Major trends in the use of occupation as therapy in Ireland 1863-1963

Introduction

The value and importance of recording and interrogating the history of healthcare services, professions and institutions is widely accepted. The history of occupational therapy internationally has been recorded and researched to varying degrees. With a few notable exceptions, major gaps exist in the recorded history of Irish occupational therapy. Published research to date includes:

• interviews with two Irish occupational therapy pioneers, Anna King (Boland and Boyle, 1997) and Ann Beckett (Patterson, 1992);

• interviews with professionally qualified occupational therapists who started working in the 1970s in Ireland (Lynch and Pettigrew, 2014);

• a report on a memorial for Ann Beckett (Cremin, 2004);

• an appreciation of Ann Beckett (Butler and Ryan, 2004); and

• historical documentary research on the use of occupation in an Irish institution from 1890 to 1920 (Prendiville and Pettigrew, 2015).

In this paper, an overview of three major transitions in the history of occupational therapy in Ireland will be presented: from moral treatment to medical patronage of occupational therapy, from medical patronage to the early/pre-professional era and finally from the early/pre-professional era to the era of professionally qualified therapists.

Recorded histories of occupational therapy in other countries (Friedland, 2011; Paterson, 2010; Wilcock, 2002) have identified that occupation was used for therapeutic purposes long before the advent of professionally trained occupational therapists or professional training programmes for occupational therapists.

Moral treatment

Moral treatment was an approach to working with people who had a mental illness and were admitted to institutions that emerged in the late eighteenth century, based on humane psychosocial care, kindness, consideration for patients and the provision of work and other activities (Peloquin, 1989; Peloquin, 1994; Prendiville and Pettigrew, 2015; Schwartz, 2003). Moral treatment often assumed quite different forms in the different jurisdictions where it was practiced and frequently featured as one among several more traditional treatment alternatives (Charland, 2011). The primary features of moral treatment were:

• first, an aim to stabilise physical and mental health and wellbeing by ensuring proper rest, nutrition and activity in a therapeutic environment;

• second, a highly patient-centred approach to treatment; and

• third, in line with its name, moral treatment was supposed to be “moral”, therefore, special attention was paid to manipulating mental and psychological variables when formulating treatment plans (Charland, 2015).

The expression of humanistic values of the moral treatment movement marked the emergence of occupation as a treatment for people who had a mental illness (Wilcock, 2002), and ultimately created the conditions for the development of occupational therapy (Peloquin, 1989; Prendiville and Pettigrew, 2015). Dr William Saunders Hallaran was an early Irish proponent of moral treatment. He authored the first Irish textbook on psychiatry, published in 1810, and was concerned about the detrimental impact on patients who were obliged “to loiter away the day in listless apathy!”. He advocated productive activities such as horticulture stating that such activity “seldom fails to confirm and to accelerate the prospect of recovery” (Hallaran, 1810, p. 101). Paterson (2014) identified that Hallaran’s (1810) textbook not only advocated for the use of occupation for the “convalescent manic” but also presents the first account of the benefits of painting. Hallaran describes a young man who was admitted to the asylum[1] in a state of acute mania and three months later was being treated as a convalescent patient. Attempts to encourage the man to engage in light work had failed; however, he was by chance discovered amusing himself colouring on the walls of his apartment and when promised colours of a “better description” “this evidently gave immediate cheerfulness to his countenance” (Hallaran, 1810, p. 105). Hallaran further describes how after being provided with the “necessary apparatus” and beginning to paint, the patient:

[…] soon became elated with the approbation he had met with, and continued to employ himself in this manner for nearly two months after, with progressive improvement as to his mental faculties, when he was dismissed cured (Hallaran, 1810, p. 105).

Freebody, (2016) identifies that Hallaran’s book (1810) and a publication by Tuke, (1813) were the first publications to specifically advocate patient work; in later years (1820-1840), a significantly greater number of publications discussed the therapeutic benefits of work including Burrows, (1828) and Ellis, (1838). There were, however, other reasons for using occupation in psychiatric institutions. As Hall, (2016), p. 314 notes:

[…] a pattern of regular daily activity was seen as conducive to less disturbed behaviour (not necessarily as therapeutic); and […] the use of patient work in utility departments kept hospital costs down.

