/ . Occup. Med. (1977) 27, 143-147 Printed in Great Britain
Occupational Mental Health in the United Kingdom* W. M. DIXON Head of Medical Services, The John Lewis Partnership toe into the cold and unwelcoming waters of primary prevention. I should like to return to further consideration of these points later. Those of us in this country who have for some years taken an interest in this subject came together in 1966 in London and others did the same in Manchester before that time. Dr Ann Hollingworth read a paper at the international meeting in Brighton in 1975 to the members of ICOMH (International Committee of Occupational Mental Health) in which she described the group's development (Hollingworth, 1975). Originally we came together at the suggestion of Dr J. A. Aldridge to share our experience of dealing with people under stress, and our meetings were—and still are—part social. We keep the group small by restricting membership to about 25 people but during the past ten years we have invited many guests to speak; some of these have subsequently joined the group, which remains primarily medical. However, the group includes a nurse, a psychologist and two managers; the doctors include psychiatrists as well as Occupational Physicians. Our practice is to meet monthly during the winter when the guest is invited to speak and discuss his paper. Most of our discussions, at least in the early years, were anecdotal, and therefore if prevention was discussed it was at the tertiary stage. For example, I might have described a case of acute depression with alcoholism in a young manager, under stress at work, and threatened with divorce. My fellows in the group would contribute from their experience and I went away more able to deal with a difficult problem. Over the years we have got to know each other well and the working atmosphere is open, predictable and usually pretty lively. There are, to quote Dr Hollingworth, 'those
I have been asked to paint a background of the state of our effectiveness in dealing with problems of occupational mental health in this country. I am afraid the resulting picture is best described as cloudy and dull, although there may be a few rays of sunshine on the horizon. We are not concerned for the moment with the rehabilitation of the mentally ill or the placement in suitable jobs of the mentally handicapped or of patients returning to work after hospitalization for psychotic diseases. We are concerned with the prevention of mental and physical diseases due to psychosocial stressors in the work environment. These attempts at prevention may be divided into three broad categories, a classification suggested by the DHSS paper: Prevention and Health: Everybody's Business (Health Departments of Great Britain and N. Ireland, 1976). Primary prevention is to anticipate where disease might strike and, by taking appropriate steps, to prevent it altogether or to minimize its effect. Secondary prevention is defined as the search for disease before it becomes manifest. Hopefully such conditions may be diagnosed at a stage when the victim is either unaware of the disease or unaware that he may even be susceptible to it. Tertiary prevention is concerned to minimize the disability when disease is already manifest. In the mental health field of occupational medicine we have been mostly concerned with the tertiary stage; some have ventured boldly into •Given at the 125th meeting of the Society on 25 March, secondary prevention and one or two have put a 1977.
143
Downloaded from http://occmed.oxfordjournals.org/ at University of California, Santa Barbara on June 30, 2015
Summary The present state of preventive occupational mental health in the UK is described. Efforts so far have concentrated on tertiary or secondary prevention but few have tackled primary prevention. 'Stress' is ill denned but is acknowledged as one factor in the causation of ischaemic heart disease and reactive depression. To reduce stress in industry requires a knowledge of management systems and some of these are outlined. The influence of the doctor on the health of an enterprise is discussed.
144
OCCUPATIONAL MEDICINE
opinion reduce its value but I would hope that others might consider our modest success and try to improve on it. The main problem about discussing occupational mental health is the difficulty in grasping a tenuous subject. Lead poisoning or trichloroethylene toxicity, for example, is a comparatively simple problem; the stressor is visible and its concentration can be measured with a fair degree of accuracy; moreover the stress or disease it produces is also measurable in both clinical terms and biochemically. In contrast, psychosocial stressors are ill defined, invisible, impalpable and intangible. Occupational health has, to its credit, largely conquered the scourges of industrial disease so graphically described in Donald Hunter's The Diseases of Occupation (1975), but it is pertinent that the latest edition of this excellent book has only 5 pages out of 1100 on Human Relations in Industry and 'stress' does not appear in the index. We have now to some extent delegated responsibility for continued prevention of those diseases caused by industrial toxicity to engineers, hygienists and technicians. Much more important, however, is, I believe, the great and increasing prevalence of stress induced disease. Perhaps it is because the scope of the subject is so wide and diffuse that people are wary of it, which may explain why meetings such as today's are relatively rare. There are two other reasons: one is that the subject is probably better discussed in small groups, and, secondly, it is in some socialist countries a political issue. We certainly found this to be true in Sweden where the Socialist Government recently passed a law to safeguard the mental—as well as the physical —health of the worker. In order to reduce this confusion it might be helpful to focus attention on two serious diseases which affect large numbers of people and for which there is as yet either no satisfactory treatment, or, at best, inadequate and frequently unsuccessful therapy. These are coronary heart disease (CHD) and reactive depression. The prevention of CHD was recently summarized by the Royal College of Physicians Working Party (1976). In that paper, stress is not given great prominence as a cause and it is concluded that 'it is difficult to prove that chronic stress contributes to the development of CHD'. However the RCP still recommends that counselling of individuals may well be of value in prevention.
