Conversation with Bruce Ritson
In this occasional series we record the views and personal experience of people who have especially contributed to the evolution of ideas in the journal's field of interest. Dr Bruce Ritson was formerly Consultant Psychiatrist at the Royal Edinburgh Hospital and Senior Lecturer at Edinburgh University. He currently chairs the medical campaign group, Scottish Health Action on Alcohol Problems (SHAAP), which is hosted by the Royal College of Physicians of Edinburgh. He has had a long and fruitful research career.
Addiction (A): Can I take you back to your medical undergraduate studies in Edinburgh in the late 1950s and early 1960s? Did you know at that point that many years later you would be immersed in a field around alcohol studies?
Bruce Ritson (BR): Not at all. I was born in Elgin close by the territory of the Speyside malts. My father joined the army at that time, and we moved around a great deal before returning to Scotland and settling in Edinburgh; there were many breweries in the city at that time—the aroma of brewing drifting across the city was a daily occurrence, but I don't think that was a significant influence. However, early in my undergraduate years I remember thinking I would like to be a psychiatrist. I suppose I ought to have discovered why by now, but I was quite drawn to it. I think I was drawn to a subject where there were many unanswered questions. I believed, misguidedly, that other specialities were more clear-cut, with right and wrong answers.
A: Who were your teachers of psychiatry?
BR: At that time Alexander Kennedy, who was a Professor of Psychiatry in Edinburgh. He was a brilliant lecturer, a charismatic figure. I remember he would get students up on stage and hypnotize them and demonstrate the powers of hypnotism; I did not volunteer. He was a most interesting man; he had a special interest in techniques of brain washing—larger than life in many ways. A little after that there was Morris Carstairs, who was particularly interested in social psychiatry and anthropology and inspired an interest in a cultural perspective on mental health. He was the Reith Lecturer in 1962: the topic was ‘This island now’, a view of the impact of social change in the United Kingdom. He had a big effect on me at that time.
A: Did he teach you one-to-one or in small groups?
BR: Large lectures and small groups and, of course, when I became more seriously involved in psychiatry, one-to-one.
A: So there were significant figures teaching you psychiatry. Other than this and the challenge of unsolved questions, was there anything else that attracted you to the subject?
BR: I was interested in how the mind worked.
A: Was there much teaching in your undergraduate course on alcohol problems? Was it seen at that point as an emerging issue?
BR: There was one memorable lecture from Professor Kennedy on ‘Alcoholism’ and drug addiction. It was really not such an issue at that time. We learned about dependency and the risks of prescribing more within therapeutics and pharmacology.
A: So you graduated MB ChB and stayed in Edinburgh at that stage?
BR: Yes, I undertook some general medicine and surgery. One of these jobs was in a ward where people who had taken overdoses came in for medical treatment, and that was interesting. I think that possibly began to influence me in a rather more specific way—not in addictions, but in psychiatry. I was interested in the circumstances that drove individuals to such desperate measures.
A: Was overdose as a form of deliberate self-harm as regular a phenomenon then as it is now?
BR: I don't think so, but it was pretty frequent and never a night would pass without cases coming in, very often drunk as well.
A: Nothing changes. So, within that job were you starting to think further about psychiatry?
BR: It is hard to know whether I was drawn to doing that particular job because I was already thinking I would like to try psychiatry, but it strengthened my view that I would like to do that.
A: Your first psychiatric post?
BR: That was in the Royal Edinburgh Hospital in general psychiatry. Morris Carstairs was there at that time, as was Frank Fish, who had a deep understanding of phenomenology and German schools of psychiatry.
A: Some famous names in there.
BR: I worked with Ian Oswald for a time. He was interested in the effects of various drugs on sleep. I was a guinea pig for him, taking substances and sleeping, or trying to sleep, wired up in the laboratory to determine their effects on sleep patterns.
A: Were there any opportunities at that time in the world of addictions? Had it established itself?
BR: I don't think it had established itself, really. There was no specific service at that time. The Nuffield Provincial Hospitals Trust in 1963 enabled Edinburgh to establish a unit for the treatment of alcoholism under the leadership of Henry Walton.
