By Irene Ilott, Gwawr Faulconbridge and Judith Pettigrew
Introduction: a pioneering place and person
Occupational therapy started at Cardiff City Mental Hospital in 1930, led by Sister Patricia Sunderland, a registered mental nurse and occupational therapist. This is noteworthy because neither Wales, nor Sunderland, have been recognised as pioneers of occupational therapy before. Sunderland’s description of a hospital wide service for in- and out-patients at Cardiff is one of the first accounts written by an occupational therapist.[1] Research to date indicates that Sunderland was the first Irish person to use the title and to write about occupational therapy in Wales.[2]
This development in Wales is striking given the context of an emergent profession. George Barton, an American architect and disability campaigner, first used the term occupational therapy in December 1914.[3] Professionalisation began in 1917 at the inaugural meeting of the National Society for the Promotion of Occupational Therapy held in upstate New York.[4] National associations were formed in Canada in 1926,[5] Scotland in 1932,[6] and England, Wales and Northern Ireland in 1936.[7] This timeline puts Wales into an international perspective and begins to counterbalance the historiography which focuses on England.[8],
The roots of occupational therapy extend beyond being named and formalised into a profession. Wilcock documents the long history of using occupation to benefit health from ancient to industrial times.[9] Early proponents offered evidence about the widespread use of occupation in American and European mental hospitals from the early nineteenth century.[10] Hall gives three reasons for engaging patients in regular, meaningful occupations:
as a continuing legacy of the humanitarian ideals of moral treatment; a pattern of regular daily activity was seen as conducive to less disturbed behaviour (not necessarily as therapeutic); and as the use of patient work in utility departments kept hospital costs down.[11]
This article draws on public documents and primary sources to present the life and legacy of Patricia Sunderland for the first time. The aims are to 1) present Sunderland’s biography in the context of the beginning of a new profession; 2) examine the reasons why Cardiff City Mental Hospital was an early adopter of occupational therapy; and 3) consider the impact of professionalisation on occupation officers, posts held by nurses and craft teachers, including Sunderland. The founding of occupational therapy in America and the spread to mental hospitals through networks of psychiatrists in Britain is outlined first. Next, the training and career of Patricia Sunderland at two mental hospitals, Cardiff and Shenley, are presented. Finally, the reasons for the neglect of some pioneers are discussed in relation to the longstanding disinterest in the history of occupational therapy within the profession and beyond.
A new profession in America spreads to the United Kingdom
Occupational therapy was launched at the first meeting of the National Society for the Promotion of Occupational Therapy held in Clifton Springs, New York between 15 to 17 March 1917. The Society was founded by eight people from diverse backgrounds interested in moral treatment, pragmatism, habit training, mental hygiene movement, curative occupations and the arts and craft movement.[12] The founders were George Edward Barton (1871-1923) an architect, William Rush Dunton Jr (1865-1966) a psychiatrist, Eleanor Clarke Slagle (1870-1942) a social worker and occupational therapist, Thomas Bessell Kidner (1866-1932) a vocational educator, Susan Cox Johnson (1875-1932) an arts and crafts teacher, Susan E Tracy (1864-1928) a nurse, Herbert James Hall (1870-1923) a physician and Isabel Gladwin Newton Barton (1891-1975) the secretary and author.[13] Their vision was the ‘advancement of occupation as a therapeutic measure; for the study of the effect of occupation upon the human being; and for the scientific dispensation of this knowledge’.[14]
Four founders, Barton, Cox Johnson, Tracy and Hall, believed nurses were best placed to administer occupation under medical direction, as an adjunct to other treatments and after additional training, with three producing manuals for nurses, attendants and others. Tracy advocated including occupation in the nursing curriculum as she had done at the Training School for Nurses of the Adams-Nervine Asylum in Boston, Massachusetts since 1906.[15] Dunton wrote for ‘the nurse in charge of a private patient … and the Nurse in the Hospital’.[16] Barton acknowledged that the expansion of Occupational Therapy and Re-education had created a demand for information, because ‘only those individuals who are devoting their entire time and attention to teaching the sick can have an adequate idea of what is included in the subject and of the tremendous complexities involved’.[17]
In 1921, the Society was renamed the American Occupational Therapy Association. It was a professional body with the remit to create a new profession, to set standards for education, practice and maintain a register of members.[18] Occupational therapy quickly spread to other English speaking countries, including Wales. The department at Cardiff City Mental Hospital opened within a decade. This historic moment was reported in the Western Mail & South Wales News which noted that
The outstanding feature of the [25th Annual] Report is the history of the department of occupational therapy which started in April 1930. Here is applied the principle of putting patients to some useful form of craft … which encourages patient to pass from simple to more complicated tasks.[19]
Dissemination through patrons and networks of psychiatrists
Occupational therapy became accepted as a new treatment through the patronage of medical practitioners and was spread through their networks and influential organisations, particularly the professional and regulatory bodies (the Royal Medico-Psychological Association and the Boards of Control for Lunacy and Mental Deficiency).
The Resident Medical Superintendents probably instigated occupational therapy at Cardiff City Mental Hospital, and it is likely that they were persuaded through their connections with other psychiatrists. The holders of this powerful position were Edwin Goodall (1906 to 1929), Peter Knight McCowan (1929 to 1937); assisted by James Stuart Ian Skottowe, the Deputy Medical Superintendent (1927 to 1932).[20] Perhaps they were influenced by David K Henderson, who introduced occupational therapy to the United Kingdom, at Glasgow Royal Mental Hospital in 1919[21] and Adolf Meyer who wrote ‘The Philosophy of Occupational Therapy’.[22] Meyer could be the linkage between them due to his work as a clinician, theorist and researcher. In his 1922 article Meyer emphasised balancing time and activity for health:
The whole of human organisation has its shape in a kind of rhythm … night and day, of sleep and waking hours, of hunger, and its gratification … work and play and rest and sleep, which our organism must be able to balance even under difficulty. The only way to attain balance in all this is actual doing, actual practice, a program of wholesome living as a basis of wholesome feeling, and thinking and fancy and interests.[23]
Henderson trained with Meyer in New York between 1908-1911 and worked with him and Eleanor Clarke Slagle, one of the founders, in Baltimore between 1913 and 1915.[24] In 1924, Henderson organised a meeting about occupational therapy for the Scottish Division of the Medico-Psychological Association in Glasgow. Dorothea Robertson, Instructress in the Occupation Department presented one of the papers. Her appointment as a ‘Teacher of Occupational Therapy’ was announced in the British Journal of Nursing (1923).[25] Robertson is believed to be the first person to hold such a post in Britain. She outlined the principles, practicalities and positive impact of 90 minute classes, which offered a variety of crafts for 100 patients.[26]
Elizabeth Casson, another psychiatrist and lifelong proponent credits Henderson with giving her the ‘first real introduction to occupational therapy’.[27] During a holiday in America in 1926, Casson visited the Boston School of Occupational Therapy and determined to set up the English equivalent. In 1929, she established a private, residential clinic for women with mental health problems at Dorset House, Clifton, Bristol. It was here that on 1 January 1930, Casson opened the first School of Occupational Therapy. The private school awarded a Diploma on successful completion of the course. Dorset House ran as a community with staff and patients sharing a routine of rest, occupations, exercise and social activities, reminiscent of Meyer’s concept of balance for wholesome living.
