A case study of the development of occupational therapy at St. Patrick’s Hospital Dublin, 1935-1969

Introduction

There is an ongoing need for occupational therapy to “honour and own its historical professional legacy” (Mahoney et al., 2017, p. 6). Researching the history of occupational therapy has numerous potential benefits for the profession. Historical research can demonstrate how key ideas have developed over time (Hocking, 2008), augment understandings of contemporary practice (Pettigrew et al., 2017a), celebrate the contributions of key individuals (Mahoney et al., 2017) and inform future professional directions (Wilcock, 2002). While a number of social ideas contributed to the emergence of occupational therapy (as described in the literature review), institutions such as hospitals, sanatoria and asylums were significant physical environments within which the profession developed (Friedland, 2011). Occupational therapists have worked in psychiatric institutions since the foundation of the profession; however, to date, there is limited research considering the historical development of occupational therapy in these institutions (for some exceptions, see Hall, 2016; Prendiville and Pettigrew, 2015; Levine, 1987). This paper considers the history of occupational therapy in St. Patrick’s University Hospital, Dublin[1] (formerly a private psychiatric hospital – currently the largest independent not-for-profit psychiatric hospital in Ireland) with the intent to document the contributions of key staff members, and analyse the development of occupational therapy at St. Patrick’s in the context of the broader healthcare system in Ireland at the time.

Literature review

The foundation of occupational therapy was informed by several diverse movements, including moral treatment, mental hygiene, the arts and crafts movement, the settlement house movement, and the need to rehabilitate injured World War I soldiers (Wilcock, 2002). Occupational therapy was officially named in 1917 in Clifton Springs, USA, when the National Society for the Promotion of Occupational Therapy (NSPOT) (which became the American Occupational Therapy Association in 1923) was formed (Quiroga, 1995). Many of the earliest proponents and patrons of occupational therapy were psychiatrists. Psychiatrist and founding member of NSPOT, William Rush Dunton Jr authored Reconstruction Therapy in 1919 (Dunton, 1919). In this seminal text, he described the central ideas of occupational therapy, namely, “that occupation is as necessary to life as food and drink […] That sick minds, sick bodies, sick souls may be healed through occupation” (p. 10). Adolf Meyer (1866-1950), another eminent psychiatrist, was an important early advocate for the therapeutic benefits of occupation (Peloquin, 1991). Scottish psychiatrist, Sir David Henderson (1884-1965), who had worked with Meyer in the USA, set up the first occupational therapy department in the United Kingdom (UK) at the Gartnavel Royal Hospital in Glasgow in 1922 (Wilcock, 2002). Psychiatrist Elizabeth Casson (1881-1954), the first female doctor to graduate from the University of Bristol (Wilcock, 2002) founded the first occupational therapy school in the UK, Dorset House in 1929 (located initially in Bristol, later in Bromsgrove, and finally in Oxford at the end of World War 2) following a visit to the USA where she observed occupational therapy (Paterson, 2008; Wilcock, 2002).

The moral treatment movement marked the emergence of occupation as a treatment for people who had a mental illness (Wilcock, 2001), and ultimately created the conditions for the development of occupational therapy (Peloquin, 1989; Prendiville and Pettigrew, 2015). In Ireland, as in other countries, occupation was used therapeutically long before there were professionally qualified occupational therapists (Pettigrew et al., 2017b). The first use of the term occupational therapy in Irish media was a newspaper article about Peamount Sanatorium, Dublin, in 1930 (Irish Times, 1930, September 12). At this time, nurses, craft workers and art teachers were running occupational therapy departments in Irish psychiatric hospitals. Some had completed short training courses in occupational therapy, but most did not have a professional qualification in this area (Cahill, 2016). The development of occupational therapy in Ireland was advocated by psychiatrists. At Grangegorman Hospital, Dublin, occupational therapy was promoted by the Resident Medical Superintendent (RMS), O’Conor Donelan, who attended the London Conference on Occupational Therapy in July 1934. He described an “interesting lecture” by American occupational therapy founder Eleanor Clarke Slage (O’Conor Donelan, 1934; Cahill, 2016). Psychiatrist Eamon O’Sullivan was a significant advocate for the therapeutic use of occupation in Ireland (Pettigrew et al., 2017b). He was RMS in St. Finan’s Mental Hospital, Killarney, CO Kerry (in south-west Ireland) and promoted the use of occupation at St. Finan’s from 1933 (Fogarty, 2007). In 1955, he published A Textbook of Occupational Therapy with Chief Reference to Psychological Medicine based on his work at St. Finan’s (O’Sullivan, 1955; Pettigrew et al., 2017b), one of the first psychosocial occupational therapy texts in Europe. The foreword for this book was written by the aforementioned psychiatrist and occupational therapy founder William Rush Dunton, Jr.

