The Use of Crafts in Occupational Therapy for the Physically Disabled

(crafts, history, physical disabilities)

Julie Crites Bissell

Zoe Mailloux

In this article, the historical use of crafts in occupational therapy for the physically disabled patient is reviewed and the results of a survey aimed at describing current craft use is presented. A questionnaire was sent to a random sample of 250 occupational therapists throughout the United States who chose physical disabilities as their specialty section. Results demonstrated that, while most therapists use crafts to some degree in their therapy programs, other treatment modalities such as therapeutic exercise and activities of daily living were used a greater percentage of the time. Reasons for using crafts, problems with Justification of craft use, and participation of certified occupational therapy assistants in craft programs are discussed. Questions are raised concerning the role of therapeutic crafts in the past and present practice of occupational therapy for the physically disabled. Recommendations are made for future research.

he use of crafts has been a central concept in occupational therapy since the founding of the profession. In the first professional journal of occupational therapy, Adolf Meyer stated, "Groups with raffia and basketwork or with various kinds of handwork and weaving and bookbinding and metal and leatherwork took the place of wall flowers and mischief makers. A

pleasure in achievement, a real pleasure in the use of activity of one's hands and muscles and a happy appreciation of time began to be used as incentives in the management of our patients .... " (I) The purpose of this article is to ex plore the roles craf ts ha ve pia yed both in the history of the profession and in practice today.

Review of the Literature

Julie Crites Bissell, M.A., OTR, is a therapist in private practice at the Perceptual Motor Center, Orange, California, and a staff therapist With the Anaheim City School District, Anaheim, Callfornia. Zoe Mailloux, M.A., OTR, is a research assistant to A . Jean Ayres, Ph.D., OTR, Torrance, Callforma; an instructor of occupational therapy at the University of Southern California, Los Angeles, California; and a staff therapist at Torrance Memorial Hospital, Torrance, California. 1900-1920. Occupational therapy during the early 20th century grew from a philosophy known as moral treatment. The basis of moral treatment was "respect for human individuality and a fundamental perception of the individual's need to engage in creative activity in relation of his fellow man." (2, p 223) Occupational therapy services first began in hospitals.for the mentally ill. It was not until World War! that its philosophy was extended to the physically disabled. A group of women known as Reconstruction Aides developed successful craft programs for war veterans and sub369

The American Journal of Occupational Therapy

sequently were involved in pOStwar reha bil i ta tion programs. According to Woodside, "the concept of occupational therapy's role in rehabilitation was one of using crafts to reactivate the minds and motivations of the mentally ill and the limbs of the veterans starting them on their way to vocational training." (3, p 227) 1920-1930. During the 1920s occupational therapists actively sought to esta blish their field as a profession that provided a unique service. They organized occupational therapy educational programs with a major emphasis on the therapeutic use of crafts (4). The articles in The Archives of Occupational Therapy and Rehabilitation continued to stress craft activities as a fundamental treatment modality. The use of crafts was discussed in terms of physical factors such as strength, coordination, and endurance, as well as psychological and social aspects such as problem solving, decision making, self-esteem development and group socialization. Journal articles about occupational therapy for the physically disabled included in-depth analyses of craft activities that reviewed the physical and cognitive processes involved in completing the craft, the equipment required, the patient population for whom the craft might be suitable, and the cost and usefulness of the craft (5-11). In discussing the use of crafts in occupational therapy, Thomas Kidner wrote, " ... the patient finds a real interest in productive work that was entirely lacking in mechanical exercises ... the patient feels a psychic urge to exercise when he is producing some useful object." (12, P 8) 1930-1940. The economic depression in the U ni ted 5 ta tes (19291941) had a substantial impact on the occupational therapy profession.

