Radically Open DBT (RO DBT): How It Works & What to Expect

What Is RO DBT?

RO DBT is a type of cognitive behavioral therapy developed by Thomas R. Lynch that targets disorders of overcontrol, such as certain eating disorders and anxiety disorders.² RO DBT is unique in that it has a focus on social signaling as the format for change. This is done by teaching clients about using and reacting to nonverbal social cues, as well as the importance of mirror neurons as a mechanism to build on.³

There are three core concepts that guide treatment in RO DBT:^2,4 

1. Receptivity and openness to new situations and experiences: Being able to try new things and to learn from the feedback and experiences one has
2. Flexible-control: Representing an ability to adapt to changing situations
3. Focus on social connection and intimacy

What Does “Radically Open” Mean?

RO DBT is called “radically open” because it holds three facets of emotional well-being to be extremely important: Flexibility, connectedness, and openness. Without these characteristics, someone’s happiness is limited.

Who Is RO DBT Best For?

Standard DBT is a wonderful treatment approach that is best used for people with intense symptoms stemming from impulsivity, extreme spontaneity, and lack of control. These people often act without fully considering the impact of their behaviors.

RO DBT is best for people on the other side of the spectrum who are overly controlled, who think too much and act too little. These people may be so concerned with making the “wrong” decision that they don’t do anything at all. This includes people with OCD and eating disorders.

What Is Overcontrol?

Overcontrol is when a person exhibits a level of self-control that limits their ability to enjoy life, be flexible when needed, and connect with others in a meaningful way. This includes:²

• High ability to not act on an urge
• High attention to detail
• Low tolerance for risk
• Difficulty expressing emotions
• Perfectionism
• High distress tolerance

RO DBT theorizes that overcontrol is a result of both biological factors in the individual, as well as influence from the environment and culture. People who exhibit overcontrol may also struggle to form meaningful social bonds due to their inflexibility, as well as an ability to mask and contain emotions.

RO DBT Vs. Standard DBT

RO DBT has some similarities with the original DBT model, although it treats fundamentally different concerns. RO DBT, similar to standard DBT, includes a skills group format, involving thorough education on new skills in a group setting. It also has an individual therapy component, and includes the practice of “phone consultation” with DBT, where the client can contact the therapist by phone based on predetermined criteria.

This table illustrates some key differences between the standard DBT and RO DBT:³

When Should Someone Choose RO DBT Over Standard DBT?

RO DBT and standard DBT target different types of disorders, so your mental health concern will determine which option would be a better fit for you.

• DBT is preferable and most effective for borderline personality disorder, ongoing suicidality, or difficulty controlling emotions.
• RO DBT targets disorders on the other end of the spectrum, where emotional expression is difficult and the person is highly controlled to a degree that it’s affecting their ability to be flexible. These disorders include OCD, anorexia, or treatment-resistant anxiety or depression.

You can also consult with a mental health professional to determine which therapy is the right fit for you.

Techniques Used in Radically Open DBT

One of the aspects that makes RO DBT unique is that it holds social connectedness as the primary mechanism of change.^2,3 RO DBT teaches people skills in a group format to allow them to learn new ways of coping and interacting with the world. Individual therapy provides space for people to process triggers, new ways of being, and implementation of the new skills they are learning.

Within RO DBT, there are three primary concepts:

1. Receptivity and openness: This refers to the ability to be open to new experiences, as well as to new feedback. New feedback allows us to grow from situations and to receive information from our environment that may challenge us.
2. Flexible-control: Flexible-control represents the ability to adapt to changing conditions in our environments.
3. Intimacy and social-connectedness: Social bonds are the fabric of our lives, and RO DBT seeks to help people use and understand social signaling to improve relationships.

Components of RO DBT Treatment

Like DBT, RO DBT is much more than just individual therapy sessions. Instead, it is a comprehensive system that involves a variety of treatments, including:

• Weekly individual therapy: The weekly individual therapy sessions will address the RO DBT framework and how the skills can be applied to the person’s unique symptoms.
• Weekly skills training: Available individually or during group sessions, weekly skills trainings address mindfulness, communication, distress tolerance, and emotional regulation.
• Phone consultations: Since new stressors regularly arise between sessions, the therapist will be readily available to address new concerns via phone contact.
• Therapist participation in RO DBT consultation meetings: Many therapists using RO DBT may meet regularly with a consultation team to discuss cases and refine their skills to better aid their caseload.

How Much Does RO DBT Cost?

