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An analysis of need assessment in the mental health context Farrally, Vicki Lea 1985

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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 C o l u m b i a ,  1972  M.A.,  The U n i v e r s i t y o f B r i t i s h C o l u m b i a ,  1975  A THESIS SUBMITTED  IN PARTIAL FULFILLMENT OF  THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE  in THE FACULTY OF GRADUATE  STUDIES  (Health Services Planning and,Administration) -  We a c c e p t to  this  t h e s i s as  conforming  the required standard  THE UNIVERSITY OF BRITISH COLUMBIA October  (c)  Vicki  1985  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. copying  of  department  this thesis for scholarly or  by  his  or  her  I further agree that permission for  purposes  representatives.  may be granted It  is  by the head of  understood  that  publication of this thesis for financial gain shall not be allowed without permission.  Department of The University of British Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3  DE-6(3/81)  extensive  copying  my or  my written  ABSTRACT Need a s s e s s m e n t methods grew o u t Mental  Health  Centre  rapid  expansion  movement.  of service,  s e r v i c e s matched t o t h e following  years  technology  and  being  Ministries  t h e r e was  a f o c u s on  began f o r a  "best model'  resources as  Health,  u s e d a an  As  fiscal  available to  an  understanding  need a s s e s s m e n t  allocative tool.  e a c h model Finally, health  an  i s seen as  context  Province.  o f f e r s an will  v a l u e s and  necessary  examination  w h i c h have and this  of the  o f the  has  the  use  a  This a  "best  Users  been of the  model  concepts  Columbia  a n a l y s i s o f some o f t h e  affect  the  constraints  for intelligent British  In  consumption  i s a r g u e d , must t h e r e f o r e c h o o s e t h e i r  and  as  "best model'.  is illusionary,  of  providing  u n i q u e needs o f a community.  a search  the  such  increasingly it  Developed d u r i n g a time  a more d e s i r a b l e g o a l .  have r e d u c e d  Community  need a s s e s s m e n t f u r t h e r d e v e l o p e d  paper argues t h a t a fit'  of the  with  tool, care  inherent choice. mental factors  o f need a s s e s s m e n t  in  in  TABLE  OF CONTENTS Page i i  Abstract Table o f Contents List  i i i  o f Figures  vi  Acknowledgements Chapter  v i i  I: I n t r o d u c t i o n  1  A. The B a c k g r o u n d  1  B. The H i s t o r y o f Community Health  Mental  Development  3  C. The E f f e c t s o f Community D e v e l o p m e n t  6  D. The End t o D e v e l o p m e n t a n d D o l l a r s  8  Chapter  I I : Mental  Illness  A. P r o b l e m s w i t h  12  Definitions  B. The I n t e r r e l a t i o n s h i p o f M e d i c a l M o d e l s o f Mental C. P o s i t i v i s t  Chapter  12 and S o c i a l  Health  vs I n t e r p r e t i v e Paradigms  I I I : A Conceptual  A. A D e f i n i t i o n  14 19  A n a l y s i s o f Need A s s e s s m e n t  o f Need  Assessment  22  B. P r o b l e m s w i t h t h e C o n c e p t  23  C. Want, Demand and Need  26  1.  Want/Demand  26  2.  Need  28  D. The L i n k a g e o f Want, Demand and Need i i i  33  E. Want, Demand and F. The G.  Need  i n Mental  Health  D i a g n o s t i c P r o c e s s - Becoming a  34  Case....36  Disease  39  IV: M o d e l s o f Need A s s e s s m e n t  44  A.  Introduction  44  B.  E p i d e m i o l o g i c a l Surveys  46  C.  Utilization  54  D.  Social  Chapter  Rates  Indicator  Approaches  1.  Poverty  2.  Social  3.  P o p u l a t i o n Subgroups  58 59  Pathology  Special  63 with  Needs  64  E. Community Group A p p r o a c h e s F. The  Chapter  V:  Relationship  Viewpoints political  Context  Introduction  B.  Boundaries  C.  P l a n n i n g Models  o f Power  74  in Planning  74 77  Incremental  2.  Rat i ona 1 Mode 1  1.  Socio-  74  1.  Values  Planning..69  i n Need A s s e s s m e n t : The  A.  D.  Between Need and  67  Model  in P o l i t i c a l  Laissez-faire  77 78  Ideology Model iv  81 86  2.  Disjointed  I n c r e m e n t a 1 i sm  3.  Goal  4.  Totalitarian  O r i e n t e d D e v e l o p m e n t a l Model Model  89  1.  The T e c h n o c r a t i c P l a n n e r  90  2.  The B u r e a u c r a t i c P l a n n e r  91  3.  The A d v o c a c y P l a n n e r  93  4.  Summary o f P l a n n i n g R o l e s  94  F. R a t i o n a l i t y  - Different  Viewpoints  Rationality  96  1.  Logical  2.  Economic R a t i o n a l i t y  97  3.  Social/Legal  98  4.  Po 1 i t i c a 1 Rat i ona 1 i t y  G. Change  Rationality  - Different  Views  97  99 100  1.  How Change  O c c u r s a n d t o Whom  101  2.  Who S h o u l d  Direct  102  Change?  H. D i s c u s s i o n  VI:  From  104  Model  A. The B r i t i s h  Chapter  87 88  E. The R o l e o f t h e P l a n n e r  Chapter  87  to Reality  105  Columbia Scene  105  1.  The D e v e l o p m e n t o f t h e C u r r e n t  2.  The New D i r e c t i o n  VII:  System..106 109  Summary and C o n c l u s i o n s  Bibl iography  114 118  v  L I S T OF  FIGURES  F i gure  Page  1.  The R e l a t i o n s h i p  2.  C h a r a c t e r i s t i c s o f Need A s s e s s m e n t  3.  The R e l a t i o n s h i p Assessment  4.  o f Need, Demand and Want Models  70  o f P l a n n i n g a n d Need  Methods  Models o f S o c i a l  34  Action  80 and P o l i t i c a l  vi  Change...83  ACKNOWLEDGEMENTS I w i s h t o t h a n k Dr. patience, thesis Court  s u p p o r t and  w o u l d be  and  g u i d a n c e - and  completed.  M c K e n z i e and  criticism  Dr.  comments.  comment on D u r i n g my  f o r her  Thanks a r e  Sam  John G r a y , M i n i s t r y o f and  Nancy W a x i e r M o r r i s o n  mental  my  health  planners  that  this  extended t o  Dr.  My  appreciation  Health,  also  goes t o  for his willingness  Dr.  to  read  this thesis. numerous y e a r s a t t h e  view o f t h e and  in that  Dr.  Anne C r i c h t o n  the  area of  the  very special  D a v i d s o n as  faith  her  Scheps f o r t h e i r h e l p f u l  University of  C o l u m b i a many p e o p l e , b o t h f a c u l t y and influenced  also  for  the  w o r l d , and  r o l e of  world.  social  policy.  her  like to  b o t h a mentor and  o f the  v ii  of thank  experience  like to  l a t e Dr.  a friend.  and  specifically  wisdom and  I would a l s o  contribution  have  in p a r t i c u l a r , of  both p s y c h o l o g i s t s  I would  for sharing  students,  British  in  acknowledge  Park  0.  Chapter  A.  The  Background  Need a s s e s s m e n t health  mentally  a radical  shift  illness.  Prior  to this  i l l had been c a r e d  time,  a s y s t e m o f community  c o s t s and t a r g e t p o p u l a t i o n s T h i s new  commitment  in the United based  The U n i t e d partial  financial  community Health  States  mental  Centres  responsibility geographical  of  centre  local  policies  reducing  based  predictable.  f e d e r a l government assumed  i n 1963  The Community  for providing services to  Mental  the  specific  A b a s i c t e n e t o f t h e community  Cohen  should  based  be b a s e d on  (1974) r e p o r t s t h a t  movement was a d e s i r e t o d e v e l o p  community  c o n t r o l over  were community  u s e o f mental  on  f o r p r o v i d i n g a system o f  (CMHC's) were e n t r u s t e d w i t h  needs o f t h a t community.  organize  While t h e  c a r e opened t h e arena  health f a c i l i t i e s .  the goals of t h i s  States to  institutionally  movement was t h a t d e p l o y m e n t o f r e s o u r c e s the  With  patients.  responsibility  areas.  o f the serious  services.  were r e a s o n a b l y  t o community  c o s t s and p o t e n t i a l  the bulk  of  f o r in large f a c i l i t i e s .  main s t y l e o f s e r v i c e d e l i v e r y was  both  1960's  in the p r o v i s i o n o f s e r v i c e t o the  1960's came t h e commitment  provide  The e a r l y  o f mental  i l l which r e s u l t e d i n a widening d e f i n i t i o n  mentally the  grew o u t o f t h e e x p a n s i o n  s e r v i c e s t o t h e community.  witnessed  mental  I: I n t r o d u c t i o n  and  t h e CMHC's, s o t h a t  b a s e d and o r i e n t e d ,  while  h o p s i t a l s by p r o v i d i n g prompt  1  one  r e s p o n s e and described The  twenty-four  and  detailed  hour  these  service. local  Need a s s e s s m e n t  needs.  mandate o f t h e CMHC q u i c k l y  expanded.  By  responsibilities  had  seriously  include also alcoholism, children  abuse.  i l l to  The  expanded from t h e o r i g i n a l  c o s t s o f s u c h an  been e n v i s i o n e d i n 1963 movement was as  born  increasing  picture  had  The  early  social  changed  initial  new  age  entered  initial  formalized  need  reflects  justification commitment was programs.  essential  The  twenty  from  social  finite  component  Originally  and  years since the  have  The  which  well  developed  d i d n o t and  recession  as s o c i a l ,  programs  t o channel  later  are r a t i o n a l i t y  funds  has  t h e g u i d e words and  social  these  throughout  accountability.  assessment  has t h u s  d e v e l o p i n g a s a means o f d i r e c t i n g 2  sense  financial  1960's a  into  of  process  continual  In t h e e a r l y  a  was  introduction  m o r a l s , t o an a l l o c a t i o n  sufficient  o f need  early  f u n d i n g such programs out o f a  of expenditures.  purpose  not  1970's t h e  in the  revenues  means, s h o r t a g e and  Twenty y e a r s  North America The  assessment  rose while national  a b u n d a n c e and  drdg  community mandate o f t h e CMHC's i n t h e  witnessed a s h i f t ,  that  By t h e e a r l y  the  dramatically.  t h e s e e x p a n s i v e h e a l t h , as well  of  and  f u n d i n g began.  o f concern regarding i n f l a t i o n into.  f o c u s on  expanded mandate c o u l d  conscience.  1960's became an  1970's a s c o s t s  1970 i t s  i n a p e r i o d o f economic abundance as  f o c u s on  with the  when  data  changed. an  expanding  health  s e r v i c e t o t h e u n i q u e needs o f a community,  a s s e s s m e n t s a r e now f o c u s s e d d e v e l o p m e n t and c o s t s . was p r o v i d i n g are  now  services  where few e x i s t e d ,  B.  continuation  Hi s t o r y o f Communi t y  by  States  Menta1  Hea1th  services  this  is exhibited  Development  have w i t n e s s e d a  t h e i r conception  i n s t i t u t i o n s i n t h e 1970's.  much c r i t i c i s m  o f t h i s process  i n t h e 1960's.  by t h e g r o w t h  In  i n mandate  Although there  has been  (eg. Bassuk and Gerson,  i n p a r t i c u l a r o f t h e l a c k o f a d e q u a t e community  resources f o r these patients, dramatic  e x p a n s i o n has n o t  i t c a n n o t be a r g u e d  1940's a new  general  Canadian Federal  Mental  hospitals  (Tyhurst,  Government e s t a b l i s h e d  Health Grants t o the provinces.  years considerable building  based that  As e a r l y a s t h e  interest in t r e a t i n g the mentally  develop within  1978)  occurred.  Canada has s e e n s i m i l a r d e v e l o p m e n t s .  the  target  t h e CMHC's a n d t h e move t o d e i n s t i t u t i o n a l i z e t h e l a r g e  federal  and  assessments  f o r c a r e c a n be d e v e l o p e d a n d t o  health  d r a m a t i c growth s i n c e United  need  issue  o f e x i s t i n g programs.  Community mental  the  the primary  used t o i d e n t i f y s p e c i f i c  g r u o p s by w h i c h p r i o r i t i e s justify  on t h e c o n t a i n m e n t o f s e r v i c e  Whereas p r e v i o u s l y  increasingly being  needs  i l l began t o  1963).  In 1948  a system o f  During t h e next t e n  p r o g r e s s was a c h i e v e d t h r o u g h t h e  of clinics,  professional  research. 3  t r a i n i n g and  increased  The  year  1950  marked t h e end o f what F o u l k e s  r e f e r s t o as t h e "asylum psychotropic towards  d r u g s was  industry".  most  t h e development  likely  (1974)  The d e v e l o p m e n t  of  t h e most s i g n i f i c a n t  o f t h e community mental  step  health  movement. Allodi  and  Kedward  (1977) s t r e s s t h a t  health  i n Canada r e a l l y  Mental  Health Association  Mind",  i n 1963.  and  emphasized  psychiatric  This  was  illness  should receive  Diagnostic  Services  Act.  psychiatry  as a s p e c i a l t y w i t h i n  this  hospital  towards  rather  based f o c u s t h i s  community b a s e d  hospitals.  illness  report  argued  m e d i c i n e and  report  was  i t not o n l y  large  b o u n d a r i e s o f mental  elevate argued f o r  still  4  a move  drew  increased  t o custody, but t o the  services.  t h e s t i g m a o f mental  t h r o u g h making t r e a t m e n t more v i s i b l e  access i b l e .  Despite  i t h e l p e d widen  health  as  I n s u r a n c e and  institutions  In d o i n g so  d i d much t o a l t e r  that  t h e same c o n s i d e r a t i o n  t r e a t m e n t as opposed  f o c u s from t h e  recommendations  of  t h a n c a r e t h r o u g h a CMHC.  t o the actual  and  The  It a l s o attempted t o  a l s o moved t h i s  definition  "More f o r t h e  under t h e H o s p i t a l  community c a r e i n t h a t  attention  Canadian  directed at psychiatrists  at the time.  illness  based  The  f o r f u r t h e r development  those with physical  hospital  1960's.  mental  in h o s p i t a l s , emphasizing the medical  domination of the f i e l d psychiatric  in the  sponsored a r e p o r t ,  report  t h e need  units  began  community  and  more  the  Its  For was  British  initiated  when Mental Provincial Health  C o l u m b i a t h e t u r n t o community b a s e d  l a r g e l y by t h e a d m i n i s t r a t i v e  Health  Services  Secretary's  Services  1961  Department t o t h e Department o f  outreach  Insurance, being  arena as P u b l i c  t h e B u r n a b y Mental  provided  c h a n g e s o f 1959  was t r a n s f e r r e d f r o m t h e  and H o s p i t a l  same o r g a n i z a t i o n a l  Health  Health  Clinic  placed  was e s t a b l i s h e d .  community s e r v i c e s t h r o u g h  Kelowna.  By 1966, t e n CMHC's were o p e r a t i n g  province,  most w i t h t r a v e l l i n g  Currently British  include  around t h e p r o v i n c e ,  as well  Vancouver and 3 a r e a  teams  General  care  Hospitals  the by  Province. Mental  care  there  Services,  based  i n 27 P s y c h i a t r i c U n i t s i n  practioners  Program, a l s o  community  environment t o approximately  5  complex.  a r e 280 p s y c h i a t r i s t s a r o u n d  provides  i l l i nd i v i d u a 1 s .  Health  4000 g e n e r a l  A Community R e s i d e n t i a l  Health  therapeutic menta11y  0  Community  a n d a t t h e Burnaby Mental  outpatient  services in  a s 8 community C a r e Teams i n  In a d d i t i o n t o t h e a p p r o x i m a t e l y offering  community  19 s u b - o f f i c e s  i n Burnaby.  is availalbe  one i n  functioning.  health  34 CMHC's w i t h  It  throughout the  stimulating  CMHC's were  community b a s e d mental  Columbia  inpatient  clinics  In  travelling  In 1962 t h e s e c o n d CMHC was o p e n e d ; t h i s  By 1975 t w e n t y - f i v e  in the  and H o s p i t a l .  clinics.  demand.  care  living  funded in a  2500 c h r o n i c a l l y  C.  The  E f f e c t s o f Communitv  The  development  detail  a b o v e , was  America and  in B r i t i s h  Columbia,  results of this  decades,  1960-1980.  closely  intertwined.  of this  o f how  t h e s e changes c o n t r i b u t e d  Likely  process  health  result  care brought  t o a much  result  demand f o r  o f t h e move t o expansion  change was  synonomous w i t h the  the subject  illness  was  an  * sick'  as  disatisfied'. parenting  Such p r o b l e m s  skills,  depressions,  11  g r i e f and  learning  Community  the  group  seriously  of  would never  l o n g as p s y c h i a t r i c  distressed as m a r i t a l  In t h e p a s t health and  6  have  illness  was  two  professionals  the  family  discord,  separation adjustments,  disabilities,  health  expanded  a u d i e n c e who  f o c u s o f mental  expanded t o embrace t h e  era of  o f t r e a t m e n t o f mental  institutionalization.  legitimate  a  i t d i d p r o v i d e t h e means  from a d i s c r e t e  potential  in the  not e n t i r e l y  movement - t h i s  changes - but  larger  been c o n s i d e r e d a s  has  This  perspective  assessment.  I t r e d u c e d t h e s t i g m a and  c o n c e p t o f mental  decades  community  t h e s e o t h e r c h a n g e s were a b l e t o o c c u r .  i n t o t h e open.  ill  illness.  significant  by w h i c h  reasons f o r  to the current  the r e s u l t i n g  o f t h e community b a s e d  several  based  was  North  examination o f the  n a t u r e o f need  t h e most s i g n i f i c a n t  c o n c e p t o f mental  The  i s important t o p r o v i d e a  the changing  community mental  An  in  across  expansion of s e r v i c e t o the  impact  s e r v i c e and  described  repeated t o varying degrees  d u r i n g t h e two  a r e no d o u b t  Development  hyperactivity,  reactive sexual  dysfunction  a n d s h y n e s s have a l 1  expanding umbrella  o f mental  health.  movement o f t h e 1960's a n d e a r l y seek h e l p  i f you d i d n ' t  feel  reason.  In many r e g i o n s  auspices  o f mental  Mental  Health  "O.K." - r e g a r d l e s s  A recent  National  presenting  population  health,  b e y o n d what a n y need a s s e s s m e n t have e n v i s i o n e d .  offer  a definitive  amelioration functioning  Institute of  combined w i t h  o f mental  health  o f mental  illness  a growing  consumer  s t r a t e g y o f t h e 1960's  I t i s now v i r t u a l l y  definition  alcohol  o f what was a  has t a k e n t h e p o t e n t i a l mental  could  of the  problem o f males  CMHC's. T h i s w i d e n i n g d e f i n i t i o n  l e g i t i m a t e c o n c e r n o f mental  far  1970's made i t "O.K." t o  (Myers e t a l , 1984) r e p o r t s  a b u s e a s t h e most f r e q u e n t within  The human p o t e n t i a l  s u b s t a n c e a b u s e moved under t h e  health.  study  moved under t h e e v e r -  impossible t o  illness.  The  and t h e enhancement o f normal  have become a j o i n t  concern,  often  i n d i s t i n g u i s h a b l e from one a n o t h e r . Associated illness  with  this  w i d e n i n g o f t h e c o n c e p t o f mental  h a s come t h e p r o l i f e r a t i o n  in the "helping  p r o f e s s i o n a l s " a n d t h e i n c r e a s i n g power o f p s y c h i a t r y . relationship mental  was n o t o n e way - t h e c o n c e p t u a l  illness  was i n p a r t a r e s u l t  medicalization, resulted the  while  expansion o f  of psychiatric  a t t h e same t i m e , t h e g r o w i n g demand  i n 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 .  mentally  physicians,  ill  This  in institutions  were c a r e d  Whereas  f o r by  n u r s e s a n d a i d e s , most o f t e n t r a i n e d w i t h i n t h e  7  same f a c i l i t i e s ,  t h e move t o t h e community  development o f other psychologists  mental  and s o c i a l  health  workers,  variety of quasi-professiona1s  encouraged the  professionals later  followed  clinical  by a  - a r t t h e r a p i s t s , music  therapists,  r e c r e a t i o n t h e r a p i s t s , case workers, health  aides  The v i s i b i l i t y  etc.  community  contributed  of the mentally  to this  i l l in the  development, as d i d t h e  e m p h a s i s on t h e " r e l a t i o n s h i p t h e r a p i e s "  et  growth  in service providers  relative  e c o n o m i c abundance  supported t h i s increasingly tremendous for  D.  medications.  has r e s u l t e d  a l . (1978) has t e r m e d t h e "mental  health  o f t h e 1960's  i n what  and  The  1970's  need  s e e m i n g t o be a b o t t o m l e s s p i t .  Despite  i n 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 ,  s e r v i c e appears t o c o n t i n u a l l y outpace  Magaro  industry".  i n d u s t r y ' s development, with  growth  new  i n p a r t made  p o s s i b l e by t h e d e v e l o p m e n t o f p s y c h o t r o p i c This  care  the demand  supply.  The End t o Deve1opment and P o l 1ars The end t o t h e d e v e l o p m e n t a l p h a s e o f s e r v i c e  development  i n 1980's  has come a b o u t a s a r e s u l t  i n t e r a c t i o n o f two m a j o r f a c t o r s : t h e combined the  r e s u l t s o f s e r v i c e expansion in the last  discussed  Britain,  effects of  two  decades,  a b o v e , and t h e w o r l d w i d e e c o n o m i c d e c l i n e  has s e e n d w i n d l i n g service  of the  sectors  resources  by t h e r i g h t  the United  States  allocated to health wing governments  and Canada.  8  and  which social  in Great  Crichton  (1983)  has  suggested  t h a t Canadian p o l i t i c s  utilitarian  liberalism,  collectivist 1980's had liberal small  democratic  1981).  held  by  health  a shift  in focus  has  337  million  six  hundred p e r c e n t .  r e l i a n c e on in  t o two  British  natural  the  incremental  (Cambell  resource  early  and  1980's.  shift  by an  drastic to  1981  - an  revenues,  At t h e  developmental  steps to  a highly centralized  and  curb  annual  C o l u m b i a grew  from  almost  particularly  has  f a c e d major  same t i m e and  to i t s  education  cuts  sectors  there  locus o f  planning  has  planning.  led primarily  by  d e c a d e s has  been  p a s t two  "rational"  evident  increase of  s e r v i c e and  in the type  e m p h a s i s on  et a l ,  o r i e n t e d government  Columbia,  health care p r o f e s s i o n s during the  through  consumption  t h e w o r l d w i d e e c o n o m i c downswing due  been a s i g n i f i c a n t  replaced  e n t r e p r e n e u r s 1ism,  in B r i t i s h  dollars  service in health, social  throughout  The  billion  1971  the  this  been p a r t i c u l a r l y  taken  From  wing o f  from the  ministries  government h e a l t h e x p e n d i t u r e s  by  right  in focus  C r e d i t P a r t y has  care expenditures.  affected  the  C o l u m b i a , where a p o p u l i s t  Social  of  e c o n o m i c downswing o f  e m p h a s i s on  production  T h i s change  in B r i t i s h  The  a  ideology  framework, emphasizing  government and  m i n i s t r i e s t o the  emphasized  c h a l l e n g e d by an  humanitarism.  l e d t o an  has  d e c i s i o n making  politically  influenced  process. A g r o w i n g p o p u l a t i o n , an illness  and  expanding d e f i n i t i o n  a reduction of available dollars  9  has  of  mental  led to  the  current only  two  o r an can  crisis  in health  obtained  of  through  (1979) o u t l i n e s two 1.  Voluntary  o f the  It  is this  geographic  need - be  set of data  classification  "the  making.  provide  of this model  current  to  used w i l l  social  scientific  scientific  technologies  community  has  can can  be  for rational been d e s c r i b e d  Need a s s e s s m e n t to  satisfy  l i e s the  as  be  to  technologies  this  crux o f the  not  i n f l u e n c e the  10  a  method - however c r u d e -  basis  a l l o c a t i o n s can  and  diagnostic  pressures  Such t e c h n i q u e s a r e greatly  pay.  i n d i c a t o r s , or  value  answers  need a s s e s s m e n t t e c h n o l o g i e s  which r e s o u r c e  to  identify  o f what a  planning  However, h e r e i n  paper.  T h u s , t o use  ability  allocation decisions  ( F a l u d i , 1973).  the  requirement.  ability  sophisticated  Rational  a p p l i c a t i o n of  p o l i c y making" can  the  Boyd  clinical  needs a s s e s s m e n t s  set of  which r e s o u r c e  satisfying  decision  social,  s y s t e m , need a s s e s s m e n t t e c h n i q u e s  p r o d u c e d a t a on based,  or the  it a reflection  a  goals  health.  demographic,  In t h e i r  r e l y i n g on  boundaries  m a i n l y t h r o u g h a s s u m i n g more  that  wants, a p r o j e c t i o n f r o m a  service  different options.  criteria,  second o p t i o n  r e s u l t in  E i t h e r of these  f o r o n e s own  b a s e d on  have a r o l e t o p l a y . quantify  I t can  possibilities:  restraint,  Rationing, or  service.  several  responsibility 2.  funding.  p o s s i b l e a c t i o n s : a narrowing of  overall dilution  be  care  argument  free.  The  generated.  to provide  based n e c e s s i t a t e s  data an  on  understanding model. value  o f the  I t has free.  To  search  Drude,  allocation  and  1982)  for a is to  " b e s t ' model ignore t h i s  service planning  process.  d e c i s i o n s must be it  concepts  become g e n e r a l l y a c c e p t e d  (Royse and  political  v a l u e s and  The  tool  understood  i s used.  11  implicit  that science o f need fact.  have become an  used t o generate as  well  i n each  as t h e  i s not  assessment Resource  increasingly data  context  for  these  i n which  Chapter A.  Problems with Before  mental  illness  Definitions  i s needs t o be was  therapist.  