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Administration and Financing

Administration

"Please note that under the mental hygiene law a person defined as mentally defective is one mentally ill and since mentally ill under the Mental Hygiene Law has equal significance with the term mental disease, it follows that an institution that cares for mentally defective is an institution for mental diseases. ..."

This quotation from an August 8, 1967, letter from the New York State Department of Social Welfare and pertaining to a private residential facility serving retarded young adults engaged in agricultural and industrial work projects illustrates a major source of the administrative problems that have been and are encountered in the development of mental retardation services. Administratively and fiscally, the mentally retarded person is claimed by the psychiatric profession as belonging in the realm of mental illness, but literature, service statistics, and psychiatric training abound with evidence that scientifically and clinically, psychiatry has been indifferent to mental retardation and largely still continues to be so.

In all the larger states of the Union one can observe a longstanding tradition that the problem of mental retardation belongs into the power structure directed by the psychiatric profession, i.e., into a department or division of mental health. As a logical consequence, the claim is made that institutions serving the mentally retarded are psychiatric institutions and must be developed under the medical model, i.e., by staffing key administrative positions on the state as well as institutional level with medical personnel and by viewing, interpreting, and structuring institutions like hospitals. Against this administrative construct stands the reality of the institution-made-to-look-like-a-hospital: the day-to-day routines encountered by the residents are not merely overwhelmingly devoid of the procedures of what the literature considers good psychiatric management, but are in many ways grossest violations of accepted psychiatric principles. Furthermore, the majority of the persons in institutions (excepting a few specialized facilities) are rarely in need of acute medical care, nor do they have acute psychiatric disturbances except for those that have resulted from the deleterious climate of the institution itself. The personnel problems which arise from this paradox of medical power structure in an essentially nonclinical setting will be reiterated in a later section on manpower. What needs to be added here is that typically the strongest force next to the superintendent is that of the business manager or steward who is geared to efficient management.

Efficient management is without doubt a useful concept but only there is clarity as-to the objective of such management. The irrationality which characterizes the management of residential facilities for the mentally retarded in this country is that it is related to the narrow mechanical objective of maintaining an institution rather than to the only tenable broad human objective, namely, the rehabilitation, education, and ameliorative treatment of the residents. The first objective considers the institution as an independent, self-fulfilling entity and is strictly internally oriented. The second objective looks upon the institution as one of many interdependent facilities and services, and judges its efficiency primarily in terms of the adequacy of residents' responses to its education, treatment, and rehabilitation programs.

While human management effectiveness is, of course, a universal consideration, it is of the most crucial significance in the field of mental retardation, where, speaking from a purely fiscal point of view, 3 or 4 years of intensive, high quality, multifaceted training and rehabilitation at $7,000 a year must be contrasted to the alternative of a routine program of institutional "care" over 25 or more years at $3,000+ a year.

Interdisciplinary Administration. Human management for the mentally retarded involves a multiplicity of disciplines (education, medicine, psychology, nursing, rehabilitation, social work, and others). Yet, true interdisciplinary collaboration is rarely encountered as a pattern of the administrative process. All the more significant is the concept of the directorate sketched by Bank-Mikkelsen in his description of the Danish mental retardation service. From the psychiatric side, Maxwell Jones (1968), the well-known British psychiatrist, recently pointed out: ". . . multiple leadership is probably the most important aspect of leadership, and it is here that there is the greatest need for change. The hierarchical structure of institutions, whether medical, industrial, or political, invest the leadership role with enormous power .... Multiple leadership means the distribution of authority and power to many people, and even more important to people who communicate freely in groups .... The principles of multiple or group leadership are difficult to apply to hospitals and infinitely more difficult to apply to the community".