Radically Open-Dialectical Behavior

Therapy for Disorders of Over-Control:

Signaling Matters

THOMAS R. LYNCH, Ph.D., FBPsS*

ROELIE J. HEMPEL, Ph.D.*
CHRISTINE DUNKLEY, DClinP#
Radically Open-Dialectical Behavior Therapy (RO-DBT) is a transdiagnostic
treatment designed to address a spectrum of difficult-to-treat disorders shar-
ing similar phenotypic and genotypic features associated with maladaptive
over-control—such as anorexia nervosa, chronic depression, and obsessive
compulsive personality disorder. Over-control has been linked to social
isolation, aloof and distant relationships, cognitive rigidity, high detailed-
focused processing, risk aversion, strong needs for structure, inhibited emo-
tional expression, and hyper-perfectionism. While resting on the dialectical
underpinnings of standard DBT, the therapeutic strategies, core skills, and
theoretical perspectives in RO-DBT often substantially differ. For example,
RO-DBT contends that emotional loneliness secondary to low openness and
social-signaling deficits represents the core problem of over-control, not
emotion dysregulation. RO-DBT also significantly differs from other treat-
ment approaches, most notably by linking the communicative functions of
emotional expression to the formation of close social bonds and via skills
targeting social-signaling and changing neurophysiological arousal. The aim
of this paper is to provide a brief overview of the core theoretical principles
and unique treatment strategies underlying RO-DBT.

KEYWORDS: Radical openness; dialectical behavior therapy; social

signaling; psychological flexibility; emotion inhibition

INTRODUCTION
Until recently, the majority of treatment interventions targeting per-
sonality disorders (PDs), including standard dialectical behavior therapy

* School of Psychology, University of Southampton, Highfield Campus, Southampton, UK,

# Southern Health NHS Foundation Trust, Hampshire, UK. Mailing address: Thomas R. Lynch,
Professor of Clinical Psychology, School of Psychology, University of Southampton, Highfield
Campus, Southampton, SO17 1BJ, United Kingdom. e-mail: [email protected]
AMERICAN JOURNAL OF PSYCHOTHERAPY, Vol. 69, No. 2, 2015

141
AMERICAN JOURNAL OF PSYCHOTHERAPY

(DBT), have tended to target borderline personality disorder (BPD)—a

disorder characterized by low inhibitory control and dysregulated/impul-
sive behavior (see Dixon-Gordon, Turner, & Chapman, 2011 for review).
In contrast, radically open-dialectical behavior therapy (RO-DBT), a new
treatment approach with strong roots in standard DBT, targets a spectrum
of disorders sharing similar genotypic and phenotypic features linked to
excessive self-control or over-control (T. R. Lynch, in press; T. R. Lynch &
Cheavens, 2008; T.R. Lynch, Hempel, & Clark, 2015; T. R. Lynch et al.,
2013).
Over-control (OC) has been linked to social isolation, aloof and
distant relationships, cognitive rigidity, high detail versus global pro-
cessing, risk aversion, strong needs for structure, inhibited emotional
expression, hyper-perfectionism, social-isolation, and the development
of severe and difficult-to-treat mental health problems, such as chronic
depression, anorexia nervosa, and obsessive compulsive personality disorder
(Asendorpf, Denissen, & van Aken, 2008; Anderluh, Tchanturia, Rabe-
Hesketh et al., 2009; B.P.Chapman & Goldberg, 2011; A.L.Chapman, Lynch,
Rosenthal, et al., 2007; Eisenberg, Fabes, Guthrie, & Reiser, 2000; Riso et al.,
2003; Zucker et al., 2007). While resting on the dialectical underpinnings of
standard DBT, the therapeutic strategies, core skills, and theoretical perspec-
tives in RO-DBT often substantially differ. For example, RO-DBT contends
that emotional loneliness secondary to low openness and social-signaling deficits
represents the core problem of over-control, not emotion dysregulation as
posited in standard DBT (Linehan, 1993). Individuals characterized by over-
controlled coping tend to be serious about life, set high personal standards,
work hard, behave appropriately, and frequently will sacrifice personal needs
in order to achieve desired goals or help others; yet inwardly they often feel
“clueless” about how to join-in with others or establish intimate bonds. Thus,
over-control works well when it comes to sitting quietly in a monastery or
building a rocket; but it creates problems when it comes to social connected-
ness.
RO-DBT is supported by 20⫹ years of translational research; including
two NIMH funded randomized controlled trials (RCTs) targeting refrac-
tory depression and comorbid OC personality dysfunction (T. R. Lynch et
al., 2007; T. R. Lynch, Morse, Mendelson, & Robins, 2003), two open-
trials targeting adult Anorexia Nervosa (Chen et al., 2014; T.R. Lynch et
al., 2013), one non-randomized trial using RO-skills alone for treatment
resistant adults with over-control (Keogh et al., in prep.), and a large
ongoing multi-center RCT targeting refractory depression and over-con-
trolled personality disorders (http://www.reframed.org.uk; Lynch chief
142
Radically Open-DBT for Over-control: Signaling Matters

investigator). The aim of this paper is to briefly outline the theoretical

foundations of RO-DBT and to overview some of the unique structural or
treatment strategies that differentiate the treatment from standard DBT
and other treatment approaches targeting chronic and/or treatment resis-
tant disorders.
A TRANSDIAGNOSTIC PERSPECTIVE: SELF-CONTROL AS AN
OVERARCHING PRINCIPLE
RO-DBT posits that bio-temperamental deficits/excesses combined
with cultural or family values for self-control functions to handicap
openness, flexible responding, and cooperative social-signaling; resulting
in habitual over-control or under-control of socio-emotional behavior
(T. R. Lynch, in press; T.R. Lynch, Hempel, & Clark, 2015; T. R. Lynch
et al., 2013)—sharing features with the well-established division be-
tween internalizing and externalizing disorders (Achenbach, 1966;
Crijnen, Achenbach, & Verhulst, 1997). Broadly speaking self-control
refers to the ability to inhibit emotional urges, impulses, and behaviors
in order to pursue long-term goals. Examples of under-controlled
disorders are conduct disorder, antisocial PD, borderline PD, and
binge-purge eating disorder; examples of OC disorders are obsessive
compulsive PD, avoidant PD, paranoid PD, and difficult-to-treat con-
ditions such as anorexia nervosa, autism spectrum disorders, and
chronic depression. Importantly, under-control and over-control are
not one-dimensional constructs—that is, they are not simply opposite
ends of a self-control continuum. They are “labels” used to describe a
complex set of bio-psycho-social behaviors shared by a spectrum of
disorders with similar genotypic/phenotypic features.
The above perspective has clear treatment implications; (i) treatments
should not assume client capabilities for openness and flexible responding
already exist, which emphasizes the need for skills-based approaches, and
(ii) undercontrolled problems require interventions designed to enhance
inhibitory control, delay gratification in order to achieve long-term goals,
plan ahead, and decrease impulsive mood-dependent behavior. Whereas,
over-controlled problems need interventions designed to relax rigid inhib-
itory control and increase openness, flexible-responding, pro-social signal-
ing, and emotional expressiveness. Thus, when it comes to treatment,
RO-DBT posits that “one size does not fit all”—instead core genotypic/
phenotypic differences between groups of disorders necessitate oftentimes
vastly different treatment approaches.
143
AMERICAN JOURNAL OF PSYCHOTHERAPY