A: I see here you wrote an article in a nursing journal on setting up a specialized alcohol unit.
BR: Yes, that's right. The unit had already been established as an out-patient service and, like many creative and innovative projects, it started in a hut next to the hospital. The role of sheds in scientific endeavour would make an interesting study. By the time I arrived the clinic had moved into a new building attached to the main hospital and had become an in-patient unit.
A: What was it called then?
BR: It was called the Unit for Treatment of Alcoholism, and was part of the academic department.
A: Right—quite bold and frank.
BR: Henry Walton was the consultant. It was quite a small team, but from the start it was a team of nurses, social workers, occupational therapists. I was very pleased to rotate there. It was a new service with excellent teaching, particularly in group therapy. At that stage I think that was my main interest, but it was then that my fascination with alcohol-related problems really started. That's how I first got exposed to it. While I was there, I got a research grant and that enabled me to stay on for another year there and do an evaluation study : the first of many which, looking back on it was fairly basic. I followed a cohort of 100 patients, half of whom had been in-patients and half out-patients for a year. I learned a great deal from those patients—first the transformation to the sober self and then the struggle to maintain that state in the face of external as well as internal pressures. They were interesting people who recovered and you saw someone coming alive again, and that was nice. I know many relapsed again afterwards, but you would get this sense of a huge change in someone. The follow-up study also showed me that many patients had lost contact, but it was not necessarily because they had relapsed catastrophically . For some it was because they felt better and believed they did not need to come back, but they and their families agreed that the decision to seek help had been a turning-point.
A: So it gave you a more positive view.
BR: Yes, because you could gain a very negative view if you simply sit in a casualty department and watch the same few people coming round and round.
A: Given that the Unit for the Treatment of Alcoholism pre-dated the concept of the alcohol dependence syndrome, were these people all alcohol-dependent, or was there a range? Were there people who we now talk about having a harmful alcohol use?
BR: Looking back, I think most of them were alcohol-dependent and most were severely dependent. It is interesting when you say ‘alcoholism’ and, in a way, it is a word I rarely use now. A strongly held view at that time was that people who were alcoholic had become so because of some underlying psychological problem. The emphasis—and this is what attracted me in the first place—was on finding out what the psychodynamics of their particular addiction were and then trying to help, usually with group psychotherapy and sometimes with individual psychotherapy or couple therapy. The focus was on finding an underlying psychic cause, which I do not think I would really go along with now. Sometimes there is an underlying cause, but often it is the outcome of chronic exposure to excessive drinking and the psychological harm is secondary.
‘It is interesting when you say ‘alcoholism’ and, in a way, it is a word I rarely use now.’
A: Yes, but there is an argument that when drug and alcohol dependence is rarer in society, that people dependent on alcohol and drugs at that point in time are more likely to be deviated from the norm in terms of personality.
BR: Certainly the population was drinking less then, although per capita consumption was beginning to rise.
A: Do you think in the last few decades, as the alcohol problems grew, that alcohol misuse becomes more normalized? That maybe there was a trend for less deviant, for the want of a better word, people to be in that category?
BR: Absolutely, I think that became very clear.
A: So, we are still in the period when you were completing your basic and higher training in psychiatry. In those years you are getting a grounding in research methodology. Can you tell me more about the research training available?
BR: Well—you say ‘getting a grounding’. I learned research by doing it and by discussing it with other researchers, and when I look back on it I think that research training should have been more structured. There was not as much training in research methodology as one might like to have seen, as I think there is now. However, there were experienced research workers in the department who were very happy to advise, but you do not always know that you do not know something. I am still not sure that there is much addiction research training, and there are very few centres that provide a training opportunity.
EXPERIENCE IN THE UNITED STATES
A: I see that at quite an early stage you have a trip to the United States for a whole year, to Harvard Medical School.