Goodall and Skottowe at Cardiff City Mental Hospital were influenced by Meyer. Skottowe trained with Meyer and worked with Henderson in Glasgow and Goodall was a peer.[28] Meyer credited Goodall with inspiring him to conduct clinical neurological research.[29] Michael notes that
The ideas of Adolf Meyer fitted comfortably alongside the practices of Welsh psychiatry … [and that Goodall] expounded Meyer’s principles and philosophy [psychobiology involved focusing on the individual patient as a whole person] at the university in Cardiff.[30]
Perhaps Goodall and Skottowe laid the groundwork for McCowan who started as Resident Medical Superintendent in May 1929. The Commissioners for the Board of Control wrote that ‘occupational therapy is evidently to form a prominent feature … and that an occupations officer is to be added to the staff’ in December 1929.[31] The next month, McCowan recommended the appointment of Sister Sunderland ‘as an occupations officer’ adding that he would arrange for the ‘necessary training of the officer’. He also estimated the cost of ‘classes in arts and crafts’ as £10.00.[32] Miss Edith C King, the Matron at Cardiff between 1927 and 1946, was probably supportive in the same way as Miss Darney, the Matron at Glasgow Royal Mental Hospital.[33]
[Figure 1] Whitchurch Hospital postcard, circa 1930. Image courtesy of Whitchurch Hospital Historical Society.
Occupational therapy was promoted by the professional and statutory bodies: the Medico-Psychological Association (MPA), which became the Royal Medico-Psychological Association (RMPA) in 1926 and the Royal College of Psychiatrists in 1971; and the Boards of Control for Lunacy and Mental Deficiency, the statutory regulatory body between 1913 and 1959.[34] The RMPA organised study tours to hospitals in Europe. Eamon O’Sullivan, a psychiatrist and pioneer of occupational therapy in Ireland, refers to a visit to Dutch mental hospitals in 1928. The purpose was to learn about the Simon method where occupations were taught on each ward and in central workshops. O’Sullivan stated that ‘The patent success of occupational therapy … made an indelible impression’ adding that many on the visit ‘immediately faced the difficult task of introducing the treatment in their respective hospitals’. Cardiff City Mental Hospital was one of the tour participants.[35]
In 1933, the Board of Control issued a landmark policy which recognised occupational therapy as a medically prescribed treatment for individuals and occupational therapists as a senior staff group. The Memorandum on Occupational Therapy for Mental Patients drew on evidence from Germany, Holland, USA, England and Wales with Cardiff named. It made recommendations about the workforce. The Memorandum referred to ‘the introduction of the occupational therapists as a new grade of staff … who, working with, but independently of the matron or chief male nurse, will carry on therapeutic treatment by occupation under the doctors’.[36] ‘One occupational therapist will be required on each side of a hospital of 1,000 beds’ plus technicians and craft teachers.[37] Nurses were expected to continue occupational and recreational treatment as part of habit training because ‘it would be useless … to instruct patients in habit training for a few hours during the day, and to allow degradation full play during the remainder of the 24 hours’.[38]
Freebody concludes that the Memorandum ‘emphasised both the medicalisation and professionalisation of occupational therapy, and set it apart from the routinised, systematic application of work that had characterised patient occupation since the mid-nineteenth century’.[39] The recognition of a new profession impacts existing professions. The Memorandum suggests that occupational therapists should be distinct from the nursing hierarchy and that ward nurses continue, rather than determine habit training regimes. This view contrasts with that held by some founders in America, who recognised the role of nurses and attendants in organising work, sport, social, recreational and spiritual activities as part of nineteenth century humane approaches to mental illness. Patricia Sunderland, as a registered mental nurse and occupational therapist, spans the boundaries of these old and new perspectives on occupation.
Patricia P.J. Sunderland career and legacy
Formative years in rural Ireland
Patricia Pauline Josephine Glynn was the youngest of four daughters of Patrick and Annie Glynn, née Mulrenin.[40] She was born on 29 June 1897 in County Sligo in the north west of Ireland. Her father served in the Royal Irish Constabulary between 1879 and 1910 before retiring and becoming a farmer. Her mother was a farmer’s daughter.
