Radically Open Dialectical Behaviour Therapy (RO DBT) was originally designed by Professor Thomas R. Lynch to treat disorders of overcontrol such as chronic depression, anorexia, obsessive compulsive personality disorder, treatment resistant anxiety, autistic spectrum disorders (ASD), and maladaptive perfectionism. Though named after Marsha Linehan’s ground-breaking treatment for borderline personality disorder (BPD), Professor Lynch’s therapeutic course radically revises and adapts dialectical behaviour therapy for disorders of overcontrol. There are three core aims at the heart of RO DBT for achieving psychological health or well-being:
1.
Openness to new experiences and/or disconfirming
feedback to enable learning.
2.
Flexibility in adapting to changing environments
and conditions.
3.
Intimacy and social connectedness with at least
one other person and belonging as part of a tribe or family.
RO DBT reminds clients of their
basic tribal nature as homo sapiens and the importance of tribal
belonging for species survival. Social signalling is important for belonging in
a tribe and RO DBT encourages clients to practice aspects of social signalling
such as the Big Three Plus One. Radical openness reminds the client that we see
things from our own perspective rather than objectively or from a neutral
vantage point. Our vision is tainted by our own subjectivism: we don’t see
things as they are, but as we are. Radical openness involves a willingness to
learn, question ourselves, and respond flexibly to unplanned events. It aims to show overcontrolled clients (often referred to as OC clients) that
they often ‘take life too seriously and that, rather than needing to learn how
to be better or work harder, they need to learn how to relax, play, and laugh
at their mistakes, with kindness’ (STM, p. 5).
There are three
philosophical aspects behind RO DBT: Hegelian dialectics, radical openness, and
self-enquiry. The word dialectic means that for everything there exists an opposite.
Light is the opposite of dark. Up is the opposite of down. Dialectics tells us
that opposing points of view can sometimes both be true or merged to form a
truth in order that we might learn something new. This is the case with a
thesis and antithesis forming a synthesis – as in the Hegelian concept. There
is always more than one side of an argument, and it is important to look for
both sides in a discussion. We must learn to move away from extremes because seeing
the world in black and white or an all or nothing way can be destructive. It is
helpful to have a more balanced view of things and achieve synthesis. The goal
of dialectics is to be able to see both sides of something and respond flexibly
to events and situations. Radical openness is also a key component of RO DBT.
It encourages clients to practice learning from disconfirming feedback.
According to Professor Lynch, radical openness involves three key steps:
1.
Acknowledging disconfirming events or feedback.
2.
Practicing self-enquiry by asking the question:
what can I learn from this?
3.
Responding flexibly and with humility to the
situation or event.
Radical openness does not mean
blind approval, naïve acceptance, or mindless acquiescence. We must use our
minds and think carefully about the events or situation, but where appropriate
we should respond with openness, flexibility, and humility. Self-enquiry is the third key aspect of philosophy
behind RO DBT. This involves a willingness to question oneself, rather than
always assuming that our own perspective is the only right way of thinking or
behaving in a situation. We could be wrong. The goal of self-enquiry is to ask
a good question, not find a good answer: what is it that I might need to learn
from this? Clients are encouraged to keep a daily RO self-enquiry journal to
practice asking questions about events and situations in their daily lives.
RO DBT is a 30-week
programme with distinct lessons for each week (some lessons on mindfulness are
repeated to reinforce the principles and practice of mindfulness as a core
element of the therapy). All page references in the following essay are to The
Skills Training Manual for Radically Open Dialectical Behaviour Therapy (2018)
by Professor Lynch – referred to in shorthand as STM. This paper aims to
explore each lesson in turn and highlight the salient points and key practices
in RO DBT as suggested by the chapter summaries and material in bold print in
the Skills Training Manual.
Lesson 1: Radical Openness (STM, pp. 51
There are three core aims within RO
DBT to achieve psychological health and wellbeing: (1) receptivity and
openness, (2) flexible control, and (3) intimacy and social connectedness (STM,
p. 51). This lesson opens with a consideration of a random inkblot to show how
everybody has different perspectives and thoughts on a given subject. The point
of the inkblot is to show that we all create our own worldview and belief
systems in which we interpret events and situations. Our experiences shape the
way in which we see the world. Some social psychologists call this ‘confirmation
bias’ (STM, p. 54). In order to learn anything, however, we must admit that we
do not know everything and that our knowledge is limited. According to
Professor Lynch, ‘Radical openness means being open to new information or
disconfirming feedback in order to learn’ (STM, p. 56). We use the skill
Flexible Mind DEFinitely to practice openness and show our willingness to learn
new facts, skills, or information:
1.
Acknowledge Distress or unwanted emotion.
2.
Use self-Enquiry to learn.
3.
Flexibly respond with humility.
Some things will cause us unwanted
distress or feelings and emotions in life. It is important to mindfully
acknowledge these emotions and the unwanted distress. You may find it helpful
to say “thinking” or “feeling” and label the thought and emotion: ‘I am aware
of the feeling of …’ or ‘I am aware of imagining …’. We use self-enquiry to
learn from our unwanted distress. We think briefly of a question we can ask
ourselves in this situation as part of self-enquiry, but we do not ruminate on
the matter. You might ask: what is it that I need to learn from this situation?
And we respond with flexibility and humility, even if we don’t know the answer.
The point is to find a good question to ask ourselves, and not necessarily a
good answer. A useful list of self-enquiry questions can be found in the Skills
Training Manual on pages 63 and 64 (Handout 1.3).
Lesson 2: Understanding Emotions (STM, pp. 73
Our brains are hardwired to
constantly scan the world and ourselves for cues or stimuli relevant to our emotional
and physical wellbeing. There are five main classes of emotionally relevant
stimuli or cues:
1.
Safety cues are stimuli associated with feeling
protected, loved, secure, and as belonging to a tribe or family. These cues
enable us to socialise safely as our body is relaxed, our breathing is slow and
deep, and our heart rate is reduced. These cues allow us to be relaxed, sociable,
contented, open, and playful.
2.
