Radically Open Dialectical Beha - Thomas R. Lynch PDF
Radically Open Dialectical Beha - Thomas R. Lynch PDF
Radically Open Dialectical Beha - Thomas R. Lynch PDF
We are tribal by nature. The survival of our species required us to develop our
capacities to form long-lasting social bonds, share valuable resources, and work
together in tribes or groups.
Psychological well-being involves the confluence of three factors: openness
(receptivity), flexibility, and social connectedness. The term radical openness
represents the confluence of these three capacities, and radical openness itself is
the core philosophical principle and core skill in RO DBT.
Social signaling matters. In disorders of overcontrol, deficits in prosocial signaling
are posited to be the core source of OC clients’ loneliness.
Core genotypic and phenotypic differences between groups of disorders necessitate
different treatment approaches.1
Overcontrol is a multifaceted paradigm involving complex transactions among
biology, environment, and individual styles of coping.
In people with disorders of overcontrol, biotemperamental deficits and excesses make
behavioral responses more rigid and thus less capable of flexible adaptation to
changing environmental conditions.
It takes willpower to turn off (that is, downregulate) willpower!
Radical openness assumes that we don’t see things as they are but rather as we are.
One secret of healthy living is the cultivation of healthy self-doubt.
Radical openness and self-enquiry are experiential and cannot be grasped on an
exclusively intellectual basis. Therapists need to practice radical openness
themselves in order to model it for their clients.
Defining Overcontrol
Maladaptive overcontrol is characterized by four core deficits:
A central tenet of RO DBT is that self-control is highly and perhaps universally valued in most
societies, and that the value placed on self-control influences how a society defines deviant or
abnormal behavior.3 Deviance from social norms involves formal violations of explicit rules (as
in criminal activity) as well as informal violations of social customs or expectations that are less
well defined, and that involve social etiquette (as in transgressions with respect to cultural
expectations around eye contact).4 Societal values and norms also influence treatment values and
goals because, arguably, treatment equates by definition to the reestablishment of “normal”
functioning.
For overcontrolled clients, societal veneration of self-control is both a blessing (these clients’
capacity for self-control is often admired) and a curse (their personal suffering, linked as it is to
overcontrol, often goes unrecognized). Indeed, OC clients set high personal standards for
themselves (and others) and are expert at not appearing deviant on the outside (that is, in public).
They are not the people fomenting riots or robbing convenience stores on a whim. They are not
the ones you see yelling at each other from across the street. They are perfectionists who tend to
see mistakes everywhere (including in themselves), and they tend to work harder than most
others to prevent future problems. They don’t need to learn how to take life more seriously, or
try harder, or plan ahead, or behave more appropriately in public. They have too much of a good
thing—their self-control is out of control, and they suffer as a result. Therefore, RO DBT,
instead of highlighting what’s “wrong” with an individual client, starts from observations about
what’s healthy in all of us and then uses these observations to guide treatment interventions.
Psychological health or well-being in RO DBT is hypothesized to involve three core
transacting features:
The core idea is that hyperperfectionist OC clients are most likely to benefit from treatment
approaches that teach them how to actively seek well-being.
The ability to inhibit our propensities for action: This means that we developed
capacities to regulate the outward expression of emotion-based action tendencies
or impulses (for example, the urge to attack or run away). Not acting on every
impulse allowed us to live in close proximity to each other because we could trust
our fellow tribe members not to automatically express a potentially damaging
action urge (for example, a desire to hit).
The ability to regulate how we signal our intentions and personal observations about
the world: This means that we developed a highly sophisticated social signaling
system that allowed us to communicate intentions and feelings (for example, an
angry glare linked to a desire to attack), without having to fully express the actual
propensity itself (for example, hitting someone). Signaling our intentions from afar
(for example, via facial expressions, gestures, or vocalizations) reduced
unnecessary expenditures of energy and provided us a safer means of resolving
conflict and initiating collaborations with others, without having to fully commit
ourselves. Plus, revealing intentions and emotions to other members of our species
was essential to creating the type of strong social bonds that are the cornerstone of
human tribes. Communicating our observations involved nonverbal behaviors,
such as gaze direction and pointing, as well as with verbal observations. Revealing
to others our observations about nature (for example, “I see a cow”) and then
receiving verification (or not) about our perception by another member of our
species (for example, “No, I see a tiger—let’s run!”) provided a huge evolutionary
advantage because our individual survival no longer depended solely on our
personal perception. This helps explain why we are so concerned about the
opinions of others.
The ability to persist and to plan for the future: The evolution of persistence and
planning likely involved the development of areas of the brain associated with
evaluating nonimmediate contingencies, as when we imagine a potential future
consequence. But persistence and planning differ in that planning involves
considering the consequences of taking a future action, whereas persistence
involves considering the consequences of ceasing to do what one is already doing
(Smith et al., 2007).
It’s important to note that when a person’s willpower is depleted, environmental cues trigger
not just bad habits, such as overeating, alcohol abuse, and overspending, but also good habits,
such as exercise, planning, and studying hard (Hofmann, Rauch, & Gawronski, 2007). Good
habits are good precisely because they promote the attainment of long-term goals; bad habits are
bad because they promote short-term pleasure or relief and impede long-term goal attainment
(Neal et al., 2013). Not surprisingly, good habits characterize overcontrolled coping, and bad
habits characterize undercontrolled coping.
Unfortunately for OC clients, being good all the time leads to trouble. OC clients are likely to
believe that it’s imperative not to reveal weakness or vulnerability. Therefore, even though
they’re highly anxious on the inside, they work hard not to let others see it on the outside, thus
placing an additional burden on their already exhausted self-control system. A type of catch-22
emerges, with excessive self-control exhausting the resources needed to control excessive self-
control, thereby making it harder to turn to alternative ways of coping (for example, taking a nap
or asking for help). The OC client may feel inside like a prisoner of self-control, but his natural
tendency to inhibit (control) the expression of his emotions makes it harder for others to know he
is distressed and be able to offer assistance.
Trained assessors blind to these allocations assessed participants seven, twelve, and eighteen
months after randomization. Our primary outcome measure was severity of depressive symptoms
on the HAM-D, measured at these three points. We allocated 250 participants by adaptive
randomization, 162 to RO DBT and 88 to TAU. Patients reported substantial comorbidity: 86
percent reported at least one comorbid Axis I disorder, and 78 percent reported at least one
comorbid Axis II disorder. In addition, the RO DBT adherence self-assessment scale (see
appendix 8) and new measures to facilitate identification of OC clients (see chapter 3) emerged
from this trial.
RO DBT offers an original perspective on the etiology and treatment of anorexia nervosa (T.
R. Lynch et al., 2013) by conceptualizing restrictive and ritualized eating as symptoms or
consequences stemming from rigid maladaptive overcontrolled coping, based in part on research
showing that OC coping preceded the development of the eating disorder. Plus, the
neuroregulatory theory that underlies RO DBT provides a novel means of understanding
compulsive self-starvation, based on neuroinhibitory relationships between the parasympathetic
and sympathetic nervous systems. Specifically, according to the RO DBT model, after periods of
intense restrictive eating, the client’s neuroregulatory system “perceives” the body’s depleted
metabolic state as life-threatening, thereby triggering the dorsal vagal complex of the
evolutionarily older parasympathetic nervous system (the PNS-DVC), which inhibits energy-
depleting action tendencies (urges to flee or fight) mediated by the sympathetic nervous system
while reducing sensitivity to pain and increasing emotional numbing (as seen, for example, in the
client’s flat affect). Thus the client’s restrictive eating develops as a means of downregulating
anxious arousal—but with a hidden price, RO DBT posits, because the flattened affect secondary
to PNS-DVC activation increases the likelihood that the client will be socially ostracized (J. J.
Gross & John, 2003; T. R. Lynch et al., 2013).
Unlike most other approaches targeting eating disorders, RO DBT considers it essential for
therapists treating AN to identify clients’ goals and values that are not solely linked to food,
weight, body shape, or other, similar issues related to eating disorders. From the outset, the RO
DBT–adherent therapist will smuggle the idea that the client is much more than an eating
disorder. This approach is purposefully designed to let the therapist attend to the client’s
psychological issues while also preventing therapy from possibly reinforcing the client’s
maladaptive AN behavior by making it the top treatment priority (for more on this point, see
“Overview of Treatment Structure and Targets,” chapter 4).
In RO DBT, mindfulness-based approaches to anorexia nervosa focus on teaching clients the
practice of urge-surfing their food-averse response tendencies (for example, sensations of
bloating, nausea, urges to vomit, and catastrophizing thoughts). In this practice, the goal is not
the client’s mindful enjoyment of food; on the contrary, the focus is on the client’s noticing
aversive sensations, emotions, and thoughts associated with food ingestion but not responding as
if such a sensation, emotion, or thought were a crisis. Instead, the client is encouraged to
dispassionately observe food-averse response tendencies and is reminded that this practice is
similar to the techniques used by sailors to overcome seasickness, or by jet pilots to overcome
severe nausea.13
Research by T. R. Lynch et al. (2013) has tested the feasibility and outcomes of using a
modification of RO DBT for the treatment of restrictive-type anorexia nervosa (AN-R) in an
inpatient setting.14 In this study, forty-seven individuals diagnosed with AN-R (the mean
admission body mass index, or BMI, was 14.43) received inpatient RO DBT (the mean length of
treatment was 21.7 weeks). Intent-to-treat (ITT) analyses demonstrated significant improvements
in weight, despite the fact that RO DBT does not emphasize weight gain and focuses instead on
the client’s gaining a life worth sharing. The increase in BMI demonstrated in the ITT analyses
was equivalent to a large effect size of 1.71, by contrast with an effect size of d = 1.2 reported for
other inpatient programs (see Hartmann, Weber, Herpertz, & Zeeck, 2011). Of those who
completed treatment, 35 percent achieved full remission, and an additional 55 percent achieved
partial remission, for an overall response rate of 90 percent. The same individuals demonstrated
significant and large improvements in ED-related psychopathology symptoms (d = 1.17), ED-
related quality-of-life issues (d = 1.03), and psychological distress (d = 1.34). These rates of
remission are encouraging, since the literature on AN recovery has demonstrated that attainment
of a higher BMI during treatment predicts better relapse prevention (Carter et al., 2012;
Commerford, Licinio, & Halmi, 1997). Furthermore, these rates of remission are comparable to
those achieved in outpatient settings and are noteworthy because they were achieved in a more
severely underweight and more chronic population.
Also promising are the results of a small case-series pilot study in which standard individual
DBT was augmented by an average of thirty-two weeks of RO skills training that addressed
overcontrol (E. Y. Chen et al., 2015). The participants were nine adult female AN outpatients,
ranging in age from nineteen to fifty-one, with an average baseline BMI of 18.7.15 Of this
sample, 75 percent met either subclinical or full criteria for the binge-purge subtype of AN. At
baseline, the majority (88 percent) had a comorbid DSM-4 Axis I disorder (such as depression),
and 63 percent had a comorbid DSM-4 Axis II disorder (such as obsessive-compulsive
personality disorder), with 25 percent reporting histories of suicidal or nonsuicidal self-injury.
Independent assessors conducted standardized clinical interviews both before and after treatment.
ITT analyses demonstrated significant rates of weight gain and menses resumption for 62 percent
of the sample by the end of treatment. Results demonstrated large effect sizes for increased BMI
(d = 1.12), and these were sustained both at six-month follow-up (d = 0.87) and at twelve-month
follow-up (d = 1.21). Furthermore, improvements in total Eating Disorder Examination scores at
the end of treatment yielded an effect size of d = 0.46, which was sustained at six-month follow-
up (d = 0.45) but declined at twelve-month follow-up (d = 0.34).
Research on using RO DBT with adult AN clients continues, in collaboration with colleagues
at Sweden’s Uppsala University, with a special emphasis on hypothesized mechanisms of
change. Preliminary research examining the efficacy of using RO DBT with treatment-resistant
adolescent AN clients is also under way, in collaboration with the South London and Maudsley
NHS Foundation Trust and the Institute of Psychiatry in London. This research includes a novel
multifamily RO skills training program.
An important issue for multicomponent treatments like RO DBT is to determine the extent to
which structural components of the treatment are also essential components. For example, how
effective is RO skills training alone in achieving important clinical outcomes? To address this
question, an independent research team (Keogh et al., 2016) used a nonrandomized controlled
design to investigate, without our involvement, the effectiveness of RO skills training alone in
the treatment of overcontrolled personality dysfunction as compared to TAU.
In this study involving treatment-resistant adult subjects (N = 117), participants were recruited
to an RO skills training group (n = 58) or, if that group was full, were placed on a waiting list
and given TAU (n = 59). The TAU participants went on to attend RO skills training sessions as
space became available.16
On sociodemographic and clinical measures there were no statistically significant differences
at baseline between the RO skills training group and the TAU group. Participants in both groups
completed a battery of measures at pretreatment and again at post-treatment. In addition,
participants in the RO skills training group completed measures at three-month follow-up as well
as measures of therapeutic alliance and group processes at the sixth and eighteenth sessions of
the training.
Of the fifty-eight people in the RO skills training condition, six dropped out, for a treatment
dropout rate of 10 percent; five did not complete postgroup measures; and forty-seven did
complete postgroup measures, for a response rate of 81.5 percent. There were no significant
differences between dropouts and treatment completers. Of the fifty-nine TAU participants,
twenty-two did not return post-treatment questionnaires; thirty-seven did complete post-
treatment questionnaires, for a response rate of 62.7 percent.
The results of this study showed significantly greater improvement in global severity of
psychological symptoms, with medium effects post-treatment, for RO skills training alone than
for TAU.17 This study is important, not only because it was conducted without the clinical
involvement or supervision of the treatment developer but also because it provides preliminary
evidence for the utility of RO skills training alone for treatment-resistant OC adults.
The sympathetic nervous system (SNS) in the ANS is generally a catabolic system that
expends energy and prepares the body for action (for example, fight-or-flight behaviors resulting
in changes such as increased heart rate, increased sweating, and increased blood flow to skeletal
muscle as well as the inhibition of the digestive system). According to our model, this system is
activated whenever a stimulus is appraised as either a potential threat or a potential reward.
Innervation of the adrenal medulla by the SNS releases the catecholamines adrenaline and
noradrenaline into the bloodstream. Therefore, the SNS tends to have a diffuse effect throughout
the body.
The parasympathetic nervous system (PNS) is generally anabolic and promotes tissue growth,
the conservation of energy, and a state of rest or digestion. Most of the PNS nerve fibers
originate in the cranial or sacral regions of the spinal cord (that is, the very top and bottom
regions of the spine), including the vagus nerve, which originates from nuclei in the brain stem
and plays a major role in the PNS. Unlike in the SNS, parasympathetic ganglia tend to be found
in or near the muscle or organ being regulated, thereby allowing the activity of the PNS to be
localized and specific. Interestingly, the PNS-dominated vagus nerve, also known as the tenth
cranial nerve, can be traced back to two origins within the brain stem: the nucleus ambiguous
and the dorsal vagal motor nucleus (DVNX). These form parts of the ventral vagal complex
(VVC; new vagus) and dorsal vagal complex (DVC; old vagus), respectively (Porges, 1995).
Both of these vagal branches function to slow heart rate, yet their broader effects are
qualitatively and quantitatively different (Porges, 1995, 2001). The PNS-VVC (new vagus) is
associated with social safety, affiliation, and exploration, whereas the PNS-DVC (old vagus) is
associated with shutdown, immobilization, and pain numbing (see Porges, 2001).
In order to account for these complexities, our model parses emotion regulation into three
broad transacting elements:
Perceptual encoding factors account for automatic preconscious regulatory processes, while
separating internal from external regulation helps explain how a person can feel anxious on the
inside yet show no overt signs of anxiety on the outside. Arousal, in our model, pertains to the
intensity of an inner experience of emotion, involving ANS-mediated visceral responses and
bodily sensations that most people refer to as “feelings,” whereas valence represents the hedonic
value assigned to an evocative stimulus (that is, positive or negative). Both arousal and valence
moderate metabolic processes linked to expenditures of energy (such as the amount of effort
employed in order to avoid a noxious stimulus) and influence the type and strength of internal
action urges and response tendencies (such as an urge to affiliate).
The Human Response
The ideal set point for humans is posited to be a state of safety, or calm readiness, that
involves a sense of receptivity and low-level processing of both internal and environmental
stimuli. However, when sensory inputs are evocative (meaning discrepant from expectations
based on stored representations; see L. Gross, 2006), or when a substantial change in sensory
neuron firing occurs, a typically unconscious evaluative process ensues that quickly assigns
valence (positive or negative) more specifically, to classify them according to five broad classes
of emotionally relevant phenomena:
Each class of stimuli reflects the end result of a natural selection process that equipped
humans to automatically attend and respond to certain types of environmental stimuli (such as
spiders or human facial expressions) linked to species survival (see Adolphs, 2008; Davis et al.,
2011; Mineka & Öhman, 2002). Each class of stimuli is also associated with its own unique
neural substrate and pattern of bodily responses, which influence our desire for affiliation with
others as well as our nonverbal social signaling (such as our facial expressivity, voice tone, and
body posture). These species-specific unconditioned stimuli elicit unconditioned responses that,
at least initially, are unalterable, although they are subject to epigenetic modulation over the
course of a person’s life, as a function of learning and brain maturation (Bendesky & Bargmann,
2011; McEwen, Eiland, Hunter, & Miller, 2012). Emotional responses can be triggered by an
internal cue (such as a bodily sensation or a memory), an external cue (such as a barking dog), or
a temporal cue (as when a particular time of day triggers the urge to smoke a cigarette).
Initial evaluations or primary appraisals of evocative stimuli occur at the sensory receptor or
preconscious level. For example, research suggests that we need at least seventeen to twenty
milliseconds (recall that one second is equal to one thousand milliseconds) to become
consciously aware of a face expressing emotion, and yet our brain-body begins physiologically
reacting to that facial expression after as short a time as four milliseconds (L. M. Williams et al.,
2004, 2006). Perceptual encoding factors function to screen out the vast array of incoming
sensory stimuli that would otherwise overwhelm the brain’s capacity to attend to relevant stimuli
essential for survival and individual well-being. If a stimulus is of low intensity, repetitive, or
both, then the generalized arousal systems fails to excite or activate higher brain areas, thereby
providing an important preconscious regulatory function. Thus the initially annoying sound of a
ticking clock, for most individuals, will habituate or fade from awareness over time, due to its
low intensity and repetitive nature. Without this, we would likely be overwhelmed by the vast
array of incoming stimuli, since a great deal of information entering the central nervous system is
irrelevant (for example, the color of the wall in front of my computer as I write this).
We need at least seventeen to twenty milliseconds to become consciously aware of a face
expressing emotion, and yet our brain-body begins physiologically reacting to that face after as
short a time as four milliseconds.
Neuroceptive tendencies also involve innate reactions to unconditioned stimuli (such as the
sight of a snake) or learned reactions to conditioned stimuli (to an infant, for example, a gun is
not emotionally evocative, whereas for an older child guns are highly evocative). Plus, the
influence of biotemperament may be most powerful at the sensory receptor level of emotional
processing because it functions to bias perception and regulation preconsciously. Fortunately,
primary appraisals can be reappraised at the central cognitive level via top-down regulatory
processes. For example, a runner sighting a curvy stick on a woodland trail is likely to exhibit a
startle response, followed quickly by the word “Snake!” and a brief heightening of defensive
arousal, yet most often the curvy shape is quickly recognized or reappraised as a stick,
whereupon autonomic defensive arousal is downregulated and the runner is returned to his prior
positive mood state. Reappraisals at the central cognitive level are also strongly influenced by
individual differences in experience. For example, children and their parents have different
reactions to seeing that a deep snow has fallen overnight, which vary further depending on
whether it is a weekday or weekend. Plus, the urging component of an internal response
tendency is a propensity for action, not the action itself—that is, feeling like hitting someone
does not mean one will automatically engage in a boxing match. Whether or not a person
actually hits another person depends greatly on his innate capacity for self-control as well as the
situation he is in, his prior learning, and his biotemperamental predispositions. As already
alluded to, our model contends that our brains are evolutionarily hardwired to detect and react to
five broad classes of emotionally relevant stimuli, described next.
NOVELTY CUES
Novelty cues are discrepant or unexpected stimuli that trigger an automatic evaluative process
designed to determine whether the cue is important for our well-being. When something
unexpected occurs, our PNS-VVC social safety system is briefly withdrawn, without SNS
activation. We are alert but not aroused. Our body is immobile but prepared to move (Bracha,
2004; Schauer & Elbert 2010); we freeze, hold our breath, and orient our attention toward the
novel cue in order to evaluate its potential significance (in milliseconds), a process known as an
“orienting response” (Bradley & Lang, 2007; Porges, 1995). The end result is the assignment of
valence (safe, threatening, rewarding, or overwhelming). If the novel stimulus is evaluated as
safe, then we return to our set point of calm readiness and are likely to signal safety to nearby
others via facial affect, body posture, and vocalizations. However, if the novel stimulus is
evaluated to be rewarding or threatening, then SNS activation occurs. Biotemperamentally
heightened detail-focused processing may make it more likely for an OC client to notice minor
discrepancies in the environment, thereby triggering more frequent orienting responses relative
to less detail-focused others, while heightened OC threat sensitivity may bias interpretations of
ambiguous stimuli toward the negative. Interestingly, across all humans, ambiguous stimuli are
rated as more unpleasant and are associated with longer reaction times relative to unambiguous
stimuli (Hock & Krohne, 2004). According the RO model of emotions, our brains are
evolutionarily hardwired to appraise ambiguous stimuli at the sensory receptor level (for
example, a blank facial expression or an unfamiliar sound) as a potential threat (since the cost of
not detecting a true threat stimulus for our ancestors living in harsh environments was too high to
ignore), whereas evolutionarily newer evaluative processes involving logic and language are
needed when primary appraisal processes at the sensory receptor level are unable to assign
valence, resulting in slower reaction times but, hopefully, more accurate appraisals and more
effective behavior in the long run. Thus OC heightened threat sensitivity is hypothesized to make
automatic assignment of negative valence to ambiguous stimuli in the present moment more
likely and top-down evaluations less likely, a process that is posited to reverse when it comes to
the evaluation of future contingencies.
REWARDING CUES
Rewarding cues are stimuli appraised as potentially gratifying or pleasurable; our sympathetic
nervous system excitatory approach system is activated. We experience a sense of anticipation
that something pleasurable is about to occur. We feel excited and elated; our heart rate goes up
and we breathe faster. Reward sensitivity is the neuroceptive tendency to detect signals of
positive reinforcement from our surroundings. It is conceptually related to the constructs of the
behavioral activation system (Gray, 1987; Gray & McNaughton, 2000; Smillie & Jackson, 2005)
and positive affectivity (Brenner, Beauchaine, & Sylvers, 2005; D. Watson & Naragon, 2009).
Signals of reward motivate excitatory approach and goal-directed activity, which lead to
increased activation of the SNS (Brenner et al., 2005), referred to in our model as SNS appetitive
reward. Individuals with high reward sensitivity are posited to exhibit heightened excitatory
responses to lower-level rewarding stimuli in comparison with lower reward sensitivity. Mania
vulnerability is an example of heightened reward sensitivity (Depue & Iacono, 1989; Depue,
Krauss, & Spoont, 1987; Meyer, Johnson, & Carver, 1999; Salavert et al., 2007), whereas
depression has been consistently linked with low reward sensitivity (Henriques & Davidson,
2000) as well as deficits in approach motivation (Shankman, Klein, Tenke, & Bruder, 2007).
When strongly activated, SNS appetitive reward response tendencies are posited to reduce PNS-
VVC empathic responding, manifested by reductions in facial affect and social cue sensitivity
(for example, one may overlook important vocal cues or facial expressions exhibited by others).
Hyper-goal-focused behavior secondary to SNS appetitive reward activation can negatively
impact the social environment (imagine someone talking over or dominating a conversation
because she is so excited by what she is thinking about or doing). The predominant overt
behavioral responses during SNS appetitive reward activation involve two general overt
behavioral responses:
Excitatory approach (for example, reaching for a delicious-looking red apple)
Pursuing, which involves hyper-goal-focused appetitive behavior (imagine a fox in a
henhouse)
Our model differentiates between anticipatory reward and consummatory reward. The term
anticipatory reward refers to approach/pursuit responses and SNS excitatory arousal (chasing
and catching the rabbit), whereas the term consummatory reward refers to reward attainment
(consuming and digesting ), PNS activation, hedonic pleasure, rest, digestion, and contentment.
THREATENING CUES
Threatening cues are stimuli appraised as potentially dangerous or harmful. Detection of threat
is related to the activation of the fight-or-flight system (Gray, 1987) and is somewhat related to
the activation of the behavioral inhibition system (Gray, 1987; Gray & McNaughton, 2000).
When we feel threatened we experience a sense of anticipation that something bad may happen
or that desired goals may be blocked. Our sympathetic nervous system is activated, triggering
feelings of anxiety, irritation, and an urge to flee or attack. Both our social safety (PNS-VVC)
empathic perception and prosocial signaling become impaired. Our body feels tense; our breath
is fast and shallow and our heart rate speeds up as we prepare to fight or take flight. For example,
we can only force a fake smile, our facial expressions are constricted, our voice tone becomes
monotonic, our gestures are tight and nonexpansive, and we are more likely to avert our gaze or
stare with hostility and misinterpret what another person says. If the level of threat arousal
continues to increase without the threat being removed, a state of fright or panic may occur; the
balance between SNS and PNS dominance may tip toward the older evolutionary system (that is,
the old vagus or PNS-DVC; see Porges, 2007), causing tonic immobility, yet the organism is still
able to escape should an opportunity arise (that is, the SNS can be reactivated).
After a pleasant evening meal, Mr. Bean decides to take a leisurely stroll in
his neighborhood. (High social safety: PNS-VVC is dominant; Mr. Bean is
relaxed and sociable.) However, on this particular night, his street seems
unusually quiet—traffic is nonexistent. (Mild novelty cue: PNS-VVC is
slightly withdrawn; Mr. Bean is curious and slightly alert.) Suddenly a white
van appears at the end of the street. It loudly accelerates toward Mr. Bean.
His body freezes, he holds his breath, and he stares intently. (High novelty
cue: PNS-VVC social safety system is further withdrawn; Mr. Bean is highly
attentive and focused.) The van screeches to a halt, and three burly men jump
out, all wearing identical white uniforms and masks. They run toward Mr.
Bean. (Moderately high threat cue: SNS defensive arousal is activated.) As
they run they chant, “Teeth! Teeth! Glorious teeth!”
Mr. Bean decides to make a run for it. (SNS flight response is activated:
Mr. Bean wants to escape and flee.) But his pursuers are too fast. They grab
him, and he tries to hit them. (SNS fight response is activated: Mr. Bean
launches a defensive attack.) But they are too strong. They throw him into
the back of the van and tie him to a reclining chair with a bright light
overhead.
Mr. Bean freezes in terror but continues to seek a means of escape. (SNS
fright response: Mr. Bean is panicked but still able to move.) Unfortunately,
the bonds are too tight, and there appears to be no means of escape. He feels
helpless. (PNS-DVC flag response: Mr. Bean feels the urge to give up.) And,
to make matters worse, the villains force his mouth open and begin poking
and prodding at his teeth with pointy objects and tubes, their efforts
accompanied by low-level whirring and gurgling sounds. Mr. Bean feels
increasingly detached from the situation and can barely hear what his
abductors are saying. (PNS-DVC shutdown is fully activated: Mr. Bean is
dissociating and fainting.)
When Mr. Bean comes to, he’s sitting in a police car next to a kindly
officer who tells him what happened. It seems that Mr. Bean is the latest
victim of the Order of Maleficent Flossing Gurus (OMFG), a reprobate cabal
of dental hygienists gone rogue. [Editor’s note: OMFG, indeed.] Mr. Bean
smiles weakly and takes a deep breath. He’s a bit worn out but pleasantly
surprised that his teeth feel so exceptionally clean and his breath is so minty
fresh. (Mr. Bean’s PNS-VVC social safety system is starting to reengage.)
The model accounts for stable and context-independent patterns of responding (also known as
personality, habits, and moods) and introduces a mechanism by which rigid habitual responses
(and biotemperamental biases) can be modified via use of skills that capitalize on neuroinhibitory
relationships between the PNS and SNS (Berntson et al., 1991; T. R. Lynch et al., 2015). It also
contends that we are evolutionarily hardwired to constantly scan the environment for the
presence of safety, novelty, reward, threat, or overwhelming reward or threat and, as a
consequence, emotional experience is ever present, albeit often at a low level of intensity that
precludes conscious awareness. Finally, the model strongly influences RO DBT treatment
strategies via its emphasis on social signaling, social safety, and the communicative and
facilitative functions of emotion, asserting that species survival and individual well-being are
strongly dependent on our ability to form long-lasting bonds and work together in tribes. Table
2.1 provides a graphical overview of the core ANS components of our neuroregulatory model
and how each is hypothesized to impact social signaling.
Table 2.1. The RO DBT Neuroregulatory Model of Emotions
Primary PNS-VVC
SNS-Ef SNS-
neural PNSc-VVCd withdrawn PNS-DVCh
(excitatory) Dg(defensive)
substrate engaged without SNSe engaged
response engaged engaged
activation
Orienting
and primary Defensive
appraisal avoidance
Social safety Excitatory Emergency
system system
engagement approach shutdown systems
(adaptive (adaptive
system system (adaptive function:
function: function:
(adaptive (adaptive conserve vital
ANS provides a promotes
function: function: energy reserves
system quick means defensive
enhances promotes needed for survival
triggered to identify fight and
intraspecies goal-pursuit when SNS
and flight
communication, behaviors that fight/flight/approach
appropriately behaviors that
facilitates social maximize goal responses are
respond to maximize
connectedness) attainment) ineffective)
environmental harm
threats or avoidance)
rewards)
Body is
Body is tense and
Body is Body is
animated and agitated Body is immobile
relaxed frozen
vivacious Heart rate and
Autonomic Breathing is Breath is Breathing is
responses slow and deep suspended Breathing is fast, shallow breathing is slowed
Heart rate is Orientation faster Heart rate Increased pain
reduced is toward cue Heart rate is is fast threshold
fast Sweating
Emotion Numb,
words Alert but
Relaxed, Excited, Anxious or unresponsive,
associated not aroused;
sociable, elated, irritated, trancelike,
with curious,
contented, passionate, defensively nonreactive,
interoceptive focused,
open, playful goal-driven aroused apathetic,
evaluative
experiencei insensitive to pain
Empathic
Social Empathic perception SNS approach,
Impact on Social signaling perception capacities and fight, and flight
social signaling capacities impaired; prosocial responses
signaling enhanced momentarily individual still signaling withdrawn; social
suspended expressive capacities signaling irrelevant
both impaired
a The term neuroception denotes how a person appraises or assesses evocative stimuli.
Primary appraisals are quick evaluations, elicited without conscious awareness and originating at
the sensory receptor level. Secondary appraisals are slower, top-down reappraisals of primary
evaluations; they involve evolutionarily newer central cognitive and conscious levels of
emotional processing.
b A cue is an emotionally evocative stimulus that occurs inside the body (a happy memory, for
example), outside the body (an unexpected loud noise), or as a function of context (the time of
day).
c PNS = parasympathetic nervous system.
d PNS-VVC = ventral vagal complex (“new” vagus) of the parasympathetic nervous system;
social safety system.
e SNS = sympathetic nervous system; activating system.
f SNS-E = SNS excitatory approach system.
g SNS-D = SNS defensive avoidance system.
h PNS-DVC = dorsal vagal complex (“old” vagus) of the parasympathetic nervous system;
shutdown system.
i The term interoceptive refers to emotion based phenomena and sensations occurring inside
the body.
Next, I review the RO DBT biosocial theory specific for disorders of overcontrol that emerged
from our neuroregulatory model. Both are essential for treatment of maladaptive overcontrol.
Our neuroregulatory model provides the basis for interventions targeting specific OC difficulties,
whereas the biosocial theory helps clinicians’ and clients’ empathic understanding of how OC
developed and was maintained over time.
The theory also posits that maladaptive OC involves both perceptual deficits (in receptivity to
change, for example) and regulatory deficits (context-inappropriate inhibited or disingenuous
expressions of emotion). Specifically, biotemperamental predispositions for heightened threat
sensitivity, diminished reward sensitivity, high inhibitory control, and heightened detail-focused
processing are posited to transact with early family, environmental, and cultural experiences
valuing correctness, performance, and self-control to result in a risk-avoidant, emotionally
constrained, and aloof/vigilant style of socioemotional coping that limits opportunities to learn
new skills and exploit positive social reinforcers. The theory emphasizes the importance of
openness and social signaling as well as the idea that optimal well-being requires the following
three elements:
Biotemperamental predispositions are powerful because they can impact perception and
regulation at the sensory receptor (preconscious) level of emotional responding and, as a
consequence, indirectly influence central cognitive functioning (such as language-based
reappraisals) and response selection (such as overt actions and social signals), without the person
being influenced ever knowing it. When extreme, they are posited to make overt behavioral
responding more rigid and less adaptive to changing environmental contingencies.20 For
example, biotemperamental predispositions for high threat sensitivity and constraint make it
more likely for an OC client to feel and appear uptight pervasively and regardless of context—at
work, at home, at the gym, or when at a party—whereas individuals with fewer
biotemperamental biases can more easily modify their behavior in order to match the context
they are in (constrained at work but able to dance with abandon at an office party).
DETAIL-FOCUSED PROCESSING
OC clients are posited to exhibit a preference for details (such as hyperawareness of small
discrepancies) and high pattern recognition (such as hyperawareness of asymmetry) over more
global patterns of processing (for example, broad perspective taking, or taking into account the
big picture). Research examining individuals diagnosed with anorexia nervosa and autism
spectrum disorders (two core OC disorders) reveals poorer performance on tasks demanding
global processing (Happé & Frith, 2006; Lang, Lopez, Stahl, Tchanturia, & Treasure, 2014;
Lang & Tchanturia, 2014) and superior capacities for detail-focused or local processing (Aloi et
al., 2015; Lopez, Tchanturia, Stahl, & Treasure, 2008, 2009; Losh et al., 2009). Detail-focused
processing is posited to represent a nonemotional biotemperamental attribute initiated at the
sensory receptor or subcortical level of processing (that is, preconsciously). As a consequence,
OC clients may be more inclined than others to notice the trees but miss the forest. It is posited to
be nonemotional because it involves basic perceptual processes pertaining to pattern recognition
(for example, a misaligned book) that can quickly become emotional. For example, noticing a
book out of alignment on a bookshelf may trigger an urge to straighten or realign the book, an
urging tendency that if blocked may lead to frustration or trigger anxiety. High detail-focused
processing combined with OC superior inhibitory control may strongly influence career,
relationship, and recreational choices. For example, OC individuals tend to engage in
recreational/career activities requiring detailed analysis (such as chess, map reading, data
analysis, or accounting), persistence, rehearsal, and self-discipline (such as ballet dancing,
skydiving, scuba diving, or mountain climbing), and they often favor solitary activities that allow
greater personal control (such as marathon running or computer gaming) over team and
interpersonal activities in which success is measured in terms of prosocial cohesion and mutual
striving.
ANTICIPATORY REWARD
The term anticipatory reward refers to appetitive or incentive motivations that in humans are
associated with feelings of desire, wanting, excitement, elation, energy, enthusiasm, and potency
(for a review, see Depue & Morrone-Strupinsky, 2005) as well as sympathetic nervous system
activation, excitatory approach behaviors, and dopamine release. Anticipatory reward responses
are also an important part of social bonding and affiliation in humans and have been linked to
unconditioned social stimuli, such as facial features (for example, attractive faces), smiles,
friendly vocalizations, and gestures (Porges, 1998). When applied to social interactions, the term
refers to the degree to which a person desires social intimacy or seeks social engagement.
OC individuals are posited to be biotemperamentally predisposed to be less sensitive to
rewarding stimuli relative to others. Reward sensitivity is defined as the threshold or set point
whereby a particular stimulus in the immediate surroundings is evaluated as potentially
rewarding or signals the possibility of positive reinforcement. Diminished reward sensitivity
makes it less likely for OC individuals to report feeling enthusiastic or joyful and to exhibit
excitatory approach behaviors. For example, a recent review of anticipatory reward factors and
related brain regions in eating disorders (Kaye, Wierenga, Bailer, Simmons, & Bischoff-Grethe,
2013) concluded that dopamine-mediated anticipatory reward is found to be higher in binge-
purge (that is, an undercontrolled disorder in our model) and lower in anorexia (that is, an
overcontrolled disorder).22
CONSUMMATORY REWARD
The term consummatory reward refers to the feelings of pleasure associated with consuming
or achieving a desired reward, experiences that have been shown to be linked with endogenous
µ-opiate release, PNS ventral vagal activation, and PNS rest/digest behaviors. In humans,
consummatory reward experiences are associated with feelings of increased interpersonal
warmth, social connectedness, contentment, an experience of satiation, and feelings of euphoria
and well-being. It is important to note that µ-opiate-mediated and µ-opiate-moderated reward
experiences are posited to be essential for humans to desire intimacy with others in the first
place; that is, the desire to socially engage with others in the present (anticipatory reward) is
highly influenced by the magnitude of pleasure experienced during social encounters in the past
(see Depue & Morrone-Strupinsky, 2005). Thus an individual with a high temperamental µ-
opiate reward system is more likely to encode neutral, low-level prosocial or ambiguous
encounters as rewarding (for example, a relatively low-intensity interaction with a store clerk
may be experienced as highly pleasurable) compared to someone with a low temperamental µ-
opiate reward system. Those with high temperamental µ-opiate reward systems would be
expected to approach socially ambiguous situations because their prior experience suggests that
they will find them pleasurable. Thus low anticipatory reward–sensitive individuals (that is, OC
individuals) are predicted to require a higher level of prosocial safety signals, not only in order to
activate their anticipatory reward system and associated excitatory approach behaviors but also
in order to experience consummatory reward or pleasure during the social interaction itself. RO
DBT posits that OC individuals exhibit low anticipatory reward responses (low reward
sensitivity), normal consummatory reward responses to nonsocial rewards, and low
consummatory reward responses to social or affiliative rewards.23
Interestingly, most research examining reward fails to distinguish between positive emotional
experience and physiological quiescence. Our neuroregulatory model contends that calm
quiescence can be distinguished from excitatory reward states in part by observing how they
impact social signaling (refer to table 2.1). For humans at least, physiological quiescence is
posited to mean social quiescence; that is, when we feel part of a tribe we feel safe, and
concomitant social safety activation (see PNS-VVC) enhances empathic responding and
prosocial signaling. In contrast, excitatory reward states are characterized by expansive social
signals and lowered empathy (via downregulation of the PNS-VVC social safety system and
upregulation of SNS excitatory reward). Plus, anticipatory reward has been linked with mental
imagery and reward approach and responsiveness, whereas consummatory reward has been
linked to openness to experience and positive affect (Gard, Gard, Kring, & John, 2006). RO DBT
posits that OC clients are less likely to experience PNS-VVC social safety, partly as a function of
high biotemperamental threat sensitivity; that is, it’s hard to have a good time at a party when
your sensory receptor system is hyperalert for potential danger.
The conundrum that OC presents for affiliative or social reward theory is that the amount of
hedonic pleasure OC clients experience from nonsocial rewards is predicted to be the same as for
other people (for a review, see Dillon et al., 2014), yet they are predicted to experience
diminished hedonic pleasure from social interactions and be less responsive to positive social
stimuli compared to other people. These hypotheses have yet to be investigated. Moreover,
similar to observations made by McAdams (1982), models examining reward responses would
benefit from separating affiliation needs (for example, fears of being alone, desires to be around
others but not necessarily intimate) from intimacy needs (for example, need for close intimate
social bonds, recognition that periods of social isolation may be necessary). Desires to affiliate or
be around other people may represent lower-order or older evolutionary responses associated
with safety in numbers, whereas desires for intimacy may represent higher-order or new
evolutionary responses associated with the facilitative function of emotional expressions and our
core tribal nature. Finally, I consider it plausible that our models would benefit if we expand the
concept of reward to include nonhedonic motivations, particularly when attempting to
understand human social interactions. For example, as noted earlier, OC individuals are posited
to be motivated to approach social interactions out of obligation or sense of duty (nonaffective
approach coping), not because they anticipate or experience them as rewarding or pleasurable.
REWARD LEARNING
Reward learning among OC clients is also posited to be negatively impacted by their habitual
avoidance of novelty or unpredictable situations. Current theories of reward learning posit that
learning occurs when prediction fails—that is, new learning is possible only when there is a
discrepancy between what was predicted to occur (based on past experience) and what actually
occurred. Learning is most robust when expectations are disrupted (that is, unpredicted), whereas
learning slows and eventually stops as outcomes become increasingly predictable (Hollerman &
Schultz, 1998). Similar to concepts articulated in RO principles of self-enquiry (see chapter 7), it
appears that learning is only possible when we encounter our “personal unknown.”
The relevance of the preceding observations when it comes to understanding OC clients is
clear; that is, their obsessive use of routine and their structured, controlled existence may make
life predictable and keep anxiety at bay but have a hidden cost when it comes to enjoying life.
Research suggests that dopamine neurons in the substantia nigra and ventral tegmental areas of
the brain are most likely to be activated by unpredictable rewarding stimuli, a process that “then
slows down as outcomes become increasingly predicted and ends when outcomes are fully
predicted” (Hollerman & Schultz, 1998, p. 304). Thus it appears that rewarding experiences and
subsequent learning depend on variety, unpredictability, and exposure to the unknown. Thus the
obsessive desire to predict all possible future outcomes and plan ahead that characterizes most
OC clients may not only prevent new learning but increase stagnation and resignation. Relatedly,
OC positive mood states are often linked to a sense of accomplishment (for example, resisting
temptation, detecting an error that others missed) rather than luck, chance, or current mood (for
example, winning the lottery). From an OC perspective, happiness must be earned and leisure
time must be self-improving. Unfortunately, OC biotemperamental capacities for superior self-
control often make it seem possible to control others and the world similarly. Next, I describe the
“nurture” component of the RO DBT biosocial theory of OC and the impact of the
sociobiographical environment on the development and maintenance of maladaptive OC.
I actually got pretty good. Finally, when I was about nine, I was invited to
perform a solo at a regional concert. I was really nervous, but I got a
standing ovation.
Because overly controlled and emotionally constricted children are likely to be inhibited and
avoid trouble, it would be reasonable to predict that caregiving adults would tend to view them
as fairly well behaved, in contrast to children prone to high-intensity pleasure (high reward
sensitivity), who are likely to be impulsive and behaviorally inappropriate (Rothbart, Ahadi,
Hersey, & Fisher, 2001). Research has demonstrated that parents subtly reinforce (via attention)
increases in children’s submissive expressions of emotion over time (defined as sad-anxious
expressions or mixed sad-anxious and happiness) but not disharmonious expressions (for
example, anger; see Chaplin, Cole, & Zahn-Waxler, 2005). Though parental responsiveness is
likely influenced by child biotemperamental predispositions (Kagan, 1994; Lewis & Weinraub,
1979), longitudinal findings suggest that parental attention to submissive emotion predicted the
level of submissive expression two years later, even after controlling for the child’s tendency for
submissive expression at preschool age, while this did not hold for disharmonious expressions
(Chaplin et al., 2005). Parents have also been shown to reward their children for inhibition of
excessive fear and discourage outward expression of anxious emotion (see Kagan, Reznick, &
Snidman, 1987b). With this in mind, it appears that the giving or withholding of attention by
parents may subtly function to reinforce submissive or inhibited emotional expression.
The preceding findings suggest that there are multiple sociobiographical influences that can
reinforce or exacerbate the development and maintenance of OC coping. For example, some OC
clients report growing up in chaotic and dramatic households or settings (for example, one or
both parents severely alcoholic or drug-addicted, frequent unpredictable geographical moves and
changes in living conditions, frequent primary caregiver changes). It is not uncommon for OC
clients to report that they undertook a caregiving role for other siblings or incapacitated parents
from a young age. In addition, maladaptive OC can also develop in healthy families or similar
contexts. Developmental research (Eisenberg et al., 2003) suggests that warm, positive parents
may inadvertently promote overcontrolled behavior in their children (Park, Belsky, Putnam, &
Crnic, 1997; Rubin, Burgess, & Hastings, 2002). Kimbrel, Nelson-Gray, and Mitchell (2007)
have suggested that overprotective parents may enhance behavioral inhibition sensitivity in their
children by inadvertently teaching or modeling that the world is a dangerous place to be feared.
For example, a five-year-old child with heightened threat sensitivity might beg a parent to
accompany him to a schoolmate’s birthday party, and when the parent does so, she notices that
the child appears to cope better. Yet this same behavior when the child is fourteen years old may
not be seen in such a positive light, especially by the adolescent’s peer group. As such, well-
intentioned parents may overtly intend to communicate that life isn’t scary but inadvertently
signal or communicate the opposite by how they behave toward the child (for example, saying,
“It is important to protect yourself”). Overprotection prevents habituation or extinction from
taking place by reducing opportunities for the child to experience normal anxiety-provoking
situations. Therapists are not immune to exhibiting similar overprotective behaviors. For
example, a therapist who believes it is essential first to reduce anticipatory anxiety before
requiring a client to attend a skills training class may inadvertently communicate that skills
training is dangerous. As one OC client observed, “If this class is so safe, then why is my
therapist so intent on ensuring that I am calm before I attend?”
We trust them; when we don’t trust someone, we hide our true intentions and mask
our inner feelings.
We are the same because we share a common bond of human fallibility.
True friendship may begin when we are able to share not only the positive aspects of our lives
but also our secret doubts, fears, and past mistakes. Thus maladaptive OC habitual masking of
inner feelings may occasionally help protect OC individuals from social disapproval yet in the
long run functions to create the very problem it was developed to prevent, leading to an
increasing sense of loneliness and isolation.
We don’t feel connected because we feel safe. We feel safe because we feel connected.
Figure 2.2.
The Kindling Effect
Chapter 3
Assessment Strategies
This chapter is designed to provide clinicians (and researchers) an overview of assessment
strategies and measures that can be used in determining the extent to which an individual
matches prototypical features associated with maladaptive overcontrol. The chapter begins by
briefly describing the basic tenets underlying RO DBT assessment approaches. Next comes a
review of the most common assessment errors and assumptions that can make the identification
of maladaptive overcontrol difficult. The RO DBT OC diagnostic protocol is then outlined, and
the chapter ends with future directions and a full description of OC-specific measures and
scoring guidelines.
Indeed, the DSM-5 (American Psychiatric Association, 2013, p. 13; see also National Institute
of Mental Health, n.d.), in order to encourage further research into common factors, purposefully
placed the section describing depressive disorders (internalizing problems) adjacent to the
section describing anxiety disorders, whereas the section describing disruptive, impulse-control,
and conduct disorders is adjacent to the section describing substance-related and addictive
disorders (externalizing problems). Moreover, the personality domains reflected in the alternative
DSM-5 model for personality disorders (see “Section III: Emerging Measures and Models,” in
American Psychiatric Association, 2013) have been further shown to comprise these higher-
order factors (that is, externalizing and internalizing problems; see Krueger & Markon, 2014).
Yet, since RO DBT was developed for a spectrum of disorders sharing core phenotypic and
genotypic features, rather than for an existing diagnostic category, we not only had to develop a
treatment to address OC deficits but also had to develop a reliable and valid means for clinicians
to identify maladaptive overcontrolled coping in their clients. Although aspects of the OC
personality prototype have certainly been described before, in varying ways (see Haslam, 2011;
Block & Block, 1980), our approach is distinct from most others in that it incorporates a wider
range of potential determinants, including biotemperament, family and environmental influences,
social connectedness, neuroregulatory factors, and style of self-control. Thus the RO DBT model
for diagnosing maladaptive overcontrol combines dimensional models (designed to assess
severity of dysfunction and biotemperament across multiple domains) with prototype models
(which facilitate “low-cost” clinical decisions via assignment of a categorical diagnosis). It is
founded on two core principles:
The measures and methods recommended in this chapter reflect these aims. However, before
we begin this journey, it is important for clinician-assessors to be aware of the common errors
and assumptions that occur when assessing problems of overcontrol.
The idea of public as opposed to private behavior does not appear in any diagnostic system for
mental disorders, such as the DSM-5 (American Psychiatric Association, 2013), or in any
personality trait–based model of psychopathology (for a review of current models, see Krueger
& Markon, 2014). Moreover, failure to account for whether a maladaptive behavior is expressed
in public or in private is probably the most common factor underlying misdiagnosis of
overcontrol (in my opinion). The word “public,” broadly speaking, refers to any behavior
expressed in the presence of another person who is not in one’s immediate family (or similar
social analogue), whereas the word “private” refers to any behavior expressed in a setting or
situation in which we believe we are unidentifiable, anonymous, or alone. But what happens in
private may be very different from what happens in public. For OC individuals, dramatic
displays of emotion (such as temper tantrums and yelling, also known as emotional leakage)
most often occur in private rather than public settings. OC individuals abhor public displays of
emotion or behavior that may attract unwanted attention or criticism; they are highly capable of
inhibiting an overt behavioral response in public, if they choose to do so. Indeed, assessors’
failure to distinguish between public and private with respect to the setting in which a
maladaptive behavior is expressed may be one of the core reasons why OC is so often
misdiagnosed. Emotional leakage in public settings should be expected at least occasionally from
OC individuals, especially in situations that feel anonymous (such as a political demonstration)
or where strong displays of emotion are expected or socially sanctioned (such as a therapy
session). Therefore, when an OC individual reports episodes of emotional leakage, it is important
to explore the social signaling aspects of the behavior by determining the magnitude of the
public exposure, for example, as well as its frequency, its intensity, and the extent to which an
outside observer would consider the behavior abnormal or context-inappropriate (see “Assessing
Emotional Leakage,” page 72).
Step 1
In step 1 of the OC diagnostic protocol, the potential OC client completes three short self-
report measures that take approximately fifteen minutes to complete and can be part of a battery
of self-report measures (involving, for example, demographics, ratings of distress, and measures
of occupational or interpersonal functioning) that clients are routinely asked to complete prior to
the first meeting with a therapist (for interested clinicians and researchers, our research team has
also created a supplemental list of OC measures, which includes measures of both hypothesized
mechanisms and outcomes):
Assessing Styles of Coping: Word-Pair Checklist (see appendix 1 for a copy of this
measure and its scoring instructions)
Personal Need for Structure measure
Acceptance and Action Questionnaire–II
At the time of this writing, there is no cutoff score for determining whether a person leans
more toward an overcontrolled or an undercontrolled style of coping. Instead, the ASC-WP
should be seen as an opportunity for individual exploration of personality style. Most of the
individuals who become OC clients will check the boxes next to words and phrases describing
OC characteristics, and so clinicians will find interpretation of these individuals’ ASC-WP scores
straightforward.
The ASC-WP can also sometimes be used to generate discussion when a particular client
appears to be struggling with knowing his style. However, most often this is not necessary—in
our experience, most of the individuals who become OC clients easily identify themselves as
overcontrolled (see “Enhancing Client Engagement via Orientation and Commitment,” chapter
5).
Less likelihood of changing beliefs in the face of new information (low openness)
Greater likelihood of stereotyping
Preference for structured rather than unstructured social events
High focus on performance
In addition, a rigid desire for structure, as determined by the PNS measure, has been shown to
improve as a function of RO DBT skills training (see Keogh et al., 2016).
Step 2
In step 2 of the OC diagnostic protocol, the clinical assessor (or therapist) conducts a
structured or semistructured diagnostic interview—a standard clinical practice. In the event that
an unstructured format is employed, the assessor should be attentive to statements suggesting the
presence of an overcontrolled style of coping. For example, if an individual reports obsessive
behaviors, the assessor should follow up with questions informed by the diagnostic criteria for
obsessive-compulsive disorder and obsessive-compulsive personality disorder to ascertain
whether either of these disorders is present. The following questions can facilitate this process:
If the interview is structured, then the assessor can use such measures as the Structured
Clinical Interview for DSM-5 (First, Williams, Karg, & Spitzer, 2015), the Structured Clinical
Interview for DSM-IV Axis II Personality Disorders (First, Gibbon, Spitzer, Williams, &
Benjamin, 1997), and the International Personality Disorder Examination (Loranger, Janca, &
Sartorius, 1997). OC Axis II personality disorders are subsumed under DSM Cluster A
(paranoid, schizoid, and schizotypal) personality disorders and Cluster C (obsessive-compulsive,
avoidant, and possibly dependent) personality disorders. Core shared features among OC
personality disorders are as follows:
Step 3 of the diagnostic protocol takes approximately seven minutes and occurs after the
clinical interview has been completed and the potential OC client has left the room where the
assessment took place. At this point, the clinician completes two measures:
The Clinician-Rated OC Trait Rating Scale, forms 3.1 and 3.2 (see appendix 2)
The Overcontrolled Global Prototype Rating Scale, forms 3.3 and 3.4 (see appendix
3)
THE CLINICIAN-RATED OC TRAIT RATING SCALE (OC-TS), FORMS 3.1 AND 3.2
The OC-TS uses a seven-point global trait rating scale to assess eight personality traits that
provide an estimate of “caseness,” or the extent to which an individual is a close match for each
of the eight OC traits. Form 3.1 provides scoring instructions and descriptions of the eight core
OC traits, and form 3.2 provides a copy of the measure itself. A score of 6 or 7 denotes
“caseness” for a particular trait, and a total score of 40 or higher on the instrument as a whole
reflects greater global OC behavior. Research examining the psychometric properties of this
scale is currently in progress. The scale can also be used also as an adjunct for purposes of
treatment planning.
The assessor who completes form 3.3 of the OC-PRS uses a 5-point key to rate the overall
similarity between a potential OC client and each of eight OC prototypical descriptive
paragraphs. As noted by Westen et al. (2010, p. 483), “For purposes of communication, ratings
of 4 or 5 denote a categorical diagnosis (‘caseness’), and a rating of 3 translates to ‘features’ or
subthreshold.” The idea is for the assessor to evaluate the potential OC client in terms of each
descriptive paragraph as a whole instead of counting individual symptoms. This format has been
shown to provide rich diagnostic data, and it avoids problems associated with memorized lists of
symptoms and with arbitrary or variable cutoffs across disorders (Westen et al., 2010). The
assessor checks the relevant box under each of the descriptive paragraphs and adds up the
numbers; a total score of 17 or higher indicates OC. With practice, the instrument can be
completed in five or six minutes, and it can be repeated over the course of treatment to monitor
clinical improvement.
For an individual with an overall score of 17 or higher on form 3.3 of the OC-PRS, the
assessor can use form 3.4 to determine whether the individual, now prototyped as OC, meets the
criteria for two OC social signaling subtypes, the overly disagreeable subtype and the overly
agreeable subtype, which differ primarily in terms of how the OC individual wants to be
perceived by others—that is, form 3.4 addresses the OC individual’s public persona. The scoring
instructions are similar to those for form 3.3. Identifying a client’s OC subtype can be highly
useful in treatment planning and targeting. For example, OC individuals whose traits are a match
with the overly agreeable subtype need to learn how to express anger directly instead of keeping
it bottled up; by contrast, those whose traits are a match with the overly disagreeable subtype
need to learn how to reveal their vulnerability to others instead of compulsively pretending to be
unfazed or strong. For more about these two subtypes and effective treatment strategies
regarding them, see chapter 9.
Future Directions
Obviously, one challenge our team encountered as we developed RO DBT for disorders of
overcontrol was that there was a vast literature examining overcontrolled coping and similar
constructs, but a comprehensive measure of overcontrolled coping that included all the elements
in our model had yet to be developed. As such, our research team, in collaboration with like-
minded colleagues (such as Lee Anna Clark), initiated a separate line of research aimed at
developing and validating several new measures that captured how we conceptualized
maladaptive overcontrol. For example, research examining the utility of a new self-report
screening questionnaire for overcontrol is in progress, as is work on measures examining
hypothesized mechanisms of change.
