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.

Portland Psychotherapy Annual Report – 2015

Hello friends and colleagues. Below is our annual report. The annual reports is part of our mission to be a responsible and transparent business that is an asset to our local and international community. We strive to be responsible stewards of the revenue provided by those clients and customers who purchase our services. We strive to use those limited resources efficiently and effectively to serve the greater good. Transparency comes through out providing updates about what we are doing with that revenue. This report summaries the most important events that occurred over the last year at Portland Psychotherapy.

OUR COMMITMENT

Portland Psychotherapy strives to make quality, evidence-based mental health services

available to all members of our community. Supporting diversity and inclusivity is a core value at Portland Psychotherapy.

OUR MISSION

is to use science to develop and guide compassionate, effective treatment and contribute to the wider community through research and training.

EVIDENCE-BASED THERAPY

is at the heart of our practice. We are dedicated to treating psychological problems with methods based on the best science available.

RESEARCH

drives everything we do. Many of our therapists are also researchers, which means that we stay up-to-date on what the research says about what works. If we can’t provide what we think is the best treatment for what a client is struggling with, we will do our best to refer them to an appropriate treatment.

OUR BUSINESS MODEL

ensures that we are on the cutting edge of what’s happening in evidence-based practice. In 2013 and 2014, about 18% of total revenue went to fund the research our center is conducting. By seeing a therapist at Portland Psychotherapy, you are also helping to support scientific research so that others may benefit.  To read more about our business model, go here.

Highlights from 2015

Clinical services. We continued to expand our clinical services in 2015. The total number of individual therapy sessions provided increased 14% from 4,877 to 5,568 sessions and group therapy sessions increased 64% from 223 to 365 sessions. We continue to provide a substantial amount of low fee services through our postdoctoral fellowship program, about the same number as last year — 509 sessions (when defined as clients paying $60 or less per session). We also started a new skills class based on Radically Open Dialectical Behavior Therapy (RODBT) and solidified our standard DBT program under the leadership of Shadee Hardy, LCSW.

Our building. Two-and-a-half years ago, we moved into our current building, but the renovation work has not stopped until this year. Finally, this year, we were finally able to install the landscaping, which heralded the ending of the renovation process! We are very appreciative that we have a beautiful and comfortable building to work in and hope that our clients feel the same way.  As part our mission to be environmentally sustainable, we also hired a solar contractor, Solterra Systems , this past fall who will be installing solar panels on our roof as soon as we get some more sunny days!

AlyssaStaffing. There were important staffing changes this year. We hired a new office assistant, Alyssa Wong (left), who has stepped into a busy role and is doing a great job. Alyssa joins our already incredible and hard-working administrative team of Debbie Addison (billing manager) and Amy Forrer (office manager) without whom this place would not run. Melissa Platt, Ph.D., transitioned from a postdoc role to a research psychologist role, specializing in research relating to shame and interpersonal trauma. We were also able to hire another postdoctoral fellow, Magda Permut, Ph.D., who is specializing in organizational issues and has been doing important work in helping Portland Psychotherapy to improve our services and maintain a values-based focus for our culture. We also had our first annual overnight employee retreat where we were able to clarify our group values and strengthen our organizational culture. Dr. Paul Guinther and his wife Lindsay Chandler added another baby to our Portland Psychotherapy family – James Martin Guinther. On a sad note, we experienced the death of our unofficial mascot, The Dalai Luoma (right), who in her determined (some might say stubborn) way, was able to come to work every day until the very end.

Research. On the research front, two new research studies were approved by our ethics review board to begin data collection and a third was submitted for approval. Portland Psychotherapy now has two research psychologists on staff with dedicated research time in addition to the two co-owners having time for research.  We have six studies in active data collection. In 2016, we are planning to hire our first full time research coordinator.

