On the Importance of Moral Imagination

Some years ago I was appointed as a non-executive director to the board of a leading Mental Health Trust. It served a culturally diverse population in a large Northern city with a population of around half a million. I had never before been involved in the delivery of mental health services at this level. I’d always seen myself as a worker at the coalface, remote from the world of the boardroom. When I joined, the Trust was in the early stages of becoming a Foundation Trust, a legacy of the last Labour Government. The official line is that because Foundation Trusts have greater financial and executive independence from the NHS, they must go through stringent procedures to ensure their standards of governance and business plans are bulletproof. Oh, and yes, I nearly forgot, deliver high quality clinical care as well. A different view, one that I now hold having witnessed the process close up, is that the real agenda behind Foundation Trusts is about dismantling the  National Health Service and opening it up to the private sector.

My suspicions were kindled when I happened to be chatting with the Chairperson before an important  meeting with the Monitor team (Monitor is the organization that approves and regulates Foundation Trusts).

‘Great thing this Foundation Trust malarkey’ he said, filling my cup with tea. ‘D’you know what?’ he continued, ‘we’ll be able to set the execs’ and non-execs’ salaries according market rates. Never mind what the NHS says.’

‘Oh? I replied, staring hard at my prawn sandwich.

‘Yes’ he said ‘and a jolly good thing if you ask me.’

Shortly after this exchange, Bob Diamond, the CE of Barclays Bank, created a national furore by accepting a £20M bonus when global capitalism was shaking at the knees and unemployment was accelerating.  I decided enough was enough and handed in my resignation.


For over thirty years, advanced liberal democracies have been through an economic and cultural revolution, and this is the focus of a book called The Spirit Level by Richard Wilkinson, trained in economics and epidemiology, and Kate Pickett, trained in epidemiology and physical anthropology (Wilkinson & Pickett, 2009). Their core argument is that the best predictor of the health and well-being of a population is its level of income inequality. They support their argument with graphs and statistics showing how income inequality in rich and poor countries, in Europe, the USA, and across the globe, is significantly correlated with measures of a wide variety of health and social problems. No matter where you look, crime, drug misuse, teenage pregnancy, educational failure, and of course, rates of mental illness, are all correlated with income inequality. High levels of income inequality are associated with higher levels of problems. The USA and UK, two countries with the highest levels of income inequality, have the highest rates of health and social problems. Countries like Japan and the Scandinavian countries that have the lowest levels of income inequality, have the lowest rates of problems. The key issue is not absolute poverty, at least not as far as the rich and relatively prosperous countries are concerned (it is of course a major problem in the poor countries of the world) but income inequality – the magnitude of the difference between the highest and lowest paid. This is clearly the case as far as mental illness is concerned, using data from the WHO World Mental Health Survey Consortium – see fig. 5.1, p. 67). The use of illegal drugs rises with income inequality. Children in countries with higher levels of income inequality have lower math and literacy scores (fig. 8.1 and 8.2, p. 106).

The interpretation of correlations is a risky venture. Looking at their graphs it is easy to believe, that they have discovered the cause of every known human and social ill. Of course they haven’t, and that’s not their claim. If A is strongly correlated with B it is impossible to know whether A causes B, or B causes A, or whether both A and B are caused by a third variable, C, about which nothing is know. As befits scientists and academics, the authors are conservative in the claims they make for the facts they present. But the fact that so many variables are related to income inequality, and not other indices such as absolute poverty, demands serious attention. How do they account for these relationships?

They draw on research from a number of scientific disciplines, neuroscience (dopamine and reward systems), psychological mechanisms (self-esteem) and the evolutionary importance of status and shame, but I am not convinced. However, their most convincing argument concerns the effect that inequalities have on how you think other people see you. Unequal societies are not only more hierarchical, but the evidence suggests that the individuals who live in such societies tend to be more selfish, solitary and individualistic. They are also more competitive and less trustful of their neighbours. In contrast, people who live in societies that have low levels of inequality tend to be more trusting, value friendship, and their communities are characterized by  mutuality, equality and reciprocity. Inequality, it seems, creates a form of subjectivity that perceives human relationships in terms of domination-submission, power and authority. How does this help us to make sense of the link between income inequality and mental health?

