CH 1 A SHORT HISTORY OF OCCUPATIONAL THERAPY IN MENTAL HEALTH.pdf

A SHORT HISTORY OF 1 OCCUPATIONAL THERAPY IN MENTAL HEALTH CATHERINE F. PATERSON C H A P T E R C O N T E N T S I...

A SHORT HISTORY OF 1 OCCUPATIONAL THERAPY IN MENTAL HEALTH CATHERINE F. PATERSON C H A P T E R C O N T E N T S INTRODUCTION 2 The Beginning of the Profession of Occupational MENTAL HEALTH AND THERAPEUTIC Therapy in Scotland 6 OCCUPATION PRE-19TH CENTURY 3 The Beginning of the Profession of Occupational Therapy in England 8 MENTAL HEALTH AND THERAPEUTIC OCCUPATION IN THE 19TH CENTURY 3 OCCUPATIONAL THERAPY IN THE 20TH CENTURY 10 MENTAL HEALTH AND SOCIAL POLICY IN THE Regulation of Occupational Therapy 11 20TH CENTURY 5 SUMMARY 12 OCCUPATIONAL THERAPY PIONEERS 6 The Beginning of the Profession of Occupational Therapy in the USA 6 INTRODUCTION evil spirits, psychological trauma, genetic inheritance, History is interesting for its own sake, but it also fa- faulty biochemistry and vulnerability to stress. Finally, cilitates our understanding of contemporary roles and the national economy and society’s willingness to pay relationships. Just as our sense of personal identity is have dictated limitations to the provision of services. rooted in family history, our professional identity and Consequently, the therapeutic use of occupation has understanding of the contexts in which we work are fluctuated in relation to medical, social, political and enhanced by knowledge of their development. This economic factors. chapter outlines the history of occupational therapy in Although the concept of the therapeutic use of oc- the field of mental health within the wider context of cupation dates back to antiquity, the term ‘occupa- the social and medical history of psychiatry and the tional therapy’ was not coined until early in the 20th development of the profession as a whole. century, and the first training course in the UK was Throughout history, the care of the mentally ill has not started until 1930. This chapter briefly surveys been dependent on prevailing attitudes and b ­ eliefs. some of the earliest references to occupation as treat- What constitutes ‘normal’ and ‘abnormal’ behav- ment; explores the moral movement in psychiatry iour, and what is considered ‘mad’ or ‘bad’ has varied and other philosophical influences in the late 18th throughout the ages. Beliefs about the causes of ­mental and early 19th centuries; discusses the contribution illness have had a significant influence on the way of psychiatrists Adolf Meyer, David Henderson and sufferers have been treated. Ideas of causation have Elizabeth Casson to the founding of the profession ­included imbalance of the humours, possession by and identifies some of the major developments in 2 Creek's Occupational Therapy and Mental Health © 2014 Elsevier Ltd. All rights reserved.  1  A SHORT HISTORY OF OCCUPATIONAL THERAPY IN MENTAL HEALTH 3 psychiatry and occupational therapy in the 20th cen- from the quiet and withdrawn, and no meaningful tury. Finally, there is a brief discussion of the profes- occupation. There was even wrongful confinement of sional organizations, training and regulation which people who were not in fact mentally ill. Traditional are important to the professionalization of occupa- medical remedies were aimed at re-establishing hu- tional therapy. moral balance and included special diets, bleeding, purging, emetics and blistering, often on a seasonal basis (Jones 1972). MENTAL HEALTH AND THERAPEUTIC OCCUPATION PRE-19TH CENTURY From the very earliest surviving manuscripts, refer- MENTAL HEALTH AND ence was made to the belief that occupation in the THERAPEUTIC OCCUPATION IN form of exercise, work, recreation and amusements, THE 19TH CENTURY can be used to improve mental and physical health. The Greek physician Hippocrates, in the 4th century Eventually, scandals, changes in public opinion and the bc, taught that the brain was the seat of the mind and example of a few asylums run on humanitarian prin- described how mental health depended on a balance ciples led to a period of reform. At the beginning of of four bodily humours: blood, choler, phlegm and the 19th century, the two asylums most celebrated for bile (Digby 1985). Galen, the most influential of the introducing reforms were the Bicêtre in Paris, under Roman physicians, in the 2nd century ad, followed Dr Philippe Pinel (1745–1826), and the York Retreat, the methods of Hippocrates. Seigel (1973, p. 276) founded by layman William Tuke (1732–1822). Pinel records that Galen, ‘advised good nursing care; de- and Tuke became internationally acclaimed for their manded kindness with the emotionally ill; employed introduction of moral treatment for the mentally ill, as physical methods hydrotherapy, showers, sweating, that is, psychological rather than physical treatment local application of heat and sunbathing …. In milder (Paterson 1997). cases he recommended travel, occupational therapy Pinel was appointed to the Bicêtre in 1794, during