A case study of the development of occupational therapy at St. Patrick’s Hospital Dublin, 1935-1969

Purpose – This paper aims to examine the relationship between psychiatry and occupational therapy in Ireland through a case study of the development of the occupational therapy department in St. Patrick’s Hospital, Dublin, from 1935 to 1969. Patronage by psychiatrists was an important factor in the professionalisation of occupational therapy internationally. Design/methodology/approach – Documentary sources and oral history interviews were analysed to conduct an instrumental case study of occupational therapy at St. Patrick’s Hospital from 1935 to 1969. Findings – The research identified key individuals associated with the development of occupational therapy at St. Patrick’s Hospital, including psychiatrist Norman Moore, occupational therapy worker Olga Gale, occupational therapist Margaret Sinclair, and social therapist Irene Violet Grey. Occupational therapy was considered by the hospital authorities to be “an important part in the treatment of all types of psychiatric illness” (Board Meeting Minutes, 1956). It aimed to develop patient’s self-esteem and facilitate social participation. To achieve these objectives, patients engaged in activities such as dances, arts and crafts, and social activities. Originality/value – This study has highlighted the contributions of key individuals, identified the links between occupational therapy and psychiatry, and provided an insight into the development of the profession in Ireland prior to the establishment of occupational therapy education in 1963. Occupational therapy practice at St. Patrick’s Hospital from 1935 to 1969 was congruent with the prevailing philosophy of occupational therapy internationally, which involved treatment through activities to enhance participation in society.


Introduction
There is an ongoing need for occupational therapy to "honour and own its historical professional legacy" (Mahoney et al., 2017, p. 6). Researching the history of occupational therapy has numerous potential benefits for the profession. Historical research can demonstrate how key ideas have developed over time (Hocking, 2008), augment understandings of contemporary practice (Pettigrew et al., 2017a), celebrate the contributions of key individuals (Mahoney et al., 2017) and inform future professional directions (Wilcock, 2002). While a number of social ideas contributed to the emergence of occupational therapy (as described in the literature review), institutions such as hospitals, sanatoria and asylums were significant physical environments within which the profession developed (Friedland, 2011). Occupational therapists have worked in psychiatric institutions since the foundation of the profession; however, to date, there is limited research considering the historical development of occupational therapy in these institutions (for some exceptions, see Prendiville and Pettigrew, 2015;Levine, 1987). This paper considers the history of occupational therapy in St. Patrick's University Hospital, Dublin[1] (formerly a private psychiatric hospitalcurrently the largest independent not-for-profit psychiatric hospital in Ireland) with the intent to document the contributions of key staff members, and analyse the development of occupational therapy at St. Patrick's in the context of the broader healthcare system in Ireland at the time.

Literature review
The foundation of occupational therapy was informed by several diverse movements, including moral treatment, mental hygiene, the arts and crafts movement, the settlement house movement, and the need to rehabilitate injured World War I soldiers (Wilcock, 2002). Occupational therapy was officially named in 1917 in Clifton Springs, USA, when the National Society for the Promotion of Occupational Therapy (NSPOT) (which became the American Occupational Therapy Association in 1923) was formed (Quiroga, 1995). Many of the earliest proponents and patrons of occupational therapy were psychiatrists. Psychiatrist and founding member of NSPOT, William Rush Dunton Jr authored Reconstruction Therapy in 1919 (Dunton, 1919). In this seminal text, he described the central ideas of occupational therapy, namely, "that occupation is as necessary to life as food and drink [. . .] That sick minds, sick bodies, sick souls may be healed through occupation" (p. 10). Adolf Meyer (1866Meyer ( -1950, another eminent psychiatrist, was an important early advocate for the therapeutic benefits of occupation (Peloquin, 1991). Scottish psychiatrist, Sir David Henderson (1884-1965, who had worked with Meyer in the USA, set up the first occupational therapy department in the United Kingdom (UK) at the Gartnavel Royal Hospital in Glasgow in 1922 (Wilcock, 2002). Psychiatrist Elizabeth Casson (1881-1954, the first female doctor to graduate from the University of Bristol (Wilcock, 2002) founded the first occupational therapy school in the UK, Dorset House in 1929 (located initially in Bristol, later in Bromsgrove, and finally in Oxford at the end of World War 2) following a visit to the USA where she observed occupational therapy (Paterson, 2008;Wilcock, 2002).
