MENTAL WELFARE
By
ELIZABETH
39
CASSON, M.D.
All therapeutics must be regarded as treatment of some form of disorder further recovery. In the study of Occupational Therapy one has to take a wide view of the disorders available for such treatment, which may be physical, and vary from a fractured or tuberculous spine to a stiff finger joint following a whitlow; or mental, and vary from a case of acute melancholia to a mild neurosis. An Occupational Therapist is therefore a member of a skilled profession parallel with that of a nurse who has completed both general and mental hospital training. Until this is accepted as a sine qua non, this great aid to recovery will remain in its infancy. At present some mental hospitals have realised their need and have made appreciable use of the method, and anyone who wishes to see it in action must visit a mental hospital or clinic, unless a trip abroad can be undertaken. Unfortunately, even in some of the best English mental hospitals, an idea is prevalent that any one who is pleasant and good tempered and who is capable of teaching basket and rug making may be regarded as being able to start an occupational department?but although occupation is thus provided, therapy is usually absent. As in the case of a physician or nurse, only thoroughly good teaching, combined with years of experience with patients can make a good Occupational Therapist, and without professional training the work is to
impossible.
Her aim is
"
be ready to carry out any activity, mental or physical, definitely prescribed and guided for the distinct purpose of contributing to and hastening recovery from disease and injury." Primarily any occupation which has a curative effect should be available for a patient's use, and the worker must have the knowledge and skill to choose the best for that patient's condition. Each case must be considered separately, and the occupation chosen as carefully as is her treatment by rest in bed, drugs, diet, washouts, vaccines, etc. Just as roast pork is not ordered for a case of gastric ulcer, so a piece of elaborate embroidery is not given to a confused patient to do, nor folk dancing expected from a case of agitated melancholia. There is an infinite variety of occupations that are available to help the patient, but only training and experience can insure that the right one be used. The training must therefore be a full one. A student may already have a knowledge of crafts, and some have had the good fortune to have taken a complete course in an art school before beginning training, but in order to understand the patient's needs and to co-operate intelligently in treatment she must go through adequate courses in psychology, anatomy, and physiology, followed by lectures and demonstrations in mental and physical diseasesto
MENTAL WELFARE
4o Various crafts have
be understood thoroughly, but practice in games and and community dancing singing are equally necessary, as her patient's full includes a return to social life. recovery Above all the student, when qualified, must be ready for work in any type of case, whether mentally or physically ill, and must have experience in the special treatment of orthopaedic patients or those who are phthisical, or suffer from heart disease. To take a few examples. Mental patients usually require much rest, especially at the beginning of a serious illness. Yet one of the most marked features of the case may be a restlessness that hinders any possibility of the necessary repose. The physician prescribes Sedative occupation," and it is the duty of the therapeutist to follow this out. While the patient is in bed various crafts are available, "winding wool, or knitting with large pins, monotonous raffia work, such as lazy squaw stitch, the ravelling of old silk stockings for other patients to weave, or listening to reading aloud. If the patient is actively minded, soap carving is often very restful. Hard white ivory soap slabs are used. A cardboard box lid to keep the bits from messing the bed, and a tool, and design are needed. The tool varies with the patient's condition. A penknife is best but is very likely contraband, a outfit. hairpin, if allowed, or if not, a wooden plasticine tool, completes the " A patient recovering from stupor receives a prescription for stimulation," and while in bed may need to do stitching that requires considerable thought and ingenuity to work out the pattern; jig-saw and cross word puzzles are often useful at this stage. As soon as the patient is up and can go to the Occupation Department, work is far more varied; and exercises and dancing and gardening can be used. Slow breathing and relaxing exercises soothe the restless patient and restore The stuperous patient feels the stimulus of others at work a sense of rhythm. and gradually joins in games and dancing. Net ball is peculiarly