and  the  t o be  due  q u e s t i o n o f what In t h e  to the  Middle  low m o r a l s r e p l a c e d  Church continued  scientific  advances o f the  nineteenth  this  l a r g e l y t o the medical  Ages  supernatural,  role of diagnostician, labeler  L a t e r , s i n and  supernatural  addressed.  throught  the Church the  power  Illness  e x a m i n i n g need a s s e s s m e n t s t h e  deviant behavior giving  I I : Mental  and  the  its role.  The  century t r a n s f e r r e d  p r o f e s s i o n where i t  rema i n s . The  late nineteenth  twentieth  century  previously  supported  referred  to.  supernatural biological as  i n one's  emergence o f a m e d i c a l  served t o take  deviant  but  biologically  germ t h e o r y  model  behavior  d i d very  e t i o l o g y or  the  Mental  condition that resulted The  c e n t u r y and  little  cure.  based mainly  of disease.  success  in producing  medical  model  any  o f mental  early  part of  "asylum  industry",  illness  was  clearly  incarceration in the out to  a s an  realm  i d e n t i f y and  Mental  illness,  obvious  evidence the  The  diseases of the  century the  definitive  extension of  the  lack of  to sustain this  s t a t u s o f the p h y s i c i a n  a p p e a r s t o have been b o l s t e r e d by a c h i e v e m e n t s physical  of  asylum.  d i s o r d e r s became v i e w e d  Despite the d i s t i n c t direct  any  i n an  nineteenth  of the  the  in the  body.  development o f the 12  psychoactive  drugs  in the  1950'^s'  again  served to b o l s t e r  though does  later  t h e m e d i c a l model  criticisms  have  pointed out t h a t  n o t n e c e s s a r i y mean e t i o l o g y .  model  c o n t i n u e d t o h o l d dominance  sociological  investigations  growth  t u r n e d t h e academic  social  causation theory  Merton,  1957;  disorder,  Brenner,  1973). and  twentieth  classification fuelled  non a d a p t i v e b e h a v i o r - a l l  Dunham, 1939;  developed quite  systems.  The  epidemiological  Hollingshead  and g l o b a l  and  measurements.  mental  i l l n e s s - mental  Mental  i l l n e s s was  health.  Mental  illness,  part o f the  work  Redlich,  Thus,  h e a l t h was  diagnosis tradition  (eg. Fan's  1958)  which  i n s t e a d on i n North  seen as a  viewed as t h e "downside"  health  become  independently of  North American  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 lists  - have  s u c h a s mental  f o c u s s i n g on d i f f e r e n t i a l  by t h e e a r l y  1951;  Terms s u c h a s b e h a v i o r  p s y c h i a t r y during the e a r l y  century,  Durkheim,  disorder.  psychiatry  North American  This  health to a  or environmental e t i o l o g y  s i c k n e s s , mental  European  behavior.  i n mental  i n t e r c h a n g e a b l e with medical terms mental  the medical  despite the beginnings of  into deviant focus  illness,  maintenance  Despite t h i s  (eg. Marxian t h e o r y ;  maladjustment  suggesting a social  of" mental  and was  and ignored  problem  America  continuum. o f mental  became v i e w e d as a s t a t e o f b a l a n c e  between an  individual  and  and o t h e r s  (eg. S a r t o r i u s ,  h i s s u r r o u n d i n g s , between  oneself  1984).  T h i s e x p a n s i v e v i e w o f mental 13  i l l n e s s was  further  advanced  by t h e Human P o t e n t i a l  non-medica11y b a s e d m e n t a l the development therapies. of  living  health  itself  as l e g i t i m a t e medical t e r r i t o r y  virtually  o f the  professions assisted in  The m e d i c a l p r o f e s s i o n  result  The growth  and advancement o f t h e r e l a t i o n s h i p - b a s e d  process o f m e d i c a l i z a t i o n The  Movement.  (eg. Conrad,  i s that a definition  impossible.  concept t h e term  Mental  suggests.  embraced  through the  1980).  o f mental  illness  problems  illness is  i s n o t t h e homogeneous  It p o t e n t i a l l y  includes a l l  forms o f " d e v i a n t " b e h a v i o r , from p s y c h o s i s t o hyperactivity. clear will  The impact on t h e d e v e l o p m e n t  - as long as t h e d e f i n i t i o n  social  m o d e l s o f mental  - have been  relationship  assessment  B.  expands demand f o r s e r v i c e  outpace supply. The two m a j o r  this  of service is  largely  illness  integrated  i n N o r t h America and  i s i m p o r t a n t when e x a m i n i n g  i n mental  of illness  explanation "physical"  s o c i e t y t h e d i s e a s e model,  is nearly  f o r physical implies  a l s o the cause. mental  a n d Soc i a 1 Mode 1s o f  I 11ness  Within western model,  need  health.  The. I n t e r - r e l a t i o n s h i p o f Med i ca1 Menta1  - medical and  universally  ailments.  or medical  a c c e p t e d as  Indeed, t h e t e r m  not o n l y t h e l o c a t i o n o f t h e problem but  T h i s has a l s o  disorders within  largely  been  t h e case f o r  t h e o r g a n i z e d and p r o f e s s i o n a l  14  health  care  system, d e s p i t e  sociologists  throughout t h i s  Some w r i t e r s  1981).  argued t h a t century place  control  socially  responsibility  ( e g . C o n r a d , 1980;  long  viewed as a powerful  and t h e m e d i c a 1 i z a t i o n  caused  has s e r v e d  was t h a t  where t h e y  psychiatry's  of confining could  o f behaviors  t o transfer the  main t a s k  I t has been  in the  civilization's  The s u c c e s s f u l  o r " p s y c h i a t r i z a t i o n ' o f t h o s e who e x h i b i t has made  unnecessary.  ideology  Medical  c o n d i t i o n as l y i n g o u t s i d e  institutionalization can d e f i n e  a  patient's  t h e realm o f "normal'  behavior  maintain the individual's r e s p o n s i b i l i t y f o r The  medical  profession  a g e n t o f power, an e l i t i s t status  quo.  position  has been  long  group t h a t  in society  it.  criticized  benefit  a s an  from t h e  They have g a i n e d a n d r e t a i n e d t h e i r  powerful  l a r g e l y due t o s u p e r s t i t i o n - man's  o f death and t h e w i t c h d o c t o r s '  presumed a b i l i t y  it  - and p a r t l y f r o m t h e s t a t u s  on  scientific  methods.  associated  Psychiatry  t h e s e two s e e m i n g l y c o n t r a d i c t o r y science  nineteenth  misfits in a  not d i s t u r b s o c i e t y .  unacceptable behavior  and  h a s l a r g e l y come  from s o c i e t y t o t h e i n d i v i d u a l .  medical  medica1ization  a n d power r e a s o n s  M e d i c i n e has been  agent o f s o c i a l seemingly  century.  have a r g u e d t h a t t h i s  about f o r p o l i t i c a l Mi s h i e r ,  t h e academic c o n t r i b u t i o n s o f  - by i d e n t i f y i n g w i t h  in turn forces  to control its reliance  c a p i t a l i z e d on  - s u p e r s t i t i o n and  medicine.  G i v e n t h e power o f t h e m e d i c a l 15  with  fear  profession  and i t s  desire to  r e t a i n the  psychiatry medical  has  model  status  vested of  illness.  - though t h i s  organized  psychiatry's  professions  to their  disciplinary course.  legislation treatment  psychiatry's view o f t h e  i n d i v i d u a l as  political  disorder  has  responsible  a  socially  social  deviant  been a r g u e d t h a t  i s a l s o backed  by  the  of  medical  is a  elitists  - have a v e s t e d  -  that  model  -  result  of  the  mental  society is i t s members - w o u l d be  in t h i s  i n t e r e s t in not  changed.  case  the  changing  soci ety. The  result  is that academically  t h e o r i e s o f mental practice point  we  illness  have one  - the  f o r needs a s s e s s m e n t  we  - a medical  have two and  a  distinct  social.  medical.  This  i s an  in health  care  planning.  16  the  amelioration  i n d i v i d u a l s , should  the  and  conditions.  f o r the  - that  on  from d i a g n o s i s  have s u g g e s t e d  caused)  behavior  -  multi-  acknowledge t h a t  causation  s o c i e t y , not  psychiatrists  To  newer mental  of  responsible  context.  f o r the  suggest t h a t I t has  (albeit  by  head o f team,  1980)  the  financial  seen  the  medical  i n t e r e s t in maintaining  o f h i s problem larger  Ingleby,  as  of  psychologists  professions  designated  (e.g.  be  compromise o f a  imperative  disallowing other  from a  can  to allow  physician at  territorial  Some w r i t e r s  only  w o r k e r s and  their  that  continuation  i s not  reluctance  and  o f what a r e  been a r g u e d  i s i m p o r t a n t as  team - w i t h  This  This  - social  territory,  i t has  i n t e r e s t s in the  viewpoint  health  quo,  In  important In  western to  be  society,  dealt  medical  model.  change o f t h e  i s by  co-opted  as t h e i r  the case.  r e c e n t l y developed them as m e d i c a l  definition  an  illness  establishment.  This  t h e newer p r o f e s s i o n s  Health care s e r v i c e s are developed  d i s o r d e r s o r abnormal  The  behavior  social  focus.  The  with  Their target is  medicalization of  mental  has  many o f  also  co-opted  c a u s a t i o n m o d e l s and  territory.  seemingly  disorders  has  individual  individual,  itself  illness  with w i t h i n the medical  establishment  into t h i s  the  mental  medical  legitimized  establishment  schizophrenic, admitting to s o c i a l l y  but m a i n t a i n i n g the  efficacy  the  of medically  is caused  based  cures. This of  i s not a r a t i o n a l  causality.  establishment powers.  It r e f l e c t s has  Medicine,  assisted  medications,  fix".  made p r o m i s e s  failed and  to provide.  treatment  mental  i n t h e mental I t has  such as  has  imply  in the the  cause nor  of  logic  medical  geared  with t h e debut o f society and  f o r the cures  the "quick  which,  h e a l t h s e c t o r , i t has  largely  pointed to  medications  i t s use  biological  cure.  17  of  i n d i c a t o r s t h a t much o f  based  in order. on  faulty  management o f a p a t i e n t does n o t  either  sense  society of their curative  o f treatment  a r g u m e n t s have been shown t o be successful  control  fifties  E.C.T. a s  d i s o r d e r is in f a c t  -  by t h e t e c h n o l o g i c a l  in the  antipsychotic  particularly  the  in persuading  development, s t a r t i n g  I t has  position  Such logic  as  necessarily  The  r e s u l t i n mental  division the  in care  most h i g h l y  turned  services.  this  certify.  physicians  group t o the  bipolar  This  disorders.  and  o f t h o s e who  distressed.  identified  including  No  sector.  basis  medicate  which  ( t h o u g h not  yet  schizophrenics  and  bulk of t h i s  in North  America  private practice  have been d e s c r i b e d  as  the  is  dissatisfied  e t i o l o g y has  been  In f a c t , p s y c h i a t r i s t s  to accept a social  ironic  causation  within  theory,  medical  turn  of  events the  biological  or  organic  have,  responsibility  right to  systems.  with a doubtless  medical  the  "manage",  group f o r  - the  *adjustment' d i s o r d e r s  In a n o t h e r  instance^^  organic  group.  quick  classification  ill,  o r g a n i c a l l y based  for this  themselves are  c h r o n i c a l l y mentally  bulk of psychiatry  i s p r i v a t e p r a c t i c e and made up  have  least trained to  illness  The  psychiatry, workers,  i s p r e c i s e l y the  f o r mental  interesting  health  power t h r o u g h t h e i r  have a r g u e d an  identified)  been an  a rule private  s e r i o u s l y and  while r e t a i n i n g t h e i r and  As  has  * s o p h i s t i c a t e d ' mental  away f r o m t h e  relegating  health  i n many a r e a s ,  of  social The  argument  being  basis  been r e l e g a t e d  is that is.  etiology  Functioning  severe cases of  18  retarded,  in nearly to  service agencies rather  unimportant, while f u n c t i o n i n g  the exception d e p r i v a t i on  mentally  every  the  than  the  is i s seen,  environmental  in  the by  case o f the mentally virtue of their  territory  ill  because o f t h e i r  Positivist Ingleby  and  establishment  system. reflect  i n nature.  - the polar  who a r e c o n s i d e r e d  medical  behavior, not n e c e s s a r i l y  vs I n t e r p r e t i v e  i s very  relevant  its etiology.  illness  t o the current  I n g l e b y has a r g u e d t h a t  positivist  and t h i s health  in their  paradigms.  illness  t h e medical within  as well  t h e s e m o d e l s s h a r e t h e same observation  framework.  He a r g u e s  ( t o him, f a u l t y ) p r e m i s e  and t h a t  constructed  on t h e same c a u s a l ,  the  sciences.  natural  v i e w assumes t h a t  there  Ingleby  free,  o p e r a t i o n a l l y and a p p l i e d  replicable fashion  is valid  m o d e l s o f mental  c a n be made o b j e c t i v e l y and v a l u e  measures c a n be d e f i n e d precise,  a s most s o c i a l  his positivist  He  v i e w a s t o what  c r e d i b l e d a t a on w h i c h t o b u i l d a t h e o r y .  includes  care  t h e s e two a p p r o a c h e s  d i f f e r e n t , mutually exclusive, they d i f f e r  opposite  problems  (1980) has d i f f e r e n t i a t e d between  suggests that  So,  Paradigms  i n t e r p r e t i v e v i e w s a b o u t mental  distinction  and  as s o c i a l  b e h a v i o r t h e y a r e n o t s e e n t o be t h e  o f t h e medical  of the mentally  C.  retarded,  theories  a r e no f e a t u r e s  that that  in a  c a n be  deterministic basis  He f u r t h e r a r g u e s t h a t  that  as i n  the positivst  d i s t i n g u i s h i n g human  b e i n g s from t h e r e s t o f n a t u r e which might n e c e s s i t a t e t h e a d o p t i o n o f a d i f f e r e n t paradigm. In f a v o r  o f t h e i n t e r p r e t i v e model 19  Ingleby  emphasizes  the  u n i q u e l y human n a t u r e  subjective behavior  1967).  t o the ethnomethodologists  1934, and r a d i c a l  The i n t e r p r e t i v e  while the p o s i t i v s t  abnormal  w i t h i n t h e broad  such  as L a i n g ,  f o r g r o u n d s and  s e e s abnormal  spectrum  v i e w makes s e n s e  reasons  b e h a v i o r as  of society, the  o f t h a t same b e h a v i o r  as a  behavior, adaptive t o the s i t u a t i o n .  This d i s t i n c t i o n  i s essential  we have d i s c u s s e d , t h e e m p h a s i s developed  i n response  service to social  f o r need a s s e s s m e n t .  theories.  model, a l b e i t  I t c a n be a r g u e d  disorder.  to the insidious incremental  systems.  t h a t t h i s has  Much o f t h i s  on one  concept  c a n be a t t r i b u t e d  power o f t h e m e d i c a l p l a n n i n g methods used  not only  p r o f e s s i o n but a l s o in developing  these  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 a r e more  thoroughly clarify  with l i p  p h y s i c i a n s and government  p l a n n e r s , a l l o w i n g a system t o e v o l v e based o f mental  As  i n h e a l t h c a r e d e l i v e r y has  t o t h e medical  been done u n c o n s c i o u s l y by b o t h  the  such as  v i e w e x a m i n e s t h e same f a c t o r s a s  Where t h e p o s i t i v i s t  interpretive  psychiatrists  view argues  causes.  coping  of  i n t e r p r e t a t i o n s a n d c o n t e x t t o t h e meaning o f any  (analogous  Garfinkel,  o f man, t h e i m p o r t a n c e  d i s c u s s e d below.  at this  rational approach,  However, i t i s i m p o r t a n t t o  p o i n t t h a t g i v e n t h e new e m p h a s i s on  p l a n n i n g as opposed t o t h e h i s t o r i c a l  incremental  p l a n n e r s a n d g o v e r n m e n t s now may have an  opportunity to j u s t i f y dominated model.  moving away f r o m  As w i l l  be d i s c u s s e d ,  this  medically  i t i s an  expensive  one,  with  little  superstitious  one,  but, as a r e s u l t seventies, this  new  thought  with the  of the  certainly  e r a , an  to efficiency.  "witchdoctor' aura  consumerism o f t h e  slipping.  It w i l l  e r a where r a t i o n a l  m o d e l s o f mental  w e l d e d t o g e t h e r may necessarily  change c o u r s e . be an  The  model  illness  instruments not  own  important  used  understanding  - has  and  value free.  within  for their  issue  21  given  medical  and  being  be  reluctant  to  i s , however, t h e r e  not o n l y our  needs  model  view  - or  of  the  Need a s s e s s m e n t m o d e l s  are  use o f them r e q u i r e s  o f t h e models about  them.  that  inextricably  h e a l t h c a r e , but a l s o  Intelligent  and  being  s t r o n g l y the medical  t o a s s e s s need.  intact  models o f c a r e .  reasons,  influenced  mental  argued  f u t u r e p l a n n e r s from  a p p r e c i a t i o n o f how  positivist mental  prevent  sixties  o f how  have been  confined t o the e x i s t i n g  Governments may,  to  illness  be  still  methods a r e  s t r e s s e d , a comprehensive understanding social  It i s a  mental  disorder inherent  Chapter A.  I I I : A Conceptual  A Definition  o f Need A s s e s s m e n t  Having e s t a b l i s h e d elastic  the importance o f a  c o n c e p t o f mental  illness  c o n t r i b u t i o n o f both medical the to  mental h e a l t h  care  need a s s e s s m e n t  as  analysis  and t h e  and s o c i a l  c a u s a t i o n models t o c a n now  be  turned  itself. exist  t h e y a r e much of either  f o r needs a s s e s s m e n t but  i n agreement.  This  is surprising  c o n c e p t o f need o r o f a s s e s s m e n t  b r i n g s about hot debate.  Of c o u r s e t h i s  problem - people a r e q u i c k t o agree t h a t a s s e s s e d , y e t have  potentially  relative  industry, attention  Various d e f i n i t i o n s surprisingly  A n a l y s i s o f Need A s s e s s m e n t  little  reflects  the basic  n e e d s must  be  understanding o f the assumptions  underlying the concepts. Bell,  W a r h e i t a n d Schwab  a s s e s s m e n t p r o g r a m c a n be most to  enumerate t h e h e a l t h  community.  utilization  area.  living  in a  and n e e d s and  i n a community.  Kami's  need a s s e s s m e n t i s any a c t i v i t y  Royse and Drude refer  living  i t as a r e s e a r c h  which  a n d / o r measures o f e i t h e r t h e  o r a b s o l u t e needs o f p e o p l e  technology,  a s an a t t e m p t  t o determine the health  patterns o f those  provides a description relative,  describe  designed  (1979) s u g g e s t s t h a t  simply defined  needs o f a p o p u l a t i o n  They f u r t h e r  planning a c t i v i t y  (1977) s u g g e s t t h a t a need  (1982),  living  in recent  in a  defined  support o f the  t o i t as a p r o c e s s o f i d e n t i f y i n g  p o p u l a t i o n s and d i r e c t i n g  programming. 22  I.Q.  target  has been  d e f i n e d as t h a t  which  I.Q.  assessment measures.  Perhaps  this  i s t h e c a s e w i t h need a s s e s s m e n t - need a s s e s s m e n t i s  that  w h i c h need a s s e s s m e n t s  B.  Problems w i t h t h e Concept  measure.  The o b j e c t i v e o f need a s s e s s m e n t  seems t o be c l e a r  identify  some t y p e o f d a t a t o f a c i l i t a t e  some t y p e o f  planning  i n some community.  lies  definitions measured. Cochran, is too  Critics 1979)  of the process  have warned  loose, with  have a c k n o w l e d g e d the f i e l d .  The  particular  or  (1979) and  need  assessment  u n r e l i a b l e methodologies have been Royse  and  refuted Drude  by  (1982),  e s s e n c e , however, o f b o t h c r i t i q u e s  "hard' approach.  who  and  The  Royse and Drude  organizations to  i n s t r u m e n t s and t h e  focus o f the c r i t i q u e s level,  t o t h e more f u n d a m e n t a l  with  level  (1974) and S i e g e l ,  amongst t h e few who  (1982) i n  l i m i t a t i o n s of the methodologies,  professional  o f new  methodological  Blum  1977;  shortcomings but encouraged p r o g r e s s i n  on n a t i o n a l  of o l d .  conceptually  critiques  c e n t r e on t h e  the development  this  Such  ( e . g . Kimmel,  i t is  a p p e a r s t o f o c u s on t h e need f o r a more  "scientific'  calling  that  i m p r e c i s e and  s u c h a s Kamis  rebuttals  in the  o f need and t h e m e t h o d o l o g i e s by w h i c h  and no s t a n d a r d s . others,  The p r o b l e m  - to  of  facilitate  standardization  appears t o remain a t  little  attention  being  paid  values.  Attkisson  and C a r s o n  (1978) a r e  seem t o be p r e p a r e d t o a t b e s t t o u c h  23  upon some o f t h e t h o r n i e r role o f values  in the process.  (1978) d i f f e r e n t i a t e assessment'.  i s s u e s , acknowledging t h e major  between  S i e g e l , A t t k i s s o n and C a r s o n  "need  They s u g g e s t t h a t  need  process  by w h i c h h e a l t h a n d s o c i a l  certain  area  the  process  needs. need  of estimating  They c i t e  Blum  identification  steps: area  are described,  identification'  while  a n d "need  "identification'  i sthe  s e r v i c e requirements need  the r e l a t i v e  "assessment'  in a  involves  importance o f those  (1974) i n d e s c r i b i n g t h e p r o c e s s  a n d a s s e s s m e n t a s i n v o l v i n g two  (a) t h e a p p l i c a t i o n o f a m e a s u r i n g t o o l  of  distinct  to a defined  a n d , (b) t h e a p p l i c a t i o n o f judgement t o a s s e s s t h e  s i g n i f i c a n c e o f the information  in order  priorities  and s e r v i c e d e v e l o p m e n t .  The values  f o r program p l a n n i n g  i m p l i c a t i o n o f t h e above t w o - s t a g e p r o c e s s  come  into play  measurement t o o l  i n t h e second  stage  information  only, the  known a s s e s s m e n t  that describe or define  c o n d i t i o n s o r s i t u a t i o n s and t h a t t h e s e necessarily  interpreting.  and e x p e c t a t i o n s  c o n d i t i o n s a r e not  o f those  They go on t o q u o t e Blum  situation  expectations those  techniques  p r e d e t e r m i n e d t o be p o s i t i v e o r n e g a t i v e .  upon t h e v a l u e s  not,  Siegel  social  suggest t h a t t h e i n t e r p r e t a t i o n o f t h e s i t u a t i o n  identical  i s that  i m p l i e d t o be a v a l u e - f r e e d e v i c e .  et a l . s t a t e that the various produce  t o determine  ( 1 9 7 4 ) , "The  a r e met, a n d a s bad by t h o s e are unrelated,  24  depends  doing the  may be s e e n a s good by t h o s e  whose v a l u e s  They  whose  value  whose v a l u e s a r e  o r who do n o t c o n n e c t  the  c o n d i t i o n t o v a l u e s may  all,  or  view  It  i s the  play before by t h e  i t as a n a t u r a l  the  mental  As  illness,  data  vs  affairs".  of data.  Ingelby  of p o s i t i v i s t  Values  collected  (1980) has  and  models  The  d e c i s i o n as  to c o l l e c t , one.  The  illness,  imply  decision reflects  treatment, types the  i t s potential  It r e f l e c t s  in question)  - and  the  occurs  but  model  or p o l i t i c a 1 / s o c i a 1  crucial  factors  negate the  the term  'assessment' as  to how  mental  goals  not  (as o p p o s e d t o  context  as  -  To  in the  Royse and  of  only  the  force -  is to  ignore  of  explore  focus  Drude  q u e s t i o n o f what  only  on  (1982) i s i s need,  by whom.  T h i s b r i n g s us back t o t h e  25  of  political  direction  industry.  i s suggested  n e g l e c t t h e more f u n d a m e n t a l i t i s d e f i n e d and  of  arbitrary  importance o f e i t h e r  health  m e t h o d o l o g i e s by w r i t e r s s u c h  an  data  the appropriateness  which c o n t r i b u t e t o the  d e v e l o p m e n t o f t h e mental  of  respectable  a l s o of the  To  illness  of  whole s y s t e m s  model  v a l u e s and  f o r c e s a t work. of  in  f o r care - maintenance,  c u l t u r e i n which t h e assessment  community  implied  the  I t i s not  a specific  cure or prevention  of care.  into  t o w h i c h m o d e l , o r what t y p e o f  i s n o t a v a l u e - f r e e one.  i t s causes,  are  paradigms  p r e j u d i c e a b o u t what c o n s t i t u t e s u s e f u l and data.  come  suggested  interpretative  the d i f f e r e n t  condition of  paper t h a t v a l u e s  interpretation  methodology used.  perceive the  state of  premise o f t h i s  q u e s t i o n asked, the  discussion  not  q u e s t i o n o f n e e d , and  the  need t o examine  t h e a s s u m p t i o n s o f want, need and  How  inter-related  these three  has a  large  C.  concepts are defined  impact on t h e t y p e o f model  p l a n n e r wi11  o f assessment a  need a r e f r e q u e n t l y  i n t e r c h a n g e a b l y though they a c t u a l l y states.  refer  Need a s s e s s m e n t may  to  upon t h e model  actually  o f assessment being used.  the d i f f e r e n t  is essential  be want  i s t h e most b a s i c  o f each o f t h e s e t h r e e  internal  same  individual.  The  activate  terms  technologies.  Cooper  is a highly  A want  an  compared  relative  and p o t e n t i a l l y  with  state,  variable  i s not s u f f i c i e n t  within  to  activate  i n t o a demand f o r  which d e t e r m i n e whether  a s e l f - a s s e s s m e n t o f want  an  individual  (for better  health)  complex.  (1975)  how  This  r e f l e c t i n g an  state  A want must be t r a n s l a t e d  factors  i n t o demand a r e  influence  norm.  individual  access to care. service.  o f the states,  assessment o f h i s health  unique t o each  will  understanding  t o appreciate the merits o f the  individual's  the  depending  Want/Demand  Want  h i s own  implications  An  used  quite  a s s e s s m e n t , demand a s s e s s m e n t o r need a s s e s s m e n t  1.  used  Need  The t e r m s want, demand and  of  and  use.  Want. Demand and  different  demand.  has d i s c u s s e d  individual  26  some o f t h e f a c t o r s  makes t h e d e c i s i o n  to  which  translate  want  i n t o demand.  have r e p o r t e d who,  little  over a ten  those with the reports and  that  of  and  n e v e r saw  of  family  job  Other f a c t o r s ,  proximity of  demand w i l l  by  the  tend to be  care,  but  either  by  the  various  what s o r t o f  i s the  also  translate  voiced  by  the  been shown  towards This  in  to  the  whatever  may  be  also  for  their social  without needs  this  The  voice  not  and  individual  of  he  care or  how  - usually will  what s o r t and  27  as  h i s demand  who  then  power  physician  - who  often,  what q u a n t i t y  of  a  for  professional  much c a r e he  r e n d e r , how  may,  who  dictates  chooses t o  i n most c a s e s have t h e  professional service  The  individual  i t i s the  i n t o need o r  need e x i s t s .  dictates  individual, is  f a c t o r s , decide to  d o e s not  what t y p e o f He  sheer  social agencies,  professional.  d e t e r m i n e what k i n d It  of  o n c e h a v i n g done t h i s ,  validates  demand but  gravitate  alter  needs.  articulated of  plus  have a l s o  available.  availability  Demand, a l t h o u g h  result  Cooper  Cooper s u g g e s t s t h a t  such a g e n c i e s p e o p l e t e n d t o into health  and  economic  a v a i l a b l e care,  c a r e happens t o  affected  t h e i r doctor  s u c h as  a f f e c t demand.  of  patients  b a c k g r o u n d have been f o u n d t o  dramatically  level  between  who  satisfaction, personality  o f manpower r e s o u r c e s ,  run,  (1965)  a v e r a g e number o f a t t e n d a n c e s .  availability  long  Shepherd  obvious d i f f e r e n c e  year p e r i o d ,  demand.  deterrents,  c i t e s Kessel  such f a c t o r s as  stability  rates  He  voice  to requires. decides and  where.  other  health  services will laboratory  be  u s e d - s u c h as  services, etc.  between demand and obligation  r o l e and (Parsons, factor  in the  advent o f grew  g i v i n g up  1958).  care  and  implied  mental  health  Laing  Goffman  2.  to the  i s an  expert.  implicit  l a r g e numbers o f  1971)  i n t o need.  "bargain'  This  and  by  Szasz  sick  professional strong With  the  human r i g h t s w h i c h  1970's, t h e r e  spurred  The  demands  increasingly  e m p h a s i s on  1960's and  field,  (1961,  has  in the  been a  growing  demand f o r  l a y p e o p l e have  questioned  is particularly  true  radical  of  the  p s y c h i a t r i s t s such  (1961) and  writers  such  as  1965).  Need  Need  is generally  o f what t h e  client  appraisal.  Boulding  need  itself  'bargain'  acknowledgement o f t h e  control  obligations.  (1960,  of the  layman and  t r a n s l a t i o n o f demand  late  these  as  of  This  awareness o f t h i s health  i s the  c o n s u m e r i s m and  in the  is part  i n h a v i n g o n e ' s wants and  i n t o need  the  This  n e e d , between  inherent  authenticated  medication, h o s p i t a l i z a t i o n ,  is often  autonomy and  e x p r e s s e d as  requires;  criticized  as  individuality  the  other  choice  the  tailoring  preferences.  professional's  demand s u g g e s t i n g  (1966) s u g g e s t s t h a t  demand, on and  the  of the  hand,  There are  being  implies  of  inputs  too  the  a  lay  concept  mechanical,  human p e r s o n .  of  denying User  autonomy, i n d i v i d u a l to individual  f u r t h e r p r o b l e m s , however.  28  view  i f need  is  viewed as t h e p r o f e s s i o n a l  which p r o f e s s i o n a l demand, autonomy choices case  i s making  implies  - the sovereign  choice,  one must  the choice.  that  In t h e c a s e o f  t h e c h o o s e r i s aware o f t h e  consumer  - which  is clearly  c o n c e p t o f need has been c r i t i c i z e d  mechanical fact.  implies  and between is a  a desired  values,  cultures.  servant  illustrated  opinions Blum  state of health. real  or professional  concretely  declared  R e c e n t work  by t h e  faced  level  with a patient  physician  belief  o f need.  definition,  that  need i s (1973)  describing  that  He m a i n t a i n s t h a t  of health  requires  need  be  Cooper  doctor-  (1975) p o i n t s  t o d e c i d e t o do n o t h i n g . " i f only  29  economics o f f e r s  in a s t a t i c ,  d e c l a r i n g demand,  (1980) f a c e t i o u s l y comment  within  an e x i s t i n g and  Donabedian  or well-being  variety  physician.  in the f i e l d  evidence t o refute t h i s identified  oriented  care.  This  suggest  definition,  or b i o l o g i c a l .  in health  o u t , even  by t h e wide  (1981)  Under t h i s  offers a similarly medically need a s a d i s t u r b a n c e  scientific  and p r a c t i c e , b o t h  and S t e i n  that  too  of e x i s t i n g values.  * h e a 1 t h d e f i c i e n c y ' , a gap between  thought o f as t r u e ,  medical  as being  (1967) has p o i n t e d  t h e c a s e o f need,  of professional  The f a c t  i t i s a r e s u l t o f some  i s not a p a s s i v e  clearly  need  that  However, a s B o u l d i n g  science is  not the  in health. The f a c t o r s a f f e c t i n g need a r e c o m p l e x .  the  question  out  that,  i t is difficult  G o l d b e r g and  for a  Huxley  p s y c h i a t r i s t s were i n  the  habit o f saying  psychiatric not  illness,  a medical  research  to their  fact,  go away'".  patterns  Considerable  "unnecessary' surgery gynaecological  manage t o f i n d surgery this  Need i s a m e d i c a l  publicity  in recent  years  a s do t h e i r  -  particularly  in the United  States  counterparts  i n need o f  and p o i n t s o u t t h a t  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 a l l o w a n c e i s  population  in the United  He f u r t h e r s u g g e s t s t h a t provision,  as d o c t o r s  realigning  their  possible  States  need t e n d s t o grow  r e a c t t o any i n c r e a s e  conception  continuum.  deprived  due t o t h e p r i c e  barrier.  i n 1ine with in supply  by  o f need f u r t h e r a l o n g t h e  He q u o t e s F e l d s t e i n (1977)  both a d m i s s i o n s and l e n g t h o f s t a y  availability.  Cooper s u g g e s t s t h a t ,  more r e s o u r c e s  devoted t o meeting  float  similar  has been g i v e n t o  made f o r t h e e x i s t e n c e o f a l a r g e m e d i c a l l y  that  considerable  a s many p a t i e n t s p e r c a p i t a British  opinion,  Cooper r e f e r s t o d a t a  h o s p i t a l surgeons twice  from  o f p r a c t i c e under  and o b s t e t r i c a l .  indicating that  "You d o n ' t have a  a s c a n be g a t h e r e d  on v a r i o u s  circumstances.  patients,  indicating  increased with  l i k e an  bed  iceberg, the  i t , t h e more need seems t o  to the surface. Other authors  Canadian context, Stoddart  and Barer  have health  indicated similar  findings.  economists such as Evans  In t h e  (1978),  (1981) a n d Roos, Gaumont a n d H o m e  have d e t a i l e d s i m i l a r  examples o f t h i s  suggest t h a t the t r a d i t i o n a l  30  phenomenon.  (1976)  They  r e l a t i o n s h i p o f s u p p l y and  demand c a n n o t be a p p l i e d t o h e a l t h c a r e b e c a u s e o f t h e physician's a b i l i t y professional increased dictated  identification  supply  being  concerns  t o f u r t h e r i n c r e a s e need, a s  Medical  as t h e p r i n c i p l e  on f u n d i n g ,  a free  other  s t u d i e s , such  study  i n t o medical  Critics  i n l i n e with  that for  manpower  and t r a i n i n g i n Canada.  needs,  Plain  each g e n e r a l  practitioner each year  t o o many d o c t o r s  result  Halliday  (Globe  between s u r g e o n tonsillectomies,  and M a i l , supply gall  provinces.  represents a cost  operating costs.  beds  used  He i n d i c a t e s  i n e a c h c r e a t i n g h i s own demand  i f a recommended p r o c e d u r e Canadian study  reported  a n d 307o t o o  f o r hospital  s e r v i c e a n d p o i n t s o u t t h a t few p e o p l e  A similar  indicate too  (1984)  t o o many d o c t o r s o f a l l t y p e s  p a t i e n t s and general  themselves  problem,  as a r e c e n t l y provincia11y-commissioned  o f $450,000 t o t h e p r o v i n c e by t h e i r  the funding.  as a p r i n c i p l e  many f a m i l y d o c t o r s w i t h i n t h e t h r e e w e s t e r n estimated  of this  r e i g n , a l i d w o u l d n e v e r be  underfunding  many d o c t o r s a l r e a d y e x i s t 5 percent  system  A s s o c i a t i o n (CM.A.) as  problem.  t h e "need' g r o w i n g  While t h e CM.A. sees  Plain  examples o f  w i t h i n t h e Canadian medicare  approach f e a r t h a t given  about  o f need a n d c i t e  related  v i e w e d by t h e C a n a d i a n  "underfunding'  put  demand t h r o u g h t h e  by t h e p h y s i c i a n .  Current are  t o generate  can determine  is actually  necessary.  done i n 1983 b y b y Le R i c h e a n d 1984)  r e p o r t e d an a s s o c i a t i o n  a n d more a p p e n d e c t o m i e s , bladder  31  o p e r a t i o n s , hysterectomies and  Caesarean s e c t i o n s  being  performed.  Demand, t h o u g h a d v o c a t e d feel  s t r o n g l y about personal  d o m i n a t i o n , can result  o f the  affecting  r e s u l t in a  several  demand.  In b o t h p h y s i c a l that the  (eg.  end  not  and  mental  o f the  a bad  valuation,  allocation  British  mentally  and  thing  up  health  basic  will,  Columbia  by  is  and  end  arenas,  i t has  of  care.  as  here.  been  shown  demand, w i t h  r e c e i v i n g more  1958).  end,  the  This  may  course.  get  a  More i s  However,  w e a l t h y do  be  regardless "more' i f  demand.  In e f f e c t , be  i s the  no  longer  services  current  32  of  the  care  offered.  in that The  * stand  i n queue'  doctor's  so on.  Handicapped  idea o f  i n queue. the  be  s u c h as  f o r Mentally  programs, w i l l  means t h a t  expected t o  d e n t i s t r y and  embraced t h e  in e f f e c t standing  this  d i c t a t i n g level  l a r g e , be  care  Association  specialized  a  most r e l e v a n t  l a r g e e f f e c t on  in the  longer  surgery,  (B.C.M.H.P.) has  as  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  no  health  appointments,  the  Redlich,  * specialized services' will  for  a  in health  to  retarded.  government w i l l  retarded  be  i n t e r e s t i n g example o f t h i s  Columbia  who  professional  division  s c a l e demanding and  in the  is left  A rather  unequal  E c o n o m i c s may  necessarily better  o f the  the  very  vs.  those  f a c t o r s w h i c h have been d i s c u s s e d  Hollingshead  good t h i n g o r  consumers and  liberties  s o c i o - e c o n o m i c c l a s s has higher  care  by  The  British  Persons  normalization  However, severely  -  without  and  profoundly  which  retarded  e v e r g e t t o t h e head o f t h e queue?  e x p e r t i s e or w i l l i n g n e s s of the severely may Lack  result  t o deal with t h i s  r e t a r d e d can be a r g u e d  i n l e s s c a r e as t h e i r  o f a v a i l a b l e a p p r o p r i a t e c a r e may  demand o v e r a p e r i o d o f t i m e . pleased  and  - and  need d i c t a t e  i s not cause  point?  service  care  t o be a s p e c i a l t y  -  acknowledged.  decreased  t h e B.C.M.H.P. be T h i s may  levels  so  turn  out  rather  results  in  standards of care.  The  L i nkage o f Want, Demand and  The  factors  not well  examination  which  involved  Need  these three concepts  However, t h e y are  conceptual  1 illustrates  and  are  crucial  o f t h e m o d e l s o f need a s s e s s m e n t .  in assessment  link these  link  understood.  a vastly different  Figure  group  of  example o f where a l l o w i n g consumer demand  professional  lowered  D.  Will  with n o r m a l i z a t i o n at that  t o be an than  demand  Lack  Each  understanding o f the  thus w i l l  affect  complex to  implies variables  i t s outcome.  the p o s s i b l e chains o f events that  concepts.  33  any  may  Figure  1:  The R e l a t i o n s h i p  WANT  o f Need,  Demand a n d Want  DEMAND  i nd i v i dua1's a s s e s s m e n t o f h e a l t h s t a t e compared w i t h h i s own i n t e r n a l norm  NEED  i n d i v i d u a l ' s wants a r t i c u l a t e d by contact with medica e s t a b l i shment  confi rmation o f s t a t e by p r a c t i t i oner  OR NEED  WANT  p r o f e s s i o n a l ' s assessment o f h e a l t h b e l o w h i s norm  DEMAND  i nd i v i dua1's acknowledgement of thi s  i nd i v i dua1's agreement through cooperation with c a r e by professional  Thus a c c e s s t o s e r v i c e may o r i g i n a t e w i t h individual  or the professional.  What s h o u l d  either the  be m e a s u r e d i n  need a s s e s s m e n t - t h e i n d i v i d u a l ' s want, t h e i n d i v i d u a l ' s demand o r t h e p r o f e s s i o n a l ' s  defined  potentially  information.  E.  quite  different  Want, Demand a n d Need Mental  value-laden. American  health  i n Menta1  need?  Hea1th  p e r h a p s e v e n more t h a n p h y s i c a l  An example o f t h i s  Psychiatric Association  there  t o no l o n g e r  h a d n e v e r been a s u b s t a n t i a l  34  health i s  i s t h e 1973 d e c i s i o n  homosexuality as a p s y c h i a t r i c disease. that  Each o f f e r s  by t h e  include  Despite the f a c t organic  cause f o r  this  * d i s e a s e ' and  homosexuality At t h e  been s e e n a s  same t i m e ,  medical  there  and  such  as  behavioral  are  becoming  discussed  and  i t i s important  mental can  health.  the  concept  Related  to this  specific and  According  treatment  later  E.C.T.,  medications cure,  insulin  shock t h e r a p y ,  influenced the  w h i c h even t h e or  need  idea t h a t medicine the medica1ization people  now  norms, need and  with  the d i a g n o s t i c process.  focus  belief  35  idea  entrenched. psychiatry  that potential  o f need.  s c i e n c e has  is a  themselves  As  cure,  Warner and  demand  promised.  t h e a n a l y s i s o f need and As  bleedings  based, the  c u r e , and has  on  that there  have come t o e x p e c t  f i x " t h a t medical  linked  in  psychotropic  i s more f i r m l y  promoted t h e  Closely  and  bromides,  environmentally  has  "technical  been  has  psychiatrists  implies a potential  the  these  value-laden  purges,  i d e a o f need  noted,  values  how  The  (1978) has  this  is psychiatry's traditional  socially  legitimizing  which  o f m e d i c a l l y d e f i n e d need  to cultural  of professionally dictated  thus  the  is.  - t h a t has  admit t o b e i n g  by  to understand  - originally  even f o r i l l s  care.  within  i n c r e a s i n g l y m e d i c a l i z e d has  elasticity  cure,  p s y c h i a t r y in other  process  expand o r c o n t r a c t , e x h i b i t i n g  relative  known  problems, h y p e r a c t i v i t y , drug The  behaviors  t o the  any  a need f o r p s y c h i a t r i c  in p a r t i c u l a r ,  l e a r n i n g problems.  contributed  being  is increasing interest  p r o f e s s i o n and,  'diseases' use,  had  d e s p i t e t h e r e not  demand i s  p r e v i o u s l y m e n t i o n e d , how  a want  becomes a demand and  how  t h a t demand  i s a complex p r o c e s s  and  particularly  mental  health.  Because o f t h i s ,  deserves separate  F.  D i agnost i c  The  d i a g n o s t i c process  for be  of  the  the  first  i n what he  extraordinary  o f the  This  care  culture  to  willingness  manifests  area  conception  i t as  or d i s a b i l i t y  importance with  and  as  the  some  h i s normal  state  examining  People d i f f e r to area  as  evidence that  can  illness  36  in formulating  and  of well-being  develops.  mental  ill-health,  literature  difficulty  (1972) p o i n t s o u t  itself  of  involves  e i t h e r p h y s i c a l o r mental  of health.  opposed t o viewing  discomfort  to  the  between what v a r i o u s i n d i v i d u a l s  to t o l e r a t e discomfort  Mechanic his  in the  individual,  in t h e i r  is a prerequisite  diagnostic process  i s a growing  norm o f  definitions  individual  as  the  regardless  system which c o n t i n u e s  come t o p e r c e i v e  variability  is reflected  concise  has  There  acknowledge as  of  dominated.  stage  of well-being.  field  process  because  d i a g n o s t i c process  p a t i e n t making a s u b j e c t i v e c o m p l a i n t change  the  diagnostic  i s important  traditional  largely medically The  so w i t h i n  validated,  Process  illness  accessing  the  i s not  attention.  The  o f model  i s or  This due  and  in t h e i r life's  a person the  is of  t o the  and  culture to  s i c k n e s s or  how  affect  clear  from  part of of  health.  way  cycle disease.  perceives  in which i t  particular strong  social  values  embodied w i t h i n  The  increasing  resulted  fact  the  related  may  perception therefore as  i t as of the  o f the  p r o b l e m as  t r e a t a b l e may  a disorder  by  life  diagnosing  clients  so m i l d l y d i s t u r b e d  probability Cummings  two  two-fifths  se1f-1imiting  that  of a l l v i s i t s  i n 1968  In t u r n ,  suggest t h a t  p e r s o n a l i t y or  same y e a r t h a t This  14  would s u g g e s t t h a t  office-based  se1f-1imiting,  percent at  visits  least  it for health  in a l l and  of  about  Mechanic  as  Cummings  character well  as  reports  were f o r s u c h  being for  not  the  disorders.  half of a l l v i s i t s  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  37  validate  Cummings and  Mechanic a l s o  of  and  p s y c h i a t r i s t s were  (1965) f u r t h e r  to treatment, yet  the  i n A m e r i c a , more t h a n  neuroses.  resistent  related  with duration  d i a g n o s e d as  similarly  transitory,  psychoneuroses  conditions  are  Rather  Cummings  to office-based  disorders  1966).  t h e y would  conditions  evidence t h a t ,  health"  many mental  t h a t most  the  "mental  presenting  treatment.  as  Thus,  individual to  with or without treatment.  (1972) c i t e s  for  without  (1965) have r e p o r t e d  years,  health  been s u g g e s t e d t h a t  recover  a p p e a r t o be  as  c y c l e and  i t and  I t has  drug  health.  (Scheff,  sway t h e  treatment. are  unhappiness,  o f mental  mental  well  has  learning d i f f i c u l t i e s ,  i t s development part  health.  normality"  views h i s d i s c o m f o r t  affect  than seeing  it  difficulties,  a person  of  marital  legitimate t e r r i t o r y  that  o f mental  "medicalization  i n p r o b l e m s s u c h as  dependence, s o c i a l being  a definition  to requiring  treatment. Despite (1980) c i t e actually within  this,  writers  evidence that  experiencing  the  normal  such as only  mental  one  therapeutic  psychotics)  not  How of the  t h e n d o e s one issue of  the  aim  the  essence  potential not  use  demand under g i v e n  services  implies  become a  the  even  need.  even  This  true  prevalence  but  True p r e v a l e n c e  will  individual's.  we  would  on  have d i s c u s s e d , not  p r o f e s s i o n a l l y generated epidemiological  diagnostic  data  r e l y on  the  and  diagnostic  question:  several  indices  utilization  is diagnosed,  a t t e n t i o n t o the  38  need  this  b a s e d on  case, r e q u i r e s  not  i s i m p o r t a n t as  classifications  one  does  This  diagnostic  how  planning,  Prevalence  As  crux has  circumstances.  i f provided.  issue of  and  i s at the  which t o base program  Need a s s e s s m e n t s r e l y i n g on  with the  large  I f needs a s s e s s m e n t  b a s e d on  a  that  i d e n t i f y i n g i n d i v i d u a l s who  need a s s e s s m e n t m o d e l s r e l y  deal  treatment  p r o f e s s i o n a l ' s assessment o f a need,  n e c e s s a r i l y the  data.  persons  schizophrenics  "case'?  i s t o a s c e r t a i n not  o v e r e s t i m a t e need,  four  treatment.  d a t a on  n e c e s s a r i l y equal  Dohrenwend  does s e e k  (the  needs a s s e s s m e n t .  of providing  of  network and  most s e r i o u s l y i l l receive  out  illness  numbers o f t h e do  M e c h a n i c and  figures  process.  To  how  one  becomes  what  is  disease?  G.  D i sease Clare  all  (1980) c i t e s  diseases,  described notion  as "social  o f disease  disease can  physical  Peter as well  i s a human n o t i o n  points  out that  techniques disease,  this  i s equally true  considerable  further  Clare  disease  as  h e a l t h and  defined illness,  conceptualized  norm'. this  with others  However, g i v e n  definition  hardly  An a c c e p t a b l e  A p o s i t i v i s t conception  beholder.  presence o f disease  of illness  i n an o r g a n i s m t h a t  but i m p l i c i t against  Of course,  that  d e p e n d s upon t h e e y e o f i s the  inhibits i t s  o f the p h y s i o l o g i c a l organs.  functioning,  measured.  nature o f  answers t h e q u e s t i o n .  definition  the  definition  the social  from  have been made t o f u r t h e r d i s t i n g u i s h between  and d i s e a s e .  functioning  i n the area,  as a " d e v i a t i o n  t h e s e two c o n s t r u c t s  the  v a l u e s and  of physical  differentiates  of  that  work done on s c a l e s a n d  suggests, along  i s best  Attempts illness  values  depends on t h e s o c i a l  i n an a t t e m p t t o measure p h y s i c a l  disease  mental  and s o c i a l  a l l quite controversial.  Clare  clearly  man a p p l i e s t h e  mores o f a p a r t i c u l a r s o c i e t y o r c u l t u r e .  mental, and c i t e s  that  He a r g u e s t h a t t h e and t h a t  o f personal  a n d do c h a n g e : d i s e a s e  whether  a s m e n t a l , m i g h t n o t be  constructions'.  c o n c e p t on b a s i s  personal  Sedgwick who q u e s t i o n s  This  is a  limiting  i n i t i s t h e a s s u m p t i o n o f some norm which n o n - f u n c t i o n i n g  c a n be  i n t h e case o f a l l but a very  o r g a n i c a l l y r e l a t e d mental  39  disorders,  this  few o f  definition  does n o t a p p l y  at a l l .  Others argue t h a t d i s e a s e entities. while  Disease  illness  disease while  i s thus  is a social  (eg. Kleinman,  the physician  and i l l n e s s  The viewing  cultural  has  s t a t e c a u s e d p r e s u m a b l y by t h e  1980).  The p a t h o l o g i s t  This allows without  relativist  and d e f i n e d  been c r i t i c i z e d  f o r minimizing  r e a l m o f mental  perspective,  health  there  that  as being  in t h e natural Inter-related social  i s obvious. questioning  Taking  i l l n e s s and  He p o i n t s o u t t h a t  we t e r m d i s e a s e s , labeling.  b u t does n o t make  Illnesses are  human j u d g e m e n t s on c o n d i t i o n s  world, e s s e n t i a l l y reliability  a  not e x i s t i n g without  a n d d e f i n i n g them.  described  stance  i t s usefulness in  he s u g g e s t s t h a t  without that  Such a  d i s c u s s i o n by  someone r e c o g n i z i n g  them d i s e a s e s  only i f  a s an i l l n e s s .  a r e human c o n s t r u c t i o n s ,  a r e processes  without  the organic-physiological  However,  (1980) f u r t h e r s t h i s  how s o m e t h i n g becomes d e f i n e d  disease  f o r diseases  a s one by t h e c u l t u r e .  the  sociological  from w i t n e s s i n g t h e  or i l l n e s s  and d i s e a s e .  Conrad  disease  takes a d i f f e r e n t p o s i t i o n ,  nature o f i l l n e s s culture-bound  sees  disease.  a c o n d i t i o n as a disease  recognized  a r e separate  viewed as a p h y s i o l o g i c a l s t a t e ,  infers disease  symptoms o f i l l n e s s . illness  and i l l n e s s  social  that  exist  constructions.  o f judgement m e r e l y r e f l e c t s t h e  consensus.  In e a r l i e r  work M e c h a n i c  40  (1966)  i n d i c a t e d t h a t t h e term  illness one  has  hand  and,  always  i t has  referred  behavior" social  concept  response  "illness medical  i n an  and  b e h a v i o r can  cultural  Gei1  a s an  illness  an  "illness  to the  reporting  than medical  be a r g u e d  and  for  mental  disorder  and  "illness  disorder  second, the  symptoms when  reflect  illness  this  in a true  t o be t h e p r o d u c t  - not medical  to the  of this  on  on  implications  self  the social  The  between  the implications  "true"  illness mental  n o t by o b j e c t i v e  disorders.  and  of tissue  or  Such a d i c h o t o m y  need a s s e s s m e n t  also  method  report. (1972) has  suggested,  h i s discomfort or d i s a b i l i t y  i n which  how  by e x a m i n a t i o n  f o r any  certainty.  