Wilkinson & Pickett argue that living in an hierarchical, mistrustful society has implications for intimate family relationships: ‘Domestic conflict and violence, parental mental illness, poverty of time and resources will all combine to affect child development.’ (Wilkinson and Pickett, 2009: 111). There is abundant evidence that income inequality has adverse effects on the quality of family life and relationships. Children living in low-income families are more likely to witness more family conflict and to experience violence  (Evans & English, 2002). Of course not all parents and families in low-income families are to be characterized in this way, but how parental experiences of income inequality, in the workplace, the dole queue, on the streets, are mediated within the family environment is bound to have an impact on family relationships and thus their children’s experiences. This is not to say that parenting difficulties and the associated problems are limited to poor families. Evidence from America indicates that across middle-class, working-class and poor families there are differences in how language is used, the organization of daily life, and the extent to which family members are connected (Lareau, 2002). However, some parents have high levels of resilience, others may become neglectful or abusive (McLoyd, 1990, McLoyd & Wilson, 1990).

At this point I must confess to a sense of unease with sociological comparisons of the family life and child-rearing practices of people from underprivileged backgrounds and their more fortunate peers, especially when many of these are based on ethnicity – Black compared with White. It is too easy to become a flâneur, a dilettante idler and gawper at other people’s misfortune, one who wanders untouched through the wastelands of misery and suffering without really doing anything about it.  Even worse, at the back of my mind there are one hundred year-old echoes, of utopian socialism and, much worse, fascism. Both these ideologies resorted to eugenic theories (upon which the Nazis acted) to solve the problems of ailing societies. But ultimately, it depends upon the purpose that such comparisons serve, and these sociological comparisons inflame my passion to want to do something about it. But what should we be doing? How should mental health professionals respond? Surely, you might argue, economic inequalities are of no concern to us? I disagree.

A paper by John Read and colleagues (Read et al, 2001) proposes a model for understanding how psychosis arises in response to the sort of adverse childhood experiences (ACEs) that are more likely to arise in the low-income, low-status families described by Wilkinson and Pickett. They make a powerful argument that although the link between ACEs, stress and psychosis has been recognized for many years, scientific research has chosen by and large to disregard this. This is because the diathesis-stress (or biopsychosocial) model assumes that diathesis is fundamentally genetic, and thus environmental factors that constitute stress, such as childhood adversity are placed exclusively in the stress component. Stress is nothing more than a non-specific precipitant that releases something more fundamental and biological. Thus ‘…the causes of the vulnerability are rarely sought in the interpersonal domain’ (Read et al, 2001:320).

Wilkinson and Pickett’s (2009) book is an important contribution that  draws attention to the links between inequality, adversity and distress. The paper by John Read and his colleagues is an important and significant step forward in helping to understand how adversity, particularly childhood adversity, and psychosis are related. But there is a piece missing from the jigsaw. What neither achieves is how, in individual cases, ACEs are understandable. This is because both resort to scientific narratives to establish casual links, but this takes us no further in understanding how the individual’s life and experience is shaped and turned into narrative by these forces. These particular narratives are not fairy tales, or soap operas, but tragic moral stories of abuse and oppression, woven into and against the broader socio-economic factors described by Wilkinson and Pickett, and borne by the warp and weft of neurodevelopmental factors described by John Read.

In her powerful personal account of her recovery from a devastating sexual attack in which she was left for dead by her assailant, philosopher Susan Brison (2002) points out that most of us share in common the belief that we live in a just world. We want to believe that nothing that is either terrible or undeserved will happen to us. Yet our personal experiences of life suggest this isn’t the case. Still, we struggle upstream against the current in maintaining this belief. In the face of trauma, abuse, and random tragedies, some authored by human agency, some not, we cling to the belief that the world is a just place. But it isn’t, and this is why we must recognize that bearing witness to injustice is an essential component of recovery; it is the missing piece in the theories and work of mental health professionals. Scientific models of trauma, whether neurodevelopmental or cognitive psychological, offer an incomplete response to what in personal and interpersonal terms is primarily a moral task.

