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Jackson M, editor. Stress in Post-War Britain, 1945–85. New York (NY): Routledge; 2015.

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Stress in Post-War Britain, 1945–85.

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Chapter 3GENDER, STRESS AND ALCOHOL ABUSE IN POST-WAR BRITAIN

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Much has been written about the history of alcohol and its abuse. However, although historians have analyzed the ways in which governments have responded to alcohol abuse, in policy terms and on medical and psychiatric of theories of alcoholism,1 far less is known historically about drinking behaviour – that is, about which individuals drank in the first place, and why. In recent research men have been identified as more likely to drink to damaging levels than women, but to be diagnosed less frequently as suffering from psychiatric disorders such as depression and anxiety.2 A MIND survey in 2009 reported that men were ‘twice as likely as women to report using alcohol as a coping strategy when they were feeling low or worried’, suggesting that for men drinking is a possible manifestation of emotional distress.3 However, with the notable exception of Mark Micale's Hysterical Men (2008), historical analyses of gender and mental illness continue to be dominated by accounts that emphasize the common association between women and psychological illness.

This chapter will examine alcohol abuse as a ‘coping mechanism’ in post-war Britain. I shall argue that a wide range of psychological symptoms were experienced by men, but that men exhibited different symptoms than women, if medical advice was sought at all. Whereas women tended to present with symptoms of low-mood, anxiety, lack of motivation and sadness, which were easy to recognize, men were more likely to self-medicate with alcohol or present with psychosomatic symptoms, including a spectrum of ill-defined disorders affecting the stomach, digestion, sleep and general well-being. Drawing on published reports, archival sources and interviews, the chapter explores a range of clinical, social and cultural forces that influenced debates about gender, alcohol abuse and psychological symptoms in three broad areas: medical surveys of alcohol use and abuse; general practice; and the workplace. I shall argue that the failure to examine drinking as a coping mechanism in men has had important implications for the broader interpretation of patterns of psychological illness since the 1950s.

Clinical and Social Surveys of Stress and Alcohol use in Men and Women

The decades following the Second World War marked a period in which a popular language of stress emerged, resonating with contemporary concerns about political instability and social change.4 Building on the earlier work of Walter Cannon (1871–1945), Adolf Meyer (1866–1950), Harold Wolff (1898–1962) and Hans Selye (1907–82), post-war stress researchers developed and explored the parameters of stress within general medicine, psychiatric epidemiology, psychology, psychosomatic medicine and occupational health.5 Mark Jackson has argued that, although the terms worry and anxiety did not disappear completely from medical and popular discourse, the term ‘stress’ increasingly began to dominate debates about the negative health consequences of the pressures of modern living. Such concerns about rising levels of stress were mobilized by those with interests in preserving health and restoring productivity after the Second World War.6 Given the significant interest among stress researchers, psychiatrists and clinicians in the social and economic determinants of health, and into the constitutional and personality factors which might dictate responses to stress, it is perhaps surprising that the role of alcohol as an ‘escape’ mechanism was largely absent from debates until the late 1970s. It was not until 1978 that the British psychologist Tom Cox, for example, noted explicitly that an individual's capacity to cope could be altered or manipulated by the consumption of alcohol, drugs and nicotine – and that these coping strategies were not unproblematic.7 Discussions about coping were similarly absent from professional debates about the use and abuse of alcohol.

Medical and philosophical theories about alcoholism and problem drinking have a long history which has been examined in detail elsewhere.8 Thom has shown how a major shift took place in the mid-twentieth century from a ‘moral’ model of alcoholism, which tended to see the problem as one of individual deficiency or ‘moral worth’, towards a disease model requiring medical treatment.9 The American biostatistician and physician Elvin Morton Jellinek (1890–1963) published his seminal piece ‘Phases of Alcohol Addiction’ in 1952 in which he highlighted the notion of ‘loss of control’ which progressed through a set of stages towards ‘rock bottom’.10 These principles were further developed by the German-born neurologist, Max Glatt (1912–2002), into a ‘U shaped’ chart depicting a ‘slippery slope’ with an upward path to recovery.11 In the 1970s, the British psychiatrist Griffith Edwards (1928–2012), who became an internationally renowned expert on addiction, coined the term ‘alcohol dependence syndrome’ which was incorporated in the World Health Organization's International Classification of Diseases in 1979. Edwards outlined the dependence syndrome in an article published in the British Medical Journal in 1976, co-written with the American psychiatrist Milton M. Gross.12 Edwards's influence on addiction studies was manifest in a prolific range of publications directed at both academic and popular readerships.13 The model of alcoholism eventually adopted by the British National Health Service (NHS) in the post-war years was based on the work of Max Glatt at his therapeutic treatment unit at Warlingham Park, Middlesex, during the 1950s.14