as d i a g n o s i s o f  report,  evidence produced  Mechanic  perceives  dichotomy  patient  b l o o d a s a r e most p h y s i c a l profound  illness.  of  which d e f i n e s a  then determines  behavior" are profound  i s based  demonstrable  As  cause  (1980) s u g g e s t s t h a t  i t i s the s o c i o - c u 1 t u r a 1 environment  relying  concept  suggests that  is relevant  conditioning  should respond  of  He  e p i d e m i o l o g i c a l s u r v e y may  individual  way  scientific  On  sense.  condition  has  in medicine.  which might  individual  behavior" rather  Illness social  help.  illness.  b e h a v i o r o f any  questioned  limited  behavior that  of  ways  condition  t o seek m e d i c a l i s any  i n two  to a  on t h e o t h e r , t o any  individual  Thus  been u s e d  i t manifests judgement o f  itself. illness  41  how  a  person  can a l s o a f f e c t  they  The  negative connotation  has  implications  f o r the  future no  of that  physiological disease  report if  discomfort.  illness  diseased.  being Few  substantiated  profound how  others  t o be  The  resulted  as  the  control  (eg.  of  as  as  well  diagnosis  exemption o f  has  Scheff,  and  agents'  in order  o b l i g a t i o n s are f o r the  s i c k r o l e t o be  undesirable  wish t o recover,  importantly, therapist,  the  1967).  exists -  control.  Thus,  establishment  as  lack of  implicit an  establishment,  role  may  in t h i s  sick  maintained: ill  the  i s an  most competent  1958).  i s the  as  are  "therapeutic  and,  of social  with physicians  42  Avoidance  the  responsibility for  institution  an  However,  by  being  (Parsons,  in t h i s  and  role.  p e r s o n must c o o p e r a t e w i t h a  therefore  medical  admit t h a t  usually a physician  behaviors  responsibilities  enforced  and  s t a t e and  come a b o u t  those while  p e r s o n must r e c o g n i z e  for  be  both t h o s e which  personal  have  and  cannot  various  b e n e f i t s of those a t t r i b u t e d with t h i s  i n e x c h a n g e two  himself  f o r m e d i c i n e as  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 ,  role,  as  any  i s thought t o  patient  diagnosis  i n enormous p o t e n t i a l  in the  treated  have  impact o f d i a g n o s i s  medicalization  have r e s u l t e d  subjective and  disorders  i f diseased  e m p h a s i s on  social  defined  disorders  basis.  diagnosis  t r e a t him,  instrument of  two  is necessary,  f u n c t i o n a l mental  l a r g e l y through the  of  r e a l m o f mental  i m p l i c a t i o n s , both f o r the  understated.  has  process  sufficient  organic  Given that  In t h e  A  lack  trade-off of  medical  control. their  How  agents,  the have  reflected already  and  imparted  been t o u c h e d  social  upon.  and  The  r e c o g n i t i o n t h a t t o be d i a g n o s e d involved  p r o c e s s , but a l s o  society's  values.  political  important  utilization model  criteria  issue  i s not o n l y a  With t h i s  - either  has  i s the lengthy  i m p l i e s an a c c e p t a n c e  of  comes t h e u n d e r s t a n d i n g  need a s s e s s m e n t t e c h n i q u e s w h i c h r e l y identified  values  on  illness.  43  that that  professionally  epidemiological indices  d a t a - c a r r y w i t h them t h e v a l u e s o f t h e  o f mental  and  or medical  Chapter A.  IV: Models  o f Need  I n t r o d u c t i on Given the previous a n a l y s i s  assumptions  i m p l i c a t i o n s o f each. assumptions  not o n l y  a b o u t mental e a c h model used  regarding  illness.  As has been  demonstrated  in that  committee'  area.  analyzing  as v a l i d  is precisely  (1982) have p r o p o s e d field  They which  They  s u g g e s t t h a t an  t h e d a t a from such  certain  current  need  research  assessment  methodologies. this  approach t h i s  s u g g e s t e d by w r i t e r s  not aim t o p r i o r i z e  o r badness,  i t could  o f t h e approaches  further  T h i s attempt t o d i f f e r e n t i a t e  models does  by  suggest that  paper attempts t o  Such an a p p r o a c h assumes t h e " m e d i c a l l y  a p p r o a c h t o need  goodness  discussed,  t o t h e same c o n c l u s i o n s a b o u t t h e  be l e d t o d i s a l l o w  (1973).  different  The m o d e l s c a n n o t be  assessment  i n t h e same a r e a .  e x t e n t o f needs  refute.  previously  Royse and Drude  lead t h e i n v e s t i g a t o r s  It  entail  r e s e a r c h t o e v a l u a t e a number o f a p p r o a c h e s  be t h e n e m p i r i c a l l y  approaches  of the  need a n d demand, b u t a l s o  s t a n d a r d s i n t h e needs  simultaneously  would  strategies  i s a conceptual system.  systematic  "expert  w i t h an a p p r e c i a t i o n  Different  interchangeably.  improving  of the underlying  o f need a n d demand, we c a n now r e v i e w t h e major  models o f need a s s e s s m e n t  it  Assessment  models  such as  indicated'  Donabedian  amongst t h e v a r i o u s i n terms o f t h e i r  u s e f u l n e s s o r n o n - u s e f u l n e s s ; n o r does  attempt t o i d e n t i f y a l l m e t h o d o l o g i c a l weaknessess  44  within  each  model.  assumption, only  Rather,  been  factor  1.  epidemiological surveys  2.  utilization  3.  social  4.  community g r o u p  the  assessment. have  rates  indicators forums  only the f i r s t  approaches model.  individual  treatment.  two  level, first  epidemiological  indicator specific  approaches  figures  seen  in the f o l l o w i n g  utilization  rates  two  models  identify  identifying  identify  "at r i s k '  cases  overview  problems a r e o f t e n  seen t o  45  -  The  social  of a  by d o i n g  discussed, this  c a u s a t i o n m o d e l , has  Thus s o c i a l  and  this  case  e s t a b l i s h m e n t a s a means o f care.  discussion,  both focus a t  "case' prevalence.  been e a r l i e r  assuming a s o c i a l  professional  broad  "true' prevalence while  areas f o r further  As has  can  community  o u t o f t h e bounds o f t h e  p o p u l a t i o n , community o r s o c i e t y and  by t h e m e d i c a l  what  the case being the focus f o r care  indices  identification.  social  be  utilize  data, only the  models d e v e l o p a s t a t i s t i c a l  identify  though  fall  i n d i c e s and  The  utilization  clearly As w i l l  epidemiological  for  is  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  medical  can  Drude s h a r e , t h a t  advocated:  group  the  in assessment  common  g e n e r a l , f o u r m a j o r m o d e l s o f need a s s e s s m e n t  Although be  t o avoid the  w h i c h o b v i o u s l y Royse and  important In  i t i s an a t t e m p t  been  model,  co-opted  identifying  indicators  areas  measuring  i n d i c a t e medical  need.  Finally,  t h e community g r o u p  t h e c a s e b u t on t h e needs question.  I t s approach  "bottom-up', t h o u g h , may  be ga i n i ng  B.  forum approach  perceived  is generally  as w i l l  insisting  is generally  e p i d e m i o l o g y ' , which T h e r e have been development  mental  disorders  community  indirect  to  generally  scientific  upon s c i e n t i f i c  rigor.  within  War  need  referred clearly  t o as  periods  i n v e s t i g a t e the true  in the United  (Weissman and K l e r m a n ,  disorder  measurement u s i n g  11.  46  disorders.  States  1978).  and o t h e r o f f i c i a l  was  key  in the  prevalence of  t o determine the frequency o f  a s mental  The  i t s assumptions.  s u r v e y s o f mental  hospital  surveys  "psychiatric  indicates  three d i s t i n c t  l e a d e r s , and  Such  "hard'  community  called.  idiocy  was  Key records and  This type of  i n f o r m a n t s and m e d i c a l  r e c o r d s were t h e p r i m a r y means o f e s t i m a t i n g World  o f the  "true' prevalence f i g u r e s .  i n a community  i n 1855  were u t i l i z e d insanity,  and  of epidemiological  attempt  undertaken  and  such p r o c e d u r e s  surveys are  assessments  populations generating  first  professional  methods, p r o d u c i n g t h e most a c c e p t a b l e and  involve case-finding  The  non  Surveys  c o n s i d e r e d t h e most r a t i o n a l  process  by t h e community i n  be d i s c u s s e d ,  Community e p i d e m i o l o g i c a l  data t o those  on  i n soph i s t i c a t i o n .  Ep i dem i o1og i ca1  assessment  f o c u s e s not  need  until  Fan's and determining  Dunham  (1939) p r o v i d e d t h e b a s i s f o r  need f o r p s y c h i a t r i c  metropolitan area  in the  examined t h e e c o l o g i c a l They f o u n d  that  1930's w i t h an distribution  d i a g n o s i s was  residence o f the p a t i e n t s , hospitalization highest  social  occurring  (1983) has  study.  He  results  because  recently  suggests that  never  rates).  which  admissions. of  of the areas  the f i r s t  of social  this  He  This time  observes  be  approach  of  step  variables  that  in  methods r e l y i n g  i n 1930  he  were u n r e l i a b l e diagnosis.  he  community o f  the  cases  ( t h e main on  cases  utilization  t o a mental  socioeconomic the  1930  hospital. "the  diagnoses  to  l a c k o f knowledge a b o u t  Finally  he  suggests that the rates p a t t e r n  differential  they represented the  m o b i l i t y o f the mentally  47  gap'  level.  due  origin.  as  would  c a r e he t e r m s  v o i c e s concern that  were m i s l e a d i n g b e c a u s e  residential  unreliable  d i d not f o r s e e t h i s  the undetected  i t varies with  earlier  produced  o f the agency  between symptom o n s e t and  Secondly,  this  into account  commited o r be a d m i t t e d  notes t h a t  reported  critiqued  they d i d not t a k e  issue, assuming-that  he  from  T h i s was  came t o t h e a t t e n t i o n  eventually  and  study  t o the area  for residents  concern o f c u r r e n t assessment  an  ecologic  the highest rates  importance  Chicago  health.  Dunham  that  the  in the  of f i r s t  related  disorganization.  towards demonstrating mental  services  i l l rather than  their  The mental  second p e r i o d  health  changes  of" e p i d e m i o l o g i c a l  developed post  i n how mental  WWII.  disorder  numbers o f men were r e j e c t e d grounds.  Despite  that  health  problems  The r e s u l t s o f t h i s i n t e r e s t as large  these disorders  expertise growing the  developed  adult  and  residents  selected  Leighton  (1962)  County.  health  of this  impairment.  surveys.  interviewed  1,000  i n midtown  o f a stable  Hollingshead  and R e d l i c h ' s  prevalence established  an important d e t e r m i n a n t o f t r e a t e d  studies  This  (1959) a s s e s s e d t h e impact o f s o c i a l  (1958) s t u d y o f t r e a t e d as  already  conditions in  by p r o b a b i l i t y s a m p l i n g  e c o n o m i c change on t h e mental inStirling  The  WWII c o n t r i b u t e d t o  a n d l e d t o l a r g e community  Midtown M a n h a t t a n s u r v e y  community  camps.  s t r e s s a s opposed t o p r e d i s p o s i t i o n .  population  Manhattan.  presumably as  l e d t o a f o c u s on  i n t e r e s t i n p r e v a l e n c e and i n s o c i a l  The  screening  in individuals  a n d knowledge d e v e l o p e d d u r i n g  general  these  numbers o f  o f concentration  screened f o r p s y c h i a t r i c i l l n e s s precipitant  large  o f war - s i t u a t i o n a l s t r e s s e s  s u c h a s combat a n d d e p r i v a t i o n that  grounds f o r  psychiatric difficulties  result o f theconditions  fact  Firstly,  i t b r o u g h t a t t e n t i o n t o mental  p r o c e s s became o f i n c r e a s e d  a  was v i e w e d .  major  f o r s e r v i c e on p s y c h i a t r i c  in general.  s e r v i c e men d e v e l o p e d  The war e f f e c t e d  the scientific  r e j e c t i o n s were q u e s t i o n e d  development i n  erareported  generally  mental high  social illness.  rates  class The  o f mental  F o r example, t h e M a n h a t t a n s t u d y r e p o r t e d 2 3 % 48  of their  subjects  substantially  Many o f t h e s t u d i e s overall  mental  classification reliability lists  made  impairment  input,  subjective  complaints  of traditional  each  s c a l e s and  t h e need f o r economical.  were t h e f o c u s .  studies  tended t o r e f l e c t t h e  in a specific  Essen-  geographical  psychiatric disorder normal  major  p e r s o n a l i t y v a r i a n t s and  ( G o l d b e r g and H u x l e y ,  illness  but a l s o  1980).  categories  had a d i f f e r e n t  T h i s use  made t h e  underlying  syndrome, c o u r s e , a n d t r e a t m e n t , a n d t h a t  biology  t h a n e n v i r o n m e n t was t h e m a j o r c o n t r i b u t i n g f a c t o r .  was c o n t r a r y  causation  which  to this  A m e r i c a n e m p h a s i s on s o c i a l  contributed  t o a more u n i t a r y  illness,  mental  health  opposite  points  on a c o n t i n u u m .  a n d mental  Weissman a n d K l e r m a n epidemiological health  such  illness  psychiatric diagnostic  assumption t h a t  This  In a d d i t i o n ,  2,550 i n h a b i t a n t s  personality deviations,  rather  s t a g e s a n d i t s low  European p s y c h i a t r i c t r a d i t i o n .  d e f i n i n g not only  etiology,  Psychiatric  s u r v e y 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  interview  area,  lists.  m a k i n g them e a s i e r a n d more  European  developing  Mo 11 e r ' s  and p r o b l e m  used measures o f  large surveys f e a s i b l e , reducing  f a c t o r s o f mental  earlier  period  was i n t h e d e v e l o p m e n t a l  Concurrent  to  of this  was a c k n o w l e d g e d .  psychiatric Social  impaired.  research.  illness  being  (1978) s u g g e s t t h a t  d e v e l o p m e n t made i m p o r t a n t They s u g g e s t t h a t 49  these  concept o f viewed as  this  period of  contributions to surveys  introduced  rigor  to  e p i d e m i o l o g y by  techniques,  standardized  statistical  analysis.  of  independent  psychosocial to the  and  of  scales cites  level,  scales  potentially  may  note,  than  such  definition the  of  i d e n t i f i c a t i o n of  1966).  From t h e  global  impairment  can  not  rates  of The  be  l a t e r were h i g h e r  least  the  "in care'  scales  used are  treated/untreated validity  stress.  of  what do  disorder  may  a  become  treatment,  possibility  may  serve to exists  On  that  perpetuate (Scheff,  viewpoint,  independent o f categories  the  diagnosis to  generate  disorders.  global the  (1972)  the  The  into diagnostic  the  suggesting  inpatient  problem a l s o  At  among  suggest that  n a t u r e o f mental  as  use.  correlations  community s a m p l e s ,  to at  mental  Mechanic  psychiatric epidemiological  translated  to question:  indicating  treatment at a l l !  oneself  conditions.  been s u g g e s t e d t h a t  r e s u l t s may  permanent when s u b j e c t e d  researchers  measures o f  measure some t r a n s i e n t  transient  p e r h a p s any  in medical  response b i a s e s .  r e t e s t a year  inpatients  more c y n i c a l  and  i t has  domain  include  is their appropriate  B r u c e Dohrenwend's work,  such  sophisticated  sensitized  such g l o b a l  s u f f e r from v a r i o u s  psychiatric that  such v a r i a b l e s  i s c o n t r o v e r s i a l , as  between t e s t and  and  in epidemiology to  value of  methodological  sampling  Furthermore, they enlarged the  e c o n o m i c f a c t o r s and  However, t h e  the  development o f  questionnaires  variables  influence  illness  the  impairment  scales 50  scales  is also  a c t u a l l y measure?  The  open  Dohrenwends s u g g e s t t h a t anxiety,  they p a r t i c u l a r l y  sadness, p s y c h o p h y s i o l o g i c a l  e n e r g y and  a perception  however, more  most h o s p i t a l i z a t i o n s ( a t facilities  prior  ill.  the  Whether t h e s e two  questionable.  self-1imi ting,  health  third  began  those  psychotic  be  or without  period of  in the  late  compared  epidemiological sixties  as  Growing  Cummings  epidemiology' developed, e p i d e m i o l o g y o f mental  in diagnosis.  shifting  health  (1965)  disorders  study  are  the  t o an  i n mental  factors  i n t e r e s t in c l a s s i f i c a t i o n reliability  i s  developments  health.  and  seriously  treatment.  stressed evidence of b i o l o g i c a l  validity  are,  health  symptoms o f t h e  g r o u p s can  of  psychosis,  community mental  sciences  in  than the  f i n d i n g s t h a t most n e u r o t i c  with  lack  in p s y c h i a t r i c  In a d d i t i o n , Cummings and  have commented on  The  least  tap  Such symptoms  neurosis  t o advent o f the  movement) r e f l e c t i n g  symptoms,  o f poor h e a l t h .  i n d i c a t i v e of the  seem t o  in medical i n mental  led to  advances  "Psychiatric  emphasis from  epidemiology of  the mental  d i sorders. A b a s i c premise u n d e r l y i n g that  a specific  disease  throughout a population defined  by  i s not but  sex,  ethnic or  characteristics  will  differ  causal  Knowledge o f t h i s  f a c t o r s w h i c h can  subgroups o f a  racial,  in the  or other  is  population, relevant  frequency of individual  uneven d i s t r i b u t i o n  t h e n be  51  studies  randomly d i s t r i b u t e d  that  age,  disease.  epidemiologic  can  further established  suggest by  other  research  techniques.  multifactorial has  mode o f  emphasized the The  in the  Epidemiological  research  United  from f i v e  a  and  to  Holzer,  Boyd, K e s s l e r Diagnostic disorders. outcome a s  basic of  and  Interview Freedman  d e p e n d i n g upon t h e  their  prevalence  recent  of c l i n i c a l  in a r e p r e s e n t a t i v e 52  of  i s on  DSM  mental  charting  illness  1 percent  to  measurement  Dohrenwend  (1980)  literature,  m a l a d a p t i o n among U.S.  future  contents.  surveys range from  sample o f  Burnham,  program's  specific  of  the  III  nature of the  to  services  George,  a background  summary o f t h e  to  continuance  of psychiatric  G o u l d , W u n s c h - H i t z i g and  in t h e i r  children  map,  of  s e r v i c e s use,  focus  this  rates  disorders,  health  The  e x i s t i n g estimates  50  true  mental  (1984) d e s c r i b e s  epidemiological  report  to estimate  Schedules - defined  from r e c e n t  technique.  drawn  i n f l u e n c i n g use  1984).  v a l l e y s and  Myers,  20,000 s u b j e c t s  d e v e l o p m e n t and  a kind of topographic  Currently,  (Reiger,  K o r f f , Anthony, H e l z e r ,  Loche,  being  This  are  mental  study f a c t o r s  Von  p e a k s and  percent,  currently  1984).  specific  h e a l t h and  factors.  i s N.I.M.H.'s  goals  i n f l u e n c i n g the  and  risk  Hough, E a t o n , L o c h e ,  incidence  study f a c t o r s  relative  The  rates of  disorders,  survey  sample s i z e o f r o u g h l y  sites.  prevalence  (Eaton,  for multiple  States  a  for psychiatric disorders  Catchment Area program  Kramer, R o b i n s , B l a z e r , s u r v e y has  increasing acceptance of  explanation  major e p i d e m i o l o g i c a l  undertaken  estimate  The  that  the  school  communities  is  unlikely  t o average  less than  Dohrenwend a n d Dohrenwend prevalence of adult organic  12 p e r c e n t .  (1980) r e p o r t  Neugebauer,  that  psychiatric disorders,  the true  with  no known  b a s i s , a t an o v e r a l l r a t e f o r t h e a g g r e g a t e d  functional  disorders  Dohrenwend  (1980) i n h i s summary c h a p t e r b r e a k s t h i s  to:  between  o f between  .6 a n d 3.0 p e r c e n t  16 a n d 25  f o r schizophrenia,  percent  f o r a f f e c t i v e psychosis,  percent  f o r neurosis  disorder.  and a b o u t  about  in a representative  13.0 p e r c e n t  show s e v e r e p s y c h o l o g i c a l  population  a t any g i v e n  of psychological discussion  disorder.  i s the fact  that  communities  psychiatric disorder. a b o u t 25 p e r c e n t  time  is experiencing  Most  importantly  disorders  t h e most s e v e r e d i s o r d e r s  received  treatment.  schizophrenics treatment. refers  and 40 p e r c e n t  to traditional  non-professional  large m i n o r i t i e s  53  have  even  never of  do n o t r e c e i v e  i s , o f course, that  network o f c a r e ) .  significant  p e r h a p s 20 p e r c e n t  of psychotics  therapeutic  that  t r e a t m e n t and t h a t  He e s t i m a t e s t h a t  (The a s s u m p t i o n  some d e g r e e  Dohrenwend h y p o t h e s i z e s  ever r e c e i v e d  of  for this  about one-quarter o f those with c l i n i c a l l y  functional  o f the  and s o m a t i c d i s t r e s s t h a t  Together, these r e s u l t s estimate that  for  3.0  f o r personality  sample o f U.S.  was n o t a c c o m p a n i e d by c l i n i c a l  only  about  between 8.0 a n d 15.0  7.0 p e r c e n t  he h y p o t h e s i z e s t h a t  population  the  down  In a d d i t i o n t o t h e s e c a s e s o f p s y c h i a t r i c  disorder,  would  percent.  treatment  s e r v i c e s as opposed t o t h e  Related  to this  indices to offer between t h o s e  i s the f a i l u r e o f epidemiological  information  who p r e s e n t  regarding  the differences  t h e m s e l v e s f o r t r e a t m e n t and  who do n o t i d e n t i f y t h e m s e l v e s a s r e q u i r i n g c a r e . r e s u l t s o f such  surveys  in t h e experts'  e y e s , b u t do n o t r e f l e c t  of the patient.  In t e r m s o f a s s e s s i n g  delivery  may o f f e r  epidemiological  rates o f "true demand  figure will  a c t u a l l y present  itself  model  able  do t h e y  of diagnosis  methodological  experts those  perceive  who  on t h e t r a d i t i o n a l  are a l s o over  mental  i n c l u s i v e , not  i s t h e end r e s u l t  Epidemiological  Becoming a p a t i e n t , o f a complex  indices, in their  estimate  t h e p r o f e s s i o n a l ' s v i e w o f need, w i l l  estimate  demand  C.  i n any s e r v i c e p l a n n i n g  chain  ability to likely  over-  endeavor.  U t i 1 i z a t i o n Rates The  model, and  whom t h e  h e a l t h d i s a b i l i t y and  p o t e n t i a l demand.  as we have d i s c u s s e d , of events.  focus  i n d i c e s f o r needs  d i f f e r e n c e between t h o s e  as having  represent  prevalence'  a n d t h u s a r e p l a g u e d by r e l a t e d  problems, they  t o make t h e c r u c i a l  i n t h e eyes  f o r care.  Thus, a major s h o r t c o m i n g o f such  medical  prevalence'  i n d i c e s are unable t o o f f e r  a s t o what p r o p o r t i o n o f t h e " t r u e  i s not only  Thus, t h e  need f o r s e r v i c e  information  assessment  those  aim o f t h e s o c i a l  survey,  i s t o review the various  agency) past  and c u r r e n t 54  or s e r v i c e  providers'  utilization  (both  s e r v i c e s rendered  individual  p a t t e r n s and  requests the  f o r s e r v i c e by c i t i z e n s  number a n d t y p e s  community.  i n an a t t e m p t  o f s e r v i c e s demanded  These data  may be s e c u r e d  and  management The  what  in their  practices regarding as an admission  counts r e s u l t i n g admissions during  a given  a different Diagnosis  Supporters but of one  i s problematic;  f i g u r e s vary  hospital, during  area  Once h a v i n g they  may be d e f i n e d  t o another.  reliability  At the services  i s poor. reliability  One o f t h e most  (1973) w h i c h r e v e a l e d  voices  made t h i s  schizophrenia  diagnosis  their  critical that in  on t h e  i n p e r f e c t l y normal  pseudo-  and a d m i t t i n g t o  diagnosis  t h e p a t i e n t s ' s t a y s , which ranged from  55  institution.  population.  diagnosed  d i d not reverse  multiple  s e c t o r s may p r o v i d e  widely.  i s t h a t o f Rosenhan  symptom o f h e a r i n g  patients.  health f a c i l i t y  name t o t h e same  case h o s p i t a l doctors  single  period to a single  government  o f contact f o r  having  o f t h i s approach defend d i a g n o s t i c  published reports  what t y p e  Institutions  because o f d u p l i c a t e d  f r o m one g e o g r a p h i c a l  same t i m e d i f f e r e n t  In c o u n t i n g  a case?  from a s i n g l e i n d i v i d u a l  What c o n s t i t u t e s a mental  by  records  a n d what d o e s n o t .  r a t e s may be m i s l e a d i n g  differently  and c u r r e n t  problems.  i s t o be c o n s i d e r e d  service qualifies Admission  structured  r a t e s a s an i n d i c a t o r o f  need p o s e s m a j o r m e t h o d o l o g i c a l  differ  particular  information.  use o f under-treatment  admissions,  in a  through  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  t o understand  a t any time 7 t o 52 d a y s ,  despite  the  fact  f u r t h e r o f any diagnostic  that  The  impression  of American  the  act of  community-based  to the  utilization  care  for that  m a t t e r ) may  that  indication of  i t i s an  labels deviant  On  the  health  mental  or  other  (Mechanic,  complain the  of  behavior. to  sinful  1962)  health  the  part  society's  The  include  hand  of treated  rates  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  p s y c h o p a t h o l o g y on  m e r e l y bad  is that  p s y c h i a t r i s t s are  indication of  mental  d i d not  value.  