Radically open dialectical behaviour therapy adapted for adolescents: a case series

Abstract

Background Overcontrol is a transdiagnostic cluster of traits associated with excessive psychological, behavioural and social inhibitory control. It is associated with psychiatric diagnoses of depression, restrictive eating disorders and/or obsessive-compulsive personality disorder. Radically Open Dialectical Behaviour Therapy is a transdiagnostic treatment for maladaptive overcontrol. This case series evaluates an adolescent adaption (RO-A) for a transdiagnostic group of adolescents identified as overcontrolled. Methods Twenty-eight adolescents were consecutively referred for RO-A from two different National and Specialist Child and Adolescent Mental Health Services between June 2017 and February 2020. Baseline self-report measures assessed overcontrol characteristics, relationship and attachment quality and mental health symptoms of depression and eating disorders, which were repeated at discharge. Results Adolescents in this case series reported high rates of depression (78.6%), self-harm (64.3%) and eating disorders (78.6%). Most (85.7%) had two or more mental health diagnoses and all had previous mental health treatments before starting RO-A. The mean number of RO-A sessions attended was 18 group-based skills classes and 21 individual sessions over a mean period of 34 weeks. Significant improvements with medium and large effect sizes were reported in cognitive flexibility (d = 1.63), risk aversion (d = 1.17), increased reward processing (d = .79) and reduced suppression of emotional expression (d = .72). Adolescents also reported feeling less socially withdrawn (d = .97), more connected to others (d = 1.03), as well as more confident (d = 1.10) and comfortable (d = .85) in attachment relationships. Symptoms of depression (d = .71), eating disorders (d = 1.06) and rates of self-harm (V = .39) also significantly improved. Exploratory correlation analyses suggest improvements in overcontrol are moderately to strongly correlated with improvements in symptoms of depression and eating disorders. Conclusions This case series provides preliminary data that RO-A may be an effective new treatment for adolescents with overcontrol and moderate to severe mental health disorders like depression and eating disorders. RO-A led to improved management of overcontrol, improved relationship quality and reduced mental health symptoms. Further evaluation is indicated by this case series, particularly for underweight young people with eating disorders. More rigorous testing of the model is required as conclusions are only tentative due to the small sample size and methodological limitations.

Group radical openness: A feasibility study

“…Their results found significant decreases in depressive symptomatology post-treatment, but these gains were not maintained at follow-up (Lynch et al, 2019). Baudinet et al (2021) found significant changes in the FFOCI-SF post-treatment in adolescents who were assessed to be overcontrolled and received an adaptation of RO DBT.…”

“…The selection of outcome measures for a novel intervention is challenging (Coster, 2013), and as overcontrol is a relatively new concept, there was a lack of specific measures related to this area. The measures in the current study were chosen based on their ability to determine overall traits of overcontrol and associated psychopathology (Baudinet et al., 2021; Hempel et al., 2018; Lynch et al., 2019). Additional measures were included to capture change in the three themes that are targeted in GRO.…”

“…They also noted that the 12 subscales demonstrate internal consistency, indicating homogeneity of content. The FFOCI‐SF has been used to explore changes in overcontrol in adolescents (Baudinet et al., 2021). For this study, the total score is used as a global indicator of the degree to which participants identify with overcontrolled traits.…”

Adolescent experience of radically open dialectical behaviour therapy: a qualitative study

“…Adaptations of RO DBT have recently been described and evaluated using uncontrolled case series designs in both the outpatient [ 21 ] and day patient setting [ 7 ] for adolescents with eating disorders, anxiety and/or mood difficulties. In both treatment contexts improvements are observed in psychiatric symptoms (eating disorder and mood), relationship quality, social withdrawal, cognitive flexibility, reward sensitivity and the maladaptive use of emotional suppression to regulate emotions [ 7 , 21 ]. These adaptations were based on informal feedback from adolescents that some of the RO DBT materials were more relevant for adults.…”

“…These adaptations were based on informal feedback from adolescents that some of the RO DBT materials were more relevant for adults. Adaptations in these uncontrolled case series’ include shortening treatment length (20 skills classes in the outpatient setting; 16 in a day patient setting instead of 30 skills classes), shorter classes (60–90 min vs 2.5 h) and amending materials to include more adolescent-focused examples and teaching materials [ 7 , 21 ]. This fits with the current study, in which RO DBT was very slightly amended (see method section).…”