This document summarizes a study exploring how neoliberal discourses shape experiences of inequality in Salford, England. The study found evidence that supports Wilkinson and Pickett's hypothesis from The Spirit Level that inequality generates health damages by lowering social status and increasing stress. However, a more prominent finding was the articulation of a "no legitimate dependency" discourse, where participants disavowed any form of dependency and assumed sole responsibility for their situations. The authors argue that internalizing neoliberal discourses of individual responsibility, combined with the destruction of protective resources, increases strain and helps explain health damages from living in an unequal society. Integrating understandings of neoliberalism can enrich perspectives on the relationship between inequality and health

1. Dependency denied: Health inequalities in the neo-liberal era
Marian Peacock, Paul Bissell*
, Jenny Owen
School of Health and Related Research (ScHARR), University of Sheffield, UK
a r t i c l e i n f o
Article history:
Received 20 February 2014
Received in revised form
4 August 2014
Accepted 7 August 2014
Available online 7 August 2014
Keywords:
United Kingdom
Health inequality
Neoliberalism
Discourses
Women's lives
No legitimate dependency
Shame
Social comparison
a b s t r a c t
The ways in which inequality generates particular population health outcomes remains a major source of
dispute within social epidemiology and medical sociology. Wilkinson and Pickett's The Spirit Level (2009),
undoubtedly galvanised thinking across the disciplines, with its emphasis on how income inequality
shapes the distribution of health and social problems. In this paper, we argue that their focus on income
inequality, whilst important, understates the role of neoliberal discourses and practises in making sense
of contemporary inequality and its health-related consequences. Many quantitative studies have
demonstrated that more neoliberal countries have poorer health compared to less neoliberal countries,
but there are few qualitative studies which explore how neoliberal discourses shape accounts and ex-
periences and what protections and resources might be available to people. This article uses findings
from a qualitative psycho-social study employing biographical-narrative interviews with women in
Salford (England) to understand experiences of inequality as posited in The Spirit Level. We found evi-
dence for the sorts of damages resulting from inequality as proposed in The Spirit Level. However, in
addition to these, the most striking finding was the repeated articulation of a discourse which we have
termed “no legitimate dependency”. This was something both painful and damaging, where dependency
of almost any sort was disavowed and responsibility was assumed by the self or “othered” in various
ways. No legitimate dependency, we propose, is a partial (and problematic) internalisation of neoliberal
discourses which becomes naturalised and unquestioned at the individual level. We speculate that these
sorts of discourses in conjunction with a destruction of protective resources (both material and discur-
sive), lead to an increase in strain and account in part for well-known damages consequent on life in an
unequal society. We conclude that integrating understandings of neoliberalism into theorising about
inequality enriches sociological perspectives in this area.
© 2014 Published by Elsevier Ltd.
1. Introduction
Since its publication in 2009, Wilkinson and Pickett's (from
here-on W&P) “The Spirit Level” (from here-on TSL) has stimulated
popular and academic debate on the subject of inequality in a way
that is probably without precedent, at least in the UK. TSL's central
argument e that unequal societies have an excess of ill-health (and
social problems) and that it is income inequality per se that is the
underlying cause e was reinforced by the findings from the Stra-
tegic Review of Health Inequalities in England (widely known as
the Marmot Review) in 2010. In the years following publication of
TSL, subsequent work by others provided robust support for the
relationship between inequality and health that W&P describe (De
Vogli, 2011; NEF, 2011; OECD, 2011; Rowlingson, 2011).
One of the novel features of TSL was that it looked beyond the
empiricism of much social epidemiology and entered the more
epistemologically challenging domains of medical sociology and
health psychology. It sought to extend the authors “psychosocial”
explanatory framework linking population health with income
inequality, as well as proposing a set of mechanisms which (they
believe) mediated this relationship. These mechanisms, they argue,
include “low social status, lack of friends and stress in early life. All
have been shown … to be seriously detrimental to health and
longevity” (TSL p39). The study we report on here explored one
aspect of this explanatory framework e the experience of shame
and social comparison which they believe flows from being of ‘low
social status’ and which forms a backdrop to life in an unequal
society (with consequences, of course, for health and well-being). A
key finding from our study, set in Salford (in north-west England),
highlighted a linked, but rather different finding from W&P's
* Corresponding author. School of Health and Related Research (ScHARR), 30
Regents Court, Regent Street, Sheffield S14DA, UK.
E-mail addresses: m.peacock@sheffield.ac.uk (M. Peacock), P.Bissell@sheffield.
ac.uk (P. Bissell).
Contents lists available at ScienceDirect
Social Science & Medicine
journal homepage: www.elsevier.com/locate/socscimed
http://dx.doi.org/10.1016/j.socscimed.2014.08.006
0277-9536/© 2014 Published by Elsevier Ltd.
Social Science & Medicine 118 (2014) 173e180

2. hypothesis e the extent to which neoliberal discourses concerning
individual responsibility appeared to have been internalised in
women's accounts of life in an unequal society. Furthermore, it was
also apparent that neoliberal discourses seemed to shape agency
and resistance in the face of inequality and the associated strains of
everyday life e and it is these aspects that we discuss in this paper.
We recognise that incorporating wider political projects and
their attendant discourses in the area of health inequalities is
epistemologically demanding, but there is a growing body of
quantitative evidence exploring the negative impacts of neoliber-
alism on health which we argue require qualitative exploration.
