A Case in Occupational Therapy

MACBETH. Canst thou not minister to a mind diseas’d,
Pluck from the memory a rooted sorrow,
Raze out the written troubles of the brain,
And with some sweet oblivious antidote
Cleanse the stuff’d bosom of that perilous stuff
Which weighs upon the heart?
DOCTOR. Therein the patient
Must, minister to himself.
— Act V, Scene 3

I

A WORD FROM THE DOCTOR

BY JOHN RATHBONE OLIVER

PHYSICIANS, I think, are more fortunate than other professional men. A lawyer may occasionally have clients who are also his friends. The same thing may happen, I suppose, to a business man. To a physician, however, t here is no pleasanter association or memory than the commingling of a past dependency and a present friendship. The writer of the following article was once a patient of mine, and I count him now among my friends.

Every psychiatrist is always interested in a patient’s description of his past mental illness. We are still a little afraid of mental illness. A man will gabble for hours about his surgical operation, but he does not like to talk or write about a past depression or a tormenting phobia. Such records, therefore, are rare. In them the physician discovers the mistakes he made and learns something for the future, for the patient often misinterprets a chance word and builds on it a whole system of anxiety about which the physician is entirely ignorant. There are two examples of this in the following paper.

There is no such thing as a ‘blanket case.’ We physicians who work in a ‘Group’ do have an arrangement that we call a ‘blanket fee.’ This means that a patient who has very little money does not have to pay the fee of each of the consultants to whom he is sent. He is merely asked to pay whatever he can reasonably afford, and then this so-called ‘blanket fee’ is divided up among the physicians who have examined him.

Secondly, I feel sure that no one in Baltimore believes that any medical institute of ours represents the highest court of medical appeal. We do what we can, but we do not pretend to be a court of last resort. With these two exceptions the description of the case in the following article is, so far as I know, accurate and very interesting.

The writer imagines that I and my colleagues cured him. Nothing could be further from the truth. With our help he cured himself. All we could do was to show him the road along which he might walk toward health, but it was he who had the courage to walk in it — and to keep on walking in it until he reached his goal.

II

THE PATIENT’S STORY

BY WILLIAM HEILMAN

FIVE years ago I left a sanitarium and took occupational therapy home with me. Discharged patients usually prefer to drop everything associated with their illness and its cure, but while I was still confined to my bed I had discovered that a handicraft was an indispensable part of the emotional reëducation which I wished to work out. I went back to my parish with a desire to become a competent amateur metal smith.

In the years that have passed since I returned from Baltimore I have managed to add the avocation of metal smithing to my work as a parson. This in itself is no remarkable achievement, but it has been invaluable as a help in reorientation. To be able to start with the idea of a brass lamp, to sketch the shape, to make the detailed drawing, to build the lamp in such a manner that the sheet-metal men, who are my friends, pronounce it a workmanlike job, — in other words, to make a daydream of a lamp come true in good honest metal, —this does something to my emotional life.

The men in overalls say that I am too particular to earn high wages on a production basis even if I wished to, but they also say that I have a persistent patience in my puttering and that what I turn out looks as if it had been made by a craftsman. The friendship and approval of these shopmen have helped sustain the enthusiasm of an amateur.

I

I was forty-eight years old when I entered a rest home in Baltimore suffering from what the psychiatrists diagnosed as a mild depression. The decision which finally brought me there was typical of the leaps in the dark which a depressed person will make.

A year or so before I was taken sick I came across a book by Dr. John Rathbone Oliver. It was entitled Fear. One Saturday night about nine o’clock I started to read it, and I finished it sometime in the early hours of Sunday. That day I went to church with the outline of a sermon in my pocket, but when it came time to preach I put aside the prepared sermon and told the story of Fear. Many people said afterward that it was the most helpful application of religion to human difficulties they had ever heard. I reread Fear many times. I had never met Dr. Oliver, but I wrote him a long letter. In a few days I had a reply. Then I learned that my Bishop and the Doctor had been fellow students both at Harvard and at the General Theological Seminary.

When my sickness came on I told the Bishop that I wanted Dr. Oliver to look me over. With my affairs in a jumble, I rushed off to Baltimore, preceded by letters and telegrams from the Bishop. In a sort of daze I found my way to Dr. Oliver s office. He talked to me quietly for an hour. At the end of the interview he called a clinic on the telephone.

