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 is RO DBT different than DBT?

Dialectical Behavior Therapy (DBT) was created back in the early 90s specifically to help people who were chronically suicidal and emotionally dysregulated, often people diagnosed with borderline personality disorder. RO DBT is a new treatment that branched off from DBT in the early 2000s and is focused on the problems of people who are emotionally overcontrolled, basically the polar opposite of who DBT is intended to help. You can read a detailed breakdown of the difference here. 

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.

“I Already ate Half a Box of Cookies, I Might As Well Eat Them All”

If you’ve ever tried to change your diet, you’ve probably experienced a situation like the following:   You’re committed to pursuing a healthy lifestyle and as part of that commitment you’ve decided to reduce the amount of processed sugar you eat. It’s been tough, but over several weeks you’ve steadily decreased it. Then, you’re invited to a friend’s birthday party. At this party there are delicious, decadent cupcakes. Everyone’s enjoying themselves eating those lovely cupcakes. Your friend asks you if you want one and you say…”Yes.” You think, “One won’t hurt! It’s a celebration.” So, you eat a cupcake. If you stopped right there, after this initial slip, it wouldn’t be a big deal. You could just go back to your plan for eating healthy. But you don’t. Before you know it, you eat a second cupcake, drink 2 cups of sparkling orange juice, and eat a bunch of candy.

You are not alone in having this experience. Time and again I hear friends and associates talk about how they ate a whole loaf of bread (those who were on the Atkins diet), ate a whole box of cookies (those on just about any diet), or ordered the Grande size nachos when they were out at a happy hour (I, myself have been guilty of ordering a mountain of nachos even though I highly value a healthy lifestyle). An interesting phenomenon can occur after this initial slip into old habits (eating or other habits we’re trying to change). This occurs so frequently that researchers have studied it and clinicians have come up with strategies to combat it. The phenomenon I’m describing is called the Abstinence Violation Effect.

Abstinence what?

The Abstinence Violation Effect (abbreviated AVE) occurs when a person lapses, or slips, into an old pattern of behavior and then continues this pattern of behavior beyond the initial slip. Let’s come back to our cupcake example to more closely examine AVE. You experienced a lapse when you ate the first cupcake (you violated your commitment to a reduced sugar diet). You then ate a whole bunch of things loaded with sugar following your initial lapse. What just happened? When we violate a commitment we’ve made to change our behavior, an interesting combination of thoughts and feelings occurs. You might have thoughts like, “well, I already had one, might as well have another!” or “I just blew my diet so it’s ruined and it doesn’t matter what I eat now, because I already blew it.” We may also feel guilt, shame, or anxiety during or after our initial slip. This pattern of negative feelings, thoughts related to our initial slip (e.g., “I blew it, might as well forego the rest of my diet today”), and actions (e.g., eating another cupcake, drinking 2 cups of juice, and eating a bunch of candy) make up the Abstinence Violation Effect.

The Abstinence Violation Effect relates to any kind of habit change

This effect applies to anyone who is trying to break a habit. That habit could relate to patterns of eating, as in the example above, or it can relate to trying to exercise more, to stop biting your finger nails, or reducing drug or alcohol use. For people who are trying to stop or cut back on drug or alcohol use,  the abstinence violation effect can turn an initial slip (e.g., one drink after a period of sobriety), into a full-blown relapse (i.e., going back to old patterns of drinking or using). The consequences of AVE can be especially high for individuals with addictions and can lead to a cycle of multiple relapses or accidental overdose.

What can I do when I experience a slip? Practical tips for combating the AVE.

Being aware that the Abstinence Violation Effect (AVE) occurs is your first step in combating it. Armed with this knowledge you can develop strategies to help you avoid or reduce the impact of AVE. Some helpful strategies for AVE include :

  • Prepare yourself for high-risk situations (e.g., places where an initial slip may occur, such as birthday parties when you are on a diet) by making a plan to reduce or avoid triggers for your old behavior. For example, you can eat before you go to the party so you are too full to eat a cupcake. You can also reduce the amount of sugar you eat during the day of the party so you can have part or all of a cupcake without going over your allotted amount of daily sugar. You can speak with your partner or friend and enlist them to help you cope with temptation when at the party. Another idea is to tell your friend at the party about your commitment and how she can help support you (e.g., not offer you cake) before the cake comes out.
  • Remind yourself of your values related to why you are changing your behavior. For example, you might remind yourself of your values (why you are making the change in your life) on a daily basis by writing them down and placing them in strategic places (the fridge, your wallet, your pocket). You can set a reminder on your phone that helps you remember your values (e.g., a picture of your kids to remind you that you are committed to a healthy lifestyle so you can be around longer).
  • Encourage yourself if you do slip. Remind yourself that many people slip when making lifestyle changes; in fact, slipping is the norm! Congratulate yourself on the changes that you have made so far and tell yourself that one slip (or even many slips) does not mean that all the time and efforts you’ve made are worthless. Remind yourself that you can recover from a slip and that you are capable of recovering from it. Beating yourself up about slipping up is not.
  • Come up with a plan for how you will recover from your slip-up. Think of concrete steps you can take to get back on track following a lapse and write these down on a piece of paper. Put this paper in a place where you can easily access it.

A slip does not need to be the end of your pursuit of positive life changes, whether it is changing your diet or cutting back or stopping use of drugs or alcohol. By being aware of the Abstinence Violation Effect and developing strategies to combat it, you can remain on or quickly return to your path of valued living.