What Is Radically Open Dialectical Behavior Therapy?

Radically Open Dialectical Behavior Therapy (RO-DBT) is a new evidence-based therapy for people who are overcontrolled. A counterintuitive idea behind the therapy is that it’s possible to have too much self-control.  Self-control refers to our ability to restrain acting on our urges, emotions, and wants in favor of longer term goals. Most of the time, self-control is good, but some people can suffer from excessive self-control. For these people, inhibiting and controlling impulses and emotions has become so habitual and automatic that they have problem relaxing control when needed. This can result in overcontrolled people being overly inhibited, perfectionistic, cautious, and feeling exhausted by social interactions.

Where does overcontrol come from?

Overcontrol comes from a combination of genetic/biological factors and social and family experiences. Bio-temperamental factors include high threat sensitivity, low reward sensitivity, high inhibitory control, and high detail-focused processing. In more plain language, this means that people who eventually become overcontrolled are born with a tendency to:

  • notice the difficult things in life
  • be more sensitive
  • be more anxious
  • feel fewer positive emotions
  • have higher capacities for self-control
  • tend to notice details that others are less likely to notice.

These biotemperamental factors combine with experiences with family, school, peers, or culture to produce overcontrol. Life experiences that contribute to overcontrol are those that teach the person that:

  • it’s very important to not make mistakes
  • showing weakness or vulnerability is dangerous or bad
  • it’s important to stay in control at all times
  • winning or succeeding is very important

Some people tend to have more of the biotemperamental factors, while some have more of the environmental factors, and some people have a lot of both. The more of these factors the person has, the more extreme their overcontrol is likely to be.

What does overcontrol look like?

It’s important to note that overcontrol is not just one trait, but a confluence of traits that all come together in this overarching concept. Some people will have more of the traits than others, but there are a number of things that overcontrolled people tend to have in common:

Overcontrolled people have a hard time relaxing their habitual emotional inhibition. People who are overcontrolled tend to be good at inhibiting their emotion-based impulses (for example, delaying gratification) and avoiding expressing emotions they don’t want to express (for example, by masking inner feelings). This often becomes so habitual that they can’t voluntarily relax inhibitory control in situations that call for flexibility, such as those that call for open expression of emotion or unrehearsed responses, for example dancing, parties, meeting new people, during play, or on a romantic date. High inhibitory control often leads overcontrolled people to prefer structured situations and order and to avoid novelty or situations where there are not clear rules about how to behave or where the outcome is uncertain. They will often find being around others for long is exhausting. This can also lead to perfectionism, a strong sense of duty or social obligation, rehearsing extensively before social situations, and high moral certitude (for example, feeling like there’s a right way to do things).

Overcontrolled people often feel lonely and lack a sense of belonging or closeness. They may have friends (perhaps even a lot of them), but don’t feel like any of those friends truly understand them. Alternately, they may not feel particularly close to anyone or may avoid social situations for the most part. They often feel like they are different from others and feel unsure about how to make friends or get closer to people. It’s also common that they may be unsure if relationships are really worth the trouble or effort.

Overcontrolled people tend to mask their expression of emotions or only share socially-acceptable emotions. This can often result in expressions of emotion that are not well-matched to the context, for example having a flat facial expression when a co-worker expresses excitement or gives them a complement. Or they may tend toward insincere or incongruent expression of emotion, for example, smiling when upset or laughing at a joke they did not find funny. As a result, many overcontrolled people may have difficulty knowing what they feel or tend to be stoic and not report distress.They may also engage in a lot of social comparison and, as a result, tend to be quite critical of themselves or others.

Overcontrolled people often find feedback difficult and are rigid and rule-governed. They are often closed off to new experiences, reluctant to try new things if unsure of the outcome, and avoid uncertainty or unplanned risks. They can be suspicious of the motives of others and tend to hide their true feelings until they get to know someone better. They may tend to have a knee-jerk reaction to defend themselves from critical feedback or may do things to avoid getting feedback because it’s so painful.

How does RO-DBT work?

RO-DBT emerged from 20 years of research into how to help people who suffer because of excessive overcontrol. The treatment pulls together experimental, longitudinal, and treatment outcome research in the form of this novel treatment. This website has an overview of the research behind RO-DBT. The most common mental health problems characterized by overcontrol are chronic depression, anorexia, and obsessive-compulsive personality. RO-DBT is meant to reach out these folks who are often suffering in silence, with few, if any others knowing how bad they are hurting.

RO-DBT is strongly informed by basic research on the facilitative and communicative functions of emotions in facilitating close social bonds. According to the theory, bio-temperamental differences combine with experience to lead overcontrolled individuals to engage in behavior that interferes with the formation of close social bonds, resulting in social isolation, loneliness, and distress. RO-DBT focuses on changing social signaling so that emotional expression is more appropriate to the social context. More appropriate emotional expression then results in increased trust and desires to affiliate from others and thereby increased social connectedness.