In addition, one new and exciting area of research pertains to the development of reliable and
valid nonverbal coding schemes for evaluating the extent to which an individual naturally
engages in prosocial signaling behaviors during interactions with others (for example, by smiling
frequently, offering eyebrow wags, and using a warm tone of voice). It is hoped that such coding
schemes can be used to augment diagnostic assessments as well as to assess hypothesized
mechanisms of change linked to improved social signaling. To this end, our research team
developed the Nonverbal Social Engagement Coding Scheme (Greville-Harris, Hempel, Karl,
Dieppe, & Lynch, 2016), which is used to code eight nonverbal behaviors (eye gaze, smiling,
frowning, laughing, and four differing patterns of head movements). Modifications of this
instrument are in progress in our lab and include improved methods of coding RO-specific
nonverbal prosocial behaviors taught in treatment.
Now You Know…
Overcontrol is a multidimensional personality construct that can be assessed
reliably in clinical settings and used as a basis for guiding treatment decisions.
Traits associated with disorders of overcontrol are sometimes taken as evidence
of other disorders, including disorders of undercontrol, because of assessors’
errors and assumptions.
A three-step protocol for diagnosing overcontrol is available. It combines
dimensional models with prototype models, and it uses potential OC clients’
self-report measures along with diagnostic interviewing and postinterview
measures completed by an assessor.
Chapter 4
Ability to delay gratification Enables resources to be saved for times of less abundance
Detail-focused processing and Increases precision and thus the likelihood that problems will be
quick pattern recognition detected and solved so that everything functions properly
RO DBT recognizes the prosocial nature of overcontrol by adopting a therapeutic stance that
simultaneously acknowledges the client’s sense of separation or difference from others. Despite
desiring social connectedness, OC clients inwardly experience themselves as outsiders and are
often clueless about how to join with others or form intimate relationships (although they are
unlikely to tell anyone about this). They feel like strangers in a strange land, often even when
around their family members, always watching but rarely ever fully participating. To help correct
this, the role of the RO DBT therapist may be best described as that of a tribal ambassador—that
is, someone who is able to appreciate the unique self-sacrifices OC individuals make to meet or
exceed community expectations and perform well, and who warmly welcomes them back into
the tribe.
It is important to understand that treatment assumptions are not truths. They help guide
behavior, but if they’re held too tightly, they can interfere with new learning.
A major aim of orientation and commitment is the therapist’s and the client’s collaborative
identification of the social signaling deficits and related factors that are blocking the client from
living according to his values and keeping him from actualizing his valued goals. Often this
process also requires helping the client identify his values and goals, which then serve to guide
treatment throughout the duration of therapy. Here, the term value denotes a principle or a
standard, which a person considers important in life, and which guides behavior, whereas the
term goal denotes some means by which that value is realized. For example, a person who holds
passion as a value may realize this value by achieving the goal of forming a romantic
partnership; another, who holds close family ties as a value, may realize this value by being a
warm and helpful parent; still another, who holds financial independence and rewarding work as
values, may realize these values by becoming gainfully and happily employed.
Engaging in intentional self-harm and suicidal actions, such as cutting, burning, and
overdosing
Exhibiting a sudden increase in suicidal ideation, urges, or plans aimed at
intentionally caused tissue damage or death32
Engaging in behaviors that are not aimed at intentionally caused tissue damage or
death but that do constitute an imminent threat to life
For example, if a client maintains a condition of being severely underweight, eats restrictively,
or purges, her behavior is seen as symptomatic of OC maladaptive responding until the moment a
physician declares the behavior to be imminently life-threatening. It is at this point that the
behavior also comes to be seen as life-threatening in RO DBT (even if the client’s goal is not
tissue damage or death), and reducing this behavior now trumps all other treatment targets. The
key word here is “imminent.” This approach provides a coherent rationale for the therapist to
avoid expressions of overconcern about medical risk when doing so might inadvertently
reinforce dysfunctional behavior. For instance, the therapist’s heightened concern about a low
body weight might unintentionally reinforce a client’s restrictive eating by conferring a special
status on the client that excuses her from normal expectations or responsibilities (T. R. Lynch et
al., 2013).33
Both issues are the responsibility of the therapist to manage (that is, a client is not blamed for
creating an alliance rupture). Although an alliance rupture represents a potential problem for the
therapist (for example, it can lead to the client’s premature dropout), in RO DBT an alliance
rupture is also seen as an opportunity for the client’s growth in that a successful repair can be
instrumental in helping an OC client learn that conflict can enhance intimacy. Thus an alliance
rupture and its subsequent repair can provide an important means for an OC client to practice the
skills needed to resolve interpersonal conflicts and to learn that expressing feelings, including
those that involve conflict or disagreement, is an important part of a normal, healthy relationship.
In addition, a successfully repaired alliance rupture is considered strong evidence of a good
working relationship between the therapist and the client. Since OC clients are expert at masking
their feelings and, despite their inner suffering, giving the appearance that all is well, in RO DBT
the therapeutic relationship is considered superficial if by the fourteenth of the thirty outpatient
sessions there have not been multiple alliance ruptures and repairs (see chapter 8 for specifics).
RO DBT therapists recognize that even though they may not have been the sole cause of an
alliance rupture, they are still responsible for repairing it.
OC Behavioral
Examples of Social Signaling Deficit
Theme
Inhibited and
Displaying one emotion to hide another (such as smiling when angry), indirect and
disingenuous
ambiguous use of language, disguised demands, low use of emotionally valenced
emotional
words, pervasive constraint of emotional expressions
expression
Hyper-detail-
Insistence on sameness, automatic rejection of critical feedback, rarely enthusiastic,
focused, overly
compulsive correction of minor errors, lying to avoid novelty
cautious behavior
Rigid, rule-
Always circumspect, polite, and appear calm or in control; high social obligation and
governed
dutifulness, compulsive self-sacrifice, moral certitude
behavior
Aloof and Rarely expressing desires for intimacy or feelings of love, walking away during
distant style of conflict, low vulnerable self-disclosure, limited validation of others, lack of reciprocity
relating during interactions—e.g. mutual smiling, laughing, or crying
Frequent social
Secretly sabotaging, lying or cheating to get ahead, eye rolls, callous smiles, disgust
comparisons, with
reactions, dismissive gestures, silent treatment, harsh gossip, sarcasm
envy or bitterness
Welcoming and checking in with the client (about one minute). This
involves greeting the client, welcoming the client back, and briefly
checking in by asking how the client is doing. The therapist should be
alert for signs of the client’s nonengagement and for indications of a
possible alliance rupture; as necessary, the therapist should address the
nonengagement or repair the rupture before proceeding. The therapist
should avoid prolonged discussion of the past week’s events until the
client’s RO DBT diary carda has been reviewed and an agenda has
been set for the session.
Reviewing the client’s diary card and agreeing on the social signaling
deficit or overt problem behavior that will be targeted for the session’s
chain analysisb (approximately six minutes). Social signaling deficits
are superseded by the presence of imminent life-threatening behavior
or by an alliance rupture.
Conducting a brief check-in about the client’s attendance at and
participation in RO skills training class (approximately one minute).
As necessary, the therapist should then assess and address any
problems.
Conducting a brief check-in about the client’s completion of the
homework assigned from the previous session (approximately three
minutes). The therapist should identify any difficulty needing further
attention and either do some quick problem solving or place the issue
on the session’s agenda as an item for discussion.
Finalizing the session’s agenda and agreeing on the amount of time
that will be spent on each agenda item (approximately three minutes).
The therapist and the client will agree, for example, on how much time
to spend on chain analysis and how much to spend on teaching and
learning a new RO skill.
Conducting a behavioral chain and solution analysis targeting the
problem behavior of the week, as identified from the diary card
(approximately twenty to twenty-five minutes). Ideally, given core RO
DBT principles that posit overcontrol as a problem of emotional
loneliness, the majority of chain analyses in RO DBT will target the
client’s OC social signaling deficits and problems linked to the client’s
overt expression of emotion rather than the client’s internal
experiences (such as thoughts, emotions, and sensations).
Discussing other agenda items (approximately fifteen minutes). For
example, the therapist may target non-OC problem behaviors (such as
restrictive eating) or other kinds of problems (difficulties finding a
job, legal difficulties). The therapist may also teach new skills (such as
loving kindness meditation) already planned for the session, celebrate
the client’s successes, or define new treatment targets derived from
OC themes.
Ending the session (approximately two minutes). The therapist should
briefly summarize the session’s events and any new skills that the
client has learned. The therapist should also include a reminder of any
specific homework that may have been assigned for the coming week
(such as a specific self-enquiry practice or RO skill).
Before treatment can begin with OC clients, they must be willing to see their
overcontrolled style of coping as a core problem.
RO DBT therapists practice radical openness and self-enquiry themselves, since
radical openness is not something that can be grasped solely via intellectual
means.
Rather than focusing solely on fixing, correcting, or improving
hyperperfectionistic OC clients, RO DBT teaches therapists to model living a
life worth sharing and to adopt the stance of tribal ambassador in order to
encourage emotionally lonely and isolated OC clients to return to the tribe.
The treatment priorities in RO DBT are, first, to reduce life-threatening
behaviors; second, to repair ruptures in the therapeutic alliance; and, third, to
address deficits in the client’s social signaling, with reference to the five OC
behavioral themes.
The five OC behavioral themes are (1) inhibited or disingenuous emotional
expression, (2) extreme caution and excessive focus on details, (3) rigid, rule-
governed behavior, (4) an aloof, distant style of relating to others, and (5)
frequent use of social comparisons along with frequent feelings of envy or
bitterness.
Chapter 5
Figure 5.1.
Individual Therapy Room Furniture Arrangement
Prior to a session with an OC client, the therapist should arrange the seating in a manner that
maximizes physical distance. OC clients generally have a greater need for personal body space
relative to others. Close body proximity is a nonverbal signal of intimacy or confrontation
(Morris, 2002). The same reasoning applies to the physical layout and seating arrangements used
in RO skills training classes. Ideally, the classroom will include a long table with chairs
positioned around it in the style of a dining room, and with some type of whiteboard or flipchart
at the front of the room for the instructor to write on. Figure 5.2 shows this type of classroom
setting. It signals that the purpose of the class is learning skills rather than participating in group
therapy, engaging in interpersonal encounters, or processing feelings. The table and room
arrangement also provide physical buffers between class members (this functions to reduce their
feeling of being exposed) while providing space for notetaking (which allows OC clients time to
downregulate without calling attention to themselves). The skills class should also and ideally be
conducted in a large and airy room that can accommodate up to nine people. A large room also
allows clients greater freedom in how they might adjust their seating or move their chairs farther
away from others without calling attention to themselves.
Figure 5.2.
RO Skills Classroom Layout
It is also very important that room temperature be considered for both individual therapy
sessions and skills training classes. A hot or very warm environment naturally triggers
perspiration in most people. For many OC clients, sweating is a conditioned stimulus linked to
anxiety and maladaptive avoidance. When working with OC clients, therapists should set room
temperatures to be lower than what might be normal; if necessary, clinics should invest in fans or
other means to cool rooms, when required. In general, the rule is to keep the room cool unless
the OC client requests that the temperature be increased.
Interestingly, most people find it easy to tell others when they are cold, but people are
amazingly reluctant to complain when they feel hot, especially in settings that are evaluative or
trigger self-consciousness (for example, a job interview). This is because feeling cold is not a
symptom of anxious arousal, whereas feeling hot is. Our experience applying this principle in
our research trials and clinical work over the years has repeatedly shown this relatively simple
factor to oftentimes profoundly influence client behavior and treatment engagement.
For example, one RO DBT therapist during clinical supervision reported that her client had
missed several sessions, and that she was concerned about treatment dropout. Review of a
videotaped session revealed fidgeting and restless body movements, behaviors that had not been
noticed by the therapist. When asked by her supervisor if the cooling fan in the room was being
used, the therapist indicated that she had stopped using the cooling fan several weeks earlier and
had checked in with her client about it by asking if he still needed the fan on now that autumn
had arrived. The client had stated, “No, I’m fine.” The supervisor suggested that, despite the
client’s previous report, the therapist turn the fan back on prior to the start of the next session and
begin the session as she normally would, without any mention or reference to the fan unless the
client brought it up. To the surprise of the therapist, the behavior of the client seemed more
engaged during that session. His body movements appeared less agitated, eye contact improved,
and he spoke more freely. The therapist kept the fan on from then on and made sure she had a
light sweater available for herself. Weeks later, when the therapist and her client were practicing
ways of activating social safety in session, the client revealed that he had been too embarrassed
to tell her that he was feeling hot when the fan was not on because he thought his therapist might
take it as criticism.
Thus therapists should always assume that seating and proximity factors are important when
working with OC clients, regardless of clients’ verbal reports to the contrary. So turn on the fan
and turn down the heat when working with OC clients, and bring layers of clothing for yourself
if you tend to get cold easily. This simple physical environmental adjustment can make an
enormous difference, especially early in therapy, when an OC client is less likely to reveal what
he may be truly feeling or thinking inside. Clients in skills class who report the room being too
cool can be encouraged to bring a light sweater with them to class, and we always like to have a
few sweaters on hand in class to be borrowed if needed. For additional information on managing
the environment in skills training classes, see the skills training manual, chapter 1.
Another major aim of the orientation and commitment stage is to collaboratively identify the
client’s valued goals, which are used to facilitate treatment targeting. Both the heightened
biotemperamental threat sensitivity that characterizes OC and the overall OC tendency to
abandon relationships mean that “foot in the door” strategies are more frequently used in RO
DBT than “door in the face” strategies when therapists want to deepen commitment.36
RO DBT commitment strategies start with a stance of humility and openness on the therapist’s
part. RO DBT acknowledges that it is the client’s right to choose the life she wishes to lead, even
if it is a miserable one (or at least to the therapist’s eyes appears miserable). RO principles
contend that it would be arrogant for a therapist to assume he knows how his OC client should
live or what she should consider important. Thus, ultimately, the RO DBT therapist
acknowledges to himself (and to his client when needed) that his client is responsible for the
choices she makes, including the choice of remaining depressed, anxious, or lonely, and that
ultimately the therapist cannot fix his OC client’s problems. Similar to the role of a national park
ranger helping someone lost in a forest, an RO DBT therapist can walk alongside his OC client
and provide a map and compass as a guide (that is, the RO DBT treatment strategies) to help his
client find her way home, but he cannot carry her out of the forest—the client must walk out on
her own.
Thus the orientation and commitment stage of RO DBT individual therapy sets the stage for
the rest of treatment. Since OC clients are highly rule-governed and generally serious about life,
it is important for therapists to avoid reinforcing these perspectives by adopting an overly
serious, formalistic, or rigid stance suggesting compliance or agreement is essential. RO DBT
principles of openness, flexibility, an easy manner (see chapter 6), and self-enquiry guide the
therapist’s behavior from the moment he first meets a client.37
Global Aims and Topics for the First and Second Sessions
Determining the client’s reasons for seeking treatment, his past treatment
experience, and his family and environmental history
Orienting the client to the type of problems the treatment is designed to help, and
confirming the client’s agreement with and general commitment to targeting
OC as the core issue
Assessing the client’s current and past history of suicidal and self-harming
behavior
Signaling the therapist’s willingness to discuss past trauma, sexual issues, and
long-held grudges and resentments
Orienting the client to the overall structure of treatment, including information
about the purpose of skills training classes, and giving the client notice that his
participation in skills class will begin during the third week of therapy.
Four Steps for Identifying Overcontrol as the Core Problem in the First Session
Say: As I mentioned earlier, one of the things I wanted to do today is
give you a bit of a sense of the treatment approach that I will be using
in our work together. Here’s what’s really interesting—researchers
from around the world have reached a type of consensus or agreement
that around age four or five it is possible to start to see the beginnings
of two differing personality or coping styles that are linked to
problems later in life. Have you ever heard about anything like that
before?
Say: One of these styles is known as undercontrolled.a As children,
undercontrolled individuals were often described as highly excitable,
overly expressive, conduct-disordered, or impulsive. When they felt
something inside, everyone knew about it! Plus, they found it hard to
plan ahead or resist temptation. When they saw a cookie, they grabbed
it and ate it up, without thinking about the consequences. They also
tended to do things according to how they felt in the moment. And
now, later in life, if they don’t feel like going to work, they just don’t
go! So when you think about yourself, now or when you were a child,
does this type of personality or coping style describe you?
Say: Perhaps you lean the other way.b The other style, known as
overcontrolled coping, is more cautious and reserved. As children,
overcontrolled individuals may have been described as shy or timid.
They tend to control or constrain expressions of emotion and are able
to delay gratification and tolerate distress for long periods of time in
order to achieve long-term goals. They tend to set high personal
standards and are likely to work harder than most to prevent future
problems, without making a big deal of it. Yet inwardly they often feel
lonely, not part of their community or excluded from it, and feeling
clueless about how to join with others or form intimate relationships,
and they often feel isolated. So when you think of yourself, now or as
a child, do you think this style might describe you better?
Say: Finally, the treatment approach I will be using—RO DBT—was
developed for problems of overcontrol but doesn’t consider
overcontrolled coping as always problematic.c On the contrary, not
only is high self-control highly valued by most societies, it’s what got
us to the moon! It takes a lot of planning and persistence to build a
spaceship. Thus, rather than attempting to get rid of your
overcontrolled coping, I hope to help you learn how to both embrace
and relinquish your tendencies toward overcontrol, flexibly and
according to the situation. What do you think when I say that?d To
what extent are you willing to target overcontrolled coping as a core
problem in our work together?
detail-focused
restrained
perfectionistic
cautious
disciplined
structured
conscientious
reserved
planful
dutiful
It is also important for therapists to avoid adopting a stance that communicates coercion or
pressure to agree with an OC label. If a client struggles with recognizing his style as
overcontrolled, therapists can take one of the following approaches:
Consider the possibility that the client is correct, thereby modeling radical openness
Experiment with different words or phrases (for example, “high self-control” or
“hyperperfectionism”) to describe the OC style
Provide homework assignments that might help trigger awareness of overcontrol
To deepen discussions with an ambivalent client, the therapist can also ask the client to
complete the instrument called Assessing Styles of Coping: Word-Pair Checklist (see appendix
1), if it has not already been completed as part of a pretreatment assessment interview, or the
therapist can assign the checklist as homework to be reviewed at the next session, although this
is generally unnecessary. In addition, as seen in the scripted discussion, it is important to note at
some point the prosocial nature of overcontrol (refer to table 4.1), without overplaying it—a
form of smuggling (see “More About Smuggling,” below).
In summary, the therapist’s overarching aim during discussions of self-control tendencies with
an OC client is to awaken an appreciation for self-exploration and a recognition that OC coping
both solves and creates problems. This involves asking, not telling, the client about how OC has
prevented her from reaching important valued goals. Early in therapy, a client’s spontaneous
disclosures of fallibility and unprompted curiosity about OC coping are good indicators of client
engagement. Finally, it is important for therapists to remember that successful treatment of OC
does not mean converting the client into a dramatic, erratic, undercontrolled person; on the
contrary, it involves helping a client learn how to appreciate her personality style and yet be able
to flexibly relinquish it when the situation calls for it.
The therapist’s overarching aim during discussions of self-control tendencies with an OC
client is to awaken an appreciation for self-exploration and a recognition that OC coping both
solves and creates problems.
OC client suicide and self-harm are usually planned, often hours, days, or even weeks
in advance (and sometimes longer).
OC self-harming behavior is usually a well-kept secret. It may have been occurring
for years without anyone knowing, or knowledge about it may be limited to
immediate family members (or very close friends and therapists). Thus OC self-
harm is rarely attention-seeking. The severity of self-inflicted injuries is carefully
controlled in order to avoid medical attention, and scars are carefully hidden. An
OC client may acquire first aid or medical training in order to treat self-inflicted
wounds on her own and avoid having to go to a hospital. Exceptions to hiding
behavior can occur, most often among OC clients with a long history of
psychiatric hospitalization, whereby dramatic displays of self-injury are often
intermittently reinforced (for example, self-injury gets an OC client placed in a
private observation room, which is preferable to the uncertainty of being part of
the general inpatient community).
OC clients may attempt suicide to punish family or close others (“When I’m gone,
you’ll be sorry”) or to get even, make a rival’s life difficult (for example, the hope
is that the client’s death will make it impossible for the rival to achieve an
important goal), or expose moral failings.
OC self-harm or suicidal behavior is more likely to be rule-governed than mood-
governed (for example, its purpose may be to restore the client’s faith in a just
world through self-punishment for perceived wrongs).
Some OC clients may romanticize suicidal behavior and consider brooding or
melancholy to be noble or creative.
Actions, plans, desires, urges, or ideation, the goal of which is to intentionally cause
tissue damage or death (for example, nonsuicidal self-injury, suicidal ideation or
urges, suicide attempts)
Behaviors that are not intentionally aimed at dying or causing tissue damage but are
an imminent threat to life (imminent life-threatening behaviors take precedence
over other targets or treatment goals; see chapter 4)
Thus, the therapist should be prepared to adjust her planned agenda for the session or may
need to extend the orientation phase of treatment when imminent life-threatening behaviors are
revealed, in order ensure client safety. In general, it is recommended that the therapist introduce
the topic and begin the assessment approximately thirty minutes into the session (or midpoint).
This allows some time to get to know the client and orient him to some aspects of the treatment
(for example, the focus on overcontrol) yet allows sufficient time for a risk assessment and a
suicide-prevention plan or self-injury-prevention plan, if needed.
The single most important risk factor for a completed suicide is a previous attempt.
Essentially, the more recent the attempt, and the more lethal the means used, the higher the risk.
An important outcome of this assessment is to obtain a commitment from a client who reports
urges, thoughts, or plans to kill or harm himself in the near future that he will not engage in self-
harm or attempt suicide before the next session and, ideally, will commit to working on
eliminating self-harm and suicidal behaviors as a core aim of treatment. The therapist can use the
following script to introduce a discussion of life-threatening behavior with an OC client:
Therapist: It turns out that research shows that many people struggling with the kinds of
problems you are experiencing can get so depressed or hopeless that they start thinking
about killing themselves or hurting themselves, and this can start at a young age. So
what I would like to do next is spend some time talking about these types of issues
with you in order to understand whether these types of issues have been a problem for
you, and the extent to which we may need to focus on them during our work together.
So my first question is…
At this point, to guide the discussion with a set of questions derived from clinical experience,
the therapist can turn to the RO DBT Semistructured Suicidality Interview (appendix 4); the
greater the number and the severity of the client’s past or current problems involving self-harm
or suicidal behavior, the more questions the therapist should expect to ask, and the more time the
therapist should expect to spend on this topic.42 The therapist should also feel free to augment
this approach with structured interviews, such as suicide and self-injury assessment protocols
(Linehan, 1993a, pp. 468–495), or self-report questionnaires, such as the Scale for Suicide
Ideation (A. T. Beck, Kovacs, & Weissman, 1979) and the Adult Suicidal Ideation Questionnaire
(W. M. Reynolds, 1991; Osman et al., 1999).
Finally, the high social comparisons that characterize overcontrolled coping can result in
frequent experiences of unhelpful envy and desires for revenge. OC individuals are more likely
to hold grudges and believe that it is morally acceptable to punish a wrongdoer. Thus it is
important to also assess desires for revenge and urges to harm others—at least briefly—during an
initial OC client risk assessment. Contrary to common assumptions that all (or most) violent acts
stem from poor impulse control, emotion dysregulation, and low distress tolerance (that is,
undercontrolled coping), our work in forensic settings with violent criminal offenders and prior
research have identified two subtypes of overcontrolled violent offenders (Hershorn &
Rosenbaum, 1991; P. J. Lane & Kling, 1979; P. J. Lane & Spruill, 1980; Quinsey, Maguire, &
Varney, 1983). Overcontrolled violent offenders are characterized as introverted, shy, timid, and
apprehensive and have significantly lower criminal histories and less institutional misconduct,
compared to other violent offenders. However, their acts of violence, though often occurring
only on one occasion, are disproportionately more violent and more likely to be revenge-focused
and planned, compared to the violence of nonovercontrolled offenders. An OC client’s superior
inhibitory control allows him to plan his revenge carefully, and his moral certitude can make
physical harm directed toward others seem like the right thing to do (recall the Columbine
massacre). Thus, when signaling a willingness to discuss past traumas and sexual issues (see the
following section), it is also important to signal a willingness to discuss past grudges, revengeful
desires or acts, and past violence.
Research shows that it is likely that at some point during our work together
you may not feel like coming to therapy, or you may want to drop out of
treatment. What I would like to ask is if you would be willing to commit to
coming back in person to discuss your concerns before you actually make the
decision to drop out. Would you be willing to give me this commitment?
Global Aims and Topics for the Third and Fourth Sessions
Identifying four to five valued goals that are important for the client, with at least one
pertaining to social connectedness
Teaching the biosocial theory for overcontrol (typically in the third session)
Teaching the key mechanism of change, linking open expression of emotion to
increased trust and social connectedness and to the importance of social signaling
in human relationships (typically in the fourth session)
Introducing the RO DBT diary card (typically in the fourth session)
When it comes to family, friends, and work, what are the things you consider most
important?
What attributes do you admire in others?
What ideals would you consider important to teach a child?
How would you like others to describe you? How would you like others to describe
you at your funeral?
Plus, for some clients, to further facilitate values clarification, it can be useful to assign as
homework worksheet 10.A (“Flexible Mind Is DEEP: Identifying Valued Goals”), found in the
skills training manual.
However, valued goals can also be obtained less formally, which can often prove therapeutic
for rule-governed OC clients (formal assessments using written materials may inadvertently
reinforce compulsive desires for structure and order). Informal values clarification begins by
noticing what appears to be important for a client—that is, our values are often reflected in the
words we use to describe ourselves and the things we like or dislike about other people or the
world. For example, a client reporting that she is not easily impressed may be signaling a value
for precision and thoughtfulness, whereas a client reporting anger at a neighbor for telling him
how to improve his internet connection might value independence or self-sufficiency. Therapists
can help clients identify their values in these moments by asking about the value behind a
reaction or statement: “It sounds like you value independence and solving problems on your
own. Do you think this might have been linked to the way you responded to your neighbor?” The
advantage of this type of interactive dialogue is that it smuggles the idea of self-exploration, and
therapists can model radical openness when guesses are rejected by a client by not holding on to
their guesses as truth. Sometimes simply asking a relevant question is all that is needed to pull
out a valued goal. For instance, a client was discussing that she no longer had relationships with
her grown son and daughter, and her daughter had recently had her first grandchild. The therapist
might simply ask, “Would you like an improved relationship with your children?” If the client
says yes, this can be highlighted as a treatment goal linked to values for close social bonds. The
therapist can delve deeper by assessing the degree to which the client’s family problems might
function to exacerbate her distress.
Discovering valued goals and linking them to problem behaviors and emotional reactions can
help OC clients begin to recognize that most of their difficulties, although often self-created,
arise from heartfelt desires to live according to prosocial values. For example, the OC client who
is horrified by her emotional leakage on a bus after yelling at a passenger for not giving up his
seat for an elderly person can be encouraged to recognize that her leakage represents a social
signaling error rather than a fundamental flaw in her character and the source of her emotional
outburst stems from a prosocial value (that is, a value to care for those in need). Ideally, by the
end of the commitment and orientation phase (that is, the first four sessions), the therapist and
client have mutually identified four to five valued goals, with at least one pertaining to social
connectedness.
Discovering valued goals and linking them to problem behaviors and emotional reactions can
help OC clients begin to recognize that most of their difficulties, although often self-created,
arise from heartfelt desires to live according to prosocial values.
The importance of values clarification when treating problems of overcontrol cannot be
overstated. OC clients are perfectionists who tend to see mistakes everywhere (including in
themselves) and work harder than most others to prevent future problems. Thus, rather than
focusing on what’s wrong, values clarification focuses on what’s right by identifying what a
client wants or desires out of life (that is, his valued goals), which facilitates engagement in
therapy; committing to change is easier when a person is able to recognize that it is his own
behavior that appears to be blocking him from achieving his valued goals.
Here are some examples of values and goals:
To raise a family
To be a warm and helpful parent to one’s children
To be gainfully and happily employed
To be more spiritual or self-aware
To find more time to contribute to others
To find more time to relax and fully appreciate one’s life
To develop or improve close relationships
To form a romantic partnership
To develop a wider network of friends
To behave more altruistically toward others or be more nonjudgmental
To get married
To be better educated (go to college or university)
To participate more freely in community activities or events
To be able to dance, sing, or socialize without self-consciousness
To learn compassion for self and others
To learn how to forgive oneself or others
To be more open to feedback and others
To laugh easily
To play more often
To find time for oneself
To accept those things that cannot be changed, without hopeless resignation or
despair
Say: Just as we are all born with different eye colors, we are all born
with different brains. Our brain influences how we perceive the world.
Now, imagine a person born with a brain that is more sensitive to
negative things and less sensitive to positive things. When this person
walks into a rose garden, his or her brain is more likely to notice the
thorns than the flowers. When you think about yourself, now or as a
child, do you think you’ve tended to notice the flowers or the thorns
more?
Say: Imagine this same person growing up in a family, a culture, or a
social environment that highly values self-control, performance, and
not making mistakes. Do you think in any way your family or early
environment could have given you the message that mistakes are
intolerable, or that you should strongly avoid ever showing weakness
or vulnerability?
Say: What might this person learn to do? What ways of coping do you
think you learned from these expectations or family rules, so to speak?
Say: First, this person might avoid taking risks, so as not to ever make
a mistake. Second, this person might learn to avoid showing any
vulnerability, even when distressed, in order to avoid appearing out of
control, by masking inner feelings or keeping a poker face. Third, this
person might learn to be cautious when getting to know new people,
which might lead others to believe that this person is aloof and distant.
What are the pros and cons of behaving in this way? How do you
think overcontrolled coping might be linked to some of the problems
you are seeking treatment for today? How might it impact other areas
of your life, such as your relationships or your success in living
according to your valued goals?
Four Steps for Teaching That Open Expression = Trust = Social Connectedness in the Fourth
Session
Say: As I mentioned at the start of our session, one of the things I want
to talk about today is the key hypothesized mechanism of change in
RO DBT. It is based on the assumption that our species’ survival
depended on our ability to form long-lasting bonds and work together
in tribes or groups. This evolutionary advantage required the
development of complex social signaling capabilities that allowed for
a quick and safe means to evaluate and/or resolve conflict and manage
potential collaborations. Thus, when it comes to being part of a tribe,
social signaling matters! Plus, in support of this, research shows that
what may matter most in intimate relationships is not what is said but
how it is said. What comes to mind when I say this? Have you ever
heard about anything like that before?
Say: Okay, but before we proceed, rather than just talking about social
signaling, I would like to conduct a little demonstration that I hope
you will find both entertaining and educational. (Use one of the
recommended stories to ensure a pithy deliverya and maximize client
learning and engagement; see “’Twas a Lovely Affair” or “I Have
Some Really Exciting News,”b later in this chapter.) After the
demonstration, ask: What was it like to interact with the person I was
role-playing? Would you like to spend more or less time with this
person after this interaction? What might this tell us about the
importance of social signaling?c
Say: The way you responded to my extremely odd social signaling
behavior is exactly how most people would respond.d Plus, there has
been a wide range of research reporting similar conclusions. For
example, experimental research has shown that suppressing emotional
expression interferes with communication, impedes relationship
development, and increases anxious arousal in both the suppressor and
those with whom they interact. Interestingly, a wide range of studies
have also shown that people like people who openly and freely
express their emotions, even when they are negative—they are
perceived as more genuine and trustworthy, compared to those who
suppress or mask their emotions. To what extent do you think your
social signaling style impacts your social relationships? How
frequently do you openly reveal inner experience or vulnerable
emotions to another person?
Say: Okay, it seems that we both agree that how a person social
signals really matters, especially when it comes to long-term intimate
relationships.e However, it is perhaps equally important to recognize
that open expression does not mean expressing emotions without
awareness or consideration. On the contrary, effective emotional
expression is always context-dependent. Lastly, it is important that we
take our time to learn more about your social signaling style before
deciding to target it for change. What do you think or feel when I say
this? How willing are you, in this moment, to target social signaling in
our work together?
aIt is essential for the therapist to mimic or playact the facial expression and
voice tone of the central character. This enables the OC client to viscerally
understand (in his or her body) the impact that social signaling has on others.
bKey point: Always pick the story that is least likely to reflect the social
signaling style of the client.
cThe therapist should be prepared to discuss supporting research (for details, see
especially chapter 2). For example, a number of studies have shown that people
become anxiously aroused when interacting with a nonexpressive person and prefer
not to spend time with that person, and emotionally constricted children have been
shown not only to experience more peer rejection during childhood but also to be
more likely to become increasingly depressed, anxious, and socially isolated over
time.
dThis statement assumes that the client has reported finding the social signaling
style portrayed by the therapist to be off-putting.
e It is important for the therapist be prepared for and to address self-deprecating
statements and Fatalistic Mind thinking from some clients—for example, “This just
proves that I’m no good, because if what you say is true, then I could have fixed
myself years ago.” (For an explanation of the concept of Fatalistic Mind, see the
skills training manual, chapter 5, lesson 11.) The therapist should help a client who
responds in this manner to recognize that getting down on himself for not
recognizing a problem earlier is not only a good way to stay miserable but also to
avoid the necessity of having to change. The therapist should encourage the client
to practice seeing problems as opportunities (for new learning and growth). From
an RO DBT perspective, if you hate the color purple but live in a purple house, you
can’t do anything about it until you notice that your house is purple.
For this story, it is essential that the therapist put on an overly polite or pro-social voice and a
phony smile that remains frozen whenever he or she is speaking the words attributed to the
coworker. Seeing a phony smile enables the client to viscerally experience what it would be like
to interact with that person; without the phony smile, the learning that is possible from this story
would remain intellectual rather than experiential. A phony smile involves moving only the lips,
with the eyes flat, and with the eyebrows kept still. The therapist should also exaggerate the
phoniness of the smile, displaying his or her teeth while making sure the smile remains static.
This drives home the point of the story, and it smuggles humor as well as the notion of not taking
oneself too seriously:
Therapist: Imagine that you’re out to lunch with a new coworker, and during the meal she
reveals some very personal information. (Begins smiling.) While smiling and nodding,
she says, “Last night I discovered that my husband is having an affair.” (Keeps
smiling.) “Plus, I found out we are now bankrupt because he has spent all of our money
on the other woman.” (Keeps smiling.) “So I decided to set fire to the house.” (Keeps
smiling.) “How was your evening?”
After reading the story aloud, the therapist asks the client to respond to the following
questions:
What would you think or feel if you interacted with someone who behaved like this?
Did the coworker’s description of her evening warrant smiling?
Would you like to spend more or less time with this coworker after this interaction?
What emotion was the coworker likely feeling but not showing? (Answer: Most
likely bitter anger.)
How might this impact a relationship?
For this story, it is essential that the therapist put on a completely unemotional, flat facial
expression and use a flat tone of voice whenever he or she is speaking the words attributed to the
coworker. Seeing a flat face enables the client to viscerally experience what it would be like to
interact with the person described in the story; without the flat face, the learning that is possible
from this story would remain intellectual rather than experiential. In order to read the story
effectively, the therapist will have to behave like a zombie. This drives home the point of the
story and smuggles in the idea that it’s okay to be silly, and that learning can still happen even—
and perhaps especially—when one is having fun:
Therapist: (Using normal tone of voice) Imagine that you’re out to lunch with a different
coworker. During the meal, he reveals some very exciting news. (Begins using a flat
face and a monotone.) He says, “Last night I discovered that I won ten million dollars
in the lottery. I was thrilled.” (Continues flat face and monotone.) “Plus it was Steven
Spielberg, the movie director, calling from Hollywood. He had just read the script that
I’d sent him on a whim, and said he loved it so much that he was sending first-class
tickets to fly me to Los Angeles to discuss making my script into a movie. I was so
happy.” (Continues flat face and monotone.) “Can you pass me the salt?”
After reading the story aloud, the therapist asks the client to respond to the following
questions:
What would you think or feel if you interacted with someone who behaved like this?
Did the coworker’s description of his evening warrant a flat face?
When we are flat-faced, what are we signaling?
How might this impact a relationship?
After telling the story, the therapist should discuss with the client what the client observed and
learned from the story and then use this to move back to the script and assess willingness on the
client’s part to target social signaling as a core part of treatment. The transcript that follows
shows how a therapist transitioned from the story back to the client and obtained commitment to
target social signaling as a core part of therapy:
Therapist: Now that we have had fun with our story, I am curious. Do you think it’s possible that
your habit of not expressing vulnerable feelings to others may have inadvertently
affected your relationships?
Client: Yeah. I hate to admit it—my blank face is my suit of armor.
Therapist: Sometimes, though, it might be nice to take off the armor. (Chuckles slightly.) After
all, it must get hot in there sometimes. (Pauses.) What is really strange, though, is that
research shows that open expression and self-disclosure, instead of making people run
away, are actually perceived by others as a safety signal. We tend to trust those who
freely express their emotions, particularly when the situation calls for it. It seems that
when we take our armor off, others feel that it is safe to take theirs off, too, and then
we can all have a picnic! (Laughs.)
Client: (Smiles) Yeah, I see your point. I guess it would be hard to eat a sandwich with a helmet
on. (Chuckles.)
Therapist: I am glad we are discussing this, because this is one of the things we believe may be
keeping you stuck in some way, with both your depression and your anxiety, but also
making you feel like an outsider. Would you be willing to consider working on
changing this in some way?
Client: What? You want me to just start expressing myself willy-nilly?
Therapist: (Senses a potential alliance rupture) No, certainly not! And don’t you dare start!
(Smiles.) Actually, though, perhaps just a little bit, with the understanding that open
expression will not involve simply having you go out and express emotions without
awareness or consideration. On the contrary, effective emotional expression is always
context-dependent. What I would like to start working on with you is the idea of
learning how to take off your armor when the situation might call for it. I think in some
ways you’ve been doing this already in our relationship. How does this feel to you?
Client: A bit scary.
Therapist: (Uses soft tone of voice) Yeah, makes sense. It’s hard to change habits. What is most
important is that we work at a pace that makes sense to you. We will not lose the
essence of who you are. You have a style of your own, and we don’t want to change
everything—that just doesn’t make sense. How are you feeling now, right in this
moment?
Therapists should be alert for and block harsh self-judgments, and clients can be reminded that
social signaling styles are influenced by a wide range of biotemperamental and sociobiographical
factors. Thus, although each of us is responsible for how we socially signal, our social signaling
can be highly influenced by factors outside our control. The good news for the client is that she
is now more aware of how her social signaling may impact others, making change more likely.
Plus, RO DBT is designed specifically to target social signaling deficits, particularly those that
negatively impact social connectedness.
Therapists should also emphasize that effective emotional expression is always context-
dependent; sometimes constraint or controlled expression is what is needed to be effective, avoid
unnecessary damage, or live by one’s values (consider a police officer arresting a suspect, or a
game of poker, or a charged discussion with one’s adolescent child). Plus, therapists should
explain that the goal of treatment is not to completely change how clients express themselves,
because everyone has a unique style. There is no right or optimal way to socially signal; each of
us has our own unique style of expression. What is important is that our style actually functions
to communicate our intentions and inner experiences to other people, especially those we desire
a close relationship with.
Finally, during the orientation and commitment stage of RO DBT, therapists should not feel
compelled to go into greater detail than what has been described so far in this chapter. The aim is
to smuggle a few new ideas to spur new ways of thinking and behaving over time, with the
understanding that the topic will reappear multiple times over the course of therapy.
Diary cards enhance memory about problematic events that will be analyzed during
individual therapy.
Diary cards reduce the amount of time spent determining the session’s agenda by
providing a quick overview of the client’s prior week.
Monitoring the frequency of a behavior can often change the behavior.
Diary cards can be used to monitor treatment progress and remind clients to practice
skills.
Diary cards are reviewed each week at the beginning of the individual therapy session
(including use of skills), and a blank card is provided each week to the client at the end of the
session. Diary cards should not be reviewed during group skills training classes because this
limits time for teaching. In RO DBT, diary cards are intended solely to be used in individual
therapy.
Therapists should obtain their clients’ commitment to discuss any desires not to complete the
diary cards before the clients stop filling them out. The following transcript provides an example
of obtaining this agreement:
Therapist: As I mentioned, the diary card is a really important part of treatment. It will not only
speed things up for us but also be a way for us to assess your commitment to change
and to treatment. Since we both know that you are here to change (Smiles)—that is,
here for treatment—we can assume this means you want to feel or get better. Is that
true?
(Client nods in ageement.)
Therapist: So I think it is important for you to know that if for some reason you don’t complete a
diary card, regardless of the reason, I will consider this a nonengagement signal that
suggests the presence of an alliance rupture. This means either that you are not finding
the treatment relevant to your unique problems or that you feel misunderstood. Most
often it means that my treatment targeting is poor—that is, it usually means that you
don’t find the targets I have identified interesting or personally relevant. So I would
like to ask for a commitment that you talk to me in person about your problems with
completing the diary cards before you stop using them. Would you be willing to do
this?
This commitment strategy works to enhance diary card completion by taking advantage of the
OC client’s natural tendencies for dutifulness and dislike of the limelight. The efficacy of
commitment involves the highlighting of a noncompleted diary card as a social signal (that is, a
signal that an alliance rupture has occurred). When presenting the concept of the diary card for
the first time, the therapist should not rush to cover every possible target or explain every detail
on the diary card. In fact, not covering every detail on the card provides the perfect (pun
intended) opportunity for clients to practice letting go of rigid needs for structure and perfect
understanding. This opportunity should ideally be revealed in a slightly tongue-in-cheek or
playfully irreverent manner by therapists. Finally, it should be explained to clients that the
primary targets on the diary card will be social signaling behaviors (for more about diary cards,
see chapter 9).
The therapist orients the client to the two-way dialogue and collaborative stance
between client and therapist (week one).
The client self-identifies (with help from the therapist) his or her OC coping style as
the core focus in treatment (week one).
The therapist assesses current and past history of suicidal and self-harming behavior
and signals a willingness to discuss past trauma, sexual issues, and long-held
grudges or resentments of the client (week one).
The client commits to discussing in person (that is, not via email, text message, or
telephone) urges to quit therapy before making the decision to drop out of
treatment (week one).
The purpose of skills training class is briefly explained and plans are made for
attendance during the third week (week two).
Four to five valued goals are identified, with at least one pertaining to social
connectednesss (weeks one to four).
The therapist orients the client to the biosocial theory for overcontrol (week three).
The client begins skills training class (week three).
The therapist briefly introduces the key hypothesized mechanism of change, which
links social signaling to social connectedness (week four).
A blank diary card is introduced and one or two behaviors are assigned to be
monitored as practice (week four).
Individualized treatment targets linked to OC themes are identified and monitored on
RO DBT diary cards (weeks four to twenty-nine).
Weekly chain and solution analyses targeting social signaling deficits are conducted,
each lasting about twenty to twenty-five minutes per session (weeks six to twenty-
nine).
Radical openness and self-enquiry skills are introduced, and the client is encouraged
to begin a practice of self-enquiry and purchase a journal to record her practice
(weeks five to thirty).
The importance of the social safety system is introduced, and RO skills designed to
activate the social safety system are taught (weeks five to six).
Loving kindness meditation (LKM) is practiced in individual therapy. The LKM
practice is recorded in session and provided to the client to help facilitate the
development of a daily practice. Individual issues and difficulties regarding LKM
are dealt with (weeks seven to eight).
Therapists should anticipate the first alliance rupture around the sixth session (weeks
four to seven).
The therapist teaches twelve questions from Flexible Mind ADOPTS that are used to
assess whether to accept or decline critical feedback and encourages the client to
practice using them when feeling criticized (weeks ten to twelve).
The therapist informally teaches Flexible Mind REVEALs skills, with a particular
emphasis on “pushback” and “don’t hurt me” responses, and uses this to facilitate
targeting indirect social signaling on the diary card (weeks thirteen to seventeen).
The therapist discusses the importance of personal self-disclosure in developing
relationships, practices Match + 1 skills from Flexible Mind ALLOWS in session,
and assigns related homework (weeks eleven to eighteen).
The therapist introduces the concept of forgiveness and informally teaches how to
grieve a loss using Flexible Mind HEART skills (weeks thirteen to twenty-four).
Ideally, by the fourteenth session the client and the therapist have had multiple
opportunities to practice repairing alliance ruptures, which in RO DBT is
considered proof of a good working relationship. Each repair (even if minor) has
ideally been linked to important treatment goals (revealing rather than masking
inner feelings, practicing openness to feedback, recognizing that conflict resolution
can be intimacy-enhancing). If there has not been an alliance rupture by the
fourteenth session, the therapist should consider the possibility that his relationship
with the OC client is superficial.
Once a successful working alliance has been established—evidenced by success at
repairing alliance ruptures—the therapist can be more confident that the OC client
will be willing to genuinely reveal her inner experience over the course of
treatment. Consequently, the therapist can purposefully move from an inquisitive
(asking) stance to a more directive or prescribing stance, since he can trust his OC
client to tell him directly when she disagrees or feels misunderstood (rather than
bottling it up inside). This therapeutic process of giving and receiving feedback
(between client and therapist) enhances opportunities for new learning and hastens
growth (weeks fourteen to twenty-nine).
At the twentieth week, the therapist reminds the client that therapy will be ending in
approximately ten weeks and then continues to briefly touch upon it each week
and to practice skills linked to grieving relationships (weeks twenty-one to thirty).
Troubleshooting regarding potential problems and relapse-prevention strategies is
outlined (weeks twenty-five to twenty-eight).
The final session is celebrated with a ritual of breaking of bread. Food and tea or
coffee are shared to symbolize the transition. Mutual reminiscence is encouraged,
highlighting notable moments and lessons learned; plans for preventing relapse are
reviewed. To close, the therapist encourages the client to keep in contact and
expresses a desire to know how the person progresses over time.
To understand why, it is important to take into account three factors our brain uses to evaluate
social interactions:
The flat face is such a powerful social signal that it is the most frequently used facial
expression of villains in Hollywood movies.
Signal detection
Context
Variability or responsivity
First, for our very early ancestors living in harsh environments, exclusion or isolation from a
tribe meant almost certain death from starvation or predation. Similarly, nonhuman primates who
are socially isolated from their community die of exposure, lack of nourishment, or predation in
a matter of days to weeks (Steklis & Kling, 1985). Thus the cost of not detecting a true
disapproval signal implicating tribal banishment was too high to ignore for our very early
ancestors, resulting in a signal-detection error bias whereby our modern brains are hardwired to
interpret low-intensity, neutral, or ambiguous social signals as disapproving. For example,
simply reducing or limiting the amount of eye contact during interactions has been shown to
trigger negative feelings associated with being ignored or ostracized (Wirth, Sacco, Hugenberg,
& Williams, 2010), and research shows that neutral expressionless faces are frequently
interpreted as hostile or disapproving and that they trigger automatic defensive arousal in the
recipient (Butler et al., 2003).
Second, the extent to which a flat facial expression emotionally impacts another person
depends a great deal on context. Flat or bland facial expressions are less likely to be emotionally
and socially impactful in situations where dampened expressions of emotion are the norm (such
as during a poker game, a business negotiation, or a funeral).
Third, variability and responsivity are relevant in situations where emotional expression is the
norm or expected (a party, a therapy session, a romantic date, or an argument with one’s spouse);
sustained flat or insincere facial expressions are much more likely to trigger negative evaluations
from recipients (for example, even seasoned speakers find blank stares and expressionless faces
disconcerting). The socioemotional consequences of flat facial expressions appear similar to
those arising from stares. Research suggests that the powerful social impact of a stare is not
solely due to the amount of time spent staring; instead, the power of a stare most often stems
from the starer’s lack of responsivity to the prosocial signals or submissive glances arising from
recipients of a stare (Ellsworth, Carlsmith, & Henson, 1972). Interestingly, the negative impact
of a stare can be mitigated by a simple smile.
Similarly, the powerful impact flat facial expressions exert on others is not solely a function of
the absence of expression. Instead, its power is derived from the conspicuous absence or low
frequency of expected or customary prosocial signals (such as smiling or affirmative head nods)
in contexts that call for free expression of emotion. An individual therapy session represents an
example of a context that encourages free expression of emotion. Since our brains are hardwired
to interpret neutral expressionless faces as hostile or disapproving (Butler et al., 2003), therapists
should expect to experience discomfort (at least occasionally) when treating flat-faced OC
clients. Plus, defensive arousal dampens social safety responses, making mutual flattened
expressions by both the therapist and the client a likely consequence. Unfortunately, when a
therapist unconsciously mimics the deadpan expression of an OC client, the therapist increases
the possibility that his flat facial expression will be interpreted as a sign of disapproval or dislike
by the threat-sensitive OC client, thereby reinforcing client self-constructs linked to being an
outsider or unlovable.
RO DBT incorporates the preceding observations into treatment interventions in the following
ways:
Skills linked to the first two components are outlined in the skills training manual. The
sections that follow describe how to target the unique social signaling deficits characterizing OC
problems and the social signaling strategies employed by RO DBT therapists to facilitate client
engagement in therapy and enhance treatment outcomes.
Eye Contact
Most people spend approximately 40 percent of their facial gazing time during interactions on
the eyes of the other person (J. M. Henderson, Williams, & Falk, 2005). Direct eye contact is
most relevant when signaling approach motivations (such as desires to affiliate or intentions to
attack). For example, research shows people look more often and longer into the eyes of a dating
partner or a person they feel close to as opposed to a stranger (Iizuka, 1992), and faces are
perceived to express more anger with direct as opposed to an averted eye gaze from the sender
(Adams & Kleck, 2003; Sander, Grandjean, Kaiser, Wehrle, & Scherer, 2007). Direct eye gaze,
when combined with specific facial expressions (for example, pursed lips or a furrowed brow),
helps facilitate accurate identification of the sender’s intentions (see figure 6.3).
Figure 6.3.
Prototypical Emotional ExpressionsAdapted from Keltner, Young, & Buswell, 1997, p. 363.
Interestingly, a blank stare lasting no more than five seconds is all that is needed to trigger
defensive emotional arousal and gaze avoidance in all humans (Ellsworth et al., 1972).
Furthermore, gaze aversion is essential when appeasement or nondominance motivations are
important (such as shame, guilt, or embarrassment). Figure 6.3 also shows the averted eyes that
characterize prototypical expressions of shame and embarrassment. Eye contact may be
irrelevant, immaterial, or superfluous when it comes to the expression of certain mood states (see
figure 6.3).
Therapists treating OC clients should expect to encounter atypical reactions to eye contact
gaze behaviors. Heightened biotemperamental threat sensitivity is posited to make it more likely
for OC clients to interpret therapist expressions of concern (for example, direct eye contact or a
slight furrowing of the brow) as disapproval. Research shows that anxiety-prone individuals with
OC features tend to pervasively avoid eye contact, independent of culture, relationship, or
context (Yardley, McDermott, Pisarski, Duchaine, & Nakayama, 2008). What is less known is
the extent to which gaze aversion or direct stares may be used by OC clients to influence the
behavior of others (see the material on disguised demands in the skills training manual, chapter
5, lesson 15) or instead represent a fundamental social signaling deficit.
Regardless, many OC clients have been intermittently reinforced to use signals of
appeasement and gaze aversion in order to block unwanted feedback or disapproval from others
(see the material on “don’t hurt me” responses in chapter 10). For example, it is common for an
OC client to look away when someone compliments her or expresses happiness—a response that,
if repeated frequently, can function to subtly punish expressions of positive emotion by others
when they are around the client—whereas other OC clients may fail to avert eye gaze when it is
called for (as when expressing guilt or embarrassment), or they may overuse hostile or blank
stares (the “look”) to purposefully stop feedback or criticism they do not want to hear but may
need to learn from (see the material on “pushback” responses in chapter 10). Finally, OC
biotemperamental threat sensitivity is posited to make atypical responses more likely when eye
gaze is directed toward the OC client, especially within the context of therapy. Direct eye contact
from a therapist that triggers OC client shutdown is referred to in RO DBT as the “deer in the
headlights” response. Recognition and treatment of this unique pattern of behavior is described
next.
Therapists treating OC clients should expect to encounter atypical gaze behaviors.
To ensure that the therapist has the client’s attention (by gaining direct eye contact)
To ensure that the client understands the importance of what is being discussed or
that the therapist cares about the client (by leaning in or using an adamant tone of
voice)
To ensure that the client understands what the therapist is saying (by repeating what
is said)
Figure 6.4.
Enjoyment and Appeasement SmilesPhotos courtesy of Dr. Lisa Parr, National Primate Research Center, Emory
University
A “deer in the headlights” response is posited to most often begin as an unconditioned or
classically conditioned anxiety response to therapist eye contact. Persistent and prolonged eye
contact is experienced as threatening by most people (Ellsworth et al., 1972). What makes
prolonged eye contact so powerful is when it is unresponsive to the reactions of others or violates
social norms (for example, staring at a waiter to attract his attention is considered okay, but
staring intently at a fellow passenger while riding the subway is not okay). Plus, top-down
executive control processes and prior learning can exacerbate defensive responses to prolonged
stares; for example, many OC clients dare not break eye contact with a therapist because they
believe it will be seen as a sign of weakness or disrespect. The entire process can occur in
seconds, escalating into panic and intense urges to flee. The dilemma for OC clients is that their
desires for escape clash with their core values for dutifulness and obligation (to behave properly,
to do the right thing, to comply with therapist requests), and their strong desires to appear self-
controlled, combined with their superior capacities for inhibitory control, make it possible for
them to grin and bear it and sit tight.
The end result of OC clients’ self-control is a series of ambiguous social signals that are
difficult to interpret because they contain mixed messages (polite smiles or head nods suggesting
engagement or agreement may be combined with wide-eyed staring or frozen and tense body
postures suggesting nonengagement, shutdown, or intense fear). Plus, the ambiguous nature of
these signals makes it likely for therapists to similarly begin to feel anxious, albeit at a lower
level, reflecting evolutionarily hardwired responses initiated at the preconscious or sensory
receptor level of processing. Thus the dilemma for therapists is that their visceral responses are
in conflict with their professional training. For example, a therapist might suddenly find herself
feeling increasingly uncomfortable with the eye contact that she herself therapeutically initiated
with her client. Her bodily discomfort reflects normal brain-body reactions to nonverbal
ambiguous social signals (blank stare, frozen posture, forced smile), yet her training tells her to
maintain eye contact at all costs or risk invalidating her client or communicating disinterest,
disapproval, or fear if she were to look away.
Lacking an alternative model, most therapists err on the side of their prior professional
training by maintaining eye contact and expressions of concern, despite continuing to feel
uncomfortable. What was intended as a prosocial therapeutic encounter can quickly begin to feel
like a stare-down contest that neither person knows how to stop. If not managed properly, panic-
driven urges to flee can evolve into client avoidance of therapy (for example, missing or showing
up late for sessions), therapist relief when a client doesn’t show up for an appointment, and
premature dropout. Plus, as mentioned, overlearned tendencies to mask inner feelings make it
less likely for OC clients to disclose their discomfort (especially early in treatment), even when
asked directly. Yet the real conundrum for the therapist is how to attend to a problem that has
been triggered by therapist attention in the first place. The answer, described next, underlies one
of the most important social signaling strategies in RO DBT, known as taking the heat off.
Heat-Off Strategies
When sensing a “deer in the headlights” response, therapists should take the heat off (that is,
remove the cue) by diverting eye contact away from the client. Breaking direct eye contact
removes the “headlights,” allowing the client the personal space needed to downregulate. A
simple break in direct eye gazing, for only a few seconds, is usually sufficient to interrupt a “deer
in the headlights” response and allow the client sufficient time to downregulate (recall, OC
clients are experts in self-control). When diverting eye contact away from a client, therapists
should avoid staring at the floor (this signals shame, sadness, or lack of confidence); instead,
therapists should break eye contact in a manner that does not call attention to it (for example,
looking briefly upward or to the side while leaning back, as if in contemplation, or downward at
a clipboard while writing a note). Following this, therapists can then feel free to reestablish eye
contact and continue to manage the session as they would normally.
Especially in the early stages of treatment, therapists should avoid highlighting to a client in
session when they are using a heat-off strategy (that is, making it a big deal). Although well
intentioned, most often this only serves to place the heat back on hyperperfectionistic OC clients
and trigger further shutdown. Thus heat-off strategies are most effective when they are delivered
as anonymous gifts. The good news is that after a strong working alliance has begun to emerge
(around the fourteenth session), therapists can begin to specifically discuss the “deer in the
headlights” phenomenon (the initial discussion should not immediately follow a “deer in the
headlights” response). Therapists can introduce the topic by saying, “You know, I have noticed
when we discuss a hot topic, or perhaps when I am too attentive—say, with my eye contact—that
you sometimes appear to shut down or freeze up. Have you ever noticed anything like this?”