Coburn (2000), for example, in a well-known debate with
Wilkinson (2000) made the case for, “go[ing] beyond the income
inequality hypothesis towards a consideration of a broader set of
the social determinants of health” (p41). This entailed evaluating
how more unequal societies get to be more unequal, and in
particular, how to integrate class and the neoliberal project into
explanations for health inequalities. Coburn argued that political
decisions and attendant discourses legitimised high levels of
inequality, demonstrating empirically that neoliberal societies had
more invidious consequences for health and well-being than more
social democratic ones. These issues merit qualitative exploration
given the historical expansion of the neoliberal project and in the
context of the increasing evidence for the toxic nature of neolib-
eralism for health (De Vogli, 2011; Hall & Taylor in, Hall and
Lamont, 2009; Collins and MacCartney, 2011).
Indeed, there have been relatively few sociologically informed
qualitative studies exploring the processes which TSL authors'
argue are the ways that inequality gets “under the skin”, (Dolan,
2007; Gibson, 2007; Davidson et al., 2008). There are even fewer
studies that begin to explore the close-grained detail of what might
underpin the finding from epidemiological studies which show
that population health trends are different in more (and less)
neoliberal societies (De Vogli, 2011; Collins and MacCartney, 2011).
Similarly, there has been little exploration of what resources might
be drawn upon to resist health damaging discourses in neo-liberal
societies (Hall and Lamont, 2009; Peacock, 2012; Scambler, 2013).
We argue that empirically examining the ideas Wilkinson and
Pickett (2009) propose in TSL (in this case, shame and social com-
parison), can shed light on the discourses, practices and processes
by which inequality, shaped by neoliberalism, is manifesting itself
in England. In particular, we focus on a particularly prominent and
damaging discourse that we identified in the accounts of our par-
ticipants and which we termed “no legitimate dependency”. This
was unanticipated in that we did not set out to explore this, but it
emerged as a core finding and can be described as a discourse
where (virtually) all forms of dependency were disavowed and
disproportionate amounts of personal responsibility were assumed
for aspects of life that we would argue are not reducible to the
personal agency of an individual. In addition, “othering” was used
by many participants as a response to protect the self from some of
the stigmatised identities that have become a feature of contem-
porary neoliberalism (Jones, 2011). In the discussion, we go on to
speculate how the no legitimate dependency discourse might
figure in the spectrum of our understandings of neoliberalism and
population health and link this with similar findings from other
areas of social policy (Hoggett et al., 2013). Before describing the
methods used, we expand on key debates in the literature.
2. Perspectives on neoliberalism, inequality and health
The central contention of TSL is that it is inequality (the size of
the income gap) that is the key to determining population health.
One of the consequences of this widening gap is an increase in
stressors due to what they describe as shaming or invidious social
comparisons:
“Greater inequality seems to heighten people's social evaluation
anxieties by increasing the importance of social status. Instead of
accepting each other as equals on the basis of our common hu-
manity as we might in more equal settings, getting the measure of
each other becomes more important as status differences widen …
If inequalities are bigger, so that some people seem to count for
almost everything and others for practically nothing, where each
one of us is placed becomes more important” (2009, p43e44).
However it is not clear that those of “low social status” actually
experience themselves as such, and there may be discursive and
practical resources which can be drawn upon to protect the self and
deflect at least in part, the damaging comparisons that W&P
describe. Such protections may be located in discourses and prac-
tices which can shape positive or protective identities but,
conversely, there may be competing discourses that undermine or
destroy such protections, and it is here that the negative impacts of
neoliberalism may come into play (Hall and Lamont, 2009). In the
debate between Coburn and Wilkinson (see above), Coburn's
contention was that more attention should be paid to the causes of
income inequalities (specifically the place of neoliberalism), rather
than simply focusing on the consequences. Coburn suggested that
Wilkinson's work underplayed these broader social and political
contexts and avoided asking what social, economic and political
processes were implicated in the increase in inequality. Coburn
argued that neoliberalism:
“produces both higher income inequality and lower social cohesion
and … either lowered health status or a health status which is not
as high as it might otherwise have been” (2000b, p137).
Wilkinson defended the centrality of inequality, challenging the
idea that his work avoided attributing political responsibility.
Connecting inequality to neoliberalism, he argued.
“limits the theory to a historically specific instance: widening in-
come differences seem likely to be damaging, almost whatever their
source.” (2000a, p998).
In a subsequent paper Coburn (2004) tested out his proposals
using comparative international data, exploring how.
“international pressures towards neo-liberal doctrines and policies
are differentially resisted by various nations because of historically
embedded variation in class and institutional structures” (p41).
Coburn showed that more neoliberal countries were highly
correlated with increased inequality. Using infant mortality as an
illustrator, he demonstrated a better fit with the index of decom-
modification (a proxy measure of the extent of neoliberalism) than
with the Gini coefficient (measuring income inequality). Similarly,
Collins and MacCartney (2011) have argued in their work on “The
Scottish Effect”, that it is the scale of the neoliberal “political attack”
on the working class that provides the most plausible explanation
for the health problems experienced in the West of Scotland e rates
that cannot be explained by indicators of deprivation alone. But it is
not just Scotland which has experienced a ‘political attack’ and its
consequences, Campbell et al. (2013, p184) comment that, “Almost
no other European countries experienced an increase in economic
inequalities on the scale of Great Britain's increase since 1979” and
that, “by the start of the 21st century e [Britain] was back at levels of
M. Peacock et al. / Social Science & Medicine 118 (2014) 173e180174

3. inequality last experienced at the height of the 1930s depression.”
(p181). Collins and MacCartney (2011) argue that:
“It is clear that post 1979 UK political attack negatively affected key
upstream determinants of health and mortality. One fairly obvious
suggestion is that these in turn, through the mediation of psycho-
social mechanisms, in addition to the more direct effects of material
deprivation, affect the more proximal downstream determinants in
terms of adverse health behaviour” (p510).