Downloaded from http://occmed.oxfordjournals.org/ at University of California, Santa Barbara on June 30, 2015
of us who will always provide thoughtful counsel, those who introduce the more obviously professional psychiatric approach, the hot-heads, the reactionaries, the activators and even the comedians'. The group has become what could be described as a time-lapsed T-group. We have discussed innumerable aspects of stress although, like everybody else, we have failed to come up with a satisfactory definition. One of the main problems is semantic—when Hans Selye (1976) first described stress in the thirties it is suggested that he really meant to use another word. His definition of stress is all embracing and primarily physiological rather than psychological. His 'general adaptation syndrome' is a nonspecific response to potentially harmful stimuli in preparation for fight or flight. If he had used engineering terminology he should have used the word 'stress' to describe the relevant external factors and 'strain' the resultant physiological reaction of the stressed individual. I believe Selye himself has now accepted that his choice of the word 'stress' was due to an initial misunderstanding. However, we now prefer to keep to the word 'stress' to describe behaviour of the patient (because after forty years it is difficult to change) and to use the word 'stressor' to describe the external and internal factors which give rise to stress. In 1970 the London Occupational Health Group helped to spawn the Windsor Conference described in Dr J. L. Kearns's book Stress in Industry (1973) and we have joined with international colleagues through ICOMH and through the Mental Health Subcommittee of the International Commission. A joint meeting which was held in Stockholm in August 1976 entitled 'Psycho-social Stressors in the Work Environment' will be continued in New York in May 1977. There have been, so far as I know, few other discussion groups set up in the UK which concentrate on this aspect of occupational health, although our colleagues in New York have a similar group chaired by Dr N. Roberts of Exxon Corporation of which Dr Alan MacClean is an active member. The New York group is much larger—about 100 members, of whom 40 attend each meeting. But we feel reasonably certain that we have reached an optimal size for such a group)—at present everyone can, and does, participate; debate is robust and straightforward. To enlarge the group would in my
OCCUPATIONAL MENTAL HEALTH
as our predecessors had to learn about organic chemistry, about lead processing and about machine tools we need to know about motivation to work and the human side of enterprise. Dr Kearns has outlined in his book Stress in Industry (1973) the various psychological problems which may arise in different systems of management. It really all started with Taylor and his workstudy—dramatized in the film It's Cheaper by the Dozen. Henry Ford successfully introduced mass production in the 1920s, and by 1927 Elton Mayo was conducting his famous experiments at the Western Electric Company in Hawthorne, Chicago. Over a period of about a year various changes in the physical environment of a workshop where girls made relays were introduced. Some changes produced improvement (for example in illumination or hours worked); some changes were apparently detrimental. But productivity rose steadily by over 30 per cent during the period under review and Mayo concluded in the simplest terms that it was because somebody 'cared'; this observation has become known as the 'Hawthorne effect'. Herzberg et al. (1966) analysed the sources of satisfaction for workers and divided them into two main groups which he called Hygiene Factors and Motivators. Hygiene factors included working conditions, salary, relationship with superiors, subordinates and peers, status and job security, and company policies. If satisfactory they contribute . to a healthy work situation but do not themselves constitute a reward; but if unsatisfactory they distract the worker and act as an irritant. Motivation factors which are the only positive incentives include a sense of achievement, recognition by colleagues, responsibility and opportunity for personal growth and advancement, and finally an inherent feeling that the work itself is of value. McGregor (1960) postulated two opposing theories concerning motivation to work which he called theory 'X' and theory 'Y'. Theory 'X' assumed that the average man dislikes work and must be coerced, directed and threatened, and that the average person avoids responsibility, has no ambition and merely needs security. Theory 'Y' assumed that work is natural to man and that he will voluntarily exercise self direction and self control if his objectives are defined and he is committed to them. The average man will seek responsibility and naturally exercise a high degree of imagination, ingenuity and creativity, and that in
