Radically Open Dialectical Behavior Therapy  (RO DBT)

Adults with overcontrol disorders such as refractory depression, anorexia nervosa, and obsessive-compulsive personality disorder

Radically Open Dialectical Behavior Therapy (RO DBT) is designed for individuals who struggle with excessive self-control, leading to emotional loneliness and social isolation. The program focuses on reducing rigid thinking, rule-governed behavior, and high moral certitude by fostering a radically open mindset. Treatment emphasizes building flexibility, openness to feedback, and authentic social connection. RO DBT combines individual therapy sessions with skills classes that teach strategies for increasing emotional expression, reducing perfectionism, and enhancing interpersonal effectiveness. The ultimate aim is to help participants “build a life worth sharing” by developing three core capacities: openness, flexibility, and social connectedness. RO DBT can be used with adolescents as well, but it was not reviewed by the CEBC for that target population.

• Agency/Affiliation: RO DBT Online BV
• Website: https://www.radicallyopen.net
• Email: support@radicallyopen.net

The goals of Radically Open Dialectical Behavior Therapy (RO DBT) are:

• Increase openness
• Increase flexibility
• Increase social connectedness
• Decrease psychopathology symptoms

The essential components of Radically Open Dialectical Behavior Therapy (RO DBT) include:

• RO DBT typically includes four key components:
  • Individual therapy (typically 1 hour)
  • Skills training classes (typically 2.5 hours with a 15-minute break)
  • Recommended therapist consultation team meetings
  • Optional between-session telephone coaching/texting
• During individual therapy, participants and therapists:
  • Establish target behaviors such as:
    • Increasing social connectedness
    • Decreasing overly cautious and hypervigilant behavior
  • Identify alternative behaviors to use in specific situations
• During the skills training class component, skills instructors cover twenty behavioral skills with groups of clients, including:
  • Openness:
    • Skills to help participants practice being receptive to new experiences
    • Feedback that contradicts their worldview
  • Flexibility:
    • Skills emphasize adapting to changing environmental conditions
  • Social connectedness:
    • Skills focus on building intimacy and social bonds with other people
  • Mindfulness:
    • Skills decrease physiological distress
    • Skills activate feelings of safety and affiliation
• Recommended therapist consultation team meetings where therapists and skills instructors:
  • Discuss any implementation challenges
  • Receive support designed to improve their capacity to treat patients.
• Optional between-session telephone coaching component where therapists can:
  • Provide as-needed support to help participants avoid harmful behaviors
  • Celebrate the successful implementation of new skills

Adult Services

Radically Open Dialectical Behavior Therapy  (RO DBT) directly provides services to adults (regardless of whether they are parents or caregivers) and addresses the following:

• Depression, Eating disorders, Obsessive Compulsive Personality Disorder (OCPD)

Recommended Intensity

Individual 1-hour session once weekly, and 2.5-hour Skills Training Class once weekly (with 15 minute break)

Recommended Duration

Approximately 30 weeks

Delivery Settings

This program is typically conducted in a(n):

• Community-based Agency / Organization / Provider
• Group or Residential Care
• Outpatient Clinic
• Virtual (Online, Smartphone, Zoom, Telephone, Video, etc.)

Homework

This program does include a homework component.

Clients are expected to complete diary cards as part of individual treatment, as well as homework assignments using worksheets as part of skills class training. Homework may also be assigned as part of individual sessions.

Languages

Radically Open Dialectical Behavior Therapy  (RO DBT) has materials available in the following languages other than English:

• Chinese
• French
• Italian
• Korean
• Polish
• Russian
• Spanish
• Swedish

For information on which materials are available in this language, please check on the program's website or contact the program representative (contact information is listed in this page).

Resources Needed to Run Program

The typical resources for implementing the program are:

• For individual sessions: A private treatment room with 2 chairs, ideally with fan or air conditioning.
• For skills classes: Large classroom table seating approx. 10 clients, white board or flip chart, fan or air conditioning, pens, handouts. It is recommended to have one instructor and a co-instructor (if more than 3 clients).