A select committee was appointed in 1817 by the House of Commons to inquire into the conditions of the lunatic poor in Ireland (Williamson, 1970). The decision to establish the committee was based on the need for public provision for accommodation of the Irish lunatic poor and the need to address the frequently appalling conditions of many publicly supported institutions in Ireland at that time (Williamson, 1970). The report of this committee and subsequent legislation led to the establishment of a network of district asylums between 1825 and 1835 in Ireland (Williamson, 1970). This network of asylums applied the enlightened principles of moral treatment (Williamson, 1970). In 1827, Elizabeth Fry (1780-1845), an English prison reformer and her brother, undertook a three-month tour of prisons, lunatic asylums, houses of industry and infirmaries in Ireland (Isba, 2010). Fry’s subsequent report describes appalling conditions in many Irish asylums (Isba, 2010); however, it also reports good practice in asylums at Limerick, Armagh and the Richmond, Dublin, where it was reported that the governors were enlightened and a large number of patients were employed in occupations including knitting, cleaning, spinning or needlework for women and gardening or weaving for men (Williamson, 1970).

By 1880, there were 22 district asylums in Ireland (Armagh, Ballinasloe, Belfast, Carlow, Castlebar, Clonmel, Cork, Down, Ennis, Enniscorthy, Kilkenny, Killarney, Letterkenny, Limerick, Londonderry, Maryborough, Monaghan, Mullingar, Omagh, Richmond, Sligo and Waterford). Inspectors of lunatics annually reported on the district asylums (Prior, 2012). Historical documentary research on the inspectors’ annual reports from 1850 to 1880 describes extensive use of work or occupation for curative purposes in these asylums (Conway, 2014). Examples listed in the reports include basket weaving, carpentry, gardening, farm work, repairing clothes and laundry. The reports reveal a view of work as vital to the patients’ health and wellbeing:

They [in reference to the farms] afford outdoor occupation, and if there be one curative or tranquilizing accessory better than another, it will be found in exercise, and the healthful employment of the insane out of doors (Inspectors of Lunatics, 1865, p. 12).

While work was largely viewed as curative and therapeutic, the working conditions were sometimes criticised. In reference to the Limerick Asylum, the inspectors stated:

I regret to observe on the wretched condition of the laundry, in which I see no less than twenty-three females actually jammed against each other at the wash tubs (Inspectors of Lunatics, 1864, p. 30).

Such reports continued and conditions often remained unchanged.

Moral treatment declined during the latter half of the nineteenth century. A number of factors contributed to its demise including dwindling optimism about recovery or cure, increasing patient numbers which defied treatment on moral principles and challenges attracting enough skilled attendants (Paterson, 2014; Scull, 1993). Overcrowding led to the necessity to employ more staff, often untrained, influencing the standard of care (Williamson, 1970). By 1835, most asylums were overcrowded, and financial pressures meant increased reliance on income from patients’ labour. Therefore, remunerative rather than therapeutically valuable work was emphasised and the focus on therapy was lost (Williamson, 1970). From the second half of the nineteenth century onwards, the use of physically fit patients for work as much for economic benefits as therapeutic benefits became widespread (for example, work in hospital kitchens and laundries) (Paterson, 2014). Despite its eventual decline, however, it is clear that similar to developments in other countries, moral treatment had a significant influence on the care of people with mental illness in Ireland in the mid-late nineteenth century. Occupation was in use for a range of reasons including for curative purposes. However, occupation was also essential to the economic survival of the institution, and people incarcerated in these institutions had little or no choice as to what occupations they could participate in. The use of occupation at this time was often only partly orientated towards therapeutic goals.

It was in the twentieth century that occupational therapy was formalised when the therapeutic use of occupation was combined with humanistic ideals. In March 1917, the founding meeting of the National Society for the Promotion of Occupational Therapy was held at Consolation House in Clifton Springs, New York (Quiroga, 1995); the name was changed to the American Occupational Therapy Association in 1923 (Licht, 1967). In the early years of the twentieth century, significant influences on the development of occupational therapy included the First World War and the resultant need for rehabilitation of soldiers and the international emergence of the idea of rehabilitation (Christiansen and Haertl, 2014; Wilcock, 2002). Rehabilitation of injured World War 1 soldiers in Ireland at British Military hospitals included the use of curative workshops which aimed to help physically disabled soldiers move from dependence to independence and employment. In the curative workshop at the Military Orthopaedic Hospital at Blackrock, Dublin, soldiers engaged in net-making (Manuel, 1918). The war also had lasting impacts on the development of psychiatry (Kelly, 2014c; Wilcock, 2002) and occupation was used therapeutically in the treatment of shell shocked soldiers including at Dublin?s Richmond War Hospital (Kelly, 2014c; Reynolds, 1992).

