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t>UBLlC HEALTH Lidka^^i



BERKELEY

LIBRARY

UNIVERSITY OF
CALIFORNIA




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PUBLIC

HEALTH
LIBRARY



OCCUPATION THERAPY

A MANUAL FOR NURSES



BY
WILLIAM RUSH DUNTON, Jr., B. S., M. A., M. D.

Assistant Physician at Sheppard and Enoch Pratt Hospitals,
Towson, Md.; Instructor in Psychiatry, Johns Hopkins University



"Occupation is the very life
of life. "—Harold Bell Wright



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> » ' » ®, » « « ,



PHILADELPHIA AND LONDON

W. B. SAUNDERS COMPANY

1915






PUBLIC
HEALTH
LIBRARY



Copyright, 1915, by W. B. Saunders Company






PRINTED IN AMERICA

PRESS OF

W. B. SAUNDERS COMPANY

PHILADELPHIA



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J > ' '



PREFACE

This little book is the outgrowth of a series of talks
which were given to the nurses at the Sheppard and
Enoch Pratt Hospital. The manner of its arrangement
is based on the course in occupation as it is there given.
Yet I have constantly had in mind the nurse in charge
of a private case who is responsible for the occupation
of her patient without having an occupation teacher or
director who can advise her as to the best method. I
have tried to emphasize the basic principles of occu-
pational therapy and have given chiefly those forms
of work which may be useful to the private nurse.

It is impossible to give directions for all occupations
and crafts without expanding the book to an abnormal
size, and it is merely desired to point the way to the
nurse whose inclinations and those of her patient lead
to a development of special forms. K'umerous refer-
ences are given to books and articles on special subjects.

A chapter on the Xurse in the Hospital has been
added and points out the chief differences between the
occupation of a patient in the hospital and one under
special care. It is believed that if the nurse has some
knowledge of the origin and history of the work in
hand that it may be made more interesting to the pa-
tient. In pursuance of this belief certain interesting
data has been made a part of the following chapters.

7



358059



8 PREFACE

The nurse should, however, realize that much more of
interest may be learned from other sources. She is
urged to provide herself with an armentarium which
should consist at least of the following:

Playing cards,

Dominoes or card dominoes,

Cribbage board.

Scrap book with puzzles and catches,

One or more picture puzzles,
and may well include also

A bed table (see p. 124 for directions in
making) .

Studies in Invalid Occupation by Susan E.
Tracy. Boston, 1910, Whitcomb & Bar-
rows.
She is also urged to cultivate a particular craft in order
that she may herself have a hobby and also that she
may have special ability in instructing her patient.

W. R. Dui^TOi^r, Jr.
Tows ox, Maryland,
August, 1915,



CONTENTS



PAGE

Historical 11

Hobbies and Their Value 21

Psychology of Occupation. 24

Mechanism of Recovery by Occupation 27

The Nurse in the Hospital 34

Puzzles, Catches, Etc 38

Reading 42

Physical Exercises 51

Card Games 55

String Work 59

Weaving 101

Paper Work 110

Wood Work 119

Picture Puzzles 128

Basketry 131

Chair Caning 154

Bookbinding 156

Collecting 166

Gardening ' 174

Nature Study 17S

Stenciling and Block Printing 179

Plastic Work 185

Drawing and Painting 192

Metal Work 200

Pyrography 210

Needlework 211

Photography 222

Music 225

Conclusion 226

Bibliography 229

Index • • 237



Occupation Therapy



HISTORICAL.



While considerable lias been written upon the history
of occupation as a therapeutic measure in the care of
mental cases, it is impossible to give credit to any phy-
sician as having been the first to apply it, or to name
the form of occupation so used. Probably its beginning
was so gradual, and yet so general, that it is impossible
to give any one person credit as discoverer, or dignify
any form of occupation as having been first used to
restore a mind diseased. Possibly the credit belongs
to a number of patients, each one of whom found a
tranquillizing influence in work casually undertaken
and so continued it in the form originally begun, or in
other ways. The physician, if he was intelligent, noted
the cause of the improvement which ensued and ap-
plied the remedy to other cases. Probably most psychi-
atrists past middle age have had such experience. Oc-
casionally we have had the big men of psychiatry writ-
ing of their experiences and of the value of occupation
or work as a therapeutic measure. Xotable instances

11



12 OCCUPATION THERAPY

are Isaac Ray^ and Lauder Lindsay,^ but too often
such opinions have been buried or dismissed with few
words in annual reports where they are inaccessible
after a few years.

