What’s the difference between institutionalisation and
deinstitutionalisation?
Deinstitutionalisation has been described as ... "the process of
re-establishing people with intellectual disability in a community
through community based services".
Another way to describe the process is ... "the relocation of people
that are supported by an organisation or service into another setting,
where they have a greater opportunity to experience the same activities
as others within that setting".
In the above descriptions, the person still uses the support systems
that are provided by an organisation or service, or within the
disability arena. Issues of funding, responsibility, accountability,
staffing and personal care, transport and medical are the
responsibility of the organisation or service. The values, behaviours
and expectations (institutions) of the organisation or service provide
the institutions of the support used in supporting the person. The goal
is to facilitate the development of valued relationships and networks
within a community, where a person is valued as a part of that
community.
When moving to another setting, the particular institutions of the
setting may become more important than the institutions of the
organisation or service that provides the service. Any setting where
people live, work or play has its own particular institutions. They
can't be avoided.
Think of any activity you are involved with.
Think of the various institutions that may be involved with the
activity.
What are the various outcomes that may be associated with the
activity?
To deinstitutionalise can then be then thought of as a process of
consciously or unconsciously adapting or modifying a person or people,
their values, behaviours, the social structure, and the environment in
which they participate. What is actually happening is a process of
reinstitutionalisation, where, the outcomes change from negatively
valued to positively valued. While institutionalisation is often
referred to the situation of people with disability (especially people
with a mental condition), it is certainly not limited to this group.
Any
person or group of people become institutionalised to a greater or
lesser degree by the community,
organisation, culture or
ethnic group
of which they are a part of.
When moving from one community to another, we take on the values,
behaviours, responsibilities and expectations (institutions) according
to our particular role within the new community. A father in one
community may be a teacher, or a student in another.
The armed forces are a good example, where the members are conditioned
to behave according to a strict regime. A bikie gang epitomises the
antisocial culture, where the establishment is seen as the enemy.
Drugs, violence and antisocial behavior characterise the members.
However, they have a code of values, ethics, conduct, as well as a
strict hierarchy. Prisons, for example, are designed to provide
positive outcomes for their members, but how often do we see these
people learn the cultures and values of the others around them? This
process of institutionalisation also happens within ethnic communities,
hospitals, nursing homes, universities and other places of learning,
religious communities, sporting communities, organisations etc. This
does not mean that we should do away with these groups or services, or
that they are bad, evil places (although some may be - a value
judgment?), on the contrary, these groups and services have valued
roles and are valued within the wider community (debatable).
The Australian Institute of Sport is an example of an accepted
institution that people aspire to becoming a part of, yet the institute
shares most of the characteristics that are ascribed to people that
were placed in asylums etc.
The athletes:
... are separated from
others in the
wider community
... are poked, prodded and their every move is monitored and recorded
... are restricted in what they can eat and drink
... have to get up and go to bed at certain times
... training routine is rigorous
... are told what they can and cant do
... are confined to the facility
... whole life within the institute is structured around training to be
the best
We also see this happening within the football community where the
players lives are institutionalised by the formal/informal cultures,
objectives, hierarchies, goals, policies, constitutions, unwritten laws
or codes of behavior etc. of the Association.
The players:
... symbols of authority
... are professionals that are bound by the code of the club
... follow a strict regime of the club
... may have a high profile within the football community
... their every move is recorded, dissected, analysed and discussed
... they aspire to play in the national AFL comp, win player of the
year etc.
etc.
The characteristics of a university (learning institution):
... authoritarian hierarchy
... symbols of authority
... restricted areas
... strict code of behaviour
... division of members into groups
... set roles, behaviours and expectations
... group activities
etc.
The same thing happens within extreme religious communities, and to a
lesser extent in other communities that are organised around a
particular agenda. Just because devalued people may spend their whole
lives in institutionalised care does not mean that they are any more or
less institutionalised than the athletes/players/students in the
examples above. It does mean that the institutions of the
athletes/players/students have positively valued outcomes, and the
institutions of devalued people living in the asylum have negatively
valued outcomes.
Quite often we see ex-members of a community are still
institutionalised in the institutions of the community that they were a
part of. Members of the armed forces, for example, can not adjust to
living in a "civilian community". This also happens when people move
from one ethnic community to another ethnic community. They may be so
institutionalised in the old culture that they can not adjust to the
institutions of the new culture. Students that are institutionalised
within the education system may also find it hard to adjust to the
"real world" and find security within the education community
(perpetual students etc.). Anyone that moves from one community to
another has to find all the local facilities, build new networks and
relationships within the new community, understand the local language,
the customs, values, behaviours, attitudes and expectations, the
culture (institutions) of the community.
