09 Jun

Relationships and Mental Health

Daughter and father

The Mental Health Foundation have released an excellent report, which you can read here, which sets out further evidence that investing in relationships is at least as important to our health and wellbeing as not smoking. Their argument, like that of Relational Thinking Network, is that  both as a society and as individuals we need urgently to prioritise relationships and tackle the barriers to forming them.

The importance of relationships for health

Looking at a range of evidence, the authors show that people who are more socially connected to family, friends, or their community are happier, physically healthier and live longer than people who are less well connected.

Indeed, a review of 148 studies concluded that:

the influence of social relationships on the risk of death are comparable with well-established risk factors for mortality such as smoking and alcohol consumption and exceed the influence of other risk factors such as physical inactivity and obesity.

They make reference to a longitudinal Harvard study, that began in 1938 and published in the 2012 book ‘Triumphs of Experience’, that found that that relationships are the most important factors for health and happiness.

Factors causing relationship problems

The report discusses a number of inter-related factors that negatively affect relationships. For example:

  • Moving away from one’s hometown, family and friends can have a very real impact on our relationships. Moving means having to adapt to a new physical and social environment. Studies suggest that one of the biggest challenges facing individuals when they move is building relationships and connecting with others.
  • Social media and other online technologies have many positives. However, the report notes that almost half of internet uses in the UK reported that the internet had not increased their contact with friends or family who had moved away.

Indeed, while they have increase our sense of belonging, online relationships cannot replace our offline relationships.

The neurochemical response that occurs during face-to-face interactions contributes to our sense of connection, understanding and ultimately wellbeing. In other words, face-to-face communication still matters.

  • Bullying can have a negative effect on people’s health. Conversely a positive experience at school, particularly with teachers, can “act as a buffer and help protect young people during this difficult time.” This is something that Relational Schools has been researching on.
  • Loneliness and isolation are a significant issue for older people. See an earlier blog post we wrote about this here.

Actions to be taken

The report ends by calling, as the Relational Thinking Network has done, for “a sea change in thinking”. We need to not only recognise the importance of relationships, (which we instinctively do), but that we take an active approach in the way we build and maintain relationships, and to tackle the barriers that prevents strong relationships from being built.


28 Jan

The junior doctors’ strike: which relationships matter most?

Junior Doctor's strike

Letter to the Times (unpublished) – On Tuesday 12th January, across the UK Junior doctors went on strike in a dispute over pay and working hours. The dispute centres around the Healthy Secretary’s (Jeremy Hunt) proposals under which ‘normal’ working hours will include weekends and evenings. This means that doctor’s pay for these anti-social hours will be greatly reduced.

This is part of a move by the government to turn the NHS into a ‘seven-day-a-week’ service. Jeremy Hunt wants to get more work out of the same workforce for the same overall cost. And as it will make it cheaper for hospitals to roster doctors during these hours, more will be working time for which they were previously paid a premium.

The important question to ask, is who are the ‘stakeholders’ in the junior doctors’ strike? Which relationships matter most?

The government argue that relationships between patients and the NHS trump all other considerations; patient care can be improved by a 24/7 service, so it is an open and shut case. But is it so simple?

Which relationships are the ‘losers’ if the government succeeds in its plans? There is no point in junior doctors working without other related professional groups – anaesthetists, bed managers, nurses, radiologists, pharmacists, social workers, and ancillary staff. Has the government thought through the effects on relationships among professionals if they come under the stress of a 7-day work pattern?

Has it considered mental health and burn-out effects, which all damage relationships both inside and outside the NHS? Has it also considered the cost to partners, children, extended families and communities if another chunk of the workforce is removed from being present in their households over weekends?

And it is not even clear that the public either want or need additional medical services on Sundays. Early trials with 7-day GP surgeries did not demonstrate public demand. There is in effect already a 7-day NHS. Those who urgently need help always get it.

Are the ‘market men’ really more important to government than those concerned for public sector efficiency and social well-being which is most people’s priority?

Author: Dr Michael Schluter CBE – founder of the Relational Thinking Network

Photo: West Suffolk Hospital, Not Hunt’s to Sell (By sasastro from Flickr).

