Occupational therapy foundations for political engagement and social transformation

Chapter 7. Occupational therapy foundations for political engagement and social transformation

Gelya Frank and Ruth Zemke




Introduction





Definition of key occupational therapy concepts related to politics and social change



Occupation ‘In occupational therapy, occupations refer to the everyday activities that people do as individuals, in families and with communities to occupy time and bring meaning and purpose to life. Occupations include things people need to, want to and are expected to do.’ (Approved by World Federation of Occupational Therapists Executive, July 2007)



Occupational apartheid refers to ‘the segregation of groups of people through the restriction or denial of access to dignified and meaningful participation in occupations of daily life on the basis of race, color, disability, national origin, age, gender, sexual preference, religion, political beliefs, status in society, or other characteristics. Occasioned by political forces, its systematic and pervasive social, cultural and economic consequences jeopardize health and wellbeing as experienced by individuals, communities and societies’ (Kronenberg & Pollard 2005a, p. 67).

These events constitute a ‘movement’ because the ideas and activities have arisen independently and heterogeneously, operating through social networks, rather than from any single, centralized source (McAdam et al., 1996 and Diani and McAdam, 2003). The small-scale demonstration and outreach projects associated with this movement mainly flourish as alternatives to formal institutions, cropping up outside national health systems and private health insurance reimbursement. Occupational therapists initiate such projects or ally with them in local communities, and the projects often rely on donations of funds and of professional expertise, or on micro-credits and volunteered labour (Yunis & Jolis 2003). Non-governmental organizations, corporate philanthropy or university-based research initiatives provide sponsorship. Some non-governmental organizations are humanitarian and secular; others have a religious mission. These projects engage individuals and communities in occupations to expand their capacity and quality of participation in larger social, economic and political structures.

Without doubt, the movement emerging in occupational therapy intersects with other global movements at this time (Keck and Sikkink, 1998 and Tarrow, 2005). This is readily indicated by the phrase ‘without borders’ used by the Occupational Therapy Without Borders project, which evokes the 1999 Nobel Peace Prize-winning organization, Doctors Without Borders (Médecins Sans Frontières 1997). Occupational therapy is one of several professions to develop a ‘without borders’ outreach. The terms used to identify the demonstration projects in the occupational therapy movement, however, reflect the profession’s uneasy alliance with biomedicine and its institutions. South African occupational therapist Ruth Watson (2004) suggests the phrase ‘community and population development’ for opportunities to engage in meaningful occupations among ‘immigrant and migrant populations, homeless people, refugees, people in war-torn regions, and historically disadvantaged individuals, groups and communities who live in poverty’ (p. 6). Brazilian occupational therapist Sandra Maria Galheigo (2005) and colleagues (Barros et al 2005) use the rubric ‘social occupational therapy’ for their approach to problems that fall outside the social welfare system. These occupational therapists reach beyond biomedicine and treating pathology to address disparities in occupational choices, which in turn are associated with disparities in health and well-being.

Addressing this set of concerns – the unevenness of global wealth, differentials in the protection of human rights and obstacles to the exercise of personal agency and political power – represents an upheaval in thinking and action within the occupational therapy profession. The overall thrust is radical but not unprecedented. We believe that interdisciplinary foundations and collaborations will help to strengthen the capacity of occupational therapy to influence social change. This was certainly the case during the progressive era in the USA, when the founding of occupational therapy was itself a social reform. It is too early to tell whether or not the profession per se will move in the direction of political engagements and social transformation. Perhaps these areas will remain outside mainstream practice. We take the position that the ideas motivating the movement are important enough to be introduced to all occupational therapy students so they may make informed choices about becoming agents of change.



