The Failure of Functionalism
The current service model that has been employed by mental health systems can best be described as “functionalism,” a term generally employed in medical sociology to denote a service model that views illness or disability as a deviance that must be corrected. The individual is subsumed beneath the disability category and her/his ability to “model” what is “normal” becomes the standard for service delivery and individual assessment.
Mental health services have replicated this paradigm throughout the service system, by making diagnosis and individual “functioning” the foundation of service delivery. For example, children with disabilities are made to endure ABA services whose explicit intent is to assert totalitarian control over a child’s behavior via the artificial construct of “appropriate behavior,” a term that has been utilized for centuries to alter the behavior of LGBTQI people, people with schizophrenia, atheists, outspoken and assertive women, and all others who did not meet the approved standards of those with institutional power and resources.
This broken paradigm inflicts lasting trauma on individuals with mental health challenges, their families, and the community as a whole. Day “programs,” group homes, behavior “management” programs, ABA programs, and even many so-called “personalized” services like independent living and supported living continue to utilize a functionalist approach that will continue to impair the ability of individuals with disabilities to be included in their communities. The continuing obsession with the “management” of behavior ignores the individual and their individual biology, and is a threat to the civil, political, and human rights of the people we are privileged to support.
It is inappropriate and counterproductive to demand that people with disabilities meet arbitrary definitions of “normalcy” and “inclusion,” whose burdens are placed solely on the individual with disabilities. We do not demand that individuals with paraplegia walk upstairs. Instead we have legislated accessibility via ramps and elevators. Yet individuals with mental health challenges are provided with no “ramps” of inclusion and acceptance within their communities, and little to no obligation is placed upon communities to open and create spaces for individuals with disabilities.
The functionalist model employed by mental health systems fails to account for the inestimable impact of disabilities upon the individual and their families, the complete and total abdication of responsibility for “inclusion” by communities, and the neuroscientific aspects of disability that may manifest in the “behaviors” that many professionals in our field feel endowed with the power to alter and change. The functionalist model ignores the trauma that disabilities have imposed on individuals and their families, trauma greatly enhanced by a service system that continues to view individuals as “broken” and in need of “repair.”
Various scientific studies, such as the renowned ACEs research, have measured the impact of trauma on the health, well-being, and performance of individuals subjected to trauma, yet few mental health services, diagnostic instruments, and service planning tools utilize a genuine trauma-informed approach. This woeful failure to assess trauma and its impact on individuals and their families is equivalent to subjecting an individual with dehydration to participate in a marathon. Many individuals with disabilities are reprimanded for failing to “go to program” or engaging in “maladaptive behavior” because the professionals who work with them are entirely unaware of their trauma history and the role it may play in their personalities, their coping strategies, and adaptations.
The reasons why mental health systems have adopted a functionalist approach are manifold, but the central reason is the valiant effort the mental health system has waged against segregation, institutionalization, and discrimination. A functionalist approach enabled the mental health system to liberate tens of thousands of individuals from institutional settings and provide many with opportunities for work, education, independent living, and “inclusion.” Indeed, the mental health system was responding to social, cultural, and political realities that required a functionalist approach to empower individuals to be “accepted” by their communities and deemed “worthy” of deinstitutionalization and inclusion.
Yet, the limitations of functionalism are becoming difficult to ignore, and the battles that the mental health system nobly fought against deinstitutionalization and segregation have largely been won, in principle. Well into the 21stcentury, many of the mental health system’s approaches are beginning to appear antiquated and incapable of addressing the current needs of individuals and their families for actual recovery and actual inclusion. Few, if any, mental health services address trauma, brain biology, or evolutionary psychology in their methodology.
The continuing functionalist approach to “mold” the individual, despite their neurology and despite their trauma history, is arguably a new form of “institutionalization” and “segregation” that must now be combatted by the mental health system, whose predominant strength has always been its ability to adapt to change and to evolve in conjunction with social and scientific realities. This paper, and its author, are calling on mental health systems and their stakeholders to articulate new paradigms and new approaches rather than to persist in the utilization of an outdated model and detrimental paradigm of functionalism.
Humanism Versus Functionalism
A humanist model begins with the individual and their biological, emotional, social, spiritual, and mental needs. Rather than molding an individual in accordance with the values, expectations, and goals of professionals, a humanist approach works towards molding the professionals and the community towards an acceptance and celebration of the individual and their families, in accordance with the individual’s values, expectations, and goals. It is truly the antithesis of the functionalist approach, because it views the professional and the community as the source of trauma, “maladaptive behavior,” and “dysfunction.”
A humanist approach borrows greatly from previous historical movements for liberation and freedom from oppression, such as Civil Rights, Suffrage, feminism, LGBTQI rights, indigenous peoples’ preservation, and other movements that confronted a power structure that sought to mold these communities in accordance with the needs and values of mostly white, mostly Christian, society. What these movements share in common is the demand for absolute inclusion without self-modification. Native American children were no longer expected to cut their long hair, African-Americans were no longer expected to “talk white” or chemically alter their hair, LGBTQI people gained the right to marry and, in many states, be free from discrimination, “gay conversion therapies” were outlawed, and women were able to have children while maintaining executive positions.
The functionalist approach celebrates work and independent living as an end in itself. The humanist approach celebrates the individual and their family, and refuses to impose any goals or objectives upon individuals and their families. Instead, the humanist approach imposes goals and objectives for the societies and professionals whose continued inability to accept conditions like autism, intellectual disability, schizophrenia, bipolar disorder, and other neurological realities is the main obstacle to genuine inclusion and genuine empowerment.
A humanist approach begins with the trauma undergone by the individual and their family as a result of the societal forces that make neurological differences a stigma. Rather than attempts to “fix” and “modify” individuals, the humanist approach starts with schools, employers, programs, professionals, and other discriminatory entities whose approaches to individuals remains the primary challenge and for whom “behavior management” is now needed. The humanist approach does not “blame” these entities but seeks to educate and enlighten these entities and demand absolute, unconditional acceptance from them for people with disabilities.
The humanist approach, unlike the functional approach, does not rank individuals in conjunction with their conformity to neurotypical values and practices, nor does it seek predetermined goals and objectives that are not in alignment with the values, wishes, needs, and dreams of the individual and their families. The humanist approach has one fundamental, overarching principle: the calmness and happiness of the individual with disabilities. This is the supreme value, whose articulation will require more from professionals, service systems, and communities than the current functionalist model, which expects the individual to bear the burden of inclusion and independence.
Individuals who refuse to work will not be judged; indeed a humanist approach prohibits judgment, arbitrary assessment, and professional determination. Instead, individuals who do not work, do not participate in program, utilize substances, engage in promiscuous behavior, or engage in other practices deemed “unhealthy” by professionals are given tools and choices that encourage informed decision-making, recognizing that all individuals, even neurotypical individuals, make choices that can be deemed “unhealthy” by the greater society.
It is time for the fields of mental health and intellectual disability services to embrace the humanist approach, to cease “one size fits all” initiatives in employment, education, and other domains engineered to privilege neurotypical society and to discriminate against those whose neurology makes conformity to professional demands not only impossible, but catastrophically traumatic to individuals and their families. Instead, a humanist approach is needed, one that not only doesn’t discriminate based on neurology, but embraces humanity in all its neurological diversity.
There is a universal neglect of the impact of the trauma of disability upon an individual and their families. Intellectual impairment can also include emotional instability, other mental health diagnoses, a lack of impulse control, and a plethora of learned responses to environments that are now deemed “maladaptive” by professionals. Indeed, the trauma of having a disability to the individual and their family remains the single biggest challenge that must be mitigated by the mental health system if it will succeed in overcoming the functionalist paradigm.
The astronomical rates of abuse, neglect, bullying, and other non-neurological trauma upon individuals and their families is also tragically underestimated. In the quest for greater employment, educational inclusion, and other professionals’ ambitions, the barriers to inclusion created by trauma are almost entirely overlooked, underestimated, or simply discarded. Individuals and families in the mental health system are generally offered services whose vendorization, development, and implementation are completely dominated by neurotypical professionals, and which exclude individuals and families entirely.
This discrimination results in a service system that cannot meet the needs of individuals and their families. The trauma of having a disability and a family member with a disability requires far more than day programs, group homes, ABA, behavior management, supported living, and other artificial constructs of the neurotypical community. The mythology that an individual with a disability will be fulfilled by a job and an apartment is as detrimental as the notion that an individual with a disability cannot have a job or live in their own apartment. Both mythologies further the neurotypical prejudice that those who do not work are “lesser” and that the trauma of a disability can be mitigated by working for Walmart.
Indeed, many of the services offered by mental health systems can greatly increase trauma and arguably become abusive towards individuals whose neurology requires modified environments and modified situations. Making people with autism work in a crowded, bustling mall can be quite terrifying and overstimulating. Making an individual with schizophrenia work in Walmart where customers and staff can be insulting, degrading, and verbally abusive is arguably a form of torture. Hence, why the individual’s perspective and that of her/his family is fundamental to defining services and creating goals and objectives.
A trauma-focused approach assesses individuals and their families in light of ALL of the trauma associated with disabilities, and makes its primary focus the healing and recovery from trauma. Healing and recovery will vary based on the individual’s trauma history, and should include ALL forms of trauma, including sexual abuse, physical abuse, financial abuse, emotional abuse, bullying, depression, anxiety, neglect, isolation, lack of self-worth, and the panoply of trauma types that are inflicted on individuals and their families.
Assessment and data instruments, as well as service planning, should proceed from trauma histories and trauma concerns. A humanist approach, unlike a functional approach, is more concerned about what the individual and her/his family are feeling and experiencing, rather than the myopic goals and objectives that the professional wishes to impose for financial, bureaucratic, and institutional reasons. The reign of quantitative measure of individual progress with bureaucratic needs is among the most profound obstacles to the self-realization of individuals and their families.
Mental health systems will need to utilize both licensed and unlicensed professionals to implement psychotherapy, counseling, peer support, mentoring, and socialization for individuals and their families. The tremendous expense of current service models like day programs, vocational programs, group homes, ABA programs, behavior management, and other functionalist approaches can easily be redesigned and/or recreated to utilize trauma-focused approaches aimed at recovery and healing.
The current functionalist approach ignores the neuroscientific differences between individuals with disabilities on behalf of a paradigm that elevates conformity with neurotypical society to be the sole criteria of the service system. To be fair, this paradigm was necessary in a social context where institutionalization and segregation were justified on the basis of neurological differences. The mental health system utilized a perspective that minimized and even ignored these substantial differences for the purpose of ensuring that there were no barriers to deinstitutionalization and integration. In light of that struggle, the functionalist approach was not merely useful, but perhaps non-negotiable.
Yet brain biology cannot be ignored simply for the laudable goal of “inclusion.” There are significant differences in the brain biology of people with mental health challenges and intellectual disabilities that must be acknowledged and supported so that individuals and their families can achieve happiness and fulfillment, as defined by them. Impulse control, executive function, emotional regulation, logical analysis, environmental awareness, and many other capabilities present in neurotypical brains have mixed manifestation in the brains of people with disabilities.
The functionalist approach yearns to “treat” these “deficits” via training, behavior modification, and other practices aimed to “normalize” the individual and prepare them for “inclusion” in environments engineered solely for neurotypical people and neurotypical behavior. The discriminatory nature of these attempts at social, cognitive, and biological engineering stem from a fundamental misappraisal of the role of the brain in human behavior, following outdated prescientific behaviorist theories of humans as “empty vessels,” awaiting proper “conditioning.”
The cruelty of demanding that an individual with neurology that makes concentration difficult, task completion difficult, impulse control difficult, and emotional regulation difficult work at a job that requires concentration, task completion, impulse control, and emotional regulation is arguably approaching the kinds of humiliation imposed on people in wheelchairs prior to ramps and elevators. Yet many individuals are pushed to work in environments that impose undue hardships and trauma, whose employers, staff, customers, and others are not only unwelcoming, but sometimes hostile. When individuals with disabilities voice their concerns, they are generally counseled to be grateful for a job whose availability is in short supply, making the individual compelled to accept trauma due to the presumed “beneficence” of the employer.
The living situations of individuals with disabilities also present tremendous challenges to themselves and their families. Many individuals have brain biologies that make living with others difficult, yet many are housed in crowded group homes that only stimulate more anxiety, depression, and trauma. Indeed, many individuals with disabilities who abuse their fellow residents do so because of impulse control issues stemming from living in an unnaturally crowded environment among other individuals with similar challenges. Psychotropic medications are sometimes introduced, not to treat a specific diagnosed mental illness, but to sedate and tranquilize an individual in a rather blatant violation of their rights.
For many individuals with disabilities, living at home can be equally traumatic. Many are subjected to “punishments” and are victims of trauma at the hands of their own family members, many of whom are overwhelmed by the individual and their set of unique needs. Many family members are entirely unaware of brain biology differences in individuals with disabilities, mainly due to functionalist discourse that aims to “normalize” individuals and preaches the neurotypical as an “ideal” to which all atypical people are supposed to achieve. Many family members are denied the information and training they need to embrace their loved one in spite of neurological differences and atypical behavior.
A mental health system that embraces neuroscientific differences will cease measuring individuals and formulating either unrealistic or unwanted expectations for individuals and their families. Instead, the goal will be empowering the individual and their family to achieve calm and happiness. Practices such as nutrition, exercise, yoga, meditation, breathing and calming strategies, laughter, appropriate physical affection, appropriate sexual intimacy, and religious/spiritual/natural/cultural communal activity are all possible avenues of achieving calm and happiness, yet whose provision in service delivery is woefully inadequate throughout the mental health service system, whose functionalist approach tends to minimize joyful mood, emotional calm, personal fulfillment, and self-actualization. Within limited functional life domains, mental health services tend to emphasize the individual’s outward conformity to the mental health system rather than the system’s conformity to the happiness and joy of the individual.
Just as neurotypical individuals with cancer, paraplegia, paralysis, pregnancy, HIV, etc. are provided accommodation, inclusion, and support in full comfort and respect for their medical challenges, individuals with disabilities must be provided accommodation, inclusion, and support in full comfort and respect for their neurological challenges. Pregnant women are not required to engage in heavy lifting, people with paraplegia are not required to crawl up stairs, and people undergoing cancer treatment are not required to work outdoors in the sun for long periods. Neither should individuals with some neurological challenges be required to live in congregate living, work in a high stress environment, or be expected to conform to the expectations of neurotypical people.
Human beings, a species of talking ape, recently evolved in Africa roughly 350,000 years ago in a jungle/wild context in which predators were abundant and access to food, water, mates, and territory was unpredictable and scarce. In this environment, humans evolved the ability to speak, hunt, and gather food, much like their primate relatives: chimpanzees, gorillas, bonobos, etc. Humans only recently created cities and civilizations where agriculture was the primary means of survival. Hence 98% of human existence has been spent in jungle contexts, and human behavior was engineered for this specific environment. Cities, homes, jobs, offices, schools, grocery stores, streets, etc. are aberrations in human history, a product of a very recent change in human means of survival.
The implications of these basic facts for assessing and evaluating human behavior are enormous and astronomical. Not only did human behavior evolve in a jungle context, but the brain, nervous system, and behavioral response mechanism evolved in response to a jungle environment where predators abound and the means of survival scarce. Fight or flight mechanisms, anger, depression, anxiety, avoidance, and many other “aberrant” human behaviors are natural responses to stress, and are a byproduct of an environment that produced humans, but in which humans no longer live.
For the mental health system, and human service systems in general, the unnamed enemy of individual progress and happiness has been stress, a neuroevolutionary response to perceptions of threat. Many human service systems see stress as a harmless byproduct whose seriousness can be mitigated by counseling individuals to be “strong,” and whose impact can be discounted in favor of bureaucratic goals like work inclusion, school inclusion, independent living, behavior modification, and other stressors. The enormous scientific research on stress, via the stress hormone cortisol, and its impact on individuals’ medical health, susceptibility to illness, mental health, financial stability, etc. are generally ignored by the human services system, or inappropriately medicated.
For individuals with disabilities, stress is a primary contributor to early death and severe medical problems and disease. Ironically, this horrific public health threat has been ignored entirely by public health systems and human service systems as a whole, leading to addiction, suicide, and middle-age illness even in the neurotypical population. Unfortunately, in an American society that sometimes privileges outdated notions of “strength” and “rugged individualism,” the impact of stress is usually dismissed by employers, human service systems, and usually the mental health system.
The mental health system can begin to see stress reduction, rather than functioning, as a primary service system goal for individuals and their families. This means that some individuals may choose not to work or attend day program, for example, yet may want to pursue hobbies like art, stamp collection, culinary arts, swimming, yoga, etc. as alternatives to both employment and traditional day services. Some individuals may need solitary living situations, and others may need one to one coaching on a part time basis to attend school, or to create a model car collection. Once the impact of stress on people with disabilities is accepted, and the corresponding need to mitigate stress is made paramount by the service system, current service delivery models can be altered to promote stress reduction, healing, and recovery from trauma.
Once the behavioral patterns of people with disabilities are understood in light of human evolution, ABA and other behavioral modification practices can be discarded in favor of scientific approaches that accept behavior as a response to an ancestral environment that no longer exists. Rather than behavioral modification services, communication services will be implemented by professionals who specialize in positive communication, smiles, joyful mood, and a genuine interest in the individual they are privileged to support. Not only is such professional intervention cheaper than licensed or certificated services; it is scientifically more appropriate and efficacious for individual fulfillment and stress reduction.
The future of human service systems for people with disabilities and other challenges will be founded on trauma recovery, neurobiology, and evolutionary psychology. The 21stcentury has unveiled brain biology as a serious contender in the realm of human services, and understanding the implications of neuroscience will revolutionize human service practices. For the mental health system, the stench of behaviorism and outdated conditioning models permeates many of the practices and service planning for individuals. Embracing neurodiversity and abandoning functionalist approaches to service will unleash the full capability of the mental health system to pioneer efforts to provide genuine inclusion for individuals, especially inclusion for their neurobiology and corresponding differences in behavior. This will necessitate the mental health system doing more to address the “maladaptive behavior” of professionals, employers, schools, and communities rather than the individuals we are privileged to support.
The next steps would be: a statewide conference on trauma and disabilities, neurobiology and disabilities, and evolutionary psychology and disabilities, staffed by preeminent scientists who can act as consultants and foster dialogue between individuals, families, and professionals regarding the service system. Public conferences and dialogue will be the preliminary steps to understanding the depth of the problem of the current functionalist perspective and to offer alternative service delivery models.
From there, professionals and individuals and families will strategize what steps are needed to educate service providers, schools, employers, and communities regarding the trauma-focused, neurobiological, and evolutionary needs of individuals. Mental health systems can foster dialogue in conjunction with legislators and other stakeholders. Legislators and other political participants can elucidate what budgetary opportunities exist for reconciling the needs of individuals and their families for trauma recovery and neurobiologically-driven services.
Each mental health system, on its own, can also initiate local grassroots dialogue about the steps needed to modify the current system to promote trauma recovery, stress reduction, and neurobiological inclusion. Dialogue will generate further ideas that are tempered by budgetary constraints and existing service system capability. The pattern of dialogue, suggestions, and planning can have enormous implications for redesigning a service system that will continue to be a leader in human services and a continuing advocate for people with disabilities and their families.
It is hoped that this paper, and its author, can be of service to mental health systems and other entities that look forward to a paradigm shift in services. What is hoped is that this paper will stimulate dialogue, research, and outreach by mental health systems and their stakeholders with individuals, families, and communities. The opportunity to create a system rooted in the continuing liberation of individuals with disabilities is one that the mental health system has never backed down from, and must be harnessed once again if the 21stcentury’s scientific discoveries and insights are to be incorporated to meet the needs of the individuals we are all privileged to support and to learn from.
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