Novel cues trigger our automatic evaluative
processes to determine whether something is good or bad for our wellbeing. We
often stand still and feel stuck or frozen. Our breath is suspended. We become
alert, curious, and evaluative. We stop, look, and listen.
3.
Rewarding cues determine whether something is
gratifying or pleasurable. They encourage us to approach or pursue. Our bodies
become animated, our breathing becomes fast, and heart rate is increased. Rewarding
cues trigger feelings of excitement, passion, and make us goal driven. We tend
to use expansive gestures during this state of mind.
4.
Threatening cues alert us to the presence of
potential danger or of something damaging. We feel the need to flee or attack –
this is known as the fight or flight response. Our bodies become tense and
agitated, we take shallow breaths, our breathing becomes fast, we become
conscious of our heart beating rapidly, and we begin to perspire. We feel
anxious, irritated, and defensively aroused. We exhibit constrained facial expression
and make tight gestures with our hands.
5.
Overwhelming cues cause us to shutdown and avoid
the situation. When we feel overwhelmed, we tend to give up and shut down our
bodily expression. The body becomes immobile, our heart rate and breathing are
slowed, we become numb, unresponsive, and disassociated. Our expressions become
flat and our voices monotone. We may faint, swoon, or dissociate.
Lesson 3: Activating Social
Safety (STM, pp. 88
According to Professor Lynch, those
who are overcontrolled are genetically hardwired to be sensitive to threats,
making it more likely that they will carry defensive moods and behaviours unintentionally
into social situations. Professor Lynch describes this as carrying our ‘hunting
dogs, shields, and swords’ into social engagements (STM, p. 88). He argues that
it is possible to improve one’s social connectedness by changing one’s
physiology or body language. Closed postures shut down conversations, whereas
open and expansive postures invite conversation and friendliness. An open
posture activates the brain’s social safety system. It is quite important to be
aware of what your eyebrows and facial muscles are doing when talking or
engaging with someone else. Their placement – up or down – matters not only to
how we feel inside, but also impacts how other people interact with us. The Big
Three Plus One is a key skill in RO DBT and there are a few steps towards
activating this posture for social safety:
If you are sitting in a chair,
begin with the Plus One by leaning back comfortably in your chair, rather than
leaning forward or scrunching yourself up. This is a Plus One because you can
only do it if you are sitting in a chair.
1.
Take a slow deep breath. This tells your brain
that all is calm.
2.
Display a closed-mouth cooperative smile. Turn
both corners of the mouth upward, signalling contentment and happiness.
3.
Use an "eyebrow wag" by raising both eyebrows, signalling raised affections and social safety.
Other ways to activate our social
safety system include using big and expansive gestures with open hands, moving
your facial muscles by smiling and with eyebrow wags, taking slow deep breaths
(using long, slow exhalations), paired muscle relaxation (squeezing and then
relaxing the muscles in your body), using touch and deep pressure such as massage
and hugs, chewing or eating food which triggers the rest and digest system, and
hearing relaxing music and the human voice, or using vision – gazing at
pictures of loved ones, pets, or beautiful landscapes. In a crisis situation,
you can rapidly change how you feel by triggering the dive reflex or by
immersing your face in ice cold water. This slows heart rate and produces a
feeling of calm. However, it should not be used if you have any history of
cardiac problems or suffer with anorexia nervosa without prior medical
approval.
Lesson 4: Enhancing Openness and
Social Connection via Loving Kindness (STM, pp. 104
The practice of loving kindness
activates our brain’s social safety system. It enhances our openness and social
connection. The goal of loving kindness is not so much about being loving
towards oneself or to others, but to trigger ‘a mood state associated with
contentment, curiosity, and desires for social engagement’ (STM, p. 104). The loving
kindness meditation in RO DBT differs from the standard Buddhist practice by
not showing loving kindness towards oneself. This is something OC clients often
find difficult. In RO DBT, the loving kindness meditation involves three steps:
(1) creating an experience of warmth, love, and kindness, (2) extending warm
feelings of love toward someone the client already cares about, and (3)
extending warm feelings towards a neutral person or stranger. It can be useful
to practice the loving kindness meditation in private before social engagements
to encourage feelings of contentment and peace. At the heart of the loving
kindness meditation is a mantra towards the other person:
May this person be at ease.
May they be content with their
life.
May they be joyful.
May they feel safe and secure.
Professor Lynch encourages the
course facilitator to make an audio recording of the meditation on pages 108 to
110 (Handout 4.1) in the Skills Training Manual for students to practice
and use outside of class.
The loving
kindness meditation involves several key steps: (1) You are encouraged to find
a comfortable seating position with feet grounded on the floor (a position in
which you are alert and not likely to fall asleep) and to lower your gaze or
close your eyes to avoid distraction. (2) You bring awareness to the breath – noticing
the inhalation and exhalation wherever you feel this in the body. (3) You find
your heart centre or that place where we tend to feel warm emotions in the
centre of our chest. You may find it helpful to place your hand over your
physical heart where you feel loving kindness the most. (4) You begin by
sending loving kindness to a person you care about (such as a family member or
a good friend). (5) You send loving kindness to a person you feel neutral about
(whom you only meet occasionally) or a stranger. (6) You bring your attention
back to your heart centre, back to the breath, back to the room, and gently
open your eyes.
Lesson 5: Engaging in Novel Behaviour (STM, pp. 114
Lesson five encourages us to engage
in novel behaviour by trying new things. According to Professor Lynch,
‘Discovery requires openness and willingness not to always have an answer. The
most effective people in the world learn something new every day’ (STM, p.
114). When learning new things, we often make mistakes – and it is okay to make
mistakes. In fact, the best way to learn something is to first make a mistake
in trying. There are four stages experienced in learning something new:
1.
Unconscious incompetence (Not knowing that we
don’t know how to do something).
2.
Conscious incompetence (Knowing that we don’t
know how to do something, but trying anyway).
3.
Conscious competence (Knowing what to do but
lacking proficiency).
4.
Unconscious competence (Knowing how to do
something with proficiency).