and, for the educated, an increasing participation in the French Revolution, when the institution housed lectures, discussions, reading and in pastime creative upwards of 200 male patients who were regarded not activities’. only as incurable but also as extremely dangerous. While the idea that madness was caused by evil Instead of blows and chains, he introduced light and spirits, witchcraft, sin or divine intervention, domi- fresh air, cleanliness, workshops and areas for walking, nated popular thinking throughout the Dark and but above all, kindliness and understanding (Batchelor Middle Ages, physicians in Europe continued to ac- 1975). Pinel wrote in his famous 1806 treatise on in- cept Hippocrates’ and Galen’s explanation of the sanity: ‘It is no longer a problem to be solved … I am humoral basis of madness well into the 18th century convinced that no useful and durable establishments … (Porter 1999). In Britain, a rich person with a mental can be founded excepting on the basis of interesting illness would likely be attended at home by a physi- and laborious employment’ (Pinel, reprinted 1962, cian or placed in a private ‘madhouse’. On the other p. 216). hand, the ‘mad’ poor were mainly treated as social de- Tuke and the Society of Friends founded the viants, classed with destitutes, vagrants and criminals. Retreat in 1796 on the Quaker principles of compas- Some were incarcerated in prisons or workhouses, or sion and humanity. The central emphasis was on try- in one of the few hospitals for pauper patients, such ing to help the patient gain enough self-discipline to as Bethlem Hospital in London. The conditions in master his illness. To this end, it was thought impor- which the mentally ill were kept, whether at home tant to create a comfortable, domestic environment in or in an institution, were appalling. They usually in- which the patient could experience normal civilized cluded the use of physical restraint (often by manacles daily living conditions, which would help the process and chains), no heat or lighting, little food, clothing, of self-control. Ann Digby (1985, p. 57) summarized bedding or sanitation, no segregation of the violent the regime: 4 SECTION 1  INFORMING PHILOSOPHY AND THEORY The need to balance the emotions and distract the The foremost of the moral physicians in Scotland patient from painful thoughts and associations was Browne. His first position was as medical super- led to the central feature of the Retreat’s moral intendent at the Montrose Asylum, where in 1837, he therapy: the creation of varied employment and wrote an influential treatise entitled What asylums amusements … the key to moral treatment lay in were, are and aught to be. He wrote: the quality of personal relationships between staff and patients. This is what makes the term moral It is not enough to have the insane playing the part treatment so elusive, and also made the treatment of busy automatons …. There must be an active, so difficult to translate successfully from the and, if possible, intelligent and willing participation Retreat to other institutions in the mid-nineteenth on the part of the labourer, and such a portion century. of interest, amusement, and mental exertion associated with the labour, that neither lassitude Although Pinel and Tuke are most frequently not fatigue may follow. The more elevated, the more credited with the introduction of moral treatment, useful the description of the occupation provided there were other asylum superintendents at the be- then, the better. ginning of the 19th century who were particularly in- (Browne 1837, p. 94). terested in the therapeutic use of occupation as part of a humane regime of care. These included William From the 1840s, the Victorian era in Britain was Hallaran (1765–1825), the first physician of the Cork characterized by the building of large public asylums Asylum; Sir William C. Ellis (1780–1839), medical on the outskirts of every large town for the ‘better care superintendent of the Hanwell Hospital and William and maintenance of lunatics’. Many of these asylums A. F. Brown (1805–1885), the first medical super- became the mental hospitals which were later closed in intendent of the Crichton Institution at Dumfries response to the care in the community policies dating (Paterson 1997). from the 1960s. Nonetheless, these institutions were, Hallaran published a book in 1810 called, On the themselves, the product of social reforms, at a time Cure of Insanity, which advocated the use of suitable when the urban industrialized working class in Britain occupation for ‘the convalescent maniac’, combin- lived in conditions of squalor and grinding poverty ing ‘corporeal action, with the regular employment (Jones 1972). of the mind’. He was the first physician to recognize However, the optimism that cures could be ef- the danger of institutional neurosis and gave the first fected through treatment in an asylum could not be account of the benefit derived from being allowed to