Abstract
The year 2017 marks 100 years since the formal naming of occupational therapy. The development of the profession was heavily influenced by the First World War and the subsequent rehabilitation efforts to which occupational therapy reconstruction aides contributed. The year 2017 also marks 100 years since the entry of the United States into World War I. Commemoration of these events and significant people is valuable in its own right, and it also provides an opportunity to reflect on the core assumptions, beliefs, values, and practices of the profession and therefore can inform current theory and practice.
Background
The involvement of occupational therapy reconstruction aides in World War I is widely acknowledged to have spurred the development of the profession (Low, 1992). The U.S. World War I rehabilitation program was based on a British model, and this program was facilitated by close connections between leading American orthopedic surgeon Joel Goldthwait and Britain’s Sir Robert Jones. The British system of rehabilitation included medical–mechanical treatment, physical therapy, massage therapy, vocational training, and engineering workshops (Linker, 2011). Advocating for a similar service, the American orthopedic surgeons presented plans to the Surgeon General claiming that their medical knowledge of injury made them most suited to manage all aspects of reconstruction, including physiotherapy, bedside occupations, curative workshops, and vocational reeducation (Gutman, 1995).
The U.S. Army began its first trial of occupational therapy at Walter Reed Hospital, Washington, DC, in February 1918, when a small carpentry shop was opened under the direction of a carpenter. Participation in carpentry boosted morale, and shortly afterward, occupational therapy reconstruction aides were appointed to an orthopedic ward (Wish-Baratz, 1989). The rehabilitation aim was “to help each patient find himself and function again as a complete man physically, socially, educationally, and economically” (Baldwin, 1919, p. 447). Examples of activities used by the occupational therapy reconstruction aides at Walter Reed include knitting, chair caning, woodworking, printing, rug making, and other crafts (Quiroga, 1995). Occupational therapy developed rapidly at the hospital; in 1918, psychologist Bird Baldwin “undertook the task of organizing a department of occupational therapy for soldiers with physical injuries” (Reed, 1984, p. 278). In a short period, the department developed from one room into seven workshops in five buildings (Wish-Baratz, 1989).
One of the first occupational therapy reconstruction aides at Walter Reed was Lena Hitchcock. Taking the U.S. Army oath on March 2, 1918 (the fourth reconstruction aide to do so), Hitchcock was stationed in the hospital until July, when she traveled to Base Hospital 9 in Chateauroux, France. That hospital accommodated 1,926 injured soldiers, and it could treat 2,250 soldiers in emergency situations. According to Base Hospital 9 Chaplain Raymond Brown (1920), it received both surgical and medical cases and was designated as an orthopedic hospital in the spring of 1918. Throughout its operation, the hospital treated 15,219 sick and wounded soldiers.
The first occupational therapy reconstruction aides sent to France (in June 1918) were posted to a neuropsychiatric Base Hospital (117) after the campaigning efforts of psychiatrist Frankwood E. Williams, who was the associate medical director of the National Committee for Mental Hygiene (Quiroga, 1995). Williams offered this first group the opportunity to go to France as “civilian aides”; although this gave them no official rank, the women saw the experience as an opportunity to prove themselves (Quiroga, 1995). They were initially coldly received, but they quickly impressed and, according to Williams, “Inside of a few weeks there came word from Colonel Salmon, Chief of the Psychiatric Division in France, that these women were worth their weight in gold and to get ready as many more as possible” (Myers, 1948, p. 209).
Occupational therapy reconstruction aides have been widely described (Bloom Hoover, 1996; Gutman, 1995; Linker, 2005, 2011; Low, 1992; Quiroga, 1995). Some were trained occupational therapists, whereas others were teachers, artists, and craftspeople; all were women who were more than 25 years old (Low, 1992). The war offered unparalleled opportunities to showcase occupational therapy’s benefits; consequently, the leaders hand-picked candidates (Quiroga, 1995). The women who served were therefore mostly well-educated; many were college graduates (Low, 1992), and many also had experience of caring for a family member or friend (Gutman 1995).
