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Radically Open Dialectical Behavior Therapy
Radically Open Dialectical Behavior Therapy (RO DBT) is a type of cognitive behavioral therapy developed by Dr. Thomas R. Lynch for disorders of overcontrol. Excessive self-control or overcontrol is a type of personality or coping style that can be identified in early childhood and can lead to social isolation, poor interpersonal functioning, and severe and difficult-to-treat mental health problems, such as anorexia nervosa, autism spectrum disorders, chronic depression, and obsessive-compulsive personality disorder (not OCD, but more related to perfectionism, orderliness, and control). 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; yet inwardly they often feel “clueless” about how to join in with others or establish intimate bonds. 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.
What Is RO DBT?
Radically Open Dialectical Behavior Therapy (RO DBT) is an evidencebased treatment developed specifically for problems of overcontrol. Radical openness is the core philosophical principle and core skill in RO DBT. The term “radical openness” means there are three important aspects of emotional well-being: openness, flexibility, and social connectedness.
RO DBT holds that “facts” and “truth” can often be misleading because we “don’t know what we don’t know,” life is constantly in flux, and there is much that influences us that we aren’t aware of. Radical openness involves a willingness to doubt or question ourselves and our convictions without falling apart. It helps relationships because it models humility and willingness to learn from what the world has to offer. RO DBT differs from other treatments by focusing on helping with deficits in social-signaling that reduce social connectedness. But what is a social signal? A social signal is any behavior a person exhibits in the presence of another person; regardless of its intention (sometimes a yawn is just a yawn) or conscious awareness (for example, an involuntary sigh). We are constantly socially signaling when around others (for example, via body movements, and voice tone), even when we are deliberately trying not to (silence can be just as powerful as nonstop talking).
The reason for this is because negative results of overcontrol are usually related to social relationships. Overcontrolled individuals see new or unfamiliar (especially social) situations as dangerous, rather than rewarding, due to biological-temperamental differences and social/historical learning experiences. Their tendencies to hide expressions of emotion make it harder for others to know their true intentions, something that is needed to form close social bonds. Consequently, RO DBT targets indirect, hidden, and constrained social signaling as the main source of emotional loneliness, isolation, and misery over problematic internal experiences (e.g., negative emotions, harsh self-judgment, distorted thinking) and treatment strategies are designed to enhance social connectedness; including new skills to activate areas of the brain associated with the social-safety system and signal cooperation by deliberately changing body postures and facial expressions (e.g. raising eyebrows when stressed), encourage genuine self-disclosure, and break down overlearned expressive inhibitory barriers (via skills designed to encourage playful behavior and candid expression).
Thus, when it comes to long-term health, what a person feels or thinks inside is considered less important in RO DBT, whereas how a person communicates or socially signals their private experience to others and its impact on social connectedness is given priority. When you are lonely it’s hard to feel happy, no matter how much you try to accept or change your circumstances, think more positively, keep busy, exercise, practice yoga, or distract yourself. Revealing intentions and emotions to other members of our species was essential to creating the types of strong social bonds that are the cornerstone of human tribes. In the long run, we are tribal beings, and we want to share our lives with other members of our species. Essentially, when we feel part of a tribe, we naturally feel safe and worry less. RO DBT is designed to help emotionally lonely overcontrolled clients learn how to make this a reality.
What Are the Components of Outpatient RO DBT?
Although RO DBT has been researched and applied clinically in a wide range of settings (inpatient, day hospital, skills training only), the approaches outlined in the published treatment manuals (Lynch, 2018a; Lynch, 2018b) are derived primarily from an outpatient model of treatment delivery. Outpatient RO DBT has four components delivered over an average of 30 weeks. The first three components are specific to patients and the final component is specific to the RO DBT therapist. Specifically, the components are:
1. Weekly individual therapy (one hour in duration)
2. Weekly skills-training class (2.5 hours in duration with 15-minute break)
3. Telephone consultation (optional)
4. Therapist participation in RO DBT consultation meetings (optional)
How Is RO DBT Different From Standard DBT?
