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It's the relationships (as Buber might say), stupid!

August 17, 2010
by H. Steven Moffic, MD
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I think that I may have been stupid in giving the title of my last blog “It’s the quality, stupid!” Not that improving quality isn’t an obvious and essential challenge for us in behavioral healthcare. But it has come to strike me that there is something even more basic for our systems to have in order to improve quality. This is good, human relationships. Until people can sit in front of a computer and get all the real help they need, live relationships will be required.

Come to think of it, maybe it was not only his famous line, “It’s The Economy, Stupid!” that helped propel Clinton to his Presidency. It was how he said it and how he related to people that made the message so acceptable. He was—and still is—a master at building relationships.

The trouble for us is that our problems in providing better quality of care may in part be caused by our less than ideal relationships. These relationships include not only the clinicians and who is served, but the administrator, administrative assistant, and any others in the system.

What has made good-enough relationships (a la Winnicott’s “good-enough mothers”) apparently harder to establish nowadays at our worksites? To me, and probably to most who have been in the field long enough, less time and less money. As a consequence, we seem to have more burnout, competition, and scapegoating.

Maybe these changes are reflected in the new names we give ourselves, as discussed in the prior “What’s in a name?” blog—names that reflect business and behavior. It’s all well and good to choose names we would prefer, but then what name unites us?

Perhaps our history provides an answer and solution. Healthcare, and especially behavioral healthcare, comes out of thousands of years of shamanistic and religious traditions that emphasized the sacred nature of our work. This work was often felt to be a calling as much as—or more than—a career. Whether healing was attributed to a human and/or a God, a relationship was at its core. Indeed, we know that the common healing element in any school of psychotherapy is the development of a therapeutic alliance.

Over a century ago, the philosopher Martin Buber tried to distill the meaning of that kind of relationship. Though difficult to translate from his idiomatic German, in English this came to be known as the I-It versus the I-Thou relationship. The “It” refers to an object, or a part. In this kind of relating, we do something to reduce symptoms of an illness, not necessarily to heal a person. The clinician or administrator tends to be objective, detached, and bureaucratic. Though “Thou” originally referred to God, it has broadened to refer to the best of human relationships. This is more than empathy and identification; it is a concrete imagining of the authenticity of the other. It includes respect and recognition of the dignity of the other. Though not mutually exclusive, Buber recommended more of the I-Thou relationships than I-It.

Buber’s influence in America spread in several directions, including three of the Rogers. Carl Rogers developed client-centered psychotherapy; Mister Rogers gave loving messages to children on television; and Rogers and Hart wrote the hit song “Thou Swell,” which began with the lyrics, “Thou swell, thou witty, thou sweet, thou grand ... ”

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Objectification of the other is a way many professionals use to maintain personal and professional boundaries. It's not to be confused with a term associated with Murray Bowen, the well known family systems therapist, "differentiation". As I understand the term, well differentiated humans are able to fully relate to the internal world of the client/child/spouse/patient/colleague/etc. without confusing their world (the thou) with one's own world. Harville Hendrix (creator of Imago Relationship Therapy) says it simply "Realizing the reality of the other".

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H. Steven Moffic

H. Steven Moffic

H. Steven Moffic, M.D. retired from the clinical practice of psychiatry and his tenured...