It is a truth not universally acknowledged that much poor health is a direct and predictable result of the actions (or inactions) of governments.
This might arise because of governments failing to address major public health threats (whether climate change or the marketing and sale of disease-inducing products) or because of government actions that have consequences for peoples’ health and wellbeing.
Perhaps researchers will properly document the adverse health impacts of the Centrelink debacle, in which a litany of “inhuman errors” has caused many thousands of people distress and anxiety.
As Richard Denniss wrote in The Guardian:
Centrelink has sent tens of thousands of letters of demand to citizens based on a computer algorithm that suggests they might have been overpaid.
In the lead up to Christmas some of the most vulnerable Australians have been forced to choose between wasting days looking for six-year-old pay slips, spending days on the phone to Centrelink, which is notorious for not answering, or to succumb to enormous pressure from their own government and repay hundreds or thousands of dollars that they might not even owe.
In this light, the Centrelink debacle can be seen as just one small element of a much larger pattern that is creating the perfect conditions for chronic stress and associated health and social problems, according to Fisher, a Research Fellow at the Southgate Institute for Health, Society & Equity at Flinders University in Adelaide.
Matt Fisher writes:
Literature on the social determinants of health identifies chronic stress as a key pathway by which social factors get ‘under the skin’ to affect physical or mental health. The health effects of exposure to stressors associated with socioeconomic disadvantage contribute to health inequalities.
Evidence from research in epidemiology and public health, social psychology, cognitive and affective neuroscience, and stress supports these related hypotheses. From a public health perspective, the importance of chronic stress as a mediator of social effects on health and health inequalities could hardly be overstated.
Thus, it is good to see that evidence on the impacts of chronic stress on health is also used to reinforce arguments for public policy action on the social determinants of health, and is sometimes recognised in health policies.
However, it is here, on the question of understanding and communicating the political and policy significance of the stress-health relationship, that the public health community has a problem.
The current approach in public health advocacy, which subsumes the issue of chronic stress within arguments for action on social determinants of health, fails to capture and communicate a much wider significance for public policy and politics.
In order to come to grips with this putative wider view, a brief preliminary sketch of the role of acute stress will be useful. It is now well known that stress arousal is a ubiquitous feature of human life. In everyday social environments, certain basic brain functions are controlling goal-directed behaviour while others are constantly, predictively evaluating events – mainly the behaviour of other people – for their emotional/motivational significance to ourselves.
When we encounter a stimulus that is associated with negative, unpleasant emotion, or is merely unexpected, then stress arousal switches on. This in turn leads to increased sensory acuity, focused attention, heart rate and blood pressure; all designed by evolution to support a rapid change in motivation and behaviour to cope with a perceived ‘threat’.
If this adaptive response succeeds, then acute stress arousal dissipates and things go on as before. In humans, acute stress plays a particular role in regulating social behaviour, because we are a social species.
Seen against this background, the conditions required to produce chronic stress are in essence quite simple. If a ‘threat’ stimulus is recurrently present and the individual concerned cannot identify and put into action some means of decisively resolving or avoiding the anticipated problem, then chronic stress arousal will follow.
With these preliminaries out the way, let’s move on to the main purpose of this article. The first several points below are about an extended view of the problem itself – the presence and effects of chronic stress in modern social environments. The second set of points are about the policy and political implications that follow.
A revised view of the problem
It’s not just about social or economic disadvantage: Public health research – coupled with other information – provides ample evidence that extended exposure to certain kinds of adverse material or psychosocial conditions is likely to cause chronic stress, and subsequently have negative effects on health.
Material conditions implicated in this way include low income, unemployment and insecure housing. Problematic psychosocial conditions include exposure to violence or racism, or a perceived lack of neighbourhood safety.
These and other factors identified as determinants of health are indeed very likely to act as stressors, and if a person is not able to exercise control over these conditions, then chronic stress may result.
However, this approach, which draws attention to the impacts of stressors on disadvantaged groups, is not well-placed to illuminate the society-wide dimensions of the problem.
Recurrent stress arousal is now a normal part of life in modern, complex social environments, because they involve all sorts of contingencies with possible affective salience (emotional significance).
We are all liable to chronic stress arousal, not through exposure to some specific adversity, but simply by the fact of spending extended periods of time out ‘in the world’, trying to get things done. Along with this basic level of demand, we have added (inter alia) rapid social, economic and technological change, urban growth, climate change, long working hours (for some), and a media environment filled with hyperbole and violence.
