Radically Open Dialectical Behavior Therapy
Radically Open Dialectical Behavior Therapy (RO DBT) is a form of cognitive behavioral treatment that builds upon Dialectical Behavior Therapy (DBT). It was developed by Dr. Thomas Lynch. It is aimed at clients with overcontrol (OC) disorders such as anorexia nervosa, chronic depression, and obsessive-compulsive disorder. RO DBT is based in biosocial theory which seeks to identify individual differences in temperament, perception/appraisal, inhibitory/regulatory control, and also the environmental factors which lead to rigid, over-controlled coping styles.  
While incorporating basic cognitive and dialectical principles, the therapeutic strategies, core skills, and theoretical perspectives utilized in RO DBT differ from other approaches and standard DBT. In contrast to interventions designed to treat emotion dysregulation, RO DBT considers emotional loneliness to be the core problem facing its patients. Thus, it targets social signaling deficits, low openness, and aloofness. The therapist is less directive, encourages independence, and emphasizes self-discovery.
The initial framework for RO DBT emerged from Thomas R. Lynch’s investigations on diagnostic comorbidity, personality disorders, and emotion regulation. Treatment development was an iterative process—i.e., clinical observation led to theory and experimental research, which informed further clinical work—the end result being a comprehensive treatment package informed by a transdiagnostic model of personality and socio-emotional functioning. Precursors of Lynch’s later work focusing on undercontrolled and overcontrolled personality styles can be seen in his initial research on two personality variables—a high need for affiliation with others (dependency/sociotropy) and a high need for independence and achievement (autonomy)—and his interest in how these, in turn, related to relationship conflict, communication problems, couple dissatisfaction, and depression. Additionally, his early studies examining the mediating role of inhibition of emotional expression between temperament (e.g., affect intensity) and psychological distress were catalysts for the development of the key hypothesized mechanism of change in RO DBT (i.e., open expression = trust = social connectedness).
Attempts to understand overcontrolled coping have led to significant reformulations regarding mental health and optimal well-being. Though self-regulation is often equated with the ability to achieve success and happiness in life, overcontrolled patients seemed to possess too much of this “good” thing. Lynch observed that though OC patients were often highly successful at being able to inhibit their quest for short-term (often pleasurable) rewards to pursue distal goals, their problem was that they appeared unable to relax control even when they desired to do so. Following this realization, Lynch posited that mental health was less about achieving happiness or success, as these experiences are transitory, but rather more about the capacity to flexibly respond to changing environmental demands. Moreover, he postulated that genuine mental health required "receptivity or openness" to environmental feedback suggesting change is necessary. Finally, he reconceptualized problems of overcontrol as fundamental problems of emotional loneliness—thereby highlighting the importance of social connectedness as the third element deemed essential for emotional well-being. These observations became a were a core part of the early treatment development phases.
The ability to inhibit emotional urges, impulses, and behaviors to pursue long-term goals is evolutionarily prosocial; thus, in most societies, the ability to exercise self-control is valued and associated with success. A greater capacity for self-control has been associated with positive outcomes in both child and adult populations, including better performance in school and work settings, better relationship functioning, and better overall psychological adjustment. However, too much self-control can be equally problematic. Excessive self-control is associated with social isolation, poor interpersonal functioning, perfectionism, rigidity, lack of emotional expression, and severe and difficult-to-treat mental health problems, such as anorexia nervosa, chronic depression, and obsessive-compulsive personality disorder.
Relatedly, an examination of the Diagnostic and Statistical Manual-Fifth Edition shows that PD involves pervasive problems with emotion/impulse control and interpersonal relationships—features linked with undercontrol and overcontrol, which overlap with the well-established division between internalizing and externalizing disorders. The core commonalities of PD characterized by overcontrol (i.e. paranoid, obsessive-compulsive, and avoidant styles) are (i) a strong desire to control one’s environment; (ii) restrained emotional expression; (iii) limited social interaction / problems with close relationships (due to mistrust, aloofness, distancing, fear or rejection/criticism); and (iv) cognitive and behavioral rigidity.
