New Approaches to Patient Work and Occupation

Abstract

Freebody demonstrates how new theories regarding the therapeutic use of occupation, developed during the early twentieth century in Germany and the USA, were received very differently by French and English psychiatrists, highlighting the disparity in their respective interpretations of mental disorder. In England, where psychiatrists had come to regard mental disorder holistically after World War I, the new approaches were adopted as curative treatments. French psychiatrists, the majority of whom maintained their belief in the physiological nature of mental disorder, largely ignored the new theories. In England, occupational therapy (either in the form of arts and crafts or of carefully allocated and supervised work around the hospital) became the hallmark of a modern hospital. In France, patient work remained much as it had done before World War I, with the exception of the Henri Rousselle Hospital in Paris.

The concept of work as a therapy for the mentally disordered (as revealed in chapter two) was originally conceived in the context of moral treatment, a psychological mode of treatment that emerged in the late eighteenth and early nineteenth centuries. Originally tailored to suit individual patient’s needs, the nature of work underwent subtle changes, becoming more routinised and formulaic, as psychiatry moved from a psychological to a physiological paradigm in the late nineteenth century. A subsequent ideological shift within psychiatry, stimulated by World War I towards a more holistic interpretation of mental disorder in England and Paris (analysed in Chap. 3), paved the way for a re-assessment of the therapeutic value of patient work. This chapter examines the new theories regarding patient occupation that emerged in the USA and Germany just before World War I. What were these new ideas, what prompted their development and how did French and English psychiatrists react to them? Did patient occupation in French and English mental hospitals change as a result of the new ideas? What were the medical and non-medical factors that either impeded or encouraged their adoption? This chapter seeks to answer these questions and to ascertain just how new the ideas were, since as Gerald Grob, Marijke Gijswijt-Hofstra and Harry Oosterhuis have pointed out, both the American and the German theories of “occupational therapy” bore a significant resemblance to early nineteenth-century moral treatment.¹ The similarities and differences between moral treatment, late nineteenth-century patient work and the two “new” types of occupational therapy are assessed.

Criticisms of Patient Work After World War I

Psychiatrists Julian Raynier (1888–1936) and Henri Beaudouin (1885–1968)² expressed their frustration with how patient work was organised in France.³ In their influential book that became known as the “bible” for asylum doctors, they claimed that work was not being used to its full therapeutic potential.⁴ Chief medical officers should not need reminding of work’s beneficial effects on a patient’s mental and physical well-being, they claimed, because this had been accepted since the early nineteenth century.⁵ Work, especially farm work, was beneficial for all patients, and the authors lamented its absence from many asylums.⁶ Contrary to the views of most contemporary French psychiatrists, who insisted on bed-rest for acute cases, they maintained that work accelerated convalescence from acute psychosis, as well as providing an excellent distraction for incurable and chronic patients. Among the benefits, patients gained “social dignity” through productive work, even if they were only able to achieve minimal results.⁷ The authors urged chief medical officers to do whatever was required to facilitate the provision of work for patients, such as buying or renting land, establishing indoor workshops, or instructing workshop managers in how to supervise patients.⁸

Psychiatrists Charles Ladame (Swiss) and Georges Demay (French) agreed that medical thinking on the suitability of work for patients at the acute stage of their illness had evolved.⁹ In their 1926 work, La thérapeutique des maladies mentales par le travail, they opined that work was now considered appropriate for acute-stage patients. It was no longer considered necessary to wait until the agitation of delirious patients had completely disappeared since work could focus their attention, channel their energy and lead to a change in habits.¹⁰ Ladame and Demay illustrated the benefit of work by citing the case of a patient suffering from delusions of persecution who remained calm when working in the fields for six days out of seven, but his delirium returned, accompanied by noisy monologues and gesticulations, on Sundays when patients did not work.¹¹ Work was beneficial for melancholic patients, either encouraging them to engage with their surroundings, or acting as a refuge and distraction. Some dementia patients were also capable of work, including those suffering from dementia praecox, for whom it was particularly beneficial, as Swiss psychiatrist Eugen Bleuler (1857–1939) had observed.¹²

Acute-stage patients needed medical surveillance, requiring workshops for these patients to be located inside the patient quarters.¹³ Such workshops could provide the kind of work found in the local area, with which patients were already familiar, such as lace-making, glove-making or weaving.¹⁴ The authors highlighted the Villejuif Asylum’s Third Section for criminal and dangerous patients, established by Henri Colin (1860–1930) in 1910, where even the most challenging patients worked. This was unusual in French asylums; an enquiry revealed that only two out of the 25 asylums surveyed had interior workshops.¹⁵ All Third Section patients were expected to engage in productive work, since criminals had to contribute to the costs of their maintenance.¹⁶ Colin claimed that many of his criminally insane patients were excellent workers.¹⁷ These patients had been unable to attend workshops in the hospital grounds in the past because they required continual surveillance. Situating the workshops inside the patients’ quarters enabled them to work, supervised by nurses experienced in manual labour, thereby improving patient behaviour without putting other inmates or staff at risk.¹⁸ The benefits of the Third Section’s interior workshops were emphasised by Dr. Calmels at the Congress of French Alienists and Neurologists in Geneva in 1926. He highlighted how patients who were normally forced to remain in their quarters with nothing to do, despite being capable of simple work, including those suffering from chronic delirium or GPI, could be given employment.¹⁹ The boredom and sadness suffered by patients forced to be idle, could be replaced by purposeful activity and an atmosphere of contentment.²⁰