World War I promoted both the growth of diversional occupational therapy (Bloom Hoover, 1996), which diverted patients’ attention from pain and negative thoughts, and the use of occupations to prepare the soldier for life after discharge, such as woodworking, bookbinding, and typewriting (Bloom Hoover, 1996).
There were two categories of reconstruction aides: occupational therapy aides and physiotherapy aides. The relationship between them has been described as characterized by both strong kinship and tension (Linker, 2005, 2011). The women who went on to be leaders of physiotherapy encouraged distance more than empathy, considering that occupational therapy served the “useful . . . calling of ‘morale boosting’” (Linker, 2005, p. 114).
The relationship between World War I reconstruction aides and orthopedists was pivotal in the acceptance by military personnel of women fulfilling this military function (Gutman, 1995). This relationship is also significant in understanding occupational therapy’s acceptance of the medical model and may have moved the profession away from the founders’ core philosophies regarding the connection among occupation, illness, and the environment (Gutman, 1995).
Historical research has illustrated how occupational therapy leaders during the war adopted various strategies, such as physician prescription, to face challenges to the occupational therapy role in vocational reeducation by vocational technical trainers (Gutman, 1997). Gutman (1997) showed how occupational therapy’s decision to associate with the medical profession promoted the credibility and prestige of the profession; however, it also ultimately compromised its role in vocational reeducation.
This body of research enriches the understanding of many contemporary issues, including the nature of interprofessional relationships as well as the scope, domain, and practice of occupational therapy. Although reference in some of the literature on reconstruction aides is made to the experiences of individual aides, there has been no in-depth analysis of their experiences, their writings, or the experiences of their patients. This article contributes to filling this gap.
Lena Hitchcock wrote a 128-page unpublished memoir, The Great Adventure (n.d.), which describes her experiences of recruitment, travel to France, living conditions, social activities, and the people she met. (Unless otherwise noted, all Hitchcock citations are to this memoir.) She also describes the development of occupational therapy. The memoir is undated, and it is uncertain when it was written. Hitchcock’s drawings in the manuscript are dated 1918–1919. The memoir was likely written—probably on the basis of diaries—after the war, when reconstruction aides (as members of the National Association of Ex-Military Reconstruction Aides or the Women’s Overseas Service League) were actively involved in including the story of women’s service in the commemorative narrative of World War I (Finkelstein, 2015). Despite the existence of this detailed autobiographical account of a pioneering occupational therapist, to date, the opportunities presented by this memoir have not been fully exploited.
Hitchcock’s memoir contains a 53-line poem titled “The Bluebirds,” which was written for the occupational therapy reconstruction aides at Base Hospital 9 by Corporal Frank Wren of the American Expeditionary Forces, who was a patient in the hospital in 1918 (Figure 1). Military records suggest that Corporal Wren enlisted in June 1916, served overseas from May 1918 to November 1918, and was honorably discharged in January 1919 (New York State Archives, 1917–1919). The soldiers nicknamed the reconstruction aides the “Bluebirds” in homage to their similarly hued uniforms. In this article, we provide insight into the practice of occupational therapy during World War I through analysis of Wren’s poem “The Bluebirds.”
“The Bluebirds,” by Frank Wren (cited in Hitchcock, n.d., pp. 56–57).
Method
Our research aim was to describe soldiers' experiences of occupational therapy in Base Hospital 9 during World War I through analysis of “The Bluebirds.” We used historical documentary research methods to analyze the unpublished memoir of Lena Hitchcock, The Great Adventure; the poem by Corporal Wren contained within the memoir; and a published history of Base Hospital 9 by Hospital Chaplain Raymond Brown (1920). Permission to access The Great Adventure was obtained from the National Museum of Health and Medicine (Silver Spring, MD) and the National World War I Museum (Kansas City, MO).
