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How is RO-DBT different from DBT?

February 14, 2017

Developed by Marsha Linehan, PhD, Dialectical Behavior Therapy (DBT) is a

cognitive behavioral treatment that was originally developed to treat chronically
suicidal individuals diagnosed with borderline personality disorder (BPD).
Radically Open-Dialectical Behavior Therapy (RO-DBT) builds upon this work.
This new therapy is a breakthrough, transdiagnostic approach (developed by
Dr. Thomas Lynch) that helps clients with extremely dicult-to-treat overcontrol
(OC) disorders such as anorexia nervosa, chronic depression, and obsessive-
compulsive disorder (OCD).

If you are already familiar with DBT, check out the main dierences between
Radically Open DBT and traditional DBT below.

DBT RO-DBT

Uses behavioral principles Uses behavioral principles

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DBT RO-DBT

Uses dialectical philosophy Uses dialectical philosophy

Developed for undercontrolled Developed for overcontrolled

clients clients

Cluster B dramatic erratic Clusters A and C overcontrolled

personality styles, mainly personality styles (e.g., avoidant,
borderline and antisocial PD obsessive compulsive, paranoid
and schizoid PDs, but also chronic
depression and anorexia nervosa)

Client has anxious attachment Client has avoidant attachment

style style

Seeks attachment with therapist Does not seek attachment with

and fears abandonment therapist and abandons
relationship easily, especially
when there is conict

Core problem Core problem

Emotion dysregulation, poor Social signaling decits, low

impulse control openness, and aloofness

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DBT RO-DBT

Suicide and self-harm Suicide and self-harm

Undercontrolled (UC) clients Overcontrolled (OC) clients

engage in self-harm and suicide at engage in self-harm and suicide at
high rates high rates

UC client suicide and self- OC client suicide and self-

harm is usually mood- harm is usually planned
dependent and unplanned OC self-harming behavior is
UC clients do not keep their usually a well-kept secret
self-harming behavior a OC self-harm and/or suicidal
secret behavior is more likely to be
UC self-harm and/or suicidal rule-governed rather than
behavior is mood-dependent mood-governede.g., to
and impulsive restore their faith in a just
world by punishing
themselves for perceived
wrongs

Therapist recognizes that Therapist recognizes that clients

undercontrolled clients need to characterized by overcontrol
do better, try harder, and/or be need to let go of always striving
more motivated to change to perform better or try harder

Therapeutic stance Therapeutic stance

Therapist uses external Therapist is less directive,

contingencies, including mild encourages independence of
aversives, takes a direct stance in action and opinion, emphasizes
order to stop dangerous, self-enquiry and self-discovery
impulsive behavior

Teaches the therapist Teaches the therapist

How to use external contingencies How to use social signaling to

to help the client gain control and enhance client engagement and
discover the reinforcing model vulnerability and
consequences of impulse control connectedness

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DBT RO-DBT

Primary therapeutic focus Primary therapeutic focus

Internal: emotion regulation skills, External: social-signaling,

gaining behavioral control, and openness, and social
distress tolerance connectedness skills

Teaches Teaches

How to avoid conict, be more Clients to increase openness,

organized, restrain impulses, delay exible responding, enhance
gratication and tolerate distress social connectedness, and
(skills already over learned or vulnerable expression of emotion
engaged in compulsively by most
OC individuals)

External contingencies, including Emphasis is on self-enquiry and

mild aversives, help the client gain self-discovery rather than impulse
control and discover the control
reinforcing consequences of
impulse control

Therapist may encourage brief Therapist encourages

disengagement from conflict engagement if a conflict exists

to reduce/avoid escalation rather than automatic

abandonment or avoidance

Therapist rewards Therapist rewards

regulated and measured candid disclosure and uninhibited

expression of emotions and expression of emotion
thoughts

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DBT RO-DBT

Treatment target hierarchy Treatment target hierarchy

1. Life-threatening behavior 1. Life-threatening behavior

e.g., suicide and self-harm e.g., suicide and self-harm
behaviors behaviors
2. Therapy-interfering 2. Therapeutic-alliance
behaviors ruptures
3. Quality-of-Life interfering 3. Maladaptive OC social
behaviors signaling stemming from
Mental health related over control
dysfunctional response Inhibited and
pattern (e.g., other disingenuous
severe DSM Axis I & IV emotional expression
Disorders) Hyper detailed focus
High risk or and overly cautious
unprotected sexual behavior
behavior Rigid and rule
Extreme nancial governed behavior
diculties Aloof and distant style
Criminal behaviors that of relating
may lead to jail High social
Seriously dysfunctional comparisons, envy,
interpersonal and bitterness
behaviors
Employment or school
related dysfunctional
behaviors
Physical health
dysfunctional
behaviors
Housing related
dysfunctional
behaviors

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DBT RO-DBT

Prioritizes therapy interfering Prioritizes therapeutic alliance

behaviors ruptures

Positioned second in the Positioned second in the

treatment hierarchy, therapy treatment hierarchy, alliance
interfering behaviors are seen as ruptures are seen as opportunities
problems necessitating change for growth thus are welcomed

Mindfulness practices informed Mindfulness practices informed

by Zen Buddhism by Malamati Sufism

Mindfulness Mindfulness

Emphasis on non-judgmental Emphasis on self-enquiry,

awareness of what is and outing-oneself, participating
intuitive knowing without planning, and the
Encourages cultivation of cultivation of healthy self-
Wise Mind responses that doubt
focus on reducing mood- Encourages cultivation of
dependent impulsive Flexible Mind responses that
responding and increasing promote relaxation of rigid,
abilities to delay immediate rule-governed control eorts
gratication in order to and an increase in context-
pursue distal goals appropriate disinhibition
and/or emotional expression

Emphasizes and prioritizes Emphasizes and prioritizes

Radical Acceptance Radical Openness

Radical Acceptance is letting go Radical Openness is actively

of ghting reality seeking the things one wants to
avoid in order to learn
It is the way to turn suering that
challenging our perceptions of
cannot be tolerated into pain that
reality, modelling humility, and a
can be tolerated (Linehan 1993).
willingness to learn

We dont see things as they are

we see things as we are (Lynch
2017).

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DBT RO-DBT

Emphasizes internal emotion Emphasizes our tribal nature and

regulation and non-mood social-connectedness
dependent actions

Does not take temperament into Prioritizes interventions

account designed to take temperament
into account

Temperament (genetics for

emotion) inuences the
perceptual and regulatory biases
clients bring into social situations
and needs to be accounted for
when treating clients

Does not target bio-temperament Targets bio-temperament

With specic skills via activation of

neural substrates

Thomas R. Lynch, PhD, is the treatment developer of Radically Open-

Dialectical Behavior Therapy (RO-DBT)a new transdiagnostic treatment
approach for disorders of emotional overcontrol, informed by 20+ years of
clinical research. Dr Lynch is currently Professor Emeritus in the School of
Psychology at the University of Southampton, and before that he was the
Director of the Duke Cognitive Behavioral Research and Treatment Program at
Duke University (USA) from 1998-2007. His upcoming books on Radically
Open Dialectical Behavior Therapy will come out early 2018.

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