In England, debate concerning the way employment was organised in mental hospitals was stimulated by an incendiary book by Dr. Montagu Lomax, entitled Experiences of an Asylum Doctor, published in 1921.²¹ The book, based on the two years Lomax spent working at Prestwich Mental Hospital in Lancashire between 1917 and 1919, criticised many aspects of asylum administration, including the provision of patient work, recreation, and exercise. The book caused a public outcry and prompted an inquiry by the Ministry of Health, led by Sir Cyril Cobb.²² Lomax deplored the type of work given to patients, the conditions of work and the fact that patients were not paid for their efforts, accusing the authorities of exploitation. He criticised the job of coir-picking: “It is unpleasant, unhealthy work, reminiscent of oakum-picking to those who have been in jail or worked as ‘casuals’ in workhouses”.²³ Lomax remarked that this type of work was “very useful” for the asylum authorities as it saved “much expense”, although the dust it generated was dangerous for patients suffering from bronchitis or other chest conditions..²⁴ It is worth noting here that in 1887 “hair-picking” (a similar task) was introduced at Littlemore where respiratory ailments, including tuberculosis and pneumonia, were rife.²⁵ At Prestwich, the “closet-barrow gang” were allocated the unenviable task of emptying the asylum’s commodes, described by Lomax as the “most unpleasant and unhealthy work of all”.²⁶ It would not have been so bad if the patient workers had been “well fed, well clothed and properly compensated”, but this was not the case.²⁷

Following these allegations, the Cobb Report, published in 1922, concluded that with regard to Prestwich Hospital “there was room for considerable development in organising the occupation of patients, both as regards the number of patients employed and the variety of work undertaken”.²⁸ Commenting on patient work more generally, Cobb noted that 57% of mental hospital patients were “usefully employed” but that over half were engaged in ward work.²⁹ This was clearly an area for improvement, particularly when compared with the “remarkable range of work” undertaken at some of the newer mental hospitals, which were equipped with modern workshops.³⁰ Cobb agreed that patients should receive some sort of remuneration, which would offer an “incentive to work” and would stimulate the patient’s self-respect.³¹ He also agreed that more should be done to “promote social life” than was currently afforded by the weekly entertainments, and that patients should be provided with more opportunities for parole and exercise.³²

Prompted by the Cobb Report, the Board of Control noted in its annual report of 1923 that “the organisation of occupations in most hospitals is not altogether satisfactory” and that “the number of patients of both sexes whose only employment is ward work is noteworthy”.³³ The commissioners remarked, “We attach so much importance to occupation as a curative agent and as a means of promoting the contentment and well-being of patients that we should like to see the organisation of industries placed upon a better footing, possibly by the appointment of an occupations officer.”³⁴ They observed that an Occupations Officer had been appointed at the recently-opened Maudsley Hospital, where provision had been made for occupation and recreation, such as carpentry, gardening and tennis.³⁵ A Royal Commission on Lunacy and Mental Disorder, ordered to further investigate Lomax’s claims, conducted its inquiries between 1924 and 1926.³⁶ The resulting Macmillan Report of 1926, which advocated the active treatment of all curable patients, indicated that further facilities for occupation and amusement should be provided and that the appointment of an occupations officer should be considered.³⁷ The findings of the Cobb and Macmillan Reports coincided with the arrival in the UK of new ideas regarding patient occupation from the USA, and would ultimately lead to a divergence in approaches to occupation in England and France.

New Ideas Regarding Patient Occupation

A new approach to using occupation therapeutically was developed in the USA in the 1910s. The National Society for the Promotion of Occupational Therapy (NSPOT) was formed in 1917, on the eve of the USA’s entry into World War I. The American version of occupational therapy, referred to henceforth as American Occupational Therapy or AOT, grew out of the collective vision of individuals from a variety of backgrounds including psychiatry, psychology, nursing, social reform, and the arts, who shared a belief in the therapeutic value of occupation. Influences included the Arts and Crafts Movement, the philosophy of pragmatism, the Work Cure, and the Mental Hygiene Movement, as Catherine Paterson and Ann Wilcock have outlined.³⁸ The emergence of AOT coincided with a “backlash” against the “extreme somaticism” of late nineteenth-century psychiatry (discussed in chap. 2). By the 1880s, as Ben Harris explains, American psychiatrists were under increasing pressure from neurologists to become more scientific in their approach to mental disease.³⁹ As a result, American psychiatrists took a far greater interest in pathology, physiology, and pharmacology, and in surgical and endocrinological treatments, and far less interest in the psychologically-oriented moral treatment. A resurgence in enthusiasm for psychological methods followed in the 1910s, associated with the rise of psychotherapy in the USA at that time.⁴⁰

Dr. Adolf Meyer developed what he called a “psychobiological” approach to psychiatry, which took account of both psychological and biological factors. He believed that “psyche” (mind) and “soma” (body) should be considered as different dimensions of the same entity. In other words, he believed in the “continuity” of mental disorder. For Meyer, mental illness was not a structural defect of the mind or body, but a lowering of an individual’s capacity to function or to adapt to his social situation. Differences between normality and abnormality, between psychosis and neurosis were not absolute, but shades of grey.⁴¹ Meyer recognised that occupation could be used to help individuals solve problems of adaptation to their environment, which he regarded as one of the main causes of mental disease.⁴² He also believed that “the proper use of time in some helpful and gratifying activity” was fundamental to the treatment of the psychiatric patient.⁴³ Meyer observed that work around the asylum did little to stimulate a patient’s interest or enthusiasm. Conversely, he noted how readily patients responded to a simple programme of craft activities, taking “a pleasure in achievement, a real pleasure in the use of and activity of [their] hands and muscles, and a happy appreciation of time”.⁴⁴ Through engaging in arts and crafts, patients learned how to organise their time and make the best use of the opportunities available to achieve their goals.⁴⁵