The moral treatment movement marked the emergence of occupation as a treatment for people who had a mental illness (Wilcock, 2001), and ultimately created the conditions for the development of occupational therapy (Peloquin, 1989;Prendiville and Pettigrew, 2015). In Ireland, as in other countries, occupation was used therapeutically long before there were professionally qualified occupational therapists (Pettigrew et al., 2017b). The first use of the term occupational therapy in Irish media was a newspaper article about Peamount Sanatorium, Dublin, in 1930(Irish Times, 1930. At this time, nurses, craft workers and art teachers were running occupational therapy departments in Irish psychiatric hospitals. Some had completed short training courses in occupational therapy, but most did not have a professional qualification in this area (Cahill, 2016). The development of occupational therapy in Ireland was advocated by psychiatrists. At Grangegorman Hospital, Dublin, occupational therapy was promoted by the Resident Medical Superintendent (RMS), O'Conor Donelan, who attended the London Conference on Occupational Therapy in July 1934. He described an "interesting lecture" by American occupational therapy founder Eleanor Clarke Slage (O'Conor Donelan, 1934;Cahill, 2016). Psychiatrist Eamon O'Sullivan was a significant advocate for the therapeutic use of occupation in Ireland (Pettigrew et al., 2017b). He was RMS in St. Finan's Mental Hospital, Killarney, CO Kerry (in south-west Ireland) and promoted the use of occupation at St. Finan's from 1933 (Fogarty, 2007). In 1955, he published A Textbook of Occupational Therapy with Chief Reference to Psychological Medicine based on his work at St. Finan's (O'Sullivan, 1955;Pettigrew et al., 2017b), one of the first psychosocial occupational therapy texts in Europe. The foreword for this book was written by the aforementioned psychiatrist and occupational therapy founder William Rush Dunton, Jr.
Professionally qualified occupational therapists (who completed three year accredited diploma courses in the UK) began to work in Ireland after World War II (Pettigrew et al., 2017b). The first was Ann Beckett (1927Beckett ( -2002 who trained at Dorset House and returned to work in Ireland in 1948 (O'Mahoney and. A small number of Irish occupational therapists who qualified in the UK worked in Ireland in the 1950s (including Anna King, Sr, Eugene Butler and Rosemary Kerrigan). In 1963, the National Organisation for Rehabilitation and the Board of the National Medical Rehabilitation Centre (now the National Rehabilitation Hospital) founded the first professional occupational therapy course in Ireland at St. Joseph's College of Occupational Therapy in Dun Laoghaire (Gregg, 2012). Joy Rook (formerly Director of Training at The Liverpool School of Occupational Therapy) was the first Director of the School; she subsequently founded the first occupational therapy school at the Ulster Polytechnic in Belfast (later named University of Ulster, Jordanstown) in 1973 (Wilcock, 2002). From 1963, students of St. Joseph's College of Occupational Therapy, Dublin, were awarded their Diploma from the Association of Occupational Therapists in the UK (Wilcock, 2002). St. Joseph's College was the only school outside the UK that was granted permission to award the Association's Diploma (Wilcock, 2002). In 1986, St. Joseph's College was incorporated into Trinity College, University of Dublin, where the first Irish occupational therapy degree programme was offered (Prendergast, 2013). In 2003, new occupational therapy courses opened at the University College Cork, National University of Ireland Galway and the University of Limerick. There are currently over 2,000 professionally qualified occupational therapists in Ireland (CORU, 2017).