When we learn a new skill, we are
often novices and will make mistakes. OC clients generally want to arrive at
unconscious competence immediately, but they need to learn that sometimes we
will make mistakes along the way as part of the learning process. We use the
skill Flexible Mind VARIEs to try new things and experiences:
1.
Verify one’s willingness to experience
something new.
2.
Check the Accuracy of hesitancy or
aversion.
3.
Relinquish compulsive planning or
rehearsal.
4.
Activate one’s social safety system and then Initiate
new behaviour.
5.
Nonjudgmentally Evaluate the outcome.
As the saying goes, ‘All work and
no play makes Jack a dull boy’. Learning something new, trying something
different, having fun can be a way to chill out and enjoy oneself. Trying
something new can also help us connect with the tribe: ‘Joining communal
activities sends a powerful message to our brain – namely, that we are part of
a tribe and have done nothing to be ashamed about’ (STM, p. 123). Doing
something new helps to break old habits and harmful repetitive behaviours. It
encourages spontaneity and participation without planning. New behaviour often leads
to new opportunities and horizons. It trains the brain to recognise that it is
okay not to have everything planned out religiously. There is a helpful list of
new things to try in the Skills Training Manual on pages 131 and 132
(Handout 5.3) such as wearing something new, doing your hair differently, listening to a new radio stations, doing the exact opposite of what you would normally do in a situation, trying a new food, driving a different way to work, and so on.
Lesson 6: How Do Emotions Help
Us? (STM, pp. 141
Pure logic often fails us when it
comes to forming relationships or even making quick decisions. We cannot all be
like Mr Spock or Commander Data from Star Trek – ‘It’s only logical’. This is
where our emotions help us. Emotions exist for a purpose. According to
Professor Lynch, they have four main functions: (1) to help us make decisions,
(2) to motivate our actions, (3) to communicate our inner experiences to
others, and (4) to help us form strong social bonds and belonging as part of a
tribe (STM, p. 141). Labelling emotions in the practice of mindfulness can be
helpful. You might say to yourself mentally “thinking” or “feeling”. This puts
some distance between yourself and the emotion you are experiencing. You may
become the observer of your heart and mind. It may be helpful to say, “I am
noticing the emotion of x, y, z”. There are four steps in RO-DBT towards
recognising and labelling our emotions:
1.
Recognise the cues that trigger our emotions
(are they internal or external?).
2.
Identify which brain-body emotion was likely
triggered by the cue by paying attention to bodily sensations.
3.
Ask how you socially signalled in this situation
to deepen your understanding.
4.
Observe action urges and desires.
Fear triggers a desire to flee or
run away. Shame triggers an urge to hide or cover oneself. Guilt motivates us to
make amends. Sadness causes us to isolate, shutdown, or deactivate. Disgust
triggers an urge to get rid of or dispel something. Joy motivates us towards visible
happiness or jumping up and down. Love encourages us to relax, be at ease, and
socialise. Curiosity motivates us to explore and discover. Think about how your
emotions impact your body and learn to label emotions clearly: ‘I am feeling
the emotion of x, y, z’. In this way, you become the observer of your emotions
rather than simply getting caught up or lost in them.
Lesson 7: Understanding
Overcontrolled Coping (STM, pp. 157
Sometimes overcontrol can be
rewarding. For example, OC clients tend to be very good at delayed
gratification such as studying three years for a degree or losing two pounds by
eating healthily every day. However, constantly delaying gratification and
drawing upon reinforced bad habits can lead to mental exhaustion. Overcontrolled
coping is time consuming and has physical and emotional consequences. OC
clients need to learn that it is okay if things don’t go perfectly, and that it
is okay not to be okay. Self-control – the ability to inhibit emotional urges
and behaviours to pursue long-term goals – is highly valued in most societies. However,
for people who struggle with disorders of overcontrol, this behaviour can be
quite problematic and lead to suffering. Learning how OC behaviour impacts us
is half the battle. Professor Lynch puts forward five strategies for learning
from and identifying patterns of overcontrolled behaviour in our lives:
1.
Look for the cues that trigger overcontrolled
coping (such as new situations or feeling exposed and vulnerable).
2.
Describe the inner experiences (thoughts,
emotions, sensations, memories/images) linked to overcontrolled coping.
3.
Identify the action urge triggered by the
unwanted experience (such as trying to escape or dominate the stressful event).
4.
Observe how overcontrolled coping manifests
itself (such as by shutting down, denying the problem, pretending not to hear
critical feedback, sulking, pouting, or walking away).
5.
Notice the consequences of overcontrolled
behaviour (such as long-term avoidance problems, defects in social signalling,
or emotional loneliness).
Lesson 8: Tribe Matters (STM, pp. 165
Human beings are better when they
work together as part of tribe. This was essential during our prehistoric past
for personal survival. Rejection from the tribe meant almost certain death. A
tribe can consist of just two or three people. Tribal bonds are formed through
self-sacrifices for the other person – without the expectation of anything in
return. Most people in modern society belong to multiple tribes (family, work colleagues,
friendship groups etc.). Your RO DBT group is an example of a tribe. We are
biologically hardwired to value tribal belonging because banishment from the
tribe was effectively a death sentence. According to Professor Lynch, ‘Self-conscious
emotions include shame, embarrassment, humiliation, and guilt. When we become
self-conscious, we doubt our status in the tribe’ (STM, p. 165). Shame is sometimes
warranted when we have purposefully harmed others or deceived members of our
tribe. Such behaviour threatens the tribe as a whole. We use the Flexible Mind
SAGE skills when feeling ashamed, embarrassed, rejected, or excluded from the
tribe.
1.
Use Self-enquiry to determine if shame is
warranted.
2.
If shame is warranted, then Appease.
3.
If shame is unwarranted, then Go opposite
to urges to hide.
4.
Show Embarrassment to enhance trust and
socially connect.