Figure 1.
A NEUROBIOSOCIAL THEORY FOR OVER-CONTROLLED DISORDERS

A NEUROBIOSOCIAL THEORY FOR OVER-CONTROL

Radically open-DBT treatment strategies targeting loneliness and social
isolation are informed by a neurobiosocial theory (T. R. Lynch, in press;
T.R. Lynch, Hempel, & Clark, 2015; T. R. Lynch et al., 2013) that
deconstructs emotion regulation into three broad temporally sequenced
components:
(1) perceptual encoding factors (sensory receptor regulation) that pre-
cede
(2) internal modulatory factors (central-cognitive regulation) which
then result in
(3) social-signals or external behavioral expressions (response selection
regulation).
Separating overt behavioral regulation from internal central-cognitive
regulation helps explain why a person can “feel” anxious inside yet not
display any “overt” signs of anxiety on the outside.
Maladaptive over-control is theorized to develop and to be maintained
through a combination of three overarching factors associated with socio-
emotional well-being: bio-temperamental and genetic predispositions (na-
ture), family-environmental influences (nurture), and self-control tenden-
cies (coping). Specifically, bio-temperamental predispositions for heightened
threat sensitivity, diminished reward sensitivity, high inhibitory control
capacities, and superior attention for details are posited to transact with
early family/cultural experiences emphasizing mistakes as intolerable and
self-control as imperative, resulting in an over-controlled coping style that
limits opportunities to learn new skills and establish close social bonds (see
Figure 1).
144
Radically Open-DBT for Over-control: Signaling Matters

Heightened OC temperamental threat sensitivity, diminished reward

sensitivity, and high detail-focused processing function to influence per-
ception; making it more likely that novel or discrepant stimuli will not only
be detected but evaluated at the sensory-receptor level as dangerous— e.g.
when walking into a rose garden, the OC brain is more likely to notice the
thorns not the flowers, as well as the misaligned brick in the garden wall.
Over-controlled heightened bio-temperamental predispositions for high
self-control are often exacerbated by cultural or family-environmental
experience. The early environment of a client with OC has often punished
making mistakes, imprecision, requests for nurturance, displays of emo-
tion, and/or playful spontaneity. In contrast, the early environment often
rewards high tolerance of pain or distress, resistance of temptation, high
achievement and winning, rigid adherence to rules, and detection of minor
errors or discrepancies. Over-controlled coping emerges as a result of
these “nature-nurture” transactions.
A major component of the biosocial theory is that individuals who are
over-controlled often unintentionally bring mood states and associated
behaviors into social situations that function to isolate them from others.
Heightened OC threat sensitivity makes it more difficult for them to enter
into their neurologically based social-safety system (T. R. Lynch, in press;
T.R. Lynch, Hempel, & Clark, 2015; T. R. Lynch et al., 2013; T. R. Lynch,
Lazarus, & Cheavens, 2015). When an individual does not feel safe, the
autonomic nervous system is activated— defensive arousal and fight or
flight responses become dominant. Facial expressions freeze, and we lose
the ability to flexibly interact with others. For the OC individual, defensive
arousal and frozen expression (or exaggerated insincere pro-social expres-
sion) is common. These behaviors are partly influenced by heightened
bio-temperamental threat sensitivity and partly influenced by social feed-
back from an early age implying that it is imperative to control oneself and
avoid an appearance of incompetence. As a consequence, clients who are
over-controlled work very hard to avoid mistakes, become increasingly
sensitive to perceived criticism, and base their self-worth on how their
performance compares to the performance of others. This can lead to
rigidly controlled and risk-averse styles of interacting that interfere with
new learning and the formation of social bonds (e.g., via automatic
rejection of feedback, avoidance of novelty or social situations, frozen or
disingenuous expressions, and compulsive desires for structure and order).
Unfortunately, extreme OC behavior elicits from others the very thing the
OC style is “designed” to prevent, that is people tend to avoid individuals
with OC and find their emotionally constricted, disingenuous, and inhib-
145
AMERICAN JOURNAL OF PSYCHOTHERAPY

ited style of expression uncomfortable to be around. Consequently, the

OC individual finds himself or herself increasingly isolated and lonely,
which exacerbates psychological distress.
Although both RO-DBT and standard DBT posit that emotions func-
tion to motivate actions and communicate intentions, RO-DBT differs from
standard DBT (and other treatments) by hypothesizing that in humans
emotions also function to facilitate the formation of strong social bonds
essential for species survival (via proprioceptive feedback; see T. R. Lynch,
in press). When compared to other animal species humans are not
particularly physically robust (e.g., we lack thick hides, protective fur, or
sharp claws). From an evolutionary perspective, our frailty necessitated the
development of a means to bond genetically diverse individuals in such a
way that survival of the tribe could override phylogenetically older “selfish”
response tendencies linked to survival of the individual. We hypothesize
that proprioceptive feedback and facial affect micro-mimicry reflect core
means by which this capacity is developed (see below). This capacity
provided us with a unique evolutionary advantage—allowing us to form
strong social bonds and share valuable resources with other members of
our species who were not in our immediate nuclear family. Consequently,
RO-DBT strongly emphasizes the tribal nature of our species—positing
that psychological well-being among humans depends greatly on our
visceral experience of social connectedness.
SIGNALING MATTERS
Research has demonstrated that masking inner feelings (or incon-
gruence between felt experience and displayed behavior) makes it more
likely that others perceive the incongruent person as untrustworthy or
inauthentic (e.g., Boone & Buck, 2003; Eisenberg et al., 2000; Kernis &
Goldman, 2006). This heightens defensive emotional arousal in those
interacting with the suppressor, and impairs the development of social
closeness (e.g., Butler et al., 2003; Srivastava, Tamir, McGonigal, John,
& Gross, 2009). In addition, individuals who habitually suppress
expressiveness report feeling more inauthentic and greater discomfort
with intimacy compared to those who do not suppress (Gross & John,
2003). Thus, signaling matters when treating clients who are over-
controlled: They are masters of self-control yet struggle communicating
openness, cooperation, and warmth— essential skills needed to estab-
lish strong social bonds. In effect, the client has closed off a two-way
channel of communication with others. Firstly, the “transmit” channel
has been closed, preventing outward expression of private emotional
146
Radically Open-DBT for Over-control: Signaling Matters