RO-DBT is typically delivered over 30 sessions of concurrent individual therapy and skills classes. It’s an active and structured therapy in which people learn concrete skills that they can adapt to their own lives and immediately put to use.

What is radical openness?

RO-DBT aims to develop radical openness, which has three components:

  1. Acknowledging stimuli that are disconfirming, unexpected, or incongruous, which are often associated with distress or unwanted emotion. This is in contrast to automatically explaining, defending, accepting, regulating, distracting, or denying what is happening in order to feel better.
  2. Self-inquiry, which involves asking oneself good questions in order to learn. This involves intentionally seeking ones’ personal unknown in order to learn from a constantly changing environment.
  3. Responding flexibly by doing what is effective in the moment, in a manner that signals humility and accounts for the needs of others.

How do I find an RO-DBT therapist?

A list of therapists around the world who have completed the RO-DBT intensive training can be found on this website. Intensive training involves two, one-week long training events approximately six months apart with therapists encouraged to get follow up supervision. We typically run an RO-DBT skills class here at Portland Psychotherapy, but there are also other local therapists on the website listed above.

If you are a therapist wanting to learn more about RO-DBT, you can buy the book here.

The Importance of Acceptance in Dealing with Obsessive-Compulsive Disorder

People with OCD are often plagued with a wide variety of painful thoughts. These include horrible images, worries they might harm themselves or others, or beliefs that they are condemned altogether. It’s natural why people would struggle with these, why they would try to push them away and get rid of them.

However, there’s a wide literature of research demonstrating that efforts to get rid of painful thoughts make them more intense and more intrusive. And there’s newer research that finds that acceptance of painful thoughts and feelings may be the most effective way for defusing OCD.

The study

OCD expert Dr. Jonathan Abramowitz’s lab looked at the relationship of two ways of dealing with OCD. The study found an advantage for mindful acceptance over brute endurance of obsessions.

One way of relating to inner experiences, called distress tolerance, refers to enduring painful emotions. This is akin to “gritting your teeth” and powering your way through it.

The other way is called psychological flexibility, the opposite of what is called experiential avoidance. One major process in psychological flexibility involves experiential acceptance, being “open and willing” to experience uncomfortable thoughts and feelings.

What the researchers found was that willingness (i.e., choosing) to accept painful thoughts and feelings was associated with lower obsessions. They further suggest that this relationship may be especially true for people who struggle with mental rituals (e.g., Pure “O”).

Limitations

There are limitations to this study. It was correlational and involved college students. The study did not specifically look at the impact of treatment.

Summary

New research suggests that how people relate to OCD-related thoughts and emotions may be important in the maintenance of OCD symptoms. Specially, people who are more willing to experience discomfort without engaging in compulsions may do better than those who can resist compulsions but do so through gritting their teeth and enduring it.

For these reasons, newer acceptance-based treatments such as Acceptance and Commitment Therapy (act for short), which already has good research support in treating OCD, may have something unique to offer.

In working with OCD, I often start with ACT skills building to help people learn to mindfully accept unwanted thoughts and emotions before moving into ERP (exposure and response prevention). In my experience, the ACT work offers people—especially those with more mental rituals—additional tools for working with OCD symptoms, and helps prepare them to engage in the tough exposure work.

If you or some you know is struggling with anxiety-related problems, please check out the Portland Psychotherapy Anxiety Clinic. If you would like to learn more about my approach to OCD specifically, check out my OCD website, where I described how I use Acceptance and Commitment Therapy to help enhance exposure and response prevention

Experts’ Favorite Apps and Books for Learning Mindfulness Meditation

Portland Psychotherapy recently asked members of the Association for Contextual Behavioral Science what they think are the best tools for learning about and practicing mindfulness meditation. Top experts from around the world chimed in to let us know about apps, recordings, books, and other resources they find to be the most useful, and we wanted to take the opportunity to pass their insights along to you.

What is Mindfulness Meditation?
Mindfulness meditation, sometimes referred to as present moment awareness training, builds skills that have been scientifically proven to improve psychological health. Dozens of scientific studies show that mindfulness training can increase well-being, reduce psychological suffering, enhance emotional processing, improve performance, and help people to focus their attention on who and what they care about the most.

Chances are that if you live in a large enough city there are probably a lot of community resources for learning about and practicing mindfulness (click here for mindfulness meditation resources in Portland, OR). For thousands of years, face-to-face interactions with professional teachers and fellow practitioners have been a reliable way to learn mindfulness meditation. Having a community of people who are supporting each other in practice is a great resource. However, there are also lots of other ways to learn to meditate. These include the options below.

We hope the following tools can be of help to you in building a kinder, more compassionate world for yourself and others.    

