A New Treatment for OCPD? A Review of RO DBT (Radically Open Dialectical Behavior Therapy)

There’s a new treatment for OCPD. Well, maybe for some with OCPD.

A few years ago, in regard to a post describing different psychotherapies for OCPD (obsessive-compulsive personality disorder), a reader asked in a comment why I hadn’t mentioned RO DBT (Radically Open Dialectical Behavior Therapy). I had been unaware of this form of therapy at the time, but have since tried to educate myself about it.

Here’s what I’ve found out, and what I think about it.

First, a disclaimer. I am not formally trained in RO DBT, nor have I been in therapy with anyone trained in RO DBT.

And, there’s a lot to it. I can’t possibly cover it all in one post. My goal here is to simply introduce readers to the theory and practice as it relates to obsessive-compulsive personality, and to share my take on it as a clinician who specializes in treating obsessive-compulsive personality.

I also hope that the discussion regarding self-control and expressiveness will spur insights into your own personality for your own personal work.

Origins of Radically Open Dialectical Behavior Therapy (RO DBT)

Thomas, R. Lynch, Ph.D, a psychologist trained in the US but now working in the UK, has been developing RO DBT over the past 20 years to help people whose personalities are characterized by “overcontrol.”

Lynch began with the treatment protocol known as Dialectical Behavior Therapy (DBT) as a model. DBT is a form of cognitive behavioral therapy originally designed for people people who suffer from Borderline Personality Disorder (BPD). People with BPD tend to be undercontrolled. They have difficulty restraining themselves, and tend to over-react to their emotions.

Lynch realized that people who are overcontrolled need a very different form of treatment, but felt that much of the structure from DBT could still be helpful to them. RO DBT follows a protocol: the weekly therapy sessions themselves are more structured, clients attend skills training sessions every week, and they have daily homework assignments.

What is Overcontrol?

Lynch believes that maladaptive overcontrol is characterized by four core deficits:

• Low receptivity and openness
• Low flexible-control
• Pervasive inhibited emotional expression and low emotional awareness
• Low social connectedness and intimacy with others

.

People who are overcontrolled also tend to be:

• detail-focused
• restrained
• perfectionistic
• cautious
• disciplined
• structured
• conscientious
• reserved
• planful
• dutiful

.

He believes that overcontrol is characteristic of anorexia, chronic depression, autism spectrum disorders, and OCPD, and offers RO DBT as a treatment for all of these conditions.

The Underlying Theory of RO DBT

According to Lynch, “Psychological well-being involves the confluence of three factors: receptivity, flexibility and social connectedness.”

Receptivity and Flexibility

People who are overcontrolled have become so rigid, and are in such a state of defensive arousal, that they’ve lost the ability to take in new information.  They are very tuned in to possible threats, and tuned out to possible rewards. This discourages them from taking risks and engaging socially.

The result is an effort to avoid mistakes by limiting self-expression. This certainly happens to many people with OCPD.

Poor Social Signaling

Limiting self-expression results in poor social signaling.

Social signaling is whatever you say or do that communicates to others. It leads to either positive or negative connections with others. This can inhibit emotional expression (for example, showing no emotions if you’re given a compliment) or lead you to pretend you feel things you don’t feel (for example acting as if you’re concerned when you really aren’t, or smiling when you really feel distressed). Or, you might appear aloof and convey that you have no interest in others, even if you do.

(My observation is that poor social signaling in obsessive-compulsives includes disinterest, distraction, disdain, aloofness, or bluntness. It often results from an unwillingness to express appreciation or admiration for others unless they are absolutely perfect.)

If your social signaling is poor, others are less likely to engage with you, which leads to even greater inhibition of expression. People then trust you less, and relationships feel less satisfying and dependable. The proverbial downward spiral takes over.

And it’s not just how much you share about yourself, but also how you share yourself, how expressive you are when you do share yourself.