experiences. Secondly, the “receive” channel has been blocked, via

automatic rejection of corrective feedback.
Hence, RO-DBT links the communicative functions of emotion to
the formation of close social bonds. Social signaling skills taught in
RO-DBT emphasize methods to activate differing neural substrates—in
particular the neural substrate associated with social-safety and activa-
tion of the parasympathetic nervous system’s ventral vagal complex
([PNS-VVC] T. R. Lynch, in press; see also Porges, 2007). This enables
a client who over-controls to naturally relax facial muscles and non-
verbally signal cooperation and friendliness; thereby facilitating recip-
rocal cooperative responses from others and more fluid social interac-
tions. Moreover, RO-DBT uniquely posits that emotional expressions
in humans evolved to facilitate the formation of close social bonds and
altruistic behaviors among genetically dissimilar individuals. This is
supported by research showing that we automatically micro-mimic (in
milliseconds) the facial expressions of others, which triggers the same
brain structures (or mirror neurons) and physiological experience of
the “mirrored” person (Montgomery & Haxby, 2008; van der Gaag,
Minderaa, & Keysers, 2007). Thus, if we observe a person micro-
grimace in pain, we tend to –without conscious awareness– micro-
grimace and as a result, via the influence of the mirror neuron system
can viscerally “know” how the other person feels inside. The facilitative
function of emotion is hypothesized to represent a core component
linked to the development of sympathy, altruism, and empathy in our
species (T.R. Lynch, in press). It helps explain why humans are willing
to risk our lives to save (or fight for) genetically dissimilar others in our
tribe (e.g., fireman going into a burning building; clashes between rival
athletic teams; T.R. Lynch, in press). Consequently, RO-DBT empha-
sizes skills that take advantage of the mirror neuron system and our
natural tendencies to micro-mimic others in order to enhance social
connectedness. In addition, RO-DBT emphasizes skills designed to
activate the PNS-VVC social-safety system, increase vulnerable self-
disclosure, break-down over-learned expressive inhibitory barriers
(e.g., participation without planning and the art of being just a little bit
silly), and signal friendliness (e.g., leaning back in one’s chair rather
than forward or raising eyebrows upward when stressed). The emphasis
on openness, social-signaling, micro-mimicry, and changing neurophys-
iological arousal differentiates RO-DBT from other therapeutic ap-
proaches; most notably those positing etiological factors linked to
metacognitive awareness, mentalization, emotion regulation, experien-
147
AMERICAN JOURNAL OF PSYCHOTHERAPY

Table 1. DIFFERENCES IN THERAPEUTIC STANCE BETWEEN STANDARD DBT

AND RO-DBT

Standard DBT RO-DBT

⻫ Therapist directedness often required in order to ⻫ The therapist is less directive and encourages
stop dangerous impulsive behavior independence of action or opinion
⻫ Therapist may encourage brief disengagement from ⻫ Therapist encourages engagement in conflict
conflict to reduce/avoid escalation rather than automatic abandonment or
avoidance
⻫ Major focus on emotion regulation skills and ⻫ Major focus on social-signaling, openness, and
gaining behavioral control social connectedness
⻫ External contingencies, including mild aversives, ⻫ Emphasis is on self-enquiry and self-discovery
help the client gain control and discover the rather than impulse control
reinforcing consequences of impulse control
⻫ Therapist recognizes that BPD clients need to do ⻫ Therapist recognizes that clients characterized
better, try harder, and/or be more motivated to by over-control need to let-go of always
change striving to perform better or try harder
⻫ Therapist appreciates that the lives of suicidal, BPD ⻫ Therapist appreciates that the lives of clients
individuals are unbearable as they are currently who over-control are miserable even though
being lived this may not always be apparent
⻫ Therapist recognizes therapy interfering behaviors ⻫ Therapist recognizes therapeutic alliance
as problems necessitating change ruptures as opportunities for growth
⻫ Therapist rewards regulated and measured ⻫ Therapist rewards candid disclosure and
expression of emotions and thoughts uninhibited expression of emotion

tial avoidance, acceptance, behavioral exposure and response preven-

tion, early childhood trauma, interpersonal problem solving, behavioral
activation, or cognitive restructuring.
THE THERAPEUTIC STANCE: DIFFERENCES BETWEEN
STANDARD DBT AND RO-DBT
The overall therapeutic stance used to teach skills to OC clients is
often dialectically opposite to approaches used in standard DBT. For
example, RO-DBT is less likely than DBT to emphasize skills that teach
how to avoid conflict, be more organized, restrain impulses, delay
gratification, or tolerate distress, because these skills are already over-
learned or engaged in compulsively by most OC individuals. Instead,
RO-DBT encourages clients to practice disinhibition, participate with-
out planning, be more open to critical feedback, and be more emo-
tionally expressive. Radical openness is not something that can be
grasped solely via intellectual means. Thus, RO-DBT requires therapists
to practice radical openness and self-enquiry themselves in order to
teach them to others— e.g. clients who are over-controlled are unlikely
to believe it is socially acceptable for an adult to play, relax, admit
fallibility, or openly express emotions unless they see their therapists
model it first. A list of some of the core differences in therapeutic stance
between standard DBT (Linehan, 1993a) and RO-DBT is outlined in
Table 1.
148
Radically Open-DBT for Over-control: Signaling Matters

STRUCTURE OF TREATMENT
RO-DBT TREATMENT MODES AND TARGETS
The functions and modes of outpatient RO-DBT are similar to those in
standard DBT (Linehan, 1993a), including weekly one hour individual
therapy sessions, weekly skills training classes, telephone coaching (as
needed), and weekly therapist consultation team meetings (over a period of
⬃30 weeks). The primary target/goal in RO-DBT is to decrease severe
behavioral over-control, emotional loneliness, and aloofness/distance
rather than decrease severe behavioral dyscontrol and mood dependent
responding as in standard DBT.
RO-DBT Orientation and Commitment
The orientation and commitment stage of RO-DBT takes up to four
sessions and includes five key components: 1) confirming self-identification
of over-control as the core problem, 2) obtaining a commitment from the
client to discuss in-person desires to drop-out of treatment before drop-
ping-out, 3) orienting the client to the RO-DBT neurobiosocial theory of
over-control, and 4) orienting the client to the RO-DBT key mechanism of
change—i.e., open expression ⫽ increased trust ⫽ social connectedness. A
major aim of the orientation and commitment stage of RO-DBT is to
identify collaboratively the factors that may be preventing the client from
living according to their valued-goals. Values are the principles or stan-
dards a person considers important in life that guide behavior— e.g. to
raise a family, to be a warm and helpful parent to one’s children, to be
gainfully and happily employed, to develop or improve close relationships,
to form a romantic partnership. Whereas, goals are the means by which a
personal value is achieved— e.g. working collaboratively on projects or
household chores in a manner that respects individual differences and
appreciates each person’s contributions. From here, the therapist can
begin the process of identifying and individualizing treatment targets.
Treatment targets in RO-DBT prioritize maladaptive social-signaling be-
haviors that function to ostracize the client and exacerbate emotional
loneliness. For example, repeatedly re-doing other people’s work (e.g.,
re-wording an email, repacking the dishwasher) sends a powerful social-
signal (e.g., that others are incompetent or cannot be trusted) that nega-
tively impacts achievement of valued-goals related to social connectedness.
Thus, “re-doing” is an obstacle because it demoralizes coworkers and
family members, while exhausting the client because it means that they are
often working harder than nearby others—leading to resentment and
burnout. Finally, the orientation and commitment phase involves the start
149
AMERICAN JOURNAL OF PSYCHOTHERAPY

