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Occup. Med. Vol. 50, No. 5, pp. 289-293, 2000
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IN-DEPTH REVIEW Occupational mental health: a brief

history
A. Fingret
Finsbury Circus Medical Centre, London, UK

This paper describes the development of occupational mental health in the United
Kingdom. It looks at the increasing involvement of occupational health staff in this
aspect of the workplace and the role played by organizational psychologists in
exploring the relationship between work and mental well-being. It provides a
background for the reviews of current knowledge described in the other papers in this
issue of Occupational Medicine.

Key words: History; occupational medicine; occupational mental health; stress.

Occup. Med. Vol. 50, 289-293, 2000

INTRODUCTION Medical Officers was founded in 1935. By 1967 it was

clear that there was a change in the nature of the
In this issue of Occupational Medicine, papers by leading workplace and the Association became the Society of
psychologists working in the field of occupational mental Occupational Medicine. This change reflected the
health have been gathered together by Briner and changed emphasis of the medical officers' work, which
Fingret. Each of them has reviewed published research had been concerned originally with the diseases arising
material to indicate the current position and has from industrial processes but now covered all types of
suggested further research that is needed to clarify the work. Further changes of emphasis have been in
relationship between work and mental health. It seemed response to increasing employment in the service sector
appropriate to preface these papers with a brief, and and scaling down of the manufacturing base. More
probably idiosyncratic, history of occupational mental recent changes in the nature of work, such as the
health, highlighting the developments in relation to increased employment of women, new technology and
occupational medicine. In the UK, the origins of the enterprise culture, appear to have resulted in a huge
occupational medicine lie in The Effects of Arts, Trades, increase and interest in, and incidence of, occupational
and Professions on Health and Longevity, a seminal work stress.
written by Charles Turner Thackrah1 in 1831 describing Occupational physicians first began to demonstrate an
the damaging physical results of work. The first interest interest in the psychological aspects of work in the 1960s.
in the psychological effects of work arose from the work An informal group of occupational health physicians,
of the Health of Munition Workers Committee, set up in psychiatrists and psychologists, which became known as
1915, which recognized that there was a reduction in the the Occupational Mental Health Discussion Group, met
performance of fatigued workers who worked increas- in London (and later in Manchester). Psychiatrists such
ingly long hours. These findings resulted in the establish- as Roger Tredgold and Alexis Brook, and psychologists
ment of the Industrial Fatigue Board in 1918. This board such as Donald Broadbent and Harold Bridger, led the
was asked to look at the relationship of hours and way in relating psychiatric morbidity to work events,
methods of work to the development of fatigue, helping a small group of occupational physicians to
efficiency and workers' health. develop this aspect of their work. Cary Cooper from the
Doctors began to work in the industrial setting at this University of Manchester Institute of Technology and
time to assess eligibility for worker's compensation. They Richard Buzzard from the National Institute of Psychol-
were not well regarded by the workers, who saw them as ogy were also of considerable influence on these groups.
a tool of management. Recognizing the need for International contacts were made, both in Europe, where
standards and best practice among doctors working in Lennart Levi was active in the Karolinian Institute, and
the industrial setting, the Association of Industrial in the United States with Alan McLean and Robert
Kahn. Each of these has written extensively on the
subject of psychology in the workplace. In 1966 the
International Committee on Occupational Mental
Correspondence to: A. Fingret, Finsbury Circus Medical Centre, 5 London Health-now the International Forum on Organizational
Wall Buildings, Finsbury Circus, London EC2M 5NS, UK. Tel: +44 (0)207
638 0909; fax: +44 (0)207 638 9211; e-mail: afingret@fcmc.co.uk Health-was formed. At the start the British Discussion

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 290 Occup. Med. Vol. 50, 2000

