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To help meet the need for attendants, houseparents, and house-parent, assistants, states as well as governmental units below the state level should establish long-term training programs for adolescents who do not have an interest in academic careers. Properly oriented, such programs could provide a human service challenge to many young people hoping for a meaningful career commitment. Some such training proems might be developed in cooperation with the public schools along the lines of the work-study models that have seen such great growth in recent years. This would permit youngsters to enroll as early as age 16. If it is advisable that the first few programs of this nature be federally supported, this might be achieved with modifications in existing manpower-oriented legislation.

Unionization as a Factor in Residential Services

Increased unionization of care worker personnel in residential facilities appears inevitable. Every effort must be made to assure the employees and their spokesman, the union, a dynamic and constructive share in long-range and day-to-day programming. At the present, unions are too often maneuvered into a posture of opposition, and then insist on rigid adherence to seniority and similar rights in ways which are detrimental to program objectives. Obviously, imagination and skillful interaction between management and union is needed to present to the union desirable alternatives to such practices. In most states, this must be done in collaboration with civil service or personnel boards, which, on their own part, need to show greater flexibility in making appropriate allowances for special needs in a residential care setting without sacrificing the essential elements of employee protection.

By the same token the promotion of care personnel in situations where union practices are no obstacle need to be examined. Promotion to middle-grade supervisory positions in many institutions is frequently not based on understanding of program objectives, skill in day-to-day work with residents, or favorable response to inservice training, but rather often results from favoritism, political influence within the institutional power-structure, or from just having put in years of service. This has brought about all too often situations where "old line" middle-grade supervisory staff stand in the way of effective program change and can neutralize the dynamic orientation and inservice training programs for new staff even if directed by carefully selected training officers.

Manpower Consequences of the Medical Model

One additional major problem in the present manpower situation in residential services arises from the pursuit of the medical model. This creates manpower problems on two accounts. First, the medical model is an illusion in the sense that most institutions have neither the resources nor the clientele for implementing a high-quality and appropriate medical hospital model. In consequence, good physicians in general avoid an institutional career, leaving the field to poorly trained or poorly adjusted colleagues and to foreign-trained physicians whose backgrounds are serious handicaps in this situation. But equally serious is a second problem. The essence of a traditional medical model is the position of preeminence reserved to the physician and through him to the nursing hierarchy. Under the best of circumstances this greatly complicates the work by competent members of other professions such as, for example, psychologists, but when the physician "in charge" is patently lacking in competence in his own field, let alone in related areas, then the institution encounters great difficulty in recruiting and keeping good nonmedical professional staff. The specialization of residences proposed by Tizard and Dunn, and discussed elsewhere in this chapter, should overcome this problem in that a service continuum would contain medically oriented and directed residences for those retarded whose major need is hospitaltype care, as well as residences for other retardates built on educational, rehabilitational, correctional, and other models directed by the appropriate disciplines.

Location and Design of Facilities

At the time of this writing, blueprints for the construction of residential facilities for the mentally retarded involving the expenditure of several hundred million dollars are on the drawing boards of state agencies throughout the nation. Most of these facilities are designed for the longevity usually expected from public buildings. That is to say, most of these buildings are expected to serve mentally retarded individuals considerably beyond the year 2000. It is all the more disconcerting that in many cases the design of these buildings reflects and incorporates concepts long considered outdated. It is hard to think of any other area of governmental activity where so many millions of dollars are expended in perpetuation of practices which have long been condemned as unsuitable and damaging in the professional literature, in the reports of governmental commissions and departments, and by concerned citizen groups.