Therapists can read aloud the description of a “deer in the headlights” (see the client example
earlier in this chapter) in order to help a client understand that he is not alone in experiencing this
problem and to facilitate a more frank discussion of how it manifests for him.
It should be explained to clients that a “deer in the headlights” response is an automatic
anxiety response, secondary to prolonged eye contact, that is most likely to occur between
strangers or people just getting to know each other. Indeed, direct eye contact has been shown to
increase defensive arousal (for example, increased heart rate, elevated skin-conductance
responses) compared to gaze aversion (Coutts & Schneider, 1975; Nichols & Champness, 1971).
Anxiety responses to eye contact vary widely across people and contexts (for example, as a
function of differing biotemperaments, cultural backgrounds, or relationship histories).
Following commitment by an OC client to target “deer in the headlights” responses in treatment,
RO DBT uses four overlapping strategies to help facilitate change:
Heat-off strategies are a core part of repairing an alliance rupture. When sensing that an
alliance rupture may be present, an RO DBT individual therapist is taught to briefly take the heat
off by redirecting her eye contact away from the client (for example, upward) or by writing on a
clipboard placed on her lap while simultaneously leaning back in her chair (away from the
client), if possible. In addition, as already suggested, knowing how and when to take the heat off
is particularly important during the early stages of therapy, when a strong working alliance is less
likely to have been fully established. Finally, heat-off strategies are essential when wanting to
reinforce new or adaptive behavior. Thus, following honest and candid expressions of emotion or
vulnerability by an OC client (for example, admitting to a therapist that he disagrees or is angry
with her), the therapist should briefly thank the client for his candid disclosure, link his
disclosure to the client’s valued goals for improved interpersonal relationships, and then be
willing to move away from the topic rather than dig deeper in order to reinforce self-disclosure
(that is, OC clients strongly dislike the limelight; thus, further exploration may function to
aversively punish self-disclosure).
Heat-On Strategies
Heat-on strategies in RO DBT are essentially the opposite of heat-off strategies. Heat-on
strategies have many guises, yet all involve some form of directed attention whereby clients feel
they are being evaluated, examined, scrutinized, or in the limelight. Examples of what OC clients
commonly perceive as heat-on stimuli include direct eye contact, giving a compliment or
praising them, repeating a request for information, or unexpected teasing (for example, playful
irreverence). Heat-on strategies help OC clients locate their edge or area of growth and deepen
self-enquiry. Rather than explaining or telling an OC client how her behavior is ineffective, an
RO DBT therapist is more likely to ask the OC client a question with open curiosity instead. For
example, during a chain analysis of an interaction with her husband, a therapist might ask a
client, “Do you think you might have assumed that you already knew what your husband was
going to say, and this might have made you less likely to actually listen openly to what he
actually said?”
When heat-on strategies are applied, most OC clients respond in three ways:
They may join with the therapist by directly answering the question in a manner that
signals a willingness to openly explore the issue.
They may delay or pause before responding, quickly defend, change the topic, push
back, or behave helplessly (see the material on “pushback” and “don’t hurt me”
responses in chapter 10), suggesting possible nonengagement.
They may exhibit behavior that is in between the preceding two (that is, it appears
they are genuinely trying to reply or engage with the discussion, and at the same
time their manner appears to have changed after being queried, or during the
subsequent discussion; for example, a “deer in the headlights” response is
possible).
Therapists should use these moments as opportunities for the client to practice more direct
communication. Both heat-on and heat-off strategies can also function to reinforce adaptive
behavior. For example, frequent and brief exposure to social attention that is not overwhelming
(putting the heat on), combined with strategic removal of social attention following candid or
vulnerable disclosures (taking the heat off), can function as a powerful incentive for open
expression of emotion, thereby indirectly enhancing social connectedness.
Genuine Smiles
Genuine smiles (also known as Duchenne smiles, enjoyment smiles, and pleasurable smiles;
see the right side of figure 6.5) reflect feelings of amusement, pleasure, contentment, or joy.
They are characterized by a slightly slower onset and longer duration relative to social smiles or
polite smiles and may not involve eye contact when exhibited in the presence of others (see the
prototypical expression of amusement shown in figure 6.3). Thus, genuine smiles may not
always represent a social signal. Yet smiles of pleasure, when observed by others, are highly
contagious; it is hard not to laugh or smile when another person expresses genuine amusement.
The genuine smile, or Duchenne smile, involves simultaneous activation of two sets of facial
muscles—the zygomaticus major, which controls the corners of the mouth, and the orbicularis
oculi, which encircles the eye socket—whereas activation of a single muscle, the zygomaticus
major, characterizes the social or polite smile (see the left side of figure 6.5).
Figure 6.5.
Polite Smile vs. Genuine Smile
The closed-mouth cooperative smile differs from the averted gaze and bowed head that
characterize the closed-mouth appeasement smile or smile of embarrassment (Sarra & Otta,
2001; see also figure 6.3). It also differs from what is known as the half smile (Linehan, 1993a).
The half smile is less expressive—that is, it does not involve stretching the lips, it is less wide,
and it is less likely to be associated with crow’s-feet wrinkles around the eyes. Instead, the half
smile is more physically similar to a burglar smile (described later in this chapter) and as a
consequence can be easily misread. Half smiles and burglar smiles are associated with a wide
range of differing emotions and intentions, from contentment to strong dislike and feeling
pleasure in another’s misfortune. For example, the intimidating nature of the high-dominance
half smile (burglar smile) shown in figure 6.7 becomes most apparent when the mouth is ignored
(cover the mouth with your hand). The world’s best-known half smile—in Leonardo da Vinci’s
painting known in English as the Mona Lisa (see figure 6.8)—is intriguing precisely because the
elusive smile on the woman’s face is so subtly shadowed that the exact nature of the smile
cannot be determined, with interpretations ranging from pleasure to disdain (Livingstone, 2000).
Figure 6.7. High-Dominance Half Smile (Burglar Smile)
Figure 6.8.
Enigmatic Half Smile
Therapists may need to practice closed-mouth cooperative smiles (for example, using a mirror)
in order to naturally apply them in session. Indeed, analysis of videotaped therapy sessions has
revealed that some therapists find it extremely difficult to break overlearned emotion expression
habits or prior professional training emphasizing the importance of appearing calm, neutral, or
concerned during therapeutic encounters and interpersonal interactions. In an attempt to go
opposite to these overlearned habits, therapists can overcorrect by smiling too much or too
intensely. Most often this translates into frozen and nonresponsive open-mouthed smiles that
display the upper teeth. The therapist’s aim is to communicate genuine affection and
cooperation; however, smiles involving displays of teeth that are held constant (that is,
nonresponsive) are quickly experienced as contrived by both the sender and receiver. The feeling
is similar to what happens when we are asked to smile for the camera but the picture is delayed
by a fumbling cameraperson—our candid smile of genuine pleasure quickly fades into a frozen
polite smile that feels increasingly phony the longer we hold it.
The good news is that there are several automatic indicators that can help verify the
genuineness of a smile. For example, it is common for an automatic deep breath or sigh of
contentment to arise almost immediately after engaging a closed-mouth cooperative smile,
implicating PNS-VVC activation. The PNS-VVC regulates not only our social signaling muscles
(head and face) but also the neuroinhibitory vagal fibers that deepen and slow breathing and
reduce cardiac output essential for signaling genuine warmth and calm friendliness during
interactions. Social safety responses can often be enhanced when the smile is accompanied by a
simultaneous upward movement of both eyebrows (see “The Eyebrow Wag,” later in this
chapter). Thus, when learning the closed-mouth cooperative smile, therapists can use their
visceral or bodily experience of social safety to guide how big to make the closed-mouth smile.
Plus, the presence of an unconscious deep breath or sigh can be used as convergent evidence that
the smile successfully activated the therapist’s social safety system, making it more likely for the
client to feel similarly (via activation of the mirror neuron system).
The Therapist as Tribal Ambassador
Rather than fixing, correcting, restricting, or improving a hyperperfectionistic OC client, RO
DBT prioritizes social connectedness by encouraging therapists to adopt a stance likened to that
of a tribal ambassador. A tribal ambassador models kindness, cooperation, and affection to
socially ostracized OC clients, saying, “Welcome home. We appreciate your desire to meet or
exceed expectations and the self-sacrifices you have made. You have worked hard and deserve a
rest.” Yet ambassadors also recognize that sometimes kindness means telling a good friend a
painful truth in order to help him achieve his valued goals, in a manner that acknowledges one’s
own potential for fallibility.
Ambassadors are also face savers—they allow a person (or country) to admit to some fault
without rubbing anyone’s nose in it. Plus, they learn the language and customs of a foreign
country without expecting the people in the foreign land to think, feel, or behave the way they
themselves do. They are able to make self-sacrifices in order to repair a damaged relationship,
without always expecting something in return. Thus ambassadors recognize that when we lend a
hand, we also simultaneously transmit a powerful message of social connectedness to the person
we are helping, one that essentially says, “You don’t owe me.” This simple act of kindness
underlies one of the core strengths of our species—that is, we are better together.
An ambassador talks to people from another country as if they were good friends. When
among friends we feel naturally less self-conscious; we relax and drop our guard. In the context
of therapy, dropping one’s guard means dropping one’s professional role (at least to some
extent). Research shows that when we are with our friends we are likely to stretch out, lie back,
and lounge around; our body gestures and facial expressions are more expansive and our use of
language is less formal; we are less polite and likely to use slang or curse words to color our
speech. For example, friends don’t try to change each other; they trust each other to do the right
thing and they respect their individual differences. Thus, by adopting a manner most often
reserved for close friends or family, we signal to OC clients that we consider them to be part of
our tribe (recall that OC is a disorder characterized by loneliness). Without saying a word, an
easy manner communicates, “I like you. I trust you to do the right thing. I believe in your
competence. I am interested in what you have to say. I am not out to cause you harm. I am no
better than you, and I am open to being wrong.”
Yet signaling an easy manner can go opposite to how a therapist has been professionally
trained. Some therapists find it difficult or awkward to lean back in a chair, temporarily avert
their gaze, or raise their eyebrows during a session with an OC client. This often reflects prior
training emphasizing the importance of sitting upright and maintaining eye contact. It can also
reflect a therapist’s personality; for example, research shows that the majority of therapists lean
toward an overcontrolled personality style or have overcontrolled family, culture, or
environmental influences (for example, “Don’t slouch”). Fortunately, our research and
experience training therapists in RO DBT has shown that the vast majority of therapists who
initially struggle modeling an easy manner can learn how to apply it with a little practice.
Importantly, an easy manner does not mean walking on eggshells or treating the client as
fragile by immediately jumping in to validate, soothe, regulate, or find a solution for a problem.
Instead, it places the responsibility back on the client by not assuming it is the therapist’s job to
make the client feel better or solve the client’s problems while signaling a willingness to lend a
hand. Thus the nondirective nature of an easy manner allows the client the space needed to
recognize that, on some level, she chooses how she responds emotionally to events in her life
(for example, no one can force a person to feel angry or sad) and begin the sometimes painful but
mostly liberating process of taking responsibility for her life without falling apart or harshly
blaming the world.
Leaning back in the chair in order to increase distance from the client
Crossing the leg nearest the client over the other leg, in order to slightly turn the
shoulders away
Taking a slow deep breath
Briefly disengaging eye contact
Raising the eyebrows
Engaging a closed-mouth smile while returning eye gaze back toward the client
Finally, when using an easy manner strategically in therapy with OC clients (for example, to
help take the heat off), therapists should resist the urge to explain to clients what they are doing,
mainly because this places the heat back on clients or may prompt attempts by clients to justify
or defend their behavior.
All of what was just described happens in seconds. Additional elements that can further
augment signaling an easy manner include slightly pausing after each client utterance in order to
allow the client time to say more, slowing how fast one is speaking, and speaking with a softer
tone of voice. If the therapist is already leaning back in her chair, she should move her body
rather than remaining frozen in the same posture (especially when tension is in the room). The
best way to manage this, without calling undue attention to what is happening, is for the therapist
to always have something to drink nearby (for example, a cup of coffee; don’t forget to ask your
client at the start of the session if he would like something to drink, too). Essentially, the
therapist should make use of this simple prop by leaning forward and taking a sip from her drink.
This breaks up a frozen body posture while signaling normality. After taking a sip from her
drink, the therapist can begin again by leaning back in her chair and then reinstitute the same
steps again (only this time, the therapist is likely to find that leaning back in her chair actually
feels more relaxed than it did a moment before).
Finally, therapists should also be careful to not overcorrect when first learning how to signal
an easy manner (for example, by smiling regardless of what the client is saying, or never leaning
forward). There are a few general principles that can help minimize such problems. First, when
struggling with signaling an easy manner, especially when first learning RO DBT, a therapist can
use his inner discomfort as an opportunity for self-enquiry. He should out himself regarding his
struggle to his consultation team, supervisor, or another therapist and practice being radically
open to any feedback that results from this. Second, avoid taking an easy manner too seriously or
applying it regardless of what might be happening in session. When a client is engaged in the
session—freely answering questions, remaining on topic, actively listening, and revealing inner
experience—nonverbal signals are likely less important (for example, leaning forward or
engaging eye contact doesn’t matter, because the client is not feeling threatened).
The very first laugh exhibited by an infant occurs when a safety signal (such as a smiling
mother) is combined with a danger signal (such as a game of peekaboo). Similarly, friendly
teasing involves a combination of danger and safety signals, most often accompanied by displays
of mutual laughter and light touching. Friends playfully and affectionately tease each other all
the time. Research shows that teasing and joking are how friends informally point out flaws in
each other, without being too heavy-handed about it. Learning how to tease and be teased is an
important part of healthy social relationships, and kindhearted teasing is how tribes, families, and
friends give feedback to each other. Plus, being able to openly listen and act upon critical
feedback provided a huge evolutionary advantage because our individual survival no longer
depended solely on our personal perceptions. This helps explain why we are so concerned about
the opinions of others.
A good tease is always kind. Most often it starts out with an unexpected provocative comment
that is delivered with an unsympathetic (expressionless or arrogant) tone of voice or intimidating
facial expression (such as a blank stare), gesture (such as finger wagging), or body posture (such
as hands on hips) that is immediately followed by laughter, gaze aversion, or postural shrinkage.
Thus a kindhearted tease momentarily introduces conflict and social distance but quickly
reestablishes social connectedness by signaling nondominant friendliness. The nondominance
signal is critical for a tease to be taken lightly (that is, as a friendly poke; see Keltner et al.,
1997). When teasing is playful and reciprocal it is socially bonding. In fact, teasing is an
important component of flirting (Shapiro, Baumeister, & Kessler, 1991). People who are okay
about being teased have an easy manner; they don’t take themselves or life too seriously and can
laugh (with their friends) at their personal foibles, gaffes, and mishaps.
A good tease is always kind.
In RO DBT, playful irreverence represents the therapeutic cousin of a good tease between
friends. Playful irreverence is part of a dialectical strategy in RO DBT that challenges the client’s
maladaptive behavior while signaling the therapist’s affection and openness. Most often playful
irreverence begins with the therapist’s nonverbal or verbal expression of incredulity or amused
bewilderment after a discrepant, odd, or illogical comment or behavior by the client (for
example, the client verbally indicates that he is unable to speak, or he reports complete lack of
animosity toward a coworker he has admitted lying about in order to get her fired), and it is
accompanied by a nondominant signal of openness and affection. Nondominance body postures
and facial expressions accompanied by or immediately following playful irreverence
communicate that we intend no harm; that is, our actions are not to be taken too seriously. Such
postures and expressions are especially important when the person teasing or playing irreverently
is in a power-up position (as in the therapist-client relationship) because they signal that the
person in the power-up position desires an egalitarian relationship and is open to feedback from
the other person. Nondominance signals combine appeasement signals (slight bowing of the
head, slight shoulder shrug, openhanded gestures) with cooperative-friendly signals (warm smile,
eyebrow wags, eye contact; see figure 6.11).
An example of playful irreverence occurred when a highly committed OC client arrived at her
third RO DBT session with a typewritten list of 117 novel activities she had done in the prior
week, whereupon her therapist responded by saying, “Wow—117 new things! That’s fantastic!
Okay, now—time for a power nap. Let’s both put our heads down and catch a few z’s!” The
therapist then mimicked a sleeping position for only a brief moment before he smiled warmly
and then sat back in his chair (that is, he moved from playful irreverence to compassionate
gravity); following this, the therapist slowed down his rate of speech and lowered his tone of
voice and then asked the client, after a closed-mouth smile and eyebrow wag, “So…why do you
think I said that?” The power nap represents a playfully irreverent (or friendly) tease, whereas
the question about the nap tells the client that the therapist is using metaphor to help the client
recognize that her well-intentioned attempts to fix her overcontrol may actually represent another
form of the OC problem itself.
Therapists should also combine nondominance and cooperative-friendly signals when
encouraging OC clients to practice candid disclosure. For example, when a client appears to be
nonengaged, a therapist might say (after dipping her head down and engaging a prolonged
shoulder shrug that is combined with a warm closed-mouth smile, raised eyebrows, and direct
eye contact in order to nonverbally signal that she is open to hearing whatever the client may
have to say, even if it’s critical of the treatment or the therapist), “I’ve noticed something seems
to have changed. Can you let me know what’s going on with you right now?” Similarly, when
making a difficult request of a client (for example, asking him to role-play in session), the
therapist should signal respect and positive regard by combining friendly signals with low-level
nondominance signals.
Figure 6.11.
Signaling Nondominance
When threatened we can flee, hide, attack, call on the aid of nearby others, or appease.
Universal signals of submission among humans include lowering the head, covering the face
with the hands or hiding the face from view, slackened posture, lowering the eyelids, casting the
eyes downward, avoiding eye contact, slumping the shoulders, and postural shrinkage.
Appeasement gestures evolved to de-escalate aggression, elicit sympathy, and regain entry into
the tribe after making a grievous error that threatened the well-being of another tribe member or
the tribe as a whole (Keltner & Harker, 1998; Tsoudis & Smith-Lovin, 1998), whereas minor
social transgressions (for example, exhibiting poor table manners or forgetting the name of a
person you have known for a long time) call for displays of embarrassment, not submission.
Embarrassment displays differ from appeasement and submissive displays linked to shame (see
figure 6.3). Both involve downward head movements and gaze aversion. Embarrassment
displays involve compressed smiles and face touching; in contrast, appeasement expressions
involve frowning and sometimes covering of the face with the hands.
Research shows that appeasement gestures must be present when a person is attempting to
repair a transgression. People distrust expressions of guilt (such as saying, “I’m sorry”) if they
are not accompanied by bodily displays prototypical of shame (postural shrinkage, lowered gaze,
blushing; see Ferguson, Brugman, White, & Eyre, 2007). Nonverbal displays of shame or
embarrassment during an apology signal that the violator values the relationship because he is
viscerally distressed by his actions, making it easier for the person who has been wronged to
trust he will not commit them again. Thus appeasement gestures are essential whenever a
therapist is attempting to repair an alliance rupture, especially when the rupture was the result of
something the therapist did (recall that repair of an alliance rupture is the responsibility of the
therapist).
Therapeutic Sighs
Sighs are common phenomena that are most often ignored or considered irrelevant when it
comes to socioemotional well-being. Frequent sighing has been linked with chronic anxiety and
post-traumatic distress (Blechert, Michael, Grossman, Lajtman, & Wilhelm, 2007; Tobin,
Jenouri, Watson, & Sackner, 1983) and negative affect (McClernon, Westman, & Rose, 2004).
Sighing has also been linked to relief of stress (Soltysik & Jelen, 2005). Yet few have linked
sighing to the communicative function of emotions.
RO DBT posits that the sounds stemming from a sigh function as a social signal when
displayed in the presence of others. Under distress or despair, a sigh can signal “Help me” or
“I’m fed up” or “I’m exhausted,” whereas sighs that accompany the relief that occurs following
the termination of a stressor may signal to other tribe members that all is well. During
interactions between people who have a close bond (for example, therapist and client), a sigh
might also signal contentment, satisfaction, or a desire to see the world from the other person’s
point of view. Thus therapists can use a sigh to signal to a client a desire for affiliation or a desire
to not engage in conflict.
Burglar Smiles
The burglar smile, or high-dominance half smile (see figure 6.7), involves a quick upturn of
the corners of the mouth into a slight smile that is not easily controlled and most often occurs
without conscious awareness. This type of smile is most likely to occur whenever a secretly held
belief, desire, or knowledge about oneself has been exposed or highlighted that would otherwise
be considered improper, bad-mannered, or inappropriate to overtly display or take pleasure in.
For instance, if you consider yourself intelligent, you are unlikely to boast about it, because you
are aware that your self-assessment is subjective and that there are many types of intelligence.
Even if you have recently won the Nobel Prize for being particularly clever, you are likely to
recognize that bragging about your accomplishment to your peers is more likely to trigger
feelings of envy, and secret desires on their part for you to encounter misfortune in the future,
than admiration. Thus, when a colleague unexpectedly reveals that she admires your brilliance,
you may express your gratitude with a slightly low-intensity but genuine smile that may be
barely detectable (a burglar smile). A burglar smile in this context is prosocial because it avoids
appearing conceited.
However, not all burglar smiles are prosocial. For example, many OC clients have secret pride
about their superior self-control abilities, an attitude that can sometimes lead them to believe they
know better or are better than others (see “The Enigma Predicament,” chapter 10), which can
function to exacerbate their sense of difference and isolation. Therapists can test for the possible
presence of secret pride by praising an OC client for possessing superior abilities in self-control
and watching to see if a burglar smile appears. Burglar smiles are also likely whenever we find
ourselves hearing about a rival’s misfortune, when we are successful at manipulating
circumstances for personal gain, or have escaped punishment or disapproval that would be
warranted if our crime were discovered (such as cheating or lying). For example, an OC client
might exhibit a burglar smile after having successfully diverted a topic away from something he
did not want to discuss or after his apparently innocent question upset a person he dislikes or
wants to punish. Rather than being experienced positively by nearby others, this type of
dominance smile has been shown to be associated with the triggering of negative affect in
recipients rather than positive (Niedenthal et al., 2010).
The problem for the OC client is that burglar smiles are more than low-level emotional
leakage; despite their low intensity and short duration, they are powerful social signals that
impact how others feel toward us. Recall that our brains are hardwired to react emotionally
within milliseconds to the slightest smile or frown. Thus, if a burglar smile stems from desires to
see another fail, secret pride, or similar nonprosocial behaviors, it is highly likely that others are
aware of the smiler’s nefarious intentions and may want to avoid him, albeit they are unlikely to
tell the smiler about this because they no longer trust him.
Teaching OC clients about burglar smiles is the first step toward reducing those behaviors that
may be unhelpful for a client’s well-being, especially for clients who may pride themselves on
being able to control others or have frequent envy. Clients can increase their awareness of
burglar smiles by recording on their diary cards when, with whom, and how often such smiles
have occurred, and what triggers them. Values clarification can be used to help a client, and
sometimes simply being aware of burglar smiles when they occur is sufficient to reduce their
frequency; it is hard to secretly gloat about another person’s misfortune when you recognize that
gloating goes against a core value to be fair-minded. Therapists can begin targeting burglar
smiles around the fourteenth session (that is, when a genuine working alliance is more likely to
be operative).
Subtle, low-intensity signals can also reflect expression habits or emotional leakage never
intended as disapproving (for example, the sender has a habit of closing his eyes when someone
is talking, or the sender has a painful toothache; see figure 6.12).
Figure 6.12.
Subtle, Low-Intensity Social Signals Are Powerful
The silent treatment represents another good example of a powerful yet indirect social signal
that is experienced as punitive by those on the receiving end and is damaging to relationships (K.
D. Williams, Shore, & Grahe, 1998). It most often occurs following a disagreement with
someone, or when a person fails to conform to expectations. It signals disagreement or anger
without overtly disclosing it, involving a sudden reduction in verbal behavior, a flattened facial
expression, and avoidance of eye contact. If asked by the recipient about the sudden change in
social signaling, the sender will usually deny the change and, with a blank face and unemotional
tone of voice, say, “No, I’m fine” or “Everything’s okay.” The sudden nature of the silent
treatment and its plausible deniability are what make it so infuriating to those on the receiving
end and so damaging to interpersonal relationships.
Addressing indirect communication (that is, disguised demands) in RO DBT involves a three-
step process:
The individual therapist introduces the problem of masking inner feelings during the
orientation and commitment phase of treatment (ideally in the third session). This
functions to introduce an often difficult or sensitive subject in therapy, during a
time when most OC clients are highly committed.
The RO skills training class explicitly teaches clients about the most common types
of maladaptive OC indirect communication and the skills needed to change them.
Explicit skills training makes what was previously a well-kept secret become
public knowledge. This makes it harder for socially conscientious OC clients to
continue pretending (to others and themselves) that a maladaptive style of indirect
signaling either does not exist or is an appropriate way to behave. Essentially,
clients lose their plausible deniability, and their sense of social obligation is likely
to compel them to practice more prosocial and direct means of communication.
The individual therapist looks for patterns of indirect communication that likely
negatively impact rejoining the tribe and achieving valued goals. As with the “I am
fine” phenomenon, in general the individual therapist highlights a potentially
maladaptive form of indirect communication only after having observed it multiple
times and over multiple sessions rather than rushing in to address a potential
problem the first time it occurs. This makes it less likely for the client to feel that
she is being unfairly criticized while simultaneously making it more difficult for
the client to deny the behavior’s occurrence.
Tribe Matters
Compared to other animals, humans are hypercooperative. We are able to share resources, work
together, and form strong bonds with genetically dissimilar others in a manner that is
unprecedented in the animal world. To accomplish this, our species is posited to have developed
a highly sophisticated social signaling system that allowed us to communicate intentions and
feelings (an angry glare linked to a desire to attack) without having to fully express the actual
propensity itself (hitting someone). Signaling intentions from afar (for example, via facial
expressions, gestures, or vocalizations) reduced unnecessary expenditures of energy and
provided a safer means to resolve conflicts or initiate collaborations with others without having
to fully commit oneself. Plus, revealing intentions and emotions to other members of our species
was essential to create the type of strong social bonds that are the cornerstone of human tribes.
When we reveal our true feelings to another person, we send a powerful social safety signal that
most often functions to increase trust and social connectedness, thereby making it more likely for
the other person to make self-sacrifices for our benefit or collaborate with us in order to
accomplish tasks and overcome obstacles that would be impossible if attempted alone. Yet our
hypercooperative nature was also accompanied by some downsides.
For example, for our very early ancestors living in harsh environments, the cost of not
detecting a true disapproval signal was too high to ignore, since tribal banishment was essentially
a death sentence from starvation or predation. As a consequence, we are constantly scanning the
facial expressions and vocalizations of other people for signs of disapproval and are biologically
predisposed to construe the intentions of others as disapproving, especially when social signals
are ambiguous. This means we are essentially a socially anxious species. Blank expressions,
furrowed brows, or slight frowns are often interpreted as disapproving, regardless of the actual
intentions of the sender (for example, some people frown or furrow their brow when intensely
listening). Plus, being rejected by a tribe hurts; research shows that social ostracism triggers the
same areas of the brain that are triggered when we experience physical pain (Eisenberger &
Lieberman, 2004). Thus we fear the pain of social exclusion, and our emotional well-being is
highly dependent on the extent to which we feel part of a tribe.
Moreover, humans are not always prosocial. As a species, we can be ruthlessly callous and
deceptive to those we dislike, or to rival members of another tribe. Yet, as individuals, we cannot
simply decide not to play the social signaling game. We are constantly socially signaling when
around others (via microexpressions and body movements), even when deliberately trying not to.
For example, silence can be just as powerful as nonstop talking. Indeed, effective social
signaling is always a two-way street, requiring both accurate transmission of inner experience or
intentions and accurate reception and openness to the transmissions of others.
Finally, the social signaling recommendations outlined in this chapter are not meant to be
applied as rigid rules. For example, therapists should avoid temptations to overcorrect (for
example, concluding that expressions of concern should never be expressed when working with
OC clients). Therapists should use contextual cues to help guide how and what they socially
signal in session. Plus, when OC clients are engaged in therapy, the social signaling behavior
displayed by a therapist may matter less. Yet, at the same time, RO DBT social signaling
strategies are principle-based. Loosely translated, an RO DBT therapist is encouraged to stop
behaving like a therapist and start behaving like a friend, in order to teach emotionally lonely and
isolated OC clients how to make genuine connections with others (often for the first time in their
lives). This is why RO DBT therapists are likened to tribal ambassadors. Ambassadors interact
with other cultures in a manner that most others reserve solely for interactions with close friends
or family. When a therapist adopts this stance, she automatically signals to OC clients that she
considers them part of her tribe. Without a word spoken, clients receive a gift of kindness that
essentially says, “I trust you, I believe in you, and I am the same as you.”
Now You Know…
The great number and variety of verbal and nonverbal social signals available to
our species increases the likelihood that our social signals will be
misinterpreted, especially when their meaning is ambiguous.
The social signaling deficits of OC clients leave them uniquely vulnerable to
being misunderstood and even ostracized. OC clients also tend to experience
intense social engagement, including therapists’ expressions of concern, as
overwhelming, intrusive, or threatening.
RO DBT therapists teach OC clients the social signaling skills that have been
shown to enhance social connectedness. Therapists also modify their in-session
nonverbal behavior in ways that enhance treatment outcomes for OC clients by
facilitating their clients’ engagement in therapy and by activating experiences
of social safety in their clients as well as in themselves.
Chapter 7
The chapter begins with tribal glue. [Editor’s note: Careful, Dr. Lynch—our attorneys have
advised us that this is a sticky proposition.]
We comply out of fear. Fear-based compliance is most often motivated by one of two
possible contingencies: we fear punishment from powerful others not in our tribe
(such as border police, an invading army, a rival gang, a mugger with a gun), or
we fear punishment (social disapproval, social exclusion, shaming rituals, solitary
confinement, a sentence of death) from powerful others within our tribe.
We comply in the moment, in order to dominate later. Dominance-based compliance
always involves some type of purposeful deception or pretending. We concede
defeat while secretly planning revenge. We compliment a rival to hide our envy.
We ingratiate ourselves to get someone to like us, only so we can use that person
later. We attempt to appear similar to another or to appear more attractive in order
gain favor. We drop names of famous people to enhance our status. We smile (not
in agreement) or physically touch someone in order to get that person to trust us.
Our compliance is logical, reason-based, or rule-governed. We capitulate to superior
reasoning, we concede a chess match when we realize that there is no way for us to
win, or we nod in agreement because it is the polite thing to do.
We comply out of kindness, passion, or love. Love-based compliance is posited to
emerge in three differing ways, the second and third of which are posited to be
linked with radical openness. First, compliance may be motivated by faith,
admiration, or respect for another person or system of belief. In this situation, we
are not required to understand why compliance is needed; we blindly accept
promises, predictions, or directions from a charismatic leader, or we concede an
argument because we have faith in the other person’s supposedly better judgment
or superior intellect, or we sacrifice ourselves for a cause or out of devotion.
Second, compliance may be motivated by curiosity or love of learning. In this
situation, we relinquish our worldview in order to understand a new culture,
purposefully seeking new ways of thinking or behaving in order to enhance self-
growth. This component of love-based compliance is closely aligned with the
practice of radical openness in that it requires us to relinquish our perspective in
order to be open to a new one. And, third, compliance may be motivated by a
desire for intimacy, closeness, or mutual understanding—a desire to be one with
another. This component of love-based compliance is closely aligned with the
practice of radical openness in that it requires us to be kind—to make sacrifices for
another person, without always expecting something in return.
RO DBT posits healthy compliance and genuine openness as prosocial sides of the same coin,
with compliance representing the overt social signal and openness the underlying mechanism.
Yet our ability to learn from others also arrived with some downsides. As our capacity to
symbolically represent and communicate our inner experience, intentions, and observations
developed, it moved from pantomime to cave drawings, from regional specific gestures to coded
gestures, from spoken language to written language, and from mathematical equations to
computer programming. The sheer amount and availability of potentially important new
information became too much for any one person to ever fully grasp, let alone master, eventually
leading to the frequently heard complaint of information overload in contemporary society. Plus,
social learning requires a person to drop his perspective (at least momentarily) in order to absorb
a new one while simultaneously trusting the source of the new information or collective wisdom
(a friend’s opinion, a tribal elder’s memory, a written document). The worry is that the source
may be wrong (“When it comes to accuracy in spear throwing, your grip is less important—what
matters most is keeping the shaft close to your body at all times during the throw”) or
intentionally deceptive (“My so-called friend is giving me the wrong advice on purpose so he
can win the tribal spear-throwing contest”).
Moreover, when it comes to treating problems of overcontrol, not only do most OC clients
find it difficult to trust—they prefer passive learning (studying alone) to interactive learning
(asking for help and seeking feedback)—they are also likely to experience interactive learning as
exhausting or frightening. It is exhausting because it requires collaboration, open listening, and
taking another person’s point of view seriously. It is frightening because it requires not just open
dialogue (and sometimes debate) but also dependence on others to achieve a desired outcome. In
addition, interactive learning almost invariably involves receiving some form of disconfirming
feedback, which can sometimes lead to disagreement or conflict. Most OC clients would rather
abandon a relationship than deal directly with interpersonal conflict, making it less likely for
them to experientially learn that disagreement often leads to new discoveries and that conflict
can be intimacy-enhancing.
RO DBT posits that there is a way forward. It involves the creation of a temporary state of
self-doubt, which does not necessitate a validity check on every source of new information or a
character reference for every person who gives us some advice. This temporary state of mind is
referred to in RO DBT as healthy self-doubt. It begins with the assumption that we don’t see
things as they are but instead see things as we are, and it is based on the notion that it is
impossible for us to ever fully rid ourselves of our personal backgrounds or biogenetic
predispositions (see table 7.1).
Table 7.1. Healthy vs. Unhealthy Self-Doubt
Thus radically open living requires a person to be open to disconfirming feedback and adapt
her behavior in a manner that also accounts for the needs of others. For example, she might strive
for perfection (but stop when feedback suggests that striving is counterproductive or damaging a
relationship), be rule-governed (except when breaking the rules is needed—for example, to save
someone’s life), or be polite and cooperative (yet be bad-tempered if the situation calls for it, as
when safety concerns are overriding).
Radical openness can trace its roots to a spiritual tradition known as Malâmati Sufism.
Malâmati Sufism originated in the ninth century in the northeast of Persia, in an area called
Khorasan (what is now Iran), and in the present day it has a strong following in Turkey and the
Balkan States. The name Malâmati comes from the Arabic word malamah, meaning “blame” and
referring to the Malâmati practice of sustained self-observation and healthy self-criticism in
order to understand one’s true motivations (Toussulis, 2011). Malâmatis believe that one cannot
achieve heightened self-awareness in isolation; as a consequence, emphasis is given to spiritual
dialogue and companionship (in Arabic, sohbet). The Malâmatis are not interested so much in
the acceptance of reality or in seeing “what is,” without illusion; rather, they look to find fault
within themselves and question their self-centered desires for power, recognition, or self-
aggrandizement.43
A core principle in RO DBT is that innate perceptual and regulatory biases make it impossible
for a person to achieve heightened self-awareness in isolation; we need others to point out our
blind spots. Truth in RO DBT is considered real yet elusive; thus, for example, “If I know
anything, it is that I don’t know everything, and neither does anyone else” (M. P. Lynch, 2004, p.
10). It is the pursuit of truth that matters, not its attainment. Rather than assuming we could ever
know reality just as it is, radical openness assumes that we all bring perceptual and regulatory
biases into every moment, and that our biases interfere with our ability to be open and to learn
from new or disconfirming information.44
Yet simply being frank or forthright with our opinions, observations, feelings, or beliefs is not
sufficient to create the type of open dialogue and equal status that characterize experiences
associated with optimal interactive learning. As such, RO DBT contends that it is essential not
only to reveal our inner experience or opinions to others but also and simultaneously to
acknowledge our own potential for fallibility. Rather than automatically assuming that the world
should change (“You need to validate me because I feel upset”) or automatically prioritizing
regulation or acceptance strategies that function to reduce arousal or lead to a sense of peace, RO
DBT posits that the truth hurts. That is, often reaching the place of most personal self-growth
involves coming to grips with (attending to) the very place we don’t want to go. Thus radical
openness means developing a passion for going opposite to where we are. It is more than
mindful awareness. It means actively seeking those areas of our lives that we want to avoid or
may find uncomfortable, in order to learn. It involves purposeful self-enquiry and a willingness
to be wrong, with an intention to change if we need to change. It is humility in action.
A practice of radical openness involves three sequential steps:
How Can You Know You’re Closed, Especially When You Think You’re Not?
The short answer to that question is that you can’t, at least not without a little help from
your friends. The longer answer has to do with research suggesting that your peers will
often be more accurate than you are at assessing your personality quirks (Oltmanns,
Friedman, Fiedler, & Turkheimer, 2004; John & Robins, 1994), and that if you think you
have fewer problems than others, your peers probably think you have more (Oltmanns,
Gleason, Klonsky, & Turkheimer, 2005). Therefore, to find out whether you’re closed-
minded, practice these skills.
When you find yourself striving to convince either yourself or someone else of
how open you are, consider your insistence on your openness as evidence of
your being closed.
Don’t always trust your gut. In the heat of the moment, when you’re in the
middle of an argument, and when you’re convinced that you are being open-
minded, don’t automatically assume that you are right. Instead, stop and ask
the person you’re interacting with for his opinion about how open you are
being. To do this, briefly disengage eye contact (to take the heat off) while
taking a slow, deep breath, and then say, “You know, I’ve got a question for
you.” Pause, make direct eye contact, and offer a closed-mouth smile. “How
open-minded do you think I am being right now? I’d really like to know
because it is something I have been working on lately. I know it’s a bit off
topic, but I’m curious. So what do you think?” Allow the other person time to
answer fully before you respond. It’s important when you ask that you not try
to feel or appear calm but instead communicate an earnest desire to openly
hear what the other person might have to say. This is a fantastic practice
because you get feedback right in the moment, and yet the very act of asking
is a powerful social safety signal.
Don’t automatically assume that you are closed. After the interaction is over,
use the other person’s feedback as an opportunity to practice radical openness
skills. For example, take out your skills training manual, turn to chapter 5,
lesson 22, handout 22.2, and practice Flexible Mind ADOPTS, using the
handout’s twelve questions to help you determine whether you should accept
or decline the feedback.
When you’re not in the heat of the moment—when the other person is not
around—you can still get a sense of how open or closed you might be in your
interactions. For example, ask yourself how willing you would be to find out
or admit that you’re wrong, that you’re not open, that you’re holding a grudge,
or that you’re feeling envious. The more energy or resistance you feel when
asking this question, the less likely it is that you are genuinely open.
Practice self-enquiry (see “Practicing Self-Enquiry and Outing Oneself,” later
in this chapter). Ask yourself, Is there something here for me to learn?
Remember that asking for feedback is anxiety-producing for all humans. Self-
consciousness, fear of disapproval, and social anxiety reflect our tribal nature
and our fundamental dependence on other people; as we’ve seen before,
exclusion from the tribe was essentially a death sentence for our primordial
ancestors, so don’t assume that the presence of anxiety means you are
necessarily closed. Practice self-enquiry (What might my anxiety tell me? Is
there something here for me to learn?) while blocking quick answers. It is the
very act of asking, not the actual feedback itself, that may be what is most
important when it comes to close social bonds. The simple act of allowing
yourself to consider the possibility that your perspective may be wrong, and
then communicating this possibility to another person by asking for candid
feedback, sends a powerful message of friendship, openness, and equality. It
allows the recipient of your message the luxury of dropping his guard because
he can viscerally sense that you are open-minded enough to listen to his point
of view.
Practicing self-enquiry by temporarily turning toward the discomfort and asking what
we might need to learn, rather than automatically regulating, distracting,
explaining, reappraising, or accepting
Flexibly responding with humility by doing what’s needed in the moment to
effectively manage the situation or adapt to changing circumstances in a manner
that accounts for the needs of others
Plus, being open to learning new things does not mean that we must reject our prior learning.
Instead, it recognizes that most often there are many ways to get to the same place (numerous
roads lead to London) or do the same thing (there are countless ways to cook potatoes); and,
because the world is in constant change, there is always something new to learn. For example,
the best scientists are humble because they realize that everything they know will eventually
evolve or change into greater knowledge. Practicing self-enquiry is particularly useful whenever
we find ourselves strongly rejecting, defending against, or automatically agreeing with feedback
that we find challenging or unexpected. Yet it can be painful because it often requires sacrificing
firmly held convictions or self-constructs. The good news is that openness frees up energy that in
the past was used to protect ourselves. It is the opposite of pretending, complacency, passivity, or
resignation. Although it does not promise bliss, equanimity, or enlightenment, what it promises
is the possibility of genuine friendship and dialogue.
Radical openness does not mean approval, naively believing, or mindlessly acquiescing.
Sometimes being closed is what is needed in the moment, and sometimes change is unnecessary.
For example, being closed-minded about eating cottage cheese when one dislikes its taste is fine,
assuming there is something else to eat. Closed-mindedness is highly useful when being attacked
by a mugger or tortured when captured in war. Being closed-minded might help protect certain
family or cultural traditions that help bind tribes together—for example, doggedly celebrating
Christmas despite no longer being religious. Openness is a behavior. Finally, radical openness is
not something that can be grasped solely via intellectual means—it is experiential. It requires
direct and repeated practice, and one’s understanding evolves over time as a function of
continued practice.
Therapists’ demoralization can occasionally stem from OC clients’ compulsive desires to fix
or solve problems, achieve mastery, or dominate other people or situations. For example, some
OC clients are so keen to fix their problem of overcontrol that they not only do what is expected
of them, such as completing diary cards or homework assignments, but also memorize, word for
word, every RO skill (to the point where they know the skills better than the therapist does), or
they independently create new assignments in order to quicken or enhance treatment progress.
Such clients’ diligence and commitment to change are admirable, and yet their hyperdiligence
represents maladaptive overcontrol in disguise (that is, compulsive fixing). Therapists can
become demoralized working with supermotivated OC clients because therapy can start to feel a
bit like a reality TV competition called Who’s the Best Fixer?
Who will come up with the best task, assignment, insight, or challenge and finally change
overcontrol, once and for all? Will it be the therapist? Will it be the client? Will the client vote
the therapist off the case? Stay tuned for next week’s session!
The therapist can start to feel increasingly inadequate if he is unable to recognize that he can
never win—not only does the client know herself better than the therapist ever will, the entire
premise of the competition is that overcontrol can be cured by working harder. The therapist can
help himself and his OC client by not competing in the first place and by helping the client
recognize that her hypermotivation to change her overcontrolled coping most likely represents
another way in which her maladaptive overcontrol is sneaking into her life. From here, the
therapist and the client can decide how they might want to proceed—for example, “Instead of
fixing, maybe we should practice how to take a nap.”
The main point is for therapists to remember that most OC maladaptive behaviors are not
necessarily obvious. Plus, OC clients are often expert at blocking unwanted feedback suggesting
change (for example, by bringing up an apparently important new topic of discussion), and when
this goes unrecognized, treatment progress slows, and the therapist may find himself losing his
normal sense of self-efficacy, may feel that the client is in charge, or may find himself bored or
experiencing a sense of dread whenever he works with a particular client. Moreover, since the
emotional displays of an overcontrolled person are often understated (particularly in public),
therapists can wrongly assume that work with OC clients may be less demanding or less
distressing than work with other clients. However, the opposite is often true. Despite their
relatively unobtrusive nature, OC clients’ behaviors strongly impact their social environment
(albeit usually with plausible deniability), and therapists are not immune to these effects.
Working with a nonexpressive and closed-minded OC client can be highly distressing and
oftentimes perplexing. Consequently, RO DBT therapists are encouraged to bring their personal
emotional reactions to their consultation teams (even if these reactions are of low intensity) and
practice self-enquiry, both to enhance their own personal growth and to help their clients make
the changes they need to in order to reach valued goals (see “Signs of Possible Burnout in a
Therapist Working with an OC Client”).
The team should attend to the client’s verbal behavior, or the language the client uses
during the interaction. Specifically, this means attending to idiosyncratic uses of
language (describing feelings as “plastic”); set responses or repetitive use of
particular phrases (“I’m fine,” “It’s okay,” “I can’t,” or pet phrases like “It’s only
common sense”); the degree of the client’s verbosity (one-word sentences, short
and clipped answers, vague and rambling or overly verbose answers, or
storytelling); and the degree to which the client actually answers the therapist’s
question (changing the topic, answering a question with a question, talking a great
deal but never answering the question, answering a question about feelings with a
report about thoughts, or frequently saying, “I don’t know”).
The team should also attend to what is not said—that is, the nonverbal social signals
of the client. These involve the voice (monotonic or musical); the rate of speech
(very slow or very fast, or changes from normal to slow or from normal to fast);
changes in voice volume (for example, the client starts whispering);
microexpressions of emotion (eye rolls, burglar smiles); changes in eye contact;
delayed response in answering certain questions, or overly quick responses; shifts
in body posture; the degree to which the client matches the therapist’s body
movements; and the frequency and degree of cooperative prosocial signals
(nodding the head in agreement, smiling) as well as whether prosocial signals are
context-appropriate. Sometimes team members can become more adept at noticing
subtle social signals if the volume is turned off and the team simply watches the
nonverbal behavior of both client and therapist.
It can be helpful to reverse a tape and replay a particular segment that either the therapist or
the team has identified as difficult, particularly when the potential problem involves a subtle
social signal. However, it is equally important for team members to avoid assuming that their
observations about a client’s nonverbal behavior represent the truth; instead, they should
consider their observations to be working hypotheses. It is also important for teams watching
videotapes to take the therapist’s verbal and nonverbal social signals into account. Often the
difficulty or the problem is transactional and occurs at the sensory receptor (preconscious) level
of emotional processing. For example, one therapist reported a vague sense of discomfort about
working with a particular client and was able to discover its source only while she and her
consultation team were reviewing a videotaped recording of the problematic session and it was
observed that each instance of the therapist’s defensiveness was preceded by a nonverbal
microexpression of contempt by the client. This observation, which came to form an essential
contribution to the client’s treatment and eventual recovery, would not have been possible
without a videorecording.
Finally, one simple way to practice increasing therapists’ skill in recognizing subtle and
indirect OC social signals is to simply stop the tape every thirty seconds and ask team members,
“At this point, is the client engaged or nonengaged in therapy?” The emphasis in RO DBT on
noticing OC clients’ engagement (or lack thereof) is twofold: first, OC clients struggle
(especially early in therapy) to openly reveal disagreement, dislike, or nonengagement to their
therapists because they feel socially obligated to try hard; and, second, when OC clients are
feeling nonengaged, they are much more likely to drop out of therapy or not show up for
sessions, without ever directly revealing their reasons. By watching videotaped sessions,
therapists can become increasingly astute at picking up subtle social signals that impact the
therapeutic relationship and, most important, the client’s sense of well-being.
Thus, if sessions are not already being taped, therapists working with OC clients should
institute videorecording of sessions as a normal part of clinical practice. Although at first this
may be anxiety-producing for both the therapist and the client, the importance of the information
gleaned from taped sessions cannot be overstated, as already noted. Clients’ consent should be
obtained, ideally in the first session or during a pre-first-session assessment. The therapist can
explain that because the types of problems the client has sought help for (anorexia nervosa, for
example, or chronic depression) are complex in nature, the videotaped sessions will enable the
therapist (and the client) to benefit from an outside perspective from other professionals, who
may notice something important or help the therapist deliver the treatment at its optimal “dose.”
This approach also smuggles concepts of radical openness early in treatment because the
therapist is signaling that she is fallible and depends on a community of fellow therapists to
ensure that she provides the best possible care for her clients.
Most clients recognize videorecording as an important and appropriate way to ensure high-
quality care, and they easily give consent. However, success in obtaining consent often depends
on how the therapist goes about asking for it. A therapist who is anxious about being
videorecorded can inadvertently communicate his anxiety to his client nonverbally (for example,
by adopting an overly apologetic or solicitous attitude when asking for consent, thus implying
that there may be something wrong or potentially dangerous about recording sessions).
Essentially, any implication on the part of the therapist that videotaping is odd, embarrassing, or
not the norm makes it more likely for the client to refuse consent. That said, regardless of how
competently a therapist asks for consent, some clients will still refuse to grant it. When this
occurs, the therapist can reintroduce the idea of videotaping at a later stage in therapy, after a
strong working alliance has been established.
Once consent for videotaping is obtained, the therapist should arrange the room in such a way
that the camera is not particularly obvious (for example, by placing it on a bookshelf) and is
positioned so that both the therapist and the client can be taped. If for some reason this is not
possible, the camera should be placed to tape the client. The camera should be started before the
client enters the room, and in general the therapist should avoid referring to the camera or to the
fact that the session is being videotaped. Over time, since taping occurs during every session,
both the therapist and the client become habituated to it. Audiotaping, for those clients who
refuse to allow videotaping, can also be done; however, audiorecordings fail to capture
nonverbal expressive behaviors, which often are extremely useful in identifying stuck points in
therapy. Finally, clients should be encouraged to bring into session their own audiorecording or
even videorecording equipment and to record sessions themselves for playback, in order to
enhance memory and learning.
When I feel tense during a team meeting, how willing am I to reveal this to my fellow
team members? What might my answer tell me about myself? About my team?
What is it that I might need to learn?
Is it possible that my feelings of defensiveness or resistance, at least in part, signal
that I do not want to fully listen to what is being suggested? Is it possible that I am
operating from Fixed Mind?47
Am I secretly blaming my team for not being supportive enough or validating? Even
if this is true or partly true, what is it that I might need to learn? What might this
tell me about myself? About my team?
Am I quickly jumping to self-blame, shutting down, or wanting to give up? Is it
possible I am operating from Fatalistic Mind?
The therapist locates and reveals her edge to the team (that is, she practices outing
herself). Outing oneself about difficulties in treating an OC client almost always
involves some type of judgmental thinking about the client or oneself, or about
emotions that are considered inappropriate for therapists to experience (such as
anger or strong dislike of a client). The therapist should not feel compelled to
reveal every private thought, sensation, or experience; the goal is to reveal what
she can and recognize that “editing” is not only unavoidable but also appropriate.
The team asks the therapist what she needs to learn from her edge. The primary
question is “What question do I need to ask myself in order to get myself to my
edge?” There is no right question; plus, when asking questions (either self-directed
or provided by the team), the goal is not to solve the problem. The team actively
blocks (without judgment) anti-self-enquiry behaviors from other team members
that function to move the therapist away from her edge. Examples of anti-self-
enquiry behaviors include soothing (“Don’t worry—everything will work out”),
validating (“I would have found that hard, too”), regulating (“Let’s all take a deep
breath”), assessing (“You must have learned this somewhere—do you know
where?”), cheerleading (“Remember, you are a really excellent therapist”),
problem solving (“You need to confront the client about this”), or encouraging
acceptance (“You need to accept that you cannot fix this problem”). The therapist
responds aloud to the team’s self-enquiry queries, and the team listens without
comment to the therapist’s responses.
The team helps the therapist stay in contact with her edge. This most often involves
simply asking, at sixty-second intervals, “Are you still at your edge, or have you
regulated?” The therapist can use her visceral experience as a way to know how
close to her edge she is (one’s edge is never peaceful).
After approximately three to five minutes, the practice ends, and the team asks the
therapist whether there was any question that emerged from the practice that she
found most likely to elicit her edge. The team encourages the therapist to use this
question for further self-enquiry practice by (ideally) committing to ask it once per
day in three- to five-minute minienquiry practices during the coming week and
then noticing what arises when she does so. The therapist should record the
images, sensations, emotions, or thoughts that are triggered by the question, along
with any observations of her attempts to regulate or avoid the practice or question,
in her RO self-enquiry journal. Each day of self-enquiry usually elicits some new
awareness.
The team should block attempts to summarize or interpret, since most often these actions
function as “answers” or “resolutions” to the self-enquiry dilemma. That is, quick answers to
self-enquiry questions are often avoidance masquerading as wisdom. This is why most self-
enquiry practices in RO DBT are encouraged to continue over days or weeks. The goal of self-
enquiry is not to find a good answer but to find a good question and then allow an answer—if
there is one—to be discovered by the practitioner and later, ideally, shared with the team. A
resolution or answer that emerges can be anticipated to become the next area of self-growth.
The team leader should also be alert for other issues not related to the four key questions just
listed. Here are some additional important questions that are useful to consider:
NOTEKEEPER’S ROLE
The notekeeper ensures that brief records are kept of decisions and actions. This notetaking is
not the same as recording minutes. Team notes are much briefer than what might normally be
considered minutes because the primary goal is simply to record major decisions (for example,
action points regarding the next steps a therapist will take with a suicidal client) or important
issues that will need to be followed up in the next meeting. Taking notes should not interfere
with the ability of the notekeeper to fully participate in the team meeting.
The team avoids discussing a client, or members spend a great deal of time discussing
only one issue or one client.
The team focuses on clients who have not yet committed to RO DBT therapy, with
little time left for discussion of clients who are already committed and working.
A team culture develops that emphasizes the imperative of fixing clients. As a result,
the team focuses on solutions, with less time spent on therapeutic relationship
issues or therapists’ feelings.
The team rarely questions consensus-driven decisions or understandings of client-
related problems or rarely evaluates the pros and cons of the team’s
recommendations.
Team members fail to discuss secretly judgmental thoughts about clients (“The client
is lying about not feeling any emotions”).
The team is overly serious. For example, team members find it difficult to laugh at
their personal foibles.
A culture of equanimity develops, with therapists’ expressions of negative emotions
or judgmental thoughts covertly frowned on, or with a permeating expectation that
team members should remain calm.
Vulnerable emotions are rarely expressed.
Team members spend a great deal of time making sure that rules and protocols are
adhered to.
Covert competition develops among team members over who is the most radically
open.
Radical openness is both the core skill and the core philosophical principle of RO
DBT.
Therapists must practice radical openness and self-enquiry themselves if they
hope to model radical openness and self-enquiry for their OC clients.
It can be difficult to know when one is open and when one is closed.
Therapists who work with OC clients but don’t normally and regularly receive
team-based consultation and support are encouraged to seek out or create and
develop this resource.
Chapter 8
OC clients, like a lot of other people, struggle with all three. Yet the feature they need the most
is the one they struggle with the most—feeling socially connected.
Indeed, RO DBT posits that the primary downsides of maladaptive overcontrol are social in
nature. For example, both low openness and pervasive constraint of emotional expression have
been repeatedly shown to exert a negative impact on the formation of close social bonds, leading
to an increasing sense of isolation from others. OC clients suffer from emotional loneliness—not
lack of contact, but lack of intimate connection with others. Thus, rather than focusing on how to
do better or try harder, the primary aim in RO DBT is to help the OC client learn how to rejoin
the tribe and establish strong social bonds with others. Consequently, the role of the therapist in
RO DBT can be likened to that of a tribal ambassador who metaphorically encourages the
socially isolated OC client to rejoin the tribe by communicating, “Welcome home. We appreciate
your desire to meet or exceed expectations and the self-sacrifices you have made. You have
worked hard and deserve a rest.”
As ambassador, the RO DBT therapist adopts a stance that models kindness, cooperation, and
playfulness rather than fixing, correcting, restricting, or improving. Plus, ambassadors don’t
expect people they interact with in other countries to think, feel, or act the way they do, or speak
the same language. They celebrate diversity and recognize that as a species we are better when
together and don’t automatically assume that their perspective is the correct one. They reach out
toward those who are different and learn their customs and language, without expecting anything
in return. Ambassadors build bridges. They are face savers—they allow a person (or country) to
admit to some fault, without rubbing anyone’s nose in it (that is, without publicly humiliating
anyone). For example, RO DBT therapists recognize that it would be arrogant to assume that
they could ever fully understand their clients and, as a consequence, are more likely to use
qualifiers in session (“Is it possible that…” or “Perhaps…”) rather than absolutes (“I know…” or
“You are…”). Ambassadors take the heat off when things get extremely tense during
negotiations by allowing the other person (and themselves) the grace of not having to
understand, resolve, or fix a problem or issue immediately. Yet they also recognize that
sometimes kindness means telling good friends painful truths in order to help them achieve their
valued goals, and they tell these painful truths in a manner that acknowledges their own potential
for fallibility. The overarching goal of RO DBT is to help the OC client create a life worth
sharing, based on the premise that our individual experience of well-being is highly dependent
on the extent to which we feel socially connected or part of a tribe.