What then becomes crucial is the extent to which one is able to balance this ‘new normal’ with times of genuine relaxation and rest. The role of electronic and digital media is particularly insidious here, because it makes the wider world of potentially stressful social behaviours psychologically available, 24 hours a day.
Thus, the effects of specific social or economic stressors – identified as determinants of health – should be understood as ‘playing into’ this widespread level of background stress demand across society at large.
It’s not just about ‘health’: The large body of evidence on social determinants of health is important, of course, but does have the effect of tying arguments for policy action to conceptions of the problem and the desired outcome defined in terms of disease or disease risk.
However, when we look at the modern world through an understanding of chronic stress and its causes, we can readily discern undesirable social and individual effects that are not about disease or disease risk as such.
A person can experience chronic stress, and be subject to real psychological suffering or disturbance, and not display the symptoms of a defined mental or physical illness.
Furthermore, a chronically stressed person, even when not subject to a diagnosable illness, may project their frustration or anger at this psychological ‘demand’ onto those closest to them, or look for relief in the diversions of addictive behaviours, or the apparent certainties of simplistic political or religious beliefs.
Speaking of beliefs, it is quite clear from an understanding of the basic neuropsychology of stress arousal, that certain kinds of (implicit or explicit) beliefs can affect a person’s dispositions to experience stress.
This follows from the fact that stress arousal is affected by the way we cognitively interpret social stimuli for their affective salience. If, for example, you happened to accept as true a false belief that a particular person at your place of work despised you, then you would be most likely to experience elevated stress arousal in their presence.
In simple terms, their presence, for you, would predict a possible aversive outcome – an aggressive encounter or humiliating exchange – even though your belief about them is false. If for some reason you felt unable to resolve the (perceived) situation, then chronic stress could take hold.
The relationship between beliefs and stress, as one would expect, is complex: the internalisation of certain beliefs about the world can contribute to acute or chronic stress arousal, and being subject to chronic stress can affect a person’s dispositions to seek out and accept certain (possibly simplistic) ideas.
On the other hand, beliefs that serve to interpret a stimulus as less threatening can help to reduce stress arousal.
It’s not just about negative impacts: There is a lot of talk about wellbeing these days, but too little scientifically-grounded, collective insight into the basic nature of wellbeing, and the conditions required for it to be developed and maintained.
What we do have focuses excessively on individuals and fails to recognise the social, economic and cultural factors affecting wellbeing in populations.
Population level data based on people’s subjective assessment of their own states offers few insights into the underlying, more fundamental cognitive and affective functions – and their interactions with social stimuli – that determine wellbeing.
Understanding stress arousal as one of several basic functions subserving social cognition and behaviour is useful because it provides essential insights into wellbeing and how it can be promoted.
I would argue that the foundations of wellbeing lie with acquiring, maintaining and exercising capacities for self-regulation of the basic cognitive and affective functions involved in social cognition: motivated, goal-directed behaviour; monitoring other people’s behaviour and flexibly adjusting one’s own behaviour in response to salient social cues; and balancing periods of aroused goal-directed, social behaviour with periods of relaxed, self-directed or contemplative activity.
Under-development of these abilities can also increase one’s vulnerability to social stressors. Chronic stress and its flow-on effects can undermine the development of these capacities in young people, and undermine their functioning in adults.
Bringing these perspectives together, we can see that the matter of understanding stress is not just about identifying the impacts of chronic stress on disease risk and incidence.
Rather, the dynamics of social cognition, social behaviour, wellbeing, stress arousal and chronic stress in modern social environments are central to most of the social issues we care about, including those which cause us much concern.
Social behaviour is determined at the intersection between the development and use of basic functions of social cognition, including regulation or dysregulation of affective arousal, relationships with other people, and internalised beliefs used to explain the world and other people’s behaviour.
Implications for politics and policy
What then does this mean for politics, public policy and public health advocacy?
To begin with, it has been frequently observed in philosophy and political science that political theories are grounded in certain fundamental ideas about human nature and society.
Market economic theory, for example, is built around the idea of human beings as rational, choice-making utility maximisers.
Deeply entrenched (possibly implicit) ways of conceptualising the nature and causes of ‘problems’ do much to determine and delimit the preferred ‘solutions’ proposed.
The beliefs about human nature and behaviour that political leaders rely on are often drawn from folk psychology; the everyday, person-in-the-street ideas people use to explain one’s own and other people’s behaviour.
