Psych 3501 Exam 3: Radically Open Dialectical Behavior Therapy

We are at a crossroads: poor treatment response

Across mental disorders, meta-analytic evidence indicates for both psychotherapy and pharmacotherapy, response rates are ~50%

30% of patients with depression have “treatment resistant depression”

50% of patients with anorexia relapse within 2 months of discharge

Having a comorbid personality disorder is associated with treatment drop out and worsened outcomes in anorexia, depression and anxiety

High comorbidity between depression, anxiety, eating disorder, and personality disorder

Many evidence-based therapies:

- Have not been tested on comorbid or chronic populations

- Neglect the role (or don’t assess) personality and personality disorders

One factor of comorbidity: Overcontrol may be present across these disorders and is rooted in personality

Overcontrol

Behavior phenotype

Transdiagnostic

Rooted in personality: a "personality style"

Biosocial model of overcontrol in RO DBT

Radically open dialectical behavior therapy (RO DBT): development

Some patients being treated with CBT, DBT, and exposure therapy were not getting better (treatment resistance)

These patients tend to be overcontrolled

RO DBT emerged from DBT over 20 years of translational treatment development

RO DBT informed by:

- Dialectical philosophy

- Behavior therapy

- Mindfulness-based approaches

- Malamati Sufism: emphasize on we don't know what we don't know, we see things as we are not as they are, bring biases to our perceptions

Radically open dialectical behavior therapy (RO DBT)

Transdiagnostic treatment

Targets maladaptive overcontrol

Does not see depressive or anxiety symptoms, disordered eating etc… as the problem to be targeted

Overcontrol is a problem of emotional loneliness (not emotion dysregulation)

Not lack of social contact, but lack of social connectedness

Emotional loneliness stems from, or is secondary to (the result of), low openness and flexibility and social signaling deficits

Four core deficits of maladaptive overcontrol

1. Lack receptivity and openness

E.g., avoiding feedback and novel situations

2. Lack flexible responding

E.g., compulsive need for structure, rigid responding

3. Lack emotional expression and awareness

E.g., inhibited or disingenuous expressions

What’s showing outside vs. what’s experiencing

4. Lack social connectedness and intimacy

E.g., aloof and distant relationships

Lead to emotional loneliness

RO DBT primary treatment targets

Social signals are treatment targets

Decrease:

- Behavioral maladaptive overcontrol and rigidity

- Aloofness

- Emotional inhibition

Increase:

- Behavioral flexibility

- Openness

- Expression of emotion

By doing this, leading to social connectedness

Social signaling matters

Social signal: any behavior done in front of another person

- May not be intentional or consciously done

- E.g., yawn, tone of voice, interrupting, avoiding, etc.

OC individuals have habitual social signaling styles as coping responses that ends hurting relationships

OC individuals bring perceptual and regulatory biases into social situations that function to isolate them from others

- Heightened threat responding and can’t adjust flexibly

Diary cards & behavioral chain analysis: social signals

Social signals tracked on diary card; targeted in chain analyses

Social signaling matters: it is not what is said, it's "how" we say it

Compared to CBT, the emphasis on emotions and thoughts is much lower

Focused on how behaviors impact interpersonal relationships and lead to emotional loneliness

OC behavioral themes to identify social signaling targets

Inhibited/disingenuous emotional expression

Overly-cautious and hypervigilant behavior

Rigid and rule governed behavior

Aloof & distant relationships

High social comparisons with envy and bitterness

"Standard DBT" vs. RO DBT: similarities

RO DBT "emerged" from standard DBT

Both based on dialectics and behavioral principles with a biosocial model

Highlight importance of mindfulness and therapeutic relationship

Structure similar:

- Weekly individual therapy

- Weekly skills class/group

- Phone coaching

- ~30 weeks

- Therapist consultation

Individual therapy structure: treatment hierarchy, diary cards to monitor treatment targets, chain and solution analysis

"Standard DBT" vs. RO DBT: differences

undercontrol vs. overcontrol

emotion dysregulation vs. emotional loneliness

internal therapeutic focus vs. external therapeutic focus

therapy-interfering behaviors vs. therapeutic alliance ruptures

informed by Zen Buddhism vs. Malamati Sufism

Emerging research evidence

Treatment-resistant depression

Project RefraMED: multi-site RCT for treatment-resistant depression

RO-DBT associated with lower depressive symptoms, high effect size

Increasing psychological flexibility and social connectedness mechanistically led to decreased depressive symptoms

Anorexia

4 feasibility trials and case series trials: large effect sizes; increase BMI, decrease eating disorder symptoms, decrease medical problems, comorbid symptoms, cognitive inflexibility and social isolation/withdrawal

Heterogeneous overcontrolled samples (transdiagnostic)

Case series: Autism Spectrum Disorder subsample decrease in global distress

Just the skills component: RO DBT skills vs. TAU: decreased overall psychopathology, distress, and emotional suppression

Adolescents

Case series for adolescents: decreased eating disorder, depressive, anxiety, self-harm symptoms and overcontrol; increased cognitive flexibility, reward processing, emotional expression

Systematic review

Emerging evidence for adolescents and adults

While RO DBT shows promise as a treatment for disorders of overcontrol, further research is needed

Big 3+1: one skill we focus on for RO DBT

When an OC individual in novel/unsafe/feels challenged:

defensive-threat system goes on alert ->

Flexibility decreases and social signaling goes to habitual coping mechanisms

"Activate social safety": physiological signal to tell my body that I'm in a safe place

Big 3+1

1. Slow deep breath (belly breath)

2. Closed-mouth cooperative smile

3. Eyebrow wag

+1 (if seated): lean back in your chair at the start

Interpersonal skills: intimacy thermometer & match + 1

Relationship that you want to move closer with

People vary in how much intimacy they desire (set points), and that is ok

Noticing intimacy differences can be helpful in understanding some relationship issues

To increase closeness/intimacy: Match + 1

Match the other person's self-disclosure and then go one level higher by revealing more personal details, genuine opinions and emotions about yourself

Get people start showing emotions without big jumps

Match + 1 is not asking questions of about the other person

Not match + 1000