The Skills Training Manual for Radically Open Dialectical Behavior Therapy: A Clinician’s Guide for Treating Disorders of Overcontrol Interview

Thomas R. Lynch, PhD, joined us for an interview on his book, The Skills Training Manual for Radically Open Dialectical Behavior Therapy: A Clinician’s Guide for Treating Disorders of Overcontrol. What follows is our questions in bold italics, and Dr. Lynch’s thoughtful responses.

The Skills Training Manual for Radically Open Dialectical Behavior Therapy: A Clinician’s Guide for Treating Disorders of Overcontrol is the skills training manual for your textbook, Radically Open Dialectical Behavior Therapy: Theory and Practice for Treating Disorders of Overcontrol.

What are the diagnoses to which you believe (RO DBT) can be applied?

Radically open dialectical behavior therapy (RO DBT) is an evidence-based treatment targeting a spectrum of disorders characterized by excessive inhibitory control, or overcontrol (OC). It is intended for clinicians treating clients with chronic problems such as refractory depression, anorexia nervosa, autism spectrum disorders, and treatment resistant anxiety—including personality disorders (PDs)  such as obsessive-compulsive PD, paranoid PD, schizoid PD, schizotypal PD, and avoidant PD. The core characteristics of OC personality disorders are: strong desire to control one’s environment; restrained emotional expression; limited social interaction and problems with close relationships due to aloofness, distancing, mistrust and fear of rejection or criticism; and cognitive and behavioral rigidity.

The key difference between RO DBT and other treatments is that rather than focusing on diagnosis (e.g., depression, anorexia)—RO DBT targets maladaptive overcontrol. For example, by conceptualizing restrictive and ritualizedeating as symptoms or consequences stemming from rigid maladaptive overcontrolled coping based on research showing that OC coping preceded the development of the eating disorder.

How do you characterize overcontrol?

RO-DBT proposes that although the ability to inhibit competing urges, impulses, behaviors, or desires is highly valued by most societies; too much self-control can sometimes lead to problems. Excessive self-control or overcontrol (OC) has been linked to social isolation, aloof interpersonal functioning, maladaptive perfectionism, disingenuous emotional expression and severe and difficult-to-treat mental health problems, such as anorexia nervosa, obsessive compulsive PD, and chronic depression. Unfortunately, for an OC client, societal veneration of self-control is both a blessing and a curse (their personal suffering, linked as it is to overcontrol, often goes unrecognized).

Maladaptive overcontrol is expressed discreetly. OC individuals are not yelling at each other from across the street or robbing convenience stores on a whim.  Indeed, OC clients set high personal standards for themselves (and others), work harder than most others toprevent future problems, and are expert at not appearing deviant on the outside (that is, in public). Oftentimes no one outside the immediate family is aware of an OC individuals’ inner psychological distress.  Although overcontrol works well when sitting quietly in a monastery or building a rocket—habitual masking or inhibition of inner feelings makes it harder to connect with others and form close social bonds. The consequence for the OC individual is intense loneliness.

Your manual provides 20 skills that can be presented in 30 lessons/30 weeks in 2 ½ hour sessions, based on RO DBT, an evidence-based treatment.

What have you found when it is used in the clinical treatment of anorexia nervosa?

Rather than solely focusing on food intake, weight gain, emotion regulation skills, or family dynamics, RO DBT prioritizes for treatment maladaptive overcontrol and social signaling deficits posited to exacerbate social isolation, emotional loneliness, and feelings of ostracism. The efficacy research to date is promising. Pilot studies of RO DBT for adult anorexia nervosa have shown significant and large improvements in weight restoration despite the fact that RO DBT does not emphasize weight gain—and large improvements in measures examining psychological distress and global functioning (Lynch et al., 2013; Chen et al., 2015).  RO DBT has also been applied to the treatment of AN adolescents and results support hypotheses stemming from the RO DBT model of overcontrol (Simic, Stewart,& Hunt, 2016; see also Astrachan-Fletcher, Giblin, Simic, & Gorder, 2018).

Each of your lesson plans is remarkably thorough and includes main points, materials needed, recommended exercises, require teaching points, homework, handouts, and worksheets. How are the clinicians responding to your lesson plans?

