Radically Open Dialectical Behavior Therapy (RO DBT) for Anorexia Nervosa: Clinical Applications in a Nutshell

Radically Open Dialectical Behavior Therapy (RO DBT) for Anorexia Nervosa: Clinical Applications in a Nutshell

By Dr. Julianna Gorder 

High achieving, perfectionistic, detail oriented, always planning ahead. Does this describe any of your client’s with anorexia nervosa? If you are a part of the majority of therapists who also tend toward an overcontrolled coping style, maybe it describes you too! Having a healthy level of self-control can have many benefits, but what happens when self-control gets out of control?

RO DBT is a transdiagnostic treatment model for disorders of overcontrol (OC), which is supported by over 20 years of research. RO DBT has demonstrated efficacy in the treatment of refractory depression (Lynch et al., 2003, 2007), adults with treatment resistant overcontrol (Keogh et al., 2016), adult anorexia nervosa (AN) (Chen et al., 2015; Lynch et al., 2013), and has also demonstrated promise when applied to the treatment of adolescents with AN (Simic, Stewart, & Hunt, 2016). The purpose of this post is to provide an overview of maladaptive overcontrol and the RO DBT treatment model, discuss how RO DBT has been used as a groundbreaking treatment for AN, and highlight several unique aspects that are particularly helpful to emphasize when learning this treatment.

Maladaptive Overcontrol 

Maladaptive overcontrol is characterized by four core deficits (Lynch, 2018):

  1. Low receptivity and openness/High avoidance of new experiences, uncertainty, and disconfirming feedback
  2. Low flexible control/High levels of rigidity and rule governed behavioral patterns
  3. Pervasive inhibited emotional expression and low emotional awareness
  4. Low social connectedness and intimacy

While there are many ways that having high self-control can be advantageous, research indicates that when it comes to self-control we can in fact have “too much of a good thing.” An ability to inhibit one’s impulses, follow rules, and sacrifice personal needs to achieve a long term goal can have many benefits; however, problems can arise when these qualities are rigidly applied without regard for appropriateness of context. For example, these qualities can be extremely helpful when studying for an exam or finishing a project for work, but can create challenges in forming intimate relationships when an individual struggles to turn these same qualities off. In fact, research shows that excessive self-control is associated with interpersonal isolation, intense emotional loneliness, and difficulty connecting with others, and has also been linked to a number of severe and difficult to treat mental health diagnoses including chronic depression, obsessive compulsive personality disorder, and AN (Lynch & Cheavens, 2008; Zucker et al. 2007). Lynch (2018) explains that individuals who struggle with maladaptive overcontrol also have a biotemperament that is highly sensitive to threat and insensitive to reward, and this makes it more likely for an individual to perceive the potential for harm within a situation rather than the potential for pleasure. RO DBT also posits that those struggling with maladaptive overcontrol spend most of their lives in a physiological state of threat, in which they experience increased heart rate, blood pressure, and pace of breath. This threatened state subsequently makes it all the more difficult to openly express emotions and form close connections with others.

RO DBT Treatment Overview

While RO DBT shares several similarities to standard DBT in implementation, it is also fundamentally different in a number of ways. At the heart of RO DBT is the idea that from an evolutionary standpoint, not only do emotions help us to communicate with one another, but they also help us to connect with one another. External expressions of internal experiences, such as cognitions and emotions, are considered social signals. A social signal is defined as any behavior that occurs in the presence of another person (Lynch, 2018), and these behaviors have the power to communicate both intended and unintended messages. While there is much that could be said on this topic, in a nutshell, when we struggle to openly and effectively express emotions, we also struggle to communicate and connect with others. Therefore, RO DBT contends that emotional loneliness is at the heart of the issue and addressing social signaling deficits is the primary mechanism of change. As Hemple, Vanderbleek, and Lynch (2018) state, “We don’t feel connected because we feel safe— we feel safe because we feel connected.” Throughout treatment, RO DBT seeks to address social signaling deficits related to five core themes:

  1. Rigid and rule governed behavior
  2. Inhibited or disingenuous emotional expression
  3. Aloof and distant relationships
  4. Overly-cautious and hypervigilant behavior
  5. High social comparisons with envy and bitterness

Overcontrol and Anorexia Nervosa

AN at the core embodies many features of maladaptive overcontrol – rigid and rule governed behaviors, extreme inhibition of needs, and high levels of perfectionism. Research also supports that AN is associated with the OC biotemperament of high threat sensitivity and low reward sensitivity (Harrison, O’Brien, Lopez, & Treasure, 2010). RO DBT contends that dietary restriction may serve several functions for an individual with AN. One of these functions involves reducing experiences of anxious physiological arousal and inducing feelings of emotional numbness (Lynch et al., 2013). Unfortunately, not only does this method of downregulating anxiety impair one’s ability to socially signal in a manner that fosters connection, it is also life threatening. A second function of dietary restriction may also involve serving as a social signal. For example, I have heard clients say things such as, “If I’m not thin, I will be unlovable,” and “I think my eating disorder makes me appear competent – like I can achieve something.” It is posited that maladaptive OC behavioral patterns preceded the development of AN, therefore, by addressing social signaling deficits in treatment, it is hypothesized that the need for an individual to over-regulate and seek safety through their eating disorder will no longer be necessary.

