Enhancing social cognition in psychosis – the potential role of open dialogue

TL;DR

This paper explores how the Finnish Open Dialogue approach might help improve social cognition in people with psychosis and their families.

Contribution

The paper suggests integrating Open Dialogue with social cognition research to improve real-world outcomes for psychosis.

Findings

Antipsychotic treatments have limited impact on psychosocial function in psychosis.

Social cognition is a promising target for intervention in psychotic conditions.

The Open Dialogue approach may uniquely benefit social cognition in psychosis.

Abstract

Research in psychotic conditions increasingly focuses on improving functional outcomes. While antipsychotic treatments can alleviate positive symptoms in some patients, they have limited impact on psychosocial function. Social cognition (SC) has emerged as a promising target for intervention, with multiple new approaches designed to enhance SC in psychotic conditions. However, the generalisability of these interventions to real-world functioning remains uncertain. We propose that the Finnish Open Dialogue (OD) approach may offer unique advantages for improving SC in individuals with psychosis and their families and suggest this as an important direction for future research. This commentary aims to bridge perspectives from SC research and OD practice, proposing avenues for integration and future research.

Full text

Overview

Research increasingly focuses on improving functional outcomes in psychotic conditions. While antipsychotics can alleviate positive symptoms in some patients^1^, their impact on psychosocial function is limited^2,3^. Social cognition (SC), the cognitive processes underlying interpersonal interactions, has emerged as a promising intervention area, as impairments in SC correlate with poorer functional outcomes. While structured SC training programs show promise, their generalisability to real-world functioning remains uncertain^4,5^.

The Open Dialogue approach to psychosis^6^, offers a dialogical, network-oriented approach that may uniquely enhance SC in subjects with psychotic conditions and their families by addressing relational and contextual dynamics, complementing existing interventions.

Here, we comment on the core principles of OD and their potential contribution to SC improvements, acknowledging that empirical studies are needed to assess these mechanisms.

This commentary bridges perspectives from SC research and OD practice, proposing avenues for integration and future research.

Social cognition

Social cognition (SC) refers to how individuals perceive, interpret, and evaluate social behaviours^7^, or simply put, “it is people thinking about people”^8^. It encompasses mental processes vital for adaptive social interactions. Research in psychotic conditions has typically focused on four main domains: emotion perception and processing, mentalizing, social perception and social knowledge, and attributional bias^4,9–12^.

Emotion perception and processing (EPP) involves perceiving and using emotions adaptively. Mentalizing or Theory of Mind (ToM) is the ability to understand others’ intentions and emotions, including detecting sincerity, deception or sarcasm. Social perception (SP) assesses the ability to identify social roles and rules from non-verbal cues, as voice intonation, mimics, proxemics. Attributional bias (AB) refers to how different individuals infer causes for events, such as attributing - or not - hostile intentions to others in ambiguous social situations^4^.

Social cognition abilities in psychotic conditions

Substantial evidence indicates that emotion processing, mentalizing, and social perception are impaired in individuals with psychotic conditions, while evidence for attributional bias is less conclusive^4,10,13^. These impairments appear to be core features, present in chronic and first-episode patients, independent of symptoms or medication, and observable at some degree in unaffected relatives and in high-risk, prodromal samples^14–16^.

Studies suggest that SC abilities are associated with functional outcomes both pre-morbidly, cross-sectionally, and longitudinally, with moderate effects^17–20^. A recent meta-analysis found that SC measures had the strongest association with psychosocial functioning among all cognitive variables, explaining more variation than intelligence measures (as IQ, working memory, executive functions)^18^.

Interventions enhancing SC may therefore significantly improve outcomes^17,18,21^ and several approaches have emerged.

Social cognition training in psychotic conditions

SC emerged at the intersection of cognitive, developmental and social psychology, and neuroscience, integrating diverse perspectives. It draws from social learning theory^22^, which emphasizes observational learning and modelling; attribution theory^23,24^, which explores how individuals infer causes for others’ behaviours; Theory of Mind frameworks^25–27^, which focus on mindreading and perspective-taking; and neuroscientific insights into social brain networks^28,29^. Attachment theory^30,31^ highlights how early caregiver relationships shape mentalizing and emotion regulation —core aspects of SC.