We also see a merging of cultures and institutions within a community
where different groups live together and share resources. Where these
new cultures and institutions are not seen as threatening or divisive
they are often used to the advantage of both groups. When these new
cultures and institutions are seen as threatening or divisive, there
may be some conflict, violence or discrimination between the groups.
The members of one group may be devalued as a group, separated,
marginalised or disenfranchised. There is usually some characteristic
of the group that is used to justify there treatment (assigned
devaluing labels etc.) that allows the community to treat the members
of the devalued community as different. They may be attacked,
discriminated against, or just ignored. Fundamental differences between
cultures and communities has resulted in riots, civil conflicts and
deaths, where members cannot resolve their differences. These
differences may become so institutionalised into the culture of the
society in which these communities live, that generations pass down
these attitudes to new generations so they become a normal part of
life. This can happen to any person or group, where they are seen as
different, or are a threat to the community as a whole.
Think of a setting/activity, and the members of the community within
the setting/activity. Think of the institutions of the setting/activity
as the paint that covers the setting/activity. We can choose to paint
the setting/activity black (outcomes are negatively valued) or white
(outcomes are positively valued), or even grey, where the outcomes are
a mix of negative and positive values that are specific to the needs of
the setting/activity.
"Social
Role Valorisation is intended to address the social and
psychological wounds that are inflicted on vulnerable people because
they are devalued, that so often come to define their lives and that in
some instances wreak life-long havoc on those who are close to them.
SRV does not in itself
propose a
'goal'. However a person who has a
goal of improving the lives of devalued people may choose to use
insights gained from SRV to cause change. They may do so by attempting
to create or support socially valued roles for people in their society,
because if a person holds valued social roles, a person is highly
likely to receive from society those good things in life that are
available or at least the opportunities for obtaining them. In other
words, all sorts of good things that other people are able to convey
are almost automatically apt to be accorded to a person who holds
societally valued roles, at least within the resources and norms of
his/her society". (Wikipedia: Social role valorisation)
"The
major goal of SRV is to create or support socially valued roles
for people in their society, because if a person holds valued social
roles, that person is highly likely to receive from society those good
things in life that are available to that society, and that can be
conveyed by it, or at least the opportunities for obtaining these. In
other words, all sorts of good things that other people are able to
convey are almost automatically apt to be accorded to a person who
holds societally valued roles, at least within the resources and norms
of his/her society." (P.1) ... "For example, while SRV brings out the
high importance of valued social roles, whether one decides to actually
provide positive roles to people, or even believes that a specific
person or group deserves valued social roles, depends on one's personal
value system, which (as noted above) has to come from somewhere other
than SRV." (P.4) (Joe Osburn: An Overview of Social Role Valorization
Theory)
It could then be argued that by applying the principles of SRV to the
particular setting that is supporting people with disability, there is
a conscious process of changing our values, behaviours, the social
structure, and the environment in which we participate, and that all
participants are being institutionalised, in behaving within a defined
set of goals, values, roles and behaviours that promote valued roles
for disadvantaged people.
From the above, it can be seen that deinstitutionalisation is the
process of changing the outcomes of a setting from a negative value
(black) to a positive value (white).
Negatively
valued
outcomes : low expectations, conform, structured
around the
needs of the staff etc.
Positively valued outcomes :
high
expectations, individual, structured around the needs of the residents
etc.
It could then be argued that disability service providers today provide
the same, or a similar model of care as the institutions of old, and
the only difference is that the outcomes of the service provider today
are positively valued (or at least by the supporters of the current
model of care).
From the above it can be seen that institutions themselves are never
good or bad. While they all contain the same or similar
characteristics, it is the values of the outcomes that determine
whether the institution is good or bad.
For the athletes who live
in
institutional care the goal is to represent Australia.
The players of the football club have a goal of playing in the finals.
Members of religious institutions have a goal of becoming closer to God.
Education institutions have a goal of providing skills and knowledge to
its members.
Corrective services have a goal of rehabilitating its members.
The goals of nursing homes and other facilities that support people
with high support needs is to provide the best care that is appropriate
to the person.
The outcomes of these institutions are seen as positively valued.
The goal of nursing homes, Asylums (a safe place) Psychiatric hospitals
etc. were originally intended to provide a better quality of life for
the residents, however over time these communities became larger and
larger. The outcome was that the residents of these communities lost a
lot of their rights and normal living conditions. The wider community
also contributed to the conditions that these people lived in by
promoting them as deviant etc. (Bethlem Royal Hospital etc.). The
outcomes of these institutions are now seen as negatively valued. By
changing the outcomes of these institutions within these buildings from
a negative value to a positive value, we change the conditions within
the buildings, where the residents have a better quality of life.