Personality researchers have supported the utility of these broad approaches via the identification of a robust hierarchical structure of personality dimensions with clear links to social functioning and psychological disorder. While undercontrolled, impulsive, dramatic, emotionally expressive children have been shown to be more likely to develop externalizing disorders, overcontrolled, emotionally constricted, risk-averse children are more likely to develop internalizing disorders and become socially isolated in adulthood.
Lynch contends that the above observations have clear treatment implications. Treatments targeting problems of undercontrol should aim to enhance inhibitory control and reduce mood-dependent behavior, whereas treatments targeting problems of overcontrol require interventions designed to relax inhibitory control and increase emotional expressiveness, receptivity, and flexibility. Yet, there has been a dearth of research examining disorders of overcontrol, despite evidence that they are highly prevalent and associated with impaired functioning and increased use of health care services. Indeed, obsessive-compulsive PD, a prototypical disorder of overcontrol, is the most prevalent personality disorder in community as well as clinical samples. The following table provides a brief overview of core differences between overcontrolled and undercontrolled coping in biotemperament, social-signaling, and family/environmental reinforcers
|Dysregulated: Hypersensitive to the presence or absence of reward||REWARD SENSITIVITY||Low: Insensitive to reward—spontaneous, unexpected, or unearned rewards|
|Variable: may be high or low||THREAT SENSITIVITY||High: Sensitive to threat, high anxious apprehension|
|Low to moderate: less detail focused more global focused processing, “sees the forest not the individual trees”||DETAIL-FOCUSED PROCESSING||High: preference for details, notices small discrepancies, superior pattern recognition, “sees the trees but not the forest”|
|Low: Disinhibited, actions responsive to current stimuli, impulsive risk taking, high tolerance for disorganization||SELF-CONTROL CAPACITY||High: Inhibited, actions responsive to consequences, risk averse, non-impulsive, prefer structure and order|
|High and variable emotional expression, emotionally labile, excitable, chaotic relationships, prone to rash action in high emotional states||SOCIAL-SIGNALING STYLE||Emotionally static, mask inner feelings or fake expressions, chronic dysphoria, non-excitable, distant and aloof relationships, prone to withdrawal in high emotional states|
|Intermittently reinforced for escalation of emotional responses and dramatic displays||FAMILY/CULTURAL/ENVIRONMENTAL INFLUENCES||Reinforced for appearing perfect, following rules, being correct, appearing calm or controlled|
Background and Overview
RO DBT shares a number of similarities with its predecessors, but is distinct in many important ways. RO DBT’s development has been informed by a wide range of philosophical, etiological, and treatment models and approaches. Most notably, these comprise dialectical philosophy and dialectical behavior therapy, mindfulness-based approaches, cognitive behavioral therapy, Gestalt therapy, motivational interviewing, basic emotion theory, affective neuroscience, personality and developmental theories, evolutionary theory, and Malâmati Sufism.
RO DBT posits the OC phenotype to be characterized by four core deficits: low receptivity and openness (e.g., low openness to disconfirming feedback, avoidance of ambiguity or uncertainty, hypervigilance to potential threat), low flexible-control (e.g., need for structure and order, perfectionism, compulsive planning, rigid and rule-governed behavior), inhibited emotional expression (e.g., suppression of negative emotions, incongruent expression of emotion, under-reporting of distress), and low social connectedness (e.g., aloof and distant relationships, envy and bitterness, reduced empathy). Disorders of overcontrol are common and yet also those least likely to respond to treatment. RO DBT contends that individuals often fail to respond to interventions because most treatment approaches are based on the erroneous assumption that categories of disorders are homogenous in nature. For example, an estimated 40-60% of unipolar depressed clients also meet criteria for comorbid personality disorder.
