Professional excellence
Over the years, I have worked with many extraordinary health-care workers — doctors, nurses, and social workers amongst others.
There are two characteristics common to their excellence. The first is clinical acumen, knowledge, and an ability to carry a task through to its conclusion. The second is a commitment to each patient. By commitment I mean ringing, worrying, checking, and chasing. By doing this oneself and not sloughing the task off to someone else.
This professional excellence is then an efficacious symbiosis of form and function: of knowledge and commitment.
Recently, I have considered what motivates the excellent health-care worker. Many things of course: philosophy, ethics, morality, and psychology — with these factors usually interwoven.
Apropos this, twice last month I came across the expression, “the need to be needed,” as another motivating factor for excellence. I was intrigued.
The need to be needed
The need to be needed suggests that a person's sense of their own significance — of meaning, of self-esteem — is rooted and dependent on someone or something outside of themselves.
There are of course nefarious people who exploit others’ need to be needed. Politicians, clergy, philanthropists, and con-men encourage neediness using the tried and true techniques of charm, hope, and exclusiveness.
At the end of the day, it is sometimes difficult to know when it is a simple need, like going to the greengrocer and buying a cabbage; or whether it is an unhealthy symbiotic relationship, like an abusive marriage. Both are needs.
The dynamics of the need to be needed are reminiscent of the process of dependency, or even addiction with risk of self-harm. That is, the object fulfilling a need (e.g., morphine for pain) becomes the need itself.
George Orwell on “Why I Write”
George Orwell knew from the age of 5 that he wanted to be a writer. He was fortunate. When he looked back on his career he discussed what motivated him to write. In an essay “Why I write”, he collated four factors — sheer egoism, aesthetic enthusiasm, historical impulses, and political purpose (Orwell, Reference Orwell1946). It is the first that I wish to share in detail:
“Sheer egoism. Desire to seem clever, to be talked about, to be remembered after death, to get your own back on the grown-ups who snubbed you in childhood, etc. It is humbug to pretend this is not a motive, and a strong one. Writers share this characteristic with scientists, artists, politicians, lawyers, soldiers, successful businessmen — in short, with the whole top crust of humanity.”
“Egoism” is not simply the ego being centric. Egoism, at least how Orwell used it, is the ego needing something to nourish itself, with the implication of inadequacy and immaturity. On the other hand, a healthy ego is self-contained and not dependent — it is independent. The need Orwell describes is perilously close to the need of being needed, which at the same time flags a lack of independence. The ego has its needs and will seek to replenish them. However, a healthy ego will not then itself become dependent on the solution.
Pyramid of Needs
Abraham Maslow described a Pyramid of Needs in “A Theory of Human Motivation” (Maslow, Reference Maslow1943). Maslow's hierarchy of needs was: physiology; safety; belongingness and love; and esteem and self-actualization. Later, he added transcendence which included altruism and spirituality. Maslow did not specify “the need to be needed” and seemed to use the words motivation and need interchangeably.
Motivating factors for the need to be needed
Depth psychology would suggest the dynamics of the needy include self-esteem, meaning, loneliness, angst, heroism, and a sense of specialness in the universe. These are also some of the core factors of our existential concerns.
Albert Camus wrote a short story, “The Adulterous Woman,” (Camus, Reference Camus and O'Brien1957) wherein he discusses existential issues:
“She (Janine) simply followed Marcel, pleased to know that someone needed her. The only joy he gave her was the knowledge that she was necessary … She did know that Marcel needed her and that she needed that need, that she lived on it night and day, at night especially – every night, when he did not want to be alone, or to age or to die … .”
Camus was making the point that the philosophy of existentialism means taking responsibility for oneself, being authentic, having independent thinking, and reflecting on ones own existence when making decisions. These dynamics are the antithesis of the need to be needed. Camus's description of the couple's relationship was as co-dependent and parasitic, like mistletoe.
Problems in health-care workers for those that need to be needed
A health-care worker that is motivated by the need to be needed can be an excellent doctor or nurse. Occasionally, though we come across problems due to this neediness:
1. Burn-out: Sometimes the unrecognized need to be needed drives the doctors to work beyond their capacity with inadequate insight into their actual degree of fatigue and failing reserves.
2. Breach of boundaries: The neediness may be so strong as to blur the appropriateness of contact with patients and/or family and could lead to poor judgment in relationships.
3. Entrapped immaturity: Not being able to clearly understand one's motivation and needs can limit personal growth.
4. Excessive clinical care: When the need to be needed is the driving motivation and there is inadequate insight, then too many reviews, tests, or treatments may result.
Conclusion
We all have needs and most are regular — love, recognition, meaning, and money.
Problems may arise when someone is motivated by their need to be needed. In the medical setting, it may make it difficult to “let go,” since there is an unconscious need to keep needing. This is particularly germane for palliative care clinicians who consult on the question of when active treatment should be stopped.
Psychologically, the degree of neediness occasionally rises to the level of dependence and even reminds us of addictive behavior.
Philosophically, Camus pointed out that the need to be needed runs against the existentialists’ belief in authenticity, independence of thought, and self-assessment as the basis for mature decision-making.
Mentors and colleagues need to be aware of neediness and make certain it does not interfere with clinical judgment, does not lead to burn-out, and does not breach patient–worker boundaries.