Both of these issues are the responsibility of the therapist to manage (that is, a client is not
blamed for creating an alliance rupture). Alliance ruptures are like the tides of the ocean: not
only are they inevitable, they are growth-enhancing because they may be, in the words of the
thirteenth-century poet Mewlana Jalaluddin Rumi (ca. 1230/2004, p. 109), “clearing you out / for
some new delight.” Fortunately, when it comes to repairing an alliance rupture, therapists can
remind their OC clients to relax, since the management of an alliance rupture is not the client’s
responsibility (at least in RO DBT).
The first step in repairing an alliance rupture is noticing that there is one going on (with OC
clients, this is harder than you might think). The primary reason why ruptures can be hard to
detect is that most OC clients, most of the time, tend to communicate indirectly. Indirect
communication is often used to avoid taking responsibility, deceive or manipulate others, or hide
inner feelings (“No, you didn’t wake me—I had to get up to answer the phone”), albeit
sometimes an indirect communicator is just being polite. Indirect communication is also much
more likely to be misinterpreted, making alliance ruptures (and interpersonal conflict or
misunderstandings) more likely.
An alliance rupture can be triggered by almost anything—a facial expression, a tone of voice,
or, for many OC clients, a simple compliment. Fortunately, there are a number of verbal and
nonverbal indicators that suggest the possibility of an alliance rupture. Therapists should be alert
for sudden changes that suggest nonengagement, as in the following examples involving clients’
verbal behavior (see also “Statements Possibly Indicating an Alliance Rupture,” page 217):
The client suddenly starts to use one-word responses, such as “Okay” or “Sure.”
The client changes from unprompted talk to prompted talk (that is, he answers
questions but does not elaborate).
The client begins to say “Hmmm” instead of “Yes,” a change that may signal
disagreement.
A previously verbose or eager client suddenly begins to qualify her responses (“I
suppose” or “I guess so” or “Yeah, but…” or “I’ll try”).
Here are some nonverbal signals that an alliance rupture may have occurred:
The client suddenly averts his gaze or turns away from the therapist.
The client slightly rolls her eyes (a disgust reaction).
The client suddenly hides or covers his face (a shame response).
The client suddenly becomes immobile or frozen or exhibits a blank face or a rigid
stare (the “deer in the headlights” response; see chapter 6).
The client suddenly furrows his brow.
The client displays unusual movement of the hands or feet.
The client suddenly displays an apparently out-of-context smile.
The client’s eyes momentarily flick away in a central or downward direction (“I’m
not sure”), in an upward direction (“You’re wrong”), or to the side (“You may be
right, but I’m not going to do what you suggest”).
The client’s lips tighten (“I’m angry at you, but I’m not going to tell you”).
The client offers a burglar smile, a subtle nonverbal indication of a possible alliance
rupture when it occurs repeatedly during a session or over many sessions, and
when it seems to be at the therapist’s expense.
Therapists must train themselves to become adept at noticing these small changes in verbal
and nonverbal behavior.
Finally, an alliance rupture is often—perhaps most often—the consequence of a simple
misunderstanding. For example, during a discussion of valued goals, one therapist shared an
example of a valued goal from her own life (“It is important for me to write”), but the client
heard something else entirely (“It is important for me to be right”). The alliance rupture that was
triggered by this exchange did not become apparent to the therapist until the next session, when
the client reported that he had been ruminating during the past week and had almost decided not
to come to the session; indeed, the only reason he had come back was that he had committed to
do so in person and to talk about any urges to quit therapy before actually doing so. He reported
feeling confused and angry about his therapist’s “hypocrisy,” and he said, “How can a therapist
ethically preach the value of not being right when the therapist herself doesn’t believe it?”
Fortunately, in this instance, the therapist and the client were able to collaboratively identify the
source of the rupture (that is, “write” doesn’t mean “right”), and the client was able to use this
experience as a reminder of a core RO skill—namely, the skill of recognizing that mere belief in
something doesn’t make that thing true. In this example, the therapist was skillfully able to
identify the trigger—but, fortunately, you don’t have to know the trigger before you can repair
an alliance rupture. Finally, the best way to tell whether there has been an alliance rupture is to
check in with the client frequently during the session and ask for information about the client’s
experience in the current moment in order to monitor the client’s engagement. Examples of
check-ins include asking, “Does that make sense?” or “Are you with me?” or “What is it that you
would like to tell me?” Essentially, check-ins work because they give a client permission to
complain, thus making it easier for the therapist to get to know who the client is (and, hopefully,
as a consequence, help the client).
“Pushback” Responses
Answering questions with a question: “Why are you asking that?” or “Why
does that matter?” or “How could this help?” or “Why should I do that?”
Sarcastic comebacks: “I’m sure it’s my fault” or “You wouldn’t want an
entirely positive session, would you?” or “Let’s do it your way” or “What
would you suggest?”
Proclamations and personal attacks: “This sounds more about you than me” or
“Perhaps you should consider using skills yourself” or “I think you are starting
to sound like my other therapist” or “Your enthusiasm is part of the game
plan”
A client who has always completed her diary cards suddenly begins arriving without
a card, or with an incomplete diary card.
A client who used to follow instructions to the letter reports that he forgot to do his
homework.
A client who has always been timely shows up late.
A client who has never missed a session fails to show up.
A client who is proud of never having called in sick at work leaves a voice message
saying that she is too ill to come to the session.
Without warning, a client who has always reported enjoying contact with his therapist
begins to screen calls from the therapist or fails to respond to the therapist’s emails
and text messages.
The examples just listed have a common feature—they all involve social signals (whether the
client intends these signals or not), which is to say that they all send a powerful message. The
question for the therapist is, for example, What is my client trying to tell me by not completing
his homework? Regardless, when these behaviors are present, they should first be viewed as
signals of potential nonengagement and understood as suggesting the presence of a possible
alliance rupture.
The following report from a therapist offers a clinical example that illustrates the importance
of being awake to subtle in-session behaviors:
Early in therapy, during the seventh session, prior to the establishment of a full working
alliance, my OC client described himself as experiencing a pervasive lack of joy in his life. I
pointed out to him that, despite this lack, he still retained a sense of humor, and as proof I
pointed to his occasional expressions of laughter during our sessions. Unbeknownst to me, my
client experienced this statement as extremely invalidating, and yet during the session he kept his
feelings tightly controlled. During the following session, I observed that he appeared less
engaged in our discussion, and I asked whether something might have happened to trigger this,
whereupon my client reported that he had almost dropped out of therapy because of what I had
said during the session before, about his having retained some joy through humor.
In the situation just described, the therapist thanked the client for his willingness to return to
therapy and reveal his true feelings about what had happened the week before. The therapist
pointed out that this represented therapeutic progress and a genuine commitment to change. She
then used this disclosure by the client to model radical openness and flexibility. She took a
moment to slow down and reflect aloud with the client about how she might have been off the
mark during the previous session. She solicited feedback from the client about how to manage
similar issues in the future, including encouragement for the client to feel free to let her know, in
the moment, whenever he disagreed with a statement she had made. Finally, the therapist
checked in with the client about his experience of this discussion, and she asked him how
relevant the therapy was at this point to the unique problems he faced.
Leaning back in one’s chair in order to increase one’s distance from the client
Crossing the leg nearest the client over one’s other leg in order to slightly turn one’s
shoulders away
Taking a slow deep breath
Briefly disengaging eye contact
Raising one’s eyebrows
Engaging a closed-mouth smile while turning one’s gaze back toward the client
The therapist should then nonjudgmentally enquire, highlight, or notice aloud what he has
observed in session that he believes may be related to an alliance rupture. At the same time, the
therapist should privately practice self-enquiry by asking himself what he may have done to
contribute to the rupture. During the discussion of an alliance rupture, the therapist should allow
the client time to reply to queries and should let go of desires to jump in and immediately start
fixing problems. The idea is for the therapist to realize that dealing with an alliance rupture and
the subsequent repair is at least equal to and perhaps even more important than any other skill he
might teach the client during the course of treatment. This also means that the therapist must
practice radical openness himself by not blaming the client.
The following transcript provides an example of repairing an alliance rupture with a client
during the fourteenth session (that is, midway through treatment):
Therapist: So I noticed that you slightly changed the topic. Is that because you were done with
what we were discussing, or is it that you wanted to work on something else? (Notices
sudden change in direction and hypothesizes presence of a possible alliance rupture.)
The therapist should note that none of these statements is actually responsive to the request for
a commitment to return in person and discuss desires to drop out before actually doing so. As
one OC client later reported to her therapist, “I knew that if I gave this commitment, I would be
obligated to follow it, and so it was actually difficult to do, although at the time you were asking
me about it, I dared not let you know this.” When commitment clarity is lacking, the therapist
should gently repeat the request, the goal being for the client to actually give a response. Most
often the client will provide this commitment (albeit sometimes with reluctance, or by implying
that it is unnecessary). Importantly, once the client’s commitment has been obtained, the client
can be reminded of it if and when the need arises. Plus, this commitment should be reobtained
repeatedly, particularly prior to the end of a session that has involved repair of an alliance
rupture, a confrontation of maladaptive behavior, or discussion of highly charged emotional
material.
When a client prematurely terminates treatment, the overall goal is to reengage him, if
possible. This is done with respect and compassion, and the process follows similar principles
whether the event involves a no-show for treatment or a formal indication of dropout. When a
no-show occurs, either for individual therapy or for skills training classes, the therapist or
instructor should immediately attempt to telephone the client. If the client answers the telephone,
a brief assessment of the problem preventing him from attending can be done, with the goal of
getting him to come back to the clinic without delay for a partial session (or back to the
classroom). This is based on the principle that some therapy is better than none and on the
importance of blocking avoidance. If the client cannot be reached in person, then a voice mail
message can be left or a text message can be sent. Voice mail is preferred because it is more
personal. Here is an example of a voice mail left by a therapist who was unsure why his client
failed to show up for a session:
Therapist: Hi, Jayne. It’s Chris from the RO DBT clinic. I couldn’t help but notice that you
didn’t make it to session today. (Pauses momentarily and then resumes, with an easy
manner.) Definitely something different for you! So I thought I might just give you a
call and see if everything is okay with you…and I’d really appreciate a call back. My
number is 555-555-5555. And, by the way, you should know that you were missed. So
call me as soon as you get this. Thanks.
And here is an example of a voice mail left by a therapist after his client wrote to say that she
wanted to discontinue therapy:
Therapist: Hi, Jayne. It’s Chris from the RO DBT clinic. I wanted to let you know that I received
your letter. I appreciate your letting me know about your concerns. (Pauses.) And I
take them seriously. (Pauses.) I would really like to continue working with you, and at
the same time I recognize that this may not reflect your experience. Clearly some
adjustments need to be made. (Pauses.) I am hoping that you will be willing to honor
our agreement that we would meet in person to discuss any issues or concerns you
might have that could result in therapy ending early. (Pauses.) So please give me a call
and let me know if our regularly scheduled session will work for you this week, or if
we need to find another time. My number is 555-555-5555. And, by the way, you
should know that I do care about what happens to you and really want to make this
work. I look forward to hearing from you, hopefully soon. Thanks.
Dropout from treatment, whether expected or unexpected, should generally be considered an
alliance rupture and should therefore automatically trigger use of engagement and attachment
strategies. The best outcome is when the client agrees to come back to therapy or at least return
for one last session. This provides an important opportunity to repair the alliance rupture. A wide
range of factors can result in a desire to end treatment prematurely; here are some examples:
Getting the client to talk about why she wants to drop out helps her learn how to successfully
engage and repair conflict. The idea is to reach out and communicate to the client that she is
cared for, that her concerns are taken seriously (as shown, for example, by her therapist’s
willingness to admit that he has done something unhelpful), and that she has done nothing wrong
(for example, by letting her know that disagreeing or disliking something is not bad). Strict
adherence to clinic protocols or quick acceptance of a client’s request to terminate treatment and
be referred elsewhere (frequently disguised as respect for a client’s wishes) can sometimes
reflect a therapist’s or a team’s wish to avoid dealing with a difficult-to-treat client. A
compassionate pause to consider options invariably provides the space needed to repair an
alliance rupture.
Alliance ruptures that lead to dropout cannot always be foreseen. It is not uncommon for a
therapist to be surprised, perplexed, or confused when it occurs without apparent warning. When
an impersonal dropout occurs—for example, when the client writes a letter or an email or leaves
a voice mail indicating that he is discontinuing therapy but avoids talking to his therapist directly
—it is probable that the therapist missed or ignored earlier warning signs of a possible alliance
rupture or that a serious rupture occurred during the last session and was either left unaddressed
or inadequately repaired. This can be shared with a client; that is, therapists model radical
openness by explicitly revealing to a client that they are aware of imagining that they may have
misunderstood something or failed to ensure that the treatment was experienced as relevant to the
client’s unique problems.
Regardless, an unexpected, personally hostile, or impersonally communicated dropout can be
painful and demoralizing for a therapist. It can feel like a personal failure. As such, dropouts
should always be discussed in the consultation team. The team should work to understand and
validate the therapist’s perspective (for example, a sense of betrayal or demoralization) and
emotions (such as anger, humiliation, despair, or relief) while maintaining phenomenological
empathy for the client. That is, the team should avoid becoming unbalanced by blaming either
the therapist or the client for what has happened. Solutions designed to treat the therapist should
focus on blocking or redefining harsh self-blame, going opposite to unjustified emotions, or
deciding how to manage justified emotions, with the goal of finding a way for the therapist to
reengage with the client. A wide range of creative attachment strategies should be entertained:
The therapist can also remind the client, if possible, of the client’s prior commitment to talk in
person with the therapist prior to dropping out of therapy. It is crucial to remind the client that
the therapist is strongly committed to working with her and understands that there is no one way
to behave or talk about issues and that everyone is not the same. Finally, regardless of the
therapist’s or team’s intensity in attempting to reengage a client, we have found that, rather than
giving up, simply staying in contact with the client (usually over a period of many months) can
serve as a powerful means to communicate caring, which leads to the client’s eventual
reengagement. The type of contact need not be complex—for example, it might involve simply
handwriting a brief note every month that expresses a sincere desire for the client to feel better
(see “Tips for Maintaining the OC Client’s Engagement,” chapter 5).
Now You Know…
Kindness Compassion
Orientation is toward questioning oneself and Orientation is toward healing oneself and others
signaling openness to others in order to learn and via empathetic understanding, validation, and
socially connect with others nonjudgmental awareness
Yet if kindness means telling a good friend a painful truth or helping someone without ever
expecting anything in return, then why do we bother—or, perhaps more specifically, what would
be the evolutionary advantage for our species? According to the RO DBT neuroregulatory model
(see chapter 2), our stress-regulation systems evolved, at least in part, to connect us to others.
They calm down when we are feeling close to people we care about, whether related to us or not,
and spike during isolation and loneliness. Even short periods of solitary confinement can derange
the mind and damage the body because of the stress they create. Feeling socially isolated from
one’s community can be as destructive to health as cigarette smoking (and is the most common
predictor of completed suicide). Acts of kindness and generosity are powerful social safety
signals that function to bind us together rather than tear us apart. Unfortunately, despite being
highly conscientious, most OC clients are clueless about how to socially signal kindness. Thus
treatment targeting in RO DBT is an iterative process whereby the OC client is incrementally
shaped to both live by his values and learn how to prosocially signal to others (that is, to behave
kindly). The strategies for accomplishing this form the basis of this chapter.
This broad treatment target hierarchy provides a means for therapists to organize an individual
therapy session and make adjustments as needed (see “Hierarchy of Treatment Targets in
Individual Therapy,” chapter 4). In general, individual therapy sessions follow a similar
structure, yet within each session therapists may purposefully move between the hierarchy levels
on more than one occasion in order to address issues emerging in the moment. Problem
behaviors that are life-threatening behaviors are given top priority. Thus, when imminent life-
threatening behavior is present, therapists should drop their agenda and prioritize keeping the
client alive. The RO DBT protocol for assessing and addressing imminent life-threatening
behaviors when working with OC clients can be found in chapter 5. The second-most important
target in RO DBT is a rupture in the therapeutic alliance between the OC client and the therapist
(see chapter 8).
Though life-threatening behavior and alliance ruptures take precedence, RO DBT posits that
social signaling deficits represent the core problem underlying OC emotional loneliness,
isolation, and psychological distress. Thus, ideally, the vast majority of therapy time is spent on
these issues. Five OC social signaling themes are posited to be uniquely influential in the
development and maintenance of OC social signaling deficits. They provide an evidence-based
framework that allows therapists to introduce previously taboo or undisclosed topics and correct
oftentimes long-held beliefs by an OC client that her difficulties are especially weird, odd, or
abnormal relative to other people. This helps start the important process of helping the socially
isolated OC client rejoin the tribe. Most important, the OC signaling themes function as the
backdrop for the creation of individualized treatment targets that are essential for achieving a life
worth sharing. The practical aspects of accomplishing this represent the core aim of this chapter.
But before one can target a social signaling deficit linked to an OC theme, it helps to know what
is meant by a social signal, which is the topic of the next section.
Essentially, undercontrolled maladaptive social signaling is by definition big (that is, more
expressive, more dramatic, more labile). Treatment targets stand out and shout their presence
when working with UC clients; their bigness is what makes them hard to ignore (and hard to
deny), whereas OC social signaling is almost always understated, controlled, and small (except
for instances of emotional leakage), making it hard know what to target for change in therapy.
Fortunately, there is a way to get around this dilemma. It begins by noticing that when it comes
to social signaling, size doesn’t matter; for example, silence can be just as powerful as nonstop
talking. Plus, from an RO DBT perspective, when it comes to interpersonal connectedness, what
we think or feel on the inside matters less than how we communicate or signal our inner
intentions and experience on the outside.
Thus social signaling matters, but knowing what to target out of the literally thousands of
microfacial expressions, body movements, gestures, and verbal statements occurring in just one
one-hour therapy session, let alone all the multitudes that occur outside of session, seems like an
impossible task. But don’t despair—there is a way forward, one that begins with the recognition
that our personal social signaling habits can bias what we see as a maladaptive social signal.
The answers that emerge from these questions should not be considered definitive (absolute
truth); instead, they are working hypotheses that are collaboratively shared with the therapist (or
recorded in the client’s RO self-enquiry journal) and targeted for change only after the client and
the therapist have agreed that these hypotheses are relevant. The best therapeutic questions are
those we don’t already believe we know the answers to (that is, questions reflecting genuine
curiosity). Rather than asking questions in order to change a client’s mind or coerce him to think
the way we do, RO DBT therapists ask questions in order to learn who the client is and
encourage him to discover for himself how he wants to live. The essential difference between
this approach and other therapeutic methods using Socratic questioning (Padesky, 1993) is the
emphasis that RO DBT places on social signaling.
Flat, deadpan expression Frequent frozen, polite smiles displaying the teeth
KEEP IT SHORT
Finally, a common mistake for a therapist when conducting a demonstration or role playing
with an OC client is making it last too long (most often because it just doesn’t seem right that a
client could grasp the impact of the social signal quickly). However, as described earlier, the type
of visceral learning we are hoping for often takes only milliseconds to occur. So keep the
demonstrations short. If the performance is exaggerated sufficiently by the therapist, then the
client’s subcortical emotion-processing system gets the point. In other words, if a therapist finds
himself trying to explain to a client what she “should have” experienced, then the therapist
should consider three possible options:
The social signal demonstrated by the therapist was not exaggerated sufficiently for
the client to experience its impact, in which case the therapist should simply try
again and increase the intensity of the signal (this is almost always the best first
thing to do).
The client is nonengaged and is communicating this indirectly by pretending not to
have seen or experienced the problem with the social signal, thereby triggering the
protocol for repairing an alliance rupture.
The social signal is not maladaptive or relevant, meaning that most people would not
find it distressing or off-putting.
The third of these options is less likely to occur, albeit, as can be seen in the example shown in
appendix 5, at least initially the yawning client would have been perfectly happy for the therapist
to simply go with the original hypothesis: that the client was just tired. Thus it is important to be
tenacious. And one last point before moving on—it is important to note that not once in the
example shown in appendix 5 does the therapist make any attempt to fix, solve, or change the
maladaptive social signal. Focusing on solutions or skills (that is, how to change the behavior)
during treatment targeting sends the wrong message; not only does it imply that you already
understand the behavior (that is, that it is maladaptive and thereby needs to be changed), it also
reinforces OC clients’ tendencies to compulsively fix. Remember, OC clients need to learn how
to chill out.
Next, I outline how to incorporate the OC social signaling themes into treatment targeting. The
themes are helpful because they ensure breadth of targeting (so that core issues are not
overlooked), and they are helpful early in therapy when treatment targeting would be useful but
in-session displays of maladaptive social signaling have yet to occur sufficiently or repetitively
enough for the therapist to use the in-session targeting protocol (see appendix 5).
There are five OC social signaling themes. Ideally, by the fourth or fifth session, the therapist
should have begun the process of identifying individualized targets (albeit, as noted earlier,
informal targeting could theoretically begin as early as the first session). Targets should be
modified and refined over the course of treatment, partly as a function of new ones emerging,
older ones improving, or simply as a function of getting to know the client better. Thus the
therapist should not make the mistake of thinking that once he has come up with a target linked
to one of the five OC social signaling themes, his work is done—far from it. Treatment targeting
is a continual process in RO DBT that ideally gets increasingly detailed and relevant to the
specific problems the client is struggling with as the client becomes more adept at revealing
rather than masking inner experience, and has had the experience of collaboratively repairing
alliance ruptures with their therapist (recall that a strong working alliance in RO DBT is posited
to have been established only after there have been multiple ruptures and repairs; see chapter 8).
The OC themes are not targets themselves; they are too broad and not specific enough to
function as targets. Instead, they ensure that the major relevant problem areas most commonly
seen in OC clients are covered during the course of treatment. Thus, although the protocol
described later in this chapter may appear formal or structured (indeed, it is labeled as such), this
does not mean it should be followed rigidly. As mentioned earlier, therapists should feel free to
integrate both formal and informal targeting approaches (and this often proves the ideal
approach). The majority of therapists report finding the more formal approach most helpful when
initially learning RO DBT, as it ensures that they are not inadvertently overlooking potentially
important targets. Yet, with increasing experience, most therapists naturally become more
flexible and often end up integrating both formal and informal approaches to targeting,
depending on what they observe in session and according to the needs of their clients. What’s
important is not the style of targeting (that is, formal or informal) but the outcome—was the
therapist able to identify relevant social signaling targets that are specific to the client? Here are
examples of some features and social signaling deficits linked to each OC theme:
Inhibited emotional expression (saying, “I’m fine” when not; exhibiting blank facial
expressions; smiling when angry; “never let them see you sweat”; low use of
emotional words; low use of big gestures and cooperative signals, such as eyebrow
wags, hand gestures when speaking, head nods, eye contact)
Overly cautious and hypervigilant behavior (planning compulsively before every
event; obsessively rehearsing what to say; avoiding novel situations; taking only
calculated risks; obsessive checking behaviors)
Rigid and rule-governed behavior (regardless of the context, acting in ways that are
dominated by prior experience and by such rules as “always be polite,” “always
work hard,” “always think before acting,” “always persist,” and “never complain”)
Aloof and distant relationships (secretly smiling when people find it hard to
understand one; rarely revealing personal information or weakness to another
person; abandoning a relationship rather than dealing directly with a conflict)
Envy and bitterness (making frequent social comparisons; engaging in harsh gossip
about a rival; pouting when angry; engaging in revengeful acts; secretly smiling
when a rival suffers; refusing help from others, or refusing to give help to others)
Finally, how themes and targets manifest behaviorally varies considerably among individuals.
Therapists should attempt to be as behaviorally specific as possible; that is, identify the form,
frequency, intensity, and function of the behaviors associated with the theme. For example,
under the theme of “aloof and distant relationships,” one client’s aloofness might be represented
by his covertly changing the topic of conversation to avoid disclosing personal information;
another client’s aloofness is exacerbated by his stern glances of disapproval directed toward
someone who is doing something he dislikes; and yet another client might maintain his aloofness
by getting others to talk whenever the topic gets personal. In order to ensure that interventions
are relevant, it is important to determine exactly how aloofness and distance are socially signaled
(for example, a person who habitually changes the topic whenever the conversation gets personal
requires an intervention that is different from the one needed for a person who walks away from
conflict). But before I review the formal protocol—formally!—I will mention a number of
common pitfalls that I have observed over the years. If these are avoided at the outset, the
therapist can save time and prevent unnecessary confusion on everyone’s part.
Information Overload
Avoid the temptation of introducing all five OC themes at the same time. Although orientation
and commitment strategies are a core part of RO DBT, when it comes to treatment targeting, too
much information delivered too soon and too fast usually creates more problems than it solves
(and can be iatrogenic). For one thing, the therapist has now placed herself in the position of
needing to explain, justify, or defend broad concepts about OC coping that were never designed
to fully capture the complexity of every OC client. OC themes are broad descriptors that help
improve therapists’ treatment targeting, not statements of fact about all OC clients. Therefore,
introduce only one OC theme at a time (that is, one per session).54
At the start of the session, during agenda setting, introduce the OC theme you want to
work on (for example, aloof and distant relationships), but remember to work on
only one theme per week.
If necessary, briefly remind the client of the purpose of OC themes in general; for
example, “OC themes are guides to help us improve treatment targeting.” Long
explanations or detailed discussions about the themes are unnecessary and can
often prove unhelpful.
Remind the client about the importance of identifying social signaling treatment
targets: “Problems of overcontrol are posited to most often pertain to feeling like
an outsider, emotionally estranged from others, and lonely. How we socially signal
strongly impacts social connectedness. Thus, rather than prioritize how you feel
inside, or what you might be thinking, RO DBT prioritizes how you communicate
your inner experience to others because how we socially signal impacts not only
how we feel about ourselves but how others feel about us.”
STEP 4: ASK THE CLIENT HOW YOU WOULD RECOGNIZE HIS OR HER OC-
THEMED BEHAVIOR
You might say, for example, “If I were a fly on the wall, how would I know you were
behaving in an aloof and distant manner?” This question functions to help both the client and the
therapist identify specifically what the maladaptive social signal looks like to an outside
observer. Thus therapists should encourage their clients to imagine what others might see when
they do this behavior—that is, to see it as would a fly on a wall watching them when the problem
behavior emerges. Since the fly cannot read a client’s mind, the metaphor helps both the
therapist and the client remain focused on finding a social signaling target linked to the theme
and then agree on the words that best describe it (that is, a label for the client’s diary card). A fly
would be unable to see thoughts or internal emotions.
Verify that the social signal identified is both relevant (as when it prevents the client from
achieving her valued goals) and pervasive (as when it is habitual, frequent, or occurs across
contexts). Thus a social signal that is highly predictable or infrequent (for example, it occurs
only on Sundays at 9 a.m.) or that occurs with only one person (for example, a particular
neighbor), though perhaps still being a problem, may not be relevant or pervasive enough to
warrant targeting. Often the best way to accomplish this is to simply ask the client to “prove”
why the social signal is really maladaptive—for example, by saying, “Yeah, but what’s wrong
with telling your husband he doesn’t know how to stack the dishwasher properly? Maybe he
doesn’t” or “But maybe it’s honest to yawn when you find your husband boring—what’s wrong
with that?” The major point is to not automatically assume that client self-reports of social
signaling targets are necessarily valid or relevant. This approach has the added advantage of
making the target more precise while simultaneously assessing the client’s actual commitment to
change (because the client must convince the therapist that the maladaptive social signal is a
problem, not the other way around). Also—again—demonstrate to the client what the social
signaling deficit looks or sounds like; don’t just talk about it.
STEP 7: MONITOR NEW TARGETS AND BLOCK THE URGE TO FIX DEFICITS
Monitor new targets using the RO DBT diary card, and block automatic urges to fix the social
signaling deficit immediately. Encourage the client to see himself as a scientist or independent
observer who has been trained to observe the extent of a potential problem before attempting to
change it. Thus, at least initially, any newly identified social signaling target should simply be
monitored the first week after it has been identified (for frequency and intensity), along with the
covariates (thoughts and emotions) associated with it, before trying to do anything about it. This
also helps smuggle the idea that not every problem in life needs to be fixed immediately and
helps ensure that the treatment target actually matters (is relevant). Thus, if after monitoring a
newly identified social signal for a week and discovering that it never occurred once during the
preceding week, rather than just automatically continuing to monitor the target, the therapist and
the client might decide to explore how it suddenly became such a rare event, or to make
adjustments in how the target is defined or monitored. As noted earlier, low-frequency and
nonpervasive social signals, although perhaps disruptive when they do occur, may be less
relevant to obtain a life worth sharing. The only exception to this is life-threatening behaviors;
because of the serious consequences linked to these behaviors, they remain important to monitor
(especially if a client has a history of suicidal behavior or self-injury), regardless of frequency,
severity, or pervasiveness.
In the following transcript of a session, a therapist uses the procedure just described and the
client’s self-report of perfectionism to individualize targets around the OC theme of rigid
behavior:
Therapist: Okay, as we discussed earlier, one of my agenda items for today’s session was to
introduce a new OC theme, known as “rigid and rule-governed behavior,” with the aim
of identifying a new treatment target. Are you ready to move on to this?
(Client nods affirmation.)
Therapist: Okay. So when I say the words “rigid and rule-governed,” what comes to mind? What
words or images appear?
Client: The first thing that came into my mind was an image of myself as a little girl, getting
furious at my sister when she rearranged my collection of china horses. I have always
preferred structure and order. Other things that came to mind were the words
“perfectionism” and “obsessive planning” as well as “being correct.”
Therapist: So one of the things you are saying is that you noticed desires for order and structure
from a young age, and words like “perfectionism,” “planning,” and “being correct.”
(Client nods affirmation.)
Therapist: How do you think the theme of rigid and rule-governed behavior manifests in your
life now? What valued goals does it prevent you from achieving or living by?
Client: Hmmm…I don’t really know for sure. My sis always says I am a stickler for details, and
it does seem to annoy her. (Pauses.) I know that I’m definitely considered a control
freak at work, but I see this as a virtue.
Therapist: Okay, so something about being a control freak, controlling things, being highly
organized, perhaps structured—something about this—and you think this type of rigid
behavior may be upsetting to others? (Links rigidity to negative social consequences.)
Client: Not upsetting. They just don’t seem to like it.
Therapist: So if I were a fly on the wall, watching you, what would I see you doing that other
people would find annoying or unwelcome? How would our fly on the wall know you
were doing something that they did not like? What actions would the fly see you do?
(Helps client refine the target.)
Client: I don’t know—maybe they’re jealous. (Smiles slightly, pauses, looks at therapist.) I guess
it is annoying to have someone telling you what to do. It is my job, but not really for
my sister. I just think most people don’t know how to keep things organized.
Therapist: So the fly on the wall would notice you telling others what to do or how to organize
something? And I am aware of imagining that the telling is not about something the
other person has asked you to help them out with or advise them about. Is that correct?
(Keeps focus on topic of perfectionism and rigid behavior by ignoring comment about
jealousy; notes client’s use of the word “jealous” for later discussions about the OC
theme of envy and bitterness; suggests instead that telling others what to do is likely to
be problematic to others because they have not requested client’s help or advice.)
Client: Yeah, that’s it.
Therapist: So maybe we could start to monitor how often you tell others what to do or try to
organize things. Shall we label this behavior of telling others what to do and use the
diary card to see how often it shows up over the next couple of weeks?
(Client nods in agreement.)
Therapist: (Smiles) This should help us know better whether this behavior of telling others what
to do is actually preventing you from reaching important goals like the one you
mentioned about improving relationships. For example, you are aware of imagining
that people find this annoying. What evidence do you have for this? (Uses client’s own
words to describe the target to be monitored and asks for clarification regarding how
client knows others are annoyed, to help verify the target’s importance and its
consequences.)
Client: Hmmm…that’s a good question. (Pauses.) My sis just tells me. She’ll say things like “I
already know what to do” or “All right, already—I see your point! Stop trying to fix
me!” Things like that. (Pauses.) But at work it’s more subtle. Sometimes people just
walk away. They don’t respond to my email even after I’ve sent it four times! It’s
really frustrating because my job is to make sure that the policy and procedures for
quality control are followed. People just don’t understand the importance of this.
Therapist: It sounds like you feel you’re not appreciated for your work.
(Client nods in agreement.)
Therapist: Maybe we can look at how being appreciated is linked to all of this. When you don’t
feel appreciated, what emotion do you think you are experiencing? (Looks for non–
social signaling behaviors and targets linked to the overt problem behavior of telling
others what to do.)
Client: Hmmm…not sure. I feel frustrated and annoyed that I’m the one that always has to make
sure everything works out. Yeah, now that you say it, I am definitely not appreciated!
Therapist: Okay, good. How about we just start out with these three behaviors? One is overtly
telling others what to do. Another involves thoughts of not being appreciated and
always needing to be responsible, or something along those lines. And the third is an
emotion of anger or annoyance. Really, this should be interesting. The idea is for us
start having you rate these three behaviors over the next couple of weeks, and then,
when we find a day when you had high-intensity bossing or telling others what to do,
we can do some analysis around telling others what to do and see if we can make sense
of it, and change things if needed. Would you be willing to do this? (Highlights two
non–social signaling behaviors and targets that are linked to telling others what to do
—one related to cognition, the other to emotion—and assesses client’s willingness to
target these behaviors in treatment.)
Client: Yeah, that sounds good. I do feel it’s my job to make things right, but I can be very bossy
—not one of my most redeeming qualities. (Smiles slightly.)
Therapist: Okay, how about this? What if we put on the diary card, under social signaling
behaviors, the behavior of telling others what to do, rated on a scale of 0 to 5, with 0
meaning that it didn’t happen at all that day. Let’s say a 3 means that you were telling
people what to do fairly often that day, and a 5 means that you were really a control
freak that day. (Pauses.)
(Client nods in agreement.)
Therapist: (Shows client diary card) Then, under non–social signaling or private behaviors and
targets, we monitor anger or annoyance and rumination about not being appreciated,
labeled something like “People are ungrateful,” and see if our hypothesis that high-
frequency brooding or thinking about how ungrateful people are, high annoyance or
anger, and high bossiness (telling others what to do) occur on the same day and are
linked to a particular interaction on that day. How does this sound to you? (Uses words
that are the same or similar to how client described her experiences when labeling the
three targets linked to the OC-themed rigid behaviors; reviews how the targets will be
rated, shows client where on the diary card they will be rated, and explains what the
ratings might accomplish.)
The therapist purposefully did not generate solution analyses for the targets and instead
encouraged the client to practice enjoying self-enquiry by first observing rather than fixing a
potential problem. Moreover, the therapist purposely did not pursue other potential targets (for
example, jealousy and envy) unrelated to the goal of exploring the OC theme of rigid behavior.
Instead, the therapist noted these privately, as possible targets that could be discussed in future
sessions.
After reviewing all the OC themes and obtaining targets for each, the therapist and the client
decided which targets were most problematic in preventing the client from achieving her valued
goals. In this case, the client’s feelings of ostracism, isolation, and loneliness were considered
core factors underlying her refractory depression. The therapist and the client agreed that the
most important target was related to the OC theme of aloof and distant relationships, with two
social signaling targets—“walking away” from conflict and “silence around others,” or going
quiet when annoyed. Since suicidal behaviors were not present, the therapist and the client
agreed that their first priority would be to monitor and conduct chain and solution analyses
around these two social signaling targets (see “OC Behavioral Chain and Solution Analyses:
Broad Principles” and “Conducting a Chain Analysis, Step-by-Step,” chapter 10).
The theme of rigid and rule-governed behavior was ranked a very close second for this client
because it was clearly associated with feelings of isolation. The social signaling target chosen for
monitoring was “bossiness” (telling other people what to do), and it was linked to feelings of
resentment and anger as well as to thoughts about being unappreciated. The third and fourth
themes—inhibited emotional expression, and envy and bitterness—were considered equivalent
in importance for this client, and both were linked to the client’s primary OC theme of aloof and
distant relationships. Individualized targets for these themes were pretending, the “I am fine”
phenomenon, secret pride, and urges for revenge.
The final OC theme for this particular client—overly cautious behavior and hypervigilance—
was evaluated as less relevant; nevertheless, this theme was targeted, albeit indirectly, via skills
that emphasized activation of the client’s social safety system (PNS-VVC) during social
interactions, which helped her enter social situations with a less guarded or wary manner.
Diary cards are essential, despite often being frustrating to complete. Diary cards are not the
treatment, but they are one of the core components that enable the treatment to be delivered
effectively. They mitigate storytelling and long explanations about events that happened during
the past week, which otherwise must be heard (when there is no diary card) in order for the
therapist to know how to structure the session and define the problematic behavior that will be
the focus of the current session’s behavioral chain analysis. Thus diary cards save valuable
session time for work on solving problems, and research shows that they improve the accuracy of
the information obtained. Indeed, if all is going to plan, only about six minutes are allocated for
in-session review of a diary card. The major point is that without a diary card, therapy becomes a
bit like finding a needle in a haystack when it comes to identifying the most maladaptive and
relevant social signaling deficit that has occurred during the client’s preceding week.
Initials/Name
Filled out in
Radically Open Major OC session: Y/N
theme this
RO DBT Diary Card ID # Started
week
Card:
Medications
Urge
Cirlce to Private Behaviors: Thoughts, Sensations,
Start Committ Emotions Other
Day Suicide Med as Drugs
Social Signaling or Other Overt Beh
Prescribed or
Day Alcohol
of Week
MON
TUES
WED
THU
FRI
SAT
SUN
Notes/comments/chain analysis: Valued goals sought this week: New self-enquiry questions:
Radical
Openness Skills Hand-
(circle each day out or Week- Week- Week- Week- Week- Week- Week-
of the week you Work- day day day day day end end
practed a sheet
particular skill)
Flexible
Mind
DEFinitely:
1.B Mon Tue Wed Thu Fri Sat Sun
Three Steps for
Radically Open
Living
The Big
Three + 1:
3.A Mon Tue Wed Thu Fri Sat Sun
Activating
Social Safety
Practiced
Loving
Kindness
4.1 Mon Tue Wed Thu Fri Sat Sun
Meditation:
Maximizing
Social Safety
Flexible
Mind VARIEs:
5.1 Mon Tue Wed Thu Fri Sat Sun
Engaging in
Novel Behavior
Flexible
Mind SAGE
Skills: Dealing
with Shame,
8.A Mon Tue Wed Thu Fri Sat Sun
Embarrassment,
and Feeling
Rejected or
Excluded
Flexible
Mind Is DEEP:
Using Values to 10.2 Mon Tue Wed Thu Fri Sat Sun
Guide Social
Signaling
Practiced
Being Kind to 11.2 Mon Tue Wed Thu Fri Sat Sun
Fixed Mind
Practiced
Learning from 11.3 Mon Tue Wed Thu Fri Sat Sun
Fatalistic Mind
Practiced
Going Opposite
11.B Mon Tue Wed Thu Fri Sat Sun
to Fatalistic
Mind
Practiced the
Awareness 12.1 Mon Tue Wed Thu Fri Sat Sun
Continuum
Mindfulness
“What” Skills:
12.2 Mon Tue Wed Thu Fri Sat Sun
Observe
Openly
Mindfulness
“What” Skills:
12.2 Mon Tue Wed Thu Fri Sat Sun
Describe with
Integrity
Mindfulness
“What” Skills:
Participate 12.2 Mon Tue Wed Thu Fri Sat Sun
Without
Planning
Mindfulness
“How” Skill:
13.1 Mon Tue Wed Thu Fri Sat Sun
With Self-
Enquiry
Mindfulness
“How” Skill:
With
14.1 Mon Tue Wed Thu Fri Sat Sun
Awareness of
Harsh
Judgments
Mindfulness
“How” Skill:
With One- 14.1 Mon Tue Wed Thu Fri Sat Sun
Mindful
Awareness
Mindfulness
“How” Skill:
14.1 Mon Tue Wed Thu Fri Sat Sun
Effectively and
with Humility
Practiced
Identifying
“Pushback” and 16.1 Mon Tue Wed Thu Fri Sat Sun
“Don’t Hurt
Me” Responses
Flexible
Mind
REVEALs:
Responding 16.2 Mon Tue Wed Thu Fri Sat Sun
with
Interpersonal
Integrity
Flexible
Mind ROCKs
ON: Enhancing 17.1 Mon Tue Wed Thu Fri Sat Sun
Interpersonal
Kindness
Practiced
Kindness First 17.B Mon Tue Wed Thu Fri Sat Sun
and Foremost
Flexible
Mind PROVEs:
Being Assertive 18.A Mon Tue Wed Thu Fri Sat Sun
with an Open
Mind
Flexible
Mind
Validated: 19.A Mon Tue Wed Thu Fri Sat Sun
Signaling
Social Situation
Flexible
Mind
ALLOWs:
21.1 Mon Tue Wed Thu Fri Sat Sun
Enhancing
Social
Connectedness
Practiced
MATCH + 1:
Establishing 21.3 Mon Tue Wed Thu Fri Sat Sun
Intimate
Relationships
Flexible
Mind ADOPTs:
22.1 Mon Tue Wed Thu Fri Sat Sun
Being Open to
Feedback
Flexible
Mind DARES
(to Let Go): 27.A Mon Tue Wed Thu Fri Sat Sun
Managing
Unhelpful Envy
Flexible
Mind Is
LIGHT: 28.A Mon Tue Wed Thu Fri Sat Sun
Changing
Bitterness
Flexible
Mind Has
HEART: 29.A Mon Tue Wed Thu Fri Sat Sun
Learning How
to Forgive
Figure 9.2. Back of Diary Card (Blank), Showing Client’s Use of RO Skills
Preferably, cards are double-sided, with targets on one side and skills usage on the other. The
day of the week a particular RO skill was used should be circled, thereby providing both the
client and the therapist a sense of what skills the client is using the most, which ones she still
needs to learn (and, if deemed essential for a particular client, which ones should be taught
informally in individual therapy), and the client’s overall commitment to skills usage. As can be
seen in the diary card template, in the far left-hand column of the card (going down) are listed the
days of the week, with each day having a corresponding row. Two broad sections of blank
columns can be seen, one for recording secondary non–social signaling behaviors and targets
(thoughts, sensations, emotions) and the other for recording primary social signaling behaviors or
other overt behaviors. The columns are left blank so that the therapist and the client can
individualize what is targeted, with the exception of the three columns that address the client’s
urges to commit suicide, the client’s compliance with taking prescribed medications, and the
client’s use of nonprescription drugs and alcohol. However, all of this can be modified according
to the needs of the client (or the program). Thus, for example, a program that targets eating
disorders may wish to add several additional prelabeled columns for high-risk behaviors related
to eating disorders. The therapist can keep a copy of each weekly diary card as part of the client’s
record and as a means of monitoring progress.
A Brief Overview of the RO DBT Diary Card Template
As mentioned earlier, the RO DBT diary card should be considered a working example or
template; that is, it can be used as is or modified as needed. The general features of the card are
as follows:
Initials or ID number: Instead of the client’s name, the client’s initials can be used for
confidentiality. The client may have an ID number assigned if he or she is part of a
research study.
Indication of whether the card was filled out during the session: If the client filled the
card out during the session, circle Y. Otherwise, circle N.
Indication of how often the card was filled out during the preceding week: The client
should record how often he filled out the diary card during the past week (for
example, every day, two to three times, four to six times, or just once).
Starting date: The client should record the date that corresponds to the start of the
week during which the card was completed.
Major OC theme for the week: The client should record the major OC social
signaling theme he is primarily focused on for the week.
Urges to commit suicide (rated from 0 to 5): For any particular day, the client should
rate urges to commit suicide, with the rating reflecting both the frequency of
suicidal thoughts and the intensity of suicidal urges. Blank columns can be
individualized to include tracking of other suicidal behaviors that may be relevant
to different clients (for example, urges to self-harm, overt actions of self-harm,
suicidal ideation, and so forth).
Client’s compliance with prescribed medication instructions: This portion of the diary
card is relevant to any current prescribed medications that a client is taking and
that may be important to monitor (for example, antidepressants). The client should
write Y (yes) or N (no) to indicate whether medications were taken as prescribed.
Client’s use of nonprescription drugs or alcohol: For alcohol, clients should specify
the type of drink (beer, cocktails or other mixed drinks, whiskey, wine, and so
forth) and the amount (number of glasses). For illicit drugs, the client should
specify the type of drug used (marijuana, heroin, speed, cocaine, and so forth). In
general, most OC clients do not abuse illicit drugs, because they tend to be rule-
governed and are motivated to appear proper and socially desirable.
Client’s notes, comments, and chain analysis: This section is designed to allow
clients a place to record any additional comments or observations that might be
relevant.
Valued goals sought during the week: This optional section is designed to help
remind clients to focus on seeking valued goals. Therapists should feel free to
modify this section or even eliminate it entirely if it is discovered not to be
particularly useful.
New self-enquiry questions: This is a very important section on the diary card. It
helps the client remember to practice self-enquiry and simultaneously provides a
structured means for the client to practice outing herself. When this section is left
blank, the therapist should consider the client’s lack of completion to be a social
signal that may reflect the presence of an alliance rupture or confusion about self-
enquiry. Regardless, when this section is left blank, the therapist should not ignore
it.
In the following transcript of a client’s twelfth session, a therapist reviews the diary card of an
OC client with a history of suicidal ideation and chronic depression; the client’s valued goals are
to have improved relationships with her family (her sister and her daughter), to find a healthy
romantic relationship, and to learn how to relax more and work less. The client and the therapist
had previously identified several social signaling targets: the silent treatment (not talking to
someone in order to punish him, but without admitting that this is what is being done),
pretending (the client saying that she is feeling fine when she is not), walking away (abandoning
a conversation without warning because it is getting too uncomfortable), and emotional leakage.
They had also identified two habitual thoughts: People are users and Why do I have to do
everything? The emotions and thoughts represent non–social signaling behavioral targets.
Therapist: (Looks at card) Okay, let’s take a look at the rest of the card. (Pauses.) Hmmm…no
suicidal thoughts or urges. Well done! (Smiles warmly, reinforcing lack of life-
threatening behavior.) Hmmm…let’s see. (Pauses; reads aloud the scored numbers
reporting the intensity of the behavior that was recorded.) On Tuesday, you rated
anger as high—it was a 4. And envy/resentment was even higher—it was a 5. Plus, you
rated blaming others high, too—it was a 5. But on Wednesday you had some high
shame—this was a 4. When you look back on it, which day last week do you think was
your worst—your most problematic? (Works to identify which day and specific
behavior to discuss in more detail, and to conduct a chain analysis.)
Client: On Tuesday, my sister and her husband came over for a visit. Sometimes I just think they
like to make me feel bad—they always act like they’re so happy.
Therapist: Hmmm…yeah, we have noticed this type of thinking before, especially when it
comes to your sister and her husband. I see, too, that on Tuesday you checked off the
silent treatment and walking away. Well done on noticing all these behaviors!
(Reinforces self-enquiry, smiles briefly, pauses.) What happened that made Tuesday so
difficult?
Client: Well, I decided that I would work on improving my relationship with my sister by asking
her and her husband over for dinner. I spent all day making her favorite foods. It was
maddening. All her sycophantic husband could do was nod and agree with everything
she said. She didn’t once comment on the food. Instead, all she talked about was how
great her new job was. It was just too much, so I decided to leave.
Therapist: Even though it was your house? (Clarifies context.)
Client: I just couldn’t stand to be there any longer. I pretended that I wanted to take a walk. But I
was so worked up, I left without a coat. Even though I was freezing, I just kept saying
to myself, I’ll be damned if I go back.
Therapist: Hmmm…wow, that seems like a really difficult time. And a perfect opportunity for us
to use our newly developed chain analysis skills. (Pauses momentarily.) Should we
target walking away as the problem behavior?
Client: Yeah, I guess so. I think I am still down on myself about what happened.
Therapist: Hmmm…yeah, maybe feeling down is the natural consequence of things like this,
especially since one of your valued goals is to reconnect with your sister. (Links
targeted problem behaviors with valued goals.) Perhaps our chain analysis can help
make sense of this. (Pauses momentarily.) Before we go there, let’s take a quick look
at the rest of the card.
The therapist then quickly looked over the remainder of the card to ensure that there were no
other major problems to address, and to gain a sense of how well the client had been using RO
skills (diary card reviews should be done quickly—within five to seven minutes). Once this was
completed, the agenda was set for the session, and a chain analysis was begun to examine the
social signaling behavioral problem of walking away as well as how it was linked to the non–
social signaling targets of envy and resentment and blaming others, and to examine how these
functioned as obstacles to the client’s achieving her goal of an improved relationship with her
sister.
Close social and familial Having closer relationships with her husband and other family members,
bonds especially her sister
Self-sufficiency
Competence Finding a job or volunteer work that will use her skills and contribute to her
Achievement family’s income
Productive work
Fairness
Being kinder to others
Kindness
Offering help without expecting anything in return
Respect and caring for
Accepting help from others
others
Envy, bitterness
Anger, resentment
Aloof, distant relationships
Sensation
Thoughts
Envy, bitterness
Fantasies of revenge
My little schemer…a Resentment
Exhaustion
Aloof, distant relationships
Rule-governed behavior
I’m not being appreciated. Envy, bitterness
Exhaustion
aThis is the label used on the client’s diary card in connection with certain behaviors.
Table 9.6. Client’s Social Signaling Behavior
Bitterness
Resentment
Turning down help
Exhaustion
Sadness
Inhibited or disingenuous expression (for example, frozen, blank, flat, or feigned and
insincere expressions not genuinely representing inner experience): Pervasive
attempts to conceal, disguise, or suppress emotional expressions, or to simulate or
pretend to be exhibiting genuine emotional expressions, are core problems for OC.
They have a massive negative impact on interpersonal relationships. Therefore,
targeting inhibited or disingenuous expressions is considered an essential
component of treatment success.
Diminished emotional experience and low emotional awareness: OC clients
frequently report diminished emotional experience and awareness in situations that
most others would report as highly emotionally charged (for example, a funeral, a
birthday party, a retirement celebration, or a disagreement with a spouse).
Emotional attenuation is diminished or undifferentiated experience of emotions,
which may be a consequence of low awareness of emotional sensations, thoughts,
or images; little experience in labeling emotions; motivational factors (for
example, not labeling or discussing emotions) that may lessen heated conflict or
reduce possible social disapproval; biotemperamental differences in emotional
reactivity; and mood states common among OC clients (such as dysphoria,
bitterness, anxiety, and irritability) that may make it difficult for OC clients to
detect when a new emotion has appeared (that is, in OC there may be a lack of
contrast effects; sadness is easier to notice if one was experiencing joy a few
minutes earlier). Therapists should remember that emotional attenuation does not
mean that clients are unemotional, despite the fact that they may genuinely be
unable to detect emotions or to label their experiences as emotions. For example,
without fear-based responses, an OC client would have long ago been run over by
a bus, since emotions allow quick reactions to relevant stimuli prior to conscious
awareness. Therapists should retain an open-minded, inquisitive stance when
clients report emotional attenuation, a stance that communicates belief in clients’
self-reports and yet challenges them to go deeper.
Therapists must repeatedly orient, teach, and model to clients the benefits of free expression of
emotion. For example, free expression of emotion can enhance creativity, validate one’s inner
experience, and signal openness and lack of deception to others. It is the essential glue needed in
order to develop genuine intimacy with others. Free expression of emotion enhances intimacy
because it signals to others that you trust them (because you are revealing your inner self) and
that you are trustworthy because you are not hiding anything. Despite the majority of people
considering blushing a highly undesirable response, resulting in attempts to control or suppress it
(Nicolaou, Paes, & Wakelin, 2006), research shows that individuals who blush and openly
display embarrassment are more likely to be trusted by others and judged more positively, and
observers report greater desires to affiliate with them, compared to a nonblushing individual in a
similar context (Feinberg et al., 2012; Dijk, Koenig, Ketelaar, & de Jong, 2011). Therapists must
also describe how micromimicry works in provoking empathy; that is, one way we understand
others’ emotions is to experience those emotions ourselves via facial micromimicry. For
example, if a person observes someone grimacing in pain, the observer immediately
microgrimaces. This sends signals to the observer’s brain, and by experiencing the emotion, the
observer is now able to understand how the other person is feeling. Explain that consciously
masking facial expressions still communicates a message (Adler & Proctor, 2007). An observer
is likely to recognize that an emotion is happening within the other person, even if it is denied or
masked (J. J. Gross & John, 2003). Explore with clients the pros and cons of expressing
emotions, and remind them that expression of emotions is context-dependent (for example, when
playing poker, a blank face is useful for placing a bet). Ask for a commitment to work on
learning how to express emotions freely.
Therapists should review handout 3.1 (“Changing Social Behavior by Changing Physiology”)
in the skills training manual.56 See also the skills training manual, chapter 5, lesson 3, for the
“Hunting Dogs, Shields, and Swords” teaching point, and recount “The Story of the Disliked
Friend.” Explore in a collaborative manner with the OC client how bringing particular mood
states or behaviors (hunting dogs, shields, and swords) into social situations can make the
situation worse. Review the rationale for changing physiology and getting into one’s social
safety system prior to social interactions; when we viscerally feel safe, we are able to naturally
and freely express our emotions. Therapists should look for opportunities to practice changing
physiological arousal in session and assign homework designed to enhance this skill. Lastly,
therapists should encourage the use of RO DBT loving kindness meditation (LKM) as a social
safety mood induction that naturally facilitates free and open expression.
OC individuals have developed inhibitory barriers that make free expression difficult. To
break these overlearned barriers down, therapists must be careful not to confirm clients’ beliefs
that emotions should always be regulated or controlled. Therapists need to model this
understanding by throwing themselves wholeheartedly into exercises designed to enhance
spontaneity, playfulness, and uninhibited emotional expression; in the skills training manual,
chapter 5, lesson 5, see “The Extremely Fun Extreme Expression Workshop” and the
mindfulness practice called “The Oompa-Loompa” or, in lesson 30, “The Mimicry Game.”
Therapists should teach how specific body postures, facial expressions, and gestures influence
physiological arousal and communicate important nonverbal information to others; in the skills
training manual, chapter 5, lesson 3, see the exercise called “The Big Three + 1.” Creativity and
playfulness can be important (for example, viewing in-session pictures or video clips showing
facial expressions of differing emotions while mimicking them together). The importance of
therapist modeling cannot be overemphasized; free expression by a therapist signals that it is a
socially appropriate behavior. Homework assignments can further enhance this (for example,
practice making different emotional expressions in a mirror or experimenting with big gestures
that signal cooperation, such as eyebrow wags combined with expansive, out-turned hand
gestures). The overall goal is to shape increased emotional expression via graduated exposure to
increasingly challenging but not overwhelming expressive opportunities.
As described earlier, the “I am fine” phenomenon refers to the tendency of many OC clients to
verbally underreport or misreport their genuine emotional states. Frequently a functional analysis
of the “I am fine” phenomenon reveals that the behavior is negatively reinforced; for example,
by denying feeling upset, a client is able to avoid discussion of a potential conflict. Therapists
can influence this by changing the consequences or reinforcers. For example, a therapist can
inform clients that whenever they say they are fine, it will be taken to mean that they are actually
not fine. Here, the therapist stops and has the client redescribe vague emotional wording or
apparent underreporting by momentarily stopping the in-session conversation, highlighting the
language used by the client (“I’m fine”), and then asking the client to describe his experience in
more detail, using emotional words. This playfully irreverent strategy, or therapeutic tease,
provides a mild aversive contingency for undifferentiated labeling, all the while shaping the
client to be more descriptive of what he may actually be experiencing. Frequency counts by the
client of how many times “I am fine” is said throughout the day can serve similar functions.
Raising awareness of changes in body sensations (or sudden lack of sensation) can help
improve emotional awareness (for example, heart rate going up, feeling flushed or hot, sweating,
tremors, feeling numb or flat, urges to urinate). For precision, it is usually best to monitor lack of
sensation (numbness) separately from change in sensation (feeling hot), and the specifics of what
is monitored on the diary card will vary from client to client. These emotional signs can then be
incorporated into chain analyses.