Prerequisite/Minimum Provider Qualifications

A qualification in a mental health (or related) field

Manual Information

There is a manual that describes how to deliver this program.

Program Manual(s)

Manual details:

• Lynch, T. R. (2018a). Radically Open Dialectical Behavior Therapy: Theory and practice for treating disorders of overcontrol. New Harbinger, an imprint of Context Press.
• Lynch, T. R. (2018b). The skills training manual for Radically Open Dialectical Behavior Therapy. New Harbinger, an imprint of Context Press.

Manuals can be purchased publicly from New Harbinger, the publisher, or websites such as Amazon.

Training Information

There is training available for this program.

Training Contact

Training Type/Location:

The training is provided by RO DBT Online B.V. and can be purchased via the website or for organization-based training via email (support@radicallyopen.net) 

Training for RO DBT can be obtained through multiple formats: 

• Live Online Training: Delivered via interactive webinars and virtual workshops. 

• In-Person Training: Offered at regional training events or onsite at the trainee’s organization upon request. 

• Organization-Based Training: Customized onsite training for agencies implementing RO DBT. 

• On-Demand Online Learning: Access to recorded modules and supplemental materials for flexible learning. 

 The training consists of 3 Levels, which can be accessed as follows: 

 Level 1 Training: Available online (on-demand or live) and in-person. 

• Level 2 Training: Available online on-demand only. 

• Level 3 Training: Always delivered live, either in-person or online. 

Training typically includes didactic instruction, experiential exercises, and practice with RO DBT protocols. 

Number of days/hours:

There are two training pathways, each consisting of three levels, depending on the skill level needed:

• RO DBT Practitioner: All knowledge and skills required to deliver the recommended outpatient RO DBT model comprising individual treatment sessions and RO Skills Training Classes.
  • Level 1: 8 hours
  • Level 2: 40.5 hours
  • Level 3: 22.5 hours
• RO Skills Instructor: A slimmed-down version of the RO DBT Practitioner pathway designed for clinicians who only wish to lead or co-lead RO Skills Classes.
  • Level 1: 8 hours
  • Level 2: 22.25 hours
  • Level 3: 13 hours
• Accredited Trainer/Supervisor: The duration to become an accredited supervisor or trainer in RO DBT varies depending on the certification process and the clinician’s skill set and experience. Typically, this takes several years.

Pre-Implementation Materials

There are no pre-implementation materials to measure organizational or provider readiness for Radically Open Dialectical Behavior Therapy .

Formal Support for Implementation

There is no formal support available for implementation of Radically Open Dialectical Behavior Therapy .

Fidelity Measures

There are fidelity measures for Radically Open Dialectical Behavior Therapy  as listed below:

RO DBT Adherence Rating Scale: 

• Fidelity is assessed through review of audio or video recordings of therapy sessions.
• The Adherence Rating Scale is used to evaluate therapist adherence to RO DBT protocols.
• This measure is available in the RO DBT textbook; however, ratings should be carried out by certified RO DBT Supervisors to ensure accuracy.
• Individuals can become certified RO DBT Supervisors through a Supervisory Assessment.
• Information about the Supervisory Assessment can be obtained by contacting support@radicallyopen.net

RO DBT Certification Program:

• Certification involves multiple examinations and ratings to confirm consistent understanding and application of RO DBT principles and techniques.
• Practitioners seeking certification submit recorded sessions for adherence review, using the aforementioned Adherence Rating Scale, by RO DBT Supervisors.
• Ongoing consultation and feedback are provided during the certification process.
• Details about the certification process can be found at: https://www.radicallyopen.net/ro-dbt-certification.html

Implementation Guides or Manuals

There are no implementation guides or manuals for Radically Open Dialectical Behavior Therapy .