The Arts and Crafts Movement of the late nineteenth century encouraged the creation of hand-made goods and offered an alternative to the perceived harshness of late nineteenth-century industrialism. It emphasised the spiritually uplifting nature of quality work and craftsmanship, attributes that resonated with the aims of occupational therapy.⁴⁶ Like the British founders of the Arts and Crafts Movement, John Ruskin (1819–1900) and William Morris (1834–96), Meyer was critical of the industrial processes of production. He maintained that “Our industrialism has created the false, because one-sided, idea of success in production to the point of overproduction, bringing with it a kind of nausea to the worker” and a loss of “the capacity and pride of workmanship”.⁴⁷ Echoes of Karl Marx (1818–83) can be detected here. Marx regarded the capitalist mode of production as “alienating” to the worker, who was deprived of control over the product, and of engaging in psychologically satisfying activity.⁴⁸ There was no dignity in the work. Marx regarded “purposeful activity” as necessary for the “realisation of the full humanity of the individual”.⁴⁹ Meyer recognised the potential of arts and crafts to enable patients to express their creativity, experiment with different materials and “give the satisfaction of completion and achievement”, thereby boosting a patient’s self-esteem.⁵⁰ Meyer believed that “the main advance of the new scheme was the blending of work and pleasure” and the fact that the activities were organised according to their appropriateness for individual patients, rather than part of an overall, centralised scheme of work.⁵¹

Meyer introduced one of the earliest programmes of AOT at the Henry Phipps Clinic, part of the Johns Hopkins Hospital, in 1913. Overseen by one of the founders of NSPOT, Eleanor Clarke Slagle, the daily routine was structured to resemble “normal” everyday life. On being woken up, patients were encouraged to bathe and dress. They were expected to do this themselves; it was considered “pointless” to try and force them to dress. This was a different approach to that adopted in most asylums where it was the nurses’ or attendants’ responsibility to dress the patients.⁵² After breakfast, during which conversation was encouraged, patients went to work in the occupation rooms. Here they were given classes in clay modelling, painting, weaving, bookbinding, knitting, leatherwork and basket weaving. These handicrafts were aimed at igniting impulses of self-interest and the desire for satisfaction essential for efficient adaptation.⁵³ In the carpentry workshops, male patients made wooden trays, tables and bookshelves, while in the needlework room, female patients made slippers, shawls and tablecloths. Patients were encouraged to send their achievements home as gifts for their families and friends.⁵⁴ Lunch was followed by rest or quiet activities on the wards. These might include reading, card-playing, letter-writing or domestic tasks, such as clearing away meal trays, sweeping, bedmaking or polishing brass fixtures. Meyer maintained that help around the wards, provided it was voluntary and pleasant and gave a sense of “helpful enjoyment”, acted as an “instrument of biological adaptation”.⁵⁵ This contrasted with the obligatory, often exploitative, labour of patients in the large public institutions, but was nonetheless focused on cultivating productivity and usefulness.

The concept of usefulness was key to the German method of occupational therapy. This also involved the re-education of the asylum patient through the establishment of a regular routine of occupation, rest and recreation. It differed from AOT in that patients were engaged in the “real work” required to run the institution, rather than in arts and crafts. This was considered important because it allowed patients to feel that their work had a useful purpose. Unlike AOT, the German method was developed by just one individual, the Dr. Hermann Simon (1867–1947). When Simon took up the position of medical director of the newly built Warstein Asylum in 1905, he discovered that the landscaping of the grounds had not been completed. With staff in short supply, Simon directed his patients to complete the work.⁵⁶ Initially he only selected those patients who were considered fit enough to work, but soon involved those who were agitated or in bed.⁵⁷ He observed that as more patients were involved, a general improvement in behaviour took place.⁵⁸ Patients became much calmer and more orderly, reducing the need for sedative drugs and isolation cells.⁵⁹ Within nine years, Simon was able to occupy c.90% of his patients. The whole atmosphere of the institution changed into one of purposeful activity, and patients took a renewed interest in their surroundings.⁶⁰ Simon realised that regular, serious activity was part of normal, everyday life and that scheduling some sort of work (however limited) into the daily routine, made the adjustment to institutional life easier for newly admitted patients.⁶¹

Simon used his experiences at Warstein to develop “More Active Therapy” (aktivere Krankenbehandlung), henceforth known as MAT. Simon instituted MAT at the Gütersloh Asylum in Westphalia, Germany, where he became medical director in 1919. His theory was published in a German psychiatric journal in 1927 and in book-form in 1929.⁶² Simon believed that every patient, even those at the acute stage of their illness, should be set to work on admission to hospital.⁶³ Patients should feel that the work assigned to them had a purpose, since this was essential to maintaining their engagement and interest in the activity. Simon maintained that “the work allocated to a patient should be real and serious” such as work in the laundry, kitchen, grounds, poultry house or offices. The patient should be paid for this work, no matter how small the amount.⁶⁴ Simon insisted that “Whatever task can be done by someone who is sick is not to be done by someone who is healthy.”⁶⁵ He also insisted that the economic value of the work was not its main goal, but that the focus should be on the benefit to the patient. Simon believed that the purpose of treatment was to “re-introduce a healthy logic into the life and mental world of the patient”.⁶⁶ Idleness, according to Simon, was not only the “root of all evil… but also of impending idiocy”.⁶⁷ In line with the principles of moral therapy, work was to be balanced by social and recreational activities. Like Ladame and Demay, Simon believed it was necessary to schedule some form of “activity” every day including Sundays.⁶⁸

