Radically Open Dialectical Behavior Therapy (RO DBT)

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Radically Open Dialectical Behavior Therapy (RO DBT)

THC Editorial Team January 11, 2023
Photo by Nathan Dumlao on Unsplash (article on RO DBT)
Photo by Nathan Dumlao on Unsplash

Contents

Radically open dialectical behavior therapy (RO DBT) is used to treat people with conditions involving excessive self-control. People who exhibit too much self-control (overcontrol) might experience problems with interpersonal relationships and social isolation. Overcontrol is thought to be present in people with chronic depression, anorexia nervosa, obsessive-compulsive personality disorder, and autism spectrum disorder. People with overcontrol tend to be hard workers with high standards who frequently ignore their personal needs to achieve goals. However, they also might struggle with connecting and forming intimate relationships with others.

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What Is Radically Open Dialectical Behavior Therapy?

RO DBT is a therapeutic approach developed to treat people with overcontrol issues. The core principle of this approach is the concept of radical openness, which includes the following three components:

  • being open
  • being flexible
  • being able to form social connections

RO DBT emphasizes that since life constantly changes, it is difficult to ascertain what constitutes truth, as people are often unaware of a myriad of circumstances that may influence facts. Being radically open means actively open to experiencing uncomfortable aspects of our lives for the benefit of learning from them. When people are radically open, they are better equipped to develop relationships with others because they are more willing to learn from others and demonstrate humility.

RO DBT practitioners focus on problems with social signaling that interfere with people’s ability to connect socially with others. Social signals are the nonverbal signs people demonstrate when they are with others.

People with overcontrol conditions tend to view unfamiliar social situations as potentially dangerous because of their personality differences and early learning experiences. They tend to hide their emotions, making it harder for others to understand their intentions and form close bonds with them. RO DBT views indirect and constrained social signals as the primary problem underlying social isolation, loneliness, and negative views of the self.

RO DBT therapists help people build skills enabling them to retrain areas of the brain that control their safety system (i.e., the brain’s responses indicating whether a situation is safe or poses a threat) in social situations. Therapists might help their clients practice different facial expressions and bodily postures. They might also help facilitate their ability to disclose their thoughts and emotions and break down inhibitions that prevent them from honestly expressing themselves or engaging in playfulness. Instead of focusing on a person’s internal thoughts or emotions, RO DBT focuses on how people signal their internal experiences and communicate with others.1

Similarities and Differences Between Dialectical Behavioral Therapy (DBT) and Radically Open Dialectical Behavior Therapy (RO DBT)

Developed through the work of psychologist Marsha Linehan in the 1980s, dialectical behavior therapy (DBT) is a well-supported, evidence-based treatment that blends the most effective interventions within behavioral psychotherapy while incorporating notions of acceptance and validation.2 Based on dialectical philosophy, DBT posits that reality comprises opposing polar forces that generate tension. DBT was initially used to treat borderline personality disorder, a particularly challenging condition whereby people experience intense and uncontrollable negative emotions. It has also been studied and shown value in treating other conditions, including bipolar disorder, and helping people who demonstrate emotional dysregulation (i.e., difficulty controlling their emotional reactions).

Although RO DBT is rooted in the dialectical approach of DBT, it differs in a few ways, including but not limited to the following:1

  • DBT focuses on impulse control; RO DBT encourages a degree of self-discovery and empowerment.
  • DBT emphasizes emotion regulation and behavioral management; RO DBT emphasizes openness and social connection.
  • DBT focuses on the impetus to change, particularly for individuals with borderline personality disorder; RO DBT targets overcontrol and helping clients let go of perfectionism.

Background/History of RO DBT

Thomas R. Lynch, Ph.D., is an American psychologist who founded RO DBT following years of research in emotional dysregulation, personality disorders, and co-occurring disorders.3 He developed the therapy through clinical observations and experimental research.  His early work focused on both overcontrol and undercontrol and how those constructs led to conflicts in relationships, depression, and communication problems. He later developed RO DBT upon recognizing that people form social connections with others by expressing themselves openly and building trust.

While being able to self-regulate emotions can enable success, individuals who are overcontrolled tend to overregulate their emotions and cannot relax their control even when they wish to do so. Instead of equating happiness with success, RO DBT holds that people achieve fulfillment by being able to respond flexibly to changing demands.

According to Lynch, in addition to the dialectical philosophy and DBT, RO DBT has been influenced by “… mindfulness-based approaches, cognitive behavioral therapy (CBT), Gestalt therapy, motivational interviewing, basic emotion theory, affective neuroscience, personality and developmental theories, evolutionary theory and Malâmati Sufism.”3

The Process of RO DBT

RO DBT views individuals’ well-being as inseparable from the larger community’s responses. Using social signals to express one’s internal experiences to other members of the community is essential, so therapists focus on how social signals affect the individual’s ability to connect with others.

RO DBT practitioners believe that (1) mental health and well-being involve being receptive and open to experiencing new things and handling feedback to enable growth and learning, (2) people need to be flexible to adapt to changes, and (3) people need intimacy and connections with one or more people for psychological health. The core skill therapists try to build is radical openness, which enables clients to rid themselves of preconceived ideas about how the world should work. The approach emphasizes candidly expressing emotions, increasing openness and flexibility, and building social relationships.3

RO DBT draws from neurobiosocial theory, which describes the process of emotion regulation as “(1) perceptual encoding factors (sensory receptor regulation) that precede (2) internal modulatory factors (central-cognitive regulation) which then result in (3) social-signals or external behavioral expressions (response selection regulation).”1 A client’s external and internal regulation mechanisms may indicate why they might experience inner anxiety while not displaying any outward signs of anxiousness.