Medical patronage

The first mention of occupational therapy identified through keyword searches of Irish newspaper archives is an article in the Irish Times in 1930 about services at Peamount Sanatorium near Dublin.

Dr Eamon O’Sullivan (1897-1966) was appointed Resident Medical Superintendent at Killarney Mental Hospital, Co Kerry in 1933. O’Sullivan developed an occupational therapy department at the hospital from the 1930s until his retirement in 1962 and was a proponent of the curative properties of occupation throughout his career. O’Sullivan described being inspired by the Simon method, (O’Sullivan, 1955). Hermann Simon, a German psychiatrist, proposed the concept of “active therapy” in 1923 to overcome detrimental consequences of living in an asylum. He advocated occupational therapy where inpatients had to work and be responsible for the results of their work and activities. Simon suggested that occupational therapy enhanced patients’ energy, their capacity of resistance, tenacity, attention, self-esteem and responsibility (Schmiedebach and Priebe, 2004).

O’Sullivan published one of the first psychosocial textbooks of occupational therapy (O’Sullivan, 1955). The foreword to the book was written by Dr William Rush Dunton Junior (O’Sullivan, 1955), an American psychiatrist and a founding member of the American Occupational Therapy Association (Peloquin, 1991). In the foreword, Dunton states, “It is pleasant to be able to say that I know of no other work on the subject, hitherto seen, which is so complete and specific”. He also praises the emphasis on “the importance of consideration of the individual in prescribing occupational therapy for mental patients” (pp. 6-8).

In 1956, O’Sullivan was awarded an MD from University College Cork for his published work on occupational therapy.

Although his contribution to occupational therapy has not been acknowledged fully in contemporary Irish occupational therapy to date, his illustrious career as a County Kerry Gaelic Athletic Association (GAA) football trainer has meant that auto-biographical notes and a biography exist (Fogarty, 2007). His commitment to occupational therapy is supported by oral history interviews that have been conducted with his former colleagues who recall his use of farm work, printing and other activities as therapy and his then national reputation as a leader in occupational therapy (Cronin, 2015).

Dr D. Kelly (inspector of psychiatric hospitals) in his report to Killarney Mental Hospital Committee in 1932 reported in the Irish Press that he was very pleased with the “occupational therapy treatment” organised by O’Sullivan. Kelly described the occupational therapy department as a “hive of industry” and complimented the “magnificently” made carpets and other products such as baskets, toys, leather-work, matting and tweeds.

A major project completed as part of O’Sullivan’s occupational therapy programme was the construction of Fitzgerald GAA Stadium, Killarney, by patients of the Mental Hospital in the 1930s. This involved levelling the pitch and hard physical labour (Fogarty, 2007) and provoked public controversy about the potential exploitation of patients (Moran, 2011); however, interviews with former staff members from the Hospital refuted these claims (Cronin, 2015). No records of patients’ perspectives on this have been located.

Psychiatrist Dr Ada English (1875-1944) also pioneered occupational therapy. English’s political contributions and career as a psychiatrist have been extensively researched (Davoren et al., 2011; Kelly, 2014a, 2014b). English began working at Connaught District Lunatic Asylum in Ballinasloe, Co Galway in 1904; however, it was not until 1941 that she was appointed as Resident Medical Superintendent. During the four decades she worked at Ballinasloe, English championed the development of therapeutic innovations including occupational therapy, and her interest in occupational therapy was acknowledged in her obituary (Kelly, 2014b).

Jennifer Creek (2007) described how occupational therapists who worked under the direction of medical staff in the early decades of the twentieth century made a clear distinction between the use of occupation as therapy and other uses such as economic purposes. At this time, the occupational therapist provided practical skills to engage patients, while the doctor provided knowledge of medical theory which enabled occupations to be used therapeutically (Creek, 2007). In discussing medical patronage of occupational therapy, Creek cites Eamon O’Sullivan’s textbook (O’Sullivan, 1955) as an example.

