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<p>“Radically open dialectical behavior therapy (RO DBT) is a truly innovative treatment, developed through</p><p>translation of neuroscience into clinical practice, integrating various influences from dialectical behavior</p><p>therapy (DBT), mindfulness-based approaches, emotion, personality and developmental theory, evolutionary</p><p>theory, and Malamati Sufism. RO DBT is applicable to a spectrum of disorders characterized by excessive</p><p>inhibitory control or overcontrol (OC). This is the first treatment that directly targets social signaling and</p><p>nonverbal aspects of communication not only in clients but also in therapists.”</p><p>—Mima Simic, MD, MRCPsych, joint head of the child and adolescent eating disorder</p><p>service, and consultant child and adolescent psychiatrist at the Maudsley Hospital in</p><p>London, UK</p><p>“A new and comprehensive statement from one of the more creative minds in evidence-based clinical inter-</p><p>vention today, RO DBT brings together a contemporary focus on a limited set of key transdiagnostic processes,</p><p>with new assessment and intervention techniques for moving them in a positive direction. Emphasizing flexi-</p><p>bility, openness, connection, and attention to social signaling, RO DBT specifies the details that can matter,</p><p>from how you arrange your consulting room furniture to how nonverbal cues signal social information. RO</p><p>DBT seems destined to make an impact on evidence-based care in many corners of clinical work. Highly</p><p>recommended.”</p><p>—Steven C. Hayes, PhD, codeveloper of acceptance and commitment therapy (ACT);</p><p>Foundation Professor of psychology at the University of Nevada, Reno; and author of Get</p><p>Out of Your Mind and Into Your Life</p><p>“RO DBT offers an intriguing reconceptualization of traditional views of internalizing and externalizing dis-</p><p>orders, and provides the clinician with valuable new tools to address a number of problems that have been</p><p>particularly resistant to standard CBT approaches. I will definitely include RO DBT theory and techniques in</p><p>my graduate-level intervention class. I know beginning clinicians in particular will be grateful to have a sys-</p><p>tematic way to approach these slow-to-warm-up clients who are difficult to establish rapport with. Their early</p><p>termination from therapy and failure to respond to traditional approaches often leaves clinicians befuddled</p><p>and critical of their own skills. RO DBT provides a compassionate way for clinicians to view this type of resis-</p><p>tant client, as well as to work on some areas that are likely to benefit them. A very welcome addition to any</p><p>clinician’s toolbox.”</p><p>—Linda W. Craighead, PhD, professor of psychology and director of clinical training at</p><p>Emory University, and author of The Appetite Awareness Workbook</p><p>A CLINICIAN’S GUIDE for</p><p>TREATING DISORDERS of OVERCONTROL</p><p>THOMAS R. LYNCH, PhD</p><p>The</p><p>SKILLS TRAINING</p><p>MANUAL for</p><p>RADICALLY OPEN</p><p>DIALECTICAL</p><p>BEHAVIOR THERAPY</p><p>Context Press</p><p>An Imprint of New Harbinger Publications, Inc.</p><p>Publisher’s Note</p><p>This publication is designed to provide accurate and authoritative information in regard to the subject matter covered.</p><p>It is sold with the understanding that the publisher is not engaged in rendering psychological, financial, legal, or other</p><p>professional services. If expert assistance or counseling is needed, the services of a competent professional should be</p><p>sought.</p><p>Distributed in Canada by Raincoast Books</p><p>Copyright © 2018 by Thomas P. Lynch</p><p>Context Press</p><p>An imprint of New Harbinger Publications, Inc.</p><p>5674 Shattuck Avenue</p><p>Oakland, CA 94609</p><p>www.newharbinger.com</p><p>Image in handout 8.3: “Have You Heard? Let Justice Be Done!,” Jackson, Peter (1922–2003) / Private Collection</p><p>/ © Look and Learn / Bridgeman Images.</p><p>“Who Makes These Changes?” from THE ESSENTIAL RUMI by Jalal al-Din Rumi, translated by Coleman</p><p>Barks. Copyright © 1997 by Coleman Barks. Used by permission.</p><p>Cover design by Amy Shoup; Acquired by Catharine Meyers;</p><p>Edited by Xavier Callahan; Indexed by James Minkin</p><p>All Rights Reserved</p><p>Library of Congress Cataloging-in-Publication Data</p><p>Names: Lynch, Thomas R. (Professor of clinical psychology), author. | Complemented by (work): Lynch,</p><p>Thomas R. (Professor of clinical psychology). Radically open dialectical behavior therapy</p><p>Title: The skills training manual for Radically open dialectical behavior therapy : a clinician’s guide for</p><p>treating disorders of overcontrol / Thomas R. Lynch.</p><p>Description: Oakland, CA : New Harbinger Publications, Inc., 2018. | Companion volume to Radically open</p><p>dialectical behavior therapy / Thomas R. Lynch. 2018. | Includes bibliographical references and index.</p><p>Identifiers: LCCN 2017040505 (print) | LCCN 2017043166 (ebook) | ISBN 9781626259324 (pdf e-book)</p><p>| ISBN 9781626259331 (ePub) | ISBN 9781626259317 (paperback)</p><p>Subjects: | MESH: Behavior Therapy--methods | Compulsive Personality Disorder--therapy | Behavior</p><p>Therapy--education | Self-Control--psychology</p><p>Classification: LCC RC489.B4 (ebook) | LCC RC489.B4 (print) | NLM WM 425 | DDC 616.89/142--dc23</p><p>LC record available at https://lccn.loc.gov/2017040505</p><p>This book is dedicated to the the most important people in my life—</p><p>my wife Erica and our daughter Kayleigh</p><p>If I know anything, it is that I don’t know everything and neither does anyone else.</p><p>— Michael P. Lynch, True to Life: Why Truth Matters</p><p>Contents</p><p>List of Radical Openness Handouts and Worksheets xvii</p><p>Chapter 1 Basic Principles, Treatment Overview, and Global Structure of Skills Training Classes 1</p><p>What Is Overcontrol? 1</p><p>Four Core Deficits 3</p><p>RO DBT Therapeutic Stance 3</p><p>Basic Assumptions 4</p><p>The Primary Mechanism of Change: Social Signaling 5</p><p>Treatment Structure and Targets 6</p><p>Individual Therapy Treatment Target Hierarchy 7</p><p>RO Skills Training: Global Aims and Targets 8</p><p>Orienting OC Clients to RO Skills Training 9</p><p>Structuring RO Skills Training Classes 11</p><p>Composition of RO Skills Training Classes 13</p><p>Think Nondiagnostically to Enhance Class Size 13</p><p>Maximize Learning by Maximizing the Physical Environment 14</p><p>Teach Directly from the Manual 16</p><p>Summary 17</p><p>Chapter 2 Dialectics, Radical Openness, and Self- Enquiry 18</p><p>Why Dialectics? 18</p><p>Why Radical Openness? 22</p><p>Why Self- Enquiry? 25</p><p>Summary 27</p><p>Chapter 3 Managing Problematic Behaviors in RO Skills Training Classes 29</p><p>When a Classroom Goes Quiet 29</p><p>Use Heat- On and Heat- Off Strategies to Shape Desired Behaviors 34</p><p>Maladaptive Social Signals That Cannot Be Ignored in Class 35</p><p>Protocol for Therapeutic Induction of Social Responsibility 42</p><p>Managing Alliance Ruptures and Repairs 45</p><p>Managing Suicidal Behavior 45</p><p>Summary 46</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>viii</p><p>Chapter 4 Using the RO Skills Training Manual 47</p><p>Deciphering an RO Lesson Plan 47</p><p>Additional Instructions for Using the Skills Manual 48</p><p>Chapter 5 The RO DBT Lesson Plans 50</p><p>Lesson 1 Radical Openness 51</p><p>Main Points for Lesson 1 51</p><p>Materials Needed 51</p><p>(Recommended) Mindfulness Practice: Mindfulness of Ambiguity 52</p><p>(Required) Class Exercise: Our Perceptual Biases: How We Become Closed to New Information 53</p><p>(Required) Teaching Points: Perceptual Biases 53</p><p>(Required) Teaching Points: What Is Psychological Health? 54</p><p>(Required) Teaching Points: To Be Open or Closed? That Is the Question! 55</p><p>(Recommended) Class Exercise: Myths of a Closed Mind 56</p><p>(Required) Teaching Point: What Is Radical Openness? 56</p><p>(Required) Teaching Point: Flexible Mind DEFinitely: Three Steps for Radically Open Living 58</p><p>Lesson 1 Homework 60</p><p>Lesson 2 Understanding Emotions 73</p><p>Main Points for Lesson 2 73</p><p>Materials Needed 73</p><p>(Recommended) Mindfulness Practice: Participate Without Planning 73</p><p>(Required) Teaching Point: Five Emotionally Relevant Cues 74</p><p>(Required) Teaching Point: Pulling It All Together 79</p><p>(Required) Story and Discussion: “So Close and Yet So Far Away” 79</p><p>Lesson 2 Homework 81</p><p>Lesson 3 Activating Social Safety 88</p><p>Main Points for Lesson 3 88</p><p>Materials Needed 88</p><p>(Required)</p><p>work-</p><p>sheets and handouts for the class. Pens and pencils should be supplied for notetaking. Instructors should</p><p>remind class members to bring their personal RO skills folders with them to each class, and instructors should</p><p>always have extra copies of the handouts and worksheets available for those who may have forgotten or mis-</p><p>placed their RO folders.</p><p>Skills instructors should also adopt a standard protocol for contacting missing class members. Typically</p><p>this involves having the coinstructor briefly step out of the room at the beginning of class (for example, during</p><p>the mindfulness practice) and make brief phone contact with all missing members, encouraging them to</p><p>attend the day’s class, if only a short period, while also assessing and blocking maladaptive behaviors. For</p><p>example, if a client says he is too depressed to come to class, the coinstructor might say, “This is exactly the</p><p>time you need to be practicing skills, by going opposite to your desire to isolate and by coming to class instead.</p><p>So I would like you to get in your car now and come to class.” The overall therapeutic stance is to strongly</p><p>signal that attendance at skills training class is essential for genuine recovery and not an optional component</p><p>of treatment. A general overview of the class structure is outlined here:</p><p>• Beginning of class. Instructors should establish a class norm of beginning class on time; delaying the</p><p>start of class can make it more difficult to cover the lesson plan for the day and/or can imply that late-</p><p>ness is okay (because “we never start on time”). Indeed, delaying the start of class to wait for missing</p><p>members can be interpreted as invalidating by those OC individuals who have arrived on time, and it</p><p>may trigger feelings of unfairness, envy, or resentment, which can subtly undermine the class’s func-</p><p>tioning, influence attendance, and/or trigger alliance ruptures. Thus, as already noted, rather than</p><p>delaying the start of class, the coinstructor should step out and telephone any members who have not</p><p>arrived and encourage them to attend.</p><p>• Brief mindfulness exercise (approximately one to ten minutes). Each class begins with a short mindfulness</p><p>exercise that, ideally, is linked to the new skill being taught during the day’s class. The exercise can be</p><p>followed by a brief discussion and sharing of observations, but discussion afterward is not required.</p><p>Plus, rather than emphasizing silent practices involving dispassionate awareness (such as mindful</p><p>breathing), RO mindfulness exercises prioritize repeated exposure to practices involving self- enquiry,</p><p>outing oneself to a fellow practitioner, and participating without planning. When it comes to partici-</p><p>pating without planning, instructors are encouraged to use the “participate without planning” prac-</p><p>tices found in this manual rather than creating their own (see “Teach Directly from the Manual,” later</p><p>in this chapter).</p><p>• Homework review (approximately forty minutes in total). Next, the instructor or coinstructor reviews the</p><p>homework that was assigned the previous week, making sure that participants have time to share how</p><p>they did. Importantly, RO diary cards should not be reviewed in RO skills training classes. Although</p><p>the RO DBT diary card includes a list of skills used during the previous week, it is intended solely for</p><p>use during individual therapy.</p><p>• Break (approximately ten to fifteen minutes). After homework review, a short break is provided. One</p><p>instructor should remain with class members during the break. This facilitates social interaction,</p><p>Basic Principles, Treatment Overview, and Global Structure of Skills Training Classes</p><p>13</p><p>provides opportunities for skills coaching, and cheerleads participation. A break also gives OC clients</p><p>an opportunity to practice social engagement skills in a nonstructured setting. Plus, a class break is a</p><p>core way for instructors to address maladaptive behaviors and/or potential alliance ruptures privately.</p><p>In addition, the break provides important opportunities for instructors to shape prosocial classroom</p><p>behavior (see “Protocol for Therapeutic Induction of Social Responsibility,” in chapter 3) or manage</p><p>potential alliance ruptures.</p><p>• Teaching of new skills for the week or lesson (approximately fifty minutes). After the break, the second half</p><p>of the class begins, with one instructor taking the lead in teaching the new material for the week.</p><p>• Assignment of homework (approximately five minutes). Just prior to the end of the class, homework is</p><p>assigned for the upcoming week (that is, the period before the next lesson). Participants are also</p><p>encouraged to continue practicing their previously learned RO skills. Instructors should look for</p><p>opportunities to augment required homework assignments with optional assignments for the entire</p><p>class and/or individualized assignments targeting specific issues relevant for a particular client.</p><p>Individualized homework assigned to a particular client should always be mutually agreed upon as</p><p>useful and, ideally, should not be overly complicated or too time- consuming to complete. Instructors</p><p>should keep a record of extra homework assignments and use it to remind themselves to ask clients</p><p>about how things went with their completion of individualized assignments.</p><p>Composition of RO Skills Training Classes</p><p>Skills classes conducted with OC clients should consist, ideally, of seven to nine participants, with two instruc-</p><p>tors. Although it seems somewhat counterintuitive, given the socially anxious nature of overcontrol, OC</p><p>clients actually experience a small class size (four or fewer members) as more difficult and/or anxiety- arousing</p><p>than a larger class size. The reason for this apparent conundrum is that OC clients dislike the limelight. Most</p><p>OC clients are uncomfortable being the center of attention during an interpersonal interaction, and a small</p><p>class size naturally allows for more individualized attention, whereas a larger class size naturally takes the heat</p><p>off anxious OC clients by making it easier for them to fade into the background for brief moments (for example,</p><p>when they need time to reflect or downregulate), without disrupting the class or attracting unwanted</p><p>attention.</p><p>Thus, on a day when there are four or fewer class members (regardless of the reason), it is recommended</p><p>that only one instructor teach (as opposed to the normal two skills instructors present in a larger class). The</p><p>presence of two instructors in a class with few members can be experienced as emotionally intense or exposing,</p><p>causing learning to suffer and commitment to wane. Instructors should avoid the temptation to base their</p><p>decisions on the opinions of class members; almost invariably, most participants will report that they are fine</p><p>or even happy for both instructors to stay (recall the prosocial nature of OC) while privately believing other-</p><p>wise and/or later regretting their consent, without letting it be known. Just as their natural tendencies to mask</p><p>inner feelings make it less likely for them to reveal that a room is too hot, they are unlikely to reveal their</p><p>discomfort about a small class size when queried (see “Maximize Learning by Maximizing the Physical</p><p>Environment,” later in this chapter).</p><p>Think Nondiagnostically to Enhance Class Size</p><p>The good news is that since overcontrol is a transdiagnostic problem cutting across a spectrum of disorders</p><p>sharing similar biotemperamental features and behaviors, it is clinically appropriate to create multidiagnostic</p><p>RO skills training classes rather than focusing solely on diagnostic status for class inclusion. Simply stated, as</p><p>long as all the members of the class share overcontrol as their style of coping (and have agreed to work on it),</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>14</p><p>their diagnostic status does not matter.* Thus, an RO skills training class might include a range of individuals</p><p>presenting with differing problems and/or diagnoses, such as</p><p>anorexia nervosa, chronic depression, autism</p><p>spectrum disorder, chronic back pain, treatment- resistant anxiety, obsessive- compulsive personality disorder,</p><p>and paranoid personality disorder. Indeed, our clinical experience suggests that multidiagnostic RO skills</p><p>training classes may represent the ideal class composition because they provide a unique opportunity for OC</p><p>clients to learn from diversity (recall that OC clients compulsively seek sameness) and lead to unexpected</p><p>clinical benefits. For example, a young adult diagnosed with anorexia nervosa may suddenly find herself sitting</p><p>next to an older adult diagnosed with chronic depression and obsessive- compulsive personality disorder. Both</p><p>are likely to quickly recognize their OC bond, linked to shared qualities/values and struggles, and, ideally, the</p><p>prospect of learning from someone who, on the surface, appears very different. Plus, it helps to not always swim</p><p>in the same pool if one desires to genuinely see the world differently and/or make important life changes. Thus,</p><p>the anorexic OC client is suddenly no longer surrounded solely by fellow “eating- disordered” classmates, who</p><p>may communally trigger frequent body weight/body image social comparisons that function to reinforce</p><p>restrictive eating or compulsive preoccupation with external appearance. Similarly, the chronically depressed</p><p>older adult may find himself challenged by a young person anxiously engaged in learning how to cope and may</p><p>feel excited about new possibilities rather than automatically assuming that nothing will change or that life is</p><p>hopeless.</p><p>In addition, since a core goal of therapy is to help an OC client learn how to form genuine, honest, and</p><p>mutually caring relationships with other people, RO DBT does not consider it a problem for class members to</p><p>socialize together outside of class. Anecdotally, we have observed in our clinical trials that, without prompting,</p><p>OC clients often independently form social networks composed of other class members upon completion of</p><p>treatment, a practice that appears to facilitate continued use of core radical openness and social connected-</p><p>ness skills. These independently formed class tribes or aftercare groups typically meet weekly, do not involve</p><p>clinical oversight, and are client- organized and client- run, with meetings most often taking place in such non-</p><p>clinical settings as a client’s home, a community meeting hall, or a local pub. Clients have been highly enthu-</p><p>siastic about these aftercare tribes, using them to stay connected, practice RO skills with like- minded people,</p><p>and sometimes even find a lifelong partner. Thus, whenever an RO skills training class independently moves</p><p>toward the creation of an OC tribe, the clinical program should celebrate clients’ ingenuity and avoid the</p><p>temptation to interfere with, direct, or manage client- generated aftercare unless specifically asked for help.</p><p>Regardless of clients’ initiatives, clinical programs are encouraged to integrate similar aftercare components,</p><p>when possible, into existing treatment pathways. Although not required formally, the benefits derived from</p><p>continued practice of RO skills can be enormous.</p><p>Maximize Learning by Maximizing the Physical</p><p>Environment</p><p>The physical therapeutic milieu can be a critical factor in enhancing clients’ engagement and achieving a</p><p>successful outcome. The reason this is given such high priority in RO DBT pertains to the innate biotempera-</p><p>mental predisposition for heightened threat sensitivity that characterizes OC clients. OC clients are more</p><p>likely to respond with low- level defensive arousal to environmental stimuli that might go unnoticed by other</p><p>* In some clinical settings, particularly those already using standard dialectical behavior therapy, there can be a temptation to</p><p>collapse overcontrolled and undercontrolled (UC) clients into one class. In general, this is not recommended, for two reasons: first,</p><p>RO skills address problems of overcontrol and fundamentally differ from the skills taught in standard DBT for problems of undercon-</p><p>trol; and, second, the talkative and effusive nature of most UC clients can inadvertently lead to domination of class discussions by</p><p>UC clients’ observations, with fewer contributions from their more restrained OC classmates. OC clients, if asked, may report being</p><p>perfectly fine with this while secretly harboring judgmental thoughts or hoping that expectations for their own personal participation</p><p>may be lessened.</p><p>Basic Principles, Treatment Overview, and Global Structure of Skills Training Classes</p><p>15</p><p>people. They are also less likely to admit to anxious defensive arousal when queried. The primary goal of treat-</p><p>ment is to help OC clients learn that social interactions can be intrinsically rewarding, and that it is possible</p><p>to experience feelings of safety around others; it is not for OC clients to overcome, defeat, or control their</p><p>social anxiety by braving it out or going opposite action.</p><p>Thus, it is helpful for therapists to proactively control the physical milieu in order to make it less likely for</p><p>OC biology to interfere with clients’ learning how to have fun, play, express themselves more freely, chill out,</p><p>and be less serious. This means accounting for a range of often subtle physical and nonverbal factors that can</p><p>enhance (or diminish) social safety experiences in OC clients. Therapists, even those who identify as leaning</p><p>toward OC, should not dismiss these factors because they themselves are not bothered, or because a client</p><p>denies discomfort.</p><p>OC clients generally have a greater need for personal body space relative to others. Close body proximity</p><p>is a nonverbal signal of intimacy or confrontation (Morris, 2002). RO skills instructors should arrange seating</p><p>in the classroom in a manner that maximizes physical distance. Ideally, this arrangement will include a long</p><p>table, with chairs positioned around it in the style of a dining room, and with some type of whiteboard or</p><p>flipchart in the front for instructors to write on (see figure 1.3). This classroom- type setting signals that the</p><p>purpose of the group is to learn skills, in the same way that one learns algebra, for example; it is not a personal</p><p>encounter or process group. The table and the room arrangement also provide a physical buffer between group</p><p>members. This functions to reduce feelings in OC clients of being exposed while also providing space for note-</p><p>taking, which can give OC clients time to regulate themselves in a less obvious manner. The skills class should,</p><p>ideally, be conducted in a large and airy room, to accommodate up to nine people. A large room also allows</p><p>clients greater freedom to adjust their seating or move their chairs farther away from others without calling</p><p>attention to themselves.</p><p>Whiteboard or</p><p>blackboard</p><p>and markers</p><p>Flipchart</p><p>(optional)</p><p>Pens, pencils,</p><p>and paper</p><p>Lead</p><p>instructor</p><p>Coinstructor</p><p>Fan</p><p>Figure 1.3. RO Skills Classroom Layout</p><p>It is also very important that room temperature be considered for skills training classes. A hot or very</p><p>warm environment naturally triggers perspiration in most people. For many OC clients, sweating is a condi-</p><p>tioned stimulus linked to anxiety and maladaptive avoidance. Instructors should set the temperature of the</p><p>classroom lower than what might be normal, and there should be a fan or some other means of cooling the</p><p>classroom, if necessary. In general, the rule is to keep the classroom cool. Class members who find the room</p><p>too cool should be encouraged to wear extra layers.</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>16</p><p>Teach Directly from the Manual</p><p>Although a wide range of potentially valid reasons can be generated in support of therapists’ personal and/or</p><p>theoretical preferences to not explicitly follow this manual when teaching RO skills, my experience training</p><p>and supervising thousands of therapists has repeatedly confirmed that deviating from the manual almost</p><p>invariably creates</p><p>more problems than it solves. The manual is designed to be used like a cookbook. When</p><p>learning a new recipe, good cooks know that the tastiest outcome is most likely if they follow the recipe.</p><p>Similarly, RO skills instructors are encouraged to follow the recipe, particularly when first learning RO skills.</p><p>Plus, using the manual smuggles a core RO principle related to humility and fallibility, a core principle that OC</p><p>clients need to learn.</p><p>The scientific, clinical, and ethical reasons for adhering to a manual, especially when first learning a new</p><p>evidence- based procedure or treatment, become apparent when one considers how one might feel about being</p><p>operated on by a heart surgeon who, one discovers, has decided to change or ignore certain parts of a new and</p><p>recently learned surgical technique without ever having gained experience with the original protocol. The</p><p>point is, people prefer heart surgeons who become experts in the delivery of a new procedure before deciding</p><p>to change it. Similarly, RO skills instructors are encouraged to allow themselves time to learn the new skills</p><p>and principles fully, and to gain expertise in teaching them, as described in the manual, before deciding to</p><p>modify, omit, or create new skills or exercises.</p><p>The type of problem that can emerge when therapists and skills trainers go off model is illustrated by the</p><p>following case. The instructors, both highly experienced therapists (albeit new to RO DBT), decided to intro-</p><p>duce a new game into their RO skills training class. It was not included in the manual but was designed to</p><p>creatively extend RO “participate without planning” exercises and, more broadly, to enhance classroom fun</p><p>and participation, since the game was designed to be played during each and every class.</p><p>The rules of the game required class members to insert into the discussion a previously selected silly word or</p><p>phrase, such as “broccoli,” “boo- boo,” “blessed art thou,” or “talking horse,” that had been written on the</p><p>whiteboard. After the silly word or phrase had been successfully inserted into a comment or statement,</p><p>teaching would be interrupted and the winner would be applauded, whereupon the winner was required to</p><p>come up with a new silly word or phrase to replace the old one. This signaled the start of a new round of</p><p>the game, and there could be several rounds per class. The instructors were careful to orient the class to the</p><p>rationale behind the game, and they obtained class members’ commitment before proceeding. To their</p><p>delight, the class not only embraced the game but also provided several helpful suggestions to make it more</p><p>fun. Enthusiasm was further bolstered by the noticeable increase in verbosity during the first two weeks of</p><p>play. In the second week, during homework review, one of the less talkative members of the class asked</p><p>permission to share a new idea for increasing the fun of the game. The instructors encouraged the client to</p><p>continue, in order to reinforce the client’s participation. The client then proceeded to describe a new rule</p><p>that required the winner not only to incorporate the silly word or phrase into a statement but also to use the</p><p>word or phrase in a grammatically correct way. The class voted to endorse the new rule, and it was</p><p>incorporated into the game that very day. The following week, a minor debate ensued concerning the</p><p>meaning of the word “grammatical,” and two class members reported feeling anxiety about not being able to</p><p>compete adequately. The skills instructors attempted to rectify the situation by using bigger gestures,</p><p>expressing enthusiasm, and reminding the class that the game was not about being perfect. During class</p><p>break, a different client revealed to an instructor that, although they remained enthusiastic about the game,</p><p>they were finding it more difficult to concentrate in class because they kept thinking about the silly word.</p><p>Moreover, the frequent minidebates about the game’s rules, and interruptions to applaud the week’s</p><p>winners, limited the time available for the instructors to teach the RO skill that was supposed to be the</p><p>main focus of the day. The instructors concluded that perhaps the new game was not such a good idea.</p><p>Basic Principles, Treatment Overview, and Global Structure of Skills Training Classes</p><p>17</p><p>Upon reflection, it is easy to see that the game just described was bound to lead to difficulties. It encouraged</p><p>competition among a highly competitive client population, without being explicit about it (that is, there were</p><p>winners but no losers); it went counter to core RO “participate without planning” principles by making it</p><p>impossible to win without some form of rehearsal or planning; and it reinforced OC maladaptive rigid and</p><p>rule- governed behavior via the rules of the game. Core RO skills training principles and structural recommen-</p><p>dations were ignored. For example, the game dominated a significant amount of class time. Not only did the</p><p>instructors design the game so that it could be played each and every class, the rules also required RO skills</p><p>teaching to stop in order for the winner to be applauded and have sufficient time to write the next silly word</p><p>or phrase on the whiteboard. Plus, rather than encouraging “participate without planning” skills, the game</p><p>encouraged multitasking and planning ahead.</p><p>Fortunately, the instructors in this real- life example quickly adjusted their teaching style and, with encour-</p><p>agement from their RO consultation team, outed their errors to their skills class the following week. The game</p><p>was transformed into a class metaphor that symbolized the importance of self- enquiry and eventually became</p><p>a class song titled “Isn’t Arrogance Fun?” During supervision, the skills instructors used this experience as an</p><p>opportunity for self- enquiry that led to important personal and professional growth. For example, self- enquiry</p><p>practice led one instructor to realize that their desire not to follow the manual stemmed partly from exhaustion</p><p>(“Oh no— not another treatment to learn!”), whereas others have reported resisting using the manual because</p><p>they believed it would reflect incompetence or suggest that they were not intelligent enough to translate the</p><p>core principles into their own words. Some have revealed choosing not to use the manual based on prior train-</p><p>ing contending that experienced therapists do better when not following manuals. Others have reported</p><p>feeling embarrassed or uncomfortable with certain aspects of the treatment itself (such as a required teaching</p><p>point necessitating role play or the dramatic reading of a story). Regardless, the main point of this section is to</p><p>encourage instructors to practice self- enquiry whenever they find themselves desiring not to use the manual.</p><p>Here are some examples of self- enquiry questions:</p><p>• To what extent do I actually follow the RO treatment manual? How much energy or resistance do I</p><p>experience when asking this question? What might this tell me about my willingness to learn a new</p><p>treatment? What is it that I need to learn?</p><p>• What am I afraid would happen if I were to comply with the manual?</p><p>• To what extent has my prior training influenced my behavior and/or openness to learn RO DBT?</p><p>What might this mean for me as a health care provider?</p><p>• How open was I when first learning RO DBT? Has my openness changed? What does this tell me</p><p>about myself? What is it that I might need to learn?