Institute on Healthcare Systems

Building a Relational Society

By Shyamal Sharma
Founder and Co-Leader, The Relational Society Project
The Heller School, Brandeis University

Relational Society Framework

Concept Paper

Introduction

“My hometown was, in the 1950s, a passable embodiment of the American Dream, a place that offered decent opportunity for all the kids in town, whatever their background. A half-century later, however, life in Port Clinton, Ohio, is a split-screen American nightmare, a community in which kids from the wrong side of the tracks that bisect the town can barely imagine the future that awaits the kids from the right side of the tracks. And the story of Port Clinton turns out to be sadly typical of America... No single town or city could possibly represent all of America, and Port Clinton in the 1950s was hardly paradise... But social class was not a major constraint on opportunities.”

We are witnessing a deepening economic divide in our health, education, civic engagement, and social fabric, as Robert Putnam (2015) describes above. Social fabric is most powerful when embedded in a dense network of reciprocal social relations. Implicit in the social fabric metaphor is Relational Society, a state of generalized reciprocity and robust social capital, created through goodwill, empathetic fellowship, and virtuous social interactions among individuals in a community as parts of a whole. We are caught in an inescapable network of mutuality, tied in a single garment of destiny, as Reverend Dr. Martin Luther King Jr. wrote in a 1963 letter from his Birmingham Alabama jail cell (The Atlantic Monthly, 2018). We humans inhabit a society that is an artful patchwork quilt where an individual patch, however beautiful, is not big enough (Jackson, 1988). A society of many virtuous but isolated individuals is not enough to surmount the challenge of inequalities and divisions of our times. We must integrate our commitments in a way that each of the parts reinforces the prosperity, resilience, and health of the larger community (Orr, 2015).

Read more below.

Assessing Proven Relational Approaches to Social Transformation

We began this Relational Society Project by interviewing subject matter experts and studying the scholarship of early influencers identified through a snowball sampling methodology. See Appendix A for a list of those individuals. In these interviews and in our readings, we sought to identify models of social change that appeared to be based on relational society concepts. We carried out these interviews using the script shown in Appendix B.

Models were then chosen for further consideration based on three criteria. First, multiple components of the model were consistent with the relational society idea. Second, the model had strong theoretical and research underpinnings. Third, the model was affiliated with people with strong credentials in their area of practice. The selected models are summarized below in Table 1.  

The message that echoed throughout our interviews and subsequent research was consistent with observations shared with us by our first interviewee, Dr. Jack Shonkoff (Shonkoff, 2019). Dr. Shonkoff, a former dean of the Brandeis Heller School and an academic pediatrician, is currently the Director of the Harvard Center on the Developing Child. The Center focuses on using the cutting edge of research in neuroscience to innovate in the early childhood field and fundamentally change the lives of children facing adversity from intergenerational trauma and toxic stress in their parents’ lives. After listening to our initial vision and rationale, he observed that the Relational Society Framework has the potential to be a “very powerful” conceptual framework and that it “totally resonates.”  

“The challenge is that very committed people have been doing this... There is rhetoric that we have evidence.  However, it has been modest, not replicable, not scalable... The amount of progress has been very small... Disparities persist.”

In short, he argued, while it is true that committed researchers and practitioners have been working on a range of issues similar to ones proposed under the relational society project, no single initiative in the United States currently spans working on a range of issues similar to ones proposed under the relational society project, and no single initiative in the United States currently spans the wider conceptual arc of the Relational Society Framework. For example, the cutting edge innovations being developed by the Harvard Center on the Developing Child and their partner sites in the United States (The Washington Innovation Cluster) and abroad (The Alberta Family Wellness Initiative in Canada, and more recent clusters in Brazil and Mexico) are limiting their focus on the impact of psychological trauma on children’s brain development and brain-deficit related behavior. While these experiments do study the psychosocial factors associated with long-term personality and behavioral traits, they do not comprise the wider social environment as it pertains to early childhood developments and its causal pathways downstream in an individual child’s later years. Another missing element in these experiments is the multi-level, multi-dimensional relationality that is integral to our proposed study design.

In our subsequent interviews and readings, we have observed much of what Dr. Shonkoff described above.  In particular, we observe a similar absence of relationality in otherwise highly admirable work. Professor Mariana Chilton (2019), who is currently writing a book “close to [our relational society project] ideas,” said she “loves the framework and ideas” and thought it to be a “fantastic” project. Professor Chilton’s exemplary research focuses on poverty and child hunger especially among populations marginalized due to race, gender, Native American ethnicity, trauma, and exploitation of our natural resources in America. Relationality is not mentioned or developed. In the context of Relational Society, Chilton introduced us to scholarly work on indigenous philosophy on human coexistence with each other and with nature by Professor Robin Wall Kimmerer (2013). This work by Kimmerer includes relationality but a model of social change is not developed. We therefore do not include her work as one of the models in our table yet wanted to note its theoretical relevance for the Relational Society Framework, particularly its emphasis on the relationship between humans and the earth.