BR: That was a formative experience for me. With the help of Morris Carstairs and a scholarship I was able to spend a year at the Laboratory of Community Psychiatry at Harvard Medical School. The leader of the programme was Gerald Caplan. The students came from all around the world and the focus was upon community mental health, a field in its infancy at that time. It was concerned with the dynamics of decision making and dealing with stress in communities and organizations by providing consultation to workers at all levels, with the aim of improving their capacity to deal effectively with their clients. For me, it strengthened my interest in social psychiatry and the importance of political and economic factors in mental health.
One of its founding ideas was the value of crisis intervention and the importance of helping people get through crises by working not directly with them, but with the agencies in the front line. Looking back on the community mental health movement at that time I think it achieved a great deal but suffered from a lack of evaluation. It also failed to address the needs of the individuals with severe mental illness, and in that respect was very different from community psychiatry in the United Kingdom, which at that time emphasized rehabilitation and support for seriously ill patients.
A: Was this more dealing with the ‘worried well’ than with mental illness, more with people with social problems rather than psychiatric? Did issues around addiction figure in this work?
BR: I have always disliked the phrase ‘worried well’. I feel we should not confine psychiatry to the seriously mentally ill. I think the ‘worried well’ deserve help, and I think psychiatrists have a lot to offer. It was not an issue then, but looking back I think your question is very appropriate. It probably did deal more with minor morbidity, although many of the people we worked with in the agencies were themselves working with people who had very serious mental illnesses and addictions, although the latter were not as frequent.
A: Not at that point in the United States with the emerging ‘hippy’ movement?
BR: That came just a little later for me. Yes, you're right, after I had worked at Boston I then had a time in California, working in a community mental health centre where there were quite a lot of psychotic people and, of course, the hippy culture and the drug scene was very alive.
A: Where in California?
BR: The Haight Ashbury district of San Francisco was famous for its drug scene then; but I was rather further away in a town called Davis, working in a community mental health service. None the less, we saw many people with what were probably drug-induced illnesses.
BR: Yes, and LSD (lysergic acid diethylamide) was popular. Drug use was particularly common: a rather fashionable thing to be involved in. Timothy Leary and people like that were prominent and people were reading all the books, as I was. It was an interesting time. I do not think it was impinging a whole lot on everyday practice, except occasionally there were emergencies of people going psychotic, but philosophically drugs to alter consciousness were talking-points.
A: In that decade, when you were at medical school and during initial psychiatric training, there was a vogue for some psychiatrists to use drugs such as LSD in the clinical setting. Did you come across that at all?
BR: Yes, I came across patients who had been given LSD therapeutically.
A: What was your sense of this treatment modality? Some people these days still argue for either ecstasy or LSD to be available for psychotherapy.
BR: I do not think I would argue for that. Like many things, I do not think it was evaluated properly. Some patients reflected that it had afforded them valuable insights into their unconscious mind. I have spoken to patients who felt very much the better after it saying ‘it really opened them up’. Others felt very little, but I did not see anybody harmed by it in a clinical sense.
A: Anyway, to summarize, the trip to Boston and California was very useful in seeing different systems and gaining new ideas.
BR: Another thing I should say is that as a student at Harvard and to a certain extent in Edinburgh, we were taught a lot of sociology which was a significant part of psychiatric training at that time, and now it has virtually vanished. It stayed with me as an important influence.
‘. . . as a student at Harvard and to a certain extent in Edinburgh, we were taught a lot of sociology which was a significant part of psychiatric training at that time, and now it has virtually vanished.’
A: Famously, the 1960s is the era of so-called ‘anti-psychiatry’, and figures such as R. D. Laing and others came to prominence with social experiments such as that at Kingsley Hall. How did that feature in your training?
BR: Laing's work was more influential at the time in philosophy and art than in psychiatry, although he encouraged the clinician to pay attention to what the psychotic individual was communicating which, in a sense, was already good practice. I think it was unfortunate that he made very many parents feel responsible for their children's illnesses, which did a great deal of harm. He was also against many forms of medication, which exacerbated much suffering. At that time I think among the ‘anti-psychiatrists’ Erving Goffman and Thomas Szasz were a much greater influence.
A: It sounds you were in a period where the biological dimension in psychiatry was being played down.
BR: I think that is very true.
