9.1 Introduction
Virginia Berridge (1990) in her history of the Society for Study and Cure of Inebriety (later to become the still extant Society for Study of Addiction) describes the period of the interwar years as
“a period of decline” in terms of the fortunes of the society. The Society did, in the end, weather and survive this period, as did the journal of the Society (British Journal of Inebriety/British Journal of Addiction/Addiction). The marked decline in the consumption of alcohol correlated with a decline in the prevalence of alcohol inebriety and the need for treatment facilities. Applications to join the society reduced and the balance of academic interest moved more towards narcotic drugs as the importance of alcohol diminished.
All the inebriate reformatories in Scotland had closed by 1925, and although the legislation that allowed their establishment was never formally rescinded it is clear from Scottish Office papers that these institutions were not in retrospect seen as successful and that there was no appetite to return to providing such separate provision. There were sporadic requests from Sheriffs, recorded in the Scottish Office papers, to utilise the Inebriate Acts, which eventually petered out in the absence of designated institutional provision.
There is a widely held lay view that alcoholics and addicts will find a way to obtain their drug of choice come what may but the experience in the era of control over alcohol doesn’t seem to support this idea.
9.2 D. K. Henderson’s 1936 Society Lecture at the Society for the Study of Inebriety
As was described earlier in the thesis, eminent Scottish psychiatrists had argued for separate provision for the inebriate. By 1936 this view had changed markedly as evidenced by the Sixteenth Norman Kerr Memorial Lecture on the topic of Alcoholism and Psychiatry given to the Society for the Study of Inebriety in London. It was delivered by the pre-eminent Scottish psychiatrist of the day, Professor David K. Henderson – he was Physician Superintendent and Professor of Psychiatry in Edinburgh and previously Physician Superintendent at Gartnavel Royal Mental Hospital in
Glasgow. In his lecture, Henderson takes a stance of embracing alcoholism as a concern for the modern mental hospital, in contrast to the views of his predecessors Yellowlees and Clouston who were arguing in favour of separation in the years preceding the Inebriates Act of 1898.
Henderson’s psychiatric worldview was very different to his nineteenth century forerunners. He had studied under Kraepelin and more importantly under Adolf Meyer in the United States.
Henderson adopted the Meyerian approach of psychobiology, which combined elements of psychoanalysis with the earlier biological theories, alongside the idea that each inpatient should be discussed at a case conference (see Morrison, 2014) where the contribution of psychological, social and biological elements could be delineated along with treatment and prognosis. The addition of the neuroses to the diagnostic system allowed Henderson and others to see alcoholism/inebriety as a more definite psychiatric concern with the heavy drinking seen as a manifestation of underlying neurosis.
In the 1936 lecture, Henderson looks back and states, in relation to alcohol control:
“Great strides in the right direction have been taken: the increase in the price of liquor, the
restriction of hours of sale, the reduction in the number of licenses, local option, increased facilities for amusement, better housing and better conditions of work, and, most important of all, a higher moral standard in relation to the use of alcohol have all exercised a beneficent influence. The improvement has been reflected in every walk of life, and our mental hospital statistics bear ample testimony to the altered conditions prevailing. Our admission rate for cases of mental disorder due to alcohol has been reduced too, from one-half to one-third, as compared with twenty-five to thirty years ago”.
For Henderson, psychiatry “is in a very specialized position in relation to studying the causes of alcoholism and carrying out appropriate care and treatment.”
Henderson challenges the view that the alcoholic is a “willful sinner” and castigates “a very famous psychiatrist” who “refused to receive into his mental hospital a patient suffering from alcoholism for the reason that he dealt with mentally ill patients only and had nothing to do with inebriates.”
For Henderson, the “victim” of alcoholism “requires skilled and considerate treatment” and Henderson believed this was something that psychiatry could provide.
From Hazel Morrison’s research at the Glasgow Royal Mental Hospital (Personal
Communication), Henderson certainly dealt with a small number of cases of alcoholism there in the 1920s. At least one of these cases had seen service in World War One and had both “shell-shock”
and alcoholism. However, unlike the current position where soldiers who have seen recent service
in Iraq and Afghanistan are seen to have increased rates of alcohol dependence in conjunction with PTSD, the observations in the 1920s suggested that this wasn’t a common comorbidity.