</p><p>• What core RO principles or interventions do I disagree with or believe are wrong? To what extent am</p><p>I holding on to an alternative treatment model? How might this impact my learning or delivery of the</p><p>treatment? What does this tell me about myself?</p><p>• To what extent do I believe that it is unfair to require me to practice RO DBT as it was intended</p><p>because of my exceptional status, training, or talent? What is it that I might need to learn?</p><p>Summary</p><p>Radically open dialectical behavior therapy (RO DBT) is an evidence- based treatment designed specifically</p><p>for</p><p>problems of overcontrol. In RO DBT, interventions emphasize the tribal nature of our species and the</p><p>importance of prosocial signaling, self- enquiry, and social connectedness for emotional well- being. The aim of</p><p>this chapter has been to provide a brief overview of core RO DBT principles and of the structural elements</p><p>that need to be considered when an RO skills training class is introduced into a clinical program.</p><p>CHAPTER 2</p><p>Dialectics, Radical Openness,</p><p>and Self- Enquiry</p><p>There are three core philosophical principles or ideas in RO DBT that strongly impact the manner in which a</p><p>therapist delivers the treatment:</p><p>1. Dialectics</p><p>2. Radical openness</p><p>3. Self- enquiry</p><p>Dialectics in RO DBT provides a theoretically coherent means for a therapist to balance and switch between</p><p>seemingly different therapeutic styles in one session— for example, playful irreverence versus compassionate</p><p>gravity. Radical openness is the core underlying principle and skill in RO DBT. It represents the confluence of</p><p>three capacities posited to be essential for emotional well- being: openness, flexibility, and social connected-</p><p>ness. Self- enquiry represents a core RO mindfulness skill that encourages the development of healthy self- doubt</p><p>in order to learn. The primary aim of this chapter will be to provide an overview of the theoretical rationale</p><p>underlying each principle and demonstrate how each influences the in- session behavior of an RO DBT thera-</p><p>pist (or RO skills trainer).</p><p>Why Dialectics?</p><p>Dialectical strategies in RO DBT share roots with the existential and dialectical philosophies found in Gestalt</p><p>therapy (Perls, 1969) and most prominently with the dialectical principles guiding interventions in standard</p><p>DBT (Linehan, 1993a). Dialectical thinking involves three developmental stages: a thesis (such as “self- control</p><p>is always necessary”), giving rise to its reaction, an antithesis (such as “too much self- control is always</p><p>unhealthy”), which contradicts and seems to negate the thesis, while the tension between these two opposite</p><p>perspectives is resolved via a synthesis of the two opposite perspectives that, ideally, results in higher- order</p><p>functioning, not simply in a compromise (for example, a synthesis using the preceding example polarities</p><p>might involve a willingness to flexibly relinquish control when the situation calls for it). Hegelian dialectics</p><p>includes five key concepts or assumptions:</p><p>1. Everything is transient and finite.</p><p>2. Everything important in life is composed of contradictions (opposing forces).</p><p>3. Gradual changes lead to crises or turning points, when one force overcomes its opponent force.</p><p>4. The world is holistic, and everything is connected and in relationship.</p><p>Dialectics, Radical Openness, and Self-Enquiry</p><p>19</p><p>5. Change is continual and transactional (that is, opposing perspectives influence each other and evolve</p><p>over time).</p><p>In RO DBT, the therapist uses dialectical principles to encourage cognitively rigid OC clients to think in</p><p>ways that are both more complex and more flexible.</p><p>An example of dialectical thinking can be seen within the RO mindfulness skill of self- enquiry. As</p><p>described in detail later in this chapter, self- enquiry requires a willingness to question one’s beliefs, perceptions,</p><p>action urges, and behaviors without falling apart or simply giving in. The dialectical tension involves balancing</p><p>trusting versus distrusting personal perceptions or ways of coping while remaining open to the possibility of</p><p>learning from disconfirming feedback. For OC clients, who tend to automatically consider their interpreta-</p><p>tions of events as absolute truths or facts, the use of dialectical thinking is often an essential factor in embrac-</p><p>ing RO self- enquiry practices and viscerally learning the value of healthy self- doubt (discussed later in this</p><p>chapter).</p><p>Dialectical thinking is also highly useful in helping to loosen OC clients’ tendencies toward inflexible</p><p>rule- governed behavior, rigid beliefs, and high moral certitude (that is, the belief that there is only one right</p><p>way to do or think about something), which can interfere with the ability to flexibly adapt to change and with</p><p>the formation of close social bonds. For example, many OC clients consider “dependence” a dirty word</p><p>(“dependence makes you weak and vulnerable to abuse”). Yet, regardless of our personal preferences, all</p><p>humans are dependent on something or someone, at least some of the time (for example, we depend on our</p><p>grocer to provide us with fresh milk, our friends to tell us the truth, our rock-climbing instructor to show us</p><p>how to tie a knot properly, and, as infants, on our parents’ affection). Moreover, our dependence on others does</p><p>not negate the value of independent living (as in standing up against moral wrongs, striving to go where no</p><p>one else has gone, saving for retirement to avoid burdening others, or voicing an unpopular opinion). Thus,</p><p>dialectical thinking is an important therapeutic tool in RO DBT. It allows a therapist to genuinely validate the</p><p>client’s perspective (“being independent keeps you from being hurt”) while maintaining its opposite (“being</p><p>dependent is essential for survival”), thereby creating the possibility for new ways of thinking and behaving (a</p><p>new synthesis) to emerge. Finally, dialectical thinking also informs therapists’ behavior during interactions</p><p>with their clients. There are two dialectical polarities that I have found to most commonly arise when working</p><p>with OC clients (see figure 2.1):</p><p>1. Nonmoving centeredness versus acquiescent letting go</p><p>2. Playful irreverence versus compassionate gravity</p><p>The next two subsections describe how they are used in RO DBT to enhance treatment.</p><p>Flexible-Mind</p><p>Nonmoving centeredness Playful irreverence</p><p>Compassionate gravity Acquiescent letting go</p><p>Figure 2.1. Dialectical Thinking in RO DBT</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>20</p><p>Therapist’s Use of Nonmoving Centeredness Versus</p><p>Acquiescent Letting Go</p><p>Nonmoving centeredness versus acquiescent letting go is the dialectical dilemma of knowing when to hold</p><p>on to rather than let go of a case formulation, a theoretical insight, or a personal conviction when working with</p><p>an OC client, in order to model core RO principles, maintain the client’s engagement, repair an alliance</p><p>rupture, and/or spur new growth. It is informed by an overarching RO DBT principle positing that therapists</p><p>as well as clients bring perceptual and regulatory biases into the treatment environment, and that these biases</p><p>influence both the therapeutic relationship and treatment outcomes. Thus, being able to recognize and know</p><p>when to let go of a bias represents an essential dialectical dilemma for therapists if they are (1) going to maxi-</p><p>mize the likelihood of forming a strong therapeutic alliance (RO DBT posits that a working alliance with an</p><p>OC client does not appear until about the fourteenth session), (2) effectively model radical openness to their</p><p>OC clients, and (3) provide alternatives for their clients’ habitual ways of behaving and thinking. No small</p><p>task! Unfortunately, mindful awareness of the dilemma will not necessarily lead to synthesis, nor will it neces-</p><p>sarily mitigate the emotional distress that can accompany the therapist’s attempts to grapple with it (for</p><p>example, letting go of firmly held convictions and standing up for one’s convictions can both be painful thera-</p><p>peutic choices). Plus, to make matters more complicated, therapists need to be biased; that is, the role of a</p><p>health care provider necessitates professional opinions about a client’s presenting problems and the best course</p><p>of treatment, also known as a case conceptualization. Indeed, case conceptualization has been described as the</p><p>“heart of evidence- based practice” (Bieling & Kuyken, 2003, p. 53). Therapists are usually trained to consider</p><p>their case formulations as reliable and generally accurate descriptions of clients’ behavior, despite research</p><p>showing that therapists often formulate widely divergent case conceptualizations for the same client (Kuyken,</p><p>Fothergill, Musa, & Chadwick, 2005). Yet, despite these difficulties, RO DBT posits that there is a way forward.</p><p>It involves the creation of a temporary state of self- doubt whenever feedback from the environment or from the</p><p>client suggests that one’s case conceptualization may be in error.</p><p>Healthy self- doubt is a core construct in RO DBT (see lesson 13); it provides the therapist with a coherent</p><p>means of relinquishing control without abdicating professional responsibility or needing to abandon a prior</p><p>perspective (see also the material on Flexible Mind DEFinitely skills in lesson 1). As one example of the advan-</p><p>tages of acquiescent letting go, a therapist in one of our research trials reported in consultation team that she</p><p>was struggling with knowing how to resolve a potential alliance rupture with her OC client. Her client had</p><p>been repeatedly dismissing any suggestion by the therapist that he was a decent human being or had prosocial</p><p>intentions by saying, “You just don’t know me. I am an evil person. I have a lot of resistance to joining the</p><p>human race. I’m essentially not a very nice person, and my past is my proof.” The therapist had attempted to</p><p>address this by pointing out factors that discounted or otherwise disproved the client’s conviction, yet each</p><p>attempt appeared only to increase his insistence on being inherently evil. Moreover, the therapist reported</p><p>feeling increasing angst, since in her worldview it was impossible for humans to be inherently evil. The team</p><p>encouraged the therapist to practice self- enquiry (that is, temporary self- doubt), which eventually led the</p><p>therapist to the personal self- discovery that it was arrogant of her to insist that no one in the world could ever</p><p>be inherently evil, enabling her to be radically open to her client’s perspective (despite the pain it generated).</p><p>During the next session, the therapist revealed her self- enquiry insight to her client (that is, that she had been</p><p>behaving arrogantly in prior sessions by assuming her worldview about evil was the only correct one). Her</p><p>personal self- work and willingness to out herself (a process discussed later in this chapter) immediately func-</p><p>tioned to change the dynamics of the therapeutic relationship— and, to the surprise of the therapist, several</p><p>sessions later the client independently revealed, “I’ve been thinking lately that maybe I’m not so evil after all.”</p><p>This real- life clinical example demonstrates the therapeutic value of being able to radically give in, or let go of</p><p>strongly held convictions no matter how logical or viscerally right they may seem. The dialectical tension</p><p>enabling the potential for new growth is only possible because the dilemma retains within itself the therapeutic</p><p>utility of doggedly retaining one’s perspective (that is, nonmoving centeredness).</p><p>Dialectics, Radical Openness, and Self-Enquiry</p><p>21</p><p>Consequently, nonmoving centeredness is the dialectical twin of acquiescent letting go. It refers to the</p><p>importance of an RO DBT therapist holding on to a personal conviction or belief about a client, despite strong</p><p>opposition from the client or the environment. The rationale for this stance may best be represented by the</p><p>RO principle of kindness first and foremost (see lesson 17). Sometimes kindness means telling good friends a</p><p>painful truth in order to help them achieve their valued goals in a manner that acknowledges the helper’s own</p><p>potential for fallibility. Thus, RO DBT therapists recognize that they may need to disagree with their OC</p><p>clients to facilitate growth (albeit the vast majority of RO DBT confrontations involve asking, not telling, the</p><p>client about his or her apparent problem; see “RO DBT Therapeutic Stance,” in chapter 8 of the RO DBT</p><p>textbook). This disagreement is usually combined with nonverbal nondominant social signals (such as a slight</p><p>bowing of the head and a shoulder shrug along with openhanded gestures, a warm smile, an eyebrow wag, and</p><p>direct eye contact; see Flexible Mind SAGE skills, lesson 8) to communicate equity and openness to critical</p><p>feedback. Nondominance signals are especially important when a person is in a power- up position yet desires</p><p>a close relationship (as in the therapist- client relationship). Importantly, this dialectical dilemma also allows for</p><p>the possibility of less open- minded signaling (or urgency) and for the use of dominant assertions of confidence</p><p>in order to block imminent life- threatening behavior (see “The RO DBT Crisis- Management Protocol,” in</p><p>chapter 5 of the RO DBT textbook).</p><p>Therapist’s Use of Playful Irreverence Versus</p><p>Compassionate Gravity</p><p>Playful irreverence versus compassionate gravity is the second most common dialectical dilemma encoun-</p><p>tered by therapists treating OC clients. It represents a dialectical means of challenging maladaptive behavior</p><p>while signaling affection and openness. The stance of playful irreverence most often begins with the therapist’s</p><p>use of a nonverbal or verbal expression of incredulity and/or amused bewilderment, accompanied by a non-</p><p>dominant signal of openness and affection and triggered by a discrepant, odd, or illogical comment or behavior</p><p>on the part of an OC client (for example, a client verbally indicates that she is unable to speak, or she reports</p><p>a complete lack of animosity toward a coworker she has admitted to having lied about in order to get him</p><p>fired).</p><p>Playful irreverence represents the therapeutic cousin of a good tease between friends. Friends playfully and</p><p>affectionately tease each other all the time. Research shows that teasing and joking are how friends informally</p><p>point out flaws in each other, without being too heavy- handed about it. Learning how to tease and be teased</p><p>is an important part of healthy social relationships, and kindhearted teasing is how tribes, families, and friends</p><p>give feedback to each other. Plus, a good tease is always kind. Most often it starts out with an unexpected,</p><p>provocative comment that is delivered with an unsympathetic (expressionless or arrogant) voice tone and/or</p><p>an intimidating facial expression (such as a blank stare), gesture (such as finger wagging), or body posture (such</p><p>as hands on hips) that is immediately followed by laughter, gaze aversion, and/or postural shrinkage. Thus, a</p><p>kindhearted tease momentarily introduces conflict and social distance but quickly reestablishes social con-</p><p>nectedness by signaling nondominant friendliness. The nondominance signal is critical for a tease to be taken</p><p>lightly (that is, as a friendly poke; see Keltner, Young, & Buswell, 1997). When teasing is playful and reciprocal,</p><p>it is socially bonding, and people who can tease in a friendly manner and enjoy being teased are more likely to</p><p>be mentally and physically healthy because they don’t take life too seriously and can laugh at their foibles and</p><p>learn from them.</p><p>Thus, when a therapist adopts a playful irreverent style with an OC client, the therapist sends a powerful</p><p>social signal that says, “I like you, and I consider you part of my tribe.” When interacting with friends, we are</p><p>likely to use more colorful and less formal forms of language (such as slang or curse words), feel free to express</p><p>our inner feelings, use more expansive gestures, adopt more relaxed postures (such as slouching), and tease or</p><p>play with each other. However, the fun thing about a tease is that it also provides corrective feedback. This</p><p>represents the essence of an RO DBT playful irreverent stance— that is, it incorporates some form of critical</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>22</p><p>feedback (such as “Really? You don’t ever desire to have a friend?”) that is accompanied by nondominant body</p><p>postures and facial expressions that communicate that the therapist likes the client and intends the client no</p><p>harm. These nonverbal signals combine appeasement signals</p><p>(such as a slight bowing of the head, a shoulder</p><p>shrug, or openhanded gestures) with cooperative- friendly signals (such as a warm smile, eyebrow wags, and</p><p>direct eye contact). Thus, playful irreverence in RO DBT encourages the therapist to drop his or her profes-</p><p>sional demeanor and adopt the behavior of a friend in order to provide socially relevant feedback to the emo-</p><p>tionally lonely and isolated OC client and encourage the client to rejoin the tribe.</p><p>Compassionate gravity represents the dialectical opposite of a playful irreverent stance. Rather than</p><p>aiming to tease and challenge, it seeks to understand and to signal sobriety (that is, that the therapist takes</p><p>the client seriously). It also functions as a way of taking the heat off a client, whereas playful irreverence puts</p><p>the heat on a client (see also “Heat- Off Strategies” and “Heat- On Strategies,” in chapter 6 of the RO DBT</p><p>textbook, and “Use Heat- On and Heat- Off Strategies to Shape Desired Behaviors,” in chapter 3 of this</p><p>manual). A stance of compassionate gravity is designed to slow down the pace of the interaction and signal</p><p>social safety to the client. The most common nonverbal changes include slowing down the pace of speaking,</p><p>speaking with a softer voice tone, slightly pausing after each utterance by the client in order to allow the client</p><p>time to say more (if the client so desires), gentle eye contact (not staring), and a warm closed- mouth smile. It</p><p>may also be accompanied by an involuntary therapeutic sigh of affiliation. Other common nonverbal signals</p><p>that accompany a stance of compassionate gravity include leaning back in one’s chair, raising one’s eyebrows</p><p>when listening to the client (or speaking), and signaling nondominant friendliness (especially during an alli-</p><p>ance rupture repair) via a slight bowing of the head, a slight shoulder shrug, and openhanded gestures com-</p><p>bined with a closed- mouth smile (see chapter 6 of the RO DBT textbook for details on each nonverbal signal).</p><p>A stance of compassionate gravity can be used in a number of differing ways, including when therapists out</p><p>themselves (as when a therapist’s personal worldview may have interfered with the therapist’s understanding</p><p>of the client’s perspective), repair an alliance rupture, signal intent listening, communicate warm friendliness,</p><p>or balance a playful irreverent comment in order to ensure that the tease is not taken the wrong way. The</p><p>overall aim is to communicate to the client, “I desire to know who you are from your perspective (not mine),</p><p>and I am taking your situation seriously.”</p><p>Why Radical Openness?</p><p>Openness and Well- Being</p><p>From my perspective, one of the most difficult challenges of being open is letting go of my personal per-</p><p>spective in order to experience the world from someone else’s point of view (especially when I think I’m right).</p><p>It is difficult because being correct matters (for example, for survival, success, job promotions, and for rockets</p><p>to land on the moon) and it is a challenge because not every perspective is correct, making the choice of which</p><p>perspective to believe a conundrum. The worry is “What if the source of new information is wrong?” (for</p><p>example, one’s grip on a spear is less important; what matters most when throwing a spear is that the shaft</p><p>remains close to the body at all times during the throw) or “What if the source is trying to deceive us?” (for</p><p>example, my so- called friend is giving me wrong advice on purpose so he can win the tribal spear- throwing</p><p>contest). Indeed, when you take a moment to think about it, openness has a lot of downsides. It requires effort-</p><p>ful control and valuable expenditures of energy, whereas habits not only demand fewer cognitive resources but</p><p>can often be equally effective as or even more effective than deliberate control efforts (for example, driving my</p><p>car doesn’t require a great deal of cognitive effort, because I am an experienced driver; plus, I probably drive</p><p>better when I don’t think about it too much). So why bother being open at all?</p><p>One reason we may bother is because we instinctively recognize the value openness brings to relation-</p><p>ships. We naturally admire open- minded individuals and desire to be close to them. For example, people yearn</p><p>to meet the Dalai Lama (that is, he attracts large crowds of people), but not so much because of his eloquence</p><p>Dialectics, Radical Openness, and Self-Enquiry</p><p>23</p><p>as a speaker, his distinctive appearance, or his prior deeds (although these may contribute); they desire to be</p><p>near him because his presence viscerally reminds them of what they already know— that is, as a species we are</p><p>better when together, and open- minded living represents the way back home. Essentially, I contend that open-</p><p>ness matters because tribe matters. When we feel part of a tribe, we feel safe. Our species survived because we</p><p>developed capacities to form long- lasting bonds and share valuable resources with people who were not in our</p><p>immediate family (that is, total strangers). Thus, for our very early ancestors living in harsh environments,</p><p>being in a tribe was essential for personal survival. Indeed, we are constantly scanning the facial expressions</p><p>and vocalizations of other people for signs of disapproval and are biologically predisposed to construe the</p><p>intentions of others as disapproving, especially when social signals are ambiguous (see chapter 6 of the RO</p><p>DBT textbook).</p><p>Open- mindedness evolved as a core means of ensuring that cooperative intentions were accurately per-</p><p>ceived, especially during interactions involving conflict. Openness is a powerful social safety signal because it</p><p>acknowledges our shared potential for fallibility and a willingness to learn from the world. It allows us the</p><p>luxury of dropping our guard because we recognize that the open- minded person is willing to hear our point</p><p>of view. Thus, despite its energy- depleting downsides, openness is posited to be a core part of a uniquely human</p><p>evolutionary advantage that allowed for unprecedented cooperation among genetically unrelated individuals</p><p>(see chapter 6 of the RO DBT textbook). In other words, open- mindedness is tribal glue— it binds together</p><p>differences and creates new, unimagined accords.</p><p>Another reason we bother being open is because we innately recognize the value of learning new things.</p><p>Tribes not only provided instrumental support (for example, helping a neighbor repair a fence after a storm, or</p><p>collectively building a wall to keep out enemies) but also allowed individuals to benefit from the collective</p><p>wisdom of their community through explicit instruction (for example, about the time of year to plant corn, or</p><p>the type of stone best for making an axe), observational learning and modeling of successful others (for</p><p>example, about how to ride a horse or throw a spear), and direct feedback (“You missed the target because you</p><p>were gripping the spear too tight”). All three require the recipient to be open- minded to the new information</p><p>or feedback for the lesson to be learned. Being open to new ideas or critical feedback from another member of</p><p>the tribe (“That’s not a cow— it’s a tiger! Let’s run!”) provided a huge evolutionary advantage for both the</p><p>open- minded individual and our species because our individual survival no longer depended solely on our</p><p>personal perceptions; see “Fun Facts: The Story of Oog- Ahh (Sometimes a Cow Is Not a Cow),” lesson 19. The</p><p>preceding observation may explain why we are so concerned about the opinions of others.</p><p>However, it can be extremely difficult to know when you are being open (versus actually closed). We tend</p><p>to pay attention to things that fit our beliefs and to ignore or dismiss things that do not. We adamantly</p><p>contend that we are open, only to discover later that we were actually closed (particularly common during</p><p>arguments), and we don’t know what we don’t know, thereby making it doubly hard to notice closed- minded</p><p>thinking, because our way of thinking feels so right!</p><p>Moreover, being open to another person’s perspective also</p><p>necessitates a willingness to trust the good intentions of the person we are interacting with and/or to believe</p><p>in the correctness of the source of collective wisdom (such as a tribal elder’s memory or a written document).</p><p>These issues highlight some of the difficulties in treating problems of overcontrol; that is, OC clients are char-</p><p>acterized by low interpersonal trust and low openness to new experience and are expert at discounting or</p><p>ignoring corrective feedback, often in very subtle ways.</p><p>Yet, despite these difficulties, RO DBT posits that there is a way forward. It involves the creation of a</p><p>temporary state of self- doubt. This temporary state of mind is referred to in RO DBT as “healthy self- doubt.”</p><p>It begins with the assumption that we don’t see things as they are but see things as we are, and it is based on</p><p>notions that it is impossible for us to ever fully rid ourselves of our personal backgrounds or biogenetic predis-</p><p>positions. Thus, it considers our perceptions of the world to be uniquely biased by who we are, and not to be</p><p>accurate perceptions of reality. This core principle is manifested most clearly in the RO mindfulness skill</p><p>known as self- enquiry, which is an essential component of the practice of radical openness more broadly</p><p>(described next).</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>24</p><p>What Is Radical Openness?</p><p>Radical openness involves developing a passion for going opposite to where you are. It represents an inten-</p><p>tion to more deeply explore areas in your life that are difficult, painful, or disturbing. It means advancing</p><p>courageously to the source of the unknown with proper humility and a willingness to sacrifice in order to learn</p><p>more from what the world has to offer. However, being open to learning new things does not mean that we</p><p>must reject our prior learning. Instead, RO recognizes that most often there are many ways to get to the same</p><p>place or do the same thing (there are endless way to get to Paris and countless ways to cook potatoes), and that</p><p>because the world is in constant change there is always something new to learn. The best scientists, for</p><p>example, are humble because they realize that everything they know will eventually evolve or change into</p><p>greater knowledge.</p><p>Radical openness is more than awareness or simply engaging in new behavior; at its most extreme, it</p><p>involves actively seeking the things one wants to avoid or may find uncomfortable in order to learn. Thus,</p><p>while it oftentimes involves trying out novel ways of behaving that may prove rewarding, it also involves pur-</p><p>poseful self- enquiry, self- exploration, and discovery. It requires cultivating a willingness to be wrong and an</p><p>ability to be open to new possibilities, with an intention to change, if change is needed. As Carl Jung might</p><p>have described it, radical openness means seeking our shadow— the parts of our personality we are not proud</p><p>of or might not wish to acknowledge. As such, it can sometimes be a difficult and scary endeavor. As a change</p><p>strategy, it requires being open to corrective feedback, identifying what change(s) may be needed, and trying</p><p>out new ways of behaving or relating to others. An important outcome for the practitioner of radical openness</p><p>is an improved capacity for flexible responding to changing circumstances.</p><p>Thus, rather than automatically assuming that the world needs to change, RO considers an unwanted</p><p>emotion, thought, or sensation in the body an opportunity for new learning. A practice of radical openness</p><p>involves three sequential steps:</p><p>1. Acknowledging the presence of a disconfirming or unexpected event that triggers a feeling of tension,</p><p>resistance, dislike, numbness, and/or desires to attack, control, or flee</p><p>2. Practicing self- enquiry by temporarily turning toward the discomfort and asking What is it that I might</p><p>need to learn? rather than automatically regulating, distracting, explaining, reappraising, or accepting</p><p>3. Flexibly responding with humility by doing what’s needed in the moment to effectively manage the</p><p>situation and/or adapt to changing circumstances in a manner that accounts for the needs of others</p><p>Importantly, radical openness does not mean approval, naively believing, or mindlessly acquiescing. Sometimes</p><p>being closed is what is needed in the moment, and/or change is unnecessary. Finally, radical openness is not</p><p>something that can be grasped solely via intellectual means; it is experiential. It requires direct and repeated</p><p>practice, and one’s understanding evolves over time as a function of continued practice. Thus, RO DBT thera-</p><p>pists and skills instructors are encouraged to develop and incorporate a personal practice of radical openness</p><p>and self- enquiry into their lives. Strategies for integrating RO and self- enquiry into supervision and consulta-</p><p>tion team meetings are described in detail in chapter 7 of the RO DBT textbook.</p><p>Differentiating Radical Openness from Radical Acceptance</p><p>It is important to note that radical openness differs from the radical acceptance skills taught as part of</p><p>standard DBT (Linehan, 1993a). Radical acceptance is letting go of fighting reality and is the way to turn suf-</p><p>fering that cannot be tolerated into pain that can be tolerated, whereas radical openness challenges our per-</p><p>ceptions of reality. Radical openness posits that we are unable to see things as they are, but instead that we see</p><p>things as we are. This also contrasts with the concept of Wise Mind in standard DBT, which emphasizes the</p><p>value of intuitive knowledge— the possibility of fundamentally knowing something as true or valid— and</p><p>which posits inner knowing as “almost always quiet” and as involving a sense of “peace” (Linehan, 1993a).</p><p>Dialectics, Radical Openness, and Self-Enquiry</p><p>25</p><p>From an RO DBT perspective, facts or truth can often be misleading, partly because we don’t know what we</p><p>don’t know, because things are constantly changing, and because there is a great deal of experience occurring</p><p>outside of our conscious awareness. Thus, RO encourages the cultivation of self- enquiry and healthy self- doubt</p><p>in order to signal humility and learn from what the world may have to offer.</p><p>Why Self- Enquiry?</p><p>A core RO DBT precept is that it is impossible for us to ever be free of personal bias or be fully aware of every</p><p>aspect of ourselves. For example, our brain is capable of being consciously aware of a thought, emotion, sensa-</p><p>tion, or image about every fifty milliseconds, making it theoretically possible for us to be consciously aware of</p><p>about eighty discrete experiences in the span of one breath. (Phew!) Indeed, studies suggest that facial affect,</p><p>especially among humans, most likely represents an evolutionarily hardwired unconditioned stimulus (from</p><p>senders) that triggers an automatic unconditioned response in recipients— we need at least seventeen to twenty</p><p>milliseconds to be consciously aware of an emotional face, yet our brain- body is already physiologically reacting</p><p>at durations as low as four milliseconds (Williams et al., 2004, 2006). This process occurs at the preconscious</p><p>sensory receptor level of emotional processing and is nonamenable to conscious emotion regulation. Plus,</p><p>individual differences in learning and experience and in biotemperament make misappraisal of an evocative</p><p>stimulus (such as interpreting a genuine offer of help as a manipulative ploy) a relatively common event.