I recently attended a webinar about Radically Open – Dialectical Behaviour Therapy (RO-DBT) presented by the originator Thomas Lynch. He is a great and engaging presenter who I have seen before. I walked away both times thinking is there something more to this that I don’t understand. Below are some of my thoughts about how we may use principles of RO-DBT in eating disorders treatment.

Some parts of RO-DBT resonate with me. It sees anorexia nervosa, particularly in its more severe and enduring form (and perhaps where autism spectrum disorder is comorbid – thought to be about 30% of women with AN), as a disorder of over-control. Whereas self-control is usually valued in society, over-control (and under-control) is seen as maladaptive.

RO-DBT in eating disorders. Figure demonstrating bell curve of self-control tendencies.

Over-control is characterised by:

  1. Low receptivity and openness to novel experiences, diminished reward sensitivity, intolerance of uncertainty, hypervigilance for threat and a tendency to discount contrary feedback.
  2. Low flexibility, which is high levels of self-control, a focus on details, a need for structure, rule governed behaviour, high social obligation and a high moral certitude (everybody must follow the rules)
  3. Inhibited emotional expression where not appropriate for the context (same expression at church, at a party and at a football game) or incongruent emotional expression (smiling when distressed, saying “I like you” when clearly you don’t) and low awareness of bodily sensations
  4. Low social connectedness and intimacy with others, manifested by distance in relationships, feeling different from others, frequent social comparisons and reduced empathy.

This does seem a pretty apt description of some people with anorexia nervosa (but not all).  There is data to support most of these features in the personality of someone with anorexia nervosa. So, RO-DBT in eating disorders has a high level of face validity. Lots of smart people are incorporating it into treatment programs. 

Social Signalling

The key treatment described in RO-DBT is to help people improve ‘social signalling’. Which at times felt a bit like showing people how you really feel. But social signalling is about using both words and facial expressions so that your brain feels safer in a social situation, and others around you feel safer. This increases a sense of social connection.  Some techniques are pretty simple – like using your eyebrows to signal that you are not a threat (look at this video https://www.youtube.com/watch?v=O6KBPGQPswQ 

for an example and because it is funny, and laughing is good). I can see how this is a good social skill for everyone to learn to increase the feeling of social connectedness. 

It seems however, that there is an assumption that feeling more socially connected would make it easier to eat. That seemed to be the proposed mechanism for change in anorexia nervosa in RO-DBT. I am not so sure that it works that way. It might, but it feels more complex than that to me. (This of course may be because I can be somewhat closed to new ideas!!)

RO-DBT Studies

There have been a few studies including RO-DBT in anorexia nervosa. It is now used in the day treatment program at Maudsley hospital in London. Research suggests that the program is helpful, but that may be because of the setting of intensive group treatment, rather than the RO-DBT itself. In another study, Lynch himself authored a paper looking at using RO-DBT in an inpatient setting. Patients gained weight – but because of the setting or the RO-DBT cannot be determined, as neither of these studies had control groups. 

There is also an interesting study that compared an individual when on a waitlist to the same individual when receiving full RO-DBT (30 individual sessions and 30 group sessions). Same problem really. I would hope that someone receiving any treatment (especially this much) would have more change than someone receiving no treatment on a waitlist. Patients also received a treatment focused on their low weight (so at best we are looking at an adjunct treatment). Not surprisingly, some treatment is better than no treatment.

Mindfulness

There is a significant mindfulness component to RO-DBT. This includes observing and not responding to urges to restrict or purge, which I think does have a central component to helping someone with anorexia nervosa. There is also a loving kindness component. One exercise that I did find helpful was what they call ‘self-reflection’. This is where you ask “what do I need to learn from this situation or emotion?”. Another example that I thought was a good question was “What do I need to learn here that would help me be more self-compassionate?”. This felt helpful.

Overall, I suspect that RO-DBT is a helpful set of techniques, to compliment treatments more focused on treating the symptoms of anorexia nervosa. Maybe.

Further Reading & Studies Mentioned

  1. Baudinet et al (2020) Targeting maladaptive overcontrol with radically open dialectical behavior therapy in a day programme for adolescents with restrictive eating disorders: an uncontrolled case series. Journal of Eating Disorders. https://jeatdisord.biomedcentral.com/articles/10.1186/s40337-020-00338-9 
  2. Hempel et al (2018) Radically Open DBT: Targeting emotional loneliness in anorexia nervosa Eating Disorders. https://www.tandfonline.com/doi/abs/10.1080/10640266.2018.1418268 
  3. Isaksson et al (2021) Radically open dialectical behavior therapy for anorexia nervosa: A multiple baseline single-case experimental design study across 13 cases. Journal of Behavior Therapy and Experimental Psychiatry. https://www.sciencedirect.com/science/article/pii/S0005791621000021 
  4. Lynch et al (2013) Radically open-dialectical behavior therapy for adult anorexia nervosa: feasibility and outcomes from an inpatient program. BMC Psychiatry Vol 13. https://link.springer.com/article/10.1186/1471-244X-13-293