A big highlight of 2015 was the initiation of our internal grant program to support advances in contextual behavioral science and evidence-based psychotherapy. The first grant dispersed was for $10,000 and was named the Aaron S. Luoma Portland Psychotherapy Behavioral Science Research Grant, in honor of Dr. Jason Luoma’s brother. Awardees included Drs. Paul Guinther, Brian Thompson, and Scott Rower. The grant has supported their ongoing work on relational frame theory and perspective taking; acceptance and commitment therapy and obsessive-compulsive disorder; and cognitive behavioral therapy for insomnia, respectively.

Portland Psychotherapy staff had seven new peer-reviewed articles accepted for publication or published in 2015:

Guinther, P. M. & Dougher, M. J. (2015). The clinical relevance of stimulus equivalence and relational frame theory in influencing the behavior of verbally competent adults. Current Opinion in Psychology, 2, 21-25.

LeJeune, J.T., & Luoma, J.B. (2015). The Integrated Scientist-Practitioner: A New Model for Combining Research and Clinical Practice in Fee-For-Service Settings. Professional Psychology Research & Practice 46(6), 421-428. Download here. 

Levin, M.E., Luoma, J.B. & Haeger, J. (2015). Decoupling as a mechanism of action in mindfulness and acceptance: A literature review. Behavior Modification, 39(6), 870-911.

Levin, M.E., Luoma, J.B., Vilardaga, R., Lillis, J., Nobles, R. & Hayes, S.C. (In Press). Examining the role of psychological inflexibility, perspective taking and empathic concern in generalized prejudice. Journal of Applied Social Psychology.

Luoma, J.B., & Platt, M. (2015). Stigma, Shame, Self-Criticism, and Compassion in Acceptance and Commitment Therapy. Current Opinion in Psychology, 2, 97-101Download here. 

Platt, M. & Freyd, J. J. (2015). Betray my trust, shame on me: Shame, dissociation, fear, and betrayal trauma. Psychological Trauma: Theory, Research, Practice, and Policy, 7(4) 398-404.

 

Thompson, B. T., Luoma, J. B., Terry, C., LeJeune, J., Guinther, P., & Robb, H. (2015). Creating a Peer-Led Acceptance and Commitment Therapy Consultation Group: The Portland Model. Journal of Contextual Behavioral Science 4(3), 144-150.

Training. In 2015 we hosted or co-hosted five training workshops for professionals. The income from these training events helps support for our research and sliding scale services. In addition to these income-generating training events, we have also hosted twelve meetings of the ACT peer consultation group. Largely due to the work of Dr. Melissa Platt, we’ve greatly increased the training material we’ve been producing on our blog, www.actwithcompassion.com. In addition, most of the clinical staff were able to travel to Berlin, Germany for the Association for Contextual Behavioral Science Annual Conference. At that conference, they were able to see center director, Dr. Jason Luoma, give the presidential plenary signaling the end of his year as president of this association of over 8000 members.

Our business model. Among the publications coming out of our center this year, we are particularly excited about our article  “The Integrated Scientist-Practitioner: A New Model for Combining Research and Clinical Practice in Fee-For-Service Settings,” published this year in Professional Psychology Research & Practice. This article represents the first time that a detailed description of the business model we have created here at Portland Psychotherapy, which we have called the “clinical-research social business model,” has been broadly available for others to read about. In the article, we describe how Portland Psychotherapy is, to our knowledge, the only organization of its kind to utilize social enterprise concepts to support research in a for-profit psychotherapy setting. In our clinical-research social business model, the profits from the income-generating activities of our center do not go to increase shareholder profits. Rather, those profits are used to serve the social good by serving as an internal, stable funding source for in-house research where the products of the research are given away to the public. Our hope is that others might also consider how concepts such as social enterprises, B-corps, and the like might work in their own setting such that making a profit and contributing to the broader social good can be mutually achievable aims.

Summary: 2015 was a good year for Portland Psychotherapy. The organization continues to mature to more fully serve our mission to use science to develop and guide compassionate, effective treatment and contribute to the wider community through research and training. These positive trends look like they will continue in 2016 and we are very optimistic about and excited to see how Portland Psychotherapy can continue to have a positive influence on our community in years to come. Please, keep in touch.