Downloaded from http://occmed.oxfordjournals.org/ at University of California, Santa Barbara on June 30, 2015
A more recent paper by C. L. Cooper and Judi Marshall (1976) quotes the classic work of Friedman and Rosenman on Type 'A' behaviour patterns (Rosenman et al. 1964). These authors have shown a relationship between certain individual behaviour patterns and the prevalence of CHD. Type 'A' was defined as that style of living which is characterized by 'Extremes of competitiveness, striving for achievement, aggressiveness, haste, impatience, restlessness, . . . feelings of being under pressure of time and under the challenge of responsibility'. After 4J years Type 'A' men had five or six times the incidence of CHD diagnosed by cardiologists unaware of their previous personality typing. There is some support for the hypothesis in a recent BMJ leader which postulates a pathogenetic mechanism, related to platelet response, for the development of CHD due to stress (British Medical Journal, 1977). The effect of stress on mental health itself one would assume is self-evident, and there is abundant anecdotal or internal evidence to support that hypothesis. For the statisticians there is also some evidence that psychosocial stressors act as a precipitating factor at the onset of mental breakdown. Schless and his co-workers (1977), taking nine life events including 'trouble with boss' and 'promotion', found them significantly more frequent in the 12 months preceding admission compared with a control group. The question is, should we now be moving ahead to advise, to counsel and to influence industrial management to prevent these diseases of the second half of the twentieth century or should we continue to fight the battles that won the last war ? If you have read Professor Stuart Sutherland's book Breakdown (1976), which includes an autobiographical account of his own acute depression and the treatment he received, you might be forgiven for thinking that prevention is not only better than cure but a good deal more successful than anything the psychiatrists, psychoanalysts or physicians can currently provide. To return to my main theme of primary, secondary and tertiary prevention, if we are to move forward from our present position of patching up the mentally sick or of prescribing exercise programmes for the recently returned coronary patient, then we must learn much more about the techniques of management, about human relations in industry, and about organizational stress. Just
145
146
OCCUPATIONAL MEDICINE
causing the situation from which one is attempting to extricate the patient. The period of counselling the individual to make his own decision to change the situation may well be prolonged over several lengthy interviews, possibly over a period of months. In my experience such a patient is often the unwilling victim of the 'Peter principle' (Peter and Hull, 1969). The Peter principle is based on the theory that in large organizations managers are promoted to the level of their own incompetence. If he can voluntarily seek a less stressful job it is far better than to be forced, perhaps after prolonged sickness absence, to accept demotion (with consequent loss of self confidence) just at a time when he needs security most urgently. You may well ask—should we doctors interfere in the processes of management before this state of affairs is reached ? We must all in this room have faced a situation where a man is appointed to a senior job which we suspect may be a disaster. It's some small satisfaction to be able to say 'I told you so', but must we be content to sit on the sidelines ? To interfere with management's most cherished privilege—that of making appointments—may be to lose our independence as medical advisers in industry. If the doctor is thought to be a sort of 'eminence grise' who influences appointments, he may be viewed with extreme suspicion; from then on, frank discussion of personal problems thought (rightly or wrongly) to adversely affect promotion prospects may cease. I come forward with no easy solution but I suggest we consider this problem seriously. We may need more research, more scientific evidence, more authority. But at the end of the day we may still, like John Snow, be faced with the need for difficult decisions on admittedly inadequate evidence. But—medicine is used to that! For some years I became a management consultant responsible for recruitment of senior managers. I thought that I could perhaps influence events at that stage and so prevent stress; and I think my colleagues were to some extent successful. We took care to interview applicants at great length—an initial interview took two to three hours. I believe that such an interview is better able to assess a man than any psychometric tests available so far. Dr R. Buzzard, the then Director of N.I.I.P., who is an expert on such testing, agreed with this conclusion.
