How is RO-DBT different from DBT? | Praxis Continuing Education and Training

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 difficult-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 differences between Radically Open DBT and traditional DBT below.

DBT	RO-DBT
Uses behavioral principles	Uses behavioral principles
Uses dialectical philosophy	Uses dialectical philosophy
Developed for undercontrolled clients Cluster B “dramatic erratic” personality styles, mainly borderline and antisocial PD	Developed 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)
Client has anxious attachment style Seeks attachment with therapist and fears abandonment	Client has 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
Suicide and self-harm 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	Suicide and self-harm 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 recognizes that undercontrolled clients need to do better, try harder, and/or be more motivated to change	Therapist recognizes that clients characterized by overcontrol need to let go of always striving to perform better or try harder
Therapeutic stance Therapist uses external contingencies, including mild aversives, takes a direct stance in order to stop dangerous, impulsive behavior	Therapeutic stance Therapist is less directive, encourages independence of action and opinion, emphasizes self-enquiry and self-discovery
Teaches the therapist How to use external contingencies to help the client gain control and discover the reinforcing consequences of impulse control	Teaches the therapist How to use social signaling to enhance client engagement and model vulnerability and connectedness
Primary therapeutic focus Internal: emotion regulation skills, gaining behavioral control, and distress tolerance	Primary therapeutic focus External: social-signaling, openness, and social connectedness skills
Teaches 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)	Teaches Clients to increase openness, flexible responding, enhance social connectedness, and vulnerable expression of emotion
External contingencies, including mild aversives, help the client gain control and discover the reinforcing consequences of impulse control	Emphasis is on self-enquiry and self-discovery rather than impulse control
Therapist may encourage brief disengagement from conflict to reduce/avoid escalation	Therapist encourages engagement if a conflict exists rather than automatic abandonment or avoidance
Therapist rewards regulated and measured expression of emotions and thoughts	Therapist rewards candid disclosure and uninhibited expression of emotion
Treatment target hierarchy Life-threatening behavior—e.g., suicide and self-harm behaviors Therapy-interfering behaviors 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	Treatment target hierarchy Life-threatening behavior—e.g., suicide and self-harm behaviors Therapeutic-alliance ruptures 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
Prioritizes therapy interfering behaviors Positioned second in the treatment hierarchy, therapy interfering behaviors are seen as problems necessitating change	Prioritizes therapeutic alliance ruptures Positioned second in the treatment hierarchy, alliance ruptures are seen as opportunities for growth – thus are welcomed
Mindfulness practices informed by Zen Buddhism	Mindfulness practices informed by Malamati Sufism
Mindfulness 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	Mindfulness 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
Emphasizes and prioritizes Radical Acceptance 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).	Emphasizes and prioritizes Radical Openness 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).
Emphasizes internal emotion regulation and non-mood dependent actions	Emphasizes our tribal nature and social-connectedness
Does not take temperament into account	Prioritizes interventions designed to take temperament into account Temperament (genetics for emotion) influences 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 specific skills via activation of neural substrates

DBT

RO-DBT

Uses behavioral principles

Uses dialectical philosophy

Developed for undercontrolled clients

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

Developed 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)

Client has anxious attachment style

Seeks attachment with therapist and fears abandonment

Client has 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

Suicide and self-harm

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

Suicide and self-harm

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

Therapist recognizes that clients characterized by overcontrol need to let go of always striving to perform better or try harder

Therapeutic stance

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

Therapeutic stance

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

Teaches the therapist

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

Teaches the therapist

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

Primary therapeutic focus

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

Primary therapeutic focus

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

Teaches

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)

Teaches

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

External contingencies, including mild aversives, help the client gain control and discover the reinforcing consequences of impulse control

Emphasis is on self-enquiry and self-discovery rather than impulse control

Therapist may encourage brief disengagement from conflict

to reduce/avoid escalation

Therapist encourages engagement if a conflict exists

rather than automatic abandonment or avoidance

Therapist rewards

regulated and measured expression of emotions and thoughts

Therapist rewards

candid disclosure and uninhibited expression of emotion

Treatment target hierarchy

Life-threatening behavior—e.g., suicide and self-harm behaviors

Therapy-interfering behaviors

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

Treatment target hierarchy

Life-threatening behavior—e.g., suicide and self-harm behaviors

Therapeutic-alliance ruptures

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

Prioritizes therapy interfering behaviors

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

Prioritizes therapeutic alliance ruptures

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

Mindfulness practices informed by Zen Buddhism

Mindfulness practices informed by Malamati Sufism

Mindfulness

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

Mindfulness

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

Emphasizes and prioritizes Radical Acceptance

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).

Emphasizes and prioritizes Radical Openness

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).

Emphasizes internal emotion regulation and non-mood dependent actions

Emphasizes our tribal nature and social-connectedness

Does not take temperament into account

Prioritizes interventions designed to take temperament into account

Temperament (genetics for emotion) influences 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 specific skills via activation of neural substrates