Guideposts of

OCCUPATIONAL
THERAPY

By

Helen P. Le Vesconte, O.T.Reg.

UNIVEHSITY OF TORONTO PRESS

Copyright, Canada, 1959, by
University or Toronto Press
Printed in Canada
Reprinted in 2018
ISBN 978-1-4875-8176-3 (paper)
 FOREWORD
Occupational therapy provides countless ave-
nues for exploration. Emanating from a central
hub mrtin avenues radiate out. These in turn give
off side roads which again lead into byways. Ad-
vances in medicine and its allied discinlines
have resulted in the subject matter required in
the training for these disciplines becoming more
and more complex. Thus it is all too easy to be-
come lost on a byway if the road plan has not been
well learned and its guide signs clearly under-
stood.
The purpose of this material is to emphasize
the main avenues, and to keep clear the relation-
ship between them and their expanding periphery.
It has been by design that a number of refer-
ences and quotations are included. It is intended
that the references be read, for some are essent-
ial to proper understanding, some are intended to
guide reading toward authoritative sources. Many
of the quotations were selected because they do
more than introduce an important name to the
reader; they give an impression of the personality
of the man. While most principles and truths have
been said many times and by many people, it is how
they are said that makes the more lasting impress-
ion upon the memory.
To Miss Isobel M. Robinson I am deeply in-
debted not only for her editorial assistance which
has- involved many hours of laborious work, but
also for the encouragement and valuable advice
which she has given throughout the preparation of
this material. I would like to express my thanks
to Dr. A.T. Jousse for his helpful suggestions,
and to the University of Toronto Press which has
done much to make publication possible. .
Finally, I would remind my students of the
White Queen's words to Alice, "Now, here you see,
it takes all the running you can do, to keep in
the same place. If you want to get somewhere else,
you must run at least twice as fast as that."

Toronto, August 1959 H.P.Le V.

iii
 CONTENTS
Foreword . iii

Section I Introduction 1
Section II Rehabilitation . ... . . . 4
Section III Occupational Therapy 8
Section IV Terminology • • 11
Section V Treatment Media or Tools 18
A. Analysis of Media 20
B. Activities of Daily Living and
Assistive Devices •••• 24
C. The Disabled Homemaker. 28
D. Handcrafts. 31
E. Industrial Skills and/or Tool
of the Trade • • • • • • • • • 34
F. Writing and Typing • • • 36
G. Recreational Activities 41
H. Cultural and Educational Media 45
1. Music • • • 45
2. Art. • • • • •••• 47
3. Academic ••••••••• 50
I. The Therapist . . . . . .. . 52
Section VI Pre-vocational Evaluation. 55
Conclusion . . . . . . . . . . . . . . . . . 59

iv
 SECTION I
INTRODUCTION
This Manual is intended primarily to meet the
needs of students as an introduction to the text-
books of occupational therapy, and in no way to
take their place.
The textbook, whether it be a general present-
ation or one devoted to a particular area of the
subject, serves to cover scope and detail rather
than to emphasize the relative weighting of areas
in professional practice. Thus, for the beginner,
the apparent mass of detail may appear confusing
and even an overwhelming :picture. The result may be
that "the woods are not seen for the trees". This
is no criticism of the textbook, but it is a recog-
nition of the need for orientation to the proper
use of the textbook, and thus to serve as a 'weigh-
ting guide' to set the proper focus at the approp-
riate time.
Guidance in setting the focus is needed, as
the student must learn to see the basic defined
areas of each rehabilitation discipline. Then as
she progresses to the further elaboration of the
potentials of each, she finds _that there are cer-
tain areas of overlapping of occupational therapy
and physiotherapy, of occupational therapy and nur-
sing, of occupational therapy and speech therapy,
etc. If at this point the basis of each discipline
is understood, she is able to see how each may
reach certain common goals in a logical and under-
standable manner. To use a familiar simile, "All
roads lead to Rome". The Neapolitan approaches from
the south by highway or byway· the Florentine ap-
proaches from the north; the Greek coming from the
east may use a long overland route alone, or the
highways of both sea and land. So it is with rehab-
ilitation. Each member of the rehabilitation team
approaches by the route in which he is versed, and
guides the patient according to his needs and po-
tentials to make the journey. Some will come mainly
by the help of one discipline; some, like the Gree~
may require several different vehicles, each at
appropriate times, but each guiding him to the same
destination. Therefore all disciplines must know
the final destination; they must be aware of other
approaches to it in addition to their own. As the
final goal is approached, they must be prepared to
1
see that the patient receives the best guide to
his final steps.
While certain basic principles remain con-
stant, methods and media may change, old methods
and media may be adapted or modified, new ones
are developed. Also, methods and media may differ
in different countries at any one time. Methods
and media in any one country alter as the struc-
ture and ideals of its society alter.
This need for continuing flexibility was aptly
stated by the late Dr. Harold Storms (lJ, first
Medical Director of the Ontario Workmen's Compen-
sation Board Clinic in Toronto. Describing the oc-
cupational therapy approach and programme at this
clinic, he said, " ••• we now have ••• a therapy not
fixed or inviolate, but one in a constant state
of change, ready to devise and invent new forms
or modifications of old, to suit an ever new set
of conditions."
Because this Manual is designed to assist the
student in a more thoughtful and discriminating
use of the textbook, much of the material is pur~
posely presented in statements and quotations from
the more familiar texts and printed material, with
the source listed for each section. Thus, having
been introduced to the philosophy behind the prob-
lems and responsibilities of the occupational
therapist, when the principles and concepts of
treatment are met in the framework of the text to
which they belong, the student should understand
more clearly the surrounding detailed material.
Over the world there are thousands of differ-
ent skills which are important to individuals;
different goals that to each are of prime impor-
tance. Some must know how to run a tractor, some
to set type, some to lay bricks. These are the
skills of their daily living, contributing to and
a vital part of their purpose in life.
In summary, the purpose of this manual is to
provide a "range-finder" through which correct
focus is obtained on the aims, methods and media
of occupational therapy, through which its goals
may be achieved; it does not include methods of
practice nor the application and specific use of
the media within the framework of treatment.
Only when the fundamental principles, con-
cepts and philosophy are learned and understood,
is the stage set for the learning of its appli-
cation and ·practice. The process from· learning to
2
practice is unending. It starts in the definitive
formal study of basic professional training, and
it continues throughout professional practice.

Reference
1. Storms, H.D.: Occupational Therapy in the
Treatment of Industrial Casualties. Can. J.
Occup. Therapy, 10:2, April, 1943.

3
 SECTION II
REHABILITATION
"Man is like an iceberg - about twenty per-
cent of his capabilities are visible above
the level and most are hidden." (1)
A broad and frequently used definition of
rehabilitation is " ••• the restoration of the
handicapped to the fullest physical, mental,
social, vocational, and economic usefulness of
which he is capable." (2). Pattison (3) describes
rehabilitation as 11 • • • a scientific organization
of convalescence to hast.e n recovery and guide the
disabled to purposeful li~ing."
Kessler l2) writes, "The history of the social
attitudes toward the disabled is one of harsh and
brutal treatment, only slightly mitigated by the
Christian tenets of charity and philanthropy.
These harsh attitudes have permeated the folk ways
and institutions of society down to modern times
••• Out of the cries of the disabled and the cat-
astrophies of two wars, a new philosopoy and at-
titude has developed which has been crystallized
in the general concepts of rehabilitation •.!'
The modern hospital is described as a p4ace
of active treatment, early ambulation, out-patient
services. But the decades-old aura that surrounds
medicine and the healing arts is still imbedded
in the minds of many laymen - the mysteries of
drugs, potions, and the doctor as a miracle worker.
"The mere fact that one is ill is accompanied by a
certain disinclination to, or disbelief that, one
can make the effort ••• Passive treatments are to
most people psychologically pleasant - they imply
no effort. Thus the patient must free himself from
the expectation and hope that it is the doctor or
the. therapist who will do that something which
will result in cure." (4)
Kessler (2) points out that in disabilities
of a temporary character such as pneumonia, frac--
ture, gastric ulcer, the patient's own "reparative
powers" are responsible for recovery after stan- ··
dard types of treatment, but that the convalescent
period may be reduced and psychogenic complications
prevented by the use of occupational therapy and
remedial exercises.
The severely disabled present a more difficult

4
problem. They are left with residual impairment,
functional and/or structural, which surgery or
medical treatment cannot eliminate; some struggle
imperfectly against the rigours of day by day
living; some surrender to the social struggle,
becoming permanently and completely dependent upon
their family or community.
It is to meet the need of this large group of
physically handicapped persons, restricted in
their working capacity and in their opportunities
for employment, that the larger concept of rehab-
ilitation has developed.
But physical handicap alone is only part of
the problem. "We must never forget, however,"
Ravesloot (5) has warned, "that the hwnan being
is not specialized; that he combines the physical,
the mental, and the emotional. Our task is to
strengthen the individual, to train him so that
he can do a great deal for himself." O'~"ialley ( 6)
points out, "Assessment of the patient's motiva-
tion must in the final analysis be the answer to
our problem. Until we have studied the patient's
motivations, we cannot hope to understand the
patient's reactions to his disability, his atti-
tude towards his work, his home and his associ-
ates."
The importance of the psychological aspects
is emphasized by Yonge (7) who states, "Far from
being a modern idea, the bearing of psychological
influences upon physical health is a very old one.
In the ancient world, in the earliest of all known
institutions of healing - the temples of Aescul-
apius - the doctor was at the same time the
priest. Medical care involved various lotions and
potions as physical measures, various activities
which today we might call occupational therapy
and physiotherapy, as well as religious ministra-
tions to the needs of the soul. Thus, at the be-
ginning of medical history, medical care was com-
prehensive or multi-directional.
"The trouble in those days was that the prac-
tice of medicine and the practice of religion were
both mixed up with magic." In the attempt to di-
vorce medicine from magic, unfortunately physi-
cians lost sight of the psychological and spiri-
tual influences upon the physical processes.
Even as far back as 400 B.C., Plato recognized
that "you could not properly cure the part unless
you paid attention to the whole." (7).
5
 Yonge continues, "The progress of medical re-
search over the years has now shown that health
and disease cannot be considered as purely physi-
cal. There is an inseparable interaction between
the physical process and the psychological exper-
iences in all illnesses. What the patient thinks
and feels has some effect, sometimes profound and
crucial effect on his physical well-being ••• The
task of rehabilitation ••• is a problem much larger
and more complex than, say, the mechanical stimu-
lation of muscular action. All useful muscular
activity is controlled by the brain ••• the brain
is the terminus not simply of mechanical nerve
impulses to all parts of the body, but also a
vast, milling crowd of fears, hopes, inclinations
and intentions which ••• may largely determine the
activity of any part of the body. So much of the
success or failure of the physical methods of
training a body to renewed activity depends on
how the patient feels and thinks about himself
and about life in general."
In illness the lack of activity quickly re-
sults in unhealthy changes, both mentally and
physically, which react upon each other. Physi-
cally these are apparent in bone, muscle, circu-
lation, coordination patterns. Feelings of pain
take hold of the attention and worries result.
Mentally there is some degree of 'let-down'. We
dwell on worries and fears. These react on the
functions - loss of sleep, loss of appetite, we
become irritable and are easily upset emotionally.
It is natural to react to illness, but some
do not show or express their reactions. Some will
adjust too well to illness which provides them
with protection or withdrawal from responsibility.
Then we have to combat invalidism.
In rehabilitation, " ••• success or lack of
success," says Rusk (8), "can be measured only by
the patient, not by those of us who work with the
patient ••• Our cardinal theme in rehabilitation
is that we work with rather than on patients and
that we remember that muscles, bones and joints
are not important as entities in themselves but
only as they help a man to function in meeting
the problems of everyday living."

