CHAPTER XXII
Occupational Therapy in Neuropsychiatry
Major Wilma L. West, AMSC, USAR
EARLY PROBLEMS
This chapter will summarize and evaluate the role of occupational therapy in military neuropsychiatry during World War II, with reference to the need for qualified personnel; the obstacles to program development, how these were met and in what sequence; and the development of programs and the roles of the participants in them.
Need for Qualified Personnel
On 12 August 1943, The Surgeon General, in Circular Letter No. 149, provided for the establishment of occupational therapy departments in Zone of Interior general hospitals. Besides specifically mentioning neuropsychiatric patients as among those for whom occupational therapy was 'a valuable adjunct to medical treatment,' this directive also stipulated that qualifications for personnel would include graduation from a school of occupational therapy approved by the American Medical Association or registration with the American Occupational Therapy Association. It is of more than passing interest to note that on 3 August 1944, about a year later, with the issuance of War Department Technical Bulletin (TB MED) 80, 'Reconditioning Program for Neuropsychiatric Patients,' both the original concept of the use of occupational therapy and the qualifications of personnel offering this service were repeated and elaborated in the following manner:
Occupational therapy enjoys a more important place in the reconditioning program for psychiatric groups than in that of most other patient groups. Therapists who are graduates of accredited schools of occupational therapy and familiar with the problem of emotional and mental disorders are available for supervision. Assistants must be selected from those with arts and crafts or manual arts training.
That the need for qualified occupational therapy personnel was more strongly urged by Army psychiatrists than by physicians in other medical specialties was at least partially attributable to the fact that occupational therapy had its beginnings, earliest recognition, and most extensive use in treatment programs for the mentally ill. Thus, many psychiatrists, commissioned in the Medical Corps directly from positions in civilian hospitals which had used occupational therapy as an integral part of psy?
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tchiatric treatment, were among the strongest supporters of this discipline's insistence on the use of qualified personnel.
That psychiatry or any other medical specialty would promote this insistence on the use of occupational therapists-at that time in virtually nonexistent supply-versus the employment of nonmedically trained personnel-in far more plentiful numbers and eager to participate in the defense effort-is worth examining. First, there was occupational therapy which, by the military's own estimate, had proved valuable to the Army's Medical Department: 'It was the consensus * * * of the officers who came most closely in contact with the occupational therapy work that to it must be credited much of the success of the neuropsychiatric wards.'1 This, however, was written of World War I and few personnel of that time, either in psychiatry or in occupational therapy, could recall this experience and urge its application in World War II. Indeed, it was as if this service and its contribution to patient care had been all but forgotten in the peacetime development of military medicine.
The five occupational therapy training schools established during or immediately after World War I remained the only facilities available and, combined, turned out less than a hundred graduates per year. Most of these personnel, shunning the red tape of the Civil Service, took positions in civilian hospitals. Then, in 1933, nearly all of the few occupational therapists in Army hospitals were discharged from service for reasons of economy. Thus, the Military Establishment made no provision for having a nucleus of qualified practitioners available for service in time of subsequent need.
Volunteer Workers Versus Professional Personnel
Second, and in direct contrast, there were available large numbers of personnel variously qualified but vitally interested in contributing to the war effort. Among these were three types of American Red Cross personnel-paid recreation workers, volunteer Gray Ladies with some craft training, and volunteer members of the Arts and Skills Corps, the latter consisting of outstanding artists and craftsmen, recruited from schools, museums, and various private endeavors, who contributed their time and talent in teaching their specialties to hospitalized servicemen.
Soon after World War II began, the professional and volunteer groups moved in somewhat different directions. Although a few occupational therapists applied for and were assigned to positions in Army hospitals at an early date, their numbers were vastly unequal to the need. Simultaneously, the professional organization was devoting its efforts to assisting The Surgeon General, through the National Research Council, to prepare for a sound and effective service by compiling basic equipment
1The Medical Department of the United States Army in the World War. Neuropsychiatry. Washington: U.S. Government Printing Office, 1929, vol. X, p. 95.
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and supply lists; by drawing up space requirements and floor plans for departments; and by specifying requirements for, and assisting in, recruiting qualified personnel and seeking military status for them. In the meantime, and during this delay in meeting personnel requirements, the Red Cross was stepping in to do the jobs on the hospital level. By stretching or converting space for recreational programs and by recruiting additional personnel, the volunteer groups were soon offering arts and crafts for patients in Army hospitals.
Why, then, did The Surgeon General proceed, nearly 2 years after the war had begun, to establish a professional occupational therapy program as 'an adjunct to medical treatment'? One can only infer that he and the medical officers and consultants in a position to advise him were convinced of the need for 'a particular type of personnel.' As Barton2 wrote, just about this time:
A correct conception of occupational therapy provides that the doctor writes the prescription for remedial work. He must outline the problem. The occupational therapist then must envision that problem in terms of a wide variety of interesting occupations which will fill the prescription. In neuropsychiatry there is an interest to be developed or emotional barriers to be overcome, outlets for tensions and needs to be found. Occupational therapists must have sufficient medical and psychiatric knowledge to be able to translate the doctor's prescription into work activity based upon the patient's needs, his interests and desires, relieving the busy medical officer of concern about the kind of job.
Early in 1944, a communication3 to Army medical installations made this concept official and standard for subsequent practice. The pertinent directive of this communication read as follows:
In order to more adequately serve the purposes of the overall program of treatment and physical reconditioning, it is deemed desirable that all art and handicraft work and related occupational therapy be supervised by the medical staff. To this end, it is directed that such activities as the volunteer Red Cross 'Arts and Skills,' the Red Cross recreational and diversional arts and crafts program, and any other volunteer activity of a similar nature be arranged and supervised by the department of occupational therapy of the hospital wherever such a department exists.
To the credit of both Red Cross and occupational therapy personnel, this arrangement proved successful in most instances. In those installations where both groups of personnel were employed, it made possible the extension of therapeutic activity programs to greater numbers of patients than could otherwise have been reached by either service alone. In those hospitals for which occupational therapy was not authorized, because of inadequate numbers of personnel-and these included station hospitals in the Zone of Interior and in all types of medical installations in oversea theaters-Red Cross and related groups conducted activity programs of unquestionable value in terms of recreation and diversion.
2Barton, W. E.: The Challenge to Occupational Therapy. Occup. Therapy 22: 262-269, December 1943.
3Letter, Deputy Surgeon General, to Commanding Generals, All Service Commands, 26 Jan. 1944, subject: Occupational Therapy Supervision Over Related Activities.
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PROBLEMS IN PROGRAM DEVELOPMENT
The three principal problems in program development are listed in the order of difficulty they posed: (1) Personnel, (2) supplies and equipment, and (3) space. Each of these factors is discussed briefly in the paragraphs which follow, as a preface to a subsequent section which details how and in what sequence these obstacles were met and solved.
Obstacles
Personnel
The lack of numbers of occupational therapists adequate to staff Army medical installations was unquestionably the single most serious deterrent to program development. Despite the fact that the war in Europe had begun in the summer of 1939 and that passage of the Selective Training and Service Act, providing authorization for military expansion, had occurred in September 1940, when Pearl Harbor was attacked on 7 December 1941 there were only 12 occupational therapists on duty in 13 Army hospitals. As the war progressed and increasingly larger numbers of U.S. military personnel were sent overseas to both the Pacific and the European theaters, evergrowing numbers of casualties were being returned to the Zone of Interior. To care for these wounded soldiers required the construction of more and more hospitals, thus widening the already serious gap between personnel supply and demand. While other professional groups staffed these military hospitals, primarily either commissioned or drafted enlisted personnel, occupational therapists-99 percent female personnel at this time-were not subject to military service and, therefore, had to be recruited from among volunteers.
Two decisions made by The Surgeon General, early in 1943, proved to be additional deterrents to recruitment. First, it was determined that occupational therapy programs would be established only in Zone of Interior hospitals; second, recognition of military status was denied occupational therapy personnel. A survey of the membership of the American Occupational Therapy Association, conducted soon after these two limitations had been established, revealed that many highly qualified personnel could have been recruited to Army service from civilian positions, if rank and oversea assignments had been offered.
Over and above these specific deterrents, there was an even more serious problem in recruitment; that is, the Army's estimated need for occupational therapists had to be matched against available numbers of professional personnel. In 1941, the Registry of the American Occupational Therapy Association listed 859 occupational therapists in the entire country, which by 1943 had increased to 1,274. With only 43 occupational therapists on duty in 30 Army hospitals, the projected need for 300 was still within reasonable limits of attainment. In early 1944, however, the
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opening of many more hospitals, with still others in the process of planning and construction, more than tripled the earlier estimate of needs and made it obvious that the military could not conceivably hope to recruit over 75 percent of the total available supply from civilian ranks. Of further particular relevance was the fact that the great majority of even the limited numbers of qualified personnel, potentially available, were employed in large State psychiatric hospitals. These institutions, already overcrowded and understaffed, were hardly disposed to freeing their personnel for military service. Thus, the establishment of war emergency training courses to train the additional numbers needed seemed inevitable.