Professor Lynch is careful to point
out that ‘minor social transgressions call for embarrassment, NOT shame or
guilt’ (STM, p. 170). We signal shame
when our transgressions violate the values and ethical norms of our tribe, and
we apologise for our behaviour. We signal social embarrassment when our
transgressions involve the minor violation of cultural conventions (for
example, speaking out of turn, stepping on someone’s toe, poor table manners, or
having flatulence in church – oops!). Blushing or showing embarrassment is
pro-social as it makes people like and trust you more on a personal level.
Lesson 9: Social Signalling
Matters! (STM, pp. 196
People cannot know about you unless
you choose to reveal yourself to them. People often trust what they see about
you, rather than what is said about you. Professor Lynch puts forward the
following equation regarding our social signalling:
OPEN EXPRESSION
= TRUST = SOCIAL CONNECTEDNESS
Other people generally like those
who openly express their emotions as they are perceived to be more genuine and
likeable, compared to those who suppress or mask their true personalities. Expression
should always be context dependent. For example, we wouldn’t express happiness
or elation at a funeral. That would be inappropriate. To form lasting bonds
with a tribe, you must reveal a little of your own vulnerability. This conveys
two powerful social signals to the other person:
1.
We trust them.
2.
We are the same because we share a common bond of
human fallibility.
Inhibited expression is when we
become frozen, insincere, or mask our real feelings. This leads to us being
perceived as untrustworthy or inauthentic. Masking can be physically and
mentally exhausting. We become socially ostracised, and we feel anxious and
depressed as a result of hiding our real feelings. By way of contrast, open
expression means the sender is perceived as trustworthy and genuine. We feel
safe and secure because of our openness and personal self-disclosure to others,
and we become valued members of the tribe.
Lesson 10: Using Social
Signalling to Live by Your Values (STM, pp. 211
Research shows that emotional
expression in humans may be grouped into three functional categories: status,
survival, and intimacy. The body supports social status emotions (such as embarrassment,
humiliation, shame, and pride). The face supports survival emotions (such as anger,
disgust, fear, enjoyment, happiness, and sadness). While touch supports
intimate emotions (such as love and sympathy). Our nonverbal signals are
important. Raised eyebrows – as in the Big Three Plus One – are universal
signals of friendship and affection. We use Flexible Mind is DEEP to socially
signal according to our values:
1.
Determine your valued goal and the
emotion you wish to express.
2.
Effectively Express by matching
nonverbal signals with valued goals.
3.
Use self-Enquiry to Examine the
outcome and learn.
4.
Practice open expression again and again.
It is important to take
responsibility for our own emotional reactions and to use self-enquiry to
reflect upon our experiences of social signalling. It is no good blaming the
other person because the interaction did not go perfectly or as you expected. It
is important to celebrate diversity in how people respond and react to
situations. Not everyone is going to react or behave like you. We are all
different and that’s what makes the world a special place in which to live. For
a helpful list of suggested valued goals, see the Skills Training Manual
pages 226 to 228 (Worksheet 10. A).
Lesson 11: Mindfulness Training
(Part 1): Over Controlled States of Mind (STM, pp. 233
OC clients often struggle with problems of closed-mindedness, learning new information, or with receiving critical feedback. As Professor Lynch puts it, ‘A closed mind is a threatened mind’ (STM, p. 233). Traditional DBT identifies three states of mind: rational, emotional, and wise mind. The goal being to achieve wise mind as the synthesis of the other states of mind. Similarly, RO DBT identifies three states of mind: fixed mind, fatalistic mind, and flexible mind. Fixed mind assumes that change is unnecessary because one already knows the answer. Fatalistic mind says change is unnecessary because there is no answer. Whereas flexible mind – the synthesis of these opposing states of mind – is open and receptive to change where needed and is a more flexible way of responding to others. Professor Lynch uses the analogy of the Titanic sinking to illustrate his point. Fixed mind would be like saying, ‘I know there is an iceberg ahead, but I am going to drive straight into anyway’. Fatalistic mind would be like saying, ‘There’s no point. Nothing can save us now’ – and crashing straight into the iceberg. Whereas flexible mind would respond with openness and humility to suggestions from the crew and consider changing course and reducing speed to avoid a collision with the iceberg. In terms of Hegelian dialectics, flexible mind is the synthesis of fixed mind (thesis) and fatalistic mind (antithesis). Adopting flexible mind enables us to learn new things and respond with humility and willingness to change where necessary.
Lesson 12: Mindfulness Training
(Part 2): The “What” Skills (STM, pp. 254
In RO DBT, as with traditional DBT,
there are three mindfulness “what” skills. These are: observe openly, describe
with integrity, and participate without planning. Observation with
an open mind means attending to what is happening in the present moment, even
when things are tough. It is the first step towards new learning because this
is the place where we are most likely to discover our “edge” or our personal
unknown. Describing with integrity means putting into words what you have
already observed. A key practice of RO DBT is known as the awareness continuum.
In order to describe with integrity, we say to ourselves “I am aware of x, y,
z”. We label our sensations, emotions, images, or thoughts and we describe
these thoughts and feelings without further explanation, rationalisation, or
justification. We notice a thought as a thought. A feeling as a feeling.
The final “what”
skill is to participate without planning. All you must do is join in with your
tribe. When we do this, we form powerful bonds with other members of our tribe.
This is something you must experience for yourself. You cannot really learn
about it by reading a textbook. You must actually go and do something fun with
friends. No matter how embarrassing or silly the behaviour, give it a go and
you will find happiness. Professor Lynch suggests a number of silly and embarrassing
things for participating without planning in your RO group: practice being a
puppet, or sailing the seven seas, or being like chicken little with the sky
falling in, or acting out a fake temper tantrum, or yelling the word tomato, or
using big gestures, speaking nonsense, going tribal, or silly walking and
talking, etc (STM, pp. 269–71).
Lesson 13: Mindfulness Training
(Part 3): Core Mindfulness “How” Skill: Self-Enquiry (STM, pp. 280
There are four “how” skills for
practicing mindfulness in RO DBT. These are with self-enquiry, with
awareness of harsh judgements, with one-mindful awareness, and effectively
and with humility. This lesson focuses on the core mindfulness “how” skill
of self-enquiry. This skill is the key to radically open living and flexibility.