Professionally qualified occupational therapists (who completed three year accredited diploma courses in the UK) began to work in Ireland after World War II (Pettigrew et al., 2017b). The first was Ann Beckett (1927-2002) who trained at Dorset House and returned to work in Ireland in 1948 (O’Mahoney and Pettigrew, 2015). A small number of Irish occupational therapists who qualified in the UK worked in Ireland in the 1950s (including Anna King, Sr, Eugene Butler and Rosemary Kerrigan). In 1963, the National Organisation for Rehabilitation and the Board of the National Medical Rehabilitation Centre (now the National Rehabilitation Hospital) founded the first professional occupational therapy course in Ireland at St. Joseph’s College of Occupational Therapy in Dun Laoghaire (Gregg, 2012). Joy Rook (formerly Director of Training at The Liverpool School of Occupational Therapy) was the first Director of the School; she subsequently founded the first occupational therapy school at the Ulster Polytechnic in Belfast (later named University of Ulster, Jordanstown) in 1973 (Wilcock, 2002). From 1963, students of St. Joseph’s College of Occupational Therapy, Dublin, were awarded their Diploma from the Association of Occupational Therapists in the UK (Wilcock, 2002). St. Joseph’s College was the only school outside the UK that was granted permission to award the Association’s Diploma (Wilcock, 2002). In 1986, St. Joseph’s College was incorporated into Trinity College, University of Dublin, where the first Irish occupational therapy degree programme was offered (Prendergast, 2013). In 2003, new occupational therapy courses opened at the University College Cork, National University of Ireland Galway and the University of Limerick. There are currently over 2,000 professionally qualified occupational therapists in Ireland (CORU, 2017).

Examining the history of a healthcare discipline in an institutional context can provide insights into how routines, governance and systems develop (Scott et al., 2000), and can explore how actors and practices emerge or become delegitimised over time (Scott et al., 2000). The disciplines of psychiatry and psychiatric nursing have previously been explored in the context of institutions. For example, a 2009 review of the history of psychiatry considers the case of several specific institutions (Beer, 2009) and reveals the social beliefs of psychiatry, critiques the profession, reveals the connections between asylums and their locations, and explores the history of disease. In short, it examines “how psychiatrists have both been influenced by, and themselves influenced, the sociocultural context within which they have worked” (Beer, 2009, p. 599). One example of the history of psychiatric nursing in institutions is Dickinson’s (2015) work on psychiatric nursing and the use of aversion therapy to “cure” homosexuality from 1935 to 1974 in psychiatric institutions in the UK. Understanding the history of psychiatric nursing in this context provides insights into how nursing was positioned in the hierarchy of the institution, illuminates broader societal beliefs and critiques the history of human rights abuses in psychiatric institutions. In comparison to the disciplines of psychiatry and psychiatric nursing, the history of occupational therapy in institutional contexts has been under-researched. The disciplines of psychiatry and psychiatric nursing have analysed their history in institutional contexts to explore key questions about their development. Examining the development of occupational therapy in a particular institution can provide similar insights into therapeutic goals, professional challenges and the role of the profession in the institution.

St. Patrick’s Hospital, Dublin, is an example of a significant Irish hospital within which occupational therapy developed at a relatively early stage (Doyle, 2014). Jonathon Swift, Dean of St. Patrick’s Cathedral and author of Gulliver’s Travels died in 1745. In his will, he left the majority of his estate to found a hospital for people with mental illness (Malcolm, 1989). It was the first psychiatric hospital in Ireland and is one of the oldest private psychiatric hospitals in the world (Clare, 1998). According to Malcolm’s (1989) history of the hospital, the standard of care deteriorated at the end of the nineteenth century because of to a poor hospital environment and inadequate staffing (Malcolm, 1989). The appointment of Richard Leeper as RMS in 1899 precipitated a period of change and improvement (Kelly, 2016). This included providing work and leisure activities for the patients, and improving the hospital environment (Kelly, 2016; Malcolm, 1989).