In the 1910s, three Glynn daughters migrated, two to England to train as mental nurses and one to work in America, fitting the pattern of migration from Ireland during the nineteenth and early twentieth centuries.[41] On 21 May 1915, Belinda Gertrude Glynn started as a probationer nurse, 1st class, at St. Edward’s Hospital, Cheddleton, Staffordshire. Her salary was £26.00.[42] Patricia followed her eldest sister the next year, starting on 21 June on the same grade and salary.[43] Cusack (2021) describes nursing as a reputable and highly respected profession in Ireland, where relatives followed family members into nursing in an asylum.[44] The sisters may have been attracted by free training, accommodation and a rare career open to women. A nurse’s residence was built at St. Edward’s Hospital[45] in the 1910s to help recruit and retain nurses. Female nurses were in demand because of the strict gender divide in the architecture, systems, patients and workforce in Victorian built asylums.[46]
Mental nurse training and becoming a Registered Mental Nurse
The Medico-Psychological Association (MPA) instigated a national training scheme for mental nurses in 1891. The syllabus was based on the Handbook for the Instruction of Attendants on the Insane first published in 1885. The training lasted two or three years after a three month probationary period. All the lectures and assessments were done by doctors. Successful staff received the ‘Certificate of Proficiency in Nursing the Insane’ awarded by the MPA.[47]
Patricia Glynn probably studied the 6th edition of the Handbook (1911). The 390-page syllabus covered symptomatology, nursing for common bodily diseases and the mind in health and disease. There were five pages about ‘occupation and amusement’ in the chapter on ‘General care and nursing the insane’. Occupation referred to both
mental and physical … where the skilled attendant can do much toward restoration … hard physical work, such as digging or gardening or laundry work, is of the greatest use in many cases, since it does not overtax the mental capacity … and properly directed recreation is of the utmost service
giving the examples of card games, dancing, attending church services and hobbies so that the ‘idea of usefulness in the world maybe brought back, if possible.’[48]
Implementation of the nurse training scheme was variable. Much depended on the Resident Medical Superintendent of each asylum.[49] William Francis Menzies (1863-1945), the Superintendent at St. Edward’s Hospital was evidently supportive. In 1920 he was President of the MPA.[50] It was not compulsory to attend the training or the final written and practical examinations. In July 1923 there were 13,495 nursing posts in 97 mental hospitals; of the 6,081 attendants only 26% held the final MPA Certificate and 12% of the 7,414 nurses.[51]
Patricia Glynn was one of the minority of nurses to qualify and be awarded the MPA Certificate. The Register of Nurses for 1925 states she gained a Cert.M.P.A 1916-1919, from the County Mental Hospital, Cheddleton, Leek. Patricia Sunderland, née Glynn was registered as a mental nurse in London on 11 April 1924.[52] She would be on the supplementary part of the register for mental nurses. State registration is a critical part of professionalisation. It was granted five years earlier with the Nurses Regulation Acts 1919, and only much later to occupational therapists with the 1960 Professions Supplementary to Medicine Act.
Life events
The early 1920s were a turbulent time for Patricia Glynn. In November 1921 she resigned due to her forthcoming marriage and the marriage bar. This policy required women to resign when they married and operated in many sectors until after the Second World War.[53] Patricia married Archer William Sunderland, an Englishman and attendant who worked at St. Edward’s Hospital from November 1913. The Staff Changes Book 1896-1920 records that in 1915 and 1916 he was paid extra for post mortem work.[54]
Less than a year later Patricia Sunderland was a widow. Archer, a 28 year old pathological and bacteriological assistant, died in September 1922. The cause of death was ulcerative endocarditis, an infection of the inner layer of the heart. Their son, Archer William Sunderland was born in the next month in Leek, Staffordshire. When Patricia registered Archer’s birth, she gave her residence as Gurteen, the Glynn family home in Ireland.
Nursing and occupational therapy at Cardiff City Mental Hospital
Patricia Sunderland seemed to thrive at Cardiff, being promoted twice. In July 1924, she became a Nursing Sister and on 1 April 1930 she was appointed Occupations Officer for the hospital.[60] McCowan announced this new post in the 22nd Annual Report, stating that Sunderland’s ‘mental nursing experience will add immeasurably to her usefulness in her present post’.[61] The Service Register records that her salary increased to £100 plus £45 for emoluments.[62] The image shows Sister Sunderland in the centre of a group with the Matron and two Medical Officers.
[Figure 2] Sister Patricia Sunderland sitting in the centre, on the ground in front of the Matron, Miss E.C. King. Dr J.S.I Skottowe, Senior Assistant Medical Officer is sitting on Matron’s right and Dr J.S. Allen, Second Assistant Medical Officer, is on her left. Date c.1927-1929. Image courtesy of Whitchurch Hospital Historical Society.
The work of the occupational therapy department is presented in the next Annual Report alongside other treatments, including continuous baths, electrical treatment and massage, ultra violet treatment and physical drill. McCowan observed that occupational therapy
continues our most important method of keeping the autistically minded patient in touch with reality … The more crafts taught in the occupational class, the more certain are we to find all patients can be interested in one or other of them. We are fortunate in having such a highly efficient and enthusiastic worker at the head of the Department as Sister Sunderland … 150 males and 160 females have passed through the occupational classes during the year under review, and the average daily attendance is 35 males and 40 females.[63]
Just two and a half years later, Sunderland’s description of a hospital wide, occupational therapy service was published in the Nursing Times.[64] She starts by asserting that ‘Cardiff Mental Hospital possesses what is regarded as a most progressive occupational therapy department’. Sunderland explains the facilities and presents the principles of using occupation as therapy, highlighting the therapeutic relationship, a facilitative environment and a variety of occupations through which patients ‘are brought back into touch with reality, their destructive tendencies are directed into useful channels, and they themselves are made happier’.
Sunderland outlines the facilities for in and out patients and refers to ‘a male occupational therapist and his assistants’ as staff members. This is probably J.C. McCammon, an attendant named in the 24th Annual Report as being in charge of occupational therapy on the male side.[65] The facilities included:
- Large occupational classrooms attended by 50-60 male and female patients between 08.30 and noon. These were ‘pleasantly situated with a southern exposure … artistically decorated … with a glass show cupboard’ to display work because the surroundings are ‘an important means of stimulating the patients’ interests and their enjoyment’.
- Classes were held in the one of the wards in the afternoon for patients with ‘degraded or disturbing behaviour’.
- Patients in bed were given ‘suitable work by the therapist’ and supervised by ward nurses.
- Out-patients from the Psychiatric Clinic at the Cardiff Royal Infirmary and discharged patients attend and volunteer in the classrooms because ‘these people are lonely … [and] regard our classroom as a social club’.
Sunderland’s account is sophisticated, sensitive and full of insights which reflect the principles of occupational therapy adopted by the National Society for the Promotion of Occupational Therapy in 1918.[66] She describes how treatment should be carefully selected and specifically directed to the individual needs, saying ‘patients must be approached carefully, and the kind of work found that will interest them’. She used a variety of novel and useful occupations; encouraged group work with patients taking part together; and through her participation observed that ‘patients are always stimulated when the therapist herself joins in the work’. A notable difference was that Sunderland deployed voluntary workers. She commended two ladies in particular for their consideration of patient needs. They had ‘recovered from mental breakdowns. They seem to understand how sensitive patients can be, and how trifling things can disturb them or hurt their feelings in a way many people quite fail to appreciate’.
