enhancement in more unequal societies, we get more narcissism, we get more psychotic symptoms. So, there is a, sort of, way in which some people respond by perhaps bigging themselves up. If status matters so much more in some societies, where you come matters more, then maybe, you know, it’s more important to be seen to be doing okay. So, it’s a, sort of, a bluffing your way through it in a sense. And then, we do see more behaviours like gambling addiction, deaths from alcoholic liver disease, signs that a third reaction is through, sort of, compensating for those feelings in some way. Dr. Umar Toseeb So, you’ve talked about the three ways in which inequality affects mental health. In the editorial, you provide a really nice visual framework for how socioeconomic inequalities between societies interacts with socioeconomic position within societies. Can we talk a bit through that? Professor Richard Wilkinson Well, it’s hard to say, really. I know – I think much – the most important thing is inequality within societies, because that’s the, sort of, hierarchy in relation to which we judge each other. It’s rich or poor, a high or low class within our society. There are international comparisons, and I think that perhaps you saw them in the collapse of the communist countries. People in those Eastern European countries and the Soviet Union began to recognise that they’d been overtaken by Western countries. But I think those sorts of things are not nearly as psychologically powerful as the inequalities within societies. Professor Kate Pickett But I think what that diagram that we used in our editorial is really showing is that in more equal societies, it’s perhaps less harmful, less painful to be at the bottom and so, the social gradient in outcomes is shallower. So, we see a steeper social gradient in more unequal countries, and we’ve seen that for health outcomes like infant mortality and other causes of mortality and educational outcomes, as well. You know, bigger gaps between rich and poor, steeper social gradients and then, being not as pronounced in the more equal countries. So, there’s the hit to your health and wellbeing that comes from living in a more unequal society and there’s also a hit that comes from being at the bottom of any society, but there is an interaction between the two. Professor Richard Wilkinson Yeah, I think one thing we haven’t said is – that’s absolutely fundamental, is that what bigger material differences between us do is create bigger social distances. Status and class matter more, you know. There are things we quite dislike thinking matter and are influenced by, but you can see all the differences in how kids do at school and in health and so on, between rich and poor. All those differences get bigger in more unequal societies. Also, social mobility, there’s much less social mobility in more unequal countries. It’s as if the, sort of, prejudices increase, the social class prejudices, for instance. You see that also in a tendency for people to be less likely to marry someone from a different class background in a more unequal country. You’re much more likely to find a partner from within your own class. It’s a nasty process and the material differences build all that up, make it more important. Dr. Umar Toseeb And if we move onto the potential for change, what evidence is there that where there’s been change in inequality, where there’s been a reduction that’s led to positive changes to child and adolescent mental health? Professor Kate Pickett We looked at changes in income inequality over a ten-year period in relation to changes in child wellbeing. The measures for that came from UNICEF, and they’ve produced measures of child wellbeing in rich countries several times since 2007. So, we were able to look at the change in wellbeing in relation to the change in income inequality. And it was statistically significantly obvious that countries that had become a bit more equal saw positive changes in their child wellbeing and countries that had become more unequal saw negative changes in their child wellbeing. And those measures of child wellbeing, they do tend to include some psychological measures, things like children’s life satisfaction. It’s not mental illness per se, but it is evidence that as societies become more unequal, children’s wellbeing fluctuates. That’s the best evidence we’ve got for children’s mental health. Dr. Umar Toseeb And one of the commentaries that I saw when the book first came out, was around issues of causality, as in whether ine – income inequality causes poorer outcomes. And I know that more recently, you’ve addressed some of those concerns. Can you just talk us through the issues of causality here? Professor Kate Pickett So – and we sometimes say that if we’d been given a pound for every time somebody said correlation doesn’t prove causality, that we would be in the top 1% and wouldn’t have to study income inequality anymore. But obviously that’s true, but sometimes when you look at a correlation, you are seeing a causal relationship. And of course, in epidemiology, what we have to do is look at a whole body of evidence and try and assess whether the observational evidence we’re looking at suggests a causal relationship. So, we have done that, sort of, within a formal epidemiological causal criteria framework and it looks very much as if this is a causal relationship. We understand the pathways. We can see that when inequality changes, outcomes change. It’s