sustained. Patients became quieter and more man- paint (Hallaran 1810, cited by Hunter and MacAlpine ageable but most were still unable to return to their 1963, p. 650). former lives. The success of the asylums led to the Ellis was appointed to the newly opened Wakefield admission of more inmates, so that their very size – Asylum in 1818, with his wife as matron. Samuel Tuke many containing 2000 or more patients – made (1784–1857) credited Ellis with: ‘the first extensive and them the antithesis of the domestic surroundings successful experiment to introduce labour system- necessary for treatment on moral principles. Many atically into our public asylums. He carried it out … asylums found it impossible to attract the number with a skill, vigour, and kindliness towards the patients and calibre of attendants required to manage dis- which were alike creditable to his understanding and turbed patients without resorting to measures of his heart’ (Tuke 1841, cited by Hunter and MacAlpine restraint. Thus, during the latter half of the 19th 1963, p. 871). While the men at Hanwell were encour- century and well into the 20th, the individualized aged either to follow their own trade or to learn a new prescription of occupation gave way to the wide- one, Lady Ellis organized the female patients under a spread use of the physically fit patients for work ‘workwoman’ to make ‘useful and fancy articles’, which in the kitchens, laundry, farms and gardens of the were then sold (Ellis 1838, reprinted in Hunter and asylums, as much for economic as for therapeutic MacAlpine 1963, p. 876). reasons (Jones 1972).  1  A SHORT HISTORY OF OCCUPATIONAL THERAPY IN MENTAL HEALTH 5 patients’ physical needs, so that the net result was: MENTAL HEALTH AND SOCIAL ‘institutionalization’. POLICY IN THE 20TH CENTURY Although the Mental Health Act of 1959 greatly re- During the early part of the 20th century, the most duced stigmatizing procedures of admission and dis- important influences on psychiatry were the theories charge, the planned measures to improve care outside of Sigmund Freud (1856–1939) and his associates mental hospitals were not uniformly achieved (Jones Alfred Adler (1870–1937) and Carl Jung (1875–1961), 1993). The 1960s saw the beginning of a sustained de- who developed psychoanalysis and psychotherapy. bate about the legitimacy of custodial care. The criti- Although these new disciplines had a significant in- cisms were led by psychiatrists Ronald Laing, David fluence on the way people thought about mental pro- Cooper and Thomas Szasz – collectively dubbed ‘anti- cesses and on private practice, they had little effect on psychiatrists’ – and by Erving Goffman, whose semi- regimes within British asylums (Shorter 1997). nal work Asylums, published in 1961, drew attention The move beyond the asylum can be traced back to the dangers of the ‘total institution’ (Pilgrim and to the changes in practice during the First World War, Rogers 1993). when the problem of shell-shock required a new re- However, the move from hospital to the commu- sponse to mental distress (Stone 1985). The Mental nity was greatly facilitated by the pharmacological Treatment Act of 1930 blurred the distinction between revolution. It began in the 1950s with chlorpromazine mental and physical illness, so that medical terminol- (a phenothiazine) for the management of schizophre- ogy was adopted; asylums becoming hospitals, for nia, and continued with lithium for manic-depressive example. The Act also further stimulated the develop- psychosis (bipolar disorder), and the tricyclic antide- ment of outpatient clinics and after-care services, as pressants (Shorter 1997). With the new confidence in well as admission of non-fee-paying patients on a vol- medication, the 1962 Hospital Plan for England and untary basis (Jones 1993). Of particular note, was the Wales stated that large psychiatric hospitals should founding of the Marlborough Day Hospital in 1946 by be closed and local authorities should develop com- Joshua Bierer (1901–1984), a pioneer in social psychia- munity services (Ministry of Health 1962). The White try, whose treatments included occupational therapy Paper of 1975 further stated that the mental hospitals (Bierer 1951). The Second World War resulted in many should be replaced by psychiatric units within district problems for mental hospitals – some had been taken general hospitals (DHSS 1975). The development of over to accommodate the war-wounded and there was depot neuroleptic drugs also facilitated the rehabilita- an acute shortage of trained staff, which severely set tion of patients with chronic schizophrenia who had back progress, and although most were taken over by difficulty with complying with oral medication (David the newly founded National Health Service in 1948, et al. 2009). lack of finance continued to be a major problem The ideological and financial pressures on the (Jones 1993). psychiatric hospitals, together with the continuing Denis Martin (1968) described mental