6
References
1. Kessler, H.H.: in Proceedings of the 7th
World Congress, International Society for
the Welfare of Cripples, 1957, p. 294.
2. Kessler, H.H.: Principles and Practices of
Rehabilitation. Philadelphia, Lea and
Febiger, 1950 pp. 15-17.
J. Pattison, H.A. {Editor): The Handicapped and
Their Rehabilitation. Springfield, Ill.,
Chas. C. Thomas, 1957, p. xii.
LeVesconte, H.P.: The 4th Therapist. Can. J.
Occup. Therapy 21:2, June 1954.
5. Ravesloot, M.J.: in Proceedings of the 6th
World Con~ress, r.s.w.c., 1954, p. 15.
6. O'Malley~ C.J.S.: in Proceedings of the 6th
World ~ongress, I.s.w.c., 1954, p. 114.
7. Yonge, K.A.: Psychological Aspects of Rehab-
ilitation. Can. J. Occup. Therapy 25:2,
June 1958.
8. Rusk, H.A.: in Proceedings of the 6th World
Congress, I.s.w.c., 1954, pp. 151-152.

7
 SECTION III
OCCUPATIONAL THERAPY
According to Licht (1), "Occupational Therapy
is remedial activity ••• Unlike most other forms
of treatment, occupational therapy is used in al-
most all aspects of patient management, embraces
a wide variety of tools and activities from all
areas of life and demands the active participation
of the patient." The participation of the patient
is emphasized also by Spackman and Willard (2)
who point out that "The majority of medical treat-
ments are administered to the patient who accepts
them with a considerable degree of passivity. On
the contrary, in occupational therapy the great
majority of the procedures used require the active
and cooperative effort of the patient to achieve
their ends. The personality of the occupational
therapist and his knowledge and ability to under-
stand the patient's reactions, to lead and stimu-
late him to active effort toward recovery of nor-
mal function is of paramount importance. The use
of himself as the most important tool of treatment
is the occupational therapist's greatest achieve-
ment."
Licht (1) also states that occupational ther-
apy "extends beyond the sphere of remedial in that
some of its applications are in preventive medi-
cine and diagnosis. In addition it is a major
factor ••• in aspects of rehabilitation which can-
not properly be called medical, as for instance,
in vocational exploration."
"The first and most basic principle of occup-
ational therapy", West (3) writes, "is its empha-
sis on treatment of an individual, rather than a
specific disease or injury." Therapy means treat-
ment or healing process. Occupational therapy
means treatment by means of participation in occu-
pation or activity. Its purpose is to motivate the
patient and assist him to achieve through his own
efforts, his best possible functional capacity.
Occupational therapy is medically prescribed
for specific objectives.
The occupational therapist carries out these
objectives by the selection and use of a variety
of methods and 'tools of treatment'.
Because the patient must participate he must
be motivated. Therefore the approach of the thera-
g
pist is an essential part of the treatment tech-
nique. Summary
1. Aims or Objectives include:
physical restoration: to maintain, regain
or increase
- joint range
- muscle power
- coordination
- tolerance of activity
mental restoration:
- to maintain, regain or increase
attention, observation, etc.
- a controlled outlet for motor and
psychomotor activity
- to serve as a diagnostic aid
- to supplement psychotherapy, convul-
sive therapy, psychosurgery
- ego strengthening
social adjustment:
- to develop satisfactory interpersonal
relationships
- to provide acceptable outlets for
drives (creative, aggressive, etc.)
supportive or preventive:
- to maintain capabilities; physical,
psychological, morale
- to prevent secondary disabilities
- adjustment to residual handicaps
prosthetic training
pre-vocational assessment
2. 'Tools of Treatment' include:
activities of daily living:
- self-help training
- assistive devices
manual activities:
- handcrafts
- industrial skills
- 'tool of the trade'
recreational activities:
- remedial games
- play and toys
cultural and educational:
- art, music, drama, etc.
- writing, typing
- academic
adapted tools and equipment
special equipment
prevocational assessment:
9
2. (continued)
- job samples
- work tests
the therapist
J. Approaches include:
- directive
- non-directive
- eclectic
- permissive

Reference
1. Licht, s.: Occupational Therapy, Principles
and Practice. 2nd ed. Ed. W.R. Dunton, S.
Licht. Springfield, Ill., Chas. C. Thomas,
1957, p. 15.
2. Spackman, c.s. and Willard, H.S.: in The
Handicapped and Their Rehabilitation, ed.
H.A. Pattison. Springfield, Ill.; Chas. C.
Thomas, 1957, p. 439.
J. West, W.: in Principles and Practices of
Rehabilitation, ed. H.H. Kessler. Phila-
delphia, Lea & Febiger, 1950, p. 118.

10
 SECTION IV
TERMINOLOGY
Terminology is defined as "A science of proper
use of words 11 , and is of maximum use when it pro-
perly corresponds to what it is supposed to repre-
sent. Our terms or words may not necessarily con-
vey the meaning which we have appointed to them
and others may have a different meaning in mind.
The terminology of most professions is made up
of various groups of words:
1. Some terms are purely technical and are
intended to convey fixed meaning. Train-
ing in a given profession includes the
learning and use of its vocabulary.
2. Some terms are borrowed from other dis-
ciplines in order to express similar con-
cepts or facts. For example, many terms
are common to both psychology and psychi-
atry - transference, identification,
rationalization, etc.
J. Finally there are 'plain English' words.
These have an important place not only in
communication with the layman and to a de-
gree with other disciplines, but in com-
munication within the profession itself.
In the area of common words, the varia-
tion may result in confusion of the in-
tended mea~ing. Consequently, careless
use of l9osely defined words not only de-
feats our effort to have. others understand
our concept, but actual misinterpretation
and erroneous information may result.
While these three categories of terms remain
constant, it is obvious that there will be changes
and additions within the categories as new areas
are developed. As the disciplines themselves can-
not remain static, neither can their terminology.
Presumably the terms of a discipline have specific
meaning; if not, then they have no value. Study of
the terminology of many professions indicates that
it is not the terms which they use that are con-
fusing and even incorrect, but it is the way in
which they are used. Some of the more common ex-
amples of this are given later in this section
and show that probably in the majority of cases,
faulty use of terms is the result of failure to
distinguish between three basic points:
11
 1. Each discipline or therapy has a specific
name (occupational therapy, physiotherapy,
etc.)
2. Each specified therapy has specific aims,
purposes or objectives.
J. Each specified therapy utilizes specific
methods, media or tools of treatment.
Therefore, an adjective may be used to indic-
ate a specific aim or media of the particular
therapy, but the adjective does not replace the
name of the therapy. When this is clearly under-
stood there seems little reason for the confusion
which all too frequently exists in this area.
In the first textbooks and professional writ-
ings of occupational therapy there is no confus-
ion in terminology. Occupational therapy is de-
fined; its aims and objectives are defined; its
methods and tools of treatment are defined in ap-
propriate and therefore meaningful tenr.s. It is
through the years, as medical requirements and
professional development expanded, that the use of
certain terms as 'labels' for pigeonholes tended
to isolate focus of attention to the disability
itself, rather than to the result of the disabil-
ity in the patient.
It is significant to note that this tendency
caused concern and dissatisfaction in many occup-
ational therapists, but the most vocal challen-
gers of poor terminology have been the physicians.
From these criticisms two ccncrete groups of terms
are presented. One utilizes simple English terms,
understandable to all disciplines and to the lay-
man. The second utilizes explicit terms presumably
familiar to, or easily learned by, the profess-
ional person.
l. Dr. Harold Storms (1',irst Medical Director of
the Workmen's Compensation Board Clinic, Tor-
onto, Ontario) following the accepted defini-
tion of occupational therapy, designated its
aims of treatment. as:
(a) physical restoration
(b) mental restoration
(c) preventive (to prevent the loss of or
to sustain morale)
2. Licht (1), in searching for uniformity and
clarity of expression, selected four short
descriptive words of Greek origin and, he
states, "universal recognition."

12
( i) Kinetic (kinetikos - relating to motion)
replacing the old word functional - to
restore or improve:
(a) muscle strength
(b} joint mobility
(c} coordination
(ii) Metric (metron - relating to measure-
ment) old word grading, used to:
(a) improve work tolerance
(b) measure progress of tolerance
(Note: "Although Kinetic Occupational
Therapy employs the principle of prog-
ressive exercise, it is the activity
rather than the timing which is empha-
sized in it. Metric Occupational Therapy
is graded effort but more important than
gradation is the fact that the increase
can and should be measured. The physical
activity of patients convalescing from
cardiac or respiratory pathology should
be increased at prescribed intervals and
with specified energy increments. This
same approach can be used diagnostically
to determine the patient's progressive
ability or therapeutically to improve
such work tolerance ••• ")
(iii) Tonic ( tonikos ·- increasing physical or
mental tone), old word diversional,
used to improve and maintain
(a} muscle tone
(b) mental tone
(Note: "The adjective which has been the
subject of greatest dissatisfaction has
been diversion~l• The term is descrip-
tive of the act but not of the object-
ive. It is difficult to understand why
a better term has not been adopted, es-
pecially since the English language is
so rich in appropriate terms ••• Tonic is
used here in the classical sense of in-
vigorating and well-being ••• 'l'onic Oc-
cupational Therapy is not just busywork
••• It must be used intelligently to be
worthy of the name 'tonic'.")
(iv) Psxchiatric (psyche-iatreia, Medical
treatment of the mind) used to favour-
ably influence:
(a) psychomotor activity

