Women's experiences of living in an unequal society: the place of shame, social comparison, and neoliberal discourses in explanation of inequalities in health

Abstract

BackgroundUnequal societies are well known to have higher rates of morbidity, premature mortality, and some types of social problems than are more equal ones. Despite debates about the robustness of these relations, there is an increasing amount of supporting evidence. But less well established and more contested are the processes that might underpin and explain this gradient in health, how inequality gets inside the body and the social body, and what might serve to protect from the damaging consequences of inequality. Psychosocial theorists have proposed that one mechanism is via shame and invidious social comparisons that could have both biological and social consequences. Social epidemiological evidence seems to support this contention, but social epidemiology has been critiqued for its theoretical “thinness” and for its marginalising of agency. People are not passive recipients of inequality; they may resist and endeavour to protect themselves. In addition, the place of wider political discourses such as neoliberalism in construction of inequalities in health is debated, questioning the argument that it is inequality per se that is the problem. MethodsThis study used a psychosocial approach to data collection and analysis. Psychosocial in this context describes a set of methods that draws together the inner and outer worlds of the person, attempting to look beneath the surface of discourse. Such studies are characterised by in-depth, repeat interviews with a few participants, resulting in rich data. These data can help to explain how epidemiological findings translate into lives, similar to the function of the single case study as used in clinical medicine. 26 biographical narrative interviews done with the Free Association Narrative Interview (FANI) method were used to explore the experiences of life in an unequal society with 13 women in northern England. Shame is a painful and difficult emotion that is likely to be denied or avoided and hard to speak of, and the approach was chosen to facilitate the exploration necessary to access this emotion. Participants were purposively recruited via local contacts to accord with the demographics of the study area. FindingsShame and social comparison were present but often not in ways that psychosocial theories might predict. The women in the study did not know their place in a hierarchy, and widespread knowledge of the extent of inequality was scarce. Shame avoidance was primarily focused on children and on protecting them from stigma by the purchasing, where possible, of appropriate goods. For the women themselves, shame was in relation to the body and to the home with cleanliness and its meanings being salient for many. But most striking was a discourse of no legitimate dependency, which most women experienced—an unhappy and often painful discourse, by which dependence on another was disavowed and self-reliance valorised, leading to increased levels of strain and distress. InterpretationThe no legitimate dependency discourse represents a part internalisation of neoliberalism that is often expressed colloquially with the language of therapy. It is manifested both as self-criticism and the holding of the self to impossible standards of non-dependence, and as the so-called othering or blame of those regarded as not sufficiently responsible. It is an unstable and unhappy discourse—none of the women wished to impart such values to their children—but one that seemed unavoidable in the absence of alternative social or collective explanations for inequalities. This discourse legitimates the nature and extent of permissible inequality and how it is lived and experienced, via a process of individual blame and responsibility. Neoliberalism has reduced the practical and discursive resources that can be drawn on to protect the self, particularly for the poorest people, such as positive collective identities, thus potentially leading to greater inequality. FundingUniversity of Sheffield.