The Relationship Between Poverty, Mental Illness and Physical Illness
Being poor, suffering from a mental illness or having a chronic physical condition is stressful and debilitating, and worse in combination. The reality is that these conditions interact in complex ways, such that having one condition places you at higher risk for the others. If you’re poor, you’re more likely to be sick and suffer from mental illness, and if you’re mentally ill, you’re more likely to be poor and sick.
What is mental illness?
A mental illness or disorder is characterized by thinking, behaving and feeling in ways that cause significant distress, impairment of functioning, and which interfere with relationships. Symptoms include alterations in thought, mood, personal habits and/or social withdrawal.
A Few Facts from the Canadian Mental Health Association:
1. 1 in 5 Ontarians within a given year experiences mental illness.
2. 35% of Ontario Disability Support Program clients have a mental illness.
3. 21% of persons with all types of disabilities in Ontario live in poverty.
4. Increasing mental health problems are highly correlated with a decrease in socioeconomic status.
Problems Interact and Become Cumulative
Living in poverty increases risk factors for health and mental health problems related to inadequate housing, poor access to health care and child care, eating poor quality food, living in neighbourhoods with guns, gangs, and violence, and in communities with polluted air and water. Poverty creates emotional, as well as financial stress, and more mental illness, and mental illness increases the likelihood of being poor.
Individuals with mental and other disabilities are three times as likely to be poor as individuals without a disability. People with serious mental illness face stigma and discrimination which add to their challenges in acquiring adequate education, employment, and housing and these, in turn, are strongly associated with mental disorders. In addition to providing income, work provides a sense of self-worth and purpose and interruptions in work can result in feelings of helplessness and hopelessness and/or a relapse of major mental illness. Depression and anxiety, in particular, are exacerbated by job loss and other stressful events such as divorce, or a death in the family.
Mental Illness and Physical Illness
Individuals with chronic and serious health conditions such as heart disease, arthritis, diabetes, cancer, and asthma are at high risk for mood disorders and individuals with mental illness, have a significant risk of developing a chronic physical condition (1). Mental illness causes changes in hormonal balances and sleep cycles which create physical stress and, in addition, the medications used to treat mental illnesses have side-effects including irregular heart rhythms, weight gain, agitation, restlessness, and gastrointestinal upsets such as constipation, diarrhea, and nausea, sexual dysfunction, and insomnia. These side effects increase vulnerability to physical distress. People with mental illness experience barriers to health care, including transportation for medical appointments, lack of an OHIP card due to not having a permanent address, and many physicians’ reluctance to accept patients with a psychiatric diagnosis, without mental health support (2).
Mental Illness and Poverty
Children and adolescents raised in poverty are two to three more times likely to develop mental health problems, most commonly, oppositional defiant disorder and conduct disorder in childhood, and anxiety disorders, depression and schizophrenia in adolescence and adulthood. People in the poorest socioeconomic group are two to three times more likely to have a mental disorder compared to the rest of the population. Poverty is also a significant risk factor for mental retardation as a result of disease, malnutrition, inadequate prenatal care, and environmental pollutants (3).
The Role of Stress
Poverty is more than a lack of financial resources and racism involves more than unequal opportunity. Those who are poor, black, indigenous, or from other stigmatized groups experience social, cultural, and interpersonal discrimination, and experience elevated levels of physical and psychological stress.
In a recent New York Times Magazine article, Linda Villarosa explored the phenomena that “black infants in America are more than twice as likely to die as white infants” and “black women are three to four times more likely to die from pregnancy-related causes than their white counterparts.” She writes that, not only do black women in the U.S. receive less care and poorer quality care before and during birth, but there is now growing evidence that “for black women in America, an inescapable atmosphere of societal and systemic racism creates a kind of toxic physiological stress, resulting in conditions-including hypertension and pre-eclampsia-that lead to higher rates of infant and maternal death” (4). In Canada, our indigenous young people experience so much stress that they commit suicide at rates which vastly exceed the rates of all other groups.
Addiction is a Mental Disorder
Mothers with addiction problems are usually poor, isolated, and harshly criticized. Many addicted mothers have difficulty interpreting the needs of their infants, expressing joy, and setting appropriate limits, as a result of their addiction, and also trauma. Inconsistency in responsiveness interferes with children’s establishment of secure attachment and ability to self-regulate. As many as 65% of children raised by mothers struggling with addictions receive a diagnosis of a mental disorder by the time they reach adolescence (5).
