January 23, 2019
RO-DBT
R A DI CA L L Y OP EN-
DI A LECT IC AL
BEHA VI OR TH ER A P Y
A L L I S O N D O N O VA N , P S Y D , L P
SARAH MCCLAREN, MA, LMFT
WHAT IS RO-DBT?
• Created by Dr. Thomas Lynch
• For DBT patients not improving
• Theory: some patients were already “overcontrolled”
• RO-DBT “markers of psychological health”
– Receptivity and Openness
– Flexible Control
– Intimacy and Connectedness
NORMAL CURVE FOR CONTROL
UNDERCONTROLS OVERCONTROLS
• Impulsive and dramatic • Emotionally constricted
• Emotionally expressive as • Risk averse
children • Socially anxious
• More likely to develop • Develop internalizing
externalizing disorders disorders
• High reward sensitivity • Threat sensitive
• Low detail-focused
processing
• Low inhibitory control
OVERCONTROLS- 4 CORE DEFICITS
Reciprocity and openness
Flexible responding
Emotional expression and awareness
Social connectedness and intimacy
HOW IS RO-DBT DIFFERENT AND SIMILAR
TO DBT?
DBT RO-DBT
Use behavioral principles and dialectic philosophy
For undercontrolled clients: Cluster B For overcontrolled clients: Clusters A
“dramatic erratic” personality styles, and C “overcontrolled” personality
mainly borderline and antisocial PD styles
(e.g., avoidant, obsessive compulsive,
paranoid and schizoid PDs, but also
chronic depression and anorexia
nervosa)
HOW IS RO-DBT DIFFERENT AND
SIMILAR TO DBT?
DBT RO-DBT
Anxious attachment style: Avoidant attachment style:
Seeks attachment with therapist and Does not seek attachment with
fears abandonment therapist and abandons relationship
easily, especially when there is
conflict
Core problem: Core problem:
Emotion dysregulation, poor impulse Social signaling deficits, low
control openness, and aloofness
HOW IS RO-DBT DIFFERENT AND
SIMILAR TO DBT?
DBT RO-DBT
Therapist recognizes Therapist recognizes clients
undercontrolled clients need to do characterized by overcontrol need to
better, try harder, and/or be more let go of always striving to perform
motivated to change better or try harder
SUICIDE AND SELF-HARM
RO-DBT
DBT OVERCONTROLLED
UNDERCONTROLLED
Engage in self-harm and Engage in self-harm and suicide at high rates
suicide at high rates Usually planned
Usually mood-dependent and Self-harming behavior is usually a well-kept
unplanned secret
Do not keep their self- Self-harm and/or suicidal behavior is more
harming behavior a secret likely to be rule-governed rather than mood-
Mood-dependent and governed—e.g., to restore their faith in a just
impulsive world by punishing themselves for perceived
wrongs
THERAPEUTIC STANCE
RO-DBT
DBT
OVERCONTROLLED
UNDERCONTROLLED
Therapist uses external Therapist is less directive,
contingencies, including mild encourages independence of
aversives, takes a direct stance action and opinion, emphasizes
in order to stop dangerous, self-enquiry and self-discovery
impulsive behavior
PRIMARY THERAPEUTIC FOCUS
RO-DBT
DBT
OVERCONTROLLED
UNDERCONTROLLED
Internal: External:
• Emotion regulation skills • Social-signaling
• Gaining behavioral control • Openness
• Distress tolerance • Social connectedness skills
THERAPIST TEACHES
RO-DBT
DBT
OVERCONTROLLED
UNDERCONTROLLED
• How to avoid conflict • Increase openness
• Be more organized • Flexible responding
• Restrain impulses • Enhance social connectedness
• Delay gratification • Vulnerable expression of
• Tolerate distress emotion
(skills already over learned or
engaged in compulsively by
most OC individuals)
EATING DISORDER SYMPTOMS FOR
UC VS OC CLIENTS
• Can experience a variety of eating disorder symptoms
• Identify the intention behind the behavior
• Is client planning out the behavior or is impulsive when engaging in the
behavior?