</p><p>Essentially, truth in RO DBT is considered real yet elusive: “If I know anything, it is that I don’t know every-</p><p>thing and neither does anyone else” (M. P. Lynch, 2004, p. 10). It is the pursuit of truth that matters, not its</p><p>attainment. Rather than assuming we can ever know reality just as it is, radical openness assumes that we all</p><p>bring perceptual and regulatory biases into every moment, and that they interfere with our ability to be open</p><p>and to learn from new or disconfirming information. This</p><p>core principle of radical openness influences treat-</p><p>ment interventions. For example, instead of automatically moving to regulate, rationalize, distract from, or</p><p>accept aversive emotional arousal, RO prioritizes actively seeking the things one wants to avoid or may find</p><p>uncomfortable, facilitated by a regular practice of self- enquiry (see lesson 13), in order to learn.</p><p>Self- enquiry involves a willingness to challenge our core beliefs— things we might normally consider facts</p><p>or truths. It acknowledges that, on some level, we are responsible for our perceptions and actions, in a manner</p><p>that avoids harsh blame of ourselves, others, or the world and encourages the cultivation of healthy self- doubt</p><p>in order to learn and live by our valued goals. It involves a willingness to question ourselves when we feel</p><p>threatened or challenged rather than automatically defending ourselves. Self- enquiry is not looking to solve</p><p>a problem or avoid discomfort. It recognizes that each new insight or understanding we achieve is always fal-</p><p>lible, limited, and/or potentially biased. Practicing self- enquiry is particularly useful whenever we find our-</p><p>selves strongly rejecting, defending against, or feigning agreement with feedback that we find challenging or</p><p>unexpected by first asking What is it that I might need to learn? rather than automatically assuming our per-</p><p>spective as correct or moving to emotionally regulate. It recognizes that in order to learn anything new, we</p><p>must first acknowledge our lack of knowledge. Thus, although self- enquiry seeks self- discovery, it remains</p><p>suspicious of quick answers, and this is why self- enquiry practices should be expected to last over days or</p><p>weeks (see lesson 13).</p><p>Self- enquiry practices in RO DBT are based on assumptions that our brains are continually detecting</p><p>discrepancies and evaluating environmental stimuli in order to adapt to changing contingencies. Our natural</p><p>set point is one of calm readiness; however, when sensory inputs are evocative, or discrepant from expecta-</p><p>tions, a quick and typically unconscious evaluative process ensues, the primary function of which is to assign</p><p>valence (positive or negative) and significance to such stimuli (that is, relevance to personal survival and/or</p><p>well- being), a process that is moderated by biotemperament and past experience. When we evaluate a stimulus</p><p>as threatening, our brain- body begins a process designed to defend itself, which naturally makes us more cau-</p><p>tious about approaching the discrepant (that is, unknown or dangerous) stimulus. Self- enquiry considers</p><p>defensive arousal helpful because it can alert us to areas in our lives where we may need to change or grow.</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>26</p><p>Thus, in RO DBT, defensive arousal (such as a feeling of resistance or dislike) is considered an opportunity for</p><p>growth. Rather than automatically assuming that the world needs to change (“You need to validate me because</p><p>I felt misunderstood by what you said”) or automatically prioritizing regulation or acceptance strategies that</p><p>functionally solve the problem, RO DBT posits that the truth hurts. This suggests that our most powerful</p><p>moments of self- growth may stem from the very things we don’t want to change or admit to as problems (that</p><p>is, the point where our known makes contact with our unknown, which is referred to as finding one’s edge in</p><p>RO DBT). The emphasis on celebrating self- doubt in RO DBT stems from two observations:</p><p>1. We don’t know everything; therefore, we will make mistakes.</p><p>2. In order to learn from our mistakes, we must attend to what we don’t know.</p><p>Self- enquiry is not ruminating about a problem, because it is not looking to solve the problem or avoid</p><p>discomfort. Indeed, the goal of self- enquiry is to find a good question, not a good answer. Quick answers are</p><p>considered to most often reflect old learning and desires to avoid genuine contact with the pain associated</p><p>with not having a solution. Thus, self- enquiry can be differentiated from other mindfulness approaches</p><p>because it actively seeks discomfort to learn and blocks immediate answers rather than simply observing dis-</p><p>comfort, metacognitively distancing from thoughts, and waiting for the experience to fade away. This is why</p><p>most self- enquiry practices are encouraged to last for days or weeks and include opportunities to practice</p><p>revealing to others what our self- examination has uncovered, a process referred to as outing oneself in RO DBT</p><p>(see lesson 13).</p><p>Outing Oneself</p><p>RO DBT posits that we can enhance our self- knowledge through the eyes of our tribe by revealing our</p><p>self- discoveries and inner experiences to another person. The importance of this when treating OC cannot be</p><p>overemphasized, since revealing fallibility or weakness to another person goes opposite to OC tendencies to</p><p>mask inner feelings. Importantly, since expressing vulnerability to another enhances rather than detracts from</p><p>others’ desires to affiliate with the self- disclosing person (see chapter 2 of the RO DBT textbook), the practice</p><p>of outing oneself can become a powerful means for OC clients to rejoin the tribe. Plus, RO DBT posits that we</p><p>need other people to reflect back our potential blind spots, since we carry perceptual and regulatory biases</p><p>with us everywhere we go. Revealing to others our observations about ourselves and the world can enhance</p><p>relationships because it models humility and willingness to learn from what the world has to offer. Moreover,</p><p>it provides an enormous opportunity for self- growth because our individual well- being no longer depends solely</p><p>on our personal perceptions. Skills instructors should be prepared to share</p><p>observations from their own practices of self- enquiry in order to encourage</p><p>clients to use self- enquiry more deeply (that is, OC clients are unlikely to believe</p><p>it is healthy to redirect attention toward discomfort or reveal fallibility unless</p><p>they see their therapists model this behavior first).</p><p>The RO Self- Enquiry Journal</p><p>RO DBT strongly encourages therapists to practice and apply radical openness skills in both their personal</p><p>and professional lives in order to be better able to model to their OC clients core RO concepts that can only</p><p>be grasped experientially (that is, they are not accessible solely via rational thought or logic). This expectation</p><p>includes an ongoing practice of self- enquiry and at least some experience with what is known in RO as self-</p><p>enquiry journaling— that is, recording in writing, in a daily diary or journal, the thoughts, images, sensations,</p><p>and emotions that arise during self- enquiry practices. This allows the therapist an opportunity to come into</p><p>contact with what it feels like from the inside out to record self- enquiry experiences in a journal and poten-</p><p>tially enhances the therapist’s personal understanding of self- enquiry.</p><p>Self- enquiry means</p><p>finding a good question,</p><p>not a good answer. may</p><p>not be apparent.</p><p>Dialectics, Radical Openness, and Self-Enquiry</p><p>27</p><p>Thus, skills instructors (and RO DBT individual therapists), when first introducing self- enquiry principles,</p><p>should encourage their OC clients to find a means of recording what has emerged during a practice of self-</p><p>enquiry (usually by writing in a journal, such as a blank leather- bound book). What is actually written is up to</p><p>the self- enquiry practitioner to decide. A core aim of an RO self- enquiry journal is to provide a means of pri-</p><p>vately recording struggles, insights, and personal questions about oneself that are expected to evolve over time</p><p>as a function of continued self- enquiry practice. Thus, instructors should remind RO class members, as needed,</p><p>that each person’s RO self- enquiry journal is a private matter, meaning that its contents need not be shared</p><p>with anyone, including therapists or other RO classmates (see also chapter 7 of the RO DBT textbook). Yet, at</p><p>the same time, RO skills instructors should</p><p>also look for opportunities to encourage class members to use their</p><p>RO self- enquiry journals creatively.</p><p>Applying Self- Enquiry in RO Skills Class</p><p>Broadly speaking, a self- enquiry question posed by an RO skills instructor to an individual class member</p><p>represents a heat- on technique. Yet heat- on is also how we all learn. Thus, when teaching RO DBT skills to</p><p>OC clients, instructors should be alert for opportunities to incorporate brief moments of individualized self-</p><p>enquiry into their teaching. Instructors should remind clients that the goal of self- enquiry is to find a good</p><p>question, not a good answer. The best self- enquiry question brings a client face to face with his or her edge (the</p><p>unknown, an inner secret that the client would prefer to avoid acknowledging, or the place where the client</p><p>doesn’t want to go). Similarly, whenever RO skills instructors experience frustration, confusion, or anxiety</p><p>regarding how an OC client reacts to an RO skill being taught, rather than assuming that the problem lies</p><p>solely with the client, they should use self- enquiry: To what extent do I really know this skill myself? Who am I to</p><p>assume that there is only one way to learn this skill? Is it possible that this skill makes no sense for a person with an</p><p>OC style of coping? What is it that I might learn from this experience?</p><p>Summary</p><p>The three guiding principles in RO DBT that strongly impact the manner in which a therapist delivers the</p><p>treatment are dialectics, radical openness, and self- enquiry. The therapist uses dialectical principles to encourage</p><p>cognitively rigid OC clients to think in ways that are both more complex and more flexible. The two most</p><p>commonly used dialectical polarities in RO DBT are nonmoving centeredness versus acquiescent letting go and</p><p>playful irreverence versus compassionate gravity. These dialectical stances can be used in combination with</p><p>radical openness and self- enquiry principles.</p><p>Radical openness involves developing a passion for going opposite to where you are. It represents an</p><p>intention to more deeply explore areas in your life that are difficult, painful, or disturbing. Radical openness</p><p>posits that we are unable to see things as they are, but instead that we see things as we are— we all bring</p><p>perceptual and regulatory biases into every moment, and these biases interfere with our ability to be open and</p><p>learn from new or disconfirming information. This core principle of radical openness influences treatment</p><p>interventions.</p><p>Being open to feedback may mean feeling threatened or challenged when the feedback doesn’t match our</p><p>perceptions of ourselves or the world. When this happens, RO DBT encourages self- enquiry practice. Self-</p><p>enquiry involves a willingness to challenge our core beliefs— things we might normally consider facts or truths.</p><p>It acknowledges that, on some level, we are responsible for our perceptions and actions, in a manner that</p><p>avoids harsh blame of ourselves, others, or the world and encourages the cultivation of healthy self- doubt in</p><p>order to learn and live by our valued goals. It involves a willingness to question ourselves when we feel threat-</p><p>ened or challenged rather than automatically defending ourselves. The goal of self- enquiry is to find a good</p><p>question, not a good answer.</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>28</p><p>Finally, RO DBT posits that we can enhance our self- knowledge through the eyes of our tribe by revealing</p><p>our self- discoveries and inner experiences to another person, a process known as outing oneself. We need</p><p>other people to reflect back our potential blind spots, since we carry perceptual and regulatory biases with us</p><p>everywhere we go. Revealing our observations about ourselves and the world to others can enhance relation-</p><p>ships because it models humility and willingness to learn from what the world has to offer.</p><p>CHAPTER 3</p><p>Managing Problematic Behaviors</p><p>in RO Skills Training Classes</p><p>In general, skills training classes with OC individuals are not problematic or difficult, at least when it comes</p><p>to the presence of chaotic and out- of- control displays of behavior. Indeed, if anything, OC skills classes are</p><p>almost always well behaved, most likely because OC clients value structure, control, and restraint and tend to</p><p>be disciplined, diligent, and dutiful during interactions with others in public. Unfortunately, being diligent or</p><p>good all the time is not only exhausting but can also get you into trouble. OC clients are prisoners of their</p><p>self- control, and their natural tendency to inhibit (control) their expressions of emotion makes it harder for</p><p>others to know their true intentions and desire to socially connect. Rather than prioritizing regulated and</p><p>controlled expression of emotion and non- mood- dependent behavior, RO skills prioritize candid expression of</p><p>emotion, playfulness, and self- enquiry in order to enhance social connectedness with others.</p><p>Thus, RO skills training classes are designed to go opposite to the natural tendencies for constraint and</p><p>control that characterize OC. Despite fears sometimes expressed by therapists first learning RO DBT, the vast</p><p>majority of RO skills training classes are anything but quiet; they are characterized instead by frequent laugh-</p><p>ter, active sharing, a genuine sense of community support, and self- discovery. (My confidence in making this</p><p>claim is based on more than twenty years of clinical and research experience in teaching, supervising, and</p><p>refining the application of RO skills training classes in programs and independent research teams around the</p><p>world, and with a wide range of ages and differing disorders; see chapter 1 of the RO DBT textbook.) Yet creat-</p><p>ing this type of excitatory learning environment requires not only awareness of core OC maladaptive behav-</p><p>iors, which can function to block communal activities (with plausible deniability), but also therapists’</p><p>self- awareness regarding the behaviors and beliefs they may bring into the therapeutic environment that may</p><p>inadvertently reinforce maladaptive overcontrol. The aim of this chapter is to provide an overview of the most</p><p>common problems skills trainers are likely to encounter when working with OC clients and of how to manage</p><p>them, using RO principles.</p><p>When a Classroom Goes Quiet</p><p>When an RO skills training class is quiet, nonresponsive, challenging, and/or seemingly nonengaged over</p><p>repeated weeks or lessons, skills training instructors should use the experience as an opportunity to practice</p><p>RO themselves. Sometimes a quiet or inhibited classroom reflects a similarly quiet or inhibited style of coping</p><p>on the part of the skills instructor(s). Our research shows that the majority of therapists lean toward overcon-</p><p>trolled coping. Thus, skills training instructors leaning toward overcontrol can sometimes inadvertently rein-</p><p>force cautious or perfectionistic tendencies in clients by striving too hard to get it right and/or by finding it</p><p>difficult to participate without planning, express vulnerability, and play or be silly when the situation calls for</p><p>it. Thus, rather than automatically assuming the difficulty lies with their OC clients, RO instructors are</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>30</p><p>encouraged to practice self- enquiry and seek supervision (such as in RO consultation team meetings) in order</p><p>to locate potential blind spots and maximize RO principle– based responding. Here are some examples of self-</p><p>enquiry questions:</p><p>• What am I socially signaling or doing that might trigger nonparticipation, nonengagement, or distrust</p><p>on my clients’ part?</p><p>• How relaxed am I when I am teaching? To what extent do I truly know the material I am teaching? To</p><p>what extent have I personally taken the time to practice the skills myself?</p><p>• Is there a part of me that does not believe this skill will work or that desires to dismiss it as irrelevant,</p><p>silly, or inappropriate?</p><p>• To what extent am</p><p>I willing to look at my own responses?</p><p>• To what extent am I expecting the world to change, or do I think that the treatment itself or the class</p><p>or client is the problem? What is it that I might need to learn?</p><p>Yet simply telling oneself to practice self- enquiry, relax, or have fun in order to improve class participation is</p><p>unlikely to work when one is surrounded by a classroom full of unresponsive, flat- faced, or disingenuous</p><p>expressions. The reason for this is that we are evolutionarily hardwired to be hypersensitive to signs of social</p><p>exclusion. For example, research shows that we can quickly spot the angry face in a crowd of people, and angry</p><p>faces hold our attention (E. Fox et al., 2000; Schupp et al., 2004). For our ancestors living in harsh environ-</p><p>ments, the cost of not detecting a true disapproval signal was too high to ignore. Tribal banishment was essen-</p><p>tially a death sentence for our primordial ancestors. Thus, we are biologically predisposed to be socially anxious,</p><p>and we are hardwired to construe the intentions of others as disapproving, especially when social signals are</p><p>ambiguous (as in a flat, neutral, or low- intensity facial expression). For example, simply reducing or limiting</p><p>the amount of eye contact during interactions has been shown to trigger negative feelings associated with</p><p>being ignored or ostracized (Wirth, Sacco, Hugenberg, & Williams, 2010).</p><p>Plus, in a situation where free expression of emotion is safe, customary, or expected (as in an RO skills</p><p>training class, on a date, in an argument with one’s spouse, or at a party), the discomfort triggered by flat (or</p><p>disingenuous) facial expressions is not due solely to the absence of expression but also to the conspicuous lack</p><p>of prosocial signaling and reciprocity (such as smiling and affirmative head nods). Thus, when OC clients</p><p>pervasively mask or constrain their inner feelings during skills training classes, our brains are likely to auto-</p><p>matically interpret this as a sign of distrust or disapproval. When nonengagement signals (for example, looking</p><p>away when asked a question) or nonresponsiveness (for example, a few seconds of blank staring) are prolonged</p><p>and displayed by several class members, we are likely to feel criticized and may start to feel self- conscious. Our</p><p>body becomes tense, our breathing becomes fast and shallow, our heart rate increases, we may begin to sweat,</p><p>and our facial expressions and body gestures feel constrained. We lose our easy manner and find it difficult to</p><p>genuinely signal friendly or cooperative intentions without feeling phony. The problem for skills training</p><p>instructors is that flat facial expressions are common when working with OC clients, thereby making discom-</p><p>fort and a low- level sense of embarrassment, shame, or self- consciousness a common experience.</p><p>To manage this, instructors must call upon their evolutionarily newer and nonemotional executive control</p><p>systems to override automatic action urges to avoid shutdown or mimicking the flat expressions displayed by</p><p>the class. Importantly, this does not mean attempting to talk oneself out of the dilemma via cognitive restruc-</p><p>turing or admonishments to focus on the facts, yet it does take advantage of similar processes linked to lan-</p><p>guage and executive control by using top- down processes and knowledge of social signaling to recognize that</p><p>feeling excluded or ostracized by the class, or by some class members, represents bottom- up evolutionarily older</p><p>signal- detection biases linked to survival of our species, and from there to use this knowledge to cheerlead the</p><p>effortful control that will be needed to go opposite to automatic tendencies to hide or inhibit expansive expres-</p><p>sions. Essentially, instructors must inhibit urges to inhibit emotional expressions when confronted with nonre-</p><p>sponsive classes and should socially signal cooperative friendliness instead (via eyebrow wags, closed- mouth</p><p>Managing Problematic Behaviors in RO Skills Training Classes</p><p>31</p><p>smiles, expansive gestures, and relaxed body postures). The good news is that expansive cooperative expres-</p><p>sions are relatively easy to display physically, whereas the bad news is that they can be psychologically hard to</p><p>display in the moment because they often go counter to a therapist’s prior training and/or can feel out of place</p><p>in the context of the instructor’s internal feelings (such as annoyance, dislike, or shame). It is important for</p><p>therapists to recognize that these reactions are unjustified, because the core goal of therapy with OC clients is</p><p>to encourage open and vulnerable expression of emotion via the therapist’s modeling, and because anxiety</p><p>responses to nonprosocial signals by others are evolutionarily hardwired and impossible to fully control even for</p><p>the most sophisticated of therapists. To change these dynamics, therapists must be willing to practice what they</p><p>preach, as best they can, by going opposite to subtle internal urges to avoid, attack, inhibit, appease, or hide,</p><p>and also by going opposite to prior professional training emphasizing the importance of restraint, by openly</p><p>expressing vulnerability and the joy of self- discovery instead of adopting a reciprocally serious or somber tone.</p><p>This signals to the entire class (and to the instructor, too) not only that there is nothing to be ashamed of when</p><p>we express ourselves but also that expressions of vulnerability or playfulness can be intimacy- enhancing.</p><p>The following list provides additional approaches for managing quiet and nonresponsive classes and/or</p><p>expands on the suggestions just made.</p><p>• Practice radical openness by directly seeking critical feedback from the class. For example, ask,</p><p>“Has something just occurred to make it harder for everyone to participate or contribute to our work</p><p>together?” This request for feedback is best delivered in a manner— balanced by compassionate gravity</p><p>(via raised eyebrows, a warm smile, a slightly lowered voice volume, a slightly slower rate of speech, and</p><p>eye contact, if possible, with each participant)— that celebrates criticism as a core means of learning</p><p>rather than one that implies cause for alarm (via a furrowed brow and a somber expression).</p><p>• Go opposite to urges to quiet down or behave in a solemn manner by purposefully employing big</p><p>gestures to pull class participants into their social safety system. As outlined earlier, a flat facial</p><p>expression is a powerful social signal that indicates distrust or dislike and pulls for a reciprocal expres-</p><p>sion in the recipients. Instructors can reverse this process by engaging in nonverbal behavior that</p><p>communicates affection and trust— for example, via a warm smile, a relaxed body posture, raised</p><p>eyebrows when listening or speaking, and/or expansive gestures.</p><p>• Randomly assign participants to read aloud the next point being covered in a handout or work-</p><p>sheet. This breaks the barrier of silence and, because everyone is asked to take a turn, functions to</p><p>smuggle the idea that classroom participation is expected. It is important for instructors not to allow</p><p>a participant to skip a turn as reader, because this smuggles the idea that passing is okay and makes it</p><p>more likely that others in the class will try to pass, too. Although nonparticipation may initially feel</p><p>safe, the client who is not participating almost invariably experiences greater anxiety and feels like an</p><p>outsider (albeit, admittedly, it is the client’s decision not to join in that creates the problem in the first</p><p>place). Instructors should be prepared to cajole, coax, sweet- talk, or entice a reluctant reader and must</p><p>reward him or her for participation (“Great job” or “Well done”). Sometimes it can help to remind</p><p>reluctant or shy participants that the heat (unwanted attention) will be taken off if they simply jump</p><p>in and read aloud (recall that OC clients dislike the limelight). Thus, as soon as a client participates</p><p>by taking a turn reading aloud (even if it is only one word), the instructor</p><p>Discussion Point: Hunting Dogs, Shields, and Swords 88</p><p>(Required) Teaching Point: The Social Safety System 89</p><p>(Required) Class Exercise: Playing with Eyebrows 90</p><p>(Required) Teaching Points: Talking Eyebrows 91</p><p>(Required) Teaching Point: Activating Our Social Safety System 91</p><p>(Required) Class Exercise: The Big Three + 1 93</p><p>(Required) Teaching Point: Expansive Gestures Communicate Safety 94</p><p>(Required) Class Exercise: Practice Big Gestures 94</p><p>(Required) Teaching Point: The “Slow Your Breath” Skill 95</p><p>(Required) Class Exercise: Slowing Our Breath 95</p><p>Contents</p><p>ix</p><p>(Required) Teaching Point: The Tense- and- Relax Skill 95</p><p>(Optional) Class Exercise: Muscle Relaxation Exercise 96</p><p>(Required) Teaching Point: Using Touch, Chewing, Hearing, and Vision Skills 96</p><p>(Required) Teaching Point 87</p><p>(Optional) Teaching Points: Downregulating Defensive Arousal via Activation of Other</p><p>Neural Substrates 97</p><p>Lesson 3 Homework 95</p><p>Lesson 4 Enhancing Openness and Social Connection via Loving Kindness 104</p><p>Main Points for Lesson 4 104</p><p>Materials Needed 104</p><p>(Required) Teaching Points: Loving Kindness Meditation 105</p><p>(Required) Class Exercise: Loving Kindness Meditation Practice 106</p><p>(Required) Discussion Points: LKM Practice 107</p><p>Lesson 4 Homework 107</p><p>Lesson 5 Engaging in Novel Behavior 114</p><p>Main Points for Lesson 5 114</p><p>Materials Needed 114</p><p>(Recommended) Mindfulness Practice: The Oompa- Loompa 114</p><p>(Required) Teaching Point: Why Engage in Novel Behavior? 116</p><p>(Required) Teaching Point: How Do We Learn Something New? 116</p><p>(Required) Teaching Point: Engaging in Novel Behavior: Flexible Mind VARIEs 117</p><p>(Required) Teaching Point: Remembering How to Play: The Art of Nonproductivity and</p><p>Being Just a Little Bit Silly 121</p><p>(Required) Class Exercise: The Extremely Fun Extreme Expression Workshop 123</p><p>(Optional) Class Exercise: If It’s Not Fun, It’s Not Play 125</p><p>Lesson 5 Homework 126</p><p>Lesson 6 How Do Emotions Help Us? 141</p><p>Main Points for Lesson 6 141</p><p>Materials Needed 141</p><p>(Recommended) Mindfulness Practice: Deal an Emotion 141</p><p>(Recommended) Class Exercise: OC Myths About Emotions 142</p><p>(Required) Teaching: Emotions Are There for a Reason 143</p><p>(Required) Story and Discussion: “The Logical Romantic” 143</p><p>(Required) Teaching Point: Why Bother Labeling Emotions? 144</p><p>(Required) Teaching Point: Four Steps to Emotion- Labeling Bliss 144</p><p>(Recommended) Teaching Point: Not Everything That’s Important Is Emotional 146</p><p>Lesson 6 Homework 147</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>x</p><p>Lesson 7 Understanding Overcontrolled Coping 157</p><p>Main Points for Lesson 7 157</p><p>Materials Needed 157</p><p>(Required) Teaching Point: Overcontrol Is a Habit That Is Hard to Kick! 157</p><p>(Required) Teaching Point: Overcontrol Can Become a Habit 158</p><p>Lesson 7 Homework 160</p><p>Lesson 8 Tribe Matters 165</p><p>Understanding Rejection and Self- Conscious Emotions</p><p>Main Points for Lesson 8 165</p><p>Materials Needed 165</p><p>(Optional) Teaching Point: Better When Together 166</p><p>(Required) Teaching Point: Got Tribe? 166</p><p>(Required) Teaching Point: What Does Tribe Mean? 167</p><p>(Required) Teaching Point: Humans Fear Social Exclusion 168</p><p>(Required) Teaching Point: Rejection: No, Thanks! 169</p><p>(Required) Teaching Point: Despite Being Painful, Shame Is Prosocial 170</p><p>(Required) Teaching Point: Self- Conscious Emotions Are Triggered During Social Interactions 171</p><p>(Required) Mini– Class Exercise: Exploring Low- Intensity Signals 172</p><p>(Optional) Teaching Point: Tribes Punish 173</p><p>(Required) Teaching Point: When Feeling Shame, Embarrassed, Rejected or Excluded, Practice</p><p>Flexible Mind SAGE 174</p><p>(Required) Mini– Class Exercise: Using the RO DBT Self- Conscious Emotions Rating</p><p>Scale Effectively 175</p><p>Lesson 8 Homework 179</p><p>Lesson 9 Social Signaling Matters! 196</p><p>Main Points for Lesson 9 196</p><p>Materials Needed 196</p><p>(Required) Class Exercise: What We Show on the Outside Matters! 197</p><p>(Required) Teaching Point: Open Expression = Trust = Social Connectedness 200</p><p>(Required) Class Exercise: Four Mini– Social Signaling Exercises 201</p><p>(Required) Teaching Point: Humans Are Expert Social Safety Detectors 203</p><p>Lesson 9 Homework 219</p><p>Lesson 10 Using Social Signaling to Live by Your Values 211</p><p>Flexible Mind Is Deep</p><p>Main Points for Lesson 10 211</p><p>Materials Needed 211</p><p>(Required) Teaching Point: The Three Functions of Emotions 212</p><p>(Required) Teaching Point: Nonverbal Social Signals Matter! 212</p><p>Contents</p><p>xi</p><p>(Recommended) Class Exercise: Apollo Eyebrows! 213</p><p>(Required) Class Exercise: “The Still Face Experiment” 214</p><p>(Required) Teaching Point: Using Social Signaling to Live by Your Values:</p><p>Flexible Mind Is DEEP 214</p><p>(Required) Class Exercise: Examining How Valued Goals Are Expressed Without Ever</p><p>Saying a Word 217</p><p>Lesson 10 Homework 219</p><p>Lesson 11 Mindfulness Training, Part 1 233</p><p>Overcontrolled States of Mind</p><p>Main Points for Lesson 11 233</p><p>Materials Needed 234</p><p>(Required) Teaching Point: Learning to Be Open About Being Closed 234</p><p>(Required) Teaching Point: Learning About Fixed Mind 235</p><p>(Optional) Discussion Point: Selfishness 235</p><p>(Required) Class Exercise: Finding My Fixed Mind 236</p><p>(Required) Teaching Point: Being Kind to Fixed Mind 238</p><p>(Required) Teaching Point: Learning About Fatalistic Mind 239</p><p>(Required) Class Exercise: Finding My Fatalistic Mind 240</p><p>(Optional) Discussion Point: Fatalistic Mind 241</p><p>(Required) Teaching Point: Challenging Fatalistic Mind 242</p><p>(Required) Teaching Points: Understanding Flexible Mind 243</p><p>(Required) Class Exercise: Finding My Flexible Mind 243</p><p>Lesson 11 Homework 244</p><p>Lesson 12 Mindfulness Training, Part 2 254</p><p>The “What” Skills</p><p>Main Points for Lesson 12 254</p><p>Materials Needed 254</p><p>(Recommended) Mindfulness Practice: Urge- Surfing 254</p><p>(Required) Teaching Point: Mindfulness “What” Skill: Observe Openly 257</p><p>(Required) Teaching Point: Describe with Integrity 259</p><p>(Required) Class Exercise: The Awareness Continuum 260</p><p>(Recommended) Teaching Point: Examples of “Describe with Integrity” Practices</p><p>for Overcontrol 263</p><p>(Required) Class Exercise: “I Am NOT Pouting!” 264</p><p>(Required) Teaching Points: Participate Without Planning 265</p><p>(Required) Class Exercise: Mini– “Participate Without Planning” Practice 271</p><p>Lesson 12 Homework 272</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>xii</p><p>Lesson 13 Mindfulness Training, Part 3 280</p><p>The Core Mindfulness “How” Skill: With Self- Enquiry</p><p>Main Points for Lesson 13 280</p><p>Materials Needed 280</p><p>(Required) Teaching Point: Introducing the “With Self- Enquiry” Skill 280</p><p>(Required) Teaching Point: What Is Self- Enquiry? 281</p><p>(Required) Teaching Point: How Does Self- Enquiry Facilitate Mindful Living? 282</p><p>(Required) Teaching Point: Deepening Our Understanding of Self- Enquiry 283</p><p>(Optional) Teaching Point: Cultivating Healthy Self- Doubt 284</p><p>(Optional) Mini– Class Exercise: Fun with Self- Doubt 286</p><p>(Optional) Self- Enquiry Practice: “Who Makes These Changes?” 