A core aim of our research and dissemination team is to encourage feedback from not only our service-users but also our service providers.  As such, we have been fortunate to benefit from a wide range of feedback. For example, Dr. Giblin from the Opal Food + Body Wisdom Eating Disorder Treatment Facility in Seattle described their experience; “Although we are still in the process of developing a systematic means of collecting outcome data, we have been encouraged by the self-reports from our clients about their experience and have witnessed the transformation of many previously considered untreatable or difficult clients as a result of their involvement in RO DBT” (Hempel et al., 2018).  The Eating Disorder Unit, Uppsala University Hospital (ala Martina Wolf-Arehult; see Hempel et al., 2018) reported that most patients experienced changes in areas of their lives not immediately related to eating disorders, such as how they act in social situations and increased warmth and closeness in relationships by using RO DBT skills.  In some cases, RO DBT was experienced as “life changing”. Interestingly, despite some initial hesitancy from clinicians to talk with young people about such complex emotions as envy and bitterness, cliniciansfrom the Child and Adolescent Eating Disorder Service at Maudsley NHS Foundation Trust London (see Hempel et al. 2018) reported that, contrary to their initial scepticism, clients were readily able to identify with these emotions and found skills classes on these topics very fitting.  Overall the response and interest has been overwhelmingly positive.

You’ve incorporate a number of Mindfulness Training Lessons which we know is a key element in DBT. What are some of the specific targets for mindfulness with RO DBT?

In RO DBT, there are three mindfulness “what” skills, each of which represents a differing aspect or way to practice mindfulness. They are; observe openly, describe with integrity, and participate without planning. The Awareness Continuum is the core RO “describe with integrity” practice and can also be used as an “outing oneself” practice. It helps the practitioner take responsibility for their inner experiences, block habitual desires to explain or justify oneself, and learn how to differentiate between thoughts, emotions, sensations, and images. It is a core means for learning how to step off the path of blame (habitual blaming of self or others). Participating without planning means learning how to passionately participate in one’s life and in one’s community and let go of compulsive planning, rehearsal, and/or obsessive needs to get it right.  In addition,  in RO DBT, there are four mindfulness “how” skills that represent the kind of attitude or state of mind to bring to a practice of mindfulness. They are; with self-enquiry, with awareness of harsh judgments, with one-mindful awareness, and effectively and with humility.

One of your mindfulness lessons involves self-inquiry and outing oneself. Why are these practices useful to those with disorders of overcontrol?

Self-enquiry is the core RO DBT mindfulness “how” skill. It is the key to radically open living. Rather than automatically assuming that the world needs to change so we can feel better, radical openness posits that we often learn the most from those areas of life that we find most challenging. Thus RO DBT considers an unwanted emotion, thought, or sensation in the body a reminder to practice self-enquiry by redirecting our attention to the challenging or threatening experience and asking, Is there something to learn here?

For OC clients, who tend to automatically consider their interpretations of events as absolute truths or facts, a regular practice of self-enquiry helps loosen rigid beliefs and maximize new learning.  In addition, self-enquiry is particularly useful whenever we find ourselves strongly rejecting, defending against, or feigning agreement with feedback that we find challenging or unexpected, rather than automatically assuming that the world needs to change so we can feel better. It requires a willingness to question one’s beliefs, perceptions, action urges, and behaviors without falling apart—recognizing that we often learn the most from those areas of life that we find most challenging.

Examples of self-enquiry questions are: 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? Am I automatically blaming the other person or the environment for my emotional reactions? If yes or maybe, then is it possible this could represent a way for me to avoid being open to the feedback?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? Is there something here to learn?

Although self-enquiry seeks self-discovery, it remains suspicious of quick answers, and this is why self-enquiry practices should be expected to last over several days. Quick answers to self-enquiry questions often reflect compulsive OC coping in disguise, old learning, rigid rules or beliefs to the effect that everything should be fixed immediately, or compulsive desires to avoid social disapproval by coming up with a solution or explanation that justifies one’s behavior. This tendency to quickly fix or answer is one of the core reasons behind the emphasis in RO DBT on revealing our self-enquiry insights and observations to caring others (as in outing ourselves to a fellow practitioner).