Simon acknowledged that it required considerable education to habituate patients to work. The physician had to assess the mental state of the patient when allocating work and deciding on the training method. Simon divided the work into five stages of increasing difficulty, which he compared to the grades of a school.⁶⁹ New patients were initially assigned simple tasks—such as helping to carry a basket or dusting furniture—and as their performance improved, they were given ever more demanding assignments.⁷⁰ The final stage, representing the normal work capacity of a healthy individual, might involve work outside the hospital, thereby strengthening a patient’s sense of responsibility and independence.⁷¹ Whilst a patient should not be allowed to become overtired, it was important to “push a patient to the upper limits of their abilities” in order that they made progress. Striking this balance was a challenge for the physician.⁷² The aim was to educate patients to take responsibility for their actions and to play a useful role in the community. This ethos, as Monica Ankele emphasises, resonated with that of other German welfare institutions during the Weimar period, such as alms-houses, youth centres and prisons, where work played a central role.⁷³

The Reception of New Approaches to Patient Occupation in England and France

England

The “new” approaches to occupational therapy began to influence how patients were occupied in England in the early 1920s, but they failed to gain traction in France outside Paris. Initially, the practices associated with AOT, rather than MAT, influenced patient occupation in England. AOT was introduced to Britain in the early 1920s, while MAT only began to attract attention in Britain in the late 1920s and early 1930s. The Scottish psychiatrist, Dr. (later “Sir”) David Henderson, who worked for Meyer in the USA before World War I, is believed to be the first psychiatrist to bring AOT to Britain.⁷⁴ Henderson had learned Meyer’s methods of identifying patients’ reaction types, analysing the significance of their social backgrounds, taking meticulous case notes, and prescribing AOT.⁷⁵ On becoming Physician-Superintendent of the Glasgow Royal Lunatic Asylum at Gartnavel, Scotland, in 1921, Henderson applied Meyer’s psychobiological approach to treatment and introduced occupational therapy.⁷⁶ In the Gartnavel Annual Report of 1922, Henderson maintained that “attempts should be made to cultivate good habits in both mind and body, to stimulate interests, and attempt in every way to reconstruct the personality”.⁷⁷ Papers from the 1924 conference on occupational therapy, organised by Henderson, were published in the Journal of Mental Science in 1925. At the conference, Henderson expressed the belief that through AOT “many recoveries are hastened, many improvements are effected, good habits are substituted for bad ones, physical and mental deterioration are retarded, and life is made more endurable for the great bulk of our permanent population”.⁷⁸

Henderson’s commitment to Meyer’s holistic approach to psychiatry and his advocacy of occupational therapy were re-affirmed in his Textbook of Psychiatry published in 1927, written with his colleague R.D. Gillespie and dedicated to Meyer. The volume became the standard textbook for postgraduate students of psychiatry, running to several editions until finally being withdrawn in the late 1970s.⁷⁹ In the chapter devoted to occupational therapy, Henderson declared that every mental hospital should have an occupational therapy department, “varied to suit the individual needs of the institution, private or parochial, rural or urban”.⁸⁰ He believed that guiding patients into “satisfactory work channels” could accomplish more than “all the drugs in the pharmacopoeia”.⁸¹ Noting that in the past, patient work frequently constituted “mere drudgery” that must have “antagonised” rather than helped many patients, he maintained that properly organised occupational therapy could inspire in patients a “spirit of hopefulness and of happiness”.⁸²

Having made few remarks on patient occupation since the war, the Board of Control began to advocate occupational therapy as a means of engaging mentally ill patients who refused, or were unable, to perform hospital maintenance work. In 1928, the Board admitted that employment had been restricted to “those patients whose readiness to work was spontaneous or needed only the urge of some small reward”.⁸³ As Henderson highlighted, many patients who had been considered unemployable could be occupied by “staff trained in teaching handicrafts” if sufficient care was taken to select an activity that appealed to the patient and was appropriate for their mental condition.⁸⁴ The Board noted in 1931 that where a “skilled occupation officer” had been appointed, as at Barming Heath, this had resulted in the “employment of types of recent and progressing cases who a few years ago would have been regarded as incapable of benefiting by such treatment”.⁸⁵

This interest in occupational therapy prompted research visits to Holland and Germany to see MAT in action. These were convened by the Royal Medico-Psychological Association (RMPA)⁸⁶ between 1928 and 1933. Visitors to the Santpoort Asylum, where MAT had been instigated in 1926, were impressed by the “silence and stillness” of the wards and by the numbers of patients engaged in activities. Only 10% of patients were unoccupied and this was mainly due to physical sickness.⁸⁷ Dr. van der Scheer, medical director of the Santpoort Asylum, explained that his patients’ mental disorder was due to educational and environmental factors. His regime was aimed at the re-education of patients through the “acquisition of new experiences” and the generation of “new conditional reflexes”.⁸⁸ Scheer, like Simon, believed that “every patient is able to do certain kinds of work” including “imbecile, demented [and] maniacal” patients.⁸⁹ Visitors noted the various types of work undertaken by patients, which varied in complexity, and the fact that other occupations included “reading, games and dancing”.⁹⁰ They also noted that “this system of occupation requires a high proportion of staff, who must co-operate in the treatment with the exercise of much patience and intelligence”.⁹¹ The Board of Control used the research from such study visits, together with existing knowledge of AOT, to produce a Memorandum on Occupation Therapy for Mental Patients in 1933. The 27-page booklet, published to encourage the introduction of occupational therapy into mental hospitals, constituted “a significant early policy document in the history of occupation”, according to John Hall.⁹²

