B. Frequently Asked Questions

Q4. What is institutionalization?

A4. Institutionalization is the placement of a person – on the grounds of his or her disability – in a centre or institution that constitutes an isolating environment for continuous or intermittent residence. In such places, everyone is subject to standard operating rules and procedures that fail to consider individual differences and requirements to the point that they resemble military barracks in terms of specific, standardized mealtimes and sleeping times; the wearing of uniforms in some cases; and the provision of basic services that are often substandard and standardized for everyone without taking into account any specific individual requirements. In these environments, the focus is on basic day-to-day services, such as providing food and drink and assisted bathing, that in most cases tend to be of very low quality, and there are no psychological, physical or educational rehabilitation programmes in place to help the development of residents. Rather, according to reliable studies, institutionalization results in decline and deterioration in the psychological, mental and physical state of individuals due to isolation, a lack of quality services, limited communication with their families and a lack of contact with the external environment.[1]

Q5. What forms of institutionalization violate the right of persons with disabilities to live independently?

A5. Some believe that the only type of institutionalization that should be prohibited involves institutions specifically established to provide round-the-clock care to persons with particularly severe intellectual disabilities. This approach does not consider mental health hospitals or boarding schools, for example, to be a form of institutionalization. Nor does it see anything wrong with the establishment of small group homes as an alternative to residential institutions in the literal sense of the term.[2]

However, the approach most consistent with the principles and provisions of the Convention on the Rights of Persons with Disabilities and human rights sees all environments that are restrictive or isolating on the basis of or because of disability as forms of institutionalization that must be ended. This includes boarding schools for persons with disabilities, mental health hospitals, so-called small group homes, and rehabilitation centres that are neither service-based nor community-based.[3] This approach sees isolation, exclusion and the guardianship approach, which takes away a person's freedom to make their own choices and decisions, as common denominators of these different forms of isolating residential services, even though their names and ways of managing or providing such services may vary.

Q6. Do the aforementioned concepts and criteria apply to mental health hospitals and, if so, why?

A6. The deinstitutionalization movement originally began in the middle of the last century as a civil rights movement in Italy, which achieved remarkable success in transforming mental health services into community-based services, enabling people with psychosocial disabilities to live in community settings that accept them, accommodate for their needs and have the facilities to provide the specialized services they need – services which exist as an integral part of the health care system and not in isolation from it.[4] Many European countries,[5] as well as the United States,[6] have witnessed a similar move towards closing mental health hospitals and residential services and transferring those receiving treatment from them to live in the community.

The reason why mental health hospitals are considered a form of institutionalization that must be abandoned, and why they are at the heart of the movement against institutionalization, lies in the fact that these hospitals operate on the basis of the detention of persons with permanent or temporary psychosocial disabilities for very long periods of time, sometimes decades, not primarily for the purpose of care or treatment, but rather to remove these persons from society and isolate them from their family environment, either on the grounds that "families are unable to provide the necessary care for them" or under the pretext that "they represent a danger to themselves and others." It is no secret that many mental health hospitals around the world have a bad reputation associated with physical and verbal violence, involuntary hospitalization, forced treatment, and the use of physical and chemical restraints to manage and control detainees.[7] For these reasons, civil rights movements in Europe and the United States are calling for these hospitals to be closed, for work to be done to achieve that end, and for the provision of inclusive community-based alternatives that accommodate people with mental disabilities and guarantee their right to live independently.

Q7. Why are boarding schools for people with disabilities considered to be a form of institutionalization?

A7. Special schools for persons with a specific type of disability, or for persons with more than one disability, have become widespread. With the implementation of inclusive education lagging behind in many parts of the world, these schools occupy significant space and provide a sense of "safety" for families as they are isolated environments where students are less likely to experience disability-based bullying from their peers and classmates. Traditionally, these schools, especially those for blind and deaf persons and those with intellectual disabilities, contain boarding sections where students reside during term-time, only going home to their families at weekends or during the midterm and summer holidays. In addition to being fundamentally non-inclusive and relying on special education methods and restrictive educational environments, these schools, by including boarding services, are essentially residential institutions in the broad sense of the term, in that they adopt a set routine for all pupils without taking into account individual differences and requirements and that physical, psychological and sexual abuse are common due to the length of residence and a lack of supervision. The separation of children from their families in these schools has the same negative impact as placement in residential institutions. The origins of boarding schools reinforce this, as they were established to separate and isolate indigenous children in America, Australia, Canada and elsewhere. They were also a means of isolating specific groups in society, as was the case during British colonial rule in some Arab countries, where, for example, the Bedouin children of Palestine were sent to receive education in such schools separately from other children.[8] Thus, boarding schools for persons with disabilities are in fact residential institutions, albeit with an educational veneer, and must therefore be included in the scope of policies, plans and programmes to put an end to institutionalization.[9]