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Cognitive · 2013

Radically Open Dialectical Behavior Therapy (RO-DBT)

Change arises from loosening overcontrol through radical openness, genuine social signalling and bonds that make it possible to learn from experience and from feedback.

Radically Open Dialectical Behavior Therapy (RO-DBT) is a transdiagnostic treatment developed by Thomas R. Lynch for problems characterised by maladaptive overcontrol, such as cognitive-behavioural rigidity, perfectionism, emotional inhibition, risk aversion, a high need for structure and interpersonal distance. Its formulation places emotional loneliness, linked to low openness and to social signalling deficits, at the centre of the suffering caused by overcontrol, and organises psychological health around three interdependent capacities: receptivity and openness to new or discrepant information, flexible control, and intimacy and social connectedness. It retains DBT's dialectical and behavioural roots, but substantially reorganises its targets and strategies: standard DBT addresses mainly undercontrol, impulsivity and mood-dependent behaviour, whereas RO-DBT seeks to relax excessive inhibitory control and to increase spontaneity, appropriate vulnerability and social cooperation; DBT-PTSD organises treatment around complex PTSD, escape strategies from traumatic emotions, dissociation and skills-assisted trauma-focused exposure, whereas RO-DBT takes as its distinctive mechanism the modification of social signals and of the patterns of isolation that maintain emotional loneliness. The intervention combines individual therapy and skills classes with self-enquiry, activation of the social safety system, practice of novel behaviours, congruent emotional expression, openness to feedback, intimacy, relational repair and brief behavioural analysis, using a hierarchy of its own that places alliance ruptures immediately after life-threatening behaviours.

Theory of change

The person changes by relaxing rigid patterns of overcontrol, opening up to discrepant information and transforming their social signals in order to increase flexibility, interpersonal safety and intimacy.

Core ideas

  1. Excessive self-control can become a stable source of psychopathology

    RO-DBT starts from the premise that discipline, inhibition, the capacity to delay gratification and distress tolerance are adaptive resources until they become too rigid and generalised. In maladaptive overcontrol, the person maintains a high level of restraint even when the context calls for spontaneity, vulnerability, flexibility or exploration, producing a clinical configuration distinct from the undercontrol problems that inspired standard DBT. (Lynch, Hempel, & Dunkley, 2015, Radically Open-Dialectical Behavior Therapy for Disorders of Over-Control: Signaling Matters; Lynch, 2018, Radically Open Dialectical Behavior Therapy).

  2. Emotional loneliness is the core problem that organises clinical overcontrol

    Rigidity and inhibition acquire their greatest clinical relevance when they interfere with the capacity to form intimate, reciprocal relationships. RO-DBT formulates that a person may appear highly competent and self-regulated while living with profound disconnection, because their signals convey distance, mistrust, superiority, resignation or emotional unavailability. This formulation shifts the axis from reducing intense emotion towards increasing openness, trust and connection. (Lynch, Hempel, & Dunkley, 2015, Radically Open-Dialectical Behavior Therapy for Disorders of Over-Control: Signaling Matters).

  3. Social signals transform the interpersonal environment that maintains the problem

    RO-DBT holds that every gesture, gaze, tone, silence or pattern of expression emitted in the presence of another person can function as social information, regardless of conscious intention. Restricted or incongruent signalling can generate less trust, withdrawal or defensive responses in others, and subsequently confirm the expectation that relationships are unsafe; modifying those signals makes it possible to alter the interpersonal loop and create new experiences of reciprocity. (Lynch, 2018, Radically Open Dialectical Behavior Therapy; Lynch, 2018, Tribe Matters).

  4. Radical openness requires an active willingness to discover that one's own perception may be incomplete

    Radical openness involves seeking information that may challenge one's own conclusions, acknowledging that blind spots exist and practising self-enquiry when tension or closing down arises. Its clinical function is to replace defensive certainty and resignation with a more flexible relationship to knowledge, while preserving critical capacity and personal choice. The skill depends on direct practice and interpersonal feedback, because a person can hardly detect on their own everything they do not know about themselves. (Lynch, 2018, Radically Open Dialectical Behavior Therapy; Lynch, 2018, The Skills Training Manual for Radically Open Dialectical Behavior Therapy).

  5. Flexible Mind differs from Wise Mind in its emphasis on fallibility and self-enquiry

    RO-DBT retains DBT's mindfulness tradition but reformulates the optimal position towards experience. Flexible Mind emphasises the capacity to maintain healthy doubt, actively seek discrepant information and consider the possibility of being wrong, whereas Wise Mind in standard DBT is built around the integration of reason and emotion and access to a balanced form of inner knowing. This difference reflects the clinical need to challenge certainty and closing down in people with overcontrol. (Lynch et al., 2013, Radically open-dialectical behavior therapy for adult anorexia nervosa; Lynch, Hempel, & Dunkley, 2015, Signaling Matters).