‘A blanket case,’ I heard him say; and there followed my name, age, and occupation.

The ‘blanket’ worried me. It brought to mind a man I had once seen in a strait-jacket. I had talked so long and was so confused that I did not ask questions.

‘I shall drive you over to the clinic in my car,’ Dr. Oliver told me. ‘Then we’ll go to the rest home. This is not going to be a case of giving you a pink pill and a pat on the back, and saying you will be all right. We are going to find out what is the matter with you.’

So we entered the doctor’s little green car, and in a few minutes we were on the stone steps at the front door of the clinic. The doctor rang the bell. As someone came to open the door, he said: ‘Beyond this clinic there is no appeal. This is a sort of medical Supreme Court.’

And into the clinic I went as a ‘blanket case.’ I have since learned the meaning of this phrase: for a strange parson, who had a little church in a distant city, the good doctor had made arrangements whereby this clinic would give its services, receiving payment only for materials used in treatment. At the time I was too ill to take in what it might imply.

II

If I had been identified as a severely depressed patient when I entered the rest home, a night nurse as well as a day nurse would probably have been put on duty to watch over me; my razor would have been taken away from me, and I should have been shaved by an attendant. Those responsible for the welfare of the depressed are always afraid of suicide. Now and then a patient who could have recovered eludes the trained watchfulness of the staff and takes his own life.

I made no actual attempt to do violence to myself, but I suffered so severely that death would have been welcome. One of my obsessions was in planning methods of quick and sure self-destruction. Now and then I was able to bring myself to the place where I gave the doctors a hint of what I was thinking, but it was not easy to do. I felt that I was holding back important information about my condition, but when I tried to speak of it words would not come.

One day when the Chief of the clinic came to see me I attempted to tell him what was in my mind. I went through the experience which the doctors call ‘blocking.’ One has a set of thoughts clearly formulated and starts to express them — then, without warning, the machinery of speech refuses to work. It seems as if all ability to think and act had been snatched away. At the same time the capacity to feel is heightened. The heart is gripped by terror, by the fear that some permanent paralysis of the mind has stopped all future usefulness. Everything that constitutes one’s own personality seems permanently out of reach.

When this happened to me the Chief sat down at my bedside. He leaned forward and put his hand on my head. I knew by the look in his eyes that he understood what I was enduring.

‘Sometimes a man in your profession feels that this kind of suffering is a judgment upon him,’ he said. ‘Now, whatever you think or feel, let me reassure you. It is nothing of the kind. It is just a sickness, and, while it is painful in the extreme, the patient always recovers.’

Without any change of feeling that I was conscious of my tears began to flow, and I was bitterly ashamed of them. Apparently the Chief did not notice them. He continued to talk in the same quiet and reassuring tone.

‘Your chart shows that you are giving us splendid coöperation,’ he went on. ‘You are helping yourself more than you realize. You really want to get well. You are encouraging us by the fine effort you are putting into your handwork. We often have patients with us a long time before they get the idea of helping themselves. The theory of handwork — or occupational therapy, as the doctors call it — is simple when a fellow once sees what it is all about. Nobody can work to a pattern and at the same time think about himself. If he starts to grind inwardly when he is trying to work, he will spoil the job. If he follows the pattern and turns out good work, he has got away from thinking about himself. That is occupational therapy in a nutshell. Make yourself a skilled hand worker when you go home, and you will not need to come back here again.’

The Chief was in my room not more than fifteen minutes, but in that brief period he gave me the compass by which I found my way out of the woods.

III

At the time of this visit I was in isolation. Isolation is a technical term which describes the conditions under which patients are put to work in rest homes. These institutions do not provide the kind of rest that comes from idleness. Their plan is to bring relief and self-forgetfulness by means of organized handwork, which takes one’s interests into new fields and challenges the attention with unfamiliar tasks that call for care and sustained application.

A patient in isolation has no visitors. No one sees him except the doctors and trained attendants — the nurses and orderlies of the institution. The patient writes no letters and receives no mail. As far as possible his associations with all his usual interests are suspended. He lives by a carefully planned schedule, made to order to fit his own problems.