People with overcontrol also tend to have low empathy, which also discourages social connection.

Treatment

Treatment for overcontrol in RO DBT is highly structured.  Clients attend both weekly therapy sessions and weekly classes. They are also asked to keep a daily “diary card.”

Therapy Sessions

Therapists are told to “stick to the script” when they are explaining the principles of RO DBT. But they are also encouraged to express themselves personally and to be silly. The therapist is encouraged to serve as a “tribal ambassador,” welcoming patients back to the human clan.  Clients are encouraged to identify the values that are important to them.

Body language gets lots of attention. Therapists teach clients about “the deliberate employment of gestures, postures, and facial expressions that communicate relaxation, friendliness, and nondominance.”

Diary Cards

Clients are required to record, on a daily basis, the presence, frequency and intensity of social signaling events, perfectionism, and rigidity.

Classes

Each class lasts for two and a half hours. Both classes and sessions focus on five themes:

1. Inhibited and disingenuous emotional expression;
2. Hyper-detailed, focused and overly cautious behavior;
3. Rigid and rule-governed behavior;
4. Aloof and distant style of relating;
5. High social comparison and envy/bitterness.

My Take on RO DBT

PROS:

I find much of the theory to be helpful and it resonates with my own experience.

Control is described as prosocial at its core. Control has its evolutionary advantages and has helped us to survive and thrive. I like both the evolutionary perspective and the recognition of the positive potential inherent in control.

RO DBT suggests that the problems over-control causes result from poor social signaling rather than narcissism or lack concern for others. It emphasizes genetic predilections, and, at the same time, acknowledges the role that family and culture play in developing a restrictive coping strategy.

RO DBT strongly encourages clients to articulate what’s most important to them. I believe that forgetting what’s really important is one of the most problematic characteristics of OCPD, so this also resonates with me.

I found it helpful to read about their treatment protocol, and suspect that it would be helpful to other clinicians as well, even if they choose not to train as RO DBT clinicians. Just as one example, some people with overcontrol may experience gaze as scrutiny, and concern as criticism, and therapists may need to turn the heat down when that occurs.

Even with the structure and scripting of the therapist’s role, RO DBT encourages its therapists to use humor, authenticity and self-revelation in service of the therapy. It also requires its therapists to undergo their own therapy. These are all laudable directions in my opinion.

CONS:

Theory

My disagreements with the theory are mostly a matter of emphasis.

It seems to me that RO DBT emphasizes social motivations at the expense of individuation and mastery as powerful motivators. The main suggestion coming out of RO DBT is that clients learn to behave and express themselves in ways that communicate that they do want connection. This is their key mechanism for change. Lynch assumes that clients feel lonely and isolated, but many of the people I see do not feel that way.

RO DBT gives less emphasis to the rich research of positive psychology and the long history and wisdom of self-realization explored by Jung, Maslow, Rogers and others. Lynch believes that all of these values are secondary to social values: we value achievement and mastery because they contribute to the social good.

It seems to me that Lynch leaves out the deep instinct for individual survival, achievement, and personal growth. Since being driven is so often a defining and intrinsic feature of the obsessive-compulsive personality, it may leave some feeling misunderstood.

Treatment

Structure and Practical Concerns

I have more questions about the treatment that RO DBT proposes. While I agree that commitment to regular sessions is essential, what happens in those sessions is more spontaneous in my approach. RO DBT is a manualized treatment, and I prefer to work more freely with whatever comes up, though always relating that material to the major themes we’ve identified.

I do find it helpful when my clients are also engaged in classes, support groups, or group therapy, and suspect that the RO DBT skills training sessions would be helpful as well. But these might not be practical for many of my patients.

I do give “homework assignments” when my clients ask for them, and on occasions when it seems essential for a client to do some work on a particular subject outside of the session. But I find that requiring them on a regular basis breeds more resistance and guilt feelings than progress.