The Board of Control’s booklet defined occupational therapy as “the treatment, under medical direction, of physical or mental disorders by the application of occupation and recreation with the object of promoting recovery, of creating new habits, and of preventing deterioration”.⁹³ Outlining the methods used in the USA, Germany and Holland and how these might be adapted for use in English mental hospitals, it also advised on staff training and the financial implications of introducing occupational therapy. The Memorandum downplayed the economic value of occupation to the hospital, stating that “the object of occupation is primarily therapeutic” and should not be viewed as a means of “providing commodities for use in the hospital at a low cost”.⁹⁴ The Board of Control were keen to make a sharp distinction between occupational therapy and mere occupation; for occupation to be therapeutic it had to be prescribed by a doctor and delivered by specialist staff trained in this “branch of medical therapy”.⁹⁵ This emphasised both the medicalisation and professionalisation of occupational therapy, and set it apart from the routinised, systematic application of work that had characterised patient occupation since the mid-nineteenth century.

The Board of Control’s Memorandum was followed in 1936 and 1938 by the publication of two further guides to providing occupation for mental patients. The first was by Dr. Richard Eager (1881–1947), former medical superintendent of the Devon Mental Hospital.⁹⁶ Eager had successfully instigated occupational therapy in Devon, following a visit to Dutch mental hospitals in 1932, where he witnessed Hermann Simon’s MAT in action. Eager maintained that where a system of occupation was introduced on “intensive lines”, as it had been in Holland, a change in the “general atmosphere” of the hospital could be detected: “the hospital which had formerly been a refuge for idlers, becomes a hive of industry”.⁹⁷ However, considerable staff cooperation was required, involving the Matron, head Male Nurse and their respective teams, all of whom had a role to play in supervising patients in various tasks. Medical staff needed to devote a “considerable amount of time in allotting patients to suitable classes” since the prescription of occupation was as important—if not more so—than the prescribing of drugs.⁹⁸ He continued, “one might even go further, and suggest that the latter might be largely dispensed with, if more attention were given to the former”.⁹⁹ The introduction of occupational therapy, Eager warned, was not a way of reducing staff numbers or a form of cheap labour. Echoing the Board’s Memorandum, he emphasised that occupational therapy was a “definite treatment, and has no relationship to the value of the work done”.¹⁰⁰ Because Eager had instigated MAT most of the occupations he discussed were related to work around the hospital, but like Simon, he also advocated amusements, recreations, and social activities such as cricket, football, Swedish drill, singing, dances, ward parties and games. It was important to engage patients in these activities which warranted just as much thought and planning as work-related activities.¹⁰¹ He also thought it was important that nurses learned basic craft activities that they could teach to patients, a practice that had been adopted at the Littlemore. Eager’s booklet was made available to medical superintendents, public health officials and members of the public.

The second publication was written by Dr. John Ivison Russell (1888–1970), medical superintendent of the Clifton Hospital, York, where he established a very active occupational therapy department. Russell was described in the British Medical Journal as “one of the foremost psychiatrists of his generation”.¹⁰² His book indicates the ongoing enthusiasm for occupational therapy in England despite the introduction of the new shock treatments by the time the book was published in 1938.¹⁰³ Russell’s recommendations were based on AOT, with a whole section of the book devoted to the execution of various arts and crafts, including woodwork, basketry, brush-making, bookbinding, matmaking, work with plaster, concrete and stone, needlework, papier maché and weaving. Russell also addressed the rationale for occupational therapy, appropriate occupations for the various psychological types of patients, how to organise the provision of occupational therapy, suggested routines for habit training and the doctor’s role in prescribing occupational therapy. The book included a specimen occupational therapy prescription for doctors to use.

The first school of occupational therapy in England, the Dorset House School of Occupational Therapy, was founded by the English physician, Elizabeth Casson, in Bristol in 1930 (see Fig. 4.1). Inspired by Henderson’s 1925 article in the Journal of Mental Science, Casson visited the occupation department of Bloomingdale Hospital in New York and the Boston School of Occupational Therapy in 1926. She wanted to find out more about occupational therapy, having been troubled by the “atmosphere of bored idleness” she encountered on the wards of the psychiatric unit where she was working.¹⁰⁴ The curriculum at Dorset House was based on AOT. Fifty per cent of the teaching was devoted to arts and crafts, which supplemented classes in anatomy, physiology and psychiatry. Casson had developed an affinity for arts and crafts whilst growing up in “a family with more than average dramatic and musical talent” and she herself had “considerable gifts in drawing and painting”.¹⁰⁵ Her tastes and accomplishments were typical of what Lauren Goodlad has referred to as a strong British, middle-class commitment to productive occupation.¹⁰⁶ Casson had been exposed to the ethos of the Arts and Crafts Movement, whilst working for Octavia Hill (1838–1912) at one of her social housing projects, before embarking on her medical training. Hill’s mentor had been John Ruskin, co-founder of the Arts and Crafts Movement. Ruskin had encouraged her to bring art, beauty and nature into the lives of her working-class tenants. This made a “deep impression” on Casson according to the first principle of Dorset House, Constance Owens.¹⁰⁷

Fig. 4.1

Student occupational therapists perfecting their weaving skills at the Dorset House School of Occupational Therapy, Bristol, in the 1930s. (Oxford Brookes University Special Collections, Dorset House School of Occupational Therapy Collection, DH/3/1/ Vol. 1)