hospitals development of effective medication, expedited the during the first half of the 20th century as benignly deinstitutionalization movement, which began slowly authoritarian, in that the satisfactory running of the in the 1960s and gained momentum with each subse- hospital depended on the submission of the patients quent piece of legislation. By the 1990s, a wide range to authority with the minimum of resistance. Methods of supported accommodation had been set up, often of dealing with those who were unable to submit in- by voluntary bodies. Nevertheless, there continued to cluded locked doors, various forms of mechanical be a need for provision for the ‘new long-stay’ patients, restraint, segregation of the sexes, heavy sedation, elec- many of whom were detained under the Mental Health troconvulsive therapy, prolonged sleep and prefrontal Act (1983), and after the closure of the psychiatric hos- leucotomy, which were administered as treatment but pitals this need was largely met by the private sector which could be perceived or even used as punishment. (Killaspy 2007). However, the same authority was, arguably, benevo- By the end of the 20th century, the widespread reli- lent, since the hospital provided security and met the ance on drugs to control symptoms had re-established 6 SECTION 1  INFORMING PHILOSOPHY AND THEORY the somatic basis of mental health problems as the activity appeared to me a fundamental issue in the dominant view, alongside precipitating psychological treatment of any neuropsychiatric patient’ (Meyer and social factors (Shorter 1997). However, medica- 1922, reprinted 1977, p. 639). In 1895, Meyer’s tion does not cure mental health problems, but helps wife, a social worker, introduced a systematic type to control symptoms and facilitate psychosocial forms of activity into the wards of the state institution of treatment. Consequently, there continues to be a in Worcester, Massachusetts, so that: ‘A pleasure need for adequate community services to maximize in achievement, a real pleasure in the use and ac- the effectiveness of interventions (Hirsch et al. 1973, tivity of one’s hands and muscles and a happy ap- cited by David et al. 2009). preciation of time began to be used as incentives in the management of our patients’ (Meyer 1922, OCCUPATIONAL THERAPY reprinted 1977, p. 640). PIONEERS Meyer is generally regarded as one of the found- ers of occupational therapy in the USA, along with The Beginning of the Profession of other professionals who were developing the use Occupational Therapy in the USA of occupation quite independently. These included At the end of the 19th century in the USA, as in Susan E. Tracy (1878–1928) a nurse; Eleanor Clarke Britain, the asylums were suffering from overcrowd- Slagle (1870–1942) a social worker; William Rush ing and economic pressures. However, there was a Dunton Jr (1868–1966) another psychiatrist and resurgence of interest in reform and in structur- George Barton (1871–1923), who was an archi- ing the patient’s day in a more productive manner, tect. Barton became an advocate after his own ill- stimulated by various antecedents. These included ness, when he experienced the beneficial effects of pragmatism, the mental hygiene movement and the directed occupation. He founded an institution in arts and crafts movement, as well as the legacy of Clifton Springs, where people with chronic ill-health the use of occupation as an integral aspect of moral could be retrained or could adjust to gainful living treatment (Paterson 2010). This led to the introduc- by means of occupation. It was at Clifton Springs in tion of an experimental 6-week course in occupa- 1917 that the National Society for the Promotion of tions for asylum attendants at the Chicago School Occupational Therapy was formed, with Barton as of Civics and Philanthropy (Quirago 1995). By its first president. In 1923, the name was changed 1915, the course lasted 2 years, and is considered to the American Occupational Therapy Association the first professional course in occupational therapy (Licht 1967). (Loomis 1992). A major influence on this development, as on The Beginning of the Profession of psychiatry on both sides of the Atlantic, was Dr Occupational Therapy in Scotland Adolf Meyer (1866–1950), who emigrated from Professor Sir David K. Henderson (1884–1965) Switzerland to America in 1892. According to Rowe (Fig. 1-1), a prominent Scottish psychiatrist during the and Mink (1993), Meyer viewed mental illness as first half of the 20th century, was much influenced by the outcome of a person’s maladaptive interaction Meyer, with whom he had worked in the USA. After with the environment. His emphasis on objective returning to Scotland, Henderson became the Medical observation of patient behaviour and on habit was Superintendent of the Gartnavel Royal Hospital in compatible with the psychology of learning that was Glasgow (Figs 1-2, 1-3), where he employed, in 1922, being developed by American pragmatists