People with mental retardation (MR) and psychiatric disabilities (PD) represent a special and diverse population among people with developmental disabilities. This is a group for which rehabilitation practice has only recently begun to be well articulated in the professional literature. Despite at least 15 years of research and concern that these people, as a whole, are inconsistently identified and that their needs for rehabilitation supports and services are inadequately addressed (Jacobson, 1982a; Jacobson & Ackerman, 1988; Reiss, Levitan, & McNally, 1982), coherent public policy regarding these people and tertiary care services for them has remained elusive. Generally, the public policy issues include the questions:
* What are the dimensions and characteristics of the population in need?
* How can they be effectively identified and assessed to guide clinical service?
* What rehabilitative services and supports are beneficial and required in order to enhance their functioning, individually and socially?
* What organization structures, management frameworks, program approaches, and financing means are conducive to effective service?
Although a detailed review of the literature on MRPD relevant to policy is beyond the scope of a single article, some generalizations can be set forth. First, the principal emphases in research and evaluation have been on epidemiology, assessment, and to a lesser degree, programmatic responses. In the realms of epidemiology and assessment substantial progress has been made and there has been an emerging picture of the population and a small number of useful screening and assessment measures have been developed and reported in the international literature.
Unfortunately, program evaluation efforts and applied research on the organization of services have remained embodied by isolated or singular models (e.g., Fletcher, 1988; Reiss, 1988a), which are not linked by common themes (such as by normalization issues, integration concerns, or enhanced functioning, e.g., as discussed by Davidson & Adams, 1989; Jacobson, 1992; Jacobson & Ackerman, 1993) and there are no multi-site cross-sectional or longitudinal studies that sample the diversity of clinical activities or organizational approaches that are now used somewhat speculatively. At the same time it is not evident that effective rehabilitative practices for these people are consistently present in the local mental health sector and can be readily adopted by rehabilitation providers or accessed directly by people with MRPD (Jacobson & Ackerman, 1988). Thus, policy formulation and pragmatic rehabilitation efforts both appear to be hindered at this time by our limited knowledge of effective intervention practices, impacting on the ability of rehabilitation practitioners to directly intervene to support people with MRPD and the ability of specialists and consultants to contribute to these efforts. However, this may be more a matter of appearance than substance, and this issue will be considered in some detail in this article.
Rather than reviewing current progress in assessment and program description, this article will also focus on policy dilemmas stemming from the historical, system, and professional practice context within which MRPD issues are being addressed. These policy dilemmas impact on opportunities available to rehabilitation professionals and other clinicians to address MRPD service and support needs through treatment or program development. A first issue is that people with MRPD represent a diverse subset of the population with developmental disabilities and the profile of this population has considerable overlap with that of other participants in vocational rehabilitation services. Data on the rehabilitation services population with developmental disabilities are presented first, to help provide a policy context.
Next, historical, system, and professional practice factors that have affected the articulation and development of MRPD policy and programs are considered. …