Occupational therapy in the world system


World system and dependency theories help to explain the distribution of occupational therapy around the world today and something about its content (Frank, 1967, Wallerstein, 1974, Wallerstein, 1980, Wallerstein, 1989 and Wallerstein, 2004). According to statistics compiled by the World Federation of Occupational Therapists, most occupational therapists are located in the USA and Europe (Townsend & Whiteford 2005; Table 7.1). The USA heads the list in number of members reported by national associations. Japan ranks second, which may reflect the impact of the USA on academic and medical institutions there after the Second World War. The Japanese Ministry of Health and Welfare established the first occupational therapy school in 1963 with a teaching staff mostly of occupational therapists from the USA (Japanese Association of Occupational Therapists website, www.jaot.or.jp/e-history.html).
















































Table 7.1 Occupational therapy national associations ranked by size, c. 2004
Data adapted from Townsend & Whiteford (2005), based on sources compiled by the World Federation of Occupational Therapists (WFOT). WFOT data are compiled from the reports of membership among national occupational therapy associations. Because accreditation and membership requirements vary from country to country, WFOT’s numbers do not necessary reflect parallel data and may under-report numbers of practising occupational therapists in a specific country. For example, the American Occupational Therapy Association is made up of about 37 000 members but, according to the AOTA website, the actual workforce includes more than 100 000 practitioners, including occupational therapists and occupational therapy assistants.
Rank Country Members
1 USA 35 692
2 Japan 20 226
3 UK 14 482
4 Germany c. 11 000
5 Sweden 9302
6 Canada 7500
7 Denmark 6198
8 Australia 3500
9 Netherlands 3312
10 Norway 2734

American and British (i.e. Anglophone) influence on occupational therapy worldwide is especially striking after grouping membership in national associations by linguistic/cultural and regional spheres (Table 7.2). While various cultures and civilizations employedoccupational approaches to health from ancient times, the professionalization of occupational therapy is recent and closely tied to the emergence of the UK and the USA as industrial powers in the 19th and early 20th centuries (Wilcock, 2001 and Wilcock, 2002). Allied victories in the First and Second World Wars lent these powers even greater economic strength and strategic global influence. These facts help to explain the impact of American and British occupational therapy on the profession, given that most national associations, including those in Europe, were established after the Second World War (World Federation of Occupational Therapists website, www.wfot.org). As Kronenberg and Pollard noted in an address to the American Occupational Therapy Association (AOTA): ‘Globally, the AOTA represents the single largest national community of occupational therapy practitioners, and the volume of literature, research, and tools it generates significantly influences the thinking, the practice, education and research of occupational therapy practitioners all over the world’ (Kronenberg & Pollard 2006, p. 617).






















































































































Table 7.2 Selected linguistic-cultural, regional and national traditions at the start of the 21st century
Data from Townsend & Whiteford (2005), based on World Federation of Occupational Therapists sources. Data are lacking for most of Latin America and numbers for Chile and Argentina seem under-reported. Assignment of countries to a particular linguistic or regional sphere is for this chapter and is not intended to preclude regrouping the data for further analyses.
Linguistic or regional sphere Influence National tradition Current membership
Anglophone American USA 57 413


USA 35 692


Japan 20 226


Republic of China (Taiwan) 744


Republic of Korea 505


Philippines 246

British UK 29 659


UK 14 482


Canada 7500


Australia 3500


India 1912


South Africa 1287


Hong Kong c. 800


Singapore 158


Bermuda 20
Scandinavia

19 749


Sweden 9302


Denmark 6198


Norway 2734


Finland 1426


Iceland 134
Western Europe

16 925


Germany c. 11 000


Netherlands 3312


France 978


Belgium 735


Spain 540


Portugal 250


Italy 110
Latin America Spanish
921


Venezuela 500


Chile 250


Argentina 171

Portuguese
890


Brazil 890

World system theory holds that, although national, traditions of professions and academic disciplines may vary according to local circumstances, their distribution and development are not random. Academic disciplines are formed and undergo transformation within systems of power. This phenomenon has been explored recently in the discipline of anthropology and the subdiscipline of medical anthropology (Krotz, 1997, Cardoso de Oliveira, 2000, Kuwayama, 2004 and Ribeiro and Escobar, 2006; also see Baer et al., 2004 and Saillant and Genest, 2006). Contributors to this conversation focus on framing anthropological scholarship and theories to reflect and respond to local realities around the globe. The same kind of effort is taking place among Japanese occupational therapy scholars, who are reworking theories about human occupation, originally framed and published in English, to make sense in Japanese culture (Kondo, 2004, Iwama, 2005 and Odawara, 2005; see also Zemke 2004). In Singapore, where occupational therapy was established in the 1930s under colonial British aegis, similar concerns are also emerging (Yang et al 2006). These examples signal a need for comparative and critical histories of the occupational therapy profession in various countries, regions and linguistic–cultural spheres.