Data Analysis
We used thematic analysis to analyze the entire Hitchcock memoir, the Wren poem, and selected excerpts from Brown’s (1920) history of Base Hospital 9. Thematic analysis can potentially provide a rich and detailed, yet complex, account of qualitative data (Braun & Clarke, 2006) and has been widely taken up in health research (Braun & Clarke, 2014). Thematic analysis is an analytic approach rather than a methodology and can be applied within a range of theoretical frameworks (Braun & Clarke, 2006). In this study, given our focus on reporting the soldiers’ experiences of occupational therapy, the overarching theoretical framework within which thematic analysis was conducted was essentialist–realist.
The six-stage guide to thematic analysis described by Braun and Clarke (2006) was adhered to. The first phase was a process of familiarization with the data through repeated reading. Initial codes were identified in the second phase and sorted into potential themes in the third phase. In the fourth phase, all themes were reviewed and discussed by the first and second authors to ensure all themes had internal homogeneity and external heterogeneity as described by Patton (1990). In other words, data within themes should cohere in a meaningful way, and there should be clear distinction among themes. In the fifth phase, themes were named and defined.
Trustworthiness
Reflexivity is a defining feature of qualitative research (Finlay, 2002). Throughout the research process, we aimed to be aware of our influence on the research process and acknowledge that the account presented here is partial and situated. Two of the three authors are experienced occupational therapists and academics and have expertise in anthropology, disability studies, and history. Throughout the research process, discussion and reflective writing were used to aid reflexivity. Contradictory values that were explicitly identified as influencing us were as follows: a desire to privilege the service user’s experience, a desire to acknowledge the contribution of a pioneering woman and occupational therapist, a desire to commemorate and celebrate the history of occupational therapy, and a desire to avoid reproducing unquestioned assumptions about the profession.
To ensure trustworthiness, we determined the origin and authorship of documents. The digital copy of the Hitchcock memoir, received from the National Museum of Health and Medicine, was compared with a second copy obtained from the National World War I Museum to ensure its authenticity. The copy from the National World War I Museum was selected as the primary source because all pages were present. To establish credibility, we cross-referenced details about Hitchcock, Brown, and Wren from other sources to ensure that they were present in Base Hospital 9 and were, respectively, staff members and a patient in 1918.
Results
Description of Therapy Activities
Brown’s (1920) history of Base Hospital 9 shows that one of its chief functions was reconstruction, and the rationale for reconstruction was “to save and reconstruct human life so that it would be useful again . . . to assist nature in restoring movement to injured parts” (p. 84). Hitchcock worked on wards for patients who sustained orthopedic injuries and later in Base Hospital 114 on psychiatric wards for “dementia patients [patients who had psychotic disorders]” (p. 108). She describes Ward 7 as an orthopedic ward:
it is a double-decker building with about 70 ambulatory cases billeted in two long rooms upstairs, each with its own washroom. Approximately 90 men occupy the beds downstairs. These are spread through three rooms. The men are trussed up in fracture frames with sandbags, ropes and pulleys keeping their poor legs in the desired position. (p. 50)
Corporal Wren’s poem describes the activities engaged in, equipment used, and the context of therapy. The poem opens with a description of the occupational therapy workshop: “There’s a wooden shack o’er there.” Hitchcock describes how commanding officers permitted their expansion from a store cupboard to a workshop:
Reluctantly, D—or Colonel Hawley—gave us three rooms in the Receiving Ward, an enormous, double, empty wooden barracks . . . The walls are rough boards through whose wide chinks the winds of winter will whistle, but what matter, it’s ours. We water stain the boards of the two small rooms a soft brown; hang blue-dyed linen curtains at the windows; build rough shelves for tools and exhibits; fashion a long work table from planks and trestles; a desk for Miss Hills [head aide] from a board resting on two crates . . . One room is Miss Hill’s office; one our preparation and exhibition space; and the long room outside is our work shop. (p. 52)
This workshop building is also described in the history of Base Hospital 9.