Although there was increasing acceptance that alcoholism was a ‘disease’, developments in policy and treatment in Britain were fragmented and piecemeal. While some commentators articulated concerns about alcohol abuse, there was still widespread denial of the problem. The first branch of Alcoholics Anonymous (AA) was founded in London in 1948, but aroused little interest among the medical profession.15 Three years later, in 1951, a consultant psychiatrist applied for funds to attend a World Health Organization conference on alcoholism. However, his application was rejected, on the grounds that ‘there was no alcoholism in England and Wales’.16 Glatt himself recalled that when he first ‘got into alcoholism’ in the early 1950s, he knew ‘not a thing about it’ and that ‘nothing much was written’ about it in Britain.17 Foreign visitors to his unit who came to learn about his treatment methods often remarked that when they had previously asked the Ministry of Health what methods were available for alcoholics in England they had all received the same response: ‘We have not got any alcoholics’.18 Despite the fact that men were significantly over-represented in statistics for alcohol abuse, prior to the 1970s there was no organized discussion about gender in British debates about alcoholism; it was simply noted to be less common in women. Efforts instead focused on establishing an accurate national estimate of alcoholics, on how best to treat the condition once diagnosed and on how to deal with the social problems caused by drunken offenders.

During the early 1960s, a number of social initiatives such as the Joseph Rowntree Steering Group on Alcoholism and the Camberwell Council on Alcoholism (CCA) were set up to examine the problem and, ostensibly, to promote preventative measures. As Thom has noted, the CCA eventually became nationally influential, partly because of the lack of other strong policy-relevant interest groups in the alcohol arena.19 The stated aim of the CCA was ‘to gauge the extent of the problem and to investigate personal, social and economic factors concerned in the causes of alcoholism’.20 However, discussion tended instead to be dominated by its ‘impact upon the life of the nation’, in particular the deleterious social consequences of alcoholism: crime, social disturbance and family breakdown. Although the condition appeared to affect men in much larger numbers than women, discussions rarely mentioned why this might be. Occasional individual accounts from alcoholics themselves illustrate the widespread denial and failure to confront the problem. One former alcoholic whose contribution was published in the Journal of Alcoholism recalled that none of his friends, work colleagues or his employer ever took him aside and spoke seriously to him. Instead, he noted that they ‘all connived in covering up … what now appears to be serious drinking bouts and their attendant hangovers’.21 This man concluded that ultimately, the situation in which he found himself was ‘all part of the rich pageant of life as we know it’, adding that, where alcohol was concerned, he was ‘slightly more blind in a whole kingdom of the partially sighted’.22

Although researchers eventually acknowledged that much problem drinking remained unreported in the community, figures that existed in 1950 suggested that alcohol consumption was comparatively low.23 This contributed to the official view from the Ministry of Health that alcohol abuse was ‘not a problem’. However, as Thom has shown, a number of other factors framed the discourse on alcohol abuse. Firstly, the power of the temperance movement had waned considerably and thus, policy action, when it came, focused on the medical aspects of alcoholism and not on preventative measures. Secondly, the general disarray of mental health services following the introduction of the NHS resulted in a lack of resources for alcohol treatment. Thirdly, and perhaps most importantly, the disease model of alcoholism legitimized medicine's role in treating the condition, viewing it as a ‘disease of the unfortunate minority’.24 Debates failed to investigate many of the social factors and life stressors that might have contributed to individual drinking habits. Indeed, the Ministry of Health was explicitly concerned to limit enquiry strictly to treatment issues, since prevention would open ‘very wide vistas' which were thought to be quite outside the scope of the Department’.25

Accounts from those working in medicine certainly reflected this approach. Casualty doctors noted that cases of alcoholism usually presented at the ‘emergency end of the disease’, and, because they were admitted to general hospitals, not psychiatric wards, as soon as they were ‘physically well’ they were discharged.26 Emphasis on the physical nature of the condition was evident in accounts by hospital doctors, one of whom noted that alcoholics rarely presented in ‘such a mental state’ that would honestly warrant compulsory detention under Section 25 of the Mental Health Act.27 During a series of seminars held by the CCA in 1970, the Registrar in charge of Casualty at King's College Hospital described his experience of treating intoxicated patients:

Should someone present himself as very depressed, we try and find a physical reason to account for this … such as an overdose of drugs … or some overwhelming disease – I wouldn't spend too long on it. If it's an acute problem, we treat them, but if it's not, then they have to go. Overdose is seen as a psychiatric emergency – alcoholics are not.28

The remaining seminar discussion focused on the physical treatments that were available, such as stomach irrigation for alcohol poisoning and the use of vitamin injections. ‘True’ psychiatric cases, one doctor noted, were assured a consultation at the Maudsley Psychiatric Hospital; however, he added, ‘you have got to find out what is the matter with him, to assess whether he should be chucked out or kept in’.29 These attitudes were in contrast to the approach taken by alcohol experts such as Glatt who, although not underestimating the importance of personality, emphasized the ‘great influence of social problems on the causation and development of alcoholism’. Indeed, one of his methods of treatment involved patients telling their ‘life stories’ – a technique he had developed previously when working with neurosis patients. Glatt worked closely with AA and claimed his methods complemented those employed by the organization.30 Despite his notable influence, the eventual development of alcohol treatment units between the early 1960s and the 1980s was slow and patchy, and treatment methods were diverse.31 Glatt noted himself that he faced considerable inertia and that ‘many doctors and professionals [were] only too keen to avoid involvement with alcoholic patients’.32 Indeed, by the late 1970s, research indicated that the majority of alcoholism referrals were not to specialist units.33 However, it is notable that, although some provision was made for women, those who were referred to treatment units were predominantly male, likely to be in their forties and from the higher social classes. ‘Skid row’ drinkers were less likely to call upon services provided and consultants were less likely to admit them to inpatient wards, a pattern that, according to Thom, remained stable until the 1980s.34

During the early 1970s, a small group within the CCA put forward a proposal to investigate women alcoholics. Although numbers of women were thought to be very small at a ratio with men of one to four, a review of the literature suggested some specific concerns – among them evidence that, within the family unit, women were usually the primary carers of children and that regular ‘drinking at home’ made it harder to detect.35 The nature of this investigation is particularly illuminating. Concerns clearly reflected long-established moralistic overtones about women and alcohol. As historians have shown, the focus has commonly been ‘not so much on women as women, but on women as mothers, and on the notion of maternal neglect’.36 The framework of the investigation into women drinkers was entirely different to that of the seminars, symposia and enquiries into drinking problems in men. To begin with, the group of professionals invited to contribute included not only medics, but sociologists and marriage guidance counsellors.37 Specific areas for research included: the role of femininity; recent changes in the social role of women; the relationship between drinking and marriage; and how conditioning, upbringing and consequent life expectations might influence drinking. The onset of drinking was noted to be regularly triggered by marital breakdown, in contrast to the assumption that alcoholism in men was likely to lead to divorce. Research questionnaires distributed via staff to patients at treatment centres asked explicit questions such as: Why did your drinking become a problem? Do you think that being a woman makes a difference to your drinking problem? Was depression a factor in your drinking?38 Staff at treatment centres were asked specifically about factors that might be unique to women in case histories, referrals and treatment. In one other rare article published on the subject, A. B. Sclare, a psychiatrist in Glasgow, had also noted that alcohol problems in women were often correlated specifically to environmental factors related to employment or domestic stress.39

Contributors to the CCA's project noted that women were more likely to be labelled as ‘depressive’, with the alcoholism treated as a secondary disease, if it was diagnosed at all.40 Hospital doctors and general practitioners (GPs) were more likely to diagnose psychoneurosis to shield a woman from the stigma of alcoholism. Because of this propensity to be diagnosed as ‘depressed’ and not ‘alcoholic’, women were more likely to appear in statistics for psychiatric referral, treatment and psychotropic drug prescriptions. Specific focus was also directed towards the role of menstruation, menopause and hysterectomy in triggering the onset of drinking, as well as possible problems associated with homosexuality, sexual identity and loneliness. In addition, conclusions from this research suggested that women reported drinking when life ‘got them down’ or when they were ‘restless and tense’, because it helped them ‘forget their worries’.41

