Using Radically Open Dialectical Behavior Therapy (RO DBT) To Treat Problems Of Overcontrol

Radically Open Dialectical Behavior Therapy (RO DBT), developed by Dr. Thomas R. Lynch, is a new treatment that has been developed and tested to address excessive self-control, or overcontrol [1]. RO DBT is a transdiagnostic treatment indicated for patients with diagnoses of chronic depression, treatment-resistant anxiety disorders, anorexia nervosa, autism spectrum disorders, and Cluster A and C personality disorders.

The problem of overcontrol

Individuals characterized by overcontrolled coping tend to be serious about life, set high personal standards, work hard, behave appropriately, and frequently will sacrifice personal needs in order to achieve desired goals or help others. However, inwardly overcontrolled individuals often feel “clueless” about how to join in with others or establish intimate bonds. Unfortunately, rigid and over-controlled coping appears to result in poor interpersonal relationships and general difficulties with adapting to changing environmental circumstances, leading to emotional loneliness, depression and other related problems [1]. Thus, overcontrol works well when it comes to sitting quietly in school or building a rocket; but it creates problems when it comes to social relationships.

Furthermore, there is evidence that people with chronic mental health problems, such as treatment resistant or chronic depression and anorexia nervosa, suffer from problems of untreated overcontrol, including maladaptive perfectionism, cognitive rigidity, insistence on sameness, strong personal needs for structure and symmetry, greater self-criticism, rigid internalised expectations, excessive control of spontaneous emotion, inordinate fears of making mistakes, aloof interpersonal functioning and social isolation [2, 3, 4, 5, 6, 7, 8, 9, 10, 11].

Overcontrolled individuals often feel “clueless” about how to join in with others or establish intimate bonds … overcontrol works well when it comes to sitting quietly in school or building a rocket; but it creates problems when it comes to social relationships

Radically Open Dialectical Behavior Therapy

Radically Open Dialectical Behavior Therapy (RO DBT) is an evidence-based treatment developed specifically for problems of overcontrol. Radical openness is the core underlying principle and skill in RO DBT. It represents the confluence of three capacities posited to be essential for emotional well-being: openness, flexibility, and social connectedness. Radical openness means developing a passion for going opposite to where we are. According to Lynch [1], it is more than mindful awareness. It means actively seeking those areas of our lives that we want to avoid or may find uncomfortable, in order to learn. It involves purposeful self-enquiry and a willingness to be wrong, with an intention to change if we need to change. Lynch [1] argues that overcontrolled clients’ superior capacities for self-control represent both a blessing and a curse. Their innate capacity for inhibitory control allows them to delay gratification and work harder than most others, yet compulsive self-control and hyper-detail-focused processing often negatively impact their relationships and their sense of well-being leading to social isolation and loneliness. Thus, rather than focusing on how to do better or try harder, the primary aim in RO DBT is to help the OC client learn how to rejoin the tribe and establish strong social bonds with others.

Radical openness means developing a passion for going opposite to where we are … It means actively seeking those areas of our lives that we want to avoid or may find uncomfortable, in order to learn.

The components of outpatient RO DBT

RO DBT is typically delivered through a combination of weekly 1-hour individual sessions and 2.5-hour skills classes over the course of 30+ weeks. The first four individual sessions are dedicated to orientation and commitment while from session five onwards the treatment focuses on targeting maladaptive social signaling and other behaviors that keep the client stuck. Clients typically start skills classes after their second individual session and continue both individual sessions and skills class for the remainder of the 30 weeks. Table 1 gives an overview of the lesson topics taught each week. Telephone support is optional; overcontrolled clients are less likely to make crisis calls but texting can be used to celebrate the successful application of skills or other successes clients have booked. Finally, although optional, it is strongly recommended that therapists form a consultation team with other RO DBT therapists to support one another and practice RO skills themselves.

While RO DBT was originally developed as an outpatient treatment program, it is now also applied in inpatient settings and forensic hospitals, for example. For an overview of different applications of RO DBT we refer the reader to the special issue on RO DBT in the Behavior Therapist.

Table 1. Overview of the 30 weekly skills class lessons in RO DBT

How is RO DBT different from other psychotherapies?

RO DBT has been described as a wholly “new” treatment, because it introduces some new theoretical perspectives and treatment interventions not found anywhere else [12, 13]. For example, RO DBT differs from most other treatments by positing that individual wellbeing is inseparable from the feelings and responses of the larger group or community. Thus, what a person feels or thinks inside or privately is considered less important in RO DBT, whereas what matters most is how a person communicates or socially signals inner or private experience to other members of the tribe and its impact on social connectedness.