13
 1. stimulation
(a) arouse interest
(b) improve concentration
2. sedation
(a) energy release
(b) lessen destructive ten-
dencies
1. aggression outlet
(b) emotional disturbance
1. emotional stability (content-
ment)
2. mood
(c) behaviour
1. behaviour (habit) training
(d) abnormal mental content
1. guilt complex
2. paranoid trends
la) crowd out delusions
(e) psychosocial activity
1. socialization
(a) interpersonal relations
(b) attitude
(i) self-respect
(ii) confidence
(iii) self control
2. provide obtainable objective
{a) gratify narcissism
(f) diagnosis
1. reaction to situation in clinic
2. identification of problem (in
psychodrama)
J. dete.nnine limit of intellectual
work capacity
4. pre-vocation exploration
(g) mental hygiene
1. overcome restlessness
2. promote good work and play
habits
Some Areas of Confusion and ~1isapplied Terms
On the basis of the premise given at the be-
ginning of this section that each therapy or dis-
cipline has a specific name, specific aims, pur-
poses or objectives, specific methods, means or
tools of treatment, it is clear that the follow-
ing are obvious examples of the misuse of terms:
Specific Therapy
The Oxford Dictionary defines 'specific' as -
"definite, distinctly formulated; relating to a
particular subject; having distinct effect in
14
curing a certain disease; a remedy or medicine."
Since all therapy (or treatment) is related to a
particular subject, all treatment is specific.
The reason for the existence and use of a therapy
is 'definitive, formulated attempt to remedy.'
The adjective 'specific' describes the physician's
'specific'selection of the particular therapy in-
dicated. (O.T., P.T., Speech, etc.) and the ther-
apist's 'specific' selection of the method and
treatment tool indicated.
Remedial Theraoy
This term is an example of redundancy of
words.
1. The medical dictionary defines therapy as
"relieving, curative, anything used in the
treatment of disease." Thus, as therapy
means remedy or healing, the adjective
remedial adds nothing to it.
2. To remedy is the aim of treatment, not a
branch of therapy, and it applies equally
to all patients whether or not they re-
quire physical restoration. There has been
a tendency in some areas to restrict this
term to the treatment of orthopaedic dis-
abilities.
This unnecessary emphasis on the term remedial
suggests that the therapist might perhaps examine
her own attitude and determine whether she is
really giving more than lip-service to the concept
of preventive medicine. Is it more important and
gratifying to the therapist to repair damage that
has been done, i.e. to right a wrong, than it is
to-prevent disability from occurring, i.e. to
maintain well-being?
Functional Thera~y
This term, like the preceding one, is restric-
ted by some to the physical disability field.
Licht (1) criticizes the use of this term on the
basis of medical teaching of its use. "The medical
student has been taught that functional means
physiologic as opposed to anatomical, thus a func-
tional disease is one in which no evidence of
structional change or pathology can be determined.
This is opposite to its meaning as previously ap-
plied in Occupational Therapy, since the muscle
or joint involvements thus treated are organic and
accurate measurements of strength and range are
possible."
All living matter has its function - the heart,
15
the glands, the muscles and the brain. It should
be noted.that for the past thirty or more years
the psychiatrist has divided mental diseases into
two categories - organic (those with demonstrable
brain pathology), and functional (those with no
demonstrable brain pathology). This is a medically
correct use of the term.
Qiversional Therapy
This term, which Licht has pointed out as
probably the most controversial, is neither in-
cluded in nor recognized by the medical diction-
ary!
The standard dictionary defines diversion as
"deflecting, deviation." There is no suggestion
of control in the deflection, nor that how or
where deviation occurs matters in the least. At
best it is a poor term in that it implies no ele-
ment of control or selection which is the basis
of therapy. Girdlestone (2) dismisses the term
'diversional' as 11 • • • a stupid name since ••• it con-
veys but half the truth." Cranfield (J) and others
point out that the objective implied by the term
is simply and meaningfully stated in the terms
'directional', 'preventive', or 'supportive'.
In contrast to the inaccurate use or transfer
of adjectives to designate certain branches of the
'parent therapy', it is recognized that within
limits, some branches of a parent therapy can be
differentiated by a particular method or tool of
treatment. For example, physiotherapy has special-
ties in hydrotherapy and electrotherapy. For some
years these branches were almost distinct and in
certain European countries are still sometimes
separated in training and practice. In Britain
and the North American continent the trend has
been to include all such divisions and branches
in the training of physiotherapists.
From the first organized training in occupa-
tional therapy, recreation, music, manual skills,
etc. were included as the tools of treatment. It
was considerably later that certain of these
skills, notably recreation and music, because of
the scope and specialization inherent in each,
became specialties, e.g. music therapy. This has
occurred mainly in the United States. While this
increase in specialties has not altered the basic
training and orientation of the occupational ther-
apist in these areas of activity, it has provided
very intensive and specialized programmes in
16
centres which required, and were financially able
to include, an increasing nwnber of specialist
personnel.
Gordon and Wellerson (4) have warned - "'fhat
concept is limited which sub-divides therapy into
isolated categories (functional, prevocational and
the like). For all the demands of rehabilitation
must be integrated into a single goal to restore a
disabled individual to his appropriate social set-
ting."
Because the occupational therapist is concern-
ed with the whole patient mentally, physically,
socially, emotionally and economically, she must
be familiar with much of the vocabulary of related
disciplines with whom she is in frequent commun-
ication.
Terminology does not remain static. It con-
stantly increases as new areas are developed. New
words are sometimes coined; some of these are
good - for example, 'orthetics' which originated
at the Georgia Warm Springs Foundation. When terms
are acquired from other disciplines, proper exam-
ination of their meaning should be made in order
to avoid misusage.

Reference
1. Licht, S.: Objectives of Occupational Therapy.
Occup. Therapy and Rehab., 26:1, Feb. 1947.
2. Girdlestone, G.R.: Occupational Therapy for
the Wounded. Can. J. Occup. Therapy, 9:2,
Oct. 1942.
J. Cranfield, H.V.: What Physical Medicine
Expects of Occupational Therapy. Can. J.
Occup. Therapy, 14:1, March 1947.
4. Gordon, E.F., and Wellerson, T.L.: Does
Occupational Therapy Meet the Demands of
Total Rehabilitation? Am. J. Occup. Therapy,
8:6, Nov./Dec. 1954.

17
 SECTION V
TREATMENT MEDIA OR "TOOLS"
There have been and will continue to be
changes in media of treatment, but even more
important is the changing emphasis on the fre-
ouencv of the use of certain media. '£his is in
part related to:
1. Concurrent development and changes in method
in medicine and its allied disciplines.
Examples include: cortisone in treatment of
rheumatoid arthritis; increased use of con-
vulsive therapy for psychiatric illness;
Salk vaccine for poliomyelitis; emphasis on
early ambulation following certain traumatic
injuries.
2. Social and economic patterns of the country
and also of specific communities and dis-
tricts. For ex·ample, heavy industry and nat-
ural resources, such as mining and lumbering
in Ontario, result in what are termed indus-
trial accidents; marine shipping and fishing
play a larger part than industry in the econ-
omy of the ¥~ritimes and Newfoundland; in
Scandinavia, in spite of the impact of the
industrial era, handcrafts have survived as
an important part of daily life and employ-
ment.
The importance of appropriate selection of
the media of treatment in any therapy is obvious,
but its importance in occupational therapy cannot
be overemphasized. Possibly in no other therapy
are so many facets present. This is the inevitable
result of the two fundamental principles on which
occupational therapy is based:
1. Its conscious direction toward the triad of
physical, psychological and vocational.
2. The active participation of the patient,
which can be sustained only if he is able to
relate his use of the treatment media to his
sense of values.
As Gordon and Wellerson (1) state: "While
simple exercises are readily accepted because the
patient understands their intent, therapy through
work must have more than a mere physical meaning.
This is because the latter involves not only the
motor capacity of the patient but also his person-
ality, attitudes, habits and intelligence."
18
 Thus, while occupational therapy has many ad-
vantages in its variety of treatment media, this
results in a greater demand on the therapist's
thought and judgement in the selection of the most
therapeutic and, at the sane time, most appropri-
ate media. If the therapist fails to give adequate
and critical thought to the selection of the treat,.
ment media, the fault lies in the therapist, not
in the inherent potential of the media as a tool
of treatment.
The basic media or tools of occupational ther-
apy may be divided into main categories. Each of
these categories is elaborated in succeeding sec-
tions.
1. Activities of - self-help training
Daily Living - self-help devices
- problems of the disabled
homemaker
2. Manual - handcrafts
- industrial skills (tool
of the trade)
- clerical
- testing of aptitude,
dexterity, trainability
3. Recreational - psychological and social
values
- remedial games
- play as a treatment media
of the child
4. Educational and - music
Cultural - art
- academic
5. The Therapist

Reference
1. Gordon, E.F. and Wellerson, T.L.: Does
Occupational Therapy Meet the Demands of
Total Rehabilitation? Am. J. Occup. Therapy,
8:6, Nov./Dec. 1954

19
 A. Analysis of Media
As the physician's selection of a medicine
is based on his analysis of its components and his
knowledge of the effects of each, so the thera-
pist's selection of her media of treatment is based
on analysis of the components of the media and
their potentials for bringing about the desired
results.
As changes have taken place in the media of
treatment, so refinements in analysis have been
made. Obviously a complete analysis of all aspects
of an occupational therapy medium would be un-
wieldy, hence analysis of the most important as-
pects are considered here.
1. Analysis of Physical and Mental Processes
Involved
This was the original type of analysis which
by 1927 had developed to the point that the
journal "Archives of Occupational Therapy",
Volume 7, published some twelve analyses,
each dealing with a specific craft - weaving,
knotting, carpentry, etc. This analysis form
included: joint actions, muscle groups, de-
grees of coordination, position of work; the
mental processes of attention, concentration,
initiative; equipment; economic aspects;
suitability to specific disability groups.
Prior even to World War I, the need for study
and understanding of the then relatively
neglected field of functional movements had
been emphasized. The text-book Applied Ana-
tomy and Kinesiology (Bowen and McKenzie)
included detailed analysis of body movements,
not only in games and sports but, of parti-
cular interest to the occupational therapist,
in industrial occupations such as handling
bricks, shovelling, pitching hay, carpentry
tools, plastering and extending into the home-
maker area, ironing, sweeping and washing.
While these analyses were not in tabulated
form, they gave an accurate picture of the
body actions involved.
2. Kinetic An~lysis
This analysis was an important advance over
the conventional · and completely objective
lists of joint and muscle actions, for it
added the factors of energy, rhythm and the
part played by the assisting hand. Credit for
20
 the development of this approach is due
largely to Dr. Sidney Licht (1) and it
should be studied by all occupational thera-
pists.
J. Activity Analysis
It is apparent that the previous analyses had
considered almost entirely the physical as-
pects of treatment media. Thus there was need
for the formulation of an analysis pattern in
terms of the therapist's approach and appli-
cation of treatment to the psychological and
emotional needs of the psychiatric patient.
"Specific aims," Fidler (2) wrote in 1947,
" ••• are of little value unless specific means
can be provided for the achievement of these
aims." Fidler describes her outline of Acti-
vity Analysis as " ••• an attempt to more
closely correlate occupational therapy with
the principles of psychiatry, the personality,
and the emotional needs of the patient ••• ".
This outline is comprehensive and the section
devoted to 'physical processes involved', in-
cluding the fatigue factor, is worthy of
study.
4. Analysis of Structure
Inherent in all functional activities, i.e.
activities which are purposeful to man, are
two qualities which further provide thera-
peutic potentials. These qualities vary in
degree within the following groups:
(a) Structured - Structured acitivities are
those in which a definite procedure is
laid down. There are right and wrong ways
of performing them, or there are degrees
of leeway within defined limits.
Examples of high structure include - knot-
ting, precision operations in skilled in-
dustry, metalwork. Structure is found in
varying degrees in - weaving, carpentry,
homemakers' tasks.
(b} Unstructured - These activities permit a
high degree of individual methods and
procedures, and therefore utilize ingen-
uity and creativeness. Examples include -
finger painting, clay, painting (art),
toy play of the young child.
Depending on the specific needs of the pati-
ent, the degree of structure or non-structure
provided in an activity may be a more import-
21
 ant consideration than the literal occupation
per se.
'fhis approach to the therapeutic activity is
important in treatment of the psychiatric patient.
Is the aim of treatment to develop the capacity to
act within defined boundaries, to accept control,
to conform? Is the aim of treatment to encourage
initiative, individuality, self-determined action?
Or is the aim of treatment to provide a situation
which permits the patient to show his capacities
and initiate his own actions, or which reveals his
dependency on direction and the security of clear-
ly defined boundaries?
Eaually, this approach is important in cer-
tain stages of treatment of physical disabilities.
In the early stages of treatment the therapist may
be concerned mainly with how a patient performs;
ultimately the employer will be concerned with the
auality and/or quantity of the worker's perform-
ance. This involves more than correct motions; it
involves what the worker sees in the job situation
which may vary from a highly repetitive, stereo-
typed performance, to one in which observation,
change and versatility are essential. 'rhe extent
of definition or the extent of 'freedom' required
in a job is one of the factors to be matched in
determining aptitude or capacity for a given job.
Thus the relationship between the limitations
or the 'freedoms' inherent in the treatment media,
and the treatment needs for control or for patient-
determined action, may be summarized as follows:
l. If the treatment media is intended to control
the patient's response to a defined action,
the use of a structured media is indicated.
2. If the treatment media is intended to elicit
a self-directed pattern of action, a minimal
degree of structure within the media provides
the opportunity and the incentive.
Finally, there is another point which, to the
student and perhaps also to members of other dis-
ciplines, may appear a contradiction to the prin-
ciples of defined treatment. That is the validity,
in certain situations, of giving the patient a
'choice' in treatment media. If the preceding con-
cepts have been understood, this doubt has been
removed. All goes back to the therapeutic need of
the patient.
(a) If the patient requires definite boundaries
and limitations on how he acts or reacts,
22
 then the therapist provides structure in the
treatment situation and all that is included
in it. Here the therapist is the rider, hold-
ing the reins which control the degree and
direction in which action takes place.
(b) If the patient must extend his boundaries,
utilize his full capacity, ingenuity, initi-
ative, then the provision cf opoortunity for
the patient to express choice is part of the
therapeutic procedure. As the degrees of the
structure vary, so the extent to which choice
is offered will vary. Though the patient is
aware of 'choice', the therapist has actually
established the choices made available to him.
Again, the selection is by the therapist.
In the treatment of the mentally ill, this
technique is frequently important. Wittkower and
Johnston (3) for example, point out the value of
undirected and unstructured media to provide a
means of discharging impulses and emotions, as a
means of communication when other avenues are
blocked, and thus helping to establish a degree of
social contact. Used by a therapist well versed in
dynamic psychopathology, this technique offers
"access to unconscious or preconscious processes
in the patient ••• "

