Why and how inequality matters.

581619 research-article2015

HSBXXX10.1177/0022146515581619Journal of Health and Social BehaviorMcLeod

Pearlin or Reeder Award invited manuscripts

Why and How Inequality Matters

Journal of Health and Social Behavior 1–17 © American Sociological Association 2015 DOI: 10.1177/0022146515581619 jhsb.sagepub.com

Jane D. McLeod1

Abstract In this article, I share some thoughts about how we might extend the study of mental health inequalities by drawing from key insights in sociology and sociological social psychology about the nature of inequality and the processes through which it is produced, maintained, and resisted. I suggest several questions from sociological research on stratification that could help us understand unexpected patterns of mental health inequalities. I also advocate for the analysis of “generic” social psychological processes through which inequalities are produced, maintained, and resisted within proximate social environments. I consider the role of two such processes—status/devaluation processes and identity processes—in mental health inequalities. I then discuss how we can strengthen connections across subfields of the sociology of mental health by applying status and identity theories to two areas of research: (1) help-seeking and (2) the effects of mental health problems on social attainments.

Keywords inequality, mental health, social psychology, socioeconomic status, stress process I am deeply grateful and humbled to have received this award. The sociology of mental health is the intellectual community in which I began my career and to which I maintain my primary allegiance. This award carries special significance because of its association with Len Pearlin and special poignancy this year due to his recent death. Len welcomed me into the community back when I was a graduate student—I still remember ASA and stress conference dinners at which all of the famous sociologists of mental health would convene over dinner and their students would sit, a bit dumbstruck, and absorb the intellectual energy. Len was central to those gatherings. Len also encouraged me through actions both large and small throughout my career. I owe him a great professional debt, as do so many of us. This award stands as testament to his deep and abiding influence on our field. In this article, I will offer comments intended to honor the spirit of Len’s work, which called on us to remember that “the sociological stake in stress research requires the careful and comprehensive analysis of information about the structural contexts of people’s lives” (Pearlin 1989:254), and whose own empirical work attended equally carefully to the “broad array of social psychological conditions that

combine over time to create stress” (Pearlin et al. 1981:337). Specifically, I will share some thoughts about how we might extend the study of mental health inequalities by drawing from sociological research on the nature of inequality and social psychological research on the processes through which inequality is produced, maintained, and resisted. I consider my comments a starting point for further discussion and elaboration as we work collectively to understand why inequality matters for mental health and as we consider why the study of inequality matters for sociologists of mental health. A brief review of articles in the Journal of Health and Social Behavior and in Society and Mental Health reveals that inequality is a topic that receives significant attention from sociologists of mental health. To gauge how much attention it receives, I conducted a rudimentary content analysis of 1

Indiana University, Bloomington, IN, USA

Corresponding Author: Jane McLeod, Department of Sociology, Indiana University, 744 Ballantine Hall, 1020 E. Kirkwood Avenue, Bloomington, IN 47405, USA. E-mail: [email protected]

Downloaded from hsb.sagepub.com at NORTH DAKOTA STATE UNIV LIB on May 29, 2015

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Journal of Health and Social Behavior

empirical articles on mental health or mental illness that were published in the Journal of Health and Social Behavior since 2000 and in Society and Mental Health since its first issue in 2011.1 In my analysis, I asked whether the article focused on mental health inequalities, counting articles if they were epidemiological (i.e., concerned with the distribution or determinants of mental health or illness) and if they presented explicit between- or within-group analyses of whether or why indicators of stratification (e.g., socioeconomic position, gender, race, sexuality, immigrant status) or of social disadvantage (e.g., neighborhood conditions) are associated with mental health or mental illness. Articles that focused on inequalities in services utilization or diagnostic practices were not counted as about mental health inequalities for purposes of this analysis. Of 35 empirical articles published in Society and Mental Health (all of which were about mental health), 14 (40%) were concerned with describing or explaining mental health inequalities. Of 178 empirical articles that focused on mental health or mental illness in the Journal of Health and Social Behavior, 100 (56%) presented analyses of mental health inequalities. Based on these numbers alone, there can be little doubt that mental health inequalities continue to occupy much of our collective attention. (See Appendix A in the online journal for details, available at http://hsb.sagepub. com/supplemental) I will build on this work to propose new considerations for research in this area. Specifically, I will: •• review the research we have conducted on whether, why, and how inequality matters for mental health; •• consider what we can learn from sociology and what sociology can learn from us about the nature of inequality; •• identify concepts from sociological social psychology that can help us understand how social disadvantage affects mental health; •• consider how these same concepts can support analysis of the implications of mental health problems for social attainments and thereby encourage integration across different areas of research within our subfield.

Goals for the Study of Mental Health Inequalities Before turning to these topics, it is worth considering the purposes our research serves. The study of

mental health inequalities affords opportunities to test, develop, and elaborate sociological theory— one reason that scholars are attracted to this line of work. Yet, many of us are drawn to this area for humanistic reasons as well: because we see poor mental health as a consequence of disadvantage and we want to develop ways to mitigate the damage. Statements of the latter goal appear regularly in the literature, as evidenced in these three quotes: •• From Len Pearlin’s 1999 chapter in the first edition of the Handbook of the Sociology of Mental Health: ||

“Sociological interest in mental health and disorder is rooted in its mission to identify elements of social life that have dysfunctional consequences” (p. 410).