Chapters by Brazilian occupational therapists Galheigo (2005) and Barros, Ghirardi and Lopes (2005) in the book Occupational Therapy Without Borders can help to illustrate issues concerning the production and circulation of professional knowledge in the world system. Galheigo and her colleagues cite Portuguese translations of European and North American thinkers including sociologist Erving Goffman (USA), philosophers Jean-Paul Sartre and Michel Foucault (France), and neo-Marxist theorist Antonio Gramsci (Italy). They are able to balance this roster of ‘imports’ with references to Brazilian educator Paulo Freire (1970), a major contributor to world discourse with his Marxist-inflected ‘pedagogy of the oppressed’. The authors also rely on a critical Brazilian literature published in Portuguese in sociology, social medicine, the history of psychiatry and occupational therapy focused on the issue of deinstitutionalization. The deinstitutionalization approach, however, originated in the North with Norwegian scholar Bengt Nirje’s theory of ‘normalization’ and subsequent publications by German-born American scholar Wolf Wolfensberger, 1975 and Wolfensberger, 1996.

While Galheigo and her colleagues’ work reflects the resilience of Brazilian intellectual resources, particularly the radical tradition associated with Paulo Freire, the occupational therapy literature published in Portuguese remains mostly inaccessible to scholars elsewhere in the world. Libraries in the USA, for example, do not tend to subscribe to Brazilian or Portuguese journals, nor is the work generally translated. Local debates are muted on the world stage, such as the following: should Brazilian occupational therapists prioritize science-driven clinical issues to meet standards in the North, and use their resources to develop evidence-based practice? Or should they prioritize politically driven conditions in cities such as São Paulo, Brasilia and Rio de Janeiro, or indigenous and rural areas such as Amazonias or Mato Grosso (Nick Pollard, personal communication, 2007)?

The situation is equally or more acute with regard to the Spanish-speaking countries of Latin America. Limited access in the North to Spanish-language literature impoverishes world discourse among occupational therapists because Spanish is the predominant national language in Central and South America. The data reported by the World Federation of Occupational Therapists on the number of occupational therapists in Latin America are sketchy (Table 7.2). Yet Latin America presents some of the most important occupational challenges in the world related to development policies because the gap in income between rich and poor is among the highest in the world (World Bank website, www.worldbank.org). According to the World Bank, Latin America is the most highly urbanized developing area: about 77% of the population lives in cities. The rate of urban growth means that the cost of meeting basic needs is also rapidly increasing, along with demands on environmental and natural resources (World Bank website). From 1990 to 2005, Latin America had the highest percentage of private investment in infrastructure among developing regions in the world. As we will discuss later, under current neoliberal policies of international development, private investment carries particular risks to a population concerning the distribution of wealth and the provision of public services. Income inequality in the region worsened in this period, as reported by the World Bank in 2003, with the richest one-tenth of the population earning 48% of the total income, while the poorest tenth earned only 1.6%.

Given such data, it is not difficult to see how the hegemony of the USA and Europe in the world system is not simply a matter of prestige. The production and circulation of knowledge has both an ideological and a material base. On the ideological side, peer review based on established Eurocentric standards results in the reproduction of such knowledge in published research and promotion of faculty in academic institutions around the world. On the material side, disciplines flourish when there is economic support for education and the proliferation of academic institutions such as universities, professional schools, libraries and laboratories. There must be salaries for faculty, resources to support research, graduate programmes, equipment and opportunities to publish. But in developing countries resources such as these are often hard to come by. Consequently, there is a tendency to rely on importing knowledge and expertise from the North and to use academic knowledge to support wealth-producing rather than poverty-eliminating initiatives.