Apps:

Free/inexpensive apps

One-Moment Meditation This app has a great graphic and goes for a minute so it can also be used with children (Free)

Smiling Mind  is modern meditation for young people. It is a unique web and App-based program, designed to help bring balance to young lives. It is a not-for-profit initiative based on a process that provides a sense of clarity, calm and contentment. (Free)

Mindfulness:The Art of Being Human aims to help you: Explore insights into the human mind and behaviour; Step out of unhelpful thinking patterns; Gain a greater sense of connection to meaningful life experiences. Mindfulness practice can help you lead a more contented, happier and meaningful life. (Free, IOS, Google Play)

ACT Coach (only on iPhone for the present, intended shortly to on Android) is entirely free and was designed by the US Department of Veterans Affairs for Veterans, Service members and others who are in Acceptance and Commitment Therapy (ACT) with a mental health professional and want to use an ACT App in conjunction with their therapy. It offers exercises, tools, information, and tracking logs so you can practice what you’re learning in your daily life. (Free)

Conscious (Android only) This app suggests a different informal mindfulness task each day. You can set reminders to prompt you during the day and you are given the opportunity to report back on your progress each evening. An interesting aspect is that you get to see how many people have signed up to the task with you, creating a sense of community in using the app.

SuperBetter increases resilience – the ability to stay strong, motivated and optimistic even in the face of difficult obstacles. Playing SuperBetter makes you more capable of getting through tough situations—and more likely to achieve the goals that matter most to you.

Honest Meditation: (*if you’re okay with crude language in the service of humor, this app is a hilarious light take on mindfulness)  (Free)

Mind the Bump: is a free Mindfulness Meditation App to help individuals and couples support their mental and emotional wellbeing in preparation for having a baby and becoming a new parent. (Free)

Free but require subscription or in-app purchases

Pacifica This app includes daily mood tracking and relaxation and mindfulness tools. (Free download but require paid monthly/yearly subscription)

Petit Bambou (French language app) is the same as Headspace but for french speaking (Free but requires subscription)

Stop, Breathe & Think A great app for computer or smartphone.  Great intro and resources for going deeper.  Has a check-in that asks questions and suggests some useful types of mindfulness practice. (Free but requires subscription for unlimited features, web, IOS, Android)

Colorfy (mobile coloring book) Choose your favorite color and give your touch to beautiful drawings. Florals, animals, patterns, mandalas, cats, gardens, famous paintings, and more. ( Free but requires subscription, IOS, Android)

Headspace is meditation made simple. Learn online, when you want, wherever you are, in just 10 minutes a day. This is fairly expensive, with a monthly subscription, which will add up over time.

Habitica is a habit-building program which treats your life like a Role Playing Game. Level up as you succeed, lose HP as you fail, earn money to buy weapons and arm or, compete with your friends.

Apps requiring payment

SmartQuit uses ACT (Acceptance and Commitment Therapy) to help people quit smoking. Developed at Fred Hutch Cancer Research Center, SmartQuit is different. Smokers create a personal plan. They become very aware of their urges to smoke. Lastly they learn new ways to notice the urge to smoke, without acting on it. SmartQuit is the first smoking cessation “app” that has been tested in a randomized control trialwith quit rates 2-3 times better than quitting on one’s own. (Free but requires subscription)

The Sleep School App  helps you practice The Sleep School sleep tools & techniques until you have mastered them for life. The app delivers The Sleep School approach across its 5 core areas in a highly interactive audio-visual format ($3.99)

Mindfulness Daily This app supports quick, effective guided practices to reduce stress/anxiety, improve performance and enhance sleep ($1.99 plus in app purchases of audio)

What’s Up? Uses techniques from ACT and CBT, including mindfulness.

ACT Companion – the Happiness Trap app: (most highly recommended) The new edition of ACT Companion features loads of new content – guided mindfulness, written and experiential exercises – from none other than Russ Harris, author of the best-selling book The Happiness Trap. Simple defusion and acceptance techniques, easy values-clarification and goal-setting tools, powerful ‘observing self’ and self-compassion exercises – you’ll find it all here. In total, the app features over three-dozen exercises and tools, including two-and-a-half hours of guided mindfulness audio tracks, many of them featuring Russ’s voice.

Salute The Desk helps you stretch and relax, right at your desk. Improve your posture and release tension through yoga poses. Feel calm and refreshed with guided relaxations. Plan your sessions and set reminders to practice. Developed by a qualified yoga, tai chi and qigong instructor. ($2.99)

buddhify states it is “the most convenient, best value and most beautiful meditation app available today. Helping people around the world reduce stress, sleep better & be present in the midst of it all.” Certainly is the best looking mindfulness app! ($4.99)

Insight Timer Free for iPhone and Android with option of purchasing upgrades, $2.99 for iPad. Worth it for the Tibetan bells alone, now expanded with many meditation practices of varying lengths.

Websites:

Books:

For kids and teens:

Mindful parenting:

Audio:

Videos:

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