Figure 2.
RO-DBT INDIVIDUAL TREATMENT TARGET HIERARCHY FOR OVER-CONTROL

of individualized treatment targets linked to five OC themes—in this case,

“re-doing” is linked to the theme “rigid and rule-governed behavior” (see
OC themes below).
RO-DBT Individual Therapy Treatment Targets
RO-DBT treatment targets are arranged according to a hierarchy of
importance; 1) reduce life-threatening behaviors, 2) repair alliance-rup-
tures, and 3) reduce OC social-signaling deficits and maladaptive overt
behaviors linked to OC themes (see Figure 2). Unlike standard DBT,
RO-DBT hierarchically targets therapeutic alliance ruptures over therapy-
interfering behaviors. Alliance-ruptures in RO-DBT are defined as: 1) the
client feels misunderstood, and/or 2) the client experiences the treatment
as not relevant to their unique problems. This is a major deviation from
standard DBT, where therapy-interfering behaviors are considered the
second most important target in the treatment hierarchy (after life threat-
ening). Broadly speaking, therapy-interfering behaviors in standard DBT
(Linehan, 1993a) refer to problem behaviors that interfere with the client
receiving the treatment (e.g., non-compliance with diary cards, not show-
ing for sessions, or refusal to speak during a session). In RO-DBT
alliance-ruptures are not considered problems; they are considered essential
150
Radically Open-DBT for Over-control: Signaling Matters

practice grounds for learning that conflict can be intimacy enhancing.

Crucially, clients who are over-controlled need to learn that expressing
inner feelings—including those involving conflict or disagreement—is part
of normal healthy relationships. Since clients characterized by OC are
expert at masking inner feelings, a strong therapeutic alliance is not
expected to develop until mid-way through treatment (i.e., ⬃14th ses-
sion)—regardless of client statements of commitment or therapist exper-
tise. Consequently, RO-DBT considers it likely that a therapeutic relation-
ship is superficial, if by the 14th session, a therapist/client dyad has not had
multiple alliance-ruptures and repairs. When an alliance rupture is sus-
pected, RO-DBT therapists are taught to adopt a stance of relaxed, yet
engaged, curiosity in order to facilitate a repair. This typically involves
seven sequential steps:
1) Dropping the current agenda or topic being discussed (e.g., chain
analysis).
2) Taking the “heat-off” by briefly disengaging eye-contact. Most OC
individuals dislike being the center of attention (i.e., the “lime-
light”). Heat-off is a skill that involves briefly shifting one’s attention
elsewhere in order to allow a hyper-threat sensitive OC client time
to self-regulate.
3) Signaling affection and cooperation by leaning back, taking a slow
deep breath, half smiling, and raising one’s eyebrows. Raised eye-
brows (or eyebrow wags) are universal signals of liking and social-
safety.
4) Inquiring about the in-session change and encouraging candid
disclosure— e.g. “I noticed something just happened” (describe
change), then “Did you notice this too? What’s going on with you
right now?”
5) Slowing the pace of the conversation, allowing time for the client to
reply to questions, reflecting back what is heard, and confirming
that the reflection was accurate.
6) Reinforcing candid self-disclosure (e.g., thanking them for the “gift
of truth”).
7) Confirming re-engagement by checking in with them before return-
ing back to the original agenda. It is important to keep repairs short
(less than 10 minutes) in order to reinforce self-disclosure (recall
that clients who over-control dislike the “limelight”).
Though life-threatening and therapeutic- alliance ruptures take prece-
dence when present; the third most important target in the RO-DBT
treatment hierarchy pertains to the reduction of maladaptive OC behaviors
151
AMERICAN JOURNAL OF PSYCHOTHERAPY

Table 2. OC BEHAVIORAL THEMES: PATH TO FLEXIBLE MIND

Maladaptive OC Theme Primary Social-Signaling Deficit—and examples

Inhibited Emotional Refers to social-signaling deficits linked to emotional expression. E.g.

Expression inhibited, constrained, and frozen facial expressions, body movements, and
gestures or overly pro-social, phony, and insincere facial expressions and
gestures; very few people may know that they have an explosive temper or
high anxiety, may rarely spontaneously laugh; find it difficult to speak about
inner feelings or reveal vulnerability; may pout or use the silent treatment to
punish others when angry.
Hyper-Vigilant and Overly- Refers to social-signaling deficits stemming from OC bio-temperamental
Cautious predispositions for high threat sensitivity, low reward sensitivity, and high
detail-focused processing. E.g., tense-monotonic voice tone; guarded and
wary when entering new situations; frequent checking and re-checking of
safety cues despite evidence that all is well, avoiding risks that cannot be
controlled or planned in advance; hyper-attentive for discrepancies or
mistakes, anxiety may interfere with their abilities to hear what another
person is saying; obsessive about details, rarely genuinely amused or content,
serious about life; may frequently notice errors that other people miss; may
feel compelled to correct mistakes made by others; may rarely relax or seek
pleasure; believe life is hard.
Rigid and Rule-Governed Refers to social-signaling deficits resulting from compulsive needs for order
Behavior and structure. E.g. high moral certitude—there is a right and wrong way to
do things; will make self-sacrifices to care for others or to do the ‘right’
thing; strong desires to be correct; hyper-perfectionism; believe that there is
a set of rules and principles that one should always adhere to; compulsive
rehearsal, premeditation, and planning; compulsive approach-coping and
fixing; excessive persistence despite evidence that it will do harm; actions
motivated by social obligation and dutifulness—rather than anticipatory
pleasure; may work obsessively.
Aloof and Distant Refers to social-signaling deficits linked to low openness and conflict
Relationships avoidance. E.g. walking-away or abandonment is the preferred solution
during interpersonal conflict; having to be around others for long time
periods is exhausting or annoying; very few people may know who they
really are; feel detached or different from others; low social-connectedness is
not necessarily due to lack of contact with others; when challenged by
someone tend to immediately deny, dismiss, or dispute the feedback; may
rarely-apologize; may believe that love is phony or naive; may secretly believe
they are superior to others.
Envy and Bitterness Refers to social-signaling deficits linked to compulsive striving, high social
comparisons, and high dominance. E.g. not easily impressed; secretly
competitive; may feel unappreciated for self-sacrifices; may consider
themselves a cynic or a martyr; may believe that most things in life don’t
work out; may do almost anything to get ahead; may be secretly proud of
their ability to tolerate pain or distress in order to achieve a goal; may see
self as too complex to ever be understood; may engage in harsh gossip and
revengeful acts; high resentment, resignation, and pessimism.