There is now substantial evidence that neoliberalism has
negative consequences for health and well-being (Navarro, 2007;
Harvey, 2007). It is relatively straightforward to grasp how
neoliberal policies can be detrimental to health; reducing health
and social care provision, for example, will widen gaps as those
who are able to pay, do so, leaving the least affluent without or
facing waits. It is also possible to glimpse something of how the
increasing emphasis on individual responsibility might cause harm
and, most starkly, harm for those with the least resources. Lupton
(2013 p39), for example, argues that “neoliberal governments
depend upon their citizens adopting their injunctions voluntarily
… the well regulated citizen takes responsibility for her or his health
and wellbeing … they do not place an economic burden on the state
by becoming ill and requiring health care”. With Rose (1996, 17)
arguing that under neo-liberalism, the individual is constituted as
one who is ‘obliged to be free’, which gives rise to practices aimed at
‘understanding and improving ourselves in relation to that which is
true, permitted and desirable’ (Rose, 1996, 153). Neo-liberal dis-
courses thus cohere around a valuing of the self-regulating, self-
surveillant and autonomous self, where those who are not equal to
this task face both strain and fears that others will judge them as
insufficiently responsible.
But explicitly including wider political discourses, which are the
focus of this paper, in researching the construction of the inner
world can be very challenging. It can be hard to map a pathway
from the global to inner experience (Archer, 2003; Scambler, 2013)
but, we would argue, it is essential if we are to understand the
nature and impacts of contemporary inequality (Bambra, 2011).
Macro political trends shape lives and leaving these out of analyses
of health and well-being restricts understanding, as Nafstad et al.
(2007) have illustrated in their study of ideology and power as
reflected in shifts in contemporary language use.
“People are now engulfed by ehearing, reading and using e the
voice of neoliberalism” (p323)
There is, of course, a rich tradition of empirical research within
medical sociology exploring lay perspectives on health inequality
and its causes and its consequences. This has made a huge contri-
bution to our understanding of agency and structure and factors
mediating this relationship (see for example, Popay et al., 1998,
2003). What we are arguing for here is something rather
different. It is a move away from the analysis and description of the
local and towards an exploration of how the macro might translate
into the individual and the discursive resources available to people
(Archer, 2003). This means considering political discourses, labour
market structures and welfare state regimes, amongst others, as
constituting the macro, and where, as Bambra (2011) puts it,
“Politics is given prominence as an overarching macro actor which
has the ability to reshape all the determinants” (p191). Moving
from the macro-political to the close grained details of lives or,
more problematically, the inner worlds of individuals, is chal-
lenging but without attempting to so much is lost from un-
derstandings of the consequences of social and political change and
the connections with health (Muntaner et al., 2011). We now move
on to consider the study and its setting.
3. The study
The study we use to illustrate the contention that there are as-
pects of neoliberal discourses which have been partially internal-
ised and which impact on health and well-being, is a qualitative
“psycho-social” study of women living in Salford, England. There are
two uses (and two spellings) of “psychosocial” in this paper; psy-
chosocial is used to in the context of social epidemiology and the
theories of W&P (in TSL), and others. Psycho-social describes the set
of methodologies which draw together the inner and outer worlds
of the subject attempting to look “beneath the surface” of discourse.
Unequal societies TSL argues, increase the risk of shaming social
comparisons since, “If the social hierarchy is seen e as it often is e
as if it were a ranking of the human race by ability, then the out-
ward signs of success or failure all make a difference” (p40).
Avoiding shame becomes more important and those at the bottom
of society suffer most as they are least equipped to defend them-
selves practically, discursively and emotionally against such com-
parisons. But all suffer, as all compare. An exploration of
sociological understandings of shame is necessarily outside the
scope of this paper (Peacock et al., 2014), but the most cursory
reflection on the way that one would be likely to react if asked in an
interview context about shame, provides an insight into how
anxiety provoking this might be and of the probable need to defend
the self against shame in most encounters. This in turn, raises
questions about how shame might be accessed and explored in an
interview context without simply evoking defensive accounts. To
this end, a “psycho-social” approach was chosen and we now turn to
describe this.
The aim of the study was to explore women's lives in an unequal
society (the UK) to see whether shame and social comparison were
salient in the ways proposed in TSL. A secondary aim was to look at
what resources might be drawn upon to protect from shaming
social comparisons and what aspects of women's lives might
worsen or sharpen the damages consequent on inequality. TSL and
the wider body of psychosocial scholarship concerning health in-
equalities, proposes a variety of biological mechanisms that may
explain the health gradient associated with unequal societies
(raised and blunted cortisol responses to stress, increased inflam-
matory processes and “allostatic” load amongst others (Marmot
and Wilkinson, 2006)). This study did not aim to appraise these
mechanisms but rather to explore what practical and discursive
aspects of life in a contemporary, unequal society might damage or
protect. Women's lives were the focus of the study as early exam-
inations of the shame literature drew our attention to the extensive
work around shame and depression (utilising the same sorts of
biological pathways as those above) and which seemed to dovetail
with the perspective of TSL (Brown et al., 1995; Brown, 2002). The
bulk of this work has focused on women and it is not clear to what
extent this can be generalised to men, hence women were selected
for this study.