The Dorset House School was initially staffed by teachers who had trained in the USA and it remained committed to AOT. This inevitably gave AOT a firm foothold in England since most of the occupational therapists that populated English interwar mental hospitals either trained at Dorset House or were trained by those who had, such as those who were employed at the Maudsley School, which opened in 1932. Dorset House’s influence, and thus the prevalence of AOT, was extended when occupational therapy’s governing body was established by a group of former Dorset House students in 1936, supported by Casson, and chaired by Constance Owens. This Association of Occupational Therapists was responsible for setting the occupational therapy syllabus, curriculum and examinations. Arts and crafts remained an integral aspect of occupational therapy in England until the 1960s. As John Hall has observed, psychiatrists Wilhelm Mayer-Gross, Eliot Slater and Martin Roth characterised occupational therapy in Britain as “being more of pastimes and hobbies than of rough manual work, as on the European continent” in their new psychiatric textbook, Clinical Psychiatry, published in 1954.¹⁰⁸

Occupational therapy was provided as soon as the Maudsley Hospital opened in 1923. The Maudsley’s medical superintendent Edward Mapother, and his successor Aubrey Lewis, both embraced the psychobiological approach of Adolf Meyer.¹⁰⁹ They recognised the benefits of psychological modes of treatment and believed that occupation had a role to play in helping patients re-adjust to their environments. The Maudsley’s commitment to occupational therapy was demonstrated by the establishment of the hospital’s own school of occupational therapy in 1932. The experience of treating war neuroses during World War I had introduced the Littlemore’s medical superintendent, Thomas Saxty Good, to the benefits of psychotherapy and occupation. Good began prescribing occupational therapy (taught by nurses rather than occupational therapists) when the Littlemore re-opened for civilians in 1923. John Porter-Phillips, physician superintendent of the Bethlem Royal Hospital, was more of an organicist and it was his long-established practice to sedate acute-stage patients, rather than occupy them. An occupational therapy department did not open at Bethlem until 1932. It took a letter from the hospital’s architect, Alfred Cheston, to the Treasurer of the Board of Governors, Lionel Faudel-Phillips, in which he stated that occupational therapy was “considered by most modern practitioners as [an] essential curative agency”, together with complaints from patients about being bored, to bring about provision of occupational therapy.¹¹⁰

France

Following attempts by Beaudouin, Raynier, Ladame and Demay to improve the use of patient work in France, French psychiatrists became aware of MAT. The theory and methods of “more active therapy” (MAT) were explained in detail to an audience of French psychiatrists attending the Congress of French-speaking alienists and neurologists at Anvers in July 1928. After the Congress, Parisian psychiatrist Paul Courbon was amongst a group of delegates invited to visit the Dutch asylum at Santpoort, where Hermann Simon’s MAT had been introduced two years earlier.¹¹¹ Courbon praised the method in the Annales Médico-psychologiques in November 1928.¹¹² Simon’s articles in the German psychiatric journal, the Allgemeine Zeitschrift (1927) and his book, Aktivere Krankenbehandlung in der Irrenanstalt (1929) were reviewed positively by Parisian psychiatrists, Paul Schiff and G. Halberstadt, in 1929, and by Jacques Vié in 1934.¹¹³ Porot, writing in L’Hygiène mentale in 1929, was also complimentary about the way patient work was organised in Dutch asylums, noting how unfavourably work in French asylums compared with the system at Santpoort.¹¹⁴ Simon shared his views directly with a French audience in 1933, also writing in L’Hygiène mentale, where he claimed that work was one of the best means of combatting agitation, impulsivity and a tendency to violence. Whilst work could not cure organic lesions, it could nonetheless strengthen a patient’s physical and mental faculties.¹¹⁵ A report on patient work presented to the Superior Council for Public Assistance in 1934 added to the growing list of recommendations for the adoption of MAT in French asylums.¹¹⁶

The arguments appeared persuasive. There were very few conditions that would prevent patients from participating in MAT. When Paul Courbon visited Santpoort, he noted that out of 1420 patients, 1273 were working. Out of the 147 unoccupied patients, 112 were too physically weak to work, leaving just 35 whose mental conditions prevented them from working. Bed-rest quarters were greatly reduced and were reserved for “organic” cases or the very agitated who were being treated with the sedative, somnifene.¹¹⁷ Porot observed that hydrotherapy equipment had been abandoned because it was no longer required to soothe agitated patients, who were now occupied. There were no patients huddled on benches, nor any crying out or shouting. Night-time agitation had practically disappeared, and isolation cells were no longer in use.¹¹⁸ All the available workforce was being used, with 85–90% of patients systematically working—either in bed, in their quarters, in the workshops, or in the grounds.¹¹⁹

Like his English colleagues who visited Santpoort, Paul Courbon was deeply impressed by the silence. During the six hours they spent working, patients were forbidden from speaking.¹²⁰ The moment patients became agitated they were removed from the work room for half an hour to rest and then brought back again. If they re-offended, they were removed for a longer period; if this proved insufficient, the patients were given the sedative somnifene. Courbon found the results of this method were “extraordinary”, while for Porot they were “revolutionary”.¹²¹ Courbon described the method of treatment as “ergothérapie” or occupational therapy, which was not a term in regular use in France prior to this period. It consisted, he explained, of re-educating the automatic responses of patients and helping them to readapt to social life.¹²² The application of MAT totally transformed the atmosphere of asylums; everywhere there was silence, concentration and an impressive discipline.¹²³ Porot believed that the methods he had witnessed at Santpoort and other Dutch asylums was not simply a way of filling the time and occupying idle hands, but a means of active therapy that countered agitation and other symptoms. It was, as Courbon claimed, “une véritable rééducation”.¹²⁴

