Deborah Blythe Doroshow. Emotionally Disturbed: A History of Caring for America's Troubled Children. Chicago: University of Chicago Press, 2019. ix + 335 pp. $45.00 (cloth), ISBN 978-0-226-62143-2.
Reviewed by Daniel J. Wilson (Muhlenberg College)
Published on H-Disability (April, 2021)
Commissioned by Iain C. Hutchison (University of Glasgow)
Emotionally Disturbed is a history of the treatment of emotionally and behaviorally disturbed children in the mid-twentieth-century United States. “Emotionally disturbed” emerged as a new diagnostic category in the 1930s and 1940s to describe children who were not mentally ill or intellectually impaired, but who exhibited abnormal emotional states and behavioral patterns. Psychiatrists, psychologists, and social workers developed residential treatment centers (RTCs) to house these children for months, or sometimes years, while they administered treatment. RTCs were developed and advertised as more humane alternatives to the large, grim, state mental asylums and institutions to which such children had typically been sent. RTCs and the therapeutic strategies that accompanied their establishment prevailed into the 1960s when the movement for deinstitutionalization and changing therapeutic theories and practices led to their abandonment. Although they never served more than a small percentage of children needing care and treatment, Deborah Blythe Doroshow argues that they represented a sincere effort to improve the care of emotionally disturbed youth and to prepare them to rejoin their families and society. While acknowledging their good intentions, Doroshow is also attentive to the significant weaknesses and flaws of this approach to treating this population.
RTCs arose out of the mental hygiene movement of the 1920s and the child guidance clinics developed to treat troubled children. Residential treatment centers were created to treat children who required more than outpatient care and as an alternative to either reform schools or large-scale mental institutions. “RTC professionals,” Doroshow argues, “were forced to seek out novel therapeutic approaches and professional structures to treat this newly identified seriously troubled group of children” (p. 3). These professionals “identified a new kind of person: the emotionally disturbed child” (p. 4). She believes that “the creation of spaces and the creation of new types of people were codependent; the identification of a population of emotionally disturbed children was necessary for the creation of RTCs, and the development of RTCs was critical to the understanding of who the disturbed child was and how he or she might best be helped” (p. 4).
Emotional disturbance as a diagnostic category with its associated treatment regime and locale arose during the post-World War II American quest to return to normality following two decades of economic depression and conflict. Emotionally troubled youth with their abnormal behaviors were seriously at odds with expected norms, and the RTCs were an effort to treat these children so they could behave appropriately and normally. As Doroshow puts it, “at RTCs, treating emotional troubles and building normal children were inextricably intertwined” (p. 4). For RTC professionals, normal children were “moderate” in their behavior and came from normal homes with two normal parents. Emotionally disturbed children exhibited extreme behaviors and often came from broken or abnormal homes and families. These professionals believed that it was often necessary to remove troubled children from abnormal situations to treat their disturbances and restore their emotional balance and behaviors to something approaching normal.
RTCs varied considerably in size and quality. Some were small, treating perhaps a dozen children, while others might house several hundred. Some RTCs were housed within larger institutions such as Bellevue Hospital in New York or the Menninger Clinic in Topeka, Kansas. Others were free-standing and independent. Most were unlocked and established as alternatives to the large, locked institutions and asylums characteristic of the early twentieth century. They were typically constructed and outfitted to resemble the normal home to which the children were expected to return. Many had small residential cottages overseen by house mothers or house parents. These places sought to establish a therapeutic milieu in which the children both lived and were treated. Psychologists, social workers, and sometimes psychiatrists spent their days observing and working with their patients in the therapeutic milieu. Understanding the basis for the child’s acting out, and working with him or her to modify their behaviors rather than punishing them for misbehaving, was at the core of the RTCs approach. RTCs were expensive to operate and could handle only a small percentage of emotionally troubled children and adolescents. Many were private patients whose parents could afford the cost. The typical patient was white and middle or upper class, although a few of the RTCs made an effort to admit black children and those from poorer families.
Doroshow traces the development of RTCs from their origins in the 1930s and 1940s. She discusses how a pioneering spirit animated many of the original advocates for RTCs and the ways in which they developed the new category of emotionally disturbed children. She also describes how and why they believed the origin of these disturbances could be traced to family pathologies. Other chapters focus on the individual therapies used with children, the casework with parents, and the therapeutic milieu that characterized RTCs. Advocates considered the therapeutic milieu a distinctive and original contribution in the treatment of this population. The therapeutic milieu “was to be warm, welcoming, and permissive, a noninstitutional institution differentiating RTCs from punitive, custodial institutions for children, such as training schools. Most importantly, the milieu would foster normality” (p. 7). The therapeutic milieu was designed to “resemble typical, white, middle-class American homes so that the children living there would have corrective experiences to erase the effects of their pathological ones at home” (p. 7). Every activity and interaction with the professional staff was “aimed at shaping normal children who represented moderation” in their emotional states and behaviors (p. 7).
Later chapters trace the decline and abandonment of RTCs in the 1960s and 1970s. Doroshow discusses “how RTCs found themselves on shaky ground in the face of increased costs, reduced funding, growing anti-institutional sentiment, and the community health movement” (p. 7). Some RTCs closed and others transformed themselves into “multiservice organizations offering a spectrum of services,” from residential to outpatient and day care options (p. 7). By the late 1970s, Doroshow finds, “residential treatment as an optimistic, progressive treatment option for the emotionally disturbed child was relegated to the margins of mental health care” (p. 8). In its place was a hodgepodge of professionals and agencies that parents had to negotiate to try to secure care for their troubled child.
Doroshow provides a thorough account of the rise and fall of residential treatment centers focused on the perspective of the professionals who developed, championed, and ran these therapeutic institutions. She provides some insight into how treatment in RTCs was experienced by the children housed and treated in them. However, children’s voices form only a small part of her study. This is due in part to a lack of sources; few first-person accounts of a stay in a RTC exist. More troubling, Doroshow quotes numerous generally positive comments and observations from resident children in official RTC publications. These comments needed more interrogation given that official publications were unlikely to publish any critical comments from their patient populations.
The book would also have been stronger had Doroshow more critically examined the standard of normality employed by RTC professionals in evaluating family life and the emotional status of their patients. Doroshow is undoubtedly correct in describing the professionals’ adherence to standards of normality in post-World War II America, but from a disability perspective that is a problematic stance, especially when normality equated only to white, middle-class families with two normal parents and normal children. Doroshow’s account would have been stronger had she explored more fully the cost to the children and their families of expecting them to conform to a single norm and treating them with a view to fostering that norm emotionally and behaviorally.
My concerns notwithstanding, Emotionally Disturbed is a valuable account of how many professionals sought to provide effective treatment and more humane care for troubled children in mid-twentieth-century America. Readers will come away with a good sense of the positive, even progressive, intentions and techniques that lay behind the movement for RTCs. They will also become acquainted with how RTCs functioned, their successes and failures, and why they were abandoned in the 1960s and 1970s as therapeutic theory changed, funding declined, and deinstitutionalization for mentally, intellectually, and behaviorally troubled children gained ground. Although RTCs had their flaws, we should not condemn them too harshly; they were a good-faith effort to help seriously emotionally disturbed children, and nothing that has replaced them has been an unqualified success.
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Citation:
Daniel J. Wilson. Review of Doroshow, Deborah Blythe, Emotionally Disturbed: A History of Caring for America's Troubled Children.
H-Disability, H-Net Reviews.
April, 2021.
URL: http://www.h-net.org/reviews/showrev.php?id=56403
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