Ethical approval was obtained from the University of Sheffield
and biographical-narrative interviews were conducted with thir-
teen women using the Free Association Narrative Interview (FANI)
method (Hollway and Jefferson, 2000, 2013) with each woman
being interviewed at least twice, resulting in a total of thirty one
interviews. The first interview was primarily biographical with the
content being participant led in order to minimise researcher
preconceptions or assumptions shaping the stories that the women
produced about their lives. First interviews were up to two hours
long with second interviews sometimes being shorter. There was a
topic guide indicating what needed to be covered across the two
M. Peacock et al. / Social Science & Medicine 118 (2014) 173e180 175

4. interviews (with the second interview being more structured to
ensure all the areas were addressed) but the aim was to use an
interview frame which produced narratives of lives rather than
responses to questions.
Frost and Hoggett (2008, p440) employed a similarly psycho-
social approach and explain that, “the “psycho” and “social” ele-
ments are not two parallel paradigms, but represent a whole
epistemological shift into theorising the passionately rational
subject … impacting on and impacted by its social world”. In the
case of the study described here, this perspective allows for a way of
talking and thinking about a painful subject such as shame e
opening up the means to explore both in the interviews and in
subsequent analyses e what might be happening as the women
talked about their lives, whilst also keeping hold of the social. We
propose that it is this psycho-social approach which allowed for the
emergence of the discourse which formed the key and unantici-
pated finding of this study.
Participants were purposively recruited through local connec-
tions with community workers and then snowballing from these,
with the intention being to reflect something of the nature of Sal-
ford both in terms of social class and of the major religious and
ethnic minorities. The youngest woman was eighteen and the
eldest seventy-two and most women described themselves as
“working class” with two women being “middle class” (Salford is
not an affluent area and has a very small middle class). Some of the
women worked in health-related, public sector or voluntary sector
jobs. Several had left school with few qualifications and had their
first child early in life. In their thirties or forties some returned to
education initially via courses offered in the local women's centre
(a charity) or in SureStart (national children and parenting ser-
vices). Education had provided access to higher quality work but
even for the women who had obtained degrees, this work was not
well paid and was often part time. Much of the work involved
“caring” of various kinds e nursing, primary school teaching,
community centre worker and these jobs exposed the women to
the harshness and poverty of the lives of many of those that they
worked with.
All the interviews were audio recorded and transcribed in full,
and in analysing the data we drew on transcripts and audio re-
cordings, extensive reflexive diaries maintained throughout the
study as well as notes, emails and texts from participants. These
were used to generate the “pen portraits” for each participant,
which are a feature of the FANI approach. The analysis proceeded
iteratively as the interviews proceeded within a data analysis group
consisting of four psycho-social researchers. The group continued to
work with the data on completion and further analysis was con-
ducted by an individual researcher “reporting” to the group. Space
does not permit a detailed exploration of the process of analysis
and sense making, but the method of analysis was modelled upon
the approach employed by Hollway and Jefferson (2013) and Frost
and Hoggett (2008). Here we focus on the findings associated with
relationships and connections between inequality and
neoliberalism.
4. Findings e the no legitimate dependency discourse
Although the primary aim of the study was to explore shame
and social comparison (and these were present if not in quite the
ways TSL would anticipate), we report on these findings briefly
elsewhere (Peacock, 2012). Here we focus on what we termed “no
legitimate dependency”. We used this term from early on in the
process of interviewing to describe what occurred, in some guise,
with every woman in the study (the quotes selected are those that
best illustrate this discourse, but there were numerous illustrations
of this). No legitimate dependency describes multi-stranded
narratives in which almost everything about participants' lives
were deemed to be the responsibility of the individual, who alone
should be able to manage whatever was happening to them and
where turning to others, or even acknowledging the need for help,
was seen as weak and unacceptable. Participants described being
alone with this responsibility (although in some circumstances it
might be acceptable to turn to partners, but with a fear that they
might not deliver and that ultimately, you would be still be on your
own). But probably most painfully, attempts to make sense of this
experience of responsibility using anything other than an individ-
ualistic frame of reference was cited as evidence of a wish to shirk
one's responsibilities and duties. In other words, taking a socially
contextualised perspective was interpreted as a self-serving
attempt to rationalise or justify either failure or personal in-
adequacy as Donna below illustrates. The pervasiveness and force
of this discourse took us by surprise and was present as a valence or
colour which permeated the women's talk.
“Our childhood, obviously it moulds us … I know that, but I also
know we become adults and we make choices because we know
what's right, what's intrinsically right for us and what's not right
for us, and I make choices that are not healthy choices. I choose … I
know that I should take more exercise but I don't, I know that I
should eat less fat, but I don't. Do you know what I mean? I have
weaknesses. I have cake, I know I shouldn't eat cake because it's not
good for me and it's not helping me feel better about myself [but]
I'm still choosing to eat it. Only me can do it, so I am responsible
aren't I?” (Donna, 39, midwife, married mother of two girls).
No legitimate dependency manifested in three ways; firstly (and
most powerfully and frequently encountered), it was conveyed in
terms of self-blame and self-criticism and the holding of the self to
impossible standards. Secondly, it was conveyed through “other-
ing”, and thirdly (and less commonly), it was conveyed as a form of
protest. The self-blaming aspect may be more powerful for women
because of the gendered way that caring is understood and the
experience of being a mother. We describe each of these themes
below but first comment on the way therapy discourses were uti-
lised and incorporated into the accounts of many of the
participants.