286</p><p>(Required) Practice: Outing Oneself 288</p><p>(Required) Practice: A Step- by- Step Self- Enquiry and “Outing Oneself” Practice 289</p><p>(Optional) Class Exercises: Examples of Self- Enquiry and “Outing Oneself” Exercises</p><p>That Can Be Practiced in Class 292</p><p>Lesson 13 Homework 292</p><p>Lesson 14 Mindfulness Training, Part 4 298</p><p>The “How” Skills</p><p>Main Points for Lesson 14 298</p><p>Materials Needed 298</p><p>(Required) Teaching Point: With Awareness of Harsh Judgments 299</p><p>(Optional) Discussion Point: Emotions 299</p><p>(Required) Teaching Point: Judgmental Thinking 300</p><p>(Required) Teaching Point: With One- Mindful Awareness 305</p><p>(Optional) Class Exercise: Everything Is Relative 307</p><p>Lesson 14 Homework 308</p><p>Lesson 15 Interpersonal Integrity, Part 1 318</p><p>Saying What We Really Mean</p><p>Main Points for Lesson 15 318</p><p>Materials Needed 318</p><p>(Required) Teaching Point: Effectively and with Humility 307</p><p>(Required) Teaching Point: Why Do We Dislike Deception? 318</p><p>(Required) Class Exercise: Mindful Awareness of Lies 319</p><p>(Required) Teaching Point: Not All Lies Are Bad 321</p><p>(Required) Teaching Point: Saying What We Really Mean</p><p>quickly responds with</p><p>thanks and then matter- of- factly directs his or her attention away from the reader (that is, takes the</p><p>heat off) and turns back to the class or to another participant while continuing with the lesson plan.</p><p>• Use body movements and meaningless vocalizations to break the tension (see the “participate</p><p>without planning” mindfulness practices in lesson 12). For example, without warning, say, “Okay,</p><p>everyone, clap your hands together.” Raise your hands and begin to clap while smiling and engaging</p><p>eye contact with class participants: “Okay, stand up.” Stand and continue clapping: “Okay, now repeat</p><p>after me!” Clap along while smiling encouragement: “Say HA” (clap), “say HA” (clap), “say HO” (clap),</p><p>“say HO” (clap), “say HA HA, HO HO, HA HA, HO HO! Okay, now waggle your body all about…</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>32</p><p>and reach to the sky…say HAAAA HAAAA HAAAA and HEE HEE HO!” Reinforce participatory</p><p>efforts, even when they are of low intensity (for example, wiggling a finger or whispering HA), by</p><p>smiling and nodding approval yet simultaneously ignoring nonparticipatory signals (such as eye rolls</p><p>and frowning). End the practice as abruptly as you began it by asking everyone to sit down: “Okay, well</p><p>done. Now let’s all sit down!” And then, with a big smile, sit down and say, “Yes?” Then, without</p><p>pausing for discussion, return to the lesson plan. Importantly, as outlined later, all “participation</p><p>without planning” practices should last no longer than thirty seconds to one minute (see lesson 12).</p><p>• Bring the tribe to the client when the client refuses to participate with the tribe. An RO skills</p><p>training class is purposefully designed to function as a tribe. In the unlikely event that a class member</p><p>refuses to stand up as instructed during a class “participate without planning” exercise like the one just</p><p>described, instructors should simply reverse their instructions, saying to class members now standing,</p><p>“Okay, good job! Now go ahead and sit back down again.” The instructor should then, with eyebrows</p><p>raised and a warm smile (and without further commentary), conduct the exercise from a seated posi-</p><p>tion. Attempt to make eye contact with refusing class members as you continue to conduct the exer-</p><p>cise (to communicate your genuine desire for them to join in with the class and to show that you do</p><p>not disapprove of them). If they meet your gaze, quickly smile and perhaps give a little wave (this</p><p>smuggles playfulness and affection; see also “Fun Facts: Teasing and Being Teased,” in lesson 22).</p><p>Importantly, instructors should conduct the next miniexercise as if nothing has happened— that is,</p><p>starting with a request for everyone to stand up. Most often, nonconforming participants will reluc-</p><p>tantly comply (they have learned that noncompliance doesn’t work), whereupon the instructor can</p><p>warmly smile (and even wink) in their direction to signal delight in their decision (during break or</p><p>after class, the instructor can privately express appreciation for their participation). However, if they</p><p>continue to refuse, instructors should simply follow exactly the same protocol already outlined. Our</p><p>experience is that, over time, participants will eventually decide it is not worth continuing to refuse</p><p>to participate (recall that they have voluntarily chosen to be part of the class), because the instructors</p><p>make it nearly impossible to avoid. This functions to bring the tribe to the nonconforming member</p><p>while simultaneously communicating several important messages, without making a big deal of it:</p><p>• Class participation is expected.</p><p>• If you don’t join us, we will join you.</p><p>• We are attached to you and respect you, which is why we are sitting back down.</p><p>• We need you to participate so that we can all experience the joy of being part of a tribe.</p><p>• Explain the dangerously attractive nature of nonparticipation. Begin by noting that humans fear</p><p>social embarrassment and humiliation to such an extent that we often decide not to participate in a</p><p>community experience. OC clients are strongly motivated to avoid real or imagined social disap-</p><p>proval. Avoiding participation with others not only is common but also feels like a good idea because</p><p>it appears to promise relief from imagined critical scrutiny— and yet, paradoxically, nonparticipation</p><p>makes one’s behavior more noteworthy because it is not a normal response among those desiring to</p><p>remain part of a tribe. Thus, nonparticipation stands out in a crowd! For example, refusing to dance</p><p>or sing at a party can often feel like independence, but in the long run it often leads to rumination</p><p>when we realize that we are the only one not participating.</p><p>• Encourage participation by reminding clients of valued goals related to helping others and con-</p><p>tributing to society (using the “Protocol for Therapeutic Induction of Social Responsibility,” described</p><p>later in this chapter). Recall that although OC clients’ social signaling deficits make it difficult for</p><p>them to experience social connectedness with others (and for others to experience social connected-</p><p>ness with them), OC behaviors, in general, are often prosocial in nature (for example, planning ahead</p><p>contributes to society). This approach is best applied in private (for example, during the class break)</p><p>Managing Problematic Behaviors in RO Skills Training Classes</p><p>33</p><p>rather than publicly with the entire class. The focus of the discussion is to encourage the client to use</p><p>self- enquiry to examine how his or her lack of participation (that is, social signaling) may impact</p><p>others in the class and to examine the extent to which this behavior fits with the client’s valued goals</p><p>(see “Lateness and Noncompletion of Homework,” later in this chapter, for additional details on how</p><p>to apply this approach).</p><p>• Take the heat off by telling a story or using a metaphor (for example, see the story that I sometimes</p><p>refer to as “It Takes Only Thirty Seconds to Know,” told in the next section). Overcontrolled clients</p><p>are less likely to volunteer personal information or ask questions in a group setting, particularly when</p><p>new to the class. Stories and metaphors help reestablish classroom participation by momentarily</p><p>removing the expectation for it (that is, taking the heat off), but without entirely losing that expecta-</p><p>tion (that is, the story links back to the topic that was being discussed). Importantly, the actual story-</p><p>telling itself should ideally be delivered in a dramatic yet lighthearted manner (that is, a slightly</p><p>tongue- in- cheek fashion) that communicates to participants that the instructors don’t take them-</p><p>selves too seriously and that joining in will be fun. OC clients tend to be overly serious about life and</p><p>to compulsively strive, and yet research shows that the capacity to laugh at oneself (without putting</p><p>oneself down) signals confident acceptance of one’s problems or weaknesses and is associated with</p><p>psychological well- being (Beermann & Ruch, 2011).</p><p>Finally, if problems with participation persist, they should be dealt with in private by one of the RO skills</p><p>instructors, either during the break or at the end of class, and/or by the client’s individual RO DBT therapist.</p><p>For more details about how RO skills instructors can deal with participation problems, see “Protocol for</p><p>Therapeutic Induction of Social Responsibility” and “Managing Alliance Ruptures and Repairs” later in this</p><p>chapter).</p><p>Using Metaphor to Take the Heat Off: “It Takes Only Thirty</p><p>Seconds to Know”</p><p>This story, a favorite of mine, is based on research conducted by Ambady and Rosenthal (1992, 1993)</p><p>and is particularly helpful in breaking the ice whenever lack of participation appears to be due to class</p><p>members’ not knowing the instructor very well (for example, during the first class). To tell this story,</p><p>begin by looking around and, if possible, making eye contact with each class member, with eyebrows</p><p>raised and a warm smile.</p><p>You know,</p><p>there was some really interesting research done at Harvard that I think you might find</p><p>extremely helpful. The study involved asking a group of people to rate a five- minute film clip of a</p><p>course taught by a professor the raters had never met. They were asked to evaluate the teacher’s</p><p>personality— for example, how dominant, empathic, honest, or warm the teacher was— and then</p><p>the researchers compared their ratings to the same ratings completed by students who had just com-</p><p>pleted a three- month course with the same professor. To their surprise, the researchers discovered</p><p>that the ratings between the two groups were nearly identical! So then, being clever researchers, they</p><p>decided to try it again with another group of research subjects, but this time they only showed the</p><p>subjects one minute of the lecture— and when they compared these subjects’ ratings to the ratings of</p><p>students taking a course from the same professor, what do you think happened? They matched</p><p>again! Almost identical ratings!” [Pause dramatically.] So what do you think happened next? [Keep</p><p>your eyebrows up; display a warm smile and, if possible, make eye contact with each class</p><p>member.] Yes! [Nod happily, as if each member has replied.] Those clever researchers said to</p><p>themselves, “Let’s make it harder— let’s shorten the film clip to just thirty seconds.” And what do you</p><p>think happened? That’s right. Another match— nearly identical ratings to those done by students</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>34</p><p>spending an entire semester with the same professor! Wow! In just thirty seconds, people can know</p><p>a great deal about a person they have only just met! Amazing! [Pause, lean back in your chair,</p><p>slow the pace of your speech, and adopt a tone of compassionate gravity.] So I guess what I</p><p>wanted to say is that although most of you have only just met me, you already know a great deal</p><p>about me because we have been talking together for more than thirty seconds. For example, I am</p><p>aware of imagining that you likely suspect that I am the type of person who enjoys hearing differing</p><p>viewpoints or is okay with things not being perfect. Plus, perhaps…[Use a nondominant social</p><p>signal; see chapter 6 of the RO DBT textbook.]…you might sense that I genuinely care about our</p><p>work together. [Pause.] So, with that in mind, I’d like to go back to my earlier question. [Pause.] As</p><p>I recall, we were talking about…[Name the topic, and repeat the unanswered question or</p><p>request for participation.]</p><p>Use Heat- On and Heat- Off Strategies to</p><p>Shape Desired Behaviors</p><p>Contingency management (such as positive and negative reinforcement or extinction principles) is a core part</p><p>of RO DBT used to reinforce target- relevant adaptive behavior and reduce target- relevant maladaptive behav-</p><p>iors (see the information about behavioral strategies in chapter 10 of the RO DBT textbook). Yet when it</p><p>comes to treating OC, knowing what to reinforce or not can be difficult, since most OC dysfunctional behav-</p><p>ior is expressed subtly. OC clients habitually mask or constrain inner feelings and work hard to maintain a</p><p>public persona of normality, despite feeling miserable inside. Their indirect social signals and natural stoicism</p><p>make them difficult to get to know. For example, when OC clients say “Maybe,” they may mean “No,” or</p><p>“Hmmm” may really mean “I don’t agree.” The problem for the therapist (and others) is that OC social signal-</p><p>ing has plausible deniability (“No, I’m fine— I just don’t feel like talking” or “No, I’m not angry— I’m just</p><p>thinking”), making direct confrontation of potentially maladaptive behavior more difficult, whereas the</p><p>problem for OC clients is that their hidden intentions and disguised demands negatively impact their relation-</p><p>ships (see lesson 15). Thus, rather than emphasizing emotion regulation, therapists working with OC clients</p><p>should look for opportunities to reinforce open and candid expressions of emotion.</p><p>Plus, almost all OC clients strongly dislike the limelight (that is, being the center of attention), making the</p><p>removal of scrutiny or attention a powerful reinforcer. Heat- on and heat- off techniques capitalize on this by</p><p>using attention- management strategies (including, for example, the time the instructor spends focusing on a</p><p>particular client) to shape OC clients’ behavior. Heat- on strategies involve some form of social attention, such</p><p>as eye contact, a question, or a request for participation. The “heat” pertains to how OC clients evaluate the</p><p>attention. Their biotemperamental predisposition for heightened threat sensitivity, combined with family and</p><p>cultural reinforcers prioritizing performance, functions to make attention or requests feel like critical evalua-</p><p>tion of performance, leading to increased self- consciousness. For example, during homework review an instruc-</p><p>tor might ask a client, “Do you think you might have assumed that you already knew what they were going to</p><p>say and that this might have made you less likely to actually listen?” This is an excellent self- enquiry question</p><p>for the client, and at the same time it also represents a heat- on strategy because it functions to direct attention</p><p>toward the client and necessitates some sort of response.</p><p>OC clients are likely to respond in three ways to an experience of having the heat turned on:</p><p>1. They may join with the instructor by directly answering the question in a manner that signals a will-</p><p>ingness to openly explore the issue.</p><p>2. They may delay or pause before responding, which may be due to a wide range of reasons. For example,</p><p>a client may delay responding because a classically conditioned shutdown response was triggered by</p><p>the query (respondent behavior), they may be using Flexible Mind to inhibit an automatic “pushback”</p><p>Managing Problematic Behaviors in RO Skills Training Classes</p><p>35</p><p>response (adaptive response), or they may be blaming themselves for not already having the problem</p><p>sorted out (maladaptive response).</p><p>3. They may exhibit behavior that is in between the two responses just described. That is, they may</p><p>appear to be genuinely trying to reply or engage with the discussion, and at the same time their</p><p>manner may appear to change once the heat is on. Skills instructors should avoid making assumptions</p><p>that particular behaviors (such as sudden silence, gaze aversion, or an increased rate of speech) provide</p><p>strong evidence of an OC client’s inner experience. Even if the instructors are correct, behaving as if</p><p>they know what is going on with an OC client (especially early in treatment) may be experienced as</p><p>disrespectful, overly provocative, or inappropriate by the client (see “The Enigma Predicament,” in</p><p>chapter 10 of the RO DBT textbook).</p><p>It is also essential for instructors to know when and how to take the heat off a client during an RO skills</p><p>training class. Heat- off strategies in RO DBT are primarily used to maximize engagement and reinforce newly</p><p>acquired adaptive behavior. They work because they briefly move the focus of attention away from the client,</p><p>but without changing the topic. This allows time for the OC client to downregulate, without making it obvious</p><p>that he or she is doing so or calling attention to it. For example, during a client’s homework review, a skills</p><p>instructor noticed that a normally highly engaged and vocal client was struggling with a certain aspect of her</p><p>homework, despite several helpful prompts from the class. Rather than continuing to focus on the client</p><p>directly, either by repeating the question or by waiting for an answer, the instructor briefly took the heat off</p><p>the client by rephrasing the question and redirecting it toward the entire class: “So, class, when you think</p><p>about the various ways people react to compliments, like in Mary’s homework, what do you think makes them</p><p>so hard for some people to give?” This gave the client a breather, without making a big deal of it, while simul-</p><p>taneously retaining the cue by not changing</p><p>the topic being discussed. The instructor then redirected atten-</p><p>tion to a now more regulated client so she could complete her homework. Sometimes simply removing eye</p><p>contact for a few seconds is all that is needed for an OC client to regulate and reengage. Other heat- off tech-</p><p>niques include telling a relevant anecdote or using a metaphor, having an instructor practice self- disclosure</p><p>about a similar self- discovery, and writing a particular teaching point on the blackboard or whiteboard when</p><p>it is relevant to the topic being discussed.</p><p>Finally, heat- on and heat- off strategies can be applied structurally. A good example is the RO DBT prin-</p><p>ciple of letting new class members know that, after introducing themselves, they are not required to speak on</p><p>their first day of class, although they are asked to participate (nonverbally, at least) in class exercises. This</p><p>exception regarding verbal participation is made only for new class members attending their first class (that is,</p><p>an open class that has been already running). The exception functions to structurally take some of the heat</p><p>off a new client and works for the class dynamics because all the older class members had the same exception</p><p>made for them on their first day. What is interesting is that taking the heat off by simply removing the onus of</p><p>speaking seems, almost paradoxically, to lead to more speaking.</p><p>Maladaptive Social Signals That Cannot Be</p><p>Ignored in Class</p><p>Most often problematic behaviors in class can be ignored, if they remain at a low level, or they can be dealt</p><p>with privately during class break or at the end of class. The vast majority are not intended to disrupt the class,</p><p>nor do they necessarily mean that a client is nonengaged. Nevertheless, among the problematic behaviors that</p><p>can emerge during skills training classes with OC clients, there are a few that, if not immediately addressed,</p><p>can interfere with the primary aim of skills training— that is, learning new skills— and, if ignored, they may</p><p>shortly come to be assumed as appropriate classroom behavior. Consider, for example, the client who inno-</p><p>cently decides to answer an incoming text message. If this behavior is not addressed, the classroom may soon</p><p>be full of texting participants, or a client who has been asked an uncomfortable question may pretend to have</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>36</p><p>received a text message in order to avoid answering (see the required teaching point “Hiding Intentions and</p><p>Disguising Demands,” in lesson 15).</p><p>Regardless of the client’s intention, when a behavior occurs that clearly has the potential to interfere with</p><p>learning skills, the best way to manage it, at least initially, is for the instructor to politely ask for it to stop. For</p><p>example, an instructor might say, “Um…Joan and Sue, can you do me a favor…and not carry on private con-</p><p>versations during class? I find it hard to concentrate.” Then, with a warm smile and an eyebrow wag, the</p><p>instructor can say, “Thanks.” Most OC clients, even when they are nonengaged or purposefully trying to</p><p>niggle the instructor or a fellow classmate, will comply with this type of direct request. The instructor can then</p><p>simply turn back to teaching and, later on, during the class break, approach the client to discuss the problem-</p><p>atic behavior further, if necessary.</p><p>I am aware of imagining that some readers may be thinking that the problem behaviors just described—</p><p>texting in class and holding private conversations— could easily have been prevented or dealt with if the</p><p>instructor had simply provided each class member with a set of written rules or guidelines and reviewed them</p><p>at the start of each class. Yet this is explicitly advised against in RO DBT— we like our therapists to have to</p><p>work hard (tee hee). Seriously, though, although providing everyone with a list of rules may seem like a good</p><p>idea, it most often creates more problems than it solves. Our experience is that providing lists of rules to OC</p><p>clients is a bit like giving heroin to a junkie to calm him down, or using gasoline to try to put out a fire. Rules,</p><p>once present, take on a life of their own with OC clients, regardless of how they are introduced (individually</p><p>with a client or with the entire class). OC clients, despite their initial enthusiasm and indications of agreement</p><p>with the use of rules proposed, are likely to carefully examine the new rules when alone, to determine whether</p><p>they actually agree with them and/or how they may need to adjust their behavior in order to comply, and then</p><p>plan accordingly (whereas undercontrolled clients are more likely to lose the list of rules and forget it ever</p><p>existed). Plus, asking OC clients to review and approve a list of rules is likely to generate new rules, improved</p><p>rules, and detailed analyses that uncover discrepancies or mistakes (such as grammatical errors and misspell-</p><p>ings) that OC clients may feel morally obligated to discuss with the class and point out to instructors. The</p><p>following scenario, described by an RO skills instructor, highlights just how quickly a list of rules can come to</p><p>dominate the attention of OC clients and interfere with learning.</p><p>When our clinic first started to learn RO DBT, we were skeptical when our trainers informed us that RO</p><p>skills training classes do not explicitly review class rules or expectations at any point in the treatment</p><p>process. We decided to test out this recommendation by developing our own list of class rules, which were</p><p>then introduced to the entire class. Reception was positive, with only a few suggestions. We were ecstatic!</p><p>Unfortunately, our ecstasy was short- lived— problems started to emerge two weeks later, during the brief</p><p>overview of the class rules at the start of the class. During this overview, one of the class members asked if</p><p>she could make a comment about the rules, and she made a suggestion to the entire class, stating,</p><p>“Although I will not mention any names, ha- ha, for several weeks now I have noticed that some class rules</p><p>seem to be at least occasionally ignored by certain members of our class. So I would like to propose that we</p><p>appoint a rule monitor to help out our busy instructors and ensure that the rules are applied fairly to all.”</p><p>This suggestion resulted in a forty- five- minute discussion about its potential merits that had to be tabled for</p><p>later because it also triggered some colorful debates about word usage, grammatical errors, and the ethics of</p><p>even having rules. It also spurred another class member to reveal that he had been working for several</p><p>weeks on a new list of rules that better represented RO principles and would like to present it to the class</p><p>the following week. However, before his request could even be addressed, the entire class suddenly became</p><p>aware that the group’s most reticent and least talkative member was silently raising her hand high in the air</p><p>and appeared to be signaling that she had something important to say. The entire class held a collective</p><p>breath as the instructor, recognizing the potentially enormous therapeutic significance of the moment,</p><p>leaned toward the client and encouraged her to speak, whereupon she said, “I too have come up with an</p><p>improved list of rules. I will bring them in next week.” The class burst into exclamations of support while</p><p>the instructors began to doubt the wisdom of class rules and wondered how they would ever cover the</p><p>material that was planned for that day.</p><p>Managing Problematic Behaviors in RO Skills Training Classes</p><p>37</p><p>The moral of the story is “Don’t give out written rules to OC clients.” However, this is not the end of our story</p><p>about problem behaviors in OC classes. There remain three additional broad classes of social signals that are</p><p>important to address directly in class because of their potential for impacting both learning and class morale:</p><p>1. “Don’t hurt me” responses</p><p>2. Harsh criticism directed at another class member</p><p>3. Noncompletion of</p><p>homework</p><p>“Don’t Hurt Me” Responses</p><p>“Don’t hurt me” responses are operant behaviors that function to block unwanted feedback or requests to</p><p>join in with a community activity (see chapter 10 of the RO DBT textbook). They are typically expressed</p><p>nonverbally via behaviors— lowered head, face covered with the hands or hidden from view, slackened posture,</p><p>lowered eyelids, eyes cast downward, avoidance of eye contact, slumped shoulders, postural shrinkage— that</p><p>collectively are associated with self- conscious emotions. The underlying message of a “don’t hurt me” response</p><p>is as follows:</p><p>You don’t understand me, and your expectations are hurting me, since normal expectations of behavior do</p><p>not or should not apply to me, due to my special status or talents, my exceptional pain or suffering, my</p><p>traumatic history, the extreme efforts I have made to contribute to society, my hard work, and my self-</p><p>sacrifices for the benefit of others. As such, it is unfair of you to fail to recognize my special status and</p><p>expect me to participate, contribute, or behave responsibly, as other members of my community are</p><p>expected to behave. Consequently, if you were a caring person, you would stop pressuring me to change,</p><p>behave appropriately, or conform with norms. For example, stop expecting me to complete my homework,</p><p>stop asking questions I don’t like, and stop expecting me to participate in class discussions or exercises.</p><p>The final hidden or indirect signal in a “don’t hurt me” response is “And if you don’t stop, I will fall apart, and</p><p>it will be your fault.”</p><p>Another way to understand the maladaptive nature of “don’t hurt me” responses is to examine the behav-</p><p>ior from the perspective of a tribe, family, or community group, since the “don’t hurt me” response always</p><p>occurs within a social context (although its cousin, self- pity, often occurs alone and frequently precedes “don’t</p><p>hurt me” social signaling). What can often be missed by recipients of “don’t hurt me” responses is that the</p><p>sender has almost always willingly chosen to be part of the community, group, or tribe in which the behavior</p><p>is exhibited; that is, the sender has not been forced into the community, group, or tribe but still expects special</p><p>treatment. “Don’t hurt me” responses have usually been intermittently reinforced by others’ well- intentioned</p><p>behavior, such as soothing, attending to, and taking care of the sender, or not bringing up potentially distress-</p><p>ing topics in order to avoid further upsetting him or her. Yet this kind of walking on eggshells can engender</p><p>social ostracism of the sender when the maladaptive signal is of long standing, pervasive, and nonresponsive</p><p>to initial attempts by others offering assistance. Similar to pouting, “don’t hurt me” responses are maladaptive</p><p>because they function to signal disagreement and nonengagement indirectly and, as a consequence, over the</p><p>long term they not only negatively impact the sender’s sense of self but also interfere with the sender’s forma-</p><p>tion of close social bonds (see information about problems associated with indirect social signals in lesson 15).</p><p>A “don’t hurt me” response can be difficult to identify because it is usually subtly expressed and disguised</p><p>to look like a respondent pain reaction (such as the cry of pain after twisting an ankle, or the sadness and grief</p><p>upon losing a friend) or like an unwarranted self- conscious emotion (as in the lowered head and averted gaze</p><p>that suggest an unjustified shame response after an appropriate self- disclosure in class). Plus, it can be engaged</p><p>with conscious intent or can occur without conscious awareness (habitually). A good way to tell the difference</p><p>between a “don’t hurt me” response, on the one hand, and a respondent pain reaction or unwarranted self-</p><p>conscious emotion, on the other, is that the “don’t hurt me” response has a relatively long duration (the entire</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>38</p><p>length of a skills training class, for example), with the intensity of the signal increasing and possibly developing</p><p>into an extinction burst if recipients fail to respond in the desired way (such as by soothing, withdrawing a</p><p>question, changing the topic, or apologizing; see the information about disguised demands in lesson 15). By</p><p>contrast, a respondent reaction, justified or not, is naturally likely to match the intensity of the eliciting stimu-</p><p>lus (the pain expressed when your foot is run over by a car is likely more extreme than when someone steps on</p><p>your toe); the behavioral expression slowly fades, usually in minutes, once the eliciting stimulus has been</p><p>removed, and it does not depend on the reactions of nearby others. Regardless, the good news is that the treat-</p><p>ment intervention is essentially the same whether the behavior is operant or respondent, varying only as a</p><p>function of context (that is, as a function of whether the behavior occurs during an individual therapy session</p><p>or during a skills training class; see the information about interventions for individual therapy in chapter 10 of</p><p>the RO DBT textbook). Since the focus of this manual is on skills training, the emphasis here will be on man-</p><p>aging this type of response in skills classes.</p><p>A “don’t hurt me” response is a big signal for an OC client to display in public (that is, outside of the</p><p>immediate family or the individual therapy room). When “don’t hurt me” responses occur in skills training</p><p>classes and are prolonged and obvious, they send a powerful message suggesting that the signaler requires some</p><p>form of help or attending to. A “don’t hurt me” response in a skills training class is often accompanied by</p><p>others’ sense of moral obligation to assist the signaler in some way, and very quickly such signals, rather than</p><p>the lesson, can subtly come to dominate the attention of the signaler’s classmates (the only exception is when</p><p>“don’t hurt me” responses have inadvertently become a class norm). Most often this felt sense of moral obliga-</p><p>tion translates into expectations for the skills training instructors to do something about the “don’t hurt me”</p><p>response, since this is seen as their job. Unfortunately, if instructors attend to the sender of the maladaptive</p><p>social signal by assessing what happened, problem solving, or soothing, they not only spend valuable class time</p><p>on behavior unrelated to the lesson for the day but are also likely to reinforce the “don’t hurt me” response (see</p><p>“Behavioral Principles and Strategies,” in chapter 10 of the RO DBT textbook). Yet if instructors completely</p><p>ignore a prolonged and obvious “don’t hurt me” response, they are likely to quickly find themselves confronted</p><p>by a room full of nonengaged OC clients who feel increasingly distressed by their instructors’ lack of action</p><p>(recall that most OC clients feel it is their moral duty to help those in distress) but who may not explicitly</p><p>reveal their distress (recall that OC clients mask inner feelings). Plus, completely ignoring a “don’t hurt me”</p><p>response can create a new class norm that it’s okay to shut down in class, or pout, or behave as if you don’t care.