Return to reality: What does the world ask of us?

Abstract

This article introduces the project Return to Reality: What Does the World Ask of Us? This project evolved from a concern that frameworks in mental health operate with knowledge as their primary mode in such a way that reality is lost from sight. This is not primarily an epistemological problem, but an ethical and existential one: ethical because a knowledge-mediated relation to the real can make us blind to the ethical imperatives found in encounters with reality; existential because to be a subject is to respond to what is real. The works of Gert Biesta are a key inspiration. We use Levinas’s, Lingis’s, and Arendt’s ideas to elaborate these concerns. A return to reality is needed; a shift from knowledge-based to reality-sensitive approaches. We relate these ideas to the Open Dialogue approach, with the key imperative of responding to the presence of those present, and to Reflecting team practices, which Tom Andersen describes as being guided by people’s bodily responses.

In a short piece titled “Ethics Before Ontology: A Few Words,” the Norwegian professor of psychiatry Tom Andersen (2001) notes that mental health practice should not take its starting point in ontology, which concerns answering the question “What is. . .?”. By this, he meant to challenge the dominant idea that the fundamental questions of mental health practice are “What is the problem?” and “How can we solve it?” (p. 12). Based on Emmanuel Levinas’s ideas, Andersen suggests that clinical practice should instead start from ethics. Instead of contemplating what things are, the vital question should be “How can I connect to ‘what is out there?’” (p. 12). In Andersen’s use, ethics refers to a “responsibility for the other (and) activities that connect one’s self with Others” (p. 11). This ethics happens in the domain of the senses, contact, and the real, demanding that those present turn to the specific reality of the unique encounter. We will return to Tom Andersen towards the end of this article.

A matter of responding, not understanding

The core idea that we introduce in this paper can be articulated as follows: a return to reality is needed in the mental health field. This is because professional rationality, in various versions, is enmeshed in models/pictures of the world. These models/pictures risk hindering the encounter with a real situation and those present in it. Seeing (or rather sensing with multiple senses) and responding to the concrete sociomaterial reality of the situation must be the vital starting point for professional practice. This reality risks being hidden behind the veil of knowledge and must not be missed for (at least) two reasons. The first is ethical: drawing on ideas found in the works of Levinas, Lingis, and Arendt, we believe that the fundamental ethical imperative, where moral begins, is found in the fact of reality as other—a moral call already affecting the professional before any understanding is established. The second reason is existential: it is through responding to reality that one arrives as a subject in the world. This origin for both ethics and subjectivity, we argue, may be obscured by various knowledge-based practices in mental health and therapy because preoccupation with knowledge and understanding (in various guises via various approaches) comes at the expense of a more direct relation and engagement with reality and the real other that one encounters.

These ethical and existential aspects that are already at work in the aesthetic and sensible domain could perhaps be summed up as follows: there is an original ethical call from the other and the world (ethics), this call comes from the outside and wants something from me; thus, I am singled out as unique and irreplaceable (existence). The call comes from outside and can only reach me through my senses when I am open to the tangibility of the real (aesthetics and sensibility).

Existence, in this sense, should not be seen as a quality of the subject, that is, that some people possess existence while others do not. The sense of existence that we refer to here is what Levinas (see below) had in mind when he used the term irreplacability; the call from the other singles me out, and it is my taking a stand (ex – sistere = out – stand/step) that is thrown into question. Thus, it is not my existence in either a temporal, spatial, or even existential sense we speak of here but existence in a relational–ethical sense. What is at stake when called is not my existence in any absolute sense, but whether I, in the moment, choose responding as my mode of existence.

It should be noted that what we are suggesting is not to approach the real with a realist vocabulary (e.g. “This is what the world really is and what really goes on”), but rather the opposite: if reality is alter, if it calls upon us in a language of its own, then we cannot cater to it by forcing it to conform to our limited human faculties. The real is not our guest; we cannot expect it to adjust to academic mores. We cannot know the real through epistemology; we can only subject to the fact of reality in existence.

The argument is also motivated by our experiences, as mental health professionals, from managing to hold theories at bay (including our own speculative ontology), to direct attention instead towards the other as alterity and difference. In our experience, a practice beginning in response and responsibility can be helpful in the single case.

Return to reality—An ongoing project

This article takes its point of departure in an ongoing project we have called Return to Reality: What Does the World Ask of Us? This project emerged from concerns related to our work as practitioners, educators, and researchers in the mental health field. Our concern was related to both experiences from clinical practice and from research and education, where a common thread seemed to be that knowledge produced outside the lives of those concerned should govern professional practice.