During this period of budget cuts and limited staff, occupational therapists looked to the American Medical Association for assistance and became a medical ancillary (13). Although journal articles in this period continued to stress the use of crafts in treatment, the focus was on improving strength, coordination, range of motion and other physical factors, with little emphasis on psychological and social aspects of treatment. For example, a series of articles provided an extensive review of the use of various activities for orthopedic disabilities (14-17). While providing a thorough analysis of the physical processes involved in the activities, the introduction to these articles incl uded a pologies for the fact that "limited time prevents our discussing the psychological aspect of orthopedic treatment." (14, P 34) 1940-1960. The advent of World War II brought an end to the depression and a new demand for occupational therapy services. With more people surviving disabling conditions, largely because of new drugs and surgical techniques, the rehabilitation movement grew and occupational therapy became aligned with it. According to Mosey, however, "Occupational therapists were uncomfortable with their operating principle that it was good for disabled people to keep active and busy doing the things they enjoyed. Rather, the occupational therapists borrowed techniques from other disciplines." (18, p 235) This trend is supported, in part, by the publication of articles concerning the treatment of physical disabilities that focused on exercise techniques more traditionally associated wi th physical therapy (1925). In addi tion, .. ed uca tional standards were revised with a shift away from arts and crafts to basic

sciences." (18, P 235) In this process, occupational therapy became more narrowly defined and specialized. According to Diasio, "therapists often dealt with only part of a patient's needs, part of his body, but not all of his needs as human being." (26, p 238) 1960-Present. The 1960s was a decade of change in which therapists questioned their role and the need for reorganization within the profession (26). Within the area of physical disabilities, therapists became more proficient in the use of various treatment techniques. However, they also seemed to show more concern for the psychological and social aspects of treatment, and many articles stressed the need for quality health care services. This trend continued into the 1970s (27, 28). It is difficult to ascertain the role crafts played in occupational therapy during this period because their use was not often discussed in the literature. However, a recent survey of physical disability settings found tha t crafts were used 10 percent of the time or less by therapists in those clinics questioned, while modalities such as exercise, hot packs and paraffin were more commonly used in treatment (29). This review of the historical literature suggests that crafts have played varying roles in the growth of the occupational therapy profession. In order to obtain a better understanding of the current role crafts play in occupational therapy for the physically disabled, the following study was conducted.

Method
Procedures. To obtain an objective survey pertaining to the use of crafts, ten occupational therapists working in a physical disability setting were asked open-ended questions a bou t their use of crafts in trea t-

370

June 1981, Volume 35, No.6

ment. Crafts were defined as tangible objects produced from resource materials such as clay, yarn, leather, or wood. A pilot survey was constructed from the responses to these initial questions and sent to all occupational therapy departments in California that treated physically disabled individuals. Based on the responses and comments, another survey was devised and sent to a computerized random sample of250 occupational therapists who were

members of the American Occupational Therapy Association and who chose physical disabilities as their specia Ity section. Of the 250 surveys sent, 173 (69%) were returned, but only 141 surveys (56% of the original 250) were returned by occupational therapists currently working in a physical disability setting. Therefore, only these 141 surveys were used in the final data analysis. Subjects. The map in Figure I is a geographic representation of the

random sample of therapists who received surveys. The geographic distribution of the therapists who responded appears similar to that of the therapists who did not respond. thus making the sample geographically representative of occupational therapists working in physical disabili ty settings in the U ni ted S ta tes. Of the 141 therapists participating in this study, 52 (37%) worked in an acute setting where the average patient stay was from I day to I

Figure 1 Geographic Representation of Occupational Therapists Responding to the Survey

00

.0 .0
0

O.

0 0.

0
0

0 0 0

:.~o .

0
~
~

't)o~

~
o No Response
Response n n

=173 = 77
The American Journal of Occupational Therapy 371

Table 1 Percentage of Treatment Ti me Devoted to Various Modalities by Therapists Who Used Crafts and Those Who Did Not Crafts Used n 102 Crafts Not Used

pists (80%) most frequently treated patients more than 35 years of age. The disability groups seen in order of frequency were victims of cerebral vascular accidents, and patients with neurological conditions, or-

=39

Therapeutic Exercise Self-Care Neurodevelopmental Techniques Home Skills Role Performance Skills Prevocational Training Crafts

26 22

35 31

Table 3 People with Whom Therapists Had the Most Difficulty Justifying the Use of Crafts (In Ranked Order)