Raising awareness of emotion can be enhanced by using the overt behaviors linked to
emotional experience as a means to facilitate labeling. For example, a personal attack of
someone (such as harsh criticism) suggests that the client is feeling anger (action urge of anger is
to attack). Bowing one’s head or covering one’s face suggests shame (action urge of shame is to
hide). By knowing which actions are linked to which emotions, a client can learn to label inner
experience in a manner similar to others. Labeling emotions makes it easier to identify likely
thoughts, sensations, and action tendencies linked to emotions and predict one’s future
behaviors. Plus, using the same words that others use to describe emotional experience enhances
social connectedness because it signals a shared or common bond. When first starting this
practice, clients may lack an emotional vocabulary. For example, one OC client was only able to
use words like “plastic,” “raw,” “fresh,” “dry,” “polished,” and “tidy” when first describing what
were posited to be inner emotional experiences. Other OC clients dislike basic emotion labels
(anger, fear, disgust) because to them they are too extreme. They may be willing to admit that
they are frustrated but may find it hard to say they are angry because to them anger equates to
yelling and screaming. In the skills training manual, chapter 5, lesson 2, therapists can read about
how to teach the way in which emotions are linked to the five neural substrates; lessons 6 and 22
show how to teach more broadly on emotions. Therapists should look for opportunities for the
client to practice labeling emotions in session; for example, the therapist can check in with a
client periodically during session by asking, “How are you feeling now?”
OC clients can find it difficult to experience and label vulnerable emotions; for example, when
sad, they may label their sadness as fatigue. During the orientation and commitment stages of
therapy, it is important for therapists to assess the presence of trauma, long-held grudges, and
other losses that may be important obstacles preventing client growth. Grief work can become an
important means to help a client let go of these painful experiences. Successful grieving requires
the brain to learn that what was before is no longer. Grief work means feeling the loss and then
letting it go (practicing regulation). Over time, the brain adjusts to the changing circumstance;
that is, we give up searching for the lost object and begin to build a new life (see the skills
training manual, chapter 5, lesson 29).
Encourage Self-Enquiry
It is important for therapists not to focus solely on changing aversive emotions. RO DBT
emphasizes the importance of self-enquiry—that is, pausing to question one’s reactions, in order
to learn, before applying a regulation strategy (such as accepting, distracting, or reappraising).
Rather than redirecting attention away from aversive emotions (for example, by attending to
neutral, non-emotion-based body sensations), RO DBT encourages clients to redirect attention
toward aversive emotions (even when they are of low intensity) and use self-enquiry first. For
example, sadness may signal that something important in one’s life has changed or that one
needs to do something different. Self-enquiry of emotion means pausing to ask oneself What
might this emotion be telling me? How open am I to feeling this emotion? Do I desire to get rid
of the emotion, deny it, or regulate it immediately? If yes or maybe, then What am I avoiding? Is
there something here to learn? Self-enquiry is nonruminative because it is not looking to solve
the problem or to regulate or avoid the discomfort. Indeed, quick answers are considered to most
often reflect old learning and desires to avoid genuine contact with the pain associated with not
having a solution. Thus self-enquiry can be differentiated from other mindfulness approaches
because it actively seeks discomfort to learn and blocks immediate answers rather than
prioritizing dispassionate observing, metacognitively distancing from thoughts, and waiting for
the experience to fade away. This is why most self-enquiry practices are encouraged to last over
days or weeks. Clients are encouraged to keep a weekly journal, a small book in which they can
record self-enquiry questions and what arises during self-enquiry practices.
Mindfulness training can also influence the appraisals or thoughts we have about emotions.
We sometimes refer to this skill as “having but not holding” an emotion—that is, allowing
oneself to fully experience, without judgment, the sensations, images, and thoughts involved in
an emotion and then to let it go (for example, by using a change strategy) while maintaining a
willingness for the emotion to return. In addition, clients can be reminded that their thoughts or
appraisals can influence emotional experience. What we think about during an emotional
experience can prolong the emotion or trigger another one (for example, the thought I hate being
angry can be a bit like putting gasoline on a fire and can refire the same emotion). Mindfulness
teaches a person to observe the response tendencies of an emotional event (for example, when
fearful, observe without judgment the urge to escape). T. R. Lynch and colleagues (2006) have
posited that this approach automatically alters the meaning or appraisal associated with an
emotion (for example, from something bad to something that just is) without the need to use
executive control to reappraise or modify one’s original emotional perception. By allowing
emotions to be experienced (exposure) without judgment, new associations are acquired (the
emotion just is, the thought just is, and the memory just is). With repeated practice, associations
between emotionally evocative stimuli and new ways of behaving or thinking become
increasingly dominant, thus making it less likely, for example, that fear will be refired by
appraisals that it is bad or dangerous (see T. R. Lynch et al., 2006). This approach—that is,
observing emotional sensations, urges, thoughts, and memories dispassionately—is the core of
most traditional mindfulness awareness treatments (J. M. G. Williams, 2010; Segal, Williams, &
Teasdale, 2002). RO DBT values both dispassionate awareness and passionate participation.
Activate the Social Safety System (PNS-VVC) Prior to Engaging in Novel Behavior
Biotemperamental biases for heightened threat sensitivity make it more likely for OC clients to
perceive new or uncertain situations as threatening (that is, defensively arousing). Therefore, it is
essential for therapists to teach OC clients how to activate the social safety system prior to
assigning behavioral activation tasks as homework. Individual therapists should not assume that
skills training classes will be sufficient in helping OC clients learn these skills. Didactic
instruction in social safety activation and troubleshooting commitment are essential parts of
individual therapy, ideally occurring by the sixth session and using the same handouts as skills
classes. This ensures that social safety skills are taught early in treatment and at least twice (that
is, once in individual therapy and once in skills class). Therapists should also not assume OC
clients to be competent in social safety activation simply because they have been instructed in
skills usage or have rehearsed these skills in a therapy session. Many OC clients fail to
appreciate the significance of these skills (at least initially), often because they assume they
should be easy, secretly regard the skills as “woo-woo” or silly (for example, loving kindness
meditation, eyebrow wags), or may not fully grasp the science behind them. Thus therapists must
assess not only commitment to practice social safety activation skills but also competency in
their performance. Without this, clients may dutifully comply with social signaling assignments
yet fail to benefit from them because they are unable to downregulate biotemperamental
predispositions for defensive arousal. The problem is not lack of willingness on the client’s part
to behave differently; the problem is that the client has insufficient experience in activating
social safety to be able to viscerally link it to positive outcomes.
Flexible Mind VARIEs skills (see the skills training manual, chapter 5, lesson 5) are designed
to facilitate success in trying out new things and going opposite to avoidance. Although these
skills are formally taught in skills class, individual therapists should informally teach them and
reinforce their use via individualized homework practices. Practices can start out with something
as simple as the client’s rearranging the furniture at home, wearing different clothes (for
example, brighter colors), taking a new route when driving to the store, or trying a new type of
food. Contrast is introduced as making life interesting. Flexible Mind VARIEs skills should not
be taught or assigned for practice before an OC client has become adept at activating the social
safety system. Over time, with increasing successful practice, the therapist can increase the
intensity of exposure to previously avoided situations, places, or people.
OC clients are hypersensitive to criticism, fear making a mistake, and often have a long
history of intermittent reinforcement associated with rigid beliefs, which makes them less
amenable to normal persuasion or logic. A type of calcified thinking can emerge that grows
stronger when challenged or exposed; like the hard external skeleton of the marine organisms
that form coral reefs, direct disturbance makes the hard deposits grow thicker.
RO DBT works with rigid beliefs and behavior by first assuming that the therapist may be
mistaken or incorrect in how she understands the problem. This provides breathing room for the
client and an opportunity for learning on both the client’s and the therapist’s part. Thus, instead
of telling an OC client that his rigid behavior or belief is invalid, distorted, or ineffective, the
therapist should ask the client, with an open mind, how his belief or why his behavior is
beneficial to him. This models radical openness on the therapist’s part while encouraging the
client to practice self-enquiry and self-disclosure. For example, a therapist noted that his OC
client described waking up in the middle of the night in order to get some pain medication for her
ailing husband as “selfish” and “controlling” rather than as an act of kindness. In this situation,
asking rather than telling might involve a question like “Can you help me understand how
helping your husband in this manner was a selfish act?” A query of this type helps the client
practice revealing inner feelings and avoids providing leading information that could influence
how the client responds.
Since a strong working alliance may not emerge until midtreatment (around the fourteenth
session), prior to this OC clients may tend to report what they think the therapist wants to hear.
When an OC client appears to be struggling with describing something, quickly moving in to
provide helpful suggestions (therapeutic mind reading) or therapeutic interpretations will not
give the client the space and time to describe her experience (or her struggle to do so) in her own
words. For example, much more is likely to be learned through open-ended questions (“What
prevents you from labeling your actions as kind?”) or questions with no clearly correct or
socially appropriate answer (“When you help your husband out in the middle of the night, does
this behavior make it more likely or less likely for you to achieve what is important for you in
life?”) than through interpretations (“Maybe you can’t allow yourself to feel kindness because
you are so self-critical”). The therapist must not overcorrect and assume that competent RO DBT
involves asking questions only. On the contrary; didactic teaching, therapeutic mind reading,
case formulation reviews, and explicit demands for change are also necessary components.
Individual therapists should look for opportunities to help their OC clients let go of rigid
desires to immediately fix or solve problems when they arise. For example, one OC client
arrived at her third RO DBT session with a list of 117 new things she had tried out the previous
week, a task that was not requested by her therapist. This behavior, though representing a strong
attempt to correct her avoidance of novelty, also represented a core issue in being able to tolerate
uncertainty. The client was applying maladaptive control efforts to correct another maladaptive
OC problem. In general, therapists should adopt a stance of nonurgency when working with OC
clients rather than somber problem solving, particularly when it comes to rigidity. Therapists
should encourage OC clients (as well as themselves) to practice allowing problems to just be,
without assuming that every apparent problem requires immediate resolution. This functions as
informal behavioral exposure to uncertainty and ambiguity. Compulsive fixing can be monitored
on diary cards, and therapists should use this to help clients realize that sometimes apparent
fixing makes matters worse. One OC client recalled how she had immediately ordered a brand-
new dishwasher after discovering that her old one was full of dirty water. It was only the next
morning, when the new one arrived, that she discovered the actual problem—a blocked drainage
pipe that was not even part of the machine. Her desire for quick control resulted not only in lost
time and money but also in the aggravation of knowing that her solution had been inappropriate.
If she had allowed herself the grace of not trying to immediately solve the problem, she might
have discovered the next morning that the problem was a drainage issue, not a mechanical one.
Awareness of this pattern became an important turning point for this client in being able to allow
natural change to occur and to let go of compulsive fixing.
Therapists should look for opportunities for OC clients to practice not working all of the time.
OC clients have forgotten the importance of play and laughter in healthy living. Therapists can
remind clients that as children (at the age of three, for example) they were able to play without
self-consciousness. Doing something new or different every day helps break down old habits and
encourages spontaneity naturally. Therapists should look for ways for their clients to practice
being less work-focused, without giving themselves a hard time about it. For example, instead of
reading another self-improvement book, OC clients should be encouraged to read magazines or
books that are fantasy-oriented, recreational, nonserious, or fictional. Homework assignments
might include practices such as leaving work early once per week, going out for a beer with work
colleagues, taking naps, daydreaming, watching comedies, taking long baths, or spending only a
set amount of time to complete a task.
Use Playful Irreverence to Challenge Rigid Beliefs and Block Compulsive Rule-Governed Behavior
Playful irreverence combined with stories and metaphors can smuggle important information
about problems or treatment strategies that otherwise might have been dismissed if presented
more formally. For example, therapists can playfully take advantage of OC tendencies to comply
with rules to block compulsive fixing by creating a new rule that must be followed—specifically,
the new rule is “You are not allowed to attempt to solve or fix a problem until twenty-four hours
after it first occurs.” Delaying compulsive fixing behaviors over a twenty-four-hour period has
several benefits for an OC individual:
It provides time for new information about the problem to emerge naturally and
blocks rash decision making that only later is discovered to have been in error or
unneeded.
Compulsive fixing is driven by fear and avoidance of uncertainty or ambiguity, but
delaying a decision or solution by twenty-four hours ensures that the person has
slept on it (during sleep, cue-driven emotional responses fade, and so it is more
likely for a new perspective on the problem to emerge in the morning).
It provides the client an opportunity to not work so hard and practice developing a
nonjudgmental sense of humor about himself and his personal foibles (see the
skills training manual, chapter 5, lesson 5, for teaching about the art of
nonproductivity).
The strategy should be delivered using playful irreverence (that is, a slightly tongue-in-cheek
manner). Playfully insisting it is imperative to adhere to the new twenty-four-hour rule on delay
of fixing, while nonverbally communicating affection, encourages the client to join with the
therapist in experimenting with novel ways to change old habits.
The following examples from therapists’ transcripts demonstrate the use of irreverence to
challenge literal belief in thoughts and help loosen rule-governed thinking (see chapter 10 for a
more detailed discussion of playful irreverence):
Therapist: Last night I made this delicious cheesy pizza with fresh mozzarella cheese, roasted
tomatoes and garlic, a bit of fresh pepper and parsley sprinkled on top, and a crunchy
crust drizzled with olive oil. I just can’t wait to get home tonight and warm it up in the
oven! (Pauses, looks at client.) But why am I telling you this?
(Client shrugs.)
Therapist: The truth is that I lied. I never made that pizza! The point is that if you, like me, are
salivating now, then we can know for a fact that thoughts don’t have to be true to
influence us. So just because you think it, that doesn’t mean it’s true. (Uses this
experience to help client understand that thoughts, even when untrue, exert a powerful
influence, both physiologically and emotionally.)
Therapist: (Wears glasses) I don’t wear glasses.
(Client freezes.)
Therapist: No—I mean it. I don’t wear glasses! (Touches the glasses he is wearing, pauses, looks
at client.) Do you believe me?
(Client shakes head no.)
Therapist: My statements about glasses are just like the thoughts in your head—they sound
convincing, but they’re not necessarily true. (Uses this experience to irreverently
challenge client’s literal belief in thoughts, and uses the story to facilitate teaching.)
Perhaps because thoughts are inside of us, we tend to believe them, even though we
can easily discount thoughts about things outside our heads. For example, we easily
discount the words coming from a radio insisting, “Send me your money, or the world
will end.” Or when a child proclaims, “I am a seven-foot-tall giant,” we know these
words are fantasy. But we don’t easily discount our own internal verbal behavior—our
own words and thoughts. (Weaves in other examples demonstrating the importance of
seeing thoughts as thoughts, not as literal truth.) So my suggestion is for us to start
practicing the skill of observing our thoughts and not seeing them as literally true. The
goal is to be able to watch them like a movie playing. As you get better at this, you
might find that some of your negative beliefs about yourself or others will start to have
less power over you. How does this sound to you? (Checks in with client to confirm
agreement.)
Rigid rule-governed behaviors, perfectionism, and compulsive desires for structure and control
can negatively impact relationships. For example, one OC client reported that she felt compelled
to redo other people’s work if she believed that they might not have done it properly, a behavior
that the therapist and the client decided was most likely reinforced by the client’s pride or sense
of accomplishment after having done a job well. However, her behavior of compulsive redoing
negatively impacted her relationships; that is, her family and coworkers experienced her redoing
as demoralizing, since their efforts rarely appeared to meet her perfectionistic standards.
Moreover, the consequences for the client were often exhaustion (redoing other people’s work
required additional effort) and an increasing sense of resentment and bitterness because she felt
that she was the only one ever doing any work (her family had essentially abandoned helping out
with most domestic chores). For other clients, rigid behaviors may have more to do with rules
pertaining to social etiquette (“always behave politely” or “always send Christmas cards”) or
dutifulness (“always reply promptly to all emails”). Mindfulness practices can focus on the
importance of nonjudgmental participation in relationships while letting go of unhelpful
rumination about what should have happened or how the other person should have behaved.
RO DBT conceptualizes compulsive desires for structure and control as inner experiences with
predictable action tendencies (action tendencies or urges that are transitory in nature). Clients can
be taught how to mindfully urge-surf compulsive desires to control, fix, or correct without
getting caught up in the thoughts associated with the urge or mindlessly giving in to the action
tendencies associated with it (for example, ruminating about a solution or rushing to fix an
apparent problem). With repeated practice, the client is able to learn that the urge, like a wave,
crests and then passes (Marlatt & Gordon, 1985). See the skills training manual, chapter 5, lesson
12, for an urge-surfing mindfulness script.
Therapists should avoid the trap of trying to change perfectionism. RO DBT encourages OC
clients to practice embracing fallibility rather than always trying to improve themselves.
Treatment of maladaptive perfectionism must start, therefore, with loving one’s shortcomings.
One RO DBT therapist, when asked by an OC client to target perfectionism, replied in a
playfully irreverent way: “I’m sorry. I can’t ethically treat your perfectionism. If I do so, I buy
into your belief that you are never good enough. That is, if I try to help you get rid of your
perfectionism, I am essentially agreeing with you that you are flawed, and I think that would be
morally wrong. There is an alternative way out of this, though, assuming you might be
interested. The path is a difficult one. Instead of changing your perfectionistic tendencies, it
requires you to first fully love or appreciate them. Interestingly, once you have genuinely
achieved this, you are by definition, in that moment, no longer a perfectionist, because you have
stopped trying to improve yourself.”
Since OC clients are risk-averse, they tend to be wary, cautious, and less trusting when
entering into new relationships, thereby making the establishment of a therapeutic alliance more
difficult (see chapter 5). Fortunately, the problems associated with establishing a strong
therapeutic alliance with OC clients are the same as or similar to those experienced by the client
with others in the real world. For example, OC clients consider abandonment the solution to
interpersonal conflict. However, conflict is inevitable in all intimate relationships. Clients should
be encouraged to view individual therapy as the ideal (and safe) place to practice conflict-
resolution skills instead of walking away, and it can be explained (using playful irreverence) that
because part of good therapy will be to provide corrective feedback (invalidating maladaptive
behavior), there should be plenty of opportunities for practice. This is why alliance ruptures are
prioritized over other behavioral targets in RO DBT for OC (second only to life-threatening
behaviors) and not considered problems per se but opportunities for skills practice. Details for
managing alliance ruptures and repairs are provided in chapter 8.
Reinforce Disagreement
For many OC clients, aloofness manifests as overly agreeable behavior that may on the
surface appear intimacy-enhancing. For example, a client may dutifully comply with homework
assignments (spending hours on detailed completion of diary cards, for instance) and may never
or only rarely disagree overtly with the therapist, and yet inwardly the client may not understand
the importance of completing a diary card, despite its having been explained, or may believe
diary cards are a waste of time or irrelevant to her problems. Despite this, she may never reveal
these concerns, while inwardly remaining disillusioned about therapy or angry at the therapist.
Consequently, therapists should consider expressions of compliance, agreement, or commitment
(particularly in the early stages of treatment) as information that may or may not reflect a client’s
true inner experience. Instead, therapists should encourage disclosures of dissension, discomfort,
ambivalence, or disagreement by redefining them as representing therapeutic progress, not
problems, and as essential steps for enhancing intimacy.
Thus, if a client discloses to the therapist that he doesn’t agree with something that the
therapist just said, the therapist should take the following three steps:
Thank the client for being honest about his feelings, and point out that doing so goes
opposite to the natural OC tendency to mask inner feelings
Seriously consider the feedback as possibly accurate, and practice self-enquiry (that
is, look for ways in which the therapist may have contributed to the issue) without
automatically assuming that the criticism reflects the client’s pathology
Work with the client on deciding what to do about the feedback (for example,
continue to observe the issue, make a change in how things are done, or stay the
same), and use this as an opportunity to teach principles associated with Flexible
Mind (see the skills training manual, chapter 5)
For some OC clients, an aloof and distant interpersonal style has been intermittently reinforced
because it functions to help them avoid painful interpersonal feedback. Appearing cold or
unapproachable can create an impression that interpersonal feedback does not matter or is
unimportant. Over time, others may stop providing feedback. Radical openness means giving up
being right, without losing your point of view. This requires a willingness to be flexible and
fallible. Therapists should encourage OC clients to use Flexible Mind ADOPTS skills as a means
for encouraging interpersonal feedback from others (see the skills training manual, chapter 5,
lesson 22).
A major skill deficit for many OC clients is that of being able to communicate understanding
and acceptance—that is, validation—of another person’s feelings, thoughts, desires, actions, and
experience. Validation enhances intimate relationships because it communicates to others that
their responses are acceptable and valued, and that they themselves matter. Individual therapists
should explicitly teach validation skills to OC clients and look for opportunities for in-session
rehearsal (see the skills training manual, chapter 5, lesson 19).
Therapists should teach opposite-action skills for envy and bitterness during individual
therapy, despite the fact that these skills will also be covered in training classes. Opposite action
for envy requires acting opposite to two differing urges—the urge to hide and the urge to attack
—whereas opposite action to bitterness involves helping others and allowing others to help,
reflecting on commonalities among people, and practicing gratitude.
Kindness is a core way of behaving in RO DBT. It encourages others to join with us rather
than go against us or move away from us. Kindness means practicing genuine humility by
acknowledging our place in the world and appreciating how all things are connected. Kindness
means giving another person the benefit of the doubt until we have more information, and even
then practicing a willingness to be wrong. Crucially, it does not mean just being “nice” to others.
In fact, sometimes the kindest thing a person might do for another is to say no or be tough.
Therapists should model kindness with their clients and encourage homework practices that will
help strengthen kindness (see the skills training manual, chapter 5, lesson 17).
It should be explained to clients that the goal of LKM practices, when used to help treat envy
and bitterness, is different from how LKM is normally practiced in RO DBT. The primary aim of
LKM is activation of the PNS-VVC-mediated social safety system. When LKM is used to help
clients with high envy or bitterness, the primary goal shifts from activating social safety to
enhancing compassion and connection with community. When used in this manner, LKM
practices can be extended to having clients direct affection, warmth, and goodwill not only
toward people they already care for and neutral others but also toward people they are struggling
with (feeling envy toward, for example), toward themselves, and toward the world. Short four-
minute LKM practices have been shown to bring significant increases in positivity and feelings
of social connectedness toward strangers as compared to a closely matched control (Hutcherson,
Seppala, & Gross, 2008). Therapists can use the LKM script provided in the skills training
manual (chapter 5, lesson 4) as a basis of practices for targeting envy and bitterness, ideally
audiorecording the practice during individual therapy (the audiorecording can be given to the
client to use at home). Finally, therapists are reminded that LKM practices for envy and
bitterness are optional and used only on an as-needed basis, whereas LKM practices aimed at
activating the PNS-VVC-mediated social safety system are required (that is, part of the standard
RO DBT protocol).
Most OC clients find it difficult to forgive themselves and other people for transgressions,
mistakes, or past harms. What is important to realize is that we all struggle with forgiveness, no
matter who we are. Forgiveness is a process, and it involves a decision to let go of pain, a
commitment to change our habitual ways of responding, and a willingness to practice skills
shown to help us be more compassionate and forgiving. It is not a promise that if we forgive, the
pain will go away. Forgiveness training is one of the most powerful clinical tools in RO DBT. It
provides an essential means of rejoining the tribe and regaining compassion for oneself and
others. Although forgiveness training is formally taught in skills training classes (see the skills
training manual, chapter 5, lesson 29), individual therapists should also teach forgiveness
principles as part of individual therapy (normally after the fourteenth session). Therapists should
remind clients that forgiveness is not approval or denial of the past but instead means taking care
of ourselves. Forgiveness is a choice; it requires an ongoing commitment to let go of past hurts in
order to grow and be mentally healthy. Finally, forgiveness is liberating because it means letting
go of past grievances, grudges, or desires for revenge in order to care for ourselves and live
according to our values; yet, as a process, it takes time and requires ongoing practice.
Be more playful, spontaneous, and less obsessive about being productive (lesson 5)
Be assertive with an open mind (lesson 18)
Reveal vulnerability to others (lesson 21)
Deal with conflict openly rather than abandoning relationships (lesson 21)
Repair a damaged relationship (lesson 21)
Apologize after a transgression (lesson 21)
Be open to critical feedback (lesson 22)
Let go of envy and bitterness (lesson 28)
Forgive themselves and others (lesson 29)
Here are some examples of individualized homework tasks that I have found useful when
working with someone who may be more overly disagreeable:
Complete a task without looking back over the details or double-checking your work.
Practice being lazy, or decrease excessive work behaviors; for example, leave work at
the same time as others, take a nap on Saturday afternoon, or read an entertaining
magazine or book that is not designed to improve who you are or make you a
better person.
Practice playing and developing hobbies or leisure activities that are not designed to
improve you.
Spend only a set amount of time to complete a task, and if you’re unable to complete
the task during this time period, practice accepting that the task can always be
completed later; allow yourself to go back to work on the task only the following
day.
Develop a sense of pride in being capable of letting go of rigid desires to work and in
not always having to be right.
Practice the art of resting; for example, take a twenty-minute power nap every day.
Practice being loose and relaxed, and find ways to be less serious; reward yourself for
letting go of rigid desires to always fix or solve problems.
Practice making minor mistakes and watching the outcome, and notice that a mistake
does not always mean that something bad will happen; at times, new learning or
unexpected and beneficial outcomes can emerge from apparent mistakes.
Practice interacting with individuals who are different, less serious, or less work-
focused; for example, go to a fair where hippies hang out.
Let go of hoarding behavior; for example, throw a newspaper away daily.
Reinforce yourself for a job well done rather than automatically moving on to the
next task; for example, after cleaning the garage, take time out to read a fun novel
or sunbathe for an hour.
When in situations that are uncertain or ambiguous, practice revealing your
uncertainty rather than always pretending to be in control.
Practice letting go of urges to tell another person what to do or how to manage a
problem.
Practice confiding in others.
Increase prosocial behaviors; for example, engage in three practices of chitchat per
week, say thank you to praise, and practice apologizing after making a mistake.
Decrease avoidance of situations where positive emotion could occur; for example,
buy a puppy.
Decrease expectations that all grievances should be repaired or wrongs righted; for
example, notice times when you are not able to fix or repair a situation, despite
your best intentions.
Genuinely play without pretending (see the skills training manual, chapter 5, lesson
5)
Reveal critical or judgmental thoughts or emotions (lessons 19 and 21)
Be open to critical feedback without falling apart (lesson 22)
Let go of needless social comparisons (lesson 28)
Forgive themselves or others (lesson 29)
Individualized homework tasks that I have found useful when working with someone who
may be overly agreeable include those that follow:
At least once a day, practice talking without rehearsing beforehand what you are
going to say.
Three times per week, practice revealing to others your honest opinion about
something, and let go of sugarcoating your opinion or trying to make it sound
cooperative.
Practice being bold and confrontational; during individual therapy, say aloud to your
therapist three judgmental thoughts you have about others, and block your
attempts to minimize any judgments or shame you may have about being or
feeling judgmental (in other words, don’t judge your judging).
Twice per day, practice being more self-interested and doing things that might only
benefit yourself rather than other people; for example, watch the television
program you like, turn off your telephone for the evening, go to the restaurant you
desire in order to eat the food you want, or make sure your boss is aware of a
recent accomplishment.
Practice appreciating and valuing your desire to behave in a socially acceptable
manner (societies need individuals to behave cooperatively in order to survive); at
the same time, practice the art of noncooperation, saying no, and standing up for
yourself rather than automatically agreeing or complying with others in order to
avoid conflict (for instance, three times per week, practice disagreeing without
apologizing).
Practice listening to another person with full attention rather than rehearsing what
you will say next, and trust that you will know what to say when the time comes.
Develop your rebel spirit; practice revealing dissent when you experience it,
communicate your concerns directly, and then be open to feedback.
Block harsh gossip about others, and use opposite-action skills for envy.
Practice revealing distress or negative emotions when you experience them, and let
go of pretending to be happy or caring when you are not.
Practice trusting what others say and giving them the benefit of the doubt; practice
trusting rather than distrusting, and allow yourself the luxury of distrust only after
three or more interactions have provided evidence that distrust is warranted.
Practice directly expressing justified anger, annoyance, or frustration in a manner that
communicates a willingness to understand the other person’s perspective.
Let go of distrustful thoughts and of the assumption that others are out to get you.
Remind yourself that others don’t always see the world the way you do or cope in the
same manner when it comes to how they express themselves (many people freely
express emotions or inner experience without giving it much thought; for example,
an undercontrolled individual is less likely to inhibit emotional expression).
Why Dialectics?
Dialectical strategies in RO DBT share roots with the existential and dialectical philosophies
found not only in Gestalt therapy (Perls, 1969) but also and most prominently in the dialectical
principles guiding interventions in standard DBT (Linehan, 1993a). Dialectical thinking involves
three developmental stages: a thesis (for example, “inhibition is useful”) that gives rise to a
reaction, its antithesis (“disinhibition is useful”), which in turn contradicts and seems to negate
the thesis, whereas the tension between these two opposite perspectives is resolved by way of a
synthesis of the two opposite perspectives, which ideally results in higher-order functioning, not
simply in a compromise (a synthesis between the polarized statements concerning the value of
inhibition versus disinhibition might involve a willingness to flexibly relinquish self-control
when the situation calls for it).
Hegelian dialectics includes five key concepts or assumptions:
In RO DBT, the therapist uses dialectical principles to encourage cognitively rigid OC clients
to think with more complexity as well as with more flexibility.
An example of dialectical thinking can be seen in the RO mindfulness skill of self-enquiry. As
described in detail in chapter 7, self-enquiry requires a willingness to question one’s beliefs,
perceptions, action urges, and behaviors without falling apart or simply giving in. The dialectical
tension involves balancing trusting versus distrusting oneself. Essentially, the question is To
what extent can I trust my personal perceptions at any given moment to accurately reflect
reality? Perhaps never, at least in absolute terms. The synthesis in RO DBT involves being able
to listen openly to criticism or feedback, without immediate denial (or agreement), and a
willingness to experience new things with an open heart, without losing track of one’s values.
Dialectical thinking is also highly useful in loosening OC clients’ tendencies toward inflexible
rule-governed behavior, rigid Fixed Mind beliefs, and high moral certitude (“There is only one
right way to do or think about something”), which can interfere with the ability to flexibly adapt
to change and the ability to form close social bonds. For example, many OC clients consider
“dependence” a dirty word (as reported by one OC client, “Dependence makes you weak and
vulnerable to abuse”). Yet, regardless of our personal preferences, all humans are dependent on
something or someone, at least some of the time; for example, we depend on our grocer to
provide us with fresh milk, on our friends to tell us the truth, on our rock-climbing instructor to
show us how to tie a knot properly, and on our parents’ affection as infants. Moreover, our
dependence on others does not negate the value of independent living, as in standing up against
moral wrongs, striving to go where no one else has gone, saving for retirement to avoid
burdening others, or voicing an unpopular opinion. Thus dialectical thinking is an important
therapeutic tool in RO DBT. It allows a therapist to genuinely validate a client’s perspective
(“Being independent keeps you from being hurt”) while maintaining its opposite (“Being
dependent is essential for survival”), thereby creating the possibility for the emergence of a new
way of thinking and behaving (a new synthesis). Finally, dialectical thinking also informs
therapists’ behavior during interactions with their clients.
In my work with OC clients, I have found that two dialectical polarities are most likely to
arise:
Figure 10.1.
Dialectical Thinking in RO DBT
The next two sections of the chapter describe how these two polarities are used in RO DBT to
enhance treatment.
Nonmoving Centeredness vs. Acquiescent Letting Go
The phrase nonmoving centeredness versus acquiescent letting go refers to the therapist’s
dialectical dilemma of knowing when to hold on to (rather than let go of) a case formulation, a
theoretical insight, or a personal conviction when working with an OC client, in order to model
core RO principles, maintain client engagement, repair an alliance rupture, or spur new growth.
It is informed by an overarching RO DBT principle positing that therapists and clients alike
bring perceptual and regulatory biases into the treatment environment, and that these biases
influence both the therapeutic relationship and treatment outcomes. Therefore, being able to
recognize and know when to let go of a bias represents an essential dialectical dilemma for the
therapist in terms of the following therapeutic tasks:
Maximizing the likelihood of forming a strong therapeutic alliance (RO DBT posits
that a strong working alliance with an OC client is unlikely until multiple alliance
ruptures have been successfully repaired over multiple sessions)
Effectively modeling radical openness for the OC client
Providing alternatives for the client’s habitual ways of behaving and thinking
No small tasks, these! However, mindful awareness of the dilemma does not necessarily lead
to synthesis, nor will it necessarily mitigate the emotional distress that can accompany the
therapist’s attempts to grapple with it (that is, both letting go of firmly held convictions and
standing up for one’s convictions can be painful therapeutic choices). Plus, to make matters more
complicated, therapists need to be biased, at least to some extent; that is, the role of a health care
provider necessitates professional opinions about a client’s presenting problems and about the
best course of treatment (such opinions are also known as a case conceptualization). Indeed, case
conceptualization has been described as “the heart of evidence-based practice” (Bieling &
Kuyken, 2003, p. 53). Therapists are usually trained to see their case conceptualizations as
reliable and generally accurate descriptions of clients’ behavior, despite research showing that
therapists often formulate widely divergent case conceptualizations for the same client (Kuyken,
Fothergill, Musa, & Chadwick, 2005). Yet, despite these difficulties, RO DBT posits that there is
a way forward. It involves the therapist’s creation of a temporary state of self-doubt whenever
feedback from the environment or the client suggests that the case conceptualization may be in
error.
Healthy self-doubt is a core construct in RO DBT (see chapter 7). It provides therapists with a
coherent means of relinquishing control without abdicating their professional responsibilities,
and without having to abandon earlier perspectives. To cite one example of the advantages of
acquiescent letting go, a therapist in one of our research trials reported to his consultation team
that he was struggling with knowing how to resolve a potential alliance rupture with his OC
client. The client had been repeatedly dismissing any suggestion by the therapist that she was a
decent human being or had prosocial intentions by saying, “You just don’t know me. I am an evil
person. I have a lot of resistance to joining the human race. I’m essentially not a very nice
person, and my past, although I have shared little of it with you, is my proof.” The therapist had
attempted to point out factors that discounted or disproved the client’s conviction, and yet each
attempt appeared only to increase the client’s insistence that she was inherently evil. Moreover,
the therapist reported feeling increasing angst, since in his worldview it was impossible for
humans to be inherently evil. The team encouraged the therapist to practice self-enquiry (that is,
to create a state of temporary self-doubt), which eventually led the therapist to the discovery that
it had been arrogant of him to assume that no one in the world could ever be inherently evil, an
insight that enabled him to be radically open to his client’s perspective, despite the pain it
generated. In the next session, the therapist revealed his insight to the client—that he had been
behaving arrogantly in prior sessions by assuming his worldview regarding evil to be the only
correct one. His personal work on himself and his willingness to out himself immediately
changed the dynamics of the therapeutic relationship and, to the surprise of the therapist, resulted
several sessions later in the client independently revealing, “I’ve been thinking lately that maybe
I’m not so evil after all.” This clinical example demonstrates the therapeutic value of being able
to radically give in, or let go of strongly held convictions, no matter how logical or viscerally
right they may seem. The creation of a state of temporary self-doubt (via self-enquiry) does not
mean approval, nor does it require a therapist to permanently let go of prior convictions; instead,
it recognizes the therapeutic utility of closed-mindedness as one possible outcome (that is,
nonmoving centeredness).
Consequently, nonmoving centeredness is the dialectical twin of acquiescent letting go. It
refers to the importance of an RO DBT therapist holding on to a personal conviction or belief
about a client, despite strong opposition from the client or the environment. The rationale for this
stance may be best represented by the RO principle of kindness first and foremost, whereby, as
discussed in previous chapters, kindness may sometimes mean telling someone a hard truth (in a
way that acknowledges one’s own fallibility) for the sake of helping her achieve a valued goal.
Thus RO DBT therapists recognize that they may need to disagree with their OC clients to
facilitate growth, albeit the vast majority of RO DBT confrontations involve asking (not telling)
clients about their apparent problems, combined with offering nonverbal, nondominant social
signals (a slight bowing of the head and a shoulder shrug along with openhanded gestures, warm
smiles, eyebrow wags, and direct eye contact to communicate equity and openness to critical
feedback). Nondominance signals are especially important when one person is in a power-up
position yet desires a close relationship (as in the therapist-client relationship). This dialectical
dilemma also allows for the possibility of less open-minded signaling (or urgency) and the use of
dominant assertions of confidence in order to block imminent life-threatening behavior.
Do I ever secretly enjoy niggling others? Have I ever been secretly proud that
I can appear nonjudgmental when in fact I am highly judgmental? Do I ever
purposefully use a niggle to control or dominate others, block unwanted
feedback, or achieve a goal?
Am I secretly proud of my ability to niggle someone? What might this say
about how I see the world and other people?
Would I encourage a young child to niggle others when things don’t go her
way or she dislikes someone? If not, then what might this tell me about my
values?
Do I enjoy being niggled? If not, then what might this tell me about my own
niggling behavior?
How would I feel if I were to suddenly discover that others actually knew my
true intentions or secret thoughts when I niggle them? What might my
response to this question tell me about my core values, or about how I truly
feel about the way I behave toward others? What is it that I might need to
learn?
Compassionate gravity represents the dialectical opposite of the stance of playful irreverence.
Rather than aiming to tease and challenge, it seeks to understand and signal sobriety (that is, it
signals that the therapist is taking the client’s concerns or reported experience seriously). It also
functions as a way of taking the heat off a client, whereas playful irreverence puts the heat on
(see also “Heat-On Strategies” and “Heat-Off Strategies,” chapter 6). A stance of compassionate
gravity is designed to slow the pace of the interaction and communicate social safety to the
client. Here are the most common nonverbal behaviors that accompany a stance of
compassionate gravity:
The therapeutic use of these nonverbal signals mimics how we speak to those we love in our
most intimate moments. They function as powerful social safety signals and reinforce client
engagement without ever having to say a word. Here are some additional nonverbal signals that
commonly accompany a stance of compassionate gravity:
A stance of compassionate gravity also signals openness and humility. For example, a
therapist who is able to admit that he is fallible, or that his personal worldview may have
interfered with his understanding of the client’s perspective, is practicing compassionate gravity.
Indeed, compassionate gravity is invariably an essential part of a successful alliance rupture
repair, or it can help balance a playfully irreverent comment in order to ensure that a therapeutic
tease is not taken the wrong way. The overall aim is to communicate a genuine desire to know
the client, from the client’s perspective.
Both compassionate gravity and playful irreverence are powerful social safety signals; a good
tease can make a person feel at home as much as a compassionate comment. Nevertheless, of the
two dialectical poles, compassionate gravity is the easier one for most therapists to operate from,
and it is often their default set point when in doubt (that is, most therapists, when in doubt about
what to do, seek to validate, soothe, or empathize), whereas playful irreverence can make
therapists feel that they are doing something wrong. Often this feeling of wrongdoing is a
function of therapists’ prior clinical training, or of common beliefs—myths, in my opinion—
about how therapists should behave (“always assume the client is right” or “always be
compassionate”). RO DBT obviously has similar values; otherwise, why would I use the word
“compassionate” in the first place? The difference is that, broadly speaking, RO DBT prioritizes
kindness over compassion when it comes to helping emotionally ostracized OC clients learn how
to rejoin the tribe (refer to table 9.1).
What’s important for therapists to remember, regardless of their personal experience or past
history of teasing or being teased, is that the research shows that teasing is how friends, family,
and tribes give each other feedback all the time, and it doesn’t lead to major meltdowns or
personal crises. Playful teasing between people is a statement of intimacy and trust, not of
nefarious intent or malicious deception (that is, playful teasing is not niggling). It occurs only
among friends and always ends with a nondominant or friendly signal, such as a smile, a head
bow, or an appeasement gesture. Such signals of nondominance and friendliness are universally
displayed across cultures, from the taunting laughter that ends with food giving of the forest
Pygmies of the Congo (Turnbull, 1962) to the playful trickery and celebratory smirk of the
Yanomamö tribe in South America (Chagnon, 1974) to the feigned aggressive giggle followed
by gaze aversion and a smile common among the Japanese to the flat-faced barb that ends with a
smile and an affirmative head nod seen in the British culture (see also Mizushima & Stapleton,
2006; Keltner, Capps, Kring, Young, & Heerey, 2001). That said, within a single culture there is
a wide range of individual differences regarding the types of teasing that are deemed acceptable
(such as a satirical comment or a cold bucket of water poured over someone else’s head), the
types of occasions deemed suitable for teasing (at funerals, some families celebrate the life of the
deceased by teasing and joking, whereas other families would see this kind of behavior as
disrespectful or uncouth), and who is allowed to be teased by whom (in some families or
cultures, for instance, a child teasing an adult is considered inappropriate). Teasing is also
moderated by individual differences in biotemperament, social status, and personality or coping
style.
Therapists are not immune to any of these influences. Plus, how therapists have been trained,
and the beliefs they hold about what is appropriate or inappropriate professional behavior (based
on prior professional training), can also influence the ease with which they feel comfortable
being playfully irreverent with their clients. Thus, when first learning RO DBT, therapists may
find therapeutic teasing and playful irreverence anxiety-producing or uncomfortable. However,
most often, upon reflection (self-enquiry), their discomfort with teasing is discovered to reflect
personal preferences, personal beliefs, and past training, not the notion that teasing is terrible or
damaging in itself; otherwise, why would friends affectionately tease each other and still remain
friends, why would teasing occur across all cultures and in similar ways, why would so many
people genuinely find kindhearted teasing amusing or fun, and why would teasing be a core part
of flirting?
Nevertheless, most therapists find therapeutic teasing difficult because their OC clients are
expert at subtly punishing any form of feedback, regardless of how it is expressed. For example,
any attempt to tease, joke, or play in session may be met with an immediate flat face. Recall that
the powerful impact that flat facial expressions exert on others is not solely a function of the
absence of expression. Instead, the power of the flat face is derived from the conspicuous
absence or low frequency of expected or customary prosocial signals (smiling, affirmative head
nods) in contexts (such as a therapy session) that call for free expression of emotion. Another
common reaction can be a “don’t hurt me” response, characterized by gaze aversion and postural
shrinkage, which implies that the therapist’s playful irreverence is hurting the client and should
stop immediately. The problem is that if the therapist immediately stops the playful irreverence,
the therapist reinforces the very behavior for which she is attempting to provide corrective
feedback via use of a therapeutic tease. Indeed, anthropological research examining the use of
teasing within tribes shows that a tease is not removed until the errant member of the tribe admits
to his wrongdoing and signals his willingness to repair the damage he has done (see the story of
Pepei in Turnbull, 1962). Thus tribes are both tough and kind because their survival depends on
every member contributing. Similarly, as tribal ambassadors, RO DBT therapists are willing to
personally suffer the pain of seeing a fellow tribal member (the client) struggle, in order to
facilitate growth, without removing the cue or opportunity for learning at the first sign of
discomfort on the client’s part. That said, as we’ll see later in this chapter, the reason for the
dialectic is that both polarities matter.
Essentially, not only do OC clients take themselves very seriously, they also subtly reinforce
everyone around them to behave seriously as well. Most often these sentiments are conditioned
to appear whenever anyone (including a therapist) dares to behave in a manner that the OC
individual disapproves of, dislikes, finds challenging, or considers inappropriate, and the
punishment is usually delivered indirectly or nonverbally (for example, a flat face, a slight scowl,
an unexpected awkward silence, averting or rolling of the eyes, or a sudden bowing of the head).
This is not meant to imply that OC clients necessarily engage in this type of behavior with
conscious intent; on the contrary, they suffer greatly and are unsure of how to change (which is
why they are seeking treatment). Yet, like most of us, OC clients know more about themselves
than they might care to admit, and genuine change is painful.
Thus, rather than immediately removing the therapeutic tease and behaving seriously, the
kindest act for therapists working with OC clients is, in my opinion, to allow themselves and
their clients the gift of friendship. That is, therapists should drop their guard in the same manner
they do when among their friends. Translated into the context of therapy, this means dropping
their professional role (at least to some extent) in the interest of helping their emotionally lonely
and socially isolated OC clients learn what it viscerally feels like to have a good friend, to
playfully engage in dialogue, to experience the self-confidence of belonging to the in-group, and
to have the sense of security that emerges from belonging to a tribe.
The kindest act for therapists working with OC clients is to allow themselves and their clients
the gift of friendship.
Before we move on, let’s return to my earlier comment, where I suggested that therapists need
not be concerned that their attempts to tease, joke, or be playfully irreverent with their clients
might be taken the wrong way (see my earlier “fuhgeddaboudit” tease). The question I left us to
ponder is “Why do you think I just said that?” Essentially, was my joke more than a joke? The
short answer is yes, it was. My teasing was purposeful and meant to facilitate learning. It was
intended to model a therapeutic tease and simultaneously highlight how a playful, irreverent
stance can function to capture attention by not always revealing everything all at once.
Hopefully, it functioned as intended (and, assuming you have not yet drifted off to sleep, thanks
for waiting). Next I describe some of the more practical features associated with this dialectic.
How Does the Therapist Know When to Be Playfully Irreverent and When to Exhibit
Compassionate Gravity?
Here is the quick answer: the more a client’s social signaling appears to represent hidden
intentions or disguised demands, the more playfully irreverent (or teasing) the therapist, whereas
the more genuinely engaged, candid, and open a client is, the more compassionate gravity the
therapist is likely to exhibit. The reason therapists need to be adept at knowing when to move
from playful irreverence to compassionate gravity, and vice versa, is twofold. First, this type of
back-and forth interchange (from play to seriousness, then back to play again) reflects the type of
ebb and flow that characterizes normal, healthy social discourse, thereby allowing an OC client
an important avenue for practicing skills. Second, it helps prevent unnecessary therapeutic
alliance ruptures. Recall that, although RO DBT values alliance ruptures as opportunities for
growth, they are not purposefully created, since that would be phony. Conflict is inevitable in all
close relationships; as such, therapists should not try to make ruptures happen; instead, they
should just be themselves, and voilà—ruptures suddenly appear, like magic! Plus, especially
during the earlier phases of treatment, OC clients are less likely to reveal negative reactions.
Most maladaptive social signals are indirectly expressed and implied; they are disguised
demands that function to block unwanted feedback or secretly influence the behavior of others,
and the person making the demand never has to admit it (see “Indirect Social Signals and
Disguised Demands,” later in this chapter). Therefore, being able to move from playful
irreverence to compassionate gravity (for example, from teasing to validating) is a very useful
skill to possess, both in real life and in work with OC clients.
However, unlike in real life, therapists have a job to do, one that requires not only that they
understand their clients as best they can but also that they be willing to provide their clients with
corrective feedback (that is, point out painful truths that may be preventing clients from
achieving their valued goals). Thus the utility of a therapeutic tease is that it provides corrective
feedback (for example, by expressing incredulity and amused bewilderment when a client uses
speech to tell you that he is unable to speak, or reports a complete lack of animosity toward a
coworker he admits having lied about in order to get her fired). An example of this is the “Oh
really…?” response, a classic RO DBT therapeutic tease. This is a form of social teasing or
questioning that most people automatically use whenever a friend suddenly reports engaging in a
behavior or a way of thinking that is opposite to or different from what the friend has previously
reported, but without acknowledging the sudden change (for example, a friend who has always
reported feeling criticized by his parents suddenly describes them as warm and caring). The “Oh
really…?” response is designed to highlight social signaling discrepancies. It is most effective
when accompanied by a signal implying disbelief (an expression of astonishment or surprise, or
a lip curl combined with a tilt of the head), which is followed almost immediately by a signal of
nondominance (a slight shoulder shrug and a warm closed-mouth smile). It implies friendly
disbelief and allows an opportunity for the client to better explain his sudden change in position,
without the therapist being overly officious, serious, or presumptuous. The therapist can use the
client’s response to “Oh really…?” to explore the discrepancy further:
Therapist: Just last week you were telling me that you hated your parents and blamed them for
everything. Now, this week, you are telling me that you have never blamed them. Isn’t
that amazing? What do you think this might tell us, and how did you ever get to this
place? (Offers eyebrow wag and warm closed-mouth smile.)
As another example of RO DBT playful irreverence, a therapist may respond to a client’s
report of feeling anxious (for example, about attending skills training class) or finding it hard to
change her habits by saying, with a calm smile, “Isn’t that wonderful.” It is irreverent because
the therapist’s statement is unlikely to be what the client expected, and it is playful because the
smile and the warmth in the therapist’s tone of voice signal friendliness while simultaneously
smuggling core RO DBT principles, without making a big deal of it (for example, one can follow
through with prior commitments and feel anxious at the same time, and finding new lifestyle
changes difficult should be celebrated as evidence of new growth and commitment).
Thus playful irreverence is challenging and confrontational, both verbally (via an unexpected
question or comment that highlights a discrepancy in a client’s behavior) and nonverbally (via an
expression of surprise, a questioning tone of voice, or a curled lip), and it is followed almost
immediately (in milliseconds) by nondominant body postures and friendly facial expressions (a
warm closed-mouth smile and a slight shoulder shrug), which universally signal to the client that
the therapist actually likes him and considers him part of the tribe. Playful irreverence can also
be used as a minor aversive contingency that functions to punish (reduce) passive and indirect
social signaling by an OC client (through the therapist’s behaving as if the indirect or disguised
demand has not been seen) until the client more directly reveals what her intentions or wishes
are. For example, rather than automatically soothing or validating an OC client who turns away,
frowns, or bows her head whenever she is asked something she would prefer not to hear, playful
irreverence continues the conversation as if all is well. This forces the OC client to escalate the
expression of the passive social signal, thereby making the maladaptive behavior more obvious
and treatment targeting easier (extreme pouting is harder to deny); or, ideally, the client decides
to explicitly communicate (via words) what she dislikes or is unhappy about (representing
therapeutic progress and also perhaps an opportunity for an alliance rupture repair).
To summarize, the rule of thumb [(I know—we aren’t supposed to be rule-governed in RO
DBT, so for my sake just keep this to yourself ) Editor’s note: I’m listening] to guide the use of
compassionate gravity versus playful irreverence in session is essentially this: the more
maladaptive the OC client’s social signaling becomes, the more playfully irreverent the therapist
becomes, and the more engaged an OC client is in session, the more compassionate and
reciprocal the therapist is likely to be (the therapist doesn’t need to provide corrective feedback,
because the client is working hard on his own). From a behavioral perspective, playful
irreverence functions in the following ways:
No matter how competent therapists may be in establishing connections with their clients or
providing helpful corrective feedback, they should always expect therapeutic teases to fail.
(Okay—not always.) Sometimes therapeutic teases fall flat because they are expressed too
weakly, whereas other times they fall flat because they are expressed too strongly. Regardless of
what happened, or why, whenever you sense that your tease was somehow not received as
intended, or that it created more confusion, simply drop the tease—that is, let go of playful
irreverence, and move toward a stance of compassionate gravity that encourages the client to join
you in self-discovery.
Take the heat off the client (for example, by briefly disengaging eye contact for one
or two seconds) and nonverbally signal compassionate gravity (for example, by
leaning back while offering a closed-mouth smile and therapeutic sigh; see “Heat-
On Strategies” and “Heat-Off Strategies,” chapter 6).
Encourage the client to explore for herself the rationale behind the therapeutic tease
by asking, “Why do you think I just said that?” while using nondominance (for
example, slight bowing of the head, a slight shoulder shrug, and openhanded
gestures) and cooperative-friendly signals (such as a warm smile, eyebrow wags,
eye contact, slowed pace of speech, and a soft tone of voice) in order to encourage
candid disclosure (see “Signaling Openness and an Easy Manner,” chapter 6).
If the client continues to signal nonengagement, use the alliance rupture repair
protocol (see “Repairing Alliance Ruptures,” chapter 4).
STEP 1
Step 1 of the protocol moves toward compassionate gravity by taking the heat off the client,
without making a big deal of it. What is important to remember is that heat-off signals work as
intended because you are not doing them all the time. Thus, despite the constant reminders
throughout this book to adopt an easy manner when working with OC clients, this does not mean
that you should always look chilled out, always lean back in your chair, always smile, always
have your eyebrows raised, and so forth. That would be pretending, and both your body-brain
and the client would know it, even though nobody would talk about it. (You wouldn’t, because
you would think this was what you were supposed to be doing, and your client wouldn’t, either,
because he would assume that you knew what you were doing. Isn’t life fun?) Behaving with an
easy manner is also context-dependent. Smiling, teasing, and lightheartedness are not always
appropriate, and many situations in life call for solemnity and expressions of concern. If you
constantly appear chilled out, you will not only seem a little strange (phony), you will also lose
important opportunities for connecting with your client. Moreover, you will no longer be able to
take advantage of a core RO strategy: leaning back in your chair works to signal social safety
only if you were leaning forward in the first instance; briefly removing eye contact works to take
the heat off only if you’ve had eye contact beforehand.
In addition, don’t forget to move—avoid sitting in the same position for too long, whether
leaning back or sitting forward. In real life, we shift our position, scratch, adjust our posture,
wiggle our fingers, tap our feet, wave our arms, and change our expressions, depending on
what’s happening in the moment (and those who sit in a frozen position or rarely adjust their
posture are read by others as a bit strange or odd, unless everyone is meditating in a Zen
monastery). So sit forward, sit back, gesture expansively when making a point, smile, frown,
look concerned, take a sip of water—it’s what real people do in real-life interactions, and I am
aware of imagining it is exactly what you do when you are among friends. Sitting still is what
therapists do (we are often trained to sit still so as not to influence the client or appear
professional), and who wants to act like a therapist?58 Sitting still is similar to the feeling we get
when we are asked to smile for the camera but the picture is delayed by a fumbling
cameraperson; our candid smile of genuine pleasure quickly fades into a frozen, polite smile that
feels increasingly phony the longer we hold it. It sends a message to your brain that danger may
be present, not safety (when a rabbit sees a fox, the first thing it does is freeze all body
movement). Real people in real-life friendly exchanges do not sit still or appear frozen—unless
they are doing some major drugs! Plus, in RO DBT, we don’t think it is possible to convince or
talk our socially ostracized and lonely OC clients into coming back to the tribe; our job as
therapists is to show them how to rejoin the tribe by behaving in the same manner with them as
we would with our friends (the only exception to this is when imminent life-threatening behavior
is present). My main point is this: when your client is engaged, it doesn’t matter how you social
signal. Leaning forward, expressions of concern, eye contact, and serious voice tones don’t
matter, because your client is engaged! Therapeutic social signaling matters primarily when your
client is nonengaged, or when you are directly challenging your client (using the RO strategy of
asking rather than telling). So relax or be tense, frown or smile, but whatever you do, make it
real.
STEP 2
Step 2 of the protocol places the heat back on the client, with a sense of open curiosity. Rather
than immediately soothing, justifying, or apologizing after an apparently unsuccessful tease, ask:
“Why do you think I just said that?” Combine that question with nonverbal signals of
nondominance and friendliness to encourage candid disclosure and reduce the possibility of
inadvertently reinforcing maladaptive indirect OC signaling and disguised demands (see
“‘Pushback’ Responses” and “‘Don’t Hurt Me’ Responses,” later in this chapter). You can
deepen compassionate gravity by explicitly explaining your therapeutic rationale for the tease—
but, ideally, only after the client has attempted to explore the possible reasons on his own.
Interestingly, even though one of the most common answers to this question from OC clients is
“I don’t know,” OC clients often know more than they care to admit. Thus, despite often
claiming ignorance, they often have some idea about what is going on (why you are teasing
them), but they just don’t want you to know that they know (not until they know you better). That
said, often they have no idea of what is happening. What’s important is that the client’s
awareness of what is happening when therapeutic teasing is going wrong doesn’t really matter;
what matters is whether the tease actually functions to help the client move closer to his valued
goals.