This is proved by the fact that one of the papers by
Dr. Ray originally appeared in his report to the Cor-
poration of Butler Hospital for 1865, and was re-
printed in the Journal of Insanity. That other men
in other hospitals were alive to the importance of occu-
pation is sho^vn by the following note for which I am
indebted to Miss Edith Kathleen Jones, Librarian at
McLean Hospital : The importance of various forms of
diversion, and especially of manual occupation, has been
recognized from its (McLean Hospital) very beginning.

In his report for 1822 Dr. Wyman writes, ^'the
amusements provided in the establishment for lunatics,
as draughts, chess, backgammon, nine-pins, swinging,
sawing wood, gardening, reading, writing, music, etc.,
divert the attention from unpleasant subjects of thought
and afford exercise both of body and mind (and) have
a powerful effect in tranquillizing the mind, breaking
up wrong associations of ideas and inducing correct
habits of thinking as well as acting."

Another Superintendent, Dr. Bell, in 1839, says that

1 Ray, I. Labor in Principal Hospitals for Insane in Great
Britain, France and Germany. Am. Jour. Ins., 1846, II, p. 359.
Ray, I. The Labor Question and Hospitals for Incurables.
American Journal of Insanity, 18G6, XXII, p. 439.

2 Lindsay, W. Lauder. Reprint from the Report of James
Murray's Royal Asylum, Perth, Scotland, for 1860-1. Md.
Psychiatric Quarterly, III, No. 1, July, 1913, p. 10.



HISTORICAL 13

^^tlie experiment of mechanical labour was here first
introduced, and the safety, expediency and immense
utility of putting tools into the hands of the patients
entirely and satisfactorily decided." And again, speak-
ing of occupation as a means of cure, ^'there is probably
no other institution in the world where the value of this
has been more fully tested than here." Although later,
owing to the class of patients received at McLean, me-
chanical and agricultural labor was abandoned for
*^some form of busy idleness," yet each superintendent
has done his share in developing this method of treat-
ment. For the men, since 1831 there has been a car-
penter's shop in which woodcarving and cabinet mak-
ing have been taught ; while the women have had lessons
in drawing and painting and have done various forms
of fancy-work.

In 1836, according to the report for that year, 50
patients worked in the carpenter's shop 6 hours a day
and made 7236 candle boxes which were sold for
$907.06. Later the boxes were not sold, though they
continued to be made. In 1836, '^100 cords of wood
were carted by patients from wharf to house, and 200
cords were sawed, split and piled."

In 1910 two rooms in the women's gjTQnasium were
prepared for industrial occupation of a somewhat dif-
ferent type ; a teacher of handicrafts was engaged, and
instruction is now given daily in baskety, leather-work,
lace-making and weaving.

There are now twelve hand looms. In 1913-11 an
addition was built on to the women's g}^nnasium, pro-



1-i OCCUPATION THERAPY

viding space for these looms. It is well lighted by win-
dows and skylight. Under it is the room used for pot-
tery making, and a kiln has been set up in a disused
kitchen. An appropriation has just been made for a
similiar enlargement of the men's gyTiinasium, in order
to provide additional occupations for them. The women
are now taught weaving, basketry (reed and raffia),
leather- work (tooling, coloring, making), pottery,
modelling, casting, knitting, ^'rake" knitting, crochet-
ing, embroidery, lace-making (pillow and crocliet), sew-
ing, bead work, tatting, stencilling, sawing picture puz-
zles, painting (portrait, still life, coloring pictures, col-
oring cards for holidays).

In the very interesting Descriptive Account of the
Friends' Asylum for the Insane, 1813-1913, Dr. Eobert
H. Chase says, ''I^o feature in the treatment of the in-
sane is more highly valued than occupation, systemat-
ically applied and judiciously carried out. Work is a
law of our nature which demands expression in the in-
sane no less than in the sane. To understand this one
has only to reflect upon the depressing effect of inaction,
then turn to the satisfaction and strength that result
from the agreeable use of one's mental and physical
]3owers. It may be seen that from the beginning
Friends' Asylum made intelligent and continuous effort
to give the patients the benefit that comes from employ-
ment and rational diversion." In the Chronology which
is in the same volume are found many events bearing
upon the occupation and diversion of patients, all show-
ing that the hospital authorities were imbued with the



HISTORICAL 15

idea that occupation was a valuable form of treatment.