FIRST CONSULTANT POST
A: So, in July 1968, a famous year in many ways, you return to the United Kingdom. You are soon to be in your first consultant's post that was an addictions-related job. Can you tell me about that?
BR: Yes. It was in England, which was new to me and it was in Nottingham. It was in one of, by now, a number of specialized regional addiction units. It served a large region and was based in Mapperley Hospital. The psychiatric service was very well known for community mental health in the British model. Community outreach for severely ill patients was being introduced. Home visits were commonplace and there were strong links with social work services. It was a very interesting time in Nottingham, because the new Medical School was just coming into being, and a lot was happening. It was relatively easy to attract resources at that stage. I think one of the things about working there was that it gave me a kind of independence. The other thing was that they had an absolutely brilliant probation service, and I worked very closely with some very talented probation officers. It certainly showed me what social work—when it was competent and well established—could really do. In that unit there were people with drug- and alcohol-related problems. It was the first time I had worked with drug addicts, who were becoming much more common.
A: Were you a full-time addiction consultant?
BR: No, I had responsibility for some general psychiatry. It was probably about 80% addictions.
A: So, here you are—a consultant, mainly in addictions. Did you feel equipped at that point to be suddenly dealing with the drug addicts in the unit? Was this a kind of baptism of fire?
BR: I suppose it was. I learned quite a lot from colleagues in other parts of England, and that was one of the things the addiction faculty of the college in later days began to develop. I learned ‘on the job’, as they say.
Only the extreme end of the spectrum of illicit drug misuse came to the clinic: mainly opiate dependence and psychotic reactions to hallucinogens and stimulants. Almost all the drug addicts were young but came from all social backgrounds.
A: What did treatment involve for addiction then?
BR: Well, I suppose influenced by prior experience and by talking to colleagues, it was largely withdrawal from whatever drug one was dependent on, mainly alcohol or opiates. After that, treatment was group work and then out-patient follow-up, often involving the family and social workers. I worked a lot with social workers, not just probation. It was, I suppose, partly social engineering, trying to get them re-established in some satisfying way of life away from the drug scene. Drug treatments did not figure greatly in the longer term. Some patients benefited from antidepressants. Patients who were alcohol-dependent were often prescribed disulfiram (Antabuse).
A: You mentioned colleagues helping, but perhaps not a good network of addiction specialists?
BR: Not really, but I could see a beginning. It was not huge. I was involved with the Alcohol Education Centre. D. L. Davies was a psychiatrist at the Maudsley Hospital and had the vision to see the importance of research and education for the development of this relatively neglected subject. He appointed Marcus Grant to direct the centre, which played a crucial role in training professionals and disseminating new knowledge. I participated in many of their courses.
A: Were you aware of the work of Griffith Edwards?
BR: Very much so. In fact, I was already aware of him even when I was doing my research with Henry Walton. I visited Griffith. I was very impressed with him. We had a great deal in common, as we both had an interest in an epidemiological perspective. The thing that struck me, quite apart from his obvious ability, was the fact that he had a team of researchers, quite an established team, and I was very envious of that.
A: No National Addiction Centre?
BR: No, but you could see it coming.
A: Were you able to do much research yourself in Nottingham?
BR: We conducted some follow-up studies. I was interested in finding out how drug addicts fared in an in-patient setting, which catered predominantly for alcoholics. I was always a little doubtful about treating the two groups in the same unit. First of all there was a big age difference—I suppose like fathers and sons—and this was the predominant theme. I felt that both parties lost out by not being able to look at separate issues.
A: So, separation of these groups would be best?
BR: Perhaps. There was, of course, individual therapy, but most activities were based on the group acting as a ‘Therapeutic Community’. This was a very strong influence at that time throughout psychiatric practice. I saw much of that through Maxwell Jones at Dingleton Hospital in the Scottish Borders. I visited quite a few Therapeutic Communities in Holland, and in the United States Therapeutic Communities were very popular, particularly with drug addicts.
A: Was there any Alcoholics Anonymous or Narcotics Anonymous influence?
BR: I saw them as a resource, and I would still say that they are a very important resource, but we did not bring them in as part of the treatment.