STEP 3
Step 3 of the protocol is designed to ensure client engagement and mutual understanding when
prolonged verbal and nonverbal indicators of nonengagement (such as gaze aversion, continued
indirect and vague answers, or lack of reciprocal laughing or smiling) suggest the existence of a
possible alliance rupture. When this occurs, therapists should use the following questions to
encourage candid disclosure and initiate the alliance rupture repair protocol (see chapter 4):
The good news is that no matter how the client responds to these types of questions, you are in
a win-win situation. By asking, not telling, you avoid making assumptions and at the same time
provide an opportunity for the client to practice revealing her inner experience more directly (a
core aim of treatment). Therapists should get in the habit of reinforcing the candid and open self-
disclosures of their OC clients, especially self-disclosures that involve critical feedback, because
this is how they will get to know their clients. I sometimes playfully refer to a client’s candid
self-disclosure (as opposed to masking) as the “gift of truth,” a process of open, honest, direct
communication that is encouraged between therapist and client. Most OC clients like having
their self-disclosures named in this way, since this is linked to valued goals for honesty and
integrity. Plus, the gift of truth can be used as a therapeutic tease (with therapists seeking
permission from their clients to return the favor by providing the gift of truth to their clients as
well as receiving it) and as a metaphor to encourage further candid disclosure from the client as
well as candid feedback from the therapist. Finally, it is important to identify candid self-
disclosure as a sign of therapeutic progress and an essential part of healthy intimate relationships.
OC clients are experts at masking inner feelings. Therefore, don’t automatically assume that
your tease or playful irreverence is not working, or that it’s not being received as intended, just
because you fail to get any feedback, or because the feedback appears negative. For example, the
staring, flat-faced client—the one you are starting to believe may deeply hate you—may actually
be working hard not to smile or crack up and may be inwardly feeling delighted, challenged, and
amazed by your antics, and yet he dares not let you know that you are getting to him, because he
has spent a lifetime convincing himself and others that he is incapable of feeling joy or pleasure
(this is a fairly common response). If he allows himself to laugh or smile, even once, then this
will prove to him that his life has been an entire sham, because happiness and positive social
connections might have been possible. When the dilemma is expressed by a client overtly,
reinforce the self-disclosure (thank him, point out how it makes you feel closer to him, and link it
to his valued goals for closer relationships), and then, rather than trying to solve the dilemma or
make it go away, encourage the client to use his conundrum (“This just proves I’m a failure”) as
the target for his self-enquiry practice of the week. This functions to smuggle two critical RO
principles:
The client, like all of us, is responsible for how he chooses to perceive the world and
himself (at least to a large extent).
Not every problem needs to be fixed immediately.
Plus, what is perhaps most important is that playful irreverence, when balanced by
compassionate gravity, allows a client to experience firsthand what it feels like to be on the
inside of a healthy interpersonal relationship, and it reflects the type of natural give-and-take and
reciprocal sharing that occur among close friends. As such, therapists should not despair when a
therapeutic tease fails to elicit a reciprocal smile or chuckle of engagement; the client may be
much closer to signaling engagement than the therapist knows. In general, since a therapeutic
tease is a form of contingency management, it theoretically should stop only after the client stops
engaging in the maladaptive social signal and engages instead in a more prosocial or socially
competent behavior (which could include an explicit request to stop teasing—a good friend stops
teasing when asked explicitly). It is also important to keep in mind that therapeutic teasing is
intended for maladaptive operant behavior, not respondent behavior (see “Discriminating
Between Operant and Respondent Behaviors,” later in this chapter). And, finally, it is important
for therapists to remember that not every atypical or off-putting social signal is maladaptive or
necessarily operant; a PNS-DVC shutdown response and the “deer in the headlights” response
are two examples of common OC client behaviors that are respondent.
By shunning labels or categories and sidestepping public commitment, OC clients can avoid
taking responsibility for their actions and can blame negative outcomes on others. If it is unclear
what a person believes or feels, then it is very difficult to criticize or hold that person
accountable. There is a wide range of ways in which this stance can be manifested. For example,
one client indicated that, if pressed for an opinion about some problem, he would generally say,
“I’ll need to get back to you on that,” with full knowledge that he would avoid ever doing so, and
with the hope that the problem would go away. Some clients, despite explicitly admitting to
characteristics of overcontrol, resist the “overcontrolled” label because acknowledging it might
mean they would have to do something different. Other clients may resist diagnostic labels in
general (such as “depression” or “personality disorder”), the conventional use of certain terms
(for example, the word “normal” as a label for their behavior), or firm commitments to change
(which they deflect by always saying, “I’ll try”). The indirect nature of these social signals is
what makes them so difficult to challenge, yet if they are not addressed, they function to
maintain OC clients’ sense of isolation by making it difficult for others to know their true beliefs.
The “don’t label me” component of the enigma predicament is one reason why the use of
written handouts in individual therapy is generally not recommended in work with OC clients
(albeit handouts and worksheets are essential for teaching RO skills in skills training classes).
After a well-intentioned therapist’s attempt to speed up treatment targeting by providing a
handout describing the five OC social signaling themes, one OC client asked, “Just what does
this therapy pretend to be doing? I am a unique individual. This therapy doesn’t allow any
variations. It feels like I’m being forced into a pigeonhole.”59 From the client’s point of view, it
was impossible for the complexity of her inner experience to be summarized in one page. The
cool thing is that the client’s observation was correct, but at the same time it is unlikely that any
form of written document, whether one or one thousand pages long, could adequately describe
the complexity of any single human being. Despite this, our human brains are hardwired to
categorize. We are highly adept at noticing and creating patterns (for example, a fluffy cloud
suddenly transforms into a bunny rabbit), and this process is so automatic that most people are
unaware of it when it is happening. Using one- or two-word descriptors to label complex patterns
of behavior, rather than outlining every possible nuance, saves time and engenders mutual
understanding when the descriptors carry shared cultural, tribal, or contextual meanings.
Interestingly, the “don’t label me” component of the enigma predicament can evolve into a
general avoidance of stating opinions, especially in public. As one client reported, “Whenever
people ask me about my opinion, I always say, ‘It depends,’ and then I ask them what they think.
It keeps me from ever having to take a stand and gives me time to figure out what they are up to.
Once I know their perspective, I can take the heat off myself by pointing out a flaw in their
perspective, without ever having to reveal what I actually believe.” These disguised social
signals are subtle enough to give an OC client plausible deniability or allow him to avoid direct
comment from those on the receiving end.
Another manifestation of this stance appeared during the early stages of therapy with one
client whenever his therapist described or reflected back what she had heard him say. The client
would listen, with little expression on his face, and then he would often simply reply, “That’s not
my problem” and sit in silence until prompted. The therapist used the alliance rupture repair
protocol to ascertain that the client’s sudden silences were intended to communicate that her
verbal reflections or descriptions, though broadly accurate, were not precise enough to be fully
sanctioned by him. She then showed him three pebbles in a bowl and asked him how many
objects he saw. The client replied that there were three objects. The therapist nodded and said,
“Yes, but suppose we had a physicist in the room, and he looked at this and said there were three
trillion objects, or electrons, in the bowl.” She offered the client a closed-mouth smile and an
eyebrow wag and then asked, “Which is the correct or more precise answer—three or three
trillion?” The client, smiling sheepishly, replied, “You’re trying to make a point, aren’t you?” He
then reluctantly admitted that, in the conditions described, there would be no correct answer.
This “physicist metaphor,” as it eventually came to be known, remained a playful inside joke and
a reminder for the client to practice letting go of rigid insistence on precision in all
circumstances. Plus, this metaphor became the impetus for major changes in how the client
socially signaled disagreement; that is, he learned to do so more directly, and with humility. The
following transcript provides another example of how the “don’t label me” component can
manifest:
Therapist: So you were feeling pretty upset, and very depressed. Do you think this could have
been a time to try to use skills? (Assesses client’s engagement.)
Client: When you’re that depressed, you can’t think of anything to do.
Therapist: I understand it’s really hard, but my question is, do you think that it might be effective
to try to use some skills? (Holds the cue.)
Client: What would you suggest? (Answers question with a question.)
Therapist: I’m not really sure (Pauses)…but we should definitely sort this out before we end
today. (Directly answers client’s query in an open manner while maintaining the cue
by not immediately providing solutions.) My question was more about your level of
commitment—whether, when you’re depressed, you think it would be worthwhile to
try to use skills. (Uses “ask, don’t tell” strategy; orients client to focus on the
question.)
Client: Not particularly. (Avoids taking a stance, signaling a possible “pushback.”)
Therapist: Let’s suppose you had a good friend who was depressed, just like your situation.
(Hypothesizes that client may be wanting to avoid this discussion, and decides to
modify the approach by using a metaphor about a good friend.) Would you tell her to
try to do something to feel better? Or would you say, “Just be depressed—there is
nothing you can do”?
Client: I haven’t the faintest idea. Listen sympathetically, I suppose. (Remains nebulous.)
Therapist: (Smiles) So you actually do have a skill that you would suggest. (Uses open curiosity,
playful irreverence, and an easy manner to keep client focused on the target of
assessing her commitment to use skills.)
Client: I do? (Implies lack of awareness.)
Therapist: Yeah. You just said it. You said you would listen sympathetically. (Pauses.) So
maybe if you were to use the skill of talking about problems, your depression might
improve. (Refers to client’s comment in a matter-of-fact and easy manner in order
determine client’s level of engagement.)
Client: Talking about problems makes matters much, much worse. (Implies that she is not
engaged in treatment.)
Therapist: So (Pauses slightly)…talking about problems makes someone feel worse? (Assesses
the meaning of client’s previous statement.)
Client: For me, it does. But for others, it seems to make them feel better. At the community
center, people are always talking to me about their problems.
Therapist: Do you like listening to other people?
Client: Not particularly. Eventually I decide that they’re an awful bore. (Pauses.) For instance,
there’s this one person—she loves to complain, she has aches in her hands, aches in
her back. (Avoids stating a firm opinion.)
Therapist: So you find this person annoying.
Client: No, not really. (Maintains ambiguous stance by appearing to reverse her earlier
statement.)
Therapist: Oh, so you actually like talking to her.
Client: No, she is a user of people. She’s like a scrawny little kitten—“poor little me.” (Avoids
joining with therapist by reversing the prior implications.)
Therapist: So you don’t like her. Maybe we should work on skills to get her to stop talking to
you! (Uses playful irreverence; retains focus on assessing client’s engagement.)
Client: No, I’m kind of fond of her. (Pauses.) She’s just a pitiful old thing. (Switches her
apparent perspective again.)
Therapist: Hmmm. I am starting to notice something happening here. Have you noticed it?
(Pauses.) I am starting to become worried that perhaps I am missing something,
because it seems that every time I try to reflect back what I just heard you say, your
reply seems to be the exact opposite of what I said. Can you give me a sense of what
you think might be happening? (Decides that exploration of a potential alliance
rupture should take priority over discussion of any other topics.)
In summary, the problem with the enigma predicament is that it maintains an OC client’s
aloofness and distance by keeping others from truly knowing the client’s inner feelings,
thoughts, doubts, or desires. In order to develop a close relationship with someone, it is
necessary to disclose private thoughts, express vulnerable emotions, and reveal faults; indeed,
genuine friendship and connectedness require vulnerable self-disclosure and being open to
another person’s feedback or differing opinions. Yet, despite this, a therapist is unlikely to
immediately challenge or target an indirect social signal that appears to be linked to the enigma
predicament, especially when first getting to know a client. As described earlier (see “Targeting
In-Session Social Signaling: Basic Principles,” chapter 9), an indirect social signal is targeted in
session only after the maladaptive social signal has been displayed multiple times over multiple
sessions. Rather than prioritizing for treatment the various emotions, moods, belief systems, or
cognitive schemas associated with enigma predicament–linked responses, RO DBT targets how
these internal experiences and beliefs are expressed on the outside, and the extent to which these
social signals impair the client’s social connectedness and interfere with his achievement of his
core valued goals.
Reinforcement
Repetitive behaviors are usually reinforced behaviors. Indeed, any behavior that occurs
repeatedly does so because it functions to produce (at least occasionally) a desirable consequence
(albeit the person may not be consciously aware of this). For example, compulsive fixing is
reinforced when this solution works; shutting down and giving up are reinforced when someone
else assumes responsibility for a problem; pretending not to hear unwanted feedback is
reinforced when others stop giving it; working obsessively may be reinforced by a promotion at
work.
A reinforcer is any consequential event that functions to increase the probability of an
antecedent behavior occurring again in the future. Importantly, not all reinforcers are rewarding
(feel good); some are relieving because they involve the removal of an aversive event (negative
reinforcement). Similarly, not all factors that function to decrease a behavioral response are
aversive; some are frustrating (extinction), and some are penalizing (negative punishment). Plus,
what is reinforcing or punishing for one person may not be for another; for example, one person
may learn to cope with unwanted feedback by pretending not to hear it, and this behavior is
reinforced when others stop providing feedback, whereas for another person the same lack of
feedback might function as an aversive contingency (punisher).
Reinforcement is a consequence that results, on average, in an increase in a behavior in a
particular situation. Positive reinforcement increases the frequency of a behavior by providing a
positive or rewarding consequence:
PUNISHMENT
Punishment is a consequence that results, on average, in a decrease in a behavior in a
particular situation. Positive punishment decreases the frequency of a behavior by providing an
aversive consequence:
Client example: A client uses a hostile or blank stare (“the look”) to purposefully
punish feedback or criticism she does not want to hear.
Therapy example: Since OC clients dislike the limelight, therapists can strategically
use heat-on techniques as an aversive contingency (see “Heat-On Strategies,”
chapter 6). Most often this involves some form of directed attention by the
therapist, whereby the client momentarily feels scrutinized (for example, direct eye
contact, repeating a request, or therapeutic teasing).
Client example: A client withdraws warmth from his voice tone when someone is
late for an appointment.
Therapy example: An inpatient unit removes a client’s telephone privileges after a
client misuses them.
EXTINCTION
Extinction reduces the likelihood of a behavior because reinforcement is no longer provided in
a particular situation. Extinction principles are used frequently in RO DBT, most often to
decrease indirect social signaling and disguised demands:
Client example: A client who never acknowledges smiles from others will likely
extinguish smiling behavior in other people, especially people the client
encounters on a regular basis.
Therapy example: A therapist is placing a “pushback” or “don’t hurt me” response
on an extinction schedule when he ignores it and carries on with his agenda as if
nothing has happened (see “‘Pushback’ Responses” and “‘Don’t Hurt Me’
Responses,” later in this chapter).
EXTINCTION BURST
An extinction burst is a temporary increase in the frequency and intensity of a behavior when
reinforcement is initially withdrawn. For most OC clients, an extinction burst involves gradual
increase in the intensity of an indirect social signal or disguised demand. An extinction burst is
like a social signaling temper tantrum—and the most effective way to respond to a temper
tantrum is to ignore it:
Client example: A client’s averted gaze (the initial indirect social signal) suddenly
transforms into the client’s lowered head, her slumped shoulders, and her hands
covering her face, almost immediately after her therapist fails to respond to the
averted gaze in the way the client desires (see “‘Don’t Hurt Me’ Responses,” later
in this chapter). In this case, the extinction burst is the sudden increase in the
intensity of the client’s nonverbal signaling.
Therapy example: The therapist ignores the client’s extinction burst until the client
displays a more adaptive social signal by directly revealing what she wants or
needs.
It is important to note, however, that if an extinction burst continues, and the client does not
offer a more direct expression of her needs, wants, or desires, the therapist should shift to the
alliance rupture repair protocol and enquire openly about what is happening. The good news is
that both approaches—either continuing to ignore the extinction burst or inquiring into what is
happening—will decrease the frequency of indirect social signals and disguised demands.
SHAPING
Shaping is the process of reinforcing successive approximations toward a desired behavior:
Client example: A client who buys a gift for every new person she meets, or who
brings cake to every meeting she attends, is using arbitrary reinforcement.
Therapy example: A therapist who says “Thank you” every time his OC client
candidly reveals her inner feelings is overusing this reinforcement strategy, and it
can quickly begin to feel arbitrary and contrived to the client. Instead, the therapist
should prioritize using nonverbal social safety signals, such as openhanded
gestures, a musical tone of voice, or eyebrow wags, since they are naturally
reinforcing for most people, regardless of cultural background or learning history.
Social
signaling Behavior is unwanted Walking away
excess
Social
Not engaging in vulnerable self-
signaling Behavior is desired but missing
disclosure
deficit
Faulty
Behavior occurs in wrong situation or Displaying a flat, nonexpressive face
stimulus
fails to occur in right situation regardless of the situation
control
Discriminating Between Operant and Respondent Behaviors
An important task for therapists working with OC clients is to determine whether the
maladaptive behavior is respondent or operant, since doing so helps guide the interventions to be
used:
Step Action(s)
The therapist is alert for subtle changes in social signaling that are discrepant, odd, or off-putting in
1 the given context (for example, the client suddenly goes quiet and exhibits a flat face after being
complimented).
The therapist directly asks about the client’s change in social signaling, but only after it has
occurred multiple times, and over multiple sessions. This step usually includes an assessment of the
extent to which the client is aware of the repetitive nature of the social signaling behavior and can
2 identify what may have triggered the change. The therapist says, for example, “I noticed just now that
you seem to have gone a bit more quiet, and now you’re looking down. Do you have a sense about
what may have happened to trigger your less expressive face?” The therapist, with eyebrows raised,
follows this question with a warm, closed-mouth smile.
The therapist asks the client to label the emotion associated with the maladaptive social signal and
3 assesses the client’s willingness to experience the emotion without engaging in the maladaptive social
signal (that is, response prevention).*
The therapist and the client collaboratively identify the stimulus (such as a compliment) that
4
triggered the maladaptive social signal.
The therapist briefly orients the client to the principles of behavioral exposure and obtains the
5
client’s commitment to practice using these principles in session as the first step.
The therapist provides the emotional cue or trigger. For example, the therapist compliments the
client and then encourages the client to practice going opposite to her automatic social signaling urges
6
and/or delivering the context-appropriate prosocial signal, such as smiling and saying “thank you”
rather than frowning, looking down, and saying nothing in response to the compliment.
The therapist repeats the cue multiple times during the session, ideally using the same or nearly the
same facial expression and voice tone each time: “Well done. Let’s try it again. Remember to go
opposite to your automatic social signaling urges, such as exhibiting a flat face and avoiding eye
7
contact, by doing the opposite, such as using a closed-mouth smile and engaging in direct eye contact.
Instead of resisting or avoiding any internal emotions or sensations, allow them, without seeing them
as good or bad—they just are.
The therapist avoids prematurely removing the cue and instead provides it repeatedly, multiple
times and across multiple sessions, allowing the client sufficient time to practice her newfound social
8 signaling skills until the client is able to engage in the appropriate response most often associated with
the cue (for example, saying “thank you,” making direct eye contact, and using a warm, closed-mouth
smile and an eyebrow wag in response to a compliment).
The therapist reinforces the client’s participation and encourages her to practice the same skills
whenever she encounters the eliciting stimulus (such as a compliment) during the coming week. The
9
therapist explains that behavioral exposure requires multiple experiences with the eliciting stimulus.
The therapist also obtains the client’s commitment to continue this type of work in future sessions.
* For skills linked to identifying emotions, see “Four Steps to Emotion-Labeling Bliss!” in the
skills training manual, chapter 5, lesson 6.
Although careful orientation to exposure principles is often ideal, sometimes spontaneous or
less planned exposure can be at least equally effective, depending on the nature of the problem.
For example, one OC client strongly believed that any form of self-soothing was both selfish and
decadent. For her, wanting two scoops of ice cream rather than one, sleeping until lunchtime, and
reading for pleasure were unnecessary indulgences that, if allowed, could only lead to an
increasingly immoral and unproductive existence. Though her frugality and strong work ethic
were admirable, she herself recognized that her insistence on frugality and prudence, combined
with her fear of being perceived as decadent, was exhausting and oftentimes prevented her from
joining in fun activities (such as partying or celebrating with others). For her, even hearing the
word “decadence” was sufficient to trigger automatic disgust and revulsion. With this as a
backdrop, her therapist suggested that informal exposure could be used to help her learn the art
of enjoying life and celebrating with her tribe. For example, during a session, her therapist might
suddenly and without warning ask his client to repeat, loudly and proudly, the word “decadence”
at random times, with her back straight and her head held high and, ideally, with a smile. The
therapist also obtained agreement from the client that he would unexpectedly say the word
“decadence” or other similarly feared words (“indulgence,” “pleasure,” “fun,” “lazy”) in session,
to further augment informal exposure practices. For example, during the middle of a chain
analysis on redoing others’ work, the therapist might suddenly and loudly say “decadence” three
times in a row, then briefly check in with the client regarding her experience of hearing the word,
while reminding her of their goal of increasing her pleasure in life, and then quickly return to the
chain analysis. For another OC client, who feared blushing, an RO DBT therapist used a similar
strategy by exposing the client to words and phrases such as “embarrassment,” “humiliation,”
“red face,” and “flushing,” a strategy that culminated in multiple practices over multiple
individual sessions, with the therapist unexpectedly asking the client to stand up, whereupon
both of them together would raise their hands toward the ceiling and proudly exclaim, in a loud
voice, “Public humiliation, I love you! Public humiliation, I love you! Public humiliation, I love
you! Public humiliation, I love you!” This sequence was then repeated multiple times over
multiple sessions; the key to success was repetition and the short duration of each exposure (each
miniexposure lasted thirty to sixty seconds at most). These brief exposures would most often end
with mutual spontaneous giggling and laughing, and later the client identified this work as a
seminal step in becoming freer to participate more fully in interactions with others. In both of the
examples just discussed, the therapists were careful to raise their eyebrows and smile during the
exposure practices, to signal affection and playfulness to their clients. Thus, in contrast to
therapists using most other exposure techniques, RO DBT therapists are likely to combine brief
exposure to nondangerous stimuli with prosocial nonverbal signals (smiling and eyebrow wags)
in order to viscerally signal that self-discovery and trying out new things call for celebration, not
seriousness, and that having fun is okay. Clients’ informal exposure to the value of disinhibition
represents one of the core reasons why it is important for therapists to practice RO skills
themselves.
In the following transcript, the therapist first orients the client to the idea of using informal
exposure and then uses informal exposure techniques to help the client learn to be more receptive
to praise and compliments:
Therapist: So I just want us to notice that whenever I compliment you, it seems that you are
likely to change the topic or somehow avoid the experience. Any praise on my part
seems to invalidate how you see yourself, as if you’re not worthy—as if you’re a piece
of crap. Yet at the same time (Pauses)…I somehow feel like it’s not right for me not to
express a genuine positive feeling I might have toward you, especially since you’ve let
it slip that you actually don’t want to feel like a piece of crap for the rest of your life.
(Ties praise to problematic beliefs that the client has regarding himself.)
Client: Well, I’ve been trying to absorb this. But it takes a conscious effort for me to absorb the
praise. Last night I was thinking about some of the positive things you’ve said. The
relationship…the idea of you caring…it takes a conscious effort for me to absorb that.
It doesn’t come natural. But, to some extent, I’m doing it…to some extent. I think, you
know, the trouble—I guess I don’t believe it, because I don’t believe it about myself. I
just figure “This guy doesn’t know anything. He doesn’t know what he’s talking
about.” (Free self-disclosure indicates client’s engagement in therapy.)
Therapist: I see your point. It’s like a dance that you do with me and with other people. What
I’m trying to get you to understand is that the dance you’ve learned is exhausting, and
it’s keeping you stuck. I know this is hard, but we need to practice some different steps
and go opposite to proving to others and yourself that you’re a piece of crap. That’s the
old dance that keeps you from ever getting close to others. You reject other people
before they can reject you, to the tune of “See, I’m Right—No One Likes Me.”
(Pauses.) There is a way out of this, though. (Pauses.) Would you be interested in
knowing about this? (Highlights problem of avoidance, using a metaphor; asks for
commitment to try something different.)
Client: Yeah. I guess it is about time.
Therapist: Okay, good. So the question is, what is the way out of this self-made trap? First it will
involve a lot of practice on your part that will probably be hard. (Pauses slightly.) Plus,
it will involve learning to accept kindness and positive feelings from others, and going
opposite to your natural tendency to avoid hearing nice things about yourself, while
letting go of that inner voice that is always self-critical. It will mean learning the steps
of a new dance. (Takes a long pause.) The actual name for this approach is “behavioral
exposure.” It’s a well-tested way to lay down new learning about old fears. (Smiles.)
Actually, my grandmother used the same principle whenever she told me to get back
on my horse after a fall and ride again. Does this seem to make sense? (Uses a
metaphor to introduce the idea that client’s behavior is a learned habit; introduces
principles of change associated with exposure; checks in with client to determine
client’s response to this approach.)
Client: Yeah, sure. Exactly.
Therapist: So, assuming you are agreeable, we’ll experiment together, and I’ll be mindful that
any praise or compliment on my part may be experienced as painful for you, but I will
not stop providing praise unless we both decide that something needs to change. That
is, we will be practicing getting back on the horse, with the idea that horseback riding
is something you can do, and that it’s important for you to have a decent life. Do you
think you would be willing to try this out? (Summarizes contingencies associated with
praise, and dialectically suggests that client needs to be aware of the pain that praise
can elicit; says that in order for behavioral exposure to work, it is important not to
remove the cue; asks for commitment.)
Do I have any energy about my client, or about the chain analysis I am about to
conduct?
Do I have a pet theory about my client?
To what extent is this influencing my behavior at this moment?
How open am I to radically considering an alternative perspective?
Is there something here for me to learn?
The best chain analyses are those that are done with open curiosity.
A brief check-in like this (it only takes a couple of seconds) should give you a sense of
whether you might be bringing into your chain analysis (and into the session) a bias or personal
edge that might interfere with the ideal stance of open curiosity (later on, you can share any bias
you discover with your RO consultation team or use it as part of a personal self-enquiry
practice).
A chain analysis can be conducted around any behavior of interest that a therapist or a client
wants to understand better, whereas a solution analysis is used to identify alternative behaviors
or skills that might prevent similar social signaling problems in the future. Occasionally a chain
analysis can be conducted in order to understand the chain of events leading to a failure to
complete a homework assignment or practice a new skill that was assigned as homework.
However, the vast majority of chain analyses should be focused on social signaling targets that
are being monitored via a diary card; in RO DBT, chain analyses are rarely used as an aversive
contingency to motivate an OC client to try harder or be more serious. (Recall that OC clients are
already too serious, and so there is no reason to encourage more seriousness, with the sole
exception of life-threatening behavior). Instead, the aim of chain analyses when working with
OC clients is to help them learn how to be their own detectives in order to discover a life worth
sharing.
There is no need for a long-drawn-out chain analysis. In fact, when working with OC clients,
short chains are often the best (recall that OC clients dislike the limelight). In RO DBT, then,
chain and solution analyses should be relatively short (ideally, around twenty minutes, although
an effective chain and solution analysis can be completed in seven to twelve minutes) and should
be conducted in a manner that encourages self-enquiry rather than more self-control. A short
chain analysis also leaves time for other agenda items, such as didactic teaching and informal
behavioral exposure. I have found that most therapists, with practice, can learn the skill of
conducting short chain and solution analyses. The key is not to get distracted by the other
potentially relevant targets that frequently emerge, and instead to take note of them for later
discussion. My general rule of thumb (there’s that rule thingy again) is to find two to four new
solutions per chain.
Appendix 6 uses a clinical example to illustrate how to set the stage for a chain analysis.
Appendix 7 uses a clinical example to illustrate the protocol for conducting a chain analysis and
a subsequent solution analysis.
Identify the distal contributing factors (also known as vulnerability factors) that may have
made it more likely for the client to engage in the problem behavior on a particular day (for
example, exhaustion stemming from compulsive cleaning or working).
Describe the consequences that immediately followed the problem behavior, with particular
emphasis on any reinforcing or punishing consequences as well as on reactions from others in
the social environment. For example, one client reported that he experienced a sense of pride
after redoing a coworker’s spreadsheet (notice that pride reinforces future redoing behavior), yet
immediately afterward he experienced exhaustion and resentment, linked to the thought Why do I
always have to be the one to make it right? In this case, the client also noticed that the coworker
had left work uncharacteristically early. The therapist helped the client use self-enquiry to
examine the possibility that his coworker’s response (leaving work early) might have represented
a potentially negative social consequence linked to the client’s compulsive urges to redo other
people’s work. Be alert for ways to influence reinforcing or punishing consequences in order to
help change the problem behavior (see Farmer & Chapman, 2016, for a review of principles of
contingency management). Most important, work to help your OC clients recognize the impact
their behavior has on the social environment, and explore whether their behavior and its impact
fit with their valued goals.
Look at each link in the chain after you write it down. Solution analyses are either conducted
after a chain analysis or woven in during a chain analysis, emphasizing skills that, had they been
used, would likely have prevented the problem behavior. Each potential solution or alternative
behavior should be linked to a specific maladaptive link that led to the problem behavior. For
example, you might ask, “Is there something else you might have said to yourself or something
else you might have done that might have been more effective? What skill might you have used
at this link if you desired to change this behavior?” It can sometimes be helpful to imagine
yourself in a predicament or situation similar to the client’s and ask yourself, What would I have
done if I were in this client’s shoes? This can facilitate creative and practical problem solving.
You should gain the client’s commitment to use identified solutions, and you should troubleshoot
factors that might make it difficult for the client to engage in those solutions. Preferably, clients
should keep a written copy of solutions nearby at all times. Copies of chain and solution analyses
are given to clients to keep as reminders. Clients are encouraged to develop the skill of doing
their own chain analyses, without the aid of a therapist. Whenever possible, look for
opportunities for clients to practice new skills in session (via role playing); the idea in treating
OC clients is not to talk about what to do but to practice doing. Finally, do not overwhelm clients
with too many solutions; the emphasis should be on quality, not quantity (in general, only two to
four new solutions per chain analysis are recommended). As an individual therapist, your role is
that of an informal skills trainer, meaning that you should not wait for a skill to be taught in skills
training class before recommending its use; instead, during individual therapy sessions, teach
informally whichever new skill may be needed.
Yet perhaps the most important questions to keep in mind when collaboratively working with
OC clients on alternative ways of social signaling are the ones that clients should ask themselves:
The last question is important because a person might desire to bend the truth for personal
gain, and yet doing so would go against a valued goal for honesty and integrity. It is important to
demonstrate and practice a new social signaling solution in session (via mini–role playing), not
just talk about it. Therapists should avoid assuming they know what a client means when the
client speaks in vague terms or uses indirect language. Rather than ignoring this lack of clarity,
therapists should reveal
Encourage clients to get in the habit of using social signals (for example,
eyebrow wags and closed-mouth smiles) that are universally prosocial.
Help clients determine what they want to express, and link it to a valued goal.
Make sure a solution is practical by imagining yourself using it in similar
circumstances. Don’t give clients solutions you would never use yourself. Ask
yourself, How would I signal my intentions or valued goals if I were in the
same situation? But remember that how you signal may not always be
effective or right for your client.
Show, don’t tell. Demonstrate and practice new social signaling solutions in
session (for example, how to lean back in a chair, affirmative head nods,
shoulder shrug combined with openhanded gestures to signal nondominance
and openness).
Remind clients to activate the social safety system prior to social interactions.
Encourage clients to match the social signaling of those with whom they are
interacting, to enhance social connectedness. The exception is when the other
person has a flat face; in this situation, encourage clients to go opposite by
using big gestures, eyebrow wags, and closed-mouth smiles.
Make sure that social signaling recommendations are unambiguous.
Encourage and reinforce candid self-disclosure and uninhibited expression of
emotion in a manner that takes into account the needs of others. Be aware of
the contexts clients are in.
Remind clients that being open to another person’s point of view socially
connects, without the need to say a word.
Write solutions down, to help clients remember to use them.
Conduct frequent check-ins to assess engagement.
Encourage self-enquiry when clients appear uncertain. Don’t try to convince
them.
Less is more. Don’t overwhelm clients with too many solutions in one session.
Build slowly over time, with three to four new solutions, at the most, per chain
analysis.
Teach specific RO skills that are relevant to clients’ social signaling problems.
Don’t depend on RO skills classes to cover relevant skills that your clients
need now.
their failure to understand (that is, out themselves) and ask (not tell) the client to practice being
more direct. Finally, everything gets easier when both the therapist and the client know the RO
skills inside and out (this is most important for therapists, so they can model RO skills and serve
as guides for their clients). Therapists should also be highly familiar with the material covered in
chapter 6 of this book and, ideally, should be practicing self-enquiry on a regular basis.
“I do what I do because that’s the way I am.” (Hidden message: “Don’t expect me to
change.”)
“I am not like other people.” (Hidden message: “I am better than other people.”)
“No, really. It’s okay. I’m fine with the decision. Let’s do it your way.” (Hidden
message: “I disagree totally and will make you pay.”)
Most OC clients signal indirectly. They tend to mask, hide, or deamplify their inner feelings,
making it harder for others to know their true intentions. For example, when an OC client says
“maybe,” he may mean “no,” or when he says “hmmm,” he may really mean “I don’t agree.”
The problem for the therapist (and others) is that OC social signaling has plausible deniability
(“No, I’m fine—I just don’t feel like talking” or “No, I’m not angry—I’m just thinking”), which
makes direct confrontation of potentially maladaptive behavior more difficult. Hidden intentions
and disguised demands negatively impact relationships. For example, OC clients are experts at
unobtrusively avoiding unwanted feedback in two apparently dissimilar ways; a “pushback”
response looks very different from a “don’t hurt me” response, yet both function to block
unwanted critical feedback. What is most important from an RO DBT perspective is how these
behaviors impact the social environment: they are posited to be problematic primarily because
they represent social signaling deficits. Both responses function primarily to prevent or stop
painful feedback, to allow OC clients to avoid engaging in a behavior, or to help OC clients
achieve a desired goal.
“Pushback” Responses
“Pushback” responses trigger the recipient’s threat system and defensive arousal (the recipient
is likely to want to flee or fight—to run away or punch the sender).62 The “I’m not telling you
what to do…” component usually allows the sender to avoid taking responsibility for trying to
control the other person or the situation. As one client put it during a chain analysis of a tension-
filled social interaction, “I was perfectly fine doing it the way they wanted, as long as they did it
the proper way, so any tension that arose was their responsibility.” Although the statement is
technically agreeable, it places blame on others for the conflict because it implies that they did
not abide by the rules that the client had decided beforehand were required for genuine
agreement.
This apparently cooperative behavior can sometimes be embedded in statements implying that
the other person is free to choose. One OC client, after being queried about an interaction that
appeared to have triggered anger or frustration, adamantly insisted, “I was not angry.” Her
therapist gently asked for clarification, whereupon the client stated, “I told you—I don’t do
anger! And if you ask me one more time about this, I am going to get up and walk right out of
this room!” The words “if you ask me one more time” offered the illusion of choice to the
therapist: if the therapist chose to keep asking, then the client could blame him when she walked
out of the session; alternatively, the therapist could choose to stop asking, and the client would
thereby avoid discussion of an unwanted topic. In this scenario, it was difficult for the therapist
not to reinforce the client’s behavior, to some extent, since the client was in the early stages of
therapy. Nonreinforcement would have required the therapist not to remove the cue, by not
changing the topic and by continuing, at least to some degree, to discuss what was happening in
the moment. Instead, the therapist realized that the client’s behavioral response suggested the
likelihood of an alliance rupture. Therefore, the therapist dropped his agenda and focused instead
on understanding the apparent rupture in the therapeutic relationship, thus modeling radical
openness and using the misunderstanding as an opportunity to practice interpersonal skills with
the client. Interestingly, repairing the alliance rupture required further discussion of anger,
including understanding what anger meant to the client. The therapist discovered that the client
believed anger meant losing control and fits of rage. Since the client rarely lost control or
exhibited intense rage in public, admitting to anger would have seemed inaccurate to her. By
using the RO DBT alliance rupture repair protocol, the therapist was able to learn more about the
client’s worldview while simultaneously avoiding removing the cue (the discussion about anger)
and blocking automatic abandonment of a relationship as the solution to a misunderstanding.
This became an important turning point for the client, who was able to use self-enquiry to
examine her adamant rejection of anger, whereupon she started to notice low-level anger and
hostility (including resentment and desires for revenge) that in the past she had denied
experiencing or avoided labeling, but that were negatively impacting her relationships. The
ability to acknowledge her previously hidden anger and its impact on others (family members)
proved to be a pivotal point of growth for her.
Another type of “pushback” behavior, which on the surface may appear to be nonavoidant,
involves declarations of responsibility or dutifulness. One client reported, “Rather than dismiss
criticism, I do exactly the opposite. I take it all on myself. It’s my entire fault. I embrace all the
criticism.” The therapist encouraged the client to reevaluate her public declarations of
responsibility by suggesting, “Although it can feel safer for all of us to criticize ourselves rather
than have someone else do it, our intentions may not always be so noble. Do you think it might
ever be possible for someone to assume all the responsibility for something in order to achieve
something else?” This line of questioning became an important step for the client toward a better
understanding of the possible functions served by her previously unquestioned behavioral
responses.
Apparently nonavoidant “pushbacks” can be manifested in many other ways, too, such as in a
quick retort or comeback, a personal attack, a defensive rebuttal, a refusal to comply, or an act of
putting the other person on the spot. These “pushbacks” can be difficult to identify because they
often appear to be signaling willingness to participate or engage with what is happening. For
example, when a therapist asks a client to show her what it looks like when he feels sad, the
client’s immediate response may be “Why do you want me to do that?” Answering a question
with a question is a common OC “pushback” behavior. On the surface, it appears engaged and
nonavoidant, yet in reality it functions to turn the tables by putting the other person on the
defensive (since the other person must now justify the question) or by diverting the discussion
from an unwanted topic. When this type of response has been observed on multiple occasions,
the therapist should start to highlight the behavior when it occurs and should also encourage the
client to do the same and then use self-enquiry to determine whether this way of behaving has
brought him closer to or taken him farther away from his valued goals (for example, to form
more intimate relationships).
Another client appeared to engage in a “pushback” after his therapist asked about his feelings
in the moment. He said, “This sounds more about you than it does about me.” In response, the
therapist modeled radical openness by nondefensively addressing his comment, without
removing the cue (that is, without allowing herself to get distracted from the importance of
knowing about how the client was feeling):
Therapist: Hmmm. I can see that you might think this. Let me think about what you said…
(pauses) I don’t know, but somehow it seems important that I ask you about your
experience, especially after giving you what I am now aware of imagining was
experienced as critical feedback. To not ask—to me, at least—would be uncaring.
What is it that I am doing that leads you to believe that my asking about your feelings
is more about me than about you?
Because the therapist did not apologize, change the topic, or defend herself, this approach
avoided reinforcing the potentially maladaptive behavior (the “pushback”). Instead, the therapist
signaled genuine caring and used “ask, don’t tell” strategies to encourage the client to reveal his
inner experience. This approach also allowed the therapist to take the client’s observation
seriously while also encouraging the client to more directly reveal what he meant (that is, go
opposite to masking his inner feelings). This interaction was an important part of helping the
client learn how to openly express difficult emotions and how to block his automatic tendencies
to blame others for his emotional reactions.
“Pushbacks” can also be communicated solely via relatively subtle nonverbal channels (a
scowl, an unexpected awkward silence during a conversation, a rolling of the eyes, frowning, or
a disinterested expression), or they can be more obvious (a controlled temper tantrum, hitting a
desk with a fist). One client described her mother this way:
When she was in one of her moods, everyone in the family knew it, but you weren’t allowed
to comment about it. She didn’t yell. She just would have this look about her that would send
people scurrying. If you were wise, you knew to be quiet, do whatever you were supposed to do,
and avoid crossing her at all costs until the mood passed, which might not happen for days.
Another client described a work colleague:
I used to respect this guy at work for his tough, no-nonsense approach. I now see he was more
overcontrolled than I am! For example, I’ve noticed that whenever he walks into a room, people
freeze—they stop talking and joking, or they change the topic. It’s almost like they’re waiting to
see what mood he’s in, or maybe they’re waiting for him to leave, because as soon as he does,
they all seem to relax—and he’s not even their boss! This really makes me wonder whether I
sometimes have the same effect on people.
These two examples illustrate how “pushbacks” can powerfully influence other people,
including therapists. Despite appearing innocuous, cordial, restrained, or proper on the surface,
the implied threats woven into many “pushbacks” send a strong message to the social
environment (“Don’t mess with me”). Moreover, direct attempts to confront “pushbacks” can be
easily rebuffed because the behavior has plausible deniability: “What—me, angry? No. I was
simply expressing my opinion.” Thus many OC clients who habitually engage in “pushback”
behavior may have little experience with direct challenges to such behavior.
The therapist must remember that “pushbacks” are most often overlearned responses,
frequently delivered without malicious intent and often with little conscious awareness. They are
part of a set of behaviors that functions to help the client avoid unwanted feedback or
suggestions for change, and the “pushbacks” have been intermittently reinforced. As such, a
“pushback” has become a dominant automatic response to stress. Remembering this can help the
therapist retain a compassionate stance when “pushbacks” occur. That said, the therapist needs to
be alert to his own inner emotional experience when working with “pushback” responses, to
ensure that he is not inadvertently reinforcing them. For example, most people are acutely aware
when a person is behaving in a hostile manner, even when the hostility is delivered with a smile.
Covert expressions of hostility tend to elicit similar feelings in recipients (people dislike being
coerced or aggressed upon). Thus the therapist can use his internal experience as a guide to
uncovering a hostile “pushback.” However, the therapist should not assume that his emotional
response necessarily signals a problem with the client; instead, these moments signal
opportunities for growth—sometimes for both the therapist and the client—that, when explored
collaboratively, help the OC client experience belonging to the tribe rather than being an
outsider.
The following example illustrates how a therapist might challenge “pushback” behavior:
Therapist: I noticed that you changed the topic. We were discussing whether it might be possible
that you actually experience anger sometimes but have learned to avoid labeling it as
an emotion. What are you feeling right now? (Maintains the cue—in this case, the
discussion about anger.)
Client: Nothing.
Therapist: Any sensation in your body?
Client: No. I don’t see how this is relevant. I told you that I rarely experience anger.
Therapist: What are you feeling right now?
Client: (Looks away) Nothing…uncomfortable. Why does this matter? (Signals “pushback.”)
Therapist: I don’t know. (Pauses.) I’m aware of thinking that maybe your avoidance of this topic
suggests that there is actually something important for us to understand. Just how
adamant are you not to discuss this? (Ignores “pushback” and directly assesses
behavior.)
Client: (Looks down; pauses) I don’t know.
Therapist: Hmmm. (Uses soft voice.) Perhaps you feel emotions more often than you care to
admit. (Pauses.) What do you think? (Ignores nondescriptive behavior; encourages
honest expression of emotions and thoughts.)
Client: It could be. I do not like emotions—never have. I’ve worked to avoid ever feeling them.
(Reengages; exhibits adaptive behavior.)
Therapist: Thanks for letting me know about this. I think talking about your avoidance might be
important. (Reinforces adaptive behavior and honest expression of emotions and
thoughts.)
As mentioned earlier, a “pushback” can be difficult to address because it may imply that the
problem is not about the “pushback’s” sender but rather about its recipient. Accusations of blame
(direct or implied) and expressions of hostility trigger defensive arousal and often defensive
actions in other people. Therapists are not immune to these normal responses. In addition,
“pushbacks” can elicit apologetic or capitulating behavior from others, and analogous
acquiescent responses by therapists can reinforce “pushbacks.” And yet the aversive emotions
triggered in session by “pushbacks” can be confusing, particularly if the therapist believes that
she should rarely experience strong emotion during sessions with clients, or that she should
always behave in a caring manner when working with clients. The therapist can become
demoralized or angry when her attempts to explicitly target these often subtle and deniable
behaviors, or to join with a client by revealing her own vulnerable emotions, are repeatedly
rebuffed, dismissed, or considered manipulative. As a result, the therapist may completely avoid
targeting possible “pushback” behavior. At the same time, premature confrontation of a
“pushback” can reinforce the behavior, since the ensuing discussion of the “pushback” behavior
directs attention away from the very topic that the client wanted to avoid in the first place (that is,
it removes the cue). Consultation teams should be alert to these factors and help therapists find a
middle ground.
The overall goal when working with “pushbacks” is for the client himself to identify them as
problem behaviors. The therapist should look for opportunities to reinforce direct and open
expression of emotions or opinions while ignoring or compassionately confronting indirect or
disingenuous expressions that may be maladaptive. Prior to obtaining commitment, “pushback”
responses are usually best managed by placing them on an extinction schedule that ignores
indirect expressions of needs and desires and responds only to direct expressions of the same.
The therapist behaves as if the “pushback” is not present, with the result that the client is
required to make his wishes known explicitly if he is going to have a chance of obtaining what
he may want. Thus the therapist, ideally, continues to behave in a positive, prosocial manner that
signals affection and appreciation for the client’s perspective. This approach is useful because it
requires the OC client to be more direct if he is going to get the therapist to take him seriously,
and it simultaneously provides opportunities for the client to practice candid self-disclosure (that
is, to engage in adaptive behavior that can be reinforced). Once commitment has been obtained,
“pushbacks” can be monitored on diary cards and incorporated into chain analyses. Learning to
let go of “pushback” behavior, and instead to directly express desires, often becomes the
cornerstone of successful treatment for many OC clients.
“Don’t hurt me” responses are operant behaviors that function to block unwanted feedback or
requests to join in with a community activity. They are typically expressed nonverbally, via
behaviors (lowering the head, covering the face with the hands or hiding the face from view,
slackening and shrinking the posture, lowering the eyelids, casting the eyes downward, avoiding
eye contact, and slumping the shoulders) that, collectively, are associated with self-conscious
emotions. The underlying message of a “don’t hurt me” response is as follows:
You don’t understand me, and your expectations are hurting me, since normal expectations for
behavior do not or should not apply to me because of my special status or talents, my exceptional
pain and suffering, my traumatic history, the extreme efforts I have made to contribute to society,
my hard work, or my self-sacrifices for the benefit of others. As such, it is unfair of you to fail to
recognize my special status and expect me to participate, contribute, or behave responsibly, as
other members of my community are expected to behave. Consequently, if you were a caring
person, you would stop pressuring me to change, behave appropriately, and conform to norms.
In other words, “Stop expecting me to complete my homework, stop asking questions I don’t
like, and stop expecting me to participate in skills class.” The final hidden or indirect message in
a “don’t hurt me” response is “And if you don’t stop, I will fall apart, and it will be your fault.”
A “don’t hurt me” response can be hard to identify, for one or more of the following reasons:
It is possible, however, to distinguish a “don’t hurt me” response from a respondent reaction:
A “don’t hurt me” response has a long duration and may last for an entire skills
training class or family meeting, whereas a respondent reaction (such as the pain
of a stubbed toe) fades quickly and independently of others’ behavior once the
eliciting stimulus is removed.
The intensity of a “don’t hurt me” response increases if a desired response (such as
soothing, withdrawal of a question, a change of topic, or an apology) is not
forthcoming, whereas a respondent reaction matches the intensity of the eliciting
stimulus.
Another way to understand the maladaptive nature of “don’t hurt me” responses is to examine
the behavior from the perspective of the tribe, family, or community group, since the “don’t hurt
me” response always occurs within a social context (although its cousin, self-pity, often occurs
alone and frequently precedes “don’t hurt me” social signaling). What can often be missed by the
recipients of a “don’t hurt me” response is that the sender has almost always willingly chosen to
be part of the community, group, or tribe in which this behavior is exhibited (that is, the sender
has not been forced to participate), and yet the sender expects special treatment. Usually an OC
client’s “don’t hurt me” responses have been intermittently reinforced by family members and
others in the community (including therapists and treatment programs), most often through well-
intentioned attempts to avoid upsetting the client by soothing her, taking care of her, or helping
her avoid apparently distressing topics—in other words, walking on eggshells around the client.
And yet “don’t hurt me” responses can engender social ostracism of the client when they are
long standing, pervasive, or nonresponsive to attempts by others to offer assistance. Similar to
pouting, “don’t hurt me” responses are maladaptive because they function to signal disagreement
and nonengagement indirectly. As a consequence, over the long term, they negatively impact the
client’s sense of self and interfere with her ability to form close social bonds.
The difficulty for the therapist is in knowing whether to reinforce (soothe) or not to reinforce
(ignore) a “don’t hurt me” response (see Farmer & Chapman, 2016). This can be tricky because
OC clients need to learn how to express and signal vulnerable emotional reactions (such as
sadness following the death of a parent) to others in a genuine manner, and yet “don’t hurt me”
responses are social signals that mimic expressions of vulnerability in order to influence the
social environment. Thus “don’t hurt me” responses masquerade as justified or warranted
reactions to distress, yet in reality they function to help the client avoid or prevent feedback or
requests for change.
In the following clinical example, during a session targeting a client’s rigid belief that he can
tell what others are thinking from their reactions to him, the therapist has been using logic and
“ask, don’t tell” strategies to lead the client toward the reluctant admission that his belief is
unlikely to be literally true. Now, at a critical point in this discussion, the client has suddenly
reported, with his head down and a sad expression, “No one has touched me for twenty years.”
This utterance might be interpreted differently in a different context, but in this case the therapist
hypothesizes that it represents a possible “don’t hurt me” response and is intended to change the
topic. Consequently, the therapist notes the new information and proceeds as follows:
Therapist: Wow, John. (Pauses.) That sounds like something we will need to talk about.
However, before we go there…(Pauses; leans back in chair; breaks eye contact; slows
pace.) I have a question for you. (Pauses; offers a half smile and an eyebrow wag;
looks at client.) Did you notice that you just changed the topic?
Using “ask, don’t tell” strategies, the therapist was able to help the client recognize and reveal
that he had purposefully changed the topic in order to avoid further discussion of the possibility
that his previously held conviction might be a fallacy. Using this as a template, the therapist and
the client were able to notice not only how he used similar avoidance tactics in other situations
but also the impact this might have been having on social relations, which became a major point
of growth for the client.
Another example of a “don’t hurt me” response can be seen in the following transcript from
the eleventh session with a forty-five-year-old OC client who has long-standing chronic
depression, lives alone, and, although on disability, manages her instrumental needs (such as
shopping and traveling to medical appointments) without assistance. The “don’t hurt me”
response occurs during a chain analysis of the client’s noncompletion of a homework assignment
(to visit her brother, who lives in the same town):
Client: I figured out the bus route I would need to use online, but I couldn’t go, because I didn’t
have anyone to go with me.
Therapist: (Leans back in chair) Hmmm. Is there a law in your brother’s neighborhood requiring
people to travel with an escort? (Offers an eyebrow wag and a half smile; uses
irreverence to challenge maladaptive behavior.)
Client: (Pauses; looks down; lowers voice volume) No, but I just can’t do things like that.
Therapist: (Hypothesizes that client’s statement is a possible “don’t hurt me” response): So why
do you think I asked the question about a law in your brother’s neighborhood? (Offers
an eyebrow wag with slight smile; ignores the “don’t hurt me” response by behaving
matter-of-factly, bringing client back to the original question, and not removing the
cue.)
Client: I don’t know. (Looks down; slumps shoulders; frowns.) I just can’t do this. I’m just so
tired…and I have a headache, too. (Changes the topic.)
Therapist: Gosh, Sarah, this could be really important. Whatever is happening right now, in how
you are talking about this with me, could be a key factor in your depression. What do
you think is happening right now? (Highlights the importance of the in-session
behavior; uses “ask, don’t tell” strategy to encourage self-enquiry.)
Client: I don’t know. (Glances briefly at therapist.)
Therapist: (Retains the cue; leans back) Well, let’s think about it. If there is no neighborhood
law requiring escorts, and if we also know that you travel alone by bus twice a week to
come here for therapy, then what does that tell us?
Client: That I’m avoidant? (Makes eye contact with therapist.)
Therapist: Or maybe you don’t really like your brother. (Smiles gently.)
(Client appears to be reengaging.)
Therapist: (Pauses slightly) Either way, we know it’s not a capability deficit. You can ride buses
without escorts. But there is something else I have noticed that seems to occur
whenever we encounter a difficulty—usually, from what I can tell, when new
behaviors are required. It involves both what you say with your words, and what you
do with your body. Do you have any idea what I am talking about? (Uses “ask, don’t
tell” strategy.)
Client: Hmmm…that I don’t look at you? (Looks at therapist.)
Therapist: Yeah, that’s part of it. You were doing it just a minute ago… Something happens, and
then it seems that you shift into a slumped position, with your head down. And, like
you said, you don’t look at me, and you start using words like “I can’t” or “It’s not
possible.” I think it’s great that you have noticed this, too. What do you think you are
trying to communicate when you do this?
The therapist used this interaction to introduce the concept of “don’t hurt me” responses and to
gain the client’s commitment to monitor them on the diary card, with the initial goal of
discovering the frequency of the behavior and whether it was linked to other targets. The
therapist smuggled the idea that the “don’t hurt me” response might be keeping the client stuck
in her chronic depression because it signaled to the social environment that she was fragile and
incompetent. Plus, when others took her off the hook by lowering their expectations or stopping
important feedback, they inadvertently reinforced future “don’t hurt me” responses. The client
agreed to allow the therapist to highlight possible in-session “don’t hurt me” behaviors and to
use them as moments for the client to practice taking responsibility for her emotional reactions
instead of expecting others or the environment to change or take care of them. It was also agreed
that the client would begin practicing going opposite to her nonverbal “don’t hurt me” behaviors
by lifting her head up instead of lowering it, putting her shoulders back rather than slumping, and
speaking with a normal voice tone and volume instead of whispering.
Similar to how “pushback” responses are treated, the goal of treating “don’t hurt me”
responses is to reinforce direct communication of emotions and thoughts and not reinforce
indirect or passive expressions of emotion or thoughts (that is, the therapist does not remove the
cue, blocks soothing, and ignores the behavior). Sometimes it can be helpful for the therapist,
using a matter-of-fact tone, to ask a nonresponsive client (one who is avoiding eye contact, has
slumped shoulders, and is whispering) to put her shoulders back and, while making eye contact
with the therapist, repeat what she has just said, without whispering. This encourages the client
to socially signal competence while also providing her an opportunity to practice direct
expression of her thoughts and emotions. If a “don’t hurt me” response intensifies (that is, if the
client puts her head down lower) or continues unabated, then the therapist, with an open mind,
should directly ask the client about the function of the behavior:
Therapist: I don’t know about you, but I’ve been noticing that something has changed or shifted
in how you are responding to our discussion. (Leans back; offers an eyebrow wag and
a half smile.) Have you noticed anything different?
If the behavior is respondent, then the client will most likely answer the query nondefensively,
freely continue discussing her experiences, and actively engage the therapist in a manner that
does not change the topic. If the behavior is operant, then the client will typically freeze, change
the topic, exaggerate the “don’t hurt me” response, or engage in “pushback” behavior (for
example, by implying that the therapist’s question is inappropriate). In the following clinical
example, the client has been repeatedly shifting in her chair, looking away, and attempting to
change the topic, and the therapist is seeking to determine whether the client’s behavior is
operant or respondent:
Therapist: (Notices change in client’s behavior) Hmmm…I am aware of imagining right now
that you don’t want to talk about this anymore. How do you want me to behave?
(Directly asks about the function of this change in client’s behavior.)
Client: I want you to be nice to me.
Therapist: (Notices possible “don’t hurt me” response; uses an easy manner) Really? (Pauses.)
Just be nice? (Pauses.) I don’t know…somehow it seems like something else. (Does
not remove the cue.)
Client: Like what?
Therapist: Like maybe you don’t want me to give you any feedback. Do you think this might be
partly true? (Confronts possibility that client’s behavior is operant.)
Client: (Pauses; looks down) Yeah…maybe so. (Exhibits adaptive behavior.)
Therapist: (Uses quiet, gentle voice tone) Yeah…that’s honest. (Pauses.) Thanks. And, by the
way, it’s also effective behavior.
(Client looks up.)
Therapist: What I mean is that acknowledging to me and to yourself that you were avoiding the
previous topic actually took some courage. Somehow, this type of expression is what I
think we need to work to have happen more often. (Pauses.) What do you think?
(Reinforces adaptive behavior.)
In summary, therapists must become adept at noticing subtle signals of nonengagement or
avoidance. “Pushback” and “don’t hurt me” responses function to block unwanted feedback or
requests to join the community, or they may indirectly signal nonengagement. A “pushback”
response usually functions to elicit acquiescence, avoidance, or submission from others, whereas
a “don’t hurt me” response functions to elicit soothing, caregiving, or nurturance. Both of these
OC operant behaviors are usually experienced as aversive by others in the social environment
and often result in recipients’ feeling confused or unsure about their own perceptions or motives.
