RO-DBT Radically OpeN - - PowerPoint Presentation

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RO-DBTRadically OpeN- Dialectical Behavior Therapy

Allison Donovan, Psyd, LP Sarah Mcclaren, Ma, LMFT

January 23, 2019

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What Is RO-DBT?Created by Dr. Thomas Lynch For DBT patients not improvingTheory: some patients were already “overcontrolled

” RO-DBT “markers of psychological health”Receptivity and Openness Flexible Control Intimacy and Connectedness

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Normal Curve for control

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UnderControlsImpulsive and dramaticEmotionally expressive as children

More likely to develop externalizing disordersHigh reward sensitivityLow detail-focused processingLow inhibitory controlEmotionally constrictedRisk averse

Socially anxiousDevelop internalizing disordersT

hreat

sensitive

OverControls

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OverControls- 4 Core Deficits

Reciprocity and opennessFlexible respondingEmotional expression and awarenessSocial connectedness and intimacy

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How is RO-DBT Different and Similar to DBT?

DBTRO-DBT

Use behavioral principles and dialectic philosophy

For

undercontrolled

clients:

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

For

overcontrolled

clients:

Clusters A and C “

overcontrolled

” personality styles

(e.g., avoidant, obsessive compulsive, paranoid and schizoid PDs, but also chronic depression and anorexia nervosa)

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How is RO-DBT Different and Similar to DBT?

DBTRO-DBT

Anxious attachment style: Seeks attachment with therapist and fears abandonment

Avoidant attachment style:

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

Core problem:

Emotion dysregulation, poor impulse control

Core problem:

Social signaling deficits, low openness, and aloofness

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How is RO-DBT Different and Similar to DBT?

DBTRO-DBT

Therapist recognizes undercontrolled clients need to do better, try harder, and/or be more motivated to change

Therapist recognizes clients characterized by

overcontrol

need to let go of always striving to perform better or try harder

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SUICIDE AND SELF-HarmDBT UnderControlled

Engage in self-harm and suicide at high rates

Usually mood-dependent and unplanned

D

o

not keep their self-harming behavior a secret

M

ood-dependent

and impulsive

RO-DBT

OverControlled

E

ngage

in self-harm and suicide at high rates

U

sually

planned

S

elf-harming

behavior is usually a well-kept secret  

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

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Therapeutic StanceTherapist uses external contingencies, including mild

aversives, takes a direct stance in order to stop dangerous, impulsive behaviorTherapist

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

DBT

UnderControlled

RO-DBT

OverControlled

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Primary Therapeutic FocusInternal:

Emotion regulation skillsGaining

behavioral control Distress tolerance

External

:

S

ocial-signaling

Openness

S

ocial

connectedness

skills

DBT

UnderControlled

RO-DBT

OverControlled

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Therapist teachesHow to avoid conflictB

e more organizedRestrain impulsesDelay gratification Tolerate distress

(skills already over learned or engaged in compulsively by most OC individuals)

I

ncrease openness

F

lexible responding

E

nhance

social

connectedness

V

ulnerable

expression of emotion

DBT

UnderControlled

RO-DBT

OverControlled

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Eating Disorder Symptoms for Uc vS Oc Clients

Can experience a variety of eating disorder symptomsIdentify the intention behind the behavior Is client planning out the behavior or is

impulsive when engaging in the behavior? Overcontrolled= planning VS Undercontrolled

= impulsivity

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DiagnosesUnderControlled

Borderline PDAntisocial PDNarcissistic PDHistrionic PDBinge/Purge EDsBipolar disorderConduct disorders

Externalizing disordersOverControlled

OCD

Paranoid PD

Avoidant PD

Schizoid PD

Anorexia nervosa

Chronic depression

Autism spectrum

Treatment resistant anxiety

Internalizing disorders

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Overly Disagreeable & Overly Agreeable SubtypesOverly Disagreeable

Motivated to be perceived as competent but not compliant Can be pro-social but are willing to be unfriendly in order to achieve an objective (even if it damages the relationship)Flat or inhibited emotional expressions when under stressMay see themselves as a lonerTough exterior- insecure and anxious interior (rarely show these emotions)

Overly Agreeable

Motivated to be seen as competent and socially acceptable

The pro-social persona can be exhausting because they feel as if they are “preforming”

Display disingenuous or incongruent expressions to their actual emotion

Pro-social behavior appears intimacy enhancing yet they fear personal disclosure

May work hard to convince their therapist they are “fine” or “ok”

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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 signalingPROBLEM! -facial expressions and body language are a big part of how human beings form bondsBig 3 + 1 skill helps OC’s activate the parasympathetic nervous system (PNS) so they are better able to socially signal and connect with peopleLean back, take a low deep breath, half smile, and eyebrows up

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Big 3 + 1

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States of MInd

Flexible Mind

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Flexible Mind DEF(initely!)D- acknowledge Distress or unwanted emotions

E- use self-EnquiryF- Flexibly-respond with humility

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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 rightFatalistic Mind:

Even if I were open it wouldn’t matter because there’s nothing I can doADOPTS skill helps people:Prepare to be open to feedback both mentally and physicallyDecide whether feedback is valid and whether to accept it

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Flexible Mind “ADOPTS”A- Acknowledge that feedback is occurringD- Describe and observe emotions, bodily sensations, thoughts

O- Open to new information by cheerleading and fully listeningP- Pinpoint what new behavior is being recommended by the feedbackT- Try out the new behaviorS- Self-sooth and reward yourself for being open and trying something new

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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 behaviorOC’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

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Flexible Mind “Varies”V- V

isualize the new behavior and describe emotions, thoughts, and sensationsA- check the Accuracy of hesitancy, aversion, or avoidanceR-

Relinquish compulsive planning, rehearsal, or preparation

I-

active one’s social-safety and then

I

nitiate the new behavior

E-

non-

judgementally

Evaluate the outcome

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Resources RO-DBT Websitehttp://www.radicallyopen.net/ Manual (February 2018)

Radically Open Dialectal Behavior Therapy: Theory and Practice for Treating Disorders of Overcontrol by Thomas R. Lynch, PhDThe Skills Training Manual for Radically Open Dialectical Behavior Therapy: A Clinician's Guide for Treating Disorders of Overcontrol by Thomas R. Lynch, PhD

m

elroseheals.com