I recently had the pleasure of talking to Deborah Doroshow about her new book, Emotionally Disturbed: A History of Caring for America’s Troubled Children, which explores the development of Residential Treatment Centers (RTCs) for “emotionally disturbed” children. The book does a masterful job of explaining how this new category of mental illness came into being and how it related to the emerging field of child psychiatry, as well as to broader changes in psychiatric theory and practice itself. I was interested in how Doroshow, who holds an MD from Harvard Medical School and is attending physician in internal medicine and oncology at Mount Sinai, came to the history of psychiatry.
Debbie: Actually my interest in the history of psychiatry predates my move into medicine. As an undergrad I had the great pleasure of taking a course called “Madness and medicine: themes in the history of psychiatry” by the amazing Anne Harrington, who has been a major influence on me ever since. My senior honors thesis was on the use of insulin coma therapy, and I was mentored by Jeremy Greene. He treated me like a graduate student, with graduate student expectations, and I published part of my thesis as an article in the Journal of the History of Medicine and Allied Sciences.
In that project, and since, I’ve been concerned with thinking about the lived experience of mental health treatments, the way that therapeutics change over time, how that’s different over time or place, an ethnographic approach really…then I went to graduate school between the 3rd and 4th year of medical school and did some directed readings with Cindy Connolly. I was interested in child psychiatry because I’d never really encountered the history of children’s health before, so my final project with Cindy was a historiographic essay on child psychiatry. There was very little scholarship in that area, mostly about child guidance. What I noticed was that these children were troubled but not seriously ill — so I wondered where the more troubled children were.
I got a hint in a report by Lauretta Bender, who was a psychiatrist at Bellevue and Creedmore. She was part of some innovative projects, like using LSD on children with schizophrenia. Her archives were at Brooklyn College, and in them I found all sorts of interesting documents: photos, music therapy records, even photographs of the puppets that were used as a therapeutic tool. There was also a report from a large national study that sought to understand RTCs and to document what they were up to.
This report was really the key to starting my project… It was published by the Child Welfare League of America (CWLA), and it looked at 15-20 centers using surveys of staff and visits made by the CWLA staff to the centers. It contained great detail about the services offered, which turned out to be very heterogeneous. Some places were wards inside hospitals, some had 15 kids, some had 300. But the goals were all similar. This report opened the door into an entire world that I had no idea existed.
And then there was this photo of the puppets. It seemed like such an odd thing, so my goal was to try and understand what these puppets meant. I talk about this in the book — how a WPA puppet expert was hired to use them as therapy with the children in the 30s, letting the children shout out to the puppets and tell them what to do in certain scenarios. The children would yell things like “Kill the sister!” It terrified visitors to hear the children yell in such an uninhibited way.
So I was always interested in where the most troubled children were and wanted to bring to life their lived experiences inside these centers.
Kylie: The idea of efficacy and how one would know whether residential treatment actually worked or not struck me as a theme for the book. Can you tell me a little about your process of trying to understand and say something conclusive about that?
Debbie: I have traditionally taken a relativistic approach to that — but most recently I refer to the masterful introduction in Jonathan Sadowsky’s book on ECT. He argues that you do have to be able to say something about a therapy’s efficacy, especially if it’s still being used today. So thinking about RTCs relativistically first: what dogged the RTC staff members was that they themselves didn’t evaluate the efficacy of their treatments. So then they weren’t able to defend themselves. Their detractors found it easy to say, “why should we keep spending money on something if we don’t know if it works?” It was their Achilles heel, really. Why didn’t they do that? Because they saw themselves as performing what they called ‘human salvage’ — they knew they couldn’t cure children, and couldn’t make them all better, but anything they did, just to have the child interact with their families, communities, was worth it. They defined efficacy in a totally different way. Even one child’s success was enough. In a way their own expectations were so low because they had a kind of savior complex; they were doing what no one else was willing to do and so any success was worth celebrating.