As a new treatment, RO DBT is both similar and dissimilar to its earlier versions of DBT. The decision to retain the terms dialectical and behavior therapy (BT) in the name of this new treatment reflects the desire to acknowledge two of its fundamental roots. Dialectical principles are used in RO DBT to encourage cognitively rigid overcontrolled clients to think and behave more flexibly. An example of dialectical thinking can be seen in the RO DBT mindfulness skill of self-enquiry. Self-enquiry requires willingness to question one’s beliefs, perceptions, action urges, and behaviors without falling apart or simply giving in. The dialectical tension involves balancing trusting versus distrusting oneself. The synthesis in RO DBT involves being able to listen openly to criticism or feedback, without immediate denial (or agreement), and a willingness to experience new things with an open heart, without losing track of one’s values. Whereas, behavior therapy principles are used to explain how certain maladaptive overcontrolled social signaling deficits are intermittently reinforced over time (for example, pouting is reinforced when it functions to block unwanted feedback) and to therapeutically reinforce and shape adaptive responses linked to establishing and maintaining close social bonds (such as vulnerable self-disclosure and candid expression of emotion).
Although RO DBT and standard DBT share this common ancestry, they differ in several important ways. Understanding their differences is important because the similarities in their names can lead to the misperception that they are substantially alike or even the same treatment. Some of the key differences between RO DBT and standard DBT include:
|RO DBT||Standard DBT|
|Target population||Developed for overcontrolled clients, such as patients with anorexia nervosa, chronic depression, and obsessive compulsive personality disorder; these would be people whose emotions are often directed inward or don’t emerge at all.||Developed for undercontrolled clients, such as patients with borderline personality disorder, substance misuse, or bipolar disorder; these would be people whose emotions often are directed outward and appear disruptive to others.|
|Primary therapeutic focus||External (interpersonal)— social signaling and social connectedness skills.||Internal (intrapersonal)— emotion regulation, impulse control, and distress tolerance skills.|
|Role of biotemperament||Emphasizes how biology influences how we perceive others and how that perception affects our actions.||Bio-temperament not directly addressed or focused on in standard DBT.|
|Mindfulness practices||Informed by Malamati Sufism.1 emphasis on self-inquiry, “outingoneself,” participating without planning, and the cultivation of healthy self-doubt. encourages Flexible-Mind responses that promote relaxation of rigid, rule-governed control efforts and an increase in context-appropriate emotional expression.||Informed by Zen buddhism emphasis on nonjudgmental awareness of “what is” and intuitive knowing. encourages cultivation of Wise-Mind responses that focus on reducing mood-dependent impulsive responding and increasing abilities to delay immediate gratification in order to pursue distal goals.|
|Therapeutic stance||Less directive, encourages independence of action and thought.||Uses external contingencies, including mild aversives, and takes a direct stance in order to stop dangerous, impulsive behavior.|
|Radical Acceptance vs Radical openness||Prioritizes Radical openness—that is, actively seeking the things one wants to avoid in order to learn – challenging our perceptions of reality, modeling humility and a willingness to learn.||Prioritizes Radical acceptance— that is, letting go of fighting reality and turning suffering that cannot be tolerated into pain that can be tolerated.|
|1The Malamatis are not so much interested in the acceptance of reality or seeing “what is” without illusion (central Zen principles), but rather they look to find fault within themselves and question their self-centered desires for power, recognition or self-aggrandizement|
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. It has been shown to be highly effective in treating chronic forms of depression with rates of full recovery from depression reported as high as 71% in some studies. Research has also demonstrated the potential utility of RO DBT in the treatment of severely underweight adults with anorexia nervosa with studies reporting significant increases in body mass index (BMI; weight gain), low rates of treatment dropout, and significant improvements in eating disorder related psychopathology.
In summary, as of summer 2017 (see http://www.radicallyopen.net/research-on-ro-dbt/ for more up-to-date information) most research support is for the treatment of chronic depression, anorexia, and maladaptive personality dysfunction in adults—with additional ongoing research examining RO DBT with violent offenders in forensic settings, among young children, and with adolescent eating disorders.
Finding an 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 that 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.: http://www.radicallyopen.net/find-a-therapist/.
To learn more about RO DBT, please visit http://www.radicallyopen.net/.
Lynch, R.T. (2018). Radically Open Dialectical Behavior Therapy: Theory and Practice for Treating Disorders of Overcontrol. Reno, NV: Context Press, an imprint of New Harbinger Publications.
Lynch, R.T. (2018). The Skills Training Manual for Radically Open Dialectical Behavior Therapy: A Clinician’s Guide for Treating Disorders of Overcontrol. Revo, NV: Context Press, an imprint of New Harbinger Publications.