RETURN TO EDINBURGH
A: You were three years in Nottingham and then you went back to Edinburgh. A post became available?
BR: Yes, working as a general psychiatrist serving one of the sectors of the city with an in-patient ward attached to it and a little bit of learning disability as well. Many of the consultants had sessions in learning disability. I thought that it was a good idea to try to re-frame the services for people with a learning disability, so I did that for about 10 years. I remained interested in alcohol-related problems. I was chairman of Edinburgh and Lothian Council on Alcohol and conducted a research project with Cairns Aitken and John Hamilton evaluating the feasibility of decriminalizing habitual drunken offenders, which was a big issue at that time. Offenders were offered detoxification in a small ward in hospital as an alternative to imprisonment. The outcome  showed that it was perfectly possible and more humane to help habitual drunken offenders outside the criminal justice system. That led to quite a longer period of work with the Council on Alcohol in Edinburgh, social work, the police and other agencies in planning a detoxification centre for habitual drunken offenders. This was a long and, in the end, a rather sorry tale of providing what, I still think, was a very good model for Edinburgh but never getting enough support to establish it. Centres were established successfully in a few other places. A lot of planning went into that, and I think some of the plans could be taken off the shelf, even now, and implemented. I learned then that cooperation and planning among professionals could be very fruitful until it came to hard cash and allocating resources.
‘Offenders were offered detoxification in a small ward in hospital as an alternative to imprisonment. The outcome showed that it was perfectly possible and more humane to help habitual drunken offenders outside the criminal justice system.’
A: I wonder about compulsion. Could you compel people who were not that motivated into actually doing quite well through intervention?
BR: Very hard to know, the way the research was structured. There was not really much element of compulsion in it, except you were being processed through the health care and social work system. I suppose the habitual drunken offender could have said ‘no, I'd rather go to prison’. No one did. Of course, relapse was common and what was really necessary was a better range of facilities for the individuals to move on into. There was the Grassmarket Project, which was run by social work—very innovative in many ways—and it had hostels, but there would always come a moment when this man—it was usually a man—would have to re-enter the community on his own. That was the time when I think most support was needed; that transition was really hard, and I think it is still really hard. Latterly we engaged an occupational therapist to work with the homeless and help them develop skills in catering for themselves and budgeting. These basic skills are important for recovery.
So, during those 10 years of general psychiatry I was keeping up the alcohol interest—on a sort of voluntary basis—but it was an interesting time.
A: Ten years later—what happens then?
BR: The consultant who had worked for many years running the unit for treatment of alcoholism, for whatever reasons, thought he would like a move to general psychiatry. We simply had a chat about it with the physician superintendent, who was a wise man; he said, ‘Okay’, so we did a swap. It is hard to imagine such an easy transition now.
A: Did you then become full time in addiction psychiatry?
BR: No, I still kept some sessions in general psychiatry and learning disability as well as work at the alcohol clinic. When I inherited it, it was called the Unit for the Treatment of Alcohol but fairly soon after we changed the name to the Alcohol Problems Clinic (APC).
A: You say ‘we’. Did you have a colleague at that stage?
BR:‘We’ refers to the whole team and the change of name was a joint decision. I was sole consultant for some years before Jonathan Chick joined me; that was a great help. That was the only change of name until after I retired, when it became the Alcohol Problem Service, with the in-patient part very generously re-named the Ritson Unit.
A: Was the APC solely an in-patient unit?
BR: In-patient and out-patient plus a little outreach: the rudiments of a community alcohol team that grew over the years. We worked closely with the Council on Alcohol and with social workers in the area. Of course, in those days we had two social workers as part of the team. They were eventually absorbed into the community teams, with a loss of experience and, I believe, quality of service to families.
A: Did the unit undertake detoxification?
BR: Yes, it was detoxification initially as a prelude to group treatment. We were still much in the group therapy mode, certainly for in-patients and then, commonly, out-patient group follow-up. I wrote about our unit in the British Journal of Addiction (now Addiction).
A: During this 20-year period in addictions, how would you characterize the trends in treatment?
