RO-DBT, New Therapy Offered for Adults with “Overcontrol” or Inhibited Emotions Challenges

Recently, our adult clinical team determined that, among clients participating in our foundational dialectical behavior therapy (DBT) and cognitive behavioral therapy (DBT) programs, some clients had different emotional and behavior challenges – challenges that are more difficult to address through a standard DBT or CBT approach.

Sometimes considered “overcontrolled,” these individuals may struggle with perfectionism, rigid thinking, an intense need for structure, and inhibited emotions. Overcontrolled clients also exhibit a lack of openness that can make meaningful relationships, as well as personal introspection and growth difficult.

To better serve the unique needs of these clients, our clinical team began working to incorporate a new evidence-based therapy into our adult treatment program called radically open DBT, or RO-DBT. Skyland Trail began referring appropriate adult patients to the new RO-DBT group in (year). Currently clients participate in RO-DBT as an additional layer on top of our CBT or DBT foundational curriculum. The adult treatment team plans to establish RO-DBT as a full core group, on level with our DBT, CBT, cognition & psychosis, and dual diagnosis programs in the near future.

What is RO-DBT?

RO-DBT is a transdiagnostic treatment for a wide variety of disorders that include symptoms with underlying themes of excessive inhibitory control or overcontrol. Typically, we all use self-control in healthy ways to inhibit urges, behaviors, or desires that we know are not in line with our values or goals. In RO-DBT, overcontrol means excessive or unhealthy self-control – not allowing any exploration of new thoughts, desires, or opportunities. Overcontrol can lead to chronic mental health problems, social isolation, loneliness, and difficulty functioning interpersonally.

Says Skyland Trail therapist Laina Beaudreau, “The primary objective of RO-DBT is to encourage self-discovery and curiosity through radical openness. Radical openness is characterized by humility and willingness to recognize our biases about ourselves, others, and the world and consider what new learning can occur if we are more open.”

The Three Core Principles of RO-DBT

The first principle of RO-DBT focuses on increasing receptivity and openness to new experiences and intentionally challenging automatic thoughts and feelings to allow space for new input. This principle targets unhealthy behaviors like avoiding new experiences and risk, hypervigilance, and discounting feedback that are often present for overcontrolled individuals.

The basis of the second core principle is improving our ability to adapt to change by allowing for some flexibility within our desire or need for control. Overcontrolled individuals frequently display a compulsive need for structure, hyper-perfectionism, rigid behavior, and intense planning or rehearsal. They struggle to tolerate change or unknowns effectively.

The final principle involves increasing intimacy and social connectedness. A propensity for low emotional awareness and inhibited expression is common for overcontrolled individuals, which can contribute to distant relationships, social comparisons, and high envy/bitterness. The overarching approach of RO-DBT includes encouragement of relaxing control and joining with others. 

Differences Between RO-DBT and DBT

Traditional DBT typically treats individuals who struggle with regulating “extreme” emotions, controlling impulsive behaviors, and sustaining relationships. Individuals appropriate for DBT at Skyland Trail often have a diagnosis of depression, bipolar disorder, or borderline personality disorder, sometimes with a co-occurring trauma-related or substance use disorder.

Skyland Trail clients assigned to RO-DBT likely have a diagnosis of depression or anxiety along with one or more co-occurring disorders or traits like obsessive-compulsive personality disorder, perfectionism, or autism spectrum disorder.

Says Skyland Trail therapist Emily Schneider, “While overcontrolled individuals also struggle to regulate their emotions effectively, they tend to inhibit their emotional expression. They may be really frustrated or sad or even excited, yet their behavior doesn’t show it. They often exert a great deal of effort to avoid experiencing and expressing emotions.”

One significant challenge among overcontrolled individuals is matching their social signaling with their intent, values, or internal experience. Many RO-DBT skills are aimed at adjusting social signaling (verbal and nonverbal) to communicate effectively with others.

Another component of RO-DBT is called self-inquiry. Says Beaudreau, “In self-inquiry,  one intentionally meditates on a question in hopes of getting closer to their ‘emotional edge,’ or the uncomfortable state we find ourselves in when considering something we’d rather avoid. The point is not to answer the question but to continue demonstrating curiosity and willingness to challenge automatic avoidance, rationalization, or justification.” Most RO-DBT skills include components of both social signaling and self-inquiry.

Clients in both DBT and RO-DBT are working to find a new balance between internal control and external response. But while clients in DBT work to increase their internal control over their external behaviors, clients in RO-DBT work to relax their internal control and open themselves to wider external expressions and experiences.

How does RO-DBT improve treatment outcomes in residential mental health treatment?

One of the core deficits of overcontrolled individuals is a lack of receptivity and flexibility with new information or ideas. In a mental health residential treatment program, the treatment team is actively asking clients to operate against this behavior. RO-DBT can be a helpful therapy to help clients “unlock” all the benefits of residential treatment by being more open to exploration and change.

Beaudreau believes that approaching someone who is resistance to the material with validation and humor can often be helpful and increase connection. Says Beaudreau, “The best advice for clients is to embrace the discomfort and be open to the possibility of new learning. The goal of RO-DBT is not to completely remove overcontrolled behaviors, the goal is to be curious about where overcontrol might not be serving our goals.”

Says Beaudreau, “Clients tend to respond well to the RO-DBT skills group as the content is unique from what they receive in other groups. Once they begin connecting with the material, they become invested in the group. Clients who struggle with rigid thinking patterns become increasingly open, flexible, and curious about themselves and others.”

Says Schneider, “I find the relationships I can develop with the clients and the relationships they can develop with each other to be the most rewarding aspect. It reflects the work and growth they are putting into challenging their overcontrolled patterns with social relationships and can be impactful for clients’ sense of self.”