Interestingly, Sunderland refers to occupational therapy in America and in general hospitals with cardiac and tuberculosis patients, indicating an understanding of different aspects of an emergent profession. In May 1917 the British Journal of Nursing announced a special issue on ‘The Modern Hospital (Chicago and St Louis)’ about ‘Occupational Therapy and Occupations for the Handicapped’. The recent interest was attributed to recognising the ‘therapeutic and economic necessity of providing suitable occupations for their wounded’.[67] Similar points are made in the Nursing Times in January 1918. The National Society for the Promotion of Occupational Therapy was mentioned, asking if there should be an equivalent society in Britain.[68] Thurstan outlined training courses and travelling scholarships for American nurses, wondering whether ‘in the near future some of the hospitals in England will follow this lead.’ [69] The Editor appends a paragraph commending Thurstan’s article to Matrons, private nurses and others because ‘occupational therapy is a subject which has not yet received sufficient attention in this country’.[70]
Just five years later, Sunderland’s account of occupational therapy at Cardiff was published, showcasing her expertise and applying the principles of practice recommended by the founders. A possible consequence was that Sunderland was ‘headhunted’ by Shenley Mental Hospital, a large, new hospital in England as she resigned to become the Occupational Therapy Officer there. Her last day at Cardiff was 24 March 1934.[71] Importantly, Sunderland’s Certificate of Service confirmed her status as an occupational therapist.[72]
Leading occupational therapy at Shenley Hospital
Sunderland established occupational therapy at Middlesex County Mental Hospital at Shenley, developing the service from 1934 until 1949. She may have been attracted by the opportunity to work in a place where ‘a feature is to be made of occupational therapy’.[73] Shenley was designed to accommodate 500 staff and 2,000 patients living in small groups in villas. There were extensive occupation, recreation, sporting and social facilities for patients and staff. Sunderland was probably in post on 31 May 1934 when the hospital was officially opened by King George V and Queen Mary.[74]
In the first Annual Report Miss P. Sunderland, Occupational Therapy Officer is listed as one of twenty Officers of the Hospital, alongside the Resident Medical Superintendent Dr G. W. Shore and the Matron, Miss Bessie Tweddle.[75] She would be appointed by Shore, who led Shenley from 1933 until his death in 1940.[76]
Although the Shenley archives do not hold staff records for this period, Sunderland is named, and occupational therapy is recorded in committee minutes and the annual reports. The first report of the Commissioners for the Board of Control praises the initial arrangements, noting that
occupational therapy is being developed in real ernest [by] Occupation Officer, Miss Sunderland, who was appointed from Cardiff … by way of a start [occupational therapy] … has been centralised in a ward on each side; [where Sunderland supervised trained male and female nurses] and further taught on alternate days, three days of men’s side and three days of the women’s side.[77]
From these small beginnings, Sunderland set up a hospital wide service that developed and innovated through wartime and peace. The service mirrored the one at Cardiff with a wide choice of crafts offered in occupation centres, on the wards and for bed bound patients. During 1939-1945 Shenley operated as a mental hospital and an emergency hospital for the military. It was affected by war damage, overcrowding, a shortfall of experienced nurses and the shortage of raw materials limited occupational therapy. Otho Fitzgerald, the Acting Medical Superintendent, acknowledged the help of two County Councillors who facilitated the ‘generous supply of Red Cross wool which has given the occupation of knitting to many ladies … [and] the necessary supplies for the wood-work department’.[78] In 1947, the Commissioners commended a new Patient Social Club, co-managed by staff and patients, for male and female patients where Sunderland, ‘the chief occupational therapist assists in the organisation of group activities’.[79]
In the post-war years Diploma qualified occupational therapists were employed at Shenley for the first time. Fitzgerald, now the Resident Medical Superintendent, anticipated this development in February 1946.[80] The establishment grew from one, Miss Sunderland, to five in 1947 and ten in 1948-49.[81] The Commissioners highlighted a ‘special feature is a daily class of 10 patients who have undergone leucotomy with a view to assessing the results of that operation on occupational performance’.[82]
Sometime in 1949 Sunderland left Shenley, perhaps retiring and returning to Ireland to be with her aging parents and son. Archer Sunderland studied medicine and became a Fellow of the Royal College of Surgeons Ireland in 1960.[83] He worked as a surgeon in County Donegal and later in County Cork. Patricia Sunderland’s departure was confirmed in a 1950 conference report which named Constance Henson as the Head Occupational Therapist at Shenley. Henson was speaking about interdepartmental relationships between the rehabilitation team alongside Fitzgerald.[84] In response to a question, Fitzgerald identified the occupational therapist as the rehabilitation officer.[85] Perhaps he was reflecting on fifteen years of working with Sunderland as he was echoing her belief that occupational therapy was about exploring future possibilities to help restore patients’ ‘harmony with the world’.[86]
Sunderland’s legacy
Sunderland died in Ballyshannon, County Donegal on 9 July 1967. The notice in the local newspaper simply states that she ‘had been in the hospital service in England until her retirement some years ago’.[87] The Irish Times wrote ‘English papers please copy’[88] signifying that this news would be of interest to readers in England.
The pioneering work of Sunderland at Cardiff, which she continued at Shenley, is preserved in the Nursing Times. Her article is significant because it reels back the timeline for occupational therapy in Wales and beyond. Sunderland started in April 1930, a few months after Casson opened the Dorset House School and two years before the Scottish Association was formed. The next issue of the Nursing Times reports the work of ‘the first occupational therapy officer in England’, Colonel de Salis at Barming Heath in Kent, an acute mental hospital for nine years. It concludes ‘this is a new, young profession that seems, in our opinion, to offer scope to mental nurses of good education’.[89] It proved so for Sunderland. Our research has revealed her distinguished career as an author and the inaugural head of occupational therapy at two, large public mental hospitals.