linked to five OC behavioral themes. These themes (see Table 2), specific
for OC problems, are used as a framework for structuring the identifica-
tion of individualized and behaviorally specific OC treatment targets. The
key in treatment targeting with OC is for the therapist to continually ask
themselves in-session: “How might this type of social-signaling— e.g. pout-
ing, looking away, flat affect, non-descript use of language, answering a
question with a question—impact the formation of a strong social bond?” or
“Would this behavior make it more likely or less likely for a person
interacting with my client to want or desire to get to know them better?”
Thus, treatment targeting and subsequent behavioral chain analyses in
RO-DBT prioritize changing problematic social-signaling deficits that func-
tion to reduce social-connectedness (e.g., turning-down help; silent treat-
ment) over problematic internal experiences (e.g., emotion dysregulation,
152
Radically Open-DBT for Over-control: Signaling Matters

distorted thinking; experiential avoidance). Individualized targets are

monitored daily on diary cards and updated regularly.
RO-DBT Skills Training
Radically Open-DBT skills training classes meet on average for ⬃30
weekly sessions—with each class lasting approximately 2.5 hours. Table 3
provides an overview of the RO-DBT skills training lesson plan—including
those from standard DBT (Linehan, 1993b; 2014) that have been adapted
for OC problems (identified by * and italics). Next we review the core
theoretical principles underlying radical openness and describe some of
the new features in RO-DBT mindfulness skills. The RO-DBT treatment
manual provides detailed skills training instructor notes and key teaching
points for all of the RO-DBT skills listed in Table 3—including user
friendly handouts/worksheets for clients (T.R. Lynch, in press).
CORE RADICAL OPENNESS
Radical openness represents the core philosophical principle and core
set of skills in RO-DBT. It is based on confluence of three overlapping
elements or capacities posited to characterize psychological health: open-
ness, flexibility, and social connectedness (with at least one other person).
As a state of mind, it entails a willingness to surrender prior preconcep-
tions about how the world should be in order to adapt to an ever-changing
environment. At its most extreme, radical openness involves actively
seeking the things one wants to avoid in order to learn. Radical openness
alerts us to areas in our life that may need to change while retaining an
appreciation for the fact that change is not always needed or optimal.
RO-DBT replaces core Zen principles in standard DBT with those
derived from Malamati-Suffism. The Malamatis are not so much interested
in the acceptance of reality or seeing “what is” without illusion (central
Zen principles), but rather they look to find fault within themselves and
question their self-centered desires for power, recognition or self-aggran-
dizement (Toussulis, 2012). Thus, radical openness involves purposeful
self-enquiry and the cultivation of healthy self-doubt. Importantly, radical
openness differs from radical acceptance taught as part of standard DBT
(Linehan, 1993a). Radical acceptance “is letting go of fighting reality” and
“is the way to turn suffering that cannot be tolerated into pain that can be
tolerated” (Linehan, 1993b, pg. 102), whereas radical openness challenges
our perceptions of reality. Indeed, radical openness posits that we are
unable to see things as they are, but instead that we see things as we are
because each of us carries perceptual and regulatory biases with us that
influence our ability to be receptive and to learn from unexpected or
153
AMERICAN JOURNAL OF PSYCHOTHERAPY

Table 3. AN OVERVIEW OF RO-DBT SKILLS TRAINING LESSONS

Lesson # Skills Taught

Lessons 1-2: Practicing Radical RO-Why be radically open? RO-Learning from Self-Enquiry, RO-Myths
Openness and Understanding of a Closed Mind, RO-Three Steps for Radically Open Living; RO-
Emotions Five Emotionally Relevant Cues, RO-Model of Emotions,
Lessons 3-4: Labelling Emotions and RO-Over-Controlled Myths about Emotions, RO-Emotions are there for
Understanding Over-Controlled a Reason, RO-Making sense of Emotional Reactions; RO-
Coping Understanding Over-controlled Coping, RO-Over-control can
become a Habit!
Lessons 5-6: OC States of Mind and RO-Mindfulness States of Mind; Fixed-Mind, Fatalistic-Mind, Flexible-
Radical Acceptance Mind; *standard DBT Letting go of Emotional Suffering; *standard
DBT Radical Acceptance skills1
Lessons 7-8: Changing Social RO-Change Social Behavior by Changing Physiology, RO-Open
Connectedness by Changing expression ⫽ Trust ⫽ Social Connectedness.
Physiology
Lessons 9-10: Mindfulness and Self- RO-Mindfulness “What” skills—*standard DBT mindfulness observe
Enquiry skills; RO-Awareness Continuum and ‘Outing-Oneself’ describe
skills; RO-participate without planning skills. RO-Mindfulness
“How” skills—RO-with awareness of judgments, RO-with self-
enquiry, *standard DBT one-mindfully skills, and *standard DBT
effectively.
Lessons 11-12: Celebrating Novelty and RO-Engaging in Novel Behavior, RO-Flexible-Mind VARIES2 in order
Going Opposite to Seriousness to learn new things,; standard DBT opposite action skills; RO-Going
Opposite to Seriousness—the Art of Non-Productivity & Being a
little bit Silly
Lessons 13-14: Learning from Corrective RO-Learning from Corrective Feedback using Flexible-Mind ADOPTS;
Feedback RO-Accept or Decline Feedback—12 Questions.
Lessons 15-16: Social-Signaling Impacts RO-Social-Signaling —“Push-Backs and Don’t Hurt Me”; RO-Myths
Relationships about Interpersonal Relationships; *standard DBT Goals of
interpersonal effectiveness and DEAR MAN-GIVE FAST skills.
Lessons 17-18: Signaling Empathy and RO-Social-Signaling Empathy and Validation; RO-Seven Ways to Signal
Validation Empathy; RO-Flexible-Mind Validates.
Lessons 19-213: Repetition of RO-States Repeat RO-States of Mind and RO-Mindfulness “What” and “How”
of Mind and Mindfulness Skills skills—including *standard DBT observe and one-mindful skills.
Lessons 22-23: Learning How to Signal RO-Intimacy Thermometer; RO-Flexible-Mind ALLOWs one to
Trust and Establish Social enhance social connectedness; RO-Match ⫹ 1 skills; RO-Levels of
Connectedness Relationship Intimacy.
Lessons 24-263: Understanding Envy, RO-understands Envy, Resentment, Bitterness, and Revenge; RO-
Resentment, Bitterness, and Revenge Flexible-Mind DAREs to let go of envy; RO-Flexible-Mind is
LIGHT when targeting bitterness.
Lessons 27-28: Learning How to Forgive RO- What is forgiveness? RO-learning to grieve, RO-Flexible-Mind has
the HEART to forgive.
Lessons 29-30: Social-Safety Induction RO-Loving-Kindness Meditation skills—activating social-safety mood
Using Loving-Kindness-Meditation states; RO-Integration Week4.
and Summing it All Up

Note1: standard DBT skills can be identified by an * and italics—they include; standard DBT Letting
go of Emotional Suffering; standard DBT radical acceptance skills; standard DBT observe and one-
mindfully skills; standard DBT effectively; standard DBT opposite action skills; standard DBT Goals of
interpersonal effectiveness and DEAR MAN-GIVE FAST skills—all of which have been modified to
some extent for OC problems.
Note2: Similar to standard DBT, acronyms are used as mnemonic aids in RO-DBT. For example, in
Lessons 27-28: Flexible-Mind has HEART, Learning How to Forgive, each letter of the acronym
HEART refers to a specific set of skills; H stands for the skill of identifying the past Hurt; E stands
for the skill of locating one’s Edge that is keeping you stuck in the past; A stands for Acknowledge that
forgiveness is a choice, R stands for Reclaim your life by grieving the your loss and practicing
forgiveness; and T stands for the importance of passing-on Thankfulness.
Note3: Lessons 19-21 are repetitions of Lessons 5-6 & 9-10 compressed into three weeks. Lessons
24-26 are expected to take three weeks.
Note4: ‘Integration Week’ is intended to provide the space for instructors and clients to ‘pull it all
together’, be creative, and/or review core skills in order to deepen their practice of radical openness.