Another o b j e c t i o n is that  pseudo s u b j e c t s  symptoms.  skills  questionable  the  be  o f the  expansion o f the  behaviors previously  i t may  reflect than  services are  "illness  illness  not  an patient  r e a c t i o n t o what i t  i s undertaken elsewhere  rather  less  (or  realm  of  thought o f in t h i s  as  paper.  behavior"  itself.  Users  a l w a y s t h o s e who  of  need i t  most. Of  equal  importance  always u t i l i z e r s : part  b e c a u s e , as  in treatment), Such f a c t o r s as  the  is a final  on  type of  this  g r o u p , not  in a of  can  being long  care  eventuality.  strategy  needers are  only  and  utilization  epidemiological  chain  56  of  not  is in (being  events.  socioeconomic  Needs a s s e s s m e n t  make p r e d i c t i o n s  approach  approaches  This  a patient  a b o u t a l l p e o p l e w i t h mental  Supporters of the broader  step  that  unmet n e e d .  earlier,  accessibility  influence this  fact  problem o f  discussed  status, this  i s the  about  disorders.  suggest that  identify  based  too  the  large  a  group f o r program p l a n n i n g , a r g u i n g t h a t t h e group not identified would to  by u t i l i z a t i o n  likely  stigma  T h i s seems a narrow a n d i n f l e x i b l e  of planning or other  - planning  barriers  Most u t i l i z a t i o n thus  this  model  without  daycare  facilities  Health  inpatient totals  relies  on d i a g n o s t i c d a t a , and  This r e f l e c t s  illness.  Diagnostic data  purposes.  f o r the mentally  system t h a t those  facilities  S e r v i c e s , t h e Mental  facility.  Health  different  operated  Centres  by  and l a r g e cumulative  are possible.  approach.  R e l y i n g on t h e m e d i c a l  questionable  reliability  care users.  justification  I t may  and r e s o u r c e  program b a s i s but o f f e r s approach o f planning. it  i n p a t i e n t and  Thus, n e i t h e r comparison o r  need  b a s i s o f demand f o r s e r v i c e s i s t o t a k e  health  are not  In B r i t i s h  i l l , use a  In s h o r t , t o d e f i n e and i d e n t i f y  with  t h e medical  H o s p i t a l Programs, which a d m i n i s t e r  classification Mental  data  o f mental  view o f t h e  t o care.  problems f o r p l a n n i n g  Columbia,  data  c a n i n c l u d e means o f r e d u c i n g  model's c r e d i b i l i t y .  theory  list  n o t u s e s e r v i c e s and a r e t h e r e f o r e n o t r e l e v a n t  planning.  concept  f i g u r e s and w a i t i n g  has i t s p o l i t i c a l  government c a n a s s u r e  model,  s o l e l y on t h e  a narrow  conceptual  i t provides  about a d i s c r e t e  data  group o f  serve the purposes o f allocation  little  well  t o t h e broad  Seemingly generating purpose  individual  spectrum "rational'  i n generating data  i t s p u b l i c that they  57  on an  with  data  which a  are providing  service. to  I t p r o v i d e s a b a s e by w h i c h  incremental  s e r v i c e s c a n be made when c o n s t r a i n e d by  additions  financial  1imits. Finally, the  utilization figures  provide  use o f s e r v i c e s a l r e a d y p r o v i d e d .  Need  i m p l i e s an attempt t o s p e c i f i c a l l y a d d r e s s heretofore  unrecognized  developmental  nature  and unmet.  o f planning.  provides a b a s i s f o r incremental a basis f o r j u s t i f i c a t i o n  D.  Soc i a 1 I n d i c a t o r The  indicator  very popular, advocates  The edited  on  earlier  Redlich and on  social  of interest  The e s s e n c e  considered  environmental  descriptive  indicator  factors  i s t h e a n a l y s i s and  is attributed  indicators  in this  Leighton  no new  information.  such  The a p p r o a c h  who  i s based  as H o l l i n g s h e a d and  Myers and R o b e r t s  (1963),  (1959)  who f o c u s s e d a t t e n t i o n  a s s o c i a t e d w i t h mental  58  t o R. Bauer  i n 1966, m a r k i n g t h e  area.  (1959),  S r o l e , L a n g e r and M i c h a e l the social  provides  These approaches c o n s i s t o f  work by r e s e a r c h e r s  (1958),  and  i n f e r e n c e s o f need f r o m  a book on s o c i a l  beginning  p l a n n i n g , a t worst  Approaches  of existing  term  a t best  i n p u b l i c records o r r e p o r t s , thus  a r e generated.  integration  Utilization  planning.  health.  c o m p i l i n g a n d making  data  t h e needs  This r e f l e c t s the  appealing t o the social  found  assessment  a p p r o a c h e s have r e c e n t l y been  o f mental  statistics  i n f o r m a t i o n about  illness.  The  a s s u m p t i o n on w h i c h s u c h t e c h n i q u e population  c h a r a c t e r i s t i c s p r e d i c t high  incidence  o f mental  f o r mental  health  The  is built  social  health  illness  and o t h e r  social  risk  and h e a l t h  indication  of the q u a l i t y o f l i f e  an  means o f e v a l u a t i n g social  i n d i c a t o r movement  highly  successful  unlike  economic t h e o r y ,  which t o d e f i n e  economic  i n a community. t o develop  1983).  However,  o f community e x i s t s by Thus s o c i a l  indicators  deductively.  i n d i c e s have been most o f t e n incidence  o f mental  p a t h o l o g y , and subgroups w i t h  c i t e d as  illness: special  needs.  Poverty Customary  income, c h r o n i c low  (Bloom  variables.  r e l a t e d t o increased  1)  used as a  i s an e f f o r t  i n d u c t i v e l y rather than  Three s p e c i f i c  social  index  assumed t o be an  and c o m p l i m e n t a r y t o t h e  no t h e o r y  relevant  have been c h o s e n  poverty,  services.  and a r e o f t e n  interventions  assessment procedure p a r a l l e l  being  need  i n d i c a t o r i s t h u s a measure o f s o c i a l  On t h e a g g r e g a t e t h e y a r e o f t e n  The  i n terms o f  and t h e c o n c o m i t a n t  problems.  global  i s that certain  indices o f poverty  unemployment, s u b s t a n d a r d  levels o f education.  t o mental  illness  different  theories  How p o v e r t y  i s unclear,  and  Redlich  low  socio-economic  in their  h o u s i n g and  actually relates  though a t l e a s t  have been p u t f o r t h .  reported  t o be a s s o c i a t e d  a r e low p e r c a p i t a  Hollingshead  1958 New Haven s t u d y  s t a t u s w i t h i n a community  with  relatively 59  three  high  that  i s found  rates of  disorder. this  Dohrenwend and Dohrenwend  research,  suggesting  economic s t a t u s of that the  social  that  associated  high  in h i s S t i r l i n g  furthered  i t was n o t s o c i o -  alone but rather position that  (1969)  the associated  was t h e c r u c i a l  rate of disorder.  stress  factor in  Leighton  (1959)  County Study, suggested t h a t a  community's d e g r e e o f i n t e g r a t i o n o r d i s i n t e g r a t i o n was related along  t o t h e mental  of i t s inhabitants.  with h i s co-workers, defined  sociocu1tura1 as:  health  a high  poverty,  indices o f  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 r e q u e n c y o f b r o k e n homes,  extensive  migration,  He,  factors  extensive  weak a n d f r a g m e n t e d  networks o f communication and r a p i d and widespread social (1959),  change. in their  Redlich's stress  A t t h e same t i m e , continuation  earlier  - disorganized  control  of Hollingshead  work, s u g g e s t e d t h a t  inter-familial  lack o f parental  - was a l s o a s s o c i a t e d  psychological  and  home, heavy r e s p o n s i b i l i t y o f t h e  mother, absence o f f a t h e r , and  Myers and R o b e r t s  with  high  guidance rates o f  disorder.  On t h e l a t e r Langer and Michael  Midtown M a n h a t t a n S t u d y , (1962) examined s o c i a l  terms o f s t r e s s - s t r a i n  model,  Srole,  class in  i n which mental  was s e e n a s a r e a c t i o n t o n o x i o u s e n v i r o n m e n t a l such as c h i l d h o o d and  economic d e p r i v a t i o n ,  socio-economic worries. 60  illness forces,  broken  homes  The i n v e s t i g a t o r s  found  that  the  s h e e r number o f  reported mental  was  the  health  particularly  most e f f i c i e n t  risk.  No  three factors  reporting  one  was  or  two  more  combination of  causal  indices purely  causal  the  i n mental  " s t r e s s ' model  stress  of  of  factors  interpretive theory,  specific  illness  factors,  mental  notion of  person  stress  absence o f  This  for  poverty  Although father  view o f and  the  theory of  result  such are  not  p o v e r t y as  mental  individual  61  the  the  •* mental  it fails  to  variability  certain  causal illness.  s u g g e s t s under which occur,  illness.  reductionist,  in a straightforward  will  the  i d e n t i f i a b l e mental  in p a r t i a l support of  i t is mainly  a  associated  i t suggests that  in  as  over-  is a direct result of  theory  illness  explanation  a  particular  health.  r e l a t i o n s h i p : p o v e r t y •* s t r e s s Although the  risk that  d i s e a s e a d h e r e s most c l o s e l y t o  Although a l s o  suggesting  was  person  number o f  p o s i t i v i s t ' s framework, certain  illness.  The  illness  socialization/environmental Within the  greater  poor, they are  in t h i s group.  factor  a hypothetical  supports the  i n mental  domain o f  represented  itself  factors.  b r o k e n homes and  the  predicting  factor  important than the  factor  as  had  factors  method o f  stress  factors.  Such e v i d e n c e one  one  s i g n i f i c a n t but  reporting  factors  identified stress  condition  offer given the  same  degree o f s t r e s s . The  second t h e o r y  regarding  the poverty-mental  illness  r e l a t i o n s h i p i s that poverty  seeking  help  f r o m mental  poverty-related barriers related access of  t o care.  other  itself  could  t o care.  illness  i n poor a r e a s  individual  of the social The  supports that  poverty  i t as o n l y a  f o r high  t h e medical  rates of  model o f  i t implies that the i l l n e s s i s  entity  socially  caused, t h a t  within the individual, i t c a n be c u r e d ,  there  and t h a t  regardless  situation.  third  drift'  explanation a n d mental  hypothesis  a medical  the higher  model  of the r e l a t i o n s h i p  illness (Myerson,  of illness  rates of illness  socio-economic c l a s s individuals  supports  treatment,  between p o v e r t y "social  r o l e and p l a c e s  rather than  exists a disease  This takes  Such an e x p l a n a t i o n  in that  individualistic  with  be a c c e s s e d .  out o f the causal  illness  w o u l d be t h a t o f any  j_f s e r v i c e ( i . e . t r e a t m e n t and c u r e )  barrier  mental  prevent  would s u g g e s t t h a t t h e r a t e  i n a poor p o p u l a t i o n  was s o u g h t o r  access-  Such f a c t o r s a r e known t o T h i s model  population  t o pay, c u l t u r a l  t r a n s p o r t a t i o n and o t h e r  problems.  one f r o m  d i s o r d e r s because o f such  f a c t o r s as i n a b i l i t y  t o care,  illness  prevents  is a result  "drifting' 62  has been t e r m e d t h e 1941).  It also  f o r i t suggests  found  i n t h e lower  of mentally-ill  down f r o m o t h e r  socio-economic  l e v e l s as a r e s u l t  of their  illness.  supports the i n d i v i d u a l i s t i c implies  incurability  available  - that  in the higher  who a r e m e n t a l l y  ill  It clearly  view o f i l l n e s s and even w i t h t h e s e r v i c e s  socio-economic  are resistant  levels,  t o treatment  ( i n t e n t i o n a l l y o r u n i n t e n t i o n a l l y ) and d r i f t lower  levels of society.  opposition  is actually  complicated  t h e mental  and s t r e s s f u l  ill  drift  down t o a  less  existence.  pathology a r e c l o s e l y  w i t h t h o s e o f p o v e r t y and t h e r e correlation addiction, mentioned  between t h e two.  indices  aforementioned, defined  of social  drug  pathology.  of social  Such  and p a r t i c u l a r l y  by L e i g h t o n  (1959) who  o f c r i m e a n d d e l i n q u e n c y a s one disintegration.  p a t h o l o g y a s an i n d i c a t o r  as t h e d e f i n i t i o n  o f mental  has a l s o  illness  w h i c h 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 ,  i n c l u d e d w i t h i n t h e mandate o f mental 63  The come  has e x p a n d e d .  d e v i a n t - s u c h a s a l c o h o l i s m and c r i m e  become  factors  i n s t u d i e s such as t h e  high frequency  Behavior  i s an o b v i o u s  Alcoholism,  of h i s indices o f socio-cultural  about  linked  c r i m e and d e l i n q u e n c y a r e t h e most o f t e n  have been examined  just  in direct  Soc i a 1 p a t h o 1 o g y Indices o f social  use  t o the  t o the "stress' theory o f poverty,  suggesting that  2)  This  those  bad o r  - has health.  To  include deviancy  of medicalization  in t h i s  - the  expansion o f the  medicine over behaviors physiological  cause.  were s e e n t o be individual, result  o f mental  individual this  by  an  and  now  the  and  health  therefore  3)  aged, the  the  which  g r o u p s most m e n t i o n e d a r e  mentally The  learning  retarded  inclusion of b a s e d on  the  and  children,  in  but  varying  with  region. of  they are  illness  age,  c h i l d r e n and assumption o f  o f mental  social  the  included  t h e s e two  i n most  o f b o t h c h i l d r e n and  64  not  aged  high  illness  class,  It i s l i k e l y within  the  the p h y s i c a l l y  i s g e n e r a l l y t h o u g h t t o be  widely  existence  or  s p e c i a 1 needs  vary  that  an  implies  estimates  estimates  in  However,  social  Epidemiological  geographic  the  w i l l f u l n e s s ) manner.  a p p e a r s t o be  likely  the  i n d i v i d u a l t o behave  ( r a t h e r than deviant  four  disabled.  of  stress, faulty  Popu1 a t i o n s u b g r o u p s w i t h The  of  or  behaviors  treatable  professional.  - high  s i m i l a r f a c t o r s causing  b a d n e s s and  known o r g a n i c  responsibility  approach a l s o supports a notion  "abnormal'  of  i n c r e a s i n g l y v i e w e d as  illness,  causation  process  domain  Whereas p r e v i o u s l y s u c h  a mental  environmental and  w h i c h have no  willful  they are  manner s u p p o r t s t h e  risk.  in c h i l d r e n around  ethnic  purely groups  group  due  and  to  though  indicator lists. the  10%,  elderly also  The places  an  additional  community  - socio-economic as well  oriented. of  b u r d e n o f s t r e s s on a d u l t s  T h u s , i t may  as r e l a t i o n s h i p  be assumed t h a t  large  numbers  either children or e l d e r l y , while bringing  themselves higher higher  rates  rates of illness  addition,  living  of illness, in their  relevant  too often  caretakers.  in marginal  syndrome o f g e r i a t r i c  other that  senility  disturbance  mental  as well  The U.S. included  contrary  as p h y s i c a l  America,  a  specific  involves  gross l o s s and  d e t e r i o r a t i o n , suggest  15% o f t h o s e o v e r  70 and  55 a r e v i c t i m s .  Community  the care  Mental  Health  o f the mentally  C e n t r e movement retarded,  t o most o f Canada where r e t a r d a t i o n i s  considered  a social  rather  inclusion of physical  than h e a l t h  handicapped  b a s e d on t h e a s s u m p t i o n t h a t greater  which  are  isolation.  a s a r e s u l t o f memory  40% o f t h o s e o v e r 80,  7.5% o f t h o s e o v e r  discussed  p o v e r t y and  to  In  t o the e l d e r l y i n North  Recent f i g u r e s f o r A l z h e i m e r ' s d i s e a s e ,  behavioral  within  also contribute  the poverty factors previously  particularly  has  in the  risk  such  problem.  i s assumed t o be individuals are at  f o r t h e d e v e l o p m e n t o f mental  emotional  disorders  inclusion  could  than the general  a l s o be a r g u e d  disabled,  and  population.  This  f o r on t h e b a s i s o f t h e  concomitant poverty o f those both retarded physically  The  and  a n d , a l s o , on t h e b a s i s o f t h e 65  increased  s t r e s s on t h e i r  explanations mental  illness,  criticisms pathology  Several As  support  though once a g a i n ,  discussed  regarding  model o f  open t o t h e same  the poverty  and s o c i a l  indices.  major problems e x i s t  deductive  Both  a s o c i a 1/environmenta1  p r e v i o u s l y mentioned t h e i r  than  care g i v e r s .  and t h e r e f o r e  with  choice  social  indicators.  i s inductive rather  i t is difficult  t o know  i f an  a d e q u a t e s e t o f i n d i c a t o r s has been c h o s e n .  Secondly,  interpretation  values  o f change o v e r  judgement - how much change is  little  evidence  Writers Goldsmith there  those  (1972) have r e p o r t e d t h a t , of social  Finally,  o f these  s u c h a s W e i s s and B u c u v a l a s  that their  on  is significant?  f o r the v a l i d i t y  i s an " o v e r s e l l '  suggests  time r e l i e s  measures.  (1980) and  i n Carol  indicators.  Weiss'  terms,  Goldsmith  p u r p o s e needs t o be c l a r i f i e d  i n c u r r e n t use a r e inadequate.  there  and t h a t  Weiss argues t h a t  this  movement c a n 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 reporting;  (2) a n a l y s i s o f s o c i a l  prediction  of future social  same t i m e she c r i t i c i z e s and  priorities,  developing  events  their  suggesting  c h a n g e , and (3) t o t h e and s o c i a l  At t h e  use i n t h e s e t t i n g o f g o a l s  t h a t the very  indicators i s value-laden;  66  life.  process o f  their  very  definition  reflects  sociopolitical  dignifying  a statistic  values.  by r e f e r r i n g  does n o t p r o v i d e t h e c o n c e p t u a l understand  it.  planning, yet given t h i s  can  be u s e d  are left  E.  f o r t h a t reason,  for citizen  identification service the-mail  framework,  How much i s not answered,  Approaches  t h e f o u r models,  consumer a d v o c a t e s allow  lack o f conceptual  i s t o o much a r e q u e s t i o n s  approaches which f o c u s and,  make d e c i s i o n s  t o t h e judgement o f t h e u s e r .  Commun i t y Group Of  indicator  framework by w h i c h t o  i n a n y manner t h e u s e r w i s h e s .  enough, and how much  t h a t by  t o i t as an  They c a n n o t by t h e m s e l v e s  for  but  Weiss s u g g e s t s  i t i s t h e community  i n on t h e l a y p e o p l e  i n a community,  have been v e r y p o p u l a r  of the last  decade.  Such  and community p a r t i c i p a t i o n  o f needs and s u b s e q u e n t  requirements. or direct  group  Surveys,  either  with the approaches inthe  establishment o f anonymous,  through-  i n t e r v i e w - b a s e d methods, a n d g r o u p  methods p r o v i d e a c i t i z e n  forum  p e r s p e c t i v e on t h e n a t u r e a n d  m a g n i t u d e o f community needs a s o p p o s e d t o t h e e x p e r t p e r s p e c t i v e w h i c h may be m i x e d w i t h issues.  By a s k i n g t h e p e o p l e  who  professional  live  vested  i n the area  one's  r e s u l t s a r e h o p e f u l l y more s e n s i t i v e t o t h e p a r t i c u l a r peculiarities  o f a r e g i o n and r e f l e c t  would a c c e p t as s e r v i c e . point  when d e a l i n g w i t h  This  i s aparticularly  communities,  67  what t h e r e s i d e n t s important  cultures or classes  f o r e i g n t o the An  experts.  additional asset  both f a m i l i a r i z e  is that  citizens  of potential f a c i l i t i e s  t h r o u g h m a k i n g them p a r t o f t h e enhance p o s s i b i l i t y  that  such approaches serve  planning  and,  process,  such s e r v i c e s w i l l  to  may  eventually  be  used. T h i s model but  rather  but  with  but  rather  While  deals  with  perceived  with  the  impressions,  present  rigor  i n d i v i d u a l and  group needs, not  group d i s s a t i s f a c t i o n .  lacking the  actually  not  The  data  with are  specific  a more a c c u r a t e  in a q u a n t i f i a b l e sense but  of  diagnosis,  rigorous, need.  they  picture of total  less to the  biometrician, There the  i s an  and  different  scientist,  y e t more a t t r a c t i v e t o t h e  f a c t o r - thus allowing  factors.  s e r v i c e w h i c h can  The be  essence  s e e n by  i s more t h a t  the  problems they themselves  D e p e n d i n g on  the  situation this  traditional allow way  health  care  not  may  is  not of  need f o r a  mean t h a t  o f f e r e d as  problems.  health  panaceas  Such an  t h a t p a r t i c u l a r community  68  cause  perceive. care  for  approach  a community t o t a r g e t b o t h p r o b l e m and  which f i t s  sociologist.  communitv a s p o t e n t i a l l y  the  s o l u t i o n s are  not  are  for a multitude  ameliorating  oriented  need -  statistician,  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  important  may  in a q u a l i t a t i v e sense.  Because o f t h e s e c h a r a c t e r i s t i c s such models attractive  needs  diagnosis  not  comments, p e r c e p t i o n s of  his  may  s o l u t i o n in  best.  the  T h i s model  is probably  i n t e r p r e t i v e model oriented  approach  responses, not  o f mental  i m p l i e s an  understanding  of gestalt.  responses  t o be  do  Despite t h i s ,  not t a k e t h a t  interpretative not  be  specific Needs a r e  causes,  This  approach,  i s p e r v a s i v e and  at  viewed t o need  as  on t h e p a r t o f t h e  c r e d i b l e by t h o s e  consumer.  wishing a  be  data  P1ann i ng  f i t on a c o n t i n u u m .  requirements  shown t o a l s o  to the c h a r a c t e r i s t i c s  "hard  assessment.  t h e models v i s a v i s t h e i r  later  and  possibility  f o u r m o d e l s o f need a s s e s s m e n t p r e s e n t e d  This will  and  p e r c e p t i o n o f need,  The  illness,  1  advertising  Re 1 a t i o n s h i p Between Need and  of  to  f o r the  The  illustrates  nor  i s not  least allows f o r the  response  shown t o c o n s i s t e n t l y  model  format.  the  i s the appropriate source o f care.  t h i s model  data' approach  F.  medical  have been shown t o a f f e c t  p r e s u m a b l y o f what  It w i l l  linked to s p e c i f i c  strictly  with  impression  for culture  medica1ization of culture  o f an  Its  i t s allowance  a r e t h e y bound by  education  illness.  alignment  and  n e c e s s a r i 1 y seen  say t h a t  in closest  of their  69  and  relate  can  be  Figure 2  assumptions scientific  regarding rigor.  in a s i m i l a r fashion  u s e r s and  their  context.  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 A s s e s s m e n t  Med i ca1 Or i e n t a t i o n  Models  Rationality  h i gh  high  1 ow  1 ow  Sc i e n t i f i c R i gor high  Ep i dem i o1og i ca1 i ndi ces Ut i 1 i z a t i on rates Soc i a 1 indi cators Community group forums  Having analyzed  these  models on an  comment c a n be made r e g a r d i n g to the planning assessment  process.  reflects  "better' data  assessment  The r e c e n t  individual  relationship  as a  e m p h a s i s on  need  " b e t t e r ' program p l a n n i n g be d e v e l o p e d .  initial  and  need a s s e s s m e n t f o r t h e p r o g r a m i n  The a s s u m p t i o n t h a t need a s s e s s m e n t  facilitate  b e t t e r program  evaluated if  planning  of the planning  and o n l y  health  e v a l u a t i o n work,  question.  rationality  group  A s p i n o f f o f need  has been t h e g r o w t h o f p r o g r a m  b a s e d on t h e  basis,  t h e a s s u m p t i o n t h a t by p r o v i d i n g a  base,  care d e l i v e r y w i l l  their  1 ow  process  through increasing has  future history will  the costs associated with  70  does  itself  n o t been  adequately  such a c t i v i t i e s  ascertain  have p r o d u c e d a  superior end,  system than the  that too  will  be  a value  Regardless of t h i s of  some o f t h e  incremental  assumptions  involved  This  sector.  As  even t e n d  to disappear  Cummings,  1965).  The  are  consideration evaluation  for  other  nurses  mental  health  also  is the  of  source of help respondents  twenty-eight  percent  and  (Cummings  and  evaluation  may  areas;  is of  71  health  patients,  health  help  old,  network  of  professions.  l a y n e t w o r k was  help  babies  health patients).  effective  f o r personal  seeking  deliver  p s y c h i a t r i s t s deal  mental  the  that the  seeking  the  p r o f e s s i o n a l s with  chronic  with  cloud  physicians  l a r g e and  associated  (1972) r e p o r t e d  prevalent percent  not  limiting  scientific  a r t i c u l a t e mental  Often  care-givers  (e.g.  in rural  inarticulate  Mechanic  t o the  the  spontaneous recovery  "treatment t e r r i t o r y '  unattractive, ignored  self  mental  In a d d i t i o n , p r o f e s s i o n a l  young, a t t r a c t i v e ,  n u r s e s and  illness  in the  in s p i t e of treatment  o f need f o r c a r e  in urban a r e a s ,  need  measurement o f  often  frequency of  efforts.  