Supplies and equipment
The second major obstacle to program development concerned supplies and equipment. The limited peacetime programs of occupational therapy in four permanent Army general hospitals had no standard listing of expendable and nonexpendable material; no table of allowances for hospitals of various sizes; and no adequate compilation of suppliers either for purchasing or to serve as a basis for cost estimates for submission to fiscal authorities. An additional problem in preparing such lists, tables, and supply sources was produced when The Surgeon General's advisers strongly urged replacement of traditional but so-called 'feminine' modalities of occupational therapy (weaving, basketry, knitting, and the like) with activities of more masculine appeal. 'If occupational therapy is to attract the enthusiastic support of the Medical Department of the Army and of military personnel in Army hospitals, it must adapt its therapeutic occupations to the changing demands of a new war.'4 Thus, such creative and manual arts as woodwork, metal work, and printing-known to the occupational therapist but not among her major skills-had to be emphasized and expanded, and new, unfamiliar activities such as plastics, electricity, and radio repair were suggested as additions. Types, quantities, and sources of equipment and materials essential to all these activities had to be investigated, and specifications for them had to be drawn up for the use of Army purchasing agents. Additionally, there was the necessity for training personnel in their use, which included both the fundamental skills involved in doing the activities and their application to the treatment of the sick and disabled.
Space
Space posed many problems for occupational therapists in the early days of the war but proved the least serious and most easily solved of all major obstacles to program development. Four5 of the five permanent
4See footnote 2, p. 653.
5Walter Reed, Fitzsimons, Brooke, and Letterman General Hospitals.-W. L. W.
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Army general hospitals had minimal occupational therapy programs and needed only to expand their facilities. As new hospitals were opened and personnel employed to initiate occupational therapy programs, adequate space was provided. The most serious problem in this respect came at about the midpoint of the war when the leasing and conversion of existing facilities and construction of new hospitals was at a peak. At this time, occupational therapy had scarcely been officially established and, thus, no space had been provided in architects' plans.
Solutions
That personnel represented the most difficult of all problems in program development destined it to be among the last solved. Thus, it was that obstacles, presented by lack of supplies, equipment, and physical space, were met and overcome at an earlier date.
Supplies and equipment
The original method of procuring equipment and supplies for occupational therapy was by local purchase through hospital funds. This proved unsatisfactory, primarily because of the time-consuming procedures of the established procurement policy. For each item, a lengthy justification had to be given, complete technical specifications had to be written, and at least three price bids were required from potential suppliers.
First steps in solving these equipment and supply problems were taken early in 1942, when the War Service Committee of the American Occupational Therapy Association worked with a committee of the National Research Council to assist the Medical Departments of both the Army and the Navy in planning occupational therapy programs. Based on estimates submitted by the occupational therapy departments at Walter Reed (Washington, D.C.), Lawson (Atlanta, Ga.), Letterman (San Francisco, Calif.), and Lovell (Ayers, Mass.) General Hospitals, this group compiled a list of basic equipment and supplies necessary to the operation of an adequate occupational therapy program. With only minor modifications to adjust the list to military needs, the recommendations were accepted and became the basis for Medical Department Equipment List 9N464, published on 22 September 1943. The list included 378 items which were authorized as standard issue to all occupational therapy departments in Army general hospitals. To make possible the purchase of selected nonstandard items deemed essential to supplement programs at different installations, annual cash allowances were authorized for local purchases. These allowances were based on the normal rated bed capacity of the hospital and ranged from $1,000 for hospitals of 1,500 beds or less to $2,500 for hospitals of 2,500 beds or more.6
6Circular Letter No. 149, Office of The Surgeon General, U.S. Army, 12 Aug. 1943.
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Although an improvement over hospital fund purchasing, Equipment List 9N464 soon proved inadequate, both in the scope of materials made available and in the amounts authorized. Underestimates in both directions were due as much to program expansion, which could not have been foreseen by original planners, as to lack of precedent in the experience of the advisory group. Then on 20 July 1944, cash allowances for supplemental local purchases were rescinded in order to protect materials which were manufactured for civilian users. With this action, revision of the supply and equipment list became urgent. The revision was submitted in the same month (July 1944) but the new list, ASF (Army Service Forces) Catalog MED 10-23, was not published until 11 January 1945. More seriously, however, procurement was not complete until June 1945, nearly a month after the war in Europe had ended. The revised list included approximately 1,000 items and, with supplemental issue of photographic materials through the Army Signal Corps and authorized local purchases of lumber, proved to be complete and satisfactory.
Space
Physical space, never a problem of the magnitude of either supplies or personnel, was sooner solved, albeit frequently on a makeshift basis in the early days of the war. Open roof areas, solaria, and unused storage buildings were among the facilities often remodeled or transferred in their original form for use by occupational therapy. Even in late 1943, when occupational therapy was officially authorized for all Zone of Interior general hospitals, the space, as stipulated in Circular Letter No. 149, was grossly inadequate: 'The space required for an occupational therapy shop will be a minimum of from 750 to 1,600 square feet.' As in the case of equipment and supplies, totally adequate provisions were made only after the war in Europe had ended. That came about in June 1945 when space recommended for occupational therapy facilities for the treatment of physically injured patients was between 2,400 and 3,750 square feet and allocations of space for diversional purposes for ambulatory patient groups were based on the bed capacity of the hospital and varied between 4,000 and 5,400 square feet.7
Interestingly enough, no official document published during or after the war made specific reference to or authorization for space for neuropsychiatric patients. It is known, however, that on 11 October 1943 recommendations were made by Maj. (later Lt. Col.) Walter E. Barton, MC, Director, Reconditioning Division, to the Hospital Construction Branch, SGO (Surgeon General's Office), concerning therapy facilities at general hospitals (fig. 56). These included provision of small occupational therapy clinics for neuropsychiatric patients only within the neuropsychiatric section. Plans for these and facilities for other special types
7Army Service Forces Circular No. 219, 13 June 1945.
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FIGURE 56.-Floor plan, occupational therapy facilites.
of patients were prepared by the Hospital Construction Branch with the approval of the Reconditioning Division.8 Except in some of the new hospitals to be built, these plans were infrequently used, the majority of hospitals having made their own adaptations or new provisions as required.
Personnel
Recruitment.-Concurrently with these efforts toward solution of space and supply problems, the infinitely greater handicap of personnel was being attacked on several fronts. Shortly after the outbreak of hostilities, the War Service Committee of the American Occupational Therapy Association initiated a campaign to recruit personnel by publicizing military service opportunities to all registered occupational therapists. In addition, newspaper, magazine, and radio publicity broadened and reemphasized military needs. Also, schools of occupational therapy were appealed to for help in direct recruitment of their graduates.
On 10 April 1943, Major Barton was assigned to the Neuropsychiatry Consultants Division, SGO, with one of his major duties that of establishing an occupational therapy service for the Army. 'The appointment of Colonel Barton for this position was particularly fortunate. His experience in civilian life as assistant superintendent of a large psychiatric hospital included supervision of a large occupational therapy department and instruction of occupational therapy students.'9
A persuasive speaker, Major Barton addressed both civilian and
8Memorandum, Lt. Col. A. L. Tynes, MC, Chief, Hospital Construction Branch, for Maj. Walter E. Barton, MC, Director, Reconditioning Division, SGO, 20 Oct. 1943, subject: Occupational Therapy Installations at General Hospitals.
9Willard, Helen S., and Spackman, Clare S. (editors): Principles of Occupational Therapy. Philadelphia: J. B. Lippincott Co., 1947, p. 330.
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military groups of various kinds on the need for more and better occupational therapy in Army hospitals. His prolific writings, published in Occupational Therapy and Rehabilitation, the American Journal of Psychiatry, and Diseases of the Nervous System, seldom failed to promote the value of dynamic activity programs in treatment of the neuropsychiatric patient. He also authored the early official documents establishing occupational therapy in the Army Medical Service and, finally, secured the appointment of an occupational therapist to the Office of The Surgeon General for the purpose of carrying on the work he had so well begun.
His successor in this effort was Mrs. Winifred C. Kahmann, Occupational Therapist, who, on 18 November 1943, became Chief of the Occupational Therapy Branch, Reconditioning Division, SGO. On this date, there were only 43 occupational therapists on duty in 30 Army hospitals in this country. With the immediate requirement estimated at 300 and the military medical program still expanding, recruitment was the single most important need. Thus, prime among Mrs. Kahmann's earliest efforts were talks at occupational therapy schools and State association meetings and correspondence and interviews with individual therapists to interpret the urgent need for qualified personnel in the Army program. In less than 2 months, she had more than doubled the number that had been on duty at the time of her appointment10 and in another 6 months had doubled it again11 and increased to 52 the number of general hospitals to which these personnel were assigned.
Training.-In the meantime, however, it had become evident that even this rate of expansion could not meet the need, for no hospital had
10The Surgeon General's Notebook, Report of the Reconditioning Division for 1-15 Jan. 1944, par. 3a: 'Thirty named general hospitals now have ninety occupational therapists on duty.'
11Annual Report, Reconditioning Division, Office of The Surgeon General, U.S. Army, 1943-44, Occupational Therapy Section, p. 8: '1 June-one hundred and eighty (180) occupational therapists are now on duty in fifty-two general hospitals.'
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its authorized strength of 1 therapist to 250 patients, and the number of therapists on duty was only 24 percent of that authorized. Thus, in March 1944, a request for the establishment of an emergency training course was forwarded to the Commanding General, Army Service Forces. In late June, this was approved,12 and during July, the first 111 students were enrolled in the new program which was initiated at five civilian schools13 under Government subsidy. It was a near heroic achievement which made this course a reality in so short a time since legal contracts had to be drawn up and arranged with the participating schools, publicity released on course availability, civil service appointments effected, and travel orders written. Many enrollees, it was subsequently revealed, had little or no notice between acceptance and assignment to school, and several confessed that the only reason they did report on schedule was that their interpretation of the travel 'orders' was a completely literal one.
