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