The process is designed to be very focused, which may appeal to some. Others may find it off-putting.

It may be a productive challenge for people who have a hard time delegating and letting go of control to engage this way, but it may also be too much of a stretch for many.

Priorities: Known or to be Discovered?

While I think it’s great that RO DBT suggests that clients name what’s most important to them, it seems to me that RO DBT has decided in advance what that is.  The therapist seems to begin with the understanding that they know what ails the client (isolation), and what they need to do differently (improve their social signaling), rather than joining with him or her to discover what the problem is and how to fix it.

RO DBT Not Specific to OCPD

RO DBT is designed for all forms of overcontrol, including autism, depression and anorexia. That’s a pretty wide net and therefore less specific to OCPD. While Lynch and his colleagues have done a lot of their own research to make sure they’re on the right track, there don’t appear to be any studies giving evidence that RO DBT can effect change in those with OCPD.

Even if it is effective for some subtypes of OCPD, it may not apply as well to all subtypes of OCPD.

For instance, it may not account for the obsessive-compulsive person who uses their perfectionism to try to control what others think of them. The people-pleaser subtype of OCPD can meet the criteria for OCPD and still be extremely over-sensitive to how they come across to others, in contrast to the clients RO DBT is designed for, who are unaware of how they come across to others.

Further, the unhealthy leader/teacher subtype of OCPD who becomes bossy or even tyrannical may not be well characterized as overcontrolling. Their tendency to be mercilessly critical calls for the development of greater self-control, rather than less.

While it’s good to acknowledge that even these clients may not accurately gauge what people really want from them, and that they might benefit from feedback on how they come across to others, the default assumptions and techniques of RO DBT may need to be altered for certain subtypes of OCPD.

Therapist as Teacher

The attempt to teach body language (e.g. smiling, eye contact, facial expression, mirroring the expressions of others) would probably leave me feeling daunted, no matter how skillful the therapist was. My own goal is to be authentic, and the suggestions for both therapist and client to monitor body language leaves me feeling self-conscious and tangled. I prefer to work from the bottom up, with emotions, so that these sorts of changes evolve organically.

The “therapist” in this program seems to be much more of a teacher than a healer or someone who engages in a joint exploration of the client’s personality and psychological needs. The therapist is described as an ambassador that welcomes the client back into the fold of humanity, which some therapists might feel comfortable with, but doesn’t resonate for me.

And some clients may be more naturally inclined to live at the edge of community, rather than smack dab in the middle of it.

The Take-Away: Can RO DBT Help with OCPD?

If you’re willing to make the commitment to the sessions, classes, and homework, and you have a good fit with your therapist, RO DBT  may well be very helpful, especially if your tendency is to control yourself in ways that limit your relationships.

Lynch and his colleagues are very savvy. Clearly a lot of thought has gone into the development of RO DBT. They prioritize checking in with clients to see how things are going, and whether the therapist is meeting their needs. A well-trained and flexible therapist might work through each of my concerns skillfully.

And each of these issues reflect clinical decisions that could go either way. It’s partly a matter of personal and practical fit for both the therapist and the client. I suspect that it would be more helpful for some subtypes of OCPD than others.

The developers of RO DBT seem to be continually refining their process, and fine-tuning it to particular populations, such as adolescents. My hope is that they continue to modify it to suit the needs of those with OCPD, and to acknowledge that OCPD looks different on different people.

Self-Monitoring Overcontrol and Social Signaling

Meanwhile, even those that may not choose to enter RO DBT can learn from it by monitoring how they inadvertently express themselves, and actively seeking feedback from others about how they come across.

People with obsessive-compulsive personalities can come across in ways they don’t intend. I’ve explored the results of this in a previous post, How Self Control and Inhibited Expression Hurt Relationships.

If we can be aware of these potential pitfalls, and more accurately convey what we really do feel, it’s more likely that we can make use of the productive potential that comes with the obsessive-compulsive personality.