Simon’s methods of MAT generated considerable interest amongst a specific cohort of French psychiatrists between 1928 and 1939.¹²⁵ These psychiatrists, mainly (although not exclusively) from Paris, shared their views nationally through the various professional journals. They recognised the benefits of a re-educative approach to treating mental disorder, based on Simon’s psychological methods and incorporating his type of occupational therapy, MAT. They were pessimistic, however, about the practicalities of introducing MAT into French asylums. There were too many impediments inherent in the French system including overcrowding; lack of funds; management issues; staff quality and training; and the ratio of staff to patients. As A. Walk commented in the English Journal of Mental Science, the “fully-developed Simon system [MAT] … involves a transformation of the hospital régime” that could only be compared with the asylum reforms introduced in the early nineteenth century.¹²⁶ Under Simon’s system, Walk maintained, “the entire institution becomes one vast occupational centre” and that the “therapeutic application of work, rest and recreation” had to be the “foremost concern” of all the asylum staff working in collaboration.¹²⁷ MAT clearly involved a fundamental change not only in the way the asylum was run, but in the attitudes and skills of staff. This represented a daunting undertaking even for an institution without the problems suffered by French asylums.

An additional factor that could have contributed to a rejection of MAT by French psychiatrists was its German origin. The French had been traditionally hostile to everything German since the defeat of France by Germany in the Franco-Prussian War of 1870–1871.¹²⁸ This defeat intensified the French sense of inferiority with regard to Germany, initiated by the loss of French scientific and medical supremacy to Germany earlier in the century.¹²⁹ The university chair in psychiatry established in Germany in 1863 demonstrated German psychiatry’s scholarly and scientific legitimacy, while the ground-breaking work of Emil Kraepelin, whose influential Textbook of Psychiatry was published in eight editions between 1883 and 1915, sealed the German victory over French psychiatry.¹³⁰ Postgraduate students flocked to Kraepelin’s clinic in Munich, rather than Paris, to study psychiatry under the “new master”.¹³¹ Those Parisian psychiatrists who advocated MAT may have been attempting to keep pace with German developments, while others rejected Simon’s methods on the grounds of anti-German sentiment.

Édouard Toulouse, on the other hand, was influenced by the American model of occupational therapy, as a result of his contact with American psychiatry through Clifford Beers (with whom he developed a close personal friendship) and the Mental Hygiene Movement.¹³² At the Henri Rousselle Hospital, patients were encouraged to keep busy. Art classes, sewing and music were among the activities provided. However, Toulouse himself was a divisive figure who did not “win over” his more neurologically oriented colleagues. They regarded his establishment of the Henri Rousselle Hospital as a threat to their modus operandi which revolved around the “closed” asylum.¹³³ Toulouse’s methods, and those of Adolf Meyer, including the prescription of occupational therapy, would eventually be adopted more widely in France after World War II.¹³⁴

The main barrier to the introduction of either AOT or MAT was the organicist stance of most French psychiatrists. The new concepts of patient work and occupation were associated with a psychological or psychobiological approach, rather than an organicist approach to psychiatry. The French psychopathological and psychoanalytical groups highlighted in Aubrey Lewis’s 1937 report “remained strictly Parisian” (i.e. Paris-based) during the interwar period and had little impact on asylums outside the capital.¹³⁵ New ideas regarding patient occupation were therefore unlikely to find favour outside Paris. Dr. Henry Christy of the provincial Asile de la Sarthe was quite clear that his treatment priorities for curable patients were actively biological, while work remained a useful means of occupying incurable and chronic patients.¹³⁶ He was adamant that “It is biology, it is neurology that has generated progress within mental medicine”.¹³⁷ Like most of his colleagues outside Paris, Christy was wedded to a rigidly organicist interpretation of mental disorder and preferred biological methods of treating acute, curable patients. The Parisian Asile Clinique also remained heavily influenced by neurology. The more psychologically oriented, younger members of the medical staff did not have a significant impact until after World War II, which helps to explain the small numbers of patient workers within the treatment sections of the Asile Clinique.

Moral Treatment, Late Nineteenth-Century Patient Work, and Occupational Therapy

The similarities between the tenets of occupational therapy, as set out in the Board of Control’s 1933 Memorandum, and early nineteenth-century moral treatment, are striking. Both were based on a psychological approach to treatment and on the belief that occupation could be curative if carefully selected, supervised and monitored. Both were aimed at modifying behaviour by engaging the patient in satisfying activities. Focusing the patient’s attention on an appropriate task distracted her from her troubles, helped her develop self-control and concentration, and boosted self-esteem. Occupations were to be selected according to patient preference, existing skills and the severity of symptoms. The occupations formed part of a daily routine that included regular hours for work, meals, rest and recreation, thereby helping to re-establish a “normal” pattern of behaviour. This was known as habit training in the early twentieth century, but the principles of establishing a routine were the same as in the early nineteenth century. Pragmatism—or what proved to be effective—informed both moral and occupational therapy. These similarities between moral and occupational therapy set both apart from the bureaucratic system of patient work that had evolved in the late nineteenth century.

One of the main practical differences between moral and occupational therapy was the grading, according to different levels of complexity, of the tasks associated with occupational therapy. This was particularly apparent with MAT. Patients were guided through five different levels of difficulty, with the earliest, easiest stage (such as litter-picking) reserved for newly admitted, acute patients, while work at the final stage, designed to be as similar as possible to normal work outside the hospital, was prescribed to patients nearly ready for discharge. This ensured that the patient was continually challenged without being overstretched. The idea of graded activities, prescribed to suit the level and abilities of the patient, had originated in the treatment of tuberculosis. The English physician Marcus Paterson, superintendent of the Brompton Hospital Sanatorium, developed a programme of graduated labour, comprising six levels of work designed to build up a patient’s stamina, in the early 1900s.¹³⁸ Paterson noticed that the programme resulted in psychological as well as physical improvement.¹³⁹ Simon may have been aware of this method of treatment for tuberculosis.

