The Importance of Openness and Authenticity in Psychotherapy

Researchers Dr. Laura Galbusera and Dr. Miriam Kyselo at the Technical University in Berlin have recently put forth a conceptual paper building on the Finnish Open Dialogue (OD) approach to psychotherapy. Their new paper highlights openness and authenticity as central to effectively delivering therapy.

“In contrast to biological psychiatry, the OD approach does not view psychiatric disorders as brain diseases but considers instead each symptom of a person’s psychological distress as an adaptive and meaningful reaction to a specific difficult life situation or context,” Galbusera and Kyselo write.

The OD approach was developed in the early 1980s as a continuation of the Finnish National Schizophrenia Project. Rather than focusing on the elimination of symptoms, OD first aims to understand their meaning through attending to the client’s perspective as well as those in their social network. The background of this approach stems from the OD intent to radically reorganize treatment systems overall to respond more closely to client needs.

In this way, the preferred mode of treatment through the OD approach is psychotherapy. Galbusera and Kyselo make the argument that this approach shows promise, highlighting studies outlining its efficacy in responding to experiences of psychosis, marked by outcomes such as returning to work or school, or the reduction in symptoms.

The authors outline the core principles of OD, including the following:

• Immediate help for the client. This involves getting in touch with the client no later than a day after they’ve reached out.
• Adopting a network perspective. This principle involves not just individual contact with a client but also requires inviting all relevant people in their life to participate in treatment team meetings. Additionally, all meetings and decisions are made in the presence, and with the agreement, of the client.
• Flexibility and mobility. Mainly, this stresses tailoring approaches to the individual needs of the client, including logistical details such as location and frequency of meetings.
• Guaranteeing responsibility. This principle is related to the idea of psychological continuity and asserts that the professionals organizing the details of treatment ought to remain consistent throughout its duration.

Galbusera and Kyselor focus on the dialogical process of OD. Stressing the crucial role that this stance takes in psychotherapy, they write:

“Proponents of OD assume that therapeutic change happens through dialogical interactions with the client instead of being steered unidirectionally by professionals. An important element of this dialogical attitude is that all participants are encouraged to tolerate uncertainty about process and outcome of the treatment, instead of trying to predefine and control the situation. Tolerance of uncertainty is thus the last basic principle of OD.”

Furthermore, this dialogic process is based on the ideas that the process of psychotherapy involves more than just the spoken words in an exchange, acknowledging a “pre-reflective reality in which the things we live through cannot be always explicitly and linguistically grasped.” This necessitates the ability of the therapist to be present yet spontaneous and open in their attention.

While the process itself is dynamic and interactive, these researchers contend that the therapist plays an active role in initiating dialogue and setting up the appropriate conditions to facilitate dialogue. Drawing from the works of theorists such as Bateson (1972), Buber (1987), Bakhtin (1984), and Rogers (1966), the authors aim to understand the specific factors that facilitate the emergence of a successful dialogic process. Following Bateson, they ask, “what is the difference that makes the difference?”

Galbusera and Kyselo maintain that openness and authenticity are the “necessary and sufficient conditions for a dialogical attitude.” Openness, as previously described, requires that therapists embrace uncertainty, acknowledging both that they can neither fully know the person in front of them nor script the specific course of therapy. This involves a skilled attentiveness and ability to meaningfully respond to the contingencies that naturally arise in the dialogic exchange. A meaningful response is defined by the extent to which it has been adapted to the client. They elaborate, saying:

“Attentive listening, acknowledging and accepting the other, respecting and taking her seriously, adapting one’s own utterances and behaviour to the ones of the other person – all this implies a basic attitude of opening up to the other.”

Yet, the authors assert that openness in and of itself is not sufficient. To only be open risks simply reversing the psychotherapeutic dynamic, positioning the therapist as a witness rather than an active participant. This, they note, strips the exchange of its “intersubjectivity,” by reducing the therapist’s participation as a subject. Therefore, the authors make an argument to include authenticity.

Their understanding of authenticity is likened to Carl Rogers’ concept of genuineness, except they integrate professionalism as a complementary, rather than a competing force. “Simply said,” the authors write, “professionals are expected to be resonating as fellow human beings.” This involves therapists not only acting upon their personal thoughts and feelings but also upon their “professional concern and knowledge.”

Authenticity is further described by the authors through the use of Bakhtin’s notion of a “penetrated word.” They write:

“Even when literally repeating another person’s words, we always add something to it, for instance, a particular tone or pitch. A response thus implies something different from what it relates to, i.e. it is penetrated by the respondent’s voice. This captures the idea of authenticity as it refers to the person’s owning of her voice in the dialogue. Authenticity thus means that the person enacting the response expresses her original contribution and through her enactment, she also ‘interferes’ with the other.”

The authors suggest that enacting openness and authenticity in this way creates a therapeutic environment characterized by both transparency and active inquiry infused with personal resonance, and professional responsibility. They conclude:

“The twofold and circular structure of openness and authenticity enables an intersubjective process in which both subjects can move and are being moved. Openness implies a certain readiness to ‘being perturbed’ by the other’s self-affirmation, whereas authenticity implies a certain willingness to ‘perturb’ the other with one’s own self-affirmation. This means that the therapist acknowledges and takes the client seriously, thus being affected by her, and at the same time she takes responsibility for her own stance and affirms it, thus also affecting the client. By this circular movement of caring for oneself and for the other, we can ensure therapeutic change is not unidirectional but instead co-evolving, and thus pertaining to the intrinsic transformative nature of dialogue.”

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Galbusera, L., & Kyselo, M. (2017). The difference that makes the difference: a conceptual analysis of the open dialogue approach. Psychosis, 1-8. (Link)