I know nothing about what the other patients were required to do. I met none of them, and heard none of their experiences. The nurses saw that we were kept apart. It requires a highly trained personnel to carry through such a programme. But I was grateful for it from my first day in the rest home. I was in no condition to withstand the down drag of another’s recital of his difficulties. Fortunately, too, I was prevented from making more trouble for myself by telling other patients my misinterpretations and rationalizations of what was happening to me. Best of all, my work periods were free from interruption.

Even while I lay in bed I was encouraged to try my hand at various crafts, evidently with the hope that I should develop enough interest in one of them to wish to go on with it. The nurses of other patients came into my room to praise the silver bracelets I had shaped for my wife and daughter. They borrowed my copper lamps to show to their friends. They looked over my hooked rug. They assisted me with the tooled-leather work, for which I had little liking. These nurses had entered into a conspiracy of kindly helpfulness. They were coming in to encourage me.

My own nurse was a Virginian. During the war, I too had lived in the South, as chaplain of a Negro Development Battalion. She liked to have me tell her the dialect stories I brought back from the army. Perhaps she really enjoyed the tales of the illiterate black soldiers, but, more than that, she was pleased that I could come out of myself enough to tell them. She knew that she was getting good professional results when she got me to talk of experiences I enjoyed remembering.

When the three weeks of isolation came to an end I knew what I wanted to do. Of the several objects I had fashioned with my hands, those which had given me the greatest pleasure in the making were the copper lamps. I wished to learn more about working in metals.

By this time I had regained my ability to walk, and my nurse was tireless in going with me all over the city of Baltimore to hardware stores, mill-supply houses, and the dealers in brass and copper, to find the materials I wanted. She went to the library and brought back Davidson’s Educational Metal Craft, and Haas on Occupational Therapy, and a dozen books on brass and copper antiques. My enthusiasm was running high, and when I was not working with my hands my nose was buried in one of these volumes.

IV

My light was supposed to be out at half past ten, but one night the supervisor found me reading at one in the morning. This breach of discipline was entered on the chart, and I was severely called to account for it by the friendly member of the clinical staff who was my daily visitor. This doctor dropped in between the hours of five and six each afternoon. He usually brought me a cigar, and with his own hands he carried dozens of books to my room. On this occasion, however, he gave me a stern scolding, pointing out that the infraction of the lightsout rule was no trifling matter. To my surprise, I put up a spirited defense.

‘Last night was not the only night I have read late,’ I shouted. ‘It was the night I was caught at it, and I don’t care a fig — it did me good. Since I have missed sleep reading about metal craft I have not thought of Joe Robinson. When three days go by, and I am so taken up with my work and reading that I do not once recall old Joe Robinson, I know I am getting better.’

‘Great!’ the doctor exclaimed. ‘But who in blue blazes is Joe Robinson? I want to know how he got on your mind.’

There was no blocking this time. With fluency and heat I held forth in a long denunciation. When I finally stopped for want of breath the doctor announced:—

‘Joe Robinson goes on your chart underscored with red ink. The Chief will smile when he meets him. You have made an important discovery. It is a great day for any man when he learns how to take an excursion into the field of his special interests to escape from the people who get on his nerves. If the shadow of any human being grows so big that he becomes a bogey man in your mind, don’t try to force yourself not to think of him. That makes the fellow develop bigger horns and uglier hoofs. Just give him the slip, as it were, and the next time you see him he will not irritate half so much. Right now Robinson has stopped being an ogre, and is nothing but a silly fat man whose pants need pressing. That’s so, is n’t it?’

The doctor had remained so long in my room that he would be late for his dinner, but he stopped at the door and filled the room with hearty laughter.

‘Your damned old Joe Robinson obsession just cannot live without attention. If you forget him, if he steals into your presence and you are so busy that you don’t notice his arrival, it will make him sick. If you keep on working and some of your copper filings fall on his head, he will shrivel up and pass out.’

V

To the two working principles I had picked up, one from the Chief and the other from my cheerful daily doctor, I added another. This came from Dr. Oliver. Ever since I returned home he has guided me by correspondence, showing me how, with the help of occupational therapy, to carry out a programme of emotional reëducation. While I was still at the sanitarium Dr. Oliver came to see me once a week. When I tried to draw him out about his writings, telling him how much Fear had helped me, he grinned, but refused to talk about himself.

‘Bother the old books I have written,’ he said. ‘The important thing is to get you well again. Now just trust us, and let us handle your problems in the way we know will help you most. That is what we are for. . . .