Fortunately the value of work, occupation, diver-
sional occupation, or whatever name maj be applied to
it, in helping the sick mind to recovery has been bet-
ter recognized in recent years, and with this recognition
has come a desire for a better understanding of how oc-
cupation aids and the best ways in which it may be
used. This is easily proved by a reference to the bibli-
ography on page 229.

With increased use of occupation it soon became ap-
parent that there must be persons specially trained to
carry out this treatment if it is to be successful. Credit
for first giving systematic training in occupation must
be given to Miss Susan E. Tracy who gave the first
course in Invalid Occupation at the Adams Xervine
near Boston in 1906. Soon after, or in 1910, she pub-
lished her book entitled Studies in Invalid Occupation,
which has given a great impetus to occupational therapy.
Miss Tracy's book w^as, however, largely written for the
teacher of occupation courses, and that part which ap-
plied especially to the mentally sick was written by Dr.
E. Stanley xVbbott of the McLean Hospital. The intro-
duction, however, by Dr. Daniel II. Fuller, then Super-
intendent of the xVdams Xervine, is an admirable expo-
sition of how nervous and mental cases may be benefited
by occupation.

In 1908 a training course in occupation for hospital
attendants was organized at the Chicago School of
Civics and Philanthropy. Miss Julia Lathrop and
Eabbi Ilirsch had been members of the State Board of



16 OCCUPATION THEKAPY

Control and had been shocked by the idleness on the
wards of the state hospitals. Feeling that public in-
terest should be aroused in state institutions and that
such idleness should not exist, Miss Lathrop and Rabbi
Ilirsch resigned from the Board of Control and organ-
ized the course. It was a most excellent one and in-
cluded inexpensive raffia work with instruction in old-
fashioned yeast dyeing by Prof. Wartz; book-binding
and pasting work; illuminating; stencilling, knotting
and weaving ; gjTiinastics and playground work, etc.

The work of Miss Tracy so impressed Miss Sarah E.
Parsons, Superintendent of I^urses at the Massachusetts
General Hospital, that in the Spring of 1911 a course
in occupation was given at the Training School of that
hospital under Miss Tracy's direction.

Probably the first nurses' occupation course in a hos-
pital for mental diseases was that given at the Sheppard
and Enoch Pratt Hospital in the Fall of 1911. A per-
sonal note may perhaps be pardoned here. This hos-
pital was first opened for patients in December, 1891,
and in August, 1895, I had the honor to be appointed
an Assistant Physician, and have been connected with
the hospital to the present. Dr. Edward 1^. Brush,
the Superintendent, had always recognized the value of
occupation as a remedial measure and had done all that
he could to further it by giving patients facilities in the
way of room, materials and necessary tools. In 1895
one man had quite a well-fitted shop for metal working,
and had made a number of electric motors and fans be-
sides numerous other articles. Others had done wood-



HISTOEICAL 17

work. Another man had assisted in the poultry yard.
These are but a few of numerous individuals that I
recall. A printing office was opened soon after my ar-
rival, which has since become a fixture and is under the
entire charge of a patient. Besides doing work for the
hospital, a number of charities have been its benefici-
aries. In 1903, when raffia work was first introduced,
a nurse was sent to learn its use, and in turn taught
many patients. Dr. Brush had for some time been
searching for a person who was fitted to teach our pa-
tients some arts and crafts, and in 1905 found a prop-
erly qualified instructor in Miss Grace E. Eields. Un-
der her instruction beautiful specimens of copper,
leather and weaving were made by patients, and grad-
ually more homely occupations were added. Some of
her especially interesting experiences have been re-
corded by Miss Fields in the American Jouryial of In-
sanity} Regular classes in such occupations as book-
binding, stencilling, block printing, metal work, wood
work, illuminating, needle-work, reed and raffia work,
weaving, etc., have been and are being given. There
are at present eleven teachers, of whom two give their
full time and the remainder part time to this work.
Occupation is regarded as one of the most valued thera-
peutic measures. A library, with a librarian in regular
attendance, and regular lectures, concerts, etc., as well
as athletics of various sorts, afford different varieties of

1 Fields, Grace E. The Effect of Occupation Upon the In-
dividual. American Journal of Insanity, LXVIII, July, 1911,
p. 103.



