How is RO-DBT different from DBT?

Cluster B “dramatic erratic” personality styles, mainly borderline and antisocial PD

Clusters A and C “overcontrolled” personality styles (e.g., avoidant, obsessive compulsive, paranoid and schizoid PDs, but also chronic depression and anorexia nervosa)

Seeks attachment with therapist and fears abandonment

Does not seek attachment with therapist and abandons relationship easily, especially when there is conflict

Emotion dysregulation, poor impulse control

Social signaling deficits, low openness, and aloofness

Undercontrolled (UC) clients engage in self-harm and suicide at high rates

• UC client suicide and self-harm is usually mood-dependent and unplanned
• UC clients do not keep their self-harming behavior a secret
• UC self-harm and/or suicidal behavior is mood-dependent and impulsive

Overcontrolled (OC) clients engage in self-harm and suicide at high rates

• OC client suicide and self-harm is usually planned
• OC self-harming behavior is usually a well-kept secret
• OC self-harm and/or suicidal behavior is more likely to be rule-governed rather than mood-governed—e.g., to restore their faith in a just world by punishing themselves for perceived wrongs

Therapist uses external contingencies, including mild aversives, takes a direct stance in order to stop dangerous, impulsive behavior

Therapist is less directive, encourages independence of action and opinion, emphasizes self-enquiry and self-discovery

How to use external contingencies to help the client gain control and discover the reinforcing consequences of impulse control

How to use social signaling to enhance client engagement and model vulnerability and connectedness

Internal: emotion regulation skills, gaining behavioral control, and distress tolerance

External: social-signaling, openness, and social connectedness skills

How to avoid conflict, be more organized, restrain impulses, delay gratification and tolerate distress (skills already over learned or engaged in compulsively by most OC individuals)

Clients to increase openness, flexible responding, enhance social connectedness, and vulnerable expression of emotion

to reduce/avoid escalation

rather than automatic abandonment or avoidance

regulated and measured expression of emotions and thoughts

candid disclosure and uninhibited expression of emotion

1. Life-threatening behavior—e.g., suicide and self-harm behaviors
2. Therapy-interfering behaviors
3. Quality-of-Life interfering behaviors
   • Mental health related dysfunctional response pattern (e.g., other severe DSM Axis I & IV Disorders)
   • High risk or unprotected sexual behavior
   • Extreme financial difficulties
   • Criminal behaviors that may lead to jail
   • Seriously dysfunctional interpersonal behaviors
   • Employment or school related dysfunctional behaviors
   • Physical health dysfunctional behaviors
   • Housing related dysfunctional behaviors

1. Life-threatening behavior—e.g., suicide and self-harm behaviors
2. Therapeutic-alliance ruptures
3. Maladaptive OC social signaling stemming from over control
   • Inhibited and disingenuous emotional expression
   • Hyper detailed focus and overly cautious behavior
   • Rigid and rule governed behavior
   • Aloof and distant style of relating
   • High social comparisons, envy, and bitterness

Positioned second in the treatment hierarchy, therapy interfering behaviors are seen as problems necessitating change

Positioned second in the treatment hierarchy, alliance ruptures are seen as opportunities for growth – thus are welcomed

• Emphasis on non-judgmental awareness of “what is” and intuitive knowing
• Encourages cultivation of Wise Mind responses that focus on reducing mood-dependent impulsive responding and increasing abilities to delay immediate gratification in order to pursue distal goals

• Emphasis on self-enquiry, “outing-oneself,” participating without planning, and the cultivation of healthy self-doubt
• Encourages cultivation of Flexible Mind responses that promote relaxation of rigid, rule-governed control efforts and an increase in context-appropriate disinhibition and/or emotional expression

Radical Acceptance is “letting go of fighting reality”

“It is the way to turn suffering that cannot be tolerated into pain that can be tolerated” (Linehan 1993).

Radical Openness is actively seeking the things one wants to avoid in order to learn—challenging our perceptions of reality, modelling humility, and a willingness to learn

“We don’t see things as they are—we see things as we are” (Lynch 2017).

Temperament (genetics for emotion) influences the perceptual and regulatory biases clients bring into social situations and needs to be accounted for when treating clients

With specific skills via activation of neural substrates