a consistent picture across lots of different outcomes and different kinds of places. The evidence suggests a causal relationship. Professor Richard Wilkinson I was actually trained partly by Sir Karl Popper, probably the greatest 20th Century Philosopher of Science, who always said, “The real test of a good theory is whether it makes successful novel predictions.” And of course, when we wrote “The Spirit Level,” we made guesses as to some of the causal mechanisms, but since then, other people have done research which has verified those links. So, for instance, we know there is more status anxiety in all income groups in more unequal countries. We know people big themselves up so they appear, sort of, higher status or whatever. Quite a number of mechanisms have become clear, but it’s also extremely plausible once you know, for instance, the literature on the causes of violence, the environmental causes of violence, how similar they are, and the modern work on the health effects of chronic stress. They affect just about all our health systems. I think there’s no doubt at all that it works as we say and it is a causal relationship. Dr. Umar Toseeb Okay, so we’ve talked about your theoretical framework and we’ve talked about the data and the evidence for it. What about policy? So, what can be done to mitigate the impacts of income inequality in child and adolescent mental health? And I suppose we could talk about it on a global level and a country level, schools, individual, family level or whichever one you – or all of them, if you want to talk about them. Professor Richard Wilkinson Well, I think it’s – I think we should start off by recognising that countries have been moving in the wrong direction for quite a long time. I mean, really, since about 1980, there’s been a strong tendency internationally for inequalities to grow within countries. And indeed, I think it’s important to realise that this isn’t a matter of a few tweaks to tax policy or whatever that can solve the problem in a couple of years. The big changes in inequality happened, for instance, since the 1930s. Inequality was at a very high point and it began to come down. It went on coming down right until the late 1970s and I think that was a process driven by the strength of the Labour movement, Social Democratic parties, the fear of communism, which actually was good for capitalism. It made capitalist countries develop welfare states and so on. But we’ve lost all that now with free market fundamentalism and I think we have to do things like develop forms of economic democracy, employee representatives on company boards and employee owners – owned companies, co-operatives. That all leads to smaller income differences, but also much more progressive taxation, policies of that kind. But they’ll need to be sustained over a decade or more to get really important benefits. Professor Kate Pickett I mean, I think I would add to that that it’s really important, from policy point of view, to be thinking about both the top and the bottom of the income distribution. So, we need to be taxing high incomes, but we need to be taxing wealth, as well, because it’s wealth inequality that’s grown the most recently. And then, that’s also the mechanism by which you have the funds to be able to do the kinds of levelling up and tackling the inequality at the bottom that you might also want to be focused on. So, having a more generous welfare system and welfare state and social security benefit. It might even go so far as deciding you want to have some level of universal basic income in the population, but certainly ensuring that people have sufficient to live with dignity and self-respect and that their livelihoods are sufficient for their physical and mental health. So, we need to work at the top and we need to work at the bottom, as well. We need to work on international financial systems as much as we need to work nationally. But you mentioned schools and neighbourhoods. We can also be thinking about what can be done at local level and even as local as within a school. I think schools, it’s quite clear, can be a place that either reinforces these sorts of social distances or it can help mitigate them. Your listeners will probably know about efforts to poverty-proof schools, for poor children to be in school without everybody knowing they’re poor, without that meaning they have differential access to different resources. Schools, I think, are where we see incredibly high levels in more unequal countries of things like bullying and schools can be tackling that. You know, it’s a consequence of an unequal society, but it’s within schools that that is being expressed. And so, I think it would be good, in terms of child and adolescent mental health, for schools always to be thinking about what are we doing to counteract that tendency in society? What are we doing to try and support equality within our schools? And I think there is much that they can do, and good schools really do it. Dr. Umar Toseeb I suppose if we just extend that to the individual level, and you talk about young peoples’ perceptions in the editorial. I suppose one of my criticisms of the current approach to mental health in the UK, or in other countries as well, is that whilst we do these things at a population level and we recognise that some of this is social and structural, but the support that we put in place is about the individual. And, you know, you change the way you think about certain situations