Twenty predictions about the future of residential services to the mentally retarded are presented. These changes imply: (1) an entirely new model of residential services; (2) increasing continuity between residential and nonresidential services; and (3) increasing acceptance of cost-benefit rationales in the decision to offer residential or other services.
From about 1850 to 1920 the field of mental retardation in the United States evolved dynamically, even if not always in desirable directions. Then a period of stagnation set in that lasted for 40 years (Wolfensberger 1969a). Now, change and ferment has returned to the field, and services and especially service-relevant concepts are evolving at a dizzying speed. Because of the historical role which institutions have played in retardation, change in this specific area of service has a special significance to the field.
In this essay, I will submit 20 hypotheses regarding the future of residential services. I believe that some of the events I am predicting are inevitable, and that it will be only a question of when, not if, they will come to pass; other predictions are seen more as high-probability statements. Some people will approve of the advent of some of the predicted events; others will not. I, myself, will not be happy to see all of these predictions fulfilled. However, to the degree it is possible, we should not let our personal feelings—one way or the other—stand in the way of attempts to assess reality. Anticipation of, and preparation for, likely future events is much more adaptive than an attitude of denial or impotent passivity. To quote an old cliche: even an army cannot prevent the arrival of an idea the time of which has come.
Most of the hypotheses to be presented here are not new; many have been advanced or suggested by various contributors to the recent book on Changing Patterns in Residential Services for the Mentally Retarded, edited by Kugel and Wolfensberger (1969), and sponsored by the President's Committee on Mental Retardation. However, I will attempt here to collate a number of the explicit predictions from that volume, to sharpen some of the implicit ones, and to formulate into predictions those recommendations made by some of the contributors that have high probability of being implemented. The rationales and bases for some of the predictions may not be immediately apparent, but for these the reader is referred to the above-mentioned book.
1. The concept of the “institution” will disappear; instead, a broader concept of “residential service” will take its place.
2. The concept of “care,” as in the phrases “residential care” or “institutional care,” will either disappear or acquire a new meaning, and be replaced by the concept of “residential service.” If the concept of “care” services survives, it will apply only to residential services which either specialize in the maintenance of life of the most severely handicapped or serve the infirm aged retardate.
3. Widely prevalent institutional practices historically derived from a perception of the retardate as either a sick person or a menace to society will be replaced by practices which emphasize the developmental capacity of the retarded. The grossly dehumanizing practices (Vail 1967) still common in today's institutions (Blatt 1969; Nirje 1969a) will yield rapidly to legal action, to parent militancy, and to popular disapprobation. In other words, the “menace model” will disappear; the “medical model” will be confined to a few highly specialized facilities (see No. 11 and 13 below); and the “developmental model” will gain vastly in acceptance. These three models are detailed elsewhere. (Wolfensberger 1969a; especially Dybwad 1969 in regard to the medical model).
4. The widely-used concept of “treatment” of institution residents, closely associated with the medical model, will be subsumed under a broader concept of “management” (or some other term) which will refer to a wide range of actions and practices—both medical and nonmedical.
5. The principle of normalization developed in Scandinavia, described by Nirje (1969b), and illustrated by Bank-Mikkelsen (1969) and Grunewald (1969) will become the most important human management principle in retardation and will govern the location, design, and operation of residential services.
6. Increasingly, newly established residential centers will be small, specialized, dispersed, and community-integrated. By small, I mean residences for six to 20 persons. Specialization refers to the identification of a single overriding function associated with a residence, such as maintenance of life, habilitation, habit shaping, shelter, detention, etc. (See No. 11 below.) Dispersal not only implies a more equal distribution of residences within larger areas such as states, but even within small areas such as cities and sections of cities. Furthermore, the distribution of residential units will closely follow the population distribution. Community integration implies location of small residences in neighborhoods affording intimate contact with ordinary citizens and ordinary community resources. These concepts are elaborated by Nirje (1969b), Tizard (1969), Dunn (1969), and Dybwad (1969).
7. Increasingly, services now considered part of residential services will be provided by other administrative structures. For instance, work training, work assignments, education, health services, recreation, and other services have characteristically been provided by the traditional institutions, and on the institution grounds—often even in the very building in which the retardate lived. In the future, residences will increasingly be viewed as places in which to sleep, eat two meals, and do some of one's living. Generally, all the services mentioned will be provided elsewhere and by ordinary community resources. Thus, children in residences will go to public community schools; community physicians, clinics, and hospitals will attend to medical problems; work training and placement will be in schools, sheltered workshops, and/or business establishments in the community; swimming, bowling, dancing, movies and such will all be shared with the nonretarded in the community; shopping will be in ordinary community stores and shopping centers rather than in canteens. (See especially Nirje in Kugel and Wolfensberger 1969.)
8. In the early U.S. institutions for the retarded, in contemporary small and usually private residences, and in many institutions abroad, some of the caretaker personnel would live in the same residential unit as the retarded, and function in a houseparent role markedly different from the typical institutional attendant role. Return to small, dispersed, normalized and normalizing community residences will be accompanied by a marked increase in the use of such live-in houseparents.
9. The trend toward community-integrated residences will be accompanied by increased local participation in the funding of residential services.
