What type of long-term rehabilitation goals should we set with our patients in rehabilitation? I have previously argued that they should be made at the level of social participation, usually several years in the future. These rehabilitation aims are typically challenging to specify for a person, and often, they seem similar to the goals of other patients. Recently, another approach based on a patient’s ‘global meaning’, which encompasses their fundamental beliefs, goals, and attitudes, has been developed as a better way to counter the pressure to set short-term, concrete functional goals. In this blog post, I will suggest a third approach based on Maslow’s hierarchy of needs. Maslow was interested in motivation, and goal setting aims to increase motivation, yet his hierarchy of needs has not been considered in goal setting and rehabilitation planning. As I researched this, I realised that considering how Maslow’s needs could be fulfilled could be an excellent checklist to improve our person-centred, holistic approach. It will be challenging but should increase our patient-centredness and improve long-term outcomes.
Table of Contents
Although the evidence supporting specific benefits from setting goals in rehabilitation is weak, goal setting is ingrained and integral to rehabilitation planning. Short and medium-term outcomes have always been the focus. Nonetheless, one must consider long-term goals because people are more likely to follow recommended activities if they understand how participation in activities with little personal meaning or benefit will help them achieve their aspirations. Understanding a person’s long-term aims and aspirations may also facilitate setting priorities among the possible courses of action.
Setting a goal specific to the patient is challenging because most people have similar priorities, usually autonomy, independence, and relationships with family and friends. One solution is to specify components, such as named family and friends or living at a particular address. This is relatively trivial.
Joost Dekker and colleagues developed a new approach. They built on a system with the acronym MEANING; the system stresses that meaning is crucial to human motivation and behaviour. Their tool started with an in-depth discussion between the person, a chaplain, and an experienced rehabilitation doctor so they understand the person’s global meaning of life. In practice, the chaplain represents a non-healthcare professional interested in people’s attitudes and beliefs, and the doctor is a healthcare professional with expertise in the person’s condition and prognosis.
Elsbeth Littooij and colleagues studied the use of this tool and found it feasible. They said, “Both clients and clinicians reported that the tool helped to set a meaningful overall rehabilitation goal and specific goals that became meaningful as they served to achieve the overall goal.” This suggests it is helpful. It is not proof of effectiveness. Moreover, this resource-intensive approach is only feasible with patients with good cognitive and communicative abilities. It may not be cost-effective and only applies to a minority of patients.
Last, the approaches used to date are empirical and not based on any structured theory of the superordinate goals to motivate people. Eighty years ago, in 1943, Abraham Maslow published his theory of motivation, proposing some fundamental needs that motivate human behaviour.
His paper is well worth reading for its clarity, the ideas it discusses, and its relevance today; it explains the well-known hierarchy of needs, adding overlooked qualifiers. I will highlight some essential parts.
It starts with 13 conclusions from an earlier paper, still valid findings. His first is, “The integrated wholeness of the organism must be one of the foundation stones of motivation theory.” I will mention a few others:
- “While behavior is almost always motivated, it is also almost always biologically, culturally and situationally determined as well.”
- Usually, a goal can be achieved in several ways, determined by cultural and cognitive considerations.
- Most behaviour will be related to more than one motivating goal.
- Human needs will form a hierarchy of pre-potency; a higher-order need will only emerge once a lower-order need has been reasonably but not fully satisfied.
- Classification of motivation must be based on goals, not drives.
His theory suggests five fundamental groups of mainly subconscious motivating needs.
The first is physiological needs, especially hunger and thirst. He adds sex but never mentions it again in discussing physiological needs. Indeed, he later writes, “Sex may be studied as a purely physiological need. Ordinarily, sexual behavior is multi-determined, that is to say, determined not only by sexual but also by other needs, chief among which are the love and affection needs.” He emphasises needs associated with prolonged severe hunger or thirst arising from insufficient food or water, not the typical feeling of an appetite.
The second group of needs concerns safety. He points out that a child shows their safety needs openly, whereas adults often suppress overt signs. He suggests that most basic safety needs are ensured by society (i.e. the state), but some remain relevant; “we can perceive the expressions of safety needs only in such phenomena as, for instance, the common preference for a job with tenure and protection, the desire for a savings account, and for insurance of various kinds”. He also links some mental illnesses to exaggerated or misplaced perceptions of threats to safety.
