Basket weaving 101-c
May 2, 2020
A few years back, during a period of extended convalescence, I began building a canoe. Hesitant to invest money into a project I wasn’t sure to finish I initially scrounged construction materials from neighborhood alleys, a self-imposed requirement that slowed construction. Our Covid-induced home quarantine provided idle time to finish the boat. I recently caned the seat bottoms, a skill outside my prior experience.
Caning is closely akin to basket weaving, an activity long associated with those in need of mental rehabilitation, at least before the advent of psychoactive medications. The term basket-case is still used to describe someone in a less than ideal state of mental stability. I found my caning activity mentally soothing and slightly addictive and have started watching for an old caned chair in the alley that I might repair. It is easy to conceive that engaging in a simple repetitive act like caning or basket making could provide desirable benefits to mental function.
The focused mental rhythm of weaving, the mental cross-crawl of moving the active strand over and under the standing strands seems like it could well be associated with improved cognitive function and emotional stability.
I recall that the late Terry Willard PhD, who ran the Wild Rose Herbal School in Calgary, suggested knitting as a therapy for chronic fatigue patients. He rationalized that humans had made all of the materials needed for daily life with their own hands through most of human evolution and that deprivation of the nearly constant mind-hand-coordinated-activity that filled the lives of our ancestors through evolutionary prehistory might cause some deficiency in mental function. He likened the output handwork created as a balance to the mental input provided by stressful stimuli. I’ve always found this thinking appealing and still have no reason to argue against it.
Something unique happens to my mind when engaged in caning and I will assume basket weaving (my basket weaving supplies, recently ordered, have yet to arrive). My mind is actively engaged and attentive to outer activity yet at the same time my awareness is relatively undirected and goes to interesting places.
At this point in most articles, I typically pivot to review the scientific literature on whatever topic I am exploring, but much to my surprise there is almost nothing published in recent years that on the therapeutic action of any craft activities. No one actually talks about baskets anymore; but there are various euphemisms that describe arts and crafts in our modern era. Shimada et al (2018) reported that ‘individualized occupational therapy’ was a useful adjunct in treating patients with schizophrenia. In their study individualized occupational therapy (IOT), consisted of a combination “… of effective psychosocial treatment programs that are very relevant to OT practice: motivational interviewing, self-monitoring, individualized visits, handicraft activities, individualized psychoeducation, and discharge planning.” But basket weaving? No, just “ … constructive handicraft activities with clear procedures and good feasibility, such as Japanese paper collages, plastic models, Japanese paper crafts, and jigsaw puzzles, were used in the handicraft activities program.” Handicraft activities were implemented 3–5 times per week. Implementation time was about 30 minutes per session at the start of OT and was gradually extended to about 60 minutes.” 
Using the search term “cognitive leisure activities” leads to a 2019 systematic review examining various activities and whether they impact cognitive decline in the elderly. The study’s authors conclude that, ‘Activities related to learning new skills, that cause strong intellectual stimulation and that include communication elements were considered particularly effective tools.” 
It wasn’t until I stumbled upon J. Laws’ 2011 article, “Crackpots and basket-cases: a history of therapeutic work and occupation”  that I realized the search needed to extend further back in time and that we were not going to find evidence based support for this therapy. The practice of art and craft therapies dates back to an era when the opinions of respected practitioners took precedence; our current requirement of proven evidence based efficacy had yet to emerge.
We need to turn back the clock more than a century to a time when art and medicine intersected or we might say, collided with one another. All the way back to the mid 1800’s when John Ruskin and William Morris initiated the birth of the Arts and Crafts Movement in Great Britain. It is from them, if from anyone, that our still retained appreciation of basket making originated. Ruskin was of the belief that machines and factory work limited human happiness and urged a return to a more authentic and simpler way of life, a romanticized version of the Middle Ages where people made their livings engaged in cottage crafts. He judged the manufactured, factory produced goods that were then becoming commonplace in the 1800’s to be “… both aesthetically and morally unsatisfying because the worker was treated like an extension of the machine, completing only a part of the finished product.” Little did he realize how far down that path we would go.