Another example of the absence of multi-level, multi-dimensional relationality is a pioneering model of assessing non-medical needs, or lived social realities, of patients in outpatient settings by Rebecca Onie, the founder of Health Leads. As an undergraduate student volunteer at the Boston Medical Center, Onie began with the idea of a “food prescription” after an otherwise healthy young patient presented with unexplained weight loss who happened to have gone hungry for lack of food, hunger was identified as the root cause of his weight loss as an incidental finding when someone in the practice thought of asking him whether he was hungry. This incident, described by Onie in her Ted Talk (2012), led to her building a low-cost, replicable model that melds the aspirations of college students and the unmet needs of health care institutions to address the link between poverty and poor health, and eventually the establishment of Health Leads. While the Health Leads model addresses social needs in a healthcare setting, it does not seek to build relationships or community by intention or design.

ReThink Health, a Rippel Foundation Initiative, is driven by the maxim that the dominant paradigm incorrectly assumes that health is produced when we pay for health care. The organization has designed a Local Health System Dynamics Model, a computer-based simulation that anticipates how a health system in a specified geographic area might respond to changes in its “Well-being Strategy Portfolio.” With technical assistance and other support from ReThink Health, local health system stewards, people or institutions, can use the simulation model to drive transformational change in the health and well-being of individuals or communities served by them.

While we recognize its design sophistication as well as its broader emphasis on social determinants of health, this model has at least two limitations in our assessment. First, the assumptions about the behavior of certain population-level variables may not be valid a priori or generalizable. Secondly, as is applicable to many similar simulation models, it may not be resilient or adaptable enough to capture real-life individual decisions made in real time in dissonance with decision-making patterns built into the simulation. Finally, we wonder about the effectiveness of the model in building robust, enduring person-to-person human relationships within a community.

Among the models we analyzed, the one that comes closest to our vision of a Relational Society is Hilary Cottam’s trailblazing work on unleashing the power of people’s untapped capabilities in high-risk vulnerable communities through the hard work of relationship-building one-one-one, often one community at a time, enabling agency and self-actualization for individuals living in despair on the margins of the society with support from England’s public welfare systems designed for restoration in the aftermath of World War II. Cottam’s community-based model of social transformation is grounded in empathetic listening for health and social care needs through the eyes of the care recipients, by one-on-one relational engagement with their lived realities in their own dwellings, and helping them realize their own capabilities in the context of these lived realities. Relationality is thus central to her model.  

At the same time, Cottam’s model argues that no matter how strong the will for change, or the power of the rhetoric behind a transformative approach, it will ultimately fail unless the technologies and programs through which participants are engaged are aligned with the 21st century era and its realities. Thus, the argument is that relationality can thrive in our current technologically intensive environment, if one-on-one human connections are intentionally kept at the center of everyday living, with technology used not to replace but rather to facilitate relationships. Outcome metrics must be changed as well.  Even when the need to grow and develop people’s capabilities is understood, if the success of a service remains determined by system-focused outcomes, rather than by capabilities grown; or when metrics emphasize costs saved rather than resources unlocked, then that service will be forced to continue to deliver in dehumanizing and disempowering ways and deep meaningful change will not be realized.

Cottam’s Participle Initiative, established over ten years ago, was at the forefront internationally of measuring capability growth at a personal level as well as understanding the wider systemic measures of success that are needed to fully embed a capability approach across public services. In sum, people in despair should be helped to build their own capabilities through an empathetic relational approach, thus enabling them to spread this approach through their own community connections. Organizations and their service delivery models must be designed to support this fundamentally relational approach. Cottam’s Participle model is thus a multi-level, multi-dimensional model of change, much more so than the other models we explored.

There is no better way to reflect on the powerful essence of the relational social transformation unleashed by Cottam’s vision and hard work than the words of Tara herself, a mother with troubled school-age children living in public housing in London’s Swindon locality and Cottam’s first community partner over ten years ago: 

“Whoever reads this, tell them not to feel sorry for me - that’s not what it’s about. I have to start changing things for the better and for the kids, too. Things are looking good already. Things need to change so that it doesn’t all happen to other people, too.” (Cottam, 2018).   

In conclusion, it is worth noting that the Relational Welfare model from Denmark has been seeking to solve many of the same issues that inspired Cottam’s early work, focused in Denmark on the municipalities through which social welfare is delivered. The Relational Welfare model has been heavily influenced by Cottam, and vice versa.

Table 1: Major Models of Relational Health and Social Transformation

Frontiers of Innovation - Harvard Center on the Developing Child - Boston, MA, USA: Jack Shonkoff 

Washington State Innovation Cluster - USA

Alberta Family Wellness Initiative - Canada

Participle - United Kingdom: Hilary Cottam 

Center for Hunger-free Communities - Philadelphia, PA, USA: Mariana Chilton

ReThink Health - Cambridge, MA, USA; Foresight - New Jersey, USA: The Rippel Foundation Health Initiatives

Health Leads - Boston, MA, USA: Rebecca Onie

Children’s Neighbourhoods - Scotland, U.K.: Claire Bynner

Relational Welfare - Joint Action Analytics, Denmark: Jacob Storch

Moral and Economic Imperatives for a Relational Society

The social fragmentation underlying tens of thousands of deaths of despair from opioid use or suicide, each a national crisis whose magnitude David Brooks compares to the December 1941 attack on Pearl Harbor, is the core challenge of our day. To paraphrase Brooks, the well-known journalist and Executive Director of Weave: The Social Fabric Project at the Aspen Institute, we all create a shared moral ecology through the daily decisions of our lives (Brooks, 2019)“We live in a hyper-individualistic culture that pays lip service to community but which actually values success above relationship, ego above care, the market above society and tribal divisions over common humanity. The question for us is:  What can I do today and tomorrow to replace loneliness, division, and distrust with high quality relationships, community and purpose?” (Brooks, 2019).

