A Comprehensive Guide to Radically Open Dialectical Behavior Therapy (RO-DBT)

Radically Open Dialectical Behavioral Therapy (RO DBT) is a treatment developed by Thomas Lynch for those who develop disorders associated with an overcontrolled (OC) personality.  OC individuals are often described as reserved and cautious, not very expressive with their emotions, and great at delaying gratification. OC individuals tend to be strong rule followers and feel a high sense of obligation in their lives (i.e., go to a birthday party because they feel they have to rather than wanting to do so). However, at times, they may experience “emotional leakage,” or emotionally breaking down once they are in private after holding it all together all day in public.

An OC personality can be really helpful in some ways. These are the people that get their work done no matter what, show up to work on time every day, work through all the nitty, gritty details of a project, and follow through on their word. They can be very organized and methodical, and they are great at planning for long-term gains (i.e., saving to buy a house). However, they can be rigid and inflexible at times (i.e., get very upset if a restaurant loses a dinner reservation and struggles with figuring out where else to go to eat) and may have difficulty receiving feedback. Patients that may benefit from this treatment include those with chronic depression and anxiety, autism spectrum disorders, Obsessive-Compulsive Personality Disorder, and Anorexia Nervosa.

What is Radically Open DBT (RO-DBT)?

Radically Open DBT (RO-DBT) is an evidence-based treatment for individuals struggling with overcontrol. It is a form of Cognitive Behavior Therapy (CBT) with an emphasis on issues of control.

Dialectical Behavior Therapy (DBT) was developed to treat consistently suicidal individuals with borderline personality disorder (BPD). RO-DBT was developed along similar principles to DBT to assist patients with issues of overcontrol.

There are three core concepts in RO-DBT:

  1. Receptiveness and Openness to New Experiences and Situations
  2. Flexible-Control
  3. Emphasis on Social Connection and Intimacy

Working on these concepts patients develop skills via “radical openness” to ease their issues of overcontrol.

How Does Over-Control Affect Mental Health?

An OC personality type can affect one’s mental health greatly. Some level of control is needed, but overcontrol can lead to isolation, loneliness, and other negative behaviors. Utilizing the core concepts in RO-DBT, patients work through issues of overcontrol to repair social skills.

RO-DBT teaches individuals to loosen their control over situations to avoid falling victim to “emotional leakage”.

What Is the Difference Between DBT and RO-DBT?

Dialectical Behavior Therapy (DBT) is a form of talk therapy to assist individuals who feel emotions extremely intensely. It combines a focus on mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. DBT helps individuals manage their emotions, handle upsetting situations with less disruption, and reduce impulsivity. DBT therapy is typically utilized for individuals with conditions such as borderline personality disorder, bipolar disorder, or substance abuse disorder.

Conversely, RO-DBT is a therapeutic practice that helps individuals increase their awareness of social signaling and build their capacity for openness. RO-DBT is a practice best suited for individuals who hold onto control too tightly, rather than those who tend to lose control.

Many incorrectly assume that RO-DBT and Dialectical Behavior Therapy (DBT) are the same thing. While RO-DBT has some similarities with DBT, these are two very different treatments. DBT primarily benefits those who have an undercontrolled (UC) personality. UC traits include being impulsive, sensation-seeking, wearing one’s heart on one’s sleeve, and acting in the here and now.  Thus, DBT can be helpful for those that have impulsive control problems, such as those with borderline personality disorder, bulimia nervosa, binge eating disorder, and substance abuse disorders. Both RO DBT and DBT combine individual therapy with skills training classes, involve tracking emotions and behaviors via diary cards, allow for telephone consultation with the individual therapist, and involve consultation teams for the group and individual therapists. However, DBT has a stronger focus on self-regulation to target emotion dysregulation whereas RO DBT is much more focused on helping individuals address social signaling and connectedness with others.

RO-DBT Training

RO-DBT can be utilized over the course of 30+ weeks combining weekly 1-hour individual sessions and weekly 2.5-hour skills building classes. RO-DBT treatment was originally created for outpatient treatment, but the treatment can also be utilized in inpatient or residential situations.

The primary principles and strategies and skills training modules used in RO-DBT include:

  • Fostering Receptivity/Increasing Flexible Responding

Because patients suffer from overcontrol, there is a focus on building skills that allow them to be receptive to a changing environment around them.