War Emergency Course.-The War Emergency Course outline was prepared in conjunction with the War Manpower Commission and the Committee on Education of the American Occupational Therapy Association. It consisted of 4 months' intensive study in basic sciences, medical subjects, and theory of applications of occupational therapy, followed by 8 months of clinical practice in Army hospitals selected as having registered occupational therapists qualified to direct this applicatory portion of the total education program. Candidates admitted to the course were selected from among applicants presenting a bachelor's degree with a major in fine or applied art or home economics with a knowledge of not less than three manual skills and of basic psychology. Those accepting training in this Government-subsidized course were expected to serve with the Army for the duration of the emergency and 6 months thereafter, if needed.
Planned to qualify a total of 600 graduates, these courses were conducted at 2- and 4-month intervals until 1 July 1945, when the last 170 students to complete didactic training entered hospital apprenticeships. Three more schools14 joined the original five in giving 21 courses which ultimately enrolled 667 students. Of this number, 605 completed the academic portion and 545 finished clinical training, 122 (18 percent) having resigned or been separated for academic failure, inability to adjust to hospital service, illness, marriage, or other reasons.
One month after the establishment of the War Emergency Course, eligibility for the 8-month clinical portion of it was extended to include students in accredited schools who had already completed the theoretical part of their education.15 This subsidy of nearly half of the required
12Army Service Forces Circular No. 189, 22 June 1944.
13Milwaukee-Downer College (26), the Universities of Illinois (23) and Southern California (24), and the Philadelphia (23) and Boston (15) Schools of Occupational Therapy.14Columbia University, Mills College, and Richmond Professional Institute of the College of William and Mary.
15Army Service Forces Circular No. 263, 15 Aug. 1944.
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training enabled the recruitment of an additional 150 civilian students who were thus placed on duty in Army hospitals nearly a year before they would otherwise have become available, assuming that they would then have volunteered for military service.
Wacs.-Had these procurement methods been initiated at an earlier date, the needs for personnel would have been met sooner and more adequately. However, with the prospect of nearly a year's time elapsing before even the first enrollees in either program could be fully qualified, it was evident that still further means had to be found to alleviate the acute personnel shortage. Therefore, on 4 November 1944, The Surgeon General recommended establishment of a course for training WAC (Women's Army Corps) personnel as assistants to occupational therapists; in less than 2 weeks, this recommendation was approved.16
Prerequisites for this course included high school education, knowledge of or ability in handicrafts, and aptitude for teaching. Candidates were secured through a general WAC recruiting campaign for medical technicians and were assigned for basic training at either Fort Oglethorpe, Ga., or Fort Des Moines, Iowa. The program of instruction for the 1-month course included 192 hours of lectures, conferences, demonstrations, and instruction in the principles and aims of occupational therapy, plus practical application of various crafts and manual skills. Training was conducted at Halloran General Hospital, Staten Island, N.Y., by a WAC officer, a registered occupational therapist, under direction of the Surgeon General's Office. On completion, trainees were returned to their service commands for assignment to hospitals having established occupational therapy departments. The 11 courses, completed between 9 December 1944 and 27 October 1945, graduated 278 occupational therapy WAC assistants who, by assuming responsibility for diversional programs in many Army hospitals, freed the occupational therapist for treatment of psychiatric, neurological, and orthopedic patients.
As events were later to prove, even these three emergency training programs failed to meet personnel requirements for occupational therapists in Army hospitals. Although the end of the war with Japan saw occupational therapy established in all 76 general and convalescent hospitals then in operation, with personnel totaling 899, 'it is to be noted that of this number only 447 were graduates and 452 were apprentices still in clinical training.'17
Other facts might also be noted about these preceding statistics. First, few if any of the general and convalescent hospitals had their authorized strengths at this time, nor did they reach them until several months after the war when deactivation of many temporary installations made possible more adequate staffing of remaining hospitals. Second, the
16Memorandum, Brig. Gen. R. W. Bliss, The Surgeon General, for Commanding General, ASF, 4 Nov. 1944, subject: Orientation Training for OT Assistants (WAC), with 1st endorsement thereto, 16 Nov. 1944.
17West, W. L.: The Future of Occupational Therapy in the Army. Am. J. Occup. Therapy 1: 91, April 1947.
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earliest date on which occupational therapists were assigned to convalescent hospitals was March 1945;18 regional and station hospitals were not authorized occupational therapy personnel until October 194519 and February 1946,20 respectively. Thus, of the 899 therapists on duty at the end of the war, with 545 being emergency-course personnel and 150 Army-trained clinical affiliates, the total number of previously qualified therapists entering military service barely exceeded 200.
DEVELOPMENT OF SPECIFIC PROGRAMS
Occupational therapy departments in World War II Army hospitals developed four specific programs for the four major classifications of hospitals; that is, general, convalescent, regional-station, and specialty. A description of the major occupational therapy programs in each situation follows.21
General Hospitals
Two types of programs, the closed ward and the open ward, were found in most of the Army hospitals which were designated as having specialty treatment services for psychiatric patients. These were necessitated by the degree of illness of the patients which, in turn, dictated their assignment to either closed or open wards.
Closed-ward program
A review of the annual reports of 16 of the 29 hospitals caring for psychiatric patients indicated that nearly all of them had some type of closed-ward program for these patients. Often, this was given priority in terms of personnel assigned and separate facilities provided, although there were occasional instances noted of referring to occupational therapy those open-ward psychiatric patients who were able to report to a general clinic area serving all types of patients. In most of these hospital reports, however, reference was made to separate occupational therapy facilities within or immediately adjacent to the neuropsychiatric wards. Where no specific building or ward area could be allocated for this purpose, therapists operating out of a central clinic transported materials and supplies into
18Semi-Monthly Report of the Reconditioning Consultants Division for the Period 1-15 March 1945, 16 Mar. 1945.
19Army Service Forces Circular No. 380, 9 Oct. 1945.
20Army Service Forces Circular No. 38, 14 Feb. 1946.
21Material for this section was gathered from various sources, such as hospital annual reports for 1944-45; published and unpublished papers on occupational therapy written during the war years; statistical, case history, and other data collected from numbers of Army hospital occupational therapy departments immediately following the war (by the Office of The Surgeon General and for purposes such as this history); and, to a lesser degree, from personal communications and conversations with Army therapists and psychiatrists.-W. L. W.
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the closed wards and conducted both individual and group activities in daily 1- or 2-hour treatment periods.
The most frequently occurring diagnoses among closed-ward patients were schizophrenia, manic depressive psychosis, occasional paranoid states, and some acute psychoneuroses. Found in smaller numbers were psychopathic personalities, mental defectives, psychosomatic disorders, hysterical paralyses, and others.
The literature of the ward period is probably representative of the objectives of therapeutic activity programs in Army hospitals during that time and indicates that the function of occupational therapy was perceived as generally supportive rather than dynamically oriented in dealing with psychopathology, as follows:
1. To prevent mental and physical deterioration.
2. To encourage socialization and a feeling of group identification.
3. To stimulate creative imagination and expression.
4. To reduce poverty of ideation.
5. To provide self-confidence and a sense of security.
For most closed-ward patients, occupational therapy was individually prescribed by the medical officers. Since psychiatry at this time was still more descriptive than dynamic, these prescriptions usually stated little more than a diagnosis of major symptomatology and, if indicated, precautions related to suicide or homicide. Potential but as yet unformed elements of the prescription were interpersonal relationships with the patient, the dynamics of group interaction, and the multidisciplinary approach (in conjunction with psychologists, social workers, and recreational personnel). For the most part, therefore, the therapist was given only a name and a clinical label or impression on the referral form.
In accordance with doctrine stated in the then current manuals on occupational therapy22 and psychiatry,23 some of the treatment principles used were as follows:
1. For schizophrenic patients:
a. Group activities to stimulate identification and interaction (for example, publishing a hospital newspaper).
b.Creative art for nonverbal expression (for example, painting and music).
c.'Dirty' activities for the untidy and the 'smearers' (for example, clay modeling and finger painting).
2.For manic patients:
a. Activities requiring gross physical motions (carpentry).
b. Work situations permitting freedom of movement without close contact (gardening).
3. For depressed patients:
22War Department TM (Technical Manual) 8-291, 'Occupational Therapy,' December 1944, ch. 5.
23Solomon, Harry C., and Yakovlev, Paul I. (editors): Manual of Military Neuropsychiatry. Philadelphia: W. B. Saunders Co., 1944, pp. 606-607.
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a. Simple, readily achieved, time-limited tasks (based on previous hobby interests).
b. Menial (janitorial) work for guilt atonement.
c. Selection of types, locations, and tools of work with awareness of suicide precautions.
4. For paranoid patients:
a. Individual work assignments involving responsibility (clerical).
b. Jobs permitting a high standard of performance (selected in accordance with individual interests and abilities).
5. For psychoneuroses-activities selected to counteract symptoms:
a. Physically demanding for the tense and restless.
b. Requiring skill and concentration for the introverted and anxious.
c. Doing something for others (family or hospitals) for the discouraged and depressed.
6. For psychopaths-strictly supervised and sternly disciplined activities (for example, industrial assignments).
7. For mental defectives-short-term tasks within their abilities to accomplish (with constant supervision, protection from ridicule, tolerance of error, and liberal praise for achievement).
8. For psychosomatic disorders-absorbing, detailed tasks to overcome concern with complaints and motivate patient toward normal interests and recovery (fig. 57).
9. For neurological problems-activities incorporating principles of physical treatment with maximum psychological motivation.
FIGURE 57.-Miniature model building in occupational therapy.
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A somewhat limited range of activities (the traditional arts and crafts, music, drama, puppetry and recreation) was used in occupational therapy programs for closed-ward patients because of precautions which, it was believed, had to be observed and because facilities off the ward were not always available. However, in situations where completely equipped work areas were provided and adequate numbers of personnel were available, a proportionately broader selection of creative and manual skills was provided.