Pre-professionally qualified/early trained occupational therapists

From the 1930s to the 1950s nurses, former patients of tuberculosis sanatoria, craft workers and others worked in occupational therapy departments as occupational therapists and used the title occupational therapist frequently without formal qualifications or training (Caden, 2014; Cahill and Pettigrew, 2016). A number of these individuals completed a six-month course in occupational therapy at Cardiff Mental Hospital including those nurses who were employed at Grangegorman Mental Hospital in Dublin (Cahill, 2016; Kelly, 2016). Evening classes in occupational therapy were commenced in North Strand Technical School Dublin in September 1952 focusing on training by arts and crafts teachers in leather work, toy making, basket work and similar subjects. The Irish Occupational Therapy Association was established by these nurses and craft teachers in March 1951 (Fanning, 1951). Over a decade later, the Association of Occupational Therapists of Ireland (AOTI) was founded by professionally qualified occupational therapists.

Donal Kelly (born 1928) was appointed as an occupational therapist in Castlerea Sanatorium, Co Roscommon in 1952. Kelly was a former tuberculosis patient who had a lengthy in-patient stay in Castlerea. An oral history interview completed with him by Caden (2014) provided a rich description of his role in the Sanatorium facilitating craft work including marquetry, embroidery and leatherwork. Kelly had experience of occupational therapy as a patient where he had observed the benefit of craft work and was appointed as an occupational therapist based on his experience without any formal qualifications or training. Kelly worked subsequently as an occupational therapist in the regional sanatorium for tuberculosis in the west of Ireland, Merlin Park, Co Galway in 1955. When tuberculosis was brought under control, Merlin Park became an orthopaedic hospital, and Kelly continued to work there as an occupational therapist until his retirement. While working at Merlin Park, Kelly described less use of craft over time and how he used his creativity to devise assistive devices. He trained in splint making with a Merlin Park plaster technician (Caden, 2014).

Kelly retired in 1992 and described his experience of working alongside a professionally qualified occupational therapist in Merlin Park for the first time towards the end of his career. Despite his initial fears, they developed a collegial working relationship (Caden, 2014). This occurrence was repeated in institutions all over the country, as the era of early/pre-professionally qualified occupational therapists overlapped with the first appointments of professionally qualified occupational therapists (Cahill and Pettigrew, 2016); in some cases, relationships were collegial, as described by Kelly, but, in other cases, there was tension and sometimes competitiveness (Cahill, 2016).

Olga Gale (1926-2014) straddles the early/pre-professional and professional occupational therapy eras in Ireland. Gale enrolled at Dorset House School of Occupational Therapy, Oxford in 1944 (Dorset House archive, 1944). Although the Dorset House records indicate that she completed the course in 1947 (student number 326) (Dorset House archive, 1947), in her oral history interview, Gale stated that she undertook two years of the course but did not complete due to ill health (Gale, 2013). Gale’s account is corroborated by the fact that she did not register as a member of the British Association of Occupational Therapy (Communication with BAOT/COT archives, Wellcome Trust). Therefore, Gale was not a professionally qualified occupational therapist but did complete the majority of an occupational therapy training programme. The curriculum and exam papers from Dorset House at that time indicate that students such as Gale were examined on psychology, psychiatry and how to use activities (including crafts) to treat physical and psychiatric conditions (Dorset House Archive, 1946). Gale was employed as an occupational therapist at St. Patrick’s Hospital Dublin from 1946 to 1948 and from 1950 to 1952 (St. Patrick’s Hospital Board, 1947, 1948, 1950, 1952; Gale, 2013), and in her interview, she recalls using basketry, sewing, drawing, glove making and embroidery as occupational therapy for a variety of therapeutic aims (Gale, 2013). Gale also held dances and invited her friends, where they and the patients danced together. These dances were very popular; she held them with the aim of reducing stigma and to give the patients an “opportunity for liberation”.

The need for occupational therapy services during the Second World War led to an increased number of educational programmes in the United Kingdom (UK) (Wilcock, 2002) and had an impact on Irish occupational therapy development, as the first professional occupational therapists began to work in Ireland post war, having trained in the UK.