Core Techniques in Clinical Practice

While there are a number of aspects of RO DBT that differentiate it from other evidence based treatments for AN, there are several that have been helpful for me to keep in the front of my mind when learning to implement this treatment:

  1. Social Signaling as a Primary Mechanism of Change: One of the biggest challenges in learning RO DBT has been to keep my focus on a client’s social signals. While the majority of treatments for adult AN focus on internal factors, such as emotional regulation, impulse control, distress tolerance, and cognitive distortions, RO DBT focuses externally on an individual’s social signals. Therefore, a client’s social signals are the primary target in treatment and not the eating disorder. However, this does not mean that the eating disorder is ignored. When eating disorder behaviors do occur, the social signals surrounding these behaviors are discussed in regards to how they interfere with connection and the clients other valued goals. For example, if a client frequently lies to friends and family in order to follow the rules of the eating disorder, “lying” would be a primary treatment target. These targets may also include microexpressions, such as a subtle curling of the upper lip, signaling contempt or a look of disgust when a client is offered a food that is “against the rules.” Eating disorder behaviors themselves, such as refusing to eat in the presence of others, are also considered social signals. Rather than asking a client how they are feeling when they engage in eating disorder behaviors, we ask, “What are you signaling?” It is not unusual within higher levels of care for clients who actively use eating disorder behaviors in the presence of their peers (e.g. smearing food around their plate, hiding food, refusing to eat) to be socially ostracized by the patient community, given that their peers typically find these behaviors to be highly activating. While the client taking microscopic bites of food is likely doing so to reduce their own anxiety, this could be a powerful social signal that sends the unintended message, “Engaging with my eating disorder is more important than causing you distress.” Given that OC biotemperament and maladaptive coping patterns are hypothesized to have preceded the development of the eating disorder, it is essential that social signals also be discussed and prioritized in regards to how they present throughout the client’s life beyond the eating disorder. For example, we want to know if there are other times that the client makes a look of disgust when their internal rules are challenged, other instances when they may lie to friends and family, and other times when following their internal rules conflicts with their values.
  2. Emphasis on Biotemperament: Given the high levels of physiological threat that OC clients experience in their lives, RO DBT teaches clients several “bottom up skills” that help increase feelings of physiological safety and reduce feelings of threat. Clients are also taught to recognize the ways their physiological experiences impact their perceptions and engagement in value-driven actions. In addition to teaching clients skills to apply in their own lives, there are also ways that we can help maximize our clients’ physiological safety in session. One of these ways involves using the mirror neuron system. By monitoring our own threat levels and sense of safety, we can socially signal that they are in a safe environment. Additionally, RO DBT emphasizes the use of playful irreverence within sessions to not only help clients relax, but also to help them learn to take life a little less seriously. 
  1. Radical Openness and Learning from Distress: While the primary focus of RO DBT is on a client’s social signals, there are also times when it can be beneficial to focus on internal experiences and perceptions. Radical openness involves a willingness to seek out and lean into those things that we want to avoid, and viewing these points of distress as opportunities to learn and grow, as well as opportunities to challenge our perceptions of reality and consider disconfirming feedback. When distress arises during treatment for clients with AN, such as during or after meals or when negatively evaluating their shape and weight, rather than viewing this distress as something that must be reduced in order to function, RO DBT therapists seek to help clients view this distress as an opportunity to grow, and to use a skill called self-enquiry to ask oneself, “Is there something I need to learn here?” 
  2. Capitalizing on the Strengths of Overcontrol: Few things are more rewarding for an OC client than identifying a problem and fixing it! Therefore, it is crucial for RO DBT therapists to help our clients see their overcontrol as a dialectic. Depending on how they apply their overcontrol, it can be both something that creates problems in their life AND an asset that helps them succeed. Although there are ways OC patterns may get in the way of a client pursuing their values, it is also our job to help our clients see that there are ways that they can use this skillset to their advantage. There is no doubt that recovery from AN is hard work. OC clients are masters at tolerating distress, inhibiting urges, and dedicating themselves toward long-term goals. All of these qualities are arguably necessary components of recovery from an eating disorder, and OC clients can absolutely use their innate skillset to tolerate distress associated with weight restoration and abstaining from urges to engage in eating disorder behaviors in order to create a life worth sharing.

For more information on RO DBT for AN, related readings include:

Astrachan-Fletcher, E., Giblin, A., Simic, M., & Gorder, J. (2018). Radically Open Dialectical

Behavior Therapy for anorexia nervosa: Connection, openness, and flexibility at the heart of recovery. the Behavior Therapist, 41, 149-153.