RO DBT is the first treatment in the world to prioritize social signaling as the primary mechanism of change [13]. This is based on research showing that overcontrolled individuals have a heightened bio-temperamental threat sensitivity that makes it more difficult for them to enter into their neurobiologically based social-safety system. When individuals feel safe, they naturally experience a desire to explore and flexibly communicate with others. To address this difficulty, RO DBT teaches clients how to use non-verbal social-signaling strategies to enhance social connectedness and express emotions in a context-appropriate way. It also teaches skills that activate areas of the brain associated with the social-safety system and desires to affiliate. Finally, radical openness involves skills for actively seeking one’s “personal unknown” in order to learn from a constantly changing environment.

How is RO DBT different from standard DBT?

Although at first glance RO DBT may seem like an adaptation of standard DBT, it differs substantially (see Luoma, Codd, & Lynch [14] for comparison between RO DBT and standard DBT). Radically Open Dialectical Behavior Therapy and standard Dialectical Behavior Therapy share a similar name because they both emphasize their common roots in dialectics and behavior therapy. Although they share this common ancestry, they differ in several substantive ways.

In contrast to standard DBT, which posits emotion dysregulation as the core problem for borderline personality disorder [15] and similar undercontrolled problems [16], RO DBT contends that emotional loneliness secondary to social-signaling deficits represent the core problem for disorders of overcontrol [1]. As a result, the skills from the RO DBT skills manual that are taught over the course of 30 weekly lessons are all new skills that differ from standard DBT [17].

Radical openness differs from radical acceptance because it involves purposefully and actively questioning one’s biases, preconceptions, and/or habitual response tendencies and blocking automatic responses that may function to avoid, regulate, inhibit, accept, or defend oneself.

For example, the skills associated with radical openness differ from the radical acceptance skills taught as part of standard DBT [15]. Radical acceptance ‘is letting go of fighting reality’ and ‘is the way to turn suffering that cannot be tolerated into pain that can be tolerated’ [15; pg. 102]. Refusal to accept that one is unable to change reality (in that moment) according to Linehan is what creates suffering. Indeed, the consequence of radically accepting ‘what is’ and letting go of rigid efforts to control, fix, or avoid the ‘truth’ of what is happening in the moment often results in a sense of peace or contentment. Radical openness differs from radical acceptance because it involves purposefully and actively questioning one’s biases, preconceptions, and/or habitual response tendencies and blocking automatic responses that may function to avoid, regulate, inhibit, accept, or defend oneself. Whereas, radical acceptance involves letting go of fighting reality; radical openness challenges our perceptions of reality. Indeed, radical openness posits that we are unable to see things as they are, but instead that we see things as we are. Each of us brings perceptual and regulatory biases with us that can influence our ability to be receptive and learn from unexpected or disconfirming information and radical openness involves a willingness to doubt or question our inner convictions or intuitions. This way of behaving also contrasts with the concept of wise-mind in standard DBT that emphasizes the value of intuitive knowledge, the possibility of fundamentally knowing something as true or valid, and posits inner knowing as “almost always quiet” and to involve a sense of “peace” [15; pg. 66]. From an RO DBT perspective, intuitive knowing can often (but not always) be misleading simply because ‘we don’t know what we don’t know’ and there is a great deal of experience occurring outside of our conscious awareness. Table 2 summarizes some of the key differences between RO DBT and standard DBT.

Table 2. Key differences between RO DBT and DBT

Several other differences between RO DBT and standard DBT exist and are well-articulated here.

Is RO DBT effective?

The evidence base for RO DBT is robust and growing. The efficacy of RO DBT has been informed by experimental, longitudinal, and correlational research, including three randomized controlled trials (RCTs) examining the feasibility, acceptability, and efficacy of RO DBT (and its earlier versions) for the treatment of maladaptive overcontrol and chronic depression [18, 19, 20], one non-controlled trial with adult anorexia nervosa inpatients [21], a case series open trial applying Radical Openness skills alone plus standard DBT with adult anorexia outpatients [22], an open trial with adolescents with anorexia nervosa demonstrating improved social connectedness after RO DBT [23], and a RO skills alone non-randomized controlled study [24]. Findings from the most recent multi-site RCT of RO DBT, conducted with 250 treatment-resistant depressed clients—80% of whom had an overcontrolled personality disorder—showed that RO DBT led to significantly greater improvements in depression symptoms after 7 months than treatment as usual, with a large effect size of 1.03 [REFRAMED; 17, 25]. In addition, participants in the RO DBT group achieved significantly better psychological flexibility than those in the control group at 7, 12 and 18 months, as well as significantly better emotional coping and expressiveness after 7 months, with the difference increasing after 12 and 18 months, suggesting that patients continue to use and improve their RO DBT skills after the end of treatment.