24 Jun

Social Capital: we’re nothing without it


Relate, the UK’s largest provider of relationships support, have launched a Best Medicine campaign “to put relationships at the heart of the NHS”. Their report details how “good quality relationships matter for our health and wellbeing and can improve health outcomes; but long-term health conditions can also have a significant impact on our relationships”. It goes on to argue that “it is important to ensure our relationships are resilient and robust if we are to draw on such relationships as assets to health and wellbeing.”

The evidence for the link between relationships and both physical and mental health is strong. Weak relationships can lead to unhealthy behaviour (for example substance abuse), whilst supportive relationships encourage health promoting behaviour, particularly for men (who are more likely see a doctor or change diet if encouraged to do so). Relationships also buffer stress with significant physiological benefits, whilst loneliness is known to damage health. A meta-analysis concluded that the influence of social relationships on the risk of death is greater than that of physical inactivity and obesity and comparable with well-established risk factors for mortality such as smoking and alcohol.

Relationships are also essential in the provision of care: 6.5 million people in the UK currently care unpaid for an ill, frail or disabled family member or friend. But 75% of carers were found by Carers UK to have difficulties in maintaining relationships and social networks due to the demands of caring. As one carer put it: “Friends have drifted away so I am exhausted from caring and have little support. I am becoming increasingly isolated and depressed.”

Over the last five years the Relationships Foundation has consistently argued for a more comprehensive family policy with clearly designated responsibility. Rather than it being seen as a narrow agenda around parenting, childcare and the funding of relationship support services, it needs to recognise how policy in all areas can both influence families and depend upon them. We’re therefore encouraged to see more relational approaches to policy being adopted across the political spectrum. The ConservativeHome website has just run a series on the family as the missing link in policy to promote ‘aspiration’ which quotes our assessment of the costs of relationship breakdown. Earlier in the year the Labour MP John Cruddas spoke at an event organised by the Relationships Alliance (of which Relate are a part). In referring to the problems that can be caused by weak relationships he concluded the:

“These problems aren’t a failure of public services or even the economy – though both these play their part. They are a failure of relationships. So we need to stop making policy as if grandparents, mothers, fathers and children exist in separate silos and not as part of a whole family. Throughout our lives we are dependent upon others for our wellbeing and sense of identity. Relationships give meaning to our lives. They bind us all together into society and give us our sense of belonging. We are literally nothing without them. …  We need government that helps create the conditions for families and people’s relationships to thrive.”

The Best Medicine campaign should therefore be seen as part of a wider movement to recognise the importance of our closest relationships, and the potential for many government departments to play a part in supporting them. Too often social capital, and particularly that which resides in families, is an invisible and neglected resource in policymaking. Relate make ten recommendations for ways in which relationships could be better addressed by the health system. These illustrate the kind of specific changes that are necessary of relational thinking is to turn into relational practice.

  1. The UK Secretary of State for Health becomes Secretary of State for Health and Wellbeing
  2. Couple, family and social relationships become a core part of the work of local Health and Wellbeing Boards
  3. Government establishes an inquiry into how relationships can be included in health policy frameworks, including outcomes frameworks
  4. The What Works Centre for Wellbeing commissions research into long term health conditions and relationships
  5. Public Health England establishes a National Health and Relationships Intelligence Network
  6. Directors of Public Health consider the best ways to gather data on the quality and stability of relationships to inform local authorities and commissioners
  7. Clinical Commissioning Groups and local authorities have a duty to undertake a ‘Family Test’ when considering new local policies and in the commissioning cycle
  8. Relationship support and impairment-specific charities partner to provide support
  9. Public Health England supports local authorities to embed plans to strengthen relationships and incorporate relationships into Joint Strategic Needs Assessment and Joint Health and Wellbeing Strategies
  10. The Department for Work and Pensions pilots a local ‘family offer’ with a focus on health and wellbeing, particularly on the couple, family and social relationships of people with long term health conditions.
22 May

Changing the Game for Drug Addicts

drugs for web

In January, we posted an article that briefly discussed a new book by Johann Hari about drug addiction. Today, Andre Van Eymeren, who worked for one of our member organisations ‘Partnering for Transformation’, writes a more in depth article based on Hari’s work.