Optimistically, globalization may offer new opportunities for exchange to occur internationally (Ribeiro & Escobar 2006). Computers and Internet access may allow diverse national and local sectors to define their own interests, needs and contributions (see, for example, the Open Access Initiative of the Open Society Institute at the Soros Foundation: www.soros.org). Realistically, however, most scholars and professionals will need to keep up with western European and American discourses to remain viable players in the global circulation of knowledge. This factor has become more pronounced since the end of the Cold War (the Berlin Wall was torn down in 1989; the Soviet Union was dissolved in 1991). The Cold War was characterized by a polarizing counterplay of Soviet Russian ideological and scholarly influences in the world against those of the ‘West’. This dynamic has been only partly replaced by focus on a new dynamic of conflicts between ‘Western democracies’ and militant Islamic nationalist movements that challenge the secularization of values associated with capitalist expansion.

What defines the ‘world system’? How did it come about, and can it be changed? Introduced by sociologist Immanuel Wallerstein, 1974, Wallerstein, 1980, Wallerstein, 1989 and Wallerstein, 2004, world system theory holds that the economies of the so-called First, Second and Third Worlds are part of a single world system that can be said to have emerged in or by the 17th century. This process, sometimes called ‘modernization’, proceeded from Europe’s colonial expansion into the Americas, Asia and Africa (see Ch. 4). The result of modernization was a division of labour and markets structured with a ‘core’ of wealth and power existing in relation to a less wealthy and powerful ‘periphery’. The core is mainly identified with the northern hemisphere (the North) and the periphery with the southern hemisphere (the South). Kronenberg and Pollard (2006) consequently call for occupational therapists to recognize that only a small percentage of the world’s population, about 6%, owns 60% of the world’s wealth, and those people tend to live in the North.

In terms of intellectual sources, Wallerstein draws on the historical materialism of Karl Marx, the broad cultural approach of French historian Fernand Braudel and Wallerstein’s own research on postcolonialism and development in Africa. One of the most important areas of contemporary anthropological theory and research has been to explore and challenge the assumption that ‘modernization’ imposes secular values and cultural uniformity throughout the world – the so-called ‘Americanization’ or ‘McDonaldization’ of world cultures (Zemke 2003). The consensus among anthropologists, however, is that cultural diversity takes new forms rather than disappearing (see, for example, the essays in Ong & Collier 2005). Consequently, it is important to pay attention to local and emergent conditions, making use of anthropological and other scholarship that can serve occupational therapy internationally (Frank and Zemke, 2006, Frank et al., 2008 and Frank et al).

A corollary to world system theory, ‘dependency theory’, holds that developed nations actively, if not always consciously, promote the dependence of poorer nations through various policies and initiatives. These nations (the North) exert control through economics, media, politics, banking and finance policies, education and all aspects of human resource development. This theory was worked out with special reference to Chile and Brazil in the 1960s by Andre Gunder Frank (1967), who served as Professor of Sociology and Economics at the University of Chile, where he was involved in reforms under the government of Salvador Allende. Frank noted that attempts by the dependent nations to resist the influences of dependency often result in economic sanctions and military invasion and control. He later experienced this himself in Chile when Allende’s government was toppled by a coup d’état in 1973 with support from the USA. The pattern was replayed the following decade in Nicaragua and El Salvador.

Through globalization policies such as the North American Free Trade Agreement (NAFTA), the periphery sells its products and labour at low prices on the world market but buys the core’s products at comparatively high prices. These practices create relatively stable structures of inequality internationally. ‘Semiperiphery’ buffer zones such as China and India serve simultaneously as core to the periphery and as periphery to the core. Some observers suggest that the valence of world power is shifting again to Asia, after centuries of Eurocentrism (Frank 1998). World system theory holds that the expansion of capitalism eventually commodifies all things, everywhere, including human labour, natural resources, land and human relationships. The effect on human occupation in the sense of how people live their everyday lives is pervasive. Not infrequently, wars are fought as a direct or indirect consequence of the structuring of global markets and development. Control of oil in the Persian Gulf was a key factor in the First Gulf War in 1991 and, many claim, important in the current American-led war in Iraq, begun in 2003.