William Morris took up Ruskin’s philosophy and ran with it and creating a decorative arts empire of textile, furniture and wallpaper designs (plus multiple books of poetry). He put the art into artisanal. Ruskin and Morris’ philosophy and ideas about home furnishing styles crossed the Atlantic and became popular among America’s well to do. “Proponents were eager reformers celebrating nature, authentic experience, and honest design. Like their British contemporaries, they displayed a patrician contempt for the system of mass production, which was keyed to lower class tastes. They advocated the use of natural materials and processes and the purchase and use of handmade items that were straightforward and simple in design. Indeed, for some advocates, the Arts-and-Crafts movement meant quality of design as much as quality of life.” 
This is no doubt the same cultural divide that we find today if we were to compare the worldviews of Whole Foods’ shoppers with those found at Walmart.
[I’ve mentioned William Morris before in connection with his wallpapers. The colorful dyes he used to manufacture the rich colors in his designs contained toxic amounts of arsenic, enough to create symptoms in homes papered with products of his manufacture. ]
The Arts and Crafts Movement reached its high point at near the same time as the epidemic of neurasthenia swept across America. Although the term neurasthenia was first used in 1829, it wasn’t until 1869 that George Miller Beard and E. H. Van Deusen of the Kalamazoo asylum, popularized the term as a medical diagnosis, even if they didn’t quite agree on a definition.  Van Deusen thought the condition was caused by social isolation and a lack of engaging activity in rural women while Beard saw the condition as something busy society women and overworked businessmen were susceptible to.
Neurasthenia was often called a weakness of the nerves. At that time, medical thinking viewed the body as akin to an electrical machine with the nervous system distributing energy. The fast paced, rapidly shifting, modern world back then, with people living in big busy cities with so much stimulation led to people to expend too much of their ‘nervous energy’ and they were left depleted. The resultant state of collapse was neurasthenia.
Possible symptoms of neurasthenia included headaches, muscle pain, weight loss, irritability, anxiety, impotence, depression, “a lack of ambition,” and both insomnia and lethargy.
Julie Breck writing in a 2016 issue of The Atlantic, describes neurasthenia, as, “… a disease of culture as much as of the mind and body. Beard thought that people in earlier societies could not have been neurasthenic because they weren’t exposed to the modern things that depleted nervous energy, particularly “steam power, the periodical press, the telegraph, the sciences, and the mental activity of women.” 
Silas Weir Mitchell (1829–1914) developed an early treatment for neurasthenia in the mid 1800s. Mitchell, who began his medical career studying rattlesnake venom but ended up specializing in nervous diseases in Civil War Veterans for most of his career, developed the Rest Cure to treat neurasthenia and hysteria in women. The Rest Cure involved six to eight weeks of isolation, bed rest, a high calorie diet, massage, and electrotherapy. For men, he suggested a very different approach. In his 1871 book, Wear and Tear: Or Hints for the Overworked, he suggested that neurasthenic men should strengthen their nervous systems by engaging in “a sturdy contest with Nature.” This idea became known as the West Cure: neurasthenic men were sent out West to engage in vigorous physical activity, prolonged periods of cattle roping, hunting, roughriding and male bonding … and to write about the experience.  Teddy Roosevelt and Walt Whitman were both among the many neurasthenics who underwent this treatment.
These treatment ideas about neurasthenia reflected underlying beliefs in traditional gender roles that some of us today would find objectionable, what we might call historical medical misogyny. The thinking was that God created men to work outdoors and if men spent too much time indoors they were at risk for neurasthenia. Women were supposed to stay home tending their households; too active a social life and time spent outside of the home left women vulnerable.
As old fashioned as some of these ideas seem, we owe many popular conventions to the accepted views from that era on how to reduce risk of neurasthenia. Creation of our national park system is often credited to the belief that neurasthenics needed to retreat into nature to heal. Nature was a healing force, an idea that some of us still cling to.
Recess times in public schools were established out of fear that sitting too long in a classroom was bad for children’s nervous systems. Activities such as bike-riding, traveling for vacations and sports leagues were popularized because of similar beliefs that they reduced risk of developing neurasthenia. 