Fairly close supervision of the work of closed-ward patients was considered mandatory in most programs for the purpose of providing support and external control of the acutely disturbed. Frequently, this required the assignment of enlisted corpsmen to duty in occupational therapy during periods when patients were engaged in activities. Shop doors were, of course, locked, and tools were carefully checked at the end of each period, before patients were returned to their wards.
Many if not all occupational therapists working with locked-ward patients wrote weekly progress notes for the information of the referring psychiatrist and for incorporation into the patient's medical record.
Another occasionally used but by no means standard method of correlating overall treatment programs was the staff conference. Attended by clinical psychologists, social workers, and occupational therapists, these meetings relayed to the psychiatrist observations by various team members on the behavior, attitude, and reactions of patients, thus providing the basis for such changes in the prescribed treatment program as might be indicated.
Open-ward programs
Since there were more open-ward patients than closed-ward patients, greater numbers of the open-ward patients were referred to occupational therapy, the ratio being 3 to 1 in some instances. Of the 14 hospitals reporting on the numbers of psychiatric patients in occupational therapy during 1945, the figures ranged from 45 per month at one hospital where occupational therapy was selective in terms of patient need ('puppets for a group psychotherapy demonstration on dependency' were used)24 to 550 patients per month at another facility where 'attendance in the Neuropsychiatric Occupational Therapy Shop is compulsory for all open-ward patients.'25 Between these extremes, hospitals reported wide variations in census of these groups, with the average being 234 patients per month.
The four basic types of military neuroses and the doctrine observed in occupational therapy for these patients were generally, as follows:26
1. Neuroses occurring before exposure to military life could have any
24Annual Report, Schick General Hospital, Clinton, Iowa, 1945, p. 126.
25Annual Report, Bushnell General Hospital, Brigham City, Utah, 12 Jan. 1946, p. 7.
26Stakel, F.: Occupational Therapy for Neuropsychiatric Patients in an Army General Hospital. Occup. Therapy 23: 225-22, October 1944.
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manifestation. In this group were patients whose difficulties dated back to childhood but were exaggerated by military service. Many of these patients were classed as psychopathic personalities. Often antisocial and with destructive tendencies, such patients were frequently disciplinary problems on the wards. Their prognosis was poor, and most of them were ultimately discharged from the service.
The therapist usually tried to incorporate these patients into the industrial therapy program. Because they were behavior problems, it was believed that any constructive activity, especially projects for the hospital, was highly advisable.
2. Neuroses caused by the restrictions of military life. The prognosis of these patients was good if an adjustment could be made, and frequently, they were returned to duty. Rarely were disciplinary problems found in this group. Their symptoms were usually tenseness, loss of appetite, inability to sleep, and depression over their failure in the service.
Often the therapist would plan a program involving fairly strenuous physical activity, such as a woodworking project, to provide a physical drainage of energy to lessen tension and anxiety. A good workout in the shop usually helped to regain appetite and often induced sleep.
3. Neuroses caused by foreign service with its homesickness and poor living conditions. These patients had poor prognoses and were usually discharged from the service. Their backgrounds frequently included neurotic behavior, and symptoms were exaggerated as soon as they were sent overseas. They were rather similar to the first group and needed socialization and constructive activity but were not necessarily antisocial. If they had psychopathic personalities, they were of the mild type.
These patients were generally worked into the industrial therapy program. Although a cooperative group, results with them were not outstanding.
4. War neuroses caused by actual combat. These cases had a good recovery prognosis but were not always returned to duty. They were largely men who had always adjusted well in civilian life and in the Army until placed under the severe strain of combat. Often they were depressed, restless, tense, sensitive to noises, and unable to sleep because of battle dreams. They were a difficult group to reach at first because of depression and restlessness, and in addition, they often had tremors of the hands when attempting to work.
With these patients, occupational therapy frequently had good results. Short projects with a high interest level such as leather work were attractive to them. Once their interest had been aroused, they were cooperative, appreciative, and showed marked improvement in a few days. If these patients showed any inclination to discuss their experiences, they were urged to do so. Some depicted combat experiences or battle dreams in various art forms and, where the patient was thus able to express himself, therapy was decidedly beneficial.
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There were three major differences between open- and closed-ward occupational therapy programs. First was the incorporation of many open-ward patients into shops serving patients with physical disabilities. In some instances, such combined groups resulted from lack of separate facilities but, in others, the practice was followed on the theory that neuropsychiatric patients, particularly those who were not so sick, might well benefit from contacts with more 'normal' groups.
A second contrast in programming was found in the wider variety of activities available to open-ward patients. Thus, in addition to the traditional arts and crafts, shops used by open-ward patients included facilities for photography and letterpress printing, areas for gardening, and power tools for extensive woodwork, plastics, and metalcraft. This is not to say that such activities were never used in closed-ward programs, but, as a general rule, the open-ward patient had a far greater range of choice.
One other type of activity-industrial therapy-was extensively used in treatment of the open-ward patient whereas it was rarely applied in locked-ward sections of the hospital. Passing reference has been made to 'industrial assignments' in discussing treatment principles for both types of patients, However, since the theory as well as the method bears further elaboration and since this feature characterized some of the most successful open-ward programs, a detailed discussion follows.
Industrial therapy
At the outset, a distinction must be made between two quite different programs, both of which were occasionally referred to as industrial therapy. The type most frequently used in treatment of the neuropsychiatric patient who had progressed beyond the need for definitive therapy involved assignment to various departments and services concerned with maintenance and operation of the hospital. Often confused with industrial therapy, because of the application of similar terms such as 'Work Therapy,' 'Job Therapy,' and 'Commercial Therapy,' were various experimental projects which involved the employment of hospital patients on subcontract work projects for war industries. These programs, often mistaken for the type of industrial therapy discussed here, were more extensively used with the physically handicapped than with the neuropsychiatric patients. The later development of these explorations in 'factory-in-hospital' programs, prevocational training, and preparation for reemployment of the handicapped within civilian industry is worthy of mention. Programs of this type in selected Veterans' Administration and civil hospitals developed largely out of the pioneering and experimental programs conducted by the military service.
More commonly used in occupational therapy programs for open-ward psychiatric patients was the industrial therapy officially defined, in TM 8-291, as 'the use of an industrial assignment or work project for its
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therapeutic effect.' The concept of this program was hardly a new one, having been traditional in State hospitals from the earliest recorded use of activity as treatment. As applied in Army hospitals, some of its aims were-
1. To reduce actual psychosomatic symptoms.
2. To return a feeling of self-sufficiency and ego strength, decreasing the patient's depression and feelings of inadequacy through graded normal work situations.
3. To employ mentally defective persons during the period of hospitalization, so that they might feel useful members of society, and to provide a means of vocational exploration.
4. To provide an opportunity to regain work habits or to brush up on a specific work experience in order to return a feeling of security in the work sphere.
5. To give the patient a situation in which he could improve his social skills by dealing with increasing numbers of people, as well as with authority, in a semisheltered and tolerant atmosphere.
Administration of the industrial therapy program included the following:
1. A job analysis, with reference to mental and personal requirements, physical demands, and environmental and industrial or other hazards.
2. The prescription, containing identifying data about the patient, his diagnosis, physical condition, mental characteristics, precautions, and purpose of prescribing occupational therapy; that is, for prevocational exploration, socialization, sedation, stimulation, or other aim.
3. Records, including summary data from the referral, supervisor's ratings and any change, with reasons therefor, made in assignment.
4. Progress reports, the rating of patients with reference to regularity of attendance, ability to follow instructions, degree of cooperation, and attitude toward assignment.
Job openings filed with the Industrial Therapy Program at Newton D. Baker General Hospital, Martinsburg, W.Va., represented a broad range of work assignments in the professional, maintenance, supply, and entertainment services of the installation.
Convalescent Hospitals
Occupational therapy programs in convalescent hospitals were markedly different from those in general hospitals. This contrast was primarily due to differences in the degree of illness of patients and in the type of facility represented by the convalescent hospital. Designed to remove neurotic patients from the more seriously ill and the formal atmosphere of hospital beds and white uniforms, these facilities were patterned after Army field units with the patients organized into battalions, dressed in duty uniforms, and generally taking care of themselves.
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Often, well over 50 percent of the patients in these hospitals were 'psychoneurotics.' Experience, primarily in combat zones, had shown that, although these patients did not require either closed-ward care or intensive individual therapy, they benefited by a comprehensive program designed to prevent the development of apathy, resentment, overconcern with somatic ailments, and fixation of symptoms. Thus, although the treatment and training were under complete medical supervision, the Army convalescent hospital featured an elaborate program of physical reconditioning, educational classes and shops, recreation, occupational therapy, and counseling.
Not all patients in this setting were referred to occupational therapy since a number of them arrived at the hospital willing and able to participate in physical reconditioning and educational classes. After vocational classification and counseling by the medical officer and social worker, such patients were assigned directly to other activities.
For others, however, occupational therapy was a prescribed treatment and considered to be the link between the treatment services of the psychiatric staff and the services of the reconditioning program. As such, occupational therapy was primarily concerned with that borderline group of patients who were too antagonistic toward or emotionally unable to cope with the more formally organized classes and activities.
In the convalescent hospital, therefore, occupational therapy was designed to meet the needs of patients whose condition demanded a partially controlled environment with supervision by medically oriented personnel. Those patients presented typical psychoneurotic symptomatology, distortion of social perspective, hostile attitudes, feelings of inadequacy, confusion, and occasional residuals of a more serious emotional disturbance. A prime aim of all services concerned with these patients was reinforcement of their ego strengths in interpersonal and group relationships.