Group was the core of the organization, with involve- researchers in the field have largely concentrated on the
ment from many European countries and the United negative rather than the salubrious effects of work.
States. The first major meeting of this group was in Unable to decide whether 'stress' was a cause or an effect
Windsor in 1970. The report of the proceedings of this Selye suggested using 'stressor' as the cause and 'stress'
conference edited by Kearns2 is the first publication by as the effect. This is now the generally accepted
an occupational physician that I can find on this subject. terminology. Lazarus6 introduced the concept of indivi-
Since the 1970s the work of occupational health dual variability in response to stressors, emphasizing the
personnel has become increasingly concerned with the role of cognitive appraisal and motivation and moving
psychological aspects of work. In Miller's questionnaire away from the purely physiological effects. Lader7
survey3 of doctors who form the Faculty of Occupational suggested that stress occurs when stimulation raises the
Medicine the most frequently encountered psychological activity of the organism more rapidly than adaptation can
problems in their practices were anxiety/depression lower it. Lazarus8 refined this further by suggesting that
(73%) and stress (56%). Although it is clear that the stress will arise when there is an imbalance between the
psychological aspects of work now form a significant part perceived demands and the perceived response capabil-
of the occupational health role this is not reflected in ity, the negative effects being enhanced if the con-
examination syllabuses for doctors, where perhaps 90% sequences of failure are perceived to be severe. Both
is concerned with physical hazards and legislation. The authors emphasized the importance of the individual's
current edition of Hunters Diseases of Occupations has no cognitive processes in determining the effects of pres-
section on psychological hazards. sure. This work was largely in the context of the
A survey for the CBI in 1996 showed just how much individual's total environment, but soon researchers
interest there was in the psychological aspects of work. developed these ideas in relation to the work environ-
Ninety-eight per cent of the companies considered that ment. Cox identified four aspects of the indivi-
the mental health of employees should be a company dual's transaction with the work environment:
concern. Eighty-one per cent believed that there should
be a company policy on the subject but only 20% actually • the demands on them,
had a policy. Undoubtedly there has been renewed • the constraints under which they have to cope,
interest as claims for stress-induced illness are mounting. • the support they receive from others in coping,
It would be interesting to know how many companies • their personal characteristics and coping resources.
now have a policy.
There has been a significant change in the approach to
mental health issues by occupational health physicians. At PSYCHOSOCIAL HAZARDS OF WORK
first their focus was on the individual in trouble, then on
ways of helping the individual to survive in the environ- Just as there has been confusion about the terminology
ment. They have now widened their focus to consider the for the effects of psychological pressure in the workplace
psychosocial hazards in the work environment, with a view there continue to be many terms used to describe these
to reducing the risks from these. This approach to pressures. Different authors use the terms: stressor,
psychosocial hazards has been pioneered by Griffith et psychosocial hazard, pressure, and the even more
a/.4 in line with the established model for controlling the confusing, stress. The author has chosen to use the
risks from physical hazards in the workplace: more clearly descriptive 'psychosocial hazard'. The
search still continues to find models to explore the
1. identifying the hazard, relationship between psychosocial hazards at work and
2. assessing the risk, health outcomes. Both of these dimensions have proved
3. reducing the risk. difficult to define and even harder to prove a cause and
effect relationship.
Early research into potential health hazards looked at
HISTORY OF OCCUPATIONAL STRESS only those pressures produced by the physical working
environment, particularly environmental extremes.13
Understanding the causes and effects of 'stress' in the Attention shifted to factors in the design and organiza-
workplace has been bedevilled by semantic dilemmas. tion of work such as paced working and workload. There
There has been a singular lack of agreement on what the was an emphasis on physical health outcomes, particu-
term means. It is usual to start with the work of Hans larly the incidence of coronary heart disease (CHD),
Selye, in particular his book The Stress of Life5, although relating these back to the characteristics of the job and of
he himself was confused, using interchangeably the term the organization of the workplace, for example, compar-
'General Adaptation Syndrome' and 'Stress Syndrome'. ing the incidence of CHD in blue collar with white collar
He described this syndrome as consisting of triphasic workers.14'15 Hinkel,16 in a series of studies in the Bell
non-specific physiological changes in response to nox- Telephone Company, found no significant effect on
ious stimuli, leading ultimately to 'stress-related' dis- CHD events from type of work or frequent change. In an
eases. He established the concept of a nonspecific interesting study Theorell17 compared CHD patients
physiological response, but ignored the interactional with a matched group in the general population by using
aspects of the response. Although Selye emphasized that a schedule of recent experience. Significant differences
challenge can produce both positive and negative effects, in work pressures were shown between the CHD group