Yes, we must work to reduce income inequalities, to make the world a less hierarchical place, and to facilitate mutual cooperation, reciprocity and trust in the ways set out by Wilkinson and Pickett in the final chapter of their excellent book. Yes, we need a new research agenda that deals explicitly with the relationship between ACEs and their neurodevelopmental consequences as John Read and his colleagues suggest. But at the same time we must recognize that before anything else is said or done, inequality, oppression and abuse are moral problems.  The great difficulty is that at the moment there is no common tongue that enables mental health professionals and academics to talk with people who experience madness and distress in ways that encompass the social, the psychological and the moral. This is a problem that can be addressed by dialogical views of human subjectivity (see, for example, Vygotsky, 1978) through which we can develop the idea of the moral imagination. We must see, feel and understand the importance of placing ourselves in the position of the Other, and bear witness to their suffering by doing our utmost to see the world through their eyes.



Brison, S. (2002) Aftermath: Violence and the Remaking of the Self. Princeton, Princeton University Press.

Evans, G. & English, K. (2002) The environment of poverty: multiple stressor exposure, psychophysiological stress, and socioemotional adjustment. Child Development, 73, 1238 – 1248.

Lareau, A. (2002) Invisible inequality: social class and childrearing in in black families and white families. American Sociological Review, 67, 747 – 776.

McLoyd, V (1990) The impact of economic hardship on black children: psychological distress, parenting, and socioemotional development. Child Development, 61, 311 – 346.

McLoyd, V. & Wilson, L. (1990) Maternal behaviour, social support, and economic conditions as predictors of distress in children. New Directions for Child and Adolescent Development. 46, 49 – 69.

Read, J., Perry, B., Moskowitz, A. & Connolly, J. (2001) The Contribution of Early Traumatic Events to Schizophrenia in Some Patient: A Traumagenic Neureodevelopmental Model. Psychiatry, 64, 319 – 345.

Vygotsky, L.S. (1978) Mind in Society: the development of higher psychological processes. London, Harvard University Press.

Wilkinson, R. & Pickett, K. (2009) The Spirit Level: Why Equality is Better for Everyone. London, Allen Lane (Penguin Books).


Related “Mad in America” Blogs:
Poverty & Mental Illness: You Can’t Have One Without the Other
Responding to Madness With Loving Receptivity: a Practical Guide
We Need Drugs 

Related “In the News” Items:
Income Differentials Cause Mental Illness
Attachment & Psychosis: Implications for Therapeutic Alliance
Questions About Childhood Trauma And Schizophrenia Settled
Childhood Adversity Increases Psychosis 



  1. Extremely interesting article which “ring a bell” in so many ways: the social inequalities,the marginalizations,the outrage at the injustices of the world, the lack of understanding of where you come from when thrown into a new but alien environment, the inability of so many mental health workers to place themselves in the “patient’s” position etc..I learned to live with it all as a war refugee child. you are always on the side-lines, you do not belong anywhere, you don’t have any money, so you become a loner and self-contained and before you know where you are, your own little world becomes more important and more fun than the rest of the society you live in.

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    • Dear Arija

      many thanks indeed for your comments. Nowhere do we see more clearly the effects of injustice. oppression and social dislocation that war refugees experience. I really am grateful to you for reminding us all about this. This blog was really an attempt to start thinking through the implications of social justice, oppression and abuse for mental health work, and I will be writing much more about it in future. I will certainly be thinking about the role of war in this.

      best wishes


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  2. Dear Phil – thanks for your post – a superb, prophetic piece of writing.

    Lots to think about and read more about. The ‘moral imagination’, wisdom and virtue, something to be pursued. Remembering fairy tales from childhood that had much to say about the big bad world we are living in. Wolves and grannies (that’s me now), princesses and frogs.

    Regards, Chrys

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    • Many thanks, Chrys, for your comments. I’m really grateful for any responses that people can give to the idea of moral imagination, and I will be writing much more about this in the weeks to come. Your point about fairy tales is really important. I was reading from Grimm to our four-year-old grand-daughter last week, and it afterwards it really brought home to me the importance (developmentally) of culture and narrative in forming our moral imaginations. Thanks for helping me to establish the link,

      best wishes


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    • Thanks, Phooey, whoever you are. Of course you can use scientific arguments to defend any political position. The genetic theories of the psychiatrist Ernst Rudin and the Nazis are a case in point. But you miss the point. My argument is an appeal to a moral argument about how we position ourselves as individuals in the face of individual experiences of suffering.

      philip thomas

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  3. Phil, thank you for your thoughtful explication of the impact of income inequality and adverse childhood events on people’s emotional well-being. If psychiatry took this reserach as seriously as they take the unscientific and unproven notions about biological brain diseases,the world would be a better place!