•• From John Mirowsky and Catherine Ross’s (2002) article on “Measurement for a Human Science”: ||

“Many researchers want to create knowledge that helps ordinary humans understand and control their own lives, so that these ordinary humans can avoid suffering, avoid making others suffer, and achieve the well-being they desire” (p. 153).

•• Summarized (although not necessarily affirmed) by Sharon Schwartz in her 2002 review of outcomes for the sociological study of mental health: ||

“Sociologists should explore the consequences of social structures on mental health with an eye toward identifying those aspects of society that produce harm” (p. 223).

Our theoretical and practical goals are interdependent. Efforts to mitigate the damaging effects of inequality depend on accurate descriptions of the nature of mental health inequalities and comprehensive explanations for their causes. These depend, in turn, on theories about the nature of inequality and the processes through which it affects mental health. We face two major challenges when addressing our goals. First, our understanding of whether and when social disadvantage is associated with mental health is incomplete and what we know about group differences in mental health is not entirely consistent with a simple story of social disadvantage. Although women are socially disadvantaged relative to men,


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McLeod they differ from men in the type, rather than the level, of mental health problems they experience (Rosenfield and Mouzon 2013). Similarly, although blacks are socially disadvantaged relative to whites, blacks do not consistently report higher levels of distress and do not have higher rates of most mental disorders (T.N. Brown et al. 1999; Kessler et al. 2005). Even the association of socioeconomic position with mental health varies by indicator and over the life course. For example, the association of education with depression appears to grow stronger with age (Kim and Durden 2007; Miech and Shanahan 2000). In contrast, the association of income with depression appears to grow weaker with age (Kim and Durden 2007), and economic hardship is more strongly associated with depression and anger among younger as compared to older adults (Mirowsky and Ross 2001; Schieman 2003). These patterns become even more complex when we consider the course of episodes. For example, the association of socioeconomic position with depression appears to be stronger for persistence than for onset (Lorant et al. 2003). Before we can develop comprehensive and satisfying theories of mental health inequalities, we must develop a clear understanding of the basic patterns of mental health across groups. General sociological research on inequality can be helpful to us when thinking about how to approach this task.2 Second, we do not yet know enough about why mental health inequalities exist to identify specific ways we might intervene to mitigate those effects. To borrow Chloe Bird’s (2014) term, most research on mental health inequalities is not “actionable.” Research is actionable if it yields specific information with which someone could act to change the current state of affairs. For research to be actionable, it must attend to what is happening in the local contexts with which decision makers are concerned and policy is implemented. In other words, identifying potentially effective actions requires that we understand not only what matters but when and why—process and how process varies across time and space. Sociological social psychology provides conceptual tools for developing theories of process. To make these abstract comments more concrete, I consider briefly where sociologists of mental health typically look for explanations for mental health inequalities. The stress process framework remains the dominant paradigm now as it was back in 2002 when Sharon Schwartz conducted a similar review (Schwartz 2002; Schwartz and Meyer 2010). For this, I focused only on articles concerned with explaining mental health inequalities. In Society and Mental Health, of the 14 empirical articles on mental health

inequalities, 1 was descriptive and did not address explanations, 2 proposed explanations outside of the stress process, and 11 (79% of articles that attempted explanation) proposed explanations that used concepts from the stress process. We see a slightly lower proportion of articles that incorporate stress concepts (73%) in the Journal of Health and Social Behavior, although this proportion increases if we omit the articles that focus on substance use.3 Assuming that we find the stress process framework useful to the study of inequality, one step we can take toward a better understanding of process is to determine which types of stressors are more common among the groups we consider socially disadvantaged. Some stressors are not (Hatch and Dohrenwend 2007; McLeod and Kessler 1990; Turner and Lloyd 2004). Women report more recent life events than men, especially those involving other people, but men report more traumatic events over the course of their lives, especially involving violence (e.g., Hatch and Dohrenwend 2007; Kessler and McLeod 1984; Turner and Avison 2003; see Rosenfield and Mouzon [2013] for a review). Likewise, people who occupy different socioeconomic positions experience different types of stressors (Dohrenwend and Dohrenwend 1969). People with low levels of income and education report more financial stressors (perhaps not surprisingly) and more assault-related violence (Hatch and Dohrenwend 2007), but work-family conflict is more common among whites, the well-educated, and professionals (Schieman, Milkie, and Glavin 2009; Schieman, Whitestone, and Van Gundy 2006). We can add depth and nuance to our explanations if we are more precise in identifying the stressors associated with specific dimensions of inequality.4 We also must analyze why stressors matter for mental health, the conditions under which they matter, and how positions in hierarchical systems of social relations affect these processes. As many others have argued (G.W. Brown and Harris 1978; Pearlin et al. 1981; Simon 1997; Thoits 2013), not all stressors are equally relevant to mental health. Stressors that threaten valued roles, goals, and ideals; self-conceptions (our identities or how we define ourselves); and self-evaluations (our sense of ourselves as valuable or worthless and efficacious or not) matter more than others. This implies that in order to understand how positions in social hierarchies influence mental health, we must understand their associations with these kinds of threats. I will look to sociological social psychology to extend our thinking about these associations. Social