5. No legitimate dependency and the therapy discourse
The ways that the women talked about their lives and sense of
responsibility drew heavily on therapy discourses. Walkerdine has
commented how, “psychological discourses and services (coun-
selling, as in chat shows, popular psychology books … women's
magazines and popular newspapers) combine with people's desire
to make something of their lives … to transform oneself into the
right kind of … subject” (2000, p3). These colloquial therapeutic
discourses comprised a significant amount of the women's talk,
particularly that of the younger women. In part, this reflects the
feminised discourses apparent in gendered spaces such as women's
magazines, but these were also readily available to many partici-
pants as components of training courses that women had under-
taken. In places such as SureStart “Confidence building”,
“assertiveness training” and “parenting skills” draw heavily on
therapeutic discourses which readily mesh with the individualised
messages of the no legitimate dependency discourse.
“I didn't know I lacked confidence I didn't know what the course
was … Went on the confidence course and, oh my God it got spelt
out to me, the things I was letting happen to me … allowing people
to treat me like that and I just learnt I could just say no and not give
M. Peacock et al. / Social Science & Medicine 118 (2014) 173e180176

5. a reason, and it changed me, it really, really, really did change my
life.” (Jo, 34, childcare worker, living with partner, two children)
This is not to argue that these courses (and discourses) are a
covert attempt to damage the women e they were widely
perceived to be of great value e but rather that the individualised
language of therapy can be readily co-opted into neoliberal dis-
courses emphasising individual responsibility and agency, but at
the cost of being unable to embrace social or collective solutions to
everyday problems. In that way, they are congruent with the no
legitimate dependency discourse.
6. Self-blame & self-criticism
One of the key ways in which the no legitimate dependency
discourse manifested itself in women's accounts was through self-
blame and self-criticism and this was a marked and pervasive
theme.
“I kind of push myself quite a lot and then when I can't do things I
feel guilty feel like I'm letting people down and I think that's
compounded from being a mother” (Annie, 52, part-time teacher,
single mother, one teenage son).
In maintaining these standards, it was both the imagined
judgements of others, both more and less intimate others, but also,
and probably most harshly, their own appraisals of themselves, that
were salient.
“It was so hard but because I allowed it I … because I had to show
the rest of the world or certainly [her partner] and his mum and
my family that, yeah I can do this and … you know I can, and look
how clean me house is and the kids have gone to school and the
kids have got clean uniforms but work was a mess and I really,
really, really sacrificed meself.” (Jo).
But the women also struggled with this discourse. It was
possible for them to occasionally acknowledge “social factors” but,
largely, this was only when it was applied to others and not to the
self (although “othering”, the second manifestation of no legitimate
dependency, robustly rebutted the application of social factors to
others as well). Donna, for example, had been able to acknowledge
the impact of the social in thinking about weight, but there was also
an anxiety that this acknowledgement may be or may be perceived
to be, an avoidance strategy for dealing with her own weight:
“It's like making excuses yeah? Because only I can do it, it's all down
to me. Yeah. Which it is ultimately, isn't it? But it is about making
the choices” (Donna).
This sense of an imperative to shoulder alone responsibility for
so much in life seemed to be composed of a mix of personal char-
acteristics, social circumstances and the wider political discourses
and experiences, what we would describe as a manifestation of the
neoliberal project as it enters the personal and discursive realm.
7. Othering
The second aspect of no legitimate dependency we encountered
in the study was othering. Othering arguably, had a protective
function as it enabled stigmatised identities to be managed and to
be pushed away from the self. This was most forcibly demonstrated
in Elsie's thoughts about disabled people.
“I hate people that are disabled wanting everything. They want all
the buildings altered so that wheelchairs can get in. Now for me, all
the new buildings from the last ten years should be wheelchair
friendly … but I would never dream of expecting a cathedral to alter
the front of their building … Like I don't agree with them getting
free parking … they get money to pay for those kind of things and it
does build up resentment you know” (72, retired married woman
with two grown up children).
It is distressing to note that Elsie has been a wheelchair user for
ten years due a degenerative neurological condition. Poignantly,
she goes on to indicate where some of this othering may be coming
from and why she might need to separate herself from what she
understands as the strident or undeserving.
“I mean people don't see you in a wheelchair anyway, they walk
over and then they look at you like it's your fault you know”
Othering, we would argue, serves to both position the self in a
safe and defensible space and to endeavour to make sense of what
is felt to have changed in the wider world. The other which is
constructed is similar to the ‘others’ that Hoggett et al. (2013, p17)
encountered in their study of anti-welfare sentiments in working
class communities, “a powerful element of fantasy is involved … these
others are not simply fictitious, but [there is a] strong element of
projection, rumour, exaggeration which nearly always seems to be
an element of these perceptions”. As shared collective protections
are lost, othering may increasingly become one of the few resources
that can be drawn upon to legitimise or make sense of ones' social
position as Maggie, below, shows (Shildrick et al., 2010).
“ I've only had a computer for about four years and people I know
who are on benefits who had bloody computers for ten years”
(Maggie, 63, retired, married, one son).
This type of comment was very common. Othering, we would
argue, needs to be understood macro-politically and it is this po-
litical aspect which is what has changed most starkly in the last
decade and become more intense. The more negative the percep-
tion of those who are considered to ‘shirk’ or are dependent be-
comes, the greater the need to demonstrate to the self and others
that you are different, responsible and non-dependent, and the
greater the potential for othering and blaming. It is worth com-
menting that this study, like that of Hoggett et al., took place some
two years prior to the current, highly visible discourses around
“shirkers and strivers” in the UK (Jones, 2011). We would argue that
the women in this study were not mirroring or reacting to this
shirker/striver discourse e rather, this discourse is powerful
because it meshes with something which appears to have been
already partially internalised.
8. Protest
The third response to the no legitimate dependency discourse
(and expressed by fewer women in the study), was protest, unease,
ambivalence or resistance.
