Thoughts on Group Service Models for People with Disabilities

groups
In my speaking and writing, I often tout the need for services to be individualized, and take issue with the congregate models we generally see from agencies and schools in the forms of group homes, day programs, and classrooms. Often, there is pushback from families and providers. I frequently hear:
– “What’s wrong with letting people socialize with each other?”
– “It’s their choice to be with each other.”
– “I’m
[Jewish, Italian, African-American, etc.] and [live, work, play] with people with my same label.”
Good points, but these arguments miss the mark. They represent a kind of binary thinking (disability groups are bad/good) that is all too common. They oversimplify social grouping, which is a sophisticated sociological phenomena. Understanding how groups function is a key to successful individual community life as well as personal self-worth. 
Groups can provide important social cohesion. This can be very positive for when an individual wants to validate his or her social identity, or share experiences with people who have some commonality. For a repressed minority group, it can be particularly important. A person can establish self-identity and take pride in it. In-group members relate with others who have shared experiences and cultural expression. Group members can form a basis for friendship, and advocacy of the shared commonality. Indeed, many people who are deaf, or who have dwarfism, for example, express strong preferences about living among others with the same life situation for a variety of reasons. And peer support groups for persons with mental illness have been shown to be helpful for group members.
But the difference on making an educated decision to voluntarily join a group for social cohesion, support, or advocacy, versus having a group experience imposed on you is huge, especially in regards to individuals with disabilities. People benefit from having a range of social experiences and participating in groups defined by different gathering reasons, and then being able to make educated choices about how they want to experience their communities. 
There is also an important social perception issue related to disenfranchised groups in which the group members are subject to negative stereotypes. What happens is that when an individual is seen as part of a group, the group commonality becomes prominent and defining. This leads to sociological issues when the commonality is not particularly valued, including prejudice and bias, intergroup hostility, and discrimination.
Group definition plays out in the context of how providers organize services. If you have a certain “functioning level,” or a label such as autism, behavior problem, intellectual disability, etc., your service experience will likely be more defined by that characteristic, rather than by your personal life needs (job, home, etc.). While a “treating-the-problem approach” is common in a medical model, it produces a severely limiting life experience for someone with a disability. They become “boxed in” by perceived and potentially misunderstood disability and support needs in terms of employment, housing, recreation, and more. Not only that, but individuals with disabilities often find themselves surrounded by others with the same disability or “level of function,” limiting access to others who might mentor, model, or perform at a higher level.
Fully understanding how to make good decisions about what groups to be a part of, in what context, and for how much of one’s life is a big decision people must make. Whom do I live with, what kind of work do I do, whom do I have fun with are major questions for us all. What professionals shouldn’t do, though, is track people into pre-made groups as answers to these questions based on their disability label. This ultimately limits the answers to those models that disability professionals have artificially created. 
So, consider the kinds of questions we ask:
  • It’s not: What disability work crew you want to join?; It’s: What kind of job do you prefer?
  • It’s not: What group home you want?; It’s: How do you want to live and with whom? 
  • It’s not: Do you want to go to the mall with other people from your residential placement?; It’s: What do you want to do for fun and with whom?

And remember, if all your previous experiences have been defined by group homes, workshops, crews and enclaves, and all your friendships have developed from group home co-residents placed by others, then saying your current situation is your “preference” is really not choosing at all. When someone understandably selects the only thing they have known, then we have failed to support him or her in understanding all the possibilities.

The Support Gap: Research to Practice and Back

Over the years, I have visited many agencies doing their work in the service of people with disabilities. In the process I’ve met many caring staff. But caring, while important, is really far from enough for people with disabilities to succeed. We also need to understand people’s goals and how to help them get there. A big problem we face is what I call the “Support Gap.”
The Support Gap has really two components. 
One relates to the flow from research to practice. It is the difference between what research has already uncovered (what we should know how to do), and what we actually do in the disability field. The size of this gap is striking. Disability thinkers have developed various impressive approaches, even technologies, if you will. We now know so much more about life planning, for example, than 20 years ago. There are a number of books and other resources available on ways to facilitate person-centered planning using various approaches. The same is true about job development and support, community living, environmental modification, assistive technology, positive behavioral support, and so on.
Unfortunately, in a system serving over a million people with developmental disabilities, most providers have not come close to using such state of the art approaches as their standard. It’s not for lack of desire; but funding, turnover, inefficient or unavailable training are too often the case they face.
The second component relates to what research hasn’t studied, or the flow from practice to research. It seems to me that anecdotally and based on studies, we have good reason to believe generally that person-centered, community approaches lead to superior results for people with disabilities. And philosophically, it makes a great deal more sense to focus on individual capacities and desired futures as opposed to deficits and remediation. 
But frankly, there is little quality research to support how best to provide these kind of services. What’s more, we know practically nothing about what specific approaches within the general person-centered paradigm work better, or when or how to use them in certain types of situations, such as in careers, community inclusion, or housing. 
Consider current housing models used for people with disabilities. The variation in cost for different residential homes is huge. Some institutional settings can run upwards of $200,000 US per resident annually, while family support or more individualized supported living costs a fraction of that amount. Even group home costs range widely from state-to-state. 
Even more important than cost, the quality of life experienced in these various settings also varies widely from model to model, including within a model from place to place. Think of it, two different six-person group homes just miles apart can produce wide-ranging outcomes in life experience and cost. 
It should trouble policymakers and taxpayers that so little is known about the outcomes of spending billions of dollars. As a result, the field argues about models on a philosophical level – what is the best approach from a cultural perspective, or whether closing an institution removes “choice,” for instance. We really need to align research and practice more efficiently. Then as we learn the answers, we can begin to align the system to what works best and is most cost-efficient, and at the same time, aligning our supports to be non-discriminatory and socially just.