encouraging to the patient who is asocial. It is very difficult not to return a ball that is thrown into your hands. Weaving, book-binding, woodwork and polishing, chair caning, all have their uses, sedative, stimulation, or rhythmical. Heart cases require a special study. Much can be done by graduating the effort required. Restlessness can be allayed by some simple craft that keeps the brain and fingers busy without exercising the arms. Orthopaedic cases provide a complete study in themselves. Occupational Therapy is applied to each special disability in the patient. If a joint is stift it can be exercised on a special fretsaw, or a loom, without the patient realising what is being done. There is considerable controversy as to whether any work carried out in the education or training of mental deficients can be called Occupational Therapy. "In the opinion of the writer it is usually not so. The ament is not necessarily disordered and the development of what mind he " has is not therapy," but education. However, in all communities there arc cases of illness, and the defectives are not immune. The Occupational Therapist to
"
"
"
MENTAL WELFARE
41
should know how to apply her art to cases of mental disorder, neuroses, injuries and general illness among mental defectives and must therefore have practice with them as part of her training. As all who are engaged in training mental defectives know, there are many of their pupils whose homes have developed various neuroses, especially an inferiority sense where a child has suffered from being continually compared unfavourably with normal brothers and sisters. The worker then has to do some real occupational therapy in choosing work that will develop a sense of self-confidence. Such cases, if neglected, arc often found in mental hospitals and have by then reached the stage of uncontrollable outbursts of temper, and the therapist can do much to restore a happier condition. In the mental hospital, however, most can be done for the patients who are intelligent; and often for them is opened out a completely new life in learning how to use faculties that till then have lain completely dormant. The aim of all psychiatrists should be to send a patient home with an outlook on life better than it has ever been before, and the Occupational Therapist can have a big share in this. The work must be costly, just as drugs are costly. Material, like medicines, must be given to patients that can make no articles worth selling, nor that can even be used in the hospital. No one can say that material is wasted, if by working on it the patient's condition is bettered. The writer has seen patients sent back from the sewing room because their work is useless." An Occupation Department that refuses such a patient is refusing her necessary treatment. There need be no waste in either the Occupational Department nor the Dispensary, but it is just as unreasonable to expect one to pay as the odier. Yet there should be an aim at producing beautiful finished work, for only by doing her best work will the patient recover her right attitude to life. The patient has fallen out of the struggle for the time, whether physically, or mentally ill, and recovery means a return to the fray. Every activity that helps one to realise the joy of victory prepares one for that struggle with difficulties that makes up most of the interest in being alive. The writer has often been asked if there is difficulty in persuading the patient to be treated by occupation. This does frequently occur, but can usually be managed by tact and firmness as in the case of other necessary treatment. A very important point to emphasise is the necessity of explaining to the patient that the occupation has been prescribed by the doctor. This is specially necessary in the wards of a general hospital, where the patients are often working women who say that They have plenty of work waiting for them at home." When once their preliminary inertia is removed they become enthusiastic and are soon vying with one another in the production of craftwork that they had no idea they had it in them to do. The same difficulty occurs in a hospital where the able-bodied patients "
"
"
"
42
MENTAL WELFARE