The cost of therapy depends on whether you’re paying out of pocket or if you have insurance. Paying for mental health therapy through your insurance is often the most affordable option, as you may only have a copay. Call the phone number on the back of your insurance card and ask about your mental health benefits.

Some therapists do not take payments through insurance companies, and instead ask clients to pay “out-of-pocket,” or to use out-of-network benefits. When this is the case, the cost can range from 120 dollars to 200 dollars, depending on the therapist’s education, experience, cost of living, and the cost of doing business in the area.⁵

How to Find a Radically Open DBT Therapist

There are multiple ways to find a therapist. You can use an online directory of skilled and experienced therapists where you can filter your search by type of therapy. Radically Open, the primary organization for RO DBT therapists, also has a directory of therapists with formal training in RO DBT.⁶ Finally, you may also contact a member of your healthcare team such as your primary care provider or psychiatrist for referrals in your area. Thankfully, DBT can be done online as well as in-person.

Key Questions to Ask an RO DBT Therapist When Considering Therapy

When starting with a new therapist, it can be helpful to consult with them first to find out if it’s a good fit. Most therapists will provide a free phone consultation so you can gauge what your relationship might be like before beginning therapy with them.

When you have found a potential RO DBT therapist, here are some key questions to ask:

Do you take my insurance? If not, what is your fee?

For better or worse, it is important to assess how you will pay for the therapy. Ask the therapist if they are in-network with the insurance you have, and if not, what their hourly rate is so you can determine if it is financially feasible for you.

What training and experience do you have with RO DBT?

Ask the potential therapist to review their training and experience with you, so you can determine that they have adequate knowledge in RO DBT. It may be helpful to assess how many years of experience they have, and approximately how many clients they have used RO DBT with.

Do you have experience treating my concerns with RO DBT?

While RO DBT can be used to treat any disorder related to overcontrol, it is still useful to ask your therapist if they have experience treating your unique concerns. This can also help you gauge their overall experience level.

What is your therapeutic style?

One of the best predictors of therapeutic outcomes is the quality of the therapeutic relationship.⁷ Because of this, when you are asking questions, ask them to tell you a little bit about their style as a therapist. As they answer this question, you can assess if you are connecting with their explanation and if you would feel comfortable with them.

Does your RO DBT therapy option include a skills group?

A key component of RO DBT is learning a new set of skills to promote connectedness and to shift social signaling. This typically takes place in a group with multiple clients and one to two therapists teaching the group the skills. Ask the potential therapist if they lead a skills group, and if there is room in the group for you to join.

What to Expect at Your First Appointment

The first appointment tends to be unique in that the therapist is conducting a high-level assessment of your concerns. During this appointment, the therapist is likely to ask you many questions about your history. This may include (but is not limited to) your mental health history, your current physical health, family mental health history, lifestyle factors, and current symptoms.

During this initial session, you can continue to assess if you feel comfortable with this therapist’s approach and style.

Is RO DBT Effective?

RO DBT is a relatively new therapy, but initial studies indicate that it can be very effective:^3,8

• A 2013 study among individuals in an inpatient program found preliminary evidence that RO DBT was effective in treating anorexia, noting that 35% were in full remission, and that 55% were in partial remission.⁹
• A study with 117 subjects with issues related to overcontrol found improved symptoms using RO-DBT.¹⁰
• In 2000, Thomas Lynch (the creator of the therapy) studied depression, personality disorders, and RO DBT. He found that RO DBT had similar positive effects when compared to medication treatment at the start, but that the RO DBT clients fared better in terms of depression symptoms after six months.¹¹
• Lynch again studied depression in 2015, finding that RO DBT led to significantly improved depression symptoms in those subjects compared to the subjects that had “treatment as usual.”¹²

While there is a continued need for randomized controlled studies, which are considered the gold standard of research, these initial findings suggest that RO DBT is effective for a variety of concerns that center on overcontrol.

Risks of RO DBT

There are few risks associated with RO DBT. The primary potential risk is in determining if RO DBT is the correct treatment: If someone is receiving treatment for a disorder of overcontrol, but that is not the core of their mental health concern, then they are not receiving the appropriate treatment and would benefit from another approach. For this reason, it is important to be open with your therapist about the symptoms you are experiencing so they can make an accurate diagnosis and provide the correct treatment.

Final Thoughts on RO DBT

Struggling with a mental health concern such as anxiety, depression, eating disorders, or OCD can be tremendously difficult. Finding and working with a therapist skilled in RO DBT can assist you in building a fulfilling and balanced life.