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=Overview= Radically Open Dialectical Behavioural Therapy (RO-DBT) is a significant adaptation of standard Dialectical behavior therapy (DBT), a psychotherapy developed by Marsha M. Linehan. RO-DBT was originally developed by Professor Tom Lynch as a trans-diagnostic treatment for mental disorders characterised by excessive inhibitory control or ‘over-control’, including chronic depression and anorexia nervosa.Thus, RO-DBT can be contrasted with standard DBT, which was developed for patients with borderline personality disorder. These patients typically present with difficulties in emotional regulation and are often described as ‘under-controlled’.

=Self-control vs. over-control= Although ‘self-control’ is typically thought to be desirable—and uncontrolled behavior is often censured—excessive self-control is an underlying factor in many treatment-resistant conditions. Excessive self-control is associated with social isolation, poor interpersonal functioning, and can result in severe and difficult-to-treat mental health problems, such as anorexia nervosa, chronic depression, and obsessive–compulsive personality disorder

=Etiology and consequences of over-control= RO-DBT is informed by a biosocial theory positing that over-control develops through an interaction of temperamental biases and early family/environmental experiences. Specifically, it is thought that individuals with heightened threat sensitivity (see also the concept of hypervigilance) and low reward sensitivity are particularly vulnerable in environments in which control is emphasised and mistakes are regarded as intolerable.

Sensitivity to threat is considered to be especially important because feeling safe activates the parasympathetic nervous system, and facilitates pleasure, social engagement and pro-social behaviours. Parasympathetic activity also mediates activity of facial muscles that are responsible for maintaining eye contact, listening to human speech and making appropriate facial expressions. As a consequence, according to the theory, people with over-control find it difficult to relax in social encounters and their ability to signal co-operation to others is severely compromised.

=Treatment targets and format= Like standard DBT, patients typically receive RO-DBT in individual sessions with a psychotherapist, with parallel attendance at group sessions. Some studies have evaluated the effect of group sessions alone. Treatment strategies in RO-DBT derive from the theory that three, interrelated traits are required for emotional well-being:


 * 1) Receptivity and openness to feedback, even when this is challenging
 * 2) Flexibility in our responses to changing environmental demands, and
 * 3) Recognition that emotions evolved to communicate, and that expressing emotion is an important social signal to others which helps us form close interpersonal bonds.

Elements of treatment in common with standard DBT

 * Mindfulness skills
 * Interpersonal effectiveness

Elements of the treatment which are new or significantly differ from standard DBT

 * Emotional regulation skills: Both DBT and RO-DBT focus on emotional regulations skills, in particular recognizing emotions as they arise and regulating non-constructive feelings. However in DBT the goal is the under-regulation of feelings arising from or leading to erratic and impulsive behaviours;whereas, RO-DBT targets patients' tendencies A) to mask their feelings and B) to engage in frequent social comparisons which typically lead to bitterness or feelings of envy. Thus, in RO-DBT techniques encourage the expression of emotions and abstinence from thoughts leading to envy or bitterness.
 * Radical Openness: Not be confused with Radical Acceptance which has proved helpful for patients who have difficulties regulating strong emotions, Radical Openness aims to help a person become more open to new experiences, especially when old ways have proven unhelpful or unsuccessful. It’s best described as a process by which one (both patient and therapist) embraces the need to make mistakes and actively tries to learn about hidden and problematic aspects of their personality by experimenting with new situations and behaviours, thus letting go of the need to control.

Elements of standard DBT which are de-emphasised by RO-DBT
Distress tolerance: Over-controlled patients typically display quite high levels of distress tolerance, and less time is spent in teaching distress tolerance in RO-DBT than standard DBT. However groups may address two related skills: self-soothing and radical acceptance, which are found to be helpful for patients who are anxious or exhibit perfectionism.

=Research on RO-DBT=
 * Published clinical trials: Although reports from clinicians are extremely promising, only limited trial data is available on the effectiveness of RO-DBT at present:
 * In a study which randomised depressed older adults (60 years and older)to antidepressant medication and medication plus RO-DBT, the medication+RO-DBT group showed significant improvement in depression as measured by a self-report questionnaire.Medication+RO-DBT patients also showed improvements on dependency and adaptive coping that, proposed act as vulnerability factors for depression;at a 6 mo follow-up of the trial, 75% of medication+RO-DBT patients were in remission from depression, compared with only 31% of patients only receiving medication.
 * A randomized trial focused on chronically depressed older adults with a personality disorder who did not respond to treatment with antidepressants . Patients treated with RO-DBT in addition to medication and clinical management reached remission in depression earlier than patients who received pharmacological treatment and clinical management alone. Moreover, the patients who received RO-DBT demonstrated an increase in interpersonal skills.
 * In a recent non-controlled trial with severely underweight adult anorexia nervosa inpatients 35% of participants achieved full remission (as measured by increase in Body Mass Index) and 55% were in partial remission.The patients also showed improvements in eating disorder-related quality of life and psychological distress.


 * Forthcoming studies:At least 2 randomised trials of RO-DBT are currently underway or in preparation.
 * REFRAMED 1: This large trial of RO-DBT for patients with chronic depression is funded by the National Institute for Health Research Efficacy and Mechanisms scheme. The trial received ethical approval on 20/06/2011 and began recruiting in 2012. It is due to report in 2016.
 * REFRAMED 2: This planned randomised trial will recruit and treat outpatients with anorexia nervosa at 6 sites including the Haldon Clinic in Exeter and the Maudsley Hospital in London (part of the Institute of Psychiatry). Funding arrangements are still to be finalised.


 * Other experimental data: Numerous experimental studies which purport to support the underlying biosocial model have been published   . Many are accessible via the Southampton University Emotion and Personality Bio-behavioural Laboratory

=RO-DBT in clinical practice= Approximately XXX health professionals are now trained in RO-DBT and are thought to apply the techniques in their clinical practice. Several clinics around the world offer RO-DBT as part of their practice. A specialist NHS eating disorder service in the UK (the Haldon Clinic in Exeter) has adopted RO-DBT as the core element of their treatment programme, and this has been welcomed by patient advocate groups including B-EAT.

=Training in RO-DBT= Several commercial providers offer RO-DBT training in Europe and the USA

=External links=


 * The web page of Professor Tom Lynch at the University of Southampton
 * An article on the core features of personality disorders by MentalHelp.net
 * Description of the study on Radically Open DBT with chronically depressed patients
 * Description of the therapeutic program of the Riley Center for Eating disorders
 * Format of RO- DBT Skills Group sessions by the  California DBT Peninsula Associates
 * The Haldon treatment approach by the Devon partnership NHS
 * Report on on the treatment programme adopted by Devon NHS Trust

=References=