“why do I get paid four times as much as the person who stacks
shelves in Tesco's? … okay I've worked and my education and all
the rest of it, but is my value to society … really four times as
much?” (Kate, 39, accountant, mother of three).
There was often a shift in what was expressed between the first
and second interviews. It seemed as though the experience of
M. Peacock et al. / Social Science & Medicine 118 (2014) 173e180 177

6. having a space to think about and consider these thoughts and
feelings, made questioning them without the fear of judgement,
possible. None of the women wanted their children to internalise
messages about the inappropriateness of dependence and many of
the women in the study had worked in “caring” jobs where they
embodied very different ideas and practices in their work.
“going back to the sort of values of consumers and everything … it's
all perpetuated that it's more important to fight to have a whatever
it is, you know, type of phone and whatever labelled clothes you
wear, than who you are as a person, so that it creates a sort of a
greed and a selfishness and I think that comes from the way society
is, the system if you like, the way society is” (Annie).
9. Strains and tensions in the discourse
Despite its pervasiveness, there was widespread discomfort
with the no legitimate dependency discourse and many places
where it was incongruent or jarring in women's lives. Participants
were often less critical of other women than they were of them-
selves, although they were critical both of particular aspects of
other women's behaviour and of the broader “something for
nothing” culture which they believed was increasing. Importantly
most of the women experienced a tension in using such discourses
when thinking of their children or those that they cared for in their
jobs. This suggests that the no legitimate dependency discourse did
not constitute evidence of the uncritical hegemony of neoliberal
discourses but represented something more uncomfortable and
troubling which flourishes in the absence of plausible alternatives.
This discomfort is not dissimilar to that described by Sennett (1998)
in his study of the personal consequences of contemporary capi-
talism, where the individualised, no commitment strategies valued
in the workplace, sat ill with what the men he studied, wanted to
model for their children.
These strains and tensions inherent within no legitimate de-
pendency can make it a highly problematic discourse. A minority of
the women seemed relatively at ease with it and took a pride in not
needing things or people, “Make the most of what you've got don't
expect other people to provide your living, you've got to try for
yourself”, or were simply satisfied with what they had. But far more
commonly, the women paid a very high price, taking on often un-
manageable burdens as their own responsibility and then blaming
themselves for their perceived failings.
“I stood at the top of the stairs and I thought, shall I just throw
myself down? Not that I wanted to kill myself but I thought if I
break a leg or arm or something, someone's going to have to look
after me so [laughs], I got to that stage where I just thought I'm sick
of looking after everybody else … and although I'm quite close to
my family, they all live, [a long distance away] although I've got a
good support of friends … a lot of the time it feels like everything's
down to me and I feel a huge sense of you know responsibility and
that really weighs me down” (Annie).
10. Discussion
The aims of this study were to explore whether shame and so-
cial comparison were salient in the ways proposed in TSL, to look at
what resources and strategies might be used to protect from such
invidious comparisons and to consider if there were aspects of the
women's lives which might worsen or sharpen the damages
consequent on inequality. However the psycho-social method that
we employed uncovered the no legitimate dependency discourse
which we propose sheds light on how neoliberalism may be
implicated in shaping women's accounts and experiences, con-
necting with the well-established, damaging consequences of life
in an unequal society. Participants did not compare themselves
with those who had more and thus felt lacking in quite the way TSL
envisages but rather, as Hoggett et al. (2013) found, they compared
with others similar to themselves and it was in these imagined
spaces that the no legitimate dependency discourse emerged and
flourished. Neoliberalism, Hoggett et al. argue, recasts vertical po-
wer relations (rich and poor) as “lateral relations between people at
the same level of society” (2013, p14). Fairness is no longer about
redistribution or equality e the eye is drawn down and sideways
and fairness becomes about what you deserve in relation to others
in the same social position. The othering that we found in Salford
illustrates this well as participants struggled with perceived un-
fairness as Maggie's account (above) shows.
Further, the pain of comparison was infused with the flavour of
individualising discourses about personal responsibility alongside a
disavowal of any forms of dependency. We would argue on the
basis of this study that inequality is best understood in relation to
the availability of neoliberal discourses such as no legitimate de-
pendency, with neoliberalism playing a considerably greater role
than psychosocial theorists would anticipate in framing accounts
and experience.
Returning to the debate between Wilkinson and Coburn which
we refer to above, what is apparent in the Salford study (and in the
small body of work exploring the embodied or psycho-social as-
pects of neoliberalism) is how neoliberalism serves to construct
discourses which impact upon the very factors that W&P place at
the centre of the damaging consequences of inequality, that is, low
social status and subordination. The focus on the individual facing
the market alone, the stripping away of the welfare state, not just in
terms of health-care provision (which Wilkinson addressed in his
response to Coburn) but the stripping away of benefits, welfare to
work policies, social housing provision, taxation and tax credits, all
are legitimised by discourses which ‘other’ and blame, and blame
the disadvantaged the most. Neoliberalism is both practical and
ideological and it is this latter aspect which is salient here. In order
to legitimise and embed the dismantling of welfare and the related
changes which characterise neoliberalism, there needs to be an
ideological rationale which is plausible (Esping-Andersen, 1990;
Navarro, 2007). This is a pro-market, anti-welfare rhetoric which
has at its centre a valorisation of individual responsibility, a
demonisation and de-legitimation of dependence, particularly
welfare dependence, and a focus on self-sufficiency and opposition
to all that is collective. As Lupton puts it.