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psychologists have analyzed “generic” processes through which inequalities are produced, maintained, and resisted within proximate social environments. These processes are generic in the sense that they “occur in multiple contexts wherein social actors face similar or analogous problems” (Schwalbe et al. 2000:421). In other words, although the specifics of these processes take different forms in different historical, institutional, and interactional contexts, the general processes are trans-situational and widely observable. By implication, these concepts help us think about similarities and differences in how inequality is experienced across contexts. I will give primary attention to symbolic processes as social psychology is best equipped to analyze them; they are most closely tied to roles, identities, and the self; and they are central to the analysis of actions and cognitive strategies people use to minimize threats (Pearlin and Schooler 1978; Thoits 2006). In sum, I will turn to sociology for ideas about how to improve our understanding of basic patterns of mental health inequalities and to sociological social psychology to understand the processes that produce them. By taking this approach, I implicitly advocate a revised goal for research on mental health inequalities: to use studies of mental health inequalities to inform sociological understandings of the nature of contemporary inequality, how social disadvantage shapes the daily lives of persons, and how people resist potentially damaging effects of disadvantage. This goal is not inconsistent with our current consensual goals, but it reorients us toward understanding process and toward our relationship to the broader discipline. I believe that this reorientation will better serve our goals as currently stated. I offer these comments mindful that studies that invoke stress exposure as an explanation for mental health inequalities often find that it explains a lot. In perhaps the most well known of these studies, Turner, Wheaton, and Lloyd (1995) found that stress exposures explained 23% of the gender difference in depressive symptoms and 33% of differences by occupational status. Other studies report both more and less explanatory power (Denton, Prus, and Walters 2004; McDonough and Walters 2001; Turner and Avison 2003). The question of how much this reflects differences in exposure versus differences in vulnerability remains unresolved because tests of vulnerability depend on the comprehensiveness of our measures of stressors (Turner et al. 1995). I would argue, though, that despite these encouraging results, we still don’t really know what we are explaining (onset vs. persistence vs.

severity or, for continuous outcomes, initial values vs. changes over time), and we don’t know much about how social disadvantage produces stress exposures and the conditions under which stressors produce mental health inequalities, beyond the general notion that part of what it means to be socially disadvantaged is to have a more stressful life. With all of this in mind, I turn to my main task: to consider what we can learn from and what we can give back to general sociological research on inequality. I will begin with research on the nature of inequality and then turn to research on how inequality is experienced in proximate life contexts. The constraints of space prevent me from addressing all possible points of convergence. I close by considering how the study of inequality can also forge connections across different areas within the sociology of mental health.

What can we Learn from and Give Back to General Sociological Research on Inequality? Social stratification refers to the unequal distribution of valued resources across social groups. Those with greater access to these resources have greater knowledge, power, and prestige which allow for easier navigation through daily life. In the contemporary United States, the most widely recognized stratification systems are based on social class, race, and gender, but my comments apply to other bases of stratification, such as age and sexualities. Systems of stratification are maintained through institutional, interpersonal, and individual processes through which dominant groups assert and maintain control over valued resources. These processes are conceived in broad terms by stratification researchers as social closure or opportunity hoarding, exploitation, boundary maintenance, and othering, among others (Massey 2007; Roscigno, Garcia, and BobbittZeher 2007; Schwalbe et al. 2000; Tilly 1998; Tomaskovic-Devey 1993). These broad processes take specific form within institutional, organizational, geographic, and interactional contexts, such as families, workplaces, neighborhoods, and friendship groups. For example, social closure, or the strategies by which groups close off opportunities to outsiders (Weber [1922] 1978), looks different in the labor market, where educational credentialing is a common strategy, than it does in residential markets, where redlining predominates (Gee 2002). By implication, to understand how inequality affects mental health,


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McLeod

Figure 1. Social Structure and Personality Framework.

Source: Modified from McLeod and Lively (2003).

we have to understand the general nature of inequality, the general processes through which it affects mental health, and how those processes differ across social contexts. This approach to mental health inequalities draws from the social structure and personality (SSP) framework from sociological social psychology (House 1981a), and I use that framework to organize my comments (see Figure 1). As seen from an SSP perspective, the social world is a set of embedded circles with the individual at the core surrounded by progressively larger and more complex social groupings, including dyads, small groups, communities, organizations and institutions, and the larger social system. SSP researchers attempt to trace the processes through which components of the larger social system affect individuals and through which individuals affect social systems via these intermediary structures. Kathryn Lively and I have argued elsewhere (McLeod and Lively 2007) that many studies of group differences in mental health adhere to the SSP framework, if not always with explicit acknowledgment.5

The Nature of Mental Health Inequalities As a first step in the analysis of the implications of societal arrangements for individual functioning, we have to understand what those arrangements are and how best to measure them. To do this, we must engage with the work of more macro-oriented sociologists.

Scholars of stratification define inequality based on the unequal distribution of eight different kinds of socially valued assets (Grusky and Ku 2008). These include some that are familiar, such as economic resources, power, and human capital, as well as others that have only begun to receive sustained attention in the past 10 to 20 years, such as cultural, social, honorific, civil, and physical assets. (Notably, although sociologists of mental health conceptualize mental health as an outcome, stratification researchers conceptualize mental health as a physical asset that is distributed differentially across social groups.) As we consider the proximate life experiences that are associated with social disadvantage, we can look to this accounting of resources for guidance. We think immediately and easily about economic resources as they translate into financial strain, power as it manifests in workplace authority, social resources in the form of social support, but perhaps less immediately or obviously about access to due process in conflicts with institutions, tacit cultural knowledge that can be used to navigate institutions effectively, and the types of stressors the absence of those resources would produce. Considering the full range of resources could help us expand the relevant stress universe (Wheaton 1994) and also to identify the stressors and resources that are most relevant to specific dimensions of inequality within specific contexts. Sociological research on stratification has also posed several specific questions about the nature of inequality that should inform our approach to studying mental health inequalities. Among these are debates about the relative merits of subjective class identification as compared to objective indicators (e.g., Emmison and Western 1990) and of gradational measures (e.g., income, education) as compared to class-based measures. With respect to the latter, there is now extensive discussion of the value of “big classes” as compared to smaller, disaggregated, occupationally based “microclasses” (e.g., Weeden and Grusky 2012). Scholars of educational stratification now highlight the importance of school resources, the quality of schooling, and academic opportunities as components of educational stratification beyond attainment itself (see Walsemann, Gee, and Ro [2013] for a review). Another set of questions concerns how much inequality there is and how it varies over time and space. Stratification researchers debate how crystallized inequality is, that is, how strong the correlations are among the various resources that define advantage and disadvantage. When correlations are


