Monday, 6 January 2020

Irish Medical Responses to Problem Drinking from Institutionalisation to Public Health: Part II

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.

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.  

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.
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

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

Dr Alice Mauger
Dr Alice Mauger is a Postdoctoral Research Fellow at the Centre for the History of Medicine in Ireland in the School of History, University College Dublin. Her research project 'Alcohol Medicine and Irish Society, c. 1890-1970' is funded by the Wellcome Trust. The project explores the evolution of medicine's role in framing and treating alcoholism in Ireland. It aims to make a significant contribution to the medical humanities, exploring historical sources to better understand and contextualise Irish society's relationship with alcohol. She was awarded a PhD by UCD in 2014 for her thesis which examined public, voluntary and private asylum care in nineteenth-century Ireland. Prior to this she completed the MA programme on the Social and Cultural History of Medicine at the UCD Centre for the History of Medicine in Ireland, UCD. Both her MA and PhD were funded by the Wellcome Trust.

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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