Downloaded from http://occmed.oxfordjournals.org/ at University of California, Santa Barbara on June 30, 2015
modern conditions only a fraction of that potential is ever realized. McGregor concluded that theory 'Y' is true and should form the basis for good management of manufacturing industry. Professor Robert Kahn, the author of Organizational Stress (Kahn et al., 1964) introduced the concepts of 'sent role conflict' and 'role ambiguity' to describe some of the psychosocial stressors prevalent in large organizations. A simple example of role conflict is represented by the machine shop foreman whose manager looks to him to produce 'X' thousand parts in 'Y' thousand man hours at 'Z' cost. His workers look to him as a father figure, the shop steward sees him as the devil incarnate and his fellow foremen as a vacillating weakling who will not stand up to the workers. He suffers frustration and uncertainty and is overanxious. Under-arousal and boredom are also stressful— or, if you like, the absence of stress is stressful to some people. On a simple biometric curve, sensory deprivation at one extreme merges into boredom from repetitive unpleasant work. At the other extreme anxiety or depression can be produced by excessive stimulation or overwork. Stress is produced at both ends of the spectrum and good adjustment in the middle. Having briefly reviewed some of the salient points in the literature of motivation to work, have we sufficient knowledge which (if applied) could reduce the stressor factors and thus prevent illness? We might perhaps emulate John Snow who in 1855 shut off the Broad Street Pump and effectively stopped a cholera epidemic—without knowing really why he was successful. Have we not reached a point where we as doctors could exert more influence to reduce the psychosocial stressors which are accepted by so many people as inevitable in modern society? I do not underestimate the practical difficulties, for if we are aware that a patient is subject to severe stress we must first ask him for his cooperation and agreement to our interceding in his work situation. He may well at this stage see the doctor as a threat to his position in society or at least in the microcosm of society which forms his occupational milieu. His place in the pecking order, his status, his territory may be threatened. To threaten, by suggesting a transfer, a demotion, a voluntary retreat from a long-established position, may create greater stress than that already
OCCUPATIONAL MENTAL HEALTH
147
Hunter D. (1975) The Diseases of Occupations, 5th ed. London, English Universities Press. Kahn R. L. et al. (1964) Organizational Stress. New York, Wiley. Kearns J. L. (1973) Stress in Industry. London, Priory Press. McGregor D. (1960) The Human Side of Enterprise. New York, McGraw-Hill. Peter J. L. and Hull R. (1969) The Peter Principle. London, REFERENCES Souvenir Press. Rosenman R. H., Friedman M., Strauss R. et al. (1964) British MedicalJournal (1977) Leading article, 1, 408. Cooper C. L. and Marshall J. (1976) Journal of Occupational Journal of the American Medical Association 189, 15. Psychiatry 49, 1. Royal College of Physicians Working Party (1976) Journal of Health Departments of Great Britain and Northern Ireland the Royal College of Physicians 10, 213. (1976) Prevention and Health: Everybody's Business. Schless A. P. et al. (1977) British Journal of Psychiatry 130, 19. Selye H. (1976) Stress in Health and Disease. London, London, HMSO. Herzberg F. et al. (1966) The Motivation to Work. New York, Butterworths. Wiley. Sutherland S. (1976) Breakdown. London, Weidenfeld & Hollingworth A. (1975) Personal communication. Nicolson.
I hope in these few words I have been able to give some food for thought which will perhaps stimulate discussion.
LUNG FUNCTION SCREENING EQUIPMENT A single breath lets you measure up to 4 major parameters* The test is simple, quick costs only 1p per subject and instrument prices start from £340 (ex vat) *PEF, FVC, FEV,, FEV%
mercuru
POLLOK CASTLE ESTATE. NEWTON MEARNS. GLASGOW G77 6NU—041-639 4944
Downloaded from http://occmed.oxfordjournals.org/ at University of California, Santa Barbara on June 30, 2015
Requests for reprints should be addressed to: Dr W. M. Dixon, John Lewis & Co., Ltd., 4, Old Cavendish Street, London W1A 1EX.