The academic sector offers a place where an analysis of occupational therapy in the world system can flourish within interdisciplinary exchanges. Such conversations can provide conceptual tools for practice in specific local contexts. Conversely, occupational therapists engaged in practice oriented toward social change can contribute important new knowledge. We quote Kurt Lewin, a social psychologist and refugee to the USA from Nazi Germany, who was interested in participant action research and its relationship to building democratic institutions. Kurt Lewin argued that ‘the best way to understand something is to try to change it’ (Greenwood & Levin 1998, p. 19).

In summary, the role of the USA and the UK in world politics and world trade seems to account for the proliferation of occupational therapy as a profession and much about its content. The dominance of the medical rehabilitation model internationally is linked to this set of influences (Gritzer & Arluke 1989). In other words, the development of occupational therapy on the world stage has been closely tied to the circulation of Western biomedicine after the Second World War. The broad scope of the Anglophone sphere helps to account also for the rapid spread of occupational science, an academic discipline founded at the University of Southern California in 1989. The acceptance of occupational science can be seen not only in the founding of the Journal of Occupational Science, published in Australia, and in associations in the English-speaking world such as the Society for the Study of Occupation: USA (www.sso-usa.org) and the Australasian Society of Occupational Scientists (asos.nfshost.com) but also in associations of occupational scientists in Japan and Taiwan (Zemke 2003).

We offer below a political history that helps to contextualize the limited social analysis and the absence of political analysis in the early occupational science literature (Yerxa et al., 1990 and Clark et al., 1991). We suggest that American occupational therapy turned away from the political and reformist tendencies of its founding years. Few analyses of gender, class and race, for example, have appeared in the professional literature of this predominantly female profession, quite in contrast with nursing, teaching and social work (Frank 1992). It does not surprise us that critical discourses calling for political engagement by occupational therapists have originated outside the USA – in Canada, Australia, New Zealand, the UK, the Netherlands, Spain, Brazil, South Africa and elsewhere.



Professional development requires audacious values and critical assessment of local conditions



As contributors to the founding of occupational science, we feel that occupational science is worthy on its own merits. Chief among these merits is the establishment of a distinctive knowledge base about the core concept of ‘occupation’. Not only does such a knowledge base provide new directions for treatment but, in the most basic logistical manner, it was essential for the legitimation and survival of occupational therapy in the academy (Abbott 1988). We note that occupational science continues to evolve (Zemke & Clark 1996) and that criticism, including self-criticism, is productive for the discipline. Although the University of Southern California chose to grant degrees in occupational science, not many others have followed. However, we observe that occupational scientists’ ‘naming and framing’ a discipline has affected the research as well as practice direction in the field of occupational therapy.


Precedents for political engagement and social reform: Hull House activism and occupational therapy’s road not taken


Occupational therapy’s origins in the USA during the progressive era (1890–1920) were political, at least among those founders associated with Chicago’s Hull House (Table 7.3). Key figures such as Julia Lathrop, Adolf Meyer and Eleanor Clarke Slagle were engaged initially in efforts to reform treatment of the mentally ill. They believed that the deplorable conditions of the urban poor were causing an increase in otherwise preventable mental illnesses. They worked on improving clinical settings, the treatment of patients with mental illness and the social conditions from which the patients came and to which they returned. Building on previous histories of the profession, it is possible to reconstruct how Pragmatist philosophy, the Arts and Crafts Movement, the Mental Hygiene Movement and the Settlement Movement were more closely intertwined with socialism and democratic political reform than has perhaps been realized (Breines, 1986, Levine, 1986 and Levine, 1987). In this light, the Arts and Crafts Movement, for example, was not simply an aesthetic revival or a hobbyist fad for personal renewal but an array of strategies to realign lopsided relationships among owners, workers and consumers (Lears, 1981 and Boris, 1986; also see Levine 1987).























