validity  need f o r p r o f e s s i o n a l  mild,  major o b s t a c l e s  therapeutic  the  been p r e v i o u s l y d i s c u s s e d ,  of conditions  of the  in the  is unlikely particularly has  the  examined.  a measure o f t h e  majority  with  be  give  health  one  can  i t i s assumed t h a t t h e  intervention.  In  judgement.  Firstly us  produced.  unanswerable q u e s t i o n ,  assessment/planning process  will  model  the  most  problems, t h i r t y - t h r e e  from a f r i e n d  from a r e l a t i v e .  and He  reported only twenty-eight  percent  professional  h e l p , and o f t h o s e  psychiatry.  Need a s s e s s m e n t  professional's territory its  appeal  service  no c u r e s .  identification  m a j o r mental  illnesses  identified  sometimes p o l i t i c a l  o f a need must  F o r many  o f m o r b i d i t y and, g i v e n  is a function of duration, Once  As p r e v i o u s l y  f o r which, a t l e a s t c u r r e n t l y ,  o f on 1y i n t e r m s o f c u r e .  prevalence.  certain  i t serves  that  t o increase as the  r e q u i r e ( i n the humanitarian  but o n l y maintained  The d e i n s t i t u t i o n a l i z a t i o n  cases  a t a high  o f both  i l l has o c c u r r e d  and  In some  i t may be u n w i s e t o i d e n t i f y  w h i c h c a n n o t be c u r e d  r e t a r d e d and m e n t a l l y  i t means  c o n d i t i o n s such  sense) maintenance c a r e .  situations  type.  i s t r u e o f most o f t h e m a j o r  Thus,  merely the i d e n t i f i c a t i o n prevalence  into  i s that there are e f f i c a c i o u s  This  illnesses.  be t h o u g h t  society.  data  q u a n t i t y , d u r a t i o n o r even  there are illnesses  psychiatric  political  Need a s s e s s m e n t  f o r the conditions identified.  we c a n o f f e r  not  c a n be s e e n t o expand t h e  ( a n d p e r h a p s t h e r e i n l i e s much o f  A second assumption treatments  choose  choose  c a n n o t be assumed t o r e a d i l y t r a n s l a t e  needs - e i t h e r  discussed  o n l y two p e r c e n t  t o the professional).  therefore,  o f h i s respondents  cost t o  the mentally  in political  contexts  w h i c h have s t r e s s e d c o s t c o n t a i n m e n t o r r e d u c t i o n .  Costs o f  community c a r e may be lower  than  costs of "lost'  clients  a r e even  who were p a y i n g  the institutional 72  institutional lower  costs but  - a t least t o those  costs!  Often  these  "lost'  clients  surface  on a n o t h e r  services' or attorney there be  general's.  i s no c u r e , o n l y  discouraged Thirdly,  sector's  caseload  In t h e s i t u a t i o n where  maintenance, a c t i v e c a s e f i n d i n g  by t h o s e  in financial  communities a r e so d i f f e r e n t a s t o r e q u i r e  (1980) r e c e n t l y studies  Area program o v e r 20,000 clinician or  e x a c t and p r e c i s e Gould e t a l .  summarized t h e r e s u l t s o f 88  epidemiological  N.I.M.H. E p i d e m i o l o g i c a l  i s examining individuals.  five  Catchment  d i f f e r e n t areas - a total o f  A t t h e same t i m e a n y s e a s o n e d  can i d e n t i f y t h e major s e r v i c e  service  that  f o r adequate p l a n n i n g .  and t h e c u r r e n t  gaps  (unmet  need)  i n a d e q u a c i e s o f h i s community - g e n e r a l l y t h e  poor, t h e e l d e r l y and t h e n o n - c o m p l i a n t  seriously  Midtown M a n h a t t a n s t u d y  one i n t w e n t y  disabled  i n treatment  Dohrenwend seriously that  "stop  and  ( S r o l e , Langner, Michael,  i l l a r e not l i n k e d t o p r o f e s s i o n a l o f care t o a l l potential  society's  i d e n t i f y i n g and j u s t s t a r t  lack o f a planning political  delivery.  The  1962).  care.  users  treating'.  Given  is likely  c a p a b i l i t y an arguement c o u l d  gaps a n d d u p l i c a t i o n s with  i d e n t i f i e d only  ill.  (1980) e s t i m a t e s t w e n t y t o f o r t y p e r c e n t o f t h e  the costs  beyond  may  control.  need a s s e s s m e n t t e n d s t o i m p l y  measurement o f h e a l t h  - social  well  be made t o  Perhaps t h e  i n t h e e x i s t i n g s y s t e m have  l e s s t o do  b a s e a n d more f r o m t h e p r o f e s s i o n a l  powers t h a t  have d i r e c t e d  It i s t h i s context that  assessment and s e r v i c e p l a n n i n g  73  the focus o f service  has a f f e c t e d  which  both  need  i s now t u r n e d t o .  Chapter A.  V: V i e w p o i n t s  i n Need  Introduct ion In a r e c e n t p a p e r on p r i o r i t y  Mental  Health Services  (Satorius,  that  t o f o r m u l a t e mental  must  reach  Underlying  into philosophy, this  setting  religion,  i s the understanding  system o f t h e s c i e n t i s t , a l s o the crux o f t h i s  The  makers  and h i s t o r y .  that the value  must a l l be a d d r e s s e d .  systems  the value This i s  paper - t h e v a l u e s o f t h e both t h e into account  has examined t h e c o n c e p t u a l  illness  decision  ethics  needs a s s e s s m e n t a s an a l l o c a t i v e t o o l .  mental  suggested  system o f t h e p l a n n e r ,  a n d t h e c o n t e x t must be t a k e n  discussion  f o r Canadian  1984) i t was  health policies  of the society, the value  tool  Assessment  The p r e v i o u s basis underlying  and t h e v a r i o u s need a s s e s s m e n t  values o f the s o c i o - p o l i t i c a l  when u s i n g  both  techniques.  e n v i r o n m e n t a r e now  addressed.  B.  Boundar i e s i n Power  i n P1ann i na  Before t u r n i n g t o these  issues,  t h e important  link of  need a s s e s s m e n t and p l a n n i n g must be e m p h a s i z e d . The  p u r p o s e o f need a s s e s s m e n t 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 t h e i d e n t i f i c a t i o n  o f some t y p e o f d a t a t o  facilitate  some t y p e o f p l a n n i n g  assessment  i s therefore inextricably  Need a s s e s s m e n t s may n o t a l w a y s implementation  but they  i n some community. with  planning.  lead t o a plan's  are linked 74  linked  Need  to the will  to plan.  Without part  this  intention  need a s s e s s m e n t s  irre1evant^ ^. 1  Given t h i s ,  need a s s e s s m e n t s  a r e bound by s i m i l a r  c o n s t r a i n t s as t h e p l a n n i n g process and  a r e f o r t h e most  Lindblom  Boulding  (1959) have d e s c r i b e d t h e c o n c e p t  rationality" equally  itself.  in reference to policy  relevant  to planning.  By t h i s  i t i s suggested  the c o g n i t i v e concerns,  boundaries  vested  orientation  1981).  Planners plan t o succeed.  and  involved. Thus, f e a s i b i l i t y  Feasibility,  n a t u r e o f need  according to Hall,  (1975) i s i n i t s b r o a d e s t  sense  s t r u c t u r e and d i s t r i b u t i o n knowledge.  o f a plan's  They f u r t h e r  must be o f  acceptance,  assessment. L a n d , P a r k e r a n d Webb  determined  of theoretical  suggest t h a t  of a plan  This i s true  - the data generated  n a t u r e as t o maximize chances thus the r e l a t i v e  i n any  and p o l i t i c a l  o f a plan's success.  a l s o o f t h e need a s s e s s m e n t such  data  which a r e a p r o d u c t o f t h e s p e c i a l  i n t e r e s t s and p h i l o s o p h i c a l  element  that  T h i s c a n be e x p a n d e d t o i n c l u d e  o f t h e major a c t o r s  i s an e s s e n t i a l  is  by t i m e a n d by a b i l i t y  t o p u t t o g e t h e r a n d a c t upon a l l t h e r e l e v a n t (Crichton,  o f "bounded  development but i t  p o l i c y makers o r p l a n n e r s a r e l i m i t e d  situation  (1967)  by t h e p r e v a i l i n g and t e c h n i c a l  feasibility  i s not  The e x c e p t i o n t o t h i s i s when need a s s e s s m e n t s a r e u s e d p u r e l y f o r p o l i t i c a l p u r p o s e s when no p l a n was i n t e n d e d o r i n t h e c a s e s where a need a s s e s s m e n t 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  entirely  i n d e p e n d e n t o f who  ideologies,  interests,  affect  the  of  plan.  any  with and  p r e j u d i c e s and  It i s t h i s T h e r e may  progress  o f any  is resolved.  feasibility  is rarely  plan's  i n which the potential  feeling  in t h i s  orientation of  proposal Hall  information  of  of those  a plan with  v a l u e s and  or  t o the  "sounding  role,  societies,  this  o u t " and  group c o n s i s t i n g municipal),  interest  first  step  groups.  A feasibility  may  be  by  This  or  program).  the the  is generally a (federal,  success their  perceived  To a c h i e v e of  (e.g.  outcome.  is rarely  exception  in successful planning  76  as  change  totalitarian  heterogeneous provincial,  p r o f e s s i o n s , advocacy groups  Crichton  is  informal  which matches  it.  study  formal  to f a c i l i t a t e  enhance a p o s i t i v e  o f governments  trade unions,  other  that  however, m a t c h i n g o f  change  this  It i s in t h i s  in question)  With t h e  power b a s e  how  commitment t o p l a n .  a 11 t h a t a r e a f f e c t e d  r e q u i r e s a power b a s e .  by  f u n c t i o n t o guage a  success.  o f needs d a t a  interests will  is dealt  feasibility  affected  apparent.  in a p o s i t i o n  the type  that  community a b o u t a p l a n n e d  P l a n n i n g means change and p o s i t i v e by  be  need a s s e s s m e n t may  o f the  limited  can  will  feasibility  et a l . p o i n t out  size of a target population  Even  particular  competing views about  acceptance  part of a process  (e.g. the  -  of f e a s i b i l i t y  immediately  looks a t a t a r g e t p r i o r  the  aspect  be  competition  context  judging  k i n d s o f c o n c l u s i o n s drawn a b o u t t h e  here. the  does t h e  (1981) s u g g e s t s  that  i s to achieve  enough  and the  c o n s e n s u s among t h e n e g o t i a t i n g  interest  groups t h a t  will  s i t down t o g e t h e r t o work on p r o b l e m s .  that  without that  agreement  planning will  they  She c a u t i o n s  fail.  How s u c h n e g o t i a t i o n s t a k e p l a c e and how c o n s e n s u s i s reached  i s beyond  t h e scope o f t h i s  important t o note t h a t resulting  major  actors will  preferences - not only planning  whatever  but a l s o  consensus  exert t h e i r  change.  C.  P1ann i ng Mode 1s Given t h e c l o s e  However,  v a l u e s and  relationship  own v i e w s o f r a t i o n a l i t y  between need  assessment  planning  i s necessary in order t o evaluate the role o f  need a s s e s s m e n t differentiate how e a c h  is  i s reached, t h e  and p l a n n i n g an u n d e r s t a n d i n g o f t h e m a j o r approaches  it  i n t e r m s o f need a s s e s s m e n t and  i n terms o f t h e i r  and  paper.  strategies.  The f o l l o w i n g a t t e m p t s t o  between t h e two major a p p r o a c h e s a n d  i s related  to certain  need  clarify  assessment  methodo1og i e s .  1.  Incrementa1 Lindblom  "the  Mode 1  (1959)  has r e f e r r e d  a r t o f muddling through".  described emphasis  to this  Crichton  (1981) has  such p l a n n e r s as problem s o l v e r s . i s on making  relatively  small  b a s e d on a c o m p a r i s o n o f a l i m i t e d  77  model a s  The  improvements,  number o f c o n c r e t e  program a l t e r n a t i v e s . taking  only  small  opportunity  L i n d b l o m has a r g u e d t h a t by  steps,  t o evaluate  d e c i s i o n makers have t h e programs a n d t e s t  acceptance, thereby maximizing described this  success.  i t as " t r o u b l e s h o o t i n g " .  method  identifies  political C r i c h t o n has  She s u g g e s t s  that  a problem, e v a l u a t e s i t ,  coordinates  t h e r e s p o n s e and endeavors t o c o n t r o l t h e  situation.  Critics  of  success  o f t h i s model  in providing  containable  f o r a health  Planning  i t s lack  system  with  costs of a  b o t h gaps a n d d u p l i c a t i o n s . c a n a l s o be c r i t i c i z e d  "squeaky wheel" approach t o p l a n n i n g loudest  care  c o s t s and p o i n t t o t h e s p i r a l i n g  s y s t e m rampant w i t h Incremental  argue t h a t  a r e a l l o c a t e d funds, with  as t h e  - t h o s e who  little  squeak  view t o t h e  broad p i c t u r e , a l t e r n a t i v e approaches o r a n t i c i p a t e d impacts o f t h e program  2.  The Rat i ona1 Faludi  as  itself.  Mode 1  (1973) d e f i n e s  the Rational  "the a p p l i c a t i o n o f s c i e n t i f i c  crude - t o p o l i c y making. conscious policies  efforts  This  t h e s i t u a t i o n a t hand.  78  i s that  the v a l i d i t y of  and a n t i c i p a t e d  implies  examining a l t e r n a t i v e s and c h o o s i n g for  means  a r e made t o i n c r e a s e  o f the environment".  model  method - however  What t h i s  i n terms o f t h e present  Planning  setting  future  goals,  the "best'  option  T h i s does not n e c e s s a r i l y  imply t o t a l  control  logical  systematic  and  anticipated  over a l l v a r i a b l e s but  impacts  approach  of several  o f comparing  a s i m i l a r model  model.  (1981) d e s c r i b e s  b e g i n n i n g by r e s e a r c h i n g alternative  choices,  operation-aligning back r e s u l t s . process to The  m a k i n g and  taking  Rational  in the  Lindblom  Model  has  (1959) who  and  feeding  ongoing  been c r i t i c i z e d suggests t h a t  Advocates  t h a n none a t a l l .  79  writers  i t calls for  i s impossible we  to  operate.  a c t and  to  thus  to  between a l t e r n a t i v e s i s  of Rational  control  by  i t i s impossible  e f f e c t s o f any  rationally  acknowledgement and  which  i n which  suggests that  the t o t a l  t o choose  impossible.  better  as  decisions,  s u g g e s t s a d y n a m i c and  "open' s y s t e m  further  anticipate attempt  model  evaluating  e x t r e m e amount o f r a t i o n a l i t y  achieve  developmental  planning.  such as Lindblom an  this  Freidman  i s s u e s , s e l e c t i n g from  t h e changes,  This  as a  a  the  alternatives.  (1967) d e s c r i b e s Crichton  rather  Planning  argue  o v e r some v a r i a b l e s i s  that  Figure  3:  The R e l a t i o n s h i p Need A s s e s s m e n t  PLANNING  NEED ASSESSMENT METHOD  Figure  o f P l a n n i n g and Methods  MODELS  INCREMENTAL  RATIONAL  - u t i 1 i z a t i on - commun i t y forum  - epidemiological indices - u t i 1 i z a t i on - s o c i a 1 i nd i c a t o r  3 presents  t h e r e l a t i o n s h i p between  Models a n d need a s s e s s m e n t m e t h o d o l o g i e s . approach r e l i e s avoids  on i n f o r m a t i o n  the "big picture".  The  from s p e c i f i c  This  planning  the Planning incremental  sources.  model has  emphasized t h e growth o f i n d i v i d u a l s e r v i c e s and t h u s emphasis the  i s on u t i l i z a t i o n  figures  It  (tojustify  " s q u e a k y w h e e l " a p p r o a c h o f community  its  growth) and  forums  (to point  d i rect i on). The R a t i o n a l  Model  thus epidemiological figures  a r e most  emphasizes t h e " b i g p i c t u r e " and  indices presenting  important.  Such  true  indices are generally  diagnostic  in nature,  N.I.M.H.'s  Epidemiological  indicators  c a n a l s o c o n t r i b u t e t o an e s t i m a t e  prevalence  when u s e d on a wide  epidemiological directly  as t h e current Catchment  scale.  i n d i c e s nor s o c i a l  translated  into care  80  prevalence  u s e o f DSM area  study.  III  in  Social  of true  Neither  i n d i c a t o r s c a n be  needs, f o r a l l i d e n t i f i e d  cases  will  not  access  rates are a necessary epidemiological Social  services.  component  Thus,  utilization  in t r a n s l a t i n g  indices into health service planning.  indicators  when t h e r e  care  i s the  are a l s o o f value, though  ideally  possibility  the  of addressing  only  social  causes o f the d i s o r d e r s . T h i s m a t c h i n g o f need a s s e s s m e n t and essential. the  Need a s s e s s m e n t s a r e o n l y a t o o l  base from which p l a n n i n g  the tool they  and  tend  D.  p l a n not  i n Po1i t i ca1  in the  particular,  on  the  r a t i o n a l i t y and or boundaries t o be  of other  between endeavor,  socio-  success  role  of the  planner.  c r e d i b l e and  o f use  force  political mental  planner,  areas.  o f change w i l l  v a l u e s and  political  h e a l t h , and  in these  t o the  the  on  interests i n power  ideologies hold health in c h a n g e and  Different  views  on  the  of  produce d i f f e r e n t c o n s t r a i n t s In t u r n , t h e will  differ  type  of  according  data to  views. Hall  with  o f the  provide  Ideo1ogy  Different  v i e w s on  r o l e o f government  these  as a r e s u l t  ideology of the  acknowledged.  quite different  held  Congruence  o n l y maximize s u c c e s s  To m a x i m i z e p l a n n i n g  must be  occur.  used t o  factors.  Va1ues  inherent  can  t o emerge t o g e t h e r  po1 i t i ca1  p l a n n i n g models i s  the  (1972) has  described p o l i t i c s  r e l a t i o n s h i p o f power o r o f  81  as  being  "concerned  influence, generally  within  the context  o f government".  (1968) d e f i n e p o l i t i c s preventing  social  c h a n g e " and " t h e a c t i v i t i e s o f organized  i n f l u e n c e government d i r e c t l y politics  deliberate  i s t h e most  in democratic  while  Politics  planning  t h a t can a s s i s t  The p l a n n e r ' s  ability  success;  the p o l i t i c a l  create  change  does p r o v i d e t h e power  political  d e c i s i o n making.  and u s e t h e p o l i t i c a l  component  determiner  c a n n o t be  the d i f f i c u l t i e s  of a  ignored  confronting the  ( C r i c h t o n , 1981).  philosophy  a n d Blum  and v a l u e s  action.  in political  Figure 3 presents  matrix.  It i s clear  assessment and p l a n n i n g w i l l ideology.  care  differ  The a c c o m p a n y i n g f i g u r e  t h e m a j o r themes  change  this  issue o f  in respect t o change t h e  d e s c r i b e t h e p e r s p e c t i v e s o f t h e major  frameworks.  version o f their  (1968) have d e a l t w i t h  In c o m p a r i n g models o f s o c i a l  in effect  political  health  suggest  provides a set o f perspectives  t o understand  t o understand  Blackburn  authors  can a l o n e  t o h i s a d v a n t a g e may be t h e l a r g e s t  when t r y i n g  social  They  f r e q u e n t l y u s e d method o f  or techniques  planner  groups t r y i n g t o  and i n d i r e c t l y " .  nor planning  countries.  b a s e , however,  plan's  of political  change.  Neither p o l i t i c s  process  a n d Blum  as "the a c t o f promoting o r  p a r t i e s and t h e a c t i v i t i e s  that  Blackburn  an a b b r e v i a t e d  that the role  o f need  according t o p o l i t i c a l helps t o i d e n t i f y  some o f  or issues relevant t o planning within the  sector.  82  Figure  4:  Models o f S o c i a l (adapted  from  Action  Blackburn  and Po1 i t i ca1 and Blum,  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  Change  1968)  Focus on New Goals Change Rational/Development Planning  Incremental/Adaptive Planning 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  SOCIAL ORDER AND CONFLICT  Narketplace the determiner, 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 order and maintains i n s t i t u t i o n s  S o c i e t y absorbs i t s conf l i c t s and changes, and expects t h a t these w i l l r e s u l t i n new deviances which w i l l c r e a t e new conf1icts  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 then become p a r t of i t  SOCIAL GOALS  Let nature take i t s course, man's i n s t i n c t s guide 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)  Society creates goals, v a l u e s , and s e l e c t s means to 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 continued s t r u g g l e s . New g o a l s are s e t .  PRIHARY HEALTH GOALS  Survival of the fittest  Treatment and rehabilitation  Prevention  Positive health  HEALTH PROGRAMS  Health 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 increase the proportion of the u n f i t  H e a l t h i s p a r t o f conformance and h e a l t h programs can r e s t o r e t h e s i c k to t h e best l e v e l o f h e a l t h t h a t can be expected  H e a l t h can be improved by planned avoidance o f v a r i o u s causes o f i l l health. Prevention of what we a r e sure we don't want i s t h e h i g h e s t practical current goal, as we a r e n ' t sure o f a l l the 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 goal  83  Totalitarian  Healers appear on demand  Marketplace medicine supplemented with government programs and private charitable programs to assist poor, and groups with special health problems. Provide limited public health services  Market, government and charitable medicine all pushed to provide a greater quantity of coordinated 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 situations 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 arrangements to temporarily assist deviants  Retraining and therapy where effective but also institutional arrangements to permanently assist deviants  Either total institutional 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 governments, and focus on enabling shifts in accordance with ability to undertake tasks  Operate and control primarily at national level  Figure 4 Models o f S o c i a l (adapted  from  Action  and P o l i t i c a l  Blackburn 84  Change  a n d Blum, 1968)  Societies  w h i c h do n o t b e l i e v e t h a t  p o s s i b l e do n o t p l a n . assures at least the  different  which r e s u l t s Each  beliefs  which  i t feels  change.  directed,  change  is possible.  change comes a b o u t ,  change and who  change  f o c u s on t h e v a r i a b l e  will  most  likely  bring  within  F o r now  be d e a l t  styles  and  beliefs  with  do  later  of planning  in fact  in this  be should  c h a p t e r , as well ideologies  that  such  in different  of their  types  individual  values  about change.  models t h a t  out in t h e i r  description  e a c h e x p r e s s e s an a t t i t u d e  p l a n n i n g and s o l v i n g  are  described  not  be d i r e c t l y compared  this  result  by v i r t u e  B l a c k b u r n and Blum p o i n t  community  different  change  i t is sufficient to identify  ideologies  and  their  facilitate  on  the various types o f r a t i o n a l i t y d i f f e r e n t  different  society  about or  change and how  to  of planning.  in plans focussed  should d i r e c t  take place w i l l  hold.  who  I s s u e s s u c h a s t o whom change s h o u l d who  It i s  is directed  t y p e s and s t y l e s  Each view r e s u l t s  variables.  as  i n how  in different  ideology w i l l  change i s  Thus, t h e e x i s t e n c e o f p l a n n i n g  a b e l i e f that  controls or directs  social  social  towards  problems.  as " e x a g g e r a t i n g " the d i f f e r e n c e s to existing  political  e x a g g e r a t i o n does h e l p t o c l a r i f y  the  of  The  models  and t h u s c a n parties  but  different  p e r s p e c t i v e s o f each. Laissez-faire government a c t i o n .  d e s c r i b e s t h e model Disjointed 85  which c a l l s  f o r least  Incrementa1ism d e s c r i b e s t h e  usual  form o f non-planning  i n western democratic  relying  m a i n l y on i n c r e m e n t a l changes  system,  b a s e d on a p l u r a l i s t  Developmental emphasis  Model  Totalitarian the Soviet  t o the existing  power b a s e .  c a n be g e n e r a l i z e d  on more r a t i o n a l Approach  and g l o b a l  societies,  The Goal  Oriented  t o the recent  planning.  The  i n c l u d e s both t h e p l a n n i n g approach o f  Union as well  as t h e a u t h o r i t a r i a n  a p p r o a c h t a k e n by many p r i v a t e  planning  c o r p o r a t i o n s a n d some  governments.  1.  The L a i s s e z - F a i r e T h i s model  version  any  h a s b o t h an a c a d e m i c  which t e n d t o d i f f e r  practical control  situation.  t e n d s t o be used the academic  Thus,  supporting individual  rather  p e o p l e money  highly  government r e g u l a t e d  freedom freedom,  instead o f forcing  v a l u e s o f t h e academic  profits  do n o t s u p p o r t t h e p r a c t i c a l  i s seen  while  t o choose  among  individual control  are held  application  services.  by many  who  o f t h e model.  As B l a c k b u r n and Blum s u g g e s t , t h e d e s i r e t o change  86  by  them t o a c c e p t  h e a l t h and s o c i a l model  than  t h e p o p u l a r model  has a r g u e d f o r l e s s b u r e a u c r a t i c  giving  These  model i s  The g o v e r n m e n t  in defence o f p r i v a t e  model,  i n any  c o m p e t i t i v e market  i n change.  