and CBT, which I don’t necessarily agree with, but we do it because we recognise that it will take a long time for us to deal with the structural issues and then we need to deal with something at the individual level. Is there more that young people can do at the individual level to try and, I don’t know, address some of this, whilst the structural changes happen? Professor Kate Pickett I think if we can engage young people in understanding these issues and also, in becoming advocates for change and campaigners for change, I think that’s beneficial in lots of ways. It’s beneficial to society, maybe that will be an additional impetus to see the kinds of change we want. I mean, I don’t think any of us would ever have guessed that a single Swedish schoolgirl deciding not to go to school on Fridays could have the impact on the environmental movement that it did. So, sometimes when young people get engaged in important issues, I think the voice and perspective that they bring to that can shift the dial. We shouldn’t discount that and we should encourage that, but also, I think becoming engaged in understanding social issues and how they affect their lives and learning how to campaign for change, is hugely beneficial to young people themselves, including in terms of their mental wellbeing. It gives them a sense of purpose. It can give them a sense of agency. It can give them solidarity if they’re working together and also, it’s building skills. So, it’s a hugely beneficial thing to do, I think, and again, it’s something that parents can encourage, schools can encourage, youth groups can encourage. Dr. Umar Toseeb And if we can just step back to the point of policy and I know, Richard, you said it’s more than one specific policy in a – in the short-term. But in the UK and more closer to home, we have a new Labour Government who wants to focus on growth so that there’s more money. Is the problem that we don’t have enough money, or is the problem wealth distribution? Professor Richard Wilkinson I do think that it’s really a great failing of the – particularly a Labour Government, not to recognise the importance of reducing inequality, particularly when we know that economic growth is bound to increase the economic burden on the environment. So, we have to tackle that at the same time, and of course, they are and the Labour Government is trying to tackle that. But it’s a bit contradictory to think that they can deal with problems through growth, and even – and people who think that the only problem is poverty. Of course, in modern – in the modern world, poverty is measured in relative terms. It’s the proportion of population getting less than half the average income or less than 60%. So, in a sense, even people who are concerned with poverty, that has very strong effects, it’s relative poverty. It’s where you are in relation to other people that matters. Professor Kate Pickett I mean, if you think about the timeline of all of this research evidence being brought together, we published “The Spirit Level,” we know – which is really a synthesis of our own and lots of other people’s research up until that point, in 2009, just as we were getting a change from New Labour into the, sort of, coalition government. And so, we didn’t – have not, since that research evidence became better known, we have not in the UK had a government who was explicitly focused on inequality. We did have the levelling up agenda and we did have David Cameron talking about the Big Society, you know, and people being in this together, when – but we never had policies that really were all geared towards shifting inequality, creating greater equality. And I think we might have some hope that with the change of government, we would get that, but I’m not yet hearing that clarity of, sort of, purpose or of rhetoric around making Britain a more equal society, with all the benefits that that can bring, but I live in hope. Dr. Umar Toseeb We all do, thank you. So, let’s talk about some gaps in the literature. Sorry, in the editorial, you talked about that the relationship between social media use and mental health and wellbeing varies by societal income inequality and that might be a gap that might need to be investigated in the literature. What are some other prominent gaps in the literature that you think would be fruitful to address? Professor Kate Pickett I mean, I think that is a huge one. I think our young people today are growing up as digital natives. It’s a completely different world to the one that I grew up in, or Rich grew up in, or even you, Umar, you know, you’re younger than us. I think we don’t yet have a clear understanding of what that is going to mean for people’s mental health and wellbeing across the life course and so, that is a really urgent need. I mean, to me, the biggest gap at the moment is just having the data that we can work with and so, so often, when you want to look at questions around child and adolescent mental health, you’re just stymied by lack of good quality data at a population level. And then, quite often, it doesn’t come attached to the things you want to understand as being related to it. So, I do a lot of work with academic colleagues across the North of England within an organisation called Health Equity North, where we’re looking at wellbeing in the North of England compared to elsewhere. And quite often, when we want to look at things like do these relationships – you know, is it – do they differ for different ethnic