Institute on Healthcare Systems

Building a Relational Society

By Shyamal Sharma
Co-PI, Relational Society Project
The Heller School, Brandeis University

Relational Society Framework

"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).

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 Relational Coordination Research Collaborative, an international community of researchers and practitioners based at The Heller School at Brandeis University, may be well-positioned to take the lead.

The RCRC's home base is Brandeis University's Heller School, whose 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 led by the RCRC, building on The Heller School's existing research and its existing relationships with experts across the academic and social spectrum.  

For a summary of the research we conducted about existing models, please visit here.


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

Reverend Dr. Martin Luther King, Jr.