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A Short History of Occupational Therapy in Mental Health

Catherine F. Paterson

INTRODUCTION

MENTAL HEALTH AND THERAPEUTIC OCCUPATION PRE-19TH CENTURY

From the very earliest surviving manuscripts, reference was made to the belief that occupation in the form of exercise, work, recreation and amusements, can be used to improve mental and physical health. The Greek physician Hippocrates, in the 4th century BC, taught that the brain was the seat of the mind and described how mental health depended on a balance of four bodily humours: blood, choler, phlegm and bile (Digby 1985). Galen, the most influential of the Roman physicians, in the 2nd century AD, followed the methods of Hippocrates. Seigel (1973, p. 276) records that Galen, ‘advised good nursing care; demanded kindness with the emotionally ill; employed as physical methods hydrotherapy, showers, sweating, local application of heat and sunbathing …. In milder cases he recommended travel, occupational therapy and, for the educated, an increasing participation in lectures, discussions, reading and in pastime creative activities’.

While the idea that madness was caused by evil spirits, witchcraft, sin or divine intervention, dominated popular thinking throughout the Dark and Middle Ages, physicians in Europe continued to accept Hippocrates’ and Galen’s explanation of the humoral basis of madness well into the 18th century (Porter 1999). In Britain, a rich person with a mental illness would likely be attended at home by a physician or placed in a private ‘madhouse’. On the other hand, the ‘mad’ poor were mainly treated as social deviants, classed with destitutes, vagrants and criminals. Some were incarcerated in prisons or workhouses, or in one of the few hospitals for pauper patients, such as Bethlem Hospital in London. The conditions in which the mentally ill were kept, whether at home or in an institution, were appalling. They usually included the use of physical restraint (often by manacles and chains), no heat or lighting, little food, clothing, bedding or sanitation, no segregation of the violent from the quiet and withdrawn, and no meaningful occupation. There was even wrongful confinement of people who were not in fact mentally ill. Traditional medical remedies were aimed at re-establishing humoral balance and included special diets, bleeding, purging, emetics and blistering, often on a seasonal basis (Jones 1972).

MENTAL HEALTH AND THERAPEUTIC OCCUPATION IN THE 19TH CENTURY

Eventually, scandals, changes in public opinion and the example of a few asylums run on humanitarian principles led to a period of reform. At the beginning of the 19th century, the two asylums most celebrated for introducing reforms were the Bicêtre in Paris, under Dr Philippe Pinel (1745–1826), and the York Retreat, founded by layman William Tuke (1732–1822). Pinel and Tuke became internationally acclaimed for their introduction of moral treatment for the mentally ill, that is, psychological rather than physical treatment (Paterson 1997).

Pinel was appointed to the Bicêtre in 1794, during the French Revolution, when the institution housed upwards of 200 male patients who were regarded not only as incurable but also as extremely dangerous. Instead of blows and chains, he introduced light and fresh air, cleanliness, workshops and areas for walking, but above all, kindliness and understanding (Batchelor 1975). Pinel wrote in his famous 1806 treatise on insanity: ‘It is no longer a problem to be solved … I am convinced that no useful and durable establishments … can be founded excepting on the basis of interesting and laborious employment’ (Pinel, reprinted 1962, p. 216).

Tuke and the Society of Friends founded the Retreat in 1796 on the Quaker principles of compassion and humanity. The central emphasis was on trying to help the patient gain enough self-discipline to master his illness. To this end, it was thought important to create a comfortable, domestic environment in which the patient could experience normal civilized daily living conditions, which would help the process of self-control. Ann Digby (1985, p. 57) summarized the regime:

Although Pinel and Tuke are most frequently credited with the introduction of moral treatment, there were other asylum superintendents at the beginning of the 19th century who were particularly interested in the therapeutic use of occupation as part of a humane regime of care. These included William Hallaran (1765–1825), the first physician of the Cork Asylum; Sir William C. Ellis (1780–1839), medical superintendent of the Hanwell Hospital and William A. F. Brown (1805–1885), the first medical superintendent of the Crichton Institution at Dumfries (Paterson 1997).

Hallaran published a book in 1810 called, On the Cure of Insanity, which advocated the use of suitable occupation for ‘the convalescent maniac’, combining ‘corporeal action, with the regular employment of the mind’. He was the first physician to recognize the danger of institutional neurosis and gave the first account of the benefit derived from being allowed to paint (Hallaran 1810, cited by Hunter and MacAlpine 1963, p. 650).