Occupational Mental Health in the United Kingdom* W. M. DIXON Head of Medical Services, The John Lewis Partnership toe into the cold and unwelcoming waters of primary prevention. I should like to return to further consideration of these points later. Those of us in this country who have for some years taken an interest in this subject came together in 1966 in London and others did the same in Manchester before that time. Dr Ann Hollingworth read a paper at the international meeting in Brighton in 1975 to the members of ICOMH (International Committee of Occupational Mental Health) in which she described the group's development (Hollingworth, 1975). Originally we came together at the suggestion of Dr J. A. Aldridge to share our experience of dealing with people under stress, and our meetings were—and still are—part social. We keep the group small by restricting membership to about 25 people but during the past ten years we have invited many guests to speak; some of these have subsequently joined the group, which remains primarily medical. However, the group includes a nurse, a psychologist and two managers; the doctors include psychiatrists as well as Occupational Physicians. Our practice is to meet monthly during the winter when the guest is invited to speak and discuss his paper. Most of our discussions, at least in the early years, were anecdotal, and therefore if prevention was discussed it was at the tertiary stage. For example, I might have described a case of acute depression with alcoholism in a young manager, under stress at work, and threatened with divorce. My fellows in the group would contribute from their experience and I went away more able to deal with a difficult problem. Over the years we have got to know each other well and the working atmosphere is open, predictable and usually pretty lively. There are, to quote Dr Hollingworth, 'those
I have been asked to paint a background of the state of our effectiveness in dealing with problems of occupational mental health in this country. I am afraid the resulting picture is best described as cloudy and dull, although there may be a few rays of sunshine on the horizon. We are not concerned for the moment with the rehabilitation of the mentally ill or the placement in suitable jobs of the mentally handicapped or of patients returning to work after hospitalization for psychotic diseases. We are concerned with the prevention of mental and physical diseases due to psychosocial stressors in the work environment. These attempts at prevention may be divided into three broad categories, a classification suggested by the DHSS paper: Prevention and Health: Everybody's Business (Health Departments of Great Britain and N. Ireland, 1976). Primary prevention is to anticipate where disease might strike and, by taking appropriate steps, to prevent it altogether or to minimize its effect. Secondary prevention is defined as the search for disease before it becomes manifest. Hopefully such conditions may be diagnosed at a stage when the victim is either unaware of the disease or unaware that he may even be susceptible to it. Tertiary prevention is concerned to minimize the disability when disease is already manifest. In the mental health field of occupational medicine we have been mostly concerned with the tertiary stage; some have ventured boldly into •Given at the 125th meeting of the Society on 25 March, secondary prevention and one or two have put a 1977.
143
Downloaded from http://occmed.oxfordjournals.org/ at University of California, Santa Barbara on June 30, 2015
Summary The present state of preventive occupational mental health in the UK is described. Efforts so far have concentrated on tertiary or secondary prevention but few have tackled primary prevention. 'Stress' is ill denned but is acknowledged as one factor in the causation of ischaemic heart disease and reactive depression. To reduce stress in industry requires a knowledge of management systems and some of these are outlined. The influence of the doctor on the health of an enterprise is discussed.
144
OCCUPATIONAL MEDICINE
opinion reduce its value but I would hope that others might consider our modest success and try to improve on it. The main problem about discussing occupational mental health is the difficulty in grasping a tenuous subject. Lead poisoning or trichloroethylene toxicity, for example, is a comparatively simple problem; the stressor is visible and its concentration can be measured with a fair degree of accuracy; moreover the stress or disease it produces is also measurable in both clinical terms and biochemically. In contrast, psychosocial stressors are ill defined, invisible, impalpable and intangible. Occupational health has, to its credit, largely conquered the scourges of industrial disease so graphically described in Donald Hunter's The Diseases of Occupation (1975), but it is pertinent that the latest edition of this excellent book has only 5 pages out of 1100 on Human Relations in Industry and 'stress' does not appear in the index. We have now to some extent delegated responsibility for continued prevention of those diseases caused by industrial toxicity to engineers, hygienists and technicians. Much more important, however, is, I believe, the great and increasing prevalence of stress induced disease. Perhaps it is because the scope of the subject is so wide and diffuse that people are wary of it, which may explain why meetings such as today's are relatively rare. There are two other reasons: one is that the subject is probably better discussed in small groups, and, secondly, it is in some socialist countries a political issue. We certainly found this to be true in Sweden where the Socialist Government recently passed a law to safeguard the mental—as well as the physical —health of the worker. In order to reduce this confusion it might be helpful to focus attention on two serious diseases which affect large numbers of people and for which there is as yet either no satisfactory treatment, or, at best, inadequate and frequently unsuccessful therapy. These are coronary heart disease (CHD) and reactive depression. The prevention of CHD was recently summarized by the Royal College of Physicians Working Party (1976). In that paper, stress is not given great prominence as a cause and it is concluded that 'it is difficult to prove that chronic stress contributes to the development of CHD'. However the RCP still recommends that counselling of individuals may well be of value in prevention.