Examining the history of a healthcare discipline in an institutional context can provide insights into how routines, governance and systems develop (Scott et al., 2000), and can explore how actors and practices emerge or become delegitimised over time (Scott et al., 2000). The disciplines of psychiatry and psychiatric nursing have previously been explored in the context of institutions. For example, a 2009 review of the history of psychiatry considers the case of several specific institutions (Beer, 2009) and reveals the social beliefs of psychiatry, critiques the profession, reveals the connections between asylums and their locations, and explores the history of disease. In short, it examines "how psychiatrists have both been influenced by, and themselves influenced, the sociocultural context within which they have worked" (Beer, 2009, p. 599). One example of the history of psychiatric nursing in institutions is Dickinson's (2015) work on psychiatric nursing and the use of aversion therapy to "cure" homosexuality from 1935 to 1974 in psychiatric institutions in the UK. Understanding the history of psychiatric nursing in this context provides insights into how nursing was positioned in the hierarchy of the institution, illuminates broader societal beliefs and critiques the history of human rights abuses in psychiatric institutions. In comparison to the disciplines of psychiatry and psychiatric nursing, the history of occupational therapy in institutional contexts has been under-researched. The disciplines of psychiatry and psychiatric nursing have analysed their history in institutional contexts to explore key questions about their development. Examining the development of occupational therapy in a particular institution can provide similar insights into therapeutic goals, professional challenges and the role of the profession in the institution.
St. Patrick's Hospital, Dublin, is an example of a significant Irish hospital within which occupational therapy developed at a relatively early stage (Doyle, 2014). Jonathon Swift, Dean of St. Patrick's Cathedral and author of Gulliver's Travels died in 1745. In his will, he left the majority of his estate to found a hospital for people with mental illness (Malcolm, 1989). It was the first psychiatric hospital in Ireland and is one of the oldest private psychiatric hospitals in the world (Clare, 1998). According to Malcolm's (1989) history of the hospital, the standard of care deteriorated at the end of the nineteenth century because of to a poor hospital environment and inadequate staffing (Malcolm, 1989). The appointment of Richard Leeper as RMS in 1899 precipitated a period of change and improvement (Kelly, 2016). This included providing work and leisure activities for the patients, and improving the hospital environment (Kelly, 2016;Malcolm, 1989).
By the mid-1950s, Ireland had the highest number of psychiatric inpatients in the world per head of the population (Browne, 1963) with approximately 20,000 people incarcerated in psychiatric institutions (Brennan, 2014). Kelly argues that these disproportionately high figures were brought about by a number of social, medical, legal, economic and political factors rather than an Irish propensity to high levels of mental illness (Kelly, 2016). An enduring Irish tendency to institutionalise has been identified (Brennan, 2014); institutions were widely used to "serve various vulnerable, troubled or troubling populations of all ages" (Gilligan, 2012, p. 129). For example, legislation provided legal mechanisms for asylum admission and asylums were frequently used to manage social deprivation, poverty and illhealth rather than mental illness (Kelly, 2016;Brennan, 2014). Institutions were an important source of employment in small Irish communities and the economic and social dependency on asylums contributed to a lack of political will to close them (O'Shea and Kennelly, 2008).
