Radically Open Dialectical Behavior Therapy (RO-DBT) for Eating Disorders, Anxiety, and Perfectionism

As a therapist who specializes in treating eating disorders and anxiety, I often encounter clients who are exceptionally self-disciplined, perfectionistic, and emotionally reserved. These individuals, while appearing composed and highly capable on the outside, are often battling significant internal struggles. Their need for rigid control—whether over food, emotions, or relationships—creates a constant undercurrent of anxiety. This is where Radically Open Dialectical Behavior Therapy (RO-DBT) can help.

RO-DBT, developed by Dr. Thomas Lynch, is unique in that it focuses on treating overcontrol, a trait common among individuals with eating disorders, chronic anxiety, and perfectionism. Overcontrol refers to excessive self-regulation and behavioral restraint, which can lead to isolation, rigidity, and emotional suppression. As Dr. Lynch explains, “Too much self-control can lead to emotional loneliness and difficulties forming close relationships”.

Overcontrol and Its Role in Eating Disorders and Anxiety

Many of my clients who struggle with eating disorders and anxiety don’t necessarily fit the typical profile of impulsivity or emotional dysregulation often associated with traditional DBT. Instead, they demonstrate an extreme level of control, especially around food and daily routines. This rigid control gives them a sense of safety and predictability, but it also creates emotional detachment and heightens their anxiety.

For example, let’s take Sonya*, a 28-year-old with anorexia and severe social anxiety. Sonya was incredibly driven and successful in her career, but her life revolved around strict routines. She controlled every meal, calorie, and interaction with an intensity that bordered on obsession. Her anxiety manifested in constant worry about how others perceived her, which led her to avoid social situations involving food. Despite her apparent composure, she was deeply lonely and overwhelmed.

One of the first concepts Sonya learned was the idea of overcontrol. As Dr. Lynch explains, “Overcontrol is adaptive in some contexts but becomes problematic when it limits our ability to connect emotionally with others and experience joy”. For Sonya, her control over food was an attempt to manage her fear of uncertainty and rejection. However, it also isolated her, both from her body’s natural needs and from the people around her.

The Challenge of Radical Openness

RO-DBT is grounded in the idea of radical openness, which involves being open to uncertainty, emotional discomfort, and feedback from others. This is often the most challenging aspect for clients, especially those who have relied on control to regulate their anxiety and eating behaviors. Radical openness is about facing the unknown with curiosity rather than fear—a concept that can feel counterintuitive to clients with overcontrol.

Larry*, a 30-year-old client with social anxiety and orthorexia, entered therapy because his life had become increasingly constrained by his need for control over his diet and social interactions. He painstakingly planned every meal to ensure it met his fastidious health standards, and his social life had dwindled drastically because of his fear of eating in public. Larry found it terrifying to even imagine loosening his grip on these routines, much less making any actual changes.

During one session, Larry learned about radical openness, which was key to his recovery. Dr. Lynch often says, “Radical openness is not about tolerating what we already know, but about being open to what we don’t know or cannot control” (Lynch, 2020). Larry’s first vulnerability challenge was to eat a meal without following his usual rigid guidelines, which would allow him to be present for the experience without fear of perfection.

It was a challenging task for Larry. He reported feeling anxious and out of control but, to his surprise, nothing catastrophic occurred. As time went on and he continued these exercises, he began to see that his rigid routines were not protecting him from harm—they were actually harming him by limiting his ability to live fully and connect with others.

Social Signaling and the Importance of Connection

A critical component of RO-DBT is the focus on social signaling and fostering deeper emotional connections with others. Many clients with overcontrolled temperaments struggle to show vulnerability or express emotions, which can lead to social isolation and further anxiety. Dr. Lynch highlights the importance of this, noting, “Healthy social signaling is the glue that binds us in meaningful relationships”.

Maria*, a 50-year-old client with a long history of bulimia, often stifled her emotions and used her eating disorder to cope with her anxiety around relationships. She prided herself on being calm and composed, but inside she felt incredibly isolated. Maria rarely showed emotional vulnerability, as she believed that it would make her appear weak or imperfect. This detachment contributed to a cycle of bingeing and purging as a means to manage her unexpressed emotions.

One main learning element of Maria’s therapy involved social signaling—how she presented herself to others and how she could become more open and engaged in her relationships. One of Maria’s challenges was to attend a family event without hiding behind her usual emotional mask. She was terrified of showing her family her genuine feelings, but in therapy she worked on small steps toward vulnerability. After the event, Maria described feeling more connected to her family than she had in years. She stated, “I realized they weren’t judging me for not being perfect. In fact, I think they were relieved to see the real me.”

This deepening of social connection was a critical turning point for Maria, as she began to understand that her eating disorder was prohibiting her from forming the deep relationships she craved.

The Transformative Power of RO-DBT

In my experience, RO-DBT is a transformative approach for clients with eating disorders and anxiety, particularly those who struggle with overcontrol. By teaching radical openness, social connectedness, and emotional flexibility, RO-DBT helps clients break free from the rigid patterns that have kept them trapped.

As Dr. Lynch wisely says, “True psychological health comes from being open to uncertainty and building connections with others, not from controlling every aspect of life”. Through RO-DBT, my clients have learned to embrace life’s unpredictability, rebuild relationships, and rediscover a sense of joy that had long been overshadowed by anxiety and perfectionism.

*Client names and identifying details have been changed.

Reference:

Lynch, Thomas R. (2018). Radically open dialectical behavior therapy: theory and practice for treating disorders of overcontrol. Oakland, CA. ISBN 978-1626259287. OCLC 1002290750