These points of reference and formulations were in stark contrast to those examined and developed in debates about male alcoholics, which did not explore what was unique about being a ‘man’ in relation to drinking. Personal testimonies from men suggest that they were not comfortable with reflective analysis of their feelings and did not link drinking to emotional worry or anxiety in the same ways as women. This is illustrated perfectly by the testimony of one recovering male alcoholic who noted, ‘The question I am often asked is “do you know what caused your drinking?”’ to which he added, ‘I am not able to isolate any particular cause or causes in myself … I am drawn to the conclusion that the most likely hypothesis is that I was conceived on the back of a brewer's dray’.42 In psychiatric settings, ‘marital discord and domestic stress’ were specifically observed as ‘precipitating factors for hospitalisation in women’,43 whereas, alcoholism was less likely to result in a man being referred for psychiatric assessment at all. In addition to analysis of the social consequences of alcoholism, the CCA's enquiry into women was thus structured around a set of research questions that were much more likely to identify social, cultural and economic factors – including life stressors – that prompted problem drinking.

Alcohol and Stress in General Practice

Some patients with alcohol problems presented in primary care. However, general practitioners (GPs) were largely concerned with how to diagnose the problem and deal with sickness certification than with why their patients might drink in the first place.44 Many felt that there was so much stigma surrounding alcoholism that they were justified in falsifying certificates when a true diagnosis might lose the patient their job. Max Glatt conceded that hospital doctors were inclined to do the same thing.45 Correspondence from the Rowntree Trust Steering Groupon Alcohol also suggests that GPs felt ‘services on the NHS were so inadequate that many h[ad] decided not to waste their own time or that of their patients by attempting further use of them’.46 GPs confirmed the general picture that alcoholic patients were usually male and that they would be most likely to present with some kind of somatic disorder that would indicate an alcohol habit – or their wives would make a visit to the family doctor to report the problem.47 Griffith Edwards warned GPs that the alcoholic often came into the surgery asking for something for ‘bad nerves’ or something for ‘his stomach’, concluding that abnormal drinking may in fact cause, precipitate, imitate or be secondary to every known psychiatric syndrome.48 The ability to recognize alcoholism, particularly in its earlier stages, was further complicated by the fact that physicians were socialized into a culture of heavy drinking at medical school. This resulted in a blurring of boundaries between abnormal and normal drinking. Indeed, by the 1980s, research had begun to uncover a significant problem with alcohol, drugs and mental illness in the medical profession. By 1982, the standardized mortality ratio for cirrhosis in doctors was three times that of the general population.49

There was little doubt among GPs, reflecting on their time in general practice, that the over-use of alcohol was commonly used by men as a coping mechanism.50 There was also a consensus among them that men tended to present with psychosomatic symptoms that were more ‘acceptable’ and less stigmatizing. John Fry (1922–94), post-war pioneer of general practice-based research, kept meticulous personal notes about his patients which were also regularly interspersed with references to male patients with dyspepsia and ‘epigastric pain’, a term used to describe pain in the gastric region (often aggravated by alcohol), for which no organic cause could be found. Such patients were often additionally described as ‘agitated’, sometimes ‘depressed’, but seldom ‘neurotic’, a term that was largely reserved for anxious women.51 Many men were diagnosed with duodenal ulcers. Fry was particularly interested in the clinical and social aspects of peptic ulcers and published widely from his observations in general practice.52 Although not considered to be the only cause of ulcers, anxiety was seen as a precipitating factor for gastric disorders, and men were thought to be less likely to ‘admit to pressures causing psychological stress’.53 Indeed, wives commonly complained to their doctors that their husbands refused to visit the surgery at all and would bemoan ‘Oh, he'll never come doctor. But if he does …’.54 Many GPs lived in their patients' communities and were often quietly aware of existing marital or familial problems. With tact, they were sometimes able to use this knowledge to elicit details about such matters from their patients.