Folk psychology works alright for everyday purposes but combined with political values it tends to produce simplistic, formulaic conceptions of the causes of, and solutions to, social problems; for example, the idea that the obesity epidemic is merely a problem of a lack of self-discipline or personal responsibility.
Viewed dispassionately, it is absurd that we spend billions of dollars on particle accelerators or medical research but are often governed by theories and values based on simplistic folk psychological beliefs and explanations.
If instead we look to psychology and psychiatry as a source of ideas to shape politics and policy, we see two profound limitations; they address mental health and illness purely as features of the individual, and they focus most attention on illness.
Thus from them we get policy responses targeted at individuals diagnosed as having an illness, and the vast body of evidence on wellbeing, mental health and illness as social phenomena, produced at the interface between individual and social environment, is effectively rendered null and void.
Thus, it is essential that an alternative, more adequate form of social psychology is mounted to counter both the simplistic formulations of ‘political folk psychology’ and the individualised approach of the mental illness industry.
Keys to this challenge are a) to locate an understanding of stress within a broader view of social cognition and behaviour, and b) to explicitly recognise that mental health and illness are always produced via the interaction between individual and environment.
This alternative set of ideas can certainly provide better explanations of problems but just as importantly it can support improved understanding of the basic conditions and capabilities required for wellbeing.
The unravelling of modern, capitalist societies: Coming now more directly to a few of the political implications of this view, it is of course essential to sustain arguments for policy action to address socioeconomic inequalities in order to reduce health inequities.
However, the issues we face go wider than socioeconomic inequality per se and need more than redistributive policies to address them effectively.
Right now in Australia (and elsewhere), we are doing poorly in cultivating basic capacities and supportive conditions for wellbeing, and at the same time creating conditions that expose our populations to significant stress demand.
Contrary to conventional wisdom about how well off we all are, and contrary to indicators such as increased life expectancy, we are producing a socio-cultural environment that, through the combination of many material and psychosocial factors, is subjecting its members to a growing level of stress demand.
The signs of the adverse impacts of this demand on people’s mental states and behaviour are everywhere; such as our appalling rates of domestic violence, alcohol and drug abuse, suicide, addictive gambling, relationship breakdowns, and rapidly increasing prescription of anti-depressants.
Public health advocates need to understand the dynamics of social cognition and stress in order to be able to talk publically about stress demand as a basic, underlying cause of a range of social problems.
The politics of belief: Recognition of the potential role of beliefs in stress psychology also has its manifestations at a population level, and the sword is double-edged.
Certain kinds of ideas – beliefs about the world – promulgated through the media, can contribute to the stress demands felt across populations; while at the same time populations subject to stress demand may be more vulnerable to simplistic or ‘extreme’ worldviews.
Politicians in Australia currently seeking to cultivate fear of ethnic or religious minorities are exploiting these vulnerabilities, but this is only one part of the story.
The broader issue is the form of politics – personified most completely in former Prime Minister Tony Abbott – which relentlessly constructs a sense of threat, mistrust and victimhood directed at the public institutions of society in general; government, education, the justice system, universities and empirical science.
It is entirely appropriate to interpret the current rise of the ‘politics of disaffection’ as a manifestation of stress demand across the population, driven by this kind of public discourse, coupled with a diminished sense of control over the conditions of one’s life.
Public health advocates need to draw attention to the debilitating effects of the politics of fear on people’s mental states, and how this can undermine political stability and rational, evidence-based approaches to policy.
A focus on conditions and capabilities for wellbeing: Finally, in constructing a policy agenda from this kind of analysis, it is crucial to put wellbeing at the centre. Amartya Sen got this right when he put the idea of human development at the core of his political philosophy.
However, the flaw in his approach is a failure to define basic conditions required for human development, and instead to shift all the ethical weight to individual choices about living a life one ‘has reason to value’.
Wellbeing is fundamentally about individuals developing and exercising some basic capabilities for self-regulation of cognitive and affective states and behaviour, and avoiding intense, acute stress or chronic stress.
Children need safe, stable, structured environments in which to develop these capabilities by exercising them in nascent form. Adults need secure, stable environments within which they are able to exercise some control over their lives.
We could well learn from holistic Indigenous conceptions of health and wellbeing as embedded in social, cultural and environmental relations.
The view of wellbeing proposed here, and the risk to it, can help to renew and reinvigorate public health arguments for a shift in resources in all areas of health and social policy away from remedial or punitive deficit approaches to a focus on building conditions and capabilities for health and wellbeing, from early childhood to adolescence, mid-life and ageing.