Implementation Cost

There have been studies of the costs of implementing Radically Open Dialectical Behavior Therapy  which are listed below:

Shearer J., Lynch T. R., Chamba, R., Clarke S., Hempel, R. J., Kingdon, D., O’Mahen, H., Remington, B., Rushbrook, S. C., Russell, I. T., Stanton, M., Swales, M., Watkins, A., Whalley, B., & Byford, S. (2019). Refractory depression – cost-effectiveness of Radically Open Dialectical Behaviour Therapy: Findings of economic evaluation of RefraMED trial. BJ Psych Open, 5(5), Article e64. https://doi.org/10.1192/bjo.2019.57 

Research on How to Implement the Program

Research has been conducted on how to implement Radically Open Dialectical Behavior Therapy  as listed below:

Johnson, L. N., Fierstein, R., Cahn, S. C., Hoch, A. L. & Twardzik, L. N. (2024). Implementation of Radically Open Dialectical Behavior Therapy in a university or college counseling setting: A case study. Journal of College Student Psychotherapy, 38(3), 427–444. https://doi.org/10.1080/87568225.2023.2191879  

Child Welfare Outcome: Child/Family Well-Being

What is included in the Relevant Published, Peer-Reviewed Research section?

• Keogh, K., Booth, R., Baird, K., Gibson, J., & Davenport, J. (2016). The Radical Openness Group: A controlled trial with 3-month follow-up. Practice Innovations, 1(2), 129–143. https://doi.org/10.1037/pri0000023

  Type of Study: Pretest–posttest study with a nonequivalent control group (Quasi-experimental)

  Sample:

  Age — Mean=41.64 years

  Participants: 117

  Race/Ethnicity — Not specified

  Gender — 48% Male

  Status — Participants were adults attending a psychiatric hospital for mental health difficulties.

  Location/Institution: Republic of Ireland

  Summary:

  The purpose of the study was to examine the effectiveness of a new Radically Open Dialectical Behavior Therapy (RO DBT) informed group intervention for over-control (OC). Participants were recruited to RO DBT or, if the treatment group was full, they were placed on a waiting list and received Treatment as Usual (TAU). Measures utilized include medical charts, the Brief Symptom Inventory (BSI), Personal Need for Structure Scale (PNS), Acceptance and Action Questionnaire, Emotional Inhibition subscale of the Emotional Control Questionnaire 2 (ECQ2), Social Safeness and Pleasure Scale (SSPS), Dialectical Behavior Therapy (DBT) Ways of Coping Checklist, and Ego Under-Control Scale (EUCS). Results indicate that compared with TAU, the RO DBT participants experienced statistically greater improvements in overall psychopathology. Statistically greater improvements were also found on secondary outcomes: (a) the Social Safeness and Pleasure Scale, (b) the Dialectical Behavior Therapy (DBT) Ways of Coping Checklist, and (c) the Desire for Structure subscale on the Personal Need for Structure Scale. At 3-month follow-up, gains were maintained for secondary outcomes (skills use). Limitations include the lack of randomization, high attrition at follow-up, and participants in the RO DTB and TAU groups were also receiving other forms of individual therapeutic support, giving concern for confounding effects. 

  Length of controlled postintervention follow-up: None.

• Lynch, T. R., Hempel, R. J., Whalley, B., Byford, S., Chamba, R., Clarke, P., Clarke, S., Kingdon, D., O'Mahen, H., Remington, B., Rushbrook, S. C., Shearer, J., Stanton, M., Swales, M., Watkins, A., & Russell, I. T. (2018). Radically Open Dialectical Behaviour Therapy for refractory depression: The RefraMED RCT. Efficacy and Mechanism Evaluation, 5(7), 1–112. https://doi.org/10.3310/eme05070

  Type of Study: Randomized controlled trial

  Sample:

  Age — RO DBT: Mean=47 years; TAU: Mean=48 years

  Participants: 250

  Race/Ethnicity — 93% British descent

  Gender — 64% Female

  Status — Participants were patients with diagnosed depression.

