Bailey’s Beach in Newport, Rhode Island was once described by the New York Times as a summer spot for “America’s ruling class,” populated by Astors, Vanderbilts and other “emerald-barnacled dinosaurs attended by uniformed retainers and underwritten by ironclad fiduciary trusts”.

When Adam Roberts, now 33, spent childhood summers there, he wasn’t quite sure how his family fitted in.

While his friends’ summer homes were among Newport’s famous Gilded Age mansions, he could see that his own parents’ house was far less grand. And unlike many club members, they worked: his mother as a tutor and waitress, his father as an artisan stone carver.

“My family had a modest lifestyle,” he says, putting air quotes around modest. “But we also had access to these hyper-privileged spaces like prep school and the beach club.”

Americans reflexively connect hard work with deservingness. The American dream promises that if we work hard enough we will be rewarded, and that those who have wealth deserve to have it. We don’t think much about why a hedge-fund manager would “deserve” exponentially more than a doctor, scientist or teacher – or whether the measure of a person’s “worth” should be only economic.

But as effort and reward become ever more disconnected, what happens when strenuous labor is met with little money, or reward comes effortlessly, sometimes via inheritance?

Roberts’ upbringing forced him to face these questions as he began to recognize just how wealthy his family really was. His paternal grandparents, who have a multi-million dollar oil fortune, paid for a full ride at Brown University.

“I didn’t know what work/study was,” he says, recalling classmates discussing loans and financial aid. His previous social experiences had primarily been with people who had more than he did – not less.

Johannes Siegrist, senior professor of work stress research at the University of Dusseldorf, coined a term to study the health effects of unfair compensation: “effort/reward imbalance” (ERI). “There are two versions,” he says. “You can either do too little and receive too much or do too much and receive too little.”

The second condition, not surprisingly, is far more common and has been the subject of much more research.

In studies that followed thousands of workers in different countries, Siegrist and others found that ERI is linked to health problems: specifically, an increased risk of coronary heart disease by about 40% and an 80% increase in the risk for depression. Since roughly one quarter of people in these studies work hard and see little gain, ERI is a significant problem in the workforce.

With rising job insecurity and stagnant wages, many workers feel as though they have no choice but to accept salaries and conditions that they would otherwise view as unfair. Research shows that over time, the proportion of jobs with high level ERI has risen, says Siegrist.

But being excessively rewarded without putting in much effort may also cause problems.

Although Siegrist cautions that the evidence is so far weak, his group does have unpublished data suggesting that feeling as though you have received unmerited reward is also associated with mental health problems.

For Roberts, the question of unearned reward became an obsession. He felt like he didn’t deserve the money he inherited, but he had no idea what to do. “I spent most of my 20s really stuck in guilt and shame around the fact that this injustice exists and I’m on the winning end in a certain way,” he says. At first, he dealt with it by hiding it or ignoring it. He’d go to parties and park his expensive new car blocks away so others wouldn’t see it.

Alternatively, he tried rationalization. “I wanted to justify it by saying, ‘Oh, I worked really hard,’” he says.

“People who have inherited wealth are more conflicted about their entitlement,” says Rachel Sherman, a sociology professor at the New School.

She interviewed dozens of wealthy people for her book Uneasy Street: The Anxiety of Affluence. She found that, in order to cope with this conflict, many simply pretend to be “self-made.” President Trump is a glaring example: even though grew up wealthy, he presents himself as an entrepreneur.

When Sherman asked an interviewee whether he deserved his $500,000 salary, he responded: “Damn right. Where I am today, I’ve earned every dime on my own.” He then conceded he’d initially received financial support from his in-laws.

Meanwhile, few who make the “I did it all myself” argument question the absurdity of seeing earnings as a measure of grit and moral worth. Does anyone really think that a CEO, whose pay is on average 271 times greater than that of his typical worker, works 271 times harder than his employees, who might actually be doing strenuous physical labor?

If this is true, today’s CEO must be running mental ultra-marathons compared to their predecessors: in the 1980s, they only made 50 times more. And so, to avoid wrestling with this illogic, the rich compare themselves to imagined welfare recipients, who lie around all day leeching off taxpayers.

The Trump administration is taking this idea to a new extreme: it has decided to let states create work requirements for Medicaid recipients, as if having healthcare could somehow deter work, as if only those who work deserve life.

After years spent feeling isolated and conflicted, Roberts decided to confront these issues. He became a national organizer for Resource Generation, a group aimed at helping rich young adults reduce inequality, partly by getting them to recognize how the wealthy can harm society. Through community organizing, the group works to connect people and intervene “at the level of systems and policy,” Roberts explains.

“I might not be able organize low-wage workers,” he says. “But I can connect with wealthy people who feel stuck and isolated and want to contribute to social justice.”

The concept of ERI allows us to better understand how a sense of fairness and justice affects health: feeling that our efforts aren’t appropriately compensated creates stress – even if the “problem” is being overly rewarded.

Unfortunately, rather than challenging inequality as it causes this stress, those at the top try to rationalize that they deserve what they have because they worked for it. And sometimes, even when they don’t work for it, the rich get the benefit of the doubt.

As When the Idle Poor Become the Idle Rich, a song from the 1940s musical Finian’s Ranbow, puts it:

When a rich man doesn’t want to work, he’s a bon vivant, yes, he’s a bon vivant

But when a poor man do
esn’t want to work

He’s a loafer, he’s a lounger, he’s a lazy good-for-nothing, he’s a jerk.

Roberts notes that with all the efforts to “solve” poverty, very little work has been done to tackle the other end of the scale. “We need to solve the intense accumulation of wealth,” he says.

Maia Szalavitz is the author of Unbroken Brain: A Revolutionary New Way of Understanding Addiction, which will be published in April. She is a 2015-16 Soros Justice Fellow and has covered addiction and neuroscience for major publications for nearly 30 years.

Co-published with The Guardian.