People admitted to psychiatric hospitals during this time describe deplorable physical conditions, overcrowding, abuse, inappropriate admission and long-term incarceration (Kelly, 2016;Prior, 2012;Rafferty, 2011;Greally, 1971). The policy of institutionalisation had its roots in nineteenth century moral treatment and was based on the premise that keeping patients in a safe environment was therapeutic (Snell, 2016). Despite the fact that the system of treatment at the time was believed to alleviate suffering (Braslow, 1997), the aforementioned perspectives reveal that abuses consistently occurred in psychiatric settings. Stanghellini and Fuchs (2013) propose that the disparity between philosophy and practice potentially occurred because of psychiatry's "well-intentioned determinism to impose their convictions of 'the good' on others, literally at any costs" (p. 33). This disparity can be further explained by examining the tendency of institutions to sustain unequal power relationships between staff and patients (Sheridan, 2006). Institutional culture can be defined as "deeply embedded patterns of organisation behavior [. . .] the shared values, assumptions, beliefs, or ideologies that members have about their organisation or its work" (Peterson and Spencer, 1991, p. 42). Inequality between staff and patients is embedded in institutional culture; is perpetuated by actions, leadership, and institutional indoctrination; and is ubiquitous and difficult to change (Simone, 2009). Goffman (1961) describes how constructing a tightly controlled schedule of daily activity is one method that institutional staff use to preserve unequal power relationshipsarranging daily activity was a common role for occupational therapy in psychiatric institutions in the early to mid-20th century (Braslow, 1997). Law (1991) identifies that bureaucracy and the power of health disciplines (including occupational therapy) can contribute to disabling environments. As there is a dearth of literature concerning the actions of occupational therapists in institutions, it is difficult to ascertain their role in sustaining or challenging institutional culture.
Exploring the history of occupational therapy in psychiatric institutions deepens the understandings of circumstances within which occupational therapy developed and identifies enduring values (Harley and Schwartz, 2013). This research aims to explore the content, development and context of occupational therapy at St. Patrick's Hospital from 1935 to 1969 through case study analysis.

Methodology
Drawing on an interpretivist perspective, historical documentary research methods and oral history were used to conduct an instrumental case study of occupational therapy development at St. Patrick's Hospital, Dublin, from 1935 to 1969. The chosen period of time   Analysing the material The research aims to construct a chronological timeline of the development of occupational therapy at St. Patrick's Hospital, Dublin, from 1935 to 1969, situating it within the broader context of institutional psychiatric care in Ireland. Chronological approaches to history describe historical events in sequence (McDowell, 2002); the approach assumes that meaning can be derived from understanding the causes of historical events. In this research, a chronological approach is used to demonstrate the context and events that led to the development of occupational therapy (McDowell, 2002). The research drew on multiple sources of data. Primary sources included material from six archival collections, and oral history interviews. Secondary sources included a published history of the hospital (Malcolm, 1989) and personal communication with family members of key individuals (see Appendix, Table AI, for details of source material). The documents and oral history interviews represent the perspective of numerous groups of people: the board members, the staff and the inspector of mental hospitals. Each of these groups had their own biases, agendas, beliefs and meanings concerning occupational therapy (Thompson, 2000). However, the results do not represent the perspectives of all groups of people who were involved with occupational therapy during the time in questionparticularly patient experiences. No accounts of patient experiences of occupational therapy during this time were identified; it was essential to be cognisant of this throughout the analysis of the collected material.  , persons identified in the interviews and documents may have living relatives who may not wish that their family members be included in the Development of occupational therapy analysis. While patient experiences are not the focus of this paper, the researchers were mindful to approach documentary and oral history material concerning patients with respect and confidentiality.

Quality in historical research
In working with historical documents, it is essential to assess their authenticity, credibility and representativeness prior to analysing the meaning (Scott, 1990;Dunne et al., 2016). In the case of this study, the source material has been drawn from official archives, published material or records of a face-to-face interview. As such, the documents can be considered authentic and have not been forged or adapted in any way. From the perspective of credibility, it is important to take into account the standpoint of the author of a document. For example, the board meetings consisted of a group of powerful men, drawn from the clergy, the military and business. The minutes mainly comprise financial details of the hospital, and decisions about money are the main issues discussed. While the board meeting minutes refer to patient welfare, types of treatment (including occupational therapy) and other hospital issues, the focus is on the main financial. Considering the standpoint of the board members who recorded the minutes of meetings allows for a clearer interpretation of the documentary sources, as it may reveal potential biases associated with that standpoint or may suggest that certain valuable information was left out. Representativeness was also taken into account by accessing material from several different sources (see Appendix) to verify the content. By comparing these sources, similarities and differences were identified and a clearer sense of historical fact emerged.