1. Licht, S.: Kinetic Analysis of Crafts and

Occupations. Occup. Therapy and Rehab.,
26:2, April 1947.
2. Fidler, Gail: Psychological Evaluation of
Occupational Therapy Activities. Am. J.
Occup. Therapy, 2:5, Sept./Oct. 1948.
3. Wittkower, E.D. and Johnston, A.M.: New
Developments In and Perspectives of
Psychiatric Occupational Therapy. Can. J.
Occup. Therapy, 25:1, March 1958.

23
B. Activities of Daily Living & Assistive Devices
Activities of Daily Living, hereafter refer-
red to as AOL, are those skills necessary to care
for oneself in the essential acts of toilet, wash-
ing, dressing, eating, writing and ambulation.
~ithout the ability to do these for himself, the
patient is dependent on and a care to others. Un-
til the patient gains or regains these skills
nothing else is as important to him.
Assistive devices for self-help therefore
may:
1. Serve as a substitute for a part or function
which is totally lacking
2. Assist or facilitate defective existing func-
tion
J. Provide stabilization
4. Permit free motion of a joint in certain dir-
ections
Most devices are improvised to facilitate
essential acts of daily living: eating, toilet,
dressing, writing, smoking, page turning; or sim-
ply to provide a hand grasp. In paralysis or
severe weakness of the shoulder for example, loss
of abduction and flexion make the hand useless, as
it cannot be moved toward the head. Thus the pat-
ient is unable to feed himself unassisted. Here a
sling suspension is an essential device.
In the upper extremity, the minimal, residual
strength of a muscle group can often be made of
functional use to enable a patient to feed himself.
Devices for such purposes must be simple, correct
in design and easy to apply, comfortable, light in
weight but sturdy, and acceptable to the patient.
According to Zimmerman (1), training in self-
help may involve:
support of the part, hand, arm or wrist, so
that the patient can utilize his existing
power and control. Such support includes a
sling, elevated table, a splint, or stabili-
zation in the case of one hand only.
adapted equipment, spoons, long handled comb
or shoe horn, glass holder, etc. These de-
vices or adaptations must be fitted to the
needs of the individual in many cases. Some
simple devices are now available commercially.
training the remaining hand to take over the
skill of the dominant hand, or increasing the
skill of the dominant hand to act without an
24
 assistant hand. Any potential of the disabled
hand should be developed to the maximum.
an assistive device to encourage the use and
thus the development of the residual capacity.
Hence training in self-help should start as early
as possible.
It cannot always be predicted for how long a
patient will need a device, or whether the need
will be permanent. Therefore, it is usually best,
both physically and psychologically, to introduce
the device as an 'immediate helper' until more
function returns. While the habit and acceptance
of dependence are ~ore difficult to break than to
acouire, it is equally true that the sooner the
patient experiences a degree of independence, the
more willing he is to continue to make greater ef-
fort to increase or retain it.
It is important to note that many devices can
be used for more than one pathological entity if
the result is the functional impairment of similar
anatomical regions.
The performance of an act during specific
treatment sessions only, is obviously of little
functional benefit to the patient. These acts are
meaningful to the patient when they are encouraged
and carried out regularly as the nonnal need for
them arises. Only then do they become self-help.
Thus, training in AOL should be the joint respons-
ibility of the nurse, the occupational therapist,
the physiotherapist, the hospital orderly and the
nursing aide, in order that the necessary carry-
over be achieved. The nursing staff is responsible
for bowel and bladder training. As the nurse is
the person most frequently and continuously in
contact with the patient, she is able to carry
over practice in transfer from bed to wheel chair,
etc., and in washing, eating and dressing techni-
ques.
The physiotherapist is responsible for cor-
rect training in ambulation, but her brief treat-
ment periods with the patient are less effective
unless the patient puts this training to use and
does so correctly.
The occupational therapist is qualified and
eauipped in the training of upper extremity func-
tion, particularly the hand; hence she is able to
evaluate the time and the means by which the pat-
ient attempts to feed and dress himself. Thus
close cooperation between the two therapists and
25
the nurse encourages the patient to benefit,
through use, from his treatments, and his recogni-
tion of their importance to him is increased.
f~rry-Over Between Nurse and Therapists
Bowel and bladder training -
initiated by - nurse
follow-up by - nurse
Transfer bed to chair -
initiated by - nurse
- physical therapist
follow-up by - nurse in ward care
Ambulation, gait, crutch walking
initiated by - physical therapist
follow-up by - nurse in ward care
- occupational therapist in
treatment activities
Eating, dressing, grooming -
initiated by - nurse
- occupational therapist
follow-up by - nurse in ward care
Writing, typing -
initiated by - occupational therapist
- speech therapist
follow-up by - coordination of speech and
occupational therapy if brain
damage present
Speech -
initiated by - speech therapist
- occupational therapist
follow-up by - nurse in personal contacts
- occupational therapist as
part of treatment programme*
* "Because of the nature of their training and
the aims of their profession, occupational thera-
pists are particularly well suited to increase the
aphasic's chance of regaining functional speech."
( 2)

If the patient needs adapted equipment for

these activities, frequently its selection and
its manufacture are the responsibility of the oc-
cupational therapist. By nature of her training
she is uniquely suited to design aids to function-
al patterns of movement and to train the patient
in their use, as she has basic knowledge of the
potentials of materials and the handling of tools.
A prominent function of occupational thera-
26
pists, in the opinion of Mead (3), is the provis-
ion of splints, supports and adaptive equipment.
This opinion is supported by Swanson (4) who
states - "The therapist is more intimately con-
cerned with the prevention and correction of de-
formity than any other person. She has a personal
interest in the patient's welfare. She is there-
fore far more likely to achieve a good splint,
performing its intended function, than a plaster
technician who may only see the patient once ••• The
occupational or physio-therapist is daily engaged
in the assessment of the patient's capabilities
and of training his abilities ••• It has already
been the experience with DuraFoam that occupation-
al therapists have shown by their enthusiastic ac-
ceptance of this material that they are capable of
developing it with new designs both for supportive
splints and self-help devices."
"Leadership in the provision of necessary
mechanical assistance is not only a challenge, but
a responsibility for the occupational therapist."
(1)

References
1. Zimmerman, M.: in Principles and Practice of
Occupational 'fherapy: Willard, H.S. and
Spackman, c.s. 2nd ed., Montreal, Lippin-
cott, 1954.
2. McGeachy, D.: The Role of the Occupational
Therapist in the Rehabilitation of Speech.
Can. J. Occup. Therapy, 23:2, June 1956.
3. Mead, S.: Occupational Therapy Five Years
Later. Am. J. Occup. Therapy, 10:4, July/
Aug. 1956.
4. Swanson, J.L.: DuraFoam, A New Material for
Making Splints. Can. J. Occup. Therapy,
25:3, Sept. 1958.

27
 C. The Disabled Homemaker
It may be surprising to learn that this cat-
egory is estimated to be the largest category of
occupational disabilities. Extensive work has been
done in this area and much valuable material pub-
lished. The basic approach to the problems of the
disabled homemaker has been included briefly in
this section because of the importance of devices,
of careful selection of utensils, and of training
in effective and therapeutic methods of carrying
out their daily tasks. This is essentially an
area of occupational therapy, but one in which
much valuable assistance can be gained from the
home economist.
Industry has contributed much to the develop-
ment of time and energy saving techniques and work
manaEement principles. These principles are. also
applicable to the disabled homemaker in order to
teach her to simplify her household tasks.
When residual disability is anticipated in
these patients, it is advisable to start the prac-
tice of fundamental skills while the patient is in
hospital. This can reduce considerably the period
of adjustment and frustration. Emmett (1) recom-
mends that "primary skill in using one hand can
best be developed in an unfamiliar medium. When
the patient has had some success with a simple
craft and training in basic activities of daily
living, the time has come, with the doctor's ap-
proval, to introduce homemaking retraining."
It is vitally important that the patient's
family be kept in the picture. Does the family see
the p~tient as an invalid to be relieved of all
responsibilities? Or are they prepared to accept
her as a participating member of the family? As
Cooksey (2) has so aptly said - "The art of living
with disability has to be learnt not only by dis-
abled people, but, also, by everyone associated
with them."
Hossack ()) reminds us that "For the disabled
woman, the prospect of resuming household activi-
ties and responsibilities can cause much apprehen-
sion. She is returning to what has been her former
job, but in many instances she no longer possesses
her former physical strength and skill. She may
fear failure, or that the work involved will be
detrimental to her present physical condition."
Change of method or procedure may solve cer-
28
tain problems; situations that place undue stress
on the handicap may be avoided. When a gadget is
thought to be necessary, it is often possible to
find the answer in something already on the market,
rather than making a special device. In training a
patient to use a gadget, or to learn a new method
to compensate for a previously known skill, it is
important that the therapist demonstrate it as the
patient will use it, and do so effectively, other-
wise the results may be unfortunate.
Possibly the patient's home may need some ad-
aptation to avoid unnecessary limitation of indep-
endence. For example, the addition of hand rails
may make the difference between confining a person
to one room as opposed to enabling her to be activ~
in her kitchen. Suggestions for changes in the
home should be studied carefully before they are
made, and thought given to how they can be carried
out. They should not be left to chance.
Slowness is often a major handicap with the
disabled. It is important then to plan in terms
of simplification of tasks, arrangement of equip-
ment and supplies, and the need to allow the nec-
essary time to accomplish a given task.
"Whatever the type or degree of disability,"
.MacCaul (4) states, "it is fundamentally the in-
dividual's personality which will determine the
issue, for no amount of physical treatment, ad-
vice, or other skilled help can be of real benefit
unless the disabled person has the will to help
himself ••• It is, therefore, important that some
form of assessment of personality be made as soon
as practicable, so that any extra time and thought
that is available may be given to the individual
most likely to benefit ••• " And further 11 • • • the
disability must be understood in terms of lack of
function as it affects everyday activities ••• Sing-
ly the physical disabilities would not be diffi-
cult to overcome. It is because they interact on
each other that the sum total is so formidable."
References
1. Emmett, R.: Adaptation of Homemaking Skills
for the Hemiplegic Woman. Am. J. Occup.
Therapy, 11:5, Sept./Oct. 1957.
2. Cooksey, F.S.: Proceedings of the ·7th World
Congress, I.S.W.C., 1957. p. 65.