It means actively pursuing the things that we may want to avoid or that make us
feel uncomfortable (our “edge”) and cultivating a willingness to learn from our
experiences. If we are prepared to be wrong and willing to change, then new
learning becomes possible for us. Moreover, we must be willing to ‘out
ourselves’ to others. In the words of Professor Lynch, ‘Self-enquiry involves
both willingness for self-examination and willingness to reveal to others what
our self-examination has uncovered. This process is known as outing oneself
in RO DBT’ (STM, p. 280). Self-enquiry encourages us to find the question that
brings us to our “edge”. The idea is to look for a good question and not
necessarily a good answer. It is the pursuit of truth that counts, not the
truth itself. Self-enquiry involves being ready and willing to challenge one’s
core beliefs. It means taking responsibility and ownership for our beliefs and
choices. It may involve turning towards those very experiences that we would
rather avoid by coming to our “edge” or personal unknown and facing our fears
head on. Unlike some skills in traditional DBT, self-enquiry is not about
‘regulation, distraction, rationalization, opposite action, self-soothing,
cheerleading, problem solving, or acceptance’ (STM, p. 282). It is about being
willing to learn from our experiences in the world and share such experiences
with others in our tribe through the process of outing oneself. Outing oneself
is the practice of self-enquiry in the presence of at least one other person
from our tribe. It helps us take responsibility for our perceptions and actions.
Lesson 14: Mindfulness Training
(Part 4): The “How” Skills (STM, pp. 298
There are four key mindfulness
“how” skills in RO DBT: with self-enquiry (see previous lesson), with
awareness of harsh judgements, with one-mindful awareness, and effectively
and with humility. This lesson focuses on the latter three “how” skills. With
respect to the second mindfulness “how” skill, our judgements can become harsh
and unkind when they are rigidly believed as if they were gospel truths. Harsh
judgements can lead to unhealthy rumination and make us less open to feedback
or learning new information. Harsh judgements can negatively affect how we
socially signal or express ourselves to others. It is important to practice
mindfulness without harsh judgements. In traditional DBT, practitioners
ring a judgement bell wherever anyone is judging themselves negatively in the
group. It could be helpful to imagine a judgement bell in your own mind when
you begin making harsh judgements about yourself or others. Learn to recognise
when this is happening and allow the thoughts to pass like clouds in the sky. You
may find it helpful to disclose some of your harsh judgements to a trusted
member of the tribe. Be honest and out yourself by practicing self-enquiry in
the presence of another person. Sometimes you may find it helpful to judge a
little and then get over it. Don’t ruminate on your judgements. Let them pass.
One-mindful
awareness is the third mindfulness “how” skill. It means doing only one
thing at a time. This will involve repeatedly turning one’s attention to the
task in hand in the present moment. In other words, it means not
multitasking. From the perspective of RO DBT, multitasking is not a helpful or a
skilful practice. Better to have focus and to be one-mindful than get caught
with our fingers in too many pies. The fourth mindfulness “how” skill in RO DBT
is effectively and with humility. Being effective means doing what
works. It means being able to adapt your behaviour and practices to ever
changing circumstances and situations in order to achieve your goals and live
for your values in a way that is fully conscious and mindful of others,
especially those in your tribe. According to Professor Lynch, this can involve
‘learning how to not always play by the rules, [and] to be less political,
to not always base decisions on winning or achievements, to let go of compulsive
striving and obsessive self-improvement, and to learn how to celebrate
ineffective moments as opportunities for growth’ (STM, p. 298). This should be
done with gentleness and humility. There is no room for boasting in the
practice of mindfulness. We simply acknowledge what has been done effectively
in the moment and let the thoughts pass from our mind’s awareness as leaves on
a stream.
Lesson 15: Interpersonal
Integrity (Part 1): Saying What we Really Mean (STM, pp. 318
It is often the case that how we
say something matters more than what we say. The attitude with which we say
something is very important. As the saying goes, ‘If we cannot say anything
kind, we shouldn’t say anything at all’. This doesn’t mean we can’t be honest
with folk; it just means that we should sweeten all our speech with kindness.
All human beings desire to be treated with honesty, dignity, and respect – or
with equity. Yet we often communicate indirectly with others, make indirect requests,
and deny ever doing so – in other words, we tell lies. When indirect speech is
used to gain unfair advantages or cause harm, then it is antisocial and should
be avoided. Everyone tells lies, but not everyone admits to doing so. Some lies
are prosocial such as white lies for example, but others are harmful such as
lying to gain an unfair advantage, cause harm, or obstruct others. It is
important to be honest and practice saying what we really mean to say.
According to Professor Lynch, ‘When apparently innocent questions become
disguised demands, relationship problems often follow … hidden intentions and
disguised demands erode goodwill’ (STM, pp. 318, 323). Say what you mean and
mean what you say. Be candid, but polite. Speak with honesty and with
kindness.
Lesson 16: Interpersonal
Integrity (Part 2): Using Flexible Mind REVEALs (STM, pp. 329
There are two common disguised
demands among OC clients known as “pushbacks” and “don’t hurt me” responses.
These are maladaptive social signals that frequently have destructive
consequences for relationships. They both block unwanted feedback and requests
to join with others. They signal non-engagement and emotional shutdown. They
are subtle attempts to control others indirectly and in such a way as to make
it plausible for the sender to deny this fact. They both imply that the fault
lies with the other person or elsewhere, rather than taking ownership for
faults. According to Professor Lynch, a “pushback” essentially says, ‘If you
were wise, you would immediately stop challenging me, asking me questions, or
giving me feedback, because I will make your life miserable if you don’t comply
with my wishes, in a way that no one can ever prove’ (STM, p. 333). A “don’t
hurt me” response, by way of contrast, essentially says, ‘If you were a nice
person, you would stop asking me to change, or stop giving me feedback, because
you would recognise the inappropriateness of what you are doing’ (STM, p. 332).