Women, in contrast, emerged in consistently larger numbers in statistics for depression and anxiety. C. A. H. Watts, a GP who published widely from research undertaken at his own practice on the subject of neurosis and depression, found that between the ages of thirty-five and fifty-five, women were at least twice as likely to consult a doctor with depression or a neurotic reaction.55 However, he also noted that men were far more prone to take their own lives and that addiction to alcohol was a ‘very common factor among suicides’.56 Although studies varied in the overall percentage of patients diagnosed with psychiatric disorders, the sex differential remained across surveys.57 However, psychosomatic and alcoholic presentations of psychological illness were not always included in data, perhaps obscuring a more accurate picture of gender patterns and differences. Anthony Ryle, for example, explicitly omitted psychosomatic disorders from his study of neurosis in general practice, arguing that the inclusion of ‘all stress disorders’ in a survey of neurosis would say more about ‘the doctor's enthusiasm for psychosomatic concepts’ than about the real ‘prevalence of disease’.58 Unsurprisingly, his findings included significantly greater numbers of women with neurosis than other studies, perhaps also reflecting his interest in obstetrics and postnatal conditions. Other research also featured anomalies that could affect the accuracy of the gendered distribution of psychological illness. Logan and Brook's Survey of Sickness, published in 1957, for example, featured greater numbers of women with psychoneurosis, but the study included a large group of unspecified ‘ill-defined illness’ and evidence that male patients attended their GPs more regularly for ‘indigestion’ and ‘gastrointestinal disturbances’.59

The difficulties involved with providing an accurate assessment of numbers with psychological disorders did not go unnoticed. Dr H. J. Walton, a psychiatrist from the University of Edinburgh observed in 1969 that the inclusion of ‘psychosomatic’ or ‘stress’ disorders in research would significantly alter the picture.60 He argued that it was possible GPs were missing psychosomatic symptoms because of their training at medical school, which placed ‘great emphasis on basic scientific investigation … physical factors or theoretical matters’.61 He added that, among medical students, ‘suspicion and scepticism about psychiatry [began] early’ and that many viewed psychiatrists as ‘emotionally unstable, confused thinkers’.62 Furthermore, he argued that the personality of individual doctors influenced their patterns of diagnosis, with some young graduates showing a lack of concern about the psychological components of illness.63 Some ‘physically orientated’ graduates actively disliked patients who presented with psychogenic aspects to their illness. Among a survey of GPs attending a postgraduate course in psychiatric medicine, Walton also discovered that over half of the attendees found alcoholics a category of patient that was ‘unacceptable’.64

This situation was widely reflected in the oral histories of GPs who noted in interviews that the ability to detect a psychosomatic complaint lay entirely in the self-taught skill of the family doctor. One doctor admitted that the only thing he could recall about training in psychological medicine was that a psychiatrist had once told him ‘the golden rule is, if you don't know whether the patient's mad, or you are – he is’. He added, ‘it gave me no insight into the cryptic or hidden psychological symptoms’.65 He also admitted that ‘the idea of hysteria as a woman's condition was still very much a popular concept in medicine, and menopausal and menstrual changes of mood … so it was very easy to be patronising’. Additionally, he proposed that his ‘ignorance’ was undoubtedly ‘moulded by the kind of habits of the practice and the habits of presentation of the practice, so [he] picked up what they were expecting and responded accordingly’.66 This particular doctor also noted that alcoholism and gastric disorders were a significant problem among male patients:

In those days, [for] what was called spastic colon [and] is now irritable bowel disease, we prescribed medicines like the ‘double-strength nerve tonic’ as a mild sedative as we thought people might be worrying. But, I don't think we really, well speaking for myself, I don't think I penetrated very far into their psychological disorders. Nor do I think they would be very willing to admit them themselves, because you know, men don't complain do they? Not much.67

In 1966, Michael Shepherd (1923–95), an influential consultant psychiatrist, noted that the average GP was ‘unlikely to invoke a psychogenic factor in any case, unless he detects in the patient signs of current psychological or emotional disorder’.68 Observing that psychosocial factors were identified more regularly in women, he suggested that this might be because doctors were simply ‘more readily able to identify them as such’.69 He argued ultimately that there was reasonable confidence among GPs about recognizing psychiatric disorder, but that there was much less confidence in their ability to relate it to causal or precipitating factors.70

