Maslow, reversed

by Neil Crowther

Across all of the public audience focus groups we’ve recently run with Survation on how to craft our messages to win support for #socialcarefuture’s vision and approach we’ve seen people’s thinking align with Maslow’s hierarchy of needs.  When people think about social care they distinguish the ‘lower order’ physiological and safety needs from ‘higher order’ needs associated with love and belonging, self-esteem and self-actualisation.  They also see these needs as sequential.  Only once primary needs are satisfied do they imagine we can afford to turn our attention to meaning, purpose, control and connection.  Moreover, they believe that at present it is only realistic to expect social care to operate at the lower order levels of the hierarchy. It strikes me that this same thought process lies behind the arguments of those calling for ‘free personal care’ as a ‘building block’. 

This understanding presents a key challenge for #socialcarefuture in winning support for our vision and approach and so our framing has to be capable of navigating it and shifting thinking.

What I believe we must avoid doing is reinforcing Maslow’s sequential hierarchy in the way we talk about our approach.  A clue to how we might do this comes from the indirect impact of COVID-19 on the health and wellbeing people who draw upon care and support.   As Adelina Comas- Herrera et al point out:

“There is concern and, increasingly, international evidence that some of the measures taken to reduce the risk of COVID-19 infections in care homes, such as closing care homes to visitors (including family members), reduction in social interactions and activities and needing to isolate, have had negative impacts on the wellbeing and mental health of people living in care homes”

I don’t believe these effects are limited to people residing in care homes.  I know from my own family’s experience that my dad’s health and wellbeing deteriorated rapidly under lockdown, not because his physiological needs were not being met, but because the rhythm of his life was disrupted, connections depleted and his scope for autonomy was diminished.  That is to say, it was the failure to achieve higher order needs around belonging, self-esteem and self-actualisation that attacked the foundations.  I don’t think our story is unique if I was to say that it felt as though he had just lost the will to live.  In a matter of weeks he went from being confused but largely contented, to agitated, uncooperative, refusing to take medication or eat and drink.   A week isolated and confined in hospital saw him lose the ability to walk or talk.  A fortnight later he died.

Megan Lewis’s lovely story shows this same process in reverse. It was only though establishing belonging and self esteem that Megan’s mental ill health began to heal and she was able to eventually establish a life and more stable health living in her own home:

But even if we start at the bottom of the pyramid, what, when and how we eat, go to bed, get dressed, wash ourselves are all deeply personal and unique.  Who sees us or supports us in these private and intimate moments is a matter that gets to heart of personal dignity and autonomy.  Self-direction too often gets attached to the ‘higher order’ needs, but it is among these supposedly ‘low level’ needs that being in control can matter most of all to us.  My dad was deeply resistant to being supported to do these things, especially by professional care workers coming into his home. Conversely, note the emphasis placed in the Shared Lives model of people ‘choosing one another’, or that which disabled people place on hiring personal assistants based not on their professional qualifications but their values and character. Self-direction matters at every level.

In the past we’ve sometimes said the difference between what we advocate and what social care most often does is between having a life and just being kept alive.  But this perhaps reaffirms the hierarchy, creating space to suggest that life and limb care is satisfying those lower order needs and we are building on top, rendering meaning, purpose, control and connection unaffordable ‘nice to haves’. 

We need to flip the narrative, showing how our focus on ‘having a life’ is the best way to ensure people are safe, well and ultimately alive. The impact of COVID-19 restrictions have brought into sharp relief what happens when this is neglected. At the same time we are sat upon a treasure trove of stories, like Meg’s, that show the dramatic improvement in people’s physical and mental wellbeing when we put meaning, purpose, connection and control first.

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