Signaling matters:

Radically Open
Dialectical Behavior
Therapy (RO DBT)
Karyn Hall, Ph.D.
Director, Dialectical
Behavior Therapies
Center
Houston, Tx
March 2019
 Financial
Disclosures
Karyn Hall is the owner and
director of Dialectical
Behavior Therapies Center
in Houston which offers
Radically Open DBT as a
treatment option.
We are at a crossroads…

■
A significant proportion of people fail to benefit from
treatment, due to chronicity, co-morbidity or pre-existing
personality problems.

■
Existing treatments are often not effective—e.g., chronic
depression, anorexia nervosa
– In the case of depression, treatments consistently help 1/3
of individuals, with another 1/3 improving but remaining
symptomatic, and the last 1/3 not improving*
*Berlim & Turecki, 2007; Rush et al., 2006; Souery et al., 1999;
Thase et al., 2007
 We are at a crossroads….
Most evidence-based therapies have been tested
on non-chronic and non-comorbid populations
WEIRD World (Bateman)
But for us clinicians…

Real-world clinicians treat comorbid and

chronic problems on a regular basis
High Rates of
Comorbidity

45% 51%
a b

52% 65%
d c
aFriborg et al. (2014)
bKessler et al, (1994)
cSwimbourne et al.
(2012)
dMartinussen et al.
(2016)
 Transdiagnostic Models and
Treatments are Funding Priorities
The National Institute of Mental Health in the US has set out Research Domain
Criteria (RDoC) to indicate their funding priorities:

Transdiagnostic Models
– Theory and research that integrate biological science with behavioural
science
– New ways of classifying psychopathology

Transdiagnostic Treatments
– Treatment approaches that account for shared genotypic and phenotypic
features rather than focusing on diagnoses  
■
Transdiagnostic treatment that aims to
treat maladaptive overcontrol
Radically
■
RO DBT is informed by 20+ years of
Open
translational treatment development Dialectical
research Behavior
Therapy (RO
■
350+ patients have received RO-DBT in DBT)
research trials throughout the world—plus,
1000s clinically
RO DBT is informed by:

Dialectical philosophy
Behavior therapy
Mindfulness-based approaches
Malamati sufism

Also informed by 20 years of transational

research
 •
Three Randomized Controlled Trials for
Refractory Depression & Overcontrolled
Personality disorders—funded by NIMH and
The NIHR-EME.
feasibility, – Lynch et al., 2003, International Journal of
Geriatric Psychiatry (N = 34)
acceptabilit – Lynch et al., 2007, American Journal of Geriatric

y, and Psychiatry (N = 35);

– Lynch et al., 2015, British Medical Journal-Open;
efficacy of Lynch et al., in press (N = 250)
RO DBT
Three open-trials (pre-post) for adults and
are
•

adolescents with Anorexia Nervosa

evidence- – Lynch et al., 2013, BMC Psychiatry (N = 47);
– Chen et al., 2014, International Journal of Eating
based Disorders (N = 9)
– Simic et al., 2017, 2018, the Behavior Therapist
Key Difference Between RO DBT & Other
Treatments

Depression, Autism,
Anorexia, Obsessive
Compulsive PD, etc.
RO DBT posits social-signaling deficits stemming from
is not considered the primary
maladaptive overcontrol as the core issue,
problem!
based on evidence showing that OC coping preceded
the development of psychopathology
Using Evolutionary Psychology
Our tribal nature required us to find a
way to

‘bind genetically diverse individuals

together’
in such a way that

‘survival of the tribe’

could override older ‘selfish’ tendencies

linked to
survival of the individual
Social bonds and self-control
Self-control = the ability to inhibit emotional urges, impulses, and
behaviors in order to pursue long-term goals

Self-control capacities enabled a person to not immediately consume

valuable resources and instead save for a ‘rainy day’
PLUS
not acting on every impulse allowed us to work together in groups
without the fear of being immediately attacked if we stepped on
someone’s toe
Lack of self-control is eye-catching!
 Overcontrol is often not recognised
Overcontrolled people ………

Are not roaming the streets in gangs—they are not causing riots;
they are not the people you see yelling at each other from across
the street

They are hyper-detail-focused perfectionists who tend to see

‘mistakes’ everywhere (including in themselves)

And tend to work harder than most to prevent future problems

without making a big deal out of it.