Corporal Wren describes the use of hammers, jig-saws, tools, snips, pliers, wood, tin, and coin, and he identifies three products in the poem: a ring, a toy, and a painting. His descriptions of the noises during therapy also offer an insight into the activities used: “Oh, it’s bang! bang! bang!, And it’s zip-zip-zip, And the hammers pound, And the jig-saws rip.” The use of these activities is clearly supported by the description of occupational therapy in the history of Base Hospital 9: “Tin cans made mechanical toys, as ambulances, aeroplanes, engines, while any kind of wood that could be found was soon turned into a useful article or toy” (Brown, 1920, p. 78).
Hitchcock’s memoir similarly describes woodwork, making toys, and painting as well as other activities: knitting, block printing, curtain making, and metalwork. It notes that before she departed New York, Hitchcock purchased “a beautiful set each of woodcarving leather and blockprinting tools” (p. 5) at Hammacher Schlemmer, and she also brought with her to France “all my own tools, really good scissors, paints, a rake, a Colonial mat frame, a small bed loom, as well as various other odds and ends” (p. 51). She refused to pack these items in the occupational therapy luggage, which subsequently did not arrive in France. Hitchcock describes the many efforts to address their lack of tools and supplies:
The dump heap has also yielded treasures—tin cans, cigar boxes and quite good-sized pieces of gumwood from the boxes in which hospital and food supplies were shipped. And from somewhere or other, Miss Hills or Hope [another occupational therapy reconstruction aide] have procured pieces of linoleum. The hospital blacksmith took some of my tools the other day and copied them. (p. 51)
Other activities that Hitchcock describes include block printing (p. 65), knitting (p. 64), weaving (p. 100), and metal work (p. 53). During Christmas 1918, she details the lengths that the aides and soldiers underwent to decorate the wards, spending “two days making ornaments from cardboard” (p. 89). Hitchcock had completed “private lessons in ambidextrous drawing, basketry and several minor crafts” (p. III) before deployment.
Experience of Engaging in Activities
Corporal Wren’s poem articulates multiple dimensions of the experience of occupational therapy. He describes the mental or emotional benefits: “things look brighter now . . . . Then from your mind your troubles spring.” Positive emotional experiences are described, including “delight” and “pleases you just fine”; “But just take their warning now, If you like gloom anyhow, That the bluebirds ruined mine for all the time.”
In the poem, occupational therapy work is described as “new and strange” and as bringing “change/To the dull routine.” Similarly, he describes how the Bluebirds “are with you then post haste” if you “are kept in bed with nothing else to do.” Greater description is provided of the emotional and mental benefits of occupational therapy than the physical rehabilitation benefits, although physical benefits are mentioned. One cited reason for occupational therapy is “If you’ve got a banged up hand,” and one of the identified outcomes is “feeling fit.” Both excerpts indicate a focus on physical function.
The reconstruction aides were frustrated by the limited time for occupational therapy because they had to work as nurse’s aides when required (Hitchcock had undertaken nurse’s aide training). She recalls how a fellow aide, Hope, had “been doing eight to nine hours nurse’s aide work in addition to O.T. [occupational therapy]” (p. 72). Time limitations may have affected their capacity to engage in therapy that was focused on physical rehabilitation: “So far none of our O.T. is orthopedically corrective, but at least it prevents the boys from drinking too much and losing all their money shooting craps” (p. 51). The use of the term “at least” indicates that Hitchcock valued “orthopedically corrective” occupational therapy. Elsewhere, she describes the use of an adapted homemade turning lathe by the occupational therapy reconstruction aides at Base Hospital 9 “for certain knee, hip and ankle cases” (p. 53).
The occupational therapy reconstruction aides also created and adapted devices. Hitchcock details how Hope constructed for one soldier, who was depressed by the loss of his upper limbs, “an ingenious leather band with slits to hold paint brush, knife, fork or spoon,” and reported that “the change in him is amazing” (p. 74). Hitchcock also describes devising a hammock for one solider to prevent pressure sores (p. 100).
Mirroring the account of Corporal Wren, Hitchcock identifies soldiers’ positive experiences of activities. She describes etching the outline of images of Naples for a homesick young Italian patient to paint, which resulted in him feeling “pleased and content” (p. 75).