Pre 1945
In 1935, occupational therapy "classes" commenced at St. Patrick's Hospital; it is reported that by 1938, a quarter of the patients were engaged in these classes (there were approximately 150 patients at St. Patrick's at that time). These classes were led by Florence Shegog, a masseuse, who had been employed at St. Patrick's Hospital in 1932 (Malcolm, 1989). The Mental Hospital Inspector Report in 1938 states that occupational and recreational therapies were being carried out with "success" (p. 34); there is no information available about the content of these classes (Mental Hospital Inspector Report, 1938) nor patients' experiences of them. A report from Leeper to the Board Meetings describes the value of engaging in activity[2] for patients with mental illness. In one case, speaking of funding a cinematograph, he states: I consider this expenditure could be amply justified in the provision for the mentally afflicted people of a constant source of amusement or a cause of mental abstraction from those depressing delusions and self [illegible] mental states which are so common accompaniments of mental disease (Leeper, personal papers, n.d).

1945-1949
Norman Moore  was employed as RMS at St. Patrick's Hospital in 1946(Board Meeting Minutes, 1946. He worked at the Crichton Royal Hospital, Dumfries, Scotland, from 1940to 1946(Board Meeting Minutes, 1946. Moore was inspired by the system of psychiatric care at the Crichton, particularly by the RMS and director of research, Wilhelm Mayer-Gross . Upon his return to Ireland to work at St. Patrick's in 1946, Moore sought to emulate the system of psychiatric care he saw at the Crichton, including the provision of occupational therapy. In the 1940s, occupational therapy was "recognised as a profession supplementary to medicine"; physicians had a role in prescribing work or recreational activities to aid recovery from disease or injury (Dorset House prospectus, 1940s, n.d.). At that time, pioneering Scottish professionally trained occupational therapist Rhonda Begg ran the occupational therapy department at the Crichton Royal (Paterson, 2010). Occupational therapy practice at the hospital aimed to allow patients to acquire useful skills, form stable relationships and allow self-expression; patients were facilitated to "spontaneously" choose activity (World Federation of Occupational Therapy, 2016). Activities included crafts, farm and garden work, domestic work and recreation activities (Personal communication with Paterson, 2015). In 1946, Moore sought to set up an occupational therapy department at St. Patrick's Hospital and employed Irishwoman Olga Gale (1926Gale ( -2014 to do so. According to her oral history interview, Gale was privately educated in Ireland and Wales (2013). She described her formative education as academic and vocational, including instruction in crafts, music and lacrosse. She stated that her experiences "put me into thinking in a wider way" and were very helpful when she set up an occupational therapy department at the age of 20 years. After school, she enrolled at Dorset House School of Occupational Therapy, Oxford, in 1944. She completed two years of the course but did not finish because of ill health (Gale, 2013). The Dorset House archive records differ from Gale's recollections; their records indicate that she completed the course (student number 326) in 1947 (Dorset House archive, 1947). However, Gale did not register as a member of the Association of Occupational Therapists in the UK (BAOT/COT archives, Wellcome Trust, n.d.) which affirms her oral history testimony. In the mid-1940s, while Norman Moore was working at the Crichton, Gale completed a placement at the hospital. She was subsequently invited by Moore to set up an occupational therapy department at St. Patrick's Hospital (Gale, 2013).
Gale recalled that she was "horrified" when she first visited St. Patrick's Hospitalshe described patients sitting in corridors in chains (Gale, 2013). She described feeling "petrified"; however, she was given a "lovely" room called the solarium. She organised activities on an individual basis; these included basketry, sewing, drawing, glove making and embroidery. She arranged for woodwork classes with a male nurse. Gale reported that the patients "treasured" the products that they made (2013). In occupational therapy at the time, craft was a significant aspect of occupational therapy education (Paterson, 2010). Exam papers from the 1940s demonstrate that activities were commonly used as treatment (Dorset House Exam Papers, 1946). Student occupational therapists were examined on psychology, psychiatry and how to use activities (including crafts) to treat physical and psychiatric conditions. The use of activities was based on a complex understanding of psychiatric illness and its impact on participation. For example, the applied psychology exam paper (June 1946) included questions on how patient attitude, interests, capacity and participation in groups inform and constitute occupational therapy. At St. Patrick's Hospital, Gale also held dances and invited her friends, where they and the patients danced together. These dances were very popular; she held them with the aim of reducing stigma and increasing self-esteem, and to give the patients an "opportunity for liberation". She met with Norman Moore each month to discuss patient progress.