Work, Stress and Alcohol

During the early 1960s, the CCA had highlighted alcohol abuse in the workplace as one major area of concern. Keen to draw attention to the hazards, experts on the effects of alcohol contributed increasingly to professional journals; however, the focus was primarily on the cost of drinking to industry and the government. Questions were rarely raised about why workers drank in the first place. A number of GPs attending an ‘information week’ coordinated by the CCA were critical of industry for failing to take the issue seriously. One doctor described industry's ‘ostrich-like attitude’ and suggested that companies were reluctant to confront alcohol abuse because of the stigma and bad press the reputation might bring.71 Griffith Edwards explicitly advised that ‘alcohol was an important industrial disease’.72 At an industrial symposium held by the CCA during the early 1960s, one contributor recalled that a reformed alcoholic and colleague of his had personally written to twelve firms, whose employees cumulatively totalled 120,000, to ask, in confidence, what policies they had adopted towards alcoholic employees.73 About one third ‘didn't bother to reply’; one company ‘took exception to the insulting suggestion that a firm of their acknowledged repute would ever employ an alcoholic’; others replied that ‘drunkenness in their area was happily a thing of the past’.74

Professional journals that focused on alcoholism nonetheless identified a number of occupations in which individuals might be vulnerable to over-drinking. Concern was directed in particular on executive workers and those with jobs in the hospitality trade where alcohol was widely available. Other types of employment that allowed abuse to go undetected were also noted. Sickness absence among casual labourers, for example, might remain hidden since workers could simply resume work when they had recovered from a drinking bout. Employers were warned to be suspicious of repeated sickness certificates for gastritis, signs of irritability, decreased performance and poor time-keeping.75 They were also advised to be alert to absences on Monday mornings, particularly ‘if a wife phoned in’, since this might indicate a weekend of heavy drinking.76 Such concerns did not go entirely unnoticed by the media, as occasional articles were released in the press highlighting the issue of sickness absence due to alcohol. One headline in 1970 warned that ‘Monday is hangover day for British Industry’, claiming that ‘a quarter of a million men in Britain will be off sick today, when all they have is a bad hangover’.77 Another item described the problem as ‘a secret illness’ and as ‘the complaint that nobody wants to talk about’.78

These problems were debated at a seminar attended by doctors, magistrates and members of industry, organized in as part of the information week, held in 1967, by the CCA. However, the debate remained focused on the consequences of drinking to industry and society, prompting one member of the audience to observe that, ‘all the talks assume that the presenting problems – familial, social and so on – were as a result of the alcohol. Can't we assume it might be the other way around?’79 The response from a magistrate was firmly that the problems that presented before him in the courts were largely the result of people ending up in trouble because of alcohol. One delegate suggested that changing social habits and increasing leisure time ‘were particularly difficult’, because men had ‘not learned to use their leisure time to do anything but drink’.80 Another made references to ‘nagging wives … worries, or whatever’, from which drink was a refuge; however, discussion continued to emphasize the way in which problems arose from the alcoholism, not the other way around.

Debates on absenteeism and sickness absence within industrial medicine were well-established by the 1960s, but focused primarily on ‘theories’ of absenteeism and on improving techniques in data collection and analyses.81 The motive behind such work was primarily the protection or enhancement of productivity. Most researchers employed a ‘disease-centred’ approach which underplayed social and emotional factors that might influence sickness patterns.82 Although numerous studies illustrated that psychoneurotic and psychosomatic illness existed among workers, few British researchers were willing to discuss alcohol, despite the fact that international studies (often published in British journals) indicated that a clear correlation existed with neurosis.83 International authors were more open about the problems of alcohol in industry and were explicit about its link with sickness absence and absenteeism. Studies from the USA, Sweden and Australia all emphasized the importance of identifying and addressing alcohol abuse in workers. W. Donald Ross's book Practical Psychiatry for Industrial Physicians (1956), for example, contained a whole chapter on ‘Alcoholism’, predicting that four million Americans were in ‘some stage’ of alcoholism. Ross noted that six out of seven of these were male and that much of the neurosis seen among women at work was a direct result of contending with an alcoholic family member at home.84 A British review of this publication acknowledged that this was a much needed book since industrial medicine was unfortunately still ‘antagonistic’ towards psychiatry. However, the reviewer cited ‘national differences’ as a ‘drawback’ of the text, noting that ‘alcoholism would hardly be considered a major problem amongst workers [in Britain]’.85 A similarly titled British publication Mental Health and Human Relations in Industry (1954), compiled from research undertaken at the Roffey Park Institute, made no mention of alcohol abuse whatsoever. This was despite the fact that the book emphasized the emotional needs of workers and that the Roffey Park Institute itself focused holistically on the well-being of industrial workers.86