</p><p>This in turn can trigger mimicry and contagion effects (particularly in classes with adolescents). The situation</p><p>can quickly escalate until instructors face a classroom full of hanging heads, averted gazes, slumped shoulders,</p><p>and faces covered with hands, hair, or clothing, with a nearly complete shutdown of learning for the entire</p><p>class and premature dropout.</p><p>Thus, prolonged “don’t hurt me” responses should not be ignored in RO DBT skills training classes. Steps</p><p>for management include those that follow:</p><p>• The instructor should matter- of- factly acknowledge the behavior and, rather than exploring the factors</p><p>that may have elicited it, simply ask the client to look up and join in with the class: “Molly, I am aware</p><p>of imagining that something has happened that makes you either sad or upset in some manner. But</p><p>can you do me a favor? Can you</p><p>pick up your pen, sit up straight, and look at the material on the page</p><p>in front of you?” The underlying tenor of the message is “Of course you can do this,” without a direct</p><p>statement— a stance that celebrates the OC client’s capabilities rather than assuming that the client</p><p>is unable to tolerate change, confrontation, or direct feedback.</p><p>• The instructor should be prepared to repeat the request for prosocial behavior in skills class, several</p><p>times if necessary, and to reinforce compliance: “Thanks, Molly. I really appreciate that.”</p><p>• The instructor should signal to the rest of the class the intention of further attending to the “don’t</p><p>hurt me” signaler’s distress in private: “And, Molly, I want you to know that no matter what is going</p><p>on, I think it is important to address it. So I would like to meet with you at break [or after class] to</p><p>Managing Problematic Behaviors in RO Skills Training Classes</p><p>39</p><p>discuss what we might need to do in order to deal with what happened and enhance your learning. In</p><p>the meantime, I would appreciate it if you would do the best you can to attend to the lesson, with the</p><p>understanding that you and I will be able to address what’s going on with you personally very shortly.</p><p>Thanks.” This message is followed by a warm closed- mouth smile from the instructor.</p><p>• If these strategies are ineffective, the instructor should say, “Okay. Well, thanks for trying. Tell you</p><p>what— in the meantime, do the best you can to join with us as we go back to reviewing homework [or</p><p>the lesson], and you and I can talk about this at break [or at the end of class].” The instructor should</p><p>then carry on with teaching, without further discussion and with the knowledge of having done his or</p><p>her job (at least from the perspective of the OC participants) by making an attempt to address the</p><p>problem in class, an attempt that also includes a plan for dealing with the problem later.</p><p>During the break, or at the end of class, the instructor should invite the client who exhibited the “don’t</p><p>hurt me” response to have a little chat about what was going on and how best to deal with it. This would</p><p>include a brief check- in about what triggered the client’s “don’t hurt me” signal in order to determine the</p><p>extent to which it was respondent behavior (which would imply problem solving), represented a possible alli-</p><p>ance rupture (which would call for an alliance rupture repair), or was a maladaptive operant behavior (that is,</p><p>an indirect social signal). As mentioned earlier, when a “don’t hurt me” response is prolonged, it is usually a</p><p>maladaptive social signal and is also what is most common (until the behavior gets shaped out of the client’s</p><p>repertoire). Regardless of whether the behavior is respondent, indicates an alliance rupture, or is operant, the</p><p>aim of this short discussion is to obtain the client’s agreement to behave appropriately in class by reminding</p><p>the client of several things:</p><p>• That he or she has a natural tendency to value doing the right thing (this is linked to high moral</p><p>certitude in OC) as well as a sense of social obligation (the instructor points out that the client’s in-</p><p>class misbehavior— that is, the engagement in “don’t hurt me” responses— is impacting the learning</p><p>of other class members)</p><p>• That the client has a superior capacity for restraint and can therefore, unlike many other people, at</p><p>least choose to appear okay and engaged in class, even when not feeling that inside</p><p>• That the client can discuss the issue further with the instructor, if necessary, as well as with his or her</p><p>individual therapist</p><p>Finally, the RO skills training manual has an entire lesson targeting indirect social signaling, including “don’t</p><p>hurt me” responses (see the information on Flexible Mind REVEALs skills in lesson 16). Thus, instructors can</p><p>remind clients who have already been through that lesson to use their Flexible Mind REVEALs skills, and</p><p>clients who have not yet come to lesson 16 can be provided with handouts from the lesson, or the instructor</p><p>can explain to them that the type of behavior they are exhibiting will be covered in an upcoming lesson. The</p><p>following script shows how one instructor discussed these points with an OC client after checking in and</p><p>conducting a brief assessment of what had triggered the client’s “don’t hurt me” response.</p><p>Instructor: Molly, one last thing before we go back to class. I would like to ask if you would be willing to do</p><p>me a favor. Here’s the thing. The problem from my perspective is that when you behave like you</p><p>did earlier in class— hanging your head and not responding immediately to questions— you send</p><p>a powerful social signal to everyone in class that may negatively impact the learning of your</p><p>fellow classmates, even if you did not intend to do so. Yet one of the things I admire about you</p><p>is that you actually are one of those people in the world who actually gives a damn. You care</p><p>about things working out and doing the right thing. Am I right about that?</p><p>(Client nods yes.)</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>40</p><p>Instructor: That’s what I thought, too. Plus, at the same time, I am aware of imagining that we would both</p><p>agree that one of your talents pertains to superior self- control, meaning you can delay gratifica-</p><p>tion, inhibit impulses, and tolerate distress in ways that others might find impossible. Would you</p><p>agree?</p><p>(Client nods yes.)</p><p>Instructor: So what I would like to ask is that you use your superior capacities for inhibitory control, and</p><p>your values linked to caring for others, to inhibit future urges to give up, hide, not participate,</p><p>or hang your head during class, in order to help your fellow classmates and not impede their</p><p>learning. (Smiles warmly.) Would you be willing to do this?</p><p>In summary, “don’t hurt me” responses are big social signals for OC clients. They have been intermittently</p><p>reinforced over time. If allowed to occur unchecked during skills training, they can subtly undermine the aims</p><p>of the class itself. When “don’t hurt me” responses occur in class, instructors should kindly and matter- of- factly</p><p>ask clients exhibiting this behavior to put their heads up and direct their attention, as best they can, toward</p><p>the lesson of the day. Instructors should also indicate that, regardless of what is going on, they would like to</p><p>talk with these clients about the behavior during break or at the end of class (see “Protocol for Therapeutic</p><p>Induction of Social Responsibility,” later in this chapter). This functions to reassure other class members that</p><p>they do not need to intervene themselves while also redirecting the class’s attention to skills acquisition.</p><p>Interestingly, OC clients who exhibit “pushback” responses in class (see “‘Pushback’ Responses,” in chapter 10</p><p>of the RO DBT textbook) generally fail to elicit similar protective behaviors among their fellow classmates.</p><p>Instead, “pushback” responses directed at an instructor are more likely to elicit urges to protect the instructor,</p><p>usually because a “pushback” often feels like a personal attack. The next section explains how to manage</p><p>personal attacks in class.</p><p>Personal Attacks</p><p>The second most common OC behavior requiring immediate attention pertains to personal attacks and</p><p>harsh critical comments directed at another class member. OC clients’ personal attacks toward other class-</p><p>mates rarely involve shouting, cursing, arm waving, foot stomping, finger pointing, fist shaking, table pound-</p><p>ing, thrown objects, or physical contact (most OC clients consider an RO skills class a public arena, whereas</p><p>OC emotional leakage is more likely in private settings). However, this does not mean that personal attacks do</p><p>not occur. If personal attacks appear in an OC skills training class, they are much more likely to be delivered</p><p>in a controlled manner and may have been rehearsed. Their controlled nature is what can make them discon-</p><p>certing. They are likely to be delivered in a tone of voice that</p><p>may be cold, clipped, sarcastic, exasperated, or</p><p>even neutral, and they may or may not involve direct eye contact. The reasons why they may occur vary widely.</p><p>For example, sometimes OC clients are critical of fellow classmates simply as a function of past experiences in</p><p>group therapy, or because they believe that learning new skills related to interpersonal relationships and open-</p><p>ness means they should practice giving feedback to others in class.</p><p>In addition, harsh judgmental comments often reflect fundamental attribution errors. An attribution bias</p><p>is a way of thinking that affects how we determine who or what is responsible for having caused some event,</p><p>or an action exhibited by someone else (Ross, 1977). The error has to do with a cognitive bias toward judging</p><p>others’ problematic behavior as revealing something fundamental about character or personality (we blame</p><p>them), whereas when we exhibit the same behavior, we judge it to be the result of circumstances or believe that</p><p>it is due to a context beyond our control (we are not to blame). For example, if Jack and Jill run up a hill to</p><p>fetch a pail of water and Jill falls down, Jack may consider Jill careless or clumsy, but if Jack himself falls down</p><p>and breaks his crown, he will be more likely to label his fall an accident and blame the uneven terrain.</p><p>Theorists have proposed that one of the reasons for this type of bias is our desire for a “just world” (Lerner,</p><p>Managing Problematic Behaviors in RO Skills Training Classes</p><p>41</p><p>1997). A just world is one where actions and events have predictable and appropriate consequences— people</p><p>get what they deserve according to how they behave. Thus, punishing a transgressor restores faith in a just</p><p>world. For example, an OC client may believe it is her moral duty to correct errors or assist instructors in teach-</p><p>ing others how to behave better.</p><p>Yet not every behavior exhibited by an OC client is morally motivated. Since being correct, winning, and</p><p>achieving matter greatly to most OC clients, they are more likely to engage in social comparisons than are less</p><p>performance- focused people. RO skills training classes can become yet another venue for OC clients to test</p><p>their competence, and this makes social comparisons among class members commonplace. Thus, a personal</p><p>attack directed at another class member may reflect unhelpful envy and premeditated revenge, motivated by a</p><p>desire for the envied person to fail or experience pain (see the discussion of schadenfreude in lesson 27). The</p><p>problem for the envious OC client is that winning by putting someone else down feels like a hollow victory</p><p>because it is achieved not through personal merit but by blocking the merit of a rival.</p><p>The good news is that the intervention for an OC client’s personal attack in class is always the same,</p><p>regardless of the underlying motive. The first step is to discriminate helpful critical feedback from an unhelpful</p><p>and harsh personal attack. There is no right answer, but a general rule is to intervene when the feedback is</p><p>unkind and when it is characterized by a conspicuous lack of prosocial signaling (for example, not smiling, lack</p><p>of head nods, blank stare). For example, a classmate saying to a fellow class member, “John, I am aware of</p><p>imagining that you are in Fatalistic Mind” would most likely not be considered a personal attack, primarily</p><p>because it includes a qualifier suggesting that the sender may be incorrect (that is, “I am aware of imagin-</p><p>ing…”). However, “You are behaving like a child” or “I don’t believe you” or “I know what you are thinking”</p><p>or “You are one of those users— poor me” are examples of feedback that is personally attacking. A personal</p><p>attack is problematic because (1) often it doesn’t take into account a context or circumstances that may be</p><p>impacting someone else’s behavior, (2) the attacker assumes that the attack is justified and/or accurate, and (3)</p><p>it implies that the attacker has special knowledge of or insight into the recipient of the attack. To put it simply,</p><p>a personal attack is identifiable by its conspicuous lack of humility.</p><p>When a personal attack is directed at another class member, instructors should immediately intervene to</p><p>block further critical feedback. This also functions to remove the necessity of a defensive comeback from the</p><p>recipient. In one RO skills class, for example, a client decided to tell a fellow class member that she found his</p><p>tendency to repeat certain words really annoying. The instructor immediately recognized this as a personal</p><p>attack and stepped in to block further unhelpful feedback:</p><p>Instructor: (Smiles) You know, June, there are groups where you can practice giving and receiving critical</p><p>feedback. However, our class is not one of them. Rather than practicing critical feedback, our</p><p>RO skills class is a group where we practice supporting each other in learning new skills. As</p><p>such, I would like to ask that you work to avoid giving critical feedback to others in class and</p><p>instead focus on helping others and yourself learn the RO skills. (Smiles.) Thanks.</p><p>Most often, simple direct instructions to clients about how to behave are all that is needed, especially when</p><p>these instructions are delivered in a manner that does not make a big deal of the fact that feedback is being</p><p>given. Any unresolved issues are discussed privately with clients during break or at the end of class. Finally, it</p><p>is important to note that this protocol is designed to deal with a personal attack by an OC client that is</p><p>directed at another class member, not a personal attack directed at a skills training instructor. When a client</p><p>harshly criticizes an instructor, the instructor should view the attack as an alliance rupture and institute the</p><p>alliance rupture repair protocol in private (that is, during the break or at the end of class).</p><p>Lateness and Noncompletion of Homework</p><p>The third most common problem behaviors likely to occur in an RO skills training class that require in-</p><p>class intervention are noncompletion of homework and its cousin, not wanting to talk about homework (that</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>42</p><p>is, passing). I have also included in this section a discussion of managing clients’ repeated lateness, even though</p><p>it does not require in- class intervention, because the strategies used to manage lateness share features with</p><p>some of those used to manage issues concerning homework. Plus, from an RO perspective, noncompletion of</p><p>homework and repeated lateness are considered social signals.</p><p>Instructors, rather than immediately assuming that a problem of lateness or noncompletion of homework</p><p>lies solely in the client, should begin by asking themselves What is this client trying to communicate to me or the</p><p>class? Is it possible that the client is experiencing an alliance rupture? This should be followed by a quick self-</p><p>enquiry practice: As a skills trainer, how may I have contributed to this problem? What is it that I might need to</p><p>learn? The good news is that, in general, issues concerning lateness and homework completion are of relatively</p><p>low frequency in most well- functioning RO classes; indeed, most OC clients compulsively complete homework</p><p>and are doggedly punctual.</p><p>The protocol for managing lateness is to take the heat off. Instructors should briefly acknowledge a late</p><p>arrival without making a fuss, by saying, for example, “It’s good to see you,” smiling warmly, adding, “Take a</p><p>seat— we are working on…,” and then returning to teaching, with a brief check- in with the client during break.</p><p>By not making a fuss about lateness, instructors make it more likely for hyper- threat- sensitive OC clients not</p><p>to associate arriving at skills class (the tribe) with being put on the spot, being interrogated, being humiliated,</p><p>or having to justify their actions (recall that OC clients dislike the limelight). Instructors can also circumvent</p><p>some issues surrounding lateness by occasionally</p><p>reminding participants that if they do arrive late for class,</p><p>they should not wait outside the door and enter only at an opportune moment (such as the end of the mindful-</p><p>ness practice or the break) but instead should enter as soon as they arrive. Instructors can explain that lateness</p><p>and interruptions are part of life and can be opportunities for practicing RO skills, not only for latecomers but</p><p>also for the entire class (if “energy” arises around classmates’ lateness, for example). At the same time, even</p><p>though heat- off techniques are used when a client arrives late, the behavior itself is targeted for change, albeit</p><p>not in class.</p><p>Protocol for Therapeutic Induction of</p><p>Social Responsibility</p><p>Similar to some of the in- private interventions used to address “don’t hurt me” responses and noncompletion</p><p>of homework, change strategies targeting clients’ lateness, noncompletion of homework, lack of participation,</p><p>or any other form of nonengagement are carried out in private, usually during the break. As in a chat about a</p><p>“don’t hurt me” response or noncompletion of homework, the aim of this chat is to help OC clients motivate</p><p>themselves to do the right thing by exhibiting behavior appropriate in a classroom setting by reminding them</p><p>of their core values for fairness. The following transcript shows how one therapist actualized this idea.</p><p>Instructor: The thing is, although I am aware of imagining that you don’t intend to disrupt the learning of</p><p>your fellow classmates, I feel obligated to let you know that [showing up late, not doing home-</p><p>work, not participating in class exercises] sends a powerful social signal that is most likely subtly</p><p>impacting the learning of the entire class. RO skills training classes are little tribes. Regardless</p><p>of the reasons why, someone who repeatedly shows up late, doesn’t participate, or doesn’t com-</p><p>plete homework is placing an unfair burden on classmates by making the source of practical</p><p>examples stem primarily from individual efforts rather than from the class as a whole. We need</p><p>the efforts of every person involved in our little tribe to make things work, not only to learn from</p><p>each other but also to build the type of camaraderie that is needed to fight the social isolation</p><p>and loneliness that characterize OC problems. Learning RO skills is a bit like joining the Three</p><p>Musketeers— all for one, and one for all! (Smiles.) We depend on you to arrive on time, ready to</p><p>go, having practiced your skills, and with a spirit of openness that encourages your fellow</p><p>Managing Problematic Behaviors in RO Skills Training Classes</p><p>43</p><p>classmates to behave similarly. (Smiles.) I know this may sound a bit silly, but it really does</p><p>matter. RO skills are not something we can learn alone, or simply by reading the text. To be fully</p><p>grasped, they depend on the passionate participation of each and every one of us— and that</p><p>means you. (Smiles warmly.) So my question to you…now that you are aware of the impact your</p><p>behavior has on other people…is whether you would be willing to use your capacities for supe-</p><p>rior inhibitory control, and your values for giving a damn, to help out your fellow musketeers…</p><p>and do your part by…[showing up on time, completing homework, participating when asked].</p><p>Managing Noncompletion of Homework</p><p>The protocol for dealing with noncompletion of homework combines the preceding heat- off strategy (a private</p><p>discussion about the problem during the break) with a heat- on strategy that addresses the issue immediately in</p><p>class. When an OC client reports not having completed his or her homework, the instructor, instead of ignor-</p><p>ing or accepting the report, admonishing the client, assessing the situation, or problem solving, should keep</p><p>the heat on the client by adopting a stance of playful irreverence (see chapter 2) that presumes commitment</p><p>and ignores signs of nonengagement— in this case, by the instructor behaving “as if” the client always intended</p><p>to complete the homework and will therefore leap at the opportunity to complete it in class (wink, wink and</p><p>tee hee). Recall that playful irreverence, also known as therapeutic teasing (see “Fun Facts: Teasing and Being</p><p>Teased,” in lesson 22), is how friends give each other feedback.</p><p>Most often this is actualized when the instructor simply asks the OC client to complete the homework in</p><p>the moment (that is, in class): “So, Tim, can you remind me what the homework assignment was for this</p><p>week?” The question should be delivered in a manner that signals genuine yet irreverent curiosity (because it</p><p>will be obvious to everyone in the room that the instructor and the client both already know the answer to</p><p>what appears to be a silly question; tee hee). This strategy works because it requires the client to say something</p><p>other than “I didn’t do my homework” while also making it clear that a discussion about homework is impos-</p><p>sible to avoid. After the client answers the question (most will), the instructor should start to go through at</p><p>least some part of the homework in class, cheerfully carrying on in a manner that communicates the instruc-</p><p>tor’s assumption of the client’s competence and commitment, and ignoring any signs of reluctance from the</p><p>client. For example, if the homework was to practice the Match + 1 skills that are part of Flexible Mind</p><p>ALLOWs (see lesson 21), then the instructor can ask the client to demonstrate the way he would have used</p><p>the skill if he had been able to do so during the preceding week. This approach both gives the client the benefit</p><p>of the doubt and provides a mild aversive contingency for noncompletion of homework (puts the heat on) by</p><p>asking the client to complete the homework (at least partially) in class— making noncompletion of homework</p><p>less likely in the future (recall OC clients dislike the limelight).</p><p>The same playful irreverent approach should be adopted when a client has completed the homework but</p><p>doesn’t want to talk about it— that is, the client wants to pass when the time comes for everyone to take turns</p><p>reporting on the homework. In this situation, when the client says, “I really don’t want to talk about it” or “I</p><p>want to pass,” the instructor should adopt a playful irreverent stance, ignore what the client said, and simply</p><p>ask instead, “Okay— so can you remind me what our homework assignment was for this week?” The following</p><p>transcript demonstrates the key principles.</p><p>Instructor: Okay, Jane. So how did your homework go?</p><p>Client: I don’t want to talk about it</p><p>Instructor: Okay. So can you remind me— what was the homework?</p><p>Client: I said I don’t want to talk about it.</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>44</p><p>Instructor: (Displays a closed- mouth smile and performs an eyebrow wag) Yeah, I get it. But can you just</p><p>remind me again what it was? Just take a look down at your skills notebook, and read off the title</p><p>on the page in front of you.</p><p>Client: (Pauses, looks down at notebook) It says “Flexible Mind ALLOWs, Match + 1 skills.”</p><p>Instructor: Thanks. So, Jane, did you do your homework?</p><p>Client: Yes, but I don’t want to talk about it.</p><p>Therapist: Sure. (Nods; displays a closed- mouth smile.) So who did you practice Match + 1 with? (Performs</p><p>an eyebrow wag.)</p><p>Client: It was someone I know at work.</p><p>Therapist: Is this the same someone you’ve talked about before? Or was it someone new?</p><p>Client: It was the same person.</p><p>Therapist: (Smiles and performs an eyebrow wag) How cool! So, if I remember correctly, this is a person you</p><p>have already decided to try to get closer to. Is that correct?</p><p>Client: Yes.</p><p>Therapist: That’s what I thought. So…well done on practicing. (Smiles.) Okay, now, everybody take out</p><p>your handout labeled “Match + 1 Intimacy Rating Scale.” (Briefly takes the heat off the client by</p><p>asking the entire class to look together at an RO handout.) Okay, Jane, when you look at this scale,</p><p>what level do you think you got to when you practiced your Match + 1 skills?</p><p>From that point, the</p><p>client shared more about what had happened during her homework practice, and it</p><p>was discovered that her desire not to talk about her homework stemmed from her belief that she had not done</p><p>a very good job. The instructor was able to use this information as a means of teaching more about the process</p><p>of forming new relationships. Finally, the instructor purposefully chose to keep Jane’s homework review shorter</p><p>than what might have been typical, in order to reinforce her for successful homework completion and for</p><p>making a direct request to pass instead of simply going quiet, pouting, or displaying a “don’t hurt me” response.</p><p>By ignoring the client’s initial request to pass on the homework review, and by asking questions that were</p><p>pertinent yet easy to answer, the instructor (1) sent a message to the client and the rest of the class, without</p><p>being too heavy-handed, that passing on homework review is not acceptable in RO DBT; (2) gave the reluctant</p><p>client an opportunity to receive positive feedback for having completed her homework, and an opportunity to</p><p>practice being flexible by reporting on her homework even though she didn’t want to; and (3) reinforced the</p><p>client’s willingness by giving her leeway and allowing her not to report on every step of her homework.</p><p>Very occasionally, OC clients may remain adamant about their requests not to talk about their homework,</p><p>regardless of how proficient the instructor is in cajoling them to give it a go. After the instructor has attempted</p><p>three times to get an OC client to join in and talk about the homework, and if the client’s nonverbal and verbal</p><p>signaling appear to show that the client is becoming increasingly distressed, tense, resistant, or adamant, the</p><p>instructor should smile warmly and take the heat off, saying, “Okay, then— well done for being direct with me.</p><p>I can see that, for whatever reason, you really don’t want to talk about your homework today. So, first, I am</p><p>really happy you did your homework— and, at least for today, let’s move on to someone else, and you and I can</p><p>chat at break. However, if you change your mind, you just let me know.” The instructor should then smile and</p><p>wink at the client, look around the room, and say, “Okay, who wants to go next?” During class break, the</p><p>instructor should check in with the client, assess for the possibility of an alliance rupture (repairing it, if neces-</p><p>sary; see the following section), and then implement the protocol for therapeutic induction of social responsi-</p><p>bility in order to prevent future attempts to pass when it comes to reviewing homework in class.</p><p>Managing Problematic Behaviors in RO Skills Training Classes</p><p>45</p><p>Managing Alliance Ruptures and Repairs</p><p>Instructors should also consider the possibility that lateness and noncompletion of homework signal the pres-</p><p>ence of an alliance rupture. Instructors should not attempt to repair an alliance rupture in class; instead, they</p><p>should assess and repair alliance ruptures in private (that is, at class break or at the end of class) and, if an</p><p>alliance rupture is present, attempt to repair the rupture before the client returns to class (see “Alliance</p><p>Ruptures and Repairs,” in chapter 8 of the RO DBT textbook). This might seem like a daunting task, consider-</p><p>ing that classroom breaks are normally scheduled for fifteen minutes. In practice, however, most alliance rup-</p><p>tures can be repaired in a few minutes; and, as outlined in the alliance rupture protocol, a repair attempt</p><p>should always be time- limited anyway (ideally, no longer than ten minutes), to avoid inadvertently punishing</p><p>the client’s efforts at self- disclosure by prolonging the repair attempt (keeping the heat on). Instructors can</p><p>reengage a repair attempt the following week, if necessary, and the client should also be encouraged to discuss</p><p>the issue with his or her individual RO DBT therapist.</p><p>Managing Suicidal Behavior</p><p>OC individuals appear composed and self- controlled on the outside, but suicidal and self- injurious behaviors</p><p>occur at disproportionately high rates among overcontrolled clients. Chapter 5 and appendix 4 of the RO DBT</p><p>textbook provide detailed assessment and intervention guidelines for suicidal behavior and nonsuicidal self-</p><p>injury, including specific assessment questions and a crisis- management protocol for managing OC clients’</p><p>imminent life- threatening behavior. OC life- threatening behaviors are often qualitatively different from those</p><p>displayed by other clinical groups. A summary of these features is outlined here:</p><p>• OC clients’ suicidal behavior and self- harm are usually planned— often hours, days, or even weeks in</p><p>advance (and sometimes longer).</p><p>• OC self- harming behavior is usually a well- kept secret. It may have been occurring for years without</p><p>anyone knowing, or knowledge about it may be limited to immediate family members (or very close</p><p>friends, plus therapists). Thus, OC self- harm is rarely attention- seeking. The severity of self- inflicted</p><p>injuries is carefully controlled in order to avoid medical attention, and scars are carefully hidden. An</p><p>OC client may acquire medical training or training in first aid in order to treat self- inflicted wounds</p><p>and avoid having to go to a hospital. Exceptions to hiding behavior can occur, most often among OC</p><p>clients with a long history of psychiatric hospitalization, with dramatic displays of self- injury often</p><p>intermittently reinforced (as when self- injury gets an OC client placed in a private observation room,</p><p>which is preferable to the uncertainty of being placed in the general inpatient community).</p><p>• OC clients may attempt suicide to punish family members or close others (“When I’m gone, you’ll be</p><p>sorry”) or to get even, expose moral failings, or make a rival’s life difficult (as when the OC client</p><p>hopes that his or her death will make it impossible for the rival to achieve an important goal).</p><p>• OC self- harm and suicidal behavior are more likely to be rule- governed than mood- governed (for</p><p>example, OC clients may try to restore their faith in a just world by punishing themselves for their</p><p>perceived wrongs).</p><p>• Some OC clients may romanticize suicidal behavior and may consider brooding or melancholy to be</p><p>noble and/or creative.