Recent perspectives, including psychological constructionism, interactionism, and embodiment theories, emphasize the relational and experiential nature of SC, proposing that interpersonal dynamics and bodily experiences shape SC development. Several authors suggest integrative perspectives^32–38^.

These theoretical frameworks inform the different SC training (SCT) interventions (for overviews see refs. ^39,40^).

Typical training practices include psychoeducation, use of visual media as pictures or short film clips to recognize emotions^41^, infer mental states^42^ or interpret social cues^11,43^, role-play scenarios, and cognitive restructuring^44^. SCT programs can be “targeted”, addressing one SC domain, or “broad-based”, addressing several SC domains. E.g., Training of Affect Recognition (TAR)^45^ addresses EPP, Metacognitive Training (MCT)^46^ primarily ToM, and Social Cognition and Interaction Training (SCIT) integrates social learning and cognitive restructuring to improve EPP, SP, and AB^47^. Some interventions combine SCT with neurocognitive training, as in Cognitive Enhancement Therapy (CET)^48^, while others employ virtual reality (VR) to enhance ecological validity^5,49–51^ or mindfulness-based trainings to improve nonverbal social attunement^52^.

While SCTs demonstrate efficacy in improving EPP, ToM and SP, meta-analyses indicate no significant impact on AB or symptom severity^5,11,53^, and mixed results on functional outcomes^5,40,53,54^, with the latest meta-analysis showing no improvements in schizophrenia^53^.

One of the main challenges of SCTs is their generalizability to real-world social interactions, and a possible “train to the test” effect, with unclear improvements in everyday social functioning^4,5,53,55^. Efforts to increase ecological validity with VR-based trainings^5,53^ have so far produced negative results, suggesting that emotional expression in virtual environments may be inadequate^51^. Additional barriers include high decline rates due to social anxiety and privacy concerns^40^.

Some scholars posit that SCTs may need critical re-evaluation, proposing more comprehensive approaches and integration with other interventions^5,51,56^.

In this context, OD may offer a relational, integrative approach that situates SC development within authentic, interactive settings, complementing existing interventions and potentially enhancing SC across individuals, families, and professional networks.

An overview of open dialogue

Open Dialogue (OD) is a family-centred, team-based, need-adapted approach originally developed in Western Lapland, Finland, for psychotic crises^57^. It provides rapid, low-threshold support based on seven core principles: immediate help, a social network perspective, flexibility and mobility, responsibility, psychological continuity, tolerance of uncertainty, and dialogue^58^. Individuals can contact the service directly, and network meetings are promptly arranged, involving all relevant persons at convenient locations. Treatment is tailored to individual needs, and may incorporate psychotherapy, trauma treatment, and social support. The initial treatment team remains responsible throughout, ensuring continuity of care. Providing prompt support and security enables tolerance of uncertainty, allowing time before committing to long-term diagnoses or treatments. All treatment decisions are made transparently and collectively^57,59^.

Central to OD is promoting dialogue among all participants: professionals facilitate open conversations where every perspective is respected, and share their thoughts and feelings aloud in “reflective conversations”, inviting the network to respond^60,61^. This collaborative process fosters mutual understanding and creates a supportive environment^62^.

OD - outcomes

OD has shown positive outcomes in symptom, functional recovery and medication use compared to standard care in Finland^6^, and these findings were sustained at the 19-year follow-up^62^. Over time in the region, the duration of untreated psychosis decreased to half month, and the incidence of schizophrenia diagnoses dropped significantly^6^. Similar outcomes have been observed in adolescents^63^. Internationally, OD led to various implementations and practices^64^, along with a forthcoming randomized controlled trial in the UK^65^.

Recent developments have introduced peer participation in Peer-Supported OD (POD)^66^, aligning with recovery-oriented models^67,68^. Throughout this commentary, the term ‘professionals’ encompasses both formal therapists and peer workers.