Table 7.3 American occupational therapy’s emergence in Chicago in relation to pragmatism, politics and social reform
Date Event
1889 Jane Addams and Ellen Gates Starr found Hull House Settlement in Chicago on Christian Socialist principles after visiting London’s Toynbee Hall
1891–3 Socialist Labor Party member Florence Kelley moves to Hull House in 1891 and makes it a centre of labour reform; her research with other Hull House women into the sweat shops in Chicago’s garment industry leads to the Illinois Factory Act 1893. Kelley then appointed Chief Factory Inspector for Illinois by reform Governor John Peter Altgeld
1893–5 Social reformer Julia Lathrop begins investigation of Illinois State mental hospitals and other institutions; mentors and works with psychiatrist Adolf Meyer at Illinois State Hospital in Kankakee to achieve asylum reforms including state examinations for interns and appointment of women physicians
1894 John Dewey appointed chair of departments of Philosophy, Psychology and Pedagogy, University of Chicago; his political thinking expands, while travelling there, by newspaper accounts of workers’ cooperation during the Pullman Strike in Chicago. He founds the Dewey Laboratory School at the university the following year and, 2 years later, becomes a trustee of Hull House
1902 Hull House resident Florence Kelley helps gain passage of the federal Pure Food and Drug Act 1902
1903 Jane Addams, Florence Kelley and others at Hull House establish the Women’s Trade Union League. Union meetings often held at Hull House and members of the settlement helped support workers during industrial disputes. As a result, some wealthy people withdraw their support from Hull House
1905 John Dewey leaves Chicago for Columbia University in New York City
1908 Eleanor Clarke Slagle takes the first course organized by Julia Lathrop and Rabbi Emil Hirsch at the Chicago School of Civics and Philanthropy to train craft teachers to work with mental patients
1910 Adolf Meyer moves from Chicago to Baltimore to direct the new Phipps Psychiatric Clinic at Johns Hopkins Medical School
1913 Eleanor Clarke Slagle moves to Baltimore for 2 years to become Director of Occupations under psychiatrist Adolf Meyer at the Phipps Clinic
1915 Slagle organizes and directs Henry B. Favill Memorial School of Occupations in Chicago, teaching courses in Curative Occupations and Recreation that continue Lathrop and Hirsch’s work; Jane Addams attends first Congress of Women’s International League for Peace and Freedom in the Hague in an effort to deter US involvement in the First World War
March 1917 Eleanor Clarke Slagle and colleagues found National Society for the Promotion of Occupational Therapy in Clifton Springs, NY
August 1917 US Surgeon General recruits occupational therapists (reconstruction aides) to serve in the First World War
1919 American women gain the right to vote by constitutional amendment
1920 Vocational Rehabilitation Act resolves a conflict between the US Veterans Administration (under the US Surgeon General) and civilian vocational counsellors. The VA’s role is restricted to medical rehabilitation (‘prevocational phase’). Consequently, occupational therapy’s scope of practice becomes defined as medical not vocational
1923 Henry B. Favill School closes when war-related need for occupational therapists ends. Eleanor Clarke Slagle becomes Director of Occupational Therapy for the New York State Mental Hygiene Commission until her death in 1942


Jane Addams and Ellen Gates Starr founded the Hull House Settlement in 1889, on the Christian Socialist model of Toynbee Hall in East London, which they had visited (Addams 2002a). The idea of an urban ‘settlement’ referred to the work of educated, service-minded young people who lived together along cooperative principles to serve the disenfranchised surrounding poor immigrant or minority community (Addams 2002a). Laissez-faire capitalism in the USA was then at its height (Zinn 2003). Rapid industrialization had resulted in an unprecedented acquisition of wealth and power by a small sector of the population – sometimes referred to as the ‘robber barons’. Immigration policies resulted in a massive influx of mostly unskilled labour from the margins of Europe. Internal migration brought African Americans from the rural south to the northern cities, while the US Supreme Court decision in the case of Plessy v Ferguson (1896) upheld ‘separate but equal’ legislation. A ‘closed-door’ policy at the national level kept out new Asian immigrants while racial discrimination targeted those already in the country. The parallels with issues today at the start of the 21st century are difficult to overlook.