Ellis was appointed to the newly opened Wakefield Asylum in 1818, with his wife as matron. Samuel Tuke (1784–1857) credited Ellis with: ‘the first extensive and successful experiment to introduce labour systematically into our public asylums. He carried it out … with a skill, vigour, and kindliness towards the patients which were alike creditable to his understanding and his heart’ (Tuke 1841, cited by Hunter and MacAlpine 1963, p. 871). While the men at Hanwell were encouraged either to follow their own trade or to learn a new one, Lady Ellis organized the female patients under a ‘workwoman’ to make ‘useful and fancy articles’, which were then sold (Ellis 1838, reprinted in Hunter and MacAlpine 1963, p. 876).

The foremost of the moral physicians in Scotland was Browne. His first position was as medical superintendent at the Montrose Asylum, where in 1837, he wrote an influential treatise entitled What asylums were, are and aught to be. He wrote:

From the 1840s, the Victorian era in Britain was characterized by the building of large public asylums on the outskirts of every large town for the ‘better care and maintenance of lunatics’. Many of these asylums became the mental hospitals which were later closed in response to the care in the community policies dating from the 1960s. Nonetheless, these institutions were, themselves, the product of social reforms, at a time when the urban industrialized working class in Britain lived in conditions of squalor and grinding poverty (Jones 1972).

However, the optimism that cures could be effected through treatment in an asylum could not be sustained. Patients became quieter and more manageable but most were still unable to return to their former lives. The success of the asylums led to the admission of more inmates, so that their very size – many containing 2000 or more patients – made them the antithesis of the domestic surroundings necessary for treatment on moral principles. Many asylums found it impossible to attract the number and calibre of attendants required to manage disturbed patients without resorting to measures of restraint. Thus, during the latter half of the 19th century and well into the 20th, the individualized prescription of occupation gave way to the widespread use of the physically fit patients for work in the kitchens, laundry, farms and gardens of the asylums, as much for economic as for therapeutic reasons (Jones 1972).

MENTAL HEALTH AND SOCIAL POLICY IN THE 20TH CENTURY

During the early part of the 20th century, the most important influences on psychiatry were the theories of Sigmund Freud (1856–1939) and his associates Alfred Adler (1870–1937) and Carl Jung (1875–1961), who developed psychoanalysis and psychotherapy. Although these new disciplines had a significant influence on the way people thought about mental processes and on private practice, they had little effect on regimes within British asylums (Shorter 1997).

The move beyond the asylum can be traced back to the changes in practice during the First World War, when the problem of shell-shock required a new response to mental distress (Stone 1985). The Mental Treatment Act of 1930 blurred the distinction between mental and physical illness, so that medical terminology was adopted; asylums becoming hospitals, for example. The Act also further stimulated the development of outpatient clinics and after-care services, as well as admission of non-fee-paying patients on a voluntary basis (Jones 1993). Of particular note, was the founding of the Marlborough Day Hospital in 1946 by Joshua Bierer (1901–1984), a pioneer in social psychiatry, whose treatments included occupational therapy (Bierer 1951). The Second World War resulted in many problems for mental hospitals – some had been taken over to accommodate the war-wounded and there was an acute shortage of trained staff, which severely set back progress, and although most were taken over by the newly founded National Health Service in 1948, lack of finance continued to be a major problem (Jones 1993).

Denis Martin (1968) described mental hospitals during the first half of the 20th century as benignly authoritarian, in that the satisfactory running of the hospital depended on the submission of the patients to authority with the minimum of resistance. Methods of dealing with those who were unable to submit included locked doors, various forms of mechanical restraint, segregation of the sexes, heavy sedation, electroconvulsive therapy, prolonged sleep and prefrontal leucotomy, which were administered as treatment but which could be perceived or even used as punishment. However, the same authority was, arguably, benevolent, since the hospital provided security and met the patients’ physical needs, so that the net result was: ‘institutionalization’.

Although the Mental Health Act of 1959 greatly reduced stigmatizing procedures of admission and discharge, the planned measures to improve care outside mental hospitals were not uniformly achieved (Jones 1993). The 1960s saw the beginning of a sustained debate about the legitimacy of custodial care. The criticisms were led by psychiatrists Ronald Laing, David Cooper and Thomas Szasz – collectively dubbed ‘antipsychiatrists’ – and by Erving Goffman, whose seminal work Asylums, published in 1961, drew attention to the dangers of the ‘total institution’ (Pilgrim and Rogers 1993).