A key inspiration is the works of educational theorist Gert Biesta. Biesta is concerned that fundamental ethical and existential aspects seem to be lost in contemporary discourse about education. He claims they have become replaced by the ethos that he refers to as learnification (Biesta, 2010), that is, by an obsession with measurable learning outcomes. However, according to Biesta, the ultimate goal of education is not to produce knowledgeable students but to make it possible for students to exist in and with the world. Such existing is something that only an “I” can do, that is, a subject relating to its freedom when responding to the reality of others and the world. Addressed from the outside, the subject is “singled out” (Biesta, 2014), and this is a kind of subjectification that is not person-centred but presupposes attention to a reality that is not of one’s own making, a “world-centredness” (Biesta, 2021). As such, subjectification is a relational and world-centred event in which both an “I” and something other are necessary but not individually sufficient elements, one could say. In the learnification of education, this subjectification is no longer given attention.

We think that Biesta’s concern for both the subject and world-centredness (in education) also can, and should, be addressed in mental health and therapy. Is there not a danger that the ethical and existential dimensions are also ruled out in the professional practices in this field? Epistemocentric rationalities do not give space for the subject to exist or allow the world to appear with its demands because one becomes captive in webs of representations of reality.

The ethical demand of the real and the reality of others may be missed in the webs of interpretations produced by professionals. Our assumption is that this is both an existential and ethical concern because it is when confronted with the ethical imperatives of reality, and called to respond, that one is awakened as a subject, or as Biesta (2020) puts it: this is when the “I” arrives.

We have already started our investigations in this project: in Sundet et al. (2018), we question the widespread idea that sense-making is at the core of human living and, hence, in practices of therapy and care. In Bøe et al. (2019), we reread some qualitative interviews about recovery from mental health troubles, seeking aspects that might have evaded the traditional hermeneutic gaze of qualitative research that only searches for meaning. Bøe (2021) suggests there is an inevitable ethical demand that comes from outside social constructions of meaning. However, we argue that this ethically real demand pulls social construction into motion, as it were. In Bøe et al. (2023), we suggest there is a dominant hermeneutical framework in qualitative research which might lead to a “loss of the world” (p. 584) because humans’ relations to the world are reduced to a matter of interpretations (in some methodological frameworks, thought of as personally constructed, while in others, as socially constructed).

In Sundet (2021), the concept of assemblage is used to indicate relationships between the medical model, the randomized control trial, and new public management that can lead to an unjust health care practice by reducing the diversity of practices. In the study, “Parent Education Beyond Learning” (Bertelsen, 2021), a multifamily group therapy programme is illuminated as a chaotic and unpredictable frame of events (as opposed to being a generic example of a “model”). The study highlights the complex and morally complicated claims that taking part in therapy lays on its participants. McLeod and Sundet (2022) argue for making as an alternative to an interventionist perspective on psychotherapy—where difference is given ontological primacy, bringing the reality of the radically new, not-met, and unknown to the centre stage of psychotherapy. In McLeod and Sundet (2020), the real as interruption is investigated through therapists’ experiences of stuckness in psychotherapy. Bertelsen and Bøe (2016) ¹ use Alphonso Lingis’s (1994a) idea that a community is dependent on each person arriving with something that is not already common. Furthermore, the paper argues that in mental health, both method-based approaches and approaches based on common factors may deprive the encounter of this “nothing-in-common-ness.”

Experiencing the significance of the real

In this article, we mainly make the case for a return to reality with theoretical reflections and relate them to practice. However, support for our argument may also be found in empirical qualitative research. In what is called recovery research, people are interviewed about what helped them recover from mental health difficulties. This research indicates that treatment procedures—built on certain ways of defining and understanding difficulties of living theoretically—do not seem to be central in what the people whose lives are the “object” of treatment experience as helpful. Instead, the aspects valued by those concerned could be referred to as “small things” (as opposed to the “big things” defined by the therapeutic–instrumental rationality and methods of psy-professionalism; Topor et al., 2018). These “small things” are particularities in the encounters and the initiatives of the professionals, such as the way the professional engages personally, their interest in the clients particularly and how they feel recognized and valued through various responses that are personal and concrete. These small things constitute something of significance that lies outside the rationality of treatment models (Bøe et al., 2019).

Hence, what is it about these “small things” that may be so significant? Do they point to a need for a return to reality? What happens is perhaps that those who meet, through these “small things,” break through some of the preestablished “big things” and come into presence as real to each other. The practitioner, as person, breaks through and becomes someone who actually responds to the user/client, as a person. The client experiences that they are being seen, sensed, as real, tangible, and unique, and that it is actually “me” that the practitioner is responding to. They both emerge as subjects, as they subject to the irreplaceable reality of each other. In a sense, this is a small thing, but at the same time, it may have a big (ethical and existential) significance for those involved.

Reality lost in three different frameworks for practice

The space for the subject and reality, we claim, is disappearing in prevailing therapeutic rationalities. The field seems dominated by models and methods for which understanding and knowledge are the fundamental building blocks. Below, we identify three broad theoretical framings that we suggest are generic to the current landscape: the model-centred, person-centred, and social constructionist frameworks. We argue that each perspective carries a specific propensity for losing touch with the reality of those involved and their situation by placing them in a web of interpretations.