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strong, the same people show up at the top and bottom of all hierarchies; when they are weak, there are status inconsistencies and people may have access to some resources that compensate for the absence of others. Stratification researchers have also evaluated cross-national, regional, cohort, and life course variation in socioeconomic inequality (see Hout and DiPrete [2006] for a review). With few exceptions (Levecque et al. 2011; Muntaner et al. 2004; Parcel, Campbell, and Zhong 2012; Schnittker 2012; Tausig and Fenwick 1994), there is little discussion of these matters among sociologists of mental health—a missed opportunity to engage with our parent discipline. By taking on these questions, we would not only extend our understanding of basic patterns of mental health inequalities but also provide new knowledge to stratification researchers. With respect to the first set of questions, analyses of the associations of mental health with alternative indicators of stratification such as subjective status or microclasses would contribute to more general debates about the relative merits of the different indicators for representing the nature and extent of inequality. With respect to the second set of questions, analyses that consider whether cross-national, regional, cohort, and life course variations in mental health inequalities map onto variations in socioeconomic inequality would inform debates about the degree to which the distributions of different socially valued assets are correlated. If mental health does not correlate as strongly as we might expect with other patterns of social disadvantage, this would suggest that inequality is not as crystallized as stratification researchers may have assumed. While researchers of socioeconomic inequality remain preoccupied with the existence of distinct social classes and with defining, describing, and explaining patterns of inequality quantitatively, researchers of racial-ethnic and gender inequality (i.e., ascriptive inequalities) have been concerned with the construction and maintenance of boundaries (Charles 2008). Feminist and critical race scholars in particular assert intersectionality as a central concept in the study of inequality (Collins 2000; Crenshaw 1991). The specific meaning of intersectionality remains contested, but the concept generally draws our attention to the multiplicity of categories to which we belong, some of which may be marginalized and others of which may be privileged; the notion that categorical intersections are more than the statistical sums or interactions of their parts; the multilevel nature of categories of oppression, from structural systems to self-representations;

and the context-specific, relational, and contingent nature of categorical memberships (Howard and Renfrow 2014). Sociologists of mental health (and, really, of health more generally) have given little attention to intersectionality. There is an emerging recognition that patterns of mental health vary across intersectional categories (Cummings and Jackson 2012; see Rosenfield and Mouzon [2013] for a review), but the notions that categorical intersections imply unique combinations of marginalization and privilege (e.g., that being a black man implies something more than the combination of being black and a man) and that the meanings of categorical intersections may vary over time and across contexts have not filtered into our research. To the extent that mental health is an indicator of privilege, orienting our analyses toward intersectionality would allow us to contribute to more general discussions of the distribution of privilege across categorical intersections and, thereby, to theories about the nature of inequality. In sum, by putting ourselves in conversation with sociological scholarship on inequality, we can identify new, potentially fruitful lines of research that would advance our understanding of the nature of inequality as well as the social distribution of mental health. Knowing what it is we are trying to explain is an essential first step in our research.

The Processes That Produce Mental Health Inequalities The next step in the study of mental health inequalities directs us to analyze the proximate experiences through which inequality impinges on the daily lives of persons and, thereby, on psychological functioning. In other words, we have to figure out what is happening in the layers of social life that intervene between macro-structures/cultures and individuals. Knowing that stress exposures and vulnerabilities are involved tells us something important about where to focus but not enough to understand the processes through which social disadvantage affects mental health and how we might intervene. For that, I encourage conversation with sociological theories of class reproduction and with social psychological theories and concepts concerned with the structure and content of situated interpersonal interactions. These theories help explain how social (dis)advantage is produced and maintained, that is, they address the concrete actions and symbolic processes through which opportunities are hoarded, boundaries constructed, and people exploited. By