Political engagement means seeking alliances and making choices



Sharp political contradictions resulted in difficult choices for the Hull House activists. As Zinn (2003) notes, President Theodore Roosevelt’s wing of the Republican Party, known as the Progressives, initiated American aggression and imperialism in the Spanish American War (1898), resulting in acquisition of the Philippines, Puerto Rico, Guam and, for a period, Cuba. Yet, the same Progressive Republicans were the standard-bearer of many of the reforms sought by the Hull House activists, including the Pure Food and Drug Act of 30 June 1906, which provided for inspection of meat products and forbade the manufacture, sale or transportation of adulterated food products or poisonous patent medicines. The USA made a further, decisive shift to intervene in international affairs with its entry and later victory in the First World War (1914–1918). Of the Hull House activists, Jane Addams voted for the Progressive Party in some elections and the Socialist Party in others. Ellen Gates Starr and Florence Kelley were socialists. Florence Kelley (1859–1932) joined Hull House in 1891 and remained until 1899, when she moved to Lillian Wald’s Henry Street Settlement on New York’s Lower East Side, a hub of reform on a par with Hull House. According to US Supreme Court Justice Felix Frankfurter, Kelley ‘had probably the largest single share in shaping the social history of the USA during the first 30 years of this century…playing a powerful if not decisive role in securing legislation for the removal of the most glaring abuses of our hectic industrialization following the Civil War’ (quoted in Sklar 1985, p. 658).

Addams and Starr initially focused on aesthetic ideals fostered by the critic John Ruskin’s essays decrying the abuses associated with industrialism. His book, The Stones of Venice (Ruskin 2007), first published in 1850–1853, was the bible of the Arts and Crafts Movement. Very soon, Addams and Starr realized that more focused political engagement was needed. Active issues on the Hull House agenda included passage of laws and policies to provide a minimum wage, 40-hour working week, overtime pay, safe working conditions, workers’ compensation and childcare (Addams, 1930, Addams, 1990, Addams, 2002b and Addams, 2002c). The Hull House residents, who were mostly educated women and who lived cooperatively, worked to organize unions; participate in strikes; improve public sanitation; establish well-baby clinics, public baths and gymnasiums; gain political rights for immigrants; and secure voting rights for women. Addams’ participation in antimilitarist protest during the First World War resulted in the formation of the Women’s International League for Peace and Freedom and the American Civil Liberties Union. Other burning issues addressed by Hull House activists included securing legislation to protect the public from toxins in the environment, guarantee the quality of food and drugs, establish special courts for juvenile offenders, and reform prisons and state mental institutions.

In the Hull House context, occupational therapy emerged from Julia Lathrop’s efforts to reform the Illinois state mental institutions (Addams 2004). State mental hospitals existed at this time, but not public or private health insurance. Consequently, there was no reimbursement for treatment of individual patients or clients outside commitment to such institutions. Although these were public, tax-supported institutions, they were mainly places of last resort where poor people with criminal histories, alcoholism, chronic mental illness, antisocial behaviour, depression or reactive psychoses were thrown together indiscriminately (Meyer 1948a). Hull House’s innovative programmes were initially supported by private wealth funnelled through personal and corporate philanthropy. The Hull House reformers worked to pass laws to regulate industrial and urban conditions, targeting the sites where injuries and illnesses occurred in order to prevent them.