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 Fingret: Occupational mental health: a brief history 291

and the control group in terms of certain experienced effects, the concept of occupational mental health arose.
work pressures. These were: The term 'mental hygiene' was first used in the 1920s.
Gradually mental health began to be seen as a positive
• change to different kind of work, concept, not merely the absence of disease. Jahoda21
• major change in the work schedule, describes positive mental health as a synthesis of who the
• change in level of responsibility, person is, where he is and where he wishes to be. This
• trouble with boss, concept was related to the workplace by Kornhauser22
• trouble with colleagues. who defined mental health as comprising those beha-
viours, attitudes, perceptions and feelings that determine
It is interesting to note that retirement and unemploy- the worker's overall effectiveness. His study of workers in
ment also increased the risk of CHD. Similarly, Clark18 automotive plants in Detroit concluded that there were
in a compilation of ISSP data that assessed what was unfavourable effects associated with routine jobs com-
important to workers found that job security (59.3%) pared with more skilled and varied ones and with paced
and an interesting job (48.7%) were far more important working. However, he suggested that the reasons for this
than high income, which was reported as important in were possibly not directly related to the job activity but to
only 24.1%. the absence of goals and challenges, feelings of low
Certain characteristics of the work environment have status, and lack of opportunities for personal develop-
been given credibility as affecting well-being. Warr has ment. 'Mental health' is a misleading term in this context
summarized these as: as it is based entirely on the medical model health/illness.
It reflects the early involvement of the medical profession
• opportunity for personal control, in recognizing adverse outcomes from work events.
• opportunity for skill use, In recent years, with increasing interest from psychol-
• externally generated goals, ogists, the term 'well-being' has come into use. The
• variety, concept of job-specific well-being has been fully explored
• environmental clarity, by Warr23'24 who describes this as people's feelings about
• availability of money, themselves in relation to their work. He also includes
• physical security, features like positive self-regard, competence, aspiration,
• supportive supervision, autonomy and integrated functioning. Unfortunately this
• opportunity for interpersonal contact, adds a further stage to the conundrum.
• valued social position.
• Do psychological hazards at work affect well-being?
Warr points out that too much as well as too little of • Does reduced well-being affect health?
several of these factors may produce adverse effects. • Does reduced well-being affect performance?
Since 1979 thinking and research in this area has been • Does poor health affect performance?
dominated by Karasek's demand/control model. In this
model he proposes that psychological strain results from These issues are reviewed thoroughly in the papers by
the demands of the work environment and the discretion Briner (pp. 299-303) and Daniels (pp. 304-309) in
available to the worker in facing these demands. Much of this issue.
the ensuing research attempting to relate adverse health
outcomes to an imbalance between demand and control
has given contradictory findings as shown in Ganster's INDIVIDUAL FACTORS
review19 of the literature. The model has been criticized as
being too simple to describe the psychological work There has been considerable research into what attri-
environment and too general to be used in the workplace.20 butes of the individual may enhance or diminish the
Since the 1980s the effect of management gurus on effects of psychosocial hazards at work. Five personality
the current work scene has introduced a whole new characteristics are widely used to describe traits and
dimension to work performance and work pressures. typical behaviours:25
The enterprise culture has created core criteria for
acceptable work performance. Individuals are expected • extroversion,
to show total commitment to the organization's mission, • neuroticism,
not only in the day to day work but in discretionary • agreeableness,
activities which blur the margin between work life and • conscientiousness,
social life. These include extended hours of work, • openness to experience.
citizenship, and skills development. Once, such activities
were regarded as discretionary behaviours, but now Cox and Griffiths26 have summarized the individual's
workers are required to demonstrate commitment. It is coping resources under four headings:
obvious that this increases the pressure on individuals
and reduces their ability to achieve a healthy balance • energy,
between work and family life. • knowledge,
In parallel with the attempts to identify the psycho- • personality,
social hazards of work by measuring adverse health • skills.