Therapists who practice RO DBT watch for subtle signs of emotion, including changes in posture, eye contact, vocal tone, rapidity of speech, and length of responses to identify social signals. They work with clients to help them learn different facial expressions, postures, and gestures that help them signal openness to others.

The components of RO DBT include individual therapy sessions, skills-training classes, and optional phone consultations. RO DBT is typically delivered in outpatient treatment over approximately 30 weekly 1-hour individual therapy sessions in addition to weekly RO DBT skills training group sessions that last about 2.5 hours each.1

The primary objectives include decreasing the client’s overcontrol and distance while encouraging candid emotional expressions, openness, and flexibility.

The Potential Benefits of RO DBT

RO DBT offers several potential benefits, including the following:3

  • increased openness to experiencing new things and ways of thinking
  • increased flexibility in emotional responses and thoughts
  • greater expressiveness of feelings of one’s inner state
  • better ability to connect with and relate to and with others
  • reduced sense of loneliness
  • increased willingness to change how one thinks and responds to emotions
  • better ability to effectively regulate emotions
  • improved well-being and quality of life

The Effectiveness of RO DBT

RO DBT has been shown to have some effectiveness in the treatment of people with depression and co-occurring personality disorders, people with anorexia nervosa, and treatment-resistant individuals who have overcontrolled personalities. A recent study indicates it might also be effective in reducing distress in people with autism spectrum disorders.4

In one study, led by Dr. Lynch, that looked at the effectiveness of DBT in treating older adults with both depression and personality disorders, researchers found that the group who received both medication and DBT showed greater clinical improvement than the group who received medication alone.5

A recent randomized study of 250 adults suffering from refractory depression, or treatment-resistant depression, found that the 162 participants who were randomly assigned to the RO DBT treatment group, plus treatment as usual, showed significantly reduced symptoms of depression immediately following treatment. However, the researchers also noted that the RO DBT group participants reported eight adverse events, whereas no one in the control group (e.g., those with treatment as usual alone) reported any. The researchers surmised that the participants in the control group might not have reported adverse events because they had less opportunity and encouragement from the facilitators to do so. However, they also noted that while the RO DBT group showed statistically significant marked improvements seven months following treatment, they did not afterward.6

Researchers evaluated RO DBT for treating people with anorexia nervosa using a single-case experimental design with various baselines across 13 individual cases. Upon completion of treatment, eight out of 13 participants (62%) were in full remission, and six were in full remission upon a 6-month follow-up.7

A recent study looked at the effectiveness of RO DBT for people with autism spectrum disorder (ASD). Researchers compared 23 people with ASD diagnoses to 25 without ASD diagnoses who underwent RO DBT. The group with ASD diagnoses showed significant improvements compared to those who did not have ASD diagnoses.4

RO DBT has also shown promise as a potential therapeutic intervention for adolescents. A study of twenty-eight adolescents referred for an adolescent version of radically open dialectical behavior therapy (RO-A) concluded that the treatment led to improved regulation of overcontrol, better relationships, and reduced mental health symptoms.8

Summary/Key Takeaways

Radically open dialectical behavior therapy is an approach to treating people with disorders involving excessive self-control. While it shows promise, it is relatively new and requires more research to determine its effectiveness. People who have difficulty expressing themselves and forming social relationships might try this approach to help them become more open, flexible, and successful in relationships.

References

  1. Lynch, T. R., Hempel, R. J., & Dunkley, C. (2015). Radically open-dialectical behavior therapy for disorders of over-control: signaling matters. American Journal of Psychotherapy, 69(2), 141–162.
    https://doi.org/10.1176/appi.psychotherapy.2015.69.2.141
  2. Chapman A. L. (2006). Dialectical behavior therapy: current indications and unique elements. Psychiatry (Edgmont (Pa. : Township)), 3(9), 62–68.
  3. Lynch, T. R. (2018). Radically open dialectical behavior therapy: Theory and practice for treating disorders of overcontrol. New Harbinger Publications, Inc.
  4. Cornwall, P. L., Simpson, S., Gibbs, C., & Morfee, V. (2021). Evaluation of radically open dialectical behaviour therapy in an adult community mental health team: Effectiveness in people with autism spectrum disorders. British Journal of Psychology Bulletin, 45(3), 146–153.
    https://doi.org/10.1192/bjb.2020.113
  5. 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.
    https://doi.org/10.1002/gps.1703
  6. Lynch, T. R., Hempel, R. J., Whalley, B., Byford, S., Chamba, R., Clarke, P., Clarke, S., Kingdon, D. G., O’Mahen, H., Remington, B., Rushbrook, S. C., Shearer, J., Stanton, M., Swales, M., Watkins, A., & Russell, I. T. (2020). 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, 216(4), 204–212.
    https://doi.org/10.1192/bjp.2019.53
  7. Isaksson, M., Ghaderi, A., Ramklint, M., & Wolf-Arehult, M. (2021). Radically open dialectical behavior therapy for anorexia nervosa: A multiple baseline single-case experimental design study across 13 cases. Journal of Behavior Therapy and Experimental Psychiatry, 71, 101637.
    https://doi.org/10.1016/j.jbtep.2021.101637
  8. Baudinet, J., Stewart, C., Bennett, E., Konstantellou, A., Parham, R., Smith, K., Hunt, K., Eisler, I., & Simic, M. (2021). Radically open dialectical behaviour therapy adapted for adolescents: A case series. BMC psychiatry, 21(1), 462.
    https://doi.org/10.1186/s12888-021-03460-3

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