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    • Many thanks, Darby. I completely agree with you. The situation is beginning to change thanks to the research of people like John Read, Richard Bentall and others, as their scientific research clearly establishes the importance of childhood adversity in relation to madness. If people had listened to what survivors have been saying for years we might have made even more rapid progress. This is another reason for developing the moral case in relation to inequality and distress.

      Best wishes to you



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  4. Very interesting article.

    Along the lines of eugenics, or social purification, if you will, I am thinking that one motivator for doctors to uncritically accept widespread drugging as a solution for emotional distress is that, symbolically, the pill “shuts the door” on the emotional distress.

    It seals it off, cauterizes it, makes it go away. Social causes or individual history are rendered unimportant but the doctor can think she or he has done something to make society better — having shoved the patient’s emotional complexity into a closet, chemically.

    From my experiences with psychiatrists, they are very uncomfortable about displays of emotion. Knowing what I know now, I would never show anger, fear, or tears to a psychiatrist — if I were a patient, it would earn me an escalated diagnosis and new prescriptions.

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    • Dear Altostrata

      This is a powerful analysis, and I agree with you. A number of people have made similar observations in the past, most notably the historian Kathleen Jones (Jones, K. (1988) Experience in Mental Health. London, Sage – see page 83).

      This is one reason why I believe the humanities are really important in the education of psychiatrists. We (even psychiatrists) engage with poetry,literature, dance and music in quite different ways. Survivor poetry, dance (e.g. Louise Pembroke’s Dedication to the Seven) is a really powerful way of getting all professionals to drop the objective gaze that dehumanises suffering.

      Many thanks indeed for raising this issue.

      bestw ishes


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    • Many thanks, Louise. Yes, I agree with you about the role of corporate capitalism. The difficulty with such analyses, however, is that it tends to polarize debate. The problems described by Wilkinson and Pickett in their book have much more complex origins. Each and every one of us is involved by virtue of our existence in structures and organisations of inequality. It really is worth reading chapter 16 of their book, where they suggested ways forward, e.g. employee ownership schemes, that reduce inequality and give everyone a stake..

      best wishes


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  5. Here is a small but I hope interesting point.

    I haven’t read, “The Spirit Level,” but I understand they say inequality is damaging for all classes. So middle class aspirations to keep up their social standing can also be a driver of extreme distress in children, especially when approaching adulthood. This may have to be combined with childhood trauma for the mix to be so strong as to push people towards serious levels of distress where diagnosis such as, “Schizophrenia,” are applied, but I think I have seen this as a cause of serious mental distress (in some cases leading to contact with services) in some people.

    Whether you see corporate capitalism as the major driver of inequality, or a useful way of finding allies (which is one way of expressing Phil’s concerns on this point) I think it is easy to see it as a major driver, if not the major driver, of the bio-medical model of mental illness which is causing so much harm. Drug company multi-million PR and marketing budgets push the ideas like Serotonin Imbalance and get them placed in national radio and television programmes for example.

    However, I think that having this kind of debate is an important part of finding enough allies to form a viable social movement sufficiently big enough to impact this problem.

    I agree that ideologies, such as contemporary anti-capitalist ones, tend to alienate a lot of people, but thinking these things over may help us find those all important allies (I think I saw the author speak at Occupy London at an event put on by the Welfare Tent).

    Mental health issues have few allies: it is either absent from political debates or seriously patronising and ill informed (eg all that 1 in 4 will suffer from a mental illness and mental illness is an illness like any other type tosh). To bring the real issues of oppression, trauma and inequality and the broad moral questions we both seem to believe underlies serious mental distress is much needed by both services and the broader public before these problems can be tackled.

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    • Thanks, John, for your points, which are all well-made. The Occupy movement draws on ordinary people’s experiences and moves the debate about the sort of world we live in away from unhelpful political polarisations (left / right etc). Most people are sick and tired of established political discourses, which is why right and left cynically dismiss what is a movement for democracy. As you say, it is vital that survivors, service users and their allies make sure that the issue of madness in placed firmly at the centre of the debate about democracy.

      thanks and best wishes


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