Downloaded from http://occmed.oxfordjournals.org/ at University of California, Santa Barbara on June 30, 2015
of us who will always provide thoughtful counsel, those who introduce the more obviously professional psychiatric approach, the hot-heads, the reactionaries, the activators and even the comedians'. The group has become what could be described as a time-lapsed T-group. We have discussed innumerable aspects of stress although, like everybody else, we have failed to come up with a satisfactory definition. One of the main problems is semantic—when Hans Selye (1976) first described stress in the thirties it is suggested that he really meant to use another word. His definition of stress is all embracing and primarily physiological rather than psychological. His 'general adaptation syndrome' is a nonspecific response to potentially harmful stimuli in preparation for fight or flight. If he had used engineering terminology he should have used the word 'stress' to describe the relevant external factors and 'strain' the resultant physiological reaction of the stressed individual. I believe Selye himself has now accepted that his choice of the word 'stress' was due to an initial misunderstanding. However, we now prefer to keep to the word 'stress' to describe behaviour of the patient (because after forty years it is difficult to change) and to use the word 'stressor' to describe the external and internal factors which give rise to stress. In 1970 the London Occupational Health Group helped to spawn the Windsor Conference described in Dr J. L. Kearns's book Stress in Industry (1973) and we have joined with international colleagues through ICOMH and through the Mental Health Subcommittee of the International Commission. A joint meeting which was held in Stockholm in August 1976 entitled 'Psycho-social Stressors in the Work Environment' will be continued in New York in May 1977. There have been, so far as I know, few other discussion groups set up in the UK which concentrate on this aspect of occupational health, although our colleagues in New York have a similar group chaired by Dr N. Roberts of Exxon Corporation of which Dr Alan MacClean is an active member. The New York group is much larger—about 100 members, of whom 40 attend each meeting. But we feel reasonably certain that we have reached an optimal size for such a group)—at present everyone can, and does, participate; debate is robust and straightforward. To enlarge the group would in my
OCCUPATIONAL MENTAL HEALTH
as our predecessors had to learn about organic chemistry, about lead processing and about machine tools we need to know about motivation to work and the human side of enterprise. Dr Kearns has outlined in his book Stress in Industry (1973) the various psychological problems which may arise in different systems of management. It really all started with Taylor and his workstudy—dramatized in the film It's Cheaper by the Dozen. Henry Ford successfully introduced mass production in the 1920s, and by 1927 Elton Mayo was conducting his famous experiments at the Western Electric Company in Hawthorne, Chicago. Over a period of about a year various changes in the physical environment of a workshop where girls made relays were introduced. Some changes produced improvement (for example in illumination or hours worked); some changes were apparently detrimental. But productivity rose steadily by over 30 per cent during the period under review and Mayo concluded in the simplest terms that it was because somebody 'cared'; this observation has become known as the 'Hawthorne effect'. Herzberg et al. (1966) analysed the sources of satisfaction for workers and divided them into two main groups which he called Hygiene Factors and Motivators. Hygiene factors included working conditions, salary, relationship with superiors, subordinates and peers, status and job security, and company policies. If satisfactory they contribute . to a healthy work situation but do not themselves constitute a reward; but if unsatisfactory they distract the worker and act as an irritant. Motivation factors which are the only positive incentives include a sense of achievement, recognition by colleagues, responsibility and opportunity for personal growth and advancement, and finally an inherent feeling that the work itself is of value. McGregor (1960) postulated two opposing theories concerning motivation to work which he called theory 'X' and theory 'Y'. Theory 'X' assumed that the average man dislikes work and must be coerced, directed and threatened, and that the average person avoids responsibility, has no ambition and merely needs security. Theory 'Y' assumed that work is natural to man and that he will voluntarily exercise self direction and self control if his objectives are defined and he is committed to them. The average man will seek responsibility and naturally exercise a high degree of imagination, ingenuity and creativity, and that in