29
3. Hossack, J.: Home Management for the Disabled.
Am. J. Occup. Therapy, 10:4, July/Aug. 1956.
4. MacCaul, G.: Proceedings of the 7th World
Congress, I.s.w.c. 1957. p. 126.

30
 D. Handcrafts
Handcrafts provide a therapeutic role
because:
1. They are adaptable and gradable:
(a) to early treatment in bed and/or restrict-
ed positions.
(b) to treatment of physical function
- joint range
- muscle power
- coordination
- tolerance of activity
(c) to treatment of mental function
- attention and concentra-
tion
- observation
- judgement
- initiative and ingenuity
(d) from minimal to unlimited interaction
with people.
2. The tools and techniques of crafts are the
basis of trades and jobs. The craftsman was
the original industrial worker, the skilled
tradesman. Many of these craftsmen were
artists whose skills have never been surpassed
J. They are suitable to all age levels, cultural
and social backgrounds.
4. They provide easily available media for real-
istic assessment of manual dexterity, pre-
cision jobs such as watch repairing, radio,
etc.
5. They provide motivation through achievement
in a wide range of interests.
To appreciate the significance of this treat-
ment medium, the two components of the word HAND-
CRAFT, should first be considered in their ap-
propriate ( and literal } sequence.
(a) Hand
Bunnell (1) points out that, "Hands from
birth are intimately connected with our mental pro-
cesses ••• the hand develops the brain and the brain
the use of the hand."
The hand is so intimately rooted into our
lives, thoughts and expressions, that it has be-
come a part of our language, e.g. handy, all hands
on deck, rule with a strong hand. From the Latin
MANUS are derived: manage, manipulate, manuscript,

31
manufacture.
In our present-day mechanical age, injuries
to hands lead the list of industrial accidents,
and are responsible for a large portion of com-
pensation expense.
The human hand has been described as the most
complex and intricate mechanism that exists.
Through its exact mechanism and tissues of great
delicacy and refinement, combined with the tough
material of which it is composed mainly, the hand
serves to provide man with certain knowledge and
control of his environment by means of:
l. Basic actions with their various modifica-
tions:
(a) finger tip pinch - grasping a cube be-
tween thumb and index or all fingers
(b) finger nail pinch - grasping a needle
between thumb and index finger
(c) lateral pinch - grasping the solid handle
of a cup between thumb and radial side of
the index finger
(d) cylindrical grasp - finger and thumb en-
veloping a cylinder
(e) ball grasp - thumb and all fingers en-
circling
(f) hook or snap grasp - 4 fingers flexed as
in carrying a suitcase
2. Sense of touch through which the hand ad-
justs to physical characteristics of:
(a) texture - hard, soft, rough, smooth,
pliable, rigid, slippery
(b) position of object grasped
(c) size and shape of object grasped
(d) temperature
Bunnell emphasizes that whenever possible a
hand should be kept moving, in that hands are
prone to stiffen, evidently because the joints are
so accurately fitted together and there are more
close fitting, gliding parts than elsewhere in the
body.
"Occupational therapy" writes Bunnell (1),
"is of real benefit in reconditioning crippled
hands. It should commence soon after the wounds
have healed and be continued until the patient is
ready for work ••• The tasks prescribed should be of
interest to the patient ••• Improvement on use is a
natural response to voluntary activity ••• Herein
lies the superiority of occupational therapy ••• "
Bunnell goes on to say- "Often the badly
32
crippled hand becomes disassociated from the brain
and the patient actually inhibits all motions of
his injured hand ••• Such a candidate for occupation-
al therapy will, in his response to his interests
and desire to work, gradually use his hand and
will then find that he can use it ••• Any light oc-
cupation with his hands, such as modelling or
painting, will serve to reconnect the hand to his
brain. Later he may change to occupations of real
exercise." And further, "An hour a day of occupat-
ional therapy is not of much use. It should be con-
tinued all day. It is by repeated motions and con-
tinuous use that the hand improves."
(For chart of activities see Bunnell: Surgery of
the Hand, page 314)
(b) Craft
Craft is defined as "skill or ingenuity, es-
pecially in the manual arts, and it is applied to
the trade or profession in which such skill is dis-
played; to an association of workmen of a particu-
lar trade; a trade gild (guild)."
It should be emphasized that the importance
of learning handcraft techniques is for two pur-
poses:
1. As a tool of treatment.
2. To gain knowledge of, and skill necessary to
use tools and materials. It is the manipu-
lation of tools and materials, not the fin-
ished product, that constitutes the treatment
tool, and only when the therapist knows
through her own experience the feel of the
tool, can she accurately analyze its use.
The particular tool or technique selected for
treatment depends on the immediate need of the
patient. For example, a hammer is a striking
tool. Striking is used in planishing copper
or silver, in driving nails, in driving rail-
road spikes. The range and power involved in
striking varies with the size and weight of
the tool, the resistance of the force which
is struck, and the position of the patient in
relation to his work. This is what the know-
ledge of tools implies for the occupational
therapist.
Reference
1. Bunnell, S.: Occupational Therapy of Hands.
Am.J.Occup.Therapy.4:4. July/Aug. 1950

33
 E. Industrial Skills and/or Tool of the Trade
It is interesting to note that the term "tool
of the trade" first became official occupational
therapy terminology at the Workmen's Compensation
Board Clinic in Toronto, in 1936.
Tool of the trade is defined as "Tools, mat-
erials, working requirements, on a level with that
required in industry."
In treatment these provide a psychologically
realistic media of treatment, and provide the only
valid testing media for the industrial accident
case.
Obviously no therapist can be master of a
trade, nor is this necessary. But she must know
the use and handling of the basic tools and mat-
erials, as well as the requirements on which jobs
are founded.
In woodwork and metalwork for example, she
learns the use and handling of hand and power
tools, which tools require strength, which.co-
ordination and skill, which joints come into action
etc.
The therapist does not teach a man his trade;
he already knows it. But she provides, at the ap-
propriate time, the best possible means for him to
regain the necessary skill, control, endurance,
and pattern of movement which he requires.
Similarily, the therapist does not train a
client in a new job or trade. She provides the
test and practice situation to demonstrate his pot-
ential ability with given tools, materials, work
situations, etc., and observes his attitude toward
this line of work. Gordon and Wellerson (1) state:
"It is to be emphasized that the use of modern
occupations is not for the purpose of training a
patient for a vocation. We feel that he can more
readily accept those media, exploited primarily
for functional exercise and pre-vocational train-
ing, which are in keeping with his own sense of
work." And further, "It follows that the type of
work therapy chosen must satisfy the functional,
psychological and vocational requirements of the
situation ••• If the chosen medium of work satisfies
merely the functional requisites of the disability,
the patient may reject it on psychological grounds
because it does not conform to his acquired work
habits."

34
Reference
1. Gordon, E.E. & Wellerson, T.L.: Does Occupat-
ional Therapy Meet the Demands of Total Re-
habilitation? Am.J.Occup.Therapy, 8:6 Nov-
Dec. 1954.

35
 F. Writing and Ty:ping
Wr_g_!.!_lg
Impairment or loss of ability to write re-
sults from various types of trauma which may oc-
cur to certain areas of the brain, the spinal cord,
and/or hand and arm. The motor pattern of writing
is a skill associated with the dominant hand; thus
in many cases the factor of dominance will be pre-
sent.
Understanding of the brain processes and the
motor patterns involved in handwriting is of major
importance to the occupational therapist. Disturb-
ance in these areas is present in an appreciable
number of cases for whom her treatment procedures
are deeply concerned. In many of these cases her
work will be closely coordinated with that of the
speech pathologist, while in others it is a part
of training in AOL, for obviously a patient who
requires assistance in feeding 'himself is likely
to need help in writing. Thus in the area of as-
sistive devices, a useful variety of writing de-
vices have been developed. (1) (2) (3).
Following are some of the more commonly met
problems:
(a) Impairment or loss of the motor pattern.
Motor function necessary for hand writing consists
of holding the writing implement, pressure on the
implement, and its movement on the paper to form
letters or symbols. While this motor pattern
varies with the individual, in general it can be
described as a digital holding, with motion oc-
curring at the proximal interphalangeal joints,
and/or slight flexion of the wrist and/or elbow
(4). Impairment of one or both components of the
motor pattern may result from poliomyelitis,
rheumatoid arthritis, osteoarthritis, contractures,
etc.
Assistive devices are freouent°ly valuable in
these cases. These will vary from the simple oppon-
ens splint (5) to the aluminum platfonn on ball
bearing casters designed by Gingras and Hardy (6);
from the intricately fitted hand shell designed
by Zimmerman (1) to the head band (1).
The upper extremity amputee, dominant side,
is also included in this group. When amputation
has occurred below the elbow, a number of thera-
pists, experienced in pre-prosthetic and prosthe-
tic training programmes, favour writing as one of
36
the first skills to be learned by the patient, us-
ing the prosthetic cuff (7). ~any of these patients
learn to write well with the pencil held in the
terminal device. While some authorities feel that
the writing skill should be retained on the domin-
ant side whenever possible, the majority are of
the opinion that the patient should make this de-
cision for himself.
The patient with multiple sclerosis nay lack
control of the writing pattern due to tremor. Some
interesting studies carried on at the Kabat Kaiser
Institutes in the United States are described by
Whitaker (8). These studies indicate that: a) the
resistance needed to control the intention tremor
can be provided while allowing for free mobility
of the arm; b) 11 • • • the writing pattern can be im-
proved without actual writing practice, which
tends to tense the patient and bore him." Free
painting with tempera poster colour was found to
be effective as a substitute for writing practice.
(b) Brain Damage
This group of patients presents an important and
interesting challenge to the occupational thera-
pist. Examples include:
(i) Hemiplegia: When damage has occurred in the
dominant hemisphere, the patient should be
taught to write with the unaffected (subdom-
inant) hand. As speech is involved in these
cases, the work of the speech pathologist and
of the occupational therapist should be
closely coordinated. McGeachy (9) considers
that writing should start early, and that the
occupational therapist is " ••• probably better
able to teach this skill than the average
speech therapist. Depending upon the cortical
damage sustained, the patient's inability to
speak may be reflected in his writing. It is
important that he learn to write, both be-
cause it removes one disability and because
it reinforces his total language recovery."
(ii) Cerebral Palsy: In treatment and training of
the cerebral palsied, writing is usually
started by the occupational therapist.
With these children, writing presents a
combination of basic motor learning with the
development of intellectual and perceptual
abilities. Handicap in these areas should be
recognized in the areas of training which
usually precede writing both chronologically
37
 and mentally, i.e. dressing, eating, and very
noticeably in the child's attempts to use
toys and play materials. 'fhus the therapist
is in a unique position to prepare the child
for education in the class room. Detailed
material on this area is described by Robin-
ault (10), Rood (11), and in a group study of
writing techniaues for the cerebral palsied
( 12).
Strauss and Lehtinen (13) emphasize the im-
portance of writing in the development of
visuo-motor perception in the brain injured
child, and the close relationship between
writing and learning to read.
All brain injured children are not cerebral
palsied. But while the severe motor involve-
ment is not present, equally difficult per-
ceptual problems may exist which are reflect-
ed in writing.
Left Handed Writing
Much of the anticipated awkwardness of learn-
ing to write with the left hand can be avoided by
following the instructions clearly outlined by
Gardner in his instruction manual Left Handed
Writing (14). While the majority of adult patients
will reouire instruction in the first few steps
only, some may require the step by step progres-
sion which would be followed in learning to type.
Typing
The typewriter has long been recognized as an
important piece of occupational therapy equipment.
In fact, most therapists consider it to be basic
equipment in practically every disability field.
As eauipment, the typewriter is 'understand-
able' and acceptable to most patients. Thus it
freauently provides a motivation to activity which
is psychologically valuable.
Typing is one of the few activities which
provide individual and equal action for all ten
digits. Equally important therape~tically, the
typewriter can be operated by substitute methods
including hand-grip typing sticks or a mouth-grip
stick. Driver and Bennett (15) consider that,
"With accurate planning of typing material the
activity is an excellent medium for muscle re-
education ••• Although these techniques are in con-
stant use in the treatment of poliomyelitis they
are proving to be of ecual value with other neuro-
36
muscular disorders." Based on extensive experience,
these authors have outlined an analysis of typing
and its application in the treatment of the polio-
myelitis oatient, including the equipment and as-
sistive devices used. This material is comprehen-
sive and well organized.
For the cerebral palsy child who is mentally
educable and physically capable of attending
school, the typewriter is often the most practical
means of written expression (12). Typin~ may in-
crease the vocational potential of some of these
patients in adult life. Unfortunately, suitable
employnent for the majority of these people is
limited.
For the bilateral arm amputee typing is used
in both pre-prosthetic and prosthetic traininv,,
and continues to be of practical value particular-
ly for those equipped for office or 'white collar'
employment.
References
1. New York University - Bellevue Medical Center:
Self-Help Devices for ~ehabilitation. Dubu-
oue, Iowa. W.C. Brown Co. Publishers, 195$.
2. Cerebral Palsy Eouipment. National Society
for Crippled Children and Adults, Inc.
Chicago.
3. Svensson, V.W. and Brennan, M.C.: The
Opponens Splint. Am. J. Occup. Therapy,
7:2, ~ar./April 1953.
4. Zimmerman, M.E.: Analysis of Adapted Eouip-
ment. Am. J. Occup. Therapy, 11:4, July/
Aug. 1957.
5. Silverstein, F.: Occupational Therapy and
the Hand Splint. Am. J. Occup. Therapy,
7:5, Sept./Oct. 1953.
6. Gingras, G. and Hardy, G.: Contribution of
Occupational Therapy in the Rehabilitation
of Quadriplegic Patients. Can. J. Occup.
Therapy, 14:3, Sept. 1947.
7. Kessler, H.H.: Principles and Practices of
Rehabilitation. Philadelphia, Lea and
Febiger, 1950, p. 238.
8. Whitaker, E.W.: A Suggested Treatment in
Occupational Therapy for Patients with
1-iultiple Sclerosis. Am. J. Occup. Therapy,
4:6 Nov./Dec. 1950.