RO DBT rests on a biosocial theory of overcontrol derived from empirical research on neuroregulatory processes involved in autonomic functioning. According to the RO DBT model, OC is considered a product of a genetic disposition towards high inhibitory control, early environmental experiences, and an avoidant and rigid coping style that limits one’s ability to learn from past experiences and adjust behavior; these factors impede the formation of close relationships. More specifically, OC manifests bio-temperamentally via heightened threat sensitivity, diminished reward sensitivity, high inhibitory control capacities, and superior attention to detail. These tendencies interact with early family/cultural experiences that overvalue emotional constraint, perfectionism, high achievement, and rigid adherence to rules and strict personal standards. Overcontrolled coping – characterized by inhibited expression, risk avoidance, perfectionism, distress over-tolerance, and covert expression – emerges through these "nature-nurture" transactions. This style of coping is intermittently negatively reinforced by reductions in arousal associated with avoidance of feared situations, and positively reinforced by achievement or performance.
- Humans are tribal by nature. Our species survival required the development of capacities to form long-lasting social bonds, share valuable resources, and work together in tribes or groups.
- Psychological well-being involves the confluence of three factors: receptivity, flexibility, and social-connectedness.
- Core genotypic/phenotypic differences between groups of disorders necessitate different treatment approaches.
- Overcontrol is a multi-faceted paradigm—involving complex transactions between biology, environment, and coping.
- Bio-temperamental deficits/excesses make behavioral responses more rigid and less able to flexibly adapt to changing environmental conditions.
- It requires willpower to “turn off” willpower!
- Social-signaling matters! Deficits in pro-social-signaling represent the core problem for overcontrolled disorders and is posited to be the source of their emotional loneliness.
- Radical openness assumes ‘we don’t see things as they are—we see things as we are’.
- One secret of ‘healthy living’ is the cultivation of ‘healthy self-doubt’.
- Radical openness and self-inquiry are experiential—they are not something that can be understood solely via intellectual means. Therapists need to practice radical openness themselves to model it to clients.
RO DBT is the first treatment to prioritize social-signaling as the primary mechanism of change by linking the communicative function of human emotions to the establishment of social connectedness. RO DBT also differs from most other treatments in positing that individual well-being 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 compared to other treatments, whereas the ways in which a person signals their inner experience to other members of the tribe is most important, and the focus is on the impact social signals have on social connectedness.
Psychological health or well-being in RO DBT is hypothesized to involve three core transacting features: 1) Receptivity and openness to new experience and disconfirming feedback, in order to learn, 2) Flexible control, in order to adapt to changing environmental conditions, and 3) Intimacy and social connectedness (with at least one other person), based on premises that species survival required capacities to form long-lasting bonds and to work in groups or tribes. The basic idea is that OC clients are more likely to benefit from treatment approaches that emphasize openness, candid expression of emotion, flexibility, and social connectedness—rather than approaches valuing dispassionate awareness, self-constraint, impulse control, or delaying gratification.
Radical Openness is the core philosophical principle and core skill in RO DBT. As a state of mind, it entails a willingness to surrender preconceptions about how the world should be. Relatedly, a core principle in RO DBT is that an individual's perceptual and regulatory biases make it impossible for him or her to achieve heightened self-awareness in isolation; we need others to point out our blind spots. Other distinguishing features include:
- RO DBT parses emotion regulation into three transacting temporal elements; (1) perceptual encoding factors (sensory receptor regulation) that precede (2) internal modulatory factors (central-cognitive regulation) which then result in (3) external behavioral expressions and overt actions (response selection regulation). Separating external regulation from internal regulation helps explain why a person can “feel” anxious inside yet not display any “overt” signs of anxiety on the outside.
- RO DBT can be distinguished from other mindfulness-based approaches by its emphasis on radical openness principles and self-enquiry practices.
- RO DBT also differs somewhat from other behavioral approaches by training therapists to be alert for subtle in-session micro- expressions of emotion, changes in eye gaze directions or contact, shifts in body posture, changes in voice tone or rate of speech, and length of verbal responses—and to recognize them as possible social-signals.