According to Joseph Stiglitz, the 2001 Nobel laureate in economics:  “When the original Progressive movement emerged during America’s late-nineteenth century Gilded Age, its main objective was to wrest democratic governance from the great monopoly capitalists... The same goes for progressive capitalism today” (Stiglitz, 2019). Stiglitz adds that:  “[A]t stake in both America and Europe is our shared prosperity and the future of representative democracy... But there is even more at stake:  our civil society and our sense of identity, both as individuals and collectively. Our economy shapes who we are, and over the past 40 years, an economy built around a core of amoral (if not immoral) materialism and profit-seeking has created a generation that embraces those values.” He recommends that our only option is “a new twenty-first century social contract to ensure that all citizens are guaranteed access to health care, education, security in retirement, affordable housing, and a decent job with decent pay.” 

While its conception is nearly as old as philosophy itself and its origin very likely as ancient as the evolution of empathy among early humans (Rifkin, 2009), social contract theory originated in the Age of Enlightenment in 18th century Europe. It posits that individuals’ moral and political obligations are dependent upon a contract or an agreement among them to form the society in which they live. It may be the ecocyclic nature of social, economic, and political behaviors that brings us to a precipice where a new social contract must replace the status quo for the survival of a civil society and perhaps the human life form itself; we must reboot our moral conduct for social and economic justice as fairness under the original position of equality as posited by John Rawls (1971). 

Implicit in Putnam’s emphasis on decent opportunities irrespective of economic class; Dr. King’s prophetic view of our common destiny; Reverend Jackson’s metaphor of a communal patchwork quilt; Brooks’ call for shifting our culture from hyper-individualism that is all about personal success, to relationality that puts relationships at the center of our lives; or Stiglitz’s thesis on the need for a new social contract – is the fierce urgency of social and economic justice now. To borrow a skillful expression from Garrett Hardin (1968) in “The Tragedy of the Commons,” our current inequality problem has no technical solution; it requires a fundamental extension of morality. 

“Common Pool Resources” in Complex Economic Systems

Hardin, an American ecologist, was calling attention to a different dilemma in his 1968 paper in Science – the damage that innocent actions by individuals can inflict on the environment. Concerned by the overpopulation problem of his time, he reasoned that the commons (i.e., a shared resource), if justifiable at all, is justifiable only under certain conditions – of mutual coercion mutually agreed upon (Hardin, 1968). 

Elinor Ostrom, a political economist and Nobel Prize laureate in economics, commented on Hardin’s portrayal of the “users of a common-pool resource—a pasture open to all—being trapped in an inexorable tragedy of overuse and destruction... consistent with the prediction of no cooperation in a prisoner’s dilemma or other social dilemma games.” She further noted that this portrayal by Hardincaptured the attention of scholars and policymakers across the world. Many presumed that all common-pool resources were owned by no one. Thus, it was thought that government officials had to impose new external variables (e.g., new policies) to prevent destruction by users who could not do anything other than destroy the resources on which their own future (as well as the rest of our futures) depended” (Ostrom, 2010).

Ostrom made the following observation about how scholarship regarding the commons has progressed since Hardin’s 1968 paper:  “Contemporary research on the outcomes of diverse institutional arrangements for governing common-pool resources and public goods at multiple scales builds on classical economic theory while developing new theory to explain phenomena that do not fit in a dichotomous world of ‘the market’ and ‘the state.’ Scholars are slowly shifting from positing simple systems to using more complex frameworks, theories, and models to understand the diversity of puzzles and problems facing humans interacting in contemporary societies. The humans we study have complex motivational structures and establish diverse private-for-profit, governmental, and community institutional arrangements that operate at multiple scales to generate productive and innovative as well as destructive and perverse outcomes” (Ostrom, 1990, 2005).

Ostrom’s scholarship on common pool resources over a period of nearly 50 years contributed a set of design principles that affect the probability of long-term survival of an institution developed by the users of a resource. One of these design principles seems particularly relevant to our conception of a relational society, i.e., “Nested Enterprises:  When a common-pool resource is closely connected to a larger social-ecological system, governance activities are organized in multiple nested layers” (Ostrom, 1990, 2005). Communities that are microcosms of the larger society are known to be complex adaptive systems, with a vast diversity of ever-dynamic nested variables involved in perpetual interdependent and reciprocal motion at multiple levels. Such complexity makes for an ambitious social experiment, but one whose time is now. 

Why is a Relational Society Needed Now?

It is apparent that the ideology of individualist, acquisitive capitalism is threatening to destroy the conditions of life on the planet, and that its conception of profit-seeking as an end in itself is disruptive to the organization of society. 

We need a more sustainable, more relational capitalism, with a substantial rebalancing of social values away from individual self-interest and profit-seeking “that violates human needs for connectedness and mutual care” (Rustin, 2013). There are therefore both moral and economic imperatives for steering ourselves to a relational society now, in addition to our evolutionary survival as a species in the longer term. We are a product of our environment in every small and large measure. Our well-being at every phase of our life cycle is determined by the kinds of relationships we have within our larger universe, but especially so by the quality of our social institutions, including family, and the kinds of relationships these institutions facilitate.  