“Neoliberalism … is characterised by an emphasis on citizens' op-
portunities to make free choices, albeit guided by the state, and
which promotes the concept of citizens voluntarily seeking to take
responsibility for their own health and welfare” (2013, p107).
It is these individualising aspects from broader neoliberal dis-
courses that seem to have gained a great deal of discursive purchase
(and which were apparent in the accounts of women in this study),
even amongst those who are opposed to neoliberal ideas, as they
can operate as guilt or a fear of being seen by others as shirking or
avoiding one's responsibilities.
Other studies which have explored areas in the UK where the
health and social consequences of neoliberalism have been most
severe provide important insights which also shed light on the
findings from this study. For example, the increases in drug, alcohol
and social problems in ex-mining areas (Parry, 2003) and what is
known as “The Scottish Effect”, (Collins and MacCartney, 2011) show
M. Peacock et al. / Social Science & Medicine 118 (2014) 173e180178

7. how neoliberalism can wreak havoc that cannot be fully accounted
for by indices of deprivation or health behaviours alone. As the
practical and discursive resources available to people are eroded,
new discourses emerge e here we identified no legitimate de-
pendency e whilst Hoggett et al. (2013) refer to “ressentiment” e a
form of resentment “associated with passivity and either lack of
agency or destructive agency” (p577). There are methodological and
geographical differences between the two studies, but there are
striking similarities of tone and experience and a sense of what may
be emerging as, “individuals accommodate themselves to the idea of
living in a world without justice” (2013, p16). No legitimate de-
pendency and “ressentiment” may be different perspectives on the
same phenomenon with both reflecting the internalisation of
neoliberal discourses and the pain, yearning, ambivalence and loss
that ensues. No legitimate dependency both reflects the weakening
of protective discourses such as collectivity and solidarity and its
internalisation further undermines such protections as turning to
others is condemned.
Structural change, particularly in (largely) working class com-
munities such as Salford, has resulted in a loss of what Frost and
Hoggett (2008) have termed “second order agency”, that is, the
opportunity to act with others to both achieve more than individual
agency would permit and to feel part of something wider than the
individual self. It is not just tangible resources such as jobs or the
protection of trades unions which are salient e there is also a loss of
collective narratives that can be drawn upon to make sense of the
world and crucially, to facilitate action and change. This loss, this
absence of readily available discursive resources, is the space where
no legitimate dependency flourishes.
11. Conclusion
We have argued here that neoliberal discourses are likely to be
highly salient to the health and social outcomes of life in an unequal
society. Such discourses are, arguably highly toxic across several
domains of life. At the heart of the no legitimate dependency
discourse there is an irresolvable tension: to occupy a morally and
socially defensible position involves a disavowal of the social and
the losses, demands and isolation that result, whilst at the same
time, most do not want others that they care for to be subjected to
such demands. Thus, across the generations or within intimate
relationships there are tensions that cannot be resolved, as no-one
wants to hold loved others to such impossible standards. Thus,
there are potentially two layers of damage from the no legitimate
dependency discourse e the damage consequent on non-
dependency and the damage of being unable to resolve satisfac-
torily the strains and contradictions that the discourse generates
across lives. For the least affluent with the least resources, this
closing off of the legitimacy of seeking support (welfare, material or
emotional) results in the greatest burdens falling on those most
unable to shoulder them. When failure results, this can only be
understood as a reflection of individual merit or effort e to seek to
explain it any other way is further evidence of one's own moral and
practical deficits.
Wilkinson's (2000) response to Coburn in 2000 was titled
“Deeper than neoliberalism”, but it seems to us that neoliberalism
itself may go deeper than was indicated at the turn of the twentieth
century when this debate took place. More than a decade on, the
basic tenets of neoliberalism and “light touch” market capitalism
have continued, gathering pace and intensity in the UK with the
recent Coalition government “reforms”. There is always a time lag
between structural economic change and change in the realm of
feelings, sense-making and behaviour, and it is important to look at
how these processes may be unfolding. As the findings from this
study indicate, looking beyond the proximal can progress
understandings of the mechanisms that underpin the damaging
consequences of inequality, and including both the discursive and
practical aspects of neoliberalism are necessary to make sense of
life in contemporary, unequal societies.
References
Archer, M.S., 2003. Structure, Agency and the Internal Conversation. Cambridge
University Press.
Bambra, C., 2011. Work, Worklessness, and the Political Economy of Health. Oxford
University Press.
Brown, G.W., Harris, T.O., Hepworth, C., 1995. Loss, humiliation and entrapment
among women developing depression: a patient and non-patient comparison.
Psychol. Med. 25 (1), 7e21.
Brown, G.W., 2002. Social roles, context and evolution in the origins of depression.
J. Health Soc. Behav. 43 (3), 255e276.
Campbell, M., Ballas, D., Dorling, D., Mitchell, R., 2013. Mortality inequalities:
Scotland versus England and Wales. Health Place 23, 179e186.
Coburn, D., 2000. Income inequality, social cohesion and the health status of
populations: the role of neo-liberalism. Soc. Sci. Med. 51 (1), 135e146.
Coburn, D., 2004. Beyond the income inequality hypothesis: class, neo-liberalism,
and health inequalities. Soc. Sci. Med. 58 (1), 41e56.
Collins, C., MacCartney, G., 2011. The impact of neoliberal “political attack” on
health: the case of the “Scottish Effect”. Int. J. Health Serv. 41 (3), 501e523.
Davidson, R., Mitchell, R., Hunt, K., 2008. Location, location, location: the role of
experience of disadvantage in lay perceptions of area inequalities in health.
Health Place 14 (2), 167e181.