Lathrop’s years at Hull House, from 1890 to 1909, focused on visiting social welfare institutions throughout Illinois and promoting reforms in public institutions for the insane, indigent, delinquent and children. Beginning in 1893, Lathrop, 35 years old, served as the first woman member of the Illinois State Board of Charities, a position she used eventually to introduce reforms such as the appointment of female physicians to state hospitals and removal of the insane from state workhouses. That same year, 1893, Lathrop met Adolf Meyer, the 26-year-old Swiss doctor of neurology and psychiatry who had just received an appointment as pathologist at the Illinois Eastern Hospital for the Insane at Kankakee. Lathrop introduced Meyer to Hull House and its approach to social issues.

As a former student of Adolf Meyer later noted, ‘Miss Lathrop came as a visitor for the State Board of Charities and Correction, open-minded, deeply concerned in her work and interested in Meyer as a European who could answer her questions about social service abroad, particularly child welfare (20 years later she became the first head of the Federal Children’s Bureau). She introduced him to Jane Addams, another vibrant woman who was doing a share of the world’s work, and to Governor Altgeld. When Meyer slipped and injured himself on a visit to the fair, Miss Lathrop had him put up for a week at Hull House, which was an excellent point of orientation in sociology’ (Lief 1948, p. 49).

Lathrop and Meyer forged an enduring alliance (Lief 1948). In 1894, Meyer responded to a public address by the well known psychiatrist, S. Weir Mitchell, who charged that doctors in mental hospitals were unscientific in their methods and had failed to contribute useful information about the insane. Meyer wrote an angry rebuttal to the new, reform-oriented Governor John Peter Altgeld to suggest that the Governor invite the hospital workers to write reports. He enlisted the help of Julia Lathrop, who induced the Governor to give the Illinois hospital physicians a chance to express their own views and visions. As a result, the Illinois State Board published a compilation of the reports, which allowed Meyer to disseminate his studies at Kankakee, in which he combined pathology and case histories, and to propose innovative methods for interviewing patients.

Lathrop used the published reports to persuade the Illinois State Board in 1895 to hold competitive examinations for medical internships in state mental hospitals, the first policy of its kind in the USA – and Meyer was appointed as an examiner (Lief 1948). Later that year, Meyer accepted a position at the State Lunatic Hospital at Worcester, Massachusetts, where he remained for the next 7 years. Much of his work focused on reorganizing how records were kept on patients, which improved classification and statistical analysis and allowed him to demonstrate that most mental illnesses were capable of amelioration. In 1902, Meyer moved to Manhattan to take a position coordinating pathological work at all 13 of New York State’s mental hospitals, introducing new methods of assessing and categorizing symptoms and acquiring the reputation of ‘having transformed the state’s insane asylums into mental hospitals’ (Lief 1948, p. 101).

While in New York, in 1907–1909, Meyer collaborated with Clifford W. Beers to establish the National Committee for Mental Hygiene, with Julia Lathrop among the small group of about a dozen founders (Meyer 1948c). Their agenda was to launch a public campaign for asylum reform following publication of A Mind that Found Itself, Beers’ (1908) account of the horrific treatment he had received in mental institutions while treated for manic depression. Meyer’s political thinking from this period comes through in a talk he gave in Baltimore in 1909, titled ‘The Problem of the State in the Care of the Insane’. Meyer used statistics to demonstrate variations in the incidence and prevalence of mental illness by class, region and cultural environment. He argued that mental illness was rising and that it was related to stressful urban conditions that undermined the well-being of vulnerable populations. He wrote in support of greater public investment to improve mental health in and outside of the asylums and in favour of early treatment to prevent chronic mental problems:



Meyer’s commitment to public services made his decision difficult when in 1908 he was offered the position of director of the new psychiatric clinic at Johns Hopkins University, a private institution. ‘For the past 15 years,’ his former student and biographer Alfred Lief (1948) wrote,



Meyer had been in state service. He preferred a state hospital system to private hospitals. Here was an offer from ‘one of the foremost medical centers established and supported by private enterprise’. How would he harmonize his orientation toward serving the community with the fact of functioning in an organization munificently endowed to pursue specialties and not having to wait for public appropriations?

Lief 1948, p. 336

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