Plus, are expert at not appearing different on the outside (in

public).
■
Under-control is linked to substance abuse, criminal
activities, domestic violence, financial difficulties,
teen pregnancy, smoking, obesity—and more!

■
Whereas, Over-control is pro-social:
-
Desires to be correct, exceeding expectations and
performing well are essential for tribal success
-
Valuing rules and fairness is needed in order to resist
powerful yet unethical individuals or harmful societal
pressures
-
Delaying gratification saves valuable resources for
less abundant times
-
Duty, obligation, and self-sacrifice help societies to
flourish and ensure that those in need are cared for
But … can you have too much of a
“good” thing?
 Too much of a good thing: the problem of
overcontrol
■
Existing research tends to see self-
control as a linear construct: more
is better

■
However: you can have too much
of a ‘good thing’
 The Self-Control Dialectic

Undercontrolled (UC) Overcontrolled (OC)

Emotionally Dysregulated and Emotionally Constricted and Risk-

Impulsive Averse
■
Borderline PD ■
Obsessive Compulsive PD
■
Antisocial PD ■
Paranoid PD
■
Narcissistic PD ■
Avoidant PD
■
Histrionic PD ■
Schizoid PD
■
Binge-Purge Eating Disorders ■
Anorexia Nervosa
■
Conduct Disorders ■
Chronic Depression
■
Bipolar Disorder ■
Autism Spectrum Disorders
■
Externalizing Disorders ■
Treatment Resistant Anxiety-
OCD
■
Overcontrol is a problem
of emotional loneliness
Secondary to
Low Openness
&
Social-Signaling Deficits
Not necessarily
lack of social contact
but
lack of social connectedness
 Four core deficits of overcontrol
1. Lack Receptivity and Openness, e.g. avoiding feedback and novel
situations
2. Lack Flexible Responding, e.g. compulsive need for structure, rigid
responding
3. Lack Emotional Expression and Awareness, e.g. inhibited or
disingenuous expressions
4. Lack Social Connectedness and Intimacy, e.g. aloof and distant
relationships

Emotional Loneliness

(Lynch, 2018; Lynch, Hempel & Clark, 2015; Lynch, Hempel & Dunkley, 2015)
 What’s your style?

See next slide

 Assessing Styles of Coping Word-Pair List
Circle the words or phrases that describe yourself; but only one word in each row.
Tally up the number in each column—the more you have in one column suggests your style
A B
Impulsive Deliberate
Impractical Practical
Naïve Worldly
Vulnerable Aloof
Risky Prudent
Talkative Quiet
Disobedient Dutiful
Fanciful Realistic
Fickle Constant
Act without thinking Think before acting
Animated Restrained
Changeable Mood Stable Mood
Haphazard Orderly
Wasteful Frugal
Affable Reserved
Impressionable Not easily Impressed
Erratic Predictable
Complaining Uncomplaining
Reactive Unreactive
Careless Fastidious
Playful Earnest
Bio-Temperament as Unifying
Principle
When it comes to understanding individual
differences in social-signaling….
..Bio-Temperament may be a unifying principle

Remarkable consistency emerging from large- scale

studies examining comorbidity:
■
A common factor may underlie chronic mental
health problems, personality disorders, and
treatment-resistant conditions (Clark, 2005;
Kendler et al., 2003; Krueger, 1999; Krueger et al.,
1998; Vollebergh et al., 2001)
 Temperament as a Unifying Principle

Undercontrolled impulsive, dramatic,

emotionally expressive children are more likely
to develop externalizing disorders (e.g., conduct
problems, illegal substance abuse, criminal activities,
borderline personality disorder) (see Eisenberg et al., 2000; Kendler, Prescott,
Myers, & Neale, 2003; Krueger, 1999)

– High reward sensitivity, global-focused processing, and low inhibitory

control
Note: BPD and Antisocial PD = high threat sensitivity too
Temperament as a Unifying Principle

Overcontrolled emotionally constricted, shy,

risk averse, socially-anxious (excluded)
children are more likely to develop
internalizing disorders (depression, anxiety)
and become socially isolated adults (see Caspi, 2000;
Chapman & Goldberg, 2011; Eisenberg et al., 2000; Markin et al., 2005).