The 1922 “Report of the War Office Committee of Enquiry into ‘Shell-Shock’” presents research that those with “war neurosis” drank much less than those who were wounded but not “nervously effected”. In fact forty-eight out of 100 subjects with war neurosis were described as teetotallers and only 6% were said to have drank excessively at some point in their life – compared to 16% in the wounded but not nervously afflicted group who only had twenty teetotallers out of 100. The shellshock cases were said to have been more likely to have parents who were alcoholics than the non-shell shock group, in keeping with theories at the time that parental alcoholism produced constitutional weakness in offspring. The fact that the mental aftermath of World War One did not produce an increase in alcoholism is a strong indicator of the effectiveness of the alcohol
consumption controls of the time.
Returning to the Henderson Norman Kerr Memorial Lecture of 1936, Henderson expands on the case for psychiatric involvement with individual heavy drinkers:
“Let me attempt to state the position quite clearly. In many instances alcohol is responsible (1) for producing certain specific types of mental disorder-e.g. delirium tremens, Korsakow’s psychosis, and chronic alcoholism; (2) it is a complicating factor in many other types of nervous and mental illness e.g., general paralysis, manic-depressive states, mental deficiency and anxiety states; and (3) most of all, is a symptom or index of an underlying nervous constitution and instability which may be determined at various levels of development, hereditary, congenital, environmental.”
This statement is very reminiscent of that of Yellowlees in his 1874 paper quoted above.
Henderson also considers the question of aetiology and, while indicating he believes there is some truth in the Freudian psychoanalytic theories of causation, he is dismissive of some of the more fanciful explanations offered by British psychoanalysts such as Glover. Compared to the previous generation of psychiatrists he sees the addition of depth psychology to the previous biological understanding – combined with consideration of social milieu – as a key to all psychiatric practice, especially to the understanding of the alcoholic.
Henderson then goes on within his published lecture to give a rich series of case vignettes from his own practice, illustrating the association of “alcoholism” with a number of criminal behaviours and medical conditions. The headings he considers are:
(a) Alcohol and homicide
(b) Alcohol and assault
Most of his vignettes are drawn from his role as an expert witness for the courts (e.g. his eleven cases of homicide) and a few are drawn from his mental hospital practice. He is particularly interested in the life history of the individuals – in each of the criminal cases Henderson finds evidence of longstanding constitutional predisposition to react adversely to the effects of alcohol.
His testimony is effective as a plea in mitigation in the majority of cases, leading in one case to the death penalty being commuted to life imprisonment.
He draws on all the cases presented to make recommendations for current and future practice in a section entitled, “Suggestions Regarding Treatment And Reform”. In this conclusion to his lecture he states that:
“The case histories which have been recorded are examples of alcoholic states which are common, which are difficult to treat, but which need not necessarily lead to any further stage of mental disintegration. Drink in each case produced a state of vainglory, of all-powerfulness and, finally, of temporary oblivion as an attempt to blot out reality and to effect a transitory over-compensation for feelings of inferiority. While I emphasize the psychological aspects, I am not forgetting the
importance of the biochemical and physiological reactions, and while the treatment of the
individual is in the forefront yet the influence on society is also kept in mind. Under treatment there is usually little or no difficulty in prevailing upon the patient to give up the use of liquor, and investigation invariably shows that the real point of attack must be the remodelling of the man’s disposition. Practically every case demonstrates that from a comparatively early age disorders of conduct were exhibited which had been determined by a variety of factors, personal or
environmental, which were susceptible of considerable modification. That point is still lost sight of – far too great an emphasis is placed on the alcoholism and far too little attention is devoted to the type of individual in whom the alcoholism is occurring. It is not the alcoholism we require to treat, it is the man himself.”
This then is his main argument expressed succinctly – for psychiatric involvement with alcoholism – and as mentioned above he is dismissive of colleagues who do not see this as part of the function of the modern mental hospital.