The model-centred framework—Losing the reality of the subject

In the model-centred framework, the troubling experience of someone is viewed as an instance of a general problem understood through a theoretical framework. Based on this understanding, a corresponding method is then applied to solve the problem, as in curing an illness. In research, this framework favours scientific proof that the corrective procedures prescribed via the model are effective (at a statistical level) for a specific problem. For this framing, the most trusted brand of scientific methodology is the randomized controlled trial. As a branch of the vernacular of evidence-based treatment, this kind of rationality originated in medicine and in the natural sciences (Sackett et al., 1996).

Adhering to a model-centred framework for practice has been criticized for objectifying and generalizing the people to be helped and their troubles, and for instrumentalizing and limiting ideas about what “help” might mean (Wifstad, 2008). People are seen and treated as carriers of general phenomena as defined by the model, rather than as real, unique subjects leading real, unique lives. One might claim that whatever is accomplished operates in an unreal domain when starting one’s practice in a model (as in beginning in a specific treatment manual when meeting with a client or patient). When generalized theoretical assumptions about a generic phenomenon or problem, such as depression, are taken as points of departure, instead of beginning in the reality of the singular lives of those concerned, statistical knowledge of cause and effect somehow comes to dominate the real singular causes and effects of the individual lives of those concerned (Anjum, 2016). The practitioner and client—as real, unique subjects in real, unique situations—are turned into exchangeable elements of an equation.

Another way to put it is that the model-centred approach is monologic in that it is only the logic of the model–method–expert circuit that is considered decisive for practice. The monologic character of such practices is visible in the way practice operates within an evidence-based framework, where professional practice equals the administration of evidence-based procedures and interventions. In such a practice, fidelity, which is the imperative that professionals should follow specific treatment procedures so that clinical practice equals (or, at least, closely approximates) a procedure for which scientific evidence of effectiveness has been established, becomes a precondition for effective treatment. The professional’s fidelity needs to be mirrored by compliance on the side of the patient, referring to the imperative that the client/patient should follow the professional’s instructions. We are concerned that the reality of the professional as (a) subject is lost in the ideal of fidelity and that the reality of the client as (a) subject is lost in the ideal of compliance. A step out of the models and a return to the real is needed, for ethical and existential reasons.

The person-centred framework—Losing the reality of the world

A person-centred approach has been suggested as a response to the ethical problems of the model-centred framework (Gask & Coventry, 2012; Hummelvoll et al., 2015). A person-centred approach places the person (the client or service user) at the centre of attention, focusing on their values, beliefs, worldview, desires, goals, and so on. These are taken as the starting point for the professional help to be given. Practice becomes a matter of nurturing and supporting the person, based on the clients’ subjective beliefs, needs, and so on. Person-centred approaches not only show individualistic tendencies (McCormack et al., 2017) but also indicate contextual orientations (Borg & Karlsson, 2017). The problem is that such person-centredness may also end up in a kind of unreal domain—namely, the “reality” confined to the individual world picture of the person and the desires and intentions derived from it. The reality of the world itself—humans and material environments alter to the client, existing in their own right—is lost in the sense that they do not inhabit a place of particular interest in this approach.

In a person-centred approach, autonomy, self-determination, and the idea of the “user as an expert” are highlighted. This model may also end up as what we may name a monologic approach—now monologic in the sense that it is only the logic of the person and their worldview that is made decisive for practice. The world—the real, as irreducible and other—is, again, lost from sight. A step out of the personally constructed world and a return to the real is needed.

We could say that both the model- and person-centred frameworks belong in a modernist paradigm. The model-centred approach is modern in that it is logocentric—based on knowledge, instrumental rationality, and a belief in a continuous enlightenment process with science at its frontiers. The person-centred approach is modern in that it takes the person and an egocentric perspective to be pivotal (“cogito, ergo sum”). The ego’s actions, experiences, and interpretations are the primary starting point.

The social constructionist framework—Losing reality in the coproduction of representations

What might be considered a third alternative, and a possible solution to the problems of both the model- and person-centred frameworks, is found in social constructionist and postmodern epistemology. Examples of practices inspired by social constructionism are dialogical, relational, narrative, and systemic approaches, particularly common in family therapy (Flaskas, 2010; Seikkula, 2011). Put simply, the social constructionist paradigm breaks with the modernist belief that knowledge is the truth about the world (model-centredness) and the belief in an autonomous sovereign ego (person-centredness). Within social constructionist epistemology, reality is considered continually cocreated in social–historical contexts through meaning-making in language. Again, it may be noted that one ends up in an unreal domain, as social constructionism is interested in how one’s conceptions or interpretations of the world are socially constructed in language. Reality, in its own right, prior to being perceived through the lenses of meaning, is lost from sight. Gergen (2011) famously claimed that social constructionism “is ontologically mute” (p. 319), ² meaning that it does not offer an ontology. Instead, social constructionism, he claims, explores possible social constructions of concepts and how they “function, for good or ill, in everyday life” (Gergen, 2011, p. 314; for further discussion, see also Clegg, 2011; Shotter, 2012).

