The perception of need varies depending upon the perspective of the person expressing the need. It is common clinical experience that patients and psychiatrists differ in their view of what the patients need. Surveys of people with major mental illnesses indicate that they commonly consider their most important needs to be financial security, friends, jobs, a good place to live, freedom from medication side-effects, and a sexual partner. Maslow defined a 'hierarchy of needs', that he believed form the basis of much human motivation.*4.) Individuals give first priority to meeting basic physiological needs for food and water before addressing safety needs such as shelter. Only when those needs are addressed do they address needs for human relationship and self-actualization. Surveys of homeless mentally ill people provide a good example. These individuals, who have very wide arrays of needs, invariably indicate that they place the need for mental health services far down on their list of priorities.(5) There is little point offering 'mental health' to a person who lacks basic necessities. Psychiatrists, on the other hand, tend to focus on symptoms and behaviour and are likely to give top priority to needs such as minimizing danger to self and others, symptom relief, personal hygiene, and avoidance of substance abuse.
In an individual case, this difference of perspective is generally dealt with by means of persuasion and negotiation between treatment provider and patient, until a compromise is arrived at and a treatment plan is implemented. In the broader system context, consumer and advocacy organizations articulate need from the perspective of both primary consumers and families of people with major mental illnesses. Disagreements among these constituencies may be strong and may lead to open conflict over controversial issues such as the need for involuntary treatment.
In systems where insurance companies are the purchasers of care they become a third party in the clinical interaction, and so their perception of need also becomes important. American insurance companies use the concept of medical necessity to determine which services they consider are needed and are willing to pay for. Decisions are made on a case-by-case basis as an aspect of utilization management. This frequently leads to conflict, because even though a patient and a doctor may agree that a specific course of treatment is indicated, the utilization manager may not consider it to be medically necessary.
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