He goes on to state that he is a realist regarding the extent to which treatment can make a difference, and adds the caveat:
“There is no panacea, no cure-all, no specific approach, but psychiatry with its patient unfolding of all the circumstances, physical, biochemical, psychological, and its weighing up of all the
constitutional reactive tendencies has a greater chance of producing better results than any other method of treatment”.
For Henderson, alcoholism is one of many behavioural conditions that should be the remit of psychiatry, under the broad heading of constitutional impairment and in some cases “unsoundness of mind”. (The latter designation allowing for involuntary treatment when it is deemed to be present.) It is in this context he then states:
“That, I am sure, is where the Inebriate Acts, introduced some years ago, but now ‘a dead letter,’
went far astray. According to these Acts, provision was made for the establishment of Retreats, Certified Inebriate Reformatories and State Inebriate Reformatories, and it is interesting to note that licences to manage Retreats could not be issued ‘to persons licensed to keep a house for the reception of lunatics.’ This, of course, implies a total failure to appreciate the close link between alcoholism and mental disorder, whereas the Reformatories, either certified or State, were much too closely identified with the prison system. These Retreats and Reformatories failed because of the lack of adequate medical treatment”.
It is in this context that Henderson then makes a plea for greater use of involuntary treatment using the existing Mental Health Legislation, based on a judgement of “Unsoundness of Mind” for the alcoholic. He additionally argues for new legislation to make using such powers easier to detain patients beyond a point of recovery from the initial presenting problem (say delirium) – this would allow treatment of the underlying constitutional disposition which in turn will be preventative or reduce the likelihood of future episodes of difficulty through alcohol. Alongside this plea for what we would now call secondary prevention he also makes a plea for primary prevention, mentioning principles of both good eugenics and also mental hygiene. (There is an interesting aside on a debate as to whether alcohol in early pregnancy might be eugenic rather than dysgenic – Henderson states it is clearly dysgenic, a position that is no longer in dispute.)
This lecture gives a fascinating insight into the practice and theory of the interwar era and a sea change in the view of alcoholism within mainstream psychiatry by the only Scottish Professor of Psychiatry of that period. Henderson’s views were, of course, widely disseminated in Great Britain and beyond through the highly successful and predominant textbook of the era (Henderson and Gillespie’s Textbook of Psychiatry).
9.3 A shift from alcohol to drugs?
A question that is often asked in relation to eras of increased control on alcohol – whether the population at risk of alcoholism shift to other forms of alcohol or other intoxicants. During these interwar years, the use of opiates and cocaine seems to have fallen away in Scotland and Britain, based on official statistics and from indicators of admissions to hospital. (This is not surprising given that greater restriction was brought in around narcotic drugs in the wake of the 1926 Rolleston Committee.)
There is some evidence of a shift towards a more dangerous form of alcohol in relation to statistics around secondary intoxication – methylated spirits or the fortification of existing forms of alcohol by the addition of methylated spirits. Such “cocktails” as “Red Biddy” and “King Fergus” were the result of such admixtures. Concern over this would culminate in legislation in the form of The Methylated Spirits (Sale by Retail) (Scotland) Act 1937. The numbers recorded with such a problem certainly rose in the 1930s, with Scotland being recorded as having a worse problem than England – but compared to the previous statistics around ethyl alcohol alone these numbers were small.
9.4 Scotland as an exemplar
The culmination of this dramatic turnaround in Scottish drinking culture was that Scotland was held up as a model for sobriety to be emulated by England in an enquiry into licensing laws in the early 1930s. The history of licensing legislation in Scotland is well set out in a paper on this topic by James Nicholls (Nicholls, 2013).
9.5 Conclusions
In an era where the problem with alcohol was seen to be diminishing, it is worth noting that Scottish psychiatry seemed more willing to embrace alcoholism as a condition worthy of mental hospital treatment. From his practice in this era, D.K. Henderson and others were arguing that all alcoholic patients had underlying psychiatric problems in relation to “nervous disposition” that were worthy of psychiatric intervention – this might in turn lead to a constitutional change that made the individual more able to withstand the temptation of alcohol and, if they were to drink, better endure the adverse effects of alcohol.