Restrict Choice? You Bet!

Numerous recent comments sent to the US Administration on Developmental Disabilities from the “Voice of the Retarded” have centered on maintaining a range of choice as the main argument against the desegregation of institutions into the community. See (http://www.envision2010.net/others.php) Institutional and sheltered work advocates have long relied on the “choice” argument to support their views. They say ending segregation removes an option for them about how they want their family member’s life to be. They go on to say community-based services can be unsafe and inadequate. 

They have set up a false choice.

It is false because we should never use taxpayer funds to segregate people who have done nothing wrong, whatever disability challenges they pose. Government sets priorities all the time about what choices it will provide its citizens and what it will pay for. There is no inherent right to be housed in an institution at taxpayer cost. If an option has been shown to be ineffective, morally objectionable, and comes at a higher cost than other community-based alternatives, it need not be an available choice. Most everyone agrees that we have a moral obligation to support our citizens with disabilities, but there is nothing implicit in that belief about doing so through an expensive, taxpayer-funded model that takes people out of society and puts them in a simulated society “for their own good” when we have more cost-effective, integrated solutions available.

As important, people don’t need institutions because some community settings offer inadequate support. People don’t need workshops because sometimes a job doesn’t work out. The solution to this is to improve community support to the quality level we know that works from research, not build substitute, artificial communities. 

Society absolutely knows how to properly support people with medical, learning and behavioral challenges without resorting to institutional or segregated placement. It also is time that institutions, an obsolete service model, are finally removed from the menu of choice. A number of states have done so with good evidence to support the improvement in quality of life for people with disabilities. With what we know today about how to support people in community settings, where all of us belong, it is simply wrong to offer segregated options, as the Supreme Court Olmstead decision implies. 

The Fallacy of the “Choice Argument”: Most People in Sheltered Workshops Want a Job

Despite numerouse national and state policies promoting integrated employment, 76% of adults with intellectual or developmental disabilities are served in facility-based, segregated programs – usually work activity centers or sheltered workshops. Whenever advocates talk about closing a sheltered workshop so the people there can get real jobs, the argument of choice is raised. “But this is where they want to be…” You are taking away their right to chose…”

In a recent article published in the Journal of Vocational Rehabilitation, authors Migliore, Mank, Grossi and Rogan look at whether or not this gap between policy and practice is in part due to the lack of interest of adults with intellectual disabilities and their families for employment outside facility-based programs.

The authors surveyed 210 adults with intellectual disabilities in 19 sheltered workshops, their respective families or caregivers, and staff members in these workshops. They found that 74% of adults with intellectual disabilities, 67% of families, and 66% of staff felt those they serve would prefer employment outside workshops, or at least consider it as an option. The majority of all groups believed that adults with intellectual disabilities can perform outside workshops if support is made available.

The study highlighted the fact that the preference for employment outside of workshops is not associated with the severity of the disability. So, who is restricting choice? Perhaps it is those who insist that employment service dollars be spent on an obsolete model.

Source: Migliore, A., Mank, D., Grossi, T., and Rogan, P. (2007). Integrated employment or sheltered workshops: Preferences of adults with intellectual disabilities, their families, and staff. Journal of Vocational Rehabilitation Vol. 26, No. 1, pp. 5–19.

Does Inclusion Restrict Choice? Or Does It Offer More?

I recently received an interesting letter from a gentleman with a disability who states the he feels “very at home among the handicapped.” He wonders why I have such a stress on inclusion. Is that not “cutting off an option?” – that of being with others who also have a disability?

A fair question. I think this notion of inclusion (meaning you are taking my choice to be with other people with disabilities) is a common misperception. Integration for any minority should not eliminate the right for that minority to decide to come together – to live, recreate, socialize, marry, share, or for political advocacy. It isn’t only one way or the other.

What I am opposed to is the forced segregation of people with disabilities. (I realize “forced” is a strong word. People can of course choose to not do anything. But generally, if you want to have an education, a job, or a place to live, your options are forced into segregated ones.)

When confronted, segregation proponents usually offer a defense that boils down to several components, one of which is, well, they like their “own kind.” I remember hearing this argument used to explain why black Americans were made to go to separate schools, or ride in the back of the bus. “They like being together.” Of course people are drawn to others who share a commonality – and that can certainly include having a disability. But that is a sad excuse for restricting equal access.

Civil rights means a level playing field and the absence of imposed segregation. It also means you have more choices and diversity about where you work, whom you socialize with, or who will be your classmate.

Let’s just take the work domain. Right now, if you want to work and you happen to have a disability, for 90% of the population with severe developmental disabilities, that means a sheltered workshop. A place where only other people with developmental disabilities will be. A job match should be about several things, including your interests, skills, and where you can be most productive. A workshop provides none of this –

So does inclusion cut off an option? On the contrary, I believe it opens them up.