Open dialogue and social cognition

OD shares various elements with other first-episode programs^69^, yet certain specific aspects may enhance SC abilities uniquely: mechanisms as learning by modelling, perspective-taking, emotion recognition and regulation, ecological validity, a relational perspective, body attunement permeate the approach. This section outlines how OD may influence each SC domain, and the theoretical background supporting that.

Relevant across all SC domains is Vygovtsky’s concept of “zone of proximal development” (ZPD)^70^, frequently referenced in OD literature. ZPD describes the metaphorical space between an individual’s current abilities and their potential development, achievable through interaction with more experienced partners, in a process of mutual cooperation, where the more experienced participant continuously adjusts their approach to support the other’s growth^71,72^.

Emotion perception and processing - EPP

The focus on emotions is central in OD, that supports emotion expression and aims at “creating a shared emotional experience”, that would allow relational healing^72,73^. Professionals pay close attention to subtle emotional shifts, and model emotional awareness by verbalizing their own emotions and bodily sensations, often echoing those of others in the conversation. Professionals proceed calmly and show that it is possible to talk about difficult experiences and to sustain difficult emotions, fostering feelings of safety in network members^72–74^.

Explicit emotion labelling is thought to enhance EPP, as accessible emotion concepts would help individuals make sense of affective experiences^32,75,76^. Moreover, labelling emotions would have a self-regulatory effect^75,77,78^, further facilitating social understanding^79^.

Social experience is considered crucial for developing emotion recognition^80^, and emotional learning thought to thrive in safe relationships^79,81,82^ and in multimodal interactions with familiar individuals^83^.

OD meetings often result in collective decisions and actions, providing participants with direct learning of how emotions can be harnessed to bring about meaningful change^84^, another central facet of EPP^85,86^.

By integrating these processes, OD may enable all participants to refine their ability to identify and interpret emotions in dynamic and complex exchanges.

Mentalizing - ToM

Through dialogues, OD participants may gain insight into both their own and others perspectives^62,72^. Reflective conversations model self-reflection and perspective-taking, scaffolding the process for the network^72,74^. Team members adapt to the network language, and work to construct a new “shared language”, where each participant can express and make sense of their experiences^72^. Through this meaning-making process, one’s personal history can be integrated into a meaningful narrative, fostering autobiographical coherence^87^.

Metacognitive and mentalization-based theories emphasize that mentalizing capacity is shaped dynamically through interpersonal dialogue and shared meaning-making^88,89^. Interactive theories suggest that real-time social interaction leads to a deeper understanding of others’ mental states than passive observation^34,90^, and autobiographical knowledge is linked to mentalizing capacities^91–94^.

Indirect empirical evidence from affine approaches also supports OD’s potential to enhance mentalizing. Mentalization-based treatment (MBT) can improve ToM in psychotic conditions^95–97^, and Family-Based Mentalization Therapy (FBMT) has improved mentalizing and family communication in high conflict families of adolescents^98–100^. While MBT/FMBT and OD differ structurally, they share non-directive therapeutic engagement, dialogical exploration, and a relational focus, suggesting similar potential benefits.

The emotional safety is also critical for sustaining a mentalizing stance, as it fosters openness to alternative interpretations of social interactions^82^.

OD may thus offer a naturalistic, interactive setting, that may enhance flexible and adaptive mentalizing in all participants.

Social perception and social knowledge (SP)

OD acknowledges non-verbal communication as a crucial component of dialogue^101^. Professional express their physical and emotional responses to the environment, modelling attunement to subtle social signals^73,74^. Mindfulness practices have been incorporated into OD trainings to support this^64^. This could encourage participants to detect and interpret intonation, gestures, posture, and proxemics, and deepen their understanding of implicit social dynamics, in line with embodiment theories, suggesting that aspects of social cognition are grounded in sensorimotor and bodily experiences^37^.