In his history, Hospital Chaplain Raymond Brown offers an excellent description of the multiple purposes of occupational therapy reconstruction:
to arouse the patient’s interest by giving them something to make, which at the same time would call into play the muscles which needed to have their function restored. The aides who were doing this work went from bedside to bedside and taught the men to make useful and beautiful things. Great good was accomplished in this way. In the first place the mind of the patient was being occupied; then the patient was using a part of his body which needed to be made strong and well again; and last but not least, he was making something that was worthwhile and could be sent to those at home as a gift. (p. 78)
Discussion
Our findings provoke reflection on enduring issues in occupational therapy: occupation-based practice, holism, and client-centered practice. Theme 1 presents a description of the activities engaged in during occupational therapy, equipment used, and the context of therapy. These findings correlate with previous studies in which researchers identified that arts and crafts were central to occupational therapy during the war (Bloom Hoover, 1996; Low, 1992). Although World War I saw an alignment with medicine, which may have moved the profession away from the core founding philosophies concerning the relationship among occupation, illness, and the environment (Gutman, 1995), this alignment is not reflected in Corporal Wren’s poem, which focuses solely on occupation-based treatment. Alongside arts and crafts, the findings reveal that workshop activities—including woodwork, toy making, and metalwork—were central to occupational therapy.
Historical and contemporary occupational therapy theories have posited that occupations “hold therapeutic power for recovery” (Pierce, 2001, p. 139). This outcome is evident in the findings based on Corporal Wren’s experiences, in which he identified mental and physical benefits of occupational therapy. Similarly, in a report on the Reconstruction Services, the purpose of occupational therapy was stated as being to increase physical function in collaboration with the physiotherapy reconstruction aides and also to divert the mind (Crane, 1927).
The earliest writings in occupational therapy articulate a clear commitment to the use of occupation for therapeutic purposes (Dunton, 1915; Meyer, 1922/1976; Slagle, 1934). However, despite this focus at the inception of the profession, since the mid to late 20th century, occupational therapists have faced challenges enacting occupation-focused approaches to treatment (Gray, 1998; Yerxa, 1990). These challenges have provoked much debate within the profession and have led to strong reaffirmation of the professional commitment to occupation (American Occupational Therapy Association, 2014; Molineux, 2004; Wilcock, 2006); they have also contributed to the development of the discipline of occupational science (Yerxa, 1993). The increased scholarship on occupation-based practice has had an impact on contemporary practice in a range of clinical areas (Müllersdorf, & Ivarsson, 2012; Ormsby, Stanley, & Jaworski, 2010; Wilson & Cordier, 2013; Wolf, Chuh, Floyd, McInnis, & Williams, 2015). The findings presented here further bolster the theoretical foundations underpinning the discipline of occupational therapy by providing evidence of the therapeutic benefits of occupation-based interventions.
Occupational therapy is underpinned by humanistic values, including holism (Yerxa, 1992). However, evidence suggests that therapists may struggle to enact holism in practice; this finding has particularly been identified in acute physical settings (Blaga & Robertson, 2008; Finlay, 2001; Robertson & Finlay, 2007). Corporal Wren’s poem describes the emotional and mental benefits of occupational therapy, and other literature has recognized the contributions of occupational therapists in both World War I (Quiroga, 1995) and World War II (Gritzer & Arluke, 1985) to soldiers with psychological trauma. Hitchcock describes working with patients on psychiatric wards. In contrast, Cogan (2014) highlighted that contemporary “occupational therapy research and service delivery to support reintegration of [U.S.] military personnel with mental health challenges into civilian life have not gained traction” (p. 479). She suggested that this finding is likely because of the “diminished presence of occupational therapy in the mental health care system” (p. 479). This lack of attention to holistic treatment is worrying given the consistently identified high rates of mental illness among service members and veterans (Hoge, Auchterlonie, & Milliken, 2006; Hoge et al., 2004; Seal, Bertenthal, Miner, Sen, & Marmar, 2007).