It should be noted that there is a great variety of approaches inspired by social constructionism. Some focus on linguistic constructions of meaning, as in narrative practices, while others are more oriented towards both bodily and ethical aspects (Bøe et al., 2015; Seikkula & Trimble, 2005) as, for example, the reflecting team approach (Andersen, 2007) and the Open Dialogue approach (Seikkula et al., 2015). It is in the approaches that primarily focus on altering the linguistic construction of meaning that we think a turn to reality might be needed.

Another turn—A (re)turn to the real

We are here at a crucial point in our argument. We have suggested that a turn from model-centredness to person-centredness and then to a social construction can be identified. We have also claimed that in all three, there is a risk of breaking with reality in ways that are ethically and existentially problematic. We will now go on to suggest another turn that we have called a return to reality, a turn from a knowledge-based approach to a reality-sensitive approach. We will argue for this turn with some ideas found in works by Levinas, Lingis, and Arendt.

Modernity involves a kind of ontological assertion—or stubbornness—that does not, and cannot, fit with reality. Can one, instead, take as a starting point a scepticism towards any claim about what the world is? For example, we find something completely different than ontological assertion/stubbornness in the works of phenomenologists such as Levinas (1985), Lingis (1994a), and Marion (2002). They are not concerned with what the world and another human are (ontology/third-person perspective) but what the world or another human does with us or asks of us as subjects (ethics/first-person perspective). They are not concerned with explaining why the world asks what it asks (third-person perspective). Ontology and epistemology are, first and foremost, speculations. However, the interest in reality that we wish to pursue in proposing a return to reality can perhaps be described as phenomenological and ethical. Marion (2002), for example, is concerned with constructing a phenomenology that can accommodate the divine but that is not about describing it or proving that it exists.

Ethical realism—The world radiates demands

What could be referred to as ethical realism suggests there is a primordial ethics inherent in reality and that reality appears to one with a claim. It is this ethical realism that we suspect that all three models described above risk missing out on. The break with reality that the various epistemological rationalities in the mental health field impose on the encounters may obscure the vital origin of ethical responsibility.

What do we mean by ethics here? The term “ethics” is often used to mean a systematic investigation of (a) values and norms that may guide behaviour, (b) the (cultural–historical) origins of these values and norms, and (c) possible procedures to apply these values and norms in specific situations, which are often characterized as ethical dilemmas (Bøe, 2021). Ethics, in this sense, becomes a theoretical or procedural concern. This is not the ethics pointed out in ethical realism. Here, ethics becomes an aspect of human existence that one inevitably faces in one’s life and to which one must relate. The ethics we point to in this paper is not conceived as something one adds to one’s life or constructs through social–cultural reflections and interpretations. Ethics, in the sense of a call or obligation to do good, is an imperative inherent in facing reality and other human beings.

The kind of ethical realism we propose resembles what Nortvedt (2012) calls “perceptual moral realism” (p. 296). A “value ladenness” is already present in what one perceives, and values are something one discovers rather than invents. Nortvedt speaks of a “moral pull” (p. 297), a kind of force that pulls us when distinct “moral realities” are revealed. Nortvedt and Nordhaug (2008) draw on Levinas’s ethics, which is “irreducible to comprehension . . . a non-cognitive understanding of moral responsibility in which passivity of consciousness, as well as affect and sensibility, plays a significant role” (p. 157). The ethical imperative is already present prior to interpretations and knowledge.

According to ethical realism, reality radiates demands. Even more, these demands are calls to respond that also awaken the subject and bind them to the world; hence, it is not only an ethical issue but also an existential issue (see, e.g., Bøe, 2021). Returning to our concern related to the meaning/knowledge-centredness in mental health, it is this ethical reality—of the other, reality, the actual event—that we fear may be obscured when practices are governed by, and operate within, webs of knowledge and interpretations.

Levinas—The subject arrives as ethical subjection

The ethical source that we fear gets lost implies not only a loss of imperatives for moral responses (ethical loss) but also the loss of the source that brings us as unique subjects into the encounter (existential loss). Emmanuel Levinas developed a fundamental ethics that brings attention to what precedes any ontology and epistemology: the face of the other, and the vulnerability exposed, that makes me responsible. His ethics is also existential in the sense that he outlines how subjectness is an ethical event. Levinas (1985) describes the subject in ethical terms: “The very node of subjectivity is knotted in ethics” (p. 95). Before being I, before being free, there is responsibility for the other:

Responsibility in fact is not a simple attribute of subjectivity, as if the latter already existed in itself; it is . . . initially for another. . . . To say here I am [me voici]. To do something for the other. To give . . . [that is] the incarnation of human subjectivity. (Levinas, 1985, p. 97)

According to Levinas, a human becomes a subject when addressed and singled out by the other. Following Levinas, Zygmunt Bauman (1993) notes that “responsibility is the first reality of the self” (p. 13). The other asks something of us, and this moral appeal pulls us, as it were, into the flux and fabric of the real as irreplaceable and responsible subjects. However, as Biesta (2018) importantly highlights, this fundamental responsibility does not imply that we positively and necessarily act responsibly vis-à-vis whatever reality affords; we can resist, succumb, accept, refuse, join in, or walk away.