Professionally qualified occupational therapists

Ann Beckett (1927-2002) was the first professionally qualified occupational therapist to practice in Ireland. An interview with Beckett conducted by Patterson (1992) and published in the Irish Journal of Occupational Therapy details her career. Beckett was introduced to occupational therapy through a magazine article with photographs of ex-servicemen being treated by occupational therapists (Patterson, 1992). Like Olga Gale, she studied at Dorset House School of Occupational Therapy. Beckett started her training in Dorset House in Bromsgrove, Worcestershire in 1945. The course was three years long, a third of which was spent acquiring and practicing clinical skills (Wallis, 1987). The first year was spent in intensive craft activities. In 1946, Beckett’s second year of training, Dorset House moved into premises on the grounds of the Churchill Hospital, Oxford – an ex-Emergency Medical Service hospital and later an Italian Prisoners of War Camp (Jones, 2013).

Beckett graduated in 1948, and on return to Ireland, she organised an interview with the then Minister for Health (Nöel Browne) to discuss the opportunities for occupational therapy in the health service. The minister could not see any possibilities for professionally qualified therapists due to the already established personnel who were working in the role (Patterson, 1992). Beckett was subsequently employed by the Irish branch of the British Red Cross, becoming the first professionally qualified occupational therapist to work in Ireland. Beckett worked with ex-servicemen and faced many challenges around clarifying the boundaries and scope of the profession (O’Mahoney, 2015).

In 1954, Beckett established an occupational therapy department at Cherry Orchard Hospital, Dublin, and two years later in the Central Remedial Clinic (CRC), Dublin (O’Mahoney, 2015). She spent 16 years developing the service in CRC and then moved to St. Joseph’s College of Occupational Therapy, Dublin where she taught practical classes – printing, woodwork, gardening and music (O’Mahoney, 2015).

Other professionally qualified early occupational therapists in Ireland include Sr. Eugene Butler, who initially worked at Cappagh Orthopaedic Hospital, Dublin (starting in 1959) and who subsequently pioneered a day service at St. Anthony’s Rehabilitation Centre, Dublin, and Anna King, who was the first professionally qualified occupational therapist at St. John of God’s Psychiatric Hospital, Dublin (Boland and Boyle, 1997; Ring, 2013).

The National Organisation for Rehabilitation and the Board of the National Medical Rehabilitation Centre (now the National Rehabilitation Hospital) established a professional training programme for occupational therapists at St. Joseph’s College of Occupational Therapy in Dun Laoghaire, Dublin in 1963 (AOTI, 2015a). This was a World Federation of Occupational Therapists-approved three-year diploma that was conferred on students by the Association of Occupational Therapists (for England, Wales and Northern Ireland). The AOTI was founded in 1965, and Ann Beckett, Sr. Eugene Butler and Anna King were among its founding members of (AOTI, 2015b). The first Director of Training at St. Joseph’s College of Occupational Therapy was Joy Rook who was previously the Director of Training at the Liverpool School of Occupational Therapy. The first cohort of students at St. Joseph’s included a large number of psychiatric nurses who had been sent by their hospitals to become professionally qualified occupational therapists. St Joseph’s College of Occupational Therapy joined the Faculty of Health Sciences, University of Dublin, Trinity College in 1986.

Conclusion

In this paper, the first 100 years of the use of occupation as therapy in Ireland has been outlined. Similar to other countries, the inception of the profession of occupational therapy has been identified as inseparable from the moral treatment era in psychiatric institutions. From the early part of the twentieth century, the advancements made under medical patronage, which led to the establishment and more formal recognition of occupational therapy within institutions, have been described. The most recent transition involved a move to recruitment of professionally qualified therapists and parallel developments in the professional organisation and the establishment of St. Joseph’s College of Occupational Therapy in 1963.

Historical research is valuable not only for recording and commemorating key events and individuals but also for enhancing our understanding of contemporary practice. The AOTI recently celebrated their 50th anniversary (AOTI, 2015a), and in 2017, it is 100 years since occupational therapy was formalised in Clifton Springs, New York, America. Occupational therapy is a relatively young profession and great opportunities exist to research its history in Ireland to capture the memories and experiences of the pioneers who laid the foundation of the profession as well as to situate the development of occupational therapy in the broader social, cultural and scientific contexts within which this currently thriving profession developed.