‘The worst mistakes a man makes,’ he went on, ‘come from trying to size things up when he is depressed. That is no time for a man to interpret anything. It certainly is the worst time to make decisions. One will always end by doing the wrong thing. As long as you live, avoid making important decisions when you are below par. You will have to learn to protect yourself from your own impatience. You cannot be somebody else. You cannot do many things which other people have no difficulty with. But you can be yourself, and in your own way you can do much that others cannot. Take your brass and copper work, with which you have made such headway in spite of the limited conditions of sick-room work — that is a gift you did not dream you had when you came here. Is n’t that so?’

‘It is a delightful discovery,’ I replied. ‘It makes me feel that I have possibilities.’

‘From your handwork and your reading you must have developed ambitions to make something worth while,’ the doctor suggested.

‘ It looks like a high thing to aim at,’ I told him, surprised and pleased at the ease with which the words came, ‘ but I have a dream of making a chalice and paten in hammered sterling silver. The equipment will cost money, and I do not know where to go for instruction, but that is what I am setting up as a goal in metal craft.’

‘You will do it yet, old man,’ the doctor prophesied. ‘It will make you a better priest and a happier man, too.’

I may say in passing that to-day the silver chalice is still a dream. The hammers and anvils needed for that kind of work are still only pictures in catalogues. There has been no money to buy them, and in the city where I live there is no one to whom I can turn for instruction. But the work in metal craft has gone on with the means that were at hand, and the therapeutic effects have been invaluable.

VI

At last the time came for me to leave the rest home. That night as the train lurched around the curves in the Pennsylvania mountains I lay awake in my berth, my mind possessed by a single idea. Not one thought did I give to the state of my health, to my old worry that I should not be well enough to carry on the work of my parish. I was recalling a tour I had once made of the shops of the public schools in the city where I live. The high spot of that tour had been the sheet-metal shop, where furnaces were glowing with heat and boys were learning to solder. I felt that I would give my right arm to be able to join that class.

As soon as I got home I called on the head of our school system, explained my case, and discovered that occupational therapy was the open-sesame to my heart’s desire. The superintendent’s daughter taught occupational therapy! Was there ever such luck? I was flooded with kindness and provided with a letter of introduction to the principal of the Technical High School.

The next morning, standing before a blackboard sketch, I as a new pupil marked out, cut, hemmed, and soldered a tin biscuit cutter. The beginning class had been in the shop since September, and it was March when I appeared. There were titters from the youngsters at seeing a man, a little gray, doing the first shop exercise, but I took them good-naturedly and went ahead. Funnels and sugar scoops followed.

As time wore on I found that I was increasingly unwilling to go through the routine of shop exercises. I could not bend my mind to them because I had caught a glimpse of something more attractive. In a religious journal I had chanced upon an illustration of a beautifully lighted church. The lamps were hexagonal, long and dignified. I took the illustration to the teacher in sheet-metal drawing, who offered to coach me in designing a lamp. Before I touched a pencil to paper I went back to the shop and made a rough model in galvanized iron of the hexagon shape I wanted to use. Then I gilded it and fitted in the glass.

As an experiment I next removed a fixture over the pulpit in my church and hung my model in its place. To my congregation the following Sunday I explained what I had done, telling my parishioners that I should be happy to fit out the church with a full set of lamps if the bare cost of materials could be provided. This was soon arranged, and I set to work.

At this time I was not aware that jumping from tin sugar scoops to ecclesiastical brass is like hurdling everything between kindergarten and college, but such leaps are characteristic of adult education. Professor Overstreet suggests the process. Have the tools lying around, with some competent person at hand to furnish help when it is needed, and let the mature learner follow his own bent.

The following June saw my six lamps hung in the church. They are severely plain, but in spite of the absence of ornamentation they required long labor in the building. Each lamp has sixty brass rivets and forty soldered joints. The design is my own, my first serious attempt at drafting.

These lamps for the church made me friends. Among them is a man who owns a sheet-metal shop in my neighborhood. I have a standing invitation to use his tools and machinery whenever I need them. Then there is a goldsmith who served a seven-year apprenticeship in Rome, and who helped me by melting and rolling the old family silver that went into the memorial choir-light shields which I built for the one hundredth anniversary of the consecration of St. Peter’s Church in Waterford, Pennsylvania. This little church has been either an aided parish or a mission through its entire existence, and I rejoiced in being privileged to make the memorials which the Bishop dedicated at the centennial services.