Therapists can use their personal emotional reactions to help differentiate between “pushback”
and “don’t hurt me” responses. A sudden desire to warmly validate, sympathize, or soothe a
client may suggest the presence of a “don’t hurt me” response, whereas a sudden desire to back
off, apologize, or justify one’s actions is more likely to reflect the presence of a “pushback”
response.
The overarching goal when working with these maladaptive OC behavioral patterns is to not
reinforce indirect or passive expressions of needs or desires and to reinforce open, honest, direct
expressions instead. When these maladaptive patterns occur, the initial response by the therapist
should be to place the behavior on an extinction schedule by continuing the discussion as if the
social signal had not been observed (that is, continue to cheerfully discuss the topic at hand). If
the client more directly reveals his intentions or inner experience, the therapist should reinforce
the disclosure (for example, by thanking the client for candidly revealing his inner experience).
However, if the behavior continues unabated or increases in intensity, without the client’s more
direct expression of his needs, wants, or desires, then the therapist should use the alliance rupture
repair protocol and ask with an open mind about what is happening. This helps the client take
responsibility for his emotional reactions and personal preferences rather than automatically
denying them or blaming them on factors outside his control—and, ideally, it leads to new self-
discoveries.
This question pertains primarily to issues of treatment adherence and fidelity. There are
several things that can help with this. For one, supervision by a certified RO DBT clinical
supervisor—that is, having an RO DBT expert rate one of your sessions to adherence—is
probably the best way. Therapists can also use the RO DBT adherence self-assessment checklist
in appendix 8. The checklist is designed to be used flexibly, depending on setting, and can be
rated either by the therapist or an independent rater. Ideally, the ratings reflect the entire session,
with a higher number of checkmarks in relevant sections suggesting higher treatment
adherence.63
Adherence ratings are also always improved when therapists stick to the manual. Broadly
speaking, adherent RO DBT therapy is identifiable by its emphasis on social signaling targets
and solutions and a therapeutic stance that is collaborative, humble, kind, playful, structured, and
challenging. My experience over the years has revealed that the first big hurdle most therapists
need to get over when first learning RO DBT is learning to see the client from a social signaling
perspective and to let go of other models that prioritize other targets or mechanisms of change
(for example, internal experience, emotion dysregulation, maladaptive schemas). Other common
misunderstandings or errors that are seen when therapists are first learning the treatment are to
assume that “flexible” means “unstructured”; to mistake “easy manner” to mean “always smiling
and being nice”; taking too long reviewing a diary card; and not conducting a chain analysis. RO
DBT is both highly structured and highly flexible, and it is highly relationship-focused. Finally,
RO DBT can be distilled down to four core components (Wow, did I just say that?):
Ensuring the client stays alive, thus necessitating the monitoring of life-threatening
behavior
Identifying and repairing alliance ruptures
Targeting social signaling deficits
Practicing radical openness skills (clients as well as therapists)
Thus therapists should be delighted (rather than concerned) when an OC client uses colorful
language, teases them, cracks a joke, or openly disagrees, because the client is sending a
powerful social signal suggesting that she trusts you and considers you part of her tribe. Yet
perhaps the most powerful means of making genuine contact with an OC client is to practice
what you preach. That is, practicing radical openness naturally brings humility into our lives, and
your OC clients are likely not to be the only ones who benefit.
Perhaps the most powerful means of making genuine contact with an OC client is to practice
what you preach.
Final Remarks
Our species has not only survived—we have thrived. But how did we do it? Our physical frailty
is proof that our survival depended on something more than individual strength, speed, or
toughness. We survived because we developed capacities to form long-term social bonds with
unrelated others, work together in tribes, and share valuable resources. But perhaps what makes
us uniquely human is not just safety in numbers but instead our willingness to make self-
sacrifices to benefit another or contribute to our tribe. RO DBT contends that human emotional
expressions evolved not just to communicate intentions but to facilitate the formation of strong
social bonds and altruistic behaviors among unrelated individuals. Our facilitative advantage
required our species to develop complex social signaling capabilities that allowed for a quick and
safe means to evaluate and resolve conflict and that resulted in unprecedented collaboration
among unrelated individuals, a unique human feature that to this day is unparalleled in the
animal world.
Indeed, we are a hypercooperative species, more so than any other animal species. We engage
in highly complex and coordinated group activities with others who are not kin and comply
without resistance to requests from complete strangers. Research shows that most humans, rather
than falling apart or running amuck when disaster strikes, are calm, orderly, and work together to
help others. During times of extreme crisis, we forget about our individual differences,
backgrounds, and beliefs and unite for a common cause (ask people closely involved in the 9/11
crisis in New York City the extent to which they were worried about whether the people they
were helping were homeless or millionaires, religious or atheists, black or white). According to
RO DBT, our mirror neuron system and capacities for micromimicry of facial affect both make it
possible for us to literally experience the pains and joys of nearby others and make empathy and
altruism a reality. This helps explain why we are willing to risk our lives to save a stranger from
drowning, or to die fighting for our nation.
RO DBT differs from most other treatments by positing that individual well-being is
inseparable from the feelings and responses of the larger group or community. Thus, when it
comes to long-term mental health and well-being, what a person feels or thinks inside or
privately is considered less important in RO DBT, whereas what matters most is how a person
communicates or social signals inner or private experience to other members of the tribe and the
impact that social signaling has on social connectedness. Feeling happy is great, but when you
are lonely it’s hard to feel happy, no matter how much you might try to accept, reappraise, or
change your circumstances, keep busy, exercise, practice yoga, or distract yourself. In the long
run, we are tribal beings, and we yearn to share our lives with other members of our species.
Essentially, when we feel part of a tribe, we naturally feel safe and worry less.
Finally, although our evolutionary heritage may compel us to instinctively care for our
children or members of our family, this is not what makes us different from other animal species.
From my perspective, our humanity is not about our superior intellectual capacities or opposable
thumbs. What makes us unique is our capacity to love someone different from ourselves. Indeed,
our capacity to form long-lasting bonds and friendships with genetically unrelated individuals is
posited to have been a key part of the evolutionary success of our species. Yet our capacity for
love is not an instinct (reflex); it doesn’t just happen or suddenly appear on our eighteenth
birthday. It is a predisposition, not a given. It is something that must be both earned and learned
and then chosen again and again over the course of our lives. It can grow or wither, depending on
what we decide and what we do, and there is no easy way out. That said, it is a joy to engage, if
one enters the room with humility.
To close…perhaps Kowock of Tribe Roc may have put it best when he explained to his tribal
chief how they could join forces with Tribe Clog to defeat a pride of ferocious, voracious lions:
We must signal vulnerability. We must wash our faces clean of war paint and freely expose
our bellies. We must not hide behind our shields but instead walk freely toward Tribe Clog with
an open heart and a willingness to reveal our fears and joys. Only then will Tribe Clog know that
we are their brothers, and only then can we band together with them and defeat the lions.
In my opinion, the risk is worth it.
Appendix 1
A B
impulsive deliberate
impractical practical
naive worldly
vulnerable aloof
risky prudent
talkative quiet
disobedient dutiful
fanciful realistic
fickle constant
animated restrained
changeable mood stable mood
haphazard orderly
wasteful frugal
affable reserved
erratic predictable
complaining uncomplaining
reactive unreactive
careless fastidious
playful earnest
intoxicated clearheaded
self-indulgent self-controlled
A B
unconventional conventional
dramatic modest
brash unobtrusive
obvious discreet
vacillating determined
unrealistic sensible
gullible shrewd
unpredictable dependable
dependent independent
improper proper
chaotic organized
susceptible impervious
unstable steadfast
volatile undemonstrative
excitable stoical
lax precise
unsystematic structured
thoughtless thoughtful
inattentive attentive
short-lived enduring
perky despondent
passionate indifferent
Instructions: Read the following descriptions of traits, and then rate each trait on the 1–7 scale in
form 3.2. A score of 6 or 7 denotes “caseness” (that is, the individual closely matches the
predicted OC trait pattern). When totaling scores, make sure you reverse scores for Openness to
experience, Affiliation needs, and Trait positive emotionality (see ** next to item); a score of 40
or higher suggests OC “caseness.”
**Openness to experience: Refers to the degree to which a person is receptive and open to new ideas and
change, novel situations, or unexpected information, including the degree to which a person is willing to listen
to critical feedback before making a judgment and is willing to admit when he or she is wrong.
**Affiliation needs: Refers to the degree to which a person values giving or receiving warmth and affection
and enjoys intimate and close social bonds with others.
Trait negative emotionality: Refers to the degree to which a person is vigilant and cautious in life, concerned
about making mistakes, and focused on what went wrong rather than what went right; also refers to the degree
to which a person experiences anxiety, worries, or is overly concerned about the future.
**Trait positive emotionality: Refers to the degree to which a person feels excited, enthusiastic, energized,
or passionate about what is happening in the current moment.
Inhibited emotional expressivity: Refers to the degree to which a person attempts to control, inhibit, restrain,
or suppress how he or she expresses inner feelings or emotions; individuals scoring high on this trait tend to be
understated in how they express emotions and/or may report that they rarely experience emotions.
Moral certitude: Refers to compulsive desires to plan for the future, extreme dutifulness, hypermorality, and
hyperperfectionism; individuals scoring high on this domain set high standards and lack the flexibility to
loosen these standards when appropriate.
Compulsive striving: Motivated to act according to what may happen and/or in order to achieve a long-term
goal rather than according to how they are feeling in the moment; they delay immediate gratification or
pleasure in order to achieve long-term goals and may persist in stressful activities in order to achieve a desired
goal, despite feedback that persistence may be harmful to them; compulsive immediate fixing occurs, whereby
any problem is treated as urgent, and this behavior leads to immediate yet ill-timed and detrimental results.
High detail-focused processing: Refers to superior detail-focused as opposed to global processing, insistence
on sameness, hypervigilance for small discrepancies, and preference for symmetry over asymmetry; an OC
client high on this trait might tend to notice grammatical mistakes that others miss, or to quickly detect a
missing data point in a complex chart.
Note: Clinicians are encouraged to use individual trait ratings to guide treatment planning (for
example, high scores on Inhibited emotional expressivity highlight the importance of targeting
this feature in treatment).
Form 3.2. Clinician-Rated OC Trait Rating Scale
1234567
**Openness to experience
-—-—-—-—-—-—-—-—-—-—
1234567
**Affiliation needs
-—-—-—-—-—-—-—-—-—-—
1234567
Trait negative emotionality
-—-—-—-—-—-—-—-—-—-—
1234567
**Trait positive emotionality
-—-—-—-—-—-—-—-—-—-—
1234567
Inhibited emotional expressivity
-—-—-—-—-—-—-—-—-—-—
1234567
Moral certitude
-—-—-—-—-—-—-—-—-—-—
1234567
Compulsive striving
-—-—-—-—-—-—-—-—-—-—
1234567
High detail-focused processing
-—-—-—-—-—-—-—-—-—-—
Note: When totaling scores, it is important to reverse scores for Openness to experience,
Affiliation needs, and Trait positive emotionality (see ** next to item).
Appendix 3
Instructions: This postinterview prototype rating scale assesses four core OC deficits (each
category of deficit has two subheadings):
After completing a clinical interview, the interviewer should read the description under each
of the eight subheadings and then, rather than counting individual symptoms, should rate the
extent to which the client matches the description as a whole, using the following 0–4 scale:
Ratings should be done after the client has left the interview room. Add up the eight
subheading scores, and then use the scale at the end of form 3.3 to determine the extent to which
the client represents the OC prototype.
Notes
Average time to complete all ratings is approximately five minutes.
OC subtypes are rated only if the client has scored 17 or higher on the global rating
scale.
The summary scoring sheet provided at the end of form 3.4 can be incorporated into
the client’s medical record.
Is more alert to the potential for harm than to the potential for reward when entering
new or unfamiliar situations; is less likely to find uncertainty or ambiguity
enjoyable, stimulating, or potentially profitable. For example, will avoid taking
unplanned risks (that is, risks for which he has not had time to prepare) and/or
dislikes scrutiny and the limelight (because it might invite criticism), despite
desiring appreciation or recognition for achievements.
Tends to avoid new, uncertain, or novel situations for which he has not been able to
prepare, especially if he can avoid them without calling attention to himself. Tends
to prefer situations where rules or prescribed roles are preordained (for example,
he will prefer a business meeting to a picnic). Will tend to chastise himself
whenever he perceives himself as making a mistake, not living up to his values, or
not behaving properly.
When confronted with feedback with which he disagrees, will tend to automatically
refute it (albeit often this is done silently), minimize it, or avoid it and/or pretend
to agree with it as a means of preventing further criticism. For example, may
respond to feedback by ruminating about a rebuttal, searching for disconfirming
evidence, shutting down, refusing to listen, counterattacking, changing the topic,
and/or behaving as if bored.
May secretly harbor resentment and/or plans for revenge if challenged, questioned, or
frustrated or may feel thwarted, overwhelmed, or hopeless about achieving a
desired goal.
To avoid critical feedback, may be reluctant to reveal true beliefs or feelings.
May reject a differing opinion on the basis of minor inaccuracies or “inappropriate”
word usage (or other perceived inconsistencies) rather than on the basis of logic or
reason.
May automatically go on the offensive or the defensive when feeling criticized (for
example, by answering a question with a question, by counterattacking, by
behaving as if he has not heard the feedback, by denial, or by providing a vague
answer).
May attempt to beat an imagined critic to the punch by criticizing or minimizing his
own accomplishments first.
Is hyperperfectionistic (for example, sets high standards for himself and others).
Is compulsively rule-governed and tends to hold strong convictions and/or have high
moral certitude (for example, believes that there is a right way and a wrong way to
behave, or believes that there is only one correct answer). May feel compelled to
follow rules of etiquette even when the rules do not make sense in a given
situation. Tends to prefer highly structured or rule-governed games (such as
chess).
May compulsively hoard information or, oftentimes, relatively meaningless objects
“just in case” they may be needed in the future.
Likely to attribute his actions to rules, not to his current mood or anticipated rewards.
For example, when asked why he went to a party, will tend to answer, “Because I
thought it was the right thing to do.”
Compelled to “fix” a problem (even a minor one) immediately rather than giving
himself time to think about it or obtaining a much-needed rest before beginning
work.
Works beyond what is needed in order to avoid being seen as incompetent (for
example, overrehearses a speech).
Has difficulty altering a planned course of action or revising a prior solution after
circumstances have changed, or after feedback that the prior way of doing things
will not be useful in the current context.
May engage in apparently high-risk sports or other activities (such as scuba diving,
skydiving, or stock trading), but the risk taking is always carefully planned or
premeditated (that is, the activity is not performed on a whim).
Exhibits compulsive persistence (for example, continues to engage in a difficult task
in order to achieve a long-term goal, even if persistence may prove damaging).
Will persist in an activity (working, running, striving) despite feedback that doing
so could result in harm to himself or others (such as physical injury or a damaged
relationship). May find it difficult to rest (by taking a nap, for example) or ask for
help when it is obvious that persisting in his current course will not prove
beneficial.
3. Deficits in Emotional Expression and Awareness
Has low awareness of emotions and bodily sensations (for example, may report
difficulty labeling and distinguishing between emotions and bodily sensations).
When depressed or anxious, may report feeling tired or fatigued rather than using
emotion words to describe mood. May adamantly insist that he does not
experience certain emotions (such as anger). May feel numb or empty when
experiencing intense emotions (especially anger). When asked about feelings,
tends to report thoughts rather than using emotion words. May use idiosyncratic
and/or peculiar language when describing emotions (for example, “I feel like
plastic”).
Tends to be stoic and uncomplaining and to minimize or discount emotional
experience (such as anger, pain, or excitement), both publicly and privately (even
with family members, for example). Reports mood states as stable and static, with
little variability or contrast in intensity. May hold idiosyncratic beliefs about
certain emotions (for example, may report never experiencing anger because to
him anger means being out of control and having fits of rage, or because he may
believe that showing fear or feeling sad is a sign of weakness or cowardice). Tends
to underreport emotions. For example, may habitually say “I’m fine” when queried
about how he feels, regardless of current mood state (even when highly distressed,
for example). Exhibits high distress tolerance; is able to tolerate pain or discomfort
without complaint for long periods and may ignore injuries or medical problems.
When angry, becomes quieter (rather than louder), as in the silent treatment; may
pout when angry but deny doing so when queried. When an outburst of anger
occurs, it tends to occur in private (for example, only in the presence of immediate
family members or a therapist), not in public places (such as at a train station or in
the street). May communicate a stance that devalues the importance of emotions
(for example, may change the topic when emotions are discussed, or may quickly
attempt to “fix” the emotional distress exhibited by another person by giving that
person advice).
Notes
Form 3.4. Overcontrolled Subtype Rating Scale
Instructions: Complete the two items in form 3.4 only if the client has scored 17 or higher on the
Overcontrolled Global Prototype Rating Scale (form 3.3). These two items should not be
completed if the client is not overcontrolled.
Little or no Some
Moderate Good match Very good
match match
match (has (has the match
(description (some
significant majority of (exemplifies
does not features
features) features) features)
apply) apply)
Has an aloof/distant
0 1 2 3 4
interpersonal style of relating
4. Deficits in
social
connectedness Highly values
and intimacy achievement, performance,
and competence (or at least 0 1 2 3 4
the appearance of
competence)
Rate the level of OC subtype (only if score on form 3.3 was 17 or higher)
Questions preceded by an asterisk (*) are indicators of high risk and should always be asked.
2. Do you sometimes wish you were dead or think that people or the world
would be better off if you were not around?
YES NO
If the client says yes, ask: When was the last time you thought this way?
Notes
3. Have you ever wanted to harm or kill yourself in order to punish others
(for example, thinking They’ll be sorry when I’m gone or This will teach
them)?
YES NO
If the client says yes, ask: Whom do you wish to punish? When was the last
time you thought this way?
Notes
*4. Have you ever come up with a specific plan to kill or harm yourself?
If the client says yes, ask: What was your plan? Have you ever told anyone
YES NO
about this?
Notes
*5. Have you ever deliberately hurt yourself without meaning to kill
yourself (for example, have you cut yourself, burned yourself, punched
yourself, put your hand through windows, punched walls, banged your head)?
If the client says yes, ask: How often do you deliberately self-harm? When
was your most recent self-harm event? What did you do? Where did you do it?
YES NO
Were other people in the immediate area (for example, in the same house), or
were you alone? If others were nearby, who were they? Did you hope you
might be discovered? What happened afterward? Did you require medical
treatment?
Notes
*6. Have you ever intentionally tried to kill yourself?
If the client says yes, ask: When was your most recent attempt? What did
you do? What happened afterward? Did you require medical treatment? Had
YES NO
you planned it in advance? Did anyone know about your plans? How many
times in the past have you attempted suicide?
Notes
*7. Do you have urges, thoughts, or plans to kill or harm yourself in the
near future?
If the client says yes, the therapist should identify the events that have
triggered the client’s response and then work collaboratively with the client to
YES NO
reduce high-risk factors before ending the session. Plus, ideally, the therapist
should obtain a commitment from the client that he or she is willing to work
on eliminating self-harm or suicidal behaviors during the course of treatment.
Notes
The following questions should be asked only if a client has endorsed suicide and self-harm as a problem.
10. How many people know about your self-harm or suicidal behavior?
If at least one person, ask: Who are they? What have you told them? How (Write
NOBODY
have they reacted? number)
Notes
Therapist: Oh, okay…you’re just tired. But have you ever noticed that you seem to get tired at
certain time points but not others in the same session? For example, whenever we talk
about diary cards? Like now, for instance? You seem to yawn more. Have you ever
noticed that?
Therapist offers warm closed-mouth smile, signals an easy manner, displays open curiosity.
Client: Not really…but now that you mention it…
Volume of client’s voice drops slightly; client offers slightly inhibited smile, averts gaze.
The client is sending a complex social signal that may indicate her mixed emotions and/or her
attempt to deamplify her emotions or conceal her true intentions. For example, the client may be
experiencing embarrassment, a prosocial self-conscious emotion (as evidenced by her inhibited
smile and averted gaze), low-level shame (as evidenced by her lowered voice volume and
averted gaze, but not her inhibited smile), or secret pride, a nonengagement signal of dominance
(as evidenced by her inhibited smile, also known as a burglar smile).
Ask the client directly about the social signal, without assuming
that you already know the answer.
Therapist: Great. So what do you think you might be trying to tell me when you yawn like that?
What’s the social signal?
Therapist offers warm closed-mouth smile, performs eyebrow wag, displays open curiosity.
Client: Nothing, really…I’m just tired.
Client uses mildly exasperated tone of voice, shrugs shoulders minutely, emits low-intensity
sigh.
The client, despite having just admitted to yawning as a possible social signal, has now
reverted to her original position (she is “just tired”). Her exasperated tone of voice, combined
with her low-level appeasement signal (a minute shoulder shrug), suggests possible
nonengagement and/or the presence of a low-level “don’t hurt me” response (see the material on
“don’t hurt me” responses, chapter 10).
Therapist: Oh, okay…you’re tired. Are you tired right now?
Therapist offers warm closed-mouth smile, raises eyebrows, uses playful and curious tone of
voice, makes direct eye contact.
The therapist recognizes the client’s sudden reversal, but instead of challenging her, he gives
her the benefit of the doubt while also showing disbelief by engaging in a low-intensity
therapeutic tease and using playful irreverence.
Client: Umm…yeah, a little bit.
Client slightly shrugs shoulders, shuffles feet, briefly breaks eye contact.
The client may be experiencing warranted (justified) low-level guilt or shame because she is
not being fully truthful about her current state of tiredness.
Stay focused on the social signaling target; avoid getting distracted
by other potential targets.
Therapist: Yeah, okay, you’re just tired…but have you ever noticed that you seem to get tired at
certain time points but not others in the same session? For example, whenever we talk
about diary cards—like now, for instance—you seem to yawn more. Have you ever
noticed that?
Therapist offers warm closed-mouth smile, displays open curiosity.
The therapist ignores the client’s possible deception and models kindness first and foremost,
keeping the focus on the social signaling target (yawning). The only exceptions to keeping the
focus on the social signaling target are the presence of imminent life-threatening behavior and a
possible alliance rupture.
Client: I think it’s just one of the problems of depression—you just feel tired.
Client uses gloomy tone of voice, slightly slumps shoulders, turns gaze slightly downward.
The client’s tone of voice, downward gaze, and slumped shoulders are highly suggestive of a
“don’t hurt me” response (see the material on “don’t hurt me” responses, chapter 10). The client
also does not actually answer the therapist’s question.
Therapist: Yeah, okay. Well, let’s think about it differently. Let’s see if this might help… Tell
me about your weekend—I think you mentioned that you spent some time with your
husband—and I will use your story to demonstrate something about what we have just
been discussing. But make sure you keep your eyes on me while you’re talking.
Therapist intermittently offers warm closed-mouth smile; uses open, curious, matter-of-fact
tone of voice.
The therapist places the potential “don’t hurt me” response on an extinction schedule by
behaving as if all is well, via his lighthearted request for the client to talk about her weekend,
which also keeps the focus on the social signaling target of yawning (see the material on “don’t
hurt me” responses, chapter 10). The therapist does not explain in advance what is going to
happen (see the material on the RO mindfulness practice of “participate without planning” in the
skills training manual, chapter 5, lesson 12).
Client: Okay. So this weekend was our once-a-month big shopping day, and Ben always comes
with me…
Client sighs briefly, uses monotonic voice.
The client’s willingness to comply with the therapist’s request to speak about her weekend
suggests engagement. Her sigh occurs at the very beginning of her verbal statement, most likely
signaling her resigned engagement (that is, her acceptance that her earlier attempts to avoid
discussing the social signaling target are not going to work) and thus indicating therapeutic
progress.
Therapist begins to yawn visibly.
Client pauses and stares briefly upon noticing therapist’s yawn.
Client: …and so when we got in the car, and the rain was absolutely pouring down—it was
really wet…
Therapist yawns again.
The therapist purposefully exaggerates his yawn to ensure the client notices it.
Client stops talking.
Client: Hmmm…I think I can see what you might be getting at.
Therapist: So what did you think when I started yawning like that while you were telling me
about your weekend? I mean, I guess that first off I should ask if you even noticed that
I was yawning.
Therapist offers warm closed-mouth smile and broader smile, giggles slightly, displays open
curiosity.
Client joins therapist in giggling, slightly covers mouth.
The client’s behavior suggests slight embarrassment, acknowledgment of yawning as a
potential problem, and engagement.
Client: I did!
Client makes direct eye contact, uses animated tone of voice, performs eyebrow wag.
The client is engaged.
Therapist: Yeah…so how did it impact you?
Therapist offers warm closed-mouth smile, performs eyebrow wag, uses warm tone of voice,
slowly nods in affirmation, slightly slows pace of speech, slightly lowers voice volume.
The therapist, by slowing his pace (rate) of speech, slightly lowering the volume of his voice,
and combining these prosocial signals with others (a warm closed-mouth smile, an eyebrow wag,
and affirmative head nodding), signals noncritical appreciation and warmth. The therapeutic use
of slower speech and lower voice volume mimics the way we speak in our most intimate
moments to those we love and functions as a powerful social safety signal and positive reinforcer
that can be delivered in seconds (see the material on compassionate gravity, chapter 10).
Client: It made me feel uncomfortable. I thought I was boring you.
Client maintains solid eye contact; her voice tone is animated.
The client is engaged.
Therapist: Those are great observations. I am guessing that behaving in a bored or disinterested
way with your daughter and your husband is not necessarily a core value of yours—
Therapist signals an easy manner, offers warm closed-mouth smile, performs eyebrow wag,
uses warm tone of voice and slightly slower pace of speech, displays open curiosity.
The therapist is purposefully choosing not to highlight the client’s display of embarrassment
because this could imply that the client is doing something wrong by revealing her vulnerability.
Focusing on the client’s embarrassment would also pull the discussion away from its primary
purpose (that is, identifying a new social signaling target).
Client nods.
Therapist: —and perhaps not even something you want to signal to other people as well.
Client: No, it’s not what I want to do, and I think it gets me into trouble. I think I might even
yawn during business meetings.
Client uses earnest tone of voice, bows head, and shrugs shoulders when making comment
about business meetings; combines these nonverbal behaviors with slight smile and eye gaze
directed toward therapist.
The client is signaling engagement and prosocial embarrassment. Although displays of
embarrassment most often involve gaze aversion, the client maintains eye contact, possibly
because she is trying to gauge the therapist’s response to her self-disclosure.
Therapist: Yeah… It’s great that you are noticing these things—and I think it’s fantastic that you
were able to share them with me…because it’s how I get to know you better, and also
maybe how you get to know yourself better. But, as we both have previously agreed,
you can be pretty tough on yourself, and we also know that when you find a problem,
watch out, because you’re going to try to fix it right away. But we also have both
agreed that sometimes your problem-solving spirit can get you into trouble, and that
it’s exhausting to try and fix everything—
Therapist pauses, smacks hand on forehead.
Therapist: Wow! And here we are, talking about you being exhausted!
Therapist smiles warmly, winks slightly, slows pace.
Therapist: So if it’s okay with you, what I would like to do is slow things down just a bit and not
immediately assume that yawning is necessarily a problem, without getting some more
data to prove our case. How does that sound when I say that to you?
Therapist signals an easy manner, displays open curiosity, slightly bows head, slightly shrugs
shoulders, makes openhanded gesture, offers warm closed-mouth smile, raises eyebrows, makes
direct eye contact.
The therapist is signaling nondominant cooperative friendliness in order to encourage the
client’s candid disclosure by combining appeasement signals (a slightly bowed head, a shoulder
shrug, openhanded gestures) with cooperative-friendly signals (a warm closed-mouth smile,
raised eyebrows, direct eye contact). The therapist checks in with the client to confirm her
engagement before proceeding.
Client: Yeah, I agree… I think sometimes I rush in too fast to fix something that I find out later
never needed fixing.
Client uses thoughtful, earnest tone of voice.
The client is engaged.
Therapist: Okay, cool. So here’s my thought. Why don’t we begin by simply monitoring
yawning for a week or so, without trying to change it. That way, we can find out just
how often it is happening, and whether there are particular times or topics where you
find yourself yawning more, or whether it only happens with certain people, like your
husband and your daughter—or, say, someone at work. I mean, it’s not as if you are
yawning all the time—like right now, for instance, you’re not yawning. How does that
sound to you when I say that?
Therapist signals an easy manner, displays open curiosity.
The therapist checks in with the client to confirm her engagement before proceeding.
Client nods.
Client: So that means I should put it on my diary card, and I’ll just note how frequently I yawn
and when it happens. Should I just count the number of yawns?
Client uses animated tone of voice, displays open curiosity.
The client is engaged and is already working on how to operationalize the therapist’s
suggestion to monitor her yawning behavior.
Therapist: Yeah, you could do a frequency count—how many yawns per day—and then, in that
little box on your diary card labeled “Notes/comments/chain analysis,” you might
make a note of whether you were with someone or alone when you yawned, and if you
were with someone, who it was, and what the topic was.
Therapist offers warm closed-mouth smile, wider smiles, and compassionate expressions of
concern (see the material on expressions of concern, chapter 6).
Therapist: Plus, it would be cool to see if any of the non–social signaling targets we have already
been monitoring, like resentment or thoughts about not being appreciated, are linked to
yawning. Finally, I also think it would be useful to add a new non–social signaling
target when it comes to yawning, and—tell me if you disagree—I think we should also
start recording each day, using our 0 to 5 scale, how rested you felt when you woke up
in the morning. It might be cool to see how your degree of tiredness comes into the
picture, considering that was one of your original hypotheses for what might be
triggering the yawns.
Remind the client to alert you if she finds herself struggling with
completion of the diary card, no matter what the reason.
Therapist: And to help with this, just as we’re trying to do with other targets we are monitoring,
if you start to find yourself not wanting to monitor yawning or anything related to it,
don’t keep it a secret!
Therapist smiles.
Therapist: Let me know, and we will sort it out together because, remember, as we have talked
about before, when you don’t complete diary cards, or partially complete them, or
pretend to complete them, you are not only making it harder for us to get you out of the
hole you sometimes describe yourself as being in, you’re also sending me a big social
signal!
Therapist smiles widely.
The therapist is signaling both the seriousness of the client completing the diary card and the
importance of the client letting the therapist know if she struggles with completing the diary
card. The therapist is attempting to convey these points in a manner that communicates his
kindhearted appreciation as well as his genuine willingness to consider other options.
Therapist: Fortunately for you and for me, at least so far this has not happened. But you never
know what might happen, and I for one would like to know. How does that sound to
you?
Client confirms agreement.
Therapist: Okay. Before we change topics, let’s make sure we have the new targets recorded on
your card.
Client nods agreement.
Appendix 6
Use the diary card to identify the social signaling target that will become the focus of the
session’s behavioral chain analysis.
Therapist: Okay, I can see here on your diary card that it seems like Sunday may have been your
worst day. It appears that you walked away, and also on Sunday you reported smiling
while angry and refusing help—though smiling while angry also occurred on Monday.
Plus, on Sunday you reported experiencing both high Fatalistic Mind signaling and
thinking and high Fixed Mind signaling and thinking on the same day. I also see that
you had high shame, self-critical thoughts, and high urges for revenge that day. You’ve
done a great job of filling this out. There are several places we could go today, but
Sunday really stands out. I know we had a special homework assignment last week that
involved asking a particular person out on a date, using your Match + 1 skills.
Therapist displays open curiosity, uses a matter-of-fact voice tone, scans client’s diary card.
The therapist is looking for the previous week’s most seriously problematic day that was
linked to a social signaling target (in this case, the target is the behavior labeled “walking
away”). Therapists should avoid spending too much time reviewing the diary card; ideally, the
review of the diary card should take approximately six or seven minutes (see “Individual
Therapy Structure and Agenda,” chapter 4). Diary cards provide a quick overview of the client’s
preceding week. The aim is to identify the problematic behavior that will become the focus of the
session’s chain analysis. Most often this problematic behavior should be one of the social
signaling deficits (that is, the “biggest,” or most conspicuous, maladaptive social signal of the
week). The only exception is that imminent life-threatening behavior takes precedence. (For an
explanation of Match + 1 skills, see the material on Flexible Mind ALLOWs in the skills training
manual, chapter 5, lesson 21.)
Therapist: So…I’m curious. Was Sunday also the day you chose to ask Mary out on a date?
Therapist offers a warm closed-mouth smile.
The therapist is checking out her personal hypothesis by asking the client whether the social
signaling target labeled “walking away” was linked to the homework assignment of asking
someone out on a date.
Client: Yeah, it was. Um…I just felt so completely miserable after asking her. It just obviously
was never going to work out. I don’t know…I just got to this place where I just started
thinking Why bother? So I just walked out.
Client maintains eye contact.
The client is engaged, although it is not exactly clear what happened.
Link target to valued goals (determine the most impactful social signaling problem when
there is more than one on the same day).
Therapist: Yeah…Okay. Well, that makes sense and seems important, especially considering
your goals to establish a long-term romantic relationship with someone. Plus, we
decided together last session that Mary might be someone you would really like to get
to know better—at the very least as a friend. So something must have happened for
you to walk away from all that, and I am aware of imagining that is not what you
wanted to socially signal.
Therapist signals an easy manner and continues to display open curiosity.
Instead of asking for clarification of the client’s preceding statement, the therapist remains
focused on the immediate goal of identifying a social signaling target for chain analysis and then
setting the agenda for the remainder of the session. A common mistake during agenda setting is
to ask for more information than is really needed; this can make review of the diary card take
much longer than intended and can eat into valuable session time. When there is more than one
maladaptive social signal recorded on the client’s diary card for a single day—a very common
occurrence—the therapist should pick the one that probably caused (or could have caused) the
most damage to the client’s relationship(s).
Client nods.
Therapist: Plus, we always want to work on the biggest social signal. So of the three social
signaling problems that occurred on Sunday—smiling while angry, refusing help, and
walking away—which one do you think was the most powerful social signal that made
it more likely, not less likely, for you to continue to feel alone and isolated from
others?
Client: Walking away. The refusing help happened afterward, and so did the smiling when
angry. But if I hadn’t screwed up and walked away, probably none of the other issues
would have happened, at least on that day…She probably won’t speak to me again.
Client’s voice tone is gloomy; client’s eyes are slightly averted.
The client remains engaged but may also be signaling Fatalistic Mind thinking or a low-level
“don’t hurt me” response.
Therapist: So it sounds like walking away would be the best target for us to take a more in-depth
look at, after we finish setting the rest of the agenda. How does that sound to you?
Therapist signals an easy manner.
The therapist avoids the temptation to problem solve or explore the issue further and instead
confirms the client’s agreement to target “walking away” as the social signaling problem that
will be targeted via chain analysis. The therapist also checks in with the client to confirm the
client’s agreement before moving on.
Client: Yeah, that sounds good.
Client has a matter-of-fact voice tone, makes direct eye contact.
The client is engaged.
The therapist and client ultimately complete setting the agenda, and the therapist briefly
checks in with the client about RO skills training classes before conducting the actual chain
analysis (see appendix 7, “Using RO DBT Chain and Solution Analysis: Principles and In-
Session Protocol”).
Appendix 7
Determine the context in which the problematic social signal occurred (the who, what,
when, where, and intensity of the signal).
Therapist: Okay, so…well done. It sounds like we are now ready to begin our chain analysis.
Let’s see if you and I can figure this out together. So, first off, where were you and
what time of day was it on Sunday when you walked away from Mary?
Therapist offers a warm closed-mouth smile, displays open curiosity.
The therapist reinforces the client’s engagement, then focuses on identifying the contextual
features surrounding the maladaptive social signal. In this case, some of the contextual
information has already been obtained (that is, Mary was the recipient of the client’s maladaptive
social signal).
Client: It was around nine in the morning. As you know, my bird-watching club always has a
little gathering over coffee for the guides, where we plan who will go with which
group and the routes that will be taken. Mary was there, just like always, along with
the typical collection of volunteer nature guides—probably twenty of them altogether.
Client’s voice tone is earnest.
The client is engaged and staying on topic.
Therapist: What about contributing factors? Was there anything going on just prior to the
prompting event, or the day before, that may have made it more likely for you to walk
away? For example, had you eaten that day? How was your sleep? Any interpersonal
conflict the day before, or just prior to the event?
Therapist signals an easy manner, uses matter-of-fact voice tone, displays open curiosity,
performs eyebrow wag.
The therapist’s questions are aimed at establishing contributing factors that may have made it
more likely for the maladaptive social signal to occur on that particular day. This should not take
more than one or two minutes; it is important not to spend too much time on contributing factors.
These are sometimes important areas for solution analysis, but therapists should spend the
majority of their time focusing on the links in the chain that were triggered by the prompting
event. In this case, the therapist and the client—now in the twenty-first session of therapy, or the
late phase of treatment—have already conducted multiple chain analyses, and so there is no need
for the therapist to define what she means when she talks about contributing factors or the
prompting event. Therapists should look for prompting events that are temporally close—ideally,
no more than thirty minutes prior to the maladaptive social signal (in reality, prompting events or
triggers most often occur within seconds to a few minutes prior to the problem social signal).
This helps prevent unnecessarily long chain analyses.
Client: Well, I was actually feeling pretty tired. I was…um…the night before, I had started to
obsess about what might happen, so I went online and started to research tips on
dating.
Client’s voice tone is earnest.
The client is engaged and staying on topic.
Client: I ran across some interesting research that you would probably like.
Client offers quick, slight smile.
Client: I decided that even though we had discussed the importance of not overplanning, it would
be best if I rehearsed everything. I gave myself a limit, though—only ten rehearsals.
Client smiles slightly.
Client: The problem is, this took longer than I had anticipated. So I didn’t get to bed my usual
time and had a pretty restless night’s sleep. I suppose it’s possible that I was more
concerned about the homework assignment than I realized.
Therapist: Well, hmmm…at least we know you give a damn!
Therapist gives a quick wink, offers a warm closed-mouth smile, gives a low-level chuckle,
displays a slight shoulder shrug.
Therapist: Recall, it wasn’t so long ago that you were adamantly trying to convince me that you
didn’t really care much about anyone or what others thought about you.
The therapist is signaling playful irreverence. Her use of the word “damn” is intentional and
signals friendship (friends use less formal language during interactions).
Therapist: At one time, you thought you might not really care about anybody—but now you are
losing sleep over them! Wow.
Therapist offers a warm closed-mouth smile, performs eyebrow wag.
The therapist suggests that losing sleep over another person is proof of caring, thus providing
corrective feedback without having to rub the client’s nose in it. This is a therapeutic tease (see
“Teasing, Nondominance, and Playful Irreverence,” chapter 6). A therapeutic tease can also be
used to lighten the mood (without making a big deal of it) and, ideally, to signal to a client that
he has not done anything wrong. In this case, the client, even though he struggled with his
homework, did practice The Match + 1 skills; he also completed his diary card and is engaged in
the session. This is important when working with hyper-self-critical OC clients—actions often
speak louder than words.
Therapist: What comes to mind when I say that to you?
Therapist leans back in chair, offers warm closed-mouth smile, emits slight therapeutic sigh.
By leaning back in her chair and offering a closed-mouth smile and a therapeutic sigh (see
“Therapeutic Sighs,” chapter 6) while checking in with the client, the therapist signals to the
client that she is not “on his case” (gloating or criticizing) but is instead really interested in his
experience.
Client: Yeah…I guess I’m starting to see your point—though I hate to admit it.
Client grins sheepishly, slightly shrugs shoulders, maintains eye contact; client’s head is
slightly bowed.
This is a complex social signal. The client is most likely signaling a blend of emotions
(prosocial embarrassment, genuine pleasure, and friendly cooperation). The embarrassment is
evidenced by the slight shoulder shrug, bowed head, and verbal acknowledgment of being
wrong. The sheepish grin is a mixture of an inhibited smile (most often seen in displays of
embarrassment) and a genuine smile of pleasure (see chapter 6). The client is acknowledging that
his prior insistence on not caring about what others think may not have been fully accurate; the
sheepish smile and the shoulder shrug function as a nonverbal repair (see appeasement gestures).
Thus the client is engaged.
Client: I am starting to think that maybe I do care…at least more than I thought in the past.
The fact that the client has joined in with the therapist suggests that his experience of her
observation is positive. If he had not lightened up, the protocol would have been for the therapist
to move immediately to compassionate gravity by leaning back in her chair and, with a warm
closed-mouth smile and an eyebrow wag, asking, “So why did you think I just said that?”
Therapist: Yeah, that makes sense to me—and thanks for letting me know.
Therapist signals an easy manner, offers a warm closed-mouth smile, performs eyebrow wag.
The therapist reinforces the client’s self-disclosure but purposefully chooses, in this case, not
to make a big deal of it (for example, by praising it more intensely or exploring more deeply).
Instead, she silently notes what the client has said and files it away to be discussed at another
time (such as in a future session). This functions to keep the focus on the chain analysis, and the
client may also experience it as more reinforcing (recall that OC clients dislike the limelight). It
is important to note, however, that there is no right answer here.
Therapist: Plus, I am aware of imagining that walking away was not something you had planned
in advance—and we know from our prior work together that, for you, walking away is
something that, from what we can tell, seems to most often serve two purposes—one,
to punish someone for doing something you don’t like, and, two, to avoid conflict. Is
that right?
Client nods.
Identify the prompting event.
Therapist: So when you think back to Sunday, what do you think might have happened to trigger
your walking away?
Therapist displays open curiosity.
Client: Well, when I arrived, instead of being behind the sign-in desk, like she’s always been in
the past, I was surprised to find her sipping a cup of coffee and talking to some new
guy who I heard had just moved up from Boston—a retired academic, if I recall
correctly. This was not what I had planned.
Client’s voice tone is earnest, although with some sarcasm as he says “a retired academic, if I
recall correctly.”
The client’s slightly sarcastic tone of voice suggests possible jealousy or envy. The client is
engaged.
Confirm that the prompting event is relevant (that is, confirm that the maladaptive social
signal essentially would not have occurred if the event had not occurred).
Therapist: So here’s my question for you. Do you think you would have still walked away if
Mary had not been talking to this new guy?
Therapist uses matter-of-fact voice tone, displays open curiosity.
The therapist is using the RO DBT strategy of asking rather than telling in order to confirm
that the prompting event identified by the client is relevant. The therapist ignores the potential
new target possibly related to envy and bitterness. Instead, she silently notes what the client has
said and files it away for later (for solution analyses, or as another possible target). This keeps
the therapist and the client focused on the chain analysis.
Client: No. When you put it that way, I’m pretty sure it wouldn’t have happened.
Client’s voice tone is earnest.
Identify the chain of events (actions, thoughts, feelings, sensations) leading up to the
maladaptive social signal.
Therapist: Okay, so you saw this new guy with Mary… So what happened next? What did you
think, feel, or do right after seeing this?
Therapist displays open curiosity.
Client: I remember thinking She’s not the woman I thought she was.
Client’s voice tone is earnest but gloomy.
The client is engaged, although the thought he reports is somewhat ambiguous. In general,
therapists should get into the habit of asking for clarification whenever an OC client is indirect in
his social signaling; for example, “When you say she’s not the women you thought she was,
what does that mean?” This provides an opportunity for the client to practice being direct, open,
and candid when revealing his inner experience (a core part of healthy relationships) and to take
responsibility for his perceptions and actions by publicly declaring them. It can also help the
therapist avoid making erroneous assumptions about the client; however, further clarification at
this stage is not a requirement.
In general, I use three broad principles to guide me in deciding whether or not to ask for
additional clarification. First, I consider the phase of treatment—the earlier the phase, the more
likely I am to ask for clarification. Second, I consider the time available for the chain analysis—
the less time I have, the less likely I am to focus on internal behaviors (thoughts, emotions, and
sensations) so that I have sufficient time to focus on social signaling deficits. Third, I remind
myself that any link in the chain, if it’s especially relevant, can always be explored again later,
during the solution analysis.
Links in the chain that pertain to ambiguous thoughts often present excellent opportunities for
a client to practice self-enquiry on his own rather than having the therapist do the work for him.
In this case, the therapist might encourage the client to use self-enquiry to sort out what his
intended meaning might be. This is especially helpful when a client reports, “I don’t know” or
struggles with knowing what a particular statement means for him. Self-enquiry can be assigned
as homework, and the question of the statement’s meaning can be revisited during the next
session.
Therapist: Okay, so you thought She’s not who I thought she was. Was there an emotion or
sensation linked to this thought?
Therapist displays open curiosity.
The therapist has moved to the next link in the chain—in this case, guessing that the client’s
thought was linked to some sort of emotion.
Client: I felt betrayed—and threatened by this other guy. He’s one of those smooth talkers. So I
guess anger, or maybe even envy or jealousy. We were just studying that in skills class.
Client uses earnest voice tone, makes direct eye contact.
The client is engaged. Plus, his ability to come up with several emotional alternatives most
likely reflects the late phase of his treatment (he has already gained a great deal of knowledge
about emotions, both in individual therapy and in skills training class).
Therapist: Okay, well done. I’m not sure we need to necessarily know the exact emotion you
felt. But I agree that anger, jealousy, or even envy might fit. Plus, I can see now why
you recorded high urges for revenge on your diary card, plus both Fatalistic Mind
thinking and Fixed Mind thinking. We can decide together later, if it seems important.
Or, if you like, you might want to take a look at that worksheet we’ve used before
—“Using Neural Substrates to Label Emotions”—as a homework assignment.
Therapist signals an easy manner, offers a warm closed-mouth smile.
The therapist is modeling flexibility, thus taking heat off an engaged client, while remaining
focused on social signaling, which is the primary focus of treatment. Therapists should get into
the habit of pulling out the skills training manual and turning to worksheet 6B when a client
struggles to identify an emotional link in the chain. This worksheet uses body sensations, urges,
and social signals to help OC clients learn to label different emotions.
Client writes therapist’s suggestions in his self-enquiry journal.
Therapist: But what I’m really curious about is how all this internal stuff started to influence
your social signaling. What happened next? How did you get from this anger to
actually approaching Mary to ask her out for a date?
Therapist displays open curiosity, offers a warm closed-mouth smile, performs eyebrow wag.
Client: I just thought Well, let’s just get it over with. But I wasn’t about to go up and ask her out
for a date when she was talking to that clown. So I waited and watched, and…
Client’s voice tone is earnest, but with a pronounced sarcastic edge.
The client is engaged and staying on topic, and he is answering the therapist’s questions
directly.
Therapist: How long did you wait?
Therapist displays open curiosity, performs eyebrow wag.
The therapist is looking for evidence of warranted (justified) jealousy. She is also choosing not
to comment on the client’s use of the word “clown,” for several reasons. First, to highlight this
word as judgmental would itself be judgmental. Second, the client may be signaling friendship
by allowing himself to use more colorful language. Third, highlighting the word “clown” would
move them away from the chain analysis and its focus on the behavior labeled “walking away.”
The therapist does note the client’s use of the word “clown,” as well as the fact that this is the
second time in the last few minutes that he has used a sarcastic tone of voice. But even though
sarcasm is a potentially important maladaptive social signal linked to the OC theme of envy and
bitterness, she chooses to collect more data before discussing it with her client, and her choice
keeps them focused on completing the chain analysis. Sarcasm most often is linked to envy,
bitterness, disdain, and/or contempt (that is, to social status–related emotions that are themselves
linked to the desire to dominate). It is a powerful indirect social signal that can negatively impact
a client’s social connectedness and go against his core values for fairness or kindness. If sarcasm
appears repeatedly over multiple sessions, then the therapist will move to address this indirect
social signal (see appendix 5, “Targeting Indirect Social Signals: In-Session Protocol”).
Client: Oh, I don’t know…I suppose it wasn’t that long. Someone came along in a few minutes
and interrupted their conversation, and the guy just wandered off with that person. So I
just marched right up to Mary—but I think by then I had forgotten everything I had
planned to say.
Client uses matter-of-fact voice tone.
The client is engaged, as evidenced by his direct answer to the question. The short duration of
the interaction between Mary and the other man suggests that the client’s jealousy was not
warranted.
Therapist: Do you remember what you were thinking about or feeling when you started to walk
toward her?
Therapist displays open curiosity.
Client: I was thinking She’s cold and calculating. She just wants to hurt me.
Client presents a flat face, uses monotonic voice tone.
Therapist: What exactly did you say to her?
Therapist displays open curiosity, offers a warm closed-mouth smile.
The therapist is focused on obtaining a detailed description of any potentially problematic
behavior.
Client: I just said, “Hey, would you like to go out sometime?”
Client uses matter-of-fact voice tone, stares at therapist.
Therapist: Really…? In exactly that tone of voice?
Therapist raises eyebrows, but without an accompanying smile; her voice tone is questioning;
she tilts her head slightly to one side and performs a lip curl (a quick upward movement of the
upper lip on one side), which is followed almost immediately by a warm closed-mouth smile and
a slight shoulder shrug.
The therapist’s nonverbal behavior—a complex social signal—takes place in less than one
second. It is a classic therapeutic tease, and I refer to it as the “Oh really…?” response. The lip
curl is a very interesting part of this tease because it normally is associated with disgust; thus
many therapists find it very difficult (at first) to use in therapy, even when they fully recognize
its therapeutic value and easily deliver the “Oh really…?” signal to their friends and family
members all the time. But this is an important social signal for therapists to give themselves
permission to use when working with hyper-threat-sensitive OC clients. It allows a therapist to
informally point out flaws, but without being too heavy-handed about it.
Client: Yeah, I figured she wouldn’t want to anyway. I was like, well, you know…I don’t know.
I just wasn’t thinking.
Client’s voice tone is gloomy; client has slightly downcast eyes, slumped shoulders, slight
postural shrinkage.
The client appears to be signaling low-level guilt or shame; his words don’t directly imply that
he believes he has done anything wrong, but his nonverbal social signaling does. Guilt stems
from one’s negative evaluation of oneself, which arises whenever one fails to live according to
one’s own values or one’s idealized self, by contrast with shame, which arises in connection with
real or imagined evaluations by others (see “Fun Facts: Shame Differs from Guilt” in the skills
training manual, chapter 5, lesson 8). Unlike shame, however, guilt has no facial, bodily, or
physiological response associated with it, and research shows that people distrust an expression
of guilt (such as saying, “I’m sorry”) if it is not accompanied by a bodily display prototypical of
shame. In this case, the client’s bodily displays—postural shrinkage, lowered gaze—are
prototypical of shame, suggesting that he values the therapeutic relationship and that it is
important to him to try hard to complete his homework assignments.
Therapist: So what did she say when you asked her out?
Therapist displays open curiosity.
The therapist is staying focused on the chain analysis rather than moving to address the
client’s possible feelings of guilt or shame or attempting to regulate the client.
Client: She said, well, she wanted to think about it.
Client’s voice tone and facial expression are flat.
Therapist: So what did you do?
Therapist displays open curiosity.
The therapist is focused on finding the important links in the chain—thoughts, actions, and
emotions.
Client: I just said, “Okay, that figures.” And then I just turned around and marched over to the
coffeemaker. I didn’t say anything more.
Client’s voice tone and facial expression remain flat.
Whenever possible, ask the client to demonstrate the maladaptive social signal; don’t
assume that you know what it looks like.
Therapist: So can you show me what it looked like when you walked away? I mean, did you
storm out or sneak away? When you marched over to the coffeemaker, was it with
military precision? I guess what I am asking is this—do you think it was clear to Mary
that you were not happy about what was going on?
Therapist shifts to more upbeat/musical voice tone, offers a warm closed-mouth smile and
slight wink.
Client stands up and walks briskly across the office.
Therapist displays open curiosity, offers a warm closed-mouth smile.
This step is not always possible to perform, because sometimes it simply doesn’t make sense
or isn’t possible to demonstrate a social signal in session. Yet it can be very important to do so;
for example, a client may report having expressed rage, but when he demonstrates what he
actually did, it becomes clear to the therapist that the way the client behaved would not be
considered maladaptive by most people. Performing this step can prevent the therapist from
inadvertently targeting adaptive behavior (recall that OC clients tend to assume any expression of
emotion is maladaptive). Sometimes this step is best performed at the very start of a chain
analysis (for example, when the therapist is reviewing the diary card and attempting to ascertain
which social signal to target). The general rule is that if the maladaptive nature of the social
signal depends on its intensity (for example, at a very low or high intensity of expression, it
might be seen as adaptive), or if the therapist for any reason doubts whether it may be
maladaptive, then the therapist, before beginning the chain analysis, should have the client
demonstrate what he did. However, this is usually not necessary, because the maladaptive
behavior is so obviously maladaptive.
Client smiles.
Client: I just said, “Okay, that figures,” but with a flat voice—not sure if I can get it right just
now…’cause you’re doing that thing again…
Client giggles slightly, smiles, makes direct eye contact.
The client is engaged. The client’s statement “you’re doing that thing again” refers to an inside
joke with the therapist (recall that this is their twenty-first session). In this case, “that thing” is
therapeutic teasing. In earlier sessions, the client has reported that he finds it hard to act
depressed or upset when the therapist teases him. This became an important area of discussion
for the client because it helped him come to grips with the fact that most often (but not always)
his hurt or sad-looking behavior is phony and is used to control people; see the material on
“don’t hurt me” responses, chapter 10; see also worksheet 16.A (“Flexible Mind REVEALs”) in
the skills training manual, chapter 5, lesson 16.
Client: I guess it sounded something like this…
Client deepens voice:
Client: “Okay, that figures.” I forgot to raise my eyebrows…and I’m pretty sure I wasn’t
smiling.
Client smiles sheepishly, then attempts to regain composure.
Identify the consequences of the problematic social signal, including possible reinforcers.
Therapist: Hmmm…so you said, “Okay, that figures” with a flat voice tone and flat face.
Client nods.
Therapist: So what happened after you walked away?
Therapist signals an easy manner, uses serious voice tone, slows pace of speech.
The therapist has moved from playful irreverence to compassionate gravity (see “Playful
Irreverence vs. Compassionate Gravity,” chapter 10).
Client: I don’t know. I went over to the coffeemaker, and I just poured myself a coffee. I just
stood in the corner and I started thinking Well, everyone has hidden motives, and they
are going to manipulate me if given the opportunity. After that, I decided to get out of
there. I left the room and sat outside on a bench. At the time, I felt almost righteous.
But when I got home, I started thinking that I was acting like a child… I just stomped
off—and then left early. I don’t know…it feels like I’m doomed for failure.
Client’s voice tone is earnest but gloomy; client makes direct eye contact, but his head is
slightly bowed.
The client is engaged and likely feeling moderate shame, which may be partly justified.
Therapist: So the consequences for you were that you felt terrible. And yet what happened is
highly understandable—I mean, you hardly had any sleep the night before. Plus, you
haven’t really ever dated anyone your entire life. So it makes sense that you might
have struggled a bit the first time you tried to put Match + 1 skills into action. So my
self-enquiry question for you is…
Therapist offers a warm closed-mouth smile.
Therapist: …are you using this as another opportunity to prove to yourself and maybe others that
you’ll never get out of this depression?
Therapist pauses; places hand up in the air, palm forward, signaling “stop.”
Therapist: But stop right there. You’re not allowed to answer that question, because it is a self-
enquiry question.
Therapist smiles warmly and giggles.
Client smiles.
Therapist: So one of the things we might want to think about today is, are you being too hard on
yourself again?
Therapist pauses.
Client is alert.
Therapist: For example—although your behavior may have not been at its best—it’s not like you
went up and punched the guy she was talking to, or yelled at her. Plus, I haven’t heard
much yet about something very important…
Therapist pauses for effect.
Therapist: Do you know what I am thinking?
Client shakes his head no.
Therapist: Well, as far as I can tell, she actually hasn’t said no to going out on a date with you.
The good news is that there is a wide range of things we can do to reverse the damage
—assuming there was any in the first place.
Therapist uses warm voice tone, offers a warm closed-mouth smile and slow affirmative head
nod, slightly slows pace of speech, and lowers voice volume.
The therapist’s slowed pace (rate) of speech, combined with a slight lowering of her voice
volume, signals noncritical appreciation and warmth when used along with other prosocial
signals, such as a warm smile, an eyebrow wag, or affirmative head nodding. The therapist also
encourages self-enquiry, but in a playful manner, thus moving between compassionate gravity
and playful irreverence.
Client: Yeah…I guess. We don’t really know.