alternatives,  initiative,  considerably  intervention.  as h a v i n g no r o l e  and a p o p u l a r  The e s s e n c e o f t h i s  by t h e p e r f e c t l y  governmental  real  Model  people a t times c o n f l i c t s institution  w i t h t h e commitments t o t h e  o f freedom o f c h o i c e ,  p e o p l e who f a v o r t h e f r e e market advocating tight  resulting ideology  c o n t r o l s on government  i n t h e same  also  supplied  serv i ces.  2.  Di s j o i n t e d  I n c r e m e n t a 1 i sm  T h i s model  i s b a s e d on t h e a c c e p t e d  a pluralist  power b a s e w h i c h a l l o w s  planning process the r o l e t h a t  legitimacy o f  input t o the  f r o m many s o u r c e s a n d t h u s  society  itself  plays  i n both  social  m a i n t e n a n c e and s o c i a l  change.  incremental  i s f o r t h e purpose o f r e a c t i n g  in nature,  Planning,  emphasizes  largely  t o problems o c c u r r i n g  as t h e system d e v e l o p s , as  opposed t o t h e g l o b a l  pursuit of actually  system  itself.  i s an a c c e p t a n c e o f a n  system  i n which t h e r e  There  t o guage t h e t o t a l  be l e g i t i m a t e l y a d d r e s s e d .  3.  Goa1-Or i e n t e d T h i s model  which  Development  s t r e s s e s t h e need f o r a c c e p t e d  as o p p o s e d t o t h e p r e v i o u s  direction  effects  because o f t h e m u l t i t u d e o f values  will  approach.  "open'  i s no end t o t h e p o s s i b l e  c o n s e q u e n c e s , an i n a b i l i t y o f any a c t i o n  planning the  It r e l i e s  incremental  "fix  goals,  i t "  on community p a r t i c i p a t i o n f o r  b u t a t t h e same t i m e , t r i e s  87  t o anticipate the  unintended any  or  action.  relying  on  undesirable The  goal  i s l o n g t e r m and  more r a t i o n a l  o n g o i n g e v a l u a t i o n and more v i s i b l e and  desired  planning  with  wings o f t h e  be  one  reflects  reflective  a of  Such d e m o c r a t i c a l l y  d e s c r i b e d as  the  the  liberalism  the  right  left  wing  and  the  effects.  roughly  ideology of entrepreneuralism  support  methods, i n c l u d i n g  o f unwanted  utilitarian  while  from  i s s e e n a s a means o f a t t a i n i n g  tradition:  opportunity  result  comprehensive,  T h i s model  community.  m o d e l s can  (1983) has  democratic  review.  a minimal  T h e s e two Crichton  planning  hand o f government b u t  s e n s i t i v e t o the  controlled  e f f e c t s w h i c h may  e q u a t e d t o what right o f the  and  the  left  western  supporting  an  equality of  wing s u p p o r t s  universal  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  welfare  state.  4.  T o t a 1 i t a r i an T h i s model  planning,  impact on  the  associated  planning  t e c h n o c r a t i c approach  "scientifically"  t o communities or lives  with  "top  important  emphasizes the  planning  responsiveness  solely  Mode 1  the  of  S o v i e t U n i o n but  down" a p p r o a c h where t h e  are only those model  offers  of those  a l m o s t no  88  without  concern  its citizens.  to  with  the  It i s not a l s o with values  i n power.  only any  deemed The  room f o r anyone  as  total other  than  " e x p e r t s ' , not a c c e p t i n g or t o l e r a t i n g  into the such the  plans.  The  change can practical  currently Great  be  being  i s on  altered  form o f the  Britain  British  not  focus  and  the  United  Columbia, o f f e r s  easily.  S t a t e s , as  similarly  f r e e m a r k e t economy s u p p o r t e d  w i t h m a s s i v e government limitations  in the  Awareness o f how the  elements o f s o c i a l  planning  -  is crucial  assessment w i l l context. and  the  base.  The  The  The  Role  Integral  as  by  freedom  government  social  change - and  of the  along  i d e o l o g i e s view  t h e r e f o r e need  to understanding  they  mix  opinions.  what t y p e t o the  and  of  chapter  affect  will  deal  need  political  focus of  actors are a l l a f u n c t i o n of t h i s  how  of  service sector  various p o l i t i c a l  of this  in  It i s a curious  r e l e v a n t or meaningful  balance and  i n both  well  little  p o s s i b l e s c o p e o f change, t h e  potential  constraints  E.  be  "expert"  the  model,  i n t e r v e n t i o n , r e g u l a t i o n and  h e a l t h and  b a s e d p r i m a r i l y on  and  Paradoxically,  large degree  choice or o p p o r t u n i t y f o r input. of  input  m a s s i v e change,  laissez-faire  espoused t o a  any  change power  with  these  the assessment o f  need.  Planner  to this  question of values  89  i n need  assessment  and  planning  is the  role  personal  values of the  positions  he o c c u p i e s  government. interests dictate  view as  of  Gilbert  and  role.  role.  well  values of  the  will  the  tend to serve  Their position  as t h e i r  Sprect  limitations  (1974) o u t l i n e d  tends  the  to  or  three contexts  potentially  Each p o s i t i o n  of  holds quite a  c r e a t e s d i f f e r e n t l y bounded  T e c h n o c r a t i c P1anner  The  t e c h n o c r a t i c planner  Gilbert  profession.  and  Sprecht's  He  i s the  p l a n based  quite  quite  different  i s the academic  primarily  independent  economics, epidemiology,  i n two  i n two  view  planner, accountable  produce the optimal  scientific  exists  c o n t e x t s which r e s u l t s  scientific  stress  the  or p e r s p e c t i v e s .  different  to  own  The  roles.  Beyond  infuence.  rationalities  1.  are the  naturally  i n which the p l a n n e r  different  planner.  v i s a v i s t h e power b a s e ,  Data c o l l e c t e d  their  planning  planner  of planner's  boundaries  o f the  to his  a c a d e m i c who  is free  upon h i s knowledge o f  demography e t c .  This  is a  a p p r o a c h t o p l a n n i n g , e x p o u s e d by t h e  towards r a t i o n a l  planning.  and  One  recent  associates a  h i g h d e g r e e o f autonomy w i t h 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 t o w a r d s t h e m e t h o d o l o g y and  taken. The  However, t h i s autonomy  i s somewhat  t e c h n o c r a t i c or academic planner  90  direction  may  illusionary.  have  relative  autonomy  in r e l a t i v e l y  considerably more the  likely  luxurious  l e s s so i n p e r i o d s that  t h e ends w i l l  c o n s t r a i n t s more r i g i d  (1975) has p o i n t e d more  likely  financial  o f r e s t r a i n t when  but  i t is  be d i c t a t e d t o him and  and v i s i b l e .  Glennerster  out that t e c h n o c r a t i c  t o occur  climates  planning  i n g o v e r n m e n t s b a s e d on  is  pluralist  power. B l a c k b u r n a n d Blum different  context  (1968) d e s c r i b e  and r o l e .  a  They s u g g e s t  that  technocratic  planning  totalitarian  " t o p down' a p p r o a c h o f c e n t r a l i z e d  g o v e r n m e n t s who  rely  is associated  quite  s o l e l y on  "experts',  t o t h e a t t i t u d e s o f t h e community. technocratic expertise  planner  b u t more  with the  insensitive  In t h i s  context  the  i s chosen f o r not o n l y h i s  importantly  perhaps f o r h i s views -  t h o s e n e c e s s a r i l y s h a r e d by t h e g o v e r n m e n t .  2.  The B u r e a u c r a t i c P1anner Bureaucratic  p l a n n e r s a r e t h o s e who  accountable to the p o l i t i c a l hierarchy.  The o v e r l a p  administrative  and  between  administrative political  the p o l i t i c a l  politics  v i s a v i s the p u b l i c  of  and  p o l i c y making f l u c t u a t e s a s a  of the r o l e that  there  are primarily  to play  i s an o v e r l a p  the technocratic  between  party  function  i n power  expects  service.  B l a c k b u r n a n d Blum's  p l a n n e r and t h e G i l b e r t and  91  Thus view  Sprecht's  view o f t h e  centralized political Gilbert  the  actual  from Blackburn  power o f t h e  and  except  Sprecht's  centralized political  planning  electorate reducing  other  - has  the  incremental  of balancing may  be  myriad o f  Gilbert  form  of  bureaucratic  or  Eckstein  lack of c o n t r o l , lack interest  groups  by  of  and  the  t h a t at the  will  resulting most  in  the  democratic  (1981) s u g g e s t s t h a t t h i s for a bureaucratic  somewhat e a s i e r a t t h e  maintenance  and  constraints faced  synonomous w i t h  of p r i o r i t i e s  incrementa1ism - the with  -  s c o p e and  Crichton  balancing  of  often resulted in a c o n s t r i c t e d role,  s e r v i c e tends t o o v e r l a p this  Blackburn  p a r t s o f government and  planning  government b u t  in terms  f a c e s many c o n s t r a i n t s .  planning  governments.  in  planning.  governments.  In g e n e r a l  planner  the  results  Blum's v i e w  a more d i l u t e d  need t o a p p e a s e v a r i o u s  professions,  This  more  government c o n t r o l , n o t  view a c c e p t s  bureaucratic  data,  and  in t o t a l i t a r i a n  (1956) a r g u e d t h a t t h e the  must be.  government.  government.  The to  view o f b u r e a u c r a t i c  Blum's v i e w assumes t o t a l possible  planner.  more a c c o u n t a b l e  planner  Sprecht's  This d i f f e r s the  power, t h e  system the  and  bureaucratic  higher  lower  levels  level  planner  of  where t h e  in operational  almost always r e s u l t  type  public  activities, in  lower r a n k s c o n c e r n e d p r i m a r i l y  activities.  92  It  c a n be s e e n ,  bureaucratic will  differ  then,  planning  t h a t t e c h n o c r a t i c and  can share  as a r e s u l t  In one c o n t e x t and  rational  this  may r e s u l t  planning.  model  being  adhered t o .  3.  The A d v o c a c y  i n broad,  reduced  the  employer  primarily along time  i s accountable  - the planner  h i s views.  tends  This type  side the early  to  Such h e l d by  t o be c h o s e n f o r o f planning  developed  need a s s e s s m e n t movement d u r i n g a was on d e v e l o p i n g  eye t o f i s c a l  hold  primarily to  philosophy  r e s p o n s i v e t o t h e needs o f p a r t i c u l a r little  i t results  his services.  t o espouse t h e s o c i a l  when t h e f o c u s  context  Planner  advocacy planner  tend  developmental  and t h e i n c r e m e n t a l  consumer g r o u p t h a t p u r c h a s e s  planners  The i s s u e i s n o t  In t h e o t h e r  scope b e i n g  the  has.  or  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 p l a n n i n g  The  role, yet  o f the degree o f c o n t r o l  power t h e government a c t u a l l y merely c e n t r a l i z a t i o n  a similar  concerns.  i m p o r t a n c e most  in this  services groups,  Such p l a n n i n g type  with continues  o f atmosphere,  when t h e r e a p p e a r s 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 t h e system. available times  resources  where g r e a t e r  increased  change.  T h i s may be i n t e r m s o f  o r i n terms o f unsteady  political  i n f l u e n c e v i a t h e media can a f f e c t In g e n e r a l , t h e more c e n t r a l i z e d t h e  93  government, t h e through t h i s  likelihood  planning  groups  rarely  n e c e s s a r y power b a s e . the  more r e c e n t  some means o f at  worse,  is rarely  Rather  influencing  major  or  politically  Roles o f the planner are c l e a r l y approach which planning  be b a s e d .  in a highly  The t e c h n o c r a t  technocrat systems  government  ultimately planning  looks a t planning  operating  rational  will  be  f o r change c a n centralized  in a broad  and  p l a n n i n g methods.  issues  The  i n a s i m i l a r manner b u t w i l l  by a more p l u r a l i s t i c  power b a s e  he must be a c c o u n t a b l e t o .  governments.  i s somewhat Ideally,  Thus,  which technocratic  illusionary  however,  in  technocratic  p l a n n i n g assumes t h e u s e o f t h e most r i g o r o u s o f t h e assessment  a  i n t h e more d e m o c r a t i c government  i n i t s pure form  democratic  operating  manner, u s i n g  can approach  constrained  may,  centralized  c h o s e n t o p r o v i d e t h e d a t a on w h i c h  developmental  in  concern, to provide  i n c r e m e n t a l change w h i c h  i n t h e need a s s e s s m e n t  totalitarian  and  attention.  contexts, or r o l e s ,  factor  -  i t tends, p a r t i c u l a r l y  times of f i s c a l  Summary o f P1anni ng The  developmental  be a f o r m o f t o k e n i s m f r o m a  unfavourable  change  have t h e b r o a d o f s c o p e  government f a c e d w i t h s o c i a l l y  4.  of effecting  means.  Advocacy interest  less  methods, s u c h a s e p i d e m i o l o g i c a l  94  methods,  need  be  attempting  t o p r o d u c e t h e most q u a n t i f i a b l e  Bureaucratic  planners  emerge  data  in centralized  base. systems o f  government b u t t h e g o v e r n m e n t ' s own c o n s t r a i n t s t e n d s t o encourage a d a p t i v e rigorous  need a s s e s s m e n t  f i g u r e s and s o c i a l Finally,  such  using the less  as u t i l i z a t i o n  surveys. i s most v i a b l e  in a  s y s t e m b u t t h e c o n s t r a i n t s o f h i s power  influence will  incremental  planning,  strategies,  t h e advocacy planner  decentralized and  and incremental  generally restrain  base  him t o a d a p t i v e a n d  p l a n n i n g t h o u g h u s u a l l y by t h e more consumer  a c c e p t a b l e methods o f community f o r u m s a n d q u e s t i o n a i r e s ^ ' 2  It  t h a t t h e r e a r e many r e a l  world c o n s t r a i n t s  which a f f e c t  t h e academic models and such  m o d e l s o f f e r e d by  both  and S p r e c h t  offer  is clear  Gilbert  insights  readily  a n d Blackman a n d Blum c a n o n l y  into p o s s i b l e s c e n a r i o s , both  i n f l u e n c e d by t h e i n d i v i d u a l  models  circumstances  being o f any  context.  Consumer g r o u p s a n d g o v e r n m e n t s o c c a s i o n a l l y a p p e a r t o c o i n c i d e w i t h t h e i r p l a n n i n g , a s was t h e c a s e 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 t h e m e n t a l l y r e t a r d e d i n 1984. B o t h g o v e r n m e n t and t h e B.C.A.M.R.P. a p p e a r e d t o a g r e e on t h e ends o f a developmental p l a n b u t 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 a g r e e m e n t was w i t h 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. a n d c o s t containment f o r t h e government.  95  F.  Rat i o n a 1 i t y - D i f f e r e n t Viewpoints  Vf ewpoi n t s  implies that  f r o m many a n g l e s and  that  t a k e on many d i f f e r e n t  t h e same p r o b l e m  the solution  forms.  The  g e n e r a l l y assumed t o  imply  that  is another's  one  value the  man's l o g i c  laden term  w o r l d - and  individual's  and  is relative  but  beliefs  about  i t s prevention.  irrational  but d i f f e r e n t  rational  i t must be  idiocy.  can  is understood  Rational  is a  t o t h e b e h o l d e r ' s view  mental No  seen  t o the problem  term  i n t h e c a s e o f mental  c o u r s e and  of  logic  c a n be  health  illness,  - the  i t s causes, i t s  p l a n n e r would admit  constraints  of  produce  to being  different  types  rationality. In t h e c a s e o f needs a s s e s s m e n t  implies  specific  want, t h e model To p a r a p h r a s e  views  about  o f mental  Boulding  the preferred  model  t h e c o n c e p t s o f n e e d , demand,  illness  (1967),  and  the p o l i t i c a l  rationality  context.  i s "bounded",  not  absolute. Arnold of  (1968) s u g g e s t s t h a t t h e r e a r e d i f f e r e n t  rationality  involved.  depending  R e l y i n g on  upon t h e k i n d o f p r o b l e m  Dies ling's  t y p e s o f r e a s o n s which  she  necessary  Depending  of  in society.  rationality  may  work she o u t l i n e s  suggests are  that  over  is  five  functionally  upon t h e v i e w p o i n t one  take precedence  96  kinds  another.  type  1.  Log i ca1  Rat i o n a 1 i t y  Logical and  effect.  concerns the  logic  of  Much o f p r o b l e m s o l v i n g d e p e n d s on  knowledge o r have o f  rationality  how  beliefs  (not  p r o b l e m s we  wish t o  solve are  disease  programs, e i t h e r p r e v e n t a t i v e  in nature,  rationality. model  are  In mental  medical  not  model  need and  should  medically  perceived  as  oriented  s e c t o r as  this  process  oriented  rational.  will  is rational.  defined  model  most  the  dictate A  defined  s o l u t i o n in order  A social  This  or  suggests that  illness  we  logical  necessitate a medically  necessitate a socially  to  be  should  need and  socially  solution.  Economi c R a t i o n a l i t y A second  rationality. assumed and of  health  a planning  health  d e p e n d e n t on  u s e d t o e x p l a i n mental  whether or  2.  in the  caused.  important  therapeutic  the  necessarily substantiated)  is p a r t i c u l a r l y control  cause  kind of In t h i s  the  resources.  The  one  i s economic r e l a t i o n s h i p s are  involve e f f i c i e n t a l l o c a t i o n s  problem o f  limited  resources,  technology, underlies  Objectives  make e c o n o m i c a l l y priorizing  case causal  decisions  t h e y p e o p l e , money o r rationality.  rationality  must be  rational  implies the  97  priorized  decisions. "best"  way  be  economic in order  Through to allocate  to  resources  to  rationality  achieve has  professional with  it  health  and  of  on t h e  cost  how o n e  to  or  "greater  problems  in  basis  many o f  current  dominate  in these  professional group  3.  Social  Without  perception rational,  in  -  of  priorizing  is  problems  the  individual  fraught  most  with  challenging priorize  brings  into  health.  Who  health  need  focus will  professionals  Who w i l l  -  benefit  -  or  the  individual?  involves  and s o c i a l  base of this  ignoring  rationality  defines  rationality  -  -  on  the  need f o r  concerted  is  ensuring  would  at and  occur  individuals economically  society action.  parameters  morally  98  and  of  expectations  action  each  logically  the  maintenance  common v a l u e s ,  is  some m e a s u r e o f  the  integration,  rationality,  basis  what  what  to  brought  Rat iona1i t y  interaction  individualized  with  the  rationality  a minimal  norms. an  or  S o c i a 1/Lega1  least  decisions  it  also  of  Who w i l l  do  conflicts  has  disease  the  today. will  but  gain"  administrators?  (society)  social  they  towards  costs  as one o f  care  Economic  problems  society  and p r e s e n t s  the  ethical  orders  problems  and on what  move  How o n e  guages  health  the  administrators  objectives.  in terms -  grown w i t h  health  a focus  maximum u t i l i t y .  of  to  function  Legal social  acceptable  and what  are  on  the  limits  o f a c t i o n t h a t might a f f e c t  T h e s e two f o r m s o f r a t i o n a l i t y  operate  particularly,  Certain  individuals  rational clients  other  such  individualized  4.  Po1 i t i ca1 Finally,  society's  other  perceive  t o imposing  i t t o be most  health prevent  action.  political  values  rationality  articulates a  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 forms f o r t h e achievement o f a l l  kinds o f r a t i o n a l i t y .  Political  rationality  make what d e c i s i o n s  whom a n d under what c o n d i t i o n s .  i d e a l s and s o c i a l  a continuum.  political  economically  Rationality  organized  Economic of  care.  kinds o f r a t i o n a l i t y  r e s o l v e s t h e q u e s t i o n o f who w i l l for  a n d i n mental  t o impose c a r e on d i f f i c u l t m e n t a l but these  through  the limits  people.  together t o  d i c t a t e the c o n s t r a i n t s o f treatment, health  other  Arnold  i d e a l s occupy o p p o s i t e  (1968) s u g g e s t s  s y s t e m t h a t has been  that  identified  ends  i t i s the  in democratic  c o u n t r i e s a s t h e f o r c e w h i c h must make a c h o i c e o f p o s i t i o n between t h e s e It  two v a l u e s .  is clear  rationality  from t h i s  t h a t whoever  d i s c u s s i o n o f types o f  i s in the position  whoever makes t h e d e c i s i o n a s t o what 99  o f power -  i s rational  - i s a key  actor  i n any  specific social  model  Logical  o f mental  indicators  cause o f cost  plan.  benefit  for  society  and  the  society at  articulates Clearly  the  political in the  large,  occur.  How  directed  influence t o the will and  E a c h has  about  control.  legal  p l a n n e r must economic  recognized  and  work.  and  and  addressed  a d i f f e r e n t goal  being useful  and  will  legitimate.  p l a n n i n g assume t h a t  change  i s v i e w e d - how  t o and  who  how  need  change.  The  should  b e l i e f as  service of  e a c h has  development.  As  to  change  i t o c c u r s , who  steer  is assessed.  n a t u r a l l y determine the  theories and  Social  Change - Di f f e r e n t Vi ews Need a s s e s s m e n t and  be  logical,  that  rationality  i s in  s o c i a l and  must be  t h u s v i e w d i f f e r e n t d a t a as  G.  t o who  i n w h i c h any  between  process.  at  or b i o l o g i c a l  approach.  while p o l i t i c a l  society  r a t i o n a l i t y that  planning  rational  b e l i e f s as  givens  is t h i s competition  in a medical  look  economic r a t i o n a l i t y h o l d s  i s the  democratic  are  does not  a  r a t i o n a l i t y makes a s s u m p t i o n s  society's  i n any  rationality It  a  legal  - one  believes  Current  rationality r o l e of  illness  i f one  illness.  r a t i o n a l i t y presupposes  the  how  i s caused assessment  earlier  two  planning.  100  related  f o c u s o f b o t h need discussed,  mental  potentially different implications service  will  is also  a disorder  c a u s a l i t y have d e v e l o p e d w i t h i n  need a s s e s s m e n t and  i t should  process -  Causality  will  for  parallel health both  1.  How C h a n g e O c c u r s  The values  question  about  negatively stable  will  by  those  society  As  on  the  conflict  views  a threat  natural  causality or  -  is  a product The  depending maintain  to  this  or  a product effect  mental  through  is  of  negative  instituting  need t o  adapt  to  to  which  of  the  on t h e  will  end,  of  view drive  is  the  well  man a s him  Given  to  these  as  either  required  views  of  himself  individual? be  different  held.  Those  make e f f o r t s and  to  social  individual  controls his  an  drives  change  will  change  those  conflict.  c a n be p e r c e i v e d  related to  a  different  relations.  means a n e m p h a s i s on t h e  101  a  natural  that  to  change tends  social  tends  disorder  perspective  change  with  a sign is  than  man a s a p r o d u c t  social  This  society's  upon t h e  individual's  health  that  be  hand  have o b s e r v e d ,  qualities  disorder  order  deviancy  response  such deviancy the  mental  society.  of  that  his  other  suggests  perspective  essential  conflicting  existing  (1968)  related  should  rather  views  order  and views  mold h i m s e l f and d e s i g n  in the  process,  and h a b i t u a t i o n ,  certain  to  On t h e  is  perceived  society  change t h a n an emphasis on  training  possessing  that  between  social  implies control,  controlled;  can be  system.  B l a c k b u r n and Blum  societal  itself  as an o n g o i n g struggle  Whom  should occur  who b e l i e v e  An e m p h a s i s o n  perspective  order  Change  integrated  welcome t h e  bring.  how c h a n g e  change.  and well  who v i e w  of  and t o  to  who curb  emphasizing  society. individual,  For  mental  a medical  model  of causation.  "fix"  t h e 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  "control" least  him.  Planning  controlling,  similarly  focussed  epidemiological  An e m p h a s i s on t h e r a p e u t i c s e r v i c e s t o  i s then  focussed  the individual. oh i n d i v i d u a l  surveys  on c h a n g i n g ,  or a t  Need a s s e s s m e n t i s  pathology,  and u t i l i z a t i o n  using  data  t o provide a  b a s i s on w h i c h t o p l a n . Conflict  theorists  human p o t e n t i a l .  view d e v i a n c y  Change  as t h e r e a l i z a t i o n o f  i s valued as a p o s i t i v e  force,  a l l o w i n g movement t o w a r d s 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 an  disorder  individual's  Deviant  behavior  of social  i s seen as d e v i a n t b e h a v i o r  resulting  reaction t o larger  processes.  i s understood  not t h e i n d i v i d u a l ,  planning  i s focussed  assessment  need.  proposals a  It i s a sign.that the  focussed  Need  on t h e impact  of society,  and Blum have s t a t e d , p l a n n i n g  and p r o g r a m s w i l l  2. The  Who  vary g r e a t l y i f they  institutions  Should  Di r e c t  related  start  people  with  or the  or society.  Change?  q u e s t i o n o f who s h o u l d  closely  case,  a p p r o a c h e s o r community f o r u m s t o  As B l a c k b u r n  o f changing  In t h i s  the society.  