Levinas (1998) states that responsibility to the other precedes our freedom and subjectivity. The strangeness and vulnerability of the other demands response, and only an “I” can give such a response, and therefore an “I” must arrive. According to Levinas, the problem is not, as Heidegger proposed, “forgetfulness of being” but “forgetfulness of the Other.” Could a forgetfulness of the other also be found in all the totalizing meaning-constructions of models in mental health?

A professionality that is too strong, in the sense that it is based on fixed knowledge and procedures, risks hiding the face of the other from us. With that, the call for care and nonviolence it radiates is also silenced. If explanations of the other become total, the unique subject seems uninteresting. As Biesta (2014) suggests, professionality needs to be weak enough to let subjects arrive. If the reality to respond to is replaced by ideas about reality, the subject, in Levinas’s ethical–existential terms, is not asked for and no one arrives in the encounter.

One could argue that in the person-centred model, there is precisely full attention to the other. However, the reality of the other that Levinas speaks of does not equal the autonomous individual or the person in the sense of the sum of thoughts, feelings, and behaviour that shape them. Furthermore, responding to the call of the other is not about giving the other what they ask for. No, the response to the call may be to give something that the other did not ask for, beyond the constraints of their personal world picture. Person-centred approaches may not take seriously how existence is (a call to) subject to the real and to what is other than you, and unknown.

Lingis—Sensitivity to the surface

Both personally and as professionals, we may get caught up in our own understanding of the world and ideas of how it works. When this happens, we relate to this understanding and ideas about reality rather than reality itself. Alphonso Lingis (1994b) ³ relates ethics to how the real and the other appear to us at the surface and speaks of imperative surfaces. Our relation to these imperative surfaces can be broken when a veil of understanding gets in the way. Lingis (1994a, p. 23) highlights “surface-sensitivity to the other” as a mode of relating that prevents us from overlooking the real other before us. The other always appears to us at the surface. This appearance interrupts any attempt to understand the other because something of another, more primordial and urgent, order comes to the fore: the other demands something from us. It is only at the surface, through the senses, and with our bodily appearance and movements (gaze, voice, hand gestures, posture) that we can affect and engage each other:

When someone . . . turns up and faces us, [their] face says, “here I am!” . . . [and] afflicts my sensibility immediately. It is felt in my eyes whose direction is confounded, whose focus softens . . . lose sight of its objectives and turn down in a recoil of respect. . . . It is felt in my voice that is in command of its own order and speaks to command, but which falters, hesitates, and loses its coherence before the nonresponse and the silence of the other. . . . The surface of the other, as surfaces of susceptibility and suffering . . . troubles my exploring, manipulating and expressive hand. (Lingis, 1994a, p. 30)

This “surface sensitivity to the other,” Lingis (1994a) contrasts with another relation to reality, which he refers to as “depth perception of the other” (p. 23), in which we engage in attempts at understanding the (supposed) underlying causes and structures determining the other’s appearance. However, in such a search for a deep/underlying “truth,” the primary ethical event of the encounter with the real is missed. The professional, model-based, gaze risks being precisely such a depth perception that does not see the real other before them. The professional gaze skips sensitivity to the surface appearance and looks straight for underlying structures and causes. Caring, responsible, interpersonal contact requires that we sense each other in the domain of surfaces, where we appear to each other. We take Lingis’s account of sensibility at the surfaces to be in line with the turn to reality that we argue for in this paper.

We believe a turn from a knowledge-based approach to a reality-sensitive approach can be identified in Lingis’s (1994a) quote above. It is about a turn—induced by the other’s appearance—from a “hard gaze” to a “softened focus,” from “own objectives” to a “recoil of respect,” from “command” to “hesitation,” and from “manipulating” to “troubled hands.” We may say that professional practice in mental health also finds itself in this tension that Lingis displays between, on the one hand, a hard gaze that is based on objectives from some model and that leads to manipulating and commanding initiatives and, on the other, a soft gaze afflicted by the other, that makes us hesitate in order not to do wrong, and being constantly troubled by the other, struggling with how to respond.

Interestingly, Lingis (1994a) explicates the difference between depth perception, in search of some underlying causes, and surface sensitivity, with readiness to be affected by the other, with reference to “recognition.” He paradoxically states that when another human being appears, to recognize them should not be to re-cognize them. To re-cognize literally would mean to think again about someone and, in a sense, this would imply that the professional turns the appearance of the other into a professionally created thought. This would mean making the relation into a matter of cognition in which we recode the other to an instance of a category. However, Lingis (1994a) sticks with the concept of re-cognition and suggests a significance that, in fact, is contrary to its etymology:

To recognize what makes its appearance is not to re-cognize, to re-code . . . it is to respond to the singular apparition. The “Wow, it’s you!” with which one responds is an exclamation that . . . responds with a surge of sensuality and with a greeting. (pp. 66–67)

Such a recognition can only belong to the surface, where the reality of the other strikes us. To look for some depth behind the reality of the other’s appearance is to annul the very site at the surface, where such a recognition can happen.