</p><p>The good news is that, in general, it is very rare for an RO skills instructor to have to manage imminent</p><p>life- threatening behavior in class (or outside of class, for that matter) when working with OC clients. The</p><p>primary exception is the RO skills instructor who is also the individual therapist for a suicidal client (this situ-</p><p>ation makes it more likely that the client will reveal a life- threatening problem to the therapist during class or</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>46</p><p>at the break). The general rule for when a client reveals life- threatening ideation, plans, or actions in class is</p><p>to thank the client for letting this information be known and then request to meet with the client during the</p><p>break (or at the end of class), as necessary, to address the issue. This reassures the class that the instructor is</p><p>taking the problem seriously, and the instructor can feel free to move on with teaching. Importantly, assess-</p><p>ment or problem solving around suicidal behavior should not be conducted in class. During the break or after</p><p>class, one of the instructors can conduct, in private, a brief assessment for imminent suicide risk. In addition,</p><p>the RO DBT crisis- management protocol should be activated if the client is unwilling to provide a commit-</p><p>ment to the instructor not to commit suicide before the next meeting with the individual therapist, or if it is</p><p>determined that the risk is sufficient to warrant immediate intervention (see “Assessing OC Life- Threatening</p><p>Behaviors” and “The RO DBT Crisis- Management Protocol,” in chapter 5 of the RO DBT textbook). When</p><p>risk is high and imminent, the following core elements of the RO DBT crisis- management protocol should be</p><p>recalled.</p><p>• Focus</p><p>on removing available lethal means and increasing short- term availability of social support.</p><p>• Remind the client of his or her prior commitments. If the client has previously made a commitment</p><p>not to self- harm or commit suicide, then remind the client of that prior commitment and of his or her</p><p>core values linked to doing the right thing, honoring prior commitments, and integrity.</p><p>• Arrange for emergency backup. Make sure the client has emergency contact numbers.</p><p>• Contract with the client not to engage in suicidal acts. If the client remains at high risk, ask the client</p><p>to call someone for a ride home. If the client appears unwilling to make the call, offer to make the call</p><p>for the client.</p><p>• For all class members, as a general rule, obtain contact information (such as phone numbers and email</p><p>addresses) of people who are in their support networks, and keep this information in a place where it</p><p>will be easily accessible to skills instructors.</p><p>• Accompany the client to the emergency room, or call emergency services or the police if suicidality</p><p>cannot be reduced, risk is high, no other support can be found, and the client refuses help.</p><p>As mentioned earlier, it is extremely rare for an RO skills instructor working with OC clients to have to</p><p>manage imminent life- threatening behavior in class. Nevertheless, instructors should be prepared to have one</p><p>instructor remain with a suicidal client, either to complete a risk assessment or to problem solve, while the</p><p>other instructor continues teaching the class. Instructors are advised to become familiar with the guidelines</p><p>for managing imminent life- threatening behaviors with OC clients, as detailed in chapter 5 of the RO DBT</p><p>textbook.</p><p>Summary</p><p>In skills training environments with OC clients, overt problematic behaviors are far less common than with</p><p>other clinical populations, partly because of the nature of the OC personality itself. If problems do emerge,</p><p>instructors are advised to recall their role as tribal ambassadors, not enforcers, when it comes to working with</p><p>hyperperfectionistic OC clients. Heat- on and heat- off principles are essential means of shaping up classes to be</p><p>fun, participatory, and educational. Most OC classes quickly develop a class norm that is supportive and par-</p><p>ticipatory. Thus, if problems persist or become contagious, it is important for instructors to step back and</p><p>conduct self- assessment and self- enquiry about how they may be contributing to the problem, and to use a</p><p>consultation team or supervisor as an outside source of feedback.</p><p>CHAPTER 4</p><p>Using the RO Skills Training Manual</p><p>This manual contains twenty new skills compressed into thirty lessons (or weeks), with RO mindfulness skills</p><p>repeated once. Each skills training session is designed to occur within a two- and- a- half- hour time frame,</p><p>including homework review, a brief break, and new teaching. Prior to the start of each lesson, instructors</p><p>should familiarize themselves with the overall aims of the lesson and should use the manual to plan the class</p><p>exercises and/or mindfulness practices and to prioritize the required teaching points (see “Structuring RO</p><p>Skills Training Classes,” in chapter 1). It is important for instructors to teach directly from the manual (as a</p><p>teacher of algebra or history might do). This smuggles to OC clients that it is okay to not know everything</p><p>while ensuring that required teaching points and exercises are not missed or forgotten (see “Teach Directly</p><p>from the Manual,” in chapter 1). Each lesson begins with the main points for that lesson, and instructors</p><p>should prioritize covering the required teaching points and exercises. Recommended and optional exercises</p><p>and teaching points can be incorporated into the lesson plan if time permits and/or can be saved for use in the</p><p>final lesson of the RO module (lesson 30, RO Integration Week).</p><p>Deciphering an RO Lesson Plan</p><p>The manual is organized according to lessons, and the headings that follow are like the legend on a map.</p><p>Instructors should be completely familiar with them in order to maximize use of the material in this manual.</p><p>A lesson may start with a quote, and a quote can also form the basis of a class discussion. It is up to the</p><p>discretion of the instructor whether or not to read the quote aloud.</p><p>Main Points for Lessons</p><p>At the start of each RO lesson, the main teaching points considered essential to be covered during the</p><p>lesson are numerically listed. Main points should be used by instructors to organize lesson plans and are par-</p><p>ticularly helpful when time constraints make coverage of all the suggested material difficult to fully review</p><p>with the class. Instructors should check prior to ending the class that all the main points have been covered.</p><p>Main points do not need to be read aloud to the class; they are listed for the benefit of the instructor only.</p><p>Materials Needed</p><p>The key materials and specific worksheets and handouts that will be needed for the lesson are listed after</p><p>the main points. At the start of each RO module, instructors should provide, ideally in a binder, a paper copy</p><p>of each handout and worksheet for the entire module.</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>48</p><p>Required, Recommended, and Optional Mindfulness Practices,</p><p>Teaching Points, Discussion Points, and Class Exercises</p><p>Skills classes consist of a number of topics, exercises, and/or discussion points for a specific lesson. Each of</p><p>these exercises and discussion points is accompanied by an indication of whether it is required, recommended,</p><p>or optional. Some lessons also include “fun facts,” indicated with a star icon (). The required sections are</p><p>essential to teaching the skills and have to be completed for the lesson. The recommended sections can be</p><p>covered in class, if time allows, and the optional sections can also be covered if time allows and the instructor</p><p>thinks they are relevant to the learning that the class needs. The fun facts are meant to be read aloud and are,</p><p>in general, optional material unless marked otherwise.</p><p>Required, recommended, and optional mindfulness practices can be found throughout the RO skills module.</p><p>When marked as optional, these practices can be incorporated into the lesson plan in any manner that the</p><p>instructor finds useful, including at the start of the lesson. Text in italics should be read aloud to the class.</p><p>Required, recommended, and optional teaching points are bulleted. The text in large print and bold italics</p><p>should be considered the essential material and are designed to be read aloud verbatim by instructors, in order</p><p>to maximize clarity and precision. Each specific bold italic teaching point typically has a number of smaller,</p><p>nonbold teaching points attached to it. Nonbold teaching points provide important supplemental information</p><p>and/or key discussion questions that can be used at the instructor’s discretion.</p><p>Required, recommended, and optional discussion points are also distributed throughout the RO skills</p><p>module. They provide instructors with a range of topics, examples, stories, metaphors, and key questions</p><p>designed to spur class discussion. Discussion points are meant to augment teaching points, not replace them.</p><p>Therefore, instructors should feel free not to ask all of the suggested questions under a discussion point when</p><p>time is limited, regardless of whether the discussion point is required, recommended, or optional.</p><p>Required, recommended, and optional class exercises are scattered throughout the RO module as well.</p><p>Instructors should strive to cover all the required exercises.</p><p>Notes to Instructors</p><p>Also scattered throughout the RO skills module are notes to instructors. The material in these notes is</p><p>supplemental but nevertheless important. Most often, notes to instructors provide additional background</p><p>about a specific point and/or additional scientific research that can be used to strengthen teaching.</p><p>Homework Assignments</p><p>Homework is assigned at the end</p><p>of each class and includes both required and optional assignments. The</p><p>homework assigned at the end of class should be reviewed during the first hour of the following class. Most</p><p>homework assignments include worksheets, and instructors should encourage class participants to use them</p><p>when completing homework assignments.</p><p>Additional Instructions for Using the Skills Manual</p><p>• Planning lessons. When planning the material that will be covered during each of the thirty lessons,</p><p>instructors should schedule a “participate without planning” mindfulness practice for the beginning</p><p>or middle of approximately fifteen lessons (or more, if possible). The emphasis on practices involving</p><p>disinhibited expression, tribal participation, and publicly revealing inner experience cannot be over-</p><p>stated when working with OC clients. “Participate without planning” practices are a core means of</p><p>Using the RO Skills Training Manual</p><p>49</p><p>helping risk-averse OC clients discover the rewards of tribal participation and break down overlearned</p><p>inhibitory barriers.</p><p>• Open groups. Instructors running an open group should avoid having clients start during RO Integration</p><p>Week (lesson 30) and allow them to start the following week instead (lesson 1).</p><p>• Self- enquiry journal. It is recommended that each client start a self- enquiry journal. An empty note-</p><p>book can be used for this purpose. Clients should be made aware of the need for a self- enquiry journal</p><p>before attending the first skills class.</p><p>• Teaching from the manual. Instructors are encouraged to “follow the recipe” when teaching RO skills.</p><p>• Reading aloud and verbatim. Instructors should get into the habit of reading aloud, and verbatim, the</p><p>scripts provided throughout the RO manual because (1) doing so smuggles to hyper- performance-</p><p>focused OC clients that appearing like a novice (that is, having to read aloud from a script) is okay,</p><p>(2) reading aloud from a script ensures that all the key constructs are covered, and (3) the words used</p><p>in most of the scripts throughout the manual have been purposefully chosen to maximize OC clients’</p><p>receptivity (recall that the primary goal of RO skills training is to learn new skills).</p><p>• Typographical indications. Generally speaking, text printed in bold indicates an instruction to the</p><p>instructor. Text printed in italics indicates that it should be read aloud to the class. Text printed in</p><p>bold italics indicates that it should be read aloud and is the most important teaching point.</p><p>• Keeping it light. Throughout the manual, “tee hee,” often combined with a smiley face (☺), signals that</p><p>the point being made represents a therapeutic tease and should ideally be delivered with a playfully</p><p>irreverent manner.</p><p>CHAPTER 5</p><p>The RO DBT Lesson Plans</p><p>LESSON 1</p><p>Radical Openness</p><p>Main Points for Lesson 1</p><p>1. We tend to pay attention to things that fit our beliefs and ignore or dismiss those things that do not.</p><p>2. We don’t know what we don’t know, and this keeps us from learning new things.</p><p>3. To learn anything new, we must acknowledge our lack of knowledge and then behave differently!</p><p>4. RO DBT considers psychological health to involve three core features: (1) receptivity and openness,</p><p>(2) flexible control, and (3) intimacy and connectedness.</p><p>5. There are pros and cons to being open, as well as to being closed.</p><p>6. We only need to practice radical openness when we are closed.</p><p>7. Radical openness involves actively seeking the things we want to avoid in order to learn. It requires</p><p>courage and humility— it is painful and liberating. It is key for participating in the community. Radical</p><p>openness does not mean approval, naively believing, or mindlessly acquiescing.</p><p>8. To practice Use Flexible Mind DEFinitely and the three steps needed for radically open living: (1)</p><p>acknowledge the presence of an unwanted private experience, (2) practice self- enquiry by turning</p><p>toward the discomfort in order to learn, and (3) flexibly respond by doing what’s needed in the</p><p>moment.</p><p>Materials Needed</p><p>• Handout 1.1 (Inkblot)</p><p>• Handout 1.2 (What Is Radical Openness?)</p><p>• Handout 1.3 (Learning from Self- Enquiry)</p><p>• (Optional) Handout 1.4 (Main Points for Lesson 1: Radical Openness)</p><p>• Worksheet 1.A (Myths of a Closed Mind)</p><p>• Worksheet 1.B (Flexible Mind DEFinitely: Three Steps for Radically Open Living)</p><p>• Worksheet 1.C (The Pros and Cons of Being Open Versus Closed to New Experience)</p><p>• Self- enquiry journal (Note: Clients will need to bring their own journal or notebook for this.)</p><p>• Whiteboard or flipchart with marker</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>52</p><p>Note to iNstructors: Each RO class normally begins with a brief mindfulness exercise or practice</p><p>prior to reviewing homework. Assuming that the RO class is an open group (that is, individuals enter the</p><p>skills class at differing times), the recommended mindfulness exercise that follows would occur at the</p><p>beginning of the class, just before reviewing the homework assigned from the previous lesson’s class.</p><p>Instructors should aim to keep practices and discussions afterward brief; in general, a mindfulness practice</p><p>and sharing of observations afterward should last approximately six to eight minutes.</p><p>(Recommended) Mindfulness Practice</p><p>Mindfulness of Ambiguity</p><p>Refer participants to handout 1.1 (Inkblot).</p><p>Use the script and questions that follow to guide the practice.</p><p>To begin our practice, place the inkblot I just gave you in front of you, in a way that will allow you to gaze</p><p>at it without having to move. Now, with awareness, take a slow deep breath and center your attention on</p><p>your inkblot. Notice any patterns or images that arise from it— and when your mind wanders, as minds</p><p>are prone to do, gently guide your attention back to the visual features or patterns you observe within your</p><p>inkblot. [Pause approximately ten seconds.] Okay, now bring your attention back to the room and let’s</p><p>discuss what you observed.</p><p>> Ask for observations. What did you observe when you examined your inkblot? Did you notice any</p><p>familiar shapes or images— for example, did anyone see a bunny rabbit?</p><p>• Highlight the range and diversity of different shapes observed by different people. Instructors should</p><p>point out that there is no perfect way to see an inkblot, and this observation applies to much of life—</p><p>that is, there is no perfect way to behave and rarely is there a perfect answer. For example, it is likely</p><p>that everyone in the class drives slightly differently, yet everyone made it today on time to class.</p><p>Radical openness begins by acknowledging our differences as opportunities for learning new things</p><p>rather than seeing them as automatically wrong or potentially threatening.</p><p>• Encourage self- enquiry. (Note: Instructors should feel compelled to ask only the required question</p><p>that follows; optional questions should be asked only if time permits.)</p><p>> (Required) Ask: To what extent do you believe that there is only one way to observe an inkblot?</p><p>What might this tell you about how you see yourself and the world? What is it you might need to</p><p>learn from this?</p><p>> (Optional) Ask: To what extent did you notice yourself socially comparing your observations of</p><p>the inkblot to the observations made by others? Were your comparisons judgmental? Of others? Of</p><p>yourself? Of something else? What might this tell you about how you see the world? What might you</p><p>need to learn?</p><p>> (Optional) Ask: Do you ever find it difficult to see both sides of an issue?</p><p>Additional discussion points might include playful challenges for the class to come up with as many ways as</p><p>possible to solve a simple problem or complete a simple task like how to eat an apple or how to do the laundry.</p><p>Lesson 1: Radical Openness</p><p>53</p><p>(Required) Class Exercise</p><p>Our Perceptual Biases: How We Become Closed</p><p>to New Information</p><p>The primary aim of this exercise is to help participants identify the potentially maladaptive ways they</p><p>deal with disconfirming feedback while also understanding</p><p>321</p><p>(Required) Mini– Class Exercise: Phony Polite Versus Impolite: What’s the Social Signal? 322</p><p>(Required) Teaching Point: Hiding Intentions and Disguising Demands 323</p><p>(Recommended) Mini– Class Exercise: Curiosity Versus Sarcasm 324</p><p>(Required) Mini– Class Exercise: “What’s the Real Meaning Behind This?” 324</p><p>Lesson 15 Homework 326</p><p>Contents</p><p>xiii</p><p>Lesson 16 Interpersonal Integrity, Part 2 329</p><p>Flexible Mind REVEALs</p><p>Main Points for Lesson 16 329</p><p>Materials Needed 329</p><p>(Required) Role Play: “Pushbacks” and “Don’t Hurt Me” Responses 329</p><p>(Required) Teaching Point: “Don’t Hurt Me” Responses 331</p><p>(Required) Teaching Point: “Pushback” Responses 333</p><p>(Required) Teaching Point: Letting Go of Habitual “Pushback” and “Don’t Hurt Me”</p><p>Responses: Flexible Mind REVEALs 334</p><p>Lesson 16 Homework 340</p><p>Lesson 17 Interpersonal Effectiveness 352</p><p>Kindness First and Foremost</p><p>Main Points for Lesson 17 352</p><p>Materials Needed 352</p><p>(Recommended) Class Exercise: OC Myths About Interpersonal Relationships 353</p><p>(Required) Teaching Point: Enhancing Interpersonal Kindness, Effectiveness, and Connectedness 354</p><p>(Required) Class Exercise: Making Flexible Mind ROCKs ON Come Alive 354</p><p>(Required) Teaching Point: Flexible Mind ROCKs ON 355</p><p>(Required) Discussion Points: Kindness First and Foremost 359</p><p>(Required) Teaching Point: Using Valued Goals to Guide Behavior 360</p><p>Lesson 17 Homework 363</p><p>Lesson 18 Being Assertive with an Open Mind 378</p><p>Main Points for Lesson 18 378</p><p>Materials Needed 378</p><p>(Required) Teaching Points: Flexible Mind PROVEs 379</p><p>(Optional) Discussion Point: The Pros and Cons of Punishment 381</p><p>(Recommended) Class Exercise: Having Fun with Asking— and Saying No! 384</p><p>(Required) Teaching Point: After the Interaction 384</p><p>Lesson 18 Homework 385</p><p>Lesson 19 Using Validation to Signal Social Inclusion 392</p><p>Main Points for Lesson 19 392</p><p>Materials Needed 392</p><p>(Required) Teaching Point: “We Are Tribe!” 395</p><p>(Optional) Discussion Points: Enhancing Intimacy 396</p><p>(Required) Teaching Point: Using Validation to Signal Social Inclusion 396</p><p>(Optional) Class Exercise: The Nonverbal Validation Game 397</p><p>(Required) Teaching Point: Reflecting Back 398</p><p>(Required) Class Exercise: Practicing Reflection 400</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>xiv</p><p>(Required) Teaching Point: Empathic Mind Reading 400</p><p>(Optional) Class Exercise: Validating Based on History 402</p><p>(Optional) Class Exercise: Differentiating Validating Based on History from Validating</p><p>Based on Normalizing 403</p><p>(Optional) Class Exercise: Signaling Trust 405</p><p>(Required) Class Exercise: Reciprocity Matters! 406</p><p>(Optional) Class Exercise: Validation on Demand 407</p><p>(Required) Teaching Point: What About Invalidation? 407</p><p>(Recommended) Minipractice: Learning How to Learn from Invalidation 410</p><p>Lesson 19 Homework 412</p><p>Lesson 20 Enhancing Social Connectedness, Part 1 418</p><p>Main Points for Lesson 20 418</p><p>Materials Needed 418</p><p>(Optional) Teaching Point: Dependency 418</p><p>(Required) Teaching Point: Friendships Can Be Hard Work 419</p><p>(Required) Class Exercise: Thinking About Distrust 419</p><p>(Required) Teaching Point: Differences in Desired Intimacy 419</p><p>(Required) Class Exercise: The Intimacy Thermometer 420</p><p>(Required) Discussion Point: What Characterizes a Genuine Friendship? 421</p><p>(Required) Teaching Points: Trusting Others 421</p><p>Lesson 20 Homework 407</p><p>Lesson 21 Enhancing Social Connectedness, Part 2 429</p><p>Main Points for Lesson 21 429</p><p>Materials Needed 429</p><p>(Required) Teaching Point: Flexible Mind ALLOWs 429</p><p>(Required) Class Exercise: “We Can Never Fully Know” 432</p><p>(Optional) Discussion Points: Hiding Versus Revealing 433</p><p>(Required) Match + 1 Class Demonstration: Self- Disclosure Matters 435</p><p>(Required) Teaching Point: Enhancing Intimacy with Match + 1 436</p><p>(Required) Class Exercise : Let’s Practice Match + 1 437</p><p>Lesson 21 Homework 439</p><p>Lesson 22 Learning from Corrective Feedback 449</p><p>Main Points for Lesson 22 449</p><p>Materials Needed 449</p><p>(Required) Class Exercise: Recalling a Time We Felt Criticized 449</p><p>(Required) Teaching Point: Being Open to Feedback from Others: Flexible Mind ADOPTS 450</p><p>(Optional) Discussion Point: Trying out Feedback 451</p><p>(Required) Class Exercise: The Many Ways People Respond to Criticism 452</p><p>(Recommended) Class Exercise: Listening to Criticism 455</p><p>Contents</p><p>xv</p><p>(Optional) Class Exercise: Demonstrating Pinpointing 456</p><p>(Required) Teaching Point: Before Trying Out a Suggested Change, Evaluate It 456</p><p>(Required) Teaching Point: Return to Teaching the Last Two Steps of Flexible Mind ADOPTS,</p><p>Using Handout 22.1 461</p><p>Lesson 22 Homework 462</p><p>Lesson 23 Mindfulness Training, Part 1 470</p><p>Overcontrolled States of Mind (Repeated from Lesson 11)</p><p>Main Points for Lesson 23 470</p><p>Materials Needed 471</p><p>Lesson 24 Mindfulness Training, Part 2 472</p><p>The “What” Skills (Repeated from Lesson 12)</p><p>Main Points for Lesson 24 472</p><p>Materials Needed 472</p><p>Lesson 25 Mindfulness Training, Part 3 473</p><p>The Core Mindfulness “How” Skill: With Self- Enquiry (Repeated from Lesson 13)</p><p>Main Points for Lesson 25 473</p><p>Materials Needed 473</p><p>Lesson 26 Mindfulness Training, Part 4 474</p><p>The “How” Skills (Repeated from Lesson 14)</p><p>Main Points for Lesson 26 474</p><p>Materials Needed 474</p><p>Lesson 27 Envy and Resentment 475</p><p>Main Points for Lesson 27 475</p><p>Materials Needed 475</p><p>(Required) Teaching Point: Envy 475</p><p>(Required) Discussion Point: Helpful or Unhelpful Envy? 477</p><p>(Required) Teaching Point: Distinguishing Helpful from Unhelpful Envy 477</p><p>(Required) Teaching Point: Flexible Mind DARES (to Let Go) 478</p><p>Lesson 27 Homework 482</p><p>Lesson 28 Cynicism, Bitterness, and Resignation 488</p><p>Main Points for Lesson 28 488</p><p>Materials Needed 488</p><p>(Recommended) Mindfulness Practice: “Who Makes These Changes?” 488</p><p>(Recommended) Mini– Class Exercise: Fun with Cynicism 489</p><p>(Required) Teaching Point: Learning from Cynicism 490</p><p>(Required) Teaching Point: Bitterness 491</p><p>(Required) Teaching Point: Flexible Mind Is LIGHT 491</p><p>Lesson 28 Homework 496</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>xvi</p><p>Lesson 29 Learning to Forgive 502</p><p>Main Points for Lesson 29 502</p><p>Materials Needed 502</p><p>(Required) Discussion Point: Understanding Forgiveness 503</p><p>(Recommended) Mindfulness Practice: Recalling a Time We Needed Forgiveness 503</p><p>(Required) Teaching Point: What Is Forgiveness? 504</p><p>(Required) Class Mindfulness Exercise: Finding a Past Injury 505</p><p>(Required) Teaching Point: Flexible Mind Has HEART 506</p><p>(Required) Class Exercise: Practicing Forgiveness 512</p><p>(Required) Teaching Points: Forgive Again and Again 513</p><p>Lesson 29 Homework 516</p><p>Lesson 30 RO Integration Week 529</p><p>Main Points for Lesson 30 529</p><p>Materials Needed 529</p><p>Integration Week Practice Examples Designed to Loosen Inhibitory Control 533</p><p>Integration Week Practices and Teaching Designed to Enhance Relationship IQ 535</p><p>Lesson 30 Homework 539</p><p>References 541</p><p>Index 549</p><p>List of Radical Openness Handouts</p><p>and Worksheets</p><p>Radical Openness Handout 1.1 Inkblot 61</p><p>Radical Openness Handout 1.2 What Is Radical Openness? 62</p><p>Radical Openness Handout 1.3 Learning from Self- Enquiry 63</p><p>Radical Openness Handout 1.4 Main Points for Lesson 1: Radical Openness 65</p><p>Radical Openness Worksheet 1.A Myths of a Closed Mind 66</p><p>Radical Openness Worksheet 1.B Flexible Mind DEFinitely: Three Steps for Radically</p><p>Open Living 68</p><p>Radical Openness Worksheet 1.C The Pros and Cons of Being Open Versus Closed to</p><p>New Experience 72</p><p>Radical Openness Handout 2.1 The RO DBT Neuroregulatory Model of Emotions 83</p><p>Radical Openness Handout 2.2 Main Points for Lesson 2: Understanding Emotions 85</p><p>Radical Openness Worksheet 2.A Identifying the Different Neural Substrates 86</p><p>Radical Openness Handout 3.1 Changing Social Interactions by Changing Physiology 98</p><p>Radical Openness Handout 3.2 Closed- Mouth Cooperative Smile 100</p><p>Radical Openness Handout 3.3 Main Points for Lesson 3: Activating Social Safety 101</p><p>Radical Openness Worksheet 3.A Activating Social Safety 102</p><p>Radical Openness Handout 4.1 A Script for Loving Kindness Meditation</p><p>that all humans struggle with being open</p><p>to feedback, to some degree.</p><p>Instructors should aim to spend approximately five to seven minutes on this exercise. Optional</p><p>questions listed here should be asked only if time permits.</p><p>Begin by asking the two required questions that follow.</p><p>> (Required) Ask: How do you respond when confronted with a different point of view about</p><p>something important?</p><p>> (Required) Ask: What is your favorite strategy to avoid hearing a different perspective?</p><p>> (Optional) Ask: Do you think other people know when you use it? What might this tell you</p><p>about yourself?</p><p>> (Optional) Ask: If you already believe you know everything about something, will you be more</p><p>or less open to feedback suggesting you are wrong?</p><p>> (Optional) Ask: If you believe the world is flat, are you more or less likely to seek out informa-</p><p>tion suggesting that the world is round?</p><p>Next: Write on a whiteboard or flipchart a list of differing strategies generated by the class.</p><p>Examples: Rehearse a rebuttal, search for disconfirming evidence, ruminate about it, shut down,</p><p>pretend not to listen, go on the attack, change the topic, behave as if one is bored, make a joke out of</p><p>it, earnestly listen, begin to automatically doubt oneself, pretend to agree when you don’t, take some</p><p>time to think about it, change the topic.</p><p>Lastly: Place an asterisk (*) next to the strategies that the class agrees are most likely to be unhelpful</p><p>or may lead to negative consequences.</p><p>(Required) Teaching Points</p><p>Perceptual Biases</p><p>• We all create our own belief systems, like it or not. Often our belief systems are so much a</p><p>part of us that we do not recognize them as beliefs; it’s like asking a fish to recognize the water!</p><p>• We tend to pay attention to things that fit our beliefs and ignore or dismiss things that</p><p>don’t.</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>54</p><p>• Social psychologists call this a “confirmation bias.” For example, if you are conservative</p><p>politically, you are likely to read or watch only conservative political newspapers or TV, and you will</p><p>read something entirely different if the opposite is true.</p><p>> Ask: What type of confirmation biases do you think are most common among overcontrolled indi-</p><p>viduals? For example, “The only way to get ahead is to make self- sacrifices,” “Planning ahead</p><p>is imperative,” “Being correct is more important than being liked by others.”</p><p>• We don’t know what we don’t know, and this keeps us from learning new things.</p><p>Sometimes we think we know something but find out later that what we actually knew was only part</p><p>of what we needed to understand.</p><p>• For example, someone living in the United States might assume that they would know how to buy</p><p>a car in France, only to discover that the laws surrounding the purchase of a vehicle in France</p><p>require a wide range of documentation never needed in the USA (such as proof of residence,</p><p>passport, utility bill, and so on).</p><p>• Plus, sometimes we don’t even know that we lack a skill and we need someone else to point this</p><p>out to us (for example, a two- year- old doesn’t know that they don’t know how to use a microwave</p><p>oven when they want their oatmeal heated).</p><p>• Not knowing what we don’t know becomes a problem when it blocks achieving important goals.</p><p>• Whenever we believe we already know the answer or feel threatened by a differing</p><p>point of view, we have already made a decision about the incoming information— that</p><p>is, it is potentially dangerous (because I feel threatened) or it is irrelevant (because I believe I already</p><p>know the answer). As a consequence, we are less receptive to potentially valuable information.</p><p>• To learn anything new, we must first acknowledge our lack of knowledge.</p><p>• To learn anything new, we must also behave or think differently! This can be painful,</p><p>anxiety- producing, and humbling.</p><p>(Required) Teaching Points</p><p>What Is Psychological Health?</p><p>• Living well is not just about self- improvement— it also requires seeking what is</p><p>healthy.</p><p>> Ask: To what extent do you believe genuine psychological health or well- being is possible? What</p><p>might your answer tell you about how you perceive the world or yourself? What is it you might need</p><p>to learn?</p><p>• To seek psychological health, it helps to first know what it means.</p><p>> Ask: What type of behaviors do psychologically healthy people display?</p><p>> Ask: What features do psychologically healthy people share?</p><p>• RO considers psychological health to involve three core features:</p><p>1. Receptivity and openness to new experience and disconfirming feedback, in order to learn.</p><p>2. Flexible control in order to adapt to changing environmental conditions.</p><p>Lesson 1: Radical Openness</p><p>55</p><p>3. Intimacy and connectedness with at least one other person. Our species survival</p><p>depended on our ability to form long- lasting bonds and work together in tribes or groups.</p><p>• Thus, more or less…according to this definition, a well- adjusted person is able to not</p><p>only be open to disconfirming feedback but also to modify their behavior to be</p><p>more effective in a manner that accounts for the needs of others.</p><p>> Ask: Can you think of examples of how these three points might manifest in a person’s life? What is</p><p>it that you might need to learn to be able to manifest these traits in your life?</p><p>(Required) Teaching Points</p><p>To Be Open or Closed? That Is the Question!</p><p>• Sometimes being closed- minded is exactly what is needed in a given moment, and/or</p><p>a recommended change may not be necessary. For example, being closed- minded about</p><p>eating cottage cheese when one dislikes its taste is fine— assuming there is something else to eat.