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McLeod so doing, they can help us identify the types of stressors and resources most likely to be associated with positions in hierarchical systems and, therefore, the most likely explanations for mental health inequalities.6 Owing to space limitations, in this article, I will review just two social psychological concepts that may prove useful in thinking about how inequality comes to life in proximate environments and to which research on mental health inequalities can contribute: status and identity. I chose these concepts because they relate most directly to roles, values, self-conceptions, and self-evaluations—threats to which appear to be especially consequential for mental health (per my earlier claim; G.W. Brown and Harris 1978; Pearlin et al. 1981; Simon 1997; Thoits 2013). These are not the only concepts we might find useful, a point to which I return in the following, but they offer entrée into a conversation about how we can better incorporate social psychological research when analyzing the processes that produce mental health inequalities. Status and Devaluation Processes. This general category encompasses what social psychologists would call status processes as well as the associated prejudice, discrimination, and stigmatization. Status processes are those through which individuals, groups, or objects are ranked as superior or inferior according to a shared standard of social value and through which those evaluations are expressed (Ridgeway and Nakagawa 2014). Status processes reflect and reinforce status beliefs, defined as shared cultural beliefs about the relative superiority or inferiority of different social categories. These beliefs involve judgments of relative value, competence, and commitment and translate into differences in esteem, evaluation, and participation and, thereby, power and influence (Ridgeway and Nakagawa 2014).7 Most research on status processes, narrowly defined, relies on experimental methods involving task-oriented groups. The results of that research support the following conclusions. (See Ridgeway and Nakagawa [2014] for a review.) When people join together in task-oriented groups, they come to those groups with performance expectations: implicit assumptions about how useful each member’s contributions will be to the task based on his or her status characteristics. These performance expectations shape actors’ behaviors in a self-fulfilling manner. Actors for whom performance expectations are low are less likely to contribute, and when they do, they are less likely to be influential and others are less likely to evaluate their contributions positively

(Berger et al. 1977). In short, status characteristics influence how people are treated in interpersonal contexts, and how influential they are, in ways that reinforce inequalities.8 They are strong candidates for explaining mental health inequalities because they work to the disadvantage of low status groups, reproduce inequality within proximate contexts, and are relevant to self-conceptions. Importantly, status processes are contingent. Some status characteristics only matter in specific task settings. For example, computer skills are relevant to certain work-related tasks but not necessarily to event planning. Other characteristics, called diffuse status characteristics, matter across most tasks. For example, race affects judgments of competence in many different task-oriented settings in the contemporary United States. The composition of groups also influences the salience of status characteristics. Gender is a salient status characteristic in mixed-sex task-oriented groups, but in, female-only groups, other status characteristics, such as race and age, become more salient (Berger et al. 1977; Ridgeway and Nakagawa 2014). This implies that status processes can help us understand variation in mental health inequalities across contexts. Status processes and the related concepts of prejudice and stigma matter to mental health for at least three reasons. First, they influence people’s abilities to succeed in conventional pursuits. For example, because math and science skills are male-typed skills in the United States, girls self-assess their math and science abilities as lower than boys’ despite similar performances. These biased selfassessments affect career aspirations and persistence in math and science fields (Correll 2001). Research on stereotype threat finds much the same. Stereotype threat refers to the anxiety that people feel about confirming negative stereotypes about a group to which they belong. African American students who are told that a test measures their ability perform less well on the test than African American students who are not given the same message and than non-minority participants (Steele 1997). The same holds true for people of low socioeconomic position (Croizet and Claire 1998). To the extent that achievements are important to some dimensions of mental health (Rosenberg 1979), status processes are implicated in mental health inequalities. Second, status processes produce stressors. Discrimination is, perhaps, the most obvious and well-studied stressor associated with status processes. Although research on the role of discrimination in mental health tends to focus on racial


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inequalities, the general status processes that support inequality hold across other dimensions. In certain contexts, women and people in lower socioeconomic positions may be evaluated as incompetent or unworthy and subject to major discriminatory actions, day-to-day experiences of discrimination, and micro-aggressions (Sue et al. 2007).9,10 When considering which proximate experiences are most relevant to explaining group differences in mental health, we should consider the specific form devaluation is most likely to take in specific proximate contexts for specific groups. Third and finally, social devaluation reduces mastery. People who are members of devalued social categories have fewer opportunities to exercise influence, power, and control and are, thereby, less likely to develop mastery, or a sense of competence and effectiveness (Mirowsky and Ross 1989). These self-evaluations impede efforts to resist stressors and move up in the status hierarchy by depriving people of essential personal skills of resistance (Callero 2014). I have focused to this point on how status processes might help us understand mental health inequalities. Research on mental health inequalities can also help us understand status processes by addressing questions about their generalizability. One set of questions about generalizability pertains to context. How far beyond task-oriented groups, such as work groups, do we observe status-based evaluations? In which contexts is status-based stress most common, and in what forms does it appear (major acts of discrimination? day-to-day discrimination? micro-aggressions?)? Answers to these questions test the scope conditions of theories of status processes. Another set of questions about generalizability pertains to how people resist devaluation. Although research on status processes acknowledges the potential for resistance, there has been little effort to understand the conditions under which resistance will be successful (and some experimental research suggesting few successful paths to resistance; see Ridgeway and Nakagawa [2014] for a review). In contrast, stress researchers have studied the emotional consequences of discrimination and other status-based stressors and how people cope with them. In this way, studies of mental health responses to devaluation and the role of social support, coping resources, and specific coping strategies in supporting mental health could inform more general theories about status processes. Identity Processes. The term identity refers to “the socially constructed categories that are used to

