History of Therapeutic Placements

My professional organization was kind enough to allow me to contribute the following article to our magazine.

A Brief History of Therapeutic Programs, Placements, and Professionals

It is said that inside every 70-year-old person is a 12-year-old screaming, “Wait a minute, what the heck just happened here?” Similarly, I have apparently turned into an “elder statesman,” someone with institutional memory . I therefore thought it might be helpful to newer practitioners and to the families we serve to provide a little background on how therapeutic consulting got to where we are and why we’re likely to stay both life-saving and controversial.

Let’s start with who we were as a profession. To a person, therapeutic consultants have a graduate degree. Some of us have a JD or an MBA, but the majority of us are licensed clinical social workers, therapists, or school psychologists. A few of us have a PhD in psychology and can administer psychoeducational assessments, sometimes called “testing.” More importantly, some number of us came to making recommendations about wilderness therapy, therapeutic boarding schools, and residential treatment centers because we needed that advice for our own families and had to invent the wheel for ourselves years ago.

We knew we were in trouble when conversations like the following became common. “What time should I pick you up from school today, honey?” “Don’t pick me up. I hope your breast cancer comes back and you die, you f***ing b**ch.”

When we heard these ugly words—repeatedly—from our adolescent child, we knew we needed more significant help than we had been getting. Having exhausted suggestions from pediatricians, psychologists, and psychiatrists; as well as advice from family, friends, and strangers in the supermarket, the parent quoted above needed recommendations for treatment.

Our sons were oppositional, defiant, angry, acting out, refusing to go to school, and underperforming when they did attend. Our daughters were anxious and depressed, acting in rather than acting out, harming themselves with disordered eating and sharp objects.

What treatment options were available? In the 19th and early 20th centuries, we didn’t have “therapeutic boarding schools.” We had asylums, reformatories, and “training schools.” If a child struggled with what we now call ADHD, Oppositional Defiant Disorder, or complex trauma, they were often labeled with “moral insanity.” The prevailing wisdom was that these children lacked character or discipline. Talk about blaming the victim!

Placements in the bad old days weren't about clinical intervention; “solutions” were about containment. If a child from a wealthy family was “difficult,” they might be sent to a military academy or a remote boarding school to be “straightened out.” For those less fortunate, the state provided industrial schools—essentially labor camps designed to keep “wayward” youth off the streets. There was no talk of neurodiversity or emotional regulation. There was only the rod and the rulebook.

The shift toward something resembling modern therapeutic placement began mid-century, spurred perhaps by the psychoanalytic movement. Therapeutic consultants were not the first to see children not as broken machines, but as wounded psyches. The 1950s and ‘60s saw the birth of the “residential treatment center” (RTC). These clinical, cold, psychiatric hospitals-lite would not be recognized or accepted today. But they represented a massive leap forward: the acknowledgment that emotional struggle required treatment, not just punishment. During this era, pioneers like Bruno Bettelheim (despite later controversies) popularized the “milieu”—the notion that the entire environment, from the dining hall to the dormitory, could be a tool for healing. This was the seed of the modern therapeutic boarding school. The one-hour therapy session as the sole catalyst for change gave way to consideration of the other 23 hours of the day.

Wilderness therapy programs, therapeutic boarding schools—an outgrowth of the old “emotional growth” boarding schools—and then residential treatment centers began with a couple of hippies who bought land in Montana or somewhere and accepted a few “tough” kids to board and teach. One of the partners—in the marriage and the facility—taught English, handled admissions, was a dorm parent, did most of the cooking, and handled the administrative tasks of sending report cards. The other half of the partnership was responsible for cutting the grass, shoveling the snow, working as a therapist, tracking the students who tried to run away, and filling out tax forms. To say this was a labor of love doesn’t begin to describe the commitment and the round-the-clock responsibilities. “Vacation” was sleeping in until 8:00 a.m. one Sunday morning a month before waking up and cooking breakfast for the half dozen “troubled teens” in residence. When the seventh adolescent enrolled, the mom-and-pop organization could hire an actual maintenance person—who also helped with the food prep, taught math, and took care of the horses.

Fast forward a few decades and many programs are now run by corporations. Therapeutic consultants are in relentless contact with one another to discern, in George McGovern’s apt term, “chicken salad from chicken shit.” We tour programs as individuals; we visit facilities on our own; we write up our perceptions; we meet constantly in groups of two or 20 of us. We have no pride of ownership. “Did you hear that Dr. So-And-So is leaving her program and starting her own facility?” “Did you get the notification that this program was bought by that one?” “That program that we all used to trust is now only concerned with their census—'heads in beds.’”

All information is available to any and all of us, so we can give updated, unfiltered intel to the families whose lives are entrusted to our care. When a family walks into our (sometimes virtual) offices, they aren’t usually looking for a history lesson. Nor do they typically care how we came to do this work that we love. They’re looking for a lifeline. They’re exhausted, frustrated, angry. Not to put too fine a point on it, but it is the sacred duty of therapeutic consultants to help our families find their way back to healing and health.

And what of the family quoted at the beginning of this essay, the young man who told his mother to do that which is anatomically impossible? Ten years on, they get along brilliantly. Words that can never be taken back are nonetheless now long in the past. Mom is expecting her first grandchild—and the gentle revenge that will come from watching her son, who was once out of control, hopefully avoid the kind of adolescence that she endured.