The third group of needs concerns close human relationships of love, belonging, and affection. Although Abraham Maslow says that “man is a perpetually wanting animal”, man is essentially a social animal, as are other primates. This need is often present, and loneliness can be considered ill health secondary to a failure to meet this need.
The next needs group concerns esteem, closely related to status and respect. This covers concepts such as self-esteem and self-respect and extends to being esteemed and respected by others. When the needs are met, a person’s self-confidence grows, whereas a failure to meet these needs leads to feelings of inferiority and helplessness.
The last and highest group within the hierarchy concerns self-actualisation of self-fulfilment, feeling that one has achieved the potential one feels one has. As Maslow said, “What a man can be, he must be.”
Are Maslow’s needs complete?
Maslow stressed that he imposed a structure upon a holistic system so that these needs are interrelated concepts and not necessarily distinct. He grouped needs into categories, so I will consider whether he missed any significant group and whether other systems might be better.
Maslow debates whether the desire to know and understand is an area of need. He wonders whether only a few people he labels “intelligent people” have this need or whether it is a general phenomenon. He also debates whether it is a personality characteristic rather than a primary condition. He concludes that “we shall postulate a basic desire to know, to be aware of reality, to get the facts, to satisfy curiosity, or as Wertheimer phrases it, to see rather than to be blind.” The nee cannot only be relevant to ‘intelligent people’; most people have particular areas of knowledge they pursue for their own sake.
Philosophers have classified human needs. For example, in their review of human needs, Yurdakul and Arar start with an Islamic categorisation by a philosopher, Ghazali. He suggested that needs formed four main groups: necessary, make life easier, make life beautiful, and give life meaning (spiritual needs).
A second Islamic philosopher, Ibn Khaldun, used five groups. The first primary need group was extensive, adding living collectively, understanding, and knowledge to physiological needs. His second group added the need to belong and have solidarity to the need for security. The third group included the requirements to excel, become wealthy, and be prosperous. His last two groups covered reward and equality and leisure and luxury. The first group subsumes Maslow’s need for social affiliation and the need for knowledge.
Tay and Diener suggest that self-actualisation has two parts: mastery and self-direction, and autonomy.
Jeevan D’Souza and Michael Gurin reviewed some other “prominent theories”. The first theory was the Hindu stages of the human life cycle: 20 years of acquiring knowledge and skills for later life; the second being a grihastha or householder, focused on love, family life and acquiring wealth; the third is being a vanaprastha or social worker, contributing to society, and the last is sanyasi (ascetic) when the person abandons family and pleasure to pursue spirituality.
This Hindu system concerns human development, with different needs occurring at various stages of life rather than being present throughout life. It does, however, suggest groups similar to other categorisations.
The second theory reviewed by D’Souza and Gurin is Erikson’s theory of psychosocial development. This proposes a person passes through eight stages – hope, will, purpose, competence, fidelity, love, care, and wisdom. The first six are self-centred, and the last two focus on society and altruism.
The third theory they consider is Freud’s theory of psyche. This theory posits a superego concerned with morality needs; D’Souza and Gurin liken morality to self-actualisation. Last, they mention Kohlberg’s theory of moral development, where the third stage concerns social contracts and character.
D’Souza and Gurin propose eight needs, divided into two groups based on Maslow’s ideas.
The first group is called ‘deficient needs’ (D-needs), representing wanted phenomena that are not automatically present at birth (i.e. are in deficit) and must be built up to give the person satisfaction and stability. These are the first four of Maslow’s needs: physiological, safety, love and belonging, and esteem.
The other group are referred to as ‘being needs’ (B-needs), and they are an expansion of the self-actualisation needs discussed by Maslow in his original 1943 paper. They are cognitive, aesthetic, self-actualisation, and self-transcendence needs.
Last, Amity Noltemeyer and colleagues used a different grouping of deficiency and growth needs. Their deficiency needs only included physiological, safety, and love, and their growth needs represented esteem and self-actualisation. They analysed data from an intervention for children in poverty (The Success Program) and interpreted their results as showing that the fulfilment of basic needs also helped fulfil growth needs.
Maslow's needs: conclusion
I conclude that needs fall into the following groups:
- Physiological (basic): the satisfaction of hunger, thirst, and sexual release.
- Safety and being secure: access to the accommodation or resources needed for basic needs.