  6. Physiology is used to make interpersonal openness possible

    Neurobiosocial theory links threat sensitivity to defensive states that restrict expressiveness, flexibility and social participation. RO-DBT teaches the person to change breathing, posture, musculature, facial expression and prosody in order to foster a state compatible with social safety, using bodily regulation as preparation for listening to feedback, taking a relational risk or staying open. The physiological aim is embedded in an interpersonal mechanism and does not simply constitute a relaxation technique. (Lynch et al., 2015, Refractory depression: mechanisms and evaluation of RO-DBT; Lynch, 2018, Radically Open Dialectical Behavior Therapy).

  7. Treating overcontrol sometimes requires the opposite direction from that used for undercontrol

    People with undercontrol usually benefit from increasing inhibition, planning, distress tolerance and the capacity to delay gratification, whereas overcontrolled people need to learn to loosen rigid control, expose themselves to novelty, disclose vulnerability and respond with greater spontaneity. This difference explains why RO-DBT shares roots with DBT yet has substantially different skills, targets and strategies. (Lynch, Hempel, & Dunkley, 2015, Radically Open-Dialectical Behavior Therapy for Disorders of Over-Control: Signaling Matters; Hempel et al., 2018, How to Differentiate Overcontrol From Undercontrol).

  8. A repaired rupture can constitute evidence of a deeper alliance

    In overcontrolled people, politeness, compliance and the absence of conflict can coexist with emotional distance and the concealment of disagreement. RO-DBT regards it as especially informative that the patient can tell the therapist they feel misunderstood, receive an open response, repair the relationship and carry on working; it therefore places alliance ruptures as the second target in the hierarchy and considers multiple successful repairs a sign of growing trust. (Lynch, Hempel, & Dunkley, 2015, Signaling Matters; Lynch, 2018, Radically Open Dialectical Behavior Therapy).

  9. Appropriate vulnerability functions as a signal of trust and belonging

    Intimacy requires that other people be able to know not only achievements and competencies, but also doubts, needs, fears, mistakes and emotions. RO-DBT trains gradual, congruent self-disclosure because systematically concealing inner experience limits reciprocity and may communicate mistrust or superiority. Skills such as outing oneself and Match + 1 turn vulnerability into an observable, gradable behaviour. (Lynch, 2018, The Skills Training Manual for Radically Open Dialectical Behavior Therapy).

  10. Values must be expressed through observable social signals

    RO-DBT distinguishes between privately valuing a quality and conveying it interpersonally. A person may regard kindness, honesty or openness as essential and yet display a posture, tone or behaviour that others receive as coldness, criticism or control. Therapeutic work connects values to concrete expressive channels and reviews the actual effect of the signals, so that a valued life is also recognisable in relationships. (Lynch, 2018, Radically Open Dialectical Behavior Therapy; Lynch, 2018, The Skills Training Manual for Radically Open Dialectical Behavior Therapy).

Influences

  • Dialectical Behavior Therapy (DBT)
  • Radical behaviourism
  • Mindfulness
  • Personality psychology
  • Models of overcontrol and undercontrol
  • Affective neuroscience
  • Psychophysiology
  • Theory of emotional regulation
  • Research on emotional expression and non-verbal communication
  • Evolutionary theory of cooperation and social belonging
  • Transdiagnostic and dimensional approaches
  • Malamati Sufism