William Dorothea Robertson (1892–1952), the first instruc- James (1842–1910) and John Dewey (1859–1952), tor in occupational therapy in Britain (Henderson and his views anticipated the biopsychosocial model 1925). Robertson, although a graduate of Cambridge adopted by many psychiatrists in the late 20th University, did not have the benefit of any training, but century. within months, she had made sufficient impact that As early as 1892, Meyer observed that: ‘The the Commissioners of the General Board of Control proper use of time in some helpful and gratifying for Scotland reported that:  1  A SHORT HISTORY OF OCCUPATIONAL THERAPY IN MENTAL HEALTH 7 For many years the advantages of farm and garden work for men and domestic work for women have been recognised from curative and ameliorative aspects and many patients have been so employed. There are, however, many patients not physically fitted for these strenuous labours or whose mental disorder such, for instance, as epilepsy, requires that they be under constant supervision. In all such cases the occupational therapy is being tried with excellent results. Patients were seen under a competent instructress making baskets, toys, rugs, etc. So successful has the treatment been that it is proposed to erect a special building within the grounds of the establishment where manifold light occupations can be carried out. (General Board of Control for Scotland 1923, p. xix). Henderson became an influential figure in the de- velopment of occupational therapy in Scotland, par- ticularly in his encouragement of the founding of the Scottish Association of Occupational Therapy (SAOT) in 1932, and in the reconstitution of the Association FIGURE 1-1  Professor Sir David K. Henderson. Reprinted after the war in 1946, when he became its president with kind permission of NHS Greater Glasgow and Clyde Archives. (Groundes Peace 1957). FIGURE 1-2  The Occupational Therapy Pavilion, Gartnavel Royal Hospital, Glasgow, 1923. Reprinted with kind permission of NHS Greater Glasgow and Clyde Archives. 8 SECTION 1  INFORMING PHILOSOPHY AND THEORY FIGURE 1-3  The interior of the Occupational Therapy Pavilion, Gartnavel Royal Hospital, Glasgow. Reprinted with kind permis- sion of NHS Greater Glasgow and Clyde Archives. The first qualified occupational therapist to work followed suit in appointing instructors, most of whom in Britain was Margaret Barr Fulton (1900–1989) held art college diplomas. By 1932, there were 11 such (Fig. 1-4), who became interested in occupational ladies who, under the direction of Fulton, and with the therapy during a holiday in the USA and who trained encouragement of Henderson, formed themselves into in Philadelphia. At first, Fulton found it difficult to find the SAOT (Groundes Peace 1957). a position. However, she was eventually given an intro- Although Fulton continued to work at the Royal duction to Henderson, who referred her to a former Aberdeen Mental Hospital until her retirement in 1963, colleague, Dr R. Dods Brown, medical superintendent her influence was considerable both throughout Scotland of the Royal Aberdeen Mental Hospital, who secured and worldwide in her capacity as one of the found- her services immediately (Paterson 1996). ers, in 1952, of the World Federation of Occupational In 1929, Dods Brown published an article entitled Therapists and as its first president (Paterson 1996). Some observations on the treatment of mental diseases, in which he gave a description of occupational therapy, The Beginning of the Profession of which was based in an army hut erected in the grounds ­Occupational Therapy in England of his hospital. His article was illustrated with case ma- Among the delegates at the conference where terial, including the reports in Box 1-1. Henderson described the occupational therapy de- Following the appointment of Robertson and partment at the Gartnavel Royal Hospital in 1924 Fulton, it appears that many Scottish mental hospitals was Dr Elizabeth Casson (1881–1954) (Fig. 1-5),  1  A SHORT HISTORY OF OCCUPATIONAL THERAPY IN MENTAL HEALTH 9 FIGURE 1-4  Miss Margaret Barr Fulton MBE. FIGURE 1-5  Dr Elizabeth Casson OBE. Reprinted by kind ­permission of the College of Occupational Therapists and Elizabeth Casson’s family. who was also destined to play an important role in movement, John Ruskin and William Morris, was a the development of occupational therapy in Britain. social reformer passionate about the development Casson first trained as a housing estate manager with of social housing. The settlement movement, creat- Octavia Hill (1838–1912), who greatly influenced ing integrated mixed communities of rich and poor, her. Hill, a friend of the leaders of the arts and crafts grew directly out of Hill’s work. Casson, appalled by BOX 1-1 FROM DODS BROWN, SOME OBSERVATIONS ON THE TREATMENT OF MENTAL DISEASES A man, aged 69, had been in hospital for several months, to do, and in this he became thoroughly interested and in- during which time he did not improve. He