14
9

14 13 4 3
0

1. Patient 2. Self (therapist) 3. Insurance Company 4. Doctors 5. Other Treatment Team Members 6. Patient's Family

craft use to their patients and to themselves (see Table 3). The predominant reasons therapists reported for not using crafts as part of their treatment program included a preference for treatment techniques that lent themselves to more precise documentation, difficulty in justifying the therapeutic use of crafts, and difficulty in doeumenting the therapeutic use of crafts (see Table 4). Another finding concerned therapists who worked in settings where

5 4
20

n = 139

Table 4 Reasons for Not Using Crafts in Occupational Therapy Prog rams (I n Ranked Order)

month; 42 (30%) worked in rehabilitation centers where the average patient stay was from I month to I year or longer. The remaining 47 (31 %) worked in less traditional settings such as private practice, home health agencies, hand clinics, and public schools. Many of the therapists (58%) treated mostly inpatients, whereas other therapists (25%) treated mostly outpatients, and the remaining therapists (17%) treated an equal number of inpatients and outpatients. The majority of thera-

thopedic condi tions, arthri tis, spinal cord injuries, head trauma, and burns.

1. Prefer treatment techniques that can be more precisely documented 2. The use of crafts is difficult to justify 3. It is difficult to document the use of crafts 4. Lack of sufficient space for craft use 5. Crafts give occupational therapists a poor image 6. Use of crafts is insulting to the patient 7. Lack of sufficient budget for craft use 8. Lack of sufficient staff for craft use

Results
Of the 141 thera pis ts incl uded in the study, 102 (72%) stated that they used cra fts as part of their trea tmen t plan to achieve therapeutic goals, whereas 39 (28%) did not. Of those who stated that they used crafts, most (51 %) reported that craft use accounted for 20 percent or less of the total occupational therapy time. Table I presents a comparison of occupational therapy time devoted to various treatment modalities for therapists who used crafts and those who did not. The most important reasons for incorporating crafts into treatment programs were to increase fine motor coordina tion, strength and endurance, and cognitive and perceptual ability (see Table 2). More than half of the therapists (63%) stated that they did not encounter problems justifying the use of crafts. However, of those who reported encountering problems (37%), the difficulty was mostly in justifying

n = 39

Table 2 Reasons for Incorporati ng Crafts into Occupational Therapy Treatment Programs (In Ranked Order)

1. Improve Fine-Motor Control 2. Improve Strength 3. Enhance Cognitive Development 4. Promote Interests 5. Improve Self-Esteem 6. Improve Decision-Making Capabilities 7. Promote Group Socialization 8. Facilitate Prevocational Training

Certified Occupational Therapy Assistants (COTAs) were also employed. Of these therapists, 81 percent used crafts in their therapy programs, and, for the majority, crafts accounted for more than 20 percen t of the occu pa tiona I thera py time. However, when COTAs were not employed, the percentage of therapistS who used crafts dropped and most of these therapists used crafts for less than 20 percent of their occupational therapy time (see Table 5).

Discussion
Several rather surprIsIng findings of this survey provided for interest-

n = 102

372

June 1981, Volume 35, No.6

Table 5 Use of Crafts When COTAs Were Employed and When They Were Not Percentage of Time Therapists Working Crafts Used with COTAs n = 72
0-10 11-20 19-30 29-40 39-50 49-60 59-70 69-80 79-90 91-100 18 19 22 18 10 5 4 2 2 0

Therapists Working without COTAs n = 30

60 17 3 7 10 3 0 0 0 0
77% used crafts less than 20% of the treatment time

63% used crafts greater than 20% of the treatment time

ing insights into the current treatment milieu of occupational therapy in physical disability settings. The most notable areas of concern pertained to the priorities of treatment goals. the problems with justification of craft use, and the role of the COTA in the use of craft acti vities. Priorities of treatment goals were noted in the finding that whether or not crafts were used, the greatest percentage of treatment time was devoted to therapeutic exercise and self-care activities. In addition, when crafts were used, the most important reasons for incorporating them into the treatment program were to increase fine motor coordination and to increase strength and endurance. However, a minor percentage of treatment time reported was devoted to home skills, role performance skills, and pre-vocational training. Furthermore, using crafts for decision making, problem solving, group socialization, and selfesteem development received low priority. These results raise several questions. For example, other members of the treatment team such as physical therapists and nurses also address problems of strengthening and self-care, but are there professionals other than occupational