39
9. McGeachy, D.J.: The Role of the Occupational
Therapist in the Rehabilitation of Speech.
Can. J. Occup. 'fherapy, 23:2, June 1956.
10. Robinault, I.: Perception Technics for the
Preschool Cerebral Palsied. Am. J. Occup.
Therapy, $:1, Jan./Feb. 1954.
11. Rood, M.S.: Writing Training as a Treatment
Procedure for Cerebral Palsy Patients.
Stanford Univ. Libraries, (Interlibrary
Loan Service), Stanford, Calif.
12. The Teaching of \'iriting to Cerebral Palsy
Patients. Am. J. Occup. Therapy, 7:6,
Nov./Dec. 1953.
13 . Strauss, A.A. and Lehtinen, L.E.: Psycho-
pathology and Education of the Brain-Injured
Child. New York, Grune and Stratton, 1947,
chap. 12.
14. Gardner, W.: Left Handed Writinr,, Instruction
~~nual. rev. ed., Danville, Ill., Inter-
state Pub., 1945.
15. Driver, M.E. and Bennett, H.L.: The Applica-
tion of Typing in the After-Care of Polio-
myelitis, Can. J. Occup. Therapy, 23:2,
Sept. 1956.

40
 G. Recreational Activities
Recreational Theraby
According toavis (1), "Recreational therapy
may be defined as any free, voluntary and express-
ive activity; motor, sensory or mental, vitalized
by an expansive play spirit, sustained by deep
rooted pleasurable attitudes and evoked by whole-
some emotional release ••• " Davis further states
that it is lt••• above all a feeling process, a
psychological phenomena ••• Equally true is the con-
cept of recreational therapy as a doing process."
It is prescribed by medical direction as an adju-
vant in treatment.
The various recreational activities must be
structured to produce a therapeutic experience for
the patient; therefore they are chosen for their
specific therapeutic value to the individual pat-
ient. More important than the activity is the
emotional atmosphere in which it is carried on,
and the relationship established between patient
and therapist.
The way in which an activity is used and the
purpose it is made to serve may vary considerably.
For example, dependin~ upon the atmosphere created
by the therapist, playing tennis becomes:
- an outlet for aggressive feelings
- a gratifying experience in learning a new
skill
- a spo~t to be practised and perfected by a
compulsive person
- for an impulsive, anti-social person, an
experience in adapting to authority, fol-
lowing prescribed rules. (2)
Recreational therapy, as distinguished from
remedial games, is directed to treatment of the
psychiatric patient and to those for whom the
psychological effect of the activity is of primary
importance. It has been noted that the majority of
psychiatric patients respond most readily to sen-
sory stimuli of the visual type, and will repeat
movements performed in their presence, whether of
the individual or the group.
Recognition of the significance of some form
of 're-creation' as a necessary part of daily life
has become increasingly important in our present
day machine age. The increasing technological ad-
vances in industry are tending more and more to:
- minimize the personal gratification of many
41
 jobs
- reduce the amount of interpersonal contact
within the work situation, for example -
the assembly line, the supermarket, the
automat
- increase the amount of leisure time
- limit the opportunity for creativeness in
many jobs. (2)
Remedial Games
Remeditlgames are defined as 'simply and
commonly used games involving physical activity,
in which equipment and/or method of playing is
adapted as treatment of physical disability.'
Blau (J) divides such games into two cate-
gories:
1. Those planned for their "specific kinetic
value, highly individualized and preferably
played with the therapist who manipulates in
such a way that the patient is encouraged to
strive against and to excel the therapist."
2. "Group games played among patients with the
direct supervision and active participation
of therapist."
In addition to the kinetic value, other values are
promotion of socialization, creation of alertness,
improvement in speech and increased attention span.
Boeshart and Blau (4) note that remedial
games provide:
(a} rhythmic contraction and relaxation of mus-
cles
(b) coordination
(c) adequate range of motion of joints
(d) graded resistance
(e} interest and competition
( f) minimum preparation
In most part they are used:
1. In early treatment:
- to mobilize stiff joints
- to strengthen weak muscles
- to re-establish neuro-muscular coordination
2. In middle and advanced stages:
- for gradation of resistance
The degree to which kinetic games are bene-
ficial depends upon the proper analysis and ap-
plication of the game selected. Most games are
extremely adaptable and may be played in a variety
of ways. Substitution of motion must be prevented
by proper positioning of the patient, clear in-
42
struction and suoervision. Examples of the motions
involved in some ' commonly used games are given in
Dunton and Licht: Occupational Therapy..,_~r-~nciples
~nd Practice, pages 94-97.
Play
In spite of the fact that the meaning of
'play' to the child differs from the meaning of
'recreation' to the adult, both have an equally
strong emotional accompaniment and individuality
of expression and performance which distinguishes
them from other forms of human activity. It is for
this reason that 'play' has been placed under the
general heading of 'Recreational Activities'.
Play is the adult's term for the occupations
and activities of children, thoueh to the child,
play is a serious business at which he works with
effort. Play includes the activities, toys and
materials which are recognized as the natural
media for the child.
For all children, toys and play provide a
direct, non-verbal· mode or channel of communica-
tion and emotional expression. Hartley, Frank and
Gold ens on ( 5) have pointed out that: "For the very
young the proximity senses of smell, taste, and
touch tend to be more important than the distance
senses of sight and hearing • •• that for the child,
his body is an organ of expression as well as of
perception, and that his attitudes toward himself
and the world about him are expressed in the way
he uses his body more fully than in his verbali-
zations.n
Treatment of the adult patient is in the main
directed toward restoration of capacities previous-
ly acquired but which through disease or injury
have been lost or diminished. For the sick child,
however, it is the development of a capacity or
capacities that hav~ been delayed or prevented.
Hence, in the treatment of the child the therapist
must understand not only the nature of the speci-
fic disability and its results, but also the dev-
elopmental level at which this interruption has
occurred. Gesell (6) describes the development or
growth of the child as a patterning process both
physically and mentally. It is essential, there-
fore, that the occupational therapist be familiar
not only with the development of control and use
of the head, trunk and limbs, but also with the
seouence of development of the more intricate pat-