“Pushbacks” are often signalled by flat facial expressions, silent treatment,
hostile stares, walking away, eye rolls, sarcasm, sneering, or mockery. “Don’t
hurt me” responses are often signalled by pouting, sulking, frowning, downcast
eyes, sighing, moaning, or begging. Both “pushbacks” and “don’t hurt me”
responses contain hidden intentions, both block critical feedback, and both attempt
to secretly control others. We use Flexible Mind REVEALs to let go of habitual
“pushback” and “don’t hurt me” responses.
1.
Recognise secret desires for control.
2.
Examine your social signalling and label
what you find.
3.
Remember your core Values.
4.
Engage with integrity by outing yourself.
5.
Practice Flexible Mind ADOPTS (See
Handout 22.1).
6.
Learn through self-enquiry.
It is important to practice being
more open and honest with people in general by revealing your likes or dislikes
and by saying what you expect from the other person in a relationship. Practice
self-enquiry to strengthen your learning – remember this includes a willingness
to question yourself and to explore the possibility that you might be mistaken.
Remember you are not a puppet master and don’t have to secretly control every
person in your life.
Lesson 17: Interpersonal
Effectiveness (STM, pp. 352
It is important to clarify your
goals and objectives in a relationship. Ask yourself the question: which one
takes priority: personal objectives, relationship objectives, or self-respect
objectives? Try not to obsessively rehearse what you are going to say in
advance of saying it – particularly if it is purely social. Obviously, if you
are giving a presentation at work, you might want to rehearse what you are
going to say in advance. But rumination on what we might say in given social
circumstances such as a birthday party or social gathering is generally unhelpful
and a waste of time. Remember your valued goals in life and live by them when
interacting with others. Always practice kindness in relationships because
kindness seasons your speech with affection and openness. Remember to tame your
tongue and only say something if you have something nice to say. Authentic
kindness means contributing to the well-being of others without
expecting anything in return. We use Flexible Mind ROCKs ON to enhance our
interpersonal kindness, effectiveness, and social connectedness.
1.
Resist the urge to control other people.
2.
Identify your interpersonal effectiveness goals
and degree of Openness.
3.
Clarify the interpersonal effectiveness
goal that is your priority.
4.
Practice Kindness first and foremost.
5.
Take into account the Other person’s Needs.
Remember the golden rule: kindness means
treating other people as we would like to be treated. It recognises that we are
better as part of a tribe when we work together as a team. Kindness is willing make
self-sacrifices for others. It recognises quirks and differences between people
in society. It doesn’t expect the world to conform to our every belief or
demand. It stands up against the powerful and against unethical behaviour. It
means admitting when you are wrong or have harmed someone else with your
actions or words. It means honesty, integrity, and truthfulness in our
relationships. It hopes that the best will come to others and celebrates their
successes and victories. It is willing to let the other person win (even
without telling them). And those who we chose to help in kindness, owe us nothing
in return. Kindness is given freely and with humility.
Lesson 18: Being Assertive with
an Open Mind (STM, pp. 378
When making requests or turning
them down, use the Flexible Mind PROVEs skill to assert yourself and your needs
with an open mind and to maximise your chances of success.
1.
Provide a brief description of the
underlying circumstances.
2.
Reveal your emotions about the
circumstances, without blaming.
3.
Acknowledge the Other person’s needs,
wants, and desires.
4.
Use you Valued goals to guide how you
socially signal your needs.
5.
Practice self-Enquiry to decide whether
(or not) to repeat your experience.
It is important to clearly explain
the issues at stake and the underlying circumstances behind your request. Use social
qualifiers like ‘From what I can tell …’ or ‘I am aware of the thought that …’
to signal open-mindedness and humility. Be ready to reveal your thoughts and
feelings about the situation without casting stones about or blaming others.
Use “I” statements to signify that you are personally taking responsibility for
your feelings and the situation. Let the other person know that you understand
their thoughts and feelings on the matter. If you are unsure, ask them to explain
things from their perspective and listen carefully.
Avoid indirect
statements or disguised demands such as “pushbacks” and “don’t hurt me”
responses. Remember to practice self-enquiry after the social interaction,
especially if you find yourself ruminating about what happened. It can be
helpful to practice 5 mins of self-enquiry and then leave the issue to rest
until your next social interaction. If you believe the relationship to be
toxic or dangerous to your well-being, make sure you have a safe plan for
ending the relationship and finding appropriate refuge.
Lesson 19: Using Validation to
Signal Social Inclusion (STM, pp. 392
We both transmit and receive
information to and from others. A breakdown in relationship can occur when
people feel misunderstood or misrepresented. Such ruptures are inevitable in
close relationships and can enhance intimacy and bonding when repaired. We use
validation to repair ruptures in relationships and signal social inclusion.
According to Professor Lynch, ‘Validation requires us to understand the other
person AND to communicate this understanding’ (STM, p. 392). The person whom
you intend to validate must feel and know that he/she is being validated,
otherwise it is not actual validation. Some behaviours, however, are invalid
such as domestic abuse or stealing from others. These require corrective
feedback or withdrawal from the relationship. The discomfort of invalidation
for our negative behaviours reminds us to practice self-enquiry with honesty
and integrity.
It is possible
to validate your partner or someone from your tribe without using any words
through such means as eye contact, turning towards them when they are speaking
to you, nodding your head to show you are listening, mimicking their facial
expressions or tone of voice, and using half smiles. By way of contrast, it is
equally possible to invalidate your partner by turning away from them, making
no eye contact, using a frozen posture and expression, or by acting bored
through yawning and looking at your watch. Remember that we feel safe when we
belong to a tribe. Our social signalling in tribal contexts in very important
to create bonding and relationships. Our brains are hardwired by evolution to
be hypersensitive for signs of social exclusion. Nobody wants to be rejected
from the tribe. In a prehistoric context such exclusion would have meant almost
certain death. Belonging to a tribe means being willing to receive feedback
from tribal members and using self-enquiry to learn from feedback and
criticism. There are several levels of validation to signal social inclusion:
being attentive, reflecting back to the other person, empathic mind reading
(‘If I were in your shoes …’), understanding someone’s story and the reasons
for their behaviour, and normalising behaviour where appropriate by welcoming
prodigals back into the tribe. We may also signal trust (‘I believe in you’)
and reciprocity (‘We are the same’) towards others.
