What is RO DBT and who is it for?

RO DBT is a transdiagnostic treatment for disorders of overcontrol (OC)

Radically Open Dialectical Behavior Therapy (RO DBT) is a transdiagnostic treatment which targets a spectrum of disorders characterised by excessive inhibitory control or overcontrol (OC). It is intended for clinicians treating clients with such chronic problems as refractory depression, anorexia nervosa and obsessive-compulsive personality disorder.

The treatment is fully manualized (Lynch, 2018a; 2018b, see 'Books on RO DBT') and the feasibility, acceptability, and efficacy of RO DBT are evidence-based, supported by more than twenty five years of clinical translational research (see 'Research on RO DBT').

RO DBT treatment involves both individual treatment sessions and skills training classes, and clinically targets five OC themes: inhibited and disingenuous emotional expression; hyper-detailed focused and overly cautious behavior; rigid and rule-governed behavior; aloof and distant style of relating; and high social comparison and envy/bitterness.

What is overcontrol and why treat it?

By 'overcontrol' we mean excessive or maladaptive self-control, to such an extent that it can lead to chronic mental health problems.

Self-control is the ability to inhibit competing urges, impulses, behaviors, or desires and delay gratification in order to pursue future goals and is often equated with success and happiness. Indeed, failures in self-control characterize many of the personal and social problems afflicting modern civilization, including substance abuse, criminal activities, domestic violence, financial difficulties, teen pregnancy, smoking, and obesity (Baumeister, Heatherton, & Tice, 1994; Moffitt et al., 2011).

However, too much self-control, or overcontrol, can be equally problematic. Overcontrol is associated with social isolation, loneliness, poor interpersonal functioning, and severe and difficult-to-treat mental health problems, such as anorexia nervosa, chronic depression, and obsessive-compulsive personality disorder (e.g., Lynch & Cheavens, 2008; Zucker et al., 2007). Individuals with disorders of overcontrol are often quietly suffering, even though their suffering may not be apparent.

Unfortunately, due to the high value most societies place on capacities to delay gratification and inhibit overt or public displays of potentially destructive emotions and impulses, problems linked with excessive inhibitory control or 'overcontrol' have received little attention, or been misunderstood, and it has been difficult for clinicians to recognize such problems.

Maladaptive overcontrol is characterized by four core deficits:

  1. Low receptivity and openness: manifested by low openness to novel, unexpected, or disconfirming feedback, avoidance of uncertainty or unplanned risks, suspiciousness, hyper-vigilance for potential threat, and marked tendencies to discount or dismiss critical feedback.
  2. Low flexible-control: manifested by compulsive needs for structure and order, hyper-perfectionism, high social obligation and dutifulness, compulsive rehearsal, premeditation, and planning, compulsive fixing and approach coping, rigid rule-governed behavior, and high moral certitude (e.g., there is only one right way of doing something).
  3. Pervasive inhibited emotional expression and low emotional awareness: manifested by context inappropriate inhibition of emotional expression (e.g., exhibiting a flat-face when complimented) and/or insincere or incongruent expressions of emotion (e.g., smiling when distressed, showing concern when not feeling it), consistent under-reporting of distress, and low awareness of body sensations.
  4. Low social connectedness and intimacy with others: manifested by aloof and distant relationships, feeling different from other people, frequent social comparisons, high envy and bitterness, and reduced empathy.

How does RO DBT differ from other treatments?

RO DBT differs significantly from other treatment approaches, most notably by linking the communicative functions of emotional expression to the formation of close social bonds and via skills targeting social-signaling, openness and flexible responding.

RO DBT is the first treatment in the world to prioritize social-signaling as the primary mechanism of change. Robust research shows that context-inappropriate suppression of emotional expression or incongruent emotional expression (that is, a mismatch between outward expression and inner experience) will make it more likely for others to perceive one as untrustworthy or inauthentic (Boone & Buck, 2003; English & John, 2013; Kernis & Goldman, 2006), and that the consequences are a reduction in one’s social connectedness and exacerbation of one’s psychological distress (Mauss et al., 2011). In this way, OC bio-temperament-based threat sensitivity, combined with overlearned tendencies to mask inner feelings, are hypothesized to engender social ostracism and loneliness, thus exacerbating psychological distress.

Fake Smiles

This is why RO DBT trains 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 also 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 social signals inner or private experience to other members of the tribe and the impact that social signaling has on social connectedness.

What is Radical Openness?

Radical openness is the core philosophical principle and core skill in RO DBT.

Radical Openness is a way of behaving as well as a state of mind, informed by the central premise that emotional well-being involves the confluence of three features: openness, flexibility and social connectedness. As a state of mind, radically open living involves actively seeking our personal unknown in order to learn from an ever-changing environment. Radical openness also enhances relationships because it models humility and the willingness to learn from what the world has to offer. As such, radical openness often requires us to sacrifice our firmly held convictions and self-constructs – and this is why the practice of radical openness can be painful.

Radical openness 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 needed.

Free Resources for More Reading on RO DBT

  1. RO DBT Factsheet: You can read more about RO-DBT on the ABCT website: RO DBT Fact Sheet.
  2. Special Issue on RO DBT in the Behavior Therapist
    In March 2018 a special issue of the Behavior Therapist was dedicated entirely to RO DBT.

    List of articles:

    • New Thinking About Old Ideas: Introduction to the Special Issue on Radically Open Dialectical Behavior Therapy
    • Tribe Matters: An Introduction to Radically Open Dialectical Behavior Therapy
    • Too Much Versus Too Little Control: The Etiology, Conceptualization, and Treatment Implications of Overcontrol and Undercontrol
    • How to Differentiate Overcontrol From Undercontrol: Findings From the RefraMED Study and Guidelines From Clinical Practice
    • Radically Open Dialectical Behavior Therapy: Shared Features and Differences With ACT, DBT, and CFT
    • Radically Open Dialectical Behavior Therapy for Anorexia Nervosa: Connection, Openness, and Flexibility at the Heart of Recovery
    • Group Radical Openness
    • Not Everything Is as It Seems: RO DBT and Overcontrolled Disorders in Forensic Settings
    • The Implementation of RO DBT in Clinical Practice