Sunderland was one of the first occupational therapists in the United Kingdom to write about occupational therapy. Her paper is listed in the Cardiff Hospital Annual Reports alongside predominantly biomedical studies published in 1932.[90] Books, chapters and leaflets tended to be written by the founders (Dunton 1919, Kidner 1930)[91] or medical patrons (Eager 1936,[92] Henderson & Gillespie 1927,[93] Russell 1938).[94] An exception is the book Theory of Occupational Therapy by Haworth and Macdonald, a British physician and occupational therapist. It was written for students and nurses and was positively reviewed in the British Nursing Journal.[95]
Figure 3 List of research publications showing Sunderland’s Nursing Times article.
The legacy of Sunderland is sustained at, and goes beyond, Cardiff and Shenley through training mental nurses. A review of Cardiff Hospital in 1934 described occupational therapy as a ‘well-established development … [where] every nurse is drafted into classes for experience before she leaves, a useful preparation for private nursing afterwards’.[96] The 28th Annual Report records that mental hospitals in Newcastle upon Tyne and West Ham sent one or more nurses for a six month course at Cardiff, to fit them to organise an occupational therapy department on return to their hospital.[97] Denbigh in Wales and Grangegorman and Ballinasloe in Ireland did so too.[98] At Shenley, Sunderland continued training nurses and in 1948 started training occupational therapy students from the London School.[99]
Sunderland’s achievements are more notable because she spanned the boundaries between a well established and emergent profession. Russell, a psychiatrist, highlighted some tensions between nursing and occupational therapy, asking
Would occupational therapists desire to be trained in mental nursing? Would the future of the profession be better … [if] occupation therapy is a special subject outside the sphere of mental nursing, or that actually it is mental nursing? He advocated the latter view as an ideal.[100]
The answer was no from the Associations and some patrons. The professional body asserted the differences between nursing and occupational therapy by developing the Diploma syllabus, approving training Schools and setting national examinations for occupational therapy applied to physical and psychological conditions.[101] Henderson encouraged the establishment of the Scottish Association.[102] Casson forthrightly expressed her opinion when talking about occupational therapy for paying mental patients. She is reported to have said that the
therapist must be a specialist carrying out the doctor’s prescription … work is far too specialised to be successful if carried out by half-trained people … Dr Casson thinks it is better for everybody if the nurses confine themselves strictly to the work of nursing.[103]
Sunderland was one of many mental nurses, craft teachers or occupation officers who played pivotal roles in the early days of occupational therapy, yet their contribution has been forgotten.
Why are some pioneers forgotten?
Occupation officers have received scant attention, unlike the founders and patrons whose records are preserved in archives and publications. Some laid foundations in practice and education, as Sunderland did, whilst others supported professionalisation, most notably in Scotland. The majority of the founder members of the Scottish Association were occupation instructors or teachers, including the first President, Margaret Menzies.[104]
A possible reason for the neglect is the tensions about ‘professional territory, identity and role boundaries’ between ‘pre-professional occupational therapy workers’ and Diploma qualified therapists. Dunne et al report that newly qualified staff in Ireland sought to establish their status by ‘using scientific reasoning and purposeful therapy, as opposed to [what they perceived as] undirected diversional activities’.[105]
The distinction between pre-professional workers and qualified therapists supports the narrative that occupational therapy only started properly with the employment of Diplomates, an approach which ignores both the long history of using occupation and the contribution of others, such as Sunderland and O’Sullivan. He founded and oversaw an occupational therapy department staffed by nurses at Killarney Mental Hospital for almost thirty years. O’Sullivan also wrote one of the first European textbooks about occupational therapy for mental patients. His significance was unknown, until re-discovered in a search for occupational therapy in Irish newspapers.[106]
Another reason why some pioneers are forgotten is the general disinterest in the history of occupational therapy, which Bing called ‘the most neglected aspect of our professional endeavours’ (1981).[107] Wilcock (2001) suggested this was because of the ‘obscure place’ of occupation within medicine; the newness and small size of professional associations; limited interest in the topic from occupational therapists and historians; and writers who tend to write about the extraordinary rather than ordinary, everyday activities.[108] In 2020 there were historical accounts about 31 of the 96 Member Organisations of the World Federation of Occupational Therapists.[109] As far as we know this is the first account about Wales.
The process of professionalisation, with associations striving for legitimacy and exercising control, is also important. The Association for England, Wales and Northern Ireland started with a broad membership criteria, accepting both practical experience or the Diploma until 1939,
so that the first members might be either those who had qualified at recognised Schools and who had held whole-time appointments as Occupational Therapists for not less than a year, or those who had a minimum of four years’ practical experience in Occupational Therapy.[110]
This was a pragmatic strategy as the Association had not yet agreed a national syllabus and system for approving training schools. The qualification was a Diploma – single for physical or psychological conditions or dual for both aspects, awarded on satisfactory completion of three year training and national examinations. Nellie Clayton and J.C. McCammon, Sunderland’s former colleagues, were accepted as full members in 1938 because of their practical experience at Cardiff.[111]
Surprisingly, Sunderland did not pursue this time limited opportunity for recognition by the professional body, although she stopped her registration with the General Nursing Council after 1940. She probably regretted this decision, when in 1947 her application for full membership of the Association was rejected, especially as this coincided with the appointment of Diploma qualified occupational therapists at Shenley. Sunderland’s status was undisputed at Cardiff and Shenley, being recognised in her status, salary and responsibility for the whole hospital. In 1938 she received £262.10 shillings, including emoluments, almost double her salary at Cardiff.[112] Fitzgerald, the Medical Superintendent corresponded with the Secretary of the Association, negotiating on Sunderland’s behalf.[113] The Association relented, acknowledging that Sunderland was ‘qualified by experience’.[114] Fitzgerald, who was Irish like Sunderland, was renowned for supporting the training of nurses and occupational therapists.[115]
This study of Sunderland points to opportunities for further research. For example, searches of nursing and medical literature may uncover more surprises like Sunderland and O’Sullivan. The broader, socio-political contexts, particularly Sunderland’s background as a migrant from rural Ireland is another direction for future research. Her circumstances are in stark contrast to those envisaged by the founders who adopted ‘an exclusionary recruitment policy that favoured upper class, highly educated, professionally experienced (white) women’.[116]
Conclusion
In 1930, Cardiff City Mental Hospital and Patricia Sunderland were at the forefront of introducing occupational therapy to the United Kingdom. Their contributions to developing services predate milestones in the professionalisation process, most notably recognition by the statutory body in 1933 and the establishment of Associations in 1932 and 1936.