De Vogli, R., 2011. Neoliberal globalisation and health in a time of economic crisis.
Soc. Theory Health 9 (4), 311e325.
Dolan, A., 2007. ‘Good luck to them if they can get it’: exploring working class men's
understandings and experiences of income inequality and material standards.
Sociol. Health Illn. 29 (5), 711e729.
Esping-Andersen, G., 1990. The Three Worlds of Welfare Capitalism. Polity Press.
Frost, L., Hoggett, P., 2008. Human agency and social suffering. Crit. Soc. Policy 28
(4), 438e460.
Gibson, A.J., 2007. What Role Does Social Capital Play in the Health of Commu-
nities? (Unpublished PhD thesis) Open University.
Hall, P., Lamont, M., 2009. Successful Societies: How Institutions and Culture Affect
Health. Cambridge University Press.
Harvey, D., 2007. Neoliberalism as creative destruction. Ann. Am. Acad. Political Soc.
Sci. 610 (1), 21e44.
Hoggett, P., Wikinson, H., Beedell, P., 2013. Fairness and the politics of resentment.
J. Soc. Policy 42 (03), 567e585.
Hollway, W., Jefferson, T., 2000. Doing Qualitative Research Differently: Free Asso-
ciation, Narrative and the Interview Method. Sage, London.
Hollway, W., Jefferson, T., 2013. Doing Qualitative Research Differently: a Psycho-
social Approach. Sage Publications Limited.
Jones, O., 2011. Chavs: the Demonisation of the Working Class. Verso, London.
Lupton, D., 2013. Fat. Routledge, Oxford.
Marmot Review, 2010. Fair Society, Healthy Lives, Strategic Review of Health In-
equalities in England Post-2010. Available at: http://www.marmotreview.org/
AssetLibrary/pdfs/Reports/FairSocietyHealthyLivesExecSummary.pdf (last
accessed 30.05.13.).
Marmot, M., Wilkinson, R.G. (Eds.), 2006. The Social Determinants of Health, second
ed. Oxford University Press.
Muntaner, C., Borrell, C., Ng, E., Chung, H., Espelt, A., Rodriguez-Sanz, M., Benach, J.,
O'Campo, P., 2011. Politics, welfare regimes, and population health: contro-
versies and evidence. Sociol. Health Illn. 33 (6), 946e964.
Nafstad, H.E., Blakar, R.M., Carlquist, E., Phelps, J.M., Ran-Hendriksen, K., 2007.
Ideology and power: the influence of current neoliberalism in society.
J. Community Appl. Soc. Psychol. 17 (4), 313e327.
Navarro, V., 2007. Neoliberalism as a class ideology; or, the political causes of the
growth of inequalities. Int. J. Health Serv. 37 (1), 47e62.
New Economics Foundation, 2011. Why the Rich Are Getting Richer: the De-
terminants of Economic Inequality, London. Available at: http://www.
neweconomics.org/publications/entry/why-the-rich-are-getting-richer (last
accessed 30.05.13.).
OECD, 2011. Divided We Stand: Why Inequality Keeps Rising. OECD. Available at:
http://www.oecd.org/els/soc/dividedwestandwhyinequalitykeepsrising.htm
(last accessed 30.05.13.).
Parry, J., 2003. The changing meaning of work: restructuring in the former coal-
mining communities of the South Wales Valleys. Work Employ. Soc. 12,
227e246.
Peacock, M., 2012. Women's experiences of living in an unequal society: the place of
shame, social comparison, and neoliberal discourses in explanation of in-
equalities in health. Lancet 380, S63.
Peacock, M., Bissell, P., Owen, J., 2014. Shaming encounters: reflections on
contemporary understandings of social inequality and health. Sociology 48 (2),
387e402.
Popay, J., Williams, G., Thomas, C., Gatrell, A., 1998. Theorising inequalities in health:
the place of lay knowledge. Sociol. Health Illn. 20 (5), 619e644.
M. Peacock et al. / Social Science & Medicine 118 (2014) 173e180 179

8. Popay, J., Bennett, S., Thomas, C., Williams, G., Gatrell, A., Bostock, L., 2003. Beyond
'beer, fags, egg and chips'? Exploring lay understandings of social inequalities in
health. Sociol. Health Illn. 25 (1), 1e23.
Rose, N., 1996. Inventing Ourselves: Psychology, Power and Personhood. NY Cam-
bridge University Press, Cambridge and New York.
Rowlingson, K., 2011. Does Income Inequality Cause Health and Social Problems?
The Joseph Rowntree Foundation (Available at: 21.05.13.).
Scambler, G., 2013. Resistance in unjust times: archer, structured agency and the
sociology of health inequalities. Sociology 47 (1), 142e156.
Sennett, R., 1998. The Corrosion of Character: the Personal Consequences of Work in
the New Capitalism. W.W. Norton and Co, New York.
Shildrick, T., MacDonald, R., Webster, C., Garthwaite, K., 2010. The Low-pay, No-pay
Cycle: Understanding Recurrent Poverty. Joseph Rowntree Foundation.
Walkerdine, V., Lucey, H., Melody, J., 2000. Growing Up Girl: Psycho-social Explo-
rations of Gender and Class. Palgrave Macmillan.
Wilkinson, R., Pickett, K.E., 2009. The Spirit Level: Why More Equal Societies Almost
Always Do Better. Penguin, London.
Wilkinson, R.G., 2000. Deeper than “neoliberalism”. A reply to David Coburn. Soc.
Sci. Med. 51 (7), 997e1000.
M. Peacock et al. / Social Science & Medicine 118 (2014) 173e180180