groups? We can’t do that because the data simply aren’t there on ethnicity in relation to some of the things we’re interested in. So, it’s a data gap more than a, sort of, research hypothesis gap that I feel is most urgent at the moment and needs most attention. We need better quality data and we need better data linkage. Professor Richard Wilkinson Yes, I think there’s a real need to shift the focus from individual factors, whatever problem you’re dealing with, I mean, whether it’s issues to do with violence or mental illness or drug policies or alcohol, you know, all these things seem to get worse with more – with greater inequality. And yet, they’re all pursued not only as separate problems, but also, as if the important thing was individual risk factors. And each time there’s a new survey that shows that mental illness, particularly in young people, seems to be deteriorating, and, you know, mental illness getting worse, the media comes out with a demand for more services, more Psychiatrists, more Psychologists, more therapy. But we have to stop and say, what on earth is it about our society that is producing this? And I’m sure that, you know, we’re only scratching the surface of that side of it, the bigger picture, what’s wrong with the whole society and the way our market economy works, the consequences of that for all of us. Dr. Umar Toseeb Thank you, and aside from the research that you do, what are you involved in, and what other initiatives, to help reduce income inequality? Professor Richard Wilkinson Well, we set up the Equality Trust about the same time as “The Spirit Level” was published. It’s now quite independent of us and campaigns for greater equality. We also served on a couple of different Fairness Commissions. A number of the big cities, I think 20/25 big cities, something like that, set up Fairness Commissions to report on how they could reduce inequality locally. So, Kate’s also been involved in trying to get her university to pay the Living Wage rather than the Minimum Wage, successfully I may say, and a number of other universities have done the same. I think we all need to be doing that in workplaces, getting our institutions to pay the Living Wage to all employees, and questioning the scale of income differences between top and bottom. It seems to me that every strike, every labour dispute, should also be raising issues to do with the scale of income differences in whatever organisation it is, and to be holding lower wages down while the people at the top are getting sometimes many millions, clearly, you know, it shouldn’t wash. Dr. Umar Toseeb Thank you and finally, what’s your take home message for our listeners? Professor Kate Pickett For me, it would be to ask them to become familiar with the literature, you know, get an understanding of these issues and then think about what their contribution could be to help make the world a more equal place and to help mitigate against the impacts of inequality. And it’s different for all of us. You know, I feel that our contribution can be to ask good research questions and to write for particular audiences, whether that’s publishing research papers in academic journals or serving on commissions or writing a book. But for other people, it might be different. You’ll have clinical listeners who can think about how to incorporate this into their clinical work. You’ll have others working with schools or other institutions who might be able to think about how best to do it in that setting. We can all, as individuals, do things like think about who we vote for, think about what we read, and think about how we talk about these issues to friends, to family, to colleagues and to children and young people themselves, actually. And so, I think giving them an understanding of how the world shapes their wellbeing, whilst also giving them the tools to try and change that, I think that’s the most important thing that we can do. Professor Richard Wilkinson I think there also has to be a shift in our, sort of, political horizons, if you like. Increasingly, it seems to me, democracy is becoming less meaningful in our societies, and I think we can deal with that, respond to it, partly by extending democracy into business institutions, corporations, into the workplace, in the, sort of, way I mentioned earlier. About half the member countries of the European Union have some legislation for employee representation on company boards. Usually it’s pretty weak, but in one or two countries, including Germany, it’s quite strong and it does seem to lead to a – it’s led to a smaller rise in income differences during the period in which neoliberalism, free market, fundamentalist ideologies, have held sway since the 19 – since the 1980s. So, it’s a matter of thinking we must do something about the power of big corporations and what wage labour means. It looks as if you can democratise it successfully. Dr. Umar Toseeb Thank you, Kate, thank you, Richard, for taking the time and sharing your insights. Fascinating, wide-ranging discussion there, thank you so much. Professor Kate Pickett Thanks for having us. Dr. Umar Toseeb Thank you. Professor Richard Wilkinson Thank you, yes. Dr. Umar Toseeb For more details, please visit the ACAMH website, www.acamh.org, and Twitter @ACAMH. ACAMH is spelt A-C-A-M-H, and don’t forget to follow us on your preferred streaming platform, let us know if you enjoy the podcast, with a rating or review, and do share with your friends and colleagues.