In the second instalment of this two-part
special, Dr Alice Mauger, Wellcome
Trust Postdoctoral Research Fellow at the UCD Centre for the History of Medicine in Ireland explores the changing approaches of medical practitioners and
psychiatrists to problem drinking in Ireland since 1922.
Read Part I here.
Read Part I here.
After the First World War, medical interest in the “drink question” began to wane and political barometers swung strongly towards attempts to limit drinking. Among the
most infamous of these tactics was the United States’ prohibition experiment,
which resulted in a nationwide ban on drinking from 1920 until 1933. Meanwhile,
the newly formed Irish Free State government lost little time overhauling
liquor regulations, restricting pub opening hours and decreasing the availability
of pub licenses. While this demonstrated state concern about both levels of drunkenness and the money being spent on drink, the same government was slow to reflect on the treatment of alcoholism.
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| New York City Deputy Police Commissioner watching agents pour liquor into sewer following a raid during the height of Prohibition. Source: United States Library of Congress's Prints and Photographs division. |
A New 'Disease View'
Beginning in the United States, a new ‘disease view’ of alcohol addiction emerged after the abolition of prohibition in 1933. The fundamental difference between this new medical concept and its nineteenth-century predecessor was the perception of drink itself. While the earlier interpretation saw alcohol as an inherently addictive substance, posing a risk for everyone, the post-prohibition version portrayed drink as harmless for most but with the potential to cause disease in a minority of vulnerable or ‘defective’ individuals – labelled alcoholics.
In
an era of mounting medical concerns over immunisation, tuberculosis and infant
mortality, accompanied by the general rise of preventative medicine, this ‘disease
view’ of alcoholism did not take hold in Ireland until after the Second World
War. In the meantime, there was a marked decrease in alcohol consumption in
Ireland during the first half of the twentieth century.
Alcoholism and Mental Hospitals
In 1945 new legislation broke ground, giving
statutory recognition to the role played by mental health services in supplying
addiction treatment. The Mental
Treatment Act, 1945 specifically provided for the admission of ‘addicts’, including
those addicted to alcohol, to mental hospitals. This signalled growing acceptance of alcoholism as a disease requiring treatment. It also cemented what was already a reality for the Irish psychiatric services. As mentioned in a previous
post, Irish mental hospitals had been principal treatment centres for
problem drinkers since the nineteenth century and by 1900, 1 in 10 admissions were attributed
to ‘intemperance in drink’.
In spite of these developments, it was not
until the 1960s that psychiatrists began openly advocating the disease theory. This
decade also saw the establishment of the first specialist wards for alcoholism in
Dublin psychiatric hospitals like St John of God’s in Stillorgan and St
Patrick’s Hospital on James’ Street. Concurrently, there was a marked rise in
the number of alcohol-related admissions to psychiatric hospitals from 561 in
1958 to 1,964 in 1967.1 It is uncertain whether these figures represented an increase in the actual numbers of alcohol-related cases presenting or in the numbers being identified. What is clear, however, is that by this point the role played by psychiatric services for alcoholism in Ireland
had crystallised and psychiatrists had apparently grown more comfortable with
this function.
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| Source: Wikimedia Commons |
Dr John G. Cooney
Possibly the most avid individual advocate of
the new disease view was Dr John G. Cooney, a consultant psychiatrist at St
Patrick’s Hospital who became one of Ireland’s leading authorities on the
psychiatric treatment of alcoholism.2 Speaking
at the North Dublin Medical Club Symposium in 1963, Cooney urged his medical
colleagues to accept the disease view:
Too often doctors have allowed their view of alcoholics to be distorted by emotional factors. Commonly their own subconscious fears regarding alcoholism have been projected on to their alcoholic patients. If one is to treat alcoholism successfully whether in hospital of in general practice one must feel as well as believe that the alcoholic is ill and suffering from a disease just as surely as a diabetic is suffering from his excess blood sugar.3
Resistance to the Disease View
The theory’s central tenet, however, did not
sit well with many Irish commentators. After all, the premise that alcoholism
constituted an inherent ‘flaw’ in the individual was a difficult pill to
swallow in a country with increasing psychiatric admissions for that very
disorder. Illustrating this point in 1962, a consultant psychiatrist at St John
of God’s, Dr Desmond McCarthy, complained:
One of the great difficulties in this country was that alcoholism was not accepted as an illness. It still carried a social stigma, a rather foolish way of looking at a serious disease. The basic illness was often hidden under other names for face-saving thus there were no reliable figures for alcoholism.4
Evidence of a persistent stigma around
alcoholism in Ireland was produced as late as 1969. Reporting on an alcoholism
seminar for general practitioners in Waterford that May, the Irish Times’
medical correspondent, David Nowlan wrote of the survival within the Irish
medical profession of ‘medieval attitudes’. Nowlan described how one general
practitioner had stood up at the end of the seminar and ‘stated quite
categorically that alcoholism was a sin in the face of God and against God’s
works deserving of only censure and moralistic indignation’.5
Social and Cultural Factors
By the 1970s, psychiatrists were devoting some
space to the impact of social and cultural change in Ireland. According to Cooney,
modernisation had brought with it a variety of new factors which were now
influencing Irish drinking habits. These included increasing social mobility in
rural Ireland leading to more money being spent on drink; the replacement of
dimly-lit, all-male pubs with brightly-lit bars and singing lounges catering to
younger married couples; expense account drinking in the cities following the
patterns of London and New York; and the centrality of alcohol on all social
occasions and in many business transactions. Cooney’s observations were not
unfounded. The 1960s had seen a massive economic boom, resulting in greater
disposable income and a dramatic climb in expenditure on drink. Inevitably,
Cooney argued, ‘all this exposure to alcohol has led, in the
opinion of many workers in the field, to an increase in alcoholism’.6
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| Campaign Poster for Public Health (Alcohol) Bill, 2015. With thanks to Alcohol Action Ireland |
A Public Health Approach to Alcohol
Cooney’s concerns about increasing exposure to
alcohol were illustrative of those in Ireland and elsewhere. The 1970s marked a
turning point in attitudes towards drink in many
countries. By now, epidemiologists were linking rising per capita consumption with a concurrent growth in alcohol-related harm, including deaths from liver cirrhosis and convictions for drunkenness and drink-driving. Alcohol therefore came to be presented, once again, as a problem for everyone rather than a minority deemed predisposed to alcoholism. Designated the ‘public health’
perspective, this approach gradually supplanted the disease concept. Yet, in
spite of the efforts of its proponents, and its acceptance and promotion by the
World Health Organisation, until quite recently governments have been reluctant
to impose corresponding legislation.
The passing of Ireland’s Public
Health (Alcohol) Act in 2018 therefore represents a landmark in alcohol
policy. It also reveals an unprecedented unity among medical responses to
problem drinking today. Internationally, it has received strong backing from
leading public health organisations and in Ireland, the Royal College of Physicians of Ireland have
partnered with national charity, Alcohol
Action Ireland, to form the Alcohol Health Alliance Ireland,
for whom a central aim has been to support the Bill. Meanwhile, the President
of the College of Psychiatrists in
Ireland, Dr John Hillery, stated in November 2017: ‘the College supports the bill in its
entirety, not a diluted version, to protect the mental health of our society’.7
Alice Mauger
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| Dr Alice Mauger |
She has published on the history of psychiatry
and alcoholism in Ireland including '"The Holy
War Against Alcohol": Alcoholism, Medicine and Psychiatry in Ireland, c.
1890–1921’ and a full-length monograph: The
Cost of Insanity in Nineteenth-Century Ireland: Public, Voluntary and Private
Asylum Care (Palgrave
Macmillan, 2017) which is available via open access and in hardcopy.
1. John G.
Cooney, ‘Rehabilitation of the Alcoholic’, Journal of the Irish Medical
Association 63, no. 396 (1970), 219-22, on 220.
2. Cooney
was responsible for the establishment of a specialist treatment programme for
alcohol-related disorders at St Patrick’s, published extensively on the topic
of alcoholism and was a founding member of the Irish National Council on
Alcoholism.
3. John G.
Cooney, ‘Alcoholism and Addiction in General Practice’, Journal of the Irish Medical Association 53, no. 314 (1963), 54-7,
on 55-6.
4. ‘Problem
of Treating Alcoholism’, Irish Times, 3 March 1962, 7.
5. David
Nowlan, ‘Hidden Disease Dangers: Doctors Discuss Alcohol’, Irish Times,
17 May 1969, 4.
6. John G.
Cooney, ‘Alcohol and the Irish’, Journal
of the Irish Colleges of Physicians and Surgeons 1, no. 2 (1971), 54.
7. ‘Public
Health (Alcohol) Bill for Discussion in
Senate Today: College highlights Alcohol’s Role in Completed and Attempted
Suicides and Mental Health Difficulties’, The
College of Psychiatrists in Ireland Blog (21 Nov 2017).
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