18 OCCUPATIOT^ THERAPY

occupations. This personal account is given in order
that the reader may appreciate the value which is placed
upon occupation hy those charged with the cure of men-
tal diseases.

About the same time and during the same month (Oc-
tober, 1011), Miss E,eba G. Cameron, Superintendent
of Curses at Taunton State Hospital, began a course in
occupational training for her nurses. Miss Cameron
has no record of the exact date of -her first class, and as
that at the Sheppard and Enoch Pratt Hospital was
given October 10, 1911, she has very graciously waived
any claim to priority. Miss Cameron has an admir-
able method of instruction. Believing, as do many of
us, that occupation is the most valuable therapeutic
agent in the care of the insane, she personally gives this
course to the junior nurses, in order that they may early
in their training realize its importance, and that the
patients may also benefit by having trained attention.
Six nurses are given instruction in the morning and in
the afternoon each nurse instructs a group of patients
in the same form of work. This method is said to
work admirably.

In 1911, from February to June, a course in Invalid
Occupation was given at Teachers' College, Columbia
University, by Miss Evelyn Collins, a kindergartner
who had had considerable post-graduate training in
manual and industrial arts, and wlio had also had
some experience in teaching nervous and mental pa-
tients in a sanitarium. This was an elective course and
occupied a three hour period during each week. It con-



HISTOEICAI, 19

sisted of lectures, practical work and demonstrations of
the forms of handicraft which have been found to be
most popular. This course is given each year.

At the Johns Hopkins Hospital, as a part of her train-
ing, the nurse is on duty for three months at the Henry
Phipps Psychiatric Clinic, during three weeks of which
she is given special instruction in occupation by Mrs.
Eleanor Clark Slagle,^ who has had extensive experi-
ence in this work, having been connected with the Chi-
cago School of Civics and Philanthropy, and having
organized the occupation work in a number of hospitals.
The nurse practically has individual attention for four
and a half hours daily, a total of eighty-one hours. She
is not taught a number of occupations, but thoroughly
learns the principles underlying the work. Peed and
raffia, simple carpentry, weaving and needle-work are
about all of the crafts which it is possible to take up in
the limited time. The training which she receives is
broad in that she is taught that occupation consists of
more than craft training, that all forms of diversion
and amusement may be used to aid in the recovery of
the patient.

At the present time (E'ovember, 1914) these are all
of the training courses in which occupations are in-
cluded that are known to me. A number of hospitals
and sanitaria, however, train their nurses in a less for-

1 Since the above was written Mrs. Slagle has taken charge
of the Occupational Centre of the Illinois Mental Hygiene
Society, and her place at the Clinic is filled by Mrs. Henrietta
G. Price.



-Y



20 OCCUPATIO]^ THEKAPY

mal and, unfortunately, less thorough way, the nurse
acquiring what she may through observation. It is
practically impossible for her to gain a knowledge of
basic principles under these circumstances, and a lec-
ture or two early in her training would be of a great
help to both her and to the patients under her charge,
'it is generally conceded that occupation is the most
valuable single therapeutic agent that we have in the
care of the mental and nervous sick, mnd it seems but
reasonable that the nurse, who can aid so much in its
application, should be taught its principles early in
her course.



HOBBIES AND THEIR VALUE.

On the other hand, there are quite a numher of able
psychiatrists who do not phice so high a value upon
occupation. In most cases this seems to he due to the
fact that not personally having a liking for manual
work of any sort they cannot appreciate how much it
/ may mean to others. The criticisms of some of these
men have been most helpful to those e^=-»s who value
occupation, as it makes us more critical of our own
work.

With but a moment's reflection it can readily be un-
derstood that an occupation which will appeal to one
individual will not to another. We probably all know
a professional man who has as a hobby gardening, or
perhaps photography or carpentry. A dentist of my
acquaintance makes clocks. An oculist spends his
spare hours during the winter in making a fishing rod,
which he tries out during his summer vacation.