In 1910 Herbert Hall, MD, opened a clinic in Marblehead, Massachusetts, promoting a ‘workcure’ for neurasthenia based on ideas borrowed from the Arts and Crafts Movement. A similar program was started in Worcester, Massachusetts, by Adolf Meyer. William Rush Dunton started one in Maryland. Patients spent a good part of their day engaging in art and craft activities. Apparently, this approach seemed to work well and spread widely. Residential workshops were created to both foster skill development and generate income through selling the items participants produced.
A textbook titled, Studies in Invalid Occupation: A Manual for Nurses and Attendants written by Susan Edith Tracy, was published in 1912. Tracy offered detailed descriptions of the arts and crafts training courses used at the Boston Nervine Hospital and her program was copied widely. The book became the blueprint for training practitioners of what later became known as occupational therapy.
Curiously, or perhaps oddly, neurasthenia seems to have entirely disappeared in the United State by the 1930s. The diagnosis was dropped from the DSM in 1980. However, The Tenth Revision of the World Health Organization’s International Classification of Diseases (ICD-10) continued to contain well-defined criteria for neurasthenia diagnosis.  Even if the disease disappeared in our country, it persisted and actually worsened for periods in other countries.
In Japan, neurasthenia is known as shinkeisui-jaku, meaning “nervousness or nervous dis- position.” The condition is often treated in Japan with Morita therapy, which involves a period of mandatory rest and isolation followed by progressively harder work, leading to resumption of one’s social role. This treatment, based on the work of a Japanese psychiatrist Shoma Morita, (1874–1938), has its basis in Zen Buddhism and is aimed at breaking the cycle of sensitivity and anxiety. The goal of Morita therapy is to ‘have the patient accept life as it is.’  The Japanese practice of ‘forest bathing’, shinrin-yoku, has been part of their national health program since 1982. 
In China, neurasthenia remains a valid medical condition defined in terms of Traditional Chinese medicine and the etiology, to no surprise, is described as a decrease in vital energy (Qi). There was a significant increase in neurasthenia cases in China during the Great Leap Forward during the 1950s to mid-1960s to the degree that it was considered a major national health issue.  Both exogenous and endogenous harmful factors reduce functioning of the five internal organ systems, (heart, spleen, liver, lungs and kidneys). In Chinese, neurasthenia is called shenjingshuairou (weakness of nerves).
The dominant fatigue expected in our American version of neurasthenia is not required in China for a diagnosis. Three of the following five symptoms are required: “weakness”, “emotional”, “excitement”, tension-induced pain, and sleep disturbance. The duration of illness must be at least 3 months, and one of the following must have occurred: disruption of work, study, daily life, or social functioning; significant distress caused by the illness; or pursuit of treatment.
Chinese immigrants to the United States appear to retain their tendency to develop neurasthenia and exhibit a symptom picture distinct from a U.S. diagnosis of depression or other categories that have been suggested as equivalents. In a 1997 study, Zheng et al showed that Chinese immigrants to Los Angeles continue to display symptoms of pure neurasthenia. 
Modern medicine describes neurasthenia as having ‘no organic basis’, and the current assumption is that the condition was psychosomatic. That idea doesn’t sit entirely well with me.
Historically, in many patients diagnosed with neurasthenia, their gastrointestinal symptoms predominated, and this subset of sufferers were typically diagnosed with “neurasthenia gastrica”. At the time, “… there was considerable debate as to how the gut interacted with the central nervous system in the development of these ailments. Some of these discussions may be seen as historical precedents for the current debates on the brain-gut-microbiota axis, particularly in relation to the so-called functional gastrointestinal disorders.”  Other researchers argue that modern maladies such as fibromyalgia, chronic fatigue and depression are simply updated manifestations of the same disease.  There is little question that at least in today’s popular wisdom that a spectrum of disease stretches between feeling stressed on one end to post traumatic stress disorder (PTSD) on the other extreme. Would neurasthenia fit somewhere on that spectrum?