It has been argued that a narrowly instrumental world view on relationships between mankind and the material world in the post-industrial revolution era and the nascent neoliberal globalization has brought us to a precipice where the status quo is unsustainable” (Rustin, 2013). Despite differences and divisions of all stripes, as well as aspirations for individualism, we are intrinsically hardwired with a fundamental human need for belonging, a source of unity, integration, completeness that we typically get from reciprocal engagement in the society. 

There are numerous indicators of the urgent need for relational repair, including observed trends in 1) loneliness and social isolation, 2) mental and behavioral health, and 3) racial bias and inequities.

Loneliness and social isolation. Recent data on loneliness and mental health or substance use disorders of epidemic proportions bear testimony to individuals’ sense of vulnerability due to the increasing prevalence of inequities, social fragmentation, and isolation in our society today. 

Analyses from an international survey of loneliness and social isolation in the United States, the United Kingdom, and Japan, conducted by the Henry J. Kaiser Family Foundation, report that more than one in five adults in the United States and the United Kingdom (22 percent, and 23 per cent respectively) compared to one in ten in Japan (9 percent) say they often or always feel lonely, feel they lack companionship, feel left out, or feel isolated from others, and many of them say their loneliness has had a negative impact on various aspects of their life. Moreover, loneliness appears to occur in parallel with reports of real-life problems and circumstances. Across the three countries, people reporting loneliness are more likely to report being down and out physically, mentally, and financially. While loneliness is often thought of as a problem mainly affecting the elderly, the majority of people reporting loneliness across countries are younger than 50 years (59 percent) and also more likely than others to report lower incomes (58 percent) (DiJulio, et al, 2018).            

Mental and behavioral health. Similarly, mental illnesses and alcohol or other substance dependence are an urgent public health issue in the United States. In 2017, nearly one in five US adults aged 18 or older lived with a mental illness. A significant subset of these adults, 11.2 million or 42.5% had a diagnosis of serious mental illness. Statistics on “deaths of despair” are even more alarming. There were more than twice as many suicides (47,173) in the US as there were homicides (19,510) (National Institutes of Health).  Opioid or other drug overdoses caused 70,237 deaths in the US in 2017. The age-adjusted rate of overdose deaths increased significantly by 9.6% from 2016 (19.8 per 100,000) to 2017 (21.7 per 100,000) (Center for Disease Control). Tens of thousands of military servicemen and their families suffer from the “invisible wounds” of war. 

Approximately 100,000 adolescents and young adults ages below 18 years have a first episode of psychosis each year in the United States (McGrath, et al, 2008). Based on diagnostic interview data from the National Comorbidity Survey Adolescent Supplement (Merikangas, et al, 2010), an estimated 49.5% of U.S. adolescents aged 13-18 had an overall lifetime prevalence of any mental disorder, with an estimated 22.2% having a severe impairment level based on DSM-IV criteria.   

Racial bias and inequities. Racism in the U.S. has been and remains pervasive, and overcoming it requires daily efforts to recognize its influence and counteract it. We need to confront one of the most important but difficult challenges any society can face: to end racism where it originates, in the thoughts and attitudes of a country that has embraced racism, overtly and covertly, for most of its history (Blumenthal, 2020). If it is not confronted successfully, we will continue to see black women dying from pregnancy-related complications at three to four times the rate of white women and black infants dying before their first birthday at more than twice the rate of white infants. Further, despite slightly lower incidence rates for breast and uterine cancers, black women have death rates for these malignancies that are 41% and 98% higher, respectively, than white women. 

The advent of high-tech healthcare solutions will only add to this challenge. The possibility, for example, that artificial intelligence will hard-wire bias into powerful decision algorithm – because it fails to capture the experiences of diverse populations – is disturbing and so is the possibility that differential access to technology will leave the poor and people of color behind as care relies on new sources of connectivity. The issue of “techquity” will soon be on the agenda of our healthcare system (Blumenthal 2020). There is sufficiently robust evidence substantiating the fact that the hardwiring of bias into decision-making algorithms, based on race and income, is not just a possibility but has indeed become a reality (Eubanks, 2018). 

Respecting many forms of our diversity, and systematically weaving them all back together into our universal social and ecological fabric is the urgent need at the heart of this thesis. And, the most enduring solution may lie in realigning the intrinsic forces – of empathy, interdependence, and cooperation – that guided us in organizing our shared humanity. 

Returning to the Roots – Our Human Bonds

Relationships matter for humans both instrumentally – to achieve goals desired by multiple stakeholders that none can achieve on their own; and emotionally – to achieve the sense of belonging that is core to our identity as human beings. Moreover, these two functions of relationships are intertwined from an evolutionary perspective, as argued by David Sloan Wilson:  we are wired emotionally to seek connection because these connections have been essential for our successful evolution as a species (Wilson, 2018).  