- Affiliation: the need to love and be loved, belong to social groups, and have friends
- Esteem: the need to be well thought of, respected by others, and have self-esteem.
- Self-actualisation: a group of needs which may be subdivided into the requirements to:
- Acquire knowledge and skills (cognitive needs)
- Adhere fully to chosen spiritual, religious, or other moral systems (moral requirements)
- Contribute as much as possible to society (social needs)
The division into deficiency needs and growth or being needs does not add anything.
Are Maslow's needs ordered?
Maslow suggests a relative prioritisation among his needs. This is usually presented as a pyramid and is often understood to be fixed and progressive.
Maslow suggested that the separation was relative, so a person started satisfying a higher-order need once a lower-order need had been partially satisfied. For example, one might have satisfaction levels of 100% for physiological, 80% for safety, 50% for belonging, 30% for esteem, and 10% for self-actualisation needs.
Maslow also allowed that the order might differ in some people because they have other priorities. However, he speculated that lack of order may be associated with mental health difficulties.
The research evidence suggests the hierarchy is not a vital feature, and only basic physiological needs may be highly prioritised.
Mariano Rojas and colleagues analysed data from a national Mexican survey of 38,300 people to test four hypotheses within Maslow’s theory, which were not supported.
- Needs are not satisfied sequentially. Maslow suggested only partial pre-potency and acknowledged that conditions might sometimes be satisfied in another order. The data suggest partial satisfaction of needs is common.
- Income is not associated with the degree of satisfaction.
- The contribution to well-being by satisfaction of a need is not proportional to its position in the hierarchy.
- The hierarchy given by Maslow is not the best possible hierarchy in this data set.
Their study suggests people follow a more balanced strategy in satisfying their needs across these domains. The data also indicated that the need for love and esteem had a more significant influence than other needs.
Louise Tay and Ed Diener found that satisfaction of needs had relatively independent effects on quality of life. For example, meeting the requirements for respect and social affiliation had a positive impact regardless of the extent to which safety and physiological needs were met. They suggest that people have a balanced life, aiming for some satisfaction in each area of necessity rather than striving to have total satisfaction with any single need.
Gülşen Yurdakul and Tayfun Arar, in a quantitative study on 240 Turkish adults and qualitative research on 12 Turkish adults. They found that the need for esteem was rated as having the highest priority, but they also found considerable variability between groups.
These studies suggest that the needs are not arranged in a fixed hierarchy, with lower-order conditions being satisfied before higher-order needs. Instead, all requirements are active simultaneously. The priority given to individual needs differs across people, possibly partially related to their culture, as, for example, some cultures seem to prioritise esteem.
Relationship to health and quality of life.
Maslow’s theory is that needs motivate behaviour because the satisfaction of need leads to the person feeling better. He specifically suggests that the failure to satisfy a need could be associated with ill health, for example, likening a lack of affiliation (integration into social groups) to the lack of a vitamin; he asks, provocatively, “Who is to say that a lack of love is less important than a lack of vitamins?” Indeed, he asks whether unsatisfied needs constitute sickness and that a person is only healthy once the lower four conditions are fully satisfied.
More generally, his theory suggests that meeting needs will satisfy someone more. Louise Tay and Ed Diener used data collected from representative populations in 123 countries to investigate the relationship between the satisfaction of needs and a person’s subjective well-being; subjective well-being is closely related to quality of life. They found that subjective well-being was related to the fulfilment of needs in a similar way across all countries and cultures, suggesting that the core human needs are universal and that satisfaction of needs is associated with better well-being.
Behaviours and needs.
Maslow’s theory concerns what motivates people to behave in specific ways; it is a theory of motivation that posits that behaviours have a purpose, in contrast to an alternative hypothesis that people have internal drives that compel them to behave in specific ways. It is a contrast between push and pull or carrot and stick.
Maslow believes that, although needs are usually unconscious, this is not always true, nor is it a necessary characteristic. He suggests that, although needs are similar across all cultures, the person’s culture influences the behaviours appropriate to satisfy a need.
In this context, he observed that many behaviours can carry several meanings or achieve several goals. For example, buying a specific house is a concrete action. Still, the house’s nature will also imply something about status, and the act of moving house may also have a meaning, such as separating from a partner. Thus, behaviours may contribute to the satisfaction of several needs. Many behaviours likely contribute to satisfying more than one need, and all requirements will involve a range of behaviours.