Women in treatment for drug use often fear that seeking prenatal care may cause them to lose custody of their infants and it is only when their infants display symptoms of withdrawal or Neonatal Abstinence Syndrome (NAS) that their drug use is discovered. Infants may show withdrawal symptoms from 48 hours to 4 weeks and, until recently, were placed in intensive care nurseries. In the past few years, however, researchers have demonstrated that opioid-dependent mothers who breast-feed their newborns experience increased self-esteem, and heightened motivation to seek or remain in treatment. Several hospitals in North America are encouraging chemically dependent mothers to keep their infants in their rooms (rooming–in), nurse them frequently, and have skin-to-skin contact which promotes bonding, and reduces the risk that they will abandon their babies. Moreover, breast-feeding has proven to treat and manage infant withdrawal such that, in many cases, no other treatment is required (6).
Stigma and Discrimination
Traits such as “crude, irresponsible, lazy, stupid, dirty, and immoral” are attributed more often to the poor than to members of the middle class (7).
Poverty significantly affects people’s dignity and self-esteem because it affects their ability to care for their families and participate in their communities. Daily, they may face insulting and “intrusive questions about the source of their income or their disability, or stereotyping about being an unreliable tenant because they receive social assistance and have a mental health issue or addiction” (8). Impoverished and homeless people often can’t make appointments because they don’t have a phone or transportation. These are significant challenges in accessing services that vulnerable individuals are simply unable to navigate, and without those services, they become socially isolated, and chronically poor. And around and around, it goes.
Poverty and the Next Generation
Karen Mossakowski found that children from low SES families in the United States were much more likely to be depressed in young adulthood than those from families with higher SES, and she concluded that the stressful conditions of persistent poverty and economic hardship in which the children were raised, as well as their poor self-esteem, caused by the parents low levels of education and occupational prestige contribute to feelings of worthlessness and helplessness which are associated with depression (9). Additionally, she hypothesized that parents who are preoccupied and stressed by the challenges of poverty may be limited in their ability to provide for their children’s social and emotional development.
Furthermore, children who attend public schools in poor neighborhoods have fewer teachers, computers, library books, and fewer extra-curricular activities, hence fewer opportunities to learn, excel, and increase their self-esteem.
Some strategies going forward:
1. Early interventions for children who require mental health services, in schools, in community centres and homeless shelters.
2. Treatment programs should incorporate problem solving and resource identification, social justice, and child care advocacy.
3. Agencies and hospitals need to be flexible about rescheduling appointments, offering transportation and reminders about appointments; planning is hard when life is so precarious. 4. More outreach services for the poor, the homeless, the addicted, and the mentally ill.
Resources
1. Canadian Mental Health Association, the Relationship between Mental Health, Mental Illness, and Chronic Physical Conditions, December, 2008.
2. Canadian Mental Health Association, Poverty and Mental Illness, November, 2007.
3. F. Reiss. (2013). Socioeconomic inequalities and mental health problems in children and adolescents: A systematic review. Social Science & Medicine, 90, 24-31.
4. Linda Villarosa, Why are black mothers and babies in the United States dying at more than double the rate of white mothers and babies? The New York Times Magazine, April 15th, 2018. 5. Shelley Cohen Konrad and Jennifer Morton, If I feel judged by you, I will not trust you: relational practice with addicted mothers, in Joan Berzoff, ed., Falling Through the Cracks: Psychodynamic Practice with Vulnerable and Oppressed Populations, Columbia University Press, 2012.
6. G.K. Welle-Strand, S. Skurtveit, L.M. Jansson, L.M. Brittelise, B. Bjarko, and E. Ravndal (2013). Breastfeeding reduces the need for withdrawal treatment in opioid-exposed infants. Acta Paediatrica, 102, 1060-1066.
7. D. W. Sue, & D. Sue (2013) Counselling the Culturally Diverse; Theory and Practice, John Wiley and Sons, New Jersey.
8. Human Rights Commission of Ontario, Policy on preventing discrimination based on mental health disabilities and addictions.
9. K.N. Mossakowski (2015). Disadvantaged Family Background and Depression among Young Adults in the United States: The Roles of Chronic Stress and Self-Esteem. Stress and Health, 31(1), 52-62.
About The Author
Janet Morrison, M.A., C. Psych Assoc. is a psychological associate in private practice and a senior lecturer at the Factor-Inwentash Faculty of Social Work, University of Toronto. Over the past 30 years she has assessed, treated and supervised treatment of children in long-term care, as well as, consulted for Children's Aid Society and group homes across Ontario.