What comes to mind when you think of drug addiction? Spaced out people, down and outers, alley ways littered with tags and needles, mental health issues, violence, the drain on society, people experiencing a lack of purpose and meaning, runaways. I guess for the most part the term conjures up fairly negative images and causes us to hold people suffering from drug addiction at arms length or further.

Some of the outcomes can of course be very scarey. People addicted to Ice for example can become violent at the slightest (perceived) provocation and the researchers are saying that the drug even begins to change brain chemistry. Currently they are not sure if this is reversible. All of this paints a pretty grim picture.

Enter into this dark landscape an article by Johann Hari, featured recently in  The Huffington Post. Based on the research for his book, Chasing the Scream: The First and Last Days of the War on Drugs, he “learned… that almost everything we have been told about addiction is wrong and there is a very different story waiting for us, if only we are ready to hear it.”

For Hari the journey has been a very personal one, beginning as a child trying to wake up a relative and not being able to. From that time he has mulled as I’m sure many of us have on what causes some people to become fixated on a drug or a behavior until they can’t stop? Learning from friends who have first hand experience, the pain of seeing a loved one battle with the ups and mostly downs of addiction and attempting to loose themselves from it and falling over and over again is excruciating. And in no way to blame them, for self-protection, eventually most family and friends remove themselves from the lives of the addicted person. Unfortunately this tends to have the effect of further cementing a lifestyle of addiction.

Hari writes, “if you had asked me what causes drug addiction at the start, I would have looked at you as if you were an idiot, and said: ‘Drugs. Duh’” As you would be aware drugs have a strong chemical hook and so if we were to take them for a period of time and suddenly stopped the belief is our body would crave them.  This theory was established through tests on rats, carried out in America. A rat placed in a cage on its own with two water bottles, one plain water, the other laced with heroin or cocaine. Time and time again the rat would become obsessed with the latter bottle till essentially it killed itself.

In the 1970’s some alternate experiments were run by, Vancouver Professor of Psychology, Bruce Alexander. He built what came to be known as Rat Park. This cage had coloured balls, the best rat food, tunnels and friends. And again the two bottles were set up. This time the results were significantly different. The rats residing at Rat Park mostly shunned the drug laced water bottle, consuming less than a quarter of the drugs the isolated rats used. None of them died. None of the rats living in the second happy environment became heavy users.

According to Hari and the studies he uses as evidence, returning soldiers from the Vietnam war provided a useful human equivalent. Many soldiers on deployment (20%) understandably used drugs to combat fear etc. When they returned 95% of that 20% simply stopped without the use rehab. What was different? Their environment. From being terrified everyday the soldiers returned to relatively pleasant home lives which left the need for the drug redundant.

Professor Alexander made a fascinating observation challenging the view that drugs are a moral failing as well as the more liberal opinion that addiction is a disease taking place in a chemically hijacked brain. He argues that addiction is an adaption. It’s got more to do with your environment than what is going on inside you. Of course your reactions to your environment may be another story. He re-ran the old experiments with the isolated rats, they became hooked, then he placed them in Rat Park and after a few twitches they got on with a happy life, addiction free, with no desire for the drug.

A further case for this theory of addiction is pain relief in hospital. For severe pain, patients effectively receive heroin at a much higher purity and potency than addicts on the street. After months of use hospital patients can simply stop. It virtually never happens that a patient then transfers their addiction to the street and they leave hospital trying to score on the way home. But the same drug wreaks havoc in the lives of users on the streets.

Hari points out, “…the drug is the same but the environment is different.” The hospital patient for the most part is going home to an environment where they are loved and cared for. The street user suffers continual isolation and rejection.

The issue then, according to Professor Peter Cohen, is not the drug but human bonding. We are created to bond to others, to form attachment, relationship. If these essentials go missing then we will bond with other things. For some this includes drugs of all sorts and others gambling and alternate addictive behaviours.

If we accept this theory of addiction then it is a huge challenge to the way we work with addicts. By in large the social services are not equipped to adapt to a relational approach to service delivery. Professionalisation of care and the perceived need for professional distance has meant in some cases a de-personalisation, particularly around people with complex needs, which are often compounded by drug addiction.

