Treatment of the Mentally Disabled: Rethinking the Community-First Idea

Abstract

In the past several decades the treatment, habilitation and education of the mentally disabled has been heavily influenced by what could be called the "community-first" movement. This movement which encompasses such developments as deinstitutionalization, the least restrictive alternative doctrine, normalization, mainstreaming,and outpatient commitment-is based on the idea that, in caring for the mentally disabled, we should favor placement in the community rather than in institutions segregated from mainstream populations. The community-first idea is not unanimously supported. But Congress, many courts, and countless advocacy groups composed of lawyers, mental health professionals and laypeople have rallied behind the community first standard as a means of providing more effective treatment, habilitation and education with fewer restrictions on liberty and less stigmatization. The burden of this article is to highlight the challenges to this near consensus. Although the community first notion clearly offers much that is good, we should recognize that in at least some contexts it has had significant adverse consequences. Some community-based approaches are based on flawed premises. Even if these flaws were eradicated, serious implementation problems abound. This article examines some of these conceptual and practical problems. The purpose of canvassing the dark side of the community-first idea is to curtail blind endorsement of it and to suggest, in a broad way, reforms of the reforms.