154
Radically Open-DBT for Over-control: Signaling Matters

disconfirming information. This way of behaving also contrasts with the

concept of wise mind in standard DBT that emphasizes the value of
intuitive knowledge, the possibility of fundamentally knowing something
as true or valid, and posits inner knowing as “almost always quiet” and to
involve a sense of “peace” (Linehan, 1993b, p. 66). From an RO-DBT
perspective, “facts” or “truth” can often be misleading partly because “we
don’t know what we don’t know”, things are constantly changing, and
there is a great deal of experience occurring outside of our conscious
awareness. Truth is considered “real yet elusive” – e.g. “If I know anything,
it is that I don’t know everything and neither does anyone else” (M. P.
Lynch, 2004; pg. 10). It is the pursuit of truth that matters—not its
attainment. Radical openness requires willingness to doubt or question
intuition or inner conviction without falling apart.
The practice of radical openness involves three steps: 1) acknowledg-
ment of environmental stimuli that are disconfirming, unexpected, or
incongruous, 2) purposeful self-enquiry into habitual or automatic emo-
tion-based response tendencies by asking “Is there something here to
learn?” –rather than automatically explaining, justifying, defending, ac-
cepting, regulating, re-appraising, distracting, or denying what is happen-
ing in order to feel better, and 3) flexibly responding by doing what is
needed to be effective in the moment in a manner that signals humility and
accounts for the needs of others (e.g., recognizing that what is “effective”
for oneself—may not be effective for others; celebrating diversity; signaling
a willingness to learn from what the world has to offer; strive for perfec-
tion, but stop when feedback suggests that striving is counterproductive or
damaging a relationship).
RO-DBT Mindfulness Skills
Mindfulness skills in RO-DBT include new OC states of mind (Fixed-
Mind, Flexible-Mind, and Fatalistic-Mind) and new “what” and “how”
skills (i.e., Awareness Continuum and “Outing-Oneself” describe skills,
“Participate without Planning” skills; “Self-Enquiry” skills, and “with
Awareness of Judgments” skills). The new mindfulness states of mind in
RO-DBT represent common OC ways of coping—that can be both
adaptive and maladaptive depending on the circumstances. For OC indi-
viduals two states of mind are most common— both of which are usually
maladaptive and occur secondary to disconfirming feedback and/or when
confronted with novelty. When challenged or uncertain, the most common
OC response is usually to search for a way to minimize, dismiss, or
disconfirm feedback in order to maintain a sense of control and order. This
155
AMERICAN JOURNAL OF PSYCHOTHERAPY

style of behaving in RO-DBT is referred to as fixed mind. Fixed mind is a

problem because it says “change is unnecessary because I already know the
answer”. The dialectic opposite of fixed mind is fatalistic mind. Whereas
fixed mind involves rigid resistance and energetic opposition to change,
fatalistic mind involves giving-up overt attempts at resistance. Fatalistic
mind can be expressed by drawn out silences, bitterness, refusals to
participate, and/or sudden acquiescence or a literal suspension of goal-
directed behavior and shut-down. Fatalistic mind is a problem because it
removes personal responsibility by implicating that “change is unnecessary
or impossible because there is no answer”. Mindful awareness of these
“states” serves as important skill practice reminders. Flexible mind forms
the synthesis between fixed and fatalistic mind states: it involves being
radically open to the possibility of change in order to learn, without
rejecting one’s past or falling apart. Importantly, although wise mind in
standard DBT and flexible mind in RO-DBT share some similar functions,
there are also important differences. For example, whereas wise mind
celebrates the importance of inner knowing and intuitive knowledge (see
Linehan, 1993b pg. 66), flexible mind celebrates self-enquiry and encour-
ages “healthy self-doubt” and compassionate challenges of our perceptions
of reality.
There are two new RO-DBT mindfulness “What” skills. The first is an
RO- “describe” skill known as the “Awareness Continuum”, which pro-
vides a structured means for a client who is over-controlled to practice
revealing inner feelings to another person—without rehearsal or planning
in advance what one might say. It also allows practitioners an opportunity
to practice how to label and differentiate between thoughts, emotions/
feelings, sensations, and images. The second RO-DBT “what” skill is
referred to as “Participating without Planning”. This skill involves learning
how to passionately participate with others without compulsive rehearsal
or obsessive needs to get it ‘right’. Participating without planning practices
should be unpredictable (i.e., they begin without any form of forewarning
or orientation) and brief (i.e., 60 seconds in duration). For example, the
instructor without any forewarning suddenly begins to make a silly face,
wave their arms about, while saying; “OK, everyone do what I do! Make a
funny face and wave your arms, like this! And this! (changing expression
while clucking and flapping like a chicken) There’s nobody here but us
chickens! Wow, look at me . . . I’m speaking nonsense! Blah-Blah. Now say
it again. Blah-Blah! Say bloo-blip and blippity-bloop! OK, now say, blippity-
be-ba-blipty bloo! (pause with warm smile, eye contact all around and
eyebrows raised) Getting better, LET’S GO LOUDER! Say, OHRAW!
156
Radically Open-DBT for Over-control: Signaling Matters

SAY OHRAWWW! SAY IT AGAIN. . .OOOHHHRAWWWW! OK, all

together now . . . LET’S START SPEAKING GOBBLITY-GOOK WHILE
WAVING OUR ARMS! IT’S A NEW LANGUAGE! Haven’t you heard?
Boo . . . boo . . . blickety-block and floppity-flow and mighty so-so!” Instruc-
tors should end by clapping their hands in celebration and encourage the
class to give themselves a round of applause. “Well done! OK, now sit
down and let’s share our observations about our mindfulness practice.” The
brief nature of the practice makes it less likely for self-consciousness to
arise and more likely for individual members to experience a sense of
positive connection or cohesion with the class as a whole—that generalizes
outside of the classroom with repeated practice. These practices are an
essential tool for teaching clients characterized by over-control how to
re-join the tribe.
There are two new RO-DBT mindfulness “How” skills. With “Self-
Enquiry” is the core RO-DBT “how” skill and the key for radically open
living. It involves actively seeking the things one wants to avoid or may find
uncomfortable in order to learn and the cultivation of a willingness to be
“wrong”—with an intention to change if needed. Self-enquiry celebrates
problems as opportunities for growth—rather than obstacles preventing us
from living fully. The core premise underlying self-enquiry stems from two
observations: 1) we do not know everything—therefore, we will make
mistakes, and 2) in order to learn from our mistakes, we must attend to our
error. Rather than seeking equanimity, wisdom, or a sense of peace,
self-enquiry helps us learn because there is no assumption that we already
know the answer. RO-DBT therapists must practice radical openness and
self-enquiry themselves in order to encourage clients to use self-enquiry
more deeply. For example, one therapist practiced outing themselves to
their client in order to illustrate how Fatalistic-Mind thinking thrives on
denial and self-deception by saying:
“Though it is hard to admit . . . during an argument, say with my partner. . .
.sometimes I purposefully become less talkative or avoid eye contact in order
to punish them for not agreeing with me; that is, I pout. If the person I’m
with asks me why I am not talking, I usually deny that I am being quiet, yet
deep down I know that I am purposefully choosing to talk less. What I find
amusing is that the more willing I am to concede to myself or the other
person that I am in Fatalistic-Mind, the harder it is for me to keep it up. I
have discovered that, for me, pouting can really only exist if I pretend it’s not
happening. Once I admit it; even just to myself; I find it difficult to maintain
because deliberate pouting is not how I want to behave or deal with conflict.
157
AMERICAN JOURNAL OF PSYCHOTHERAPY