therapists available to address home skills, role performance skills, and pre-vocational training? And, since craft activities often involve motor functions and cognitive processes similar to those needed to perform functional activities involved in home, role performance, and prevocational skills (30), could increased use of crafts in occupational therapy help balance the overall treatment program and reduce duplication of services? In addition, because many craft activities are easily adapted for group situations (30) would the increased use of crafts help promote socialization skills? Also of interest were the problems with justification of craft use and the reasons given for not using crafts. The majority of therapists had difficulty in justifying the use of crafts to the patient and to themselves. The highest ranked reasons for not using crafts were, "I prefer treatment techniques which lend themselves to more precise documentation" and "It is difficult to justify the therapeutic use of crafts." Do these findings suggest that there is a basic lack of confidence in the use of crafts as a therapeutic modality from within the profession? Does this lack of confidence stem from an

insufficient theory base concerning the use of crafts in occupational therapy? Finally, since crafts were used more often by therapists who worked in settings that employed COTAs, it seems likely that COTAs may be able to play an important role in the therapeutic use of crafts. However, in the majority of cases in this study, OTRs were responsible for not only prescribing the craft activity, but also for carrying out the treatment when using crafts and for documenting the patient's performance in craft activities. Would the employment of COTAs make the use of crafts more feasible in various treatment settings? In addition, could COTAs possibly take on more responsibilty in their participation in craft programs?

Concl usions and Recommenda lions

The purpose of this article is not to advocate the use of crafts but, rather, to explore their role in both the past and the present practice of occupational therapy for the physically disabled and to raise questions about therapeutic craft use. According to the historical literature of the profession, the therapeutic use of crafts once allowed a means of addressing the multidimensional needs of the patient in accordance with the philosophy of moral treatment. It appears that the role crafts played in occupational therapy in the area of physical disabilities shifted as the underlying adherence to the original philosophy of the profession also changed. As scientific advancements and overall medical progress brought changes that emphasized technique rather than theory, treatment modalities that appeared more preCIse were substituted for craft activities in therapy. 373

The American Journal of Occupational Therapy

Concerning the current role of craft use in occupational therapy for the physically disabled, the results of this survey suggest that therapists are using techniq ues not particularly unique to occupational therapy. Overall, the occupational therapists surveyed seemed to stress the physical aspects of therapy with less emphasis on the psychological and social domains of treatment. In times of high medical costs and increased concern for efficiency, occupational therapists must strive to provide an effective means of addressing the original values and goals of the profession. Whatever modalities are used, occupational therapists must consider how those modalities correspond to a unified body of knowledge. Could the therapeutic use of crafts assist once again in meeting those values and goals unique to occupational therapy within a unified framework? The apparent lack of confidence in the use of crafts as a therapeutic modality from within the profession indicates several areas of need. Further research is necessary in the area of documentation and justification of the effectiveness of craft use. Such research would be most beneficial if it addressed not only the types of treatment most effecti ve in facilitating muscle strength and coordination, but also those modalities most useful in enhancing patient adj ustment to disability and adaptation to life role. In addition, more research is needed concerning craft use in different areas of occupational therapy practice to determine the role of craft use in the trea tment of other disability groups. Another area of need is an overall re-evaluation of therapeutic craft activities in the occupational therapy educational process. If therapists are ha ving difficul ty justifying craft use, perhaps more theory

should be included in the crafts skills classes in order to provide the therapist with a clearer understanding of the purposes and dimensions of craft activity. On the other hand, if therapeutic crafts are no longer considered a cen tral concept of occupational therapy practice, there may be a need to revise the curricula pertaining to craft use. Finally, perhaps all therapists would benefit from reviewing the early historical literature of the profession where the use of crafts provided a foundation for occupational therapy's contribution as a professional service. A better understanding of these foundations may prove an effective means for understanding our purpose and for promoting unified growth of the profession.