Current RO DBT research, training, and clinical work has extended to different age groups (children, adolescents, older adults), different disorders (anorexia, chronic depression, autism, OC personality disorders, treatment-resistant anxiety), different cultures and countries in Europe and North America, and different settings (forensic, inpatient, outpatient). For example, Gilbert et al. recently published a validation study of the Overcontrol in Youth Checklist (OCYC), a developmentally valid measure of overcontrol that identifies this transdiagnostic risk factor early in development, in children aged 4-7 years old [26].

The RO DBT Research website lists the most up-to-date research.

More information

Finding a RO DBT therapist

Patients interested in pursuing RO DBT should take measures to identify a licensed clinician adequately trained in RO DBT. A useful minimal benchmark of adequate training is the successful completion of a 10-day intensive training program in RO DBT delivered by a Radically Open Ltd. sanctioned trainer. In addition, the completion of individual supervision through an approved RO supervisor is desirable. Ensuring a potential therapist has satisfied these guidelines increases the likelihood of receiving the treatment with fidelity and competence. The most reliable location for identifying such a provider is the therapist directory maintained by Radically Open Ltd. which can be found here.

Finding a RO DBT trainer or supervisor

The most reliable location for identifying an approved RO DBT trainer or supervisor is maintained by Radically Open Ltd. which can be found here.

Additional resources

To learn more about RO DBT, please visit http://www.radicallyopen.net/.

About the author

Dr Roelie Hempel is one of the founders and co-directors of Radically Open Ltd, the RO DBT training and dissemination company. Prior to this, she was a post-doctoral research fellow at the Psychology department of the University of Southampton where she project-managed a multi-site randomised controlled trial investigating the efficacy and effectiveness of RO DBT for clients with chronic and treatment-resistant depression (project RefraMED; Lynch et al., 2019) and several other research projects.

References

[1] Lynch, T. R. (2018b). Radically Open Dialectical Behavior Therapy: Theory and Practice for Treating Disorders of Overcontrol. Reno, NV: Context Press, an imprint of New Harbinger Publications, Inc.

[2] Asendorpf, J. B., Denissen, J. J. A., & van Aken, M. A. G. (2008). Inhibited and aggressive preschool children at 23 years of age: Personality and social transitions into adulthood. Developmental Psychology, 44(4), 997-1011. doi:10.1037/0012-1649.44.4.997

[3] Chapman, A. L., Lynch, T. R., Rosenthal, M. Z., Cheavens, J. S., Smoski, M. J., & Krishnan, K. R. R. (2007). Risk aversion among depressed older adults with obsessive compulsive personality disorder. Cognitive Therapy and Research, 31(2), 161-174.

[4] Chapman, B. P., & Goldberg, L. R. (2011). Replicability and 40-year predictive power of childhood ARC types. Journal of Personality and Social Psychology, 101(3), 593-606. doi:10.1037/a0024289; 10.1037/a0024289.supp (Supplemental)

[5] Eisenberg, N., Fabes, R. A., Guthrie, I. K., & Reiser, M. (2000). Dispositional emotionality and regulation: Their role in predicting quality of social functioning. Journal of Personality and Social Psychology, 78(1), 136-157. doi:10.1037/0022-3514.78.1.136

[6] Fairburn, C. G. (2005). Evidence-Based Treatment of Anorexia Nervosa. International Journal of Eating Disorders, 37(Suppl), S26-S30. doi:10.1002/eat.20112

[7] Franco-Paredes, K., Mancilla-Díaz, J. M., Vázquez-Arévalo, R., López-Aguilar, X., & Álvarez-Rayón, G. (2005). Perfectionism and Eating Disorders: A Review of the Literature. European Eating Disorders Review, 13(1), 61-70. doi:10.1002/erv.605

[8] Lynch, T. R., Hempel, R. J., Titley, M., Burford, S., & Gray, K. L. H. (2012). Anorexia Nervosa: The Problem of Over-Control. Paper presented at the Association for Behavioral and Cognitive Therapies Annual Convention, National Harbor, Maryland, USA.

[9] Riso, L. P., Miyatake, R. K., & Thase, M. E. (2002). The search for determinants of chronic depression: a review of six factors. Journal of Affective Disorders, 70(2), 103-115.