A biographical approach and document analysis confirm Sunderland was a pioneer. Her single article is a serial first: written by an Irish occupational therapist, about Wales and about occupational therapy. As an author, Sunderland asserted her dual identity as a registered mental nurse and occupational therapist. Professionally, she personified the vision of some of the founders by extending or enhancing the role of nurses; and as a widow, she negotiated the marriage bar and succeeded in a second career.
Patricia Sunderland led occupational therapy at Cardiff and Shenley, two large public mental hospitals from 1930 to 1949. She was appointed by, and had the undoubted support of the Resident Medical Superintendents. Finally, in 1947 Sunderland was accepted by the professional body as an occupational therapist qualified by experience. This research reveals the significance of Wales, particularly Cardiff and Patricia Sunderland for the first time. Her story expands understandings of pioneer places and people during the formative years of a new profession.
Acknowledgements
The authors would like to thank Ian Beech, Cardiff and Vale University Health Board, Cathays Heritage Library Cardiff, Glamorgan Archives, Colin David Ilott, London Metropolitan Archives, Peer Reviewers, Royal College of Nursing Library and Heritage Centre, Royal College of Psychiatrists, Royal College of Surgeons in Ireland Heritage Collections, Staffordshire Record Office and Whitchurch Hospital Historical Society.
End notes
[1] Patricia Sunderland, ‘Occupational Therapy’, Nursing Times 22 October 1932, 1080-81.
[2] Judith Pettigrew, Katie Robinson, Bríd Dunne and Jennifer O’ Mahoney, ‘Major trends in the use of occupation as therapy in Ireland 1863-1963’, Irish Journal of Occupational Therapy 45/1 (2017), 4-14.
[3] George Barton, Teaching the Sick. A Manual of Occupational Therapy and Re-education (Philadelphia and London: W.B. Saunders Company, 1919), 17.
[4] Lori Andersen and Kathlyn Reed (eds), The History of Occupational Therapy: the first century (Thorofare, SLACK Incorporated, 2017), 15-49.
[5] Judith Friedland, Isobel Robinson and Thelma Cardwell, ‘In the Beginning. CAOT from 1926-1939’, Occupational Therapy Now 3/1 (2000), 15-9.
[6] Catherine Paterson, ‘The Development of Occupational Therapy in Scotland 1900-1960’ (Unpublished PhD thesis, University of Aberdeen, 2002).
[7] Evelyn Macdonald, ‘The History of the Association of Occupational Therapists’, Occupational Therapy 20/3 (1957), 13-6.
[8] Ann Wilcock, Occupation of Health. Volume 2. A Journey from Prescription to Self Health. A history of occupational therapy in the United Kingdom during the twentieth century and source book of archival material (London: British College of Occupational Therapists, 2001); Jane Freebody, Work and Occupation in French and English Mental Hospitals, c.1918-1939 (Cham: Palgrave Macmillan, 2023).
[9] Wilcock, Occupation of Health. Volume 1.
[10] William Dunton, Occupational Therapy A Manual for Nurses (Philadelphia and London: W.B. Saunders Company, 1915), 11-20; Eamon N. M. O’Sullivan, Textbook of Occupational Therapy with Chief Reference to Psychological Medicine (London: H.K. Lewis & Co. Ltd. 1955), 1-18.
[11] John Hall, ‘From Work and Occupation to Occupational Therapy: the policies of professionalization in English mental hospitals from 1919 to 1959’ in Work, Psychiatry and Society, C.1750-2015, ed. by Waltraud Ernst (Manchester: Manchester University Press, 2016), 314.
[12] Andersen and Reed, History of Occupational Therapy, 15-49.
[13] Brief biographies of the eight founders available at: http://www.otcentennial.org/100-influential-people [Accessed 26 September 2023].
[14] Andersen and Reed, History of Occupational Therapy, 46.
[15] Susan Tracy, Studies in Invalid Occupation. A Manual for Nurses and Attendants (Boston: Whitcomb & Barrows, 1910), 16.
[16] Dunton, ‘Occupational Therapy, 7.
[17] Barton, Teaching the Sick, 5.
[18] Andersen and Reed, History of Occupational Therapy, 89-123.
[19] Anonymous, ‘Mental Hospital’s Record. Highest Rate of Recoveries’, Western Mail & South Wales News, 12 July 1933, 10.
[20] Ian Beech, ‘Minding the Medicine and Medicalising the Mind: investigating the cultural and social history of Cardiff City Mental Hospital 1908-1930’ (Unpublished PhD thesis, University of Glamorgan, 2011).
[21] David Henderson, ‘Occupational Therapy. A Series of Papers read at a Meeting of the Scottish Division held at the Glasgow Royal Mental Hospital on Friday, May 2, 1924’ Journal of Mental Science, 71/292 (1925), 65.
[22] Adolf Meyer, ‘The Philosophy of Occupational Therapy’, Archives of Occupational Therapy 1/1 (1922), 1-10.
[23] Ibid. 6.
[24] Paterson, ‘Occupational Therapy in Scotland’, 92.
[25] Anonymous, ‘New Appointments at Glasgow Royal Mental Hospital, Teacher of Occupational Therapy’, British Journal of Nursing, 21 April 1923, 253.
[26] Henderson, ‘Occupational Therapy’, 75-80.
[27] Elizabeth Casson, ‘The story of Dorset House School of Occupational Therapy 1930-1986. Part 1 1930-1945 Forward written by Dr Casson in 1950’, 2. Available at: https://radar.brookes.ac.uk/radar/items/0e1a57fb-0d56-4596-8732-7b1684cf1425/1/ [Accessed 25 August 2023].
[28] Anonymous, ‘Obituary, J.S.I.Skottowe’, British Medical Journal, 288 (1984), 866.
[29] Pamela Michael, ‘Welsh Psychiatry during the Interwar Years, and the impact of American and German Inspirations and Resources’ in International Relations in Psychiatry. Britain, Germany and the United States to World War 11, ed. by Volker Roelcke, Paul Weindling and Louise Westwood (Rochester: University of Rochester Press, 2010), 215.
[30] Ibid. 202.