Again, because the precautions were minimal and the activity potential was greater in these than in general hospital patients, a wider variety of modalities was offered. Dividing the sections of the total occupational therapy area into machine shop, quiet shop, art studio, and the like, patients were permitted to move freely between activities with a minimum of direction from supervisory personnel. In contrast with techniques employed for the psychotic, it was found that convalescent hospital patients responded better to more freedom in choice and process of activity. Daily attendance in this casual kind of environment tended to reduce hostile attitudes and to foster the self-confidence and security so needed by these patients.
Prescriptions from referring psychiatrists usually requested observation and a report on social relationships and behavior, on work tolerance, and on educational or vocational aptitudes. The findings of the occupational therapist were used in screening patients who had made sufficient progress in the treatment situation to warrant reassignment to the edu?
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cational program. For some patients, the successful completion of one activity in occupational therapy provided the self-assurance needed to attempt something more advanced. Others required a longer period of adjustment in this more sheltered setting but, ultimately, found that they wanted to progress to a more advanced and technical level. When such attitudes and abilities were first observed in a patient, the occupational therapist might recommend reevaluation by medical and consulting personnel and thus help expedite the patient's transfer to an educational class or pretechnical shop.
With the end of the war in the summer of 1945, the average stay of patients in convalescent hospitals as well as in all other Army medical facilities was greatly shortened. At this stage of program development, the practice of using occupational therapy to screen patients for educational reconditioning (in those installations where this function was predominant) became impractical and it was thereafter used as an alternate rather than as a preliminary assignment. Medical referrals continued to single out the more severely ill patients and also those who, although not so sick, requested occupational therapy in order to achieve improvement in a shorter period of time.
The cross section of patients seen in these hospitals invariably included those who needed a variety of short-term projects with tangible results. For these patients, and for those needing to rebuild powers of concentration, to resolve problems in interpersonal relationships, to test performance ability, to seek attainable levels of achievement, occupational therapy afforded a wide range of interest-motivating activities.
Regional and Station Hospitals
As has been previously noted, personnel shortages precluded assignment of occupational therapists to regional and station hospitals during the war period. Thus, to all intents and purposes, there were no officially recognized or professionally staffed occupational therapy departments in these installations during the time period with which this history is concerned. Yet reports from station and regional hospitals contain accounts of programs termed 'occupational therapy,' which in some instances are so obviously worthy of the name as to warrant discussion and inclusion in this section.
Zone of Interior
One of these 'occupational therapy' programs was initiated early in 1943, in conjunction with reconditioning, at the Harmony Church Annex of the Fort Benning Regional Hospital, Ga. The following highlights the 'occupational therapy' portion of the reconditioning program recorded in 'History of Reconditioning of Military Personnel Returning to Duty':
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The plan of the whole program was to relieve the psychological malady of 'hospitalitis' and to prepare the men physically and mentally for return to their own units in the quickest possible time.
* * * * * * *In addition to regular calisthenic periods, physical exercise in the nature of occupational therapy was encouraged by the special atmosphere surrounding this Hospital Annex. Among the projects constructed and worked on by trainees were a chicken house and a garden which contributed not only to the health of the men participating in the construction and working of these activities, but to the menus at the Annex mess hall. In addition, a carpenter shop was operated by the trainees and equipment for the operation of the Annex, as well as visual aids to be used in the instructional program, were made in this shop by the trainees.
Under the guidance of a Sanitary Corps officer, trainees who were interested in masonry and bricklaying constructed a full-size out-door model sanitary area, consisting of twelve units including an underground trench incinerator, human waste vaults, garbage disposal plants, improvised outdoor showers, an underground food storage vault and other units. This area contributed, by way of occupational therapy, and was later used as a demonstration area for lectures in field sanitation and sanitary appliances. Other projects which contributed to the occupational therapy programs, and likewise to the facilities of the Hospital Annex, were a barbecue pit, a fish pond, an archery range, fences, a rustic park constructed from native pines and various areas for the use of game equipment.
Another account27 of interest and ingenuity of the supervising psychiatrist described a do-it-yourself occupational therapy program organized at a station hospital during the war years. In this instance, lack of support from command prompted the chief psychiatrist to solicit $5 donations from his staff to place in a 'kitty' in order to purchase supplies and tools to implement the salvage material which was being used. After the initial supplies were purchased, they were sold to the patients at cost, thus maintaining the 'kitty' for continuous purchases. This little nest egg was periodically swelled by donations from local religious, fraternal, and other organizations. These donations permitted the furnishing of materials to patients without charge.
Supplies, however, were still scarce and when no funds for purchases were offered, 'scrounging' for material often became necessary. The salvage dump was frequently visited. Paint, varnish, shellac, and sandpaper were obtained from the paintshop. One project, done very quietly, was the sanding, refinishing, and varnishing of every bedside table in the hospital. The bedside tables, of the oak-folding type, were refinished to look like new. Then, one of the patients who had been a commercial sign painter in civilian life was motivated by his physician to redo a number of makeshift hospital signs in a standard size, format, and lettering style. Gradually, as more and more of the new signs began to appear around the hospital, the commanding officer tracked down the source of this professional appearing work and, impressed by a form of occupational therapy which did not consist of basket weaving and crocheting, asked the insti?
27Personal interview with Lt. Col. Robert J. Bernucci, MC, Neuropsychiatric Service, Camp Livingston, La., 1942-45.-W. L. W.
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gating psychiatrist how much was needed in monthly funds to expand the program. Having indicated that $100 a month would probably be adequate, the psychiatric staff was overwhelmed to receive, within 2 days, authorization to draw $300 monthly from the hospital fund.28 Although both patients (given 'kitty' money and authority to purchase materials while on furlough) and staff (using local resources) shopped with abandon, the maximum they could spend in any one month was $150. Additional materials were requisitioned from the hospital table of allowances, for some of which ingenious justification was required.
Therapeutic activities at this hospital, however, included more than handicrafts. The patients, no less ingenious than their medical officer, made a simple jigsaw almost entirely of wood, its only metal parts being the saw blade, two small bolts, and a single bedspring salvaged from a damaged hospital cot. Numerous similar activities at this and other hospitals were conceived and, by various means, implemented as treatment for neuropsychiatric patients in regional and station hospitals before official establishment of occupational therapy programs in 1945-46.
Oversea theaters
In theaters of operations, occupational therapy was, perhaps, more urgently needed and results obtained more dramatically gratifying than in the Zone of Interior. American Red Cross recreation workers and personnel of the Army's Special Services ran hobby shops and variously organized arts and crafts programs in many of the larger general hospitals. In many station hospitals, however, not even these personnel were available to conduct activity programs, and it again devolved upon the individual medical officer to utilize such personnel and material resources as he could recruit to 'treat' his neuropsychiatric patients. The following is an extract from the account of how and why one medical officer made occupational therapy available to patients at a station hospital in the Southwest Pacific Area:29
The subject of this letter might be called 'The Rehabilitation of Soldiers With War Neuroses.'
What happens to the people of a country like the United States when they get called to fight in an Army that has been hamstrung, held down, undertrained, poorly supplied, and ill-equipped because the people of the United States lacked the foresight and backbone to see what was coming and back up the President when he tried to do something about it? Well, they get drafted awfully fast, they don't get much training and they go overseas fast as hell because if they didn't there wouldn't be anybody at
28In 1944, Shulack pointed out: 'It is not generally known that hospital funds may be used to assist in this field, but following is an extract from AR 210-50, par. 4a, which clearly indicates: 'Hospital Fund: Object-To supplement the activities of supply services in contributing to the comfort, pleasure, contentment and the mental and physical improvement of the sick in the hospital to which the fund pertains * * *.'" See Shulack, N. R.: Occupational-Recreational Programs in Neuropsychiatric Sections of Army Station Hospitals. War Med. 5: 109-116, February 1944.
29Personal letter from Capt. Charles E. Test, MC, 126th Station Hospital, San Francisco, Calif., 7 Oct. 1944 (recipient unknown).
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all to handle the military situation * * *. That's why trained machinists, concert pianists, great authors, skilled chemists, university professors, and thousands of other specialists end up in the infantry carrying a gun instead of in a job suited to their qualifications.
They didn't even have time to train these soldiers properly in 1942, or to give combat troops firing practice they should have had. And this is what happened. Those men sweated it out in the SWPA [Southwest Pacific Area]. They went into battle over the Owen-Stanley Range, carrying their equipment on their backs. They made frontal assaults on prepared Japanese positions, and in lots and lots of cases after the day's combat mission was over, a rifle company ended up with a second lieutenant or even a buck sergeant in command-every other company officer and noncom [non?commissioned officer] was killed or wounded or missing * * *. The pilots flew mission after mission in planes that didn't contain a single original part-planes put together piece by piece out of salvaged parts-they call that 'cannibalizing.' I watched them do it. And they did it when they were sick. When they, too, had anemia, and temperatures up to 103, and all the rest of it. And the older men-35 to 40 years old-too old for the Infantry even in those tough times-they unloaded the ships in New Guinea-24-hour shifts, no time off, and lots of them had double hernias, varicose veins, arteriosclerotic heart disease, etc., etc. I took care of lots and lots of those men * * *.
And here's what happened. A good many of those men cracked up-they got so they couldn't stand the sound of an air-raid siren, they crawled under the bed screaming when the 'ack-ack' started, and they got so tremulous they couldn't write. They became so irritable you couldn't live with them; they got recurrent, persistent headaches, dizzy spells, low back pain, functional nausea and vomiting, anxiety neuroses, full-blown conversion hysteria, and every other symptom and sign of an insoluble, unconscious, unbearable mental conflict that you can think of.