spoke to no-one, deed enthusiastic, and when his discharge was being dis- and would not employ himself in any way. He seemed to be cussed, he was reluctant to leave the institution. He made a deteriorating rapidly, and to be passing into dementia. He thoroughly good recovery. was sent to ‘The Hut’ every day, but for more than a week A woman who had been in a depressed, and somewhat he showed not the slightest interest in anything he saw nor agitated condition, and who had maintained almost com- what was said to him. Later he was induced to do a little plete silence for about two years, and who, on account of de- sandpapering, which he did in an entirely mechanical way. lusions of unworthiness, had refused her food, and had been After a time he was given a fret saw to use, and this seemed tube-fed for several months, was put to the occupational to arouse some interest in him. As the days passed it was therapy department. From that time she began to converse, apparent that his interest was growing more and more, not and to take an interest in things outside herself. She im- only in the work, but also in his personal appearance, be- proved steadily and rapidly, and was discharged recovered. cause one day he objected to the sawdust getting on his clothes. As time went on he was given more difficult work Dods Brown 1929, p. 684–685) 10 SECTION 1  INFORMING PHILOSOPHY AND THEORY the neglect of the poor, qualified as one of the first Lecture delivered at the annual conference of the women doctors at Bristol in 1919, and chose to spe- College of Occupational Therapists. cialize in psychological medicine. In 1926, while on holiday in America, she visited an occupational ther- OCCUPATIONAL THERAPY IN THE apy department at Bloomingdale Hospital, New York, 20TH CENTURY and the Boston School of Occupational Therapy, where the idea of an English school on similar lines Since the first occupational therapy departments was conceived (Casson 1955). were opened in the UK over 80 years ago, the places At that time, Casson was employed at the Holloway where occupational therapists work and the col- Sanatorium, where there was a tradition of many leagues they work with have changed markedly. forms of occupation, including games, entertainments Occupational therapists have continually adapted in and the annual sports day. One of the instructresses, response to changes in healthcare, demography, so- Alice Constance Tebbit (1906–1976), later Mrs Glyn cial and political policy, and technology; and their Owens, obtained a scholarship at the Philadelphia own knowledge base and skills have developed con- School of Occupational Therapy and qualified in 1929 siderably. The pioneering occupational therapists (Casson 1955). worked in mental hospitals, mainly treating acute By this time, Casson had fulfilled her ambition admission patients and those long-term patients of founding a residential clinic for women psychi- whose condition precluded them from working in atric patients at Dorset House in Bristol, to which one of the ancillary services of the hospital. They was attached the first school of occupational therapy were based in departments where groups of patients in the UK, which opened on 1 January 1930, with attended classes centred mainly on the arts and Tebbit as its first principal. The school later moved crafts, and technicians, especially for woodwork and to Dorset House in Oxford, where it is now part of pottery, were often employed. Occupational thera- the Oxford Brookes University. At the Bristol clinic, pists also participated in the wide range of social Casson decided: and recreational activities which characterized most mental hospitals (Paterson 2010). to establish a treatment centre where each patient’s By the late 1950s, home units had been introduced daily life would be so planned that it fitted the to prepare patients for discharge and a greater em- individual’s need like a well tailored garment. She phasis was placed on social, self-care and home-care planned that each member of the household, whether skills (Thomlinson and Kerr 1959). By the 1960s, so- patient or staff, should feel an integral part of the cial psychiatry had stimulated the introduction of day whole and each would contribute, according to hospitals and group psychotherapy to many hospitals. capacity, to the welfare of the whole. There would be Hester Monteath recalled that with the introduction no sharp social or professional distinctions between of the new drugs at that time: ‘The impact of the phe- members of staff …. In this community everyone nothiazines on the long-stay hospital was to stimulate would be essential and therefore would feel valued an unattractive backwater into a scene of great activ- and valuable. ity with patients, formerly doomed to a life sentence (Owens 1955, p. 96). in hospital, receptive to treatment and rehabilitation’ (Monteath 1980, p. 16). This philosophy anticipated the concept of the ther- At a time of low unemployment and a thriving apeutic community developed after the Second World manufacturing industry in the UK, one of the changes War by, among others, Maxwell Jones (1907–1990) was the development of industrial units alongside the and David Clark (1920–2010), who both had studied occupational therapy departments to replace hos- under Henderson (Clark 2005). pital utility units as a focus of vocational rehabilita- Dr Casson was a source of inspiration and encour- tion (Davidson 1963). Payment to patients was often agement to occupational therapists throughout her regulated by the application of behavioural psychology life, which is commemorated by the Casson Memorial (Willson 1983).  