Chen, E.Y., Segal, K., Weissman, J., Zeffiro, T.A., Gallop, R., Linehan, M.M., …Lynch, T.R.

(2015). Adapting dialectical behavior therapy for outpatient adult anorexia nervosa- A pilot study. The International Journal of Eating Disorders, 48(1), 123-132.

Hempel R., Vanderbleek, E., & Lynch, T.R. (2018). Radically open DBT: Targeting emotional

loneliness in anorexia nervosa. Eating Disorders: The Journal of Treatment and Prevention, 26(1), 92-104.

Lynch. T.R., Gray, K.L., 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.

Lynch, T.R. & Hempel, R.J. (2016). Signaling matters: Radically open-dialectical behavior

therapy for anorexia nervosa. In T. Wade (Ed.), Encyclopedia of feeding and eating disorders (pp.1-10). Singapore, Singapore: Springer, Singapore.

If you are interested in learning more about becoming trained in RO DBT, please visit: http://www.radicallyopen.net/training-events/.

About the author:

Dr. Julianna Gorder is a postdoctoral fellow at UCSD Eating Disorders Center. Dr. Gorder completed her two-week intensive training in RO DBT with treatment developer, Thomas Lynch, and has experience administering RO DBT for eating disorders within residential through outpatient levels of care. She has also served as an officer on the RO DBT Student Board since 2017. Dr. Gorder earned her Psy.D. from The Chicago School of Professional Psychology and has extensive experience treating eating disorders at all levels of care. Prior to coming to UCSD, she received specialized training in the treatment of eating disorders at Eating Recovery Center of Chicago and the Eating Disorders Program at University of Chicago. Her research interests include defining recovery from an eating disorder, the impact of biotemperament and emotion regulation style on eating disorder presentation, as well as the impacts of trauma on the development and maintenance of eating disorders.

References:

Astrachan-Fletcher, E., Giblin, A., Simic, M., & Gorder, J. (2018). Radically Open Dialectical

Behavior Therapy for anorexia nervosa: Connection, openness, and flexibility at the heart of recovery. the Behavior Therapist, 41, 149-153.

Chen, E.Y., Segal, K., Weissman, J., Zeffiro, T.A., Gallop, R., Linehan, M.M., …Lynch, T.R.

(2015). Adapting dialectical behavior therapy for outpatient adult anorexia nervosa- A pilot study. The International Journal of Eating Disorders, 48(1), 123-132. doi:10.1002/eat.22360.

Harrison, A., O’Brien, N., Lopez, C., & Treasure, J. (2010). Sensitivity to reward and

punishment in eating disorders. Psychiatry Research, 177(1-2), 1-11.

Hempel R., Vanderbleek, E., & Lynch, T.R. (2018). Radically open DBT: Targeting emotional

loneliness in anorexia nervosa. Eating Disorders: The Journal of Treatment and Prevention, 26(1), 92-104.

Keogh, K., Booth, R., Baird, K., & Davenport, J. (2016). The Radical Openness Group: A

controlled trial with 3 month follow-up. Practice Innovations, 1(2) 129-143.

Lynch, T. R. (2018). Radically open dialectical behavior therapy: Theory and practice for

treating disorders of overcontrol. Reno, NV: Context Press, an imprint of New Harbinger Publications, Inc.

Lynch, T.R. & Cheavens, J.S. (2008). Dialectical behavior therapy for comorbid personality

disorders. Journal of Clinical Psychology, 64(2), 154-167.

Lynch, T.R., Cheavens, J.S., Cukrowicz, K.C., Thorp, S.R., Bronner, L., & Beyer, J. (2007).

Treatment of older adults with comorbid personality disorder and depression: A dialectical behavior therapy approach. International Journal of Geriatric Psychiatry, 22(2), 131-143.

Lynch. T.R., Gray, K.L., 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. doi:10.1186/1471-244x-13-293.

Lynch, T.R. & Hempel, R.J. (2016). Signaling matters: Radically open-dialectical behavior

therapy for anorexia nervosa. In T. Wade (Ed.), Encyclopedia of feeding and eating disorders (pp.1-10). Singapore, Singapore: Springer, Singapore.

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.

Simic, M., Stewart, C., Hunt, K. (2016). Preliminary outcomes applying Radically Open

Dialectical Behavior Therapy (RO DBT) to adolescents with anorexia nervosa. Symposium presentation at the 44th BaBCP Conference and 2016, Bellfast: Undercontrolled or Overcontrolled- That is the Question: Using Evidence-Based Transdiagnostic Theory to Guide Clinical Decision-Making.

Zucker, N.L., Losh, M., Bulik, C.M., Labar, K.S., Piven, J., & Pelphrey, K.A. (2007). Anorexia

nervosa and autism spectrum disorders: Guided investigation of social cognitive endophenotypes. Psychological Bulletin, 133(6), 976-1006.

 

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