43
terns of the hands, fingers, sensory perceptions,
language, intelligence, adaptive and social be-
haviour. Each and all of these follow an orderly
plan.
Limitation in attention span of the normal
child varies not only with age level but with the
individual child; hence variety and change in
activity are essential. This is even more impor-
tant with the sick child, particularly those suf-
fering from certain types of trauma.
Control of activity is frequently of major
importance in treatment of the sick child, but
the type and purpose of the control may vary. For
example:
- it may be reduction in the amount of activ-
ity and limitation of the type of activity
for the child with rheumatic fever, where
the aim is relatively complete rest, but
the disease itself does not immobilize the
child.
- it may be directed toward maintaining a
given amount of daily expenditure of physi-
cal energy while a diabetic child is under
observation in the hospital.
In both these situations, control must be
carefully set up in a manner acceptable and ap-
propriate to the child.
References
1. Davis, J.E.: in Occupational Therapy, Prin-
ciples and Practice. 2nd ed. ed. Dunton,
W.H. and Licht, S. Springfield, Ill. Chas.
C. Thomas 1957. pp. 101-102.
2. Stachowiak, J.G.: Recreational Therapy. Am.
J. Occup. Therapy 11 :4, July/Aug. 1957.
J. Blau, L.: in Occupational Therapy, Principles
and Practice. 2nd ed. ed. Dunton, W.R. and
Licht, S. Springfield, Ill. Chas. C. Thomas
1957, pp. 92-93.
4. Boeshart, L. K. and Blau, L.: Remedial Games
as an Occupational Therapy Modality in
Treatment of Physical Disabilities. Am. J.
Occup. Therapy, 5:2, Mar./Apr. 1951.
5. Hartley, R.E., Frank, L.K., Goldenson, R.M.:
Understanding Children's Play. Columbia
University Press.
6. Gesell, A. et al: The First Five Years of
Life. New York Harper & Bros. 1940
44
 H. Cultural and Educational
1. Music
In music we find a universal language, a
heritage common to man. Throughout the ages, the
histories of all cultures from the primitive tribe
to modern times, of the religions and of medicine
indicate an age old recognition that music exerts
certain effects upon the human being. In the early
history of medicine the healing effects of music
were noted. In fact, the use of music for this pur-
pose is considered by many to be as old as the
history of music itself.
"Music is not something which we merely hear
but it is something we feel. It is an emotional
experience ~hich results in response both physical
and mental." (l) These physical and mental respon-
ses to music can be utilized therapeutically as
follows:
a. Physiologically, music can stimulate or relax
various body processes such as metabolism,
blood pressure, response to voluntary activ-
ity. Precision is increased by accompaniment
of appropriate rhythm.
b. Psychologically, attention is attracted and
its span is increased; self control is sub-
consciously induced by the discipline of
rhythm; imagination is stimulated.
c. Emotionally, music is a powerful agent in
creating and changing mood; emotions and
drives can be released in a socially accept-
able manner. For example, the emotional re-
sponse to martial music, to church music, to
the dance band, are easily recognized in
others and in ourselves.
d. Socially, music produces a feeling of well
being and acceptance through the relaxation
of tension. Thus it creates rapport between
those with little in common.
As a treatment medium, music can provide ac-
tive participation or passive participation on the
part of the patient. It can be used in treatment
of the individual or as a group medium. Over a
considerable period of time the value of music as
a treatment medium in occupational therapy has
been demonstrated and has received approval of
physicians in the following areas:
a. Emotional and psychological disorders in both
adults and children. {l) (2)
45
b. Physical disabilities such as facial paraly-
sis (3), following plastic surgery of the
face, respiratory conditions when exercise of
the lungs is indicated, in the re-education
of muscle and patterns of co-ordination.
c. rreatment and training of the cerebral pal-
sied (4) and other patients suffering from
brain damage, for example the aphasic patient.
In addition to these specific uses, music has
therapeutic values in what is termed 'hospital
management' of patients, particularly those who
reouire prolonged care. In this area special
training in music is not necessary, provided the
leader has knowledge of the patients' musical pre-
ferences and can thus provide suitable material.
Finally, it is interesting to note the use of
music in certain medical centres before, during
and after surgery, E.C.T., etc.
References
1. Kingsmill, E.: Music as Therapy. Can. J.
Occup. Therapy, 22:3, Sept. 1955.
2. Van de Wall, W.: Music as a V~ntal Discipline.
Arch. of Occup. Therapy, vol. 2, Feb. 1923.
3. Beals, R.G.: A Study of Occupational Therapy
in Bell's Palsy. Am. J. Occup. Therapy,
5:5, Sept./Oct. 1951.
4. Snow, W.B. and Fields, B.: Music as an Ad-
junct in the Training of Children with
Cerebral Palsy. Occup. Therapy and Rehab.,
29:3, June 1950.
2. Art
The forms of art referred to in this section,
and which are those most commonly used as treat-
ment media, are two creative forms - painting and
modelling.
Art, like music, is a universal form of ex-
pression. It is a creative outlet in which indiv-
iduality is expressed and from which one achieves
a certain kind of satisfaction independent of a
utility or practical value.
There are different theories as to why prim-
itive man first decorated various objects with
paintings and drawings which in no way increased
their usefulness. Some consider that this was
man's basic desire for self-expression from which
he achieved personal pleasure.- Others suggest that
he first decorated his possessions to gain admir-
ation from others. This latter theory may explain
why many people express the desire to paint but
are reluctant to attempt it. They fear that their
efforts will not gain the admiration of nor give
pleasure to others.
Yet if the manual or manipulative side of
painting is examined, we see that actually it de-
mands far less coordination and dexterity than,
for example, watchmaking, engraving or typesetting.
Manual skills are learned by practice and persis-
tent effort. In art, however, the learning of
rules and the practice in their application play
but a minor part. It is the imagination, the in-
tellectual appreciation of the sense of balance,
of colour, of form, combined with the drive to
express something, that distinguishes the artist
from the artisan.
In the creative or expressive arts the 'cen-
sor' too often plays an inhibiting role. Thus, in
treatment of certain psychiatric disorders, paint-
ing and modelling become media of expression ac-
ceptable to the patient above other forms.
An example is the dethroning of the censor in
the manic patient. In his excellent text book, Haas
(1) has described a manic patient who had had no
previous training or experience in art. With the
unquestioning self-confidence, lack of inhibition,
and disregard of the possibility of criticism of
his efforts which are characteristic of the manic,
this man painted with skill and a display of art-
istic ability. But as he began to recover, his
freedom of expression and his self-confidence in
47
oerformance, i.e. handling the brush, diminished
as self-censorship of his work returned.
In the deeoly inhibited patient and the sen-
sitive Psychoneurotic patient.we find that paint-
ing and modelling, for example, are outlets for
expression of the thoughts, feelings and drives
which the oatient is unable and/or unwilling to
express v·erbally. Thus the censor, though resented,
retains power over the more customary form of ver-
bal communication, is by-passed, and-the patient
achieves expression through these other channels
of communication.
One other type of psychiatric patient for
whom expression through the materials of art is
important, is the regressed patient. Here we see
the patient returning to the early language of the
child which precedes his development of useful
langua~e and writing with any degree of success.
For a considerable time, painting with varicus
media, finser nainting, and modelling have been
used under direction of the osvchiatrist to oro-
V:ide diagnostic material. Wittkower and Johnston
(2) describe thi use of art " ••• as a device to ex-
olore Preconscious and unconscious processes and
to observe changes in personality structure under
treatment." Thus it is apparent that in psychia-
tric occupational therapy, the function of the
therapist· is not to teach art but to provide the
patient with an opportunity for an emotional ex-
perience, the results of which are both therapeu-
tic and revealing.
From the field of physical disability, the
following are a few examples of the therapeutic
use of art:
a. The hemiplegic patient with paralysis of the
dominant hand frequently gains remarkable
early success in oil painting and crayon
colouring, for which he uses his sub-dominant
hand. Though the affected hand may respond in
varying degrees to treatment, it is generally
accented that lead hand skill rarely returns.
Therefore the sooner the skill of the unaf-
fected hand is increased, the earlier and
greater is the degree of independence achi-
eved by the patient. Activities in which
these patients can experience early accomp-
lishment with the minimum sense of effort in
the performance, are important in helping to
reduce the frustration which is frequently
48
 present. An interesting case is described by
Owen {J) of an accomplished artist who became
as adept in using his left hand as he had
been previously with his right.
b. In the treatment of median nerve lesions,
Wynn Parry (4) includes finger painting among
the activities which can be used about 24
days after suture, and later pottery to build
up muscle strength. Painting, drawing and
writing he considers to be contra-indicated
due to the prolonged static holding of the
thumb. He suggests the early use of pottery
for radial nerve lesions, and to encourage
use of the extensor d1gitorum in the case of
lesion of the ulnar nerve.
c. When there has been complete loss of all
motor function, we have no better example of
vocational rehabilitation than that of Earl
Bailey, the well-known Canadian artist from
Lunenburg, Nova Scotia. Completely paralysed
as the result of poliomyelitis, Earl Bailey
learned to paint in oils, holding his brush
in his mouth*. The accomplishment of Bailey
and others with extreme physical disability,
seems to prove the statement that the skill
of the artist lies not in the hand but in the
head.
* Note: One of Bailey's paintings was purchased
by the National Gallery, Ottawa. Perhaps
even more remarkable than his management
of the brush, are the artist's beautiful
lino print blocks which were cut with
great precision and skill.
References
1. Haas, L. J.: Occupational Therapy for the
Mentally and Nervously Ill. ¥dlwaukee,
Bruce Pub. Co., 1925.
2. Wittkower, E.D. and Johnston, A.M.: New
Developments In and Perspectives of Psych-
iatric Occupational Therapy. Can. J. Occup.
Therapy, 25:1, ¥~rch 1958.
J. Owen, T.: Occupational Therapy and Neurolog-
ical Disorders. Can. J. Occup. Therapy
22:2, June 1955.
4. Wynn Parry, C.B.: Rehabilitation of the Hand.
London, Butterworth & Co. (Publishers) Ltd.,
1958. Pp. 88-90.
49
). Academic
Study of academic and commercial subjects may
constitute an important part of the rehabilitation
programme of certain patients, particularily those
within the age group in which education is norm-
ally gained. It is also indicated for patients
whose employment potential will be increased by
the development of latent aptitudes, i.e. oatients
for whom change of vocation is indicated medically.
Psychologically, the building or re-building
of a sense of vocational capability may change the
patient's whole attitude toward treatment.
Education is a long-term process, therefore
it provides a sustained motivation which is import-
ant for patients who are undergoing a prolonged
period of hospitalization, extending over a period
of months and .sometimes years. Examples include:
the tuberculous, aphasic, children who require
extensive orthopedic repair.
For the psychiatric patient study of academic
and commercial subjects provides mental discipline
by utilizing the faculties of memory, concentrat-
ion and reasoning. Pre-vocational assessment of the
psychiatric patient equals in importance that of
the physically handicapped. In the attempt to eval-
uate the patient's potentials for training, his
mental acuity must be estimated.
Teaching is, of course, a highly developed
profession, and the addition of trained teachers
to hospital staff has been welcomed by the treat-
ment team.
If academic education is to be part of the
therapeutic process it must be coordinated with
the total activity programme of the patient. Thus
the place and contribution of education in treat-
ment should be understood by all members of the
team.
Because the occupational therapist's contact
with the patient occurs earlier, and is more pro-
longed than that of the t.eacher, the therapist is
frequently in a position to introduce academic
work in a form which the patient is ready to ·
accept and from which he will benefit. While most
therapists are not prepared to carry out exten-
sive academic teaching, they should know· the
sources from which it is available. - In children's
hospitals for example, the occupational therapist
will frequently include school work in her pro-
50
gramme with the rheumatic fever child, and with
the diabetic child whose total daily activity must
be accurately watched and recorded.
For further information and guidance on the
indications and contra-indications for the use of
academic study as a part of the therapeutic pro-
gramme, the reader is referred to the text,
"Occupational Therapy, Principles and Practice" by
Dunton and Licht, chapter S.

51
 I. The Therapist
The basic tool of treatment is the therapist.
On her depends the success of any and all tools.
Her ability to understand and to motivate the pat-
ient realistically is essential.
Occupational therapy demands that the patient
DO for himself. Berkeley (1) describes the volun-
tary effort of the patient as "the driving force
of the programme." The therapist must do more than
teach the patient how it is done, she must train
him to do it by doing it himself. Therefore the
patient must be motivated to DO, whether or not
the therapist is there to urge him on. To accomP-
lish this the therapist must:
1. Know what the patient needs and what the pat-
ient thinks he needs.
2. See beyond the immediate goal of a recovered
part, to the ultimate goal of the patient in
his future life.
J. Find a realistic medium and be skillful in
adapting it if necessary, but still keep it
acceptable to the patient.
4. Have sound medical knowledge combined with
her own intelligence and observation, to pro-
vide treatment in a form best suited to the
patient. There is no 'textbook list' for this.
5. Be continually alert to recognize whether the
patient is progressing as an independent per-
son or, as an obedient and conforming child,
he is continuing to lean upon her.
Huntting (2) writes " ••• it would seem that
the therapist need put fully as much thought and
effort into how he can use himself as a tool as in
what activity he will use and how he is to grade
it. I do not mean to minimize the need of planning
and grading activity carefully, but rather to
stress the fact that for each patient worked with
there needs to be two tools- the activity and th.e-
self."
"To know one's self," says Boynton (2}, "is
certainly a major step ••• we must also know our-
selves in relation to our patients." Boynton pro-
ceeds to draw an analogue between the function of
the occupational therapist a~ she assists in the
recovery process of the patient, and the function
of a catalyst.
"The therapist,, 11 Boynton continues, obviously