What about
invalidation? Sometimes invalidation can be harmful, especially if it has roots
going back to childhood. Even so, some kinds of invalidation are important for
our survival and well-being as it protects the tribe from antisocial behaviour.
Our goal should be to use invalidation as an opportunity for growth and
learning (‘You did this wrong, but next time …’). It is important to use the
discomfort of receiving disconfirming feedback or criticism as an opportunity
to practice self-enquiry and to learn from our mistakes.
Lesson 20: Enhancing Social
Connectedness (Part 1) (STM, pp. 418
In the process of enhancing social
connectedness, it is generally true that we like people who like us in return.
We must be ready to take the risk of being disliked by others, especially when
we out ourselves or disclose our true self to someone else. There is no such thing
as a knight in shining armour or a beautiful princess waiting to sweep us away.
We must put ourselves out there with humility and expose ourselves to being
liked or disliked by others. Genuine friendships or romantic relationships
require a lot of care and attention. Close friends tend to be relaxed in each
other’s company and learn to trust each other as social bonding increases. The
relationship should be nonexploitative and both friends/partners should feel
perfectly safe in each other’s company. People tend to vary in how much
intimacy they desire, and we should accept this nonjudgmentally. There is no
right or wrong when it comes to how much intimacy you desire. As part of a
tribe – even a global tribe – we are all dependent on each other and this is
true whether we like it or not. We need to work together for our survival,
happiness, and well-being. Being close or intimate with others requires
practice and opens us to vulnerability. The good news is that research suggests
you only need to find one friend or close relationship to feel content and
happy. Two is a much a tribe as twenty. It is the quality of the relationship
that matters, not the quantity. Old wounds in tribal relations can always be
repaired by signalling a willingness to reengage and apologise where necessary.
Lesson 21: Enhancing Social
Connectedness (Part 2) (STM, pp. 429
As we suggested in the previous
lesson, it is not how many friends you have that counts, but the quality of
relationships and social connectedness that matters. You may have a thousand
friends on Facebook or Twitter and yet have no meaningful relationships in the
real world. You only need one friend or close relationship – someone who is
willing to make self-sacrifices for you and care for you when you are in
distress. Friends help us feel socially secure. Higher levels of intimacy
increase our social safety. In RO-DBT, we use the Match Plus One skill to help
us with forming close social bonds. Revealing our personal feelings to others
allows the opportunity for reciprocal revelations from our friends. Close
relationships mean not only knowing what a person is proud of or has achieved
in life, but also having an awareness of the things they struggle with such as
their inner fears or doubts. We use Flexible Mind ALLOWs to enhance our social
connectedness:
1.
Assess your commitment to improve the
relationship.
2.
Look for concrete evidence that mistrust
is justified.
3.
Loosen your grip on past hurts and fears.
4.
Out yourself by revealing your inner
feelings.
5.
Welcome feedback and continue to
dialogue.
Self-disclosure or outing oneself
in a relationship communicates to the other person that you trust them, believe
them, and that you intend them no harm. Outing yourself makes it more likely
that the other person will reciprocate and share their own vulnerabilities with
you. Be willing to learn from corrective feedback and ready to apologise and
make amends when you have done or said something inappropriate.
The Match Plus
One scale is a form of intimacy rating for forming social connectedness and
friendships. It provides the basic steps in getting to know someone and in
enhancing an existing relationship. When you first get to know someone,
interactions tend to be less personal and intimate – conversation tends to be
general and nonspecific. Chitchat is an important skill to learn when meeting
people for the first time. By using the Match Plus One scale, you can build
upon the basis of general chitchat to a more fulfilling relationship. You might
begin a relationship by talking about everyday events such as the weather or
the traffic conditions (level 1–2). You might progress to talking about
politics, parenting, or philosophy (level 3–4). You might begin talking about
private feelings or emotional judgements such as one’s true feelings about a
supervisor in the workplace (level 5–6). You may consider revealing personal feelings
about your relationship with other person (‘I really like you’) (level 7–8). At
the highest levels, you may consider expressing feelings of affection or desire
for more intimacy with the other person (level 9), or feelings of love and a
desire for a long-term committed relationship (level 10).
Lesson 22: Learning from
Corrective Feedback (STM, pp. 449
The most successful and effective
people in the world are open to disconfirming and critical feedback. They are
able to learn from their experiences and flexibly alter their behaviour in
order to adapt to ever-changing environments and circumstances in the world.
Tension in your body during an interaction may indicate that it is time to
practice being open by using the Big Three Plus One to signal open mindedness
and willingness to learn. Being radically open to critical feedback means being
willing to be wrong, without losing your own perspective or automatically
giving in to the argument. We use Flexible Mind ADOPTS to facilitate learning
from corrective feedback:
1.
Acknowledge that painful feedback is
occurring.
2.
Describe and observe emotions, bodily
sensations, and thoughts.
3.
Be Open to new information by
cheerleading and fully listening.
4.
Pinpoint what new behaviour is being
recommended by the feedback.
5.
Try out the new behaviour.
6.
Self-soothe and reward yourself for being
open and trying something new.
If you are not aware that someone
is giving you unwelcome or disconfirming feedback, then you will never be able
to learn from it. Tension in the body generally means that it is time to
practice being open. It is important to practice self-enquiry when we find
ourselves resisting openness to the feedback or new information. Not all
feedback is correct, but even in unwarranted feedback there may be a grain of
truth which we can learn about ourselves. Remember to reward yourself for being
open to corrective feedback with pleasurable things like a relaxing bath, a day
out at the seaside, or a naughty bar of chocolate.