Downloaded from http://occmed.oxfordjournals.org/ at University of California, Santa Barbara on June 30, 2015
A more recent paper by C. L. Cooper and Judi Marshall (1976) quotes the classic work of Friedman and Rosenman on Type 'A' behaviour patterns (Rosenman et al. 1964). These authors have shown a relationship between certain individual behaviour patterns and the prevalence of CHD. Type 'A' was defined as that style of living which is characterized by 'Extremes of competitiveness, striving for achievement, aggressiveness, haste, impatience, restlessness, . . . feelings of being under pressure of time and under the challenge of responsibility'. After 4J years Type 'A' men had five or six times the incidence of CHD diagnosed by cardiologists unaware of their previous personality typing. There is some support for the hypothesis in a recent BMJ leader which postulates a pathogenetic mechanism, related to platelet response, for the development of CHD due to stress (British Medical Journal, 1977). The effect of stress on mental health itself one would assume is self-evident, and there is abundant anecdotal or internal evidence to support that hypothesis. For the statisticians there is also some evidence that psychosocial stressors act as a precipitating factor at the onset of mental breakdown. Schless and his co-workers (1977), taking nine life events including 'trouble with boss' and 'promotion', found them significantly more frequent in the 12 months preceding admission compared with a control group. The question is, should we now be moving ahead to advise, to counsel and to influence industrial management to prevent these diseases of the second half of the twentieth century or should we continue to fight the battles that won the last war ? If you have read Professor Stuart Sutherland's book Breakdown (1976), which includes an autobiographical account of his own acute depression and the treatment he received, you might be forgiven for thinking that prevention is not only better than cure but a good deal more successful than anything the psychiatrists, psychoanalysts or physicians can currently provide. To return to my main theme of primary, secondary and tertiary prevention, if we are to move forward from our present position of patching up the mentally sick or of prescribing exercise programmes for the recently returned coronary patient, then we must learn much more about the techniques of management, about human relations in industry, and about organizational stress. Just
145
146
OCCUPATIONAL MEDICINE
causing the situation from which one is attempting to extricate the patient. The period of counselling the individual to make his own decision to change the situation may well be prolonged over several lengthy interviews, possibly over a period of months. In my experience such a patient is often the unwilling victim of the 'Peter principle' (Peter and Hull, 1969). The Peter principle is based on the theory that in large organizations managers are promoted to the level of their own incompetence. If he can voluntarily seek a less stressful job it is far better than to be forced, perhaps after prolonged sickness absence, to accept demotion (with consequent loss of self confidence) just at a time when he needs security most urgently. You may well ask—should we doctors interfere in the processes of management before this state of affairs is reached ? We must all in this room have faced a situation where a man is appointed to a senior job which we suspect may be a disaster. It's some small satisfaction to be able to say 'I told you so', but must we be content to sit on the sidelines ? To interfere with management's most cherished privilege—that of making appointments—may be to lose our independence as medical advisers in industry. If the doctor is thought to be a sort of 'eminence grise' who influences appointments, he may be viewed with extreme suspicion; from then on, frank discussion of personal problems thought (rightly or wrongly) to adversely affect promotion prospects may cease. I come forward with no easy solution but I suggest we consider this problem seriously. We may need more research, more scientific evidence, more authority. But at the end of the day we may still, like John Snow, be faced with the need for difficult decisions on admittedly inadequate evidence. But—medicine is used to that! For some years I became a management consultant responsible for recruitment of senior managers. I thought that I could perhaps influence events at that stage and so prevent stress; and I think my colleagues were to some extent successful. We took care to interview applicants at great length—an initial interview took two to three hours. I believe that such an interview is better able to assess a man than any psychometric tests available so far. Dr R. Buzzard, the then Director of N.I.I.P., who is an expert on such testing, agreed with this conclusion.