If we are to believe the points that Hari raises and take on board people’s need for bonding relationships, then as service providers the concern will not only be for the individual but for their network of relationships, their community if you like. Now many of these might be burnt but focusing on their relational web will be a starting point in the recovery process. Quite often people addicted to drugs will find themselves homeless and in boarding houses. How can housing providers work to ensure positive environments where relationships and attachments will form, which will negate the need for the drug. In Melbourne there are an increasing number of rooming houses that focus these concerns. Servants of Hawthorn and Magpie’s Nest are two examples.

This approach to working with people addicted to drugs also provides a window for churches, Rotary, Lions and other welfare minded community organisations. People with addictions often need new networks of relationships, opportunity to connect with people who will share life and journey with them. Obviously if there are family and friends left in the addict’s life who can provide these relationships in a positive environment that is a better option. But if these relationships have been burnt alternate connections are needed.

As humans we have an innate need to connect meaningfully with others, why then do we seem to have the propensity to deny this connection to people who it could be argued need it the most?

31 Mar

Translating the best…to the rest


I was at Jamie’s Italian recently in Liverpool. The menu had all the trademarks of the man’s appreciation of simple quality. The décor combined a sense of kitchen with a marketplace. The staff, albeit without a hint of Essex, had a familiar enthusiasm about the food they were serving (apparently they are trained to know about each recipe). It worked – a tried and tested approach with a distinctly local character, crammed full of customers.

But it doesn’t always work. The chain’s flagship Istanbul branch reportedly filed for bankruptcy earlier this year.

A restaurant offers a combination of concept, venue, recipe, ingredients, a chef’s skill, service and customers. The mix of these elements is often dynamic and subtle. Knowing how a great restaurant is working today does not tell you how it got to be great, let alone how to replicate it elsewhere. Which is why successfully rolling out a complex package to a wider constituency is challenging.

The NHS England Vanguard programme of New Models of Care has set out its stall to explore scaleable and replicable solutions. It is planned that the first wave of sites will pave the way for a group of early followers within a matter of months and years. Simon Stevens described the choice of Vanguard sites being made on the basis that they were already ‘performing strongly and have good relationships’. Selecting sites with strong relationships makes sense, as the success of an organisation depends on how well it connects internally and externally. The biggest challenges lie post-vanguard: how to translate what works for established partnerships (that also have access to a coordinated support programme and a share of £200m) into success for the rest.

Prominent amongst these challenges is how to replicate relational capital. Relational capital already exists within the Vanguard sites. Like an established restaurant, these sites have the wherewithal to adapt to improve customer service. How those sites got their strong relationships and how to help others build strong relationships is a different question.

Taking another example, it is striking how the relationships (some of them longstanding) behind devo Manc were so crucial in getting the agreement for devolved health and social care budgets for the city region. Where capital is less developed, as amongst some of the hoped for early followers, the parties to the relationships will need help to develop the capital they need. Unlike financial capital, relational capital cannot simply be transferred from headquarters. Adopting only the model or method or even providing the finances will not be the whole package for the post-vanguard sites, as numerous examples of public sector ‘pilot-itis’ testify.

The Vanguard has a real opportunity to address this. If NHS England generates a detailed understanding of the relational capital fuelling the first wave of sites, it can support the next wave to develop good relationships more quickly. Many areas struggle to broker trust and common purpose amongst stakeholders, finding themselves battling organisational self-preservation and chequered histories of engagement. However, relational capital can now be quantified and explained in ways that can be adopted by another system relatively quickly. Introducing a common language and understanding of inter-organisational relationship will practically help areas ‘make it real here, regardless of where we are starting from’. With this sort of outcome, the New Models of Care programme will truly be transformative.

This article was originally published by Renuma, one of our member organisations, and is republished here with their permission.

03 Feb

Hello my name is…

Hospital care

CAMBRIDGE – Dr Kate Granger is health consultant and a terminally ill cancer patient. While she was in hospital last summer, she observed that many of the staff looking after her did not introduce themselves. In fact, the doctor who told her she had cancer didn’t even look her in the eye. She felt that she didn’t matter and that those treating her didn’t care who she was.