By the mid-1950s, Ireland had the highest number of psychiatric inpatients in the world per head of the population (Browne, 1963) with approximately 20,000 people incarcerated in psychiatric institutions (Brennan, 2014). Kelly argues that these disproportionately high figures were brought about by a number of social, medical, legal, economic and political factors rather than an Irish propensity to high levels of mental illness (Kelly, 2016). An enduring Irish tendency to institutionalise has been identified (Brennan, 2014); institutions were widely used to “serve various vulnerable, troubled or troubling populations of all ages” (Gilligan, 2012, p. 129). For example, legislation provided legal mechanisms for asylum admission and asylums were frequently used to manage social deprivation, poverty and ill-health rather than mental illness (Kelly, 2016; Brennan, 2014). Institutions were an important source of employment in small Irish communities and the economic and social dependency on asylums contributed to a lack of political will to close them (O’Shea and Kennelly, 2008).

People admitted to psychiatric hospitals during this time describe deplorable physical conditions, overcrowding, abuse, inappropriate admission and long-term incarceration (Kelly, 2016; Prior, 2012; Rafferty, 2011; Greally, 1971). The policy of institutionalisation had its roots in nineteenth century moral treatment and was based on the premise that keeping patients in a safe environment was therapeutic (Snell, 2016). Despite the fact that the system of treatment at the time was believed to alleviate suffering (Braslow, 1997), the aforementioned perspectives reveal that abuses consistently occurred in psychiatric settings. Stanghellini and Fuchs (2013) propose that the disparity between philosophy and practice potentially occurred because of psychiatry’s “well-intentioned determinism to impose their convictions of ‘the good’ on others, literally at any costs” (p. 33). This disparity can be further explained by examining the tendency of institutions to sustain unequal power relationships between staff and patients (Sheridan, 2006). Institutional culture can be defined as “deeply embedded patterns of organisation behavior […] the shared values, assumptions, beliefs, or ideologies that members have about their organisation or its work” (Peterson and Spencer, 1991, p. 42). Inequality between staff and patients is embedded in institutional culture; is perpetuated by actions, leadership, and institutional indoctrination; and is ubiquitous and difficult to change (Simone, 2009). Goffman (1961) describes how constructing a tightly controlled schedule of daily activity is one method that institutional staff use to preserve unequal power relationships – arranging daily activity was a common role for occupational therapy in psychiatric institutions in the early to mid-20th century (Braslow, 1997). Law (1991) identifies that bureaucracy and the power of health disciplines (including occupational therapy) can contribute to disabling environments. As there is a dearth of literature concerning the actions of occupational therapists in institutions, it is difficult to ascertain their role in sustaining or challenging institutional culture.

Exploring the history of occupational therapy in psychiatric institutions deepens the understandings of circumstances within which occupational therapy developed and identifies enduring values (Harley and Schwartz, 2013). This research aims to explore the content, development and context of occupational therapy at St. Patrick’s Hospital from 1935 to 1969 through case study analysis.

Methodology

Drawing on an interpretivist perspective, historical documentary research methods and oral history were used to conduct an instrumental case study of occupational therapy development at St. Patrick’s Hospital, Dublin, from 1935 to 1969. The chosen period of time (1935-1969) reflects the period from the earliest mention of occupational therapy at St. Patrick’s Hospital in 1935 to the first employment of a St. Joseph’s College of Occupational Therapy graduate (Catherine Buggy) in 1969.

Findings

Discussion

This case study of the development of occupational therapy at St. Patrick’s Hospital provides an insight into occupational therapy in Ireland from 1935 to 1969 and draws attention to the close links between the profession and psychiatry. The influence of Moore was integral to the development of occupational therapy at St. Patrick’s Hospital. This is comparable to other Irish psychiatric hospitals at the time, where medical patronage was central to founding and promoting occupational therapy services. Two significant examples include the aforementioned Eamon O’Sullivan at St. Finan’s Hospital in Killarney (Pettigrew et al., 2017b), and Ada English at St. Bridget’s Hospital in Ballinasloe (Kelly, 2014). Patronage by psychiatrists was an important factor in the professionalisation of occupational therapy internationally (Friedland, 2011), and as noted earlier, some of the key founders of the profession were psychiatrists. Moore’s obituary describes him as a “therapeutic enthusiast” (Clare, 1996), who was keen to explore and promote new types of psychiatric treatment. He was an important early proponent of occupational therapy in Ireland.