– Low reward sensitivity, high detail-focused processing, high threat sensitivity and
high inhibitory control
Bio-Temperament Matters!
Family and Cultural
influences:
For Undercontrolled…
The Person Learns

“If I escalate my
emotional
signaling—then
good things may
happen”
 Whereas…
for Overcontrolled…

The Person Learns

“If I inhibit my
emotional
signalling—
then good things
may happen”

A proper cup of tea will restore my

normality
But…when the Context Calls
for Emotional Expression ….
...and Emotion is Not Expressed
…then signaling matters!
 emotionally reacting to a facial
expression at 4 milliseconds (LaFrance,
2013)

Emotions – We become anxiously aroused

evolved to when interacting with a non-
communicate expressive person AND we prefer
not to affiliate with them (Gross,
and facilitate 2002; Butler & Gross., 2003;
Barnsley, Hempel, & Lynch,
the formation 2011).
of strong
social bonds… – Open expression of emotion—
even when the emotion is
negative—signals trustworthiness
and increases social
The Still Face experiment
Thus...
How we socially-signal
strongly impacts our
relationships
 A novel key
mechanism of
change in
RO DBT
Open Expression = Trust = Social Connectedness

Overcontrol Flexible-Control
To Form Long-Lasting Intimate
Bonds
You Must Reveal Vulnerability
When we reveal our private feelings, concerns, or beliefs
to another person—
we transmit two powerful pro-social messages

1) We Trust them—When we don't trust someone

we hide our true intentions and mask our inner
feelings

2) We are the same as them—e.g., because we

share a common bond of human fallibility
Note: Open expression DOES
NOT mean…
simply
“Expressing emotions without
Awareness or consideration”

On the contrary…. effective

emotional expression is always
CONTEXT dependent
As therapists, we are
signaling too…

What we signal matters…especially, when

treating OC individuals

i.e., anxious and threat sensitive individuals

are taught to believe that revealing emotions
or appearing vulnerable is dangerous or
inappropriate
Using Neuroregulatory Theory to Enhance Engagement
(Lynch, Hempel, & Clark, 2015; Lynch, 2018)

■
Five emotionally relevant stimuli each linked with
unique neural substrates
—safety, novelty, reward, threat, overwhelming

■
The neuroregulatory system is bi-directional (mind-body
unity)
■
Broadly speaking…when one neural substrate is “ON”
the other is “OFF”

■
When it comes to OC: What’s most important is the
 Social Safety System: ventral vagal complex of
the parasympathetic nervous system; PNS-VVC

■
When our social safety system (PNS-VVC) is activated we feel calm, relaxed, and
sociable. Our breathing is slow and deep and our heart rate is reduced. We are more
likely to want to approach and touch others; and we can effortlessly make eye contact
(without feeling self-conscious)

■
Our social safety system innervates muscles in our body needed to communicate and
form close social bonds (Porges, 2007), including:
– Voice-box muscles (laryngeal and pharyngeal muscles) allowing a musical tone of
voice signaling warmth and friendliness
– Middle ear muscles allowing us to hear human speech better
– Facial muscles allowing us to signal genuine friendly intentions and smiles e.g., via
a genuine smile of pleasure
– Diaphragm muscles linked to slow and deep breathing and sighs of contentment
– Neck muscles allowing us to direct our gaze
Using social
safety to
enhance
clinical
outcomes
Therapeutic Use of Micro-Mimicry and Mirror
Neurons: using social-signalling to enhance OC client
engagement
Talking Eyebrows
Greeting Exercise
When Tension is Present…
Use the Big 3 + 1!
Slow The Pace and Chill-Out

Step 1: take a deep breath,

Step 2: raise your eyebrows,
Step 3: engage a warm
closed-mouth smile; and
(+1): lean back in your chair (if
you are sitting)
 Let's Practice

The Big Three+1

So…What is…

Radical
Openness?
RO DBT considers…
Openness
a
Powerful Social-Signal
RO—Developing a passion for going
opposite to where you are