As a result she’s started the ‘Hello my name is…’ campaign (#hellomynameis), to encourage health workers to introduce themselves to patients and remind them about the importance of introductions in the delivery of care. For Granger this goes further than ‘just’ knowing someone’s name: “It is about making a human connection, beginning a therapeutic relationship and building trust. In my mind it is the first rung on the ladder to providing compassionate care.”

It reminds healthcare staff (and indeed all of us), that relationships are fundamental to healthcare. The NHS has been under lots of pressure recently, but relationships cannot be neglected. Treatment and care are delivered through relationships, and relationships represent a large part of the support system through which patients recover health.

So we welcome Dr Granger’s campaign, which will bring peoples’ focus back to the vital importance of strong relationships in healthcare.

You can read more here.


07 Jan

Drugs: “a war on” or “a relational approach to”?

drugs for web

LONDON /CAMBRIDGE – The story of Johann Hari has a complicated and dark chapter. In 2011 the  ex-columnist fell from grace after it turned out that he had been plagiarising.   Reading the interview with Hari in the Guardian in which he speaks out for the first time about ‘that time’, raises a lot of relational questions.  Perhaps it should not be surprising that it surfaces in his new book on the war on drugs as well: “What I learned is that the opposite of addiction is not sobriety. The opposite of addiction is human connection.”

Hari wanted to write this book, not to have an argument but “to understand it”. He traveled the world, met people all over who in one way or another were interested or involved with (the war on) drugs. One of them, a retired psychology professor in Vancouver, opened his eyes to the ‘relational’ factor. Experiments with rats showed that they were more likely to take drugs when they were isolated and alone, than in an environment where they could flourish with space, things and friends to play with. Professor Bruce Alexander discovered “that we’ve fundamentally misunderstood what addiction is. It isn’t a moral failing. It isn’t a disease. Addiction is an adaptation to your environment. It’s not ‘you'; it’s the cage you live in”, says Hari.

And according to him this understanding should have massive implications for the war on drugs: “Our laws are built around the belief that drug addicts need to be punished to stop them. But if pain and trauma and isolation cause addiction, then inflicting more pain and trauma and isolation is not going to solve that addiction. It’s actually going to deepen it.”

The “war on drugs” needs to change its approach. It is calling for a relational (social and political) answer, and not just for an individual change of heart.


24 Nov

Thinking about relationships in health


CAMBRIDGE/YORK – It’s becoming more and more clear how important strong relationships are for the quality of healthcare. A conference  early next year, organised by one of our member organizations Whole Systems Partnership, is exploring the role that relationships play in health and care policy and strategy.

The conference, entitled Thinking about Relationships in Health, will take place over 24 hours on Thursday 12th/Friday 13th February, 2015, at the National Railway Museum in York.  It will be led by Dr. Jonathan Shapiro, lead academic and Chair of a large UK Mental Health Trust, and Peter Lacey,  Director of Whole Systems Partnership.  It will also include contributions from other visiting speakers and Whole Systems Partnership Research Associate, Dr. Paul Grimshaw, who has recently joined WSP through the Knowledge Transfer Partnership programme in association with the University of Leeds School of Healthcare Studies.

For more information, or to book online, click here.

17 Nov

Bullying in the workplace: looking at the relationships as well as the individuals

Workplace Bullying

CAMBRIDGE – A survey of UNISON Trades Union members in 2011 suggested that up to 60% had been bullied or witnessed bullying at work in the previous year. Last year, and for the second year running, 24% of NHS employees working in hospital trusts in England said that they had ‘personally experienced harassment, bullying or abuse at work’ from a manager, team leader or colleague. ‘Bullying culture’ is a term repeatedly used to describe elements of the UK police, the armed forces, NHS and teaching. Abusive environments often appear to originate from the very top of public sector organisations. It is clear that this can radically affect our experience of public service.

But what is going on here? Are these service professions really so abusive? There’s plenty of published and private anecdote to suggest they can be. But it’s also true to say that a stretched and financially embattled service may begin to exhibit a whole load of unintended behaviours. The issue is complex. We are left to wonder how much of the apparent abuse results from unpleasant personalities exerting influence on their peers, their managers or their subordinates and how much results from well-intentioned managers deferring to an oppressive organisational culture or just struggling to manage the pressure. In some cases it may even be that a compliant about bullying is itself a way to bully management.