Perhaps, in line with Lingis’s (1994a) point here, we could say that in all three frameworks discussed above—the model-centred, person-centred, and social constructionist—there is a danger that recognizing the other is converted into a re-cognizing: theoretical re-cognization in the model-centred framework, a personal re-cognization in the person-centred framework, and ever more sophisticated ways of socially “co-re-cognizing” in the social constructionist framework?

Lingis’s (1994a) description of depth perception indicates how professional approaches within a model-based framework are based on the application of preestablished knowledge to detect the underlying structures that can explain the other, the problem, or the situation. A strong professional gaze in mental health practices looks straight through the surface of the other and searches for something problematic or pathological in underlying causes and structures that should be there, according to a theoretical framework.

Conversely, in surface sensitivity, the practitioner’s voice, again in Lingis’s (1994a) words, “falters, hesitates, loses its coherence” (p. 30), and the professional is troubled when using their “exploring, manipulating and expressive hands.” The therapist’s focus is displaced; it is no longer about finding the truth behind the appearance of the other but about how to go on and respond in the actual encounter in ways that uphold the dialogue that those present now have dared to enter, preventing the dialogue from collapsing. The possibility of this encounter-afflicted disruption is vital for practice, and practice may be ethically and existentially problematic if there is no space for such a disruption. A weak practice, which leaves open the possibility of being caught off guard and disrupted, welcomes the subjects, and brings the ethical imperatives of the reality into visibility.

When we place understanding before acting, the readiness and obligation to simply respond to existence vanish. Since the call to respond is always and foremost ethical, any efforts to establish the ontological and epistemological status and foundations of what is present are ethically dubious. Rather than trying to comprehend the underlying causes and structures, we should give attention to the surface. Otherwise, we risk overlooking the primary ethical event of encountering reality. This encounter is a subjection to the real, an ethical realist conditioning of our existence and practice. ⁴

Arendt—The value of the surface

In Arendt (1978), we also find the idea that there are ethical imperatives inherent in reality. Like Lingis, she argues for a primacy of the surface, and in ethical terms, as she points to “the real that claims” (p. 4). As we will see, Arendt is convinced that to look for “true being” only beneath this surface is fallacious; it is the appearance at the surface that is real, she argues. In her book, The Life of the Mind, Arendt describes, with reference to her well-known reports on the trial against Adolf Eichmann, what set off the explorations of the book: “[Conventionality] protects us against reality, that is, the claim on our thinking attention that all events and facts make by virtue of their existence. . . . Eichmann knew of no such claim at all” (p. 4).

Reality comes with a claim, Arendt (1978) states. According to her, this claim may tell us to stop, and to withdraw from what is happening or what we are doing, because what is happening is not ethically right. This call to stop and withdraw from what you are doing, or are part of, comes from surface appearances. Arendt wants to restore the value of this surface. In her argument for this, she offers a profound critique of the way Western science and philosophy is caught up in what she calls “metaphysical fallacies” (p. 12). The (fallacious) metaphysical idea is that, as she puts it, “true being” is only found beneath “mere appearance” (p. 23). The problem is as follows: the consequence of this metaphysical prejudice is that the surface is not given any attention, other than something that should be cleared away. The “claiming reality” that speaks at the surfaces is overlooked.

“Since we live in an appearing world,” Arendt (1978) rhetorically asks, “is it not much more plausible that the relevant and the meaningful in this world of ours should be located precisely on the surface?” (p. 27). Similar to Lingis, Arendt (1978) highlights the danger of the professional–scientific idea that the “real” reality is hidden beneath what appears to us. She notes the ethical ⁵ dangers of this belief in underlying structures and causes:

The scientist . . . cuts open the visible body to look at its interior . . . by means of all sorts of sophisticated equipment that deprives them of the exterior properties through which they show themselves to our natural senses. . . . The guiding notion (is) that appearances . . . must have grounds that are not appearances. . . . efforts to find something beyond appearances have always ended with rather violent invectives against “mere appearances.” (p. 24)

Humans have their vitality originating from the reality of the surface through moving and being moved, hearing and being heard, seeing and being seen, and touching and being touched (Arendt, 1978, p. 29). The other—appearing in the flesh, with their face, eyes, hands, posture and gestures—speaks to us, singles us out, and calls us to respond. Professional intentionality, with its ambition to understand underlying causes and structures and intervene based on these, risks overlooking the reality encountered and, with it, the ethical imperative immanent in this reality.

For our present purposes, Arendt’s turn to the surface, her warning against privileging what is presumed to lie beneath, is perhaps most apt as a critique of the model-centred framework. However, we may also argue that the person-centred model and the social constructionist framework operate based on the idea (or “fallacy”) that representational structures—personal or social—are what should be dealt with rather than the reality found at the surface, where we appear to each other.