Acknowledgments
Appreciation is expressed to Patty Shiokari, COTA, and Elizabeth Yerxa, Ed.D., OTR, for their assistance in this research process. We also thank all the therapists who responded to the survey.
REFERENCES 1. Meyer A: The philosophy of occupation therapy. Arch Occup Ther 1: 1-10, 1922 2. Bockoven JS: Legacy of moral treatment-1800's to 1910. Am J Occup Ther25: 223-225, 1971 3. Woodside HH: The development of occupational therapy-1910-1929. Am J Occup Ther 25: 226-230, 1971 4. Report of the Committee on Teaching Methods. Occup Ther Rehab 7: 287300, 1928 5. Haas LJ: Weaving frame for bedside occupational therapy. Occup Ther Rehab 4 135-139, 1925 6. Dunton WR: Economic studies of crafts. Occup TherRehab5: 135-142,239-308, 1926 7. Davis CB: The therapeutic value of toy making. Arch Occup Ther 2: 359-375, 1923 8. Dunton WR, Haas LJ, Kidner TB: Report of the Committee on Installations and Advice. Occup Ther Rehab 7: 2933,1928 9. Dunton WR, Haas LJ, Kidner TB: Analysis of crafts-continuation of the Re-

port of the Committee on Installations and Advice. Occup Ther Rehab 7: 131136,1928 10. Dunton WR, Haas LJ, Kidner TB: Analysis of crafts-continuation of the Report of the Committee on Installations and Advice. Occup Ther Rehab 8: 339-343,1929 11. Buckknox M: Mexican trades and crafts. Occup Ther Rehab 10: 319-337, 1931 12. Kidner TB: Occupational therapy: Its development, scope and possibilities. Occup TherRehab 10: 1-11,1931 13. Rerek MD: Thedepression years-1929 to 1941. Am J Occup Ther25: 231-233, 1971 14. Taylor M, Packard D, McNary H, Hickinson LM: Anatomical considerations and technique in using occupations as exercise for orthopedic disabilities. Occup Ther Rehab 13: 13-34, 1934 15. Vink G: Use of waste materials. Occup Ther Rehab 13: 257 -259, 1934 16. Haas LJ: The circular bag loom. Occup Ther Rehab 13: 329-335, 1934 17. Haas LJ: The saddle bag loom. Occup Ther Rehab 13: 337-343, 1934 18. Mosey AC: Involvement in the rehabilitation movement-1942 to 1960. Am J Occup Ther 25: 234-236,1971 19. Licht S: The objectives of occupational therapy. Occup Ther Rehab 26: 17-22, 1947 20. Licht S: Kinetic analysis of crafts and occupations. Occup Ther Rehab 26: 75-78,1947 21. Licht S: Dosage in kinetic occupational therapy. Occup Ther Rehab 26: 75-78, 1947 22. Licht S: Modifications of tools and activities in kinetic occupational therapy. Occup Ther Rehab 26: 240-247, 1947 23. Dening K, Devoe F: A program of mat exercises for paraplegic patients. Occup Ther Rehab 26: 231-239, 1947 24.Johnson F: Device to supply more comprehensive kinetic therapy in occupational therapy. Am J Occup Ther 8: 158-161,1954 25. Brunnstrom S: Motor behavior of adult hemiplegic patients. Am J Occup Ther 15: 6-12,1961 26. Diasio K: The modern era-1960 to 1970. Am J Occup Ther 25: 237-242, 1971 27. Wiemer RB: Some concepts of prevention as an aspect of community health. Am J Occup Ther 26: 1-9, 1972 28. Mosey AC: Meeting health needs. Am J Occup Ther 27: 13-17, 1973 29. Eliason ML, Gohl-Giese A: A question of professional boundaries: Implications for educational programs. Am J Occup Ther33: 175-179, 1979 30. Willard H, Spackman C: Occupational Therapy, Philadelphia, PA: J.B. lippincott Co., 1971

374

June 1981, Volume 35, No.6