52
enters into the 'reaction' ••• He does not become a
part of the final product but some of him is con-
sumed in the process. He is not permanently chang-
ed and may be 'used' repeatedly in similar operat-
ionS•••'therapeutic catalysts' subtly but defin-
itely change over the years with increasing skill
and understanding, this process is one of matur-
ation ••• " As there are different chemical catal-
ysts so there are different types of occupational
therapists, i.e. "those who are skillful in de-
veloping good interpersonal relationships with
neuropsychiatric patients; those whose talents are
most evident in working with brain-injured child-
ren; and those who are the ingenious gadgeteers
who seem to have a limitless supply of useful
adaptive devices to assist the disabled patient in
achieving independence." The role of the occupat-
ional therapist is "essentially a catalytic relat-
ionship ••• We cannot properly become a pa.rt of the
end result by virtue of the fact that our goal for
the patient is to make him independent of us.
Should dependency develop we have defeated our own
purpose. Dependency on us is permissible during
the recovery process but is hot desirable as the
treatment periods draw closer to termination."
The art of human relations, Bernhardt (4)
maintains, can be learned. Through insight, not
only into others but equally into ourselves, we
can learn to deal more effectively with other
people. How then doe~ the therapist learn to under-
stand her patient?
1. By empathy, which is an attempt to see things
as the patient sees them; to try to under-
stand the patient's point of view. Consider
the uncertainty and the fear which may be the
patient's initial reaction to an entirely new
situation.
2. By understanding the patient's motivation. He
may verbalize very convincingly but his per-
formance may belie his words. The reverse of
course may be equally true. ~s the patient
motivated to want recovery and self-depend-
ence or does he, like Hamlet, prefer to
••• suffer those ills we have
Than fly to those we know not of.
J. By recognition and respect for the patient's
goals - immediate, intermediate and ultimate.
Are we attempting to appreciate the patient's
goals, rather than to graft on our own ideas
53
 of what he ought to accomplish? It is futile
to explore vocational capacities for example,
when the patient is unable to take care of
his daily needs.
So the wise therapist will first control and
direct the patient. Then, like the pilot and his
trainee, both must share the controls. Only when
the controls are taken over by the patient himself
is he exerting his maximum capacities to achieve
his maximum success.
References
1. Berkeley, J.: Assessment of the Injured Work-
man. Can.J.Occup.Therapy, 20:1, March 1953.
2. Huntting, I.: The Importance of Interaction
Between Patient and Occupational Therapist.
Am.J.Occup.Therapy, 7:3, May/June 1953.
3. Boynton, B.L.: Refining Our Resources. Am.J.
Occup.Therapy, 8:2. March/April 1954.
4. Bernhardt, K.S.: Human Relations. Can.J.
Occup.Therapy, 22:4, Dec. 1955.

54
 SECTION VI
PRE-VOCATIONAL EVALUATION
Activities used for pre-vocational evaluation
involve a sampling of actual jobs; the patient is
tested for both the quality and quantity of his
performance. In this manner his potentials can be
matched against the standards used by the employer.
The pre-vocational evaluation progratlnle brings
the atmosphere of -the world of work to the patient.
Therefore, in this situation actual working con-
ditions should be simulated as realistically as
possible.
Because the occupational therapist has had
particular experience in observing people at work,
relating to others and to situations, her observa-
tions of the patient in the controlled work situ-
ation can add materially to the information con-
cerning his vocational potentialities. Psycholog-
ical tests make an important contribution but a-
lone do not give complete information on the pat-
ient's actual performance and his reactions in
work situations.
Patients who have had little or nc work ex-
perience, or those for whom extreme changes in oc-
cupation are required, are assessed on several
different jobs within the mental and physical cap-
acity in which his employment is feasible. The
type of jobs selected will differ to a certain de-
gree in different communities, depending on local
employment opportunities. The occupational thera-
pist must therefore gain broad, over-all knowledge
of job requirements and the demands of industry.
'Samples' of jobs appropriate for the evalu-
ation programme are available from various sources.
Fot- example:
- subcontract worl(. may be obtainable from
manufacturers. This work includes such
operations as packaging by count or weight,
small articles or materials (cup hooks,
screws, thumb tacks, paper in assorted
colours); assembling 'Do-It-Yourself' kits;
machine stitching and bundling paper shower-
slippers, etc.
- a series of sample projects may be selected
which involve handling of the tools and
materials commonly used in the production
of a variety of commercial articles. The
55
 procedures required in these test areas
enable the therapist or the vocational
supervisor to appraise fundamental hand
skill, manipulation of gross and fine ob-
jects, the patients's reaction to noise,
tempo, etc., his ability to understand and
follow directions, etc. (1). This procedure
has been successfully us~d at the Institute
for the Crippled and Disabled, New York
City.
- any ingenious occupational therapist will
find that she already has many potentials
for such tests in her standard equipment
and supplies.
The concept of pre-vocational assessment or
evaluation is not new, but increasing interest in·
and recognition of its function in today's rehab-
ilitation process is challenging. While its value
and purpose are obvious in rehabilitation centres,
it should not be limited to these. An outstanding
example of the value of such a programme has been
demonstrated at the Highland View Hospital, Cleve-
land, Ohio (2). Here a sheltered workshop has been
developed in which the procedures of pre-vocation-
al testing, sub-contract work, and carefully
selected and adapted testing methods have been
carried out with most gratifying results. All oc-
cupational therapists concerned with the needs of
long term treatment and/or severely disabled per-
sons should familiarize themselves with the illum-
inating material which has been published on this
programme.
The pre-vocational evaluation area has impor-
tant implications also for those practising in the
psychiatric field. Referring, for example, to the
effects of the ataraxic drugs, Scheeley (3)
states: "More pati_ents will be ready medically to
return to the community. Many of these patients
were in their teens when they became ill and were
admitted to the hospital. They never learned a
trade. Others ••• have forgotten their trade ••• The
occupational therapist will, therefore, have more
patients taking the first steps toward a trade or
a skill. Occupational therapy will be expected to
serve as the gateway to industrial therapy, voca-
tional training and vocational placement."
Work Tests and Assessment
The best test of work capacity is work it-
self. Tolerance for work can be measured by the
56
patient's reaction to work, which can be of prog-
nostic and rehabilitative value. In these situa-
tions the occupational activities should be care-
fully selected to provide, as far as possible, a
reality situation which is comparable to the fut-
ure vocation or avocation of the worker.
"The use of occupational therapy to develop
work tolerance in a controlled situation has long
been recognized in the treatment of tuberculosis
cases. It is well recognized in the field of in-
dustrial injuries where the patient must be graded
up to activity eauivalent to that of his job. It
is of equal importance for cardiac patients and
many others with debilitating conditions." (4)
The terms Work Test and Work Assessment are
both used in the final stages of the physical med-
icine programme. An example of these procedures
in the field of industrial accidents and outlined
by Hood (5), is taken from the program.~es of the
Ontario Workmen's Compensation Board Rehabilita-
tion Centre, Malton, and of the Vancouver Work-
men's Compensation Board Clinic, Vancouver, B.C.
A Work Test is ordered by the doctor on the
presumption that the patient will return to
his former job or some soecific job. The oc-
cupational therapist therefore keeps this
job in mind when setting up and directing the
Work Test. The Test takes approximately five
days during which the patient carries out t1.~
specified programme for six hours daily.
Other physical medicine treatments are discon-
tinued during the Test.
In this trial situation, the occupational
therapist observes the patient's performance,
recording speed, coordination, attitude,
pain, and any other pertinent factors. As all
tools and eouipment cannot be duplicated, the
therapist must at times improvise and borrow
from other trades, using tools which give
similar movements and- require approximately
the same degree of physical capacity and per-
formance. She must learn to understand the
reauirements of many types of work, tools
used, physical strength-required, and working
conditions.
!_IJ.9rk Asses~_!Tient. The occupational therapist
proceeds on the understanding that because of
the degree of remaining disability, the pat-
ient must be placed in another tYPe of job.
57
 Therefore his physical capacity must be mea-
sured and charted, as a guide in selecting
other suitable employment.
This Assessment generally takes about
three days to complete. Here the occupation-
al therapist is attempting to assess the
physical capacity of the patient by observ-
ing and charting how long he can stand, how
far he can walk, what weights he can carry,
how long he can sit, etc. The findings are
charted on a special form and may be used by
the doctor and the rehabilitation officer,
as a guide to helping the patient return to
suitable employment.
References
1. The Pre-vocational Unit in a Rehabilitation
Center. Office of Vocational Rehabilitat-
ion, Washington, D.c.
2. Izutsu, S. : A Sheltered Workshop in a Hosp-
ital Setting. Can. J. Occup. Therapy, 26:1,
March 1959.
J. Scheeley, W.: The Ataraxic Drugs and Occupa-
tional Therapy. Am. J. Occup. Therapy,
11:4, July/Aug. 1957.
4. Soackman, c.s. and Willard, H.S.: in The
Handicapped and Their Rehabilitation. ed.
H.A. Pattison, Springfield, Ill. Chas. C.
Thomas, 1957. p. 443.
5. Hood, M.: Occupational Therapy - Work Tests
and Assessment. Can. J. Occup. Therapy,
2J:2, June 1956.

58
 CONCLUSION
In the last analysis, successful rehabilita-
tion can be achieved only when eaual attention is
given to both the disabilities and the capabili-
ties of the patient. It might even be said, that
emphasis on the importance of an individual's cap-
abilities is one of the major contributions of the
rehabilitation concept.
The craftsman of the Uiddle Ages was not only
a master of a tool, he was master of his trade.
Thus he had the skill to adapt or devise ways in
which to meet the particular problem at hand.
The tools of occupational therapy are the
tools of daily living, the tools of accomplish-
ment. Properly selected and adapted, these tools
provide treatment of the disability, and at the
same time utilize the capabilities cf the patient.
As the tool must be carefully selected, so
must the instrument to measure the tool's effect-
iveness be carefully selected, and the specific
point which represents capability marked on the
measure. To locate this point correctly demands
understanding of the total individual. It is here
that the science of treatment must be combined
with the perspective of the artist.
'£his whole philosophy has been so well ex-
pressed by Rusk (1) that it is fitting to conclude
with it.
"Society only pays for two things: the skill
in your hands and what you have in your head. But
I am afraid we have carried out subconsciously
through the generations - a strong mind in a strong
body. To be able you must be physically able.
Nothing could be more fallacious. Everyone knows
that the average person only uses a fraction of
his physical capacity in daily living because with
modern transportation and modern technology it is
not necessary to use more. We have forgotten the
fact, however, that you don't have to run a foot
race or play tennis or be violent in sports to be
the finest doctor, lawyer, diamond cutter, clerk,
elevator operator or one of the thousand occupa-
tions, yes a thousand times ten thousand occupa-
tions, and yet only until recently have we begun
to feel the actuality of the situation. Once you
understand it, you realize that the normal person
is often handicapped because of the fact that we
do not use all our capacities and ~he other people
59
with handicaps must use them and develop them to
their full capacity •••
"It was beautifully expressed to me recently
in my own country by a friend who said: 'You know,
I think if you analyze the whole problem critical-
ly and philosophically, you will find it is the
so-called normal who are handicapped. ~le are handi-
capped because we have never had to go through the
heat of the kiln. Fine china is not made by putting
clay in the sun. It is only when it goes through
the heat of the kiln and once it passes the firing
test it is no longer clay but porcelain. Unfortun-
ately, because of the fact that some of us have
not had to work to our capacity, we remain unbaked
or partially baked clay, when a crisis might have
made us porcelain'."
Reference
1. Rusk, H.A.: in Proceedings of the 6th World
Congress, I.S.W.C. 1954, p. 213.

60