* * * the Colonel decided that men with mental disabilities could be better treated, better diagnosed, and more of them sent back to duty of one sort or another if they were sent to specialized, neuropsychiatric hospitals, where the professional staff from the commanding officer on down consisted of men with psychiatric experience. No such hospital existed in the Army, so he took ordinary hospitals, relieved all the surgeons and internists, and replaced them with psychiatrists. He also decided that it would be a good idea if the patients in these hospitals had a little something to do, to keep from lying in bed all day and thinking about their symptoms, and to give them a chance to do something useful. * * * build up their ego a little-give them a sense of accomplishment, and prove to them that they weren't useless to the Army and to themselves as they might think. So he arranged for these hospitals to have a little extra equipment-some picks and shovels, rakes and hoes, and seeds-so they could plant a garden and get some fresh vegetables to eat; and some hammers, saws, and planes so they could build a few trinkets, or maybe even some furniture the hospital could use. In November 1943, he told me that he wanted me to plan and direct such an Occupational Therapy program in one of the Neuropsychiatric Hospitals he was then in the process of organizing.
So I did. And I've learned an awful lot in the process, just since May 13, 1944. First of all, I learned that it was hard to convince the average psychiatrist that Occupational Therapy was anything more than basket weaving. And I learned that it was hard to get the patients interested. They like to play baseball, but they didn't think much of digging in the garden, and at first they didn't think much of doing any work in the carpenter shop, until they learned that the only way they could avoid having to keep all their toilet articles on the ground was to go down to the shop and build themselves a bedside table.
I began to get some results too. One or two patients who had been given up for lost by the ward officer made apparently complete recoveries when they found some-
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thing-some activity-some field of interest, suited to their abilities * * *. As Karl Menninger puts it, they learned how to play.
I found that it took a wide variety of activities to satisfy the interests of our varied patient population. And they began to show a little more enthusiasm for the program. I had to get more hammers, saws and planes for them; I had to get some old broken-down trucks for the automobile mechanics to work on, a transit and some marine engines for the boys from the Amphibious Engineers to work on, a transit and some draughting instruments for the men who had had some experience or interest in that line. I had to get power saws so they could build furniture for the hospital more easily, and faster.
The patients love it. Six of them lay on their backs in the mud every day for a week rebuilding a * * * truck-someone had made them mad by saying it couldn't be rebuilt. We use that truck every day now. After the Ordnance vehicle inspector looked that rebuilt truck over, he sent us out two jeeps to work on. And every bit of that work was done by neuropsychiatric patients.
Why do they like it, and how does it work? * * * Well, it isn't work to them-it's play. I keep it on that basis. They work on their own time, voluntarily, and when they get tired, or want to go out and play baseball all afternoon, they can. All the pressure and strain of ordinary military duty are eliminated. And they can do the kind of work they like best. I think they get a sense of security, of safety, of protection from working at the same old stuff they did in civil life. Secondly, they accomplish something-they construct something-something practical and useful * * *. They can work off some of their neurotic tension through productive activity. And they learn something. They get a bit of education in some subject they're interested in.
What does the Army get out of all this? Well, it helps to get the patients well, and conserves manpower in this theater. A limited amount of repair work on Army equipment and vehicles which would otherwise be scrapped is accomplished. Patients who need reassignment or reclassification are trained for their new jobs and given practical trials in them. The psychiatrist gets a chance to observe their behavior under conditions much more like the real world than the ordinary hospital presents.
I think that probably the biggest reason why such a rehabilitation program works is that most of our soldier patients aren't as sick as we used to think they were. Their illness is due more to situational factors than to unconscious emotional conflicts. They don't need deep or drastic psychotherapy-all they need is a chance to relax, a little understanding of their problems, something to get interested in, a goal they can reach, and a chance to start over again-a fresh start in a new job, either in or out of the Army.
Specialty Hospitals
Mason and Darnall General Hospitals were designated as specialty hospitals of neuropsychiatry. Primarily, these were for the care of psychotic patients, but some patients with severe neurotic reactions were also admitted. Mason General Hospital housed more than 3,000 patients and Darnall General Hospital provided for almost 1,000.
Since the occupational therapy service at Mason General Hospital was, in every respect, one of the most extensive in the Zone of Interior, a summary of its growth and development is included here.
One of the psychiatrists at Mason General Hospital outlined the status and function of occupational therapy at that hospital in the following manner:30
30Cotton, H. A., Jr.: Reconditioning Neuropsychiatric Patients in the Army. Mil. Surgeon 97: 453-454, December 1945.
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TABLE 65.-Occupational Therapy Program at Mason General Hospital, 1944-45
Month | Facilities/Equipment/Supplies | Personnel | Patient census | Activities/Innovations |
January | One large shop with a few basic woodworking tools. Activities included woodworking, art, and jewelry. The OT Section was a compound of the Neuropsychiatric Service. | 8 enlisted men and 1 WAC. | 600-700 open ward patients assigned daily to industrial therapy. Approximately 60 patients (mostly open ward) assigned to shop. | Industrial therapy assignments involved hospital details such as wards, mess office and hospital maintenance. All assignments had medical approval. |
February | Initial equipment unpacked, inventoried and stored. Storeroom and office established. System of tool-checking devised for protection of patients. | Senior therapist assigned. | Referral of closed ward patients to OT initiated. | Industrial therapy innovations: basic instructions compiled and made available to ward officers and nurses; weekly progress reports on patients initiated; a daily consolidated report of patient placement throughout the hospital maintained. Closed ward patients stained 300 pieces of ward furniture (cubicles, shelving, etc.). |
March | Improvements made in workshop by Post Engineers. Standard shelving for storeroom completed. | Staff therapist added and put in charge of workshop. | Prescribed patients increased to 110. Industrial therapy assigned a daily average of 383 patients. | |
April | Red Cross craft equipment used to supplement existing OT supplies | 4 EMs transferred out of section. 2 staff therapists assigned. | Industrial therapy assigned 363 patients daily. | The School of Military Neuropsychiatry became responsible for its own industrial therapy program. Monthly assignment sheets stabilized patients' assignments. |
May | ----- | Staff OT added to assume responsibility for industrial therapy program. Gray ladies assigned to the workshop. | Industrial therapy assigned 435 patients daily. POW wards enrolled 11 patients in OT. | Occupational therapy instituted on the German Prisoner of War ward. Due to lack of detachment personnel, 12 new jobs for patients were established. |
June | A second shop was opened for "sedative" crafts (leather work, art, ceramics and weaving). | ----- | Industrial therapy assigned 470 patients daily (only 100 of these being open ward.) Workshop attendance was 200 patients per week. | |
July | ----- | New staff OT assigned. | Total patient census in 2 workshops was 504. | Work therapy transferred to Reconditioning. Emphasis placed on patient projects vs. hospital work. The CO approved a RX and Progress Report Form. OT discontinued for POWs and started on female ward. |
August | ----- | 4 EMs, 2 WACs, 1 apprentice OT and 1 Red Cross Arts and Skills sculptress assigned. | Total patients treated: 808. | An exhibit for the Office of War Information was prepared for oversea consumption. |
September | ----- | 1 WAC assigned. | Total patients treated: 715 | OT cooperated with Special Services on 2 patient projects: a puppet program and an all-patient play for which OT directed the making of props, costumes, scenery and the printed program. |
October | 1300 lbs. of aluminum contributed by Republic Aviation Corps and 500 lbs. of self-hardening clay and glazes donated by Arts and Skills Corps. | 2 EMs assigned. | Total patients treated: 888. | The painting of murals as a patient project for decorating the Red Cross Recreation Hall was approved by the Commanding Officer and the project begun. |
November | Two OT shops opened at the Edgewood Division. | 2 Arts and Skills Corps members assigned. | Total patients treated: 1,302. | The OT Section began the two-month training period for four students of the War Emergency Course. |
December | Donations of running supplies received. | 2 EMs and 1 WAC assigned to Edgewood. | Total patients treated: 1,166. | The Red Cross Recreation Hall murals were completed and hung. Major monthly activity was directed toward establishment of the OT Program at the Edgewood Division. |
Summary for 1944. | At both the Brentwood and Edgewood Divisions, there were: 2 large shops, 1 office, 1 storeroom. | 1 Senior OT, 4 staff OTs, 5 Appr. OTs, 8 EMs, 4 WACs, 1 Secretary, 6 Gray Ladies, and 6 Arts and Skills Corps members daily/ | Average daily treatments at the two divisions: 200 patients each. | |
Summary for 1945. | Additions to Brentwood Division in July: greenhouse, photographic lab and typing room; to Edgewood Division in August: large art and ceramic shop. Supplies and equipment were made adequate through use of 3 channels: increasing T/E levels in supply catalog to meet higher requirements of specialty hospital; weekly truck deliveries from Reconditioning Surplus Warehouse at Camp Upton; receipt of expendable and nonexpendable donations from several community agencies, Red Cross and the Hospital Council. | Losses due to medical discharges, overseas assignments and transfers: 5 civilians, 4 WACs and 24 EMs. Civilian craft instructors emloyed to compensate for EM losses. 75 students of War Emergency Course trained. Arts and Skills Corps reorganized and numbers increased to 25 daily. | Range of patients treated: 333-760, with daily average for the year of 534. | Ward work was instituted on the medical-surgical-psychotic ward in April and on the shock treatment wards in May. This served the double function of treating shock and suicidal patients, there-to-fore inadequately covered, and of extending student training to include experience with very ill patients. New activities made available to patients included photography, metalwork, ceramics, modelmaking and typing; and the level of craftsmanship was far superior to that previously offered. The student training program in occupational therapy was the largest in the country. |
Source: Compiled from Annual Report, Mason General Hospital, for the year 1944, pp. 79-83, and for the year 1945, pp. 4-6.