Gale's initial salary was £150 per annumthis was increased in 1948 to £175 and later that year to £200 (Board Meeting Minutes, 1948). In the UK at that time, occupational therapists earned a salary of £240-£270. (The Times, 1946, July 13 (Board Meeting Minutes, 1950). She was assisted in her work by a nurse (whose name is not recorded) and later by Violet McTear, an occupational therapy assistant (Gale 2013, Board Meeting Minutes, 1948. McTear was married to James McTear, the head male nurse. The Board Meeting minutes and Malcolm's history of the hospital were searched to find information about Violet McTear; unsuccessful attempts were also made to locate her surviving family. Therefore, little is known about her work at St. Patrick's or how she began working in the occupational therapy department.

1950-1954
Following Gale's period of employment at St. Patrick's Hospital, it appears that for a few months, occupational therapy assistants solely staffed the occupational therapy department. In May 1952, the Board Meeting Minutes state "Owing to the recent additions to the staff of the Occupational Therapy Department, it was decided that no further appointment was required at the moment". However, a few months later, Margaret Sinclair (1930Sinclair ( -1984, a qualified occupational therapist was employed.
Sinclair was employed as an occupational therapist at St. Patrick's Hospital, Dublin, in February 1953(Board Meeting Minutes, 1953. The Minutes state: The Medical Superintendent reported on the interview granted to applicants for the position of Occupational Therapist to the Hospital, and it was agreed that Miss Margaret Sinclair of [address removed], who is at present in a similar position in the City Hospital Belfast, should be appointed at a salary in accordance with the official salary of the Association of Occupational Therapists (Board Meeting Minutes, 1953).

Sinclair was born in Dublin and was awarded the Diploma of the Association of Occupational
Therapists in the UKher family recollect that she was based in London (likely at the London School of Occupational Therapy which opened in 1935). She graduated in 1951 (Personal communication with son, 2015). She registered as a member of the Association of Occupational Therapists in the UK in 1952 (COT/BAOT archive, 1952) and the St Patrick's Hospital Board Meeting minutes of her employment stated that she was to be paid the "British Association" salary (Board Meeting Minutes, 1952). At that time, occupational therapists in the UK were paid £412 per annum (The Times, 1951, September 26). Sinclair worked at St. Patrick's Hospital for six months; her period of employment ceased in October 1953 at the end of her probationary period. The reason for this is unknown.

1955-1960
A social therapist named Irene Gray  began to work at St. Patrick's Hospital in 1955. The Board Meeting Minutes state that: The Medical Superintendent reported that he had been endeavouring for some time to obtain the services of a suitable social therapist for the hospital and he now recommended the appointment of Miss Irene V Gray. Excellent references and report on Miss Gray's experience were noted and her appointment was approved at a salary of £500 per annum, for a probationary period of six months in the first instance (Board Meeting Minutes, 1955).
Gray's work at the hospital was closely related to the occupational therapy department. She organised activities such as debates, lectures and play readingsa circular prepared with details of social therapy suggests that these activities were "designed to instruct the patients and occupy their time in a useful and pleasurable way" (Board Meeting Minutes, 1956). This circular states that "suitable occupation and recreation play an important part in the treatment of all forms of psychiatric illness" (Board Meeting Minutes, 1956). Occupational therapy "classes" are described; the circular states that "various handicrafts including rug making, basketry, leather work, weaving, and carpentry are taught". The circular also described recreational activities (such as television and outings) and physical exercise classes at the hospital. Irene Grey had a nursing backgroundshe trained at the Adelaide Hospital in Dublin (Personal communication with family, 2015). A significant aspect of Grey's contribution to the hospital was the annual Garden Fete which she organised (Board Meeting Minutes, 1958). The money raised from this event was used to contribute to the purchase of a hard tennis court for the use of patients at the hospital. The Board members were very complimentary of her role in organising this event. Gray died from a cerebral aneurysm in 1962 seven years after her appointment as social therapist at St. Patrick's Hospital (Personal communication with family, 2015).