By 1974, 34 per cent of major American industrial employers had adopted some form of programme to provide assistance to alcoholics.87 Some companies developed ambitious and innovative schemes offering confidential support to workers on any aspect troubling them, not just relating to alcohol abuse, but also to family or marital problems and indebtedness. The aim was thus to ‘get to the root cause … and save the employee's job’.88 In contrast, by 1979 commentators in Britain were forced to acknowledge how ‘slow’ they had been to recognize the problem.89 Herbert Berger, a physician from New York, speaking to an international audience of physicians and AA, was critical of the broad emphasis on treatment because it underplayed the causative aspects of alcoholism.90 He argued that alcohol was only a secondary aetiology, and that the primary condition was the patient's inability ‘to cope with the vicissitudes of his environment’, warning that medics and AA were failing in the arena of prevention by waiting for the patient to ‘hit rock bottom’.91

Women rarely featured in debates about industry and alcohol, although they were a source of concern in research on absenteeism and sickness absence. Most studies indicated that women were more frequently absent than men and that this was broadly the case across many different types of employment. For women, frequent absenteeism (a short period of undefined absence, which may or may not have been due to illness), was explained by their need to undertake family responsibilities in addition to their paid work.92 Thus, it was assumed that one of the ways in which women coped with shouldering dual responsibilities was to take short periods of time off work to look after sick children or when other family members needed them. A well-cited study of industrial workers in France, published in 1962, argued that ‘frequent absence means that there is a conflict between life at work and outside’, and that ‘female absenteeism cannot be explained by elementary biological or family factors alone’.93 Although a number of factors emerged as important influences, including the nature of the work performed and the distance women lived from their place of work, a key conclusion was that many women felt that their ‘proper place would be, and should always have been, at home’.94 Home responsibilities nonetheless could only account for part of the explanation, since women also appeared in certified sickness statistics for psychological disorders more frequently than men. However, many of the reports in industry were affected by the methodological anomalies of general practice-based research. The classification of disorders differed greatly between studies, a problem exacerbated by the unreliability of doctors' certificates.

One key theme that emerged in research on sickness absence was that men appeared more frequently in data for gastric disorders and in groups of illnesses labelled as ‘vague’ or ‘ill-defined’. Fraser's study of neurosis in factory workers in 1947 found that, although women outnumbered men significantly in numbers of ‘definite neurosis’, men predominated in the group of ‘disabling psychosomatic illness’ which included dyspepsia.95 Ager and Raffle's study of London transport workers also identified a growing tendency for absences attributed to vague diagnoses (gastritis, fibrositis, sprains, and anxiety states), an observation supported in the report Off Sick (1971), published by the Office for Health Economics.96 Ager and Raffle concluded that this general rising trend of ‘sickness’ was counter to ‘generally improved health’ and was therefore more likely to be a reflection of broader discontent with the social system than a true picture of morbidity.97

Literature on industrial health during the period suggests that where nervous strain and mental illness were explicitly correlated with stress, it was usually occupational stress that featured in analysis. In 1976, Cary Cooper and Judi Marshall argued that there were three separate dimensions to stress-related disease: the personal characteristics of the individual; stress related to the workplace; and pressures external to the work environment, such as family problems and financial difficulties. Their ‘model of stresses at work’ aimed to establish how these aspects combined to create symptoms of occupational ill-health, such as raised blood pressure, drinking and depression, sometimes leading to coronary heart disease and mental illness.98 During the 1980s researchers increasingly began to acknowledge that studies had placed too great an emphasis on unemployment, physical and chemical health hazards and absenteeism, while mental illness had been of ‘subsidiary interest’.99 New research began to chart an apparent increase in cases of psychiatric illness. Authors noted that studies in the past had been hindered by a number of complicating factors, not least the ‘unreliability’ of diagnoses on GP certificates and confusion surrounding physical symptoms that might have an emotional cause.100 All work that had been thus far undertaken also related to the health of workers in industry and large organizations, yet, as Albert Cherns pointed out in 1975, 60 per cent of men worked for small firms where there was no data available at all.101 During the late 1970s and 1980s, the focus of attention shifted to the well-being of executive workers, in part framed by the political context and Thatcher's free-market economics. It was also energized by the theories of the cardiologists Meyer Friedman (1910–2001) and Ray Rosenman on Type A personalities, which heightened anxieties about the impact of work-related stress on executives – a concern that was largely focused on men.102