However, the move from hospital to the community was greatly facilitated by the pharmacological revolution. It began in the 1950s with chlorpromazine (a phenothiazine) for the management of schizophrenia, and continued with lithium for manic-depressive psychosis (bipolar disorder), and the tricyclic antidepressants (Shorter 1997). With the new confidence in medication, the 1962 Hospital Plan for England and Wales stated that large psychiatric hospitals should be closed and local authorities should develop community services (Ministry of Health 1962). The White Paper of 1975 further stated that the mental hospitals should be replaced by psychiatric units within district general hospitals (DHSS 1975). The development of depot neuroleptic drugs also facilitated the rehabilitation of patients with chronic schizophrenia who had difficulty with complying with oral medication (David et al. 2009).

The ideological and financial pressures on the psychiatric hospitals, together with the continuing development of effective medication, expedited the deinstitutionalization movement, which began slowly in the 1960s and gained momentum with each subsequent piece of legislation. By the 1990s, a wide range of supported accommodation had been set up, often by voluntary bodies. Nevertheless, there continued to be a need for provision for the ‘new long-stay’ patients, many of whom were detained under the Mental Health Act (1983), and after the closure of the psychiatric hospitals this need was largely met by the private sector (Killaspy 2007).

By the end of the 20th century, the widespread reliance on drugs to control symptoms had re-established the somatic basis of mental health problems as the dominant view, alongside precipitating psychological and social factors (Shorter 1997). However, medication does not cure mental health problems, but helps to control symptoms and facilitate psychosocial forms of treatment. Consequently, there continues to be a need for adequate community services to maximize the effectiveness of interventions (Hirsch et al. 1973, cited by David et al. 2009).

OCCUPATIONAL THERAPY PIONEERS

The Beginning of the Profession of Occupational Therapy in the USA

At the end of the 19th century in the USA, as in Britain, the asylums were suffering from overcrowding and economic pressures. However, there was a resurgence of interest in reform and in structuring the patient’s day in a more productive manner, stimulated by various antecedents. These included pragmatism, the mental hygiene movement and the arts and crafts movement, as well as the legacy of the use of occupation as an integral aspect of moral treatment (Paterson 2010). This led to the introduction of an experimental 6-week course in occupations for asylum attendants at the Chicago School of Civics and Philanthropy (Quirago 1995). By 1915, the course lasted 2 years, and is considered the first professional course in occupational therapy (Loomis 1992).

A major influence on this development, as on psychiatry on both sides of the Atlantic, was Dr Adolf Meyer (1866–1950), who emigrated from Switzerland to America in 1892. According to Rowe and Mink (1993), Meyer viewed mental illness as the outcome of a person’s maladaptive interaction with the environment. His emphasis on objective observation of patient behaviour and on habit was compatible with the psychology of learning that was being developed by American pragmatists William James (1842–1910) and John Dewey (1859–1952), and his views anticipated the biopsychosocial model adopted by many psychiatrists in the late 20th century.

As early as 1892, Meyer observed that: ‘The proper use of time in some helpful and gratifying activity appeared to me a fundamental issue in the treatment of any neuropsychiatric patient’ (Meyer 1922, reprinted 1977, p. 639). In 1895, Meyer’s wife, a social worker, introduced a systematic type of activity into the wards of the state institution in Worcester, Massachusetts, so that: ‘A pleasure in achievement, a real pleasure in the use and activity of one’s hands and muscles and a happy appreciation of time began to be used as incentives in the management of our patients’ (Meyer 1922, reprinted 1977, p. 640).

Meyer is generally regarded as one of the founders of occupational therapy in the USA, along with other professionals who were developing the use of occupation quite independently. These included Susan E. Tracy (1878–1928) a nurse; Eleanor Clarke Slagle (1870–1942) a social worker; William Rush Dunton Jr (1868–1966) another psychiatrist and George Barton (1871–1923), who was an architect. Barton became an advocate after his own illness, when he experienced the beneficial effects of directed occupation. He founded an institution in Clifton Springs, where people with chronic ill-health could be retrained or could adjust to gainful living by means of occupation. It was at Clifton Springs in 1917 that the National Society for the Promotion of Occupational Therapy was formed, with Barton as its first president. In 1923, the name was changed to the American Occupational Therapy Association (Licht 1967).

The Beginning of the Profession of Occupational Therapy in Scotland

Professor Sir David K. Henderson (1884–1965) (Fig. 1-1), a prominent Scottish psychiatrist during the first half of the 20th century, was much influenced by Meyer, with whom he had worked in the USA. After returning to Scotland, Henderson became the Medical Superintendent of the Gartnavel Royal Hospital in Glasgow (Figs 1-2, 1-3), where he employed, in 1922, Dorothea Robertson (1892–1952), the first instructor in occupational therapy in Britain (Henderson 1925). Robertson, although a graduate of Cambridge University, did not have the benefit of any training, but within months, she had made sufficient impact that the Commissioners of the General Board of Control for Scotland reported that:

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