Portland Psychotherapy Research Grants Awarded

The Research Lab at Portland Psychotherapy is proud to announce they have developed and implemented the first cycle of an internal research grant program to support advances in contextual behavioral science and evidence-based psychotherapy. The first grant was dispersed in 2015 and named the Aaron S. Luoma Portland Psychotherapy Behavioral Science Research Grant/Award, in honor of Dr. Jason Luoma’s brother. Awardees included Drs. Paul Guinther, Brian Thompson, and Scott Rower. The grant has supported their ongoing work on RFT and perspective taking, ACT and OCD, and CBT-I and insomnia, respectively. A new grant cycle is underway in 2016 to continue supporting these researchers and Portland Psychotherapy’s mission of contributing to the wider community through scientific research, compassionate treatment, and effective training.

Follow up on the Valkee device that shines light in your ears.

This post is a follow up to something one of our researchers wrote two years ago about a device called the “Valkee” that shines light into your ears using a device that looks a lot like an iPod. The device supposedly cures seasonal affective disorder and is now being marketed in the USA. I felt the need to post an update to alert consumers to this device that uses slick marketing, but which does not appear to have produced any direct evidence to show that is more than a placebo in the treatment of seasonal affective disorder.  Here’s what we said about it two years ago:

It’s not available in the U.S. yet, but a Finnish company is marketing a new device called “Valkee.” It looks like an iPod, except instead of digital music, the headphones shine light into your ear. Yes, that’s right, the Valkee has small ear buds that shine light into your ear.

Why would shining bright light in your ear help with seasonal depression? Here’s where things turn a little fuzzy.

In the two years since we originally posted about this device and in the seven years since it was first created, the company has yet to generate any data showing that the device works better than a placebo for seasonal affective disorder. Placebo controlled trials are not that hard to do and the lack of such research is very concerning. Placebo effects can be quite strong and because of this effect, it can sometimes be hard to know whether a device works because it actually works, or just because people think it will work. In the case of the Valkee, the existing evidence points to the idea that the device works only because people expect it to work.

Thus, my recommendation is, if you are suffering from seasonal affective disorder, save the money you would have spent on the Valkee and use it instead to buy a more affordable and much more proven light therapy device. We review some of them here. If you want to read more about the controversy around this device, you can read more herehere, and here.

BTW, whenever I see a device or treatment that I’ve never heard of before, I always Google the name of that treatment and the word “scam” in Google. This applies whenever I see something new, in the service of being an informed consumer. If you google the item plus the word scam, you may find a range of relevant articles that can help you better evaluate whatever it is. Don’t believe us about the Valkee, do your own research before you make a purchase. Google “Valkee scam” and read what comes up.

Update 11/4/14: A Valkee-related team appears to have published their first trial designed to compare the Valkee to a placebo for seasonal affective disorder. The results showed that the Valkee was no better than what was identified as the placebo condition during trial registration. See the published study here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4207317/ and here: http://clinicaltrials.gov/ct2/show/NCT01293409)?

I also found a new page where different people are discussing the Valkee device, in case you want to read more: http://tech.eu/features/215/valkee-conundrum-ive-shining-bright-light-brain-weeks-now-dont-know/

How to avoid jet lag while travelling

We’ve written a few posts in the past (#1, #2) about using light therapy to regulate your circadian rhythms. As a person who has a hard time with the Portland winters, I regularly use light therapy in the fall and winter to avoid the winter blues. Light therapy is a very well proven treatment for the winter blues and seasonal depression that has few side effects.

For many years, it has been known that the effective use of light therapy and sunglasses can help you avoid jet lat and adjust more rapidly to a new  time zone. However, it difficult to figure out how to use these tools correctly. Now there’s a new, free website which makes the task of figuring out how to prevent jet lag much easier. You just enter your travel details and it generates a schedule that you can print out and follow. It’s really easy. And now that some good light therapy devices have gotten down to $50 or so, this is now a cheap and easy way to prevent jet lag. Check it out:

http://www.jetlagrooster.com/