• Overcontrolled= planning VS Undercontrolled = impulsivity
DIAGNOSES OVERCONTROLLED
UNDERCONTROLLED • OCD
• Borderline PD • Paranoid PD
• Antisocial PD • Avoidant PD
• Narcissistic PD • Schizoid PD
• Histrionic PD • Anorexia nervosa
• Binge/Purge EDs • Chronic depression
• Bipolar disorder • Autism spectrum
• Conduct disorders • Treatment resistant anxiety
• Externalizing disorders • Internalizing disorders
OVERLY DISAGREEABLE &
OVERLY AGREEABLE SUBTYPES
OVERLY DISAGREEABLE OVERLY AGREEABLE
• Motivated to be perceived as competent
• Motivated to be seen as competent and
but not compliant
socially acceptable
• Can be pro-social but are willing to be
• The pro-social persona can be exhausting
unfriendly in order to achieve an objective
because they feel as if they are “preforming”
(even if it damages the relationship)
• Display disingenuous or incongruent
• Flat or inhibited emotional expressions
expressions to their actual emotion
when under stress
• Pro-social behavior appears intimacy
• May see themselves as a loner
enhancing yet they fear personal disclosure
• Tough exterior- insecure and anxious
• May work hard to convince their therapist
interior (rarely show these emotions)
they are “fine” or “ok”
SOCIAL SIGNALING
• Overcontrol has a problem of “loneliness”
• OC’s are very “threat sensitive”
• Because of this, they often find themselves in “fight or flight mode,”
• SNS system activation causes bodily tension and inhibition of social signaling
– PROBLEM! -facial expressions and body language are a big part of how
human beings form bonds
• Big 3 + 1 skill
– helps OC’s activate the parasympathetic nervous system (PNS) so they are better
able to socially signal and connect with people
– Lean back, take a low deep breath, half smile, and eyebrows up
BIG 3 + 1
STATES OF MIND
Flexible Mind
Fixed Fatalistic
Mind Mind
FLEXIBLE MIND DEF(INITELY!)
D- acknowledge Distress or unwanted emotions
E- use self-Enquiry
F- Flexibly-respond with humility
FLEXIBLE MIND “ADOPTS”
• OC’s struggle with being open to critical feedback from others
• Fixed Mind: I don’t need to be open because they’re wrong and
I’m right
• Fatalistic Mind: Even if I were open it wouldn’t matter because
there’s nothing I can do
• ADOPTS skill helps people:
– Prepare to be open to feedback both mentally and physically
– Decide whether feedback is valid and whether to accept it
FLEXIBLE MIND “ADOPTS”
• A- Acknowledge that feedback is occurring
• D- Describe and observe emotions, bodily sensations, thoughts
• O- Open to new information by cheerleading and fully listening
• P- Pinpoint what new behavior is being recommended by the
feedback
• T- Try out the new behavior
• S- Self-sooth and reward yourself for being open and trying
something new
FLEXIBLE MIND “VARIES”
• Once a patient is able to be open to feedback and identify that a
change is needed, it is still a struggle to engage in the new behavior
• OC’s worry about how they will be perceived by others, whether
they will be “good” at the new behavior, and perfectionism and fear
of failure often get in the way
• Flexible Mind VARIEs identifies the steps to initiating and
evaluating the outcome of engaging in a novel behavior
FLEXIBLE MIND “VARIES”
V- Visualize the new behavior and describe emotions, thoughts, and
sensations
A- check the Accuracy of hesitancy, aversion, or avoidance
R- Relinquish compulsive planning, rehearsal, or preparation
I- active one’s social-safety and then Initiate the new behavior
E- non-judgementally Evaluate the outcome
RESOURCES
• RO-DBT Website
– http://www.radicallyopen.net/
• Manual (February 2018)
– Radically Open Dialectal Behavior Therapy: Theory and Practice for Treating Disorders of
Overcontrol by Thomas R. Lynch, PhD
– The Skills Training Manual for Radically Open Dialectical Behavior Therapy: A Clinician's Guide
for Treating Disorders of Overcontrol by Thomas R. Lynch, PhD
melroseheals.com