  Location/Institution: Dorset, Hampshire, and North Wales, United Kingdom

  Summary:

  The purpose of the study was to evaluate the efficacy, cost-effectiveness, and therapeutic mechanisms of Radically Open Dialectical Behavior Therapy (RO DBT) for patients with refractory depression. Participants were randomized to either RO DBT plus treatment as usual (TAU) or TAU alone. Measures utilized include the Acceptance and Action Questionnaire–II (AAQ‑II), Adult Service Use Schedule (AD‑SUS), Balanced Inventory of Desirable Responding–Short Form (BIDR‑16), California Psychotherapy Alliance Scales (CALPAS), Credibility/Expectancy Questionnaire (CEQ), Client Satisfaction Questionnaire‑8 (CSQ‑8), Dialectical Behavior Therapy Ways of Coping Checklist (DBT‑WCCL), Emotional Approach Coping Scale (EAC), Frost Multidimensional Perfectionism Scale (FMPS), Invalidating Childhood Experiences Scale (ICES), Inventory of Interpersonal Problems–Personality Disorders–25 items (IIP‑PD‑25), Longitudinal Interval Follow‑up Evaluation – Range of Impaired Functioning Tool (LIFE‑RIFT), Measure of Parenting Style (MOPS), Modified Scale for Suicidal Ideation (MSSI), NEO Five‑Factor Inventory – Conscientiousness Subscale (NEO FFI‑C), Positive and Negative Affect Schedule (PANAS), Patient Health Questionnaire‑9 (PHQ‑9), Personal Need for Structure (PNS), Suicidal Behaviors Questionnaire (SBQ), Social Support Questionnaire (SSQ), Schwartz Values Scale (SVS), Urgency Premeditation Perseverance Sensation Seeking Scale (UPPS), and White Bear Suppression Inventory (WBSI). Results indicate that the difference between RO DBT and TAU in the primary outcome at 12 months was not statistically significant. Nevertheless, after 7 months, participants randomized to RO DBT had substantially and significantly reduced depressive symptoms, relative to TAU. Thereafter, RO DBT remained the better treatment with net, but non-significant, reductions after 12 months and after 18 months. Participants randomized to RO DBT reported significantly better psychological flexibility and emotional coping than TAU participants; these differences increased over time. From the perspective of the National Health Service (NHS) and personal social services, RO DBT was not cost-effective; the incremental cost-effectiveness ratio was £220,000 per QALY, which is considerably above the willingness-to-pay threshold of £30,000 set by the National Institute for Health and Care Excellence (NICE). RO DBT participants reported eight possible serious adverse reactions compared with none by TAU participants; however, it is believed that this imbalance was a result of major differences in reporting opportunities. Limitations include the high attrition rate at follow-up and the fact that participants receiving RO DBT continued to receive TAU as well.

  Length of controlled postintervention follow-up: 5 months and 11 months.

• Lynch, T. R., Hempel, R. J., Whalley, B., Byford, S., Chamba, R., Clarke, P., Clarke, S., Kingdon, D., O'Mahen, H., Remington, B., Rushbrook, S. C., Shearer, J., Stanton, M., Swales, M., Watkins, A., & Russell, I. T. (2020). Refractory depression—Mechanisms and efficacy of Radically Open Dialectical Behaviour Therapy (RefraMED): Findings of a randomised trial on benefits and harms. The British Journal of Psychiatry, 216(4), 204–212. https://doi.org/10.1192/bjp.2019.5

  Type of Study: Randomized controlled trial

  Sample:

  Age — 35–55 years

  Participants: 250

  Race/Ethnicity — Not specified

  Gender — 66% Female

  Status — Participants were patients with diagnosed depression.