[31] Council Minute Books, Report of Commissioners of the Board of Control from 16 December 1929, Cathays Heritage Library, Cardiff.
[32] Council Minute Books, 30 January 1930, 1470 Appointment Occupations Officer Cathays Heritage Library, Cardiff.
[33] Henderson, ‘Occupational Therapy’, 65.
[34] Hall, ‘From Work and Occupation’.
[35] O’Sullivan, Textbook of Occupational Therapy, 13-14.
[36] Board of Control, Memorandum on Occupational Therapy for Mental Patients (London: HMSO,1933), 15. Available at: https://radar.brookes.ac.uk/radar/items/6193364f-4c6d-41df-8d0c-75a0696e72a5/1/DH-5-2-1.pdf [Accessed 25 August 2023].
[37] Ibid. 23.
[38] Ibid. 17.
[39] Freebody, Work and Occupation, 147.
[40] There is sparse information available for Patricia Glynn’s three sisters: Belinda Gertrude Glynn (1889-1976) married Albert Edward Hurst in 1922 and the couple had two daughters; Belinda worked as a mental nurse at Cheshire County Mental Hospital, Macclesfield, in 1939. Eliza Glynn (1891-) cannot be traced. Annie Kathleen Glynn (1894-) sailed to Ellis Island, New York in 1912.
[41] Paul O’Leary, ‘Immigration and Integration: a study of the Irish in Wales, 1789-1922’ (Unpublished PhD thesis, University of Wales, 1989).
[42] St Edward’s Asylum Cheddleton Staff Changes Book 1896-1920, Glynn Belinda Gertrude, 186. Staffordshire Record Office D7841/3/1.
[43] St Edward’s Asylum Cheddleton Staff Changes Book 1896-1920, Glynn Patricia Pauline Josephine, 200. Staffordshire Record Office D7841/3/1.
[44] Eithne Cusack, ‘A Narrative History of Psychiatric / Mental Health Nursing in the Asylum / Mental Hospital System in Ireland from 1940 to 1970’ (Unpublished EdD thesis, Dublin City University, 2021), 148.
[45] Lucy Smith, Inside the Asylum: a short history of St. Edward’s Hospital, Cheddleton. Staffordshire Archives and Heritage, (2021). Available at: https://shcvolunteers.wordpress.com/2021/12/07/inside-the-asylum-a-short-history-of-st-edwards-hospital-cheddleton/ [Accessed 15 August 2023].
[46] Claire Chatterton, ‘An Unsuitable Job for a Woman? Gender and mental health nursing’, Bulletin of the UK Association for the History of Nursing 2 (2013), 44–9.
[47] Claire Chatterton, ‘Training Mental Health Nurses in the United Kingdom– a Historical Overview. Part One: pre 1948’, Bulletin of the UK Association for the History of Nursing 3 (2014), 22-32.
[48] Royal Medico-Psychological Association, Handbook for Attendants on the Insane 6th Edition (London: Baillière, Tindall and Cox, 1911), 335-40. Available at: https://wellcomecollection.org/works/j9t3ac7n [Accessed 15 August 2023].
[49] Chatterton, ‘Training mental health nurses’, 25.
[50] Royal College of Psychiatrists, Presidents of the Medico-Psychological Association 1909–1971. Available at: https://www.rcpsych.ac.uk/about-us/exploring-our-history/ [Accessed 15 August 2023].
[51] Michael Arton, ‘The Professionalisation of Mental Nursing in Great Britain, 1850-1950’ (Unpublished PhD thesis, University College London, 1998), 148.
[52] Ancestry.com. UK & Ireland Nursing Registers,1898-1968. Available at: https://www.ancestry.co.uk/ [Accessed 14 August 2023].
[53] Royal College of Nursing, ‘Exhibition, Who Cares? A History of emotions in nursing. Motherly hearts’ Available at: https://www.rcn.org.uk/library-exhibitions/Who-cares-emotions-in-nursing [Accessed 14 August 2023].
[54] St Edward’s Asylum Cheddleton Staff Changes Book 1896-1920, Sunderland Archer William, 200. Staffordshire Record Office D7841/3/1.
[55] Cardiff City Mental Hospital Service Register 1923-1938, Patricia Pauline Sunderland 1224. Glamorgan Archives DHWH/11/3.
[56] Royal Irish Constabulary Force Funds – Widows’ And Orphans’ Gratuities, Glynn Patrick Service, Number 44876, Royal Irish Constabulary Service Records 1816-1922 HO 184/221. Available at: https://www.findmypast.co.uk [Accessed 14 August 2023].
[57] Cardiff City Mental Hospital, Staff Service Register No. 401-800. 1911-1922, Belinda Gertrude Glynn, No. 759. Glamorgan Archive Whitchurch Hospital, DHWH/11/2.
[58] Smith, ‘Inside the Asylum’; Beech, ‘Minding the Medicine’.
[59] O’Leary, ‘Immigration and Integration’.
[60] Cardiff City Mental Hospital Female Staff Register 1908-1932. Patricia Pauline Sunderland, 52. Glamorgan Archive Whitchurch Hospital, DHWH/11/6.
[61] City of Cardiff The Mental Hospital Twenty-Second Annual Report for the Year 1929, Cathays Heritage Library, Cardiff, 38.
[62] Service Register 1923-1938, Patricia Pauline Sunderland. Glamorgan Archives.
[63] City of Cardiff The Mental Hospital Twenty-Third Annual Report for the Year 1930, Cathays Heritage Library, Cardiff, 23-4.
[64] Sunderland, ‘Occupational Therapy’, 1080-1.
[65] City of Cardiff The Mental Hospital Twenty-Fourth Annual Report for the Year 1931, Whitchurch Hospital Historical Society 15.
[66] Andersen and Reed, History of Occupational Therapy, 92-4.
[67] Anonymous, ‘The Modern Hospital (Chicago and St Louis)’, The British Journal of Nursing, 26 May 1917, 369.
[68] Nursing Notes, ‘Occupational Therapy’, The Nursing Times, 12 January 1918, 34.
[69] Violetta Thurstan, ‘Art and Medicine’, The British Journal of Nursing (1927), 272.
[70] Ethel Fenwick, [Untitled paragraph], The British Journal of Nursing (1927), 272.
[71] Female Staff Register, Patricia Pauline Sunderland, 52.