In line with Arendt, we can perhaps say that the practitioner or therapist’s first imperative is to be attentive to the appearance of the other (at the surface). What is happening in the actual encounter? How does the actual person come into presence as sensuous (visible, audible, touchable)? How can I respond? Following this, being attentive and open to be affected by the appearance of the other should perhaps be the primary mode of any encounter in mental health practice. The presence of the other—their face, gestures, voice—comes with a claim. Attentiveness to this claim should include a readiness to be interrupted, in the sense that knowledge and professional intentions should be held loosely and with hesitance. This readiness involves stopping the course of (professional) action when it does not leave space for the other, or when a sense of doing harm occurs—a readiness to withdraw from the course of events, a withdrawal to thinking, ⁶ and then reengage in new ways, with other responses.

A real(ist) practice

In what ways can we rethink mental health and therapy practices as a way of turning towards the real? Is it possible to free practice from its captivity in an endless matrix of knowledge and interpretations? As humans, we encounter reality—the other human, other earthlings, the earth itself—through the ethical claims it lays on us. Reality shows itself in all kinds of ways, sometimes as a call for personal responsibility (as when one encounters vulnerability or a need for care). However, knowledge and interpretation are not what is called for. When another human being addresses one as a therapist or mental health professional, asking for help, it is not an algorithmic itinerary of prescripted interventions that are of immediate concern (although many may undoubtedly want such a response as well, and benefit from it). What is called for is one’s attention and willingness, a “yes” instead of “no” to their plea.

Can practices be guided by this acceptance of the otherness of the world and the alterity of other humans in ways unaccounted for by the modern (model- and person-centred) or postmodern (social constructionist) epistemology? In the field of mental health, one could say that any ontology (i.e., claims about what something is and the nature of its existence), whether biological, psychodynamic, recovery-oriented, systemic, or other, that contains a clear understanding of what people’s problems are, risks becoming a straitjacket that excludes the unique appearance of the subject. However, could scepticism towards all forms of ontological claims redirect us as professionals to other ways of approaching the real and others, where the reality that we approach becomes something tangible that we turn to (and that calls upon us) and where reality does not become something ontological that frames us or gives us meaning? Ethics is always an open event of a “not yet,” a choice to be made in the hands of a subject.

Again, the question is not what the world is or what the world is to me, but how it affects me and what it demands of me. The world summons me, but the world is, in its existence, both infinite and incomprehensible. What we are aiming for in this article is perhaps a practical and ethical realism that does not have its premise in any description, understanding, or explanation of reality but in the direct encounter with it and other humans in it. This implies a different way of relating to the reality of the other than both theoretical positive realism and social constructionism—a practical and ethical realism that does not depend on first understanding reality.

As integrated parts of the ruling apparatus, with its ethos of accountability and risk aversion, much of what mental health practitioners and therapists are required to do has little, if anything, to do with attending to what appears at the surface or harnessing their own freedom, let alone the freedom of those who seek their services. Accordingly, the first purpose of therapy and mental health practices must always be to secure or, in many cases, restore a connection to the real. If practitioners constantly strive, through knowledge-centred practices, to look beyond what appears (e.g., looking beyond singular symptoms to connect them in common clusters of diagnostic criteria) or choose their own intendedly curative actions based on theoretical models for intervention, or if patients, clients, or service users navigate their lives under the guidance of particular models for good and/or healthy living, then the relation to the reality of the situation evaporates.

However, if a professional practice is to serve the purpose of assisting people in being free, then attention must (also) be directed elsewhere. Where is that? Well, we suggest it should simply be called reality.

The fall (and rise) of professionality

Does this mean that professionality should be given up altogether? Are we, as professionals, forced into an impossible dilemma: if I act professionally, I act unethically, and if I act ethically, I give up being professional? Two different responses to this dilemma could be suggested (as our argument could be read in at least two different ways): first, one might say that the return to reality and reality-sensitive responsiveness we argue for must always be the point of departure. In instrumental approaches based in fixed, predefined knowledge structures, professionals quickly skip being attentive and responsive to who is really there, and they go straight to assessment and diagnostic procedures, looking for what is beneath the surface, only perceptible to the qualified eye. However, when attention to the suffering other is the starting point, this leaves the professional with a responsibility to help. And it could be argued that in order to exercise this responsibility, the professional should make use of professional knowledge and methods to help (see, e.g., Larner, 2015).

Another line of argument is that the encounters that a reality-sensitive approach can foster is in itself making a crucial difference for the one in need of help. What we refer to as mental disorders, like for instance psychosis, could be approached as a person’s break with reality (Johnstone & Boyle, 2018; Seikkula, 2019). In this vein, Fuchs (2017) suggests that mental disorders could be understood in terms of intercorporeal responsivity that is impaired, a kind of interaffective desynchronization (Fuchs, 2017, p. 260). Rosa (2020) suggest that a depressive condition is characterized by how “the resonance [with the world] has fallen mute and ‘nothing speaks to us anymore’” (p. 27). Such notions of what we refer to as mental health difficulties would imply that the responsibility and responsiveness that is generated from a reality-sensitive approach may be what it takes to bring the person back into play with reality and others, an interplay that was lost.

