Addiction Research and Theory
The Hierarchy of Needs and care planning in addiction services: What Maslow can tell us about addressing competing priorities?
D. BEST1, E. DAY1, T. McCARTHY2, I. DARLINGTON3,
& K. PINCHBECK1
1Department of Psychiatry, University of Birmingham, Birmingham, B15 2QZ UK, 2National Treatment Agency, Hercules House, London, UK, and 3Homeless Link, London, UK
(Received 17 December 2007; accepted 18 December 2007)
‘‘It is quite true that man lives by bread alone – when there is no bread. But what happens
to man’s desire when there is plenty of bread and when his belly is chronically filled? At once
other (and ‘higher’) needs emerge and these, rather than physiological hungers, dominate
the organism. And when these in turn are satisfied, again new (and still ‘higher’) needs
emerge and so on. This is what we mean by saying that the basic human needs are organised
into a hierarchy of relative prepotency.’’ (Maslow 1943, p. 375)
The recent publication of a series of documents providing guidance for practice in the
drug misuse treatment field in the UK (Orange Guidelines, Department of Health, 2007)
has raised questions as to the exact role of the ‘drug worker’. Guidance from the National
Treatment Agency highlights the central role of key working and case management within
drug treatment, and NICE guidelines about psychosocial treatments for drug user
emphasises the effectiveness of brief and targeted interventions over broader and more
humanistic psychological approaches. This will feel like a dramatic change in direction for
many staff working in the field, and will not sit easily with many of them. However, such a
strategy is part of a series of moves to standardise the quality of drug treatment services in the
UK, and support for this broad strategy comes from a well established source.
Abraham Maslow proposed his theory of a ‘Hierarchy of Needs’ in a paper entitled
A Theory of Human Motivation in 1943, and this is presented graphically below. Although
later in his career, Maslow focussed increasingly on higher-order needs and the relationship
Correspondence: Professor David Best, Department of Psychiatry, University of Birmingham, Queen Elizabeth Psychiatric
Hospital, Birmingham, B15 2QZ, UK. E-mail: d.w.best@bham.ac.uk
ISSN 1606-6359 print/ISSN 1476-7392 online � 2008 Informa UK Ltd. DOI: 10.1080/16066350701875185
between self-actualisation and transcendence, from an addictions treatment perspective we
should turn our attention to the base of the pyramid (Figure 1).
What is frequently described as a model of motivation, and utilised in workplace theories
of staff functioning and drive, has considerable ramifications for the treatment of individuals
with complex and multi-axial problems. The presenting needs of drug users accessing adult
treatment services are frequently bewildering in their complexity, often involving multiple
substance use, physical and psychological health problems, relationship and family
difficulties and little stability provided by reliable accommodation, regular employment or
non-using friendship networks. As Robins has argued in her discussion of Vietnam veterans
returning to the US, ‘drug users who appear for treatments have special problems that will
not be solved just by getting them off drugs’ (Robins 1993, p. 1050).
As Maslow went on to argue in the 1943 article, ‘If all other needs are unsatisfied, and the
organism is then dominated by the physiological needs, all other needs may become simply
non-existent or be pushed into the background. It is then fair to characterise the whole
organism by saying simply that it is hungry, for consciousness is almost completely pre-
empted by hunger’ (Maslow 1943, p. 372). The parallels with drug-seeking are obvious, as
they are with the basic physiological problems associated with drug deprivation, withdrawals,
craving and anhedonia. At initial treatment presentation, it is therefore, likely that other key
issues are masked, and that only where equally pressing deprivations, most likely those
caused by homelessness or significant mental or physical morbidities, are met will these arise
as presenting needs.
There are two fundamental implications of the model for the delivery of treatment – that
lower-level interventions must precede higher-order ones, and second that higher-order
needs are unlikely to emerge in the initial contact stages. This has fundamental implications
for what we are trying to achieve in drug treatment services and places huge importance on
care planning and review as core components of the treatment process. In other words, the
major emphasis on comprehensive assessment is misplaced according to a hierarchy of needs
model, where needs other than the most urgent are unlikely to emerge. Thus, it is only
through treating care planning as treatment that it is realistic to expect a treatment journey to
be effective. As clients and workers manage the basic physiological needs (through
prescribing, detoxification and so on), can treatment start to look at issues of safety, then
belonging, esteem and addressing more spiritual needs.
Figure 1. The Hierarchy of needs.
306 D. Best et al.
The second implication of this model is for what treatment workers do. While managing
the immediate physical distress of addiction is paramount, the hierarchy of needs would
suggest that any further gains in treatment are predicated on a care planning approach that is
not ‘addiction-specific’ but is trans-disciplinary and grounded on the client’s emerging
pattern of needs. It would suggest that for many clients what is needed initially is case-
support rather than ‘psychological change’ and clients will be sceptical about the benefits of
counselling if their needs are not compatible with the middle and higher-order levels of the
pyramid. For many clients, the key tasks will be around benefits and housing, access to
psychiatric services and GPs, and with little need for targeting lasting change in drug use
until these issues have been addressed.
However, it is not clear that statutory treatment services are geared to this kind of
generic case working, with key worker appointment systems based on an unrealistic model
of ‘therapeutic intervention’. As Carroll and Rounsaville (2003) have argued, there are now
more than a dozen well-evidenced psychosocial interventions with credible evidence bases,
yet their deployment is inconsistent and implementation fidelity is poor. Part of this is
because we do not always account for the stage of the client (for which the hierarchy offers a
heuristic method) and the abiding needs that should shape the care planning process and, at
a team level, should shape workforce planning and team training. The hierarchy of needs
also offers a model for clinical supervision and performance management of services. The
aim of treatment should be a ‘hierarchical journey’ with care plan reviews addressing
transitions in the level of need to be addressed and creating resulting action plans.
Furthermore, in a drug treatment system dominated by maintenance prescribing, it is a
model for change – the stabilising goal of maintenance is viable for those struggling to
address safety and physiological needs, but once these are achieved in a sustainable way,
then the rationale for maintenance is likely to diminish and continued change, through
escalating the hierarchy, which should become a more primary goal.
References
Carroll K, Rounsaville B. 2003. A vision of the next generation of behavioral therapies research in the addictions.
Addiction 102(6):850–862.
Department of Health (England) and the devolved administrations 2007. Drug Misuse and Dependence: UK
Guidelines on Clinical Management. London: Department of Health (England), the Scottish Government,
Welsh Assembly Government and Northern Ireland Executive.
Maslow A. 1943. A theory of human motivation. Psychological Review 50:370–396.
Robins L. 1993. Vietnam veterans’ rapid recovery from heroin addiction: A fluke or normal expectation. Addiction
88:1041–1054.
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