establish meaningful understandings of persons” (Callero 2014:275). Some identities are based in social roles, such as “mother” or “corporative executive”; others are based in social categories, such as “woman” or “African American.” They can be experienced as individual (i.e., I am a woman) or as collective (i.e., I am part of the group of women) in nature. Identities highlight the personal meanings and social connections that derive from role occupancy and categorical memberships. They involve expectations of self and others for feelings, attitudes, and behaviors. As such, they serve as guides to action and reaction, and they give us meaning and purpose. Identities give us a way to think about the stressors and resources that are implicated in mental health inequalities in at least five ways. First, the identities to which we have access are influenced by sociodemographic characteristics that represent positions in social hierarchies (Thoits and Virshup 1997). Blacks are less likely than whites to occupy potentially salutary identities, such as spouse and worker (D.B. Elliott et al. 2012; Jacobsen and Mather 2010). By implication, the likelihood of identity entries and exits is also differentially distributed. Marital separations and divorces, loss of a job, and deaths of family members are all more common among people in lower socioeconomic positions and among racial-ethnic minorities (McLeod and Kessler 1990; Umberson et al. 2014). Considering the identities associated with dimensions of stratification can help us make more precise predictions about the stressors associated with inequality. For example, race and sexuality are associated with the likelihood of being married, but gender is not.11 Second, the positions we occupy in social hierarchies also influence the likelihood that we are able to confirm our identities in interaction with others (Burke 1991). Identity disconfirmation is associated with negative emotions (e.g., Stets and Harrod 2004), linking identity processes to mental health. Because people in socially disadvantaged positions have less power and fewer resources to control the situation, they are at greater risk of identity disconfirmation. For example, Jackson, Thoits, and Taylor (1995) found that African Americans who held positions of authority within the workplace often found it difficult to assert that authority because of the responses of others. People can avoid the negative emotions associated with identity disconfirmations by, for example, reinterpreting the situation or deemphasizing the prominence of that identity (McCall and Simmons 1978; Pearlin and Schooler 1978; Thoits 1995). Yet, these strate-


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McLeod gies may also be less available to people in disadvantaged positions (Pearlin and Schooler 1978). Third, the intersection of role and categorical identities gives rise to differential distributions of identity conflicts—situations in which two or more identities make incompatible demands (Pearlin 1989). For example, parenthood and employment (or, more generally, family and work life) make competing demands that may be difficult to reconcile. The conflict is especially keen for women because of the differing role expectations of mothers and fathers; we expect the former to privilege children over work and the latter the opposite. This creates identity conflicts that generate heightened stress and diminish well-being for employed mothers (Pearlin 1989; Simon 1995).12 Fourth, identities also influence the meanings people attach to objective life conditions. The different social roles that women and men occupy may give different types of life stressors more or less salience, leading to differences in reports of stress exposures or in the evaluation of those stressors (Kessler and McLeod 1984; Simon 1995). Collective identities also offer a way of understanding the world that can shape perceptions of potential stressors. For example, African Americans who have a strong collective identity are more likely to attribute unfair treatment to discrimination (Sellers and Shelton 2003). This suggests that the same objective condition, including the conditions covered under the rubric of stressors, may be perceived differently depending on one’s identity (McLeod 2012). Finally, identities bring us into community with others in ways that ameliorate or exacerbate the effects of inequality. These communities may be real, composed of people we meet in the context of enacting an identity (the essence of social integration). They may also be symbolic communities that provide a sense of meaning and purpose. Although the collective identities that result from this process can reinforce inequality, by supporting the construction of competing interests and the intergroup conflict, opportunity hoarding, and exploitation that follow (Bobo and Hutchings 1996; Lamont and Molnár 2002), they also offer a path through which people can resist the effects of inequality. Positive group identities can preserve self-esteem and mastery among members of disadvantaged groups (Phinney, Cantu, and Kurtz 1997; Portes and Rumbaut 2001; Umaña-Taylor and Updegraff 2007). In sum, the concept of identity offers another way to develop predictions about which stressors and resources are likely to be implicated in mental health

inequalities and about compensatory processes that dampen the effects of inequality on mental health. At the same time, research on inequality, identity-relevant stressors, and mental health offers tests of identity theory predictions in naturalistic settings. For example, by studying the distribution of stressors related to identity disconfirmations, we can help clarify the conditions under which identity disconfirmations are most common and under which they generate negative emotional responses. Other Relevant Social Psychological Processes. There are other social psychological concepts I could have discussed but, owing to limitations of space, did not. Chief among these are social exchange (Cook 2014) and justice (Hegtvedt and Isom 2014). Each gives us another way to think about how social disadvantage affects mental health and the conditions under which people are able to resist those effects. Social exchange theories direct us to consider how people’s positions in exchange networks affect their power and influence in the exchange and the inequalities that result from exchanges in which actors have differential access to resources (Cook 2014). These theories could prove especially useful for understanding how the structure and content of people’s social networks, and their access to material and symbolic resources, are implicated in mental health inequalities. Theories of justice explain how people develop evaluations of whether inequalities are fair or unfair and the emotional and behavioral responses to those evaluations (Hegtvedt and Isom 2014), with obvious relevance to the study of mental health. I focused on status and identity not because they are the only relevant concepts but because they resonate most strongly with stressbased explanations for mental health inequalities. They also forge the strongest connections across subareas within the sociology of mental health, a topic to which I now turn.