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Occupational therapy is one of the oldest and most valued forms of reconditioning for psychiatric patients. The work is carried on under the supervision of a staff of registered occupational therapists who have received special instruction and are familiar with the problems of the nervous and mental disorders which they are called upon to treat. Facilities include several large and well-equipped shops with a wide range of activities and projects.
Patients are assigned to Occupational Therapy on the basis of prescriptions signed by medical officers. The Occupational Therapists are given complete information as to the diagnosis, treatment indicated and results desired. Reports as to the patient's progress and reactions are rendered to the ward officers for incorporation in the medical records.
Table 65 presents highlights of the occupational therapy program at Mason General Hospital for the years 1944-45.
In the 'History of the Reconditioning Service, Mason General Hospital, 1943-46,' major problems and accomplishments were evaluated as follows:
The Occupational Therapy section at Mason General Hospital at its height offered medical treatment through supervised craft work to over 900 patients per day. The figure, 900, represented roughly one-third of the total number of available patients and was achieved when the hospital was carrying its greatest patient load. Thereafter, through the dropping of the hospital census, the average coverage since August 1945 has fluctuated between 50 and 60 percent of the total hospital census per day. Remembering that not all patients were well enough to receive treatment every day, the total percentage of patients reached by the section was probably much higher than 50 percent * * *.
The building of such a department has of necessity entailed many problems. Major among these problems are the following: Physical equipment (including space and tools), Expendables, Coverage, Personnel and Patient Approach. Each will be considered in turn.
* * * * * * *Space requirements for Occupational Therapy are inevitably high. Fortunately for this section the hospital administration recognized this fact early. The section was consequently in a state of constant expansion until February 1946.
* * * * * * *Variety and quantity of tools are essential to the smooth operation of an Occupational Therapy section. * * * Original issue of Occupational Therapy equipment was made in February 1944 on the basis of a supply list originated by the Surgeon General's Office. Tools so issued were inadequate in both quantity and quality and the list was cancelled on 1 July 1944. It was replaced the following February (1945) by MED 10-23, the current Occupational Therapy Supply List. The majority of the items on this list were doubled, and in some cases items were multiplied by as much as six. In the interim period between July 1944 and February 1945, some equipment source had to be found, not only to replace broken items but to fill gaps in the original list. The two sources tapped most frequently and most successfully were donation and surplus * * *
Even more important than physical equipment are expendable supplies. Basically there must be a constant flow into the department of standard expendables in sufficient variety to allow not only for normal needs but also for experimentation. The same list for tools which expired in July had contained the allotment for running supplies, and the loss of expendables was extremely critical. The solution to this problem was akin to that of the non-expendables. When MED 10-23 came out, the allotment level was raised to about four times the normal level for the general hospital. Quantities
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of supplies were obtained from Camp Upton * * * local airplane companies (and) the Arts and Skills Corps * * *. Finally, during the last year, hospital purchases have been made for the section * * *.
Patient coverage was a source of deep concern to the section until June 1945. It was essential that the organization be such that all patients could potentially receive Occupational Therapy if they so desired. Until May 1945, the shops were the only avenue of reaching the patients. Although the patient load was high, there were, nonetheless, many patients, particularly shock treatment patients, who were too ill to be treated in the shops which allowed liberal and free use of tools. In May 1945, the Chief of the Neuropsychiatric Service consented to the establishment of a ward program for shock treatment patients on a nontool basis. This program was tremendously successful and eventually expanded until it covered eight wards * * *. Such a program served as a splendid introduction to Occupational Therapy, not only to those patients who became better and eventually came down to the shops, but also to members of the detachment whose understanding of the department's purpose had theretofore been somewhat limited.
The problem in personnel arose from the allotment of therapists through the Surgeon General's Office. The quota, as established, was one therapist to every 250 patients in the general hospital. The general hospital will, out of every 250 patients, have 25 to 30 patients whose conditions are such that Occupational Therapy is indicated. One therapist can well handle such a number. Mason General Hospital, however, was an all-psychiatric hospital, and as such potentially all patients were eligible for Occupational Therapy. No rise in quota was ever formally allowed. Supplementation was necessary. Sources were three-military, voluntary, and civilian. Enlisted men were assigned from Headquarters whenever possible. Assignment was on the basis of skilled trades such as carpentry, photography, jewelry, and gardening. These men were, for the most part, a transient group but their assistance at all times was greatly appreciated. Members of the WAC were also assigned. These young women attended a training class for O.T. Assistants given at Halloran General Hospital. They were a more stable group and were of great value. Voluntary assistance at first came from the Gray Ladies and later from the formation of an Arts and Skills Corps by the Red Cross. Skilled artists from the surrounding territory volunteered their services for one day a week * * *. The civilian source had two facets. The Army, finding the number of therapists inadequate for its needs generally, instituted the War Emergency Course for Occupational Therapists, students of which were trained at this institution. Not enough can ever be said in praise of those students. The number of students trained at Mason General Hospital was sometimes as high as 25 at a time. These young women made possible the ward program. They filled all the instructing gaps. They were more work for the section, but they paid ample dividends. * * * When the student training program ended, the discharge criteria for enlisted personnel had been established and the hospital hired and trained civilian instructors to fill vacancies * * *.
A few words should be said about the Occupational Therapists who have been at this hospital for the last year. It is an exceptional staff and it should well be for it was selected from the hundred odd students who were trained at this installation.
* * * * * * *The neuropsychiatric hospital has a particularly difficult problem to consider in its approach to patients through Occupational Therapy. 'Medicine' per se is an unattractive thing to the average patient and to 'have' to make something makes most psychiatric patients rebellious. Solutions to this problem were numerous. The first was in attitude. No patient was ever forced to participate in Occupational Therapy. All patients, however, were encouraged to participate. The shops were attractively decorated and the atmosphere in them was uniformly friendly, hospitable and gay. The second was craft selection. An attempt was made to institute crafts
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which would be of natural interest to the patients. Crafts used were: carpentry, jewelry, plastics, printing, typing, photography, ceramic, stenciling, art, weaving, and leatherwork * * *. The technique of suggestion was used at all times to direct the patient into the right craft for him but no formal medical 'treatment' concept ever reached the surface of the shops' activities.
* * * * * * *The principal source of problems to Occupational Therapy at Mason General Hospital lay in the disproportion inevitably created by applying standards for the ordinary general hospital to an all-psychiatric hospital. In time, however, to all these problems some solution was found * * *.
In retrospect, the following comments31 further elaborate upon the treatment data, already discussed, with additional remarks evaluating achievements in the specialty program at Mason General Hospital:
First, it should be noted that the preceding quoted comments were written in December 1946, when Mason General Hospital was deactivated. They were set forth for a reading public presumed to be thoroughly familiar with the Army medical program in general and in particular with the participation of Mason General Hospital in that program. Thus, no mention was made that Mason General Hospital, in addition to being a treatment center, was also a reception-classification-redistribution center for neuropsychiatric patients. Because of this additional designation, there was at all times in the hospital a percentage of patients whose stay was too short to permit definitive treatment. Although an occupational therapy program for such patients was initially attempted, it could be little more than a general activity program and soon proved to be impractical. In consideration, therefore, of this constantly shifting component of the overall hospital census, the percentage of patients who were eligible for treatment and who did receive occupational therapy was actually higher than the report indicated.
Remaining comments on the Mason General Hospital program can be divided into three areas relative to treatment, educational, and administrative functions of the occupational therapy staff.
With reference to patient treatment, the therapists reversed some traditionally restricting procedures and added new concepts to professional practice. The first of these was their demonstration that neuropsychiatric patients need not be prohibited from using tools appropriate to the activities in which they were engaged. With adequate protection and supervision and with accurate tool checks, the therapists learned that almost any tool could be used in occupational therapy. This was a calculated risk, taken as such with the full knowledge and consent of the psychiatric and administrative authorities of the hospital and it worked. 'We had, out of all the thousands of patient treatments, only one serious accident-an attempted throat slashing by an extremely suicidal patient. The patient lived, so actually we had no casualties.' Obviously, occupational therapy
31Personal communication, Dagny Hoff Roseboro, Chief Occupational Therapist, Mason General Hospital, to the author.
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programs with shock treatment and locked-ward patients were more limited, but not drastically so, and such restrictions were dictated by the needs of the patients and not by an overall protective regulation. With this free use of tools, there was created a nonprohibitive working environment, and the evils of a restricted activity situation were avoided.
Another reversal of traditional treatment function came about when the chief occupational therapist insisted on removal of the industrial therapy program from the jurisdiction of the Occupational Therapy Department. In her opinion, the 'use' of this program was obvious but its therapy very dubious. Furthermore, it was believed that (1) little in the education of the therapist was preparatory for conducting the type of industrial program which was carried out at Mason General Hospital, and (2) not all of the 800 patients listed on the daily roster of this program could be appropriately 'treated' by assignment to the available activities.32
An area in which the occupational therapy staff of Mason General Hospital obtained possibly better-than-average success was that of reporting on patients. Digested references to their regular, comprehensive, and treatment-centered reports frequently appeared in the medical records, and when time permitted, staff members attended and reported verbally at conferences. With the unusually large patient population at Mason General Hospital and the consequently reduced opportunity for the psychiatrist to know individual patients, this reporting function may well have assumed greater importance than in the average psychiatric hospital.