My self-enquiry work around this has helped me live more fully according to
my values.”
The willingness of the therapist to reveal weakness without falling apart or
harsh self-blame functioned to encourage the client to behave similarly—in
this case, the client revealed for the first time that he often secretly tried to
undermine others and sometimes lied to obtain a desired goal. The client’s
self-disclosure of a previously well-guarded “secret” resulted in the iden-
tification of important treatment targets linked to envy and bitterness.
Outing one’s personality quirks or weaknesses to another person goes
opposite to OC tendencies of masking inner feelings—therefore, the
importance of this when treating OC cannot be overstated. Plus, since
expressing vulnerability to others functions to enhance intimacy and
desires to affiliate, the practice of outing oneself when used in other
areas of life can become a powerful means for OC clients to rejoin the
tribe. Practicing self-enquiry is particularly useful whenever we find
ourselves strongly rejecting, defending against, or agreeing with feed-
back that we find challenging or unexpected. Self-enquiry begins by
asking: “Is there something to learn here?” Examples of self-enquiry
questions include:
⻫ Is it possible that my bodily tension means that I am not fully open to
the feedback? If yes or possible, then: What am I avoiding? Is there
something here to learn?
⻫ Do I find myself wanting to automatically explain, defend, or discount
the other person’s feedback or what is happening? If yes or maybe, then:
Is this a sign that I may not be truly open?
⻫ Do I believe that further self-examination is unnecessary because I have
already worked out the problem, know the answer, or have done the
necessary self-work about the issue being discussed? If yes or maybe,
then: Is it possible that I am not willing to truly examine my personal
responses?
The second new “how” skill in RO-DBT mindfulness is “Awareness of
Unhelpful Judgments”. Our brains are hard-wired to evaluate the extent we
“like or dislike” what is happening to us each and every moment. Thus,
from an RO-DBT perspective we are always judging and our perceptual
biases influence our relationships and how we socially-signal. RO-DBT
encourages clients to use self-enquiry to learn how judgments impact
relationships and social-signaling. For example, by asking:
⻫ When I am self-critical or self-judgmental, how do I behave around
others? For example, do I hide my face, avoid eye contact, slump my
shoulders, and/or lower my head? Do I speak with a lower volume or
158
Radically Open-DBT for Over-control: Signaling Matters

slower pace? Or do I tell others that I am overwhelmed and/or unable

to cope?
⻫ How does my self-critical social-signaling impact others? What might
my self-judgmental social-signals tell me about my desires or aspira-
tions? What am I trying to communicate when I behave in this way?
RO-DBT Skills Generalization: Building Bridges to Enhance
Social-Connectedness
In standard DBT, the function of enhancing skills generalization is
most frequently accomplished via the use of telephone skills coaching by
the individual therapist (see Linehan, 1993a). In general, OC clients are
less likely to utilize this mode. As one client characterized by over-control
explained “I just don’t do crisis.” In our current RO-DBT multi-center
RCT (project REFRAMED) the majority of ‘skills coaching’ involves
clients learning to celebrate success by text-messaging their therapist when
the use of an RO-skill ‘worked’ or using text-messaging to practice
‘outing-themselves’ when they experience new insight or learning follow-
ing a practice of self-enquiry. In addition, RO-DBT encourages therapists
to invite families, partners, or caregivers to participate in treatment. The
RO-DBT treatment manual (T.R. Lynch, in press) includes RO-couple
therapy and RO-multi-family treatment protocols. Treatment strategies
with families, couples, and other important members of a client’s social
network typically involve: 1) educating the family/partner/caregiver about
the RO-DBT neurobiosocial theory and linking this to the treatment
strategies being used with the client; 2) explicit training in core RO-DBT
skills to facilitate skills generalization; 3) modeling and encouraging dia-
lectical thinking, e.g., demonstrating that there can be more than one way
of thinking about something; and 4) encouraging the family/partner/
caregiver to embrace a spirit of radical openness and “self-inquiry” when
problems or challenges arise.
RO-DBT Consultation and Supervision: Practicing Radical
Openness Ourselves
Therapists using RO-DBT ideally build into their treatment program a
means to support therapists to practice radical openness themselves and
support them in effectively delivering the treatment. This most often
translates into a weekly therapist consultation team meeting. In RO-DBT
a consultation team meeting is highly recommended, but not required. The
rationale for making the consultation team optional is partly influenced by
the less severe crisis generating behavior seen among clients characterized
by over-control, as well as practical, since the majority of therapists treating
159
AMERICAN JOURNAL OF PSYCHOTHERAPY

over-controlled problems do not traditionally work in teams. Therapists

without teams are encouraged to find a means to re-create the function an
RO-consultation team (e.g., virtual teams; supervision). Consultation team
meetings serve several important functions, including reducing therapist
burnout, providing support for therapists, improving phenomenological
empathy for clients, and providing treatment planning guidance. Plus, a
major assumption in RO-DBT is that to help clients learn to be more open,
flexible, and socially connected, therapists must practice the same skills in
order to be able to model them to their clients. Thus, the consultation team
in RO-DBT is considered an important means by which therapists can
“practice what they preach” to their clients.

SUMMARY AND CONCLUSIONS

RO-DBT is a new transdiagnostic treatment targeting a spectrum of
disorders characterized by excessive inhibitory control or over-control.
Reflecting recent National Institute of Mental Health (NIMH) Research
Domain Criteria (RDoC) initiatives (http://www.nimh.nih.gov/research-
priorities/rdoc/nimh-research-domain-criteria-rdoc.shtml), RO-DBT pos-
its that core genotypic/phenotypic differences between groups of disorders
often necessitate vastly different treatment approaches. The treatment
uniquely exploits bottom-up peripheral nervous system processes to reg-
ulate OC bio-temperamental perceptual and regulatory biases— e.g. teach-
ing skills to stimulate a neural substrate associated with social-safety and
desires to affiliate (i.e., PNS-VVC). RO-DBT also introduces a unique
mechanism of therapeutic change by linking the communicative and facil-
itative functions of emotional expression to the formation of close social
bonds. This translates into novel social-signaling skills designed to enhance
social connectedness that take advantage of the mirror neuron system and
our natural tendencies to micro-mimic others—a key component differ-
entiating RO-DBT from other treatments. Finally, a central premise of
RO-DBT is that well-being requires receptivity and flexible adaptation to
changing environmental demands, as well as a capacity to form close
long-lasting relationships. This definition differentiates perceptual and
reactive factors from regulatory and control factors, while acknowledging
the relational nature of our species. Well-adjusted persons are able to be
open to disconfirming feedback, and modify their behavior, in a manner
that accounts for the needs of others, as a means of optimizing perfor-
mance.
160
Radically Open-DBT for Over-control: Signaling Matters