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 292 Occup. Med. Vol. 50, 2000

Several areas of individual characteristics have been To this should be added:

identified as being significant to the experience of well-
being at work. The effect on behaviour at work of • audit of the psychological and physical work environ-
personality type A or type B, as described by Friedman ment.
and Rosenman,27 still has some adherents. However,
their original proposition that such behaviour is sig- Numerous stress measurement tools have been
nificantly related to the incidence of CHD has now developed, some of the best known of which are:
generally been discounted. Personality types have also
been used to maximize the person/job fit and to assist in • the General Health Questionnaire,37
team construction.28'29 There is evidence that the • the Stress Arousal Check List,38
personality traits 'positive affectivity' and 'negative • the Pressure Management Indicator.39
affectivity' influence the individual's response to their
environment. Elliot et a/.30 demonstrated that negative These are all validated questionnaires which have
affectivity is predictive of low job well-being. Additional been used in many different settings. Rick and Briner
factors mediating the response of any individual are other (pp. 310-314 in this issue) explore in depth the
environmental experiences both historical and current, problems of assessing damage to psychological health
general fitness, level of social support and the expecta- using such stress audit tools.
tions engendered by the prevailing discourse and
equivalent work. Silvester et a/.31 in a study of UK and
German engineers demonstrated clearly the significant INTERVENTION
differences in attribution which can occur in different
cultures. Smith (pp. 294-298 in this issue) appears to confirm
that at least 20% of the workforce perceive significant
stress arising from the workplace and that this is a
MEDICAL/PHYSIOLOGICAL EFFECTS growing problem. Their further research to look at the
influence of demographic factors, socio-economic posi-
There are many studies measuring physiological changes tion and the nature of the job should assist in the
in response to potentially stressful situations at work. At development of appropriate interventions.
first these were within laboratories but there are now The management of occupational mental health is an
many on-site measurements of physiological changes industry in itself. Four main types of intervention have
associated with particular workplaces.32'33 The question been developed:
arises, do these short-term physiological changes lead to
disease as suggested by Selye's General Adaptation • organizational,
Syndrome? As mentioned previously most of the initial • training the individual to recognize and manage
studies in this area attempted to define the relationship pressure,
between specific illnesses and workplace stress. Early • preventative counselling,
work in this area explored a possible relationship with • treatment of the stressed individual.
coronary heart disease, peptic ulcer34 and 'neurosis'.35
Since then a diversity of illnesses have been associated The occupational physicians' role was initially per-
with workplace stress, including cancer. This no longer ceived as treatment but now it is not unusual for them to
appears to be a major area of research. be involved at all or any of the levels of intervention. The
occupational health team should be best placed to
recognize the development of individual stress and
MEASUREMENT OF STRESS organizational malaise. The increasing interest by man-
agers in workplace stress due to its apparent increase and
Much of the research depends on self-report question- to the increasing risk of litigation has facilitated the
naires or interviews, which inevitably raises questions of development of interventions. However, too often the
validity particularly in the perception of workplace organization is more interested in the process rather than
stressors. Three factors need particular consideration: the outcome. It is essential that when initiating interven-
the psychological attributes of the individual, the norms tions an evaluation process is included not the least to
of the social discourse in which the perceptions develop determine what intervention/s are appropriate.40 Rey-
and the general (context-free) well-being of the subject. nold's review (pp. 315-319 in this issue) of the efficacy
Several authors have emphasized the need to be of the various interventions does not leave us with
cognisant of these factors.23 Bailey and Bhagat36 powerful ammunition to persuade managers not only
recommended a three-sided approach to measuring that something needs to be done but that something
stress: effective can be done.
Objective measurement of outcomes has been hin-
• objective and subjective antecedents to the experience, dered by the practical difficulties of mounting adequate
including health status; research in work groups. Constant change, which is
• self report; occurring in most organizations, means that there is no
• physiological measurements, health status. steady state to measure, subverting longitudinal studies.

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 Fingret: Occupational mental health: a brief history 293

In addition, such is the pervasive insecurity of the 20. Kristensen TS. The demand-control-support model:
workplace today that workers are averse to revealing any methodological challenges for future research. Stress Med-
weakness or providing frank evaluations even with the icine. 1995; 11: 17-26.
guarantee of confidentiality. 21. Jahoda M. Positive Mental Health. New York: Basic Books,
1958.
The final paper in this issue of Occupational Medicine
22. Kornhauser A. Mental Health of the Industrial Worker. New
attempts to draw together the suggestions for progress York: Wiley, 1965.
towards better information on the effects of work on 23. Warr PB. Decision latitude, job demands and employee
mental health outlined by all the authors. well-being. Work and Stress 1990; 4: 285-294.
24. Warr PB. Well-being and the workplace. In: Kahneman D,
El Diener X, Schwarz N, eds. Foundations of Hedonic
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