Finally, perhaps the most significant advance in treatment concept was made in the occupational therapy staff's reemphasis on use of self in treatment, as follows:
We learned to take hold of a patient where we found him and to move him, with professional guidance when we needed it, in the direction we wanted him to go. Nor did we do this by crafts and activities alone. We also learned to use ourselves and our auxiliary personnel (enlisted men and women, civilian employees and various volunteers) for our own health-giving qualities and I often assigned patients to given activities being handled by specific people because of an effect needed by the patient. The effect was a total effect in which the personality of the well person was of paramount importance. Although some of our colleagues seem to feel that this is new, I personally feel that it's as old as occupational therapy itself and the only thing that is 'new' about it is the emphasis.
An application of this could be found in the selection of our staff. I added only therapists who amplified a central OT personality or core; I selected them with reference not only to the department's needs but also with reference to their own needs. It was this which made them such a successful group. Separately, they were wonderful women but together they formed a unit which was unbeatable. To outreach themselves was normal for them. They were strengthened by each other. And of course, when we separated, each person fell back to his own basic personality with a real sense of loss. This was not such an unusual experience. Counterparts can be found in military and navy experience throughout the whole war. Carlson's Raiders are one example.
32These points concerning the misuse of industrial programs and the lack of preparation of the occupational therapist for their supervision have been noted by others and have a degree of validity. It is only fair, however, to point out that such has not always been, nor does it need to be, the case.-W. L. W.
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In educational activities, therapists at Mason General Hospital were also extremely active. They lectured regularly to the Army's School of Military Neuropsychiatry, which was located at the hospital, and were thus able to orient large numbers of medical personnel who were subsequently assigned to other hospitals. The house staff were kept apprised of occupational therapy functions by oral and written reports on patients they referred. Constant effort was directed toward the inservice training of the Occupational Therapy Department's own staff, including therapists, enlisted personnel, volunteers, and students. The occupational therapy program was the largest conducted in any Army hospital and included extensive course outlines for formal lectures and demonstrations as well as planned applicatory experiences during the period of clinical affiliation. There was also lay education achieved by the considerable publicity devoted to military medicine in general and Mason General Hospital's psychiatric program in particular. For example, Walter and John Huston's documentary (the film, 'Let There Be Light') on psychiatric casualties was partly filmed in Mason General Hospital's Occupational Therapy Department and used their personnel.
One final achievement must be classed as administrative. This was the transfer of occupational therapy from the jurisdiction of the Reconditioning Service to that of the Neuropsychiatric Service. Although there was much discussion during the war (and has been since) on both sides of this question of the administrative placement of occupational therapy, its reassignment in this instance permitted its greater use as a therapeutic agent.33
IN RETROSPECT
As was noted in the opening sentence of this section on occupational therapy, it was the intent of the author both to summarize and to evaluate the role of this treatment adjunct of military neuropsychiatry. It is therefore assumed that the reader has been left with a firm idea that although many laudable efforts were made, on both central administrative and local clinical levels, to overcome obstacles to program development, many major problems were solved only after the war had ended.
Thus, for the perfectionist and the too-ready critic, the story of World War II occupational therapy might be dismissed with the comment 'too little and too late.' A better summation, however, would indicate that such a comment could characterize many aspects of the war itself and, thus, of the medical services. One has only to reflect on Captain Test's
33Mason General Hospital was not alone among Army hospitals in effecting this local reversal of central policy. Several other general hospitals made similar shifts in assignments which made the Occupational Therapy Department responsible, for treatment, to the Medical Service where patients of that service were concerned, and for administrative purposes, to the Reconditioning Service. These included hospitals designated as centers for the treatment of orthopedic and neuromuscular conditions as well as those designated as neuropsychiatric centers.-W. L. W.
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commentary on the general overall unpreparedness (p. 672) to understand that serious problems were also inevitable in occupational therapy, for which solutions could only tardily be found.
One other point of evaluation, concerned more with the quality of professional philosophies and procedures than with technical handicaps of personnel, space, and supplies, has heretofore been only briefly mentioned, and this merits additional comment. This is the inference from the record that occupational therapy programs were far more concerned with the activities engaged in and projects made by the patients than with the dynamic mechanism and therapeutic effect of these on the patient and his disease process. In fairness to the occupational therapists, trained primarily to carry out the orders of the physician's prescription, at least a portion of the blame for this rather literal application of their services to treatment of the patient must be borne by the referring and supervising psychiatrists. It should be also noted that, until nearly the midpoint of the war, psychiatry was only a branch or section of the medical service. This virtual stepchild relationship to medicine as a whole was reflected as much in its at first unimaginative and limited use of adjuncts, such as occupational therapy, as in its own physical location, traditionally, at the end of the last ramp on the most remote wards of the hospitals. After 1943, when psychiatry was elevated to equal status with medicine and surgery on the tables of organization of Army hospitals, there were increasing instances of a more dynamic psychiatry and thus of more insightful use of occupational therapy.
Conversely, in fairness to psychiatrists, there are occupational therapists, in both military and civilian practice today, who tend to credit Army psychiatric personnel and programs with changing concepts and practices in contemporary occupational therapy. Among present-day emphasis in patient services, for example, are the selection of activities with greater reference to individual patient needs, and the therapeutic use of self and group techniques and the multidisciplinary approach to patient treatment. That some of these current developments came from seeds planted in the military hospitals seems credible for several reasons, as follows:
1. Prewar occupational therapy consisted largely of understaffed, overcrowded, activity-centered programs for female patients or for deteriorated, chronic male 'psychotics.' Weaving and basketry were the symbols of practice. Increasingly, today, occupational therapy is an integral part of admission and acute treatment services, of day and night hospitals, of halfway homes, and of mental hygiene clinics and other outpatient facilities. More specific individual and group techniques are demanded by the psychiatrist, and a more realistic scope of vocationally related activities characterizes the modern treatment program.
2. Group therapy, rarely applicable with the regressed schizophrenics who made up such a large proportion of the pre-World War II psychiatric hospital census, was successfully used with the large numbers of acutely
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ill patients seen in Army hospitals more immediately following onset of neurotic or psychotic symptoms. One hospital,34 for example, reported the following:
Group therapy was continued as a very necessary part of the program because of the overwhelming patient load. It became apparent, however, that a standardized method for all therapists in the hospital should be written in order to insure a uniform quality of therapy. Accordingly, a manual was organized and distributed which contained specific instructions for the carrying out of an adequate group therapy program for the type of patients treated at this hospital.
Use of these techniques, essentially new to occupational therapists, particularly in conjunction with other professional groups (for example, psychologists and social workers) serving the patient, was unquestionably a growth-producing factor in the history of this profession's development.
3. The all-important aim of the Army Medical Service-to get the patient back to duty or at least out of the hospital to make room for ever-mounting admissions-exerted pressure for maximum utilization of treatment services. To provide additional personnel for such services and also to guard against the potential danger of women working with acutely ill and disturbed patients, common practice was to assign corpsmen to occupational therapy. These enlisted personnel filled other than guard roles, many of them bringing to the section manual skills in the more 'masculine' activities appropriate to the military setting. It is believed that their extensive utilization in Army occupational therapy programs paved the way for recognition and certification of civilian assistants and aides, which was established by the American Occupational Therapy Association.
That these and other supposed influences on occupational therapy might have occurred without or aside from the military experience is a legitimate hypothesis. That the wartime experience of occupational therapists who witnessed the effect of more dynamic use of activities and of psychiatrists who challenged them and others to evaluate critically and subsequently improve their service was also a factor seems an equally reasonable possibility.
Past and present aside, however, the future may perhaps be viewed with more assurance than speculation. If prepared in no more than the areas which proved to be major bottlenecks in World War II, occupational therapy history, if consulted, should provide a head start on program development in the event of future need. First, future guidance would certainly consider training for top priority to be started early enough to insure availability of qualified personnel to carry out programs. Second, both trainees and graduate personnel should be included within the military framework in order to facilitate recruitment and assignment of personnel. Third, there is extensively recorded experience with the types and levels of supplies and equipment essential to servicing given numbers
34Annual Report, Welch Convalescent Hospital, 1945, p. 18.
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of patients and clinical conditions and with the importance of making these accessible through Army channels. Fourth, there exists a file of architects' blueprints, for remodeling or new construction, which include special requirements for occupational therapy in military hospitals.
Finally, it is hoped that in a parallel future situation, occupational therapy will be given the opportunity to prove that it has a place in oversea or in theater of operations hospitals. Such value was proved in the World War I experience of reconstruction aids serving with the American Expeditionary Forces in France, has since been attested by the recorded experience of numerous military personnel serving in oversea theaters in World War II, and is logically substantiated in this concluding quotation:35
The use of occupation exclusively or primarily for the sake of its therapeutic value represents an indispensable aid in the management of neurotic, psychotic, as well as of all convalescent patients. Occupational therapy should be applied at all points of treatment from forward echelon aid station to the last point of evacuation in the psychiatric section of a named general hospital. As soon as the removal from immediate danger, a good meal, a clean bed, a sedative, and the ministration of a nurse have allayed the acute mental upset, the soldier should be directed to some useful work in the interest of the group in which he finds himself. Overly sympathetic and protective attitude on the part of medical officers and attendant personnel, while the patient remains idle, leads to further slackening of his morale and a tendency to morbid introspection. On the contrary, when given something interesting or useful to do, the feeling of personal worth is enhanced and the desire to be well again and to join the group in unselfish striving towards a common goal is stimulated.
35Barton, Walter E.: Occupational Therapy. In Manual of Military Neuropsychiatry. Harry C. Solomon and Paul I. Yakovlev (editors). Philadelphia: W. B. Saunders Co., 1944, p. 605.