Interpreting social cues within context is fundamental to SP^102^. The collaborative meaning-making process engages all participants in constructing a coherent understanding of situations^62,87^, and the collective decision-making process can provide direct opportunities for social negotiation, collaboration, and conflict resolution, giving insight about social roles and relational dynamics. This is consistent with interactionist perspectives, positing that both interacting socially^38,90^ and engaging in joint action with others^33^ would give access to more information about the behaviour of one’s partners, than their simple observation.

Improvements in SP are linked to enhanced functional outcomes, prompting calls for SP-focused interventions^11,39,40^. OD may provide an ecologically valid approach by embedding SP learning in dynamic, real-world interactions.

Attributional bias

Individuals with psychotic conditions may tend to perceiving hostility in ambiguous social situations^13^, increasing the risk of delusional beliefs, anxiety, agitation, and depressive symptoms^103^: transparency in OD discussions and decisions may dispel assumptions and misunderstandings^62^, promoting more balanced attributions. OD’s personalized approach may also enhance trust in the system^104^, thus promoting epistemic trust and openness to new information that may arise^105,106^.

Individuals in psychotic crises can also often feel lonely and isolated, which can increase pessimism and negative biases^107^. OD collaborative problem-solving and collective engagement in common goals may enhance trust and belonging, and peer involvement further contribute to normalization, stigma reduction and hope fostering^64,108,109^, potentially supporting more benign attributional styles^107^.

Constructing coherent autobiographical narratives may also help individuals reinterpret past and current experiences through a relational lens, fostering self-other differentiation and reducing extreme attributions of blame or hostility^87^.

OD may offer a relational pathway to cognitive flexibility and social belonging by fostering trust and mutual understanding within real social-relational contexts.

Summary on SC and OD

OD holds the potential to enhance each subdomain of social cognition.

Interventions targeting multiple domains simultaneously appear most beneficial^5,55^. Individuals with psychotic experiences are not a homogeneous group: their social cognition is linked to unique life contexts and relationships, highlighting the need for flexible approaches^110^.

Addressing compatibility and contextual considerations

OD’s relational stance contrasts with individualist paradigms underlying SC research. However, these perspectives may be complementary. Rather than focusing solely on the individual, OD addresses relational dynamics, potentially enhancing SC across entire networks. This may create a mutually reinforcing process that improves communication patterns and reduces distress within the broader system. Positive results of MBTs applied to families^100,111^, align with OD’s emphasis on shared responsibility for change.

Given that cognition alone does not fully account for social functioning^18,112^, researchers advocate for combining SC training with broader psychosocial interventions^53,56^. OD integrative and network-based approach may already offer such comprehensive support^113^.

Psychosis research increasingly incorporates “personal recovery”, alongside symptom and functional outcomes^112,114^. OD aligns with recovery-informed interventions^68,114^, potentially expanding the spectrum of its meaningful outcomes^115,116^.

The global applicability of OD requires careful evaluation. In Finland, OD allows direct service access without referrals or diagnoses, a model rarely replicable elsewhere. Adaptations often require structural adjustments^64^. Also, while OD has gained international clinical interest, empirical research outside Finland remains limited, highlighting the need for further study^64,65^.

Conclusions

OD holds promise to enhance SC in psychosis through its foundation in dialogue, transparency, and mutual respect: “Dialogue increases reflexivity”^73^.

Its relational focus suggests it as a complementary approach to existing interventions: the inclusion of family members may improve the entire network’s social cognition, enhancing communication and reducing distress. Family participation may also address challenges as recruitment difficulties due to social anxiety or privacy issues^40^.

The theoretical nature of these claims should be acknowledged. Future studies could assess SC outcomes pre- and post-OD intervention or compare OD with standard SCT programs. Examining SC changes across the entire network appears relevant. Additionally, exploring OD’s applicability in populations with primary SC deficits, such as autism spectrum conditions, could expand its relevance beyond psychosis.

These reflections are particularly relevant in the context of the global mental health crisis, where experts advocate for a transformation of mental health systems, by addressing social environment, adopting rights-based approaches, involving peers, implementing psychosocial interventions, and ensuring continuity of care^117^. OD is well-aligned with such principles, suggesting its potential as one model for future mental health practices.