The most fundamental aspects of our psychology were permanently shaped by the “social leap” our ancestors made from the rainforest to the savannah. In their struggle to survive on the open grasslands, our ancestors prioritized teamwork and sociality over physical prowess, creating an entirely new kind of intelligence that would forever alter our place on this planet (von Hippel, 2018). It can be argued that this intelligence comprised empathy and relationality among other psychological and behavioral attributes.  Relationality, i.e., making empathetic connection, recognizing interdependence, and engaging in reciprocal activity, therefore, is the fundamental characteristic of a healthy human condition. Relationality transcends specific relationships to capture the essence of interactions and assumptions of interdependence that drive behaviors at multiple levels of organizing. 

Conditions Critical to Building Resilient Relationships

Relationships characterized by a sense of “we-ness” (dyadic unity) and high mutual trust are more likely to elicit positive attributional processes and relational sensemaking (Olekalns, 2020). Besides a sense of we-ness (unity) or belonging and high mutual trust, shared values are foundationally critical for human relationships to be resilient from routine threats in the course of collective action. In our current environment, we need action at multiple levels of organizing, with individual participants who are convinced that we are all in “this” together – uniting with open minds and shared values, to develop shared goals, shared knowledge, and mutual respect in order to engage in crucial problem-solving. What underlies “this” here is catalyzing change, in our mindset, from “me” to “us” as interdependent social beings, and in our individual behavior, from seeking personal short-term gratification to building a holistic community that we co-create and sustain – a social ecosystem that supports the pursuit of growth and well-being for all while respecting and preserving our individuality and privacy. 

At the same time, humans have an intrinsic need for self-actualization, not at the expense of belonging and relationship, but in the context of belonging and relationship and enabled by belonging and relationship.  In his thesis, Abraham Maslow (1943) described self-actualization as the highest of all human motivational needs. More recent versions of this thinking, for example self-determination theory by Deci and Ryan (2008), and growth-in-connection theory by Jean Baker Miller (2012), also argue that flourishing of the self occurs in the context of belonging and relationship, not prior to and not at the expense of belonging and relationship.

Relational resilience is key to relationships at all levels – individuals, dyads, teams, units, or organizations, in other words from micro to macro levels (Olekalns, 2020). This is applicable to formal and informal relationships in work settings. The same is true in the context of a complex, multi-level change effort such as Relational Society where interdependence and intentional reciprocity in relationships are fundamental to robust social activity. Moreover, designing intentional systems for repair (from routine threats) is crucial to relational resilience, such that they become an integral part of building and sustaining high-quality relationships based on shared values, shared goals, trust, and mutual respect. Relational repair and resilience, when embedded as systemic structural design principles, perpetuate a culture of trust and are sustainable despite turnover in individual leaders and other influencers. 

We intend to build a model of Relational Society on principles that become its core DNA, with capacity for adaptive mutations within and between system components. To make progress toward a relational society, we propose a theoretical framework, i.e., Relational Coordination, that comprises the key principles of human relations and can serve as a bridge between empathy and connection at the micro level, and social contracts and design principles at the macro level.

Relational Coordination Theory as a Meso Theory to Bridge Between Micro and Macro

According to organizational scholar Jody Hoffer Gittell, relational coordination is a mutually reinforcing process of communicating and relating for the purpose of task integration – it is the coordination of human activity through relationships of shared goals, shared knowledge and mutual respect, supported by frequent, timely, accurate, problem-solving communication (see Figure 1 below). High levels of relational coordination break down silos and enhance the quality of interdependent relationships; this process of coordinated collective action leads to better outcomes for multiple stakeholders with the potential for system transformation (Gittell, 2006). 

Figure 1:  The Mutually Reinforcing Dimensions of Relational Coordination

Mutually reinforcing dimensions of relational coordination

These mutually reinforcing dynamics of relational coordination were originally discovered through field research in the US airline and healthcare industries with findings that were reported in The Southwest Airlines Way (Gittell, 2003) and High Performance Healthcare (Gittell, 2009). To carry out this research, a validated tool was developed to measure relational coordination as a network of ties between interdependent roles. Figures 2 and 3 show these networks as they were conceptualized and measured in the two original studies.

Figure 2: Flight Departures - A Coordination Challenge

Flight Departures - A Coordination Challenge 

Figure 3: Patient Care - A Coordination Challenge

Patient Care - A Coordination Challenge

Relational coordination is not just relevant for flight departures and patient care, however. It is expected to drive desired performance outcomes whenever multiple roles are needed to work interdependently in the context of uncertainty and time constraints. See Figure 4. Over the years, relational coordination theory and its analytic methods have been tested through extensive research in dozens of industries and in dozens of countries around the world. There is now a substantial body of empirical evidence suggesting that high levels of relational coordination in individual, organizational, and cross-organizational networks improve outcomes for multiple stakeholders, and that low levels of relational coordination significantly reduce the potential to achieve such outcomes (Gittell, Logan & Bolton, 2020). Relational coordination is arguably essential for achieving transformational change toward a relational society and the Relational Coordination Research Collaborative – a scholar/practitioner community founded in 2011 at Brandeis University’s Heller School with partners around the US and beyond – has been working to develop methods to support this transformation (Gittell, 2016).      

