Processes of change in a randomized clinical trial of radically open dialectical behavior therapy (RO DBT) for adults with treatment-refractory depression.

OBJECTIVE: Radically open dialectical behavior therapy (RO DBT) is an empirically supported psychotherapy for treatment-refractory depression (TRD) that targets psychological inflexibility and interpersonal functioning within the context of maladaptive overcontrol. However, it is unknown whether change in these mechanistic processes is associated with decreased symptoms. This study tested whether change in psychological inflexibility and interpersonal functioning is associated with change in depressive symptoms in RO DBT. METHOD: Adults with TRD from The Refractory Depression: Mechanisms and Efficacy of RO DBT (RefraMED) randomized controlled trial of RO DBT, n = 250; M (SD) age = 47.2 (11.5); 65% female; 90% White, were assigned to RO DBT or treatment as usual. Psychological inflexibility and interpersonal functioning were assessed at baseline, 3 (midtreatment), 7 (posttreatment), 12, and 18 months. Mediation analyses and latent growth curve modeling (LGCM) assessed whether change in psychological inflexibility and interpersonal functioning was associated with change in depressive symptoms. RESULTS: The effect of RO DBT in decreasing depressive symptoms was mediated by changes in psychological inflexibility and interpersonal functioning at 3 (95% CI [-2.35, -0.15]; [-1.29, -0.04], respectively), 7 (95% CI [-2.80, -0.41]; [-3.39, -0.02]), and only psychological inflexibility at 18 (95% CI [-3.22, -0.62]) months. LGCM indicated only in RO DBT was a decrease in psychological inflexibility through 18 months associated with a decrease in depressive symptoms (B = 0.13, p < .001). CONCLUSIONS: This supports RO DBT theory about targeting processes related to maladaptive overcontrol. Interpersonal functioning, and in particular, psychological flexibility, may be mechanisms that decrease depressive symptoms in RO DBT for TRD. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Ethical and Legal Guidance for Mental Health Practitioners Who Wish to Conduct Research in a Private Practice Setting.

Mental health practitioners, even when they have research training, rarely contribute to the scientific literature. One reason for this may be that they need help addressing the ethical and legal issues they encounter as they contemplate undertaking research in a clinical practice setting. To address that need, we offer several types of guidance for conducting research in a private practice setting in a way that meets high ethical and legal standards. We describe the situations in which ethical review of a research proposal by a federally registered institutional review board (IRB) is legally required, and identify alternate mechanisms that practitioners can use to obtain an ethical review when a formal IRB review is not required by law. We discuss legal and ethical requirements of conducting single-case studies in a practice setting. We provide a rationale, and free and inexpensive options, for obtaining a formal certificate of training in human subjects research. And we offer guidance for obtaining informed consent and Health Insurance Portability and Accountability Act (HIPAA) authorization from research participants. We conclude with a brief discussion of other legal and professional issues to consider when conducting research in private practice.

Radically Open Dialectical Behavior Therapy (RO DBT) in the treatment of perfectionism: A case study.

We present the case of an adult male ("Jake") with chronic Anorexia Nervosa, buttressed by dysfunctional levels of perfectionism and aggravated by long-standing mood and anxiety disturbance, successfully treated with Radically Open Dialectical Behavior Therapy (RO DBT). RO DBT is an evidence-based, transdiagnostic psychotherapy designed to address perfectionistic overcontrolled coping through teaching flexibility, openness, and healthy self-doubt. We illustrate this treatment approach by means of describing its application to this case, including discussing core RO DBT treatment strategies and providing sample dialogues. Also demonstrated are the importance of case conceptualization strategies specific to overcontrolled individuals, unique challenges with attending to alliance ruptures with this population such as difficulty discriminating when they occur, and the importance of prioritizing social signaling as a treatment target. Jake's Anorexia Nervosa was in remission at the conclusion of treatment.

Radically Open Dialectical Behavior Therapy: Social Signaling, Transdiagnostic Utility and Current Evidence.

At the core of an overcontrolled personality and coping style is a tendency to have too much self-control, exhibiting as behavioral and cognitive inflexibility, high inhibition of emotion, high detail-focused processing and perfectionism, and a lack of social connectedness. Overcontrol underlies a wide variety of psychiatric illnesses and as such, an innovative transdiagnostic therapy called Radically Open Dialectical Behavior Therapy (RO DBT) has been developed to treat disorders characterized by overcontrol. RO DBT targets maladaptive social signaling in order to help individuals "rejoin the tribe," hypothesizing that increasing social connectedness by means of targeting social signaling is the central mechanism of change in treatment. Because RO DBT is used for individuals with an overcontrolled personality style, rather than individual disordered symptoms, it can be used transdiagnostically across a range of comorbid disorders, including treatment-resistant depression and anxiety, anorexia nervosa, and personality disorders such as obsessive-compulsive personality disorder. The current article introduces this novel treatment approach and discusses its emphasis on social signaling and its transdiagnostic nature. We then provide the first review of existing literature testing the efficacy of RO DBT across clinical populations, discuss issues related to assessment of overcontrol, and speculate on future directions for this novel therapy.