do the housework or work in the laundry. If, however, the occupation department is attractive, its atmosphere draws the patient to it, and nothing makes one more anxious to begin work than the sight of other people enjoying what are It is a they doing. great mistake to let patients leave off going to the Occupation Department because they are working. Part of the treatment should be to have the privilege of a few hours a week there in any case. Although much Occupational Therapy must be done in bed the department itself is the more important. If possible it should be separated from the hospital, certainly it "should have its own rooms. There is a definitely good behind for a time, and changing the effect in leaving the hospital wards from to being aided to carry out work, games, atmosphere being nursed, individuals. as music, etc., responsible Out-patients can come daily to complete their cure, after they are well enough to go home, and the department both in general and mental hospitals " school of recovery." Without assistance, conbecomes a much loved valescence is often a depressing period, and any method of shortening it should be undertaken. In England the Insurance laws complicate matters seriously. If well enough to go home and attend hospital as an out-patient, some steady work is much the best method of continuing the cure, but unless the patient be well enough to go to work regularly and be signed off benefit," he is allowed to undertake no work at all. To such a patient the advantage of an Occupational Department, working in close touch with the hospital cannot be over estimated. The physician or surgeon still gives the prescription, and keeps in close touch with the worker who guides the occupation ordered. In America the Insurance Companies actually pay for the Occupational Therapy for cases of fracture, etc., as by doing so they reduce the length of time and disability and their consequent compensation costs. It is hoped that before long Occupation Centres will be established in connection with all the large general hospitals where in- and out-patients, and all classes of disablement, can be treated. Some reference should be made to the subject of training. Until lately there has been no School of Occupational Therapy in the British Isles, and the usual custom has been to go to one of the American schools, of which the best known are at Philadelphia and Boston. The course takes almost 18 months, three terms being spent at the school in the study of the theory of the profession and the necessary crafts, after which the student goes on to the various general, orthopaedic, tuberculous, and mental hospitals, all over America, getting about a month's practice in each institution. The school then gives a Diploma that is recognised as a qualification for practice. So far the only school in England is that started by the writer at Dorset House, Clifton, in charge of Miss Constance Tebbit, who went to America for training, and holds the Diploma of the Philadelphia School for Occupational Therapy. Students have lectures in all necessary subjects, and obtain practice with patients in the writer's residential clinic, and in the various general and "
"
MENTAL WELFARE
43
in Bristol. The students live together in a house in the garden but share the community life of Dorset House and have plenty of opportunity for folk dancing,
special hospitals
games, etc. The prospects for professional Occupational Therapists at present are fair, but, as in the case of all pioneer work, are not as certain as in the case of the older vocations. There is a growing demand for trained workers in mental hospitals, but much propaganda work has to be done before the need for their appointment to general and other hospitals is recognised on this side of the Atlantic. Whenever a vacancy occurs in a mental hospital there is no doubt that a trained worker has far more chance of the appointment than anyone else, and so far the demand for the students from the Dorset House School has exceeded the supply.
By
ELIZABETH
39
CASSON, M.D.
All therapeutics must be regarded as treatment of some form of disorder further recovery. In the study of Occupational Therapy one has to take a wide view of the disorders available for such treatment, which may be physical, and vary from a fractured or tuberculous spine to a stiff finger joint following a whitlow; or mental, and vary from a case of acute melancholia to a mild neurosis. An Occupational Therapist is therefore a member of a skilled profession parallel with that of a nurse who has completed both general and mental hospital training. Until this is accepted as a sine qua non, this great aid to recovery will remain in its infancy. At present some mental hospitals have realised their need and have made appreciable use of the method, and anyone who wishes to see it in action must visit a mental hospital or clinic, unless a trip abroad can be undertaken. Unfortunately, even in some of the best English mental hospitals, an idea is prevalent that any one who is pleasant and good tempered and who is capable of teaching basket and rug making may be regarded as being able to start an occupational department?but although occupation is thus provided, therapy is usually absent. As in the case of a physician or nurse, only thoroughly good teaching, combined with years of experience with patients can make a good Occupational Therapist, and without professional training the work is to
impossible.