This case study of St. Patrick’s Hospital reveals key individuals central to the development of occupational therapy services, including occupational therapy worker Olga Gale, occupational therapist Margaret Sinclair, social therapist Irene Violet Grey and psychiatrist Norman Moore. While there is no evidence of formal multidisciplinary team working, the research provides an early example of occupational therapy in Ireland working alongside other professional groups.

The foundational ideas of occupational therapy are based on humanistic and pragmatic principles which propose that the mind, body and environment are interrelated, and suggest that human beings can control their health through what they do (Creek, 2008). Early occupational therapy developed “broad and balanced programmes of activity” based on these principles (Creek, 2008, p. 32). This case study shows that a significant aspect of occupational therapy treatment at St. Patrick’s included needlework, art, woodwork and basketry. Arts and crafts were used at that time to provide patients with a sense of agency and control (Hooper and Wood, 2002), to restore dignity (Paterson, 2010), to develop skills and improve function (Horghagen et al., 2007), to facilitate emotional expression and autonomy (Hocking, 2008) and to provide a sense of meaning during potentially long hospital stays (Horghagen et al., 2007). Occupational therapy practice at St. Patrick’s reflected the philosophy and practice of the discipline internationally.

Social therapy has been conceptualised in a number of ways over the years. Eagar (a British psychiatrist) described social therapy as a key characteristic of occupational therapy work in 1930 (Wilcock, 2002). In the 1940s and 1950s, it was considered to be a form of therapy that could benefit society as a whole, to promote more harmonious, just communities (Jaques, 1947). Crawford described social therapy as an essential aspect of therapy alongside, yet distinct from, psychiatric social work, occupational therapy and industrial therapy, consisting of outings, patient journals, social clubs and other entertainments (Crawford, 1962). According to the descriptions of Irene Gray’s work as a social therapist at the hospital (Board Meeting Minutes, 1956), it appears that she aimed to achieve similar goals. The types of activities employed by Irene Gray are commonly used as interventions by occupational therapists today (Creek and Lougher, 2011).

Occupational therapists have worked in psychiatric institutions since the foundation of the profession. In considering the role of occupational therapy in these institutions, it is important to critically examine how occupational therapy historically has sustained or challenged institutional culture. Occupational therapists can be considered agents of social control; and contemporary occupational therapy theory emphasises the requirement to ethically balance the needs of clients with the needs of the service (Kronenberg and Pollard, 2005). Occupational therapists attempting to initiate change in medical bureaucracies have reported issues of power and politics, and the challenge of integrating the differing cultural visions of staff and service user groups (Cook, 1995). This case study provides scant evidence that occupational therapists attempted to address issues such as the inappropriate use of restraint or challenged the institutional culture at St. Patrick’s Hospital. Gale’s interview revealed that the dances she arranged aimed to reduce stigma and increase opportunities for “liberation” (Gale, 2013). Occupational therapy was a new, emergent health profession in 1950s Ireland dependant on the patronage and advocacy of other professional groups. The prevailing socio-political culture of 1950’s Ireland (Brennan, 2014), combined with the profession’s minority status (Clouston and Whitcombe, 2008) and a focus on professionalisation precluded attention to issues of institutional power and service user rights (Saks, 2009) which have been explored in depth within occupational therapy in recent years (Hammell and Iwama, 2012; Galheigo, 2011; Whiteford and Hocking, 2011). The system of institutional care continues to influence mental health services in Ireland despite a move to community care in recent decades (Barry, 2015). Kelly (2016) argues that, historically, mental healthcare reforms in Ireland eventually tend towards increased institutional care; he cautions that history must inform present day decision-making, policy and practice to avoid repeating this pattern in the future. Occupational therapy needs to advocate for healthcare policy and practice that transfers power from institutions to service users (Barry, 2015; Lloyd and Williams, 2009).

Conclusion

The era discussed in this paper, 1935-1969, was a time of significant change in mental health services and in occupational therapy. Rates of psychiatric institutionalisation in Ireland peaked in 1956 and subsequently began to steadily fall (Brennan, 2014). The profession of occupational therapy was in its infancy in Ireland during the time in question prior to the establishment of the first occupational therapy educational programme in 1963. A number of cultural and professional factors have been identified which precluded occupational therapists from challenging institutional culture; the role of occupational therapy in sustaining or challenging institutional culture warrants further research. This paper provides an insight into the therapeutic goals and the role of occupational therapy at St. Patrick’s Hospital from 1935 to 1969 and situates the development there in a broader international context.