Applications Beyond Epidemiology Thus far, I have emphasized how we might approach the study of mental health inequalities by strengthening our alliance with relevant research from sociology and sociological social psychology. We can also strengthen connections among ourselves by applying these theories and concepts to the study of help-seeking and the effects of mental health problems on social attainments. Connecting among ourselves is especially important to the extent that population patterns of mental health and illness


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encompass onset, course of illness, recurrence, and length of episode and reflect processes of selection and causation over the life course (McLeod and Pavalko 2008). Status offers insight into whether people receive care for mental health problems and the quality of care they receive. Research on doctor-patient interactions for physical health care demonstrates that many treatment disparities can be attributed to physician devaluation of minority and poor patients (Lutfey and Freese 2005; van Ryn and Burke 2000). African Americans are no more likely than whites to experience episodes of major depression, but the episodes they experience are longer and more severe (Williams et al. 2007). Differences in the quality of treatment may be an explanation. African Americans are less likely than white Americans to receive formal treatment for mental health problems, and the treatment they receive is less likely to meet minimally adequate standards (Snowden 2012). Status also offers us a way to analyze the reciprocal effects of mental health problems on socioeconomic attainment. Research on labeling theory demonstrates the pervasive prejudice and discrimination that accompany serious mental illness, both in reality and in expectation (Link et al. 1989). Children with mental health problems, especially behavioral problems, encounter diminished expectations from parents and teachers that, over time, reduce their academic performance (McLeod and Fettes 2007; McLeod and Kaiser 2004; McLeod, Uemura, and Rohrman 2012). Although statements about the primacy of social causation over social selection appear frequently, we cannot deny that mental health problems affect people’s interactions with other people and with institutions and that those interactions affect people’s social achievements. The process through which that happens is deeply sociological and deserving of our full attention. By studying mental illness as a status characteristic (Lucas and Phelan 2012), we can develop a more precise understanding of the types of discrimination that people with mental illness encounter, the generalizability of the stigma of mental illness, and the reciprocal processes through which inequality and mental illness are associated over the life course (McLeod and Pavalko 2008). Identity, too, is a concept that can be applied to the study of help-seeking and reciprocal effects. Of particular note is the importance of mental illness identities in shaping people’s responses to illness, their willingness to seek formal treatment, and the success of that treatment (Karp 1996). People who

accept mental illness identities are more likely to seek formal treatment and find treatment helpful. Accepting a mental illness identity has risks, however, to the extent that embracing the identity can subject people to more discrimination. People can use a variety of identity strategies to counteract that discrimination, but no strategy is easy or assured of success (Thoits 2011). What I am arguing, in essence, is that current patterns of mental health inequalities are the product of life course processes of causation and selection in which people navigate the stresses and satisfactions of daily life and move into and out of social institutions, sometimes with the assistance of friends, families, and formal providers and sometimes not. Status and identity processes run through causation, selection, and help-seeking, linking each to the other, producing coherence in individual lives and convergence in our diverse intellectual agendas.

Closing Thoughts My goal in this article was to suggest how we might extend the study of mental health inequalities by engaging more intentionally with sociology and sociological social psychology. I have identified concepts and questions that extend that engagement, strengthen our connections with our parent disciplines, and support integration across subareas. I offer three summary comments about why inequality matters. The first is that whether and why inequality matters for mental health depend on the specific dimension of inequality and the institutional and interpersonal context. Sociological research on inequality offers empirical evidence and conceptual tools with which to analyze these contingencies. For example, attention to the multiple forms of resources that define inequality may help us understand differences in the association of social disadvantage with mental health to the extent that different dimensions of inequality implicate different types and combinations of resources. Inconsistencies in resource allocations may help us understand why some forms of disadvantage are not associated with mental health: if the presence of some resources, such as social support, can ameliorate the absence of others, such as workplace authority (House 1981b). Attending to specific contexts helps us think about how inequality affects daily life in those contexts and how we might intervene. One methodological implication of acknowledging contingencies is the need to complement


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McLeod broad-based survey studies with studies of specific stressors, groups, or contexts—job loss, recessions, Alzheimer caregiving, neighborhoods, workplaces, families. There are people already doing this work (Aneshensel et al. 1995; Moen et al. 2011; Tausig and Fenwick 1994); my comments are intended to highlight what these studies contribute to general research on mental health inequalities. Contextspecific studies can lead to generalizable conclusions if we follow an approach akin to experimental research or historical research. That approach involves analyzing process within specific contexts and abstracting up from those context-specific studies to develop more generalized understandings (Maxwell 1996). It has the advantage of making contingencies central while also making our research more actionable. Second, inequality arises and is maintained through deliberate, conscious, oppressive action but also through unconscious, implicit processes. It relies on unequal distributions of material resources but also on cultural, honorific, civil, and social resources. Among other social psychological concepts, status and identity bring these other types of resources to the center of the analysis, enriching our understanding of the stress process while also identifying alternative paths through which social disadvantage damages mental health. Of special note, these concepts acknowledge people’s agency when navigating an unequal world (Thoits 2006). People can reframe situations, redirect their energies, and change the salience of identities to reduce the threat of social disadvantage. It is in these complex contingencies that we are likely to find the most satisfying explanations for both expected and unexpected patterns of mental health inequalities. Finally, inequality matters to sociologists of mental health because it has the potential to integrate the sociology of mental health with sociology and work across our subfields. This integration is important for at least two reasons. First, we can develop more complete explanations for mental health inequalities and more actionable recommendations to reduce them by drawing on the full array of theories and concepts our parent discipline has to offer. Complex patterns require attention to multiple levels of social life and to a range of proximate processes. No single theory or concept is likely to prove sufficient. Second, and perhaps as important, engaging more deeply with our parent discipline may increase the status of mental health research among sociologists. Much as mental illness holds lower status than physical health in national conversations about health (e.g., in prestige rankings

among providers [Album and Westin 2008] and in discussions of insurance parity), the sociology of mental health occupies a relatively low status position within sociology and within medical sociology (Wheaton 2001). Demonstrating our relevance to more general research on social inequality is one path to asserting our centrality to our parent discipline.