Those shields were made of copper, surmounted by copper crowns, with rippling sheet-copper pennants on the sides. Each shield bears three silver medallions and a crusader’s cross of silver on the copper background. To get the precious metal we melted great-grandmothers’ thimbles and old worn spoons that came over the mountains on oxcarts from Boston and Philadelphia. Our design, borrowed from one of the world’s best makers of ecclesiastical lighting fixtures, was adapted to the materials we wished to use and to my own limited ability as a metal worker.

The newspapers published elaborate photographs of the old church, and carried a long and glowing story. I sent the papers to Dr. Oliver, who wrote that I was one of his most satisfactory patients. No doubt it seemed good to him that I was able to throw my heart into the glorification of St. Peter’s Church. But there have also been times when I know that I have been one of the doctor’s most disheartening problems. In the depths of despondency I have written him letters that made him say I was caught in the backwash of my old difficulties.

For example, I sent him a furious letter when he asked me if I had read Sir William Osler’s A Way of Life, that remarkable lecture which the great physician and teacher delivered years ago to the students at Yale. I wrote Dr. Oliver that Osier was nothing to me because he had never suffered from depression; that the book had so infuriated me when I tried to read it in the rest home that I had slammed it across the room. The reply I received from the doctor was sharp, but it was several days before I caught an insight that made for readjustment. Several days later I was soldering a pair of spectacle frames for a man out of work who had no money to pay for repairs; while I was bent over this small task it dawned upon me that my antipathy for Sir William Osler was born of my illness, and that its resurgence in me was an anachronism now that I was recovered. So I wrote the doctor again, telling him how occupational therapy had once more lowered my emotional pressure, and that I had pitched another warped attitude into the scrap heap. Back from Baltimore came a new gift edition of A Way of Life, with the introduction from the pen of John Rathbone Oliver, and on the flyleaf some kindly words in the doctor’s difficult hand.

After reading the book, I drove down to the Bishop’s and persuaded him to let me leave it on his desk. The next time the Bishop called on me he had the volume in his hand when I met him at the door. ‘To divide life into daytight compartments,’ the Bishop said, ‘and to put the Osler quality into each day — what men we should be if we could do it!’

VII

To be sure, I still have occasional bad days, along with glorious ones, and occupational therapy still helps. The blessings of handicraft are not yet exhausted.

A few evenings ago two Boy Scouts came to my back door, each with a coffee can in his hand. A week before I had promised to help them make pierced tin lanterns so that they could qualify for merit badges in metal work, but I had forgotten all about it and was very much upset when they arrived. Some little thing had gone wrong, and I was taking it too seriously. In a moment, however, the three of us went to work in the little shop I have in my basement. A layout for the nail holes was traced on the cans, and we made a conical roof pattern. In a very short time I had the boys busy. The candle sockets were cut out and soldered in place. At ten o’clock the work was finished, with a big loop handle riveted to the roof of each lantern.

In a box of odds and ends I retrieved some stubs of candles that had been burned short in the sevenbranch lights on the altar. It was a dark night, and the street lamp at the corner was temporarily out. The lads hurried homeward, light streaming from their lanterns.

As I watched them depart I wondered where I had seen something which those lanterns reminded me of. Somewhere, in some picture I had seen, there was just such a lantern. It came to me with the association in reverse order, words first: ‘Behold, I stand at the door and knock.’ That familiar lantern shape was in Holman Hunt’s picture, ‘The Light of the World.’

I talked this experience over with a spiritual adviser who helps me greatly with my interpretations of life.

‘What a gamut you run,’ he exclaimed, ‘in your emotional experiences with your handwork! Two Boy Scouts come to see you and find you in a blistering rage. You calm down and help them with their project, not stopping a moment or letting them rest until the work is completed. You crown the evening by putting a burning altar light into each boy’s lantern, and then you wonder why it was that you thought of Holman Hunt’s “Light of the World.” You ought to be reminded, I think, that the Lord Himself was a workingman, and in the good providence of things He may have come to the door of your house and knocked with a soldering iron or a pair of tin snips.’