Key references

  • Lynch, T. R. (2018). Radically Open Dialectical Behavior Therapy: Theory and Practice for Treating Disorders of Overcontrol. Oakland, CA: Context Press/New Harbinger Publications.
  • Lynch, T. R. (2018). The Skills Training Manual for Radically Open Dialectical Behavior Therapy: A Clinician's Guide for Treating Disorders of Overcontrol. Oakland, CA: Context Press/New Harbinger Publications.
  • Lynch, T. R., Hempel, R. J., & Dunkley, C. (2015). Radically Open-Dialectical Behavior Therapy for Disorders of Over-Control: Signaling Matters. American Journal of Psychotherapy, 69(2), 141–162.
  • Lynch, T. R., Gray, K. L. H., Hempel, R. J., Titley, M., Chen, E. Y., & O'Mahen, H. A. (2013). Radically open-dialectical behavior therapy for adult anorexia nervosa: feasibility and outcomes from an inpatient program. BMC Psychiatry, 13, 293. https://doi.org/10.1186/1471-244X-13-293
  • Lynch, T. R., Whalley, B., Hempel, R. J., Byford, S., Clarke, P., Clarke, S., Kingdon, D., O'Mahen, H., Russell, I. T., Shearer, J., Stanton, M., Swales, M., Watkins, A., & Remington, B. (2015). Refractory depression: mechanisms and evaluation of radically open dialectical behaviour therapy (RO-DBT) [RefraMED]: protocol for randomised trial. BMJ Open, 5, e008857. https://doi.org/10.1136/bmjopen-2015-008857
  • Lynch, T. R., Hempel, R. J., Whalley, B., Byford, S., Chamba, R., Clarke, P., Clarke, S., Kingdon, D., O'Mahen, H., Remington, B., Rushbrook, S. C., Shearer, J., Stanton, M., Swales, M., Watkins, A., & Russell, I. T. (2018). Radically open dialectical behaviour therapy for refractory depression: the RefraMED RCT. Efficacy and Mechanism Evaluation, 5(7). https://doi.org/10.3310/eme05070
  • Lynch, T. R., Hempel, R. J., Whalley, B., Byford, S., Chamba, R., Clarke, P., Clarke, S., Kingdon, D. G., O'Mahen, H., Remington, B., Rushbrook, S. C., Shearer, J., Stanton, M., Swales, M., Watkins, A., & Russell, I. T. (2020). Refractory depression – mechanisms and efficacy of radically open dialectical behaviour therapy (RefraMED): findings of a randomised trial on benefits and harms. British Journal of Psychiatry, 216(4), 204–212. https://doi.org/10.1192/bjp.2019.53
  • Lynch, T. R., Morse, J. Q., Mendelson, T., & Robins, C. J. (2003). Dialectical Behavior Therapy for Depressed Older Adults: A Randomized Pilot Study. American Journal of Geriatric Psychiatry, 11(1), 33–45.
  • Lynch, T. R., Cheavens, J. S., Cukrowicz, K. C., Thorp, S. R., Bronner, L., & Beyer, J. (2007). Treatment of older adults with co-morbid personality disorder and depression: a dialectical behavior therapy approach. International Journal of Geriatric Psychiatry, 22(2), 131–143. https://doi.org/10.1002/gps.1703
  • Lynch, T. R. (2018). Tribe Matters: An Introduction to Radically Open Dialectical Behavior Therapy. The Behavior Therapist, 41(3), 116–125.
  • Hempel, R. J., Rushbrook, S. C., O'Mahen, H., & Lynch, T. R. (2018). How to Differentiate Overcontrol From Undercontrol: Findings From the RefraMED Study and Guidelines From Clinical Practice. The Behavior Therapist, 41(3), 132–142.
  • Luoma, J. B., Codd, R. T., III, & Lynch, T. R. (2018). Radically Open Dialectical Behavior Therapy: Shared Features and Differences With ACT, DBT, and CFT. The Behavior Therapist, 41(3), 142–149.
  • Hempel, R. J., Booth, R., Giblin, A., Hamilton, L., Hoch, A., Portner, J., Tomcik, N., Rushbrook, S. C., Simic, M., Hunt, K., & Wolf-Arehult, M. (2018). The Implementation of RO DBT in Clinical Practice. The Behavior Therapist, 41(3), 161–173.
  • Linehan, M. M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press.
  • Linehan, M. M. (2015). DBT Skills Training Manual (2nd ed.). New York: Guilford Press.
  • Steil, R., Dyer, A., Priebe, K., Kleindienst, N., & Bohus, M. (2011). Dialectical behavior therapy for posttraumatic stress disorder related to childhood sexual abuse: a pilot study of an intensive residential treatment program. Journal of Traumatic Stress, 24(1), 102–106. https://doi.org/10.1002/jts.20617
  • Bohus, M., Kleindienst, N., Hahn, C., Müller-Engelmann, M., Ludäscher, P., Steil, R., Fydrich, T., Kuehner, C., Resick, P. A., Stiglmayr, C., Schmahl, C., & Priebe, K. (2020). Dialectical Behavior Therapy for Posttraumatic Stress Disorder (DBT-PTSD) Compared With Cognitive Processing Therapy in Complex Presentations of PTSD in Women Survivors of Childhood Abuse: A Randomized Clinical Trial. JAMA Psychiatry, 77(12), 1235–1245.
  • Lynch, T. R., & Little, J. N. (2026). The Radically Open Dialectical Behavior Therapy Workbook: Skills to Overcome the Paradox of Perfectionism, Anxiety, Depression & Other Disorders of Overcontrol. Oakland, CA: New Harbinger Publications.