Alternatively we can place people with high support needs (severe
disability, aged etc.) in other community based services that are
designed to provide a better quality of life (deinstitutionalise).
People with high support needs may find it difficult to develop these
new networks and relationships and become isolated. The aged may lose
the support networks that they had (their families have moved, their
friends have passed away etc.). Depending on the person's needs, the
person may be dependent on one or more services (transport, home help,
personal help, financial help, medical needs, skills development,
special equipment etc.) that are not available in the wider community.
The person then has to rely on an organisation or service provided that
has the resources to support the person, The organisation or service
provider has its own formal/informal cultures, values, expectations,
objectives, hierarchies, goals, policies, constitutions, unwritten laws
or codes of behaviour etc. (institutions) that the person has to fit
into. Whether the person is advantaged or disadvantaged by these
institutions depends on whether these institutions have positively or
negatively valued outcomes.
Think of any activity you are involved in:
what are the objectives of
the activity?
what is the structure of the activity?
what are your relationships within the activity?
what are the formal and informal beliefs, values, roles, expectations
and behaviours within the activity?
are the institutions of the setting and the activity positively,
negatively valued or a mixture?
Full circle
Is this the future of services that support people with high support
needs
(aged, severe disability etc.) ????
While asyulms were origionally a place of safety or retreat from
society, they
became places of hardship, deprivation and depravation. What started as
small hospital facilities soon became large buildings that supported
hundreds of people. Built around a medical model of care, a culture
evolved that enabled a small number of people to support a large number
of people. Social policy
was to hide these groups behind walls, where society was protected from
the activities that happened within those walls. There has been a great
deal written about the values, behaviours and attitudes of the system
that supported the residents of these buildings within society. Because
they were in long term institutional care, the term "Institution"
referred to the building, the culture and the outcomes of the building
and the culture. While the charasteristicts of this institutional care
was similar to other institutions, the outcomes were different. Today,
we see small services evolve into organisations that
support different groups within society. Organisations are getting
larger to cope with increased demand for
services. As an organisation gets larger, more resources are needed to
support the organisation. Things wear out and need replacing. New
equipment and technology
replaces old and outdated equipment and technology. Direct care staff
need to be increased to meet the needs of its clients, which means more
support staff are needed to meet the needs of the direct care staff.
The
organisation also has its own needs in fulfilling its
role in providing for the needs of people with disability.
If the
service provider can not provide for its own needs or the needs
of its clients, the culture and institutions of the service provider
change,
so that the basic needs of its clients can be met, and other
needs that are considered as not important are not met.
For example the normal staff ratio may be 1 staff to 4 clients. As the
service grows, and the service can not get the extra staff because of a
lack of funding, skills or available workforce, then the service has to
prioritise needs as well as ration resources. Because the service
provides direct intervention in supporting its clients there may be no
other service that can provide support. The result is that the service
may become the Asylum that Goffman, Wolfensberger
and others wrote about in the past.
This is most noticeable in nursing homes where costs increase and
suitable staff are scarce. The nursing home tries to cut costs and
ration resources and as a result the clients are not getting all their
needs met. Hospitals are also suffering from a lack of skills and
resources. People are not getting the proper care, patients are left in
corridors because of a lack of space, etc. etc. This also happens
within disability service organisations
where the needs of the organisation become more important than the
needs of the clients. Administration, OHS, payroll, maintain, staff
training, policy development, volunteer coordination, area
coordination,
medical staff, transport, recreational, employment, direct support
staff, relief management, relief staff - just to name a few
roles
that
the organisation
may have - may mean that there are 200+ people supporting 100 clients.
When providing the most
appropriate
care for people with high support
needs ...
1) The community is not
where the
person is living, but where the
person participates, shares experiences and has valued relationships
with others.
2) People with high support needs (severe disability, aged etc.)
will always need support structures as a part of their lives.
3) The amount of participation in a community (living, education,
employment or recreation) is directly related to the skills and
resources of the person, and, the skills and resources of the
community that the person wishes to participate in.
4) Institutions are going to be around in one form or another
whether we like it or not, It is the way that they are used that is the
problem.
5) The institutions of a society towards a particular group
determine the way the group participates in society.
6) The institutions of a particular government department,
organisation,
profession or service define the way the person is supported within
that society.
7) Facilities that support people with high support needs do not
need to be the nursing homes or prisons in the
sense
that they are today, but can become warm inviting community places that
offer a range of services to the community, as well as be a part of the
wider community within that society.
8) People with high support needs are a minority group in our
society, and will have the same problems as other minority groups in
being a part of society.
Peter Anderson
http://www.psawa.com