In 1957, a major building project was approved at St. Patrick's Hospital (Board Meeting Minutes, 1957). This included the building of an occupational therapy department, recreation hall and outpatient's department. The amount approved for the project was £27,391 (Board Meeting Minutes, 1958), and it was identified as a significant undertaking by the board. The fact that an occupational therapy department and a recreation hall were a major aspect of this building work suggests the centrality of therapeutic activity at St. Patrick's Hospital. Moore invited his mentor from the Crichton Royal, Mayer-Gross, to officially open the new facility in 1960 (Irish Times, 1960).

1960-1969
Despite the Board Meeting Minutes evidence that an occupational therapy department was the central aspect of the building work, a professionally qualified occupational therapist was not employed in the department until 1969department until (Buggy, 2015department until , 2016. Catherine Buggy graduated from St. Joseph's College of Occupational Therapy, Dublin, in 1969 and was awarded the Diploma of the Association of Occupational Therapists in the UK. She worked as an occupational therapist at St. Patrick's Hospital for one year in 1969 before leaving to work in the UK. While at St. Patrick's she worked mainly with adolescents. She reported that her interventions served multiple purposes, for example, facilitating social participation and observing clients during activities to evaluate factors such as social interaction and anxiety. She was unaware whether there were any professional occupational therapists at St. Patrick's prior to her employment. She perceived that medical staff were positive about the role of occupational therapy at that time.

Discussion
This case study of the development of occupational therapy at St. Patrick's Hospital provides an insight into occupational therapy in Ireland from 1935 to 1969 and draws attention to the close links between the profession and psychiatry. The influence of Moore was integral to the development of occupational therapy at St. Patrick's Hospital. This is comparable to other Irish psychiatric hospitals at the time, where medical patronage was central to founding and promoting occupational therapy services. Two significant examples include the aforementioned Eamon O'Sullivan at St. Finan's Hospital in Killarney (Pettigrew et al., 2017b), and Ada English at St. Bridget's Hospital in Ballinasloe (Kelly, 2014). Patronage by psychiatrists was an important factor in the professionalisation of occupational therapy internationally (Friedland, 2011), and as noted earlier, some of the key founders of the profession were psychiatrists. Moore's obituary describes him as a "therapeutic enthusiast" (Clare, 1996), who was keen to explore and promote new types of psychiatric treatment. He was an important early proponent of occupational therapy in Ireland.
This case study of St. Patrick's Hospital reveals key individuals central to the development of occupational therapy services, including occupational therapy worker Olga Gale, occupational therapist Margaret Sinclair, social therapist Irene Violet Grey and Development of occupational therapy psychiatrist Norman Moore. While there is no evidence of formal multidisciplinary team working, the research provides an early example of occupational therapy in Ireland working alongside other professional groups. The foundational ideas of occupational therapy are based on humanistic and pragmatic principles which propose that the mind, body and environment are interrelated, and suggest that human beings can control their health through what they do (Creek, 2008). Early occupational therapy developed "broad and balanced programmes of activity" based on these principles (Creek, 2008, p. 32). This case study shows that a significant aspect of occupational therapy treatment at St. Patrick's included needlework, art, woodwork and basketry. Arts and crafts were used at that time to provide patients with a sense of agency and control (Hooper and Wood, 2002), to restore dignity (Paterson, 2010), to develop skills and improve function (Horghagen et al., 2007), to facilitate emotional expression and autonomy (Hocking, 2008) and to provide a sense of meaning during potentially long hospital stays (Horghagen et al., 2007). Occupational therapy practice at St. Patrick's reflected the philosophy and practice of the discipline internationally.