Figure 4:  Building a Relational Society - A Coordination Challenge Building a Relational Society - A Coordination Challenge

Building a relational society is a monumental enterprise, as diverse and complex as human society and the larger ecosystem around it. To build a relational society, multiple avenues may be pursued; for example : 1) building assets in marginalized communities to increase equity, 2) creating schools and communities that support the healthy development of all children and youth, 3) creating equitable, inclusive and integrated systems for maintaining behavioral and physical health at all stages of the life cycle, 4) supporting businesses to engage in socially responsible behaviors that reinvest in sustaining our common pool resources such as global climate and our ecosystem, and 5) developing the capacity of individuals and institutions to constructively resolve conflicts for social good. 

Each of these avenues for building a relational society should engage at three distinct levels, we argue, in order to contribute in a sustainable way to the health and well-being of individuals. At the micro level, a relational society fosters human empathy as an essential underpinning for belonging and connection; at the meso level, a relational society fosters coordinated collective action among interdependent entities; and at the macro level, a relational society develops institutions to support these dynamics. Our Relational Society Framework is summarized below in Figure 5, with three levels of engagement. 

Figure 5: Relational Society Framework at Three Levels of Engagement

Relational Society Framework

Significance of the Relational Society Project

We are at a watershed moment in American society and in other societies around the world. We have come back full circle to our urgent need for social justice after having made a very small amount of progress toward a kinder and more equitable order since the 1950s and 1960s social movements including the Great Society and the battle for Civil Rights (Shonkoff, 2019). While it is true that committed researchers and practitioners have been working on a range of issues similar to ones proposed under the relational society project, no single initiative in the United States currently spans the wider conceptual arc of the relational society framework. The Heller School at Brandeis University, may be well-positioned to take the lead.

The Heller School's mission is to develop knowledge for advancing social justice. The next phase of the research project proposed in this report is envisioned as one element of a larger social experiment with a home base at the Heller School, building on the school's existing research and its existing relationships with experts across the academic and social spectrum.

References

Atlantic Monthly (2018).  “Special Issue on King,” February. Washington DC: The Atlantic Monthly Group.

Blumenthal, DM. (2020).  “Racism in the U.S. needs to be recognized and confronted.” Modern Healthcare. Jan. 18.

Brooks, D (2019).  “Culture of compassion.”  The New York Times, Feb. 18.   

Brooks, D (2019). Weave: The Social Fabric Project.  Aspen Institute.  https://www.aspeninstitute.org/programs/weave-the-social-fabric-initiative/

Centers for Disease Control (2017).  https://www.cdc.gov/drugoverdose/data/statedeaths.html

Chilton MM City (2019).  Personal Communication: August 15.

City Health Dashboard (2018).  https://www.cityhealthdashboard.com

Cottam, H (2018).  Radical Help: How Can We Remake the Relationships between Us and Revolutionise the Welfare State.  London, UK: Virago Little, Brown Book Group.  

Cutcher-Gershenfeld, J, Haberman M, Nolan JM (2012).  RAPID: Stakeholder Alignment for EarthCube. 

Deci, EL & Ryan, RM (2008). "Self-determination theory: A macro theory of human motivation, development, and health." Canadian psychology/Psychologie canadienne, 49(3): 182.

Eubanks, V (2018).  Automating Inequality: How High-tech Tools Profile, Police, and Punish the Poor.  New York, NY: St. Martin’s Press.

Felitti, VJ, et al (1998).  “Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) study.” American Journal of Preventive Medicine, 14(4): 245-258.

Follett, MP (1966).  “The psychology of control.”  In Hugh Cabot & Joseph A. Kahl, eds. Human Relations: Concepts and Cases in Concrete Social Science, Vol I.   Cambridge, MA: Harvard University Press.

Gittell, JH, Bolton, R & Logan, C (2020).  Relational Coordination Theory: A Systematic Review of the Evidence.  Heller School, Brandeis University Working Paper.

Gittell, JH (2016).  Transforming Relationships for High Performance:  The Power of Relational Coordination.  Palo Alto, CA:  Stanford University Press.

Gittell, JH (2009).  High Performance Healthcare: Using Relationships to Achieve Quality, Efficiency and Resilience.  New York, NY:  McGraw-Hill.

Gittell, JH (2006). "Relational coordination: Coordinating work through relationships of shared goals, shared knowledge and mutual respect." Relational Perspectives in Organizational Studies: A Research Companion, pp. 74-94.

Gittell, JH (2003).  The Southwest Airlines Way: Using the Power of Relationships to Achieve High Performance.  New York, NY:  McGraw-Hill.

Hardin, GJ (1968). “The tragedy of the commons.” Science, 162(3859): 1243-1248.

Jackson, Rev. JL (1988). Democratic National Convention Speech. July 19. https://www.pbs.org/wgbh/pages/frontline/jesse/speeches/jesse88speech.html

Kawachi I & Kennedy BP (2006).  The Health of Nations: Why Inequality Is Harmful to Your Health.  New York, NY: The New Press.

Kimmerer, Robin Wall (2013).  Braiding Sweetgrass: Indigenous Wisdom, Scientific Knowledge, and the Teachings of Plants.  Minneapolis, MN: Milkweed Editions. 

Maslow, AH (1943).  “A theory of motivation.”  Psychology Review, 50: 370-396.