BR: Looking at it from Edinburgh, I think the trend was increasing emphasis on out-patient treatment, and then on community outreach with community nurses. We always kept the in-patient service and the in-patient unit began to be a detoxification unit for some, although most people detoxified at home. Some then stayed for an in-patient group programme lasting up to 3 weeks. In recent years we have had more day patients, and now there is a day patient unit where group work and follow-up continues. The content of therapy has moved from predominantly psychodynamic to more cognitive–behavioural approaches. I have always worried about matching: how we can tailor the treatment to meet the needs of the individual. Despite many attempts, research has not shed much light on this.
The changed emphasis was influenced by an evaluation study Jonathan and I conducted . We studied the influence of intensity of treatment on outcome and found that for some there were advantages of intensity in terms of subsequent service utilization, but many progressed well with less input. Interestingly, shortly before I ended my time there, and I understand it is more so now, more very physically damaged patients were being referred, reinforcing the need to retain an in-patient unit.
A: Patients with liver disease?
BR: Liver disease, brain damage and poor nutrition. The other thing we began to do was outreach into other hospitals. Jonathan had completed a well-known study looking at brief intervention in the general hospital. We also provided a service to the psychiatric hospital itself, where we had training programmes for staff within the psychiatric hospital to improve detection rates and provide brief intervention.
A: That is fascinating, because often the psychiatric part becomes neglected. I get the impression of a busy clinical unit with a strong research ethos that was also acting as an important training facility.
BR: Looking back, I would like to have had the opportunity to make it more of a research institute, because I think we had the opportunity to train more research workers.
A: Talking about research I am very aware that Martin and Moira Plant were around in Edinburgh. What was your link with them?
BR: I worked very closely with them. Moira was the charge nurse at the unit when I came to it. Martin worked with Norman Kreitman in the Medical Research Council (MRC) epidemiology unit and then subsequently set up his own unit that Moira joined. The experience of social research going on at the same time as clinical work was invaluable.
A: Right, well thanks for summarizing the core clinical job as such. Your CV reveals many interests beyond that, many not in the addictions world but many related to alcohol and addiction studies. So, can we talk about training and your involvement with the Medical Council on Alcohol (MCA)?
BR: The MCA has been important for me; it was a meeting place for clinicians working with alcohol problems and it has promoted education for undergraduate and postgraduate doctors. It has also played an important part in raising medical and public awareness of alcohol and health. I have enjoyed writing the handbook for students and other practitioners with Marsha Morgan. It has proved very popular, and we have just completed a new edition . I still do not think there are enough training posts in research in addictions, although the Alcohol Education and Research Council (AERC), with which I was involved for some time, tried to do something in that respect by providing support for people doing a PhD in alcohol studies. I am pleased there are more Chairs in addiction studies being created, because that was virtually unknown previously.
A: There is also the Royal College of Psychiatrists. You were involved with the Faculty of Substance Misuse and you chaired this at one point. I think most interestingly at that point, you were part of a campaign—if that is the right word—to try to have a separate specialist accreditation for addictions. What's your view on this now?
BR: Well, I am still in favour of it. When I was chairman it was quite a struggle to get a faculty established. There was quite a lot of opposition from colleagues in general psychiatry. We managed to move it from a section to a faculty and I think that was important. I can see that there are arguments saying you do not want to split off from mainstream psychiatry, but I think that anxiety was misplaced, and we have so many topics that are unique to our speciality which are otherwise overlooked. Of course, this may reflect the way different people think of psychiatry—something we talked about earlier. We have always had to take a broader perspective given the cultural, economic and political factors that impinge so crucially on our patients. It is interesting that neurobiological and genetic studies are now making important discoveries for our field that are already influencing treatment and our view of dependence. One major achievement by the college was producing Alcohol Our Favourite Drug, in 1986  which was a follow up to a college report published in 1979. I was chairman of a very strong team of authors. It was hugely influential and caused many people to think about alcohol as a ‘drug’ for the first time. Other medical groups produced similar reports just after that. I think this reflected a growing awareness that alcohol problems were getting out of hand.