So a challenge for boards and regulators alike is to be able to distinguish between personal harassment arising from persistent and deliberate behaviour of another and the disempowerment of staff undermined by cultural and structural behaviours (e.g. unmanageable workload). The solutions to these two scenarios are clearly very different. Standard approaches include wielding a performance review stick with which to beat bad managers, pushing workforce through leadership training or values programmes in the hope that culture improves or even quietly shuffling people into other jobs. In isolation, these approaches can risk missing the point or simply being unrealistic and unsustainable.

Another approach is to build a fuller and franker understanding of the relationships at work in the organisation and identify where dysfunction needs to be addressed. On the whole, changing relationships that have abusive consequences is a more transformational activity than dealing with individuals who are bullies. Add in the wider organisational performance pay-offs of improved employee relationship and the investment of effort begins to look compelling.

Addressing relational dysfunction is a challenging activity, especially at the scale of a hospital trust or a Local Government Department. The effectiveness of the intervention is largely related to the quality of the insight into the issue. Relationship can be considered in terms of its strength in a number of related aspects, such as power, communication and history. Each of these aspects can be measured. This detailed insight identifies a range of possible levers for change – effective relationship does not necessarily hinge on individuals liking each other and is certainly not constrained by the involvement of differing personalities. Where some aspects of a relationship are fixed, there are usually other dimensions that can be adjusted to bring the desired improvement.

In partnership with Relational Research, companies like Renuma Consulting are working to help the public sector become a measurably less abusive place to work. They are enabling organisations to invest in their employee and inter-departmental relationships, as well as developing tools that equip boards with a more informative and accurate picture of their organisation’s culture, avoiding the “worrying disconnect” between management and frontline staff.

Renuma Consulting is one of the member organisations of the Relational Thinking network and was established to help organisations understand what is happening in their critical relationships and then find ways to improve those relationships. For more information, contact: info@renumaconsulting.com.

15 Oct

Time bombs in your NHS Trust?

Risk Management

What does low relational capital look like in the NHS? Poor relationships between management and clinicians? Staff and patients not listened to? Lack of openness and transparency? Lack of compassion, even? The Francis Report cites this familiar list of issues as directly causing the breakdown of patient care in Mid Staffs Hospital. Many of them went undetected by the governance structures and statutory audit bodies, giving trust boards a potential problem – are there similar time bombs ticking in their organisation?

Boards want to identify the risks in their organisation so that they can mitigate them and reduce the likelihood of a catastrophic event. Performance indicators pinpoint specific outcomes but often miss underlying relational and cultural problems e.g. professional distrust, cultural ill treatment, lack of engagement and low morale.

In case there was need of any other incentive to build greater relational capital in NHS hospital trusts, expenditure on clinical litigation is estimated to reach £19Bn in the near future. A significant part of this is due to relationship breakdown, either between staff or between patients and the trust. To what extent is that avoidable?Risk Management
Practical solutions

Some of the benefits of building better relational capital are:
• staff interacting more effectively and professionally
• employees that are closely known by their line management
• a culture that is more open and honest
• a board that is permeable (rather than shut off) and responsive (rather than silent)

It is possible to measure relational risk in an organisation using tools such as Relational Proximity®. This diagnostic mapping not only highlights specific weaknesses within teams or departments but also points towards focused improvement action that could be taken. The measurement of Relational risk includes numerous components, including lack of communication and information flow, inconsistency, power imbalance and dissonance. It goes beyond measuring the incidence of catastrophic events to addressing the conditions in which such events are possible. For example, early identification of a power imbalance can prevent the reduction in staff participation and motivation that usually follows.

Because relationship is fundamental to human systems such as the NHS, these measures equip boards to respond to the challenges proposed by the Francis report. Apart from these very topical challenges, building up relational capital is a Good Thing – it improves staff wellbeing, reduces sickness absence and improves productivity through proper care being delivered first time.

In the midst of the ongoing financial challenge, where human resource continues to be under such pressure, perhaps now is the time to seriously address the need for improved relationships at the heart of our care system.

This blog appeared on the website of Renuma, a consulting company that helps organisations to understand what is happening in their key relationships and equips them to improve. For more about their work, see here