10. Specialization in the function of residences will be accompanied by their being modeled on specific and characteristic disciplinary modes of functioning, as in areas such as correction, education, habilitation, medicine, psychology, and social work. Residential units will be administered by persons from that discipline which provides the primary service in which the residence is specialized (Dunn 1969).
11. Optimal specialization will probably result in the creation of 10 to 12 types of residential facilities. Briefly, these are summarized in Table 1. More detailed descriptions of these residential service types, inspired by the writings of Dunn and Tizard (e.g., Dunn 1969 and Tizard 1969), can be found in Nebraska's Governor's Citizen Study Committee (1968a, 1968b), and in Menolascino, Clark and Wolfensberger (1968a, 1968b). Residential units of types 3, 4, and 8 will be by far the most common ones.
12. Residential services for retarded persons above the ages of 45 to 50 will be provided increasingly by facilities that are oriented toward the aged generally, rather than the retarded specifically (Dunn 1969).
13. The greater the specialization of small residences, the more likely it is that traditional institutions eventually will disappear entirely. The main reason traditional institutions still exist even in countries which are most progressive in regard to residential services (such as Denmark and Sweden) is, I believe, the fact that these countries have developed only about four or five specialized types of residences.
14. A number of trends will result in reduced incidence of severely damaged infants; although counteracted by prolonged life expectancy of retarded persons, the net effect will contribute toward a reduction in need for residential places for retardates below the age of about 40 years (Tizard 1969). Need-reducing trends will include:
a. Further preventive advancements in medicine relevant to reproduction and child health;
b. Improvement of health services to and the quality of life of disadvantaged and high-risk mothers and children;
c. Continuing reduction of the birthrate consequent to increased practice of contraception by women generally and teenage and other high-risk mothers specifically;
d. Increased legalization and practice of abortion in high—risk pregnancies;
e. Extension of early childhood education, especially to children exposed to influences greatly adverse to intellectual growth; and
f. Increase in adoptive and foster placement of retarded children, in part due to: (1) more aggressive agency pursuit of such placements; (2) increased acceptance of deviancy on the part of the public; and (3) development of more realistic support structures, such as family services, counseling and financial subsidy for such placements.
15. Because of further increase in the longevity of the retarded, there will be increasing demand for residential places for the adult retardate above the age of about 40 years (Tizard 1969).
16. Development of comprehensive community services and support systems to families will also contribute to a reduction of the proportion of residential places for all age groups except for adults above the age of about 40 to 45. Particularly, the implementation of family sub-sidies in lieu of residential placement will contribute significantly to a lowering of demands for removal of retarded persons from the family home (Wolfensberger, 1969b).
17. The advent of the predicted small, specialized, dispersed, community-integrated residences will:
a. Result in an increase in short-term residential placements;
b. Reduce the relative need for long-term residential placements (except for the above-45 age group), and will do so in a multiplicative fashion if comprehensive community services are also available;
c. Result in more overnight and extended home visits by both long-term and short-term residents; and
d. In many cases be more economical than similarly staffed large all-purpose institutional residences for equivalent types of retardates.
18. The multiplicative effect posited under 17b will be enhanced where continua of residential and non-residential services are administered by a single agency.
19. With the advent of most of the predicted developments, and excluding the effect of uncertain events such as war, epidemics, and economic chaos, the need for group residential places for retardates below the age of about 40 to 45 will be about .3 to .5 per thousand persons in the general population below ages 40 to 45, in contrast to the currently inadequate overall rate of about 1.2 per thousand. No prediction is ventured regarding the ratio of places for retardates above the ages of about 40 to 45.
20. There will be increasing acceptance of cost-benefit rationales in human services. Decisions to utilize residential services will be based on probabilistic cost-benefit estimates, which are empirically supported and which take into account the likely benefits to retardate, family, and society, as well as a wide range of service options and their social and financial costs. The current practice of basing service decisions on essentially clinical as well as highly inconsistent judgments will be devalued (Wolfensberger 1969b).
Human management practices almost invariably follow prevailing cultural values. Because of a series of historical accidents, our residential practices are even further behind cultural values than most cultural practices. Thus, there must and will be change! Not only are the present practices of residential services outdated, but the very model is from another age—an age less tolerant of deviancies and with peculiar perceptions of the nature and role of the mentally retarded. By changing this model, we are merely catching up, since we are already 40 years behind what is known about the retarded.
The specific predictions made here may or may not come true, but the predicted trends appear to be in the air and consistent with our zeitgeist. And the zeitgeist all around us, in almost every human endeavor, is not much for the patching up of broken models; it discards them for new ones. The model implied by Nirje, Dunn, Tizard, and Dybwad is the only one on the horizon that is both truly new and consistent with contemporary values.
The writing of this paper was supported by USPHS Grant No. HD 00370 from the National Institute of Child Health and Human Development. The paper is based on a presentation given at the 1968 convention of the National Association for Retarded Children in Detroit. I thank Frank Menolascino, Paul Pearson, and Angela Hilton for critical readings of earlier drafts which resulted in significant revisions.
Originally published in 1969: Mental Retardation, 7, 51–54.