Assuming neurasthenia was something ‘real’ and not just in the sufferers’ heads, there are questions that I am unable to answer. Is, or was, neurasthenia a matter of nature or nurture or something else altogether? Was it a disease of the times? Could there be a genetic component that predisposes some people to neurasthenia leaving them more vulnerable? Could it have been infectious, the aftermath of a bacterial or viral infection? We know today of some rather strange repercussions of parasitic infections that seem to take control of the host’s behavior. Toxoplasma probably is the most famous of these.  Evidence is mounting that fibromyalgia has a genetic component  and that something distinct is chemically amiss in the blood of those with chronic fatigue.  A more primary question is whether neurasthenia is, or was, a real condition? If the many physical symptoms attributed to neurasthenia have no organic basis and were just psychosomatic, then we are left in an awkward place. Historically many fundamental beliefs of the naturopathic profession were developed parallel to the neurasthenic ‘epidemic’ in the U.S. and many of the philosophic and treatment approaches we employ still reflect that history.
Our critics might say that naturopathic medicine evolved around treating an imaginary condition and has continued into the present day treating other imaginary conditions that have come along to replace neurasthenia. Think of the many conditions that we and our colleagues specialize in that have never been accepted as ‘real’ by mainstream physicians. Many of these ‘conditions’ have come into and out of fashion over the years even in our own practices. We, of course, prefer to view our profession as on the cutting edge of scientific discovery and believe our colleagues are more accepting of new theories and treatments, long before mainstream medicine, but what if we are wrong?
Perhaps neurasthenia really was just some sort of psychosomatic illness that is triggered by stress? Symptoms pictures of other psychological diseases do seem to evolve over time.
Basket weaving and the other arts and crafts seem to have been dropped from most modern occupational therapy training curricula. To this outsider, occupational therapy is now more about teaching patients how to perform activities of daily living after mishaps; accidents, strokes, functional degeneration and so on. I suspect the practice of arts and craft has become similar to the practice of spinal manipulation for osteopathic doctors, ‘something they used to do.’ No one is going to risk their academic career to study basket weaving unless one’s goal is to win an Ignoble Award.
Some things may not need randomized controlled trials to prove their worth. [We don’t need a control group to prove the worth of parachutes. Well, that has changed. In 2018 a RCT of parachutes was published and concluded that they don’t make a difference in survival.] While basket weaving isn’t that popular, knitting is commonplace. Ask any habitual knitter if they would agree to willingly stop knitting for a few weeks so that you might assess changes in their mental well-being; their adamant refusal should convince you that they experience benefits they do not want to forego. Just the expression on their face should be adequate evidence.
While we don’t have the sort of data on basket weaving that I had hoped to quote you, we can make some educated guesses. Consider other therapies once used to treat neurasthenia and what we know about the impact of those therapies on health. Spending time in nature was seen as curative. Today we know a lot about what nature exposure does to our physiology and mental health. If we make an educated guess that basketry does something similar, there’s a good chance we will be correct.
Exercise was also considered therapeutic for neurasthenia. At least for men as part of the West Cure. To suggest that that there might be a different response to the same treatment that might vary by the patient’s gender is probably not worth our consideration these days.
Perhaps neurasthenia was an era appropriate response to stress. We now speak of ‘adrenal fatigue’ in much the same way as doctors a century ago spoke about neurasthenia. In considering the older therapeutic interventions, the dramatic differences between Rest Cure and West Cure stand out and might have theoretical application. What would our modern equivalent be to a West Cure? What kind of impact would more time in nature, rigorous exercise, and fresh air have on adrenal dysregulation in contrast to enforced rest? Clearly, we will not segregate treatment prescriptions based solely on gender. Yet we might wonder if there is a dichotomy of possible treatments the we might segregate patients between. Is there a way to predict who might do better with rest and who would do better with a rigorous approach? One approach might lower cortisol demand and production while the other might increase it. Either approach might serve to rebalance hypothalamic function.
Whatever the case, I need to pause now and check our front porch to see if the UPS truck has dropped off my basket making materials that I am waiting for, somewhat anxiously.
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