Her aim is
"
be ready to carry out any activity, mental or physical, definitely prescribed and guided for the distinct purpose of contributing to and hastening recovery from disease and injury." Primarily any occupation which has a curative effect should be available for a patient's use, and the worker must have the knowledge and skill to choose the best for that patient's condition. Each case must be considered separately, and the occupation chosen as carefully as is her treatment by rest in bed, drugs, diet, washouts, vaccines, etc. Just as roast pork is not ordered for a case of gastric ulcer, so a piece of elaborate embroidery is not given to a confused patient to do, nor folk dancing expected from a case of agitated melancholia. There is an infinite variety of occupations that are available to help the patient, but only training and experience can insure that the right one be used. The training must therefore be a full one. A student may already have a knowledge of crafts, and some have had the good fortune to have taken a complete course in an art school before beginning training, but in order to understand the patient's needs and to co-operate intelligently in treatment she must go through adequate courses in psychology, anatomy, and physiology, followed by lectures and demonstrations in mental and physical diseasesto
MENTAL WELFARE
4o Various crafts have
be understood thoroughly, but practice in games and and community dancing singing are equally necessary, as her patient's full includes a return to social life. recovery Above all the student, when qualified, must be ready for work in any type of case, whether mentally or physically ill, and must have experience in the special treatment of orthopaedic patients or those who are phthisical, or suffer from heart disease. To take a few examples. Mental patients usually require much rest, especially at the beginning of a serious illness. Yet one of the most marked features of the case may be a restlessness that hinders any possibility of the necessary repose. The physician prescribes Sedative occupation," and it is the duty of the therapeutist to follow this out. While the patient is in bed various crafts are available, "winding wool, or knitting with large pins, monotonous raffia work, such as lazy squaw stitch, the ravelling of old silk stockings for other patients to weave, or listening to reading aloud. If the patient is actively minded, soap carving is often very restful. Hard white ivory soap slabs are used. A cardboard box lid to keep the bits from messing the bed, and a tool, and design are needed. The tool varies with the patient's condition. A penknife is best but is very likely contraband, a outfit. hairpin, if allowed, or if not, a wooden plasticine tool, completes the " A patient recovering from stupor receives a prescription for stimulation," and while in bed may need to do stitching that requires considerable thought and ingenuity to work out the pattern; jig-saw and cross word puzzles are often useful at this stage. As soon as the patient is up and can go to the Occupation Department, work is far more varied; and exercises and dancing and gardening can be used. Slow breathing and relaxing exercises soothe the restless patient and restore The stuperous patient feels the stimulus of others at work a sense of rhythm. and gradually joins in games and dancing. Net ball is peculiarly encouraging to the patient who is asocial. It is very difficult not to return a ball that is thrown into your hands. Weaving, book-binding, woodwork and polishing, chair caning, all have their uses, sedative, stimulation, or rhythmical. Heart cases require a special study. Much can be done by graduating the effort required. Restlessness can be allayed by some simple craft that keeps the brain and fingers busy without exercising the arms. Orthopaedic cases provide a complete study in themselves. Occupational Therapy is applied to each special disability in the patient. If a joint is stift it can be exercised on a special fretsaw, or a loom, without the patient realising what is being done. There is considerable controversy as to whether any work carried out in the education or training of mental deficients can be called Occupational Therapy. "In the opinion of the writer it is usually not so. The ament is not necessarily disordered and the development of what mind he " has is not therapy," but education. However, in all communities there arc cases of illness, and the defectives are not immune. The Occupational Therapist to
"
"
"
MENTAL WELFARE
41
should know how to apply her art to cases of mental disorder, neuroses, injuries and general illness among mental defectives and must therefore have practice with them as part of her training. As all who are engaged in training mental defectives know, there are many of their pupils whose homes have developed various neuroses, especially an inferiority sense where a child has suffered from being continually compared unfavourably with normal brothers and sisters. The worker then has to do some real occupational therapy in choosing work that will develop a sense of self-confidence. Such cases, if neglected, arc often found in mental hospitals and have by then reached the stage of uncontrollable outbursts of temper, and the therapist can do much to restore a happier condition. In the mental hospital, however, most can be done for the patients who are intelligent; and often for them is opened out a completely new life in learning how to use faculties that till then have lain completely dormant. The aim of all psychiatrists should be to send a patient home with an outlook on life better than it has ever been before, and the Occupational Therapist can have a big share in this. The work must be costly, just as drugs are costly. Material, like medicines, must be