[10] Safer, D. L., & Chen, E. Y. (2011). Anorexia nervosa as a disorder of emotion dysregulation: Theory, evidence, and treatment implications. Clinical Psychology: Science and Practice, 18(3), 203-207. doi:10.1111/j.1468-2850.2011.01251.x

[11] Zucker, N. L., Losh, M., Bulik, C. M., LaBar, K. S., Piven, J., & Pelphrey, K. A. (2007). Anorexia nervosa and autism spectrum disorders: Guided investigation of social cognitive endophenotypes. Psychological Bulletin, 133(6), 976-1006.

[12] Brus, M. (2019). Book Review: Radically Open Dialectical Behavior Therapy: Theory and Practice for Treating Disorders of Overcontrol. . Journal of the American Academy of Child & Adolescent Psychiatry, 58(5), 547-549.

[13] Codd, R. T., III, & Craighead, L. (2018). New Thinking about Old Ideas: Introduction to special issue on Radically Open Dialectical Behavior Therapy. The Behavior Therapist, 41(3), 109-114.

[14] Luoma, J. B., Codd, R. T., III, & Lynch, T. R. (2018). Radically Open Dialectical Behavior Therapy: Shared Features and Differences with ACT, DBT, and CFT. The Behavior Therapist, 41(3), 142-149.

[15] Linehan, M. M. (1993). Skills training manual for treating borderline personality disorder. New York: Guilford Press.

[16] Lynch, T. R., Chapman, A. L., Rosenthal, M. Z., Kuo, J. R., & Linehan, M. M. (2006). Mechanisms of change in dialectical behavior therapy: theoretical and empirical observations. Journal of Clinical Psychology, 62(4), 459-480. doi:10.1002/jclp.20243

[17] Lynch, T. R. (2018a). Radically Open Dialectical Behavior Therapy Skills Manual. Reno, NV: Context Press, an imprint of New Harbinger Publications, Inc.

[18] Lynch, T. R., Cheavens, J. S., Cukrowicz, K. C., Thorp, S. R., Bronner, L., & Beyer, J. (2007). Treatment of older adults with co-morbid personality disorder and depression: a dialectical behavior therapy approach. International Journal of Geriatric Psychiatry, 22(2), 131-143. doi:10.1002/gps.1703

[19] Lynch, T. R., Hempel, R. J., Whalley, B., Byford, S., Chamba, R., Clarke, P., . . . Russell, I. T. (2019). Refractory depression – mechanisms and efficacy of radically open dialectical behaviour therapy (RefraMED): findings of a randomised trial on benefits and harms. The British Journal of Psychiatry, 1-9. doi:10.1192/bjp.2019.53

[20] Lynch, T. R., Morse, J. Q., Mendelson, T., & Robins, C. J. (2003). Dialectical behavior therapy for depressed older adults: a randomized pilot study. American Journal of Geriatric Psychiatry, 11(1), 33-45.

[21] Lynch, T. R., Gray, K. L., Hempel, R. J., Titley, M., Chen, E. Y., & O’Mahen, H. A. (2013). Radically open-dialectical behavior therapy for adult anorexia nervosa: feasibility and outcomes from an inpatient program. BMC Psychiatry, 13, 293. doi:10.1186/1471-244x-13-293

[22] Chen, E. Y., Segal, K., Weissman, J., Zeffiro, T. A., Gallop, R., Linehan, M. M., . . . Lynch, T. R. (2015). Adapting dialectical behavior therapy for outpatient adult anorexia nervosa-A pilot study. International Journal of Eating Disorders, 48(1), 123-132. doi:10.1002/eat.22360

[23] Simic, M., Stewart, C., Bottrill, S., Zirit, M., & Hunt, K. (2017). Radically Open Dialectical Behavior Therapy for adolescents following partial response to family therapy for anorexia nervosa. Paper presented at the Annual Conference Academy of Eating Disorders, ICED, Prague.

[24] Keogh, K., Booth, R., Baird, K., Gibson, J., & Davenport, J. (2016). The Radical Openness Group: A controlled trial with 3-month follow-up. Practice Innovations, 1(2), 129.

[25] Lynch, T. R., Hempel, R. J., Whalley, B., Byford, S., Chambra, R., Clarke, P., . . . Russell, I. T. (2018). Radically open dialectical behaviour therapy for refractory depression: the RefraMED RCT. Efficacy Mechanism Evaluation, 5(7).

[26] Gilbert, K. E., Barch, D. M., & Luby, J. (2019). The Overcontrol in Youth Checklist: Validation of a behavioral measure of overcontrol in preschool aged children Child Psychiatry and Human Development.