REFERENCES
Achenbach, Thomas M. (1966). The classification of children’s psychiatric symptoms: A factor-analytic
study. Psychological Monographs: General and Applied, 80(7), 1-37. doi: 10.1037/h0093906
Anderluh M, Tchanturia K, Rabe-Hesketh S, et al. (2009). Lifetime course of eating disorders: design
and validity testing of a new strategy to define the eating disorders phenotype. Psychological
Medicine 39(01), 105-14.
Asendorpf, Jens B., Denissen, Jaap J. A., & van Aken, Marcel A. G. (2008). Inhibited and aggressive
preschool children at 23 years of age: Personality and social transitions into adulthood.
Developmental Psychology, 44(4), 997-1011. doi: 10.1037/0012-1649.44.4.997
Boone, R. Thomas, & Buck, Ross. (2003). Emotional expressivity and trustworthiness: the role of
nonverbal behavior in the evolution of cooperation. Journal of Nonverbal Behavior, 27(3),
163-182. doi: 10.1023/a:1025341931128
Butler, Emily A., Egloff, Boris, Wlhelm, Frank H., Smith, Nancy C., Erickson, Elizabeth A., & Gross,
James J. (2003). The social consequences of expressive suppression. Emotion, 3(1), 48-67.
Chapman, Benjamin P., & Goldberg, Lewis R. (2011). Replicability and 40-year predictive power of
childhood ARC types. Journal of Personality and Social Psychology, 101(3), 593-606. doi:
10.1037/a0024289 1.10.1037/a0024289.supp (Supplemental)
Chapman AL, Lynch TR, Rosenthal MZ, et al. (2007). Risk aversion among depressed older adults with
obsessive compulsive personality disorder. Cognitive Therapy and Research 2007; 31(2), 161-74.
Chen, E.J., Segal, K., Weissman, J., Zeffiro, T.A., Gallop, R., Linehan, M.M., Bohus, M., & Lynch, T.R.
(under review). An Adaptation of Dialectical Behavior Therapy for Anorexia Nervosa.
Crijnen, Alfons A. M., Achenbach, Thomas M., & Verhulst, Frank C. (1997). Comparisons of
problems reported by parents of children in 12 cultures: Total problems, externalizing, and
internalizing. Journal of the American Academy of Child & Adolescent Psychiatry, 36(9),
1269-1277. doi: 10.1097/00004583-199709000-00020
Dixon-Gordon, Katherine L., Turner, Brianna J., & Chapman, Alexander L. (2011). Psychotherapy for
personality disorders. International Review of Psychiatry, 23(3), 282-302. doi: doi:10.3109/
09540261.2011.586992
Eisenberg, Nancy, Fabes, Richard A., Guthrie, Ivanna K., & Reiser, Mark. (2000). Dispositional
emotionality and regulation: Their role in predicting quality of social functioning. Journal of
Personality and Social Psychology, 78(1), 136-157.
Gross, James J., & John, Oliver P. (2003). Individual differences in two emotion regulation processes:
Implications for affect, relationships, and well-being. Journal of Personality and Social Psychol-
ogy, 85(2), 348-362. doi: 10.1037/0022-3514.85.2.348
Kernis, Michael H., & Goldman, Brian M. (2006). A multicomponent conceptualization of authen-
ticity: Theory and research. In M. P. Zanna (Ed.), Advances in experimental social psychology,
Vol 38. (Vol. 38, pp. 283-357). San Diego, CA US: Elsevier Academic Press.
Keogh, K., Booth, R., Baird, K., Gibson, J., & Davenport, J. (in prep.) A Radically Open Dialectically
Behaviour Therapy (RO-DBT) informed group intervention for over-control: A controlled trial
with 3-month follow-up. Department of Psychology, St Patrick’s Mental Health Services &
Trinity College, Dublin, Ireland.
Linehan, M. M. (1993a). Cognitive Behavioral Treatment of Borderline Personality Disorder. New York:
Guilford Press.
Linehan, M. M. (1993b). Skills training manual for treating borderline personality disorder. New York:
Guilford Press.
Lynch, Michael P. (2004). True to life: Why truth matters. Cambridge, MA US: MIT Press.
Lynch, T. R. (in press). Radically Open Dialectical Behavior Therapy for Disorders of Over-control. New
York: Guilford Press.
Lynch, T. R., & Cheavens, Jennifer S. (2008). Dialectical behavior therapy for comorbid personality
disorders. Journal of Clinical Psychology, 64(2), 154-167. doi: 10.1002/jclp.20449
Lynch, T. R., Cheavens, Jennifer S., Cukrowicz, Kelly C., Thorp, Steven R., Bronner, Leslie, & Beyer,
John. (2007). Treatment of older adults with co-morbid personality disorder and depression: A
dialectical behavior therapy approach. International Journal of Geriatric Psychiatry, 22(2),
131-143.
Lynch, T. R., Gray, K. L., Hempel, R. J., Titley, M., Chen, E. Y., & O’Mahen, H. A. (2013). Radically

161
AMERICAN JOURNAL OF PSYCHOTHERAPY

open-dialectical behavior therapy for adult anorexia nervosa: feasibility and outcomes from an
inclient program. BMC Psychiatry, 13, 293. doi: 10.1186/1471-244x-13-293
Lynch, T. R., Lazarus, S., & Cheavens, J.S. (in press). Mindfulness interventions for emotion
dysregulation disorders: From self-control to selfregulation. In K. Brown, D. Creswell & R.
Ryan (Eds.), Handbook of Mindfulness: Theory and Research. New York: Guilford Press.
Lynch, T. R., Morse, Jennifer Q., Mendelson, Tamar, & Robins, Clive J. (2003). Dialectical behavior
therapy for depressed older adults: A randomized pilot study. American Journal of Geriatric
Psychiatry, 11(1), 33-45.
Montgomery, Kimberly J., & Haxby, James V. (2008). Mirror neuron system differentially activated by
facial expressions and social hand gestures: A functional magnetic resonance imaging study.
Journal of Cognitive Neuroscience, 20(10), 1866-1877. doi: 10.1162/jocn.2008.20127
Porges, Stephen W. (2007). The polyvagal perspective. Biological Psychology, 74(2), 116-143.
Riso, L. P., Blandino, J. A., Penna, S., Dacey, S., Grant, M. M., Du Toit, P. L., . . . Ulmer, C. S. (2003).
Cognitive aspects of chronic depression. Journal of Abnormal Psychology, 112(1), 72-80.
Srivastava, S., Tamir, M., McGonigal, K. M., John, O. P., & Gross, J. J. (2009). The social costs of
emotional suppression: A prospective study of the transition to college. Journal of Personality
and Social Psychology, 96(4), 883-897. doi: 10.1037/a0014755
van der Gaag, Christiaan, Minderaa, Ruud B., & Keysers, Christian. (2007). Facial expressions: What
the mirror neuron system can and cannot tell us. Social Neuroscience, 2(3-4), 179-222. doi:
10.1080/17470910701376878
Zucker, Nancy L., Losh, Molly, Bulik, Cynthia M., LaBar, Kevin S., Piven, Joseph, & Pelphrey, Kevin
A. (2007). Anorexia nervosa and autism spectrum disorders: Guided investigation of social
cognitive endophenotypes. Psychological Bulletin, 133(6), 976-1006.

162