‘When I was chairman it was quite a struggle to get a faculty established. There was quite a lot of opposition from colleagues in general psychiatry.’
A: Very much one success and one relative failure in the training sphere—the faculty was established but the specialist training accreditation never went through. It strikes me that in many places addiction services have become more separated, possibly more in England than in Scotland. Do you see a case for addictions breaking the tie with psychiatry, or would that be a step too far?
BR: I am sure it is worth exploring. After all, general medicine, primary care and public health, for example, have a great deal of involvement with alcohol and drugs dependence. Perhaps just as much as psychiatry, some would say. There might be a case for combining all these into a medical addiction speciality. When I worked in Australia with David Hawks, the Alcohol and Drug Authority had recently been established separately from other elements of health care, and seemed to work well.
A: You also had some involvement with the World Health Organization (WHO).
BR: Yes, in many different roles and places. Joy Moser at WHO was a key figure in raising awareness of the global challenge presented by alcohol use, particularly in developing countries. I was involved in the International Community Response to Alcohol Problems Project , which took place across three continents in Mexico, Zambia and Scotland. Using research tools that were essentially similar, we surveyed the drinking habits and problems in each location, and then found out how these problems were construed and managed. I think one of the great strengths in that study was a genuine attempt to use, as closely as possible, similar instruments in very different settings. I think what one learned from it was that there are big differences, particularly over the nature of services. Listening to the problem drinkers in these countries, however, there were more similarities than differences. The wife of a Zambian drinker was worried about his drinking in much the same way as the wife of a Scottish drinker. Different organizations played more prominent roles in each country: for instance, the Church in Mexico, native healers in Zambia and general practitioners in Scotland. The Edinburgh arm of the study provided a baseline for a repeat study, where we were able to demonstrate that after a significant increase on tax on alcohol, heavy drinkers reduced their consumption even more than moderate drinkers in response to such price increases . I was then asked to coordinate a somewhat similar study in the WHO European region. Many more countries were involved, but with very little core funding. In consequence it was less tightly designed. Some collaborators used their own resources and virtually repeated the earlier study, whereas others took a more qualitative approach. We learned a great deal from each other and were able to raise awareness of the problem, facilitate the development of a research base in places where little existed, and encourage a coordinated response at local levels. Many examples of good practice came from this work , and I would love to have the opportunity of finding out how these have progressed over the years. One thing that struck me listening to some of the agencies, particularly some of the senior politicians, was how firmly rooted in everyone's mind was the ‘alcoholic’. You could go and talk about hazardous drinking and alcohol-related problems but in their mind it was the image of the alcoholic. Scotland was the same then but I see a change now, and politicians have a much broader view of the effects of drinking, and hence preventive strategies.
A: Did you gain an impression of the widely reported difference between northern and southern European patterns of drinking?
BR: Yes the distinction between northern and southern Europe was evident, but influenced strongly by economic factors, age, gender and availability. Big changes have occurred, however, in recent years, with urbanization and the prominence of a drinking youth culture.
A: Moving on, one theme throughout your career, shown in the books and articles you have written, is an eye on the bigger picture, seeing the epidemic growing and the importance of prevention and alcohol policies. We are in a very interesting situation now in Scotland, where you chair Scottish Health Action on Alcohol Problems (SHAAP), and also the Scottish Intercollegiate Group on Alcohol (SIGA). We do seem to have channels into a Scottish Government that I hope is seriously minded about tackling the alcohol problems. Can you perhaps try to talk around that whole theme over the last few decades?
BR: One of the things that has happened in Scotland in the last 10 years or so is the willingness of the medical profession to unite to tackle this problem: general practice, surgery, physicians, psychiatrists, paediatricians, public health clinicians and so on, all recognizing the damage alcohol is causing. SIGA was formed to reflect this.