Those who have read the Yailima letters of Robert
Louis Stevenson may recall that in one of them he
speaks of having exhausted himself physically by doing
some garden work which he might have had some one
I else do for six pence while he was earning almost as
many pounds by his writing. This has always seemed
to me to be an excellent illustration of how strong the
craving for a manual occupation may be in a mental

21



/



22 OCCUPATION THERAPY

worker. Here was Stevenson in the last stage of con-
sumption, a man pre-eminently doing intellectual work,
deriving great pleasure and satisfaction from going out
and weeding his garden for a couple of hours. Per-
sonally, I know that after my day's work at the hos-
pital an hour or two in the garden with cultivator or
hoe will often relieve me of a headache when resting
upon the porch will not. The phj^siological explana-
tion is quite simple. We all know that Wood flows in
an increased quantity to the organ that is actively func-
tioning, its need of nourishment and the excretion of
waste products being greater; therefore, it is but na-
tural that after a prolonged period of mental activity the
brain cells should experience a certain amount of fatigue
of which we are conscious, and by muscular activity we
not only give our brains a rest from mental work by
ceasing to do it, but we relieve the cells of actual phy-
sical work by diverting the increased blood current to
other organs. It would be easy to find instances of th is
desire for a change in the form of w^ork, andf^The
Hobbies of Great Men" would make a very entertain-
ing study. It would certainly be interesting to com-
pare the different methods they had of coming off their
pedestals. We are apt to invest our heroes with halos
and consider them as belonging to a race different from
ourselves, so that it is comforting to find that they are
human after all. Ricliard Watson Gilder has recorded
how Grover Cleveland spent a number of hours chang-
ing a broken multiplying reel to a simple one. He
says, 'The very difficult, not to say unnecessary char-



f



HOBBIES AND THEIR VALUE 23

acter of the labor (he must be the possessor of twenty
reels in all ! ) appeared to give him pleasure, and noth-
ing more than the production of something simple —
that quality so characteristic of his mental habit."

But another individual may prefer music, or to study
the Latin poets, as does one celebrated neurologist. In
other words, an intellectual occupation is desired rather
than a manual one. Sometimes we can hardly dignify
the hobby by the term intellectual, as the late Chief
Justice Fuller relaxed by reading dime novels, and an
eminent internist during his vacation reads the light
novels which have been published during the previous
winter.

Those having it, whatever the hobby may be, are
fortunate in having something which serves them as a

' safety valve and prevents their brooding and worrying
over the petty annoyances of the day's work.

We must, therefore, study carefully to learn what
form of occupation is most suitable for our patient, and

^ if no specific directions have been given by the phy-
sician it is the duty of the nurse to do this.



PSYCHOLOGY OF OCCUPATION.

It must be remembered tbat usually tbe emotions are
profoundly disturbed, the patient being depressed,
elated or apathetic. Kibot has sliown^ that the power
of attention, both spontaneous and voluntary, is de-
pendent upon the emotion, and we can frequently best
help our patient by training the attention. This can
most easily be done by arousing his interest in some-
thing, which m.ay be accomplished in various ways.
Frequently it may be accomplished by asking that
something be done as a personal favor (e. g., sorting
out cancelled stamps, folding papers, arranging clip-
pings, etc.) or that something be made as a gift for
one of whom the patient is fond, or by doing something
unusual in his presence and persuading him to do it^^
The tact and ingenuity of the nurse is often most
severely tested in getting a patient started on occupa-
tion. As a rule the effort should be directed to arouse
the patient in something with which he is unfamiliar.

Having succeeded in arousing our patient's atten-
tion, we must be careful not to do harm by allowing
him to become fatigued. We must remember that his
power of fixing his attention is weak, and we must
not continue it too long. This principle has been

1 The Psychology of Attention. Translation, 1896. The
Open Court Publishing Co., Chicago.

24



PSYCHOLOGY OF OCCUPATION 25

recognized by educators for years and is the reason for
the short lesson periods with frequent short recesses,
and for the short working periods in certain vocations,
such as telephone girls and the girls who inspect the
little steel balls which are used to form ball bearings.
This fatigue may be avoided by a change of the form
of occupation.

The primary purpose of occupation may be said to
be to divert the patient's attention from unpleasant
subjects, as in the case of one depressed. Or in a case
of dementia praecox where the subject is given to
day-dreaming or so-called mental rumination, occupa-
tion is given to keep the patient's train of thought in
more healthy channels. In a case of mild excitement
/ occupation will keep the patient's mind more contin-
uously on one subject than is possible if he has not this
stimulus to control his attention. In cases of marked
excitement it is usually impossible to use occupation in
treatment which is usually directed toward securing
rest. AVhen convalescence is begun occupation will be
of value.

In cases of dementia of various sorts the purpose


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