Client shrugs.
Therapist: Has anything else happened since? For example, have you tried to contact Mary and
repair any damage done?
Therapist displays open curiosity.
The therapist is starting to move toward solution analysis (see chapter 10).
Client: No. I assumed she wouldn’t want to hear from me.
Client’s head is bowed.
Conduct a solution analysis after completing the chain (remember not to overwhelm the
client with too many solutions from one chain; you can build over time).
Therapist: Yeah, feeling ashamed is not a good way to start the day.
Therapist offers a warm closed-mouth smile.
Therapist: What I would like us to do now is go back and look at each link on the chain and see
if we can come up with skills that you might use the next time. For example, we
probably need to talk about your tone of voice when asking what kept you from
practicing Match + 1, and maybe what walking away from the scene communicates to
others. Would you be willing to do this?
Client nods yes.
Therapist: To start, just how committed were you to genuinely practicing Match + 1 in the first
place?
Therapist signals an easy manner, displays open curiosity.
The therapist is orienting the client to the next step of the chain analysis—finding solutions for
each maladaptive link in the chain. She reviews several previously highlighted maladaptive links
in the chain as potential areas for work and starts the solution analysis by first assessing the
degree of the client’s commitment to completing his homework assignment (that is, using Match
+ 1 skills to ask someone out on a date).
Appendix 8
Place a checkmark in the box next to each statement that accurately describes the treatment
environment.
Ideally, chairs in individual therapy settings should be positioned at a 45-degree angle to each
other, and in a manner that maximizes physical distance. Room temperature is set lower than
normal.
If there is no central air conditioning, T uses an electric fan or similar means to cool the room
(people will tell others when they are cold but are less likely to reveal when they feel hot because
of links between feeling hot and anxiety).
T has a cup of water (tea, coffee) for himself/herself and offers C something to drink (water,
tea, coffee) at the start of session.
II. RO DBT Individual Therapy, Orientation/Commitment Phase
(Sessions 1–4)
Place a checkmark in the box next to each statement that accurately describes what happens
during the session.
A. Session 1
T orients C to the two-way dialogue and collaborative stance between C and T in RO DBT at
the very start of the first session (for example, by explaining that RO DBT involves therapeutic
dialogue between C and T that may at times require T to interrupt C or direct the discussion
toward particular topics).
T briefly orients C to the aims and structure of the first session (for example, T obtains some
important background information and determines the extent to which RO DBT represents a
good treatment fit for C).
T obtains agreement from C that C’s personality style is best described as overcontrolled and
that C is committed to target maladaptive OC behaviors as a core part of therapy.
T uses the steps in the RO DBT script to guide the discussion (see “Four Steps for Identifying
Overcontrol as the Core Problem in the First Session,” chapter 5).
The discussion is time-limited (approximately ten minutes) and conducted with an easy
manner.
T acts out the bodily gestures and facial expressions that typify each style in order to make it
viscerally apparent to C which style best fits C.
T uses dramatic, overstated, and exaggerated facial expressions, gestures, and tones of voice
when describing the undercontrolled style of coping.
T displays a calmer and more precise, constrained, and controlled manner when describing the
overcontrolled or OC style of coping.
T assesses current and past history of suicidal and self-harming behavior (typically, this
assessment starts about thirty minutes into the session, to allow sufficient time for the risk
assessment and suicide/self-injury prevention plan, if needed).
T uses the RO DBT Semistructured Suicidality Interview (see appendix 4) to guide suicide
assessment.
T addresses any imminent life-threatening behavior in the moment, using principles from the
RO DBT crisis-management protocol (see chapter 5) as needed to guide his/her interventions.
T obtains C’s commitment to return for at least one more session to discuss in person (not via
email, text message, or telephone) any urges or thoughts about dropping out of therapy before
actually making a decision to drop out; T tells C, “I have faith in your ability to follow through
with your prior commitments.”
B. Session 1 or 2
T uses RO DBT teaching scripts to facilitate the introduction of the RO DBT neurobiosocial
theory for overcontrol and RO DBT hypothesized mechanism of change.
T continues, as necessary, to orient C to the overall structure of treatment and to the principles
of the treatment.
T identifies two to four of C’s valued goals, with at least one (such as forming a romantic
partnership, improving close relationships, raising a family, being a warm and helpful parent, or
being gainfully and happily employed) linked to C’s social connectedness; see the skills training
manual, worksheet 10.A (“Flexible Mind Is DEEP: Identifying Valued Goals”).
T orients C to the RO DBT diary card.
III. RO DBT Individual Therapy, Working Phase (Sessions 5–29)
Place a checkmark in the box next to each statement that accurately describes what happens
during the session.
A. Timing and Sequencing Strategies
T identifies and monitors on diary cards at least three to five core social signaling targets
linked to OC themes at any given time during the course of therapy (social signaling targets are
expected to change slowly over time, be refined, and/or be replaced with new ones as the client
improves).
T conducts a chain and solution analysis of a social signaling target each session (it is
recognized that at least occasionally some sessions will not include a formal chain analysis, but T
should consider two or more sessions in a row without a chain analysis problematic).
T introduces the importance of learning skills to activate the social safetey system in order to
address core OC biotemperamental predispositions (such as heightened threat sensitivity;
sessions 5–7).
T explicitly teaches and practices, in session, RO skills designed to activate the social safety
system (for example, the Big Three + 1; sessions 5–7).
T explains the importance of the RO self-enquiry journal and shows C an example of a journal
entry (by using the examples in chapter 7, for instance, or by showing C an example from T’s
personal RO journal; sessions 5–9).
T encourages C to use the self-enquiry handouts and worksheets in the skills training manual
to facilitate self-enquiry practices (see handout 1.3, “Learning from Self-Enquiry”; sessions 5–9).
T introduces loving kindness meditation (LKM) and conducts an LKM practice in session for
approximately fifteen minutes (sessions 7–9).
T sticks to the LKM script provided in the skills training manual.
T elicits observations from C after the first LKM practice and troubleshoots problems.
T makes an audiorecording in session of the LKM practice (using C’s smartphone, for
example) and encourages C to use the recording each day to facilitate LKM practice.
T monitors LKM on the diary card.
T introduces the twelve questions in Flexible Mind ADOPTs that are used to assess whether to
accept or decline critical feedback and encourages C to practice using them when feeling
criticized (sessions 10–12).
T informally teaches Flexible Mind REVEALs skills, with a particular emphasis on
“pushback” and “don’t hurt me” responses, and uses this to facilitate targeting indirect social
signaling on the diary card (sessions 13–17).
T discusses the importance of personal self-disclosure in developing relationships, practices
Match + 1 skills in session, and assigns related homework (sessions 11–18).
T introduces the concept of forgiveness and informally teaches Flexible Mind Has HEART
skills (sessions 13–24).
Ideally, by session 14 T and C will have had multiple opportunities to practice alliance rupture
repairs—proof of a good working relationship in RO DBT.
Each repair (even if minor) has been linked, ideally, to C’s values and treatment goals.a
T reminds C—ideally, at least ten weeks prior to the end of RO DBT therapy—that therapy
will be ending soon (for example, during session 20 in the thirty-week RO DBT outpatient
treatment model).
T teaches C, as necessary, how to grieve the ending of relationships without falling apart (see
the skills training manual, handout 29.3, “Strengthening Forgiveness Through Grief Work”).
T reviews key RO skills as part of a relapse-prevention plan (sessions 25–28).
T uses last session to celebrate C’s life and notice with C the changes C has made over time.
Minor changes are celebrated as much as more major ones, and reminiscences of notable therapy
moments are often shared. Food and tea or coffee may be shared, to symbolize the transition, and
T, ideally, encourages C to keep in contact over time (assuming that C would like to).
B. Individual Therapy Session Agenda
Place a checkmark in the box next to each statement that accurately describes what happens
during the session.
A. RO DBT Therapeutic Stance
T is responsive to and flexible regarding what is happening in the moment rather than
operating from a predetermined plan or professional role (that is, T knows how to leave his/her
professional “game face” at home).
T has a relaxed professional style that models radical openness and self-enquiry.
T treats C as a person of equal status by operating from a stance of open curiosity and
willingness to learn from C who C is rather than telling C who C is.
T is able to reveal vulnerability and laugh with kindness at his/her own mistakes or personal
foibles.
T celebrates unwanted difficulties and emotions as opportunities to receive feedback from
one’s tribe and practice self-enquiry.
T uses dialectical thinking and behavior to enhance flexible responding (for example, T is kind
yet tough, open yet firm, unpredictable yet structured, playful yet serious, self-assured yet
humble).
T interacts with C as he/she would with a friend or family member (when we are with friends,
we tend to stretch out, lie back, or lounge around; our gestures and facial expressions are more
expansive, we are less polite, and we are more likely to use slang or curse words to color our
speech).
B. RO DBT Global Therapeutic Stance Checklist
The following questions are designed to assess general principles related to an RO DBT
therapeutic stance, with a rating of 1 meaning “not at all” and a rating of 7 meaning “to a great
extent.” If possible, you should compare your ratings of a session with an independent
colleague’s ratings of the same session (this procedure often helps identify blind spots).
To a
Not at Very Quite a Very
A little Moderately great
all slightly bit much
extent
Place a checkmark in the box next to each statement that accurately describes what happens
during the session.
T drops his/her agenda (that is, T stops talking about current topic as soon as he/she decides
there may be an alliance rupture to attend to).
T takes the heat off C by briefly disengaging eye contact.
T signals friendly cooperation and affection by leaning back in his/her chair, engaging a
therapeutic sigh, slowing the pace of conversation, and offering a warm closed-mouth smile and
an eyebrow wag.
While signaling nondominant friendliness (slightly bowed head, slight shoulder shrug, and
openhanded gestures combined with a warm closed-mouth smile, an eyebrow wag, and eye
contact), T enquires about the change observed in session. (For example, T says, “I noticed that
something just changed,” describes the change, and asks, “What’s going on with you right
now?”)
T allows C time to reply to questions, reflects back what C says, and then confirms C’s
agreement.
T reinforces C’s self-disclosure (for example, by thanking C).
T practices radical openness during the repair.
T keeps the repair short (less than ten minutes).
T checks in with C and reconfirms C’s engagement in therapy before moving back to original
agenda.
T does not apologize to C for the alliance rupture unless T has actually done something wrong
(for example, forgotten an appointment or shown up late).
V. Treatment Targeting Principles and Strategies
Place a checkmark in the box next to each statement that accurately describes what happens
during the session.
A. Global Principles
T uses the RO DBT treatment target hierarchy to guide in-session behavior (for example, if
imminent life-threatening behavior suddenly emerges in session, it will take top priority).
T reminds C that RO DBT considers noncompletion of diary cards, showing up late, missing
sessions, and noncompletion of homework to be social signals that are intended to communicate
something.
T prioritizes social signaling deficits over inner experience (such as dysregulated emotion,
maladaptive cognition, lack of metacognitive awareness, or past traumatic memories) and other
non–social signaling issues (such as medication or restricted eating), with the exception being
imminent life-threatening behavior.
T formulates problem as a relational issue.
T is alert to C’s in-session social signaling behavior as a potential source of new treatment
targets.
B. Prioritizing of Social Signaling Targets
Place a checkmark in the box next to each statement that accurately describes what happens
during the session.
A. Contingency-Management Strategies
T helps C identify the function of a social signal by discussing the eliciting stimuli, the
reinforcers that maintain the social signal, and the extent to which the social signal fits C’s core
valued goals.
T reinforces C’s candid self-disclosure and uninhibited expression of emotion in session; for
example, T expresses appreciation or thanks whenever C initiates vulnerable self-disclosure, but
without making a big deal of it (recall that OC clients dislike the limelight).
T uses heat-off strategies to reinforce C’s engagement, new learning, and/or practice of RO
skills.
T uses heat-on strategies to reduce, punish, or extinguish a maladaptive social signal.
B. Indirect Social Signals, Hidden Intentions, and Disguised
Demands
Global Principles
T educates C about indirect social signals, their function, how they can be easily
misinterpreted, and how they can negatively impact relationships.h
T encourages C to notice C’s nonverbal social signaling habits (for example, how often C
genuinely smiles with pleasure, how often C uses a polite smile, how often C uses a burglar
smile, how often C purposefully doesn’t smile, how often C uses eyebrow wags or openhanded
gestures, and so on).
T encourages C to use self-enquiry to examine the extent to which C’s social signaling habits
fit with valued goals; for example, T encourages C to use self-enquiry questions like To what
extent am I proud of how I socially signaled? and Would I teach a child to signal similarly? and
What is it I need to learn?
T reflects back to C T’s own perplexity or confusion regarding C’s indirect social signal, but
only after it has occurred repeatedly; for example, T says, “I’ve noticed that on multiple
occasions, whenever I’ve asked about how you are feeling, especially about difficult topics, you
seem to always respond by saying that you are fine. My question is, are you always really fine?”
T teaches, models, or practices key RO social signaling skills in session, such as Flexible
Mind ADOPTS and Flexible Mind REVEALs (see the skills training manual).
T uses instances of indirect, incongruous, and ambiguous social signaling in session as
opportunities to practice social signaling skills (for example, the skill of asserting with humility
that one desires a close relationship with someone by combining nondominance and cooperative-
friendly signals).
T displays a nonchalant, straightforward, playful manner when discussing “pushback” and
“don’t hurt me” responses, disguised demands, and indirect signaling.
SOLUTION ANALYSES
T prioritizes social signaling solutions over changing internal experience (for example, T
teaches C skills of signaling friendly openness to a potential friend rather than teaching C how to
feel less social anxiety).
T conducts a solution analysis after or during the chain analysis.
T collaboratively works with C to identify solutions for the most serious link in the chain.
T links solutions to C’s valued goals.
T shows rather than tells C how to improve or change social signaling habits (for example, T
demonstrates a new social signaling skill in session and asks C to practice it in session).
T reminds C to activate the social safety system prior to social interactions (for example, via
LKM practice or the Big Three + 1).
T encourages C to practice self-enquiry when C appears uncertain rather than trying to
convince C of T’s own perspective.
T and C practice the new skill or social signaling solution in session, via mini–role playing,
and T ensures that solutions are specific and practical (for example, T doesn’t tell C to practice a
skill without first ensuring that it will actually work in C’s circumstances).
T encourages C to write down solutions in the RO self-enquiry journal to help facilitate
practice; if necessary, T writes the solutions down for C and provides C a copy of the solutions at
the end of the session.
T conducts frequent check-ins to assess C’s engagement.
T does not overwhelm C with too many solutions in one session.l
In individual therapy, T teaches relevant RO skills as part of solution analysis instead of
waiting for an RO skills class to cover at some point in the future a skill that C needs now.
VII. Nonverbal Social Signaling Strategies
Place a checkmark in the box next to each statement that accurately describes what happens
during the session.
T adjusts his/her body posture, eye gaze, voice tone, and facial expressions according to what
is happening in the moment.
T nonverbally takes heat off C by…
Leaning back in his/her chair in order to increase distance from C
Crossing the leg nearest C over the other leg in order to slightly turn shoulders away
Taking a slow deep breath or therapeutic sigh
Briefly disengaging eye contact
Raising eyebrows
Engaging a closed-mouth smile when returning eye gaze back toward C
To encourage candid disclosure, T signals nondominant cooperative friendliness by combining
appeasement signals (slightly bowed head, shoulder shrug, and openhanded gestures) with
cooperative-friendly signals (warm closed-mouth smile, raised eyebrows, direct eye contact).
Instead of just talking about C’s social signal, T demonstrates it by playfully acting it out (for
example, by using a silly voice, or suddenly presenting a flat face, or feigning a burp, and so on).
T models for C, and practices with C, universal nonverbal signals of affection, friendship,
trust, and social safety (such as a warm closed-mouth smile, a genuine smile of pleasure, an
eyebrow wag, an affirmative head nod, a musical tone of voice, and openhanded gestures).
T uses role playing and in-session practices to help expand C’s social signaling repertoire.
VIII. Dialectical Strategies
Place a checkmark in the box next to each statement that accurately describes what happens
during the session.
A. Playful Irreverence vs. Compassionate Gravity
T balances playful irreverence and compassionate gravity (for example, moving from
playfulness to seriousness and then back again to playfulness throughout the session).
T affectionately teases, cajoles, jests with, and pokes C in the manner reserved for close
friends (for example, to give C critical feedback without making a big deal of it, or to help C
learn how not to take himself/herself so seriously).
When C turns away, frowns, or bows his/her head upon encountering something he/she
dislikes, T momentarily increases playful irreverence by continuing as if all is well rather than
automatically soothing or validating C.
T uses compassionate gravity to reinforce C’s adaptive behavior and C’s candid, open,
vulnerable expressions of emotion (for example, T slows pace and engages a softer voice tone,
gentle eye contact, and a warm closed-mouth smile).
B. Nonmoving Centeredness vs. Acquiescent Letting Go
T balances nonmoving centeredness with acquiescent letting go.
T operates from a stance of acquiescent letting go in order to repair an alliance rupture or
trigger C’s healthy self-doubt and C’s self-enquiry regarding a pet theory.
T operates from a stance of nonmoving centeredness (for example, T remains firm in the
conviction that humans are social animals or that suicide and self-injury are not options,
regardless of strong opposition from C.
IX. RO Skills Training Principles
Place a checkmark in the box next to each statement that accurately describes the RO skills
training environment, the training itself, and/or the behavior of the instructor(s).
A. Physical/Structural and Global Principles
Instructor practices radical openness by directly seeking critical feedback from the class; for
example, the instructor asks, “Has something just occurred to make it harder for everyone to
participate or contribute to our work together?”
Instructor, confronted with a classroom of blank stares and flat faces, goes opposite to his/her
urges to quiet down or behave in a solemn manner by purposefully employing expansive
expressions and gestures.
Instructor randomly assign participants to read aloud the next point being covered on a
handout or worksheet, in order to break the barrier of silence.
Instructor uses bodily movements and meaningless vocalizations to break tension; for
example, instructor says, without warning, “Okay, everyone, stand up and clap your hands
together!”n
Instructor takes heat off class by telling a story or using a metaphor.
C. Instructor Uses Therapeutic Induction of Social Responsibility
During break or after class, instructor has a private chat or discussion with a participant in
order to remind him/her of prior commitments, describe the impact that his/her behavior may be
having on other class members, or encourage him/her to behave more appropriately in order to
contribute to the well-being of the tribe.o
Instructor reminds participant of his/her core values for fairness and doing the right thing, in
order to help motivate more appropriate behavior in class, and gains participant’s commitment to
show up on time, complete homework, participate in class exercises, or contribute to discussions.
D. Instructor Effectively and Frequently Uses “Participate Without
Planning” Practices
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Thomas R. Lynch, PhD, FBPsS, is professor emeritus of clinical psychology at the University
of Southampton school of psychology. Previously, he was director of the Duke Cognitive-
Behavioral Research and Treatment Program at Duke University from 1998–2007. He relocated
to Exeter University in the UK in 2007. Lynch’s primary research interests include
understanding and developing novel treatments for mood and personality disorders using a
translational line of inquiry that combines basic neurobiobehavioral science with the most recent
technological advances in intervention research. He is founder of radically open dialectical
behavior therapy (RO DBT).
Lynch has received numerous awards and special recognitions from organizations such as the
National Institutes of Health-US (NIMH, NIDA), Medical Research Council-UK (MRC-EME),
and the National Alliance for Research on Schizophrenia and Depression (NARSAD). His
research has been recognized in the Science and Advances Section of the National Institutes of
Health Congressional Justification Report; and he is a recipient of the John M. Rhoades
Psychotherapy Research Endowment, and a Beck Institute Scholar.
Index
A
about this book, 2–3
Acceptance and Action Questionnaire–II (AAQ-II), 79–80
acquiescent letting go, 299–301, 449
active learning, 181
adherent RO DBT, 371–372
Adult Suicidal Ideation Questionnaire, 115
affiliation needs, 53, 382
agenda setting, 206
alexithymia, 63
alliance ruptures, 213–222; diary card noncompletion and, 259; recognizing, 213–219;
repairing, 91, 219–222, 284–285, 312, 442; social signals indicating, 218; statements indicating,
217; treatment dropout based on, 225–226; triggers for, 214, 221; value of, 211, 212, 215. See
also therapeutic alliance
aloofness: social signaling deficit linked to, 93, 247; treatment strategies for, 284–286
altruistic behavior, 18, 66, 349
“always have an answer, even if it’s a question” stance, 323
anorexia nervosa (AN): flat facial expression in, 333; mortality rate of, 109; overcontrol
related to, 26; respondent behavior observed in, 333; RO DBT for treating, 26–28
anticipatory reward, 40, 51, 52
antithesis in dialectical thinking, 297
anxiety disorders, 30
appeasement signals, 156, 167, 169
appeasement smile, 151–152, 156
approach coping, 14, 49, 75, 335
arbitrary reinforcement, 330–331
arousal, 35, 36
ask, don’t tell approach, 279–280, 366
assessing overcontrol, 69–83; clinician measures for, 81–82; common errors and problems in,
70–76; conceptual framework for, 69–70; core principles of, 70; diagnostic protocol for, 76–82;
future directions in, 83; interview process for, 80–81; related to life-threatening behaviors, 114–
115; self-report measures for, 77–80
Assessing Styles of Coping: Word-Pair Checklist (ASC-WP), 77–79, 108, 377–379
audiotaping therapy sessions, 200
autism spectrum disorders (ASD), 30
autonomic nervous system (ANS), 34–35, 274
aversive contingencies, 335
avoidance coping, 14, 48, 75, 335
avoidant PD (AVPD), 63
awareness: diminished emotional, 390–391; nonjudgmental, 276
B
barrier gesture, 175
behavioral exposure, 273–274, 335–336
behavioral principles, 327, 328–331
behavioral reinforcement theory, 327
behavioral strategies, 334–347; behavioral exposure, 335–336; brief exposure, 336; chain and
solution analysis, 341–347; checklist for assessing, 445–447; informal exposure, 336–341;
reinforcement, 334–335
behavioral themes. See social signaling themes
behaviors: definition of, 331; hypervigilant, 247, 277–278; life-threatening, 90–91, 114–118;
overly cautious, 92, 247, 277–278; parsing from social signaling, 331–333; private vs. public,
70–71, 72; punished vs. rewarded, 57–58; respondent vs. operant, 333–334; self-injurious, 74–
75, 109–118; social signaling problems and, 333
big gestures, 166
biological social signals, 347–358
biosocial theory for disorders of overcontrol, 46–65; anticipatory reward and, 52;
consummatory reward and, 52–54; coping component in, 60–65; detail-focused processing and,
50; explanatory overview of, 46; graphic representation of, 47; inhibitory control and, 48–50;
nature component in, 47–54; nurture component in, 54–60; reward learning and, 54; reward
sensitivity and, 51; teaching to clients, 126–129; threat sensitivity and, 51
biotemperament, 10; biosocial theory and, 47–48; neuroregulatory theory and, 17; targeting
overcontrolled, 356
bitterness: social signaling deficit linked to, 93, 247; treatment strategies for, 286–289
blame, accusations of, 363
Blatt, Sidney, 65
blushing, 156, 271, 339
body sensations, 274
Bohus, Martin, 274
bottom-up primary appraisals, 241
brief exposure, 336
brief relational therapy (BRT), 212
bullying, victims of, 61
burglar smiles, 159, 170–171, 322–323
burnout, therapist, 197
Butler, Emily, 62
C
candid disclosure, 168, 224, 312–313, 357
caring, communicating, 116, 166, 227
cautious behavior: social signaling deficit linked to, 92, 247; treatment strategies for, 277–278
centeredness, nonmoving, 299–301
central nervous system (CNS), 34
chain analysis, 93, 341–347; checklist on assessing, 446–447; in-session protocol for, 419–
431; principles for conducting, 341–342, 419–431; setting the stage for, 415–417; solution
analysis and, 346–347, 431; step-by-step description of, 342–347
chain of events, 343–344, 423–427
change: allowing natural, 280; celebrating client, 354–355
checklists: Assessing Styles of Coping: Word-Pair Checklist, 77–79, 108, 377–379; RO DBT
Adherence: A Self-Assessment Checklist, 433–451
cheerleading behavior, 373
childhood traumas: overcontrol problems related to, 55–56; signaling willingness to discuss,
118–120
Clark, Lee Anna, 83
classrooms: physical layout for, 99; working with quiet, 450
client engagement, 97–137; commitment problems and, 137–138; enhancing through
sequencing, 140–142; orientation and commitment for, 100–137; physical environment for, 97–
100; tips for maintaining, 139; treatment dropout and, 120–121; written materials and, 102–103
clinical examples: of in-session diary card review, 266–267; of OC theme-based targeting,
253–257; of repairing alliance ruptures, 219–221
Clinician-Rated OC Trait Rating Scale (OC-TS), 81, 383
closed-mindedness, 184; excitatory reward states and, 185–186; positive examples of, 190;
skills for noticing, 188–189
closed-mouth cooperative smiles, 158–160
coding schemes, 83
collaboration, benefits of, 180
collectivist approach, 315, 370
commitment: issues pertaining to, 100–101; obtaining from clients, 89, 104–109; overcontrol
problems and, 137–138; related to treatment dropout, 120–121, 223–224; to skills training class,
121–122; three key principles of, 224. See also orientation and commitment stage
communication: evolution of emotions for, 18; indirect, 171–173, 213–214, 235–236
community, 12–14
compassion, 230–231
compassionate gravity: description of, 303–304; playful irreverence vs., 307, 310–311, 313,
449
competent behavior, 76
compliance, 180–181
compulsive desires, 283
compulsive fixing, 280, 281, 328
compulsive striving, 49, 382
concern, expression of, 245
conditioned stimulus (CS), 336
conflict, interpersonal, 284
confrontation strategies, 168
connecting gestures, 165, 166
consequences of behavior, 346, 429–430
consultation teams, 88, 198–207; dropouts discussed with, 226–227; functions served by, 192;
monitoring the functioning of, 206–207; review of therapy videos by, 198–200; self-enquiry
practiced by, 203–205; structure for meetings of, 205–206
consummatory reward, 40, 51, 52–54
context-appropriate expression, 63, 356
context-inappropriate suppression, 18
contingency-management strategies, 445
control: inhibitory, 14, 48–50; maladaptive, 280; self-, 7, 12–15, 17. See also overcontrol;
undercontrol
cooperative social signaling, 156–160, 167, 168
coping: approach, 14, 49, 75, 335; assessing styles of, 377–379; avoidance, 14, 48, 75, 335;
maladaptive, 46, 60–65; repressive, 63; vigilance, 49
corrective feedback, 129, 198, 307–308
covert lying, 112
creative attachment strategies, 227
crisis-management protocol, 115–118
critical feedback, 285, 358
cues: novelty, 38–39; overwhelming, 41–43; rewarding, 39–40; social safety, 37–38;
threatening, 40
culture bound social signals, 347–358
curiosity: alliance ruptures and open, 220; chain analyses done with, 341; treatment targeting
based on, 239–240
D
da Vinci, Leonardo, 159
Darwin, Charles, 18
“deer in the headlights” response, 151–153, 154, 313, 337
defensive arousal, 154, 359
demonstrating: maladaptive social signals, 244–245, 249; overcontrol vs. undercontrol, 105,
107n
demoralized therapists, 193–195
denials, 217
dependence, 298
depression: humiliation associated with, 287; research on RO DBT for, 21–25; reward
sensitivity and, 40; suicidal behavior and, 109; vocal indications of, 174, 243
desires, urge-surfing, 283
detail-focused processing, 50, 184–185, 382
detective metaphor, 341
deviant behavior, 11
diagnosing overcontrol, 76–82; clinician measures for, 81–82; diagnostic interview for, 80–81;
self-report measures for, 77–80
Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 8, 69–70
diagnostic interview, 80–81
dialectical behavior therapy (DBT), 19–20, 297
dialectical dilemmas, 299–313, 316–317; nonmoving centeredness vs. acquiescent letting go,
299–301; playful irreverence vs. compassionate gravity, 301–313
dialectical thinking: checklist on working with, 449; descriptive overview of, 297–299; rigid
thinking loosened through, 314–316
diary cards, 136–137, 257–267; essential use of, 257–258; lack of targets on, 344;
noncompletion of, 258–260; overview on using, 264–265; protocol for in-session review of,
265–267; social signaling recorded on, 260; structural features of, 261–264; template for, 262–
263
didactic instruction, 181, 271, 278
dimensional ratings, 261
disagreement: encouraging, 224; reinforcing, 285; subtle signs of, 217
disclosure, candid, 168, 224
disconfirming feedback, 186
disguised demands, 307, 358–369
disingenuous emotional expressions: negative impact of, 60–64, 66; treatment strategies
addressing, 270–277
display rules, 347
distant relationships: social signaling deficit linked to, 93, 247; treatment strategies for, 284–
286
distress tolerance, 65
“don’t hurt me” responses, 364–369; alliance ruptures and, 217; checklist on managing, 446;
difficulty identifying, 364; examples of challenging, 366–367, 368–369; intervening with, 367–
368, 369–370; overly agreeable subtype and, 294; respondent reactions vs., 364–365; therapist
reactions to, 369; underlying message of, 364
“don’t label me” stance, 324–327
“door in the face” strategies, 101, 233
dorsal vagal complex (DVC), 35, 41–42, 273
dorsal vagal motor nucleus (DVNX), 35
dropout problems. See treatment dropout
Duchenne smiles, 157
E
easy manner, 163–165
EATS acronym, 343
edge, 155, 191, 204
Ekman, Paul, 241
embarrassment displays, 156, 169, 245, 271
emotional attenuation, 270–271
emotional expression: assessing deficits in, 390–392; human evolution and, 18–19; inhibited
or disingenuous, 60–61, 66, 92, 247, 382; providing didactics on, 271; suppressors of, 61–62;
universality of, 349; variability and responsivity in, 148. See also facial expressions; social
signaling
emotional leakage, 71; assessing in clients, 72–73; discussing with clients, 137–138;
inadvertent experience of, 316
emotional loneliness, 210, 239
emotionally relevant phenomena, 35
emotions: collectivist model of, 315; didactics on freely expressing, 271; evolution and
expression of, 18–19; facial expressions and, 39, 60–61, 66; inhibited expression of, 92, 247;
invalidation of, 316; labeling of, 274–275; linked to social signaling targets, 252; mindfulness of,
276–277; neuroregulatory model of, 33–46; suppressed expression of, 61–63
empathic responses: OC individuals and, 66; prosodic matching in, 174
engagement. See client engagement
enigma predicament, 217, 318–327; “always have an answer, even if it’s a question” stance,
323; “don’t label me” stance, 324–327; “I am not like other people” stance, 319–321; “no one is
capable of understanding me” stance, 322–323
enigmatic half smiles, 160
enjoyment smiles, 157
environment for therapy, 97–100
envy: social signaling deficit linked to, 93, 247; treatment strategies for, 286–289
evolutionary theory, 12–13, 18, 39, 145, 348
exaggerating social signals, 244
exhaustion: excessive self-control related to, 15, 17; social situations associated with, 16
expansive gestures, 166
exposure: behavioral, 273–274, 335–336; brief, 336; informal, 336–341
expression of emotions. See emotional expression
Expression of the Emotions in Man and Animals, The (Darwin), 18
externalizing problems, 69, 70
extinction, 329
extinction burst, 329–330
eye contact, 149–151; “deer in the headlights” response to, 152, 154; heat-off and heat-on
strategies of, 153, 155
eyebrow wags, 162–163
F
facial expressions: emotions related to, 39; eyebrow wags as, 162–163; flat or bland, 147–148;
inhibited or disingenuous, 60–61, 66; mimicry of, 146–147, 148; prototypical, 150; smiles as,
156–160; therapist use of, 149. See also nonverbal behaviors; social signaling
fairness, 349, 451
family psychopathology, 55–56, 59–60
Fatalistic Mind thinking, 132n
feedback: corrective, 129, 198, 307–308; direct, 182; disconfirming, 186; openness to critical,
285; proprioceptive, 18, 19, 356; requesting, 188, 189
fight-or-flight response, 18, 66
first impressions, 241
fixed reinforcement, 331
fixing OC problems, 249–250, 280
flat face, 147–148, 305, 313, 333
Flexible Mind ADOPTS skills, 285
Flexible Mind VARIEs skills, 278
flexible responding, 389–390
flirting, 167, 305
“foot in the door” strategies, 101, 233
forensic settings: overcontrolled offenders in, 118; RO DBT used in, 29–30
forgiveness training, 289
friendship, foundation of, 191–192
functional analytic psychotherapy (FAP), 212–213
furniture arrangement for therapy, 98–100
G
gaze aversion, 150
genuine smiles, 157
Gestalt therapy, 297
gestures, connecting, 165, 166
goals. See valued goals
grief work, 275, 341
grudges: held by OC individuals, 118, 287; signaling willingness to discuss, 118–120
guilt: expressions of, 169; therapeutic induction of, 345
H
habits, 15, 17
half smiles, 159, 160
healthy self-doubt: cultivation of, 184, 190, 300; unhealthy self-doubt vs., 183
heat-off strategies, 153–155, 310–311
heat-on strategies, 155
Hegelian dialectics, 297–298
hidden intentions, 307, 358
hierarchy of treatment targets. See treatment target hierarchy
high detail-focused processing, 50, 382
high-dominance half smile, 159, 170–171
homework assignments: for developing mindfulness of emotions, 276–277; for overly
agreeable subtype, 294–295; for overly disagreeable subtype, 291–292
hostility, covert, 362
human responses, 35–37
human survival, 373–374
humiliation, 137, 287, 339
humility, 1, 87, 101, 187, 304
hypervigilant behavior: social signaling deficit linked to, 92, 247; treatment strategies for,
277–278
I
“I am fine” phenomenon, 171–172, 175, 272–273
“I am not like other people” stance, 319–321
“I Have Some Really Exciting News” story, 133–135
impression management, 50
incongruent emotional expression, 18
indirect social signals, 171–173; alliance ruptures and, 213–214; challenge of targeting, 238,
327; checklist for working with, 445; common styles of, 242–243; disguised demands and, 358–
360; guidelines for changing, 357; in-session protocol for targeting, 405–414; interpersonal
damage caused by, 235–236; positive examples of, 355; silent treatment as example of, 243–244;
social connectedness and, 332
individual therapy: aims of skills training vs., 103n; orientation and commitment stage of,
100–137; sequence for delivering, 140–142, 437–438; session agenda for, 438–439; treatment
hierarchy for structuring, 93–95
informal exposure: grief work using, 341; habituating to feared stimuli using, 336–340;
summary of steps in, 337–338
information overload, 248
inhibited emotional expression: description of, 382; negative impact of, 60–64, 66; treatment
strategies addressing, 270–277
inhibitory barriers, 272
inhibitory control, 14, 48–50
innate biological social signals, 347–358
in-session protocols: for setting the stage for chain analysis, 415–417; for targeting indirect
social signals, 405–414; for using chain and solution analysis, 419–431
insight, need for, 248–249
interactive learning, 181, 182–183
intermittent reinforcement, 331
internalizing problems, 69, 70
interpersonal conflicts, 284
interpersonal transgressions, 287
interviews: diagnostic, 80–81; suicidality, 401–404
intimacy: assessing deficits in, 393–395. See also social connectedness
J
journal, self-enquiry, 200–203
K
kindling effect, 67, 68
kindness, 230–231, 288
L
labeling: emotions, 274–275; social signals, 251; stance of shunning, 324–327
learning: basic principles of, 328–331; negative impacts on, 64–65; reward, 51, 54, 336;
social, 181–183
life worth sharing, 232–233
life-threatening behaviors: assessing in therapy, 114–115; crisis-management protocol for,
115–118; reducing in clients, 90–91
loving kindness meditation (LKM) practices, 288–289
low openness, 64–65
low-intensity social signals, 172–173
lying: covert, 112; detection of, 241
M
maladaptive coping, 46, 60–65; low openness and rigid responding as, 64–65; masking inner
feelings as, 60–64
maladaptive overcontrol: core deficits of, 8; factors converging in, 46
maladaptive perfectionism, 64–65
maladaptive social signals, 170–175; burglar smiles, 170–171; demonstrating to clients, 244–
245, 249; determining the context for, 419; indirect communication, 171–173, 213–214, 235–
236; prosody and voice tone, 173–175, 243
Malâmati Sufism, 187
mania vulnerability, 39
masking inner feelings, 60–64
Match + 1 skills, 286
mental health. See psychological health or well-being
mimicry and micromimicry, 146–147, 148, 271
mindfulness-based approaches: anorexia nervosa treatment using, 27; homework on emotions
and, 276–277; nonjudgmental awareness in, 276
mirror neurons, 146, 356
mobilization behavior, 18
Mona Lisa (painting), 159–160
moral certitude, 8, 110, 118, 298, 382
motivational interviewing, 212
N
narcissistic personality disorder, 319
natural change, 280
natural reinforcement, 330–331
nature factors, 46, 47–48
negative punishment, 329
negative reinforcement, 327, 328
negative self-views, 64
neuroregulatory model of emotions, 17, 33–46; explanatory overview of, 33–34; human
responses and, 35–37; novelty cues and, 38–39; overwhelming cues and, 41–43; parasympathetic
nervous system and, 34–35; rewarding cues and, 39–40; social safety cues and, 37–38; summary
of basic postulates in, 43–45; sympathetic nervous system and, 34; threatening cues and, 40
niggling, 302, 303
“no one is capable of understanding me” stance, 322–323
noncommittal responses, 217
noncompliance, 180
nondominance signals, 167, 168–169, 301
nonjudgmental awareness, 276
nonmoving centeredness, 299–301, 449
nonproductivity, art of, 281
nonsuicidal self-injurious (NSSI) behavior, 74–75, 109
nonverbal behaviors: checklist on working with, 448; coding scheme for, 83; compassionate
gravity and, 303–304; human detection of, 240–241; indicative of alliance ruptures, 215–216;
teaching therapists to use, 148. See also facial expressions; social signaling
Nonverbal Social Engagement Coding Scheme, 83
“normal” word exercise, 320
notekeepers, 206
novelty cues, 38–39
numbness, monitoring, 274
nurture factors, 46, 54–60
O
observational learning, 181, 182
obsessive-compulsive disorder (OCD), 30
obsessive-compulsive personality disorder (OCPD), 30
“Oh really...?” response, 307–308
open curiosity, 220, 341
open-mindedness, 178, 179, 185
openness: assessing deficits in, 387–388; compliance and, 180–181; to critical feedback, 285;
to experience, 53, 109, 382; healthy self-doubt and, 183, 184; rigid responding and low, 64–65;
social learning and, 181–183; socially signaling of, 163–165; trait, 179; as tribal glue, 178. See
also radical openness
operant behaviors, 334, 368
opposite-action skills, 288
orientation and commitment stage, 100–137; checklist for assessing, 434–436; commitment to
skills training in, 121–122; crisis-management protocol in, 115–118; diary cards introduced in,
136–137; explanatory overview of, 89, 100–101; first and second sessions in, 101–122; linking
social signaling to connectedness in, 129–135; obtaining commitment from clients in, 89, 104–
109; sexual issues discussed in, 118–120; social connectedness valued goals identified in, 122–
126; suicidal behavior and self-harm considered in, 109–115; teaching the biosocial theory for
overcontrol in, 126–129; third and fourth sessions in, 122–137; traumas and grudges discussed
in, 118–120
orienting response, 38
outing oneself, 191–192, 203, 204
overcontrol (OC), 1, 7–8; assessment of, 69–83; behavioral themes related to, 92–93, 95, 246–
247, 250–257; biosocial theory for disorders of, 46–65; commitment problems unique to, 137–
138; core deficits of maladaptive, 8; identifying as core problem, 106–107; obtaining
commitments from clients to target, 104–109; personality disorders associated with, 8–9, 10, 11;
prototypical features of, 78; self-harming behavior related to, 74–75, 109–113; social signaling
deficits and, 92–93, 236–237; trait rating scale for, 81, 383; treatment-resistant disorders of, 28–
29. See also self-control
Overcontrolled Global Prototype Rating Scale (OC-PRS), 81, 82, 386–400
Overcontrolled Subtype Rating Scale, 397–399
overly agreeable subtype, 82, 292–295; homework tasks for, 294–295; rating scale for
assessing, 398–399; treatment targets for, 294
overly disagreeable subtype, 82, 290–292; homework tasks for, 291–292; rating scale for
assessing, 397–398; treatment targets for, 290–291
overprotective parents, 60
overwhelming cues, 41–43
P
parasympathetic nervous system (PNS), 17, 34–35, 185
parents, overcontrol problems related to, 55–56, 59–60
parrhésia, concept of, 191
participate without planning practices, 336, 408, 451
passive learning, 181, 182
perfectionism: learning to embrace, 283–284; rigidity expressed as maladaptive, 64–65
Personal Need for Structure (PNS) measure, 79
personal space requirements, 98, 165
personal unknown, 1, 54, 373
personality disorders (PDs): associated with overcontrol, 8–9, 10, 11; DSM-5 system for
assessing, 76–77; shared features among OC, 80–81
personality styles, client vs. therapist, 196–197
physical environment: checklist for assessing, 433; enhancing client engagement via, 97–100
physicist metaphor, 325
physiological arousal, 272
planning: evolution of, 13; participation without, 336, 408, 451
Plato’s Protagoras, 14
plausible deniability, 171, 302, 332, 358, 362
play, encouraging, 281
playful irreverence, 301–313; behavioral functions of, 309; compassionate gravity vs., 307,
310–311, 313, 449; descriptions of, 301–302, 307–308; protocol following unsuccessful use of,
310–313; social signaling with, 167–168; teasing and, 167, 301–302, 304–305, 307; treatment
strategy using, 281–282
pleasurable smiles, 157
PNS-DVC shutdown response, 41, 313
polite smiles, 157–158
positive punishment, 329
positive reinforcement, 328
pouting behavior, 334, 365
pride, secret, 65, 170, 217, 321
private behavior, 70–71, 72
problem solving, 373
Project RefraMED, 25
prompting events, 343, 422–423
proprioceptive feedback, 18, 19, 356
prosocial aspects of overcontrol, 108
prosocial signaling: absent vs. excessive, 243; therapeutic use of, 156–160
prosody, 173–175
psychological health or well-being: core transacting features of, 11–12, 46, 209–210;
importance of defining, 11–12; social connectedness related to, 374
public behavior, 70–71, 72
public persona, 71, 289
punishment, 57, 327, 329, 335
“pushback” responses, 358–364; alliance ruptures and, 217; checklist on managing, 446;
components of, 358; difficulty addressing, 363; example of challenging, 362–363; intervening
with, 363–364, 369–370; niggling related to, 302; nonverbal signals indicating, 359, 361; overly
disagreeable subtype and, 290; therapist reactions to, 369
Q
quick fixes, 249–250
R
radical acceptance, 190
radical openness, 1, 87, 95, 177, 186–190; core capacities in, 186; description of, 187, 189–
190; noticing closed-mindedness vs., 188–189; radical acceptance vs., 190; self-enquiry and,
189, 190; spiritual roots of, 187; steps in practice of, 187, 189; therapist practice of, 373. See also
openness
radically open dialectical behavior therapy (RO DBT), 1; assessment strategies in, 69–83;
basic postulates of, 11–19; biosocial theory for disorders of overcontrol, 46–65; commonly asked
questions about, 371–373; core tenets and assumptions of, 1–2, 86–88; crisis-management
protocol in, 115–118; development of, 19–20; four core components of, 372; neuroregulatory
model of emotions, 33–46; orientation and commitment in, 89, 100–137; physical environment
for, 97–100; psychological health in, 12; radical openness in, 177–190; research on efficacy of,
20–30; self-assessment of adherence to, 433–451; self-enquiry practice in, 189, 190–192;
sequence for treatment, 140–142; silliness in, 4–5; skills training in, 28–29, 88; social signaling
in, 145–176; team consultation and supervision in, 192–207; therapeutic alliance in, 209–227;
treatment structure and targets in, 88–95
radically open living, 232–233
randomized controlled trials (RCTs), 20–25
rank-ordering themes and targets, 253
rating scales: Clinician-Rated OC Trait Rating Scale, 81, 383; Overcontrolled Global
Prototype Rating Scale, 386–400; Overcontrolled Subtype Rating Scale, 397–399
reassuring, refraining from, 373
rebellious activities, 75
receptivity: assessing deficits in, 387–388; to novel or discrepant feedback, 46, 186, 209. See
also openness
reciprocity, 349
reinforcement, 328; fixed vs. intermittent, 331; of maladaptive OC behavior, 334; natural vs.
arbitrary, 330–331; positive vs. negative, 328; shaping adaptive responses with, 334–335
repairing alliance ruptures, 91, 219–222; open curiosity for, 220; protocol and checklist for,
442; relationship-enhancement skills linked to, 284–285; signs of success in, 222; transcript
example of, 219–221; unsuccessful teases and, 312–313
repetitive behaviors, 328
repressive coping, 63
repressors, 49–50
research on RO DBT, 20–30; for anorexia nervosa, 27–28; for anxiety disorders, 30; for
autism spectrum disorders, 30; for depression, 21–25; for forensic populations, 29–30
respondent behaviors, 333–334, 368
reward: anticipatory, 40, 51, 52; behaviors eliciting, 58; consummatory, 40, 51, 52–54
reward learning, 51, 54, 336
reward sensitivity, 39–40, 51, 52
rewarding cues, 39–40
rigid behavior: dialectical thinking and, 314–316; negative impact of, 64–65, 283; social
signaling deficit linked to, 92, 247; treatment strategies for, 278–284
risk-taking behavior: assessment of, 76; avoidance of unplanned, 65
RO DBT. See radically open dialectical behavior therapy
RO DBT Adherence: A Self-Assessment Checklist, 433–451
RO DBT Semistructured Suicidality Interview, 114, 401–404
rule-governed behavior, 75; assessing in clients, 138; dialectical thinking and, 314–316; self-
harm and, 111, 113; social signaling deficit linked to, 92, 247; treatment strategies for, 278–284
Rumi, Mewlana Jalaluddin, 213
S
safety, feelings of, 18
Scale for Suicide Ideation, 115
scripts, 105, 126
seating considerations, 98–99
secret pride, 65, 170, 217, 321
self-assessment: of RO DBT adherence, 433–451; of therapeutic alliance, 372
self-blame, 203, 221
self-control: deficient vs. excessive, 7; evolutionary value of, 12–14; exhaustion associated
with, 15, 17; hidden costs of, 14–15. See also overcontrol
self-critical individuals, 65
self-deprecating statements, 132n
self-disclosure, 286, 294, 312–313, 357
self-doubt: cultivation of healthy, 184, 190, 300; healthy vs. unhealthy, 183
self-enquiry: behaviors undermining, 373; determining questions for, 373; dialectical thinking
and, 298; diary card noncompletion and, 258–260; encouraging in clients, 275–276; journal for,
200–203; niggling and, 303; practice of, 189, 190–192; questions for therapist, 193–195, 203;
radical openness and, 189, 190; related to social signaling, 240, 248–249; team consultation and,
203–205
self-enquiry journal, 200–203
self-injurious behaviors: assessing in therapy, 74–75, 114–115; crisis-management protocol
for, 115–118; overcontrol disorders and, 74–75, 109–113
self-judgments, 135
self-pity, 365
self-report measures, 77–80; Acceptance and Action Questionnaire–II, 79–80; Assessing
Styles of Coping: Word-Pair Checklist, 77–79, 108, 377–379; Personal Need for Structure
measure, 79
self-verification theory, 110
self-views, 64
sensitizers, 49
sensory receptor processes, 75
sequence for treatment, 140–142
sexual issues, 118–120
shame, expressions of, 169
shaping, 330
showing vs. telling, 244–245, 357
shutdown response, 273–274, 337
sighs, therapeutic, 169–170
signal detection, 147
silent treatment, 173, 243–244
silliness, therapeutic value of, 4–5
skills training, 28–29; aims of individual therapy vs., 103n; checklist based on principles of,
450–451; eliciting client’s commitment to, 121–122; treatment structure related to, 88
Skills Training Manual for Radically Open Dialectical Behavior Therapy (T.R. Lynch), 1
smiles, 156–160; appeasement, 151–152, 156; burglar, 159, 170–171, 322–323; closed-mouth
cooperative, 158–160; genuine, 157; half, 159–160; polite or social, 157–158
smuggling, 108, 355
SNS appetitive reward activation, 39, 40
social comparisons: social signaling deficit linked to, 93, 247; treatment strategies for, 286–
289
social connectedness: assessing deficits in, 393–395; behavioral exposure for enhancing, 335–
336; gestures and touch indicating, 165–166; identifying valued goals linked to, 122–126;
linking social signaling to, 129–135, 350, 357; negative impact of masking feelings on, 60–64
social exclusion, 55, 67
social inclusion, 286
social learning, 181–183
social responsibility, 451
social safety cues, 37–38
social safety system, 18, 37–38, 277–278, 357
social signaling, 13, 66–67, 145–176; absent vs. excessive prosocial, 243; addressing deficits
in, 91–92, 234; alliance ruptures and, 218; appeasement, submission, and embarrassment, 169;
behavioral themes related to, 92–93, 246–247, 250–257; characteristics of problematic, 333;
connecting gestures and touch as, 165–166; cooperative or prosocial, 156–160, 167, 168; “deer
in the headlights” response to, 151–153; definition of, 234–235, 331; demonstrating to clients,
244–245, 249; diary card noncompletion as, 258–260; evolutionary development of, 145, 331–
332; explanatory overview of, 145–146; eye contact as, 149–151, 152; eyebrow wag as, 162–
163; flat facial expressions and, 147–148; heat-off strategies of, 153–155, 310–311; heat-on
strategies of, 155; human detection of, 240–241; indirect, 171–173, 213–214, 235–236, 332;
innate biological vs. culture bound, 347–358; managing maladaptive, 170–175; mimicry as form
of, 146–147, 148; nondominance signals as, 167, 168–169; openness and an easy manner as,
163–165; overcontrolled vs. undercontrolled, 236–237; parsing behavior from, 331–333; playful
irreverence as, 167–168; prosody and voice tone as, 173–175, 243; self-enquiry related to, 240,
248–249; sighs as form of, 169–170; smiling as form of, 156–160, 170–171; social
connectedness linked to, 129–135, 350, 357; targeting in-session, 240–257, 405–414; teasing as
form of, 166–167; therapist use of, 149, 160, 161–170; tribal considerations in, 175–176; valued
goals related to, 356, 357. See also facial expressions; nonverbal behaviors
social signaling subtypes, 289–295; overly agreeable subtype, 82, 292–295, 398–399; overly
disagreeable subtype, 82, 290–292, 397–398
social signaling themes, 92–93; checklist on working with, 444; clinical example of working
with, 253–257; enhancing treatment targeting with, 246–247; step-by-step treatment targeting
with, 250–257
social situations: changing physiological arousal prior to, 272; mental exhaustion in response
to, 16
social smiles, 157–158
sociobiological influences, 55
Socratic questioning, 240
solution analysis, 346–347, 431, 447
soothing, refraining from, 245, 373
speech: indirect social signals and, 355; nonverbal components of, 173–175, 243
stalling tactic, 351, 353, 354
staring, 148, 150
steady reinforcement, 331
stoicism, 172
stress-response systems, 66
structuring treatment. See treatment structure
submission signals, 169
subtypes. See social signaling subtypes
suicidal behavior: assessing in clients, 114–115, 401–404; crisis-management protocol for,
115–118; interview for assessing, 401–404; overcontrol disorders and, 109–113
supervision, 88, 177, 192–196, 371
suppressors, 61–62
sympathetic nervous system (SNS), 17, 34, 185, 273
synthesis in dialectical thinking, 297
T
targets of treatment. See treatment targeting
team consultations. See consultation teams
teasing, 166–167; corrective feedback through, 307–308; playful irreverence and, 301–302,
304–305, 307; protocol following unsuccessful use of, 310–313
telephone consultation, 88
telling vs. showing, 249
temperature of therapy room, 99–100
therapeutic alliance, 209–227; characteristics of, 211–213; checklist for assessing, 440–442;
orienting clients to, 214–215; premature treatment dropout and, 223–227; recognizing ruptures
in, 213–219; repairing ruptures in, 91, 219–222; self-assessment of, 372; statements indicating
ruptures in, 217; touch for enhancing, 165–166; triggers for ruptures in, 214, 221; value of
ruptures in, 211, 212, 215
therapeutic stance, 209–210, 440–441
therapeutic teasing. See teasing
therapists: consultation teams for, 88, 198–207; personality styles of clients vs., 196–197;
practice of radical openness by, 373; self-assessment of RO DBT adherence for, 433–451; self-
enquiry practice for, 193–195, 200–205; signs of possible burnout in, 197; social signaling used
by, 149, 160, 161–170; support required by, 193–196; as tribal ambassadors, 86, 161, 176, 210;
videorecording of sessions by, 199–200
thesis in dialectical thinking, 297
thoughts: depression and the suppression of, 61; linked to social signaling targets, 252. See
also dialectical thinking
threat sensitivity, 51
threatening cues, 40
tone of voice, 173–175, 243
top-down reappraisals, 241
touch, social signaling through, 165–166
trait openness, 179
traits: descriptions of, 384; OC Rating Scale for, 81, 383
traumas: overcontrol problems related to, 55–56, 287; signaling willingness to discuss, 118–
120; touch aversion related to, 165
treatment dropout: commitment from clients to discuss, 120–121, 223–224; factors resulting
in, 225–226; prevention of premature, 223–227
treatment strategies, 270–295; for inhibited emotional expression, 270–277; for overly
cautious and hypervigilant behavior, 277–278; for rigid and rule-governed behavior, 278–284
treatment structure, 88–95; hierarchy of treatment targets, 89–93, 233–240; individual therapy
agenda and, 93–95; orientation and commitment stage, 89
treatment target hierarchy, 89–95, 233–240; addressing social signaling deficits, 91–93, 234,
240–257; reducing life-threatening behaviors, 90–91, 234; repairing alliance ruptures, 91, 234;
structuring therapy sessions using, 93
treatment targeting, 240–269; checklist for assessing, 443–444; common pitfalls in, 248–250;
dealing with lack of targets in, 344–345; enhancing with social signaling themes, 246–247;
example of OC theme-based, 253–257; knowing what to target in, 235–237; monitoring with
diary cards, 257–267; of problematic social signaling in session, 242–246, 405–414; social
signaling subtypes to improve, 289–295; step-by-step with social signaling themes, 250–253;
valued goals and themes in, 267–269
tribal ambassadors, 86, 161, 176, 210
tribes: learning in, 181–183; openness as the glue in, 178; social signaling in, 175–176
trustworthiness, 146, 174, 271, 286, 345
“‘Twas a Lovely Affair” story, 132–133
U
unconditioned stimulus (US), 336
undercontrol (UC): assessing problems of, 69, 70, 76; demonstrating overcontrol vs., 105,
107n; personality disorders associated with, 9, 11; social signaling indicative of, 236–237
unhealthy self-doubt, 183
urge-surfing, 27, 283
V
valence, 35
validation skills, 286, 291
valued goals: identifying for social connectedness, 122–126; integrating with themes and
targets, 267–269; linking OC themes to, 250; social signals reflecting, 356, 357
variable reinforcement, 331
ventral vagal complex (VVC), 18, 35
video of therapy sessions: benefits of recording, 199–200; consultation team review of, 198–
199
vigilance coping, 49
violent offenders: overcontrolled, 118; RO DBT used with, 29–30
visceral learning, 245
voice mail messages, 225
voice tone, 173–175, 243
vulnerability, revealing, 63, 286, 290
vulnerability factors, 343, 420–422
W
walking away, 252, 269, 351
well-being. See psychological health or well-being
Westen, Drew, 82
“Why do you think I just said that?” question, 310, 311
Williams, L. M., 149, 156, 163
willpower, depletion of, 15, 17
word repetition, 320, 338–339
word-pair checklist, 77–79, 108, 377–379
working alliance. See therapeutic alliance
working phase of therapy, 437–439
worldview biases, 184
written materials, 102–103, 324
Y
yawning protocol, 242
“you don’t understand me” stance, 322–323
1 …or, On the Importance of Being Absolutely, Positively, Indubitably, Superlatively, Incorrigibly, Unapologetically, Side-
Splittingly, Over-the-Top, Spew-Coffee-Out-Your-Nose, Damn-the-Torpedoes SILLY