</p><p>Closed- mindedness is highly useful when being attacked by a mugger or tortured when captured in</p><p>war. Being closed- minded might help protect certain family traditions— for example, doggedly cele-</p><p>brating Christmas despite no longer believing in it.</p><p>• The advantages of closed- mindedness almost always pertain to avoidance or</p><p>dominance.</p><p>• Being closed- minded may help a person avoid a feeling— for example, of being out of control,</p><p>awkward, embarrassed, stressed, or uncertain.</p><p>• Being closed- minded may also help a person win a fight or an argument, defeat a rival, prove one’s</p><p>superiority, or achieve a goal.</p><p>• Being closed- minded often seems like a good idea at the time— that is, when we are in the midst</p><p>of doing it.</p><p>• Closed- mindedness has short- term gains but most often results in long- term negative</p><p>consequences. For example, refusing to listen to feedback that smoking can cause cancer may allow</p><p>you to continue smoking but eventually result in cancer, a stroke, and many hospital bills. Refusing to</p><p>listen to feedback that you are arrogant may maintain your self- esteem but lead to a lonely and isolated</p><p>existence.</p><p>• Yet open- mindedness is not all fun and games! It can be painful because it often requires</p><p>sacrificing firmly held convictions or self- constructs in order to learn or live by one’s values.</p><p>• However, openness is the only way to learn something new. Whether it is learning to play</p><p>the violin, to ride a horse, or to maintain a marriage, learning anything or improving how we behave</p><p>always requires openness.</p><p>• Openness also enhances relationships because it models humility and willingness to</p><p>learn from what the world has to offer. Openness signals to another person that you are</p><p>willing to hear their opinion without automatically discounting it. Importantly, openness does not</p><p>mean approval, naively believing, mindlessly giving in, or resignation.</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>56</p><p>(Recommended) Class Exercise</p><p>Myths of a Closed Mind</p><p>Refer participants to worksheet 1.A (Myths of a Closed Mind).</p><p>Instruct the class to place a checkmark in the box next to each myth in worksheet 1.A that they</p><p>believe to be true or somewhat true.</p><p>Divide participants into pairs. Have each member of the pair choose a myth that they strongly believe</p><p>in and then</p><p>take turns practicing self- enquiry and outing themselves about their respective myths. The</p><p>steps for conducting this exercise are outlined here:</p><p>1. The revealing partner— that is, the person who is outing themselves— begins by reading aloud</p><p>their myth three times in a row to their partner.</p><p>2. The listening partner then reads aloud several of the self- enquiry questions found on the work-</p><p>sheet. For example, What is it that you need to learn from this myth? What might this myth be telling</p><p>you about yourself and your life? Does the thought of reexamining this myth elicit tension? If so, then</p><p>what might this mean? How open are you to thinking differently about this myth? If you are not open</p><p>or only partly open, then what might this mean?</p><p>3. Pairs should then switch roles, with the listener now taking the role of outing themselves by</p><p>speaking aloud the images, thoughts, and memories linked to the myth they have chosen for</p><p>their practice.</p><p>4. After each pair has played both roles at least once, instructors should encourage participants</p><p>to share their observations about the exercise with the entire class.</p><p>Participants should incorporate questions they found most provocative into their daily practice of</p><p>self- enquiry and record their resulting observations in the self- enquiry journal.</p><p>(Required) Teaching Point</p><p>What Is Radical Openness?</p><p>Refer participants to handout 1.2 (What Is Radical Openness?).</p><p>• Radical openness means being open to new information or disconfirming feedback in order to learn.</p><p>• Radical openness helps us learn to celebrate self- discovery— it is freedom from being stuck.</p><p>• Radical openness can be rewarding— it often involves trying out novel ways of behaving that may help</p><p>us cope more effectively.</p><p>• Radical openness is courageous— it alerts us to areas of our life that may need to change.</p><p>• Radical openness enhances relationships— it models humility and readiness to learn from what the</p><p>world has to offer.</p><p>• Radical openness involves purposeful self- enquiry and a willingness to acknowledge one’s fallibility—</p><p>with an intention to change (if needed). It can be both painful and liberating.</p><p>Lesson 1: Radical Openness</p><p>57</p><p>• Radical openness challenges our perceptions of reality. We don’t see things as they are— we see things as</p><p>we are.</p><p>• Being open to learning new things involves a willingness to consider that there are many ways to get</p><p>to the same place.</p><p>• Radical openness takes responsibility for our personal reactions and emotions— rather than automati-</p><p>cally blaming others or the world.</p><p>• Radical openness helps us adapt to an ever- changing environment.</p><p>• Radical openness is not…</p><p>• Approval, naively believing, or mindlessly giving in</p><p>• Assuming one already knows the answer</p><p>• Something that can solely be understood intellectually— it requires direct and repeated practice</p><p>• Rejecting the past</p><p>• Expecting good things to happen</p><p>• Always changing</p><p>• Being rigid about being open</p><p>Note to iNstructors: Use examples from your own life or others you may have collected over</p><p>time to enhance the preceding teaching. For example, the best scientists realize that current knowledge</p><p>will eventually change and evolve into greater knowledge. Science is a process of discovery: a more sophis-</p><p>ticated idea eventually replaces old theory. Ask participants for examples of times they have been open to</p><p>new things and this has led to new knowledge or skills. For example, numerous roads lead to Chicago;</p><p>there are countless ways to cook potatoes. Trying to appear perfect, to never make a mistake, is not only</p><p>impossible but also exhausting! Openness frees energy that in the past was used to protect oneself; it is the</p><p>opposite of pretending. Importantly, radical openness does not mean approval, naively believing, or mind-</p><p>lessly acquiescing. Sometimes being closed is what is needed in the moment, and/or change is not</p><p>necessary.</p><p>Note to iNstructors: The extent of existing knowledge about self- enquiry and radical openness,</p><p>both as concepts and skills, will vary depending on whether skills class is open (that is, participants can</p><p>join the class at any time) or closed (that is, each skills class starts and ends with the same individuals,</p><p>with new members joining at a later time). For closed groups, this will be the first time any of the partici-</p><p>pants will have likely encountered concepts of self- enquiry and radical openness. However, for open</p><p>groups, many of the clients may have already been exposed to these concepts in other skills classes or via</p><p>individual therapy.</p><p>• Radical openness is the core skill in RO DBT. It functions as the cornerstone for all other RO</p><p>skills.</p><p>• Small moments of closed- mindedness frequently offer just as many opportunities for</p><p>self- discovery as big moments (for example, disliking someone cutting you off in traffic may be</p><p>just as important to practice RO with as an argument with your spouse).</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>58</p><p>(Required) Teaching Point</p><p>Flexible Mind DEFinitely: Three Steps for Radically Open Living</p><p>Refer participants to worksheet 1.B (Flexible Mind DEFinitely: Three Steps for Radically Open Living).</p><p>Note to iNstructors: When teaching Flexible Mind DEFinitely, you are essentially teaching the</p><p>core skill for the entire RO skills training course. Participants should be encouraged to carry Flexible</p><p>Mind DEFinitely and self- enquiry questions with them (if possible) to refer to when they find themselves</p><p>in Fixed or Fatalistic Mind. Individual therapists may need to teach Flexible Mind DEFinitely in individ-</p><p>ual therapy if their client enters the sequence of skills training after lesson 1 has been taught (this ensures</p><p>that the client does not have to wait until the skills cycle repeats itself to learn the skill). Teach directly</p><p>from handout 1.3 (Learning from Self- Enquiry) and worksheet 1.B (Flexible Mind DEFinitely: Three</p><p>Steps for Radically Open Living). The teaching points that follow do not cover all of the material that is</p><p>on the worksheets (use the following points to supplement teaching). Since both are assigned as required</p><p>homework, it is important for instructors to take the time to ensure that participants are familiar with</p><p>both handout 1.3 and worksheet 1.B before requesting participants to use them on their own.</p><p>Note to iNstructors: When teaching Flexible Mind DEFinitely, write out the acronym (DEF) on</p><p>a flipchart or whiteboard with each letter arranged vertically in a column but without teaching or naming</p><p>the specific skill that each letter signifies. Next, starting with the first letter in the acronym (D in DEF),</p><p>teach the skills associated with each letter in the acronym using the key points outlined here, until you</p><p>have covered all of the skills associated with each individual letter. Importantly, only write out on the</p><p>whiteboard or flipchart the global description of what each letter actually stands for when you are teaching</p><p>the skills associated with its corresponding letter. This teaching method avoids long explanations about</p><p>the use of certain words in the acronym and/or premature teaching of concepts. The meaning of each</p><p>letter is only revealed during the formal teaching of the skills associated with it.</p><p>Flexible Mind DEFinitely</p><p>D Acknowledge Distress or unwanted emotion</p><p>e Use self- Enquiry to learn</p><p>F Flexibly respond with humility</p><p>Note to iNstructors: Instructors should familiarize participants with how to use worksheet 1.B</p><p>(Flexible Mind DEFinitely: Three Steps for Radically Open Living) and handout 1.3 (Learning from Self-</p><p>Enquiry) in their upcoming homework assignment.</p><p>D Acknowledge Distress or unwanted emotion (for example, annoyance,</p><p>anxiety, tension in the body, numbness).</p><p>• Radical openness is the core skill in RO DBT. In many ways, it underlies all others. So, you</p><p>DEFinitely will want to practice your DEF skills (☺).</p><p>Lesson 1: Radical Openness</p><p>59</p><p>• We only really need radical openness when we are closed.</p><p>Most often this occurs when we</p><p>encounter a novel or uncertain situation, when we feel invalidated or criticized, and/or when our</p><p>expectations and beliefs about the world, ourselves, and other people are challenged.</p><p>• Unwanted emotions are often secretly wanted. The drama of trying to regulate, control,</p><p>accept, or change an unwanted emotion allows us to pretend we are so busy regulating that we just</p><p>haven’t had time to truly self- examine what the unwanted emotion may actually be trying to say (that</p><p>is, teach us: “Oops— I was so busy regulating that I forgot to look at what I was avoiding” ☺). This</p><p>can sometimes lead to a crash (for example, emotional leakage).</p><p>E Use self-Enquiry to learn from the distress rather than automatically attempt-</p><p>ing to regulate, distract, change, deny, or accept.</p><p>• Turn toward the emotional distress and practice self- enquiry in order to learn.</p><p>• Self- enquiry in the heat of the moment may simply mean silently asking oneself What is it that</p><p>I might need to learn from this unwanted experience?</p><p>• Remember to keep self- enquiry practices brief (five minutes or less). Prolonged practices often</p><p>(but not always) reflect strong (often hidden) desires to find some sort of solution. Of course, if this</p><p>happens, use self- enquiry to explore your intense need for solutions ☺.</p><p>• Remember to be slightly suspicions of quick answers or urges to justify your actions</p><p>when practicing self- enquiry.</p><p>F Flexibly respond with humility by doing what’s needed in the moment, in a</p><p>manner that accounts for the needs of others.</p><p>• Flexible responding means taking responsibility for our personal reactions to the</p><p>world (including our unwanted emotions).</p><p>• Be suspicious when you check the facts. Recall that our perceptions cannot help but be limited</p><p>(by our biology and personal experience). So what I consider a fact may not, in fact, be a fact to you.</p><p>Okay, let’s see if I can say that faster! (tee hee ☺)</p><p>• Be careful not to overdo problem solving. Remember that for most OC individuals their motto</p><p>is “When in doubt, apply more self- control.” Thus, most OC clients tend to be compulsive fixers.</p><p>Note to iNstructors: Although for some in the class this may be their first exposure to the</p><p>concept of self- enquiry, it will not be their last. Instructors can let participants know that RO mindfulness</p><p>training also emphasizes self- enquiry and will be covered in greater detail in other lessons. That said, most</p><p>participants quickly grasp the core idea of self- enquiry after looking over the self- enquiry questions pro-</p><p>vided in handout 1.3 (Learning from Self- Enquiry).</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>60</p><p>Lesson 1 Homework</p><p>1. (Required) Worksheet 1.B (Flexible Mind DEFinitely: Three Steps for Radically</p><p>Open Living). Instructors should encourage participants to use handout 1.3 (Learning from Self-</p><p>Enquiry) to facilitate their practice of step 2 of Flexible Mind DEFinitely. Ask if there are any ques-</p><p>tions about how to use the worksheet.</p><p>2. (Required) Encourage class participants to carry a copy of handout 1.3 (Learning</p><p>from Self- Enquiry) with them, ideally for the entire duration of their treatment and wherever they</p><p>go. Encourage them to use these self- enquiry question examples to kick- start their own practice or</p><p>when they are finding it difficult to find a question on their own. Ask if there are any questions about</p><p>self- enquiry or how to use the handout before assigning it as homework.</p><p>3. (Recommended) Worksheet 1.A (Myths of a Closed Mind). Quickly review the instructions on</p><p>how to use this worksheet. Encourage participants to use this worksheet to enhance their practice of</p><p>radical openness in the coming week.</p><p>4. (Optional) Worksheet 1.C (The Pros and Cons of Being Open Versus Closed to New Experience).</p><p>Use worksheet 1.C to deepen participants’ understanding about the advantages and disadvantages of</p><p>open- minded versus closed- minded behavior.</p><p>Lesson 1: Radical Openness</p><p>61</p><p>Radical Openness Handout 1.1</p><p>Inkblot</p><p>[[M01-Inkblot]]</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>62</p><p>Radical Openness Handout 1.2</p><p>What Is Radical Openness?</p><p>• Radical openness means being open to new information or disconfirming feedback in order to learn.</p><p>• Radical openness helps us learn to celebrate self- discovery— it is freedom from being stuck.</p><p>• Radical openness can be rewarding— it often involves trying out novel ways of behaving that may help</p><p>us cope more effectively.</p><p>• Radical openness is courageous— it alerts us to areas of our life that may need to change.</p><p>• Radical openness enhances relationships— it models humility and readiness to learn from what the</p><p>world has to offer.</p><p>• Radical openness involves purposeful self- enquiry and a willingness to acknowledge one’s fallibility—</p><p>with an intention to change (if needed). It can be both painful and liberating.</p><p>• Radical openness challenges our perceptions of reality. We don’t see things as they are— we see things as</p><p>we are.</p><p>• Being open to learning new things involves a willingness to consider that there are many ways to get</p><p>to the same place.</p><p>• Radical openness takes responsibility for our personal reactions and emotions— rather than automati-</p><p>cally blaming others or the world.</p><p>• Radical openness helps us adapt to an ever- changing environment.</p><p>Radical Openness Is Not…</p><p>• Approval, naively believing, or mindlessly giving in</p><p>• Assuming one already knows the answer</p><p>• Something that can solely be understood intellectually— it requires direct and repeated practice</p><p>• Rejecting the past</p><p>• Expecting good things to happen</p><p>• Always changing</p><p>• Being rigid about being open</p><p>Lesson 1: Radical Openness</p><p>63</p><p>Radical Openness Handout 1.3</p><p>Learning from Self- Enquiry</p><p>Instructions: Use the sample questions that follow to enhance your practice of radical openness; see work-</p><p>sheet 1.B (Flexible Mind DEFinitely: Three Steps for Radically Open Living).</p><p>Carry a copy of this list with you and write down in your RO self- enquiry journal new questions you</p><p>discover.</p><p>¾ Is it possible that my bodily tension means that I am not fully open to the feedback? If yes or possibly, then</p><p>what am I avoiding? Is there something here to learn?</p><p>¾ Is the resistance, dislike, and tension I am feeling helpful? What is it that I might need to learn from my</p><p>closed- mindedness?</p><p>¾ Do I find myself wanting to automatically explain, defend, or discount the other person’s feedback or what is</p><p>happening? If yes or maybe, then is this a sign that I may not be truly open?</p><p>¾ Am I finding it hard to question my point of view or even engage in self- enquiry? If yes or maybe, then what</p><p>might this mean?</p><p>¾ Am I talking more quickly or immediately responding to the other person’s feedback or questions? Am I</p><p>holding my breath or breathing more quickly? Has my heart rate changed? If yes or maybe, then what does</p><p>this mean? What is driving me to respond so quickly? Is it possible I am feeling threatened?</p><p>¾ Am I able to truly pause and consider the possibility that I may be wrong or may need to change? Am I saying</p><p>to myself “I know I am right” no matter what they say or how things seem? Or do I feel like shutting down,</p><p>quitting, or giving up? If yes or maybe, then is it possible that I am operating out of Fixed or Fatalistic Mind?</p><p>What is it that I fear?</p><p>¾ Am I resisting being open to this feedback because part of me believes that doing so will change an essential</p><p>part of who I am? If yes or maybe, then what might this mean? What am I afraid of?</p><p>¾ Am I automatically blaming the other person or the environment for my emotional reactions? If yes or maybe,</p><p>then is it possible this could represent a way for me to avoid being open to the feedback?</p><p>¾ Do I believe that I know what the intentions are of the person giving me the disconfirming feedback? For</p><p>example, am I assuming that they are trying to promote themselves? Or do I believe that they are trying to</p><p>manipulate, coerce, or intimidate me? If yes or maybe, then is it possible that I am not really giving them a</p><p>chance? What am I afraid might happen if I were to momentarily drop my perspective?</p><p>¾ Do I think it is unfair to fully listen to someone who I believe is not listening to me? If yes or sometimes, then</p><p>is it possible this is occurring now? If yes or maybe, then why do I need things to be fair?</p><p>¾ Do I feel invalidated, hurt, unappreciated, or misunderstood by the person giving me the disconfirming feed-</p><p>back? Is there a part of me that believes it is important for them to acknowledge (or apologize) that they do</p><p>not understand me before I would be willing to fully consider their position? If yes or maybe, then why do I</p><p>need to be understood? Why do I need to be validated? Is it possible this desire might subtly block openness on</p><p>my part by requiring the other person to change first?</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>64</p><p>¾ Do I believe that further self- examination is unnecessary because I have already worked out the problem,</p><p>know the answer, or have done the necessary self- work about the issue being discussed? If yes or maybe, then</p><p>is it possible that I am not willing to truly examine my personal responses? Why do I feel so convinced that I</p><p>already know the answer? What do I fear I may lose?</p><p>¾ Do I desire to capitulate, give up, or agree with the feedback? If yes or maybe, then is it possible that my agree-</p><p>ment is disguised avoidance? Am I agreeing in order to avoid conflict, not because I truly believe they are</p><p>right? What might this mean?</p><p>¾ Is the feedback I am being given something that I have heard from others before? If so, what might this mean?</p><p>Is it possible that there is something to learn from this feedback?</p><p>If you find yourself resisting self- enquiry or feeling nothing, use self- enquiry to explore this further by</p><p>asking…</p><p>¾ What might my resistance be trying to tell me? What is it I need to learn?</p><p>¾ What does my resistance tell me about myself or my willingness to engage in learning this new skill?</p><p>¾ What am I resisting? Is there something important for me to acknowledge or recognize about myself or the</p><p>current moment?</p><p>¾ Is it possible that I am numbing out or shutting down in order to avoid taking responsibility or make important</p><p>changes? What is it that I need to learn?</p><p>Use the following space to record new self- enquiry questions that emerge for you over time.</p><p>Lesson 1: Radical Openness</p><p>65</p><p>Radical Openness Handout 1.4</p><p>Main Points for Lesson 1: Radical Openness</p><p>1. We tend to pay attention to things that fit our beliefs and ignore or dismiss those things that do not.</p><p>2. We don’t know what we don’t know, and this keeps us from learning new things.</p><p>3. To learn anything new, we must acknowledge our lack of knowledge and then behave differently!</p><p>4. RO DBT considers psychological health to involve three core features: (1) receptivity and openness,</p><p>(2) flexible control, and (3) intimacy and connectedness.</p><p>5. There are pros and cons to being open, as well as to being closed.</p><p>6. We only need to practice radical openness when we are closed.</p><p>7. Radical openness enhances relationships because it models humility and a willingness to learn from</p><p>the world. Yet, it can be both painful and liberating because it often requires sacrificing firmly held</p><p>convictions or beliefs in order to learn or connect with another.</p><p>8. To practice Use Flexible Mind DEFinitely and the three steps needed for open living: (1) acknowledge</p><p>the presence of an unwanted private experience, (2) practice self- enquiry by turning toward the dis-</p><p>comfort in order to learn, and (3) flexibly respond by doing what’s needed in the moment.</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>66</p><p>Radical Openness Worksheet 1.A</p><p>Myths of a Closed Mind</p><p>Instructions: Place a checkmark in the box next to each myth you believe is true or somewhat true.</p><p>� Being open means others can use you. Only idiots are open.</p><p>� If you don’t have an opinion on how things should be, you’ll get hurt.</p><p>� Planning ahead is always imperative.</p><p>� There is a right and wrong way to do things and that’s the way it is.</p><p>� Behaving correctly is the most important thing in life.</p><p>� I have tried everything there is to try. There is nothing new out there.</p><p>� Even if I tried something new, it won’t help.</p><p>� You can’t teach an old dog a new trick.</p><p>� If I try something new and it works, I was a fool for not trying it before.</p><p>� If I try something new, then it means I was wrong.</p><p>� New things are for gullible fools.</p><p>� Doing something different means giving up my values.</p><p>� It doesn’t matter what you say or how things seem, when I am right about something I know I am</p><p>correct.</p><p>� Doing what I always do just feels right.</p><p>� It is always important to do things properly.</p><p>� Rules are there to be followed— especially mine.</p><p>In the following space, write out any other myths you may have about emotions that were not</p><p>mentioned.</p><p>Lesson 1: Radical Openness</p><p>67</p><p>Next: Pick one of the preceding myths that you strongly believe in and practice self- enquiry about the</p><p>myth over the next week.</p><p>• Remember to keep your self- enquiry practices short in duration— for example, not much longer</p><p>than five minutes. The goal of self- enquiry is to find a good question that brings you closer to your edge</p><p>or personal unknown (the place you don’t want to go), in order to learn. After a week, move to another</p><p>myth and repeat your self- enquiry practice.</p><p>• Remember to record in your RO self- enquiry journal the images, thoughts, emotions, and sensations</p><p>that emerge when you practice self- enquiry about your myths.</p><p>• Remember to practice being suspicious of quick answers to self- enquiry questions. Allow any</p><p>answers to your self- enquiry practice to emerge over time.</p><p>• Remember, self- enquiry does not automatically assume that a myth is wrong, bad, or dysfunc-</p><p>tional. Use the following questions to enhance your practice.</p><p>¾ What might I need to learn from this myth?</p><p>¾ What might this myth be telling me about myself and my life?</p><p>¾ Am I feeling tense doing this exercise?</p><p>¾ Am I feeling tense right now? If so, then what might this mean? What is it that I might need to learn?</p><p>¾ How open am I to thinking differently about this myth or changing the myth?</p><p>¾ If I am not open or only partly open, then what might this mean?</p><p>¾ How does holding on to this myth help me live more fully?</p><p>¾ How might changing this myth help me live more fully?</p><p>¾ What might my resistance to changing this myth be telling me?</p><p>¾ Is there something to learn from my resistance?</p><p>¾ What does holding on to this myth tell me about myself?</p><p>¾ What do I fear might happen if I momentarily let go of this myth?</p><p>¾ What is it that I need to learn?</p><p>Use the following space to record additional self- enquiry questions or observations that emerged from</p><p>your practice.</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>68</p><p>Radical Openness Worksheet 1.B</p><p>Flexible Mind DEFinitely: Three Steps</p><p>for Radically Open Living</p><p>Flexible Mind DEFinitely</p><p>D Acknowledge Distress or unwanted emotion</p><p>e Use self-Enquiry to learn</p><p>F Flexibly respond with humility</p><p>Instructions: Look for a time in the coming week when you find yourself feeling tense, irritated, annoyed,</p><p>uncertain, invalidated, criticized, fearful, judgmental, numb, shut down, closed, resisting, ruminating, or dis-</p><p>liking something and then use the following skills to practice radical openness.</p><p>• Remember, we only need to practice radical openness when we are closed— plus, small moments</p><p>are just as important as big ones (for example, disliking someone cutting you off in traffic may be just</p><p>as important to practice RO with as an argument with your spouse).</p><p>D Acknowledge Distress or unwanted emotion (for example, annoyance,</p><p>anxiety, tension in the body, numbness).</p><p>Place a checkmark in the</p><p>boxes next to the questions that best address your unwanted experience.</p><p>� Were you in a novel or uncertain situation?</p><p>� Did you feel invalidated, misunderstood, or criticized?</p><p>� Were your expectations or beliefs about the world, other people, or yourself being challenged?</p><p>Other circumstances.</p><p>Describe in the following space what happened. Where were you when it happened? Who were you with?</p><p>What did you feel inside your body?</p><p>Lesson 1: Radical Openness</p><p>69</p><p>E Use self-Enquiry to learn from the distress rather than automatically attempt-</p><p>ing to regulate, distract, change, deny, or accept.</p><p>Place a checkmark in the boxes that best describe the skill you practiced.</p><p>� In the heat of the moment, I turned toward my discomfort and asked What do I need to learn? rather</p><p>than automatically regulating, distracting, fixing, or trying to accept.</p><p>� Made a commitment to practice self- enquiry on multiple days after the event had passed.</p><p>� Remembered that self- enquiry means finding a good question that brings me closer to my edge (my</p><p>personal unknown), not finding a good answer.</p><p>� Found my edge by turning my mind to the very thing I don’t want to think about or admit having.</p><p>� Celebrated finding my edge as an opportunity for growth.</p><p>� Recorded my edge in my RO self- enquiry journal and used it to focus my self- enquiry practice.</p><p>� Pinpointed a question that elicited my edge.</p><p>� Used a self- enquiry question from handout 1.2 (What Is Radical Openness?) to enhance my</p><p>practice.</p><p>� Remembered that the best self- enquiry question is the one I dislike the most.</p><p>� Set aside five minutes per day over a period of several days to ask my self- enquiry question and recorded</p><p>what emerged each day in my RO self- enquiry journal.</p><p>� Purposefully kept my self- enquiry practices brief (five minutes or less) by recognizing that prolonged</p><p>practices are often disguised attempts to prove I am working hard, punish myself, or solve the problem</p><p>in order to feel better.</p><p>� Practiced being slightly suspicious of quick answers or urges to justify my actions when asking my self-</p><p>enquiry question.</p><p>� Remembered that ruminating or brooding is not self- enquiry— it is me trying to solve the problem or</p><p>regulate/avoid my discomfort.</p><p>� Blocked blaming myself, others, or the world during my practice of self- enquiry.</p><p>� Noticed secret attempts to avoid my edge or downregulate during a self- enquiry practice and used this</p><p>to deepen my understanding rather than as another opportunity to get down on myself.</p><p>� Blocked attempts to be perfect at self- enquiry.</p><p>� When I found myself resisting self- enquiry, I used self- enquiry to explore my resistance, using the ques-</p><p>tions from handout 1.3 (Learning from Self- Enquiry).</p><p>Record in the following space the self- enquiry question(s) you found most useful.</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>70</p><p>F Flexibly respond with humility by doing what’s needed in the moment, in a</p><p>manner that accounts for the needs of others.</p><p>Place a checkmark in the boxes next to the skills you practiced.</p><p>� Acknowledged that flexible responding is freely chosen by me; no one can force me to be flexible.</p><p>� Activated my social safety system to maximize my flexible responding (for example, by closed- mouth</p><p>smiling with eyebrows raised while slowing and deepening my breathing).</p><p>� Used stall tactics to block automatic, habitual, and quick responding. Check all that apply.</p><p>� Reminded myself it is okay to take time to reflect— not every problem needs immediate fixing.</p><p>� Let two to three days pass before making a decision or responding to an emotionally evocative</p><p>event (for example, an email, request, or telephone call).</p><p>� Communicated to another person that I needed some time to reflect on what had just happened—</p><p>including how I may have contributed to it— before making a decision about what to do or dis-</p><p>cussing it further, and then used this time to practice self- enquiry.</p><p>� Reminded myself that stalling does not mean walking away or abandoning the problem, my</p><p>responsibility, or the relationship. It means taking a short break to practice self- enquiry and then</p><p>reengaging with the issue.</p><p>� Practiced living according to my values by taking responsibility for my personal reactions and responses</p><p>to the world. Check all that apply.</p><p>� Blocked my automatic tendency to blame others or expect the world to change when things did</p><p>not go as expected.</p><p>� Reminded myself that no one can force me to feel something.</p><p>� Practiced outing myself about secret desires to pout, stonewall, walk away, or obstruct another</p><p>person or an event instead of pretending that I was not upset, that the other person made me do</p><p>it, or that they got what was coming to them.</p><p>� Gave others the benefit of the doubt (for example, by assuming that they mean well and/or are</p><p>doing the best they can to cope effectively).</p><p>� Challenged my rigid belief that I was correct or right by reminding myself that we don’t see things</p><p>as they are, but that we see things as we are.