■
Radical openness is more than awareness—it is
actively seeking the things one wants to avoid or
may find uncomfortable in order to learn.
■
It involves purposeful self-enquiry and
cultivating a willingness to be “wrong” with an
intention to change if needed.
 Radical Openness is NOT Radical
Acceptance
■
Radical Acceptance “is letting go of fighting reality” and
“is the way to turn suffering that cannot be tolerated into
pain that can be tolerated”(Linehan, 1993; pg. 102)

■
Radical Openness challenges our perceptions of reality.
“We don’t see things as they are—we see things as we
are.”
 Examples of Self-Enquiry Questions
■
Is it possible that my bodily tension means that I am not fully open to the
feedback? If yes or possible, then: What am I avoiding? Is there something
here to learn?

■
 Do I find myself wanting to automatically explain, defend, or discount the
other person’s feedback or what is happening? If yes or maybe, then: Is this a
sign that I may not be truly open?

■
Do I believe that further self-examination is unnecessary because I have
already worked out the problem, know the answer, or have done the
necessary self-work about the issue being discussed? If yes or maybe,
then: Is it possible that I am not willing to truly examine my personal
responses?
RO DBT
Treatment
Delivery &
Structure
 Modes for Outpatient RO DBT (~30
weeks)
1. 1. Outpatient Individual Session: 1 hour per week

2. Outpatient Skills Training Class: 2.5 hours per week (with 15

minute break)

3. Telephone Consultation: as needed (but rarely used by most OC

patients)

4. Therapists’ Consultation Meeting (optional but recommended):

practicing radical openness ourselves
Radically Open Dialectical Behaviour
Therapy – primary treatment targets

Socially
Connected
RO-DBT Individual Treatment Target
Hierarchy
 RO DBT Treatment Structure:
Orientation & Commitment
■
(Sessions 1-4)
Sequencing is important in RO DBT!

■
Individual Treatment Sessions 1 to 4: Orientation & Commitment
– Session 1 – Self-Identification of OC
– Session 2 – Begin to identify valued-goals & Orient to RO Skills Class
(to start in week 3)
– Session 3 – Biosocial Theory
– Session 4 – Key Mechanism of Change

■
Individual Treatment Sessions 5 to 30+: Treatment Targeting
– Targeting of maladaptive social signaling behaviors that keeps the
client stuck
 Clients start RO Skills Class in week
3
•
The client starts skills classes in week 3 (see module 1 for a
full list of classes)

•
Individual treatment continues until the client has completed all
skills classes
RO-DBT
Consultation Team

Practicing Radical Openness

ourselves…

to enhance our capabilities and

motivation to stay within the
treatment frame

See Chapter 7 of RO DBT Textbook, p.192-

 A summary…
RO DBT considers it
essential to…
■
Address OC bio-temperamental biases—by changing
physiology

■
Target social isolation by teaching social-signalling
skills

■
Encourage openness and self-enquiry in order to learn
from an ever changing world
 Thank you for listening!

For more information, visit us at

About the Treatment Developer
Thomas R. Lynch, Ph.D FBPsS is a Professor in the School of Psychology and Founder of
the Radially Open Research Institute at the University of Southampton, United Kingdom.
He moved to the UK in 2007 from Duke University where he was the Director of the
Duke Cognitive Behavioral Research and Treatment Program from 1998-2007. As
principal investigator he has been the recipient of a wide range of grant funding—
including seven research grants from the National Institutes of Health (NIH USA), a
multi-centre grant from the Medical Research Council (MRC UK), a National Alliance for
Research on Schizophrenia and Depression (NARSAD) research award, an American
Foundation for Suicide Prevention (AFSP) award, and a John A. Hartford Foundation
grant. His research has been recognized in the Science and Advances Section of the
National Institute of Health FY 2005 Congressional Justification Report. He is a recipient
of the John M. Rhoades Psychotherapy Research Endowment, is a Beck Institute
Scholar, and is a Grandfathered Fellow in the Academy of Cognitive Therapy and the
British Psychological Society. He is the treatment developer of Radically Open-
Dialectical Behavior Therapy (RO-DBT) as well as a senior international trainer in
Dialectical Behavior
For more Therapy (DBT).
information about RO-DBT go to
www.radicallyopen.net