1  A SHORT HISTORY OF OCCUPATIONAL THERAPY IN MENTAL HEALTH 11 As consumer goods became more available and students to qualify in either physical or psychiatric craftwork less popular, creative therapies such as practice, and launched a journal (Anon 1955; Hume drama, art, creative writing, music, various forms of and Lock 1982). From 1939 to 1945 the Association exercise, gardening and poetry became more prevalent was immersed in the war effort, including the organi- (Willson 1983). Occupational therapists were becom- zation of shortened courses for occupational therapy ing evermore specialist in distinct areas of practice auxiliaries for the military hospitals (Macdonald 1957). such as learning disabilities, child, adolescent and fo- After the war, in 1948, the whole management of rensic psychiatry, and care of the elderly. Techniques, healthcare services was revolutionized by the forma- such as relaxation, social skills training, anxiety tion of the National Health Service, whereby respon- management, desensitization, reality orientation, as- sibility for all psychiatric services, except some small sertiveness training and counselling were also being homes, became a national rather than a local author- increasingly applied (Willson 1983, 1984). By 1988, ity responsibility, with services being free at the point occupational therapists in the UK were basing their of delivery. Most occupational therapists became em- treatment on much more clearly defined theoretical ployees of the NHS (Paterson 1998). frameworks – psychoanalytic theory, behaviourism, A commission was soon set-up to consider the staff- humanistic approaches and developmental theories – ing and training requirements of the new service, and and were becoming interested in the emerging occupa- representatives of the AOT and SAOT became involved tional therapy theories emanating from the USA, such in protracted negotiations on how occupational therapy as Gary Kielhofner’s Model of Human Occupation should be regulated. The Professions Supplementary (Finlay 1988). These theoretical frameworks stimu- to Medicine Act (1960) provided for boards for each lated a revival of interest in the concept of occupation, paramedical profession, regulated by the Council of and Yerxa et al.’s proposal for a formalized academic Professions Supplementary to Medicine (CPSM) re- discipline named ‘occupational science’ in 1989, has sponsible to the Privy Council (Mendez 1978). The Act inspired a resurgence in pride in the term (Ilott and was significant, in that it recognized the need for properly Mounter 2000). qualified and registered occupational therapists to work By the 1990s, occupational therapists were work- in the NHS and the diplomas of the two associations ing in a complex system of mental health provision were recognized as qualifications for entry to the regis- provided by the NHS, local authority, non-statutory ter. The CPSM was replaced by the Health Professions agencies and charities, and in a broad range of clinical Council in April 2002, which changed its name to the and community environments. Despite the challenges, Health and Care Professions Council in August 2012. by the end of the century, Ormston (2002) considered This body is now responsible for standards of education, that occupational therapists, with their training, were continual professional development and conduct. well placed to undertake the generic work necessary In 1952, Owens, the then Principal of the Liverpool for a multidisciplinary team to be effective. However, School, hosted a meeting to form the World Federation this should not be at the expense of their specialist role of Occupational Therapists (WFOT). The constitution in using occupation to enhance people’s functioning drawn up required that the AOT and SAOT should be and quality of life. jointly represented on the WFOT Council, which led to the Joint Council of the Associations of Occupational Regulation of Occupational Therapy Therapy in the UK. Cooperation between the two as- While the Scottish Association of Occupational sociations inevitably led to amalgamation and to the Therapy (SAOT) had been formed in 1932, the formation of the British Association of Occupational Association of Occupational Therapists (AOT), cover- Therapists in 1974 (Paterson 2007). ing the rest of the UK, had its