Lesson 23–26: Mindfulness
Training (Repeated from Lessons 11–14) (STM, pp. 470
Lesson 27: Envy and Resentment (STM, pp. 475
RO DBT also considers some of the
darker aspects of human nature such as envy, resentment, cynicism, bitterness,
and resignation. According to Professor Lynch, ‘Envy is experienced whenever
someone compares themselves unfavourably to others, and unhelpful envy occurs
when we believe their advantage over us is unwarranted’ (STM, p. 475). The
Welsh hymnwriter and poet Williams Pantycelyn described envy in an
eighteenth-century pamphlet as being like a monstrous crocodile in the heart: a green-eyed monster which consumes and destroys us. There are five steps for
challenging unhelpful and destructive envy. We follow the acronym Flexible Mind
DARES:
1.
Determine if you are experiencing
unhelpful envy.
2.
Admit your envy and decide whether you
want to change it.
3.
Recognise envious thoughts and action
urges.
4.
Go opposite to Envious anger.
5.
Go opposite to Shameful envy.
Unhelpful envy brings together two emotions:
shame and anger and such feelings create action urges for secret revenge.
Challenging envy requires opposite action. We must go opposite to shame’s urge
to hide and anger’s urge to attack. Opposite action requires that we go all the
way by letting go of ill will towards the other person and by revealing our
envious feelings to them.
Lesson 28: Cynicism, Bitterness,
and Resignation (STM, pp. 488
A cynic is a person who believes
that other people are motivated by self-interest and greed, rather than any
kind of altruism. A cynic might say something like this: ‘Life sucks,
and then you die’ (STM, p. 490). But despite their pessimism, cynics enable
societies to grow by challenging social, economic, and political norms by such
means as whistleblowing, investigative journalism, or publicly exposing the
wrongdoings of an organisation or company. Cynics generally don’t expect good
things to happen, and cynicism becomes harmful when it leads to bitterness and
hate. While some cynicism is helpful towards critical thinking in society,
prolonged and intensive cynicism may lead to bitterness and undue pessimism.
‘Bitterness is characterized by a pessimistic, hateful, discouraged, and
resentful outlook on life’ (STM, p. 491). Changing feelings of bitterness and
resignation requires five key steps summarised in RO DBT as Flexible Mind is
LIGHT:
1.
Label your bitterness using self-enquiry.
2.
Notice bitter Intentions by examining
action urges.
3.
Go opposite to bitter beliefs.
4.
Help others and allow others to Help.
5.
Practice kindness and be Thankful.
To change bitterness, we practice
kindness first and foremost. We learn how to give and receive help and we
practice being thankful for the people and things we do have in life. We look
for good news stories and events – uplifting narratives that demonstrate the
altruism and compassion of humankind. We reflect on what we share in common
with other human beings. We learn to interact with people who have different
ways of dressing, thinking, or acting than ourselves. We celebrate diversity in
life. We listen to people who are from different backgrounds and cultures to
ourselves and who may hold different values or morals to us. We pass on the
gift of kindness without expecting anything in return. Simply be thankful for all you have in life: for
family, for friends, for a roof over your head, for warmth, love, and food in
your belly. Be thankful for life and for your very breath. And greet each day
with thankfulness in your heart.
Lesson 29: Learning to Forgive (STM, pp. 502
Learning to forgive others or
ourselves can be tricky for OC clients, especially those struggling with past
trauma or guilt. Forgiveness does not
mean we approve of what happened in the past. It does not mean reconciliation.
It does not mean opening yourself up to be hurt again. Forgiveness means that
we take care of our own well-being first and learn to let go of feelings of
useless anger, resentment, or self-blame. To let go of a past grievance, RO DBT
brings us to our “edge” or personal unknown that keeps us holding on to past
hurt or guilt. You must choose to forgive. It is costly. A person cannot be
forced to forgive others, neither can someone be forced to accept forgiveness
when it is freely offered. We use Flexible Mind has HEART to practice
forgiveness towards others:
1.
Identify the past Hurt.
2.
Locate your Edge that is keeping you
stuck in the past.
3.
Acknowledge that forgiveness is a choice.
4.
Reclaim your life by grieving your loss
and practicing forgiveness.
5.
Practice Thankfulness and then pass it
on.
Forgiveness requires ongoing
commitment to let go of past hurt and shame. We forgive and keep on forgiving. There
is a story in the Bible about forgiveness and how many times we should forgive
someone. Peter comes to Jesus and asks him: ‘Lord, how many times shall I
forgive my brother or sister who sins against me? Up to seven times?’ Jesus
answered him, ‘I tell you, not seven times, but seventy-seven times’ (Matthew
18:21–22). In other words, there is no limit to how many times we should
forgive a person. That doesn’t mean approval of what they have done, but it
means we learn to let go of resentment towards them for their actions. We
should also remind ourselves of all the times in our own lives when we have
needed forgiveness from others. Nobody is perfect. Everyone needs to be
forgiven at some point in their lives. Remember to practice thankfulness for
forgiveness and pass on the joy to others.
Lesson 30: RO Integration Week (STM, pp. 529
The final week is meant to
encourage some fun and happiness. Instructors may use it as a catch-up lesson
or opportunity to summarise the key points within RO DBT. There is no real
curriculum or goals to achieve in this lesson. Instructors and clients can be
creative in what they do to summarise the salient point arising in the study of
RO DBT. Most importantly, clients should congratulate themselves for completing
30 weeks of intensive group therapy. It is a big achievement and worth
celebrating both individually and as a tribe. Think of integration week as you
would a graduation ceremony from university or college. It is a time to
celebrate and be happy for all the work you have done.
References
Hall, Karyn D., Ellen
Astrachan-Fletcher, and Mima Simic (eds), The Radically Open DBT Workbook
for Eating Disorders (Oakland, 2022).
Lynch, Thomas R., Radically Open
Dialectical Behaviour Therapy: Theory and Practice for Treating Disorders of
Overcontrol (Oakland, CA, 2018).
Lynch, Thomas, R., The Skills
Training Manual for Radically Open Dialectical Behaviour Therapy (Oakland,
CA, 2018).
N.B. I would like to thank my friends in our RO DBT group for all their insights and contributions and my especial thanks to the facilitators of our course (Mike, Bev, Hayley, and Hannah) for all their support and guidance.
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