"The Myth of Clinical Judgment" notes

The next episode of Alyssa reads a thing and shares notes is for "The myth of clinical judgment" in the Journal of Social Issues. Citation:

Biklen, Douglas. "The myth of clinical judgment." Journal of Social Issues 44.1 (1988): 127-140.

Biklen notes that people with have historically faced exclusion from education, social rejection, limited physical access to society, and segregation within institutions, and that typically people facing such treatment would be considered a marginalized minority.

“Yet the more common tendency has been to view people with disabilities as (a) victimized by a disabling condition and (b) in need of treatment-- not of rights.” (128)

Officially, the appropriateness of educational and residential treatment, placement, and supports for people with disabilities is considered a matter for professional (clinical) judgement.

“The more severe the disability, the greater the likelihood that the person will be regarded more as a “patient” than as an object of discrimination. Indeed, identification as a patient would seem to preclude identification or status as an oppressed minority.” (128)

Note (from me, not Biklen) also that this still presumes a way of judging a spectrum of severity, from less severe to more severe. However, any such judgment will be socially constructed and is based against what society expects people to be able to do and how society expects people to look, move, and act.

Professions such as special education, psychology, and rehabilitation for people with disability work through individual assessment, diagnosis, and placement. However, the available options for professionals to place people with disabilities in need to be considered.

Biklen notes that the US government policy has been to avoid placement of people with disabilities in separate classes or schools without demonstration of benefits from the segregation and evidence that integration is not possible, not by administrative concerns such as equipment, specialists, or specialized programs.

“Educators expectations for student performance appear greater for students involved in useful and age-appropriate (and more integrated) rather than nonfunctional (and potentially more segregated) activities.” (132)

Oh hi, presumption of competence showing up more when we're not segregated.

In AY 1982-3, 68% of all children with disabilities were primarily educated in regular classrooms, 25% in separate classes within the regular education building, and 7% in separate schools or other environments (home/hospital) (U.S. Department of Education, 1985, p. 36.)

However, classifying by type of disability, we find that learning disabilities and speech disabilities are typically included while all other groups are more likely to be segregated.

State by state variation in segregation for students labeled with intellectual or emotional disabilities, as well as with multiple disabilities has been extremely wide. Because of the reality that state of residence has an extremely large effect on placement in a mainstream or segregated school, Biklen questions the assumption that placement is done by clinical judgment, despite the claim of clinical judgment. State funding for private school or institutional placement is a strong indicator of actual placement, as do admissions tests or lack thereof.

It seems that people with more severe disabilities get even greater benefit from integration and access to the community than people whose disabilities are considered more “mild.” At least, in terms of how professionals define improvement and benefit, but I'll take it because it favors “stop segregating people and claiming it's for their own good, dagnabbit.”

When examining patterns of residential placements and institution closure, factors such as Medicaid fund use, court oversight, bureaucratic concerns, jurisdictional disputes, public opinion towards people with disabilities, federal funding, availability of alternative placements, pressure to convert institutions for people with disabilities into prisons, and pressure from advocacy groups were found to have a greater effect than professional judgments.

Despite the professional authority supposedly in charge of many life aspects for people with disabilities, including who lives in group homes, who lives in instutions, and who is supported living in the community, the influence of other forces tends to have more importance than said medical/professional judgments. However, the primary factors still aren't the choices of the people with disabilities themselves.

“The solution to the problem of clinical judgement being overwhelmed by nonclinical forces is not more, better, and therefore more influential clinical judgement. Rather, the problem is in the current model of disability services, which treats questions that are both political and professional-- such as where and how people shall live or be educated-- as if they were purely professional ones.” (137)

“The conditions faced by people with disabilities are those that plague other minorities: social isolation, insufficient and unequal treatment, economic dependency, high unemployment, poor housing, and an unusually high rate of instutionalization. It serves the interests of neither professionals nor their clients-- indeed, it perpetuates a myth-- to ignore people's need for political and economic changes while offering them only clinical treatment. This seems particularly wrong and harmful when the treatment itself becomes an extension of political and economic disenfranchisement. Put another way, people with disabilities are more likely to achieve increased self-determination, real choice, and power if they cease being defined as clients whose future rests in the hands of professionals, and are instead recognized as a minority group.” (137.)