Downloaded from http://occmed.oxfordjournals.org/ at University of California, Santa Barbara on June 30, 2015
modern conditions only a fraction of that potential is ever realized. McGregor concluded that theory 'Y' is true and should form the basis for good management of manufacturing industry. Professor Robert Kahn, the author of Organizational Stress (Kahn et al., 1964) introduced the concepts of 'sent role conflict' and 'role ambiguity' to describe some of the psychosocial stressors prevalent in large organizations. A simple example of role conflict is represented by the machine shop foreman whose manager looks to him to produce 'X' thousand parts in 'Y' thousand man hours at 'Z' cost. His workers look to him as a father figure, the shop steward sees him as the devil incarnate and his fellow foremen as a vacillating weakling who will not stand up to the workers. He suffers frustration and uncertainty and is overanxious. Under-arousal and boredom are also stressful— or, if you like, the absence of stress is stressful to some people. On a simple biometric curve, sensory deprivation at one extreme merges into boredom from repetitive unpleasant work. At the other extreme anxiety or depression can be produced by excessive stimulation or overwork. Stress is produced at both ends of the spectrum and good adjustment in the middle. Having briefly reviewed some of the salient points in the literature of motivation to work, have we sufficient knowledge which (if applied) could reduce the stressor factors and thus prevent illness? We might perhaps emulate John Snow who in 1855 shut off the Broad Street Pump and effectively stopped a cholera epidemic—without knowing really why he was successful. Have we not reached a point where we as doctors could exert more influence to reduce the psychosocial stressors which are accepted by so many people as inevitable in modern society? I do not underestimate the practical difficulties, for if we are aware that a patient is subject to severe stress we must first ask him for his cooperation and agreement to our interceding in his work situation. He may well at this stage see the doctor as a threat to his position in society or at least in the microcosm of society which forms his occupational milieu. His place in the pecking order, his status, his territory may be threatened. To threaten, by suggesting a transfer, a demotion, a voluntary retreat from a long-established position, may create greater stress than that already
OCCUPATIONAL MENTAL HEALTH
147
Hunter D. (1975) The Diseases of Occupations, 5th ed. London, English Universities Press. Kahn R. L. et al. (1964) Organizational Stress. New York, Wiley. Kearns J. L. (1973) Stress in Industry. London, Priory Press. McGregor D. (1960) The Human Side of Enterprise. New York, McGraw-Hill. Peter J. L. and Hull R. (1969) The Peter Principle. London, REFERENCES Souvenir Press. Rosenman R. H., Friedman M., Strauss R. et al. (1964) British MedicalJournal (1977) Leading article, 1, 408. Cooper C. L. and Marshall J. (1976) Journal of Occupational Journal of the American Medical Association 189, 15. Psychiatry 49, 1. Royal College of Physicians Working Party (1976) Journal of Health Departments of Great Britain and Northern Ireland the Royal College of Physicians 10, 213. (1976) Prevention and Health: Everybody's Business. Schless A. P. et al. (1977) British Journal of Psychiatry 130, 19. Selye H. (1976) Stress in Health and Disease. London, London, HMSO. Herzberg F. et al. (1966) The Motivation to Work. New York, Butterworths. Wiley. Sutherland S. (1976) Breakdown. London, Weidenfeld & Hollingworth A. (1975) Personal communication. Nicolson.
I hope in these few words I have been able to give some food for thought which will perhaps stimulate discussion.
LUNG FUNCTION SCREENING EQUIPMENT A single breath lets you measure up to 4 major parameters* The test is simple, quick costs only 1p per subject and instrument prices start from £340 (ex vat) *PEF, FVC, FEV,, FEV%
mercuru
POLLOK CASTLE ESTATE. NEWTON MEARNS. GLASGOW G77 6NU—041-639 4944
Downloaded from http://occmed.oxfordjournals.org/ at University of California, Santa Barbara on June 30, 2015
Requests for reprints should be addressed to: Dr W. M. Dixon, John Lewis & Co., Ltd., 4, Old Cavendish Street, London W1A 1EX.