Acknowledgments Many thanks to Pam Jackson, Eliza Pavalko, Bernice Pescosolido, and Peggy Thoits for their support during the preparation of this address and to the editor and reviewers for their encouraging and challenging comments on this manuscript.

Notes 1. Articles on mental health inequalities appear in other journals. I restrict the analysis to these two journals because they are the two official American Sociological Association journals devoted to sociological research on health and mental health and as such should provide a good representation of work in these areas. I omitted from the analysis all reviews and award addresses. 2. The apparent inconsistencies may reflect subgroup differences in expressions of poor health. Women appear more likely to express distress as depression or anxiety whereas men express distress as substance use (Rosenfield and Mouzon 2013). Kleinman (1977) presented evidence that Chinese patients with mental disorders were more likely than U.S. patients to experience somatic symptoms, a pattern he attributed to the highly stigmatized nature of mental illness in Chinese culture. This same pattern has been observed among Chinese patients in the United States (Takeuchi et al. 2002), and a variant of this argument has been advanced to explain the higher rates of major depression among whites as compared to blacks (and correspondingly, the higher rates of physical health problems among blacks as compared to whites; McLeod, Erving, and Caputo 2014). Because studies often consider either physical or mental health but not both, our understanding of the association of inequality with health is incomplete. Many thanks to an anonymous reviewer for this point. 3. The articles that did not invoke the stress process focused on gender and used gendered norms of emotional expression, the low status of femininity, or gender attitudes as explanations (e.g., Barrett and White 2002; Christie-Mizell and Peralta 2009; Rosenfield, Lennon, and White 2005); focused on socioeconomic position and used social capital without reference to social support or integration (e.g., Dufur, Parcel, and McKune 2008; Haines,


12

4.

5.

6.

7.

8.

Journal of Health and Social Behavior Beggs, and Hurlbert 2011; Parcel, Campbell, and Zhong 2012; Song 2011); presented nonspecific arguments about the role of social disadvantage in mental health (e.g., Kelley-Moore and Ferraro 2005; Spence, Adkins, and Dupre 2011); or implicated family processes (Conger et al. 2009; Maimon, Browning, and Brooks-Gunn 2010; McLeod and Nonnemaker 2000). Articles on substance use often invoke explanations grounded in socialization or peer influences. One potentially useful approach involves contextual ratings of life stress, such as those advocated by G.W. Brown and Harris (1978) and Dohrenwend and colleagues (1993). The challenge in using this approach is that although we may be able to identify stressors that share common characteristics (e.g., involving threats to social goals), it is not clear how one would target interventions to the abstract populations sharing those characteristics. I would be remiss if I did not acknowledge that not everyone finds this way of thinking about macromicro relations appealing. Symbolic interactionists, in particular, find the division of “levels” of analysis misleading to the extent that social structures are created through social interaction. Yet, whether or not one subscribes to this way of thinking about macro-micro relations, the framework is a useful organizing device for analysis. I apply it here to consider our collective progress toward understanding the implications of inequality for mental health as well as potentially fruitful lines of future research. The interactions on which I focus are shaped by the structure and culture of local geographic and institutional contexts—neighborhoods, workplaces, and so on (e.g., M. Elliott 2000; Gorman 2006). I set aside questions about how contexts shape these processes for now in favor of focusing on the interactions themselves. By definition, status beliefs are shared by the oppressors and the oppressed alike. In this way, status beliefs differ from prejudice, which is defined as “the process of stereotyping and aversion that may persist even in the face of countervailing evidence” (See and Wilson 1988:227) and involves attitudes and opinions that may or may not be shared by those who are the targets of the stereotyping and aversion. Despite the association of status processes with experimental research, the construction and expression of status are more general processes that occur in other contexts and that have been studied extensively by symbolic interactionists (Sauder 2005). Deference rituals are a common feature of interaction (Goffman 1967). We often express relative status without even thinking about it; for example, we know that we are expected to use honorific forms of address to greet a superior. Behaving in this way signals respect; not behaving in this way signals disrespect and places us at risk of a range of formal and

9.

10.

11.

12.

informal sanctions (Anderson 1999; Schwalbe and Shay 2014). Certain stressors from common inventories have clear connections to status processes, such as “you feel like being a housewife is not appreciated” or “your supervisor is always monitoring what you do.” This suggests a potentially greater role for status-based stressors in research on gender and socioeconomic health inequalities, especially if we link status-based stressors to the specific types of mental health problems they are likely to produce. Turner and Avison (2003) found that young men report more discrimination events than women. However, these differences may reflect the greater likelihood that young men are engaged in social contexts (e.g., workplace) in which discrimination is more likely. I have used obligatory roles in my examples, which are positively associated with mental health but in contingent fashion, namely, when experiences in the role are not stressful. Voluntary identities, which appear to have more consistent mental health benefits, may also be more available to the advantaged (Thoits 1992). Some research indicates that expectations for mothers and fathers vary by race and socioeconomic position, suggesting that identity conflicts between parenthood and employment may be more pronounced for white women (Broman 1991; McLoyd 1993; Rosenfield and Mouzon 2013).

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Author Biography Jane D. McLeod is Professor of Sociology and Associate Dean for social and historical sciences and graduate education in the College of Arts and Sciences at Indiana University. Her current projects focus on mental health inequalities and the life course of at-risk youth. She is coeditor (with Ed Lawler and Michael Schwalbe) of the recently published Handbook of the Social Psychology of Inequality.


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