McGrath, JJ, Saha, S, Chant, D, & Welham, J (2008). Schizophrenia: A concise overview of incidence, prevalence, and mortalityEpidemiologic Reviews30(1), 67–76. (Citation source: NIMH) 

Merikangas, KR, He, JP, Burstein, M, Swanson, SA, Avenevoli, S, Cui, L, Benjet, C, Georgiades, K &

Swendsen, J (2010).  “Lifetime prevalence of mental disorders in U.S. adolescents: Results from the National Comorbidity Survey Replication--Adolescent Supplement (NCS-A).” Journal of American Academy of Child and Adolescent Psychiatry, 49(10): 980-9.

Miller, J (2012). Toward a New Psychology of Women. Boston, MA:  Beacon Press.

Newman KS, O’Brien RL (2011).  Taxing the Poor: Doing Damage to the Truly Disadvantaged.  Los Angeles, CA: University of California Press, Ltd.

North, DC (1990). Institutions, Institutional Change and Economic Performance. Cambridge, UK: Cambridge University Press (From Elinor Ostrom 2010).

North, DC (2005). Understanding the Process of Economic Change. Princeton, NJ: Princeton University Press (From Elinor Ostrom 2010).

Olekalns, M, Caza, BB & Vogus, TJ. (2020).  “Gradual drifts, abrupt shocks: From relationship fractures to relational resilience.”  Academy of Management Annals, 14(1): 1-28.

Orr, DW (2005).  Ecological Literacy:  Educating Our Children for a Sustainable World.  Sierra Club Books.

Onie, R (2012). https://www.ted.com/talks/rebecca_onie_what_if_our_health_care_system_kept_us_healthy

Ostrom, EC (2010). “Beyond markets and states: Polycentric governance of complex economic systems.” American Economic Review, 100(3): 641–694. https://www.aeaweb.org/articles.php?doi=10.1257/aer.100.3.641. Accessed August 8, 2019.

Ostrom, EC (1990). Governing the Commons: The Evolution of Institutions for Collective Action. Cambridge, UK: Cambridge University Press, 1990.

Ostrom, EC (2005). Understanding Institutional Diversity. Princeton, NJ: Princeton University Press.

Piaget, JW (1966). “Our developing social interactions: The rules of the game.” In Hugh Cabot & Joseph A. Kahl, eds. Human Relations: Concepts and Cases in Concrete Social Science, Vol I.  Cambridge, MA: Harvard University Press.

Putnam, RD (2015). Our Kids: The American Dream in Crisis. New York, NY: Simon & Schuster, Inc.

Rifkin, J (2009). RSA ANIMATE: The Empathic Civilisation. https://youtu.be/l7AWnfFRc7g

Rawls, JB (1971). A Theory of Justice. Cambridge, Massachusetts: Harvard University Press. 

Rustin, M (2013). “A relational society.  Soundings: A Journal of Politics and Culture, 54: 23-36.

Shonkoff, JP (2019).  Personal communication: August 14.

Stiglitz, JE (2019). The Economy We Need. Project Syndicate.

von Hippel, W (2018).  The Social Leap: The New Evolutionary Science of Who We Are, Where We Come From, and What Makes Us Happy.  New York, NY: HarperCollins Publishers.

Williams GC, Patrick H, Niemiec CP, Ryan RM, Deci EL, & Lavigne HM (2011).  The Smoker’s Health Project: A Self-determination theory intervention to facilitate maintenance of tobacco abstinence.  Contemporary Clinical Trials, 32(4): 535-543. 

Wilson, DS (2019).  This View of Life: Completing the Darwinian Revolution.  Penguin Random House.

Appendix A: Representative List of Subject Matter Experts and Influencers

Dr. Jack Shonkoff, Director of the Harvard Center on the Developing Child; Former Dean of Brandeis Heller School (August 14)**

Dr. Charles Homer, Chief of Improvement Evaluation, EMPath Boston; DAS, Children’s Health Policy US-HHS under the Obama administration; Founding President and CEO of National Initiative for Children’s Healthcare Quality (August 15)**

Dr. Mariana Chilton, Professor Drexel Dornsife School of Public Health and Director of the Center for Hunger-Free Communities; Co-PI for the multi-site national Children’s HealthWatch research network (August 16)**

Dr. Marshall Ganz, Senior Lecturer in Leadership, Organizing, and Civil Society, Harvard Kennedy School of Government** 

Dr. Michael Rustin, Dean of Social Sciences, University of East London, UK*

Hilary Cottam, Innovator and Social Entrepreneur, UK; Author of Radical Help: How We can Remake the Relationships Between Us and Revolutionize the Welfare State (2018)*

Dr. Dolores Acevedo-Garcia, Professor of Human Development and Social Policy, Brandeis Heller School*

Dusan Stojicic, Brandeis Heller School; Leadership Development Coach, WeOwnIt**

Laurie Burnett, Education Consultant, Assabet Valley Collaborative **

Dr. Pedja Stojicic, Project Director, Rethink Health and the Rippel Foundation**

Bryan Stevenson JD, Founder and Executive Director, Equal Justice Initiative; Author of Just Mercy (2014)*

Dr. Virginia Eubanks, Professor SUNY Albany; Author of Automating Inequality (2018); Co-founder of Our Power, Our Knowledge 

Dr. Claire Bynner, Research Team Lead, Children’s Neighbourhood Network, University of Glasgow UK*