Social therapy has been conceptualised in a number of ways over the years. Eagar (a British psychiatrist) described social therapy as a key characteristic of occupational therapy work in 1930 (Wilcock, 2002). In the 1940s and 1950s, it was considered to be a form of therapy that could benefit society as a whole, to promote more harmonious, just communities (Jaques, 1947). Crawford described social therapy as an essential aspect of therapy alongside, yet distinct from, psychiatric social work, occupational therapy and industrial therapy, consisting of outings, patient journals, social clubs and other entertainments (Crawford, 1962). According to the descriptions of Irene Gray's work as a social therapist at the hospital (Board Meeting Minutes, 1956), it appears that she aimed to achieve similar goals. The types of activities employed by Irene Gray are commonly used as interventions by occupational therapists today (Creek and Lougher, 2011).
Occupational therapists have worked in psychiatric institutions since the foundation of the profession. In considering the role of occupational therapy in these institutions, it is important to critically examine how occupational therapy historically has sustained or challenged institutional culture. Occupational therapists can be considered agents of social control; and contemporary occupational therapy theory emphasises the requirement to ethically balance the needs of clients with the needs of the service (Kronenberg and Pollard, 2005). Occupational therapists attempting to initiate change in medical bureaucracies have reported issues of power and politics, and the challenge of integrating the differing cultural visions of staff and service user groups (Cook, 1995). This case study provides scant evidence that occupational therapists attempted to address issues such as the inappropriate use of restraint or challenged the institutional culture at St. Patrick's Hospital. Gale's interview revealed that the dances she arranged aimed to reduce stigma and increase opportunities for "liberation" (Gale, 2013). Occupational therapy was a new, emergent health profession in 1950s Ireland dependant on the patronage and advocacy of other professional groups. The prevailing socio-political culture of 1950's Ireland (Brennan, 2014), combined with the profession's minority status (Clouston and Whitcombe, 2008) and a focus on professionalisation precluded attention to issues of institutional power and service user rights (Saks, 2009) which have been explored in depth within occupational therapy in recent years (Hammell and Iwama, 2012;Galheigo, 2011;Whiteford and Hocking, 2011). The system of institutional care continues to influence mental health services in Ireland despite a move to community care in recent decades (Barry, 2015). Kelly (2016) argues that, historically, mental healthcare reforms in Ireland eventually tend towards increased institutional care; he cautions that history must inform present day decision-making, policy and practice to avoid repeating this pattern in the future. Occupational therapy needs to advocate for healthcare policy and practice that transfers power from institutions to service users (Barry, 2015;Lloyd and Williams, 2009).

Conclusion
The era discussed in this paper, 1935-1969, was a time of significant change in mental health services and in occupational therapy. Rates of psychiatric institutionalisation in Ireland peaked in 1956 and subsequently began to steadily fall (Brennan, 2014). The profession of occupational therapy was in its infancy in Ireland during the time in question prior to the establishment of the first occupational therapy educational programme in 1963. A number of cultural and professional factors have been identified which precluded occupational therapists from challenging institutional culture; the role of occupational therapy in sustaining or challenging institutional culture warrants further research. This paper provides an insight into the therapeutic goals and the role of occupational therapy at St. Patrick's Hospital from 1935 to 1969 and situates the development there in a broader international context. Hospital" is used throughout this paper consistent with its name from 1935 to 1969.
2. The term "occupation" was widely used in occupational therapy literature in the 1920sfollowing this, the use of the term declined until the 1980s. The term "activity" was most commonly used from the 1930s to 1960s; the use of the term activity has subsequently declined. Occupation is the most widely used term currently: this arguably reflects the professions current focus (Bauerschmidt and Nelson, 2011). Given that activity was the term most widely used from 1935 to 1969, it is used in this section.