Historical material has frequently been used in debates on professional dilemmas and as a source of inspiration (Molineux, 2004; Royeen, 2003). In this work, we have identified enduring beliefs and values, such as the nature of the therapist–service user relationship and the therapeutic use of occupation. However, work to date has focused on, and therefore has privileged, the accounts of occupational therapists and early pioneers rather than the accounts of service users. The tendency in occupational therapy to unquestioningly accept the pronouncements of distinguished and respected occupational therapists and to substitute authority for evidence has been critiqued (Hammell, 2009). In contrast, in this article, the writings of a solider recipient of occupational therapy are foregrounded and corroborated by the writings of an early therapist and a hospital chaplain who observed occupational therapy.
Patient-centered health care and patient involvement in research are movements that have had major influences on the health care and research landscape in recent years (Domecq et al., 2014; Mroz, Pitonyak, Fogelberg, & Leland, 2015; Ocloo & Matthews, 2016), with emerging evidence of the enhanced quality and appropriateness of research completed with patient involvement (Brett et al., 2014) and positive impacts on health services (Mockford, Staniszewska, Griffiths, & Herron-Marx, 2012; Ocloo & Matthews, 2016). Occupational therapy theory has emphasized humanistic principles in working with service users since its inception. Scholarship within the profession has consistently valued the service user’s account as reflected in attention to the therapeutic relationship, client-centered practice, narrative approaches, qualitative inquiry, and participatory approaches. Yet again, a disconnect between theory and practice appears to exist, with a wealth of evidence attesting to failures in practice to realize these ideals (Hammell, 2013; Solman & Clouston, 2016; Taylor, Lee, Kielhofner, & Ketkar, 2009).
Commemoration of events and significant people is valuable in its own right and provides an opportunity to reflect on the profession’s core assumptions and practices. It enables occupational therapy practitioners to see how past ideals reverberate today and can inform theory and practice. “Reflect on the Past to Shape the Future,” the title of Mayers’ (2000) Casson Memorial Lecture, highlights the importance of history to occupational therapy. Historical research provides a contextual understanding of how practice developed over time and allows practitioners to reflect on core philosophical premises and their present standing in the profession.
Implications for Occupational Therapy Practice and Research
The findings of the study have the following implications for occupational therapy practice and research:
Analysis of the poem revealed holistic practice addressing both physical and mental health. Difficulty enacting holistic practice has been identified for decades (Finlay, 2001). Greater attention to addressing the physical health, rather than the mental health, needs of service members and veterans is an ongoing issue.
To ensure client-centered practice is realized, occupational therapy practitioners should elicit and value the experience of service users.
These findings support the groundswell of calls for the use of occupation as the means and end of therapy.
Opportunities presented by Lena Hitchcock’s memoir have not been fully exploited. The memoir contains drawings and photographs, and other memorabilia are available that warrant attention.
Future research on the writings and accounts of early occupational therapists and service users is required to more fully understand continuities and discontinuities in occupational therapy theory and practice and influences on practice over time.
This study underscores the ongoing value of researching and disseminating the experiences of occupational therapy service users to inform practice.
Limitations
The poem “The Bluebirds” was written for the reconstruction aides, and therefore it is inevitably complimentary and offers no criticism of occupational therapy. Findings must be interpreted in light of the audience for whom it was written. The poem is limited in length and content; therefore, the account is only partial. To address this limitation, inclusion of two other sources was undertaken. Audio recordings of Lena Hitchcock contained in the American Occupational Therapy Foundation archives are being digitized at present and were not available.
Conclusion
Exploration of the soldiers’ experiences of occupational therapy during World War I revealed much continuity between practice 100 years ago and present day. Arts and crafts as well as workshop-based activities that were used in occupational therapy then remain in use today. In previous historical studies, researchers have identified core philosophical premises about the use of occupation as therapy. These premises are supported by the account of a soldier recipient of occupational therapy who articulated positive dimensions of the experience of engaging in activities, including emotional benefits, diversion, and orthopedic benefits. Through foregrounding the soldier’s account, in this article, we redress the imbalance in research of this type to date in which the service user’s voice has frequently been silenced and the accounts of occupational therapists have been privileged.