  Location/Institution: Dorset, Hampshire, and North Wales, United Kingdom

  Summary:

  The study used the same sample as Lynch et al. (2018). The purpose of the study was to compare Radically Open Dialectical Behavior Therapy (RO DBT) plus treatment as usual (TAU) for refractory depression with TAU alone. Participants were randomized to either RO DBT plus treatment as usual (TAU) or TAU alone. Measures utilized include the Hamilton Rating Scale for Depression, Longitudinal Interval Follow-up Evaluation – Range of Impaired Functioning Tool (LIFE-RIFT), Acceptance & Action Questionnaire-II (AAQ-II), Emotional Approach Coping (EAC) scale, Patient Health Questionnaire-9 (PHQ-9), and the Social Support Questionnaire (SSQ-3). Results indicate that after 7 months, immediately following therapy, RO DBT had significantly reduced depressive symptoms relative to TAU. After 12 months, the difference of RO DBT was not significant, nor was it at 18 months. Throughout RO DBT, participants reported significantly better psychological flexibility and emotional coping than controls. However, they reported eight possible serious adverse reactions compared with none in the TAU alone group. Limitations include the wide variation in definitions of refractory and treatment‑resistant depression that constrain the generalizability of the findings, shortfalls in recruitment and analyzable sample size (250 recruited [91% of target] and 190 analyzed [76%]), unexpectedly large therapist heterogeneity, and the resulting loss of statistical power that, despite achieving the target effect size at 12 months, prevented the pre‑planned analyses from reaching significance beyond month 7.

  Length of controlled postintervention follow-up: 5 months and 11 months.

• Gilbert, K., Codd, R. T. III, Hoyniak, C., Tillman, R., Baudinet, J., Pires, P. P., Hempel, R., Russell, I., & Lynch, T. R. (2023). Processes of change in a randomized clinical trial of Radically Open Dialectical Behavior Therapy (RO DBT) for adults with treatment-refractory depression. Journal of Consulting and Clinical Psychology, 91(2), 71–81. https://doi.org/10.1037/ccp0000795

  Type of Study: Randomized controlled trial

  Sample:

  Age — Mean=42.7 years

  Participants: 250

  Race/Ethnicity — 90% White

  Gender — 65% Female

  Status — Participants were patients with diagnosed depression.

  Location/Institution: Dorset, Hampshire, and North Wales, United Kingdom

  Summary:

  The study used the same sample as Lynch et al. (2018). The purpose of the study was to test whether change in psychological inflexibility and interpersonal functioning was associated with change in depressive symptoms in Radically Open Dialectical Behavior Therapy (RO DBT). Participants were randomized to either RO DBT plus treatment as usual (TAU) or TAU alone. Measures utilized include the Hamilton Depression Rating Scale (HAM-D), Social Support Questionnaire (SSQ-3), Inventory of Interpersonal Problems (IIP), and the Action and Acceptance Questionnaire-II. Results indicate that the effect of RO DBT in decreasing depressive symptoms was mediated by changes in psychological inflexibility and interpersonal functioning at 3 months, 7 months, and only psychological inflexibility at 18 months, respectively. Limitations include the predominantly White U.K. sample limiting generalizability to more diverse populations, the absence of tests for other overcontrol‑related symptoms such as eating pathology or anxiety, and reliance on self‑reported measures of psychological inflexibility and interpersonal functioning rather than behavioral or neural assessments. 

  Length of controlled postintervention follow-up: 5 months and 11 months.

• Fennig, M., Agali, U., Looby, M., & Gilbert, K. (2024). Telehealth-delivered Radically Open Dialectical Behavior Therapy for adolescents (RO DBT-A): A pilot mixed-methods study. American Journal of Psychotherapy, 77(2), 46–54. https://doi.org/10.1176/appi.psychotherapy.20230025

  Type of Study: Pretest–posttest study with a nonequivalent control group (Quasi-experimental)

  Sample:

  Age — 13–21 years (Mean=16.74 years)

  Participants: 20

  Race/Ethnicity — 75% White, 5% Asian, 5% Hispanic/Latino, and 5% Mixed

  Gender — 100% Female

  Status — Participants were youth showing symptoms of eating disorders, anxiety, or depression.