Self-enquiry involves both willingness for self-examination and willingness to reveal to others what self-examinationuncovered. This process is known as outing oneself in RO DBT. The core idea behind outing oneself mindfulness practices in RO DBT is that we need other people to reflect back our blind spots because we don’t know what we don’t know, things are constantly changing, and there is a great deal of experience occurring outside of our conscious awareness. Outing one’s personality quirks or weaknesses publicly goes opposite to OC tendencies to mask inner feelings and is a powerful means toenhance relationships because it models humility and willingness to learn from what the world has to offer. When we reveal vulnerability, we signal to others that we are the same as them (not superior), and that we are open to new learning. The RO skills training manual provides step-by-step instructions on how to practice self-enquiry and outing oneself.  Readers interested in knowing more can read the blog pages written by RO DBT therapists pertaining to self-enquiry at www,radicallyopen.net.

Can you please speak to your point that “excessive self-control is maintained because it is rewarding”?

For the overcontrolled individual, their motto is “When in doubt, apply more self-control,” irrespective of circumstances or potential consequences.Overcontrolled coping persists because it gets rewarded (or reinforced), at least occasionally. For example, pretending to be OK can sometimes prevent conflict, working long hours may sometimes result in a job promotion, planning ahead can often prevent a future problem, following rules usually makes life easier, losing two pounds by not succumbing to urges to eat may trigger feelings of pride and a sense of achievement. Plus, overcontrolled coping is not always problematic. For example, innate capacities to inhibit impulses, plan ahead, and delay gratification make OC clients the doers, savers, planners and fixers of the world. They are the guests who help clean up after the party and the people who save for their retirement so as not to burden others. They strive for moderation in all aspects of their lives and value honesty, fairness, and doing the right thing.

Unfortunately, maladaptive overcontrol also creates long-term problems—particularly when it comes to social-connectedness. For example, avoidance of risk may prevent learning something new, compulsive controlling or fixing can also result in exhaustion and burnout, which can be exacerbated if one’s hard work or self-sacrifices are not appreciated (sufficiently) by others, leading to resentment and bitterness. Plus, despite its generally understated nature, overcontrolled behavior strongly impacts other people. For example, the silent treatment is a subtle yet powerful social signal of disapproval or anger.Both low openness and pervasive constraint of emotional expression have been repeatedly shown to exert a negative impact on the formation of close social bonds, leading to an increasing sense of isolation from others. OC clients suffer from emotional loneliness—not lack of contactbut lack of connection with others. Rather than focusing on how to do better or try harder, the primary aim in RO DBT is to help OC clients learn how to rejoin their tribe and establish strong social bonds with others.

The Skills Training Manual for Radically Open Dialectical Behavior Therapy: A Clinician’s Guide for Treating Disorders of Overcontrol (Paperback)
by Thomas R. Lynch PhD FBPsS

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Radically Open Dialectical Behavior Therapy: Theory and Practice for Treating Disorders of Overcontrol (Hardcover)
by Thomas R. Lynch PhD FBPsS

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About the author:

Thomas R. Lynch, PhD, is Professor Emeritus of Clinical Psychology at the University of Southampton. He was formerly Director of the Duke Cognitive Behavioural Research and Treatment Program at Duke University, Professor at Exeter University, and Director of the Emotion and Personality Bio-behavioural Laboratory at the University of Southampton. Professor Lynch is the treatment developer of Radically Open-Dialectical Behaviour Therapy (RO-DBT)—a new transdiagnostic treatment approach informed by 20 years of clinical research. Dr. Lynch’s primary research interests are understanding and developing novel treatments for mood and personality disorders using a translational line of inquiry that combines basic neurobiobehavioral science with the most recent technological advances in intervention research.  He is the founder of radically open dialectical behavior therapy (RO DBT).  Dr. Lynch has received numerous awards and special recognitions from organizations such as the National Institutes of Health-US (NIMH, NIDA), Medical Research Council-UK (MRC-EME), and the National Alliance for Research on Schizophrenia and Depression (NARSAD). His research has been recognized in the Science and Advances Section of the National Institute of Health Congressional Justification Report; and he is a recipient of the John M. Rhoades Psychotherapy Research Endowment and a Beck Institute Scholar.

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