Conclusion

Despite considerable interest in the associations between the stress of life and sickness, during the post-war period a form of ‘collective silence’ continued to surround the ways in which men coped with emotions and associated factors such as alcoholism and psychosomatic symptoms. In the workplace and during leisure activities, ideas about the degree to which it was seen as appropriate to admit to emotional difficulties discouraged men from seeking help for problems both at work and at home. Men appeared unable or unwilling to reflect on the causes of their problems. Leaders in industry were reluctant to acknowledge alcoholism or mental illness in the workforce, due to fears that the stigma might adversely affect the standing of their business. GPs and hospital physicians were poorly trained in psychological medicine and, until the late 1970s, were usually male and therefore affected by the same difficulties when challenged to be reflective or emotionally expressive. Many unwittingly colluded with stereotypical views about femininity and masculinity, providing psychiatric diagnoses for women and somatic diagnoses for men. Quite often, both the male patient and doctor were satisfied with a somatic diagnosis and looked no further.

During the 1970s, when concern was eventually raised about female alcoholism, research questions were constructed around a completely different framework, one less focused on aspects of treatment and diagnosis and more on what it might be about the female role that caused women to abuse alcohol. Betsy Thom has argued that the feminist movement of the 1960s was instrumental in this respect, since it had begun to frame women's health issues in political, social and economic terms. It thus provided the ideological motivation for explanations of women's use and misuse of alcohol, emphasizing the social and psychological context of drinking.103 For men, there was no corresponding initiative that questioned aspects of the male role that might impact on their well-being and ability to cope. This was compounded by the dominance of the disease theory during the 1950s and 1960s which assumed the alcoholic to be in the minority, diverting attention away from broader consumption levels and social factors in causation. According to Thom, a shift away from the disease theory towards a public health model of prevention did not come until the 1980s.104 The problem was exacerbated further by the fact that manufacturers of alcoholic beverages directly targeted men in their advertising campaigns which promoted drinking as not only a pleasurable pastime, but also increasingly as a way to relieve stress.105 These advertisements appeared widely in daily newspapers, but also in publications directed exclusively at men such as Lilliput and Men Only. As Lemle and Mishkind noted in 1989, through the second half of the twentieth century, social drinking increasingly became a primary cultural symbol of ‘manliness’.106 Heavy drinking symbolized greater masculinity than lighter drinking and the more a man tolerated his alcohol, the more manly he was deemed.107 Accounts from a Mass Observation investigation into public houses and drinking confirm indeed that working-class men were inclined to drink to appear ‘tough’ and to fit in with their peers. Beer-drinking was also widely associated with increased sexual performance.108

In his discussion of male emotional illness, Mark Micale notes of the Victorian era that, ‘the homogeneously male medical community contrived to ignore an entire field of potential study’.109 Of present times, he is more optimistic, suggesting that Western medicine no longer plays a commanding role in producing the dominant fictions of masculinity. We now live, Micale argues, in ‘a fundamentally new environment for viewing and discussing gender and masculinity’. However, he notes that ‘it would be foolish to contend that this process is complete’.110 He is right to be cautious since, as this chapter has shown, during the decades following the Second World War, there were few formal discussions about psychological illness and coping in men, despite evidence that many male cases existed either undiagnosed in the community, or presenting in primary care complicated by psychosomatic symptoms. In contrast, a gendered landscape that assumed that women were more likely to experience mental illness provided fertile ground for academics, clinicians and social commentators alike. Recent research indicates that the number of men experiencing common mental disorders is still underestimated, a problem exacerbated when practitioners rely on their male patients' ability to volunteer information about mental health concerns.111 Suicide statistics from the mid-twentieth century continue to show that men are persistently more likely to end their own lives; perhaps a consequence of their failure to seek help for psychological disorders.112 It is clear from these recent studies that social and cultural factors continue to influence ideas about masculinity, femininity, vulnerability to stress and ways of coping, just as they did in the decades after the Second World War.

Acknowledgements

This research was funded by the Wellcome Trust, grant number WT091661MA. I would like to thank the Trust for their continued support. I would also like to thank the fifteen retired general practitioners who were interviewed for this project.

© Taylor & Francis 2015, © Mark Jackson 2015.

The Open Access version of this book, available at www.tandfebooks.com, has been made available under a Creative Commons Attribution-Non Commercial-No Derivatives 3.0 license.

Monographs, or book chapters, which are outputs of Wellcome Trust funding have been made freely available as part of the Wellcome Trust's open access policy

Bookshelf ID: NBK436954PMID: 28661622

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