On the other hand, some behaviours may be undertaken without being in response to any need. For example, an itch may be scratched, or a fly swatted simply because they were felt necessary.
Maslow's needs: synthesis.
What can we conclude? First, the concept of needs and their relationship to motivation and subjective well-being seems well established; needs exist, they are a significant determinant of behaviour, and their satisfaction improves a person’s well-being and quality of life. Second, they must be considered as a whole; there are many needs, and the overall balance and proportion of fulfilment determines motivation and quality of life. Different needs’ priorities vary between people, and the hierarchy, if any, is weak. Third, categorisation is arbitrary. Maslow’s classification into five groups is reasonably secure, but splitting self-actualisation into three subcategories may be helpful.
Maslow's needs and rehabilitation goals.
What does this mean for rehabilitation planning and the setting of goals?
At present, goal setting typically starts from the person’s stated interests, wishes, and priorities. However, it is easy for the person to overlook some relevant goals, perhaps because they think they are outside the remit of the rehabilitation professional. The professional may not raise an issue because they do not think of it or feel it is too sensitive.
Long-term goals often include social relationships, independence, and possibly vocational activities. They rarely cover anything like status and esteem or the components of self-actualisation.
We should explicitly consider a person’s needs in all five domains. To help. One could give the patient (or their family) something to read about needs in the different groups and what needs they consider they may have.
Will the person’s physiological needs be met? This will encompass having the resources needed to obtain and prepare food, the ability to prepare it, and being able to eat and drink it. If the person cannot undertake some activities, how will they be met and, most importantly, will the person know they will be met and have some control over the activities?
Will the person be safe and secure and feel safe and secure? How much uncertainty will they face? Can they control and influence matters of safety and security?
Love and affiliation
Will the person have or be able to achieve emotionally satisfying social relationships? Are there sufficient social networks? How will the person increase, establish, or maintain their involvement in social groups? The harmful effects of loneliness and the extra difficulties faced by people with disabilities are well known.
How will the person achieve and maintain esteem and respect from other people known to them? Fulfilling a person’s esteem needs will be challenging; it is a complex topic. Nonetheless, asking what makes someone feel good about themselves and how they think others see them may open up some valuable avenues to gain an insight into what the person feels they need to achieve to feel respected by others and satisfied with their roles.
This is the most challenging topic to discuss with a patient, but it is crucial to consider it. Asking questions about how someone would wish to be remembered, what they are best at and how they could improve, or what part of their life is most essential to them might open the topic. Another approach is to build on any priorities, interests, or ambitions they mention. One could suggest areas such as acquiring knowledge and skills, contributing to society, or fulfilling religious or spiritual goals.
In practice, considering these areas of need in any detail will take time and effort, and it cannot be undertaken thoroughly for every patient. On the other hand, a person with complex rehabilitation needs likely to be involved in rehabilitation for months may benefit from fully considering these needs, especially if the person is expected to have significant long-term changes from their pre-morbid state. In other words, while the principles remain valid, implementation must be adapted to the clinical situation.
At a minimum, one should consider all five main areas of need and explore how the requirements will be met. Reasons for exploring in more detail include:
- Any unexpected or inexplicable problems in the planned rehabilitation. If significant, these difficulties may arise from an unidentified need that the patient has and is worried about.
- A significant change in the person’s situation that will significantly alter their previous ways of satisfying most of their needs.
The types of questions to ask are:
- Will the person dependably have or receive sufficient food and fluid? Sexual relief could be considered actively in someone unable to masturbate or naturally obtain relief from another person.
- Will the person live in suitable, safe and secure accommodation and be able to summon help if an emergency arises?
- Will the person have or be able to develop close relationships with one or a few people sufficient to meet their needs for belonging and affiliation?
- Will the person have social roles that offer them some status among a group of people sufficient to meet their needs for respect and esteem?
- Will the person be able to work towards whatever life goals they have?
If it is apparent that an area of need will not be satisfied, one should discuss the matter with the person to identify potential ways to satisfy the need partially.
Considering a patient’s psychosocial needs and how illness may have disrupted their achievement should increase your patient-centredness. It might increase the relevance of your rehabilitation advice and actions. The topics are sensitive. Discussing them is challenging and threatening to the person and the professional. Nevertheless, using the five or six needed areas as a checklist or aide memoire could lead patients and the rehabilitation team to make surprising and influential decisions.