</p><p>� Reminded myself that it is arrogant to assume that the world or other people should conform to</p><p>my expectations or beliefs.</p><p>� Remembered that I don’t know what I don’t know, in order to be more receptive to what was hap-</p><p>pening in the moment.</p><p>� Practiced a willingness to be wrong without falling apart or giving up.</p><p>� Practiced surrendering arrogance (for example, by acknowledging the fallibility inherent in all</p><p>humans or by recalling times when my convictions were proven wrong).</p><p>� Practiced letting go of desires to control or dominate other people.</p><p>Lesson 1: Radical Openness</p><p>71</p><p>� Practiced celebrating diversity by recognizing that there are many ways to live, behave, or think.</p><p>� Practiced celebrating problems as opportunities for new learning rather than obstacles preventing me</p><p>from enjoying my life.</p><p>� Practiced seeing the big picture and letting go of detail- focused processing by asking…</p><p>� Does what I noticed really matter in the long run?</p><p>� What are the downsides of holding on to my detailed observation?</p><p>� What other valued goals may be negatively impacted by my insistence on this?</p><p>� Used my desired level of intimacy to guide how I would respond by asking…</p><p>� Should I persist or suspend the behavior I had been engaging in prior to the unwanted experience?</p><p>� Should I inhibit or disinhibit my action urges?</p><p>� Should I express or constrain what I am feeling inside?</p><p>� Should I reveal or edit what my beliefs, expectations, or inner thoughts are?</p><p>� Practiced being flexible about flexibility; sometimes being closed may be what is needed in the</p><p>moment, and/or change is not necessary.</p><p>Describe other ways you may have practiced flexible responding in the following space.</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>72</p><p>Radical Openness Worksheet 1.C</p><p>The Pros and Cons of Being Open Versus</p><p>Closed to New Experience</p><p>Make a list of pros and cons for being open to new experience, trying out new things, tolerating the distress</p><p>of not having an answer, or being seen as inexperienced. Also make a list of pros and cons for being closed to</p><p>new experience or solely basing a decision on the past.</p><p>Being open to new experience Being closed to new experience</p><p>PROS</p><p>CONS</p><p>LESSON 2</p><p>Understanding Emotions</p><p>Main Points for Lesson 2</p><p>1. Our neurosensory system is constantly scanning the world and ourselves for the presence of cues or</p><p>stimuli relevant to our well- being.</p><p>2. Our brains are hardwired to detect and react to five broad classes of emotionally relevant stimuli or</p><p>cues.</p><p>3. Safety cues are stimuli associated with feeling protected, secure, loved, fulfilled, cared for, and part of</p><p>a community or tribe.</p><p>4. Novel cues are discrepant or unexpected stimuli that trigger an automatic evaluative process designed</p><p>to determine whether the cue is important for our well- being.</p><p>5. Rewarding cues are cues appraised as potentially</p><p>gratifying or pleasurable.</p><p>6. Threatening cues are cues appraised as potentially dangerous or damaging.</p><p>7. Overwhelming cues trigger our emergency shutdown system.</p><p>8. We are never unemotional, because we are always in one of the five emotional- mood states.</p><p>9. Broadly speaking, when one emotional system is on, the other four are off, or inhibited.</p><p>10. Finally, when an emotional response tendency is ineffective, we move to another neuroregulatory</p><p>response.</p><p>Materials Needed</p><p>• Handout 2.1 (The RO DBT Neuroregulatory Model of Emotions)</p><p>• (Optional) Handout 2.2 (Main Points for Lesson 2: Understanding Emotions)</p><p>• Worksheet 2.A (Identifying the Different Neural Substrates)</p><p>• Whiteboard or flipchart with marker</p><p>(Recommended) Mindfulness Practice</p><p>Participate Without Planning</p><p>Pick a “participate without planning” exercise from one of the examples provided in the RO mindful-</p><p>ness skills training module in lesson 12. For example, practice “I am NOT pouting!” (also known as “Let’s</p><p>Have a Temper Tantrum”) or “Yippee, I’m a Puppet!” Remember that a “participate without planning” practice</p><p>should not begin with an orientation to or forewarning about the practice, and it should be of short duration</p><p>(thirty seconds to four minutes).</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>74</p><p>Note to iNstructors: Instructors can refer back to this mindfulness practice when teaching</p><p>handout 2.1 (The RO DBT Neuroregulatory Model of Emotions) to help participants start practicing</p><p>using the model to label their emotional experience. For example, ask participants to see if they can iden-</p><p>tify the cues that may have triggered their novelty- evaluative system during the mindfulness practice at</p><p>the start of the class and to identify the behaviors that suggest this system was active. This process can be</p><p>repeated as each section of the model is taught— for example, when teaching about reward cues— asking</p><p>whether anyone noticed their reward system being activated during the practice and use their experience</p><p>to augment teaching points. Instructors should be ready to share which system they had activated during</p><p>the mindfulness practice, too, and use their personal experience as possible teaching examples.</p><p> Fun Facts: Neuroception Occurs in Milliseconds!</p><p>Neuroception can occur in milliseconds and without conscious awareness: we don’t even know we</p><p>are doing it. Our brains are constantly scanning our environment for cues. For most people the</p><p>natural set point is a state of safety, of calm readiness, of openness to new stimuli, with ongoing,</p><p>low- level processing of environmental inputs. However, when our brains detect something different</p><p>or new in the environment or within our body or mind, a quick and typically unconscious</p><p>evaluative process ensues, the primary function of which is to assign valence and significance to</p><p>such stimuli— more specifically, to classify them as safe, novel, rewarding, threatening,</p><p>overwhelming, or some combination thereof, such as when a stimulus has both rewarding and</p><p>threatening aspects (imagine a hive dripping with honey and swarming with bees).</p><p>• Our brains are hardwired to detect and react to five broad classes of emotionally</p><p>relevant stimuli or cues.</p><p>1. Safety cues are stimuli associated with feeling protected, secure, loved, fulfilled,</p><p>cared for, and part of a community or tribe.</p><p>• Our natural set point is one of safety, a state of calm readiness and openness,</p><p>which includes an ongoing low- level processing of environmental inputs or stimuli.</p><p>• Safety cues are stimuli that trigger this set point: a calm- friendly state linked</p><p>to a brain- neural substrate known as the ventral vagal complex (VVC), which</p><p>is part of the parasympathetic nervous system (PNS; Porges, 2011).</p><p>(Required) Teaching Point</p><p>Five Emotionally Relevant Cues</p><p>Refer participants to handout 2.1 (The RO DBT Neuroregulatory Model of Emotions).</p><p>• Our neurosensory system is constantly scanning the world and ourselves for the pres-</p><p>ence of cues or stimuli relevant to our well- being. Cues can occur inside the body (for</p><p>example, a thought or image), outside the body (for example, a loud bang), or contextually (for</p><p>example, a time of day evokes urges to smoke a cigarette).</p><p>• This scanning process, known as neuroception in our model, is what defines our emo-</p><p>tions and is constantly being updated or modified by experience.</p><p>Lesson 2: Understanding Emotions</p><p>75</p><p>• Our calm- friendly or PNS- VVC social safety system controls how we com-</p><p>municate nonverbally, that is, via our facial muscles (allowing us to effortlessly make</p><p>facial expressions), our voice box muscles (allowing us to have a musical tone of voice), our</p><p>middle ear muscles (allowing us to tighten our ear drum so we can hear human speech better),</p><p>and our neck muscles (allowing us to direct our gaze and ears).</p><p>• Social safety activation is characterized by feelings of contentment, well- being,</p><p>receptivity, curiosity, and desires to socialize.</p><p>• When the social safety system is on, our body feels relaxed, our heart rate</p><p>slows, our breathing slows and deepens, and we feel that it is safe to openly</p><p>express our emotions (for example, via facial expressions). We feel approachable,</p><p>sociable, and receptive. We are more likely to make eye contact, we more accurately hear</p><p>what others are saying, and we are more likely to want to touch and be touched by another</p><p>person. Plus, we can hit the high notes in a song! (Recall the muscles innervated by the PNS-</p><p>VVC.) We are also more likely to explore our environment with curiosity, thereby maximizing</p><p>our potential for discovery and learning.</p><p>• Examples of safety cues: a warm cup of milk, a stroll in the park, a laughing child, a hug, a per-</p><p>son’s voice, a warm smile, stroking a beloved pet, sitting by a warm fire, a happy memory, an image</p><p>of a loving parent, a thought of a good friend, a pleasant meal with a friend, and so forth</p><p>> Ask: What cues trigger feelings of safety in you? How often do you think you feel social safety?</p><p>2. Novel cues are discrepant or unexpected stimuli that trigger an automatic evaluative</p><p>process designed to determine whether the cue is important for our well- being.</p><p>• When something unexpected occurs, our calm- friendly state is briefly withdrawn.</p><p>We don’t feel aroused, but neither are we relaxed.</p><p>• We freeze, hold our breath, our heart rate and blood pressure increase, and we</p><p>turn our attention toward the novel cue. Our body is immobile but prepared to move</p><p>(Bracha, 2004; Schauer & Elbert, 2010).</p><p>“A Story of Two Friends.” Read the following text aloud: Imagine you are walking with a friend down</p><p>your neighborhood street, having just finished a nice cup of tea. You both comment on the unusual quiet—</p><p>traffic seems nonexistent. You notice ahead in the distance, on the other side of the street, what looks like a</p><p>large crowd of people. Both of you stop and stare, holding your breath as you strain to discern what’s happening.</p><p>Something is peculiar; many of the people are standing in the middle of the street. You can see that some people</p><p>are laughing as if something’s hilarious; others are shaking their heads as if in disapproval. You continue to</p><p>stare— your brain is trying to figure out what the significance of this unexpected event is. Is this a good thing</p><p>or a bad thing? Will it be helpful or harmful to move closer?</p><p>• The story illustrates how, when unexpected, novel, or discrepant things occur, our brain quickly</p><p>tries to determine whether what is happening is important to our well- being.</p><p>• This evaluative process is automatic: it can happen so fast (in milliseconds) that</p><p>we often have no awareness of it.</p><p>• Examples of novelty cues: a barking parrot, a loud bang in a church, a teacher slapping a student,</p><p>a lottery ticket with a winning number, a spacecraft landing in our backyard, a book misaligned,</p><p>a critical comment by a friend</p><p>> Ask: What are recent examples of novel cues in your life? How did you evaluate them (that</p><p>is, safe,</p><p>rewarding, threatening)?</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>76</p><p>3. Rewarding cues are cues appraised as potentially gratifying or pleasurable.</p><p>Continue “A Story of Two Friends” by reading the following text aloud: Let’s return to our story</p><p>about the two friends. As you recall, our story concluded with you and your friend unexpectedly encountering</p><p>a crowd of people in the middle your neighborhood street. Your novelty- evaluation system was triggered by this</p><p>event, which momentarily deactivated your social safety system. You both stopped and stared intently at the</p><p>crowd, trying to ascertain its significance. Now let’s imagine that your friend is delighted by this new discovery!</p><p>They want to approach it. They smile broadly, turn to you, and excitedly exclaim, “Wow, it’s a parade! Let’s</p><p>go see!” They begin tugging on your sleeve and urge you to move closer.</p><p>• Your fictional friend in the story evaluated the novel cue (the unexpected crowd of people) as a</p><p>potential reward.</p><p>> Ask: In real life, how do you think you would have responded? Would your evaluation of the event have</p><p>been the same as your fictional friend’s? What might your answer tell you about yourself?</p><p>• When we evaluate a novel cue as rewarding, our sympathetic nervous system</p><p>(SNS) excitatory approach system is activated. See handout 2.1 (The RO DBT</p><p>Neuroregulatory Model of Emotions).</p><p>• We experience a sense of anticipation that something pleasurable is about to occur.</p><p>• We feel excited and elated— our heart rate goes up and we breathe faster.</p><p>• We experience urges to approach or pursue the potential reward.</p><p>• Our conversations are more animated, making us more fun to be around.</p><p>> Ask: What cues trigger rewarding or pleasurable experiences for you? How often do you feel excited</p><p>and animated?</p><p>• However, there are some downsides to reward states.</p><p>• The more extreme or strongly activated a reward state is, the less active is the</p><p>PNS- VVC social safety system. We may find it hard to rest or relax. For example, under</p><p>high reward states a person may feel so excited that they cannot sleep, which can lead to</p><p>mental and physical exhaustion if it persists.</p><p>• We can become hyper- goal- focused and less open to non- reward- related stimuli.</p><p>For example, we may be unaware that our conversations solely focus on describing how we</p><p>will achieve our desired goal or may feel bored/disinterested if someone tries to talk about</p><p>something unrelated to our reward state.</p><p>• We may lose our ability to read subtle (and sometimes not so subtle) social</p><p>cues. For example, we may fail to notice that another person appears to be in pain, or that</p><p>they may be feeling angry or sad about something, or that they look bored and may want to</p><p>change the topic.</p><p>• We may become overly expressive. For example, we may express emotions or feelings</p><p>that are context- inappropriate (for example, begin to giggle during a funeral), may become</p><p>self- focused or dominating during social interactions (for example, exclaim exceptional</p><p>knowledge of Asian cooking to the owner of a Chinese restaurant and then order food for</p><p>everyone at our table without their permission), and/or may be unaware that we are speaking</p><p>louder and faster than others.</p><p>Lesson 2: Understanding Emotions</p><p>77</p><p> Fun Facts: Not All Aggression Is Due to Anger</p><p>Although most textbooks use the term “fight or flight” when describing the emotional action urges</p><p>triggered by threat, to be more accurate, the order of the wording should probably be reversed (that is,</p><p>“flight or fight”). When threatened, an animal’s first response is to run away (flight); only after the</p><p>animal is trapped does defensive attack behavior emerge (fighting). Although “fight” addresses many</p><p>of the types of aggressive behavior we may occasionally witness or read about (or sometimes engage</p><p>in), it doesn’t explain aggressive behavior that feels pleasurable— that is, it does not account for</p><p>nondefensive aggressive- approach behaviors. Nondefensive aggressive attacks also involve heightened</p><p>SNS activation, but in this case, the active SNS system is the reward system (not the defensive</p><p>system). Reward activation and pursuit behaviors are commonly seen in predatory species (for</p><p>example, imagine the behavior of a fox in a henhouse). Thus, the aggressive energy of the champion</p><p>boxer, the bloodlust of a soldier during battle, the satisfaction of revenge, and the pleasure associated</p><p>with winning are not a consequence of defensive anger. Although anger may spur us to attack, we</p><p>generally dislike experiencing it, because feeling threatened is not fun, whereas winning, control, and</p><p>power are pleasurable.</p><p>> Ask: What are other examples of aggressive pursuit behaviors? What might this tell us</p><p>about desires to dominate? To what extent do you like to dominate, win, or control</p><p>situations or other people? What might this tell you about yourself?</p><p>Note to iNstructors: For OC clients, differentiating between anger and aggression can be impor-</p><p>tant. It is common for OC clients to deny feeling anger, yet most will admit to desires to win, achieve, or</p><p>dominate.</p><p>4. Threatening cues are cues appraised as potentially dangerous or damaging.</p><p>Continue “A Story of Two Friends” by reading the following text aloud: Let’s return again to our story</p><p>of the two friends. Our last episode ended with your friend’s SNS reward and excitatory approach system being</p><p>activated, leading them to excitedly encourage you to join them in their pursuit of what they believe is a parade.</p><p>Now let’s imagine that your appraisal of the situation is different than your friend’s. Rather than seeing the</p><p>mass of people as potentially rewarding, your brain perceives it as potentially dangerous. While your friend</p><p>excitedly smiles and urges you to join them, your body tenses, your heart begins to race, and your facial expres-</p><p>sion becomes flat. Your easy manner is long gone. You grab your friend and earnestly shout, “NO, it’s not a</p><p>parade, it’s a riot. We need to get out of here! RUN!” You pull your friend toward you and begin running away</p><p>from the crowd. You are sweating and breathing fast as you run, and you don’t dare look back.</p><p>• In the final episode of our story— in contrast to your friend— you interpreted the crowd of people</p><p>as a potential threat.</p><p>• The lesson of “A Story of Two Friends” shows that people can be in exactly the same situation yet</p><p>interpret it in exactly opposite ways! Both feel true to the person interpreting, which is why they</p><p>can sometimes trigger arguments.</p><p>> Ask: How often do you interpret things differently from other people? How often do you think your</p><p>disagreements with others pertain to differing interpretations about events? What might this tell you?</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>78</p><p>Note to iNstructors: This can be a good time to smuggle in a brief “participate without plan-</p><p>ning” practice. Say: It’s like becoming one of those zombies you see in horror films. Raise your eyebrows, smile</p><p>warmly, and then, without further preamble say: Okay, everyone stand up! Place your arms straight out in</p><p>front of you, parallel to the ground. Now let your hands dangle. Great! Okay, now let’s all practice being zombies!</p><p>Begin to moan loudly, and shuffle about with your arms held straight out in front of you while encouraging</p><p>the class to do the same. After about thirty seconds, tell the class to sit down, smile broadly, and say: Wow,</p><p>that was fun! or Wow, I sure needed that! Encourage a quick round of applause. Then immediately move</p><p>back to teaching the next point, without further comment or discussion (see “Instructor Guidelines for</p><p>‘Participate Without Planning’ Practices,” in lesson 12).</p><p>• When we feel threatened, we experience a sense of anticipation that something</p><p>bad may happen and/or that desired goals may be blocked.</p><p>• Our sympathetic nervous system is activated, triggering feelings of anxiety, irrita-</p><p>tion, and</p><p>an urge to flee or attack.</p><p>• Our body feels tense; our breath is fast and shallow, and our heart rate speeds up</p><p>as we prepare for flight or fight.</p><p>• Both our social safety– driven (PNS- VVC) empathetic perception and prosocial</p><p>signaling become impaired. For example, we can only force a fake smile, our facial expres-</p><p>sions are constricted, our voice tone becomes monotonic, our gestures are tight and nonexpan-</p><p>sive, and we are more likely to avert our gaze or stare with hostility and misinterpret what another</p><p>person says.</p><p>> Ask: What cues trigger threat for you? How often do you think you are in a state of anxious</p><p>irritation?</p><p>5. Overwhelming cues trigger our emergency shutdown system.</p><p>• Imagine being chased by a hungry bear: you try to run away, but it is too fast; you</p><p>try to fight it off, but it is too strong.</p><p>• When our emotion- based actions are ineffective or overwhelmed (for example, it</p><p>looks like we are going to be dinner for a bear), our brain- body copes by turning</p><p>off our flight/fight/approach behaviors in order to conserve energy and maximize</p><p>survival.</p><p>• Our heart rate, breathing, and body movements slow down— we become immo-</p><p>bilized. Our social safety signaling is deactivated— we lose all facial expression.</p><p>• It’s like becoming one of those zombies you see in horror films.</p><p>• Our parasympathetic nervous system’s dorsal vagal complex (PNS- DVC) is trig-</p><p>gered. Interestingly, this neural substrate is evolutionarily older than the other emotion systems—</p><p>for example, frogs have a PNS- DVC shutdown response, too.</p><p>• Like a zombie, we look and feel emotionally numb. Fear, anger, and other power-</p><p>ful emotions fade.</p><p>• We experience pain less intensely. We may dissociate or faint.</p><p>> Ask: What cues do you experience as overwhelming? How often do you think you are in this state?</p><p>How often do you feel shut down? What triggers it?</p><p>Lesson 2: Understanding Emotions</p><p>79</p><p>(Required) Teaching Point</p><p>Pulling It All Together</p><p>• We are never unemotional, because we are always in one of the five emotional- mood</p><p>states. We always feel something, even when the duration of the emotional sensation is so low in</p><p>intensity or so quick as to be barely noticeable.</p><p>• Broadly speaking, when one emotional system is on, the other four are off, or inhib-</p><p>ited. For example, a person cannot feel both extremely angry and extremely contented at the same</p><p>moment in time. That said, sometimes two (or more) neural substrates are coactivated (for example,</p><p>that first date with someone you just met over the internet).</p><p>• Finally, when an emotional response tendency is ineffective, we move to another</p><p>neuroregulatory response.</p><p>(Required) Story and Discussion</p><p>“So Close and Yet So Far Away”</p><p>Note to iNstructors: The following story is broken into chapters. Instructors should read aloud</p><p>each short chapter and ask the underlying embedded questions before moving on to read the next chapter.</p><p>Encourage participants to use handout 2.1 (The RO DBT Neuroregulatory Model of Emotions) to facili-</p><p>tate answering the questions.</p><p>Chapter 1: The Setting</p><p>Imagine a teenager named Sally, whose idol is Johnny Depp, the famous movie star. She is at the airport,</p><p>traveling with her loving grandparents, who have decided to treat her to a special trip to a movie set in the</p><p>Caribbean Islands. (Can you guess which movie?) Their plane isn’t scheduled to depart for another two</p><p>hours, so they have plenty of time. Grandfather buys everyone a cup of their favorite tea, and they all decide</p><p>to enjoy it while waiting in the boarding area. Sally finishes her tea and then quietly rests her head on the</p><p>shoulder of her grandmother, who gently strokes her hair. Just as her eyes begin to close, she remembers how</p><p>her grandmother used to love reading her bedtime stories. Gently smiling, she takes a slow deep breath.</p><p>> Ask: What neural substrate (part of the brain) has most likely been triggered in Sally? What eliciting</p><p>cues helped you make your decision? What action tendencies, actions, and/or expressions further</p><p>confirm your choice?</p><p>Answer: The neural substrate is the PNS- VVC social safety system. The eliciting cues</p><p>include the airplane is on time; she is traveling with members of her family who deeply care</p><p>about her; she had just finished a cup of her favorite tea; her grandmother is gently stroking</p><p>her hair; and a comforting memory from childhood occurred.</p><p>The confirming action tendencies, actions, and expressions include resting her head on</p><p>her grandmother’s shoulder; eyes beginning to close; smiling gently; and a deep cleansing</p><p>breath upon recalling the memory.</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>80</p><p>Chapter 2: The Discrepancy</p><p>While resting quietly, Sally begins to notice that the noise level around her family’s seating area is</p><p>different— it suddenly seems unusually quiet.</p><p>> Ask: What neural substrate (part of the brain) is likely to have been at least partially withdrawn,</p><p>and what was the cue that triggered this?</p><p>Answer: The PNS- VVC social safety system has been partially withdrawn due to the unex-</p><p>pected change in the ambient level of noise— her sensory system has detected a novel</p><p>stimulus.</p><p>Chapter 3: “What Is It?”</p><p>Sally is feeling less drowsy; she lifts her head from her grandmother’s shoulder, scans the area, and listens</p><p>intently. The people in the seats next to her family are now standing— they appear to be staring intently</p><p>at something. She looks to see what it is and spots a large crowd gathered around what appears to be an</p><p>arrivals gate.</p><p>> Ask: What neural substrate (part of the brain) is now fully activated? What cues triggered it? And</p><p>what action tendencies, actions, and/or expressions further confirm its presence?</p><p>Answer: Her novelty- orienting system is now fully activated and the social safety system has</p><p>withdrawn. The eliciting cues include staring behavior exhibited by nearby others; unex-</p><p>pected presence of a crowd of people all looking in the same direction.</p><p>The action tendencies, actions, and/or expressions confirming this include she feels alert</p><p>but not aroused, and she adjusts her body posture from one of relaxation (head down) to one</p><p>of alertness (head up). Without necessarily even being aware, Sally’s brain is working to assign</p><p>significance to the novel stimuli— that is, to what extent may it be relevant to her personal</p><p>well- being? Is it unimportant (that is, safe, meaning she can return to resting) or is it impor-</p><p>tant (that is, potentially rewarding/threatening, meaning she might need to get active)?</p><p>Note to iNstructors: Instructors can use the preceding section of the story to point out how the</p><p>behavior of others influenced the behavior of Sally— that is, she directed her gaze in the same direction as</p><p>those nearby. Research shows that we are hardwired to experience urges to direct our gaze in the same</p><p>direction of a person staring intently in a different direction from our own. This provided us with a huge</p><p>survival advantage because our individual survival no longer depended solely on our personal perceptions.</p><p>In the story, without conscious awareness, Sally used the gaze direction of her neighbors to enhance her</p><p>awareness of her environment. It also helps explain why we are so concerned about the perceptions of</p><p>others— because deep down we know that what others see may impact our personal well- being.</p><p>Chapter 4: The Mad Dash</p><p>Without warning, the crowd suddenly breaks into applause. A few people seem to be excitedly shouting.</p><p>With a smile, Sally turns to her grandparents and says, “Let’s go see what’s happening!” The applause</p><p>continues; her heart begins to race, her breath quickens, and she feels flushed. As she gets closer she spots</p><p>the source of the crowd’s applause. It’s Johnny! It’s Johnny Depp! Here in person— right now! She squeals</p><p>with delight and sprints toward him shouting, “Johnny, Johnny, Johnny— I love you! I love you!” She fails to</p><p>notice the stern looks she is getting from others as she pushes them aside,</p><p>leaps over them, or steps on their</p><p>toes. She only has eyes for her Johnny! Her grandparents hurry to catch up.</p><p>Lesson 2: Understanding Emotions</p><p>81</p><p>> Ask: What neural substrate (part of the brain) is now fully activated? What cues triggered it? And</p><p>what action tendencies, actions, and/or expressions further confirm its presence?</p><p>Answer: Her SNS excitatory arousal system has been strongly activated and her social</p><p>safety system (PNS- VVC) is disengaged. The eliciting cues include the sound of applause</p><p>and, of course, spotting her idol— Johnny Depp!</p><p>The action tendencies, actions, and/or expressions confirming this include her body is</p><p>animated; heart and breath rate increase; she feels flushed; she excitedly approaches her</p><p>reward and becomes hyper- goal- focused; her empathetic perception becomes impaired— for</p><p>example, she ignores stern looks and appears to not realize that she is pushing and stepping</p><p>on people in her single- minded pursuit of her desired goal.</p><p>Chapter 5: The Crash</p><p>Sally is determined to get to her Johnny! She hurdles three startled elders and vaults two picture- snapping</p><p>reporters. She gets within five feet of her beloved, only to smack into three muscle- bound bodyguards blocking</p><p>her way. She cannot move them— they are impassable. But her Johnny is right there— within arm’s reach!</p><p>He is turning toward her and looking right at her! And then he does the unimaginable— he looks directly at</p><p>her and smiles! She feels light- headed, her knees go wobbly. It’s like she’s peering down a long tunnel— she</p><p>can no longer hear the roar of the crowd. It looks like Johnny is trying to say something to her…is he perhaps</p><p>trying to say…. “I love you”? She suddenly feels numb all over— and then faints!</p><p>> Ask: What neural substrate was activated? What cues helped you determine this? Why did she</p><p>faint?</p><p>Answer: The parasympathetic nervous system’s dorsal vagal complex (PNS- DVC) shut-</p><p>down system was activated. The eliciting cue was overwhelming reward. Although expe-</p><p>riences of overwhelming reward are rare, when they occur the brain responds in the same way</p><p>it would to overwhelming threat. In Sally’s case, a DVC shutdown response was triggered after</p><p>her high- energy- consuming SNS excitatory approach behaviors were blocked by the three</p><p>bodyguards. Plus, the reward value of the stimulus did not dissipate but instead increased in</p><p>intensity (for example, when Mr. Depp smiled at her).</p><p>Why fainting? Acquisition and consumption of her reward (presumably a hug and a kiss)</p><p>became not only impossible but a waste of valuable energy. As a consequence, her evolution-</p><p>arily older emergency shutdown system (PNS- DVC) was triggered, manifested by fainting.</p><p>Real- life examples of this can be found in 1960s film clips showing teenagers fainting during</p><p>press conferences given by the Beatles.</p><p>Note to iNstructors: Rather than triggering reward responses, the preceding event triggered</p><p>threat and avoidance responses in Sally’s grandparents. Instructors can use this to illustrate how the same</p><p>or a similar stimulus can trigger a completely different response among different people as a function of</p><p>differing experiences and biotemperaments. Despite this, the grandparents used self- control to overcome</p><p>their automatic urges to run away, and by doing so they were able to ensure their granddaughter’s well-</p><p>being (for example, they were able to convince a nearby police officer not to arrest her and were able to</p><p>catch her when she fainted).</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>82</p><p>Note to iNstructors: The preceding story also illustrates how our neuroregulatory system nor-</p><p>mally operates: from safety to novelty to reward/threat activation or back to safety, and finally to shutdown</p><p>if the threat/reward increases in intensity and/or does not dissipate and the evolutionarily prepared flight/</p><p>fight/approach response tendencies are ineffective or blocked. Examples of times when shutdown responses</p><p>can be observed include the zoned- out and numbed expression seen among victims of kidnapping or</p><p>torture, the blank look of someone who is starving or severely dehydrated, the person who is afraid of</p><p>flying who faints upon entering an aircraft.</p><p>Lesson 2 Homework</p><p>1. (Required) Worksheet 2.A (Identifying the Different Neural Substrates). Ask if</p><p>there are any questions about how to use the worksheet.</p><p>2. (Optional) Encourage participants to practice self- enquiry when they observe an unwanted</p><p>emotion, using the sample questions in handout 1.3 (Learning from Self- Enquiