AN ANALYSIS OF NEED ASSESSMENT IN THE MENTAL HEALTH CONTEXT BY VICKI LEA FARRALLY B.A., The U n i v e r s i t y o f B r i t i s h Columbia, 1972 M.A., The U n i v e r s i t y o f B r i t i s h Columbia, 1975 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE i n THE FACULTY OF GRADUATE STUDIES (Health S e r v i c e s P l a n n i n g a n d , A d m i n i s t r a t i o n ) -We accept t h i s t h e s i s as conforming t o the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA October 1985 (c) V i c k i Lea F a r r a l l y , 1985 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of The University of British Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 DE-6(3/81) ABSTRACT Need assessment methods grew out o f the Community Mental Health Centre movement. Developed d u r i n g a time o f r a p i d expansion of s e r v i c e , t h e r e was a focus on p r o v i d i n g s e r v i c e s matched t o the unique needs o f a community. In the f o l l o w i n g years need assessment f u r t h e r developed as a technology and a search began f o r a "best model'. T h i s paper argues t h a t a "best model' i s i l l u s i o n a r y , a "best f i t ' being a more d e s i r a b l e g o a l . As f i s c a l c o n s t r a i n t s have reduced the r e s o u r c e s a v a i l a b l e t o consumption M i n i s t r i e s such as Health, need assessment has been i n c r e a s i n g l y used a an a l l o c a t i v e t o o l . Users o f the t o o l , i t i s argued, must t h e r e f o r e choose t h e i r model with care and an understanding o f the values and concepts inherent in each model i s seen as necessary f o r i n t e l l i g e n t c h o i c e . F i n a l l y , an examination o f the B r i t i s h Columbia mental h e a l t h context o f f e r s an a n a l y s i s o f some o f the f a c t o r s which have and w i l l a f f e c t the use o f need assessment in t h i s P r o v i n c e . TABLE OF CONTENTS Page A b s t r a c t i i Table o f Contents i i i L i s t o f F i g u r e s v i Acknowledgements v i i Chapter I: I n t r o d u c t i o n 1 A. The Background 1 B. The H i s t o r y o f Community Mental Health Development 3 C. The E f f e c t s o f Community Development 6 D. The End t o Development and D o l l a r s 8 Chapter I I : Mental I l l n e s s 12 A. Problems with D e f i n i t i o n s 12 B. The I n t e r r e l a t i o n s h i p o f Medical and S o c i a l Models o f Mental Health 14 C. P o s i t i v i s t vs I n t e r p r e t i v e Paradigms 19 Chapter I I I : A Conceptual A n a l y s i s o f Need Assessment A. A D e f i n i t i o n o f Need Assessment 22 B. Problems with the Concept 23 C. Want, Demand and Need 26 1. Want/Demand 26 2. Need 28 D. The Linkage o f Want, Demand and Need 33 i i i E. Want, Demand and Need in Mental Health 34 F. The D i a g n o s t i c Process - Becoming a Case....36 G. Disease 39 Chapter IV: Models o f Need Assessment 44 A. I n t r o d u c t i o n 44 B. E p i d e m i o l o g i c a l Surveys 46 C. U t i l i z a t i o n Rates 54 D. S o c i a l I n d i c a t o r Approaches 58 1. Poverty 59 2. S o c i a l Pathology 63 3. P o p u l a t i o n Subgroups with S p e c i a l Needs 64 E. Community Group Approaches 67 F. The R e l a t i o n s h i p Between Need and Planning..69 Chapter V: Viewpoints i n Need Assessment: The S o c i o -p o l i t i c a l Context 74 A. I n t r o d u c t i o n 74 B. Boundaries o f Power in Planning 74 C. P l a n n i n g Models 77 1. Incremental Model 77 2 . Rat i ona 1 Mode 1 78 D. Values i n P o l i t i c a l Ideology 81 1. L a i s s e z - f a i r e Model 86 i v 2. D i s j o i n t e d I ncrementa 1 i sm 87 3. Goal O r i e n t e d Developmental Model 87 4. T o t a l i t a r i a n Model 88 E. The Role o f the Planner 89 1. The T e c h n o c r a t i c Planner 90 2. The B u r e a u c r a t i c Planner 91 3. The Advocacy Planner 93 4. Summary o f Planning Roles 94 F. R a t i o n a l i t y - D i f f e r e n t Viewpoints 96 1. L o g i c a l R a t i o n a l i t y 97 2. Economic R a t i o n a l i t y 97 3. S o c i a l / L e g a l R a t i o n a l i t y 98 4. Po 1 i t i ca 1 Rat i ona 1 i t y 99 G. Change - D i f f e r e n t Views 100 1. How Change Occurs and t o Whom 101 2. Who Should D i r e c t Change? 102 H. D i s c u s s i o n 104 Chapter VI: From Model t o R e a l i t y 105 A. The B r i t i s h Columbia Scene 105 1. The Development o f the Current System..106 2. The New D i r e c t i o n 109 Chapter V I I : Summary and Conclusions 114 B i b l iography 118 v LIST OF FIGURES F i gure Page 1. The R e l a t i o n s h i p o f Need, Demand and Want 34 2. C h a r a c t e r i s t i c s o f Need Assessment Models 70 3. The R e l a t i o n s h i p o f Planning and Need Assessment Methods 80 4. Models o f S o c i a l A c t i o n and P o l i t i c a l Change...83 v i ACKNOWLEDGEMENTS I wish t o thank Dr. Nancy Waxier Morrison f o r her p a t i e n c e , support and guidance - and f o r her f a i t h t h a t t h i s t h e s i s would be completed. Thanks are a l s o extended t o Dr. Court McKenzie and Dr. Sam Scheps f o r t h e i r h e l p f u l c r i t i c i s m and comments. My a p p r e c i a t i o n a l s o goes t o Dr. John Gray, M i n i s t r y o f Health, f o r h i s w i l l i n g n e s s t o read and comment on t h i s t h e s i s . During my numerous years a t the U n i v e r s i t y o f B r i t i s h Columbia many people, both f a c u l t y and s t u d e n t s , have i n f l u e n c e d my view o f the world, and i n p a r t i c u l a r , o f mental h e a l t h and the r o l e o f both p s y c h o l o g i s t s and o f planners in t h a t world. I would l i k e t o s p e c i f i c a l l y thank Dr. Anne C r i c h t o n f o r s h a r i n g her wisdom and experience in the area o f s o c i a l p o l i c y . I would a l s o l i k e t o acknowledge the very s p e c i a l c o n t r i b u t i o n o f the l a t e Dr. Park 0 . Davidson as both a mentor and a f r i e n d . v i i Chapter I: I n t r o d u c t i o n A. The Background Need assessment grew out o f the expansion o f mental h e a l t h s e r v i c e s t o the community. The e a r l y 1960's witnessed a r a d i c a l s h i f t in the p r o v i s i o n o f s e r v i c e t o the ment a l l y i l l which r e s u l t e d in a widening d e f i n i t i o n o f mental i l l n e s s . P r i o r t o t h i s time, the bulk o f the s e r i o u s m e n t a l l y i l l had been cared f o r in larg e f a c i l i t i e s . With the 1960's came the commitment i n the United S t a t e s t o pro v i d e a system o f community based s e r v i c e s . While the main s t y l e o f s e r v i c e d e l i v e r y was i n s t i t u t i o n a l l y based c o s t s and t a r g e t p o p u l a t i o n s were reasonably p r e d i c t a b l e . T h i s new commitment t o community care opened the arena on both c o s t s and p o t e n t i a l p a t i e n t s . The United S t a t e s f e d e r a l government assumed i n 1963 p a r t i a l f i n a n c i a l r e s p o n s i b i l i t y f o r p r o v i d i n g a system o f community mental h e a l t h f a c i l i t i e s . The Community Mental Health Centres (CMHC's) were e n t r u s t e d with the r e s p o n s i b i l i t y f o r p r o v i d i n g s e r v i c e s t o s p e c i f i c geographical a r e a s . A b a s i c t e n e t o f the community based movement was t h a t deployment o f resources should be based on the needs o f t h a t community. Cohen (1974) r e p o r t s t h a t one of the goals o f t h i s movement was a d e s i r e t o develop and or g a n i z e l o c a l community c o n t r o l over the CMHC's, so t h a t c e n t r e p o l i c i e s were community based and o r i e n t e d , while r e d u c i n g use o f mental h o p s i t a l s by p r o v i d i n g prompt 1 response and twenty-four hour s e r v i c e . Need assessment data d e s c r i b e d and d e t a i l e d these l o c a l needs. The mandate o f the CMHC q u i c k l y expanded. By 1970 i t s r e s p o n s i b i l i t i e s had expanded from the o r i g i n a l focus on the s e r i o u s l y i l l t o i n c l u d e a l s o a l c o h o l i s m , c h i l d r e n and drdg abuse. The c o s t s o f such an expanded mandate co u l d not have been e n v i s i o n e d in 1963 when i n i t i a l f u n d i n g began. The movement was born in a p e r i o d o f economic abundance as well as i n c r e a s i n g s o c i a l c o n s c i e n c e . By the e a r l y 1970's the p i c t u r e had changed d r a m a t i c a l l y . The focus on f o r m a l i z e d need assessment which developed with the i n i t i a l community mandate o f the CMHC's in the e a r l y 1960's became an e s s e n t i a l component in the e a r l y 1970's as c o s t s rose while n a t i o n a l revenues d i d not and a new age o f concern r e g a r d i n g i n f l a t i o n and r e c e s s i o n was entered i n t o . The twenty years s i n c e the i n t r o d u c t i o n o f these expansive h e a l t h , as well as s o c i a l , programs has witnessed a s h i f t , from f u n d i n g such programs out o f a sense of abundance and s o c i a l morals, t o an a l l o c a t i o n process t h a t r e f l e c t s f i n i t e means, shortage and c o n t i n u a l f i n a n c i a l j u s t i f i c a t i o n o f e xpenditures. In the e a r l y 1960's a s o c i a l commitment was s u f f i c i e n t t o channel funds i n t o these programs. Twenty years l a t e r the guide words throughout North America are r a t i o n a l i t y and a c c o u n t a b i l i t y . The purpose o f need assessment has thus changed. O r i g i n a l l y d e v e l o p i n g as a means o f d i r e c t i n g an expanding 2 h e a l t h s e r v i c e t o the unique needs o f a community, needs assessments are now focussed on the containment o f s e r v i c e development and c o s t s . Whereas p r e v i o u s l y the primary issue was p r o v i d i n g s e r v i c e s where few e x i s t e d , need assessments are now i n c r e a s i n g l y being used t o i d e n t i f y s p e c i f i c t a r g e t gruops by which p r i o r i t i e s f o r care can be developed and t o j u s t i f y c o n t i n u a t i o n o f e x i s t i n g programs. B. Hi s t o r y o f Communi t y Menta1 Hea1th Development Community mental h e a l t h s e r v i c e s have witnessed a dramatic growth s i n c e t h e i r conception in the 1960's. In the United S t a t e s t h i s i s e x h i b i t e d by the growth in mandate by the CMHC's and the move t o d e i n s t i t u t i o n a l i z e the la r g e f e d e r a l i n s t i t u t i o n s in the 1970's. Although t h e r e has been much c r i t i c i s m o f t h i s process (eg. Bassuk and Gerson, 1978) and in p a r t i c u l a r o f the lack o f adequate community based resources f o r these p a t i e n t s , i t can not be argued t h a t dramatic expansion has not occ u r r e d . Canada has seen s i m i l a r developments. As e a r l y as the 1940's a new i n t e r e s t in t r e a t i n g the m e n t a l l y i l l began t o develop w i t h i n general h o s p i t a l s (Tyhurst, 1963). In 1948 the Canadian Federal Government e s t a b l i s h e d a system o f Mental Health Grants t o the p r o v i n c e s . During the next t en years c o n s i d e r a b l e progress was achieved through the b u i l d i n g o f c l i n i c s , p r o f e s s i o n a l t r a i n i n g and inc r e a s e d r e s e a r c h . 3 The year 1950 marked the end o f what Foulkes (1974) r e f e r s t o as the "asylum i n d u s t r y " . The development o f p s y c h o t r o p i c drugs was most l i k e l y the most s i g n i f i c a n t step towards the development o f the community mental h e a l t h movement. A l l o d i and Kedward (1977) s t r e s s t h a t community mental h e a l t h in Canada r e a l l y began in the 1960's. The Canadian Mental Health A s s o c i a t i o n sponsored a r e p o r t , "More f o r the Mind", in 1963. T h i s r e p o r t was d i r e c t e d a t p s y c h i a t r i s t s and emphasized the need f o r f u r t h e r development o f p s y c h i a t r i c u n i t s in h o s p i t a l s , emphasizing the medical domination o f the f i e l d a t the time. The r e p o r t argued t h a t p s y c h i a t r i c i l l n e s s should r e c e i v e the same c o n s i d e r a t i o n as those with p h y s i c a l i l l n e s s under the H o s p i t a l Insurance and D i a g n o s t i c S e r v i c e s Act. It a l s o attempted t o e l e v a t e p s y c h i a t r y as a s p e c i a l t y w i t h i n medicine and argued f o r h o s p i t a l based r a t h e r than care through a CMHC. Despite t h i s h o s p i t a l based focus t h i s r e p o r t was s t i l l a move towards community care in t h a t i t not o n l y drew inc r e a s e d a t t e n t i o n t o the a c t u a l treatment as opposed t o custody, but a l s o moved t h i s focus from the large i n s t i t u t i o n s t o the community based h o s p i t a l s . In doing so i t helped widen the d e f i n i t i o n and boundaries o f mental h e a l t h s e r v i c e s . Its recommendations d i d much t o a l t e r the stigma o f mental i l l n e s s through making treatment more v i s i b l e and more access i b l e . 4 For B r i t i s h Columbia the t u r n t o community based care was i n i t i a t e d l a r g e l y by the a d m i n i s t r a t i v e changes o f 1959 when Mental Health S e r v i c e s was t r a n s f e r r e d from the P r o v i n c i a l S e c r e t a r y ' s Department t o the Department o f Health S e r v i c e s and H o s p i t a l Insurance, being p l a c e d in the same o r g a n i z a t i o n a l arena as P u b l i c Health and H o s p i t a l . In 1961 the Burnaby Mental Health C l i n i c was e s t a b l i s h e d . It prov i d e d outreach community s e r v i c e s through t r a v e l l i n g c l i n i c s . In 1962 the second CMHC was opened; t h i s one i n Kelowna. By 1966, ten CMHC's were o p e r a t i n g throughout the pr o v i n c e , most with t r a v e l l i n g c l i n i c s s t i m u l a t i n g community demand. By 1975 t w e n t y - f i v e CMHC's were f u n c t i o n i n g . C u r r e n t l y community based mental h e a l t h s e r v i c e s in B r i t i s h Columbia i n c l u d e 34 CMHC's with 19 s u b - o f f i c e s around the p r o v i n c e , as well as 8 community Care Teams i n Vancouver and 3 area teams i n Burnaby. Community based i n p a t i e n t care i s a v a i l a l b e in 27 P s y c h i a t r i c U n i t s i n General H o s p i t a l s and a t the Burnaby Mental Health complex. In a d d i t i o n t o the approximately 4000 general p r a c t i o n e r s o f f e r i n g o u t p a t i e n t care t h e r e are 280 p s y c h i a t r i s t s around the Province. 0 A Community R e s i d e n t i a l Program, a l s o funded by Mental Health S e r v i c e s , p r o v i d e s community l i v i n g in a t h e r a p e u t i c environment t o approximately 2500 c h r o n i c a l l y menta11y i l l i nd i v i dua1s. 5 C. The E f f e c t s o f Communitv Development The development i n B r i t i s h Columbia, d e s c r i b e d in d e t a i l above, was repeated t o v a r y i n g degrees a c r o s s North America d u r i n g the two decades, 1960-1980. The reasons f o r and r e s u l t s o f t h i s expansion o f s e r v i c e t o the community are no doubt c l o s e l y i n t e r t w i n e d . An examination o f the impact o f t h i s process i s important t o p r o v i d e a p e r s p e c t i v e o f how these changes c o n t r i b u t e d t o the c u r r e n t demand f o r s e r v i c e and the changing nature o f need assessment. L i k e l y the most s i g n i f i c a n t r e s u l t o f the move t o community mental h e a l t h was the r e s u l t i n g expansion in the concept o f mental i l l n e s s . T h i s change was not e n t i r e l y a r e s u l t o f the community based movement - t h i s was an era o f s e v e r a l s i g n i f i c a n t changes - but i t d i d p r o v i d e the means by which these other changes were a b l e t o o c c u r . Community based care brought the s u b j e c t o f treatment o f mental h e a l t h i n t o the open. It reduced the stigma and expanded the concept o f mental i l l n e s s from a d i s c r e t e group o f s e r i o u s l y i l l t o a much l a r g e r p o t e n t i a l audience who would never have been c o n s i d e r e d as * s i c k ' as long as p s y c h i a t r i c i l l n e s s was synonomous with i n s t i t u t i o n a l i z a t i o n . In the past two decades the l e g i t i m a t e focus o f mental h e a l t h p r o f e s s i o n a l s has expanded t o embrace the 11 d i s t r e s s e d and the d i s a t i s f i e d ' . Such problems as m a r i t a l f a m i l y d i s c o r d , p a r e n t i n g s k i l l s , g r i e f and s e p a r a t i o n adjustments, r e a c t i v e d e p r e s s i o n s , l e a r n i n g d i s a b i l i t i e s , h y p e r a c t i v i t y , sexual 6 d y s f u n c t i o n and shyness have al1 moved under the ever-expanding umbrella o f mental h e a l t h . The human p o t e n t i a l movement o f the 1960's and e a r l y 1970's made i t "O.K." t o seek help i f you d i d n ' t f e e l "O.K." - r e g a r d l e s s o f the reason. In many re g i o n s substance abuse moved under the ausp i c e s o f mental h e a l t h . A recent National I n s t i t u t e o f Mental Health study (Myers et a l , 1984) r e p o r t s a l c o h o l abuse as the most fre q u e n t p r e s e n t i n g problem o f males w i t h i n CMHC's. T h i s widening d e f i n i t i o n o f what was a l e g i t i m a t e concern o f mental h e a l t h , combined with a growing p o p u l a t i o n has taken the p o t e n t i a l mental h e a l t h consumer f a r beyond what any need assessment s t r a t e g y o f the 1960's co u l d have e n v i s i o n e d . It i s now v i r t u a l l y impossible t o o f f e r a d e f i n i t i v e d e f i n i t i o n o f mental i l l n e s s . The a m e l i o r a t i o n o f mental i l l n e s s and the enhancement o f normal f u n c t i o n i n g have become a j o i n t concern, o f t e n i n d i s t i n g u i s h a b l e from one another. A s s o c i a t e d with t h i s widening o f the concept o f mental i l l n e s s has come the p r o l i f e r a t i o n in the " h e l p i n g p r o f e s s i o n a l s " and the i n c r e a s i n g power o f p s y c h i a t r y . T h i s r e l a t i o n s h i p was not one way - the conceptual expansion o f mental i l l n e s s was in p a r t a r e s u l t o f p s y c h i a t r i c m e d i c a l i z a t i o n , while a t the same time, the growing demand r e s u l t e d in i n c r e a s i n g numbers o f p r o f e s s i o n a l s . Whereas the m e n t a l l y i l l in i n s t i t u t i o n s were cared f o r by p h y s i c i a n s , nurses and a i d e s , most o f t e n t r a i n e d w i t h i n the 7 same f a c i l i t i e s , the move t o the community encouraged the development o f other mental h e a l t h p r o f e s s i o n a l s - c l i n i c a l p s y c h o l o g i s t s and s o c i a l workers, l a t e r f o l l o w e d by a v a r i e t y o f q u a s i - p r o f e s s i o n a 1 s - a r t t h e r a p i s t s , music t h e r a p i s t s , r e c r e a t i o n t h e r a p i s t s , case workers, h e a l t h care a i d e s e t c . The v i s i b i l i t y o f the m e n t a l l y i l l in the community c o n t r i b u t e d t o t h i s development, as d i d the new emphasis on the " r e l a t i o n s h i p t h e r a p i e s " in p a r t made p o s s i b l e by the development o f p s y c h o t r o p i c medications. T h i s growth in s e r v i c e p r o v i d e r s has r e s u l t e d i n what Magaro et a l . (1978) has termed the "mental h e a l t h i n d u s t r y " . The r e l a t i v e economic abundance o f the 1960's and 1970's supported t h i s i n d u s t r y ' s development, with need i n c r e a s i n g l y seeming t o be a bottomless p i t . Despite the tremendous growth in s e r v i c e s and s e r v i c e p r o v i d e r s , demand f o r s e r v i c e appears t o c o n t i n u a l l y outpace supply. D. The End t o Deve1opment and Pol 1ars The end t o the developmental phase o f s e r v i c e development in 1980's has come about as a r e s u l t o f the i n t e r a c t i o n o f two major f a c t o r s : the combined e f f e c t s o f the r e s u l t s o f s e r v i c e expansion in the l a s t two decades, d i s c u s s e d above, and the worldwide economic d e c l i n e which has seen d w i n d l i n g r e s o u r c e s a l l o c a t e d t o h e a l t h and s o c i a l s e r v i c e s e c t o r s by the r i g h t wing governments in Great B r i t a i n , the United S t a t e s and Canada. C r i c h t o n (1983) has 8 suggested t h a t Canadian p o l i t i c s has emphasized a u t i l i t a r i a n l i b e r a l i s m , c h a l l e n g e d by an ideology o f c o l l e c t i v i s t humanitarism. The economic downswing o f the 1980's had led t o an emphasis on the r i g h t wing o f t h i s l i b e r a l democratic framework, emphasizing entrepreneurs 1ism, small government and a s h i f t in focus from the consumption m i n i s t r i e s t o the p r o d u c t i o n m i n i s t r i e s (Cambell et a l , 1981). T h i s change in focus has been p a r t i c u l a r l y e v i d e n t in B r i t i s h Columbia, where a p o p u l i s t o r i e n t e d government hel d by S o c i a l C r e d i t P a r t y has taken d r a s t i c steps t o curb h e a l t h care e x p e n d i t u r e s . From 1971 t o 1981 annual government h e a l t h expenditures in B r i t i s h Columbia grew from 337 m i l l i o n t o two b i l l i o n d o l l a r s - an i n c r e a s e o f almost s i x hundred percent. B r i t i s h Columbia, p a r t i c u l a r l y a f f e c t e d by the worldwide economic downswing due t o i t s r e l i a n c e on n a t u r a l resource revenues, has f a c e d major cuts in s e r v i c e i n h e a l t h , s o c i a l s e r v i c e and education s e c t o r s throughout the e a r l y 1980's. At the same time t h e r e has been a s i g n i f i c a n t s h i f t i n the type and locus o f p l a n n i n g . The incremental and developmental p l a n n i n g l e d p r i m a r i l y by h e a l t h care p r o f e s s i o n s d u r i n g the past two decades has been r e p l a c e d by an emphasis on " r a t i o n a l " d e c i s i o n making through a h i g h l y c e n t r a l i z e d and p o l i t i c a l l y i n f l u e n c e d p r o c e s s . A growing p o p u l a t i o n , an expanding d e f i n i t i o n o f mental i l l n e s s and a r e d u c t i o n o f a v a i l a b l e d o l l a r s has led t o the 9 c u r r e n t c r i s i s in h e a l t h care f u n d i n g . It can r e s u l t i n o n l y two p o s s i b l e a c t i o n s : a narrowing o f s e r v i c e boundaries or an o v e r a l l d i l u t i o n o f s e r v i c e . E i t h e r o f these goals can be o b t a i n e d through s e v e r a l d i f f e r e n t o p t i o n s . Boyd (1979) o u t l i n e s two o f the p o s s i b i l i t i e s : 1. V o l u n t a r y r e s t r a i n t , mainly through assuming more r e s p o n s i b i l i t y f o r ones own h e a l t h . 2. R a t i o n i n g , based on demographic, s o c i a l , c l i n i c a l or geographic c r i t e r i a , or the a b i l i t y t o pay. It i s t h i s second o p t i o n t h a t needs assessments t e c h n o l o g i e s have a r o l e t o p l a y . In t h e i r a b i l i t y t o i d e n t i f y and q u a n t i f y need - be i t a r e f l e c t i o n o f what a community wants, a p r o j e c t i o n from a set o f s o c i a l i n d i c a t o r s , or a s e t o f data r e l y i n g on a s o p h i s t i c a t e d d i a g n o s t i c c l a s s i f i c a t i o n system, need assessment techniques can produce data on which resource a l l o c a t i o n d e c i s i o n s can be based, s a t i s f y i n g the c u r r e n t pressures f o r r a t i o n a l d e c i s i o n making. R a t i o n a l p l a n n i n g has been d e s c r i b e d as "the a p p l i c a t i o n o f s c i e n t i f i c method - however crude - t o p o l i c y making" ( F a l u d i , 1973). Need assessment t e c h n o l o g i e s can p r o v i d e the s c i e n t i f i c b a s i s t o s a t i s f y t h i s requirement. However, h e r e i n l i e s the crux o f the argument o f t h i s paper. Such techniques are not value f r e e . The model used w i l l g r e a t l y i n f l u e n c e the answers generated. Thus, t o use need assessment t e c h n o l o g i e s t o p r o v i d e data on which resource a l l o c a t i o n s can be based n e c e s s i t a t e s an 10 understanding o f the values and concepts i m p l i c i t i n each model. It has become g e n e r a l l y accepted t h a t s c i e n c e i s not value f r e e . To search f o r a "best' model o f need assessment (Royse and Drude, 1982) i s t o ignore t h i s f a c t . Resource a l l o c a t i o n and s e r v i c e p l a n n i n g have become an i n c r e a s i n g l y p o l i t i c a l p r o c e s s . The t o o l used t o generate data f o r these d e c i s i o n s must be understood as well as the context i n which i t i s used. 11 Chapter I I : Mental I l l n e s s A. Problems with D e f i n i t i o n s Before examining need assessments the q u e s t i o n o f what mental i l l n e s s i s needs t o be addressed. In the Middle Ages dev i a n t behavior was throught t o be due t o the s u p e r n a t u r a l , g i v i n g the Church the r o l e o f d i a g n o s t i c i a n , l a b e l e r and t h e r a p i s t . L a t e r , s i n and low morals r e p l a c e d the supernatural and the Church continued i t s r o l e . The s c i e n t i f i c advances o f the n i n e t e e n t h c e n t u r y t r a n s f e r r e d t h i s power l a r g e l y t o the medical p r o f e s s i o n where i t rema i ns. The l a t e n i n e t e e n t h century and e a r l y p a r t o f the t w e n t i e t h century supported the "asylum i n d u s t r y " , p r e v i o u s l y r e f e r r e d t o . Mental i l l n e s s was c l e a r l y any c o n d i t i o n t h a t r e s u l t e d i n one's i n c a r c e r a t i o n i n an asylum. The emergence o f a medical model in the n i n e t e e n t h century served t o take d e v i a n t behavior out o f the realm o f the supernatural but d i d very l i t t l e t o i d e n t i f y and d e f i n i t i v e b i o l o g i c a l e t i o l o g y or cure. Mental d i s o r d e r s became viewed as b i o l o g i c a l l y based mainly as an obvious e x t e n s i o n o f the germ theory o f d i s e a s e . Despite the d i s t i n c t lack o f success in producing any d i r e c t evidence t o s u s t a i n t h i s medical model o f mental i l l n e s s , the s t a t u s o f the p h y s i c i a n appears t o have been b o l s t e r e d by achievements in the p h y s i c a l d i s e a s e s o f the body. The development o f the p s y c h o a c t i v e drugs in the 1950'^s' 12 again served t o b o l s t e r the medical model of" mental i l l n e s s , though l a t e r c r i t i c i s m s have po i n t e d out t h a t maintenance does not n e c e s s a r i y mean e t i o l o g y . Despite t h i s the medical model continued t o ho l d dominance d e s p i t e the beginnings o f s o c i o l o g i c a l i n v e s t i g a t i o n s i n t o d e v i a n t b ehavior. T h i s growth turned the academic focus in mental h e a l t h t o a s o c i a l c a u s a t i o n theory (eg. Marxian theory; Durkheim, 1951; Merton, 1957; Brenner, 1973). Terms such as behavior d i s o r d e r , maladjustment and non a d a p t i v e behavior - a l l suggesting a s o c i a l or environmental e t i o l o g y - have become interchangeable with medical terms such as mental i l l n e s s , mental s i c k n e s s , mental d i s o r d e r . European p s y c h i a t r y developed q u i t e independently o f North American p s y c h i a t r y d u r i n g the e a r l y p a r t o f the t w e n t i e t h century, f o c u s s i n g on d i f f e r e n t i a l d i a g n o s i s and c l a s s i f i c a t i o n systems. The North American t r a d i t i o n was f u e l l e d by the e a r l y e p i d e m i o l o g i c a l work (eg. Fan's and Dunham, 1939; H o l l i n g s h e a d and R e d l i c h , 1958) which ignored such c l a s s i f i c a t i o n systems, f o c u s s i n g i n s t e a d on problem l i s t s and g l o b a l measurements. Thus, i n North America mental i l l n e s s - mental h e a l t h was seen as a continuum. Mental i l l n e s s was viewed as the "downside" o f mental h e a l t h . Mental h e a l t h became viewed as a s t a t e o f balance between an i n d i v i d u a l and h i s surroundings, between o n e s e l f and o t h e r s (eg. S a r t o r i u s , 1984). T h i s expansive view o f mental i l l n e s s was f u r t h e r 13 advanced by the Human P o t e n t i a l Movement. The growth o f the non-medica11y based mental h e a l t h p r o f e s s i o n s a s s i s t e d in the development and advancement o f the r e l a t i o n s h i p - b a s e d t h e r a p i e s . The medical p r o f e s s i o n i t s e l f embraced problems o f l i v i n g as l e g i t i m a t e medical t e r r i t o r y through the process o f m e d i c a l i z a t i o n (eg. Conrad, 1980). The r e s u l t i s t h a t a d e f i n i t i o n o f mental i l l n e s s i s v i r t u a l l y i m possible. Mental i l l n e s s i s not the homogeneous concept the term suggests. It p o t e n t i a l l y i n c l u d e s a l l forms o f " d e v i a n t " behavior, from p s y c h o s i s t o h y p e r a c t i v i t y . The impact on the development o f s e r v i c e i s c l e a r - as long as the d e f i n i t i o n expands demand f o r s e r v i c e w i l l outpace supply. The two major models o f mental i l l n e s s - medical and s o c i a l - have been l a r g e l y i n t e g r a t e d i n North America and t h i s r e l a t i o n s h i p i s important when examining need assessment in mental h e a l t h . B. The. I n t e r - r e l a t i o n s h i p o f Med i ca1 and Soc i a 1 Mode 1s o f Menta1 I 11ness Within western s o c i e t y the d i s e a s e model, or medical model, o f i l l n e s s i s n e a r l y u n i v e r s a l l y accepted as e x p l a n a t i o n f o r p h y s i c a l a i l m e n t s . Indeed, the term " p h y s i c a l " i m p l i e s not o n l y the l o c a t i o n o f the problem but a l s o the cause. T h i s has a l s o l a r g e l y been the case f o r mental d i s o r d e r s w i t h i n the organized and p r o f e s s i o n a l 14 h e a l t h care system, d e s p i t e the academic c o n t r i b u t i o n s o f s o c i o l o g i s t s throughout t h i s century. Some w r i t e r s have argued t h a t t h i s has l a r g e l y come about f o r p o l i t i c a l and power reasons (eg. Conrad, 1980; Mi s h i e r , 1981). Medicine has been long viewed as a powerful agent o f s o c i a l c o n t r o l and the m e d i c a 1 i z a t i o n o f behaviors seemingly s o c i a l l y caused has served t o t r a n s f e r the r e s p o n s i b i l i t y from s o c i e t y t o the i n d i v i d u a l . It has been argued t h a t medical p s y c h i a t r y ' s main task i n the ni n e t e e n t h century was t h a t o f c o n f i n i n g c i v i l i z a t i o n ' s m i s f i t s in a pl a c e where they c o u l d not d i s t u r b s o c i e t y . The s u c c e s s f u l m e d i c a 1 i z a t i o n or " p s y c h i a t r i z a t i o n ' o f those who e x h i b i t unacceptable behavior has made i n s t i t u t i o n a l i z a t i o n unnecessary. Medical ideology can d e f i n e a p a t i e n t ' s c o n d i t i o n as l y i n g o u t s i d e the realm o f "normal' behavior and maintain the i n d i v i d u a l ' s r e s p o n s i b i l i t y f o r i t . The medical p r o f e s s i o n has been long c r i t i c i z e d as an agent o f power, an e l i t i s t group t h a t b e n e f i t from the st a t u s quo. They have gained and r e t a i n e d t h e i r powerful p o s i t i o n i n s o c i e t y l a r g e l y due t o s u p e r s t i t i o n - man's f e a r o f death and the w i t c h d o c t o r s ' presumed a b i l i t y t o c o n t r o l i t - and p a r t l y from the s t a t u s a s s o c i a t e d with i t s r e l i a n c e on s c i e n t i f i c methods. P s y c h i a t r y i n t u r n c a p i t a l i z e d on these two seemingly c o n t r a d i c t o r y f o r c e s - s u p e r s t i t i o n and sc i e n c e - by i d e n t i f y i n g with medicine. Given the power o f the medical p r o f e s s i o n and i t s 15 d e s i r e t o r e t a i n the s t a t u s quo, i t has been argued t h a t p s y c h i a t r y has vested i n t e r e s t s i n the c o n t i n u a t i o n o f the medical model o f i l l n e s s . T h i s i s not o n l y from a f i n a n c i a l viewpoint - though t h i s i s important as can be seen by o r g a n i z e d p s y c h i a t r y ' s r e l u c t a n c e t o a l l o w the newer mental h e a l t h p r o f e s s i o n s - s o c i a l workers and p s y c h o l o g i s t s - on t o t h e i r t e r r i t o r y , and t h e i r compromise o f a m u l t i -d i s c i p l i n a r y team - with p h y s i c i a n a t head o f team, o f course. T h i s t e r r i t o r i a l imperative i s a l s o backed by l e g i s l a t i o n d i s a l l o w i n g o t h e r p r o f e s s i o n s from d i a g n o s i s and treatment o f what are d e s i g n a t e d as medical c o n d i t i o n s . Some w r i t e r s (e.g. Ingleby, 1980) have suggested t h a t p s y c h i a t r y ' s i n t e r e s t in m a i n t a i n i n g the medical model - the view o f the i n d i v i d u a l as r e s p o n s i b l e f o r the a m e l i o r a t i o n o f h i s problem ( a l b e i t s o c i a l l y caused) i s a r e s u l t o f the l a r g e r p o l i t i c a l c o n t e x t . To acknowledge t h a t mental d i s o r d e r has a s o c i a l c a u s a t i o n - t h a t s o c i e t y i s r e s p o n s i b l e f o r the d e v i a n t behavior o f i t s members - would suggest t h a t s o c i e t y , not i n d i v i d u a l s , should be changed. It has been argued t h a t the e l i t i s t s - i n t h i s case the p s y c h i a t r i s t s - have a vested i n t e r e s t in not changing s o c i e t y . The r e s u l t i s t h a t a c a d e m i c a l l y we have two d i s t i n c t t h e o r i e s o f mental i l l n e s s - a medical and a s o c i a l . In p r a c t i c e we have one - the medical. T h i s i s an important p o i n t f o r needs assessment in h e a l t h care p l a n n i n g . In 16 western s o c i e t y , mental i l l n e s s i s by d e f i n i t i o n an i l l n e s s t o be d e a l t with w i t h i n the medical e s t a b l i s h m e n t . T h i s medical establishment has co-opted the newer p r o f e s s i o n s i n t o t h i s model. Health care s e r v i c e s are developed with change o f the i n d i v i d u a l as t h e i r f o c u s . T h e i r t a r g e t i s the i n d i v i d u a l , the case. The m e d i c a l i z a t i o n o f mental d i s o r d e r s or abnormal behavior has a l s o co-opted many o f the r e c e n t l y developed s o c i a l c a u s a t i o n models and l e g i t i m i z e d them as medical t e r r i t o r y . The medical establishment i s i t s e l f seemingly s c h i z o p h r e n i c , a d m i t t i n g t o s o c i a l l y caused d i s o r d e r s but m a i n t a i n i n g the e f f i c a c y o f m e d i c a l l y based c u r e s . T h i s i s not a r a t i o n a l p o s i t i o n - in the sense o f l o g i c o f c a u s a l i t y . It r e f l e c t s the c o n t r o l the medical establishment has in persuading s o c i e t y o f t h e i r c u r a t i v e powers. Medicine, a s s i s t e d by the t e c h n o l o g i c a l development, s t a r t i n g in the f i f t i e s with the debut o f the a n t i p s y c h o t i c medications, has geared s o c i e t y f o r the "quick f i x " . It has made promises o f treatment and cures which, p a r t i c u l a r l y in the mental h e a l t h s e c t o r , i t has l a r g e l y f a i l e d t o p r o v i d e . It has p o i n t e d t o i t s use o f medications and treatment such as E.C.T. as i n d i c a t o r s t h a t much o f mental d i s o r d e r i s in f a c t b i o l o g i c a l in o r d e r . Such arguments have been shown t o be based on f a u l t y l o g i c as s u c c e s s f u l management o f a p a t i e n t does not n e c e s s a r i l y imply e i t h e r cause nor cure. 17 The r e s u l t in mental h e a l t h has been an i n t e r e s t i n g d i v i s i o n in care s e r v i c e s . As a r u l e p r i v a t e p s y c h i a t r y , the most h i g h l y * s o p h i s t i c a t e d ' mental h e a l t h workers, have turned away from the s e r i o u s l y and c h r o n i c a l l y m e n t a l l y i l l , r e l e g a t i n g t h i s group t o the l e a s t t r a i n e d t o "manage", while r e t a i n i n g t h e i r power through t h e i r r i g h t t o medicate and c e r t i f y . T h i s i s p r e c i s e l y the group f o r which p h y s i c i a n s have argued an o r g a n i c b a s i s (though not yet i d e n t i f i e d ) f o r mental i l l n e s s - the s c h i z o p h r e n i c s and b i p o l a r d i s o r d e r s . The bulk o f p s y c h i a t r y in North America i s p r i v a t e p r a c t i c e and the bulk o f t h i s p r i v a t e p r a c t i c e i s made up o f those who have been d e s c r i b e d as the d i s s a t i s f i e d and d i s t r e s s e d . No o r g a n i c a l l y based e t i o l o g y has been i d e n t i f i e d f o r t h i s group. In f a c t , p s y c h i a t r i s t s themselves are quick t o accept a s o c i a l c a u s a t i o n t h e o r y , i n c l u d i n g *adjustment' d i s o r d e r s w i t h i n medical c l a s s i f i c a t i o n systems. In another i r o n i c t u r n o f events the m e n t a l l y r e t a r d e d , with a d o u b t l e s s b i o l o g i c a l or o r g a n i c b a s i s in n e a r l y every i n s t a n c e ^ ^ have, in many areas, been r e l e g a t e d t o the r e s p o n s i b i l i t y o f s o c i a l s e r v i c e agencies r a t h e r than the medical s e c t o r . The argument i s t h a t e t i o l o g y i s unimportant, while f u n c t i o n i n g i s . F u n c t i o n i n g i s seen, in the e x c e p t i o n being severe cases o f environmental depr i vat i on 18 the case o f the men t a l l y r e t a r d e d , as s o c i a l i n nature. So, by v i r t u e o f t h e i r behavior they are not seen t o be the t e r r i t o r y o f the medical establishment - the p o l a r o p p o s i t e o f the men t a l l y i l l who are co n s i d e r e d medical problems because o f t h e i r behavior, not n e c e s s a r i l y i t s e t i o l o g y . C. P o s i t i v i s t vs I n t e r p r e t i v e Paradigms Ingleby (1980) has d i f f e r e n t i a t e d between p o s i t i v i s t and i n t e r p r e t i v e views about mental i l l n e s s and t h i s d i s t i n c t i o n i s very r e l e v a n t t o the c u r r e n t h e a l t h care system. Ingleby has argued t h a t these two approaches r e f l e c t d i f f e r e n t , mutually e x c l u s i v e , paradigms. He suggests t h a t they d i f f e r i n t h e i r view as t o what i s v a l i d and c r e d i b l e data on which t o b u i l d a t h e o r y . Ingleby i n c l u d e s the medical as well as most s o c i a l models o f mental i l l n e s s w i t h i n h i s p o s i t i v i s t framework. He argues t h a t these models share the same (to him, f a u l t y ) premise t h a t o b s e r v a t i o n can be made o b j e c t i v e l y and value f r e e , t h a t measures can be d e f i n e d o p e r a t i o n a l l y and a p p l i e d in a p r e c i s e , r e p l i c a b l e f a s h i o n and t h a t t h e o r i e s can be c o n s t r u c t e d on the same c a u s a l , d e t e r m i n i s t i c b a s i s as in the n a t u r a l s c i e n c e s . He f u r t h e r argues t h a t the p o s i t i v s t view assumes t h a t t h e r e a r e no f e a t u r e s d i s t i n g u i s h i n g human beings from the r e s t o f nature which might n e c e s s i t a t e the adoption o f a d i f f e r e n t paradigm. In f a v o r o f the i n t e r p r e t i v e model Ingleby emphasizes 19 the u n i q u e l y human nature o f man, the importance o f s u b j e c t i v e i n t e r p r e t a t i o n s and context t o the meaning o f any behavior (analogous t o the ethnomethodologists such as G a r f i n k e l , 1934, and r a d i c a l p s y c h i a t r i s t s such as L a i n g , 1967). The i n t e r p r e t i v e view argues f o r grounds and reasons while the p o s i t i v s t view examines the same f a c t o r s as causes. Where the p o s i t i v i s t sees abnormal behavior as abnormal w i t h i n the broad spectrum o f s o c i e t y , the i n t e r p r e t i v e view makes sense o f t h a t same behavior as a coping behavior, a d a p t i v e t o the s i t u a t i o n . T h i s d i s t i n c t i o n i s e s s e n t i a l f o r need assessment. As we have d i s c u s s e d , the emphasis i n h e a l t h care d e l i v e r y has developed i n response t o the medical model, a l b e i t with l i p s e r v i c e t o s o c i a l t h e o r i e s . It can be argued t h a t t h i s has been done u n c o n s c i o u s l y by both p h y s i c i a n s and government pla n n e r s , a l l o w i n g a system t o evolve based on one concept o f mental d i s o r d e r . Much o f t h i s can be a t t r i b u t e d not o n l y t o the i n s i d i o u s power o f the medical p r o f e s s i o n but a l s o the incremental p l a n n i n g methods used i n d e v e l o p i n g these systems. The r e l a t i o n s h i p o f needs and p l a n n i n g are more thoroughly d i s c u s s e d below. However, i t i s important t o c l a r i f y a t t h i s p o i n t t h a t given the new emphasis on r a t i o n a l p l a n n i n g as opposed t o the h i s t o r i c a l incremental approach, planners and governments now may have an o p p o r t u n i t y t o j u s t i f y moving away from t h i s m e d i c a l l y dominated model. As w i l l be d i s c u s s e d , i t i s an expensive one, with l i t t l e thought t o e f f i c i e n c y . It i s a s u p e r s t i t i o u s one, with the "witchdoctor' aura s t i l l i n t a c t but, as a r e s u l t o f the consumerism o f the s i x t i e s and s e v e n t i e s , c e r t a i n l y s l i p p i n g . It w i l l be argued t h a t given t h i s new e r a , an era where r a t i o n a l methods are being s t r e s s e d , a comprehensive understanding o f how medical and s o c i a l models o f mental i l l n e s s have been i n e x t r i c a b l y welded t o g e t h e r may prevent f u t u r e p l a n n e r s from being n e c e s s a r i l y c o n f i n e d t o the e x i s t i n g models o f c a r e . Governments may, f o r t h e i r own reasons, be r e l u c t a n t t o change course. The important issue i s , however, t h e r e needs t o be an a p p r e c i a t i o n o f how s t r o n g l y the medical model - or p o s i t i v i s t model - has i n f l u e n c e d not o n l y our view o f mental i l l n e s s and mental h e a l t h care, but a l s o the instruments used t o assess need. Need assessment models are not value f r e e . I n t e l l i g e n t use o f them r e q u i r e s understanding o f the models about mental d i s o r d e r inherent w i t h i n them. 21 Chapter I I I : A Conceptual A n a l y s i s o f Need Assessment A. A D e f i n i t i o n o f Need Assessment Having e s t a b l i s h e d the importance o f a p o t e n t i a l l y e l a s t i c concept o f mental i l l n e s s and the r e l a t i v e c o n t r i b u t i o n o f both medical and s o c i a l c a u s a t i o n models t o the mental h e a l t h care i n d u s t r y , a t t e n t i o n can now be turned t o need assessment i t s e l f . V a rious d e f i n i t i o n s e x i s t f o r needs assessment but s u r p r i s i n g l y they are much in agreement. T h i s i s s u r p r i s i n g as a n a l y s i s o f e i t h e r concept o f need or o f assessment b r i n g s about hot debate. Of course t h i s r e f l e c t s the b a s i c problem - people are quick t o agree t h a t needs must be assessed, yet have l i t t l e understanding o f the assumptions u n d e r l y i n g the concepts. B e l l , Warheit and Schwab (1977) suggest t h a t a need assessment program can be most simply d e f i n e d as an attempt to enumerate the h e a l t h needs o f a p o p u l a t i o n l i v i n g i n a community. They f u r t h e r d e s c r i b e i t as a r e s e a r c h and pl a n n i n g a c t i v i t y designed t o determine the h e a l t h needs and u t i l i z a t i o n p a t t e r n s o f those l i v i n g in a community. Kami's (1979) suggests t h a t need assessment i s any a c t i v i t y which p r o v i d e s a d e s c r i p t i o n and/or measures o f e i t h e r the r e l a t i v e , or a b s o l u t e needs o f people l i v i n g in a d e f i n e d a r e a . Royse and Drude (1982), in recent support o f the technology, r e f e r t o i t as a process o f i d e n t i f y i n g t a r g e t p o p u l a t i o n s and d i r e c t i n g programming. I.Q. has been 22 d e f i n e d as t h a t which I.Q. assessment measures. Perhaps t h i s i s the case with need assessment - need assessment i s t h a t which need assessments measure. B. Problems with the Concept The o b j e c t i v e o f need assessment seems t o be c l e a r - t o i d e n t i f y some type o f data t o f a c i l i t a t e some type o f pl a n n i n g i n some community. The problem l i e s i n the d e f i n i t i o n s o f need and the methodologies by which i t i s measured. C r i t i c s o f the process (e.g. Kimmel, 1977; Cochran, 1979) have warned t h a t c o n c e p t u a l l y need assessment i s too loose, with imprecise and u n r e l i a b l e methodologies and no standards. Such c r i t i q u e s have been r e f u t e d by o t h e r s , such as Kamis (1979) and Royse and Drude (1982), who have acknowledged shortcomings but encouraged progress in the f i e l d . The essence, however, o f both c r i t i q u e s and r e b u t t a l s appears t o focus on the need f o r a more " s c i e n t i f i c ' or "hard' approach. Royse and Drude (1982) i n p a r t i c u l a r c e n t r e on the l i m i t a t i o n s o f the methodologies, c a l l i n g on n a t i o n a l p r o f e s s i o n a l o r g a n i z a t i o n s t o f a c i l i t a t e the development o f new instruments and the s t a n d a r d i z a t i o n o f o l d . The focus o f the c r i t i q u e s appears t o remain a t t h i s methodological l e v e l , with l i t t l e a t t e n t i o n being p a i d t o the more fundamental l e v e l o f v a l u e s . Blum (1974) and S i e g e l , A t t k i s s o n and Carson (1978) are amongst the few who seem t o be prepared t o a t best touch 23 upon some o f the t h o r n i e r i s s u e s , acknowledging the major r o l e o f values in the proc e s s . S i e g e l , A t t k i s s o n and Carson (1978) d i f f e r e n t i a t e between "need i d e n t i f i c a t i o n ' and "need assessment'. They suggest t h a t need " i d e n t i f i c a t i o n ' i s the process by which h e a l t h and s o c i a l s e r v i c e requirements i n a c e r t a i n area are d e s c r i b e d , while need "assessment' i n v o l v e s the process o f e s t i m a t i n g the r e l a t i v e importance o f those needs. They c i t e Blum (1974) in d e s c r i b i n g the process o f need i d e n t i f i c a t i o n and assessment as i n v o l v i n g two d i s t i n c t s t e p s : (a) the a p p l i c a t i o n o f a measuring t o o l t o a d e f i n e d area and, (b) the a p p l i c a t i o n o f judgement t o assess the s i g n i f i c a n c e o f the i n f o r m a t i o n in order t o determine p r i o r i t i e s f o r program p l a n n i n g and s e r v i c e development. The i m p l i c a t i o n o f the above two-stage process i s t h a t values come i n t o p l a y in the second stage o n l y , the measurement t o o l implied t o be a v a l u e - f r e e d e v i c e . S i e g e l et a l . s t a t e t h a t the v a r i o u s known assessment techniques produce i n f o r m a t i o n t h a t d e s c r i b e or d e f i n e s o c i a l c o n d i t i o n s or s i t u a t i o n s and t h a t these c o n d i t i o n s are not n e c e s s a r i l y predetermined t o be p o s i t i v e or n e g a t i v e . They suggest t h a t the i n t e r p r e t a t i o n o f the s i t u a t i o n depends upon the values and e x p e c t a t i o n s o f those doing the i n t e r p r e t i n g . They go on t o quote Blum (1974), "The i d e n t i c a l s i t u a t i o n may be seen as good by those whose value e x p e c t a t i o n s a re met, and as bad by those whose values are not, those whose values a re u n r e l a t e d , or who do not connect 24 the c o n d i t i o n t o values may not p e r c e i v e the c o n d i t i o n o f a l l , or view i t as a n a t u r a l s t a t e o f a f f a i r s " . It i s the premise o f t h i s paper t h a t values come i n t o p l a y before the i n t e r p r e t a t i o n o f data. Values are implied by the q u e s t i o n asked, the data c o l l e c t e d and the methodology used. As Ingelby (1980) has suggested in d i s c u s s i o n o f p o s i t i v i s t vs i n t e r p r e t a t i v e paradigms o f mental i l l n e s s , the d i f f e r e n t models imply whole systems o f p r e j u d i c e about what c o n s t i t u t e s u s e f u l and r e s p e c t a b l e data. The d e c i s i o n as t o which model, or what type o f data t o c o l l e c t , i s not a v a l u e - f r e e one. It i s not an a r b i t r a r y one. The d e c i s i o n r e f l e c t s a s p e c i f i c model o f mental i l l n e s s , i t s causes, i t s p o t e n t i a l f o r care - maintenance, treatment, cure or p r e v e n t i o n - and the a p p r o p r i a t e n e s s o f types o f c a r e . It r e f l e c t s the values and g o a l s not o n l y o f the c u l t u r e i n which the assessment (as opposed t o the community in question) occurs but a l s o o f the p o l i t i c a l f o r c e s a t work. To negate the importance o f e i t h e r f o r c e -model o f i l l n e s s or p o l i t i c a 1 / s o c i a 1 context - i s t o ignore c r u c i a l f a c t o r s which c o n t r i b u t e t o the d i r e c t i o n o f development o f the mental h e a l t h i n d u s t r y . To e x p l o r e o n l y the term 'assessment' as i s suggested in the focus on methodologies by w r i t e r s such as Royse and Drude (1982) i s t o n e g l e c t the more fundamental q u e s t i o n o f what i s need, how i t i s d e f i n e d and by whom. Thi s b r i n g s us back t o the q u e s t i o n o f need, and the 25 need t o examine the assumptions o f want, need and demand. How these t h r e e i n t e r - r e l a t e d concepts are d e f i n e d and used has a l a r g e impact on the type o f model o f assessment a planner wi11 use. C. Want. Demand and Need The terms want, demand and need are f r e q u e n t l y used int e r c h a n g e a b l y though they a c t u a l l y r e f e r t o q u i t e d i f f e r e n t s t a t e s . Need assessment may a c t u a l l y be want assessment, demand assessment or need assessment depending upon the model o f assessment being used. An understanding o f the d i f f e r e n t i m p l i c a t i o n s o f each o f these t h r e e terms i s e s s e n t i a l t o a p p r e c i a t e the m e r i t s o f the t e c h n o l o g i e s . 1. Want/Demand Want i s the most b a s i c o f the s t a t e s , r e f l e c t i n g an i n d i v i d u a l ' s assessment o f h i s h e a l t h s t a t e compared with h i s own i n t e r n a l norm. T h i s i s a h i g h l y r e l a t i v e s t a t e , unique t o each i n d i v i d u a l and p o t e n t i a l l y v a r i a b l e w i t h i n the same i n d i v i d u a l . A want i s not s u f f i c i e n t t o a c t i v a t e access t o c a r e . A want must be t r a n s l a t e d i n t o a demand f o r s e r v i c e . The f a c t o r s which determine whether an i n d i v i d u a l w i l l a c t i v a t e a sel f - a s s e s s m e n t o f want ( f o r b e t t e r h ealth) i n t o demand are complex. Cooper (1975) has d i s c u s s e d some o f the f a c t o r s which i n f l u e n c e how an i n d i v i d u a l makes the d e c i s i o n t o t r a n s l a t e 26 want i n t o demand. He c i t e s Kessel and Shepherd (1965) who have r e p o r t e d l i t t l e obvious d i f f e r e n c e between p a t i e n t s who, over a ten year p e r i o d , never saw t h e i r doctor and those with the average number o f attendances. Cooper r e p o r t s t h a t such f a c t o r s as job s a t i s f a c t i o n , p e r s o n a l i t y and s t a b i l i t y o f f a m i l y background have been found t o a l t e r r a t e s o f demand. Other f a c t o r s , such as economic d e t e r r e n t s , p r o x i m i t y o f a v a i l a b l e c a r e , p l u s sheer a v a i l a b i l i t y o f manpower re s o u r c e s , have a l s o been shown t o d r a m a t i c a l l y a f f e c t demand. Cooper suggests t h a t i n the long run, demand w i l l tend t o g r a v i t a t e towards whatever l e v e l o f care happens t o be a v a i l a b l e . T h i s may be a l s o a f f e c t e d by the a v a i l a b i l i t y o f s o c i a l a g e n c i e s , f o r without such agencies people tend t o t r a n s l a t e t h e i r s o c i a l needs i n t o h e a l t h needs. Demand, although v o i c e d by the i n d i v i d u a l , i s a r t i c u l a t e d by the p r o f e s s i o n a l . The i n d i v i d u a l may, as a r e s u l t o f v a r i o u s f a c t o r s , decide t o v o i c e h i s demand f o r care, but once having done t h i s , i t i s the p r o f e s s i o n a l who e i t h e r v a l i d a t e s t h i s i n t o need or not and who then d i c t a t e s what s o r t o f need e x i s t s . The i n d i v i d u a l chooses t o v o i c e demand but does not in most cases have the power t o determine what k i n d o f c a r e or how much care he r e q u i r e s . It i s the p r o f e s s i o n a l - u s u a l l y p h y s i c i a n - who decides what type o f s e r v i c e he w i l l render, how o f t e n , and where. He a l s o d i c t a t e s what s o r t and what q u a n t i t y o f other h e a l t h 27 s e r v i c e s w i l l be used - such as medication, h o s p i t a l i z a t i o n , l a b o r a t o r y s e r v i c e s , e t c . T h i s i s p a r t o f the 'bargain' between demand and need, between layman and expert. The o b l i g a t i o n inherent in having one's wants and demands a u t h e n t i c a t e d i n t o need i s the acknowledgement o f the s i c k r o l e and the g i v i n g up o f c o n t r o l t o the p r o f e s s i o n a l (Parsons, 1958). T h i s i t s e l f i s an i n c r e a s i n g l y s t r o n g f a c t o r i n the t r a n s l a t i o n o f demand i n t o need. With the advent o f consumerism and emphasis on human r i g h t s which grew in the l a t e 1960's and 1970's, t h e r e has been a growing awareness o f t h i s i m p l i c i t "bargain' i n the demand f o r h e a l t h care and l a r g e numbers o f lay people have questioned these imp l i e d o b l i g a t i o n s . T h i s i s p a r t i c u l a r l y t r u e o f the mental h e a l t h f i e l d , spurred by r a d i c a l p s y c h i a t r i s t s such as Laing (1960, 1971) and Szasz (1961) and w r i t e r s such as Goffman (1961, 1965). 2. Need Need i s g e n e r a l l y expressed as the p r o f e s s i o n a l ' s view o f what the c l i e n t r e q u i r e s ; demand sugges t i n g a lay a p p r a i s a l . Boulding (1966) suggests t h a t the concept o f need i s o f t e n c r i t i c i z e d as being too mechanical, denying autonomy and i n d i v i d u a l i t y o f the human person. User demand, on the other hand, implies autonomy, i n d i v i d u a l c h o i c e and the t a i l o r i n g o f inputs t o i n d i v i d u a l p r e f e r e n c e s . There are f u r t h e r problems, however. i f need 28 i s viewed as the p r o f e s s i o n a l c h o i c e , one must q u e s t i o n which p r o f e s s i o n a l i s making the c h o i c e . In the case o f demand, autonomy im p l i e s t h a t the chooser i s aware o f the cho i c e s - the sov e r e i g n consumer - which i s c l e a r l y not the case in h e a l t h . The f a c t o r s a f f e c t i n g need are complex. The f a c t t h a t the concept o f need has been c r i t i c i z e d as being too mechanical i m p l i e s t h a t i t i s a r e s u l t o f some s c i e n t i f i c f a c t . However, as Boulding (1967) has p o i n t e d out, even s c i e n c e i s not a p a s s i v e servant o f e x i s t i n g v a l u e s . T h i s i s c l e a r l y the case o f need, i l l u s t r a t e d by the wide v a r i e t y o f p r o f e s s i o n a l values, o p i n i o n s and p r a c t i c e , both w i t h i n and between c u l t u r e s . Blum and S t e i n (1981) suggest t h a t need i s a *hea1th d e f i c i e n c y ' , a gap between an e x i s t i n g and a d e s i r e d s t a t e o f h e a l t h . Under t h i s d e f i n i t i o n , need i s thought o f as t r u e , r e a l or b i o l o g i c a l . Donabedian (1973) o f f e r s a s i m i l a r l y m e d i c a l l y o r i e n t e d d e f i n i t i o n , d e s c r i b i n g need as a d i s t u r b a n c e i n h e a l t h or w e l l - b e i n g t h a t r e q u i r e s medical or p r o f e s s i o n a l c a r e . He maintains t h a t need be c o n c r e t e l y d e c l a r e d by the p h y s i c i a n . Recent work in the f i e l d o f h e a l t h economics o f f e r s evidence t o r e f u t e t h i s b e l i e f i n a s t a t i c , d o c t o r -i d e n t i f i e d l e v e l o f need. Cooper (1975) p o i n t s out t h a t , faced with a p a t i e n t d e c l a r i n g demand, i t i s d i f f i c u l t f o r a p h y s i c i a n t o de c i d e t o do nothing. Goldberg and Huxley (1980) f a c e t i o u s l y comment " i f o n l y p s y c h i a t r i s t s were in 29 the h a b i t o f sa y i n g t o t h e i r p a t i e n t s , "You don't have a p s y c h i a t r i c i l l n e s s , go away'". Need i s a medical o p i n i o n , not a medical f a c t , as can be gathered from c o n s i d e r a b l e r e s e a r c h on v a r i o u s p a t t e r n s o f p r a c t i c e under s i m i l a r circumstances. C o n s i d e r a b l e p u b l i c i t y has been given t o "unnecessary' surgery i n re c e n t years - p a r t i c u l a r l y g y n a e c o l o g i c a l and o b s t e t r i c a l . Cooper r e f e r s t o data i n d i c a t i n g t h a t h o s p i t a l surgeons in the United S t a t e s manage t o f i n d twice as many p a t i e n t s per c a p i t a in need o f surgery as do t h e i r B r i t i s h c o u n t e r p a r t s and p o i n t s out t h a t t h i s d i f f e r e n c e i s made more s u r p r i s i n g when allowance i s made f o r the e x i s t e n c e o f a larg e m e d i c a l l y d e p r i v e d p o p u l a t i o n in the United S t a t e s due t o the p r i c e b a r r i e r . He f u r t h e r suggests t h a t need tends t o grow i n 1ine with p r o v i s i o n , as d o c t o r s r e a c t t o any i n c r e a s e in supply by r e a l i g n i n g t h e i r c o nception o f need f u r t h e r along the p o s s i b l e continuum. He quotes F e l d s t e i n (1977) i n d i c a t i n g t h a t both admissions and length o f s t a y i n c r e a s e d with bed a v a i l a b i l i t y . Cooper suggests t h a t , l i k e an i c e b e r g , the more reso u r c e s devoted t o meeting i t , the more need seems t o f l o a t t o the s u r f a c e . Other authors have i n d i c a t e d s i m i l a r f i n d i n g s . In the Canadian con t e x t , h e a l t h economists such as Evans (1978), Stoddart and Barer (1981) and Roos, Gaumont and Home (1976) have d e t a i l e d s i m i l a r examples o f t h i s phenomenon. They suggest t h a t the t r a d i t i o n a l r e l a t i o n s h i p o f supply and 30 demand cannot be a p p l i e d t o h e a l t h care because o f the p h y s i c i a n ' s a b i l i t y t o generate demand through the p r o f e s s i o n a l i d e n t i f i c a t i o n o f need and c i t e examples o f incr e a s e d supply being r e l a t e d t o f u r t h e r i n c r e a s e need, as d i c t a t e d by the p h y s i c i a n . Current concerns w i t h i n the Canadian medicare system are viewed by the Canadian Medical A s s o c i a t i o n (CM.A.) as "underfunding' as the p r i n c i p l e problem. C r i t i c s o f t h i s approach f e a r t h a t given a f r e e r e i g n , a l i d would never be put on funding , the "need' growing in l i n e with the fund i n g . While the CM.A. sees underfunding as a p r i n c i p l e problem, other s t u d i e s , such as a r e c e n t l y provincia 1 1y-commissioned study i n t o medical manpower and t r a i n i n g needs, i n d i c a t e too many doc t o r s a l r e a d y e x i s t i n Canada. P l a i n (1984) r e p o r t e d about 5 percent too many doc t o r s o f a l l types and 307o too many f a m i l y d o c t o r s w i t h i n the th r e e western p r o v i n c e s . P l a i n estimated each general p r a c t i t i o n e r r e p r e s e n t s a co s t o f $450,000 t o the p r o v i n c e each year f o r h o s p i t a l beds used by t h e i r p a t i e n t s and general o p e r a t i n g c o s t s . He i n d i c a t e s t h a t too many doc t o r s r e s u l t in each c r e a t i n g h i s own demand f o r s e r v i c e and p o i n t s out t h a t few people can determine themselves i f a recommended procedure i s a c t u a l l y necessary. A s i m i l a r Canadian study done in 1983 by by Le Riche and H a l l i d a y (Globe and M a i l , 1984) r e p o r t e d an a s s o c i a t i o n between surgeon supply and more appendectomies, t o n s i l l e c t o m i e s , g a l l bladder o p e r a t i o n s , hysterectomies and 31 Caesarean s e c t i o n s being performed. Demand, though advocated by consumers and those who f e e l s t r o n g l y about personal l i b e r t i e s vs. p r o f e s s i o n a l domination, can r e s u l t in a very unequal d i v i s i o n as a r e s u l t o f the s e v e r a l f a c t o r s which have been d i s c u s s e d as a f f e c t i n g demand. Economics may be the most r e l e v a n t here. In both p h y s i c a l and mental h e a l t h arenas, i t has been shown t h a t socio-economic c l a s s has a large e f f e c t on demand, with the higher end o f the s c a l e demanding and r e c e i v i n g more care (eg. H o l l i n g s h e a d and R e d l i c h , 1958). T h i s may be a good t h i n g or a bad t h i n g i n the end, o f course. More i s not n e c e s s a r i l y b e t t e r in h e a l t h c a r e . However, r e g a r d l e s s o f the v a l u a t i o n , in the end the wealthy do get "more' i f a l l o c a t i o n i s l e f t up t o demand. A r a t h e r i n t e r e s t i n g example o f t h i s i s the c u r r e n t B r i t i s h Columbia government's p o l i c y t o d e - i n s t i t u t i o n a 1 i z e the m e n t a l l y r e t a r d e d . In e f f e c t , t h i s means t h a t the government w i l l no longer be d i c t a t i n g l e v e l o f care i n t h a t * s p e c i a l i z e d s e r v i c e s ' w i l l no longer be o f f e r e d . The r e t a r d e d w i l l , by and l a r g e , be expected t o * stand in queue' f o r b a s i c h e a l t h care s e r v i c e s such as d o c t o r ' s appointments, surgery, d e n t i s t r y and so on. The B r i t i s h Columbia A s s o c i a t i o n f o r M e n t a l l y Handicapped Persons (B.C.M.H.P.) has embraced the idea o f n o r m a l i z a t i o n - which i s i n e f f e c t s t a n d i n g i n queue. However, without s p e c i a l i z e d programs, w i l l the s e v e r e l y and p r o f o u n d l y 32 r e t a r d e d ever get t o the head o f the queue? Lack o f e x p e r t i s e or w i l l i n g n e s s t o deal with t h i s group - and care o f the s e v e r e l y r e t a r d e d can be argued t o be a s p e c i a l t y -may r e s u l t i n l e s s care as t h e i r demand i s not acknowledged. Lack o f a v a i l a b l e a p p r o p r i a t e care may cause decreased demand over a p e r i o d o f time. W i l l the B.C.M.H.P. be so pleased with n o r m a l i z a t i o n a t t h a t p o i n t ? T h i s may t u r n out t o be an example o f where a l l o w i n g consumer demand r a t h e r than p r o f e s s i o n a l need d i c t a t e s e r v i c e l e v e l s r e s u l t s i n lowered standards o f c a r e . D. The L i nkage o f Want, Demand and Need The f a c t o r s which l i n k these t h r e e concepts are complex and not well understood. However, they are c r u c i a l t o any examination o f the models o f need assessment. Each i m p l i e s a v a s t l y d i f f e r e n t conceptual understanding o f the v a r i a b l e s i n v o l v e d in assessment and thus w i l l a f f e c t i t s outcome. F i g u r e 1 i l l u s t r a t e s the p o s s i b l e chains o f events t h a t may l i n k these concepts. 33 F i g u r e 1: The R e l a t i o n s h i p o f Need, Demand and Want WANT DEMAND NEED i nd i v i dua1's assessment o f h e a l t h s t a t e compared with h i s own i n t e r n a l norm i n d i v i d u a l ' s wants a r t i c u l a t e d by conta c t with medica e s t a b l i shment c o n f i rmation o f s t a t e by pr a c t i t i oner NEED p r o f e s s i o n a l ' s assessment o f h e a l t h below h i s norm OR WANT i nd i v i dua1's acknowledgement o f t h i s DEMAND i nd i v i dua1's agreement through co-op e r a t i o n with care by p r o f e s s i o n a l Thus access t o s e r v i c e may o r i g i n a t e with e i t h e r the i n d i v i d u a l or the p r o f e s s i o n a l . What should be measured i n need assessment - the i n d i v i d u a l ' s want, the i n d i v i d u a l ' s demand or the p r o f e s s i o n a l ' s d e f i n e d need? Each o f f e r s p o t e n t i a l l y q u i t e d i f f e r e n t i n f o r m a t i o n . E. Want, Demand and Need in Menta1 Hea1th Mental h e a l t h perhaps even more than p h y s i c a l h e a l t h i s val u e - l a d e n . An example o f t h i s i s the 1973 d e c i s i o n by the American P s y c h i a t r i c A s s o c i a t i o n t o no longer i n c l u d e homosexuality as a p s y c h i a t r i c d i s e a s e . Despite the f a c t t h a t t h e r e had never been a s u b s t a n t i a l o r g a n i c cause f o r 34 t h i s * d i s e a s e ' and d e s p i t e t h e r e not being any known cure, homosexuality had been seen as a need f o r p s y c h i a t r i c c a r e . At the same time, t h e r e i s i n c r e a s i n g i n t e r e s t w i t h i n the medical p r o f e s s i o n and, in p a r t i c u l a r , p s y c h i a t r y in other ' d i s e a s e s ' such as b e h a v i o r a l problems, h y p e r a c t i v i t y , drug use, and l e a r n i n g problems. The process by which these behaviors are becoming i n c r e a s i n g l y m e d i c a l i z e d has been d i s c u s s e d and i t i s important t o understand t h i s has c o n t r i b u t e d t o the e l a s t i c i t y o f m e d i c a l l y d e f i n e d need in mental h e a l t h . According t o c u l t u r a l values and norms, need can expand or c o n t r a c t , e x h i b i t i n g how v a l u e - l a d e n and r e l a t i v e the concept i s . Related t o t h i s i s p s y c h i a t r y ' s t r a d i t i o n a l focus on s p e c i f i c treatment - o r i g i n a l l y purges, bromides, b l e e d i n g s and l a t e r E.C.T., i n s u l i n shock therapy, p s y c h o t r o p i c medications - t h a t has i n f l u e n c e d the b e l i e f t h a t t h e r e i s a cure, even f o r i l l s which even the p s y c h i a t r i s t s themselves admit t o being s o c i a l l y or e n v i r o n m e n t a l l y based, the idea o f p r o f e s s i o n a l l y d i c t a t e d need i s more f i r m l y entrenched. The idea o f need implies a p o t e n t i a l cure, and p s y c h i a t r y has promoted the idea t h a t medicine has t h a t p o t e n t i a l cure, thus l e g i t i m i z i n g the m e d i c a 1 i z a t i o n o f need. As Warner (1978) has noted, people now have come t o expect and demand the " t e c h n i c a l f i x " t h a t medical s c i e n c e has promised. C l o s e l y l i n k e d with the a n a l y s i s o f need and demand i s the d i a g n o s t i c p r o c e s s . As p r e v i o u s l y mentioned, how a want 35 becomes a demand and how t h a t demand i s or i s not v a l i d a t e d , i s a complex process and p a r t i c u l a r l y so w i t h i n the f i e l d o f mental h e a l t h . Because o f t h i s , the d i a g n o s t i c process deserves separate a t t e n t i o n . F. The D i agnost i c Process The d i a g n o s t i c process i s important because r e g a r d l e s s o f model o f i l l n e s s the d i a g n o s t i c process i s a p r e r e q u i s i t e f o r a c c e s s i n g the t r a d i t i o n a l care system which continues t o be l a r g e l y m e d i c a l l y dominated. The f i r s t stage o f the d i a g n o s t i c process i n v o l v e s the p a t i e n t making a s u b j e c t i v e complaint o f i l l - h e a l t h , some change in what he has come t o p e r c e i v e as h i s normal s t a t e o f w e l l - b e i n g . There i s a growing l i t e r a t u r e examining the e x t r a o r d i n a r y v a r i a b i l i t y between what v a r i o u s i n d i v i d u a l s acknowledge as the norm o f e i t h e r p h y s i c a l or mental h e a l t h . T h i s i s r e f l e c t e d in the d i f f i c u l t y in f o r m u l a t i n g c l e a r and c o n c i s e d e f i n i t i o n s o f h e a l t h . People d i f f e r from i n d i v i d u a l t o i n d i v i d u a l , area t o area and c u l t u r e t o c u l t u r e in t h e i r c o nception o f w e l l - b e i n g and i n t h e i r w i l l i n g n e s s t o t o l e r a t e d i s c o m f o r t as p a r t o f l i f e ' s c y c l e as opposed t o viewing i t as evidence o f s i c k n e s s or d i s e a s e . Mechanic (1972) p o i n t s out t h a t how a person p e r c e i v e s h i s d i s c o m f o r t or d i s a b i l i t y can a f f e c t the way in which i t manifests i t s e l f and develops. T h i s i s o f p a r t i c u l a r importance with mental i l l n e s s due t o the s t r o n g s o c i a l 36 values embodied w i t h i n a d e f i n i t i o n o f mental h e a l t h . The i n c r e a s i n g " m e d i c a l i z a t i o n o f n o r m a l i t y " has r e s u l t e d in problems such as m a r i t a l unhappiness, drug dependence, s o c i a l d i f f i c u l t i e s , l e a r n i n g d i f f i c u l t i e s , as being the l e g i t i m a t e t e r r i t o r y o f mental h e a l t h . Thus, the f a c t t h a t a person views h i s d i s c o m f o r t as "mental h e a l t h " r e l a t e d may a f f e c t i t s development ( S c h e f f , 1966). Rather than s e e i n g i t as p a r t o f the l i f e c y c l e and t r a n s i t o r y , the p e r c e p t i o n o f the problem as mental h e a l t h r e l a t e d and t h e r e f o r e t r e a t a b l e may well sway the i n d i v i d u a l t o v a l i d a t e i t as a d i s o r d e r by d i a g n o s i n g i t and p r e s e n t i n g i t f o r treatment. It has been suggested t h a t many mental h e a l t h c l i e n t s are so m i l d l y d i s t u r b e d t h a t they would in a l l p r o b a b i l i t y recover without treatment. Cummings and Cummings (1965) have r e p o r t e d t h a t most psychoneuroses appear t o be s e 1 f - 1 i m i t i n g c o n d i t i o n s with d u r a t i o n o f about two y e a r s , with or without treatment. In t u r n , Mechanic (1972) c i t e s evidence t h a t , i n 1968 in America, more than t w o - f i f t h s o f a l l v i s i t s t o o f f i c e - b a s e d p s y c h i a t r i s t s were f o r c o n d i t i o n s diagnosed as neuroses. Cummings and Cummings (1965) f u r t h e r suggest t h a t p e r s o n a l i t y or c h a r a c t e r d i s o r d e r s are s i m i l a r l y s e 1 f - 1 i m i t i n g , as well as being r e s i s t e n t t o treatment, yet Mechanic a l s o r e p o r t s f o r the same year t h a t 14 percent o f v i s i t s were f o r such d i s o r d e r s . T h i s would suggest t h a t a t l e a s t h a l f o f a l l v i s i t s t o o f f i c e - b a s e d p s y c h i a t r i s t s were f o r c o n d i t i o n s not r e q u i r i n g 37 treatment. Despite t h i s , w r i t e r s such as Mechanic and Dohrenwend (1980) c i t e evidence t h a t o n l y one out o f f o u r persons a c t u a l l y e x p e r i e n c i n g mental i l l n e s s does seek treatment w i t h i n the normal t h e r a p e u t i c network and t h a t even larg e numbers o f the most s e r i o u s l y i l l (the s c h i z o p h r e n i c s and p s y c h o t i c s ) do not r e c e i v e treatment. How then does one become a "case'? T h i s i s a t the crux o f the i s s u e o f needs assessment. If needs assessment has the aim o f p r o v i d i n g data on which t o base program p l a n n i n g , the essence i s t o a s c e r t a i n not t r u e p r e v a l e n c e but p o t e n t i a l demand under given circumstances. Prevalence does not n e c e s s a r i l y equal need. True pre v a l e n c e w i l l o v e restimate need, i d e n t i f y i n g i n d i v i d u a l s who would not use s e r v i c e s even i f p r o v i d e d . As we have d i s c u s s e d , need implies the p r o f e s s i o n a l ' s assessment o f a need, not n e c e s s a r i l y the i n d i v i d u a l ' s . T h i s i s important as s e v e r a l need assessment models r e l y on t h i s p r o f e s s i o n a l l y generated data. Need assessments r e l y i n g on e p i d e m i o l o g i c a l i n d i c e s based on d i a g n o s t i c c l a s s i f i c a t i o n s and u t i l i z a t i o n f i g u r e s based on d i a g n o s t i c data r e l y on the d i a g n o s t i c p r o c e s s . To deal with the issue o f how one i s diagnosed, how one becomes a case, r e q u i r e s a t t e n t i o n t o the q u e s t i o n : what i s disease? 38 G. D i sease C l a r e (1980) c i t e s Peter Sedgwick who qu e s t i o n s whether a l l d i s e a s e s , p h y s i c a l as well as mental, might not be d e s c r i b e d as " s o c i a l c o n s t r u c t i o n s ' . He argues t h a t the no t i o n o f d i s e a s e i s a human n o t i o n and t h a t man a p p l i e s the di s e a s e concept on b a s i s o f personal and s o c i a l values t h a t can and do change: d i s e a s e depends on the s o c i a l values and personal mores o f a p a r t i c u l a r s o c i e t y or c u l t u r e . C l a r e p o i n t s out t h a t t h i s i s e q u a l l y t r u e o f p h y s i c a l d i s e a s e as mental, and c i t e s c o n s i d e r a b l e work done on s c a l e s and techniques in an attempt t o measure p h y s i c a l h e a l t h and d i s e a s e , a l l q u i t e c o n t r o v e r s i a l . C l a r e f u r t h e r suggests, along with o t h e r s i n the area, t h a t d i s e a s e i s best c o n c e p t u a l i z e d as a " d e v i a t i o n from c l e a r l y d e f i n e d norm'. However, given the s o c i a l nature o f mental i l l n e s s , t h i s d e f i n i t i o n h a r d l y answers the q u e s t i o n . Attempts have been made t o f u r t h e r d i s t i n g u i s h between i l l n e s s and d i s e a s e . An a c c e p t a b l e d e f i n i t i o n t h a t d i f f e r e n t i a t e s these two c o n s t r u c t s depends upon the eye o f the beholder. A p o s i t i v i s t conception o f i l l n e s s i s the presence o f d i s e a s e i n an organism t h a t i n h i b i t s i t s f u n c t i o n i n g o f the p h y s i o l o g i c a l organs. T h i s i s a l i m i t i n g d e f i n i t i o n but i m p l i c i t i n i t i s the assumption o f some norm of f u n c t i o n i n g , a g a i n s t which n o n - f u n c t i o n i n g can be measured. Of course, in the case o f a l l but a very few o f the o r g a n i c a l l y r e l a t e d mental d i s o r d e r s , t h i s d e f i n i t i o n 39 does not apply a t a l l . Others argue t h a t d i s e a s e and i l l n e s s a re separate e n t i t i e s . Disease i s thus viewed as a p h y s i o l o g i c a l s t a t e , while i l l n e s s i s a s o c i a l s t a t e caused presumably by the di s e a s e (eg. Kleinman, 1980). The p a t h o l o g i s t sees d i s e a s e while the p h y s i c i a n i n f e r s d i s e a s e from w i t n e s s i n g the symptoms o f i l l n e s s . T h i s a l l o w s f o r d i s e a s e s without i l l n e s s and i l l n e s s without d i s e a s e . The c u l t u r a l r e l a t i v i s t takes a d i f f e r e n t p o s i t i o n , viewing a c o n d i t i o n as a d i s e a s e or i l l n e s s o n l y i f reco g n i z e d and d e f i n e d as one by the c u l t u r e . Such a stance has been c r i t i c i z e d f o r mi n i m i z i n g the o r g a n i c - p h y s i o l o g i c a l nature o f i l l n e s s and d i s e a s e . However, i t s u s e f u l n e s s in the culture-bound realm o f mental h e a l t h i s obvious. Conrad (1980) f u r t h e r s t h i s d i s c u s s i o n by q u e s t i o n i n g how something becomes d e f i n e d as an i l l n e s s . Taking a s o c i o l o g i c a l p e r s p e c t i v e , he suggests t h a t i l l n e s s and d i s e a s e a re human c o n s t r u c t i o n s , not e x i s t i n g without someone r e c o g n i z i n g and d e f i n i n g them. He p o i n t s out t h a t t h e r e are processes t h a t we term d i s e a s e s , but does not make them d i s e a s e s without t h a t l a b e l i n g . I l l n e s s e s are d e s c r i b e d as being human judgements on c o n d i t i o n s t h a t e x i s t in the n a t u r a l world, e s s e n t i a l l y s o c i a l c o n s t r u c t i o n s . I n t e r - r e l a t e d r e l i a b i l i t y o f judgement merely r e f l e c t s the s o c i a l consensus. In e a r l i e r work Mechanic (1966) i n d i c a t e d t h a t the term 40 i l l n e s s has always been used in two ways in medicine. On one hand i t has r e f e r r e d t o a l i m i t e d s c i e n t i f i c concept and, on the o t h e r , t o any c o n d i t i o n which might cause an i n d i v i d u a l t o seek medical h e l p . He suggests t h a t " i l l n e s s b e havior" i s any behavior t h a t i s r e l e v a n t t o the second, s o c i a l concept o f i l l n e s s . Gei1 (1980) suggests t h a t the response behavior o f any i n d i v i d u a l r e p o r t i n g symptoms when questioned in an e p i d e m i o l o g i c a l survey may r e f l e c t t h i s " i l l n e s s b e h a v i o r " r a t h e r than medical i l l n e s s in a t r u e medical sense. I l l n e s s behavior can be argued t o be the product o f s o c i a l and c u l t u r a l c o n d i t i o n i n g - not medical c e r t a i n t y . Thus i t i s the socio-cu1tura1 environment which d e f i n e s a c o n d i t i o n as an i l l n e s s and then determines how the i n d i v i d u a l should respond t o the i l l n e s s . The i m p l i c a t i o n s f o r mental d i s o r d e r o f t h i s dichotomy between " t r u e " i l l n e s s and " i l l n e s s b e h a v i o r " a r e profound as d i a g n o s i s o f mental d i s o r d e r i s based on p a t i e n t r e p o r t , not by o b j e c t i v e and demonstrable evidence produced by examination o f t i s s u e or blood as are most p h y s i c a l d i s o r d e r s . Such a dichotomy a l s o has profound i m p l i c a t i o n s f o r any need assessment method r e l y i n g on s e l f r e p o r t . As Mechanic (1972) has suggested, how a person p e r c e i v e s h i s d i s c o m f o r t or d i s a b i l i t y can a l s o a f f e c t they way i n which i t manifests i t s e l f . The negative c o n n o t a t i o n o f the s o c i a l judgement o f i l l n e s s has i m p l i c a t i o n s f o r the 41 f u t u r e o f t h a t d i s c o m f o r t . In the realm o f mental d i s o r d e r s no p h y s i o l o g i c a l d i s e a s e process i s necessary, s u b j e c t i v e r e p o r t i l l n e s s being s u f f i c i e n t t o be d e f i n e d and t r e a t e d as i f d i s e a s e d . Few f u n c t i o n a l mental d i s o r d e r s have any s u b s t a n t i a t e d o r g a n i c b a s i s . Given t h a t d i a g n o s i s as i f d i s e a s e d i s thought t o have profound i m p l i c a t i o n s , both f o r the p a t i e n t h i m s e l f and f o r how o t h e r s t r e a t him, the impact o f d i a g n o s i s cannot be u n derstated. The emphasis on d i a g n o s i s has come about l a r g e l y through the m e d i c a l i z a t i o n o f v a r i o u s behaviors and has r e s u l t e d i n enormous p o t e n t i a l f o r medicine as an instrument o f s o c i a l c o n t r o l (eg. S c h e f f , 1967). Avoidance o f r e s p o n s i b i l i t y f o r one's a c t i o n s , both those which may have r e s u l t e d i n the d i a g n o s i s and those while in t h i s s i c k r o l e , as well as exemption o f personal r e s p o n s i b i l i t i e s are two b e n e f i t s o f those a t t r i b u t e d with t h i s r o l e . However, in exchange two o b l i g a t i o n s are enforced by the " t h e r a p e u t i c agents' in order f o r the s i c k r o l e t o be maintained: the person must re c o g n i z e and admit t h a t being i l l i s an u n d e s i r a b l e s t a t e and wish t o r e c o v e r , and, most impo r t a n t l y , the person must cooperate with a competent t h e r a p i s t , u s u a l l y a p h y s i c i a n (Parsons, 1958). A t r a d e - o f f t h e r e f o r e e x i s t s - lack o f r e s p o n s i b i l i t y f o r lack o f c o n t r o l . Thus, i m p l i c i t in t h i s r o l e i s the medical establishment as an i n s t i t u t i o n o f s o c i a l c o n t r o l . How the medical e s t a b l i s h m e n t , with p h y s i c i a n s as t h e i r agents, have 42 r e f l e c t e d and imparted s o c i a l and p o l i t i c a l values has a l r e a d y been touched upon. The important i s s u e i s the r e c o g n i t i o n t h a t t o be diagnosed i s not o n l y a lengthy and i n v o l v e d p r o c e s s , but a l s o i m p l i e s an acceptance o f t h a t s o c i e t y ' s v a l u e s . With t h i s comes the understanding t h a t need assessment techniques which r e l y on p r o f e s s i o n a l l y i d e n t i f i e d c r i t e r i a - e i t h e r e p i d e m i o l o g i c a l i n d i c e s or u t i l i z a t i o n data - c a r r y with them the values o f the medical model o f mental i l l n e s s . 43 Chapter IV: Models o f Need Assessment A . Introduct i on Given the pr e v i o u s a n a l y s i s o f the u n d e r l y i n g assumptions o f need and demand, we can now review the major models o f need assessment with an a p p r e c i a t i o n o f the i m p l i c a t i o n s o f each. D i f f e r e n t s t r a t e g i e s e n t a i l d i f f e r e n t assumptions not o n l y r e g a r d i n g need and demand, but a l s o about mental i l l n e s s . As has been p r e v i o u s l y d i s c u s s e d , each model i s a conceptual system. The models cannot be used interchangeably. Royse and Drude (1982) have proposed improving standards i n the needs assessment f i e l d by syste m a t i c r e s e a r c h t o e v a l u a t e a number o f approaches s i m u l t a n e o u s l y in the same ar e a . They suggest t h a t i t co u l d be then e m p i r i c a l l y demonstrated which o f the approaches lead the i n v e s t i g a t o r s t o the same c o n c l u s i o n s about the extent o f needs in t h a t a r e a . They f u r t h e r suggest t h a t an "expert committee' a n a l y z i n g the data from such r e s e a r c h would be l e d t o d i s a l l o w c e r t a i n c u r r e n t need assessment approaches as v a l i d methodologies. It i s p r e c i s e l y t h i s approach t h i s paper attempts t o r e f u t e . Such an approach assumes the " m e d i c a l l y i n d i c a t e d ' approach t o need suggested by w r i t e r s such as Donabedian (1973). T h i s attempt t o d i f f e r e n t i a t e amongst the v a r i o u s models does not aim t o p r i o r i z e models in terms o f t h e i r goodness or badness, u s e f u l n e s s or non-usefulness; nor does i t attempt t o i d e n t i f y a l l methodological weaknessess w i t h i n 44 each model. Rather, i t i s an attempt t o a v o i d the common assumption, which o b v i o u s l y Royse and Drude share, t h a t the o n l y important f a c t o r in assessment i s assessment. In g e n e r a l , f o u r major models o f need assessment have been advocated: 1. e p i d e m i o l o g i c a l surveys 2. u t i l i z a t i o n r a t e s 3. s o c i a l i n d i c a t o r s 4. community group forums Although o n l y the f i r s t two approaches u t i l i z e what can be c o n s i d e r e d as m e d i c a l l y o r i e n t e d data, o n l y the community group approaches c l e a r l y f a l l out o f the bounds o f the broad medical model. As w i l l be seen in the f o l l o w i n g d i s c u s s i o n , e p i d e m i o l o g i c a l i n d i c e s and u t i l i z a t i o n r a t e s both focus a t the i n d i v i d u a l l e v e l , the case being the focus f o r care and treatment. The f i r s t two models i d e n t i f y cases -e p i d e m i o l o g i c a l i n d i c e s i d e n t i f y i n g " t r u e ' p r e v a l e n c e while u t i l i z a t i o n f i g u r e s i d e n t i f y "case' p r e v a l e n c e . The s o c i a l i n d i c a t o r models develop a s t a t i s t i c a l overview o f a s p e c i f i c p o p u l a t i o n , community or s o c i e t y and by doing t h i s can i d e n t i f y "at r i s k ' areas f o r f u r t h e r case i d e n t i f i c a t i o n . As has been e a r l i e r d i s c u s s e d , t h i s model, though assuming a s o c i a l c a u s a t i o n model, has been co-opted by the medical establishment as a means o f i d e n t i f y i n g areas f o r p r o f e s s i o n a l c a r e . Thus s o c i a l i n d i c a t o r s measuring s o c i a l problems are o f t e n seen t o i n d i c a t e medical need. 45 F i n a l l y , the community group forum approach focuses not on the case but on the needs p e r c e i v e d by the community in q u e s t i o n . I t s approach i s g e n e r a l l y non p r o f e s s i o n a l and "bottom-up', though, as w i l l be d i s c u s s e d , such procedures may be ga i n i ng i n soph i s t i c a t i on. B. Ep i dem i o1og i ca1 Surveys Community e p i d e m i o l o g i c a l surveys are g e n e r a l l y c o n s i d e r e d the most r a t i o n a l and s c i e n t i f i c o f the need assessment methods, producing the most a c c e p t a b l e and "hard' data t o those i n s i s t i n g upon s c i e n t i f i c r i g o r . Such surveys i n v o l v e c a s e - f i n d i n g assessments w i t h i n community p o p u l a t i o n s g e n e r a t i n g " t r u e ' prevalence f i g u r e s . The process i s g e n e r a l l y r e f e r r e d t o as " p s y c h i a t r i c epidemiology', which c l e a r l y i n d i c a t e s i t s assumptions. There have been t h r e e d i s t i n c t p e r i o d s i n the development o f e p i d e m i o l o g i c a l surveys o f mental d i s o r d e r s . The f i r s t attempt t o i n v e s t i g a t e the t r u e p r e v a l e n c e o f mental d i s o r d e r s i n a community in the United S t a t e s was undertaken i n 1855 (Weissman and Klerman, 1978). Key community l e a d e r s , and h o s p i t a l and other o f f i c i a l r ecords were u t i l i z e d t o determine the frequency o f i d i o c y and i n s a n i t y , as mental d i s o r d e r was c a l l e d . T h i s type o f i n d i r e c t measurement u s i n g key informants and medical records were the primary means o f e s t i m a t i n g need u n t i l World War 11. 46 Fan's and Dunham (1939) provided the b a s i s f o r determining need f o r p s y c h i a t r i c s e r v i c e s in the Chicago m e t r o p o l i t a n area in the 1930's with an e c o l o g i c study which examined the e c o l o g i c a l d i s t r i b u t i o n o f f i r s t admissions. They found t h a t d i a g n o s i s was r e l a t e d t o the area o f r e s i d e n c e o f the p a t i e n t s , the highest r a t e s o f h o s p i t a l i z a t i o n o c c u r r i n g f o r r e s i d e n t s from the areas o f h i g h e s t s o c i a l d i s o r g a n i z a t i o n . T h i s was the f i r s t step towards demonstrating the importance o f s o c i a l v a r i a b l e s i n mental h e a l t h . Dunham (1983) has r e c e n t l y c r i t i q u e d t h i s e a r l i e r study. He suggests t h a t t h i s approach produced u n r e l i a b l e r e s u l t s because they d i d not take i n t o account the cases t h a t never came t o the a t t e n t i o n o f the agency (the main concern o f c u r r e n t assessment methods r e l y i n g on u t i l i z a t i o n r a t e s ) . He observes t h a t i n 1930 he d i d not f o r s e e t h i s as an i s s u e , assuming-that the undetected cases would e v e n t u a l l y be commited or be admitted t o a mental h o s p i t a l . T h i s time between symptom onset and care he terms "the gap' and he notes t h a t i t v a r i e s with socioeconomic l e v e l . Secondly, he v o i c e s concern t h a t the 1930 diagnoses were u n r e l i a b l e due t o lack o f knowledge about d i f f e r e n t i a l d i a g n o s i s . F i n a l l y he suggests t h a t the r a t e s p a t t e r n r e p o r t e d were m i s l e a d i n g because they represented the r e s i d e n t i a l m o b i l i t y o f the mentally i l l r a t h e r than t h e i r community o f o r i g i n . 47 The second p e r i o d of" e p i d e m i o l o g i c a l development i n mental h e a l t h developed post WWII. The war e f f e c t e d major changes i n how mental d i s o r d e r was viewed. F i r s t l y , l a r g e numbers o f men were r e j e c t e d f o r s e r v i c e on p s y c h i a t r i c grounds. Despite t h a t the s c i e n t i f i c grounds f o r these r e j e c t i o n s were questioned i t brought a t t e n t i o n t o mental h e a l t h problems in g e n e r a l . The r e s u l t s o f t h i s s c r e e n i n g process became o f incr e a s e d i n t e r e s t as la r g e numbers o f s e r v i c e men developed p s y c h i a t r i c d i f f i c u l t i e s presumably as a r e s u l t o f the c o n d i t i o n s o f war - s i t u a t i o n a l s t r e s s e s such as combat and d e p r i v a t i o n o f c o n c e n t r a t i o n camps. The f a c t t h a t these d i s o r d e r s developed in i n d i v i d u a l s a l r e a d y screened f o r p s y c h i a t r i c i l l n e s s led t o a focus on p r e c i p i t a n t s t r e s s as opposed t o p r e d i s p o s i t i o n . T h i s e x p e r t i s e and knowledge developed d u r i n g WWII c o n t r i b u t e d t o growing i n t e r e s t i n preval e n c e and in s o c i a l c o n d i t i o n s in the general p o p u l a t i o n and led t o large community surveys. The Midtown Manhattan survey (1962) interviewed 1,000 a d u l t r e s i d e n t s s e l e c t e d by p r o b a b i l i t y sampling in midtown Manhattan. Leighton (1959) assessed the impact o f s o c i a l and economic change on the mental h e a l t h o f a s t a b l e community in S t i r l i n g County. H o l l i n g s h e a d and R e d l i c h ' s (1958) study o f t r e a t e d p r e v a l e n c e e s t a b l i s h e d s o c i a l c l a s s as an important determinant o f t r e a t e d mental i l l n e s s . The s t u d i e s o f t h i s era r e p o r t e d g e n e r a l l y high r a t e s o f mental impairment. For example, the Manhattan study r e p o r t e d 23% 48 o f t h e i r s u b j e c t s s u b s t a n t i a l l y impaired. Many o f the s t u d i e s o f t h i s p e r i o d used measures o f o v e r a l l mental impairment and problem l i s t s . P s y c h i a t r i c c l a s s i f i c a t i o n was i n the developmental stages and i t s low r e l i a b i l i t y was acknowledged. In a d d i t i o n , such s c a l e s and l i s t s made large surveys f e a s i b l e , r e d u c i n g the need f o r p s y c h i a t r i c input, making them e a s i e r and more economical. S o c i a l f a c t o r s o f mental i l l n e s s were the f o c u s . Concurrent European s t u d i e s tended t o r e f l e c t the e a r l i e r d e v e l o p i n g European p s y c h i a t r i c t r a d i t i o n . Essen-Mo 11 e r ' s survey o f Lund, Sweden, used t r a i n e d p s y c h i a t r i s t s t o i n t e r v i e w 2,550 i n h a b i t a n t s i n a s p e c i f i c geographical a r e a , d e f i n i n g not o n l y p s y c h i a t r i c d i s o r d e r but a l s o major p e r s o n a l i t y d e v i a t i o n s , normal p e r s o n a l i t y v a r i a n t s and s u b j e c t i v e complaints (Goldberg and Huxley, 1980). T h i s use o f t r a d i t i o n a l p s y c h i a t r i c d i a g n o s t i c c a t e g o r i e s made the assumption t h a t each i l l n e s s had a d i f f e r e n t u n d e r l y i n g e t i o l o g y , syndrome, course, and treatment, and t h a t b i o l o g y r a t h e r than environment was the major c o n t r i b u t i n g f a c t o r . T h i s was c o n t r a r y t o t h i s American emphasis on s o c i a l c a u s a t i o n which c o n t r i b u t e d t o a more u n i t a r y concept o f i l l n e s s , mental h e a l t h and mental i l l n e s s being viewed as op p o s i t e p o i n t s on a continuum. Weissman and Klerman (1978) suggest t h a t t h i s p e r i o d o f e p i d e m i o l o g i c a l development made important c o n t r i b u t i o n s t o h e a l t h r e s e a r c h . They suggest t h a t these surveys introduced 49 r i g o r t o epidemiology by the development o f sampling techniques, s t a n d a r d i z e d q u e s t i o n n a i r e s and s o p h i s t i c a t e d s t a t i s t i c a l a n a l y s i s . Furthermore, they e n l a r g e d the domain of independent v a r i a b l e s i n epidemiology t o i n c l u d e p s y c h o s o c i a l and economic f a c t o r s and s e n s i t i z e d r e s e a r c h e r s t o the i n f l u e n c e o f such v a r i a b l e s in medical c o n d i t i o n s . However, the value o f such g l o b a l measures o f mental i l l n e s s i s c o n t r o v e r s i a l , as i s t h e i r a p p r o p r i a t e use. At the methodological l e v e l , i t has been suggested t h a t the s c a l e s s u f f e r from v a r i o u s response b i a s e s . Mechanic (1972) c i t e s Bruce Dohrenwend's work, i n d i c a t i n g c o r r e l a t i o n s between t e s t and r e t e s t a year l a t e r were higher among p s y c h i a t r i c i n p a t i e n t s than community samples, sugge s t i n g t h a t such s c a l e s may measure some t r a n s i e n t s t r e s s . On a more c y n i c a l note, such r e s u l t s may suggest t h a t the p o t e n t i a l l y t r a n s i e n t nature o f mental d i s o r d e r may become permanent when su b j e c t e d t o a t l e a s t i n p a t i e n t treatment, and perhaps any treatment a t a l l ! The p o s s i b i l i t y t h a t d e f i n i t i o n o f o n e s e l f as " i n c a r e ' may serve t o perpetuate the i d e n t i f i c a t i o n o f the problem a l s o e x i s t s ( S c h e f f , 1966). From the p s y c h i a t r i c e p i d e m i o l o g i c a l viewpoint, the g l o b a l impairment s c a l e s used are independent o f d i a g n o s i s can not be t r a n s l a t e d i n t o d i a g n o s t i c c a t e g o r i e s t o generate r a t e s o f t r e a t e d / u n t r e a t e d d i s o r d e r s . The v a l i d i t y o f g l o b a l impairment s c a l e s i s a l s o open t o q u e s t i o n : what do the s c a l e s a c t u a l l y measure? The 50 Dohrenwends suggest t h a t they p a r t i c u l a r l y seem t o tap a n x i e t y , sadness, p s y c h o p h y s i o l o g i c a l symptoms, lack o f energy and a p e r c e p t i o n o f poor h e a l t h . Such symptoms a r e , however, more i n d i c a t i v e o f the n e u r o s i s than the p s y c h o s i s , most h o s p i t a l i z a t i o n s (at l e a s t those in p s y c h i a t r i c f a c i l i t i e s p r i o r t o advent o f the community mental h e a l t h movement) r e f l e c t i n g the p s y c h o t i c symptoms o f the s e r i o u s l y i l l . Whether these two groups can be compared i s q u e s t i o n a b l e . In a d d i t i o n , Cummings and Cummings (1965) have commented on f i n d i n g s t h a t most n e u r o t i c d i s o r d e r s are s e l f - 1 i m i t i n g , with or without treatment. The t h i r d p e r i o d o f e p i d e m i o l o g i c a l study i n mental h e a l t h began in the l a t e s i x t i e s as developments in medical s c i e n c e s s t r e s s e d evidence o f b i o l o g i c a l f a c t o r s in mental h e a l t h . Growing i n t e r e s t in c l a s s i f i c a t i o n l e d t o advances in v a l i d i t y and r e l i a b i l i t y i n d i a g n o s i s . " P s y c h i a t r i c epidemiology' developed, s h i f t i n g the emphasis from the epidemiology o f mental h e a l t h t o an epidemiology o f mental d i s o r d e r s . A b a s i c premise u n d e r l y i n g e p i d e m i o l o g i c s t u d i e s i s t h a t a s p e c i f i c d i s e a s e i s not randomly d i s t r i b u t e d throughout a p o p u l a t i o n but t h a t subgroups o f a p o p u l a t i o n , d e f i n e d by age, sex, e t h n i c or r a c i a l , or other r e l e v a n t c h a r a c t e r i s t i c s w i l l d i f f e r i n the frequency o f i n d i v i d u a l d i s e a s e . Knowledge o f t h i s uneven d i s t r i b u t i o n can suggest causal f a c t o r s which can then be f u r t h e r e s t a b l i s h e d by 51 other r e s e a r c h t e c h n i q u e s . The i n c r e a s i n g acceptance o f a m u l t i f a c t o r i a l mode o f e x p l a n a t i o n f o r p s y c h i a t r i c d i s o r d e r s has emphasized the r e s e a r c h f o r m u l t i p l e r i s k f a c t o r s . The major e p i d e m i o l o g i c a l survey c u r r e n t l y being undertaken in the United S t a t e s i s N.I.M.H.'s E p i d e m i o l o g i c a l Catchment Area program (Reiger, Myers, Kramer, Robins, B l a z e r , Hough, Eaton, Loche, 1984). T h i s survey has a sample s i z e o f roughly 20,000 s u b j e c t s drawn from f i v e s i t e s . The b a s i c goals are t o estimate r a t e s o f prevalence and i n c i d e n c e o f s p e c i f i c mental d i s o r d e r s , t o estimate r a t e s o f h e a l t h and mental h e a l t h s e r v i c e s use, t o study f a c t o r s i n f l u e n c i n g the development and continuance o f d i s o r d e r s , and t o study f a c t o r s i n f l u e n c i n g use o f s e r v i c e s (Eaton, H o l z e r , Von K o r f f , Anthony, H e l z e r , George, Burnham, Boyd, K e s s l e r and Loche, 1984). The focus i s on the D i a g n o s t i c Interview Schedules - d e f i n e d DSM III mental d i s o r d e r s . Freedman (1984) d e s c r i b e s t h i s program's f u t u r e outcome as a kind o f topographic map, a background c h a r t i n g r e l a t i v e peaks and v a l l e y s and t h e i r s p e c i f i c c o n t e n t s . C u r r e n t l y , e x i s t i n g estimates o f p s y c h i a t r i c i l l n e s s from recent e p i d e m i o l o g i c a l surveys range from 1 percent t o 50 percent, depending upon the nature o f the measurement technique. Gould, Wunsch-Hitzig and Dohrenwend (1980) r e p o r t in t h e i r recent summary o f the l i t e r a t u r e , t h a t the t r u e prevalence o f c l i n i c a l maladaption among school c h i l d r e n in a r e p r e s e n t a t i v e sample o f U.S. communities i s 52 u n l i k e l y t o average l e s s than 12 percent. Neugebauer, Dohrenwend and Dohrenwend (1980) r e p o r t t h a t the t r u e p revalence o f a d u l t p s y c h i a t r i c d i s o r d e r s , with no known or g a n i c b a s i s , a t an o v e r a l l r a t e f o r the aggregated f u n c t i o n a l d i s o r d e r s o f between 16 and 25 pe r c e n t . Dohrenwend (1980) in h i s summary chapter breaks t h i s down t o : between .6 and 3.0 percent f o r s c h i z o p h r e n i a , about 3.0 percent f o r a f f e c t i v e p s y c h o s i s , between 8.0 and 15.0 percent f o r n e u r o s i s and about 7.0 percent f o r p e r s o n a l i t y d i s o r d e r . In a d d i t i o n t o these cases o f p s y c h i a t r i c d i s o r d e r , he hypothesizes t h a t about 13.0 percent o f the p o p u l a t i o n in a r e p r e s e n t a t i v e sample o f U.S. communities would show severe p s y c h o l o g i c a l and somatic d i s t r e s s t h a t was not accompanied by c l i n i c a l p s y c h i a t r i c d i s o r d e r . Together, these r e s u l t s estimate t h a t about 25 percent o f the p o p u l a t i o n a t any giv e n time i s e x p e r i e n c i n g some degree o f p s y c h o l o g i c a l d i s o r d e r . Most importantly f o r t h i s d i s c u s s i o n i s the f a c t t h a t Dohrenwend hypothesizes t h a t o n l y about one-quarter o f those with c l i n i c a l l y s i g n i f i c a n t f u n c t i o n a l d i s o r d e r s ever r e c e i v e d treatment and t h a t even f o r the most severe d i s o r d e r s l a r g e m i n o r i t i e s have never r e c e i v e d treatment. He estimates t h a t perhaps 20 percent o f s c h i z o p h r e n i c s and 40 percent o f p s y c h o t i c s do not r e c e i v e treatment. (The assumption i s , o f course, t h a t treatment r e f e r s t o t r a d i t i o n a l t h e r a p e u t i c s e r v i c e s as opposed t o the no n - p r o f e s s i o n a l network o f c a r e ) . 53 Related t o t h i s i s the f a i l u r e o f e p i d e m i o l o g i c a l i n d i c e s t o o f f e r i n f o r m a t i o n r e g a r d i n g the d i f f e r e n c e s between those who present themselves f o r treatment and those who do not i d e n t i f y themselves as r e q u i r i n g c a r e . Thus, the r e s u l t s o f such surveys may o f f e r r a t e s o f "true p r e v a l e n c e ' in the e x p e r t s ' eyes, but do not r e f l e c t demand in the eyes o f the p a t i e n t . In terms o f a s s e s s i n g need f o r s e r v i c e d e l i v e r y e p i d e m i o l o g i c a l i n d i c e s are unable t o o f f e r i n f o r m a t i o n as t o what p r o p o r t i o n o f the "true p r e v a l e n c e ' f i g u r e w i l l a c t u a l l y present i t s e l f f o r c a r e . Thus, a major shortcoming o f such i n d i c e s f o r needs assessment i s not o n l y do they focus on the t r a d i t i o n a l medical model o f d i a g n o s i s and thus are plagued by r e l a t e d methodological problems, they are a l s o over i n c l u s i v e , not abl e t o make the c r u c i a l d i f f e r e n c e between those whom the experts p e r c e i v e as having mental h e a l t h d i s a b i l i t y and those who repr e s e n t p o t e n t i a l demand. Becoming a p a t i e n t , as we have d i s c u s s e d , i s the end r e s u l t o f a complex ch a i n o f events. E p i d e m i o l o g i c a l i n d i c e s , i n t h e i r a b i l i t y t o estimate the p r o f e s s i o n a l ' s view o f need, w i l l l i k e l y over-estimate demand in any s e r v i c e p l a n n i n g endeavor. C. U t i 1 i z a t i o n Rates The aim o f the s o c i a l survey, or s e r v i c e u t i l i z a t i o n model, i s t o review the v a r i o u s p r o v i d e r s ' (both i n d i v i d u a l and agency) past and c u r r e n t s e r v i c e s rendered p a t t e r n s and 54 requests f o r s e r v i c e by c i t i z e n s in an attempt t o understand the number and types o f s e r v i c e s demanded in a p a r t i c u l a r community. These data may be secured through s t r u c t u r e d i n t e r v i e w s and e x t r a p o l a t i o n s from past and c u r r e n t records and management i n f o r m a t i o n . The use o f under-treatment r a t e s as an i n d i c a t o r o f need poses major methodological problems. In cou n t i n g admissions, what i s t o be co n s i d e r e d a case? I n s t i t u t i o n s d i f f e r in t h e i r p r a c t i c e s r e g a r d i n g what type o f co n t a c t f o r s e r v i c e q u a l i f i e s as an admission and what does not. Admission r a t e s may be m i s l e a d i n g because o f d u p l i c a t e d counts r e s u l t i n g from a s i n g l e i n d i v i d u a l having m u l t i p l e admissions d u r i n g a given p e r i o d t o a s i n g l e i n s t i t u t i o n . What c o n s t i t u t e s a mental h e a l t h f a c i l i t y may be d e f i n e d d i f f e r e n t l y from one geographical area t o another. At the same time d i f f e r e n t government s e c t o r s may pr o v i d e s e r v i c e s by a d i f f e r e n t name t o the same p o p u l a t i o n . Diagnosis i s pro b l e m a t i c ; r e l i a b i l i t y i s poor. Supporters o f t h i s approach defend d i a g n o s t i c r e l i a b i l i t y but p u b l i s h e d f i g u r e s vary widely. One o f the most c r i t i c a l o f r e p o r t s i s t h a t o f Rosenhan (1973) which r e v e a l e d t h a t i n one case h o s p i t a l d o c t o r s diagnosed s c h i z o p h r e n i a on the s i n g l e symptom o f hearing v o i c e s in p e r f e c t l y normal pseudo-p a t i e n t s . Once having made t h i s d i a g n o s i s and a d m i t t i n g t o h o s p i t a l , they d i d not r e v e r s e t h e i r d i a g n o s i s a t any time d u r i n g the p a t i e n t s ' s t a y s , which ranged from 7 t o 52 days, 55 d e s p i t e the f a c t t h a t the pseudo s u b j e c t s d i d not complain f u r t h e r o f any symptoms. The impression i s t h a t the d i a g n o s t i c s k i l l s o f American p s y c h i a t r i s t s are o f q u e s t i o n a b l e value. Another o b j e c t i o n t o the u t i l i z a t i o n o f t r e a t e d r a t e s i s t h a t the a c t o f h o s p i t a l i z a t i o n f o r p s y c h i a t r i c care (or community-based care f o r t h a t matter) may be l e s s an i n d i c a t i o n o f psychopathology on the p a r t o f the p a t i e n t t h a t i t i s an i n d i c a t i o n o f s o c i e t y ' s r e a c t i o n t o what i t l a b e l s d e v i a n t behavior. The expansion o f the realm o f mental h e a l t h t o i n c l u d e behaviors p r e v i o u s l y thought o f as merely bad or s i n f u l i s undertaken elsewhere in t h i s paper. On the other hand i t may r e f l e c t " i l l n e s s b e h a v i o r " (Mechanic, 1962) r a t h e r than i l l n e s s i t s e l f . Users o f mental h e a l t h s e r v i c e s are not always those who need i t most. Of equal importance i s the f a c t t h a t needers are not always u t i l i z e r s : the problem o f unmet need. T h i s i s i n p a r t because, as d i s c u s s e d e a r l i e r , being a p a t i e n t (being in t r e a t m e n t ) , i s a f i n a l step in a long c h a i n o f events. Such f a c t o r s as a c c e s s i b i l i t y o f care and socioeconomic s t a t u s , i n f l u e n c e t h i s e v e n t u a l i t y . Needs assessment based on t h i s type o f s t r a t e g y can o n l y make p r e d i c t i o n s about t h i s group, not about a l l people with mental d i s o r d e r s . Supporters o f the u t i l i z a t i o n approach suggest t h a t the broader e p i d e m i o l o g i c a l approaches i d e n t i f y too l a r g e a 56 group f o r program p l a n n i n g , arguing t h a t the group not i d e n t i f i e d by u t i l i z a t i o n f i g u r e s and w a i t i n g l i s t data would l i k e l y not use s e r v i c e s and are t h e r e f o r e not r e l e v a n t to p l a n n i n g . T h i s seems a narrow and i n f l e x i b l e view o f the concept o f p l a n n i n g - p l a n n i n g can i n c l u d e means o f reducing stigma or other b a r r i e r s t o c a r e . Most u t i l i z a t i o n data r e l i e s on d i a g n o s t i c data, and thus t h i s model's c r e d i b i l i t y . T h i s r e f l e c t s the medical model t h e o r y o f mental i l l n e s s . D i a g n o s t i c data are not without problems f o r p l a n n i n g purposes. In B r i t i s h Columbia, H o s p i t a l Programs, which a d m i n i s t e r i n p a t i e n t and daycare f a c i l i t i e s f o r the mentally i l l , use a d i f f e r e n t c l a s s i f i c a t i o n system t h a t those f a c i l i t i e s operated by Mental Health S e r v i c e s , the Mental Health Centres and large i n p a t i e n t f a c i l i t y . Thus, n e i t h e r comparison or cumulative t o t a l s a re p o s s i b l e . In s h o r t , t o d e f i n e and i d e n t i f y need s o l e l y on the b a s i s o f demand f o r s e r v i c e s i s t o take a narrow conceptual approach. R e l y i n g on the medical model, i t pr o v i d e s data with q u e s t i o n a b l e r e l i a b i l i t y about a d i s c r e t e group o f h e a l t h care u s e r s . It may serve the purposes o f j u s t i f i c a t i o n and resource a l l o c a t i o n well on an i n d i v i d u a l program b a s i s but o f f e r s l i t t l e t o the broad spectrum approach o f p l a n n i n g . Seemingly g e n e r a t i n g " r a t i o n a l ' data i t has i t s p o l i t i c a l purpose i n g e n e r a t i n g data with which a government can assure i t s p u b l i c t h a t they are p r o v i d i n g 57 s e r v i c e . It prov i d e s a base by which incremental a d d i t i o n s t o s e r v i c e s can be made when c o n s t r a i n e d by f i n a n c i a l 1 i m i t s . F i n a l l y , u t i l i z a t i o n f i g u r e s p r o v i d e i n f o r m a t i o n about the use o f s e r v i c e s a l r e a d y provided. Need assessment implies an attempt t o s p e c i f i c a l l y address the needs h e r e t o f o r e unrecognized and unmet. T h i s r e f l e c t s the developmental nature o f p l a n n i n g . U t i l i z a t i o n a t best p r o v i d e s a b a s i s f o r incremental p l a n n i n g , a t worst p r o v i d e s a b a s i s f o r j u s t i f i c a t i o n p l a n n i n g . D. Soc i a 1 Indi c a t o r Approaches The i n d i c a t o r approaches have r e c e n t l y been c o n s i d e r e d very popular, a p p e a l i n g t o the s o c i a l and environmental advocates o f mental h e a l t h . These approaches c o n s i s t o f co m p i l i n g and making i n f e r e n c e s o f need from d e s c r i p t i v e s t a t i s t i c s found in p u b l i c records or r e p o r t s , thus no new data are generated. The essence i s the a n a l y s i s and i n t e g r a t i o n o f e x i s t i n g i n f o r m a t i o n . The term s o c i a l i n d i c a t o r i s a t t r i b u t e d t o R. Bauer who e d i t e d a book on s o c i a l i n d i c a t o r s i n 1966, marking the beginning o f i n t e r e s t in t h i s a r ea. The approach i s based on e a r l i e r work by r e s e a r c h e r s such as H o l l i n g s h e a d and R e d l i c h (1958), Leighton (1959), Myers and Roberts (1959) and S r o l e , Langer and Michael (1963), who fo c u s s e d a t t e n t i o n on the s o c i a l f a c t o r s a s s o c i a t e d with mental i l l n e s s . The 58 assumption on which such technique i s b u i l t i s t h a t c e r t a i n p o p u l a t i o n c h a r a c t e r i s t i c s p r e d i c t high r i s k in terms o f in c i d e n c e o f mental h e a l t h i l l n e s s and the concomitant need f o r mental h e a l t h and oth e r s o c i a l and h e a l t h s e r v i c e s . The s o c i a l i n d i c a t o r i s thus a measure o f s o c i a l problems. On the aggregate they are o f t e n assumed t o be an i n d i c a t i o n o f the q u a l i t y o f l i f e and are o f t e n used as a gl o b a l means o f e v a l u a t i n g i n t e r v e n t i o n s in a community. The s o c i a l i n d i c a t o r movement i s an e f f o r t t o develop an assessment procedure p a r a l l e l and complimentary t o the h i g h l y s u c c e s s f u l economic index (Bloom 1983). However, u n l i k e economic theory, no the o r y o f community e x i s t s by which t o d e f i n e r e l e v a n t v a r i a b l e s . Thus s o c i a l i n d i c a t o r s have been chosen i n d u c t i v e l y r a t h e r than d e d u c t i v e l y . Three s p e c i f i c i n d i c e s have been most o f t e n c i t e d as being r e l a t e d t o increased i n c i d e n c e o f mental i l l n e s s : poverty, s o c i a l pathology, and subgroups with s p e c i a l needs. 1) Poverty Customary i n d i c e s o f poverty are low per c a p i t a income, c h r o n i c unemployment, substandard housing and low l e v e l s o f ed u c a t i o n . How poverty a c t u a l l y r e l a t e s t o mental i l l n e s s i s u n c l e a r , though a t l e a s t t h r e e d i f f e r e n t t h e o r i e s have been put f o r t h . H o l l i n g s h e a d and R e d l i c h r e p o r t e d i n t h e i r 1958 New Haven study t h a t low socio-economic s t a t u s w i t h i n a community i s found t o be a s s o c i a t e d with r e l a t i v e l y high r a t e s o f 59 d i s o r d e r . Dohrenwend and Dohrenwend (1969) f u r t h e r e d t h i s r e s e a r c h , s u g g e s t i n g t h a t i t was not s o c i o -economic s t a t u s alone but r a t h e r the a s s o c i a t e d s t r e s s o f t h a t s o c i a l p o s i t i o n t h a t was the c r u c i a l f a c t o r in the a s s o c i a t e d high r a t e o f d i s o r d e r . Leighton (1959) in h i s S t i r l i n g County Study, suggested t h a t a community's degree o f i n t e g r a t i o n or d i s i n t e g r a t i o n was r e l a t e d t o the mental h e a l t h o f i t s i n h a b i t a n t s . He, along with h i s co-workers, d e f i n e d i n d i c e s o f sociocu1tura1 d i s i n t e g r a t i o n , i n c l u d i n g such f a c t o r s as: a high frequency o f broken homes, e x t e n s i v e poverty, e x t e n s i v e m i g r a t i o n , weak and fragmented networks o f communication and r a p i d and widespread s o c i a l change. At the same time, Myers and Roberts (1959), i n t h e i r c o n t i n u a t i o n o f H o l l i n g s h e a d and R e d l i c h ' s e a r l i e r work, suggested t h a t i n t e r - f a m i l i a l s t r e s s - d i s o r g a n i z e d home, heavy r e s p o n s i b i l i t y o f the mother, absence o f f a t h e r , lack o f pa r e n t a l guidance and c o n t r o l - was a l s o a s s o c i a t e d with high r a t e s o f p s y c h o l o g i c a l d i s o r d e r . On the l a t e r Midtown Manhattan Study, S r o l e , Langer and Michael (1962) examined s o c i a l c l a s s in terms o f s t r e s s - s t r a i n model, in which mental i l l n e s s was seen as a r e a c t i o n t o noxious environmental f o r c e s , such as c h i l d h o o d economic d e p r i v a t i o n , broken homes and socio-economic w o r r i e s . The i n v e s t i g a t o r s found 60 t h a t the sheer number o f i d e n t i f i e d s t r e s s f a c t o r s r e p o r t e d was the most e f f i c i e n t method o f p r e d i c t i n g mental h e a l t h r i s k . No one s t r e s s f a c t o r i t s e l f was p a r t i c u l a r l y s i g n i f i c a n t but a h y p o t h e t i c a l person r e p o r t i n g t h r e e f a c t o r s had g r e a t e r r i s k t h a t a person r e p o r t i n g one or two f a c t o r s . The number o f s t r e s s f a c t o r s was more important than the p a r t i c u l a r combination o f f a c t o r s . Such evidence supports the n o t i o n o f poverty as one causal f a c t o r in mental h e a l t h . Although such i n d i c e s as broken homes and absence o f f a t h e r are not p u r e l y the domain o f the poor, they are o v er-represented in t h i s group. T h i s view o f p overty as a causal f a c t o r i n mental i l l n e s s and the a s s o c i a t e d " s t r e s s ' model o f d i s e a s e adheres most c l o s e l y t o the s o c i a l i z a t i o n / e n v i r o n m e n t a l t h e o r y o f mental i l l n e s s . Within the p o s i t i v i s t ' s framework, i t suggests t h a t the s t r e s s o f c e r t a i n f a c t o r s r e s u l t in i d e n t i f i a b l e mental i l l n e s s . Although a l s o i n p a r t i a l support o f the i n t e r p r e t i v e t h e o r y , i t i s mainly r e d u c t i o n i s t , s uggesting i l l n e s s i s a d i r e c t r e s u l t o f c e r t a i n s p e c i f i c f a c t o r s , in a s t r a i g h t f o r w a r d causal r e l a t i o n s h i p : p overty •* s t r e s s •* mental i l l n e s s . Although the t h e o r y suggests under which c o n d i t i o n mental i l l n e s s w i l l occur, i t f a i l s t o o f f e r e x p l a n a t i o n f o r i n d i v i d u a l v a r i a b i l i t y g iven the same 61 degree o f s t r e s s . The second th e o r y r e g a r d i n g the poverty-mental i l l n e s s r e l a t i o n s h i p i s t h a t poverty prevents one from seeking help from mental d i s o r d e r s because o f such p o v e r t y - r e l a t e d f a c t o r s as i n a b i l i t y t o pay, c u l t u r a l b a r r i e r s t o care, t r a n s p o r t a t i o n and other a c c e s s -r e l a t e d problems. Such f a c t o r s are known t o prevent access t o care. T h i s model would suggest t h a t the r a t e o f i l l n e s s in a poor p o p u l a t i o n would be t h a t o f any other p o p u l a t i o n j_f s e r v i c e ( i . e . treatment and cure) was sought or c o u l d be accessed. T h i s takes poverty i t s e l f out o f the causal r o l e and p l a c e s i t as o n l y a b a r r i e r t o care. Such an e x p l a n a t i o n f o r high r a t e s o f i l l n e s s i n poor areas supports the medical model o f mental i l l n e s s in t h a t i t im p l i e s t h a t the i l l n e s s i s i n d i v i d u a l i s t i c r a t h e r than s o c i a l l y caused, t h a t t h e r e e x i s t s a d i s e a s e e n t i t y w i t h i n the i n d i v i d u a l , and t h a t with i n d i v i d u a l treatment, i t can be cured, r e g a r d l e s s o f the s o c i a l s i t u a t i o n . The t h i r d e x p l a n a t i o n o f the r e l a t i o n s h i p between poverty and mental i l l n e s s has been termed the " s o c i a l d r i f t ' h ypothesis (Myerson, 1941). It a l s o supports a medical model o f i l l n e s s f o r i t suggests t h a t the higher r a t e s o f i l l n e s s found i n the lower socio-economic c l a s s i s a r e s u l t o f m e n t a l l y - i l l i n d i v i d u a l s " d r i f t i n g ' down from other socio-economic 62 l e v e l s as a r e s u l t o f t h e i r i l l n e s s . It c l e a r l y supports the i n d i v i d u a l i s t i c view o f i l l n e s s and impl i e s i n c u r a b i l i t y - t h a t even with the s e r v i c e s a v a i l a b l e in the higher socio-economic l e v e l s , those who are men t a l l y i l l a r e r e s i s t a n t t o treatment ( i n t e n t i o n a l l y or u n i n t e n t i o n a l l y ) and d r i f t t o the lower l e v e l s o f s o c i e t y . T h i s i s a c t u a l l y i n d i r e c t o p p o s i t i o n t o the " s t r e s s ' theory o f poverty, sug g e s t i n g t h a t the mental i l l d r i f t down t o a l e s s complicated and s t r e s s f u l e x i s t e n c e . 2) Soc i a 1 patho1ogy Indices o f s o c i a l pathology are c l o s e l y l i n k e d with those o f poverty and th e r e i s an obvious c o r r e l a t i o n between the two. A l c o h o l i s m , drug a d d i c t i o n , crime and delinquency are the most o f t e n mentioned i n d i c e s o f s o c i a l pathology. Such f a c t o r s have been examined i n s t u d i e s such as the aforementioned, and p a r t i c u l a r l y by Leig h t o n (1959) who d e f i n e d high frequency o f crime and delinquency as one o f h i s i n d i c e s o f s o c i o - c u l t u r a l d i s i n t e g r a t i o n . The use o f s o c i a l pathology as an i n d i c a t o r has a l s o come about as the d e f i n i t i o n o f mental i l l n e s s has expanded. Behavior which was p r e v i o u s l y c o n s i d e r e d s i n f u l , bad or j u s t d e v i a n t - such as a l c o h o l i s m and crime - has become i n c l u d e d w i t h i n the mandate o f mental h e a l t h . 63 To i n c l u d e deviancy i n t h i s manner supports the process o f m e d i c a l i z a t i o n - the expansion o f the domain o f medicine over behaviors which have no known o r g a n i c or p h y s i o l o g i c a l cause. Whereas p r e v i o u s l y such behaviors were seen t o be w i l l f u l and the r e s p o n s i b i l i t y o f the i n d i v i d u a l , they are now i n c r e a s i n g l y viewed as the r e s u l t o f mental i l l n e s s , and t h e r e f o r e t r e a t a b l e in an i n d i v i d u a l by a mental h e a l t h p r o f e s s i o n a l . However, t h i s approach a l s o supports a n o t i o n o f s o c i a l or environmental c a u s a t i o n - high s t r e s s , f a u l t y l e a r n i n g and s i m i l a r f a c t o r s causing the i n d i v i d u a l t o behave in an "abnormal' ( r a t h e r than d e v i a n t which i m p l i e s badness and w i l l f u l n e s s ) manner. 3) Popu1 a t i o n subgroups with s p e c i a 1 needs The f o u r groups most mentioned are c h i l d r e n , the aged, the m e n t a l l y r e t a r d e d and the p h y s i c a l l y d i s a b l e d . The i n c l u s i o n o f c h i l d r e n and the aged appears t o be based on the assumption o f high r i s k . E p i d e m i o l o g i c a l estimates o f mental i l l n e s s in c h i l d r e n vary widely but i s g e n e r a l l y thought t o be around 10%, l i k e l y v a r y i n g with age, s o c i a l c l a s s , e t h n i c group and geographic r e g i o n . It i s l i k e l y not p u r e l y due t o estimates o f i l l n e s s w i t h i n these two groups though t h a t they are i n c l u d e d i n most i n d i c a t o r l i s t s . The e x i s t e n c e o f both c h i l d r e n and the e l d e r l y a l s o p l a c e s 64 an a d d i t i o n a l burden o f s t r e s s on a d u l t s i n the community - socio-economic as well as r e l a t i o n s h i p o r i e n t e d . Thus, i t may be assumed t h a t l a r g e numbers o f e i t h e r c h i l d r e n or e l d e r l y , w hile b r i n g i n g w i t h i n themselves higher r a t e s o f i l l n e s s , a l s o c o n t r i b u t e t o higher r a t e s o f i l l n e s s in t h e i r c a r e t a k e r s . In a d d i t i o n , the poverty f a c t o r s p r e v i o u s l y d i s c u s s e d are p a r t i c u l a r l y r e l e v a n t t o the e l d e r l y in North America, l i v i n g too o f t e n in marginal poverty and i s o l a t i o n . Recent f i g u r e s f o r Alzheimer's d i s e a s e , a s p e c i f i c syndrome o f g e r i a t r i c s e n i l i t y which i n v o l v e s gross b e h a v i o r a l d i s t u r b a n c e as a r e s u l t o f memory l o s s and other mental as well as p h y s i c a l d e t e r i o r a t i o n , suggest t h a t 40% o f those over 80, 15% o f those over 70 and 7.5% o f those over 55 are v i c t i m s . The U.S. Community Mental Health Centre movement has i n c l u d e d the care o f the m e n t a l l y r e t a r d e d , c o n t r a r y t o most o f Canada where r e t a r d a t i o n i s co n s i d e r e d a s o c i a l r a t h e r than h e a l t h problem. The i n c l u s i o n o f p h y s i c a l handicapped i s assumed t o be based on the assumption t h a t such i n d i v i d u a l s are a t g r e a t e r r i s k f o r the development o f mental and emotional d i s o r d e r s than the general p o p u l a t i o n . T h i s i n c l u s i o n c o u l d a l s o be argued f o r on the b a s i s o f the concomitant poverty o f those both r e t a r d e d and p h y s i c a l l y d i s a b l e d , and, a l s o , on the b a s i s o f the 65 increased s t r e s s on t h e i r care g i v e r s . Both e x p l a n a t i o n s support a s o c i a 1/environmenta1 model o f mental i l l n e s s , though once agai n , open t o the same c r i t i c i s m s d i s c u s s e d r e g a r d i n g the poverty and s o c i a l pathology i n d i c e s . Several major problems e x i s t with s o c i a l i n d i c a t o r s . As p r e v i o u s l y mentioned t h e i r c h o i c e i s i n d u c t i v e r a t h e r than d e d u c t i v e and t h e r e f o r e i t i s d i f f i c u l t t o know i f an adequate set o f i n d i c a t o r s has been chosen. Secondly, i n t e r p r e t a t i o n o f change over time r e l i e s on values judgement - how much change i s s i g n i f i c a n t ? F i n a l l y , t h e r e i s l i t t l e evidence f o r the v a l i d i t y o f these measures. W r i t e r s such as Weiss and Bucuvalas (1980) and Goldsmith (1972) have r e p o r t e d t h a t , i n Carol Weiss' terms, t h e r e i s an " o v e r s e l l ' o f s o c i a l i n d i c a t o r s . Goldsmith suggests t h a t t h e i r purpose needs t o be c l a r i f i e d and t h a t those in c u r r e n t use are inadequate. Weiss argues t h a t t h i s movement can c o n t r i b u t e t o (1) improved d e s c r i p t i v e r e p o r t i n g ; (2) a n a l y s i s o f s o c i a l change, and (3) t o the p r e d i c t i o n o f f u t u r e s o c i a l events and s o c i a l l i f e . At the same time she c r i t i c i z e s t h e i r use in the s e t t i n g o f goals and p r i o r i t i e s , s u g g e s t i n g t h a t the very process o f dev e l o p i n g i n d i c a t o r s i s va l u e - l a d e n ; t h e i r very d e f i n i t i o n 66 r e f l e c t s s o c i o p o l i t i c a l v a l u e s . Weiss suggests t h a t by d i g n i f y i n g a s t a t i s t i c by r e f e r r i n g t o i t as an i n d i c a t o r does not p r o v i d e the conceptual framework by which t o understand i t . They can not by themselves make d e c i s i o n s f o r p l a n n i n g , yet given t h i s lack o f conceptual framework, can be used in any manner the user wishes. How much i s enough, and how much i s too much are qu e s t i o n s not answered, but are l e f t t o the judgement o f the user. E. Commun i t y Group Approaches Of the fo u r models, i t i s the community group approaches which focus in on the lay people i n a community, and, f o r t h a t reason, have been very popular with the consumer advocates o f the l a s t decade. Such approaches al l o w f o r c i t i z e n and community p a r t i c i p a t i o n in the i d e n t i f i c a t i o n o f needs and subsequent establishment o f s e r v i c e requirements. Surveys, e i t h e r anonymous, through-the-mail or d i r e c t interview-based methods, and group forum methods pr o v i d e a c i t i z e n p e r s p e c t i v e on the nature and magnitude o f community needs as opposed t o the expert p e r s p e c t i v e which may be mixed with p r o f e s s i o n a l vested i s s u e s . By a s k i n g the people who l i v e i n the area one's r e s u l t s a re h o p e f u l l y more s e n s i t i v e t o the p a r t i c u l a r p e c u l i a r i t i e s o f a r e g i o n and r e f l e c t what the r e s i d e n t s would accept as s e r v i c e . T h i s i s a p a r t i c u l a r l y important p o i n t when d e a l i n g with communities, c u l t u r e s or c l a s s e s 67 f o r e i g n t o the e x p e r t s . An a d d i t i o n a l a s s e t i s t h a t such approaches serve t o both f a m i l i a r i z e c i t i z e n s o f p o t e n t i a l f a c i l i t i e s and, through making them p a r t o f the p l a n n i n g process, may enhance p o s s i b i l i t y t h a t such s e r v i c e s w i l l e v e n t u a l l y be used. T h i s model d e a l s not with the i n d i v i d u a l and h i s needs but r a t h e r with p e r c e i v e d group needs, not with d i a g n o s i s but with group d i s s a t i s f a c t i o n . The data are not r i g o r o u s , but r a t h e r impressions, comments, p e r c e p t i o n s o f need. While l a c k i n g the r i g o r o f s p e c i f i c d i a g n o s i s , they may a c t u a l l y present a more a c c u r a t e p i c t u r e o f t o t a l need - not in a q u a n t i f i a b l e sense but in a q u a l i t a t i v e sense. Because o f these c h a r a c t e r i s t i c s such models are a t t r a c t i v e l e s s t o the s c i e n t i s t , s t a t i s t i c i a n , b i o m e t r i c i a n , and yet more a t t r a c t i v e t o the s o c i o l o g i s t . There i s an i m p l i c a t i o n i n such s t u d i e s t h a t cause i s not the important f a c t o r - thus a l l o w i n g f o r a m u l t i t u d e o f d i f f e r e n t f a c t o r s . The essence i s more t h a t need f o r a s e r v i c e which can be seen by the communitv as p o t e n t i a l l y a m e l i o r a t i n g the problems they themselves p e r c e i v e . Depending on the s i t u a t i o n t h i s may mean t h a t h e a l t h care o r i e n t e d s o l u t i o n s are not o f f e r e d as panaceas f o r t r a d i t i o n a l h e a l t h care problems. Such an approach may a l l o w a community t o t a r g e t both problem and s o l u t i o n in the way which f i t s t h a t p a r t i c u l a r community b e s t . 68 T h i s model i s probably i n c l o s e s t alignment with the i n t e r p r e t i v e model o f mental i l l n e s s . Its impression o r i e n t e d approach and i t s allowance f o r c u l t u r e s p e c i f i c responses, i m p l i e s an understanding o f g e s t a l t . Needs are not n e c e s s a r i 1 y seen t o be l i n k e d t o s p e c i f i c causes, nor are they bound by s t r i c t l y medical format. T h i s i s not t o say t h a t responses do not take t h a t approach, f o r the 1 m e d i c a 1 i z a t i o n o f c u l t u r e i s p e r v a s i v e and a d v e r t i s i n g and education have been shown t o a f f e c t p e r c e p t i o n o f need, and presumably o f what i s the a p p r o p r i a t e source o f care. Despite t h i s , t h i s model a t l e a s t a l l o w s f o r the p o s s i b i l i t y o f an i n t e r p r e t a t i v e response on the p a r t o f the consumer. It w i l l not be viewed as c r e d i b l e by those wishing a "hard data' approach t o need assessment. F. The Re 1 a t i onsh i p Between Need and P1ann i ng The f o u r models o f need assessment presented can be shown t o c o n s i s t e n t l y f i t on a continuum. F i g u r e 2 i l l u s t r a t e s the models v i s a v i s t h e i r assumptions r e g a r d i n g model o f i l l n e s s , data requirements and s c i e n t i f i c r i g o r . T h i s w i l l l a t e r be shown t o a l s o r e l a t e in a s i m i l a r f a s h i o n t o the c h a r a c t e r i s t i c s o f t h e i r users and t h e i r c o ntext. 69 F i g u r e 2: C h a r a c t e r i s t i c s o f Need Assessment Models Med i ca1 Or i e n t at ion R a t i o n a l i t y Sc i ent i f i c R i gor h i gh high high Ep i dem i o1og i ca1 i ndi ces Ut i 1 i z a t i on r a t e s Soc i a 1 in d i c a t o r s Community group forums Having analyzed these models on an i n d i v i d u a l b a s i s , comment can be made r e g a r d i n g t h e i r r e l a t i o n s h i p as a group t o the p l a n n i n g p r o c e s s . The recent emphasis on need assessment r e f l e c t s the assumption t h a t by p r o v i d i n g a " b e t t e r ' data base, " b e t t e r ' program p l a n n i n g and h e a l t h care d e l i v e r y w i l l be developed. A s p i n o f f o f need assessment has been the growth o f program e v a l u a t i o n work, based on the i n i t i a l need assessment f o r the program i n q u e s t i o n . The assumption t h a t need assessment does f a c i l i t a t e b e t t e r program p l a n n i n g through i n c r e a s i n g r a t i o n a l i t y o f the p l a n n i n g process has i t s e l f not been evaluated and o n l y f u t u r e h i s t o r y w i l l adequately a s c e r t a i n i f the c o s t s a s s o c i a t e d with such a c t i v i t i e s have produced a 1 ow 1 ow 1 ow 70 s u p e r i o r system than the incremental model produced. In the end, t h a t too w i l l be a value judgement. Regardless o f t h i s unanswerable q u e s t i o n , the v a l i d i t y o f some o f the assumptions i n v o l v e d i n the need assessment/planning process can be examined. F i r s t l y i t i s assumed t h a t the measurement o f i l l n e s s w i l l g i v e us a measure o f the need f o r p r o f e s s i o n a l i n t e r v e n t i o n . T h i s i s u n l i k e l y p a r t i c u l a r l y in the mental h e a l t h s e c t o r . As has been p r e v i o u s l y d i s c u s s e d , the m a j o r i t y o f c o n d i t i o n s are m i l d , o f t e n s e l f l i m i t i n g and even tend t o disappear in s p i t e o f treatment (Cummings and Cummings, 1965). The frequency o f spontaneous recove r y i s one o f the major o b s t a c l e s t o the s c i e n t i f i c e v a l u a t i o n o f t h e r a p e u t i c e f f o r t s . In a d d i t i o n , p r o f e s s i o n a l c o n s i d e r a t i o n f o r "treatment t e r r i t o r y ' may c l o u d the e v a l u a t i o n o f need f o r care (e.g. p h y s i c i a n s d e l i v e r babies in urban areas, nurses in r u r a l areas; p s y c h i a t r i s t s deal with young, a t t r a c t i v e , a r t i c u l a t e mental h e a l t h p a t i e n t s , nurses and other mental h e a l t h p r o f e s s i o n a l s with o l d , u n a t t r a c t i v e , i n a r t i c u l a t e c h r o n i c mental h e a l t h p a t i e n t s ) . Often ignored a l s o i s the l a r g e and e f f e c t i v e network o f c a r e - g i v e r s not a s s o c i a t e d with the h e a l t h p r o f e s s i o n s . Mechanic (1972) r e p o r t e d t h a t the lay network was the most p r e v a l e n t source o f help f o r personal problems, t h i r t y - t h r e e percent o f respondents seeking help from a f r i e n d and twenty-eight percent seeking help from a r e l a t i v e . He 71 r e p o r t e d o n l y twenty-eight percent o f h i s respondents choose p r o f e s s i o n a l h e l p , and o f those o n l y two percent choose p s y c h i a t r y . Need assessment can be seen t o expand the p r o f e s s i o n a l ' s t e r r i t o r y (and perhaps t h e r e i n l i e s much o f i t s appeal t o the p r o f e s s i o n a l ) . Need assessment data t h e r e f o r e , can not be assumed t o r e a d i l y t r a n s l a t e i n t o s e r v i c e needs - e i t h e r q u a n t i t y , d u r a t i o n or even type. A second assumption i s t h a t t h e r e are e f f i c a c i o u s treatments f o r the c o n d i t i o n s i d e n t i f i e d . As p r e v i o u s l y d i s c u s s e d t h e r e are i l l n e s s e s f o r which, a t l e a s t c u r r e n t l y , we can o f f e r no cures. T h i s i s t r u e o f most o f the major p s y c h i a t r i c i l l n e s s e s . Thus, i d e n t i f i c a t i o n o f a need must not be thought o f on 1y in terms o f cure. For many i t means merely the i d e n t i f i c a t i o n o f m o r b i d i t y and, given t h a t prevalence i s a f u n c t i o n o f d u r a t i o n , i t serves t o i n c r e a s e p r e v a l e n c e . Once i d e n t i f i e d c e r t a i n c o n d i t i o n s such as the major mental i l l n e s s e s r e q u i r e ( i n the humanitarian and sometimes p o l i t i c a l sense) maintenance c a r e . In some p o l i t i c a l s i t u a t i o n s i t may be unwise t o i d e n t i f y cases which can not be cured but o n l y maintained a t a high c o s t t o s o c i e t y . The d e i n s t i t u t i o n a l i z a t i o n o f both the men t a l l y r e t a r d e d and men t a l l y i l l has oc c u r r e d i n p o l i t i c a l contexts which have s t r e s s e d c o s t containment or r e d u c t i o n . Costs o f community care may be lower than i n s t i t u t i o n a l c o s t s but c o s t s o f " l o s t ' c l i e n t s a re even lower - a t l e a s t t o those who were paying the i n s t i t u t i o n a l c o s t s ! Often these " l o s t ' 72 c l i e n t s s u r f a c e on another s e c t o r ' s c a s e l o a d - s o c i a l s e r v i c e s ' or a t t o r n e y g e n e r a l ' s . In the s i t u a t i o n where t h e r e i s no cure, o n l y maintenance, a c t i v e c a s e f i n d i n g may be discouraged by those i n f i n a n c i a l c o n t r o l . T h i r d l y , need assessment tends t o imply t h a t communities are so d i f f e r e n t as t o r e q u i r e exact and p r e c i s e measurement o f h e a l t h f o r adequate p l a n n i n g . Gould et a l . (1980) r e c e n t l y summarized the r e s u l t s o f 88 e p i d e m i o l o g i c a l s t u d i e s and the c u r r e n t N.I.M.H. E p i d e m i o l o g i c a l Catchment Area program i s examining f i v e d i f f e r e n t areas - a t o t a l o f over 20,000 i n d i v i d u a l s . At the same time any seasoned c l i n i c i a n can i d e n t i f y the major s e r v i c e gaps (unmet need) or s e r v i c e inadequacies o f h i s community - g e n e r a l l y the poor, the e l d e r l y and the non-compliant s e r i o u s l y i l l . The Midtown Manhattan study i d e n t i f i e d o n l y one i n twenty d i s a b l e d in treatment ( S r o l e , Langner, Mic h a e l , 1962). Dohrenwend (1980) estimates twenty t o f o r t y percent o f the s e r i o u s l y i l l a re not l i n k e d t o p r o f e s s i o n a l c a r e . Given t h a t the c o s t s o f care t o a l l p o t e n t i a l users i s l i k e l y well beyond s o c i e t y ' s c a p a b i l i t y an arguement c o u l d be made t o "stop i d e n t i f y i n g and j u s t s t a r t t r e a t i n g ' . Perhaps the gaps and d u p l i c a t i o n s in the e x i s t i n g system have l e s s t o do with lack o f a pl a n n i n g base and more from the p r o f e s s i o n a l and p o l i t i c a l powers t h a t have d i r e c t e d the focus o f s e r v i c e d e l i v e r y . It i s t h i s context t h a t has a f f e c t e d both need assessment and s e r v i c e p l a n n i n g which i s now turned t o . 73 Chapter V: Viewpoints in Need Assessment A. Introduct ion In a re c e n t paper on p r i o r i t y s e t t i n g f o r Canadian Mental Health S e r v i c e s ( S a t o r i u s , 1984) i t was suggested t h a t t o formulate mental h e a l t h p o l i c i e s d e c i s i o n makers must reach i n t o p h i l o s o p h y , r e l i g i o n , e t h i c s and h i s t o r y . U n d e r l y i n g t h i s i s the understanding t h a t the value systems o f the s o c i e t y , the value system o f the pla n n e r , the value system o f the s c i e n t i s t , must a l l be addressed. T h i s i s a l s o the crux o f t h i s paper - the values o f the both the t o o l and the context must be taken i n t o account when us i n g needs assessment as an a l l o c a t i v e t o o l . The p r e v i o u s d i s c u s s i o n has examined the conceptual b a s i s u n d e r l y i n g both mental i l l n e s s and the v a r i o u s need assessment t e c h n i q u e s . The values o f the s o c i o - p o l i t i c a l environment are now addressed. B. Boundar i es i n Power i n P1ann i na Before t u r n i n g t o these i s s u e s , the important l i n k o f need assessment and p l a n n i n g must be emphasized. The purpose o f need assessment was p r e v i o u s l y l o o s e l y d e f i n e d as the i d e n t i f i c a t i o n o f some type o f data t o f a c i l i t a t e some type o f p l a n n i n g in some community. Need assessment i s t h e r e f o r e i n e x t r i c a b l y l i n k e d with p l a n n i n g . Need assessments may not always lead t o a plan's implementation but they are l i n k e d t o the w i l l t o p l a n . 74 Without t h i s i n t e n t i o n need assessments are f o r the most p a r t i r r e 1 e v a n t ^ 1 ^ . Given t h i s , need assessments are bound by s i m i l a r c o n s t r a i n t s as the p l a n n i n g process i t s e l f . Boulding (1967) and Lindblom (1959) have d e s c r i b e d the concept o f "bounded r a t i o n a l i t y " i n r e f e r e n c e t o p o l i c y development but i t i s e q u a l l y r e l e v a n t t o p l a n n i n g . By t h i s i t i s suggested t h a t p o l i c y makers or planners are l i m i t e d by time and by a b i l i t y t o put together and a c t upon a l l the r e l e v a n t data in any s i t u a t i o n ( C r i c h t o n , 1981). T h i s can be expanded t o i n c l u d e the c o g n i t i v e boundaries which are a product o f the s p e c i a l concerns, vested i n t e r e s t s and p h i l o s o p h i c a l and p o l i t i c a l o r i e n t a t i o n o f the major a c t o r s i n v o l v e d . Planners plan t o succeed. Thus, f e a s i b i l i t y o f a plan i s an e s s e n t i a l element o f a plan's success. T h i s i s t r u e a l s o o f the need assessment - the data generated must be o f such nature as t o maximize chances o f a plan's acceptance, and thus the r e l a t i v e nature o f need assessment. F e a s i b i l i t y , a c c o r d i n g t o H a l l , Land, Parker and Webb (1975) i s i n i t s broadest sense determined by the p r e v a i l i n g s t r u c t u r e and d i s t r i b u t i o n o f t h e o r e t i c a l and t e c h n i c a l knowledge. They f u r t h e r suggest t h a t f e a s i b i l i t y i s not The e x c e p t i o n t o t h i s i s when need assessments are used p u r e l y f o r p o l i t i c a l purposes when no pl a n was intended or i n the cases where a need assessment i s done " a f t e r the f a c t " , f o r e i t h e r l e g i s l a t i v e or p o l i t i c a l reasons. 75 e n t i r e l y independent o f who does the judging - p a r t i c u l a r i d e o l o g i e s , i n t e r e s t s , p r e j u d i c e s and i n f o r m a t i o n w i l l a f f e c t the kinds o f c o n c l u s i o n s drawn about the f e a s i b i l i t y o f any p l a n . It i s t h i s aspect o f f e a s i b i l i t y t h a t i s d e a l t with here. There may be competing views about f e a s i b i l i t y and the progress o f any proposal can be a f f e c t e d by how t h i s c o m p etition i s r e s o l v e d . H a l l et a l . p o i n t out t h a t f e a s i b i l i t y i s r a r e l y immediately apparent. It i s in t h i s context in which the need assessment may f u n c t i o n t o guage a plan's p o t e n t i a l acceptance or success. A f e a s i b i l i t y study looks a t a t a r g e t p r i o r t o the commitment t o p l a n . T h i s i s p a r t o f a process o f "sounding out" and may be formal (e.g. the s i z e o f a t a r g e t p o p u l a t i o n in question) or informal (e.g. the f e e l i n g o f the community about a planned program). Even in t h i s l i m i t e d r o l e , however, matching o f the o r i e n t a t i o n o f those in a p o s i t i o n t o f a c i l i t a t e the success of a plan with the type o f needs data which matches t h e i r values and i n t e r e s t s w i l l enhance a p o s i t i v e outcome. Planning means change and change i s r a r e l y p e r c e i v e d as p o s i t i v e by a 11 t h a t are a f f e c t e d by i t . To achieve change r e q u i r e s a power base. With the e x c e p t i o n o f t o t a l i t a r i a n s o c i e t i e s , t h i s power base i s g e n e r a l l y a heterogeneous group c o n s i s t i n g o f governments ( f e d e r a l , p r o v i n c i a l , m u n i c i p a l ) , t r a d e unions, p r o f e s s i o n s , advocacy groups and other i n t e r e s t groups. C r i c h t o n (1981) suggests t h a t the f i r s t s tep in s u c c e s s f u l p l a n n i n g i s t o achieve enough 76 consensus among the n e g o t i a t i n g i n t e r e s t groups t h a t they w i l l s i t down tog e t h e r t o work on problems. She c a u t i o n s t h a t without t h a t agreement p l a n n i n g w i l l f a i l . How such n e g o t i a t i o n s take plac e and how consensus i s reached i s beyond the scope o f t h i s paper. However, i t i s important t o note t h a t whatever consensus i s reached, the r e s u l t i n g major a c t o r s w i l l e x e r t t h e i r values and pr e f e r e n c e s - not o n l y in terms o f need assessment and pla n n i n g but a l s o in terms o f t h e i r own views o f r a t i o n a l i t y and change. C. P1ann i ng Mode 1s Given the c l o s e r e l a t i o n s h i p between need assessment and p l a n n i n g an understanding o f the major p l a n n i n g approaches i s necessary in order t o ev a l u a t e the r o l e o f need assessment s t r a t e g i e s . The f o l l o w i n g attempts t o d i f f e r e n t i a t e between the two major approaches and c l a r i f y how each i s r e l a t e d t o c e r t a i n need assessment methodo1og i es. 1 . Incrementa1 Mode 1 Lindblom (1959) has r e f e r r e d t o t h i s model as "the a r t o f muddling through". C r i c h t o n (1981) has d e s c r i b e d such planners as problem s o l v e r s . The emphasis i s on making r e l a t i v e l y small improvements, based on a comparison o f a l i m i t e d number o f concre t e 77 program a l t e r n a t i v e s . Lindblom has argued t h a t by t a k i n g o n l y small s t e p s , d e c i s i o n makers have the o p p o r t u n i t y t o ev a l u a t e programs and t e s t p o l i t i c a l acceptance, thereby maximizing success. C r i c h t o n has d e s c r i b e d i t as " t r o u b l e s h o o t i n g " . She suggests t h a t t h i s method i d e n t i f i e s a problem, e v a l u a t e s i t , c o o r d i n a t e s the response and endeavors t o c o n t r o l the s i t u a t i o n . C r i t i c s o f t h i s model argue t h a t i t s lack o f success in p r o v i d i n g f o r a h e a l t h care system with c o n t a i n a b l e c o s t s and p o i n t t o the s p i r a l i n g c o s t s o f a system rampant with both gaps and d u p l i c a t i o n s . Incremental Planning can a l s o be c r i t i c i z e d as the "squeaky wheel" approach t o pl a n n i n g - those who squeak loudest a re a l l o c a t e d funds, with l i t t l e view t o the broad p i c t u r e , a l t e r n a t i v e approaches or a n t i c i p a t e d impacts o f the program i t s e l f . 2. The Rat i ona1 Mode 1 F a l u d i (1973) d e f i n e s the Ra t i o n a l Planning model as "the a p p l i c a t i o n o f s c i e n t i f i c method - however crude - t o p o l i c y making. What t h i s means i s t h a t conscious e f f o r t s are made t o inc r e a s e the v a l i d i t y o f p o l i c i e s in terms o f the present and a n t i c i p a t e d f u t u r e o f the environment". T h i s implies s e t t i n g g o a l s , examining a l t e r n a t i v e s and choosing the "best' o p t i o n f o r the s i t u a t i o n a t hand. T h i s does not n e c e s s a r i l y 78 imply t o t a l c o n t r o l over a l l v a r i a b l e s but r a t h e r a l o g i c a l and sys t e m a t i c approach o f comparing the a n t i c i p a t e d impacts o f several a l t e r n a t i v e s . Freidman (1967) d e s c r i b e s a s i m i l a r model as a developmental model. C r i c h t o n (1981) d e s c r i b e s t h i s model as beginning by r e s e a r c h i n g i s s u e s , s e l e c t i n g from a l t e r n a t i v e c h o i c e s , making and t a k i n g d e c i s i o n s , o p e r a t i o n - a l i g n i n g the changes, e v a l u a t i n g and f e e d i n g back r e s u l t s . T h i s suggests a dynamic and ongoing process t o p l a n n i n g . The Rational Model has been c r i t i c i z e d by w r i t e r s such as Lindblom (1959) who suggests t h a t i t c a l l s f o r an extreme amount o f r a t i o n a l i t y which i s impossible t o achieve i n the "open' system in which we operate. Lindblom f u r t h e r suggests t h a t i t i s impossible t o a n t i c i p a t e the t o t a l e f f e c t s o f any a c t and thus t o attempt t o choose r a t i o n a l l y between a l t e r n a t i v e s i s imp o s s i b l e . Advocates o f Ra t i o n a l P l a n n i n g argue t h a t acknowledgement and c o n t r o l over some v a r i a b l e s i s b e t t e r than none a t a l l . 79 F i g u r e 3: The R e l a t i o n s h i p o f Planning and Need Assessment Methods PLANNING MODELS INCREMENTAL RATIONAL NEED ASSESSMENT METHOD - ut i 1 i z a t i on - commun i t y forum - e p i d e m i o l o g i c a l i n d i c e s - ut i 1 i z a t i on - soc i a 1 i nd i c a t o r F i g u r e 3 presents the r e l a t i o n s h i p between the Planning Models and need assessment methodologies. The incremental approach r e l i e s on inf o r m a t i o n from s p e c i f i c sources. It avoids the " b i g p i c t u r e " . T h i s p l a n n i n g model has emphasized the growth o f i n d i v i d u a l s e r v i c e s and thus i t s emphasis i s on u t i l i z a t i o n f i g u r e s (to j u s t i f y growth) and the "squeaky wheel" approach o f community forums (to p o i n t d i r e c t i on). The Rat i o n a l Model emphasizes the " b i g p i c t u r e " and thus e p i d e m i o l o g i c a l i n d i c e s p r e s e n t i n g t r u e prevalence f i g u r e s are most important. Such i n d i c e s are g e n e r a l l y d i a g n o s t i c in nature, as the c u r r e n t use o f DSM III in N.I.M.H.'s E p i d e m i o l o g i c a l Catchment area study. S o c i a l i n d i c a t o r s can a l s o c o n t r i b u t e t o an estimate o f t r u e prevalence when used on a wide s c a l e . N e i t h e r e p i d e m i o l o g i c a l i n d i c e s nor s o c i a l i n d i c a t o r s can be d i r e c t l y t r a n s l a t e d i n t o care needs, f o r a l l i d e n t i f i e d 80 cases w i l l not access care s e r v i c e s . Thus, u t i l i z a t i o n r a t e s are a necessary component in t r a n s l a t i n g e p i d e m i o l o g i c a l i n d i c e s i n t o h e a l t h s e r v i c e p l a n n i n g . S o c i a l i n d i c a t o r s are a l s o o f value, though i d e a l l y o n l y when t h e r e i s the p o s s i b i l i t y o f a d d r e s s i n g the s o c i a l causes o f the d i s o r d e r s . T h i s matching o f need assessment and p l a n n i n g models i s e s s e n t i a l . Need assessments are o n l y a t o o l used t o p r o v i d e the base from which p l a n n i n g can occur. Congruence between the t o o l and plan not o n l y maximize success o f the endeavor, they tend t o emerge t o g e t h e r as a r e s u l t o f other s o c i o -po1 i t i ca1 f a c t o r s . D. Va1ues in Po1i t i ca1 Ideo1ogy To maximize p l a n n i n g success the values and i n t e r e s t s inherent i n the ideology o f the p o l i t i c a l f o r c e in power must be acknowledged. D i f f e r e n t p o l i t i c a l i d e o l o g i e s hold q u i t e d i f f e r e n t views on h e a l t h , and mental h e a l t h i n p a r t i c u l a r , on the r o l e o f the planner, on change and on the r o l e o f government in these a r e a s . D i f f e r e n t views o f r a t i o n a l i t y and o f change w i l l produce d i f f e r e n t c o n s t r a i n t s or boundaries t o the planner. In t u r n , the type o f data held t o be c r e d i b l e and o f use w i l l d i f f e r a c c o r d i n g t o these views. H a l l (1972) has d e s c r i b e d p o l i t i c s as being "concerned with the r e l a t i o n s h i p o f power or o f i n f l u e n c e , g e n e r a l l y 81 w i t h i n the context o f government". Blackburn and Blum (1968) d e f i n e p o l i t i c s as "the a c t o f promoting or pr e v e n t i n g s o c i a l change" and "the a c t i v i t i e s o f p o l i t i c a l p a r t i e s and the a c t i v i t i e s o f org a n i z e d groups t r y i n g t o i n f l u e n c e government d i r e c t l y and i n d i r e c t l y " . They suggest t h a t p o l i t i c s i s the most f r e q u e n t l y used method of d e l i b e r a t e change. Nei t h e r p o l i t i c s nor pl a n n i n g can alone c r e a t e change in democratic c o u n t r i e s . P o l i t i c s does p r o v i d e the power base, however, while p l a n n i n g p r o v i d e s a s e t o f p e r s p e c t i v e s or techniques t h a t can a s s i s t p o l i t i c a l d e c i s i o n making. The planner's a b i l i t y t o understand and use the p o l i t i c a l process t o h i s advantage may be the l a r g e s t determiner o f a plan's success; the p o l i t i c a l component can not be ignored when t r y i n g t o understand the d i f f i c u l t i e s c o n f r o n t i n g the planner ( C r i c h t o n , 1981). Blackburn and Blum (1968) have d e a l t with t h i s i s s u e o f phil o s o p h y and values i n p o l i t i c a l change in r e s p e c t t o s o c i a l a c t i o n . In comparing models o f s o c i a l change the authors in e f f e c t d e s c r i b e the p e r s p e c t i v e s o f the major p o l i t i c a l frameworks. F i g u r e 3 presents an a b b r e v i a t e d v e r s i o n o f t h e i r matrix. It i s c l e a r t h a t the r o l e o f need assessment and p l a n n i n g w i l l d i f f e r a c c o r d i n g t o p o l i t i c a l i d eology. The accompanying f i g u r e helps t o i d e n t i f y some o f the major themes or issu e s r e l e v a n t t o p l a n n i n g w i t h i n the h e a l t h care s e c t o r . 82 F i g u r e 4: Models o f S o c i a l A c t i o n and (adapted from Blackburn and Po1 i t i ca1 Change Blum, 1968) Focus on E q u i l i b r i u m C o n s e r v a t i o n and Homeostasis Focus on New G o a l s Change I n c r e m e n t a l / A d a p t i v e P l a n n i n g R a t i o n a l / D e v e l o p m e n t P l a n n i n g L a i s s e z Fa i r e D i s j o i n t e d Incremental ism Goal O r i e n t e d Developmental P l a n n i n g T o t a l i t a r i a n SOCIAL ORDER AND CONFLICT N a r k e t p l a c e the d e t e r m i n e r , s o c i e t y i s what we f i n d . S o c i e t y g r e a t e r than i t s p a r t s , c r e a t e s o r d e r and m a i n t a i n s i n s t i t u t i o n s S o c i e t y a b s o r b s i t s con-f l i c t s and changes, and e x p e c t s t h a t t h e s e w i l l r e s u l t i n new d e v i a n c e s which w i l l c r e a t e new c o n f 1 i c t s Han c r e a t e s new s o c i e t i e s as d e v i a n t s h e l p remake s o c i e t y and t h e n become p a r t o f i t SOCIAL GOALS Let n a t u r e t a k e i t s c o u r s e , man's i n s t i n c t s g u i de him w e l l Order and consensus a r e s o c i e t a l g o a l s , man needs s o c i a l i z i n g ( s c h o o l i n g and r e t u r n t o t h e path) S o c i e t y c r e a t e s g o a l s , v a l u e s , and s e l e c t s means t o overcome t h e u n d e s i r e d and a v o i d t h e unexpected S o c i e t y c r e a t e d by man, and r e p r e s e n t s r e s u l t s o f c o n t i n u e d s t r u g g l e s . New g o a l s a r e s e t . PRIHARY HEALTH GOALS S u r v i v a l o f t h e f i t t e s t Treatment and r e h a b i l i t a t i o n P r e v e n t i o n P o s i t i v e h e a l t h HEALTH PROGRAMS H e a l t h i s one element o f s u r -v i v a l and h e a l t h programs o n l y i n c r e a s e t h e p r o p o r t i o n o f t h e u n f i t H e a l t h i s p a r t o f con-formance and h e a l t h p r o -grams can r e s t o r e t h e s i c k t o t h e b e s t l e v e l o f h e a l t h t h a t can be e x p e c t e d H e a l t h can be improved by planne d a v o i d a n c e o f v a r i o u s causes o f i l l h e a l t h . P r e v e n t i o n o f what we a r e s u r e we don't want i s t h e h i g h e s t p r a c t i c a l c u r r e n t g o a l , as we a r e n ' t s u r e o f a l l t h e t h i n g s we do want H e a l t h can be d e f i n e d p o s i t i v e l y and i s a top p r i o r i t y g o a l 83 Healers appear on demand Marketplace medicine sup-plemented with government programs and private charitable programs to assist poor, and groups with special health prob-lems. Provide limited public health services Market, government and charitable medicine all pushed to provide a greater quantity of co-ordinated services. Any method used which delivers without sacrificing other major values Government medicine Making market freer and more competitive would eliminate need for government activity Remedy undesirable sit-uations as they become intolerable, patch up and use ad hoc planning when problems are really bad Democrati ca11y contro11ed planning helps society correct the unwanted, avoid the unintended, and reach what is desired. Evaluate old and plan for new achievable goals on basis of trials Make ideal goal our immediate target. Planning on a massive scale can bring society to its new goals As market dictates Piecemeal or ad hoc changes Broad interrelated changes Total reorganization Survival of the fittest plus charity Retraining and therapy to help deviant become a competitive individual, institutional arrange-ments to temporarily assist deviants Retraining and therapy where effective but also institutional arrange-ments to permanently assist deviants Either total insti-tutional izaton or total rejection No one Those with power from money, election to office or voluntary organization Whoever has most rational and popular plan Technologists No intervention from higher levels of government Assistance from higher levels of government only on request, as for new plans Work jointly on planning at all levels of govern-ments, and focus on enabling shifts in accordance with ability to undertake tasks Operate and control primarily at national level F i g u r e 4 Models o f S o c i a l A c t i o n and P o l i t i c a l Change (adapted from Blackburn and Blum, 1968) 84 S o c i e t i e s which do not b e l i e v e t h a t s o c i a l change i s p o s s i b l e do not p l a n . Thus, the e x i s t e n c e o f p l a n n i n g assures a t l e a s t a b e l i e f t h a t change i s p o s s i b l e . It i s the d i f f e r e n t b e l i e f s in how change comes about, who c o n t r o l s or d i r e c t s change and who change i s d i r e c t e d t o which r e s u l t s i n d i f f e r e n t types and s t y l e s o f p l a n n i n g . Each ideology w i l l focus on the v a r i a b l e w i t h i n s o c i e t y which i t f e e l s w i l l most l i k e l y b r i n g about or f a c i l i t a t e change. Each view r e s u l t s in plans f o c u s s e d on d i f f e r e n t v a r i a b l e s . Issues such as t o whom change should be d i r e c t e d , who should d i r e c t change and how change should take p l a c e w i l l be d e a l t with l a t e r i n t h i s chapter, as well as the v a r i o u s types o f r a t i o n a l i t y d i f f e r e n t i d e o l o g i e s h o l d . For now i t i s s u f f i c i e n t t o i d e n t i f y t h a t such d i f f e r e n t i d e o l o g i e s do in f a c t r e s u l t i n d i f f e r e n t types and s t y l e s o f p l a n n i n g by v i r t u e o f t h e i r i n d i v i d u a l values and b e l i e f s about change. Blackburn and Blum p o i n t out in t h e i r d e s c r i p t i o n o f t h e i r models t h a t each expresses an a t t i t u d e towards community p l a n n i n g and s o l v i n g s o c i a l problems. The models are d e s c r i b e d as "exaggerating" the d i f f e r e n c e s and thus can not be d i r e c t l y compared t o e x i s t i n g p o l i t i c a l p a r t i e s but t h i s exaggeration does help t o c l a r i f y the d i f f e r e n t p e r s p e c t i v e s o f each. L a i s s e z - f a i r e d e s c r i b e s the model which c a l l s f o r l e a s t government a c t i o n . D i s j o i n t e d Incrementa1ism d e s c r i b e s the 85 usual form o f non-planning in western democratic s o c i e t i e s , r e l y i n g mainly on incremental changes t o the e x i s t i n g system, based on a p l u r a l i s t power base. The Goal O r i e n t e d Developmental Model can be g e n e r a l i z e d t o the recent emphasis on more r a t i o n a l and gl o b a l p l a n n i n g . The T o t a l i t a r i a n Approach i n c l u d e s both the p l a n n i n g approach o f the S o v i e t Union as well as the a u t h o r i t a r i a n p l a n n i n g approach taken by many p r i v a t e c o r p o r a t i o n s and some governments. 1. The Lai s s e z - F a i re Model T h i s model has both an academic and a popular v e r s i o n which tend t o d i f f e r c o n s i d e r a b l y in any p r a c t i c a l s i t u a t i o n . The essence o f t h i s model i s c o n t r o l by the p e r f e c t l y c o m p e t i t i v e market r a t h e r than any governmental i n t e r v e n t i o n . The government i s seen as having no r o l e i n change. Thus, the popular model tends t o be used in defence o f p r i v a t e p r o f i t s w h i le the academic model, s u p p o r t i n g freedom t o choose among r e a l a l t e r n a t i v e s , i n d i v i d u a l freedom, i n d i v i d u a l i n i t i a t i v e , has argued f o r le s s b u r e a u c r a t i c c o n t r o l by g i v i n g people money i n s t e a d o f f o r c i n g them t o accept h i g h l y government r e g u l a t e d h e a l t h and s o c i a l s e r v i c e s . These values o f the academic model are h e l d by many who do not support the p r a c t i c a l a p p l i c a t i o n o f the model. As Blackburn and Blum suggest, the d e s i r e t o change 86 people a t times c o n f l i c t s with the commitments t o the i n s t i t u t i o n o f freedom o f c h o i c e , r e s u l t i n g in the same people who f a v o r the f r e e market ideology a l s o a d v o c a t i n g t i g h t c o n t r o l s on government s u p p l i e d serv i c es. 2. Di s j o i n t e d Incrementa1i sm Th i s model i s based on the accepted l e g i t i m a c y o f a p l u r a l i s t power base which al l o w s input t o the pl a n n i n g process from many sources and thus emphasizes the r o l e t h a t s o c i e t y i t s e l f p l a y s in both s o c i a l maintenance and s o c i a l change. P l a n n i n g , l a r g e l y incremental in nature, i s f o r the purpose o f r e a c t i n g t o problems o c c u r r i n g as the system develops, as opposed t o the g l o b a l p u r s u i t o f a c t u a l l y p l a n n i n g the system i t s e l f . There i s an acceptance o f an "open' system i n which t h e r e i s no end t o the p o s s i b l e consequences, an i n a b i l i t y t o guage the t o t a l e f f e c t s o f any a c t i o n because o f the m u l t i t u d e o f values which w i l l be l e g i t i m a t e l y addressed. 3. Goa1-Or i ented Development T h i s model s t r e s s e s the need f o r accepted g o a l s , as opposed t o the p r e v i o u s incremental " f i x i t " approach. It r e l i e s on community p a r t i c i p a t i o n f o r d i r e c t i o n but a t the same time, t r i e s t o a n t i c i p a t e the 87 unintended or u n d e s i r a b l e e f f e c t s which may r e s u l t from any a c t i o n . The goal i s long term and comprehensive, r e l y i n g on more r a t i o n a l p l a n n i n g methods, i n c l u d i n g ongoing e v a l u a t i o n and review. T h i s model r e f l e c t s a more v i s i b l e hand o f government but one r e f l e c t i v e o f and s e n s i t i v e t o the community. Such d e m o c r a t i c a l l y c o n t r o l l e d p l a n n i n g i s seen as a means o f a t t a i n i n g the d e s i r e d with a minimal o f unwanted e f f e c t s . These two models can be roughly equated t o what C r i c h t o n (1983) has d e s c r i b e d as the r i g h t and the l e f t wings o f the u t i l i t a r i a n l i b e r a l i s m o f the western democratic t r a d i t i o n : the r i g h t wing s u p p o r t i n g an ideology o f e n t r e p r e n e u r a l i s m and e q u a l i t y o f o p p o r t u n i t y while the l e f t wing supports u n i v e r s a l support s e r v i c e s , e q u a l i t y o f c o n d i t i o n and the w e l f a r e s t a t e . 4. Tota1i t a r i an Mode 1 Th i s model emphasizes the t e c h n o c r a t i c approach to p l a n n i n g , p l a n n i n g " s c i e n t i f i c a l l y " without responsiveness t o communities or concern with the impact on the l i v e s o f i t s c i t i z e n s . It i s not o n l y a s s o c i a t e d with the S o v i e t Union but a l s o with any s o l e l y "top down" approach where the values deemed as important are o n l y those o f those i n power. The t o t a l p l a n n i n g model o f f e r s almost no room f o r anyone other 88 than "experts', not a c c e p t i n g or t o l e r a t i n g any input i n t o the p l a n s . The focus i s on massive change, and such change can not be a l t e r e d e a s i l y . P a r a d o x i c a l l y , the p r a c t i c a l form o f the l a i s s e z - f a i r e model, c u r r e n t l y being espoused t o a l a r g e degree in both Great B r i t a i n and the United S t a t e s , as well as in B r i t i s h Columbia, o f f e r s s i m i l a r l y l i t t l e freedom o f c h o i c e or o p p o r t u n i t y f o r input. It i s a c u r i o u s mix of f r e e market economy supported by government along with massive government i n t e r v e n t i o n , r e g u l a t i o n and l i m i t a t i o n s in the h e a l t h and s o c i a l s e r v i c e s e c t o r based p r i m a r i l y on "expert" o p i n i o n s . Awareness o f how the v a r i o u s p o l i t i c a l i d e o l o g i e s view the elements o f s o c i a l change - and t h e r e f o r e need and p l a n n i n g - i s c r u c i a l t o understanding what type o f need assessment w i l l be r e l e v a n t or meaningful t o the p o l i t i c a l c ontext. The p o s s i b l e scope o f change, the focus o f change and the p o t e n t i a l a c t o r s are a l l a f u n c t i o n o f t h i s power base. The balance o f t h i s chapter w i l l deal with these c o n s t r a i n t s and how they a f f e c t the assessment o f need. E. The Role o f the Planner Integral t o t h i s q u e s t i o n o f values in need assessment 89 and p l a n n i n g i s the r o l e o f the planner. Beyond the personal values o f the planner are the values o f the p o s i t i o n s he occupies v i s a v i s the power base, the government. Data c o l l e c t e d n a t u r a l l y w i l l tend t o serve the i n t e r e s t s o f planner's own r o l e . T h e i r p o s i t i o n tends t o d i c t a t e t h e i r view as well as t h e i r l i m i t a t i o n s or boundaries o f infuence. G i l b e r t and Sprect (1974) o u t l i n e d t h r e e contexts o f p l a n n i n g i n which the planner p o t e n t i a l l y holds q u i t e a d i f f e r e n t r o l e . Each p o s i t i o n c r e a t e s d i f f e r e n t l y bounded r a t i o n a l i t i e s or p e r s p e c t i v e s . 1. The Technocrat i c P1anner The t e c h n o c r a t i c planner e x i s t s i n two q u i t e d i f f e r e n t contexts which r e s u l t s in two q u i t e d i f f e r e n t r o l e s . G i l b e r t and Sprecht's view i s the academic and s c i e n t i f i c planner, accountable p r i m a r i l y t o h i s p r o f e s s i o n . He i s the independent academic who i s f r e e t o produce the optimal p l a n based upon h i s knowledge o f economics, epidemiology, demography e t c . T h i s i s a s c i e n t i f i c approach t o p l a n n i n g , expoused by the recent s t r e s s towards r a t i o n a l p l a n n i n g . One a s s o c i a t e s a high degree o f autonomy with t e c h n o c r a t i c p l a n n i n g , with r e s p e c t towards the methodology and d i r e c t i o n taken. However, t h i s autonomy i s somewhat i l l u s i o n a r y . The t e c h n o c r a t i c or academic planner may have r e l a t i v e 90 autonomy in r e l a t i v e l y l u x u r i o u s f i n a n c i a l c l i m a t e s but c o n s i d e r a b l y l e s s so i n p e r i o d s o f r e s t r a i n t when i t i s more l i k e l y t h a t the ends w i l l be d i c t a t e d t o him and the c o n s t r a i n t s more r i g i d and v i s i b l e . G l e n n e r s t e r (1975) has p o i n t e d out t h a t t e c h n o c r a t i c p l a n n i n g i s more l i k e l y t o occur i n governments based on p l u r a l i s t power. Blackburn and Blum (1968) d e s c r i b e a q u i t e d i f f e r e n t context and r o l e . They suggest t h a t t e c h n o c r a t i c p l a n n i n g i s a s s o c i a t e d with the t o t a l i t a r i a n "top down' approach o f c e n t r a l i z e d governments who r e l y s o l e l y on "experts', i n s e n s i t i v e t o the a t t i t u d e s o f the community. In t h i s context the t e c h n o c r a t i c planner i s chosen f o r not o n l y h i s e x p e r t i s e but more importantly perhaps f o r h i s views -those n e c e s s a r i l y shared by the government. 2. The Bureaucrat i c P1anner B u r e a u c r a t i c planners are those who are p r i m a r i l y accountable t o the p o l i t i c a l and a d m i n i s t r a t i v e h i e r a r c h y . The o v e r l a p between p o l i t i c a l and a d m i n i s t r a t i v e p o l i c y making f l u c t u a t e s as a f u n c t i o n o f the r o l e t h a t the p o l i t i c a l p a r t y i n power expects p o l i t i c s t o p l a y v i s a v i s the p u b l i c s e r v i c e . Thus the r e i s an o v e r l a p between Blackburn and Blum's view o f the t e c h n o c r a t i c planner and the G i l b e r t and 91 Sprecht's view o f the b u r e a u c r a t i c planner. The more c e n t r a l i z e d the power, the more accountable t o the p o l i t i c a l system the planner must be. T h i s r e s u l t s in G i l b e r t and Sprecht's view o f b u r e a u c r a t i c p l a n n i n g . T h i s d i f f e r s from Blackburn and Blum's view in terms o f the a c t u a l power o f the government. Blackburn and Blum's view assumes t o t a l government c o n t r o l , not p o s s i b l e except i n t o t a l i t a r i a n governments. G i l b e r t and Sprecht's view accepts a more d i l u t e d form o f c e n t r a l i z e d government. In general b u r e a u c r a t i c or p o l i t i c a l p l a n n i n g f a c e s many c o n s t r a i n t s . E c k s t e i n (1956) argued t h a t the myriad o f c o n s t r a i n t s f a c e d by the b u r e a u c r a t i c planner - lack o f c o n t r o l , lack o f data, need t o appease v a r i o u s i n t e r e s t groups and p r o f e s s i o n s , other p a r t s o f government and the e l e c t o r a t e - has o f t e n r e s u l t e d i n a c o n s t r i c t e d r o l e , r educing the p l a n n i n g scope and r e s u l t i n g i n the incremental p l a n n i n g synonomous with most democratic governments. C r i c h t o n (1981) suggests t h a t t h i s type o f b a l a n c i n g o f p r i o r i t i e s f o r a b u r e a u c r a t i c planner may be somewhat e a s i e r a t the higher l e v e l s of government but t h a t a t the lower l e v e l where the p u b l i c s e r v i c e tends t o o v e r l a p in o p e r a t i o n a l a c t i v i t i e s , t h i s b a l a n c i n g w i l l almost always r e s u l t in incrementa1ism - the lower ranks concerned p r i m a r i l y with maintenance a c t i v i t i e s . 92 It can be seen, then, t h a t t e c h n o c r a t i c and b u r e a u c r a t i c p l a n n i n g can share a s i m i l a r r o l e , yet w i l l d i f f e r as a r e s u l t o f the degree o f c o n t r o l or power the government a c t u a l l y has. The is s u e i s not merely c e n t r a l i z a t i o n but r a t h e r a b s o l u t e a u t h o r i t y . In one context t h i s may r e s u l t i n broad, developmental and r a t i o n a l p l a n n i n g . In the other context i t r e s u l t s in p l a n n i n g scope being reduced and the incremental model being adhered t o . 3. The Advocacy Planner The advocacy planner i s accountable p r i m a r i l y t o the consumer group t h a t purchases h i s s e r v i c e s . Such planners tend t o espouse the s o c i a l p h i l o s o p h y h e l d by the employer - the planner tends t o be chosen f o r p r i m a r i l y h i s views. T h i s type o f p l a n n i n g developed along s i d e the e a r l y need assessment movement d u r i n g a time when the focus was on dev e l o p i n g s e r v i c e s r e s p o n s i v e t o the needs o f p a r t i c u l a r groups, with l i t t l e eye t o f i s c a l concerns. Such p l a n n i n g continues t o h o l d importance most in t h i s type o f atmosphere, when t h e r e appears t o be c o n s i d e r a b l e o p p o r t u n i t y t o i n f l u e n c e the system. T h i s may be in terms o f a v a i l a b l e resources or i n terms o f unsteady p o l i t i c a l times where g r e a t e r i n f l u e n c e v i a the media can a f f e c t i n c r e a s e d change. In g e n e r a l , the more c e n t r a l i z e d the 93 government, the l e s s l i k e l i h o o d o f e f f e c t i n g change through t h i s means. Advocacy p l a n n i n g i s r a r e l y developmental -i n t e r e s t groups r a r e l y have the broad o f scope and necessary power base. Rather i t tends, p a r t i c u l a r l y in the more recent times o f f i s c a l concern, t o p r o v i d e some means o f i n f l u e n c i n g incremental change which may, at worse, be a form o f tokenism from a c e n t r a l i z e d government f a c e d with s o c i a l l y or p o l i t i c a l l y unfavourable a t t e n t i o n . 4. Summary o f P1anni ng Roles The c o n t e x t s , or r o l e s , o f the planner are c l e a r l y a major f a c t o r i n the need assessment approach which w i l l be chosen t o p r o v i d e the data on which p l a n n i n g f o r change can be based. The t e c h n o c r a t o p e r a t i n g i n a h i g h l y c e n t r a l i z e d t o t a l i t a r i a n government looks a t p l a n n i n g in a broad and developmental manner, us i n g r a t i o n a l p l a n n i n g methods. The t e c h n o c r a t o p e r a t i n g in the more democratic government systems can approach i s s u e s i n a s i m i l a r manner but w i l l be c o n s t r a i n e d by a more p l u r a l i s t i c power base which u l t i m a t e l y he must be accountable t o . Thus, t e c h n o c r a t i c p l a n n i n g in i t s pure form i s somewhat i l l u s i o n a r y i n democratic governments. I d e a l l y , however, t e c h n o c r a t i c p l a n n i n g assumes the use o f the most r i g o r o u s o f the need assessment methods, such as e p i d e m i o l o g i c a l methods, 94 attempting t o produce the most q u a n t i f i a b l e data base. B u r e a u c r a t i c planners emerge in c e n t r a l i z e d systems o f government but the government's own c o n s t r a i n t s tends t o encourage a d a p t i v e and incremental p l a n n i n g , u s i n g the le s s r i g o r o u s need assessment s t r a t e g i e s , such as u t i l i z a t i o n f i g u r e s and s o c i a l surveys. F i n a l l y , the advocacy planner i s most v i a b l e i n a d e c e n t r a l i z e d system but the c o n s t r a i n t s o f h i s power base and i n f l u e n c e w i l l g e n e r a l l y r e s t r a i n him t o a d a p t i v e and incremental p l a n n i n g though u s u a l l y by the more consumer a c c e p t a b l e methods o f community forums and q u e s t i o n a i r e s ^ 2 ' It i s c l e a r t h a t t h e r e a re many r e a l world c o n s t r a i n t s which a f f e c t the academic models and such models o f f e r e d by both G i l b e r t and Sprecht and Blackman and Blum can o n l y o f f e r i n s i g h t s i n t o p o s s i b l e s c e n a r i o s , both models being r e a d i l y i n f l u e n c e d by the i n d i v i d u a l circumstances o f any context. Consumer groups and governments o c c a s i o n a l l y appear t o c o i n c i d e with t h e i r p l a n n i n g , as was the case i n B r i t i s h Columbia's d e i n s t i t u t i o n a l i z a t i o n o f the menta l l y r e t a r d e d in 1984. Both government and the B.C.A.M.R.P. appeared t o agree on the ends o f a developmental p l a n but c a r e f u l a n a l y s i s would suggest t h a t t h i s agreement was with v a s t l y d i f f e r e n t i n t e n t i o n s - n o r m a l i z a t i o n f o r B.C.A.M.R.P. and c o s t containment f o r the government. 95 F. Rat i o n a 1 i t y - D i f f e r e n t Vf ewpoi nts Viewpoints implies t h a t the same problem can be seen from many angles and t h a t the s o l u t i o n t o the problem can take on many d i f f e r e n t forms. The term r a t i o n a l i s g e n e r a l l y assumed t o imply l o g i c but i t must be understood t h a t one man's l o g i c i s another's i d i o c y . R a t i o n a l i s a value laden term and i s r e l a t i v e t o the beholder's view o f the world - and in the case o f mental h e a l t h - the i n d i v i d u a l ' s b e l i e f s about mental i l l n e s s , i t s causes, i t s course and i t s p r e v e n t i o n . No planner would admit t o being i r r a t i o n a l but d i f f e r e n t c o n s t r a i n t s produce d i f f e r e n t types o f r a t i o n a l i t y . In the case o f needs assessment the p r e f e r r e d model imp l i e s s p e c i f i c views about the concepts o f need, demand, want, the model of mental i l l n e s s and the p o l i t i c a l c o n text. To paraphrase Boulding (1967), r a t i o n a l i t y i s "bounded", not a b s o l u t e . A r n o l d (1968) suggests t h a t t h e r e are d i f f e r e n t kinds o f r a t i o n a l i t y depending upon the kind o f problem t h a t i s i n v o l v e d . R e l y i n g on Dies l i n g ' s work she o u t l i n e s f i v e types o f reasons which she suggests are f u n c t i o n a l l y necessary in s o c i e t y . Depending upon the viewpoint one type o f r a t i o n a l i t y may take precedence over another. 96 1. Log i ca1 Rat i o n a 1 i t y L o g i c a l r a t i o n a l i t y concerns the l o g i c o f cause and e f f e c t . Much o f problem s o l v i n g depends on the knowledge or b e l i e f s (not n e c e s s a r i l y s u b s t a n t i a t e d ) we have o f how problems we wish t o s o l v e are caused. T h i s i s p a r t i c u l a r l y important i n the h e a l t h s e c t o r as most d i s e a s e c o n t r o l programs, e i t h e r p r e v e n t a t i v e or t h e r a p e u t i c in nature, are dependent on l o g i c a l r a t i o n a l i t y . In mental h e a l t h t h i s suggests t h a t the model used t o e x p l a i n mental i l l n e s s w i l l d i c t a t e whether or not a p l a n n i n g process i s r a t i o n a l . A medical model should n e c e s s i t a t e a m e d i c a l l y d e f i n e d need and m e d i c a l l y o r i e n t e d s o l u t i o n in order t o be p e r c e i v e d as r a t i o n a l . A s o c i a l model should n e c e s s i t a t e a s o c i a l l y d e f i n e d need and s o c i a l l y o r i e n t e d s o l u t i o n . 2. Economi c R a t i o n a l i t y A second kind o f r a t i o n a l i t y i s economic r a t i o n a l i t y . In t h i s case causal r e l a t i o n s h i p s are assumed and the d e c i s i o n s i n v o l v e e f f i c i e n t a l l o c a t i o n s o f r e s o u r c e s . The problem o f l i m i t e d r e s o u r c e s , be they people, money or technology, u n d e r l i e s economic r a t i o n a l i t y . O b j e c t i v e s must be p r i o r i z e d i n order t o make econ o m i c a l l y r a t i o n a l d e c i s i o n s . Through p r i o r i z i n g one i m p l i e s the "best" way t o a l l o c a t e 97 r e s o u r c e s t o a c h i e v e maximum u t i l i t y . E c o n o m i c r a t i o n a l i t y h a s g r o w n w i t h t h e move t o w a r d s p r o f e s s i o n a l h e a l t h a d m i n i s t r a t o r s b u t h a s a l s o b r o u g h t w i t h i t a f o c u s o n t h e e t h i c a l p r o b l e m s o f p r i o r i z i n g h e a l t h o b j e c t i v e s . How o n e o r d e r s d i s e a s e p r o b l e m s -i n t e r m s o f c o s t t o s o c i e t y o r c o s t s t o t h e i n d i v i d u a l - a n d how o n e g u a g e s " g r e a t e r g a i n " i s f r a u g h t w i t h p r o b l e m s a n d p r e s e n t s a s o n e o f t h e m o s t c h a l l e n g i n g p r o b l e m s i n h e a l t h c a r e t o d a y . Who w i l l p r i o r i z e n e e d a n d o n w h a t b a s i s t h e y w i l l d o i t b r i n g s i n t o f o c u s many o f t h e c u r r e n t c o n f l i c t s i n h e a l t h . Who w i l l d o m i n a t e i n t h e s e d e c i s i o n s - h e a l t h p r o f e s s i o n a l s o r p r o f e s s i o n a l a d m i n i s t r a t o r s ? Who w i l l b e n e f i t - t h e g r o u p ( s o c i e t y ) o r t h e i n d i v i d u a l ? 3 . S o c i a 1/Lega1 R a t i o n a 1 i t y S o c i a l r a t i o n a l i t y i n v o l v e s t h e m a i n t e n a n c e o f s o c i a l i n t e r a c t i o n a n d s o c i a l i n t e g r a t i o n , e n s u r i n g a t l e a s t a m i n i m a l b a s e o f common v a l u e s , e x p e c t a t i o n s a n d n o r m s . W i t h o u t t h i s r a t i o n a l i t y , a c t i o n w o u l d o c c u r o n a n i n d i v i d u a l i z e d b a s i s - o n e a c h i n d i v i d u a l s p e r c e p t i o n o f w h a t i s l o g i c a l l y a n d e c o n o m i c a l l y r a t i o n a l , i g n o r i n g t h e n e e d f o r s o c i e t y t o f u n c t i o n w i t h some m e a s u r e o f c o n c e r t e d a c t i o n . L e g a l r a t i o n a l i t y d e f i n e s t h e p a r a m e t e r s o f s o c i a l r a t i o n a l i t y - w h a t i s m o r a l l y a c c e p t a b l e a n d w h a t a r e 98 the l i m i t s o f a c t i o n t h a t might a f f e c t other people. These two forms o f r a t i o n a l i t y operate t o g e t h e r t o d i c t a t e the c o n s t r a i n t s o f treatment, and in mental h e a l t h p a r t i c u l a r l y , the l i m i t s t o imposing c a r e . C e r t a i n i n d i v i d u a l s p e r c e i v e i t t o be most e c o n o m i c a l l y r a t i o n a l t o impose care on d i f f i c u l t mental h e a l t h c l i e n t s but these other kinds o f r a t i o n a l i t y prevent such i n d i v i d u a l i z e d a c t i o n . 4. Po1 i t i ca1 R a t i o n a l i t y F i n a l l y , p o l i t i c a l r a t i o n a l i t y a r t i c u l a t e s a s o c i e t y ' s values about a u t h o r i t y and r e s p o n s i b i l i t y through o r g a n i z e d forms f o r the achievement o f a l l other kinds o f r a t i o n a l i t y . P o l i t i c a l r a t i o n a l i t y r e s o l v e s the q u e s t i o n o f who w i l l make what d e c i s i o n s f o r whom and under what c o n d i t i o n s . Economic i d e a l s and s o c i a l i d e a l s occupy o p p o s i t e ends o f a continuum. A r n o l d (1968) suggests t h a t i t i s the p o l i t i c a l system t h a t has been i d e n t i f i e d in democratic c o u n t r i e s as the f o r c e which must make a c h o i c e o f p o s i t i o n between these two valu e s . It i s c l e a r from t h i s d i s c u s s i o n o f types o f r a t i o n a l i t y t h a t whoever i s i n the p o s i t i o n o f power -whoever makes the d e c i s i o n as t o what i s r a t i o n a l - i s a key 99 a c t o r in any p l a n . L o g i c a l r a t i o n a l i t y presupposes a s p e c i f i c model o f mental i l l n e s s - one does not look a t s o c i a l i n d i c a t o r s i f one b e l i e v e s in a medical or b i o l o g i c a l cause o f i l l n e s s . Current economic r a t i o n a l i t y holds t h a t c o s t b e n e f i t f o r s o c i e t y i s the r a t i o n a l approach. S o c i a l r a t i o n a l i t y and legal r a t i o n a l i t y makes assumptions about the r o l e o f s o c i e t y a t l a r g e , while p o l i t i c a l r a t i o n a l i t y a r t i c u l a t e s a s o c i e t y ' s b e l i e f s as t o who i s in c o n t r o l . C l e a r l y i n any democratic s o c i e t y s o c i a l and l e g a l r a t i o n a l i t y are the givens in which any planner must work. It i s t h i s c o mpetition between l o g i c a l , economic and p o l i t i c a l r a t i o n a l i t y t h a t must be r e c o g n i z e d and addressed in the p l a n n i n g process. Each has a d i f f e r e n t goal and w i l l thus view d i f f e r e n t data as being u s e f u l and l e g i t i m a t e . G. Change - Di f f e r e n t Vi ews Need assessment and p l a n n i n g assume t h a t change w i l l o c cur. How change i s viewed - how i t o c c u r s , who i t should be d i r e c t e d t o and who should s t e e r the process - w i l l i n f l u e n c e how need i s a s sessed. C a u s a l i t y i s a l s o r e l a t e d t o the change. The b e l i e f as t o how a d i s o r d e r i s caused w i l l n a t u r a l l y determine the focus o f both need assessment and s e r v i c e development. As e a r l i e r d i s c u s s e d , two p a r a l l e l t h e o r i e s o f c a u s a l i t y have developed w i t h i n mental h e a l t h and each has p o t e n t i a l l y d i f f e r e n t i m p l i c a t i o n s f o r both need assessment and s e r v i c e p l a n n i n g . 100 1 . How C h a n g e O c c u r s a n d t o Whom The q u e s t i o n o f how c h a n g e s h o u l d o c c u r i s r e l a t e d t o v a l u e s a b o u t c h a n g e . C h a n g e i t s e l f c a n b e p e r c e i v e d n e g a t i v e l y b y t h o s e who b e l i e v e t h a t s o c i e t y s h o u l d b e a s t a b l e a n d w e l l i n t e g r a t e d s y s t e m . On t h e o t h e r h a n d t h o s e who v i e w s o c i e t y a s a n o n g o i n g p r o c e s s , r a t h e r t h a n a n e n d , w i l l w e l c o m e t h e s t r u g g l e b e t w e e n v i e w s t h a t c h a n g e t e n d s t o b r i n g . An e m p h a s i s o n s o c i a l o r d e r s u g g e s t s a d i f f e r e n t p e r s p e c t i v e o n c h a n g e t h a n a n e m p h a s i s o n s o c i a l c o n f l i c t . A s B l a c k b u r n a n d B l u m ( 1 9 6 8 ) h a v e o b s e r v e d , s o c i a l o r d e r i m p l i e s c o n t r o l , a n d v i e w s man a s a p r o d u c t o f s o c i e t a l t r a i n i n g a n d h a b i t u a t i o n , w i t h n a t u r a l d r i v e s w e l l c o n t r o l l e d ; t h e c o n f l i c t p e r s p e c t i v e t e n d s t o v i e w man a s p o s s e s s i n g c e r t a i n e s s e n t i a l q u a l i t i e s w h i c h d r i v e h i m t o m o l d h i m s e l f a n d d e s i g n h i s s o c i a l r e l a t i o n s . G i v e n t h e s e c o n f l i c t i n g v i e w s m e n t a l d i s o r d e r c a n b e p e r c e i v e d a s e i t h e r a t h r e a t t o n a t u r a l o r d e r o r a s i g n t h a t c h a n g e i s r e q u i r e d i n t h e e x i s t i n g s o c i e t y . T h i s i s r e l a t e d t o t h e v i e w s o f c a u s a l i t y - i s d e v i a n c y a p r o d u c t o f t h e i n d i v i d u a l h i m s e l f o r a p r o d u c t o f s o c i e t y ' s e f f e c t on t h e i n d i v i d u a l ? The r e s p o n s e t o m e n t a l d i s o r d e r w i l l b e d i f f e r e n t d e p e n d i n g u p o n t h e p e r s p e c t i v e o f c h a n g e h e l d . T h o s e who m a i n t a i n t h a t c h a n g e i s n e g a t i v e w i l l make e f f o r t s t o c u r b s u c h d e v i a n c y t h r o u g h i n s t i t u t i n g c o n t r o l s a n d e m p h a s i z i n g t h e i n d i v i d u a l ' s n e e d t o a d a p t t o h i s s o c i e t y . F o r m e n t a l h e a l t h t h i s means a n e m p h a s i s o n t h e i n d i v i d u a l , a m e d i c a l 101 model o f c a u s a t i o n . An emphasis on t h e r a p e u t i c s e r v i c e s t o " f i x " the d e v i a n t and a r e l i a n c e on i n s t i t u t i o n s t o " c o n t r o l " him. Planning i s then focussed on changing, or a t l e a s t c o n t r o l l i n g , the i n d i v i d u a l . Need assessment i s s i m i l a r l y f ocussed oh i n d i v i d u a l pathology, u s i n g e p i d e m i o l o g i c a l surveys and u t i l i z a t i o n data t o pr o v i d e a b a s i s on which t o p l a n . C o n f l i c t t h e o r i s t s view deviancy as the r e a l i z a t i o n o f human p o t e n t i a l . Change i s valued as a p o s i t i v e f o r c e , a l l o w i n g movement towards a b e t t e r f u n c t i o n i n g s o c i e t y . Mental d i s o r d e r i s seen as d e v i a n t behavior r e s u l t i n g from an i n d i v i d u a l ' s r e a c t i o n t o l a r g e r s o c i e t a l p r o c e s s e s . Deviant behavior i s understood t o r e s u l t from the pre s s u r e o f s o c i a l c o n d i t i o n s on i n d i v i d u a l s . It i s a s i g n . t h a t the s o c i e t y , not the i n d i v i d u a l , must be changed. In t h i s case, p l a n n i n g i s focussed on changing the s o c i e t y . Need assessment i s s i m i l a r l y f o c u s s e d on the impact o f s o c i e t y , u s i n g s o c i a l i n d i c a t o r approaches or community forums t o assess need. As Blackburn and Blum have s t a t e d , p l a n n i n g p r o p o s a l s and programs w i l l vary g r e a t l y i f they s t a r t with a s t r o n g b i a s toward the o b j e c t o f changing people or the o b j e c t o f changing i n s t i t u t i o n s or s o c i e t y . 2. Who Should Di r e c t Change? The q u e s t i o n o f who should f a c i l i t a t e and d i r e c t change i s c l o s e l y r e l a t e d t o how change should come about. 102 D i f f e r e n t p l a n n i n g models make d i f f e r e n t assumptions as t o who has t h i s c o n t r o l or power and t o what degree. Government has t r a d i t i o n a l l y p rovided the power base through which changes in the h e a l t h s e c t o r have been d i r e c t e d . U n t i l the 1960's the d i r e c t i o n which change took was l a r g e l y d i c t a t e d by the h e a l t h p r o f e s s i o n s . The consumerism o f the s i x t i e s and s e v e n t i e s l e d t o i n c r e a s e d p a r t i c i p a t i o n by communities and advocacy groups. The e i g h t i e s ' concern f o r c o s t containment has r e s u l t e d in the t r a n s f e r o f power in d i r e c t i o n s from both h e a l t h p r o f e s s i o n a l s and consumers t o government i t s e l f . Concerned with d e c l i n i n g revenues, large d e f i c i t s and v o t e r s ' r e l u c t a n c e t o accept tax i n c r e a s e s , p o l i t i c i a n s have put a p s y c h o l o g i c a l l i d on spending and have looked towards p r o f e s s i o n a l managers t o curb c o s t s and d i r e c t the necessary changes t o accomplish t h i s . Governments are thus f a c e d with t a k i n g on the onerous job o f meeting with v o t e r s ' approval while j u g g l i n g the i n t e r e s t s o f s t r o n g l o b b i e s such as the h e a l t h p r o f e s s i o n a l s , t r a d e unions and advocacy groups. The r e l a t i o n s h i p between the " p o l i t i c a l p l a n n e r s " and " p r o f e s s i o n a l " planners has thus in c r e a s e d in importance. C r i c h t o n suggests t h a t in any government t h e r e i s an o v e r l a p between these p o l i t i c a l and the a d m i n i s t r a t i v e f u n c t i o n s and t h a t the r e l a t i v e emphasis p l a c e d on each o f these two f o r us depends l a r g e l y upon the p o l i t i c a l p a r t y in power. As p r e v i o u s l y d i s c u s s e d , who does have t h i s r o l e 103 w i l l a f f e c t how need i s viewed and what type o f pl a n n i n g w i l l be favoured. H. D i s c u s s i o n The f o r e g o i n g merely touches upon some o f the many major f a c t o r s which need t o be taken i n t o account when a n t i c i p a t i n g use o f a need assessment t o o l . It i s o f f e r e d in the endeavour t o c l a r i f y the misconception t h a t a "best' model o f need assessment e x i s t s . The arguement o f t h i s paper has emphasized the need t o examine the values h e l d by each need assessment model and, in t u r n , the values o f the context in which t h a t t o o l i s t o be u t i l i z e d . A "best f i t ' must be the u l t i m a t e g o a l , a s e n s i t i v e a n a l y s i s o f both t o o l and context. Where the power l i e s and how i t i s d i s t r i b u t e d , what r o l e the planner holds w i t h i n t h i s sytem, what views o f change and r a t i o n a l i t y are a l l c o n t r i b u t i n g f a c t o r s t o t h i s "best f i t ' . A c l e a r and l o g i c a l l i n e a r model can not be developed, the circumstances surrounding each s c e n a r i o being complex. T h i s paper does not argue f o r a formula, matrix or cookbook approach. The crux o f t h i s t h e s i s i s t h a t a " i f t h i s , then t h a t " approach can not be taken. Each s i t u a t i o n i s unique and the planner, when f a c e d with choosing a need assessment t o o l with which t o b u i l d a data base f o r p l a n n i n g , must be s e n s i t i v e t o al1 o f the is s u e s r a i s e d . The exact c o n f i g u r a -t i o n o f r e l a t i v e f a c t o r s w i l l be unique t o each s i t u a t i o n . 104 Chapter VI: From Model t o R e a l i t y A. The Br i t i sh Co 1umbia Scene T h i s paper has argued t h a t the d e c i s i o n o f which need assessment t o o l t o use, or what type o f data t o c o l l e c t and base resource a l l o c a t i o n on, i s n e i t h e r a value f r e e nor a r b i t r a r y one. Rather, i t i s a d e c i s i o n t h a t r e f l e c t s a s p e c i f i c view not o n l y o f mental i l l n e s s , i t s cause and i t s p o t e n t i a l f o r cure or c a r e , but a l s o a s o c i o - p o l i t i c a l view o f need, o f d i s e a s e , o f p l a n n i n g , o f change, and the r o l e t h a t government may want t o p l a y in any o f these a r e a s . Academic models abound in a l l arenas but too o f t e n they have l i t t l e r e l e v a n c e t o the r e a l world. T h i s i s l e s s l i k e l y in the s o c i a l p o l i c y realm s i n c e i n t h i s area models are o f t e n based not on an academic's view o f what should or c o u l d be but r a t h e r a r e f l e c t i o n o f what has or does occur. These models are o f t e n b u i l t as an e x p l a n a t i o n o f what does e x i s t (eg. Blackburn and Blum, 1968; Marmor, 1970; G i l b e r t and Sprecht, 1974). Despite t h i s l i n k with the r e a l world no one p l a n n i n g model can adequately d e s c r i b e any s p e c i f i c s i t u a t i o n . The emphasis o f t h i s paper has been the need t o be s e n s i t i v e t o the p a r t i c u l a r v a r i a b l e s o f each i n d i v i d u a l c ontext, a v o i d i n g a "cookbook" approach t o need assessment. With t h i s s e n s i t i v i t y in mind, i t i s e s s e n t i a l t o a p p r e c i a t e t h a t no one model - be i t o f need assessment, o f p l a n n i n g , o f change, or o f p o l i t i c a l ideology - can be used t o adequately d e s c r i b e or e x p l a i n the B r i t i s h Columbia, or any 105 o t h e r , mental h e a l t h scene. Rather, such models o f f e r some guides by which some sense can be made o f what i s i n v a r i a b l y a h i g h l y complex p r o c e s s . 1. The Deve1opment o f the Current System The c u r r e n t B r i t i s h Columbia community based mental h e a l t h s e r v i c e d e l i v e r y system was d e s c r i b e d in Chapter One o f t h i s paper. There i s no simple e x p l a n a t i o n by which the development o f t h i s now very comprehensive system can be ex p l a i n e d . The system developed s l o w l y over n e a r l y twenty years, weathering p o l i t i c a l changes, s o c i a l changes, and b u r e a u c r a t i c changes. The f a c t t h a t i n 1985 n e a r l y every area o f B r i t i s h Columbia i s served by a m u 1 t i d i s c i p 1 i n a r y o u t p a t i e n t mental h e a l t h team which a l s o o f f e r s easy access t o both r e s i d e n t i a l care and i n p a t i e n t c a r e i s in r e a l i t y a c r e d i t t o the much maligned incremental p l a n n i n g method. The s o c i o - p o l i t i c a l context d u r i n g the m a j o r i t y o f t h i s development was i n f l u e n c e d by se v e r a l f a c t o r s : the r e l a t i v e f i n a n c i a l p r o s p e r i t y o f the 1960's and e a r l y 1970's which allowed f o r development o f h e a l t h and s o c i a l s e r v i c e s , the d e s i r e o f the Premier, then W.A.C. Bennett, t o be seen as a p a t e r n a l i s t i c p o p u l i s t , p r o v i d i n g f o r h i s people (Morley et a l , 1981), the concomittant community mental h e a l t h development in the United S t a t e s , and the r e l i a n c e on h e a l t h p r o f e s s i o n a l s t o s t e e r development o f s e r v i c e s . The c u r r e n t l y e x i s t i n g community mental h e a l t h system i n B r i t i s h 106 Columbia developed in a r a t h e r piecemeal or incremental f a s h i o n , a r e s u l t o f a l l o f these f a c t o r s . Need was "obvious" - the development o f community based s e r v i c e s t o keep i n pace with changes i n mental h e a l t h care d e l i v e r y happening a t d i f f e r e n t paces throughout North America. As d i s c u s s e d i n Chapter One, t h i s development was l a r g e l y s t e e r e d and f u e l l e d by p s y c h i a t r i s t s who argued t h a t p s y c h i a t r i c i l l n e s s should r e c e i v e the same c o n s i d e r a t i o n and importance as p h y s i c a l i l l n e s s . The r e p o r t More f o r the Mind (1963) d i d much t o l e g i t i m i z e the f u t u r e development o f community based care. Thus, need was i n i t i a l l y very much m e d i c a l l y d e f i n e d . The p l a n n i n g model was g e n e r a l l y incremental i n nature. The r o l e o f planner was h e l d by the h e a l t h care p r o f e s s i o n a l . Actual p o l i t i c a l i d e ology had c o n s i d e r a b l y l e s s t o do with the development o f h e a l t h care s e r v i c e s i n B r i t i s h Columbia d u r i n g the W.A.C. Bennett y e a r s . Morely et a l , (1981) suggest t h a t throughout the f i r s t twenty years t h a t the S o c i a l C r e d i t Party was i n power in B r i t i s h Columbia, the p a r t y ideology had l i t t l e t o do with the government. Rather, the p a r t y p r o v i d e d a convenient e l e c t o r a l framework f o r a pragmatic and developmental o r i e n t e d government through the dominance o f one man, the Premier, and the c e n t r a l i z a t i o n o f p o l i t i c a l d e c i s i o n making. W.A.C. Bennett demonstrated t h a t h i s government was a "government d e d i c a t e d t o growth". The b u r e a u c r a t i c and a d m i n i s t r a t i v e h i s t o r y o f 107 the B r i t i s h Columbia M i n i s t r y o f Health and the development o f the c u r r e n t Mental Health S e r v i c e s present i n t e r e s t i n g h i s t o r y i n t h e i r own but these d e t a i l s are beyond the scope o f t h i s paper. The important issue here i s t h a t the system as i t e x i s t s today developed l a r g e l y as a f u n c t i o n o f an incremental, p r o f e s s i o n a l l y dominated p l a n n i n g process, f a c i l i t a t e d by a government d e d i c a t e d t o growth in a time o f r e l a t i v e f i n a n c i a l p r o s p e r i t y . Much o f the c u r r e n t community based mental h e a l t h system was i n p l a c e by the time the New Democratic P a r t y came t o power in 1972. T h e i r a d m i n i s t r a t i o n was b r i e f , though a lengthy document, The Foulkes Report on Hea1th S e c u r i t y f o r B r i t i sh Columbians (1973) was prepared d u r i n g t h i s time as a comprehensive plan f o r the p r o v i n c e . C r i c h t o n (1981) p o i n t s out t h a t Foulkes' paper was l e s s o f a plan and more a statement o f s o c i a l p h i l o s o p h y . The Foulkes Report was an i n n o v a t i v e approach t o p r o v i d i n g h e a l t h care s e r v i c e s , a developmental plan p o i n t i n g new d i r e c t i o n s f o r n e a r l y every aspect o f h e a l t h c a r e . C r i c h t o n p o i n t s out t h a t t h i s r e p o r t was r e a l l y an example o f advocacy p l a n n i n g , not the a d a p t i v e and b u r e a u c r a t i c p l a n n i n g r e q u i r e d by a new government f a c e d with a p u b l i c s e r v i c e and h e a l t h care system f i r m l y entrenched by the twenty year h i s t o r y o f the p r e v i o u s a d m i n i s t r a t i o n . The New Democratic Party's era o f power was s h o r t l i v e d and i n 1975 the S o c i a l C r e d i t Party was r e t u r n e d t o power, 108 B i l l Bennett now Premier. As p r e v i o u s l y d i s c u s s e d the l a t e 1970's a l s o witnessed the end t o the developmental phase i n h e a l t h and s o c i a l s e r v i c e s . Many f a c t o r s c o n t r i b u t e d t o t h i s : d e c l i n i n g revenues ( p a r t i c u l a r l y in the B r i t i s h Columbian resource based economy), the combined e f f e c t s o f d r a s t i c s e r v i c e expansion o f the past two decades, the growth in p o p u l a t i o n , the i n c r e a s e i n c o s t o f h e a l t h care technology are amongst many. Cambel1 et a l , (1981) have d i s c u s s e d the r e s u l t i n g s h i f t in focus from the consumption m i n i s t r i e s which had enjoyed development d o l l a r s , t o the p r o d u c t i o n m i n i s t r i e s , which would h o p e f u l l y produce d o l l a r s . T h i s change in focus has been c l e a r l y e v i d e n t in B r i t i s h Columbia where major e f f o r t s have been made t o curb development and h e a l t h care expenditures. 2. The New D i r e c t i o n As development o f h e a l t h care s e r v i c e s came t o an end a new process of j u s t i f i c a t i o n o f s e r v i c e s has developed. A B.C. M i n i s t r y r e p o r t , R e g i o n a 1 i z a t i o n o f Hea1th Care in BC (1981) commented on the process o f resource a l l o c a t i o n . It s p e c i f i e d t h a t resources be d i s t r i b u t e d r a t i o n a l l y and e q u i t a b l y w i t h i n the o v e r a l l o b j e c t i v e s o f improved e f f i c i e n c y and e f f e c t i v e n e s s o f the h e a l t h care system. The emphasis has thus moved t o a process o f a c c o u n t a b i l i t y and j u s t i f i c a t i o n f o r programs and s e r v i c e s . As fewer d o l l a r s became a v a i l a b l e t o such consumption m i n i s t r i e s as Health, 109 the need t o e i t h e r narrow s e r v i c e boundaries, or d i l u t e s e r v i c e became apparent. As we have d i s c u s s e d , Boyd (1979) has o u t l i n e d how these o p t i o n s can be achieved. The r a t i o n i n g o f s e r v i c e s has become necessary and i t i s here where need assessment has developed a renewed r o l e . The p l a n n i n g process has changed d r a m a t i c a l l y from the p r o f e s s i o n a l l y d i r e c t e d incremental approach o f the e a r l i e r e r a . As d i s c u s s e d in Chapter One, the M i n i s t r y o f Health has experienced a major s h i f t from the d i r e c t i o n o f h e a l t h care p r o f e s s i o n a l s t o the d i r e c t i o n o f p r o f e s s i o n a l managers. As Cambel1 et a l , (1981) have i n d i c a t e d , the m a j o r i t y o f d e c i s i o n makers in the s e n i o r l e v e l s o f the M i n i s t r y are no longer p h y s i c i a n s but are managers chosen f o r t h e i r a d m i n i s t r a t i v e e x p e r t i s e . Thus, the focus has moved from program content and p r o f e s s i o n a l e x c e l l e n c e t o a d m i n i s t r a t i v e a c c o u n t a b i 1 i t y . In Mental Health S e r v i c e s t h i s has been evidenced by no s e n i o r p o s i t i o n s being h e l d by p s y c h i a t r i s t s (one c o n s u l t i n g p s y c h i a t r i s t s t i l l e x i s t s ) . At the same time a new o r g a n i z a t i o n a l s t r u c t u r e has provided f o r Regional Managers, d i r e c t l y r e s p o n s i b l e t o the D i r e c t o r o f Mental Health S e r v i c e s . The focus o f these managers - a t i t l e t h a t was r e c e n t l y changed from Regional C o o r d i n a t o r - appears t o be p r i m a r i l y a d m i n i s t r a t i v e , p r o v i d i n g the f a c t s and f i g u r e s o f caseloads f o r a c c o u n t a b i l i t y r e q u i r e d f o r continued e x i s t e n c e o f programs. Program D i r e c t o r s e x i s t a t 1 10 Headquarters but the c u r r e n t o r g a n i z a t i o n a l c h a r t does not p r o v i d e any formal connection between the D i r e c t o r s o s t e n s i b l y r e s p o n s i b l e f o r Programs and the managers r e s p o n s i b l e f o r r e g i o n a l a d m i n i s t r a t i o n . The p o l i c i e s o f the Mental Health Centres are beginning t o r e f l e c t t h i s s t r u c t u r e . S e r v i c e boundaries are being narrowed, the focus being i n c r e a s i n g l y p l a c e d on o n l y the s e r i o u s l y m e n t a l l y i l l . The r e g i o n a l s t r u c t u r e serves t o encourage s t a n d a r d i z a t i o n o f s e r v i c e , q u i t e o p p o s i t e t o the o r i g i n a l d i r e c t i o n o f the community based movement which s t r e s s e d resource development on the b a s i s o f the unique needs o f each community. The i n t r o d u c t i o n o f a management inf o r m a t i o n system, r e l y i n g on the DSM III d i a g n o s t i c c l a s s i f i c a t i o n scheme, in l a t e 1985, w i l l serve t o f u r t h e r d e l i n e a t e boundaries and s t a n d a r d i z e s e r v i c e . P l anning i n t h i s c ontext, the M i n i s t r y l e v e l , has thus become a h i g h l y b u r e a u c r a t i c process, argued t o be r a t i o n a l and u s i n g mainly u t i l i z a t i o n r a t e s as a data base f o r resource a l l o c a t i o n . However, the broader context p r e s e n t s a c o n t r a d i t i o n o f t h i s . The c u r r e n t government, based on a p o p u l i s t ideology, has emphasized a t r a d i t i o n a l l y l a i s s e z -f a i r e approach, de-emphaisizing government involvement in e i t h e r p l a n n i n g or s e r v i c e s . Despite t h i s , a t the M i n i s t r y l e v e l , c o n t r o l o f s e r v i c e d e l i v e r y appears t o be becoming o f paramount importance as the goals of a c c o u n t a b i l i t y and e f f i c i e n c y compete with the ideology o f small government. 1 1 1 As d i s c u s s e d in Chapter F i v e , the academic mode) o f l a i s s e z -f a i r e and i t s popular v e r s i o n o f t e n become confused in any p r a c t i c a l s i t u a t i o n . Thus, we c u r r e n t l y have the i n t e r e s t i n g s c e n a r i o o f a government whose p o l i t i c a l i deology f a v o r s f r e e market ideology, while i t s p r a c t i c a l a p p l i c a t i o n r e s u l t s i n t i g h t e r c o n t r o l s and increased government i n t e r v e n t i o n in the p r o v i s i o n o f h e a l t h and s o c i a l s e r v i c e s . Where does need assessment stand i n t h i s complex s i t u a t i o n ? Those adhering t o f r e e market ideology w i l l argue t h a t need assessment i s l a r g e l y i r r e l e v a n t , as the government should have l i t t l e r o l e in p l a n n i n g . The a t t i t u d e h e l d towards the m e n t a l l y i l l and o t h e r such d e v i a n t s i s one o f minimal care, a focus on the s u r v i v a l o f the f i t t e s t , e q u a l i t y o f o p p o r t u n i t y , and c h a r i t y t o those who are unable t o compete in the f r e e market. On the other hand, in the p r a c t i c a l a p p l i c a t i o n o f such ideology, t h e r e i s a focus on what Blackburn and Blum (1968) have i d e n t i f i e d as t e c h n o c r a t i c p l a n n i n g . In t h i s context the planner i s chosen more l i k e l y f o r h i s views than h i s e x p e r t i s e , the ends being a l r e a d y d i c t a t e d by a "top down' management approach. In t h i s s c e n a r i o , the l a i s s e z - f a i r e ideology i s c o n t r a s t e d with a very t o t a l i t a r i a n approach t o p l a n n i n g . In t h i s case, when a l s o compounded by the f i s c a l r e s t r a i n t o f the 1980's, need assessment becomes the t o o l o f 112 resource a l l o c a t i o n , which i s more o f t e n used t o j u s t i f y e x i s t i n g programs than t o serve as a source o f d i r e c t i o n f o r new ones. U t i l i z a t i o n r a t e s are the most common t o o l , s e r v i n g not o n l y t o p r o v i d e a c c o u n t a b i l i t y data but a l s o t o emphasize t h a t s e r v i c e s are in f a c t being p r o v i d e d , t a k i n g the focus away from e x i s t i n g gaps or inadequacies. Thus, change i s not f a v o r e d , development not sought. T h i s approach tends t o , a t b e s t , maintain the s t a t u s quo, while a t worst, reduce s e r v i c e l e v e l s . 1 13 Chapter V I I : Summary and Con c l u s i o n s T h i s paper has focu s s e d on the r e l a t i o n s h i p o f need assessment t o the p l a n n i n g process. Need assessment i s a necessary t o o l o f the p l a n n i n g process and i s thus i n e x t r i c a b l y l i n k e d t o the same i n f l u e n c e s as the p l a n n i n g process i t s e l f . Need assessment can thus not be examined as a stand-alone technology in the way s t a t i s t i c a l methods are viewed. There cannot be a "best' method, but r a t h e r a ' b e s t - f i t ' , given the values o f the model and the values o f the context. T h i s view o f need assessment as beyond a technology has r e s u l t e d l a r g e l y from i t s changing r o l e . Developing o r i g i n a l l y as a method o f d i r e c t i n g d e v e l o p i n g s e r v i c e s t o the unique needs o f s p e c i f i c communities, i t s r o l e has changed with the changing economic c l i m a t e which has witnessed a major s h i f t w i t h i n government from s e r v i c e development t o s e r v i c e containmnet and j u s t i f i c a t i o n . With t h i s s h i f t need assessment has developed an a l l o c a t i v e f u n c t i o n , used as much, i f not more, t o c u r t a i l or j u s t i f y s e r v i c e s as t o develop s e r v i c e s . T h i s paper has argued t h a t t o use need assessment t e c h n o l o g i e s t o pr o v i d e a b a s i s f o r a l l o c a t i v e d e c i s i o n s n e c e s s i t a t e s an understanding o f the values and concepts, both i m p l i c i t w i t h i n the model and w i t h i n the pl a n n i n g context. Need assessments are not done without some i n t e n t t o p l a n and achievement o f t h a t plan w i l l n e c e s s i t a t e 114 understanding the s o c i o - p o l i t i c a l c o ntext. The power base by which a plan i s achieved i s i n v a r i a b l y p o l i t i c a l , though the extent t h i s i s t r u e w i l l vary with the p o l i t i c a l i deo1ogy. I n t e l l i g e n c e has been f a c e i t i o u s l y d e f i n e d as what i n t e l l i g e n c e t e s t s measure. Need has o f t e n been viewed in the past in the same manner - t h a t which need assessments measure. T h i s paper has endeavoured t o p o r t r a y need as a f a r more complex and e l a s t i c concept, i t s assessment dependent upon i t s d e f i n i t i o n . Need has been viewed as synonomous with want or demand but as need assessment has taken on an a l l o c a t i v e f u n c t i o n a c l e a r e r a n a l y s i s and d e f i n i t i o n i s r e q u i r e d , the values i m p l i c i t in the d e f i n i t i o n o f need d i c t a t i n g the assessment t o o l along with the values o f the user or context. Mental i l l n e s s i s i t s e l f an i l l u s i o n a r y concept, a p r e c i s e u n i v e r s a l l y accepted d e f i n i t i o n does not e x i s t . U n l i k e p h y s i c a l i l l n e s s , n e i t h e r e t i o l o g y nor treatment i s c l e a r , r e l y i n g i n s t e a d on v a r i o u s t h e o r e t i c a l models -u s u a l l y the medical and s o c i a l models. De s p i t e these two d i f f e r e n t models, or understandings, o f mental i l l n e s s , the t r a d i t i o n a l s e r v i c e d e l i v e r y model has r e l i e d on the medical model and development has been d i c t a t e d l a r g e l y by the medical p r o f e s s i o n a l . As p o p u l a t i o n has i n c r e a s e d while d o l l a r s a v a i l a b l e t o h e a l t h care have been capped, i t has become re c o g n i z e d t h a t 115 need i s p o t e n t i a l l y i n f i n i t e and t h i s f a c t has c o n t r i b u t e d t o a c u r t a i l i n g o f the t r a d i t i o n a l r o l e o f the p r o f e s s i o n a l in d i c t a t i n g s e r v i c e requirements. T h i s acceptance o f an i n f i n i t e l e v e l o f need, yet with d e c l i n i n g r e s o u r c e s a v a i l a b l e , has led t o a new emphasis on r a t i o n i n g . The problem o f b a l a n c i n g ever expanding needs and s c a r c e resources must be r e s o l v e d and methods o f r a t i o n i n g have been developed t o address t h i s problem. Thus, the emphasis on p r o f e s s i o n a l l y d i c t a t e d need has been reduced in favour o f a more a d m i n i s t r a t i v e l y d i c t a t e d l e v e l o f demand - demand being p o t e n t i a l l y f i n i t e and t h e o r e t i c a l l y measurable. It i s with these changes t h a t the r o l e o f need assessment i s now d e v e l o p i n g i n t o an a l l o c a t i v e r a t h e r than developmental t o o l . With t h i s change comes an i n c r e a s i n g need t o f i t need assessment technology i n t o the p l a n n i n g process i t s e l f , with an a p p r e c i a t i o n o f the d i f f i c u l t i e s c o n f r o n t i n g planners in the implementation o f t h e i r p l a n s . Thus a c l e a r e r understanding o f the r o l e o f the planner, h i s methods and the s o c i o p o l i t i c a l context i n which he must operate i s e s s e n t i a l t o ensure a p p r o p r i a t e and maximum use o f the need assessment t e c h n o l o g i e s . T h i s paper was not intended t o p r i o r i z e need assessment t e c h n o l o g i e s , nor p r o v i d e a framework f o r t h e i r use. Rather, i t s i n t e n t has been t o e l u c i d a t e the values and concepts i m p l i c i t in the need assessment t e c h n o l o g i e s and s t r e s s the importance o f l i n k i n g these with the values o f 1 16 both the user and h i s context. Need assessment can not be viewed simply as a technology. 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An analysis of need assessment in the mental health context Farrally, Vicki Lea 1985
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