  Location/Institution: St. Louis, Missouri

  Summary:

  The purpose of the study was to test the preliminary efficacy of telehealth-delivered RO DBT-A [now called Radically Open Dialectical Behavior Therapy (RO DBT)] in a heterogeneous clinical sample of youths. Participants were receiving either RO DBT-A or opted to choose other treatment or no treatment, which served as the control comparison group. Measures utilized include the Overcontrol in Youth Checklist – Adolescent Self-Report (OCYC-A), Youth Over‑ and Under‑Control Screening Measure (YOU‑C), The Temporal Experience of Pleasure Scale, Eating Disorder Examination–Questionnaire, Child Depression Inventory (CDI), Pediatric Quality of Life Enjoyment and Satisfaction Questionnaire, Social Connectedness Scale, and a qualitative interview. Results indicate that the intervention group showed significant improvements in depression and quality of life compared with the control group. From baseline to posttreatment, youths receiving RO DBT-A demonstrated significant improvements in maladaptive overcontrol, anxiety, and depression. Limitations include the lack of randomization, small sample size, lack of information on the controlled follow-up length for the intervention group, and a concern for generalizability given an all-female and predominantly white sample. 

  Length of controlled postintervention follow-up: None

• Steinhoff, M. F., Baudinet, J., Hempel, R. J., Tillman, R., Lynch, T. R., & Gilbert, K. E. (2026). Obsessive–compulsive personality disorder in Radically Open Dialectical Behavior Therapy for treatment-refractory depression. Personality Disorders: Theory, Research, and Treatment, 17(2), 178–188. https://doi.org/10.1037/per0000754

  Type of Study: Randomized controlled trial

  Sample:

  Age — Mean=47.7 years

  Participants: 250

  Race/Ethnicity — 98% White, 2% Multiracial, 1% Asian, and 1% Middle Eastern

  Gender — 65% Female

  Status — Participants were patients with diagnosed depression who may or may not have OCPD.

  Location/Institution: Dorset, Hampshire, and North Wales, United Kingdom

  Summary:

  The study used the same sample as Lynch et al. (2018). The purpose of the study was to examine the efficacy of Radically Open Dialectical Behavior Therapy (RO DBT) for treatment-resistant depression (TRD) among individuals with and without obsessive compulsive personality disorder (OCPD). Participants were randomized to either RO DBT plus treatment as usual (TAU) or TAU alone. Measures utilized include the Hamilton Depression Rating Scale (HAM-D), Structured Clinical Interviews for DSM-IV (SCID), Action and Acceptance Questionnaire-II (AAQ-II), Emotional Approach Coping scale (EAC), Social Support Questionnaire (SSQ), Inventory of Interpersonal Problems, and the Inventory of Interpersonal Problems–Personality Disorders. Results indicate that at 12 months, participants with OCPD had significantly improved emotional approach coping (emotion recognition and communication) and psychological flexibility in RO DBT+TAU (versus TAU alone), with no significant differences observed for depression or interpersonal functioning. OCPD presence did not predict any outcomes within the RO DBT group, nor moderate the effect of treatment on outcomes, suggesting treatment effects were not significantly inhibited by OCPD presence. Limitations include assessing OCPD only at baseline, leaving it unknown whether RO DBT aided OCPD remission, not measuring OCPD symptom severity during treatment, the restriction of the sample to individuals seeking treatment for TRD, which limits generalizability to those with other OCPD‑comorbid conditions or other personality disorders, and the predominantly White sample, which further limits applicability to more diverse populations.

  Length of controlled postintervention follow-up: 5 months.

• Hempel, R. J. (2019). Using Radically Open Dialectical Behavior Therapy (RO DBT) to treat problems of overcontrol. https://www.psychologytools.com/articles/using-radically-open-dialectical-behavior-therapy-ro-dbt-to-treat-problems-of-overcontrol 

• Society of Clinical Psychology. (2026). Radically Open Dialectical Behavior Therapy for Disorders of Overcontrol: Psychological treatments (Chambliss). https://societyofclinicalpsychology.org/psychological-treatments-archive/radically-open-dialectical-behavior-therapy-for-disorders-of-overcontrol/