Open Dialogue approach—Real responsibility?

As a possible conclusion, we turn to a specific form of practice, namely the Open Dialogue approach (Seikkula & Arnkil, 2013), to indicate what a turn to reality can be about in practice. In this approach persons from the social network of the client are invited to meet when a crisis occurs. The aim of the practice is to generate dialogue—that is, to invite the voices and utterances of all present into interplay. The practitioner’s primary task is to make sure that everyone is given response and the corporeal–expressive sides to the responsiveness are as much important as the content of what is said (Bøe et al., 2015; Seikkula et al., 2015).

The guidelines for practice (Seikkula & Arnkil, 2013) in the Open Dialogue approach are not instructive in the sense that they state what the practitioner should say or do in a meeting. Instead, they urge practitioners to be attentive to the reality of every unique encounter, leaving the professionals to decide how to respond based on what happens and what is expressed.

We have argued for the existence of a problematic knowledge-centredness in the model-centred-, the person centred-, and the social constructivist framework. We see in Open Dialogue aspects that break with all these rationalities. First, the approach breaks with model-centredness in that it does not take its point of departure in specific diagnoses or definitions of the problem at hand to prescribe specific procedures. Second, it breaks with person-centredness because the primary aim is to generate dialogue between persons, not to support the individual person in pursuing their personal needs and goals. Third, although Open Dialogue has been developed in close relation to social constructivist epistemology, the primary aim of the practice it begets is not to instigate change through new narratives or new understanding, but through the practitioners’ listening and responding to generate dialogue and responsiveness in the domain of vitality and expressiveness.

One of the core principles in Open Dialogue is that the practitioners should tolerate uncertainty (Seikkula, 2011, p. 184). This principle helps the practitioners to avoid invading the meeting with professional understanding and interventions which would narrow the space for the other participants to, in the vocabulary we have used above, exist in the presence of others. In Open Dialogue, the practitioner’s task is to respond and invest themselves in ways that generate a dialogue that stays open. In line with Lingis’s (1994a) ideas, this responsiveness emanates from surface-sensitivity rather than depth perception. The principle of tolerating uncertainty could even be seen as a readiness to be interrupted in the professional gaze and intentions. In Lingis’s vocabulary, the voice of the practitioner may “falter and hesitate,” their (professional) “gaze is softened,” their (professional) “manipulative hand is troubled.” A real affliction is happening, and dialogue and responsiveness can be re-vitalized.

In line with Arendt’s ideas, it is what happens at the surface that comes into attention through Open Dialogue. The primary objective of Open Dialogue is to bring about responsiveness in terms of seeing and being seen, hearing and being heard, moving and being moved. Attending to what happens at the surface is in tune with Arendt’s (1978) argument for the primacy of the world of appearance, and her claim that “most relevant and meaningful in this world of ours [is] located precisely at the surface” (p. 27).

According to Levinas’s ethics, the subject is not an entity, but an event that happens when subjecting, responding, to others and their call. So, we suggest that the Open Dialogue meeting facilitates an event in which subjects can “happen” in the responsibility that is awakened across the interlocutors (see Bøe et al., 2013, 2015). A meeting facilitated in Open Dialogue can be considered an ethical and existential event, a place where a call for responsibility and care becomes a decisive aspect, and a precondition for the interlocutors to engage in the dialogue.

Postlude

Returning to Tom Andersen and his practice, perhaps he hints at what returning to the real and being guided by reality can be about. Andersen (2021) describes how his practice—not only what he did and said as a therapist, but also, as he underlines, what he refrained from doing and saying—was guided by what he refers to as a sense of unease. This unease, he describes as something that kept intruding on his practice and made him stop doing and saying things that appeared to him as wrong. He states that the unease came from an attention towards the others present: the clients and their families when present; how they appeared, breathed, and moved; and how they reacted to what happened. When their appearance signalled that something was not right, this gave him this sense of unease. These signs told him to stop doing something even before he had any ideas about what was wrong or ideas about what else to do or say. In an interview, Andersen (2023) notes that what is essential in conversations with families in distress is that those who want to talk should be allowed to talk about what they want to talk about. Likewise, those who do not want to talk should be allowed not to. He adds that one should be attentive to how those present react to what is going on in the conversation. One will notice whether they become engaged when it turns into a living conversation that “works” good or if the conversation, as he puts it, goes too far and it is time to find other ways to go on. One can sense this in their breathing, he says. For example, if people stop breathing or hold their breath, this may be a sign that one has gone too far. Andersen notes that practitioners must be sensitive towards these things, and this requires attending to the reality of the surfaces, where we can sense, touch, and move each other.

Being sensitive to the others’ appearance guided him in his practice. When he stopped doing what the signals at the surface told him might be wrong, new ways emerged. Andersen (1992, 2021, p. 39) notes that perhaps it was his ethical and aesthetic sensibility that made him a good practitioner and that the practice had the surfaces as its domain.