- RO DBT contends that human emotional expressions evolved not just to communicate intentions, but to facilitate the formation of strong social bonds and altruistic behaviors among unrelated individuals. Consequently, RO DBT teaches therapists non-verbal social-signaling strategies designed to enhance client engagement and learning—e.g., gestures, postures, and facial expressions that universally signal openness, non-dominance, and friendly intentions. These non-verbal strategies often differ vastly from how therapists have been trained in other therapies.
- RO DBT teaches therapists how to balance playful irreverence with compassionate gravity, and to use therapeutic teasing as a core means of challenging maladaptive behavior.
- RO DBT does not consider treatment compliance, declarations of commitment, or lack of conflict as indicators of a strong therapeutic relationship. Indeed, alliance ruptures (those that are repaired) are considered working proof of a solid therapeutic relationship in RO DBT.
- RO DBT introduces a wholly unique approach to the use of behavioral exposure with particular relevance to OC populations—involving conditioning of consummatory reward experiences to brief exposures to tribal participation (Lynch, 2018a).
- RO DBT skills take a “bottom-up” approach to changing overlearned and maladaptive strategies that perpetuate OC. By activating areas of the ventral vagal complex associated with feelings of social safety (through purposive modification of overt and covert body language, facial expressions, and emotional expression), RO DBT utilizes physiology as a therapeutic mechanism of change.
Treatment Structure and Targets
RO DBT is typically administered in an outpatient treatment setting. Outpatient RO DBT has four components delivered over an average of 30 weeks, including:
- Weekly individual therapy (one hour in duration)
- Weekly skills-training class (2.5 hours in duration with 15-minute break)
- Telephone consultation (optional, and utilized by patients less than in standard DBT)
- Therapist participation in RO DBT consultation meetings (optional)
RO DBT’s primary objectives involve decreasing problematic overcontrol and aloofness/distance, while increasing flexibility, openness, and vulnerable expression of emotion. RO DBT identifies constrained social signaling as the main source of emotional loneliness and isolation over internal experiences (e.g., negative emotions, harsh self-judgment, distorted thinking); hence, treatment strategies are designed to enhance social connectedness through prosocial signaling and candid expression.
There are three ways in which RO DBT incorporates these aims into treatment interventions:
- It teaches clients context-appropriate emotional expression and nonverbal signaling strategies that have been shown to enhance social connectedness.
- It targets OC deficits and excesses by teaching OC clients skills designed to activate areas of the brain associated with the social safety system, and it encourages clients to use these skills prior to engaging in social interactions. This approach enables an overcontrolled client to naturally send nonverbal signals of friendliness, thereby facilitating reciprocal responses from others.
- It teaches therapists how to elicit activation of the social safety system in their clients by educating them about the deliberate use of gestures, postures, and facial expressions that communicate relaxation, friendliness, and non-dominance. This treatment aspect highlights the need for therapists to practice radical openness skills in their personal lives, since overcontrolled clients are unlikely to believe that it’s socially acceptable to play, relax, admit fallibility, or openly express emotions unless their therapists model such behavior first.
The clinical assessment of OC is a multi-step process. OC-relevant questionnaires are used to identify core traits and are integrated with data obtained from clinical interviews. Clinicians then complete an OC Global Prototype Rating Scale and ascertain whether the client appears to match more closely the Overly-Agreeable or the Overly-Disagreeable subtype. Finally, clinician-rated impressions of OC traits are used to supplement diagnostic impressions and guide treatment planning. These instruments can be found in the RO DBT treatment manual.
RO DBT is supported by myriad research, including two NIMH funded randomized controlled trials (RCTs) targeting refractory depression and comorbid OC personality dysfunction, two trials targeting adult Anorexia Nervosa, one non-randomized trial using RO DBT skills with treatment-resistant adults with overcontrolled tendencies, and a large ongoing multi-center RCT targeting refractory depression and overcontrolled personality disorders.
Training and consultation
The central point of contact for training and supervision in RO DBT is Radically Open Ltd. The company offers intensive training and lists upcoming one-day introductory training details of which can be found on their website.
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