inaugural meeting in One of the outcomes of this amalgamation was re- 1935, when Owens (née Tebbit) was elected chairper- vision of training, particularly the phasing out of the son. In the few years leading up to the Second World national diploma examinations, a system which had War, the AOT organized the first national examina- become unwieldy with increasing numbers of stu- tions in occupational therapy, which initially allowed dents. The new system of validation of courses paved 12 SECTION 1  INFORMING PHILOSOPHY AND THEORY the way for the development of degree courses, the first Browne, W.A.F., 1837. What Asylums were, are and aught to be. being approved in Belfast and Edinburgh in 1986 (Jay Reprinted in: Scull, A., 1991. The Asylum as Utopia: W A F Browne and the Mid-Nineteenth Century Consolidation of Psychiatry. et al. 1992). Since then, the profession has achieved Tavistock/Routledge, London, pp. 1–231. all-graduate status and is increasingly focused on re- Casson, E., 1955. How the Dorset House School of Occupational search and evidence-based practice. Therapy came into being. Occup. Ther. 18 (3), 92–94. Clark, D., 2005. Therapeutic Memories: Maxwell Jones. Available at: http://archive.pettrust.org.uk/pubs-dhclark-maxjones.htm SUMMARY (accessed 21.09.11.). David, A.S., Gibbs, A., Patel, M.X., 2009. Long-acting antipsychotic Historically, the use of occupation as an integral aspect medication and the outcome of schizophrenia. In: Gattaz, W.F., of treatment has fluctuated in relation to prevailing Gerardo, B. (Eds.), Advances in Schizophrenia Research. Springer, ideas about the causes of mental illness and other so- New York, pp. 403–416. cial and political factors. Of particular importance was Davidson, J.E., 1963. The occupational therapist in industrial work the moral treatment developed in small asylums in the in the mental field. Occup. Ther. 26 (5), 12–14. Department of Health and Social Security (DHSS), 1975. Better early 19th century, where individualized programmes Services for the Mentally Ill. HMSO, London. of work and leisure and good interpersonal relation- Digby, A., 1985. Moral treatment at the retreat, 1796–1846. In: ships between staff and patients were paramount. Bynum, W.T., Porter, R., Shepherd, M. (Eds.), The anatomy of From the inspiration of three psychiatrists and a madness: essays on the history of psychiatry, vol. I. Tavistock, handful of remarkable pioneering occupational thera- London, pp. 52–72. Dods Brown, R., 1929. Some observations on the treatment of men- pists, the profession has developed in the relatively tal diseases. Edinb. Med. J. 36 (11), 657–686. short period of some 80 years, so that by 2011, there Ellis, W.C., 1838. A treatise on the nature, symptoms, causes, and were over 32000 registered occupational therapists in treatment of insanity, with practical observations on lunatic the UK. Having been involved in the treatment of the asylums, and a description of the pauper lunatic asylum for the most intractable problems within psychiatric hospi- county of Middlesex at Hanwell, with detailed account of its man- agement. Holdsworth, London. tals before the introduction of effective drugs in the Finlay, L., 1988. Occupational Therapy in Psychiatry. Croom Helm, 1950s and the gradual deinstitutionalization of pa- London. tients since then, the profession has an even greater General Board of Control for Scotland, 1923. Tenth Annual Report. challenge in the 21st century. Occupational therapists HMSO, Edinburgh. are now required to provide services to a wide range Groundes Peace, Z., 1957. An outline of the development of occupa- of service users, from the young to the very old, in di- tional therapy in Scotland. Scott. J. Occup. Ther. 30, 16–43. Goffman, E., 1961. Asylums: Essays on the Social Situation of Mental verse settings and fulfilling varying roles within teams. Patients and Other Inmates. Anchor Books, New York. In the ever-changing organization and structure of Henderson, D.K., 1925. Occupational therapy. J. Ment. Sci. 71 (292), the health, social and voluntary services, they need to 59–73. be proactive in the provision of effective services for Hirsch, S.R., Gaind, R., Rohde, P.D., Stevens, B.C., Wing, J.K., 1973. people with mental health problems, wherever they Outpatient maintenance of chronic schizophrenic patients with long-acting fluphenazine: double-blind placebo. Br. Med. J. 1 may be. Occupational therapists should continue to be (5854), 633–637. mindful of the humanistic ideals on which the profes- Hume, C.A., Lock, S.J., 1982. The golden jubilee, 1932–1982: an his- sion was founded: the belief in the therapeutic value torical survey. Br. J. Occup. Ther. 45 (5), 151–153. of meaningful occupation, the importance of the envi- Hunter, R., MacAlpine, I., 1963. Three hundred years of psychiatry, ronment and of satisfying interpersonal relationships, 1535–1860. Oxford University Press, London. Ilott, I., Mounter, C., 2000. 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