First of all, our concern was to make sure that doctors were properly trained. The evidence that brief interventions and motivational interviewing, particularly in primary care, can be effective makes it essential that doctors and nurses in primary care and in hospitals know how to recognize harmful and hazardous drinking and respond appropriately. Secondly, we drew attention to Scotland's appalling record in deaths from liver disease. The Scottish government was responsive to our concerns and gave SIGA a grant to conduct a scoping study to examine the need for a medical advocacy group that would draw attention to this problem, and promote evidence-based preventive strategies. Following positive recognition that such a group was needed we formed SHAAP, which proceeded to advocate measures that were likely to reduce the ever-growing burden of alcohol-related harm in Scotland. Books such as Alcohol No Ordinary Commodity and before that Tackling Alcohol Together—to which I contributed—set out what can be done in the United Kingdom, based upon sound evidence. These and other reports demonstrated the need to act together and make sure that the public and politicians have a clear understanding of the problem and the action required to tackle it. Scotland having its own government has been helpful; we now have much more Scottish data and much easier access to decision making. Certainly, the present government recognizes (who could not?) that alcohol is causing huge harm to Scotland, particularly in areas of deprivation, of which we have many. The government has been encouraged by the success of the measures to ban smoking in public places that they championed before England. This may have helped leaders to see that public health measures can prove to be politically popular, as well as effective. Health has a specific mention as one of the pillars of the Licensing Act introduced this year in Scotland. Minimum unit pricing is something SHAAP also advocates, and we have prepared evidence about its probable benefits. The present government is keen to introduce this, but has to convince other parties to set aside political considerations and support it.
A: It is an exciting time, as you say.
BR: And it is good to see doctors from different specialties working together; that has been cheering.
A: A slightly mischievous question—I missed the recent conference you helped to organize in Edinburgh—the Royal Society Conference. Do you think it has finally been proven that the Scots drink more than the English?
BR: Yes and no. It is clear that some other parts of the United Kingdom have comparable drinking habits. Even within Scotland there is a great deal of variation. We have a disproportionate number of areas of severe social deprivation, which have a particularly high toll of alcohol-related morbidity. Interestingly, sales data suggest a much greater gulf between Scots and English consumption levels than is evident from survey responses.
A: There is one final area to discuss—your involvement as a medical adviser to the Driver and Vehicle Licensing Agency (DVLA). What are your thoughts on the legal limit for alcohol for driving and other measures?
BR: I was Chairman of the Alcohol and Drugs Advisory Committee for some years. We dealt with many individual cases, but we also advised on policy issues. Speaking personally, I think we should have lowered the limit and come into line with almost all the other countries in western Europe. I hope that change will be made soon.
A: Can you tell me about your many interests outside the medical field?
BR: One interest that is not totally unrelated has been a concern about the damaging effects of ‘total institutions’. This, along with a belief that none of us is all good or all bad, brought me to an interest in criminal justice and penal reform. I was chairman of the Scottish Howard League for penal reform for many years, and remain a member of the Scottish Consortium on Crime and Criminal Justice.
I have a belief that the quality of the environment in institutions of all kinds is important for residents, staff and visitors. It is an important measure of a civilized concern for others and ourselves. This has led me to become Chairman of ‘Art in Healthcare’, which is a charity that provides artworks for health care settings and encourages contemporary artists to provide works for this field. I have also been a very amateur painter for a number of years, which has certainly helped me to appreciate the skill of artists.
‘I have a belief that the quality of the environment in institutions of all kinds is important for residents, staff and visitors. It is an important measure of a civilized concern for others and ourselves.’
I continue to play rather geriatric squash regularly and enjoy hill-walking when time allows.
A: If you had your career over again, do you think you would be where you are today? I get the impression that you have been happy with the direction your career took.
BR: Yes, I have found it very stimulating and enjoyable. The patients I have worked with are often very dejected and rejected, and it is great to see them regaining control over their lives. So much more could be done to help them by providing prompt assessment and treatment. As a discipline, addiction studies is wonderfully varied, encompassing many different sciences including clinical medicine, psychology, social science, public health, politics, economics, genetics and neurobiology. I have always felt it important to avoid being drawn into entrenched positions of political or clinical certainties or becoming overwhelmed by deadening bureaucracy. There was always scope to move to another area of interest, plenty of ambiguity that I enjoy.