[72] Cardiff City Mental Hospital, Whitchurch near Cardiff, Certificate of Service, Patricia Pauline Sunderland No. 43 dated 22 February 1934. Glamorgan Archive Whitchurch Hospital, DHWH/11/7.
[73] Anonymous, ‘England and Wales, ‘New Middlesex County Mental Hospital’ British Medical Journal1/3814 (1934), 257.
[74] Anonymous, ‘Shenley Mental Hospital. Opening by the King’ British Medical Journal 1/3831 (1934), 1043.
[75] First Annual Report relating to the Middlesex County Mental Hospital at Shenley 1934-35, 39, London Metropolitan Archives, H49/A/09/001.
[76] Anonymous, ‘Obituary, William George Shaw’, British Medical Journal, 1/ 4142 (1940), 874.
[77] First Annual Report 1934-35, 51, London Metropolitan Archives H49/A/09/001.
[78] Standing Sub Committee 1944-1946, Shenley Hospital Acting Medical Superintendent’s Annual Report for the Year 1944, 123, London Metropolitan Archives, H49 A 04 011.
[79] Commissioners Report Book 1934-1959, 5th December 1947, London Metropolitan Archives, H49 A 10 001.
[80] Standing Sub Committee 1944-1946, Shenley Hospital Acting Medical Superintendent’s Annual Report for the Year 1945, 5, London Metropolitan Archives, H49 A 04 011.
[81] Commissioners Report Book 5th December 1947, and Commissioners Report Book 11th November 1948, both H49 A 10 001.
[82] Commissioners Report Book 5th December 1947, H49 A 10 001.
[83] Sarah Timmins, ‘RCSI Registry of Candidates Admitted to Fellowship (1960): 19 February ’60 Archer William Patrick Sunderland’ Royal College of Surgeons Ireland: Personal Communication, 26 May 2023.
[84] Anonymous, ‘Interdepartmental Relationships Between the Rehabilitation Team’ Occupational Therapy 13/3 (1950), 14-28.
[85] Ibid. 26.
[86] Sunderland, ‘Occupational Therapy’, 1080.
[87] Anonymous, ‘Late Mrs P. Sunderland’, Roscommon Herald, 21 July 1967, 16.
[88] Anonymous, ‘Death Notice’, Irish Times, 11 July 1967, 18.
[89] Anonymous, ‘Occupational therapy’ The Nursing Times, 26 November (1932), 1209-10.
[90] Cardiff City Mental Hospital, ‘Thirty-ninth annual report for the year 1946’ 25. Available at https://wellcomecollection.org/works/casbxpm2 [Accessed 18 August 2023]
[91] Judith Friedland, ‘Thomas Bessell Kidner and the Development of Occupational Therapy in the United Kingdom: establishing the links’, British Journal of Occupational Therapy 70/7 (2007), 292-300.
[92] Wilcock, Occupation of Health. Volume 2, 150-3.
[93] Paterson, ‘Occupational Therapy in Scotland’, 115.
[94] Wilcock, Occupation of Health. Volume 2, 153-156.
[95] Anonymous, ‘Book review Theory of Occupational Therapy’, The British Journal of Nursing, (1940), 211-2.
[96] H.M.B-F, ‘Cardiff City Mental Hospital’, The Nursing Times 24 February 1934, 173.
[97] City of Cardiff The Mental Hospital Twenty-Eighth Annual Report for the Year 1935, Whitchurch Hospital Historical Society 13.
[98] Wilcock, Occupation of Health. Volume 2, 172; Rebecca Cahill and Judith Pettigrew, ‘Development of Occupational Therapy in Grangegorman Hospital, Dublin: 1934-1954’, Irish Journal of Occupational Therapy 48/1 (2020), 69-87.
[99] Second Annual Report relating to the Middlesex County Mental Hospital at Shenley 1935-36, 52, London Metropolitan Archives, H49/A/09/002; Standing Sub Committee Feb 1948-June 1948, 14 February 1946, 15, London Metropolitan Archives, H49 A 04 013.
[100] J. Ivison Russell, ‘Occupational Therapy & Mental Nursing’, Occupational Therapy 1/1 (1938), 17.
[101] Evelyn Macdonald, ‘The History of the Association of Occupational Therapists Chapter 11 1936-1939’,Occupational Therapy 20/4 (1957), 14-6.
[102] Paterson, ‘Occupational Therapy in Scotland’, 108.
[103] Anonymous, ‘Occupational Therapy for Paying Mental Patients’, British Medical Journal 2/3695 (1931), 813.
[104] Paterson, ‘Occupational Therapy in Scotland’, 111.
[105] Bríd Dunne, Judith Pettigrew and Katie Robinson, ‘An oral history of occupational therapy education in the Republic of Ireland’, British Journal of Occupational Therapy 81/12 (2018), 718.
[106] Judith Pettigrew and Katie Robinson, ‘Dr Eamon O’Sullivan: psychiatrist and forgotten pioneer of occupational therapy’, Irish Journal of Psychological Medicine 14 July 2022, 1-7.
[107] Robert Bing, ‘Occupational therapy revisited: a paraphrastic history’, America Journal of Occupational Therapy 35/8 (1981), 514.
[108] Wilcock, Occupation of Health. Volume 1, 2-4.
[109] Irene Ilott and Judi Edmans, ‘Opinion piece: history matters – evidence and proposals for action’, World Federation of Occupational Therapists Bulletin 77/1 (2020), 49-57.
[110] Macdonald, ‘History of the Association 1936-1939’, 14.
[111] Anonymous, ‘Members of the Association’, Occupational Therapy, 1/1 (1938), 29-32.
[112] Standing Sub Committee 19 November 1938, 101, London Metropolitan Archives, H49 A 04 007.
[113] Standing Sub Committee 1946-1948, Medical Superintendent’s Report 19 October 1946, 77, London Metropolitan Archives, H49 A 04 013.
[114] Ibid. 10 May 1947, 215.
[115] Benedicta FitzGerald, ‘Otho William Strangman Fitzgerald’ British Medical Journal 321/7261 (2000), 640.
[116] Wendy Colman, ‘Recruitment Standards and Practices in Occupational Therapy’, American Journal of Occupational Therapy 44/8 (1990), 746.