The tasks comprising AOT were based on arts and crafts, while with MAT the tasks comprised work around the hospital. That said, the line between what comprised work that contributed to the institution and what constituted arts and crafts could be blurred, as in the cases of woodwork, rug making or basketry. It really depended on the intended purpose of the items being made, whether they were for use in the institution or for the patients themselves. Within the context of AOT, activities based on arts and crafts were aimed at enabling the patient to produce an item that was aesthetically pleasing. The process of making the item by hand should be satisfying and the finished product should instil pride. The skill of the therapist was to inspire the patient, to identify a craft for which the patient had an affinity and that was not too difficult (or too simple) for their ability and condition. The rationale for MAT, on the other hand, was to give patients a sense of genuine purpose—a feeling that what they were doing was useful and contributed to their community.

There was nothing intrinsically different about the type of work outlined in Simon’s programme and the work performed by patients in the late nineteenth century, since both were based on the work required to maintain the institution. The difference lay in the way it was prescribed, such as the grading of tasks, the meticulous supervision by nursing and medical staff, and the condition of the patients to whom it was allocated. Almost all patients, including the acutely ill, were given some sort of productive work, according to the principles of MAT. Simon believed that even patients at the acute stage of their illness should be occupied. Late nineteenth-century patient work was limited to patients who required little supervision, namely calm, incurable and chronic patients and convalescents. Patients were allocated tasks according to where their labour was needed, rather than on the basis of their needs. Patient work, while still provided within the framework of moral treatment, no longer took account of the patient’s individual preferences, aptitudes and skills, and the patient’s progress was not closely monitored by a doctor. Late nineteenth-century psychiatrists, while continuing to believe in the benefits of occupation as a distraction, no longer regarded it as curative, and occupation ceased to be considered suitable for patients at the acute stage of their illness.

MAT required total commitment from the chief medical officer; the existence of medical officers to assist with supervision; sufficient numbers of well-trained, competent nurses; and enough flexibility within the system to allow for a re-organisation of the hospital regime. In most French mental hospitals during the interwar period, the above requirements were lacking. In particular, support for occupational therapy was less likely to be forthcoming from French chief medical officers than their English counterparts either because of French psychiatrists’ preference for biological modes of treatment or because they remained wedded to a custodial model of care. In both cases an adherence to an organicist interpretation of mental disorder led to a rejection of occupation for acute cases or for patients who required significant supervision. For all of these reasons, MAT was not adopted in French mental hospitals during the interwar period, despite the recommendations of certain Parisian psychiatrists.

In England, where a psychobiological rather than a neurological approach prevailed, occupational therapy was used curatively and was considered appropriate for acute patients, including those who were still confined to bed. Arts and crafts were also used to engage patients who refused, or were unable, to perform hospital maintenance work. As Henderson had noted, under the late nineteenth-century system of work, many patients remained unemployed, either because of “inefficiency, helplessness, or poor general state of health”, while the new system of occupational therapy was designed to appeal to those who had never been employed and to “stimulate anew” those who had failed.¹⁴⁰ It was noted by the Board of Control that many patients who had been considered unemployable could be occupied by “staff trained in teaching handicrafts” if sufficient care was taken to select an activity that appealed to patients and was appropriate for their mental condition.¹⁴¹ Psychiatrist A. Walk agreed that the employment of an occupational therapist made a significant difference to the conditions of patients who had previously been idle.¹⁴²

Walk suggested that the introduction of AOT only benefited a certain number of patients and left “untouched the general character of the hospital”. Hospitals that adopted MAT, on the other hand, were “transformed” into hives of productive activity, with almost all patients engaged in supervised occupation of some kind.¹⁴³ The recommendations of the Board of Control’s Memorandum, however, indicated that all occupations, whether arts and crafts or work around the hospital, should be focused on the therapeutic benefits to the patient, rather than on the maintenance requirements of the institution. In a departure from the stance taken before World War I, the financial benefits of work around the hospital (discussed in chap. 5) were downplayed by the Board of Control. The introduction of occupational therapy for acute patients, and for those with severe symptoms who had previously been idle, marked a significant change in the way these patients were treated in English mental hospitals. If much of the work around an institution serving a mixed clientele continued to be performed by incurable and chronic and convalescent patients, the primary aim of this work—in theory at least—was to benefit the patient.

Conclusion

From this analysis, it appears that occupational therapy represented a return to the principles of moral treatment. Occupational therapy, whether based on arts and crafts or on work around the hospital, can be seen as a more sophisticated form of the individualised work programmes that comprised moral treatment. Formalised in medical practice and through the training and professional qualifications of its practitioners, occupational therapy was a medicalised and professsionalised version of moral treatment. As such, occupational therapy provides an example of a therapeutic method that was not entirely new, but a re-envisaged form of a pre-existing approach to treating the mentally ill. The curative use of occupation followed in the wake of changes within psychiatric ideology from psychological, to physiological, and to psychobiological perspectives, and from therapeutic optimism to pessimism and back to optimism. In England, and at the Henri Rousselle Hospital in Paris, occupational therapy became a recognised form of treatment for acute cases by psychiatrists who had embraced Adolf Meyer’s psychobiological stance and who believed in the curability of mental disorder. In provincial France, where most psychiatrists continued to adhere to a physiological interpretation of mental disorder, patient work remained in the style of the late nineteenth century. Here, the benefits of work to the institution were at least as important as those to the patient, not least because the provision of work was limited to incurable, chronic and convalescent patients. The financial implications of patient work and occupational therapy are discussed in chap. 5.