A different way of looking at it is asking from our perspective, did residential treatment for children work? It is an appropriate question to attempt to answer. To start, I found no evidence that they were abusive. They may have been, but there is no evidence. I think they helped children; I don’t know how much, but for some children they provided a place to go, surrounded by people who wanted to help them, and that did make a difference for some. Also, people working in RTCs knew it was hard to return children to bad environments, especially when they had been living in a place where children felt valued. There was plenty of evidence that RTCs were positive places — there are memoirs, there are children’s own recollections. I have been careful to present their words as their own.
Kylie: In many ways, your book is about the history of a concept — “emotionally disturbed” — and in that approach you deal with the complexity of changing labels and diagnoses. How challenging was that to negotiate in your research?
Debbie: On this, I just privileged my sources. I’m not a big user of theory, for better or worse. My approach (largely thanks to Anne Harrington) is to really just listen to the sources, to let the theory come out of the sources. The past has already happened, and it’s our privilege to be able to be able to interpret that. My actors were extremely self-aware, and they spoke frequently about what it meant to be emotionally disturbed, what ‘the milieu’ was, what terms they should use for non-professional residential workers. This made my job a lot easier. I’ve always been attuned to and interested in changing diagnostic criteria over time, even as a physician. For example, I’m a lung cancer doctor. We used to think that there were two main kinds of lung cancer and we treated them differently … but new tests and new technologies have enabled us to create many more categories of lung cancer, all of which are treated differently. Psychiatry is no different from internal medicine in this — our tests, technologies, understanding, all change. That awareness flows between my medical and historical interests.
Kylie: Children’s RTCs were designed to try and ameliorate the worst practices of child psychiatry and to have children not just left in large custodial institutions. Yet as you demonstrate, there is both a class and racial element to that project. Can you talk a little about how you think race and class affected who was admitted to RTCs and how that affected treatment success?
Debbie: Well, let’s start with race. Most of the centers were run by social liberals. Their admission policies spelled out that they were race-blind, but they really didn’t have many minority children, except of course for places like Bellevue and Wiltwyck, which was designed primarily for African American children. So the rest of the RTCs would say things like “We’d be glad to have them but we haven’t because we would have to hire an African American house mother” or they would wonder whether the minority child could adjust. So they’re still segregated in the sense that African American kids usually went to different places. As liberal as they were, they were still cautious and they were also part of their local community, and their admissions patterns reflect those community practices at the time..
The private RTCs like Southard were expensive, so they mostly attracted white, middle-class children. However, most RTCs served the needs of their local communities. For example, Hawthorne Cedar Knolls in Westchester County was linked to the Jewish community and the Jewish Board of Guardians. Many RTCs were free or offered payment on a sliding scale, supported by local and national foundations and philanthropies.
Kylie: Late in the book you talk about a return to “punitive rehabilitation” and the way that “psychological distress was not acknowledged as a contributing factor to a child’s behavior.” You talk about the lack of services and the reliance on the juvenile justice system as a form of mental health care. This is a complicated issue — I’m curious about what in American society has enabled this return to not just a lack of investment, as you say, but an apparent lack of empathy?
Debbie: In some ways, this is way beyond my expertise, and so much has been written on the way that the War on Drugs and the War on Crime have served to criminalize African American and Latinx youth. There seems to be now this heightened feeling of ‘otherness’ towards black and brown children when it comes to mental health and health more generally. While cancer is often seen as the great equalizer, you’ll notice that mostly white children are used to advertise for donations to childhood cancer organizations. I think there’s just this feeling that the problems that people who don’t look like “us” have are not our responsibility. My sense too is that perhaps there’s been a feeling of loss of community. Given our modern mobility, this may have caused a disconnect between local communities and social services. RTCs were supported by their communities; they were a source of pride and attracted volunteers who were proud of their work there. Now we’re playing hot potato with troubled children and no one wants to care for them.