  • Openness 

Similar to building up receptivity, patients will also work on their ability to be open to a changing environment and new situations.

  • Self-Enquiry

Self-enquiry is a mindfulness practice that patients can use to better understand themselves and why they interact with the world in the way they do. This can be done in a variety of ways such as through journaling.

  • Social Signaling 

Maladaptive social signaling in individuals suffering from overcontrol prevents them from being able to relate to others. When patients improve social signals, interpersonal relationships benefit.

RO-DBT has proven results. An Anorexia Nervosa study found that 62% of all patients were in full remission when RO-DBT treatment was completed. Another RO-DBT study found the treatment to be effective in helping adults with autism spectrum disorders.

Target Population and Indications for RO-DBT

RO-DBT can be an effective treatment for individuals with eating disorders, personality disorders, treatment resistant depression or anxiety, and more. When overcontrol is a key factor in a patient’s mental illness RO-DBT may be an effective option.

Radically Open Dialectical Behavior Therapy for Overcontrolled Personality

The biosocial theory behind RO DBT explains that OC individuals have brains that zoom in on the negative or threatening aspects of a situation before seeing the positives. This predisposition interacts with being raised in an environment that encourages or praises high levels of self-control in one’s life (i.e., doing homework without one’s parents needing to remind them to do so), performing at a high level (i.e., getting good grades, doing well in sports, receiving accolades), and avoiding making errors. These individuals end up avoiding uncertain situations, holding back their emotions out of fear that others may see them as being out of control, and become guarded in social situations, appearing to others to be withdrawn.  Their lack of vulnerability and difficulty expressing what they are really feeling leads others to struggle to relate to them, so they end up feeling lonely and isolated.  Thus, RO DBT operates under the assumption that increasing connectedness to others can improve psychological functioning, thus targeting emotional expression. Additionally, RO DBT encourages being open to hearing other points of view so that one can learn as well as learning to be flexible in responding to varying situations.

Thomas Lynch describes that the five main behavioral targets of RO DBT include

  1.  Being socially distant or reserved
  2.  Inflexible, rule-governed behaviors
  3. Focusing on the details rather than the big picture of a situation and being overly cautious
  4. Demonstrating emotional expressions that are inconsistent with how one is really feeling
  5. Comparing oneself to others, leading to resentment and envy.

In RO DBT, patients work with their therapists on identifying personal goals consistent with these behavioral targets, connecting these goals to the problems that brought them into treatment. For instance, a patient may bring up that he/she would like to deepen relationships with others, be more flexible when things don’t go according to plan or let go of past grudges to help fight depression and anxiety.

When Is RO-DBT Not Effective?

RO-DBT may not always be an effective form of therapy for individuals suffering from issues of overcontrol. Psychotherapist Gary Trosclair points out the limitations of the therapy in treating certain patients with overcontrol, “​​The people-pleaser subtype of OCPD can meet the criteria for OCPD and still be extremely over-sensitive to how they come across to others, in contrast to the clients RO DBT is designed for, who are unaware of how they come across to others.” he writes in his review of RO-DBT treatment.

No form of therapy is a one-size fits all solution. Every patient is unique, and each treatment plan needs to be individualized.

Effectiveness and Research Findings

RO-DBT has been found to be an effective treatment for a spectrum of disorders that include issues of overcontrol. It has been informed by years of peer reviewed research.

These studies find that RO-DBT helps patients improve their social connectedness, build openness and receptibility, and increase mindfulness.

Who Offers RO-DBT and What Resources are Available

When seeking out a new treatment it is always best to have a discussion with your primary care provider or healthcare professional. They may be able to offer referrals to clinics or other practitioners who can help.

This RO-DBT website offers information, training for therapists – including workbooks and textbooks, and blogs on RO-DBT. There are also several podcasts and videos for patients interested in RO-DBT.

Insurance and cost may be potential barriers to RO-DBT. Reaching out to therapists to see if they offer sliding scale fees, community discounts, or payment plans is a great way to ease financial concern.

Why Lindner Center of HOPE?

Lindner Center of HOPE offers comprehensive and personal care to all our patients. We treat a variety of mental health and substance abuse disorders using many proven therapeutic practices including RO-DBT. Contact us today to learn more about what we have to offer.