In 1943, Abraham Maslow published “A Theory of Human Motivation,” a paper that explained a framework of people’s needs that ultimately influence their individual behaviour. If we consider Maslow’s (1943) theory where the first stage or foundation of the hierarchy must be satisfied before moving on or achieving the next, dysphagia and the challenges it brings falls into this first stage and then continues to impact every stage that proceeds. In 2007, Satter applied her own hierarchy of food needs to Maslow’s theory which demonstrated how a person’s access to food and nutrition can influence their behaviour and relationship with mealtime. Although Satter refers to food needs from a nutritional perspective rather than a dysphagic one, the same pattern of continuing impact is seen through every stage of the theory.
PHYSIOLOGICAL NEEDS
Maslow defines the first stage or the base of our needs as physiological, the basic necessities for survival such as food, water, shelter and our overall health. Satter explains in terms of food management, that it is about having enough food and the tendency to choose food that time and time again has proven to satiate hunger and sustain this satisfaction, often energy rich foods. So how does dysphagia impact our “physiological needs”? Dysphagia isn’t directly associated with socioeconomic status or financial access to resources such as food however when people encounter food modifications as a part of their health management the access to their typical diet changes. The food that someone might instinctively choose that usually satisfies their hunger and fills and sustains them, as Satter put it, is no longer accessible to them in the way they are used to. Ducking down to the shops, pre packaged snacks, steak night at the pub or Uber Eats on a Friday night no longer holds all the answers. The change in health status is an adjustment in itself but no longer being able to access a basic necessity such as food and drink in the way you have your whole life can really shake someone’s foundations.
SAFETY
Safety is defined as the things that bring order, predictability and control to someone’s life. Things like financial security, law and order, and… healthcare. Further to this, the idea that a person is motivated to live with freedom from fear and some kind of medical stability. Satter implies that at this level, a person should be able to cast judgment on what they deem as “acceptable” food to consume and in socially acceptable ways- whatever that may look like to the individual, and also that it remains accessible in this way.
The idea of freedom from fear and avoiding medical emergencies falls into this category which directly corresponds to the lived experience of someone with dysphagia. For some this pertains to having ongoing and sustainable access to foods that are considered safe for their swallowing needs. In the more severe cases, there can be fear surrounding meal times particularly if a person feels inclined to stray from food and drink recommendations as this can lead to choking and/or aspiration. For those not overseeing the preparation of their own foods and drinks, this can also mean there are risks outside of their control that could impact their medical status and safety.
LOVE AND BELONGING
Love and belonging is exactly as it sounds. It describes one’s need to feel loved and to feel as though they belong through relationships, connectedness with others and being part of a group. Satter explains that through the lens of food management, this tier considers one’s food preferences and emotional attachment to food.
Barriers and changes to socialising as a result of dysphagia including social isolation fall into this category. A person’s need to feel included and to be a part of something is often met through sharing meals with others. This can pertain to meals with family and with friends, as a part of cultural tradition and norms, or simply as a means to meet others and connect. Sometimes, meals that are shared as a means to be included and connect with others are often unable to be shared with people with dysphagia because of an inability to manage regular foods.
This barrier can manifest as social isolation, for example when a person eats separately or eats something different to others who are present, or in some cases when a person prefers to be present but not participate in the mealtime at all. Another change within this stage can be the way that food is used to give and receive love and affection. One might consider how a person prepares food and drink to show they care for another. Sometimes, a person cannot receive this affection in the way it is intended or as they usually would if they are unable to consume or share the notion that is regular food or drink. On the other end, one might not know how to prepare an appropriate “gift” or meal as a means to demonstrate their affection for someone with dysphagia.
ESTEEM
Maslow’s next stage of esteem is defined by our self-respect and our self-esteem. Our self esteem is often derived from our perception of ourselves and how we believe others perceive us, building the grounds for our confidence and independence. Satter explains that at this stage, one has the confidence to make novel choices around food and try new things without the fear of lack or waste.
In terms of dysphagia, Maslow’s stage of esteem is troubled with the emotional changes and disruptions to routine and the normalcy of living. Research shows that the changes and challenges described in the previous stages can often result in feelings of anxiety, depression, anger, frustration and low confidence or self esteem. At this level, regardless of whether or not their health, nutritional and emotional needs are being met, the adjustment to major change and new idea or perception of self due to dysphagia can impact one’s esteem.
SELF ACTUALISATION
The previous four of Maslow’s stages are considered the “deficiency” needs which require some level of satisfaction before a person can focus on or reach self actualisation, a realm where the focus is on experiences, fulfillment and creativity- a “growth” or “being need,” as Maslow explains. Satter labels this level as “Instrumental Food” and at this stage, a person might be in a position where food is readily available enough and a range of food is accessed comfortably enough that someone can make choices based on “physical, cognitive or spiritual” desires. This could translate to someone making choices based on political opinions, such as avoiding animal based products, or avoiding food items to enhance health or resist disease such as people choosing organic foods or going sugar free.
People living with a mild dysphagia may very well make it to this stage given a range of food consistencies are still available and not often too difficult to prepare. However, those with moderate to severe dysphagia may find it difficult to attain this level due to such significant limitations in consistencies of food. In general, there are less resources and options available to people with the more severe dysphagia including pre-made options as well as guidance for preparation at home. That’s not to say it cannot be achieved, however the path to attain this level compared to others becomes much more challenging.
Knowing how Maslow’s hierarchy depicts our needs and motivations, it’s easy to see how dysphagia can impact so many aspects of one’s life. Having Satter weigh in from a food management perspective also allows us to see how our perspective and relationship with food changes based on our nutritional needs. Together, they highlight how closely food is related to our wellbeing in all aspects and what gaps people living with dysphagia might come across.
The gaps identified in one’s needs when living with dysphagia are complex. Some can be resolved through sharing resources, knowledge and building culinary skills, while others require the broader community to have an understanding and awareness of the lived experience. The Fourth Place is seeking to create a platform to share the resources and knowledge that will empower people living with dysphagia and their supporters to get inspired, skilled and creative in filling the more practical gaps of one’s needs. The Fourth Place is also aiming to raise awareness and understanding of dysphagia so that the barriers to inclusion and connectedness become less. Ultimately though, and using Maslow’s words, the idea is to make the path to self actualisation via our experiences with food less daunting and less challenging for people living with dysphagia.
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