given to patients that can make no articles worth selling, nor that can even be used in the hospital. No one can say that material is wasted, if by working on it the patient's condition is bettered. The writer has seen patients sent back from the sewing room because their work is useless." An Occupation Department that refuses such a patient is refusing her necessary treatment. There need be no waste in either the Occupational Department nor the Dispensary, but it is just as unreasonable to expect one to pay as the odier. Yet there should be an aim at producing beautiful finished work, for only by doing her best work will the patient recover her right attitude to life. The patient has fallen out of the struggle for the time, whether physically, or mentally ill, and recovery means a return to the fray. Every activity that helps one to realise the joy of victory prepares one for that struggle with difficulties that makes up most of the interest in being alive. The writer has often been asked if there is difficulty in persuading the patient to be treated by occupation. This does frequently occur, but can usually be managed by tact and firmness as in the case of other necessary treatment. A very important point to emphasise is the necessity of explaining to the patient that the occupation has been prescribed by the doctor. This is specially necessary in the wards of a general hospital, where the patients are often working women who say that They have plenty of work waiting for them at home." When once their preliminary inertia is removed they become enthusiastic and are soon vying with one another in the production of craftwork that they had no idea they had it in them to do. The same difficulty occurs in a hospital where the able-bodied patients "
"
"
"
42
MENTAL WELFARE
do the housework or work in the laundry. If, however, the occupation department is attractive, its atmosphere draws the patient to it, and nothing makes one more anxious to begin work than the sight of other people enjoying what are It is a they doing. great mistake to let patients leave off going to the Occupation Department because they are working. Part of the treatment should be to have the privilege of a few hours a week there in any case. Although much Occupational Therapy must be done in bed the department itself is the more important. If possible it should be separated from the hospital, certainly it "should have its own rooms. There is a definitely good behind for a time, and changing the effect in leaving the hospital wards from to being aided to carry out work, games, atmosphere being nursed, individuals. as music, etc., responsible Out-patients can come daily to complete their cure, after they are well enough to go home, and the department both in general and mental hospitals " school of recovery." Without assistance, conbecomes a much loved valescence is often a depressing period, and any method of shortening it should be undertaken. In England the Insurance laws complicate matters seriously. If well enough to go home and attend hospital as an out-patient, some steady work is much the best method of continuing the cure, but unless the patient be well enough to go to work regularly and be signed off benefit," he is allowed to undertake no work at all. To such a patient the advantage of an Occupational Department, working in close touch with the hospital cannot be over estimated. The physician or surgeon still gives the prescription, and keeps in close touch with the worker who guides the occupation ordered. In America the Insurance Companies actually pay for the Occupational Therapy for cases of fracture, etc., as by doing so they reduce the length of time and disability and their consequent compensation costs. It is hoped that before long Occupation Centres will be established in connection with all the large general hospitals where in- and out-patients, and all classes of disablement, can be treated. Some reference should be made to the subject of training. Until lately there has been no School of Occupational Therapy in the British Isles, and the usual custom has been to go to one of the American schools, of which the best known are at Philadelphia and Boston. The course takes almost 18 months, three terms being spent at the school in the study of the theory of the profession and the necessary crafts, after which the student goes on to the various general, orthopaedic, tuberculous, and mental hospitals, all over America, getting about a month's practice in each institution. The school then gives a Diploma that is recognised as a qualification for practice. So far the only school in England is that started by the writer at Dorset House, Clifton, in charge of Miss Constance Tebbit, who went to America for training, and holds the Diploma of the Philadelphia School for Occupational Therapy. Students have lectures in all necessary subjects, and obtain practice with patients in the writer's residential clinic, and in the various general and "
"
MENTAL WELFARE
43
in Bristol. The students live together in a house in the garden but share the community life of Dorset House and have plenty of opportunity for folk dancing,
special hospitals
games, etc. The prospects for professional Occupational Therapists at present are fair, but, as in the case of all pioneer work, are not as certain as in the case of the older vocations. There is a growing demand for trained workers in mental hospitals, but much propaganda work has to be done before the need for their appointment to general and other hospitals is recognised on this side of the Atlantic. Whenever a vacancy occurs in a mental hospital there is no doubt that a trained worker has far more chance of the appointment than anyone else, and so far the demand for the students from the Dorset House School has exceeded the supply.