Sir Harry Burns, Professor Global Public Health, University of Strathclyde, Scotland UK

Dr. Robert Putnam, Professor of Public Policy/Harvard; Author of Bowling Alone (2000), Our Kids (2015)

Dr. Vivek Murthy, Former Surgeon-General, US 

Dr. David Weil, Dean, Brandeis Heller School

Thomas Piketty, Capital in the Twenty-First Century (2013)

Elinor Ostrom (deceased, 2012), Governing the Commons (1990), Nobel Laureate 2009  

Prof. John Rawls (deceased, 2002)

Prof. Michael Sandel

*One-on-one outreach in August/September 2019
**One-on-one meetings in August/September 2019

Appendix B: Script for Interviewing Subject Matter Experts

Dear Colleague,

Many thanks for making the time for our upcoming meeting. I am sharing these few documents with you for background (please see attached; cited below in blue italics). 

The first is the small grant proposal I wrote to a private family foundation this past May and was funded for the Relational Society project

As I had mentioned in my introductory email, I am collaborating as co-PI with Jody Hoffer Gittell on this study. I have been following Jody’s scholarship on Relational Coordination for many years with absolute delight. Attached is her book chapter New Directions for Relational Coordination Theory published in the Oxford Handbook of Positive Organizational Scholarship.  

The 2013 essay, A Relational Society by Michael Rustin (UK), inspired me to think about the delivery of health and social care services from a new paradigm. It was hard for me to miss the potential synergy between the two constructs – Rustin’s Relational Society, and Jody’s Relational Coordination theory. The other article, The Economy We Need by Joseph Stiglitz, gave me further grounding to think it through.  

Given this backdrop, here is a snapshot of my thought process, for steering our conversation:

  • We human beings, while autonomous, are social beings and, therefore, individual freedom and choice cannot be sustained outside of the wider social context 

  • We are a product of our opportunities and consequently our global environment

  • Our health and well-being are highly interdependent and, therefore, we need strong social foundations and frameworks that are both equitable and balanced, as well as resilient

  • Given the many dire challenges we face as a society, the status quo is untenable 

  • In the absence of political will and corporate apathy, and despite the enormity of challenges, a relational society approach is our immediate and most viable hope

  • So, where can we start, and how do we operationalize the relational society construct into practice? 

    • Where? – Specific high-needs population/s, such as children and families with poor health status and chronic special needs due to “toxic stress” from insecure income, housing, food and nutrition, parenting, domestic life, neighborhoods, schooling, perinatal or intergenerational trauma, and/or access to primary and specialty care      

    • How?

      • Design a robust model of relational action from the population’s perspective, the population’s perspective being NOT perceived needs but their “lived reality,” 

      • That upends the emphasis on managing scarcity to building capacity through human connections and value-based problem-solving,

      • The values being empathy as in John Rawls’ Original Position (Attached – Page 212, A Theory of Justice), passionate humility, mutual trust and respect, clear shared goals, shared knowledge, multi-dimensionality, and distributed leadership, with various stakeholders coming together in this social coproduction process as parts of the whole.    

Appendix C: Selected Resources for Health-Related Social, Emotional, and Structural Needs Assessment

Micro:  Comprehensive Needs Assessment

  • Health Leads Living Conditions/Social Needs Assessment Tool  
  • The CDC-Kaiser Adverse Childhood Experiences Survey  
  • CMS Accountable Health Communities Health-Related Social Needs (AHC-HRSN) Screening Tool (10-item Core questionnaire; with eight supplemental domains)   
  • Core Questionnaire (10 items)
       Housing Stability
       Food Insecurity
       Transportation Needs
       Utility Support Needs
       Interpersonal Safety
  • Supplemental Domains (26 items, ranging 1-3 questions per domain)
       Employment
       Family and community support
       Education
       Physical activity
       Substance use
       Mental health
       Disabilities
  • Assessment of Self-Determination (Williams GC et al, 2011) 
       Autonomous Self-regulation
       Perceived Competence
       Perceived Need Support from Health Care Practitioners
       Perceived Need Support from Important Others 

Meso: Relational Coordination

  • Relational Coordination Survey Tool (7 Dimensions)
       Frequent communication
       Timely communication
       Accurate communication
       Problem solving communication
       Shared goals
       Shared knowledge
       Mutual respect

Macro: Social Policy Design, Stakeholder Alignment, and Public Policy Framework   

  • Healthier and More Equitable Communities (36 Measures of Health, Factors That Shape Health, and Drivers of Health Equity for Local Solutions: City Health Dashboard, 2018)a
  • Public Health (10 measures)
  • Social and Economic Factors (10 measures)
  • Health Behaviors (5 measures)

  • Physical Environment (6 measures)

  • Clinical Care (5 measures) Stakeholder Alignment Assessment (Cutcher-Gershenfeld, J et al, 2012)

  • Comparative Evidence-Base on Societal Impact of Public Policies (Kawachi I & Kennedy BP, 2006; Newman KS, et al 2011)
       Taxation
       Health and Social Policy
       Firearms and Public Safety
       Law and Criminal Justice
       Environment 

“We are caught in an inescapable network of mutuality, tied in a single garment of destiny.”

Reverend Dr. Martin Luther King Jr.

With generous support from the Topol Family Foundation