s t r o n g b i a s toward t h e o b j e c t o f changing  object  is  indicator  from t h e p r e s s u r e  must be c h a n g e d .  on c h a n g i n g  is similarly  social  assess  to result  c o n d i t i o n s on i n d i v i d u a l s .  society,  using  societal  from  facilitate  t o how change s h o u l d  102  and d i r e c t  come a b o u t .  change  Different who  has  planning  this  control  Government has which changes Until  the  dictated sixties  or  in the  health  1960's t h e by  the  and  power and  traditionally  health  sector  led to  has  increased  resulted  from both h e a l t h  government  itself. voters'  reluctance  towards p r o f e s s i o n a l  meeting with of  strong  voters'  approval  s u c h as  advocacy groups.  "political  planners" in  Crichton overlap  in  consumers  l i d on  and  The  to large  increases,  spending  and  on  and  this. the  onerous  j u g g l i n g the  health  job  of  interests  professionals,  trade  r e l a t i o n s h i p between  "professional" planners  suggests that  i n any  between t h e s e p o l i t i c a l and  t h e s e two  f o r us  As  power  has  the thus  importance.  functions  power.  transfer of  for  managers t o c u r b c o s t s  while  the  the  e i g h t i e s ' concern  with taking  u n i o n s and  increased  largely  p a r t i c i p a t i o n by  to accept tax  a psychological  thus faced  lobbies  directed.  consumerism o f  n e c e s s a r y changes t o a c c o m p l i s h  Governments a r e  through  Concerned with d e c l i n i n g revenues,  have  the  power b a s e  p r o f e s s i o n a l s and  have p u t  direct  The  in the  politicians looked  the  The  to  degree.  have been  professions.  directions  and  provided  advocacy groups.  containment  deficits  t o what  d i r e c t i o n w h i c h change t o o k was  seventies  c o m m u n i t i e s and cost  m o d e l s make d i f f e r e n t a s s u m p t i o n s as  that  the  relative  depends  previously  government t h e r e  and  the  administrative  emphasis p l a c e d  l a r g e l y upon t h e  discussed,  103  who  i s an  on  political  does have t h i s  each  of  party role  in  will  affect  will  be f a v o u r e d .  H.  Discussion The  major  how need  i s v i e w e d and what t y p e o f p l a n n i n g  f o r e g o i n g m e r e l y t o u c h e s upon some o f t h e many  factors  anticipating  w h i c h need t o be t a k e n i n t o a c c o u n t when u s e o f a need a s s e s s m e n t t o o l .  in t h e endeavour t o c l a r i f y model  o f need a s s e s s m e n t  p a p e r has e m p h a s i z e d  It is offered  the misconception that  exists.  The arguement  t h e need t o examine and, i n t u r n ,  context  i s t o be u t i l i z e d .  tool  must be t h e u l t i m a t e g o a l , and  context.  distributed,  factors  to this  A clear  A "best  l i e s and how  i t  o f both  "best  and r a t i o n a l i t y  l i n e a r model  c a n n o t be d e v e l o p e d ,  The c r u x o f t h i s  thesis  i s that  a "if  this,  Each s i t u a t i o n  w i t h which t o b u i l d  tion  factors  assessment  a d a t a b a s e f o r p l a n n i n g , must be  t o al1 o f the issues raised.  of relative  then  i s unique  and t h e p l a n n e r , when f a c e d w i t h c h o o s i n g a need  sensitive  complex.  n o t a r g u e f o r a f o r m u l a , m a t r i x o r cookbook  t h a t " a p p r o a c h c a n n o t be t a k e n .  tool  sytem,  are a l l contributing  t h e c i r c u m s t a n c e s s u r r o u n d i n g each s c e n a r i o b e i n g  approach.  tool  fit'.  and l o g i c a l  T h i s p a p e r does  fit'  is  what r o l e t h e p l a n n e r h o l d s w i t h i n t h i s  what v i e w s o f change  h e l d by  the values o f the  a sensitive analysis  Where t h e power  "best'  of this  the values  e a c h need a s s e s s m e n t model i n which t h a t  a  will  104  The e x a c t  be u n i q u e t o e a c h  configura-  situation.  Chapter VI:  A.  The  From Model  Br i t i sh Co 1umbia  specific  one.  Rather,  government Academic little  likely  may  want t o p l a y  models  abound  policy  are often  and S p r e c h t , 1974).  situation.  world.  realm since  built  The  reflects  and t h e  This in t h i s  area  Blum,  1968;  of this  Marmor,  link  1970;  p a p e r has been  With t h i s  i t is essential  o f change,  - be  world  specific to  individual assessment.  to appreciate  i t o f need a s s e s s m e n t , o f  or of p o l i t i c a l  or  does  t h e need  a p p r o a c h t o need  no one model  models  Gilbert  with the real  c o n t e x t , a v o i d i n g a "cookbook" i n mind,  they  o f what has o r does o c c u r .  v a r i a b l e s o f each  that  role  v i e w o f what s h o u l d  be s e n s i t i v e t o t h e p a r t i c u l a r  sensitivity  view  i s less  can a d e q u a t e l y d e s c r i b e any  emphasis  a  i t s c a u s e and i t s  a s an e x p l a n a t i o n o f what  Despite t h i s  p l a n n i n g model  nor  i n any o f t h e s e a r e a s .  b a s e d n o t on an a c a d e m i c ' s  ( e g . B l a c k b u r n and  no one  illness,  and  i n a l l arenas but t o o o f t e n  c o u l d be b u t r a t h e r a r e f l e c t i o n  exist  need  but a l s o a s o c i o - p o l i t i c a l  relevance to the real  T h e s e models  that  o f p l a n n i n g , o f change,  in the social  are often  o f which  i s neither a value free  i t is a decision  f o r cure or care,  o f need, o f d i s e a s e ,  have  on,  v i e w n o t o n l y o f mental  potential  that  the d e c i s i o n  t o u s e , o r what t y p e o f d a t a t o c o l l e c t  base r e s o u r c e a l l o c a t i o n arbitrary  Reality  Scene  T h i s p a p e r has a r g u e d t h a t assessment t o o l  to  planning,  i d e o l o g y - can be u s e d t o  adequately describe or explain  105  the B r i t i s h  Columbia, or  any  o t h e r , mental  health  g u i d e s by w h i c h a highly  scene.  Rather, such models o f f e r  some s e n s e c a n be made o f what  complex  The Deve1opment o f t h e C u r r e n t  The  current  British  service delivery  of this  paper.  is invariably  process.  1.  health  There  Columbia  System  community b a s e d  s y s t e m was d e s c r i b e d  mental  i n C h a p t e r One  i s no s i m p l e e x p l a n a t i o n by w h i c h t h e  development  of this  explained.  The s y s t e m d e v e l o p e d s l o w l y o v e r n e a r l y  now v e r y c o m p r e h e n s i v e  years, weathering p o l i t i c a l bureaucratic  changes.  area o f B r i t i s h outpatient  mental  financial  was  social  that  i n 1985 n e a r l y  c a r e and i n p a t i e n t  every  easy a c c e s s  care i s in r e a l i t y a  incremental planning  method.  context during the majority o f t h i s  influenced  by s e v e r a l  factors:  p r o s p e r i t y o f t h e 1960's a n d e a r l y  f o r development  twenty  changes, and  h e a l t h team w h i c h a l s o o f f e r s  socio-political  development  s y s t e m c a n be  i s s e r v e d by a m u 1 t i d i s c i p 1 i n a r y  t o t h e much m a l i g n e d  The  allowed  changes,  The f a c t  Columbia  t o both r e s i d e n t i a l credit  some  o f h e a l t h and s o c i a l  the r e l a t i v e  1970's  which  services, the  d e s i r e o f t h e P r e m i e r , t h e n W.A.C. B e n n e t t , t o be s e e n a s a paternalistic al,  populist,  providing  f o r h i s people  1981), t h e c o n c o m i t t a n t community mental  development  in the United  existing  health  S t a t e s , and t h e r e l i a n c e  p r o f e s s i o n a l s t o s t e e r development currently  (Morley e t  community mental 106  of services. health  system  on h e a l t h  The in British  Columbia developed fashion,  a result  i n a r a t h e r piecemeal  o f a l l o f these f a c t o r s .  Need was " o b v i o u s " s e r v i c e s t o keep delivery  largely  i n pace with  As d i s c u s s e d steered  psychiatric and  - t h e d e v e l o p m e n t o f community  and f u e l l e d  illness  should  planning  Actual with  illness.  The r e p o r t  the  party  incremental  defined.  i n nature.  The  was h e l d by t h e h e a l t h c a r e p r o f e s s i o n a l . ideology  had c o n s i d e r a b l y services  t h e W.A.C. B e n n e t t y e a r s .  Credit Party ideology  Rather, t h e party for  More f o r t h e  v e r y much m e d i c a l l y  (1981) s u g g e s t t h a t t h r o u g h o u t t h e f i r s t Social  that  t h e f u t u r e development o f  t h e development o f h e a l t h care  the  who a r g u e d  r e c e i v e t h e same c o n s i d e r a t i o n  was g e n e r a l l y  political  Columbia d u r i n g  North  care.  model  r o l e o f planner  care  d e v e l o p m e n t was  by p s y c h i a t r i s t s  T h u s , need was i n i t i a l l y The  based  health  paces throughout  (1963) d i d much t o l e g i t i m i z e  community b a s e d  i n mental  i n C h a p t e r One, t h i s  importance as p h y s i c a l  Mind  changes  happening a t d i f f e r e n t  America.  o r incremental  was i n power  provided  a convenient  a pragmatic and developmental  in British  Morely e t a l , twenty years  in British  h a d l i t t l e t o do w i t h  l e s s t o do  that  Columbia,  t h e government. electoral  oriented  framework  government  t h r o u g h t h e d o m i n a n c e o f one man, t h e P r e m i e r , a n d t h e centralization  of political  demonstrated t h a t to  growth".  d e c i s i o n making.  W.A.C. B e n n e t t  h i s g o v e r n m e n t was a "government  The b u r e a u c r a t i c 107  dedicated  and a d m i n i s t r a t i v e h i s t o r y o f  the  British  o f the  Columbia  current  Mental  history  in t h e i r  of this  paper.  as  M i n i s t r y of Health  own The  Health but  Services  i t e x i s t s today developed  incremental, facilitated relative  issue here l a r g e l y as  a government d e d i c a t e d  financial  Much o f t h e  current by  the  i n 1972.  time the  Security  f o r B r i t i sh C o l u m b i a n s  t i m e as  document, The  (1981) p o i n t s  plan  more a s t a t e m e n t o f  nearly that not  an  the  out  innovative  of  The and  that  process,  t o growth  in a time  of  Democratic  plan  (1973) was f o r the  Foulkes'  prepared  care.  really  adaptive  and  bureaucratic  p a p e r was  philosophy.  the  less of  The  Foulkes  health  care  points  example o f a d v o c a c y planning  twenty year  a  directions for  Crichton  a p u b l i c s e r v i c e and by  during  province.  p o i n t i n g new  an  Party  Hea1th  was  with  New  health  F o u l k e s R e p o r t on  social  health  system f i r m l y entrenched previous  an  brief,  report  government f a c e d  system  a function of  approach t o p r o v i d i n g  a developmental  every aspect  this  the  scope  was  a comprehensive plan  Crichton  services,  is that  Their administration  lengthy  R e p o r t was  beyond t h e  community b a s e d mental  though a  and  interesting  prosperity.  in place  came t o power  this  are  development  p r o f e s s i o n a l l y dominated p l a n n i n g by  s y s t e m was  the  present  these d e t a i l s  important  and  planning,  required health  out  by  a  new  care  h i s t o r y of  the  administration. New  i n 1975  Democratic the  Party's  e r a o f power was  Social Credit Party 108  was  returned  short to  lived  power,  Bill  B e n n e t t now  Premier.  As p r e v i o u s l y d i s c u s s e d  the  late  1970's a l s o w i t n e s s e d t h e end t o t h e d e v e l o p m e n t a l p h a s e i n h e a l t h and this:  social  declining  Columbian drastic growth  services.  revenues  Many f a c t o r s  (particularly  contributed  in the  British  r e s o u r c e b a s e d economy), t h e combined  service  e x p a n s i o n o f t h e p a s t two  in population, the  increase  in cost of health  Cambel1  discussed  i n focus from t h e  ministries  which  British  This  change  Columbia  development  2.  and  The  B.C.  in focus  care  efforts  (1981)  to the  been  evident  made t o c u r b  of health  report,  care services of services  came t o an end a  has d e v e l o p e d .  R e g i o n a 1 i z a t i o n o f Hea1th  Care  that  r e s o u r c e s be d i s t r i b u t e d  equitably within e f f i c i e n c y and emphasis  the o v e r a l l  rationally  objectives of  e f f e c t i v e n e s s o f the health  f o r programs  and  services.  became a v a i l a b l e t o s u c h c o n s u m p t i o n 109  It  and  improved care  system.  has t h u s moved t o a p r o c e s s o f a c c o u n t a b i l i t y  justification  A  i n BC  commented on t h e p r o c e s s o f r e s o u r c e a l l o c a t i o n .  specified  in  expenditures.  process of j u s t i f i c a t i o n Ministry  have  produce  clearly  have  care  consumption  dollars,  hopefully  has been  of  Direction  As d e v e l o p m e n t new  w h i c h would  where m a j o r health  New  e t a l , (1981)  had e n j o y e d d e v e l o p m e n t  production ministries, dollars.  shift  effects  decades, the  t e c h n o l o g y a r e amongst many. the r e s u l t i n g  to  The and  As f e w e r  dollars  m i n i s t r i e s as  Health,  the  need t o  e i t h e r narrow s e r v i c e b o u n d a r i e s ,  s e r v i c e became a p p a r e n t . has  outlined  rationing  how  we  these options  have d i s c u s s e d , can  be  has  become n e c e s s a r y and  where need a s s e s s m e n t  has  d e v e l o p e d a renewed  planning  p r o c e s s has  professionally directed era. has care  As  discussed  e x p e r i e n c e d a major s h i f t  managers. majority  As of  their  no  senior  Health  still  organizational directly Services. recently primarily  but  expertise. and  Services held  exists).  structure  responsible The  senior  focus  has  t o the  by At  the  levels of  the  managers  professional  this  has  chosen  focus  has  excellence  to  been e v i d e n c e d  by  p s y c h i a t r i s t s (one the  same t i m e a  provided  Mental  new  administrative,  providing  the  programs.  Program D i r e c t o r s 1 10  that  - appears t o  f a c t s and  for  Managers,  Health  o f t h e s e managers - a t i t l e Coordinator  at  was be  figures  continued exist  no  consulting  f o r Regional  Director of  changed from Regional  of  indicated,  Thus, the  caseloads for a c c o u n t a b i l i t y required existence  are  health  accountabi1ity.  p o s i t i o n s being  psychiatrist  Health  professional  in the  the  earlier  Ministry of  d i r e c t i o n of  moved f r o m p r o g r a m c o n t e n t  In Mental  from  d i r e c t i o n of  physicians  administrative  administrative  the  e t a l , (1981) have  longer  role.  from the  d e c i s i o n makers  Ministry are for  Cambel1  i t i s here  approach of the  i n C h a p t e r One,  (1979)  The  changed d r a m a t i c a l l y  incremental  p r o f e s s i o n a l s t o the  Boyd  achieved.  services  The  of  As  or d i l u t e  of  Headquarters but p r o v i d e any ostensibly  to  formal  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  connection  this  narrowed, t h e  of the  Mental  structure.  focus  seriously mentally  being ill.  Health  original  direction  stressed  resource  are  beginning  Service boundaries  are  being  increasingly The  of the  scheme,  boundaries  The  Planning  in t h i s  the  on  the  using mainly  resource  1985,  standardize  context,  a  utilization  allocation.  populist faire  i d e o l o g y , has  the  planning  level,  control  paramount efficiency  or  the  The  unique  III d i a g n o s t i c  will  serve to f u r t h e r  service.  Ministry level,  has  a r g u e d t o be  r a t e s as a d a t a  thus  rational  base f o r  context  presents  c u r r e n t g o v e r n m e n t , b a s e d on  emphasized a t r a d i t i o n a l l y  approach, de-emphaisizing  either  b a s i s o f the  However, t h e b r o a d e r  contradition of t h i s .  to  quite opposite to  DSM  become a h i g h l y b u r e a u c r a t i c p r o c e s s , and  the  i n t r o d u c t i o n o f a management  in late  and  only  community b a s e d movement w h i c h  system, r e l y i n g  classification  p l a c e d on  regional s t r u c t u r e serves  d e v e l o p m e n t on  needs o f e a c h community.  delineate  managers  Centres  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 ,  information  the  for regional administration.  policies  reflect  not  between t h e D i r e c t o r s  r e s p o n s i b l e f o r Programs and  responsible The  the  services.  government  Despite t h i s ,  laissez-  involvement  in  at the M i n i s t r y  o f s e r v i c e d e l i v e r y a p p e a r s t o be  becoming  importance as  the  goals of a c c o u n t a b i l i t y  compete w i t h  the  ideology of  11 1  a  small  and  government.  of  As  discussed  faire  and  practical  in Chapter  F i v e , t h e a c a d e m i c mode) o f  i t s popular  v e r s i o n o f t e n become c o n f u s e d  situation.  T h u s , we  interesting  s c e n a r i o o f a government whose  i d e o l o g y f a v o r s f r e e market application government social  c u r r e n t l y have  results  the  increased  provision of health  and  services.  Where does need a s s e s s m e n t situation?  Those a d h e r i n g  government  should  have  stand  is largely  little  role  attitude  h e l d towards the m e n t a l l y  deviants  i s one  the  fittest,  who  are On  in t h i s  t o f r e e market  a r g u e t h a t need a s s e s s m e n t  o f minimal  t o compete  the other  hand,  in the  ill  such  and  free  practical  as t e c h n o c r a t i c p l a n n i n g .  expertise,  i s c h o s e n more the  ends b e i n g  management a p p r o a c h . ideology  other  application and  Blum  In t h i s  of  those  scenario, the  by a  of  such  (1968)  context  f o r h i s views than  already dictated  i s contrasted with  survival  charity to  what B l a c k b u r n  likely  In t h i s  the  the  market.  have  identified  as The  c a r e , a f o c u s on  in the  will  in planning.  i s a f o c u s on  planner  ideology  e q u a l i t y o f o p p o r t u n i t y , and  unable  complex  irrelevant,  ideology, there  the  any  i t s practical  c o n t r o l s and  i n t e r v e n t i o n in the  in  political  ideology, while  in t i g h t e r  laissez-  his  " t o p down'  laissez-faire  a very t o t a l i t a r i a n  approach  to  planning. In t h i s restraint  case,  o f the  when a l s o compounded by t h e  fiscal  1980's, need a s s e s s m e n t becomes t h e t o o l 112  of  resource  allocation,  existing  programs t h a n  new  ones.  serving  which  Utilization  i s more o f t e n u s e d t o  t o s e r v e as a s o u r c e  emphasize t h a t s e r v i c e s a r e the  f o c u s away f r o m e x i s t i n g  change  i s not  approach tends at worst,  of direction  r a t e s a r e t h e most common  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 in f a c t gaps o r  being  reduce s e r v i c e  levels.  1 13  data  but  provided,  sought.  the  for  tool,  inadequacies.  f a v o r e d , development not to, at best, maintain  justify  also to taking Thus,  This  s t a t u s quo,  while  Chapter V I I : T h i s paper assessment  has f o c u s s e d on t h e r e l a t i o n s h i p  t o the planning  necessary tool inextricably process  Summary and C o n c l u s i o n s  process.  of the planning  Need a s s e s s m e n t  i n f l u e n c e s as t h e p l a n n i n g  Need a s s e s s m e n t  c a n t h u s n o t be examined  a s t a n d - a l o n e t e c h n o l o g y i n t h e way s t a t i s t i c a l viewed.  methods a r e  g i v e n t h e v a l u e s o f t h e model  and t h e v a l u e s o f  context. This  resulted  view o f need a s s e s s m e n t a s beyond largely  originally  from  i t s changing r o l e .  a s a method o f d i r e c t i n g  t h e u n i q u e needs o f s p e c i f i c changed  development shift  function,  shift  within  a t e c h n o l o g y has  Developing  developing  communities,  w i t h t h e c h a n g i n g economic  w i t n e s s e d a major  this  as  T h e r e c a n n o t be a " b e s t ' method, b u t r a t h e r a  'best-fit', the  is a  p r o c e s s and i s t h u s  l i n k e d t o t h e same  itself.  o f need  services to  i t s r o l e has  c l i m a t e w h i c h has  government  from  service  t o s e r v i c e containmnet and j u s t i f i c a t i o n . need a s s e s s m e n t  u s e d a s much,  s e r v i c e s as t o develop  With  has d e v e l o p e d an a l l o c a t i v e  i f n o t more, t o c u r t a i l  or j u s t i f y  services.  T h i s p a p e r has a r g u e d t h a t t o u s e need technologies t o provide a basis  assessment  forallocative  decisions  n e c e s s i t a t e s an u n d e r s t a n d i n g o f t h e v a l u e s a n d c o n c e p t s , both  implicit  context.  within  t h e model  and w i t h i n  the planning  Need a s s e s s m e n t s a r e n o t done w i t h o u t some  t o p l a n and a c h i e v e m e n t  o f that 114  plan w i l l  necessitate  intent  understanding  the s o c i o - p o l i t i c a l  by w h i c h a p l a n  i s achieved  the  is true will  extent t h i s  context.  is invariably  The power political,  vary with the  base though  political  i deo1ogy. I n t e l l i g e n c e has been  faceitiously  i n t e l l i g e n c e t e s t s measure. the past  d e f i n e d a s what  Need has o f t e n been  i n t h e same manner - t h a t w h i c h need  measure.  viewed i n  assessments  T h i s p a p e r has e n d e a v o u r e d t o p o r t r a y need a s a  f a r more complex dependent  upon  and  elastic  concept,  its definition.  i t s assessment  Need has been  viewed as  synonomous w i t h want o r demand b u t as need a s s e s s m e n t taken  on an a l l o c a t i v e  function a clearer  definition  i s required, the values  definition  o f need d i c t a t i n g  the  values o f the user or Mental  precise  illness  clear,  relying  and  along  with  concept,  does not  social  models.  model  exist.  nor t r e a t m e n t models  has r e l i e d  two  illness, on t h e  largely  is  -  Despite these  o f mental  has been d i c t a t e d  a  the  medical  by t h e  professional.  As p o p u l a t i o n has health  definition  neither etiology  service delivery  and d e v e l o p m e n t  medical  illusionary  models, o r u n d e r s t a n d i n g s ,  traditional model  an  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  u s u a l l y the medical different  in the  the assessment t o o l  is itself  illness,  implicit  and  context.  u n i v e r s a l l y accepted  Unlike physical  analysis  has  c a r e have been  increased while d o l l a r s capped, 115  available  to  i t has become r e c o g n i z e d t h a t  need  is potentially  to a c u r t a i l i n g in d i c t a t i n g infinite  this  fact  has c o n t r i b u t e d  r o l e of the  requirements.  has  l e d t o a new  r e s o u r c e s must be been d e v e l o p e d  e m p h a s i s on  expanding  r e s o l v e d and  t o address  this  professional  This acceptance  o f need, y e t w i t h d e c l i n i n g  problem o f b a l a n c i n g ever  on  and  of the t r a d i t i o n a l  service  level  available,  infinite  rationing.  needs and  scarce  Thus, t h e  need has  been r e d u c e d  o f a more a d m i n i s t r a t i v e l y  dictated  level  It  i s with  assessment  these  i s now  developmental  finite  and  changes t h a t t h e  tool.  process  itself,  confronting  planners  Thus a c l e a r e r methods and operate of the  w i t h an  in the  implementation o f the  sociopolitical  is essential  into the  a p p r e c i a t i o n of the  understanding  the  role of  change comes an  need t o f i t need a s s e s s m e n t t e c h n o l o g y  t o ensure  in favour  need rather  than  increasing planning  difficulties of their  r o l e o f the  context  emphasis  measurable.  i n t o an a l l o c a t i v e  With t h i s  have  o f demand - demand  theoretically  developing  The  methods o f r a t i o n i n g problem.  an  resources  professionally dictated  being p o t e n t i a l l y  of  planner,  i n w h i c h he  a p p r o p r i a t e and  plans. his  must  maximum  use  need a s s e s s m e n t t e c h n o l o g i e s .  T h i s p a p e r was technologies, Rather, concepts  nor  i t s intent implicit  s t r e s s the  not  intended to p r i o r i z e  need  p r o v i d e a framework f o r t h e i r has  been t o e l u c i d a t e t h e  in the  importance  of  assessment  use.  values  and  need a s s e s s m e n t t e c h n o l o g i e s linking 1 16  these with the  values  and of  b o t h t h e u s e r and h i s c o n t e x t .  Need a s s e s s m e n t  viewed  I t s new  s i m p l y as a t e c h n o l o g y .  allocative political use  tool realm  has g i v e n  i t new  of rationing  status  role  c a n n o t be  a s an  in the p o t e n t i a l l y  scarce service  r e s o u r c e s and  o f a n y o f t h e v a r i o u s need a s s e s s m e n t t e c h n o l o g i e s must  appreciate  this.  117  B i b1i o g r a p h y  A l l o d i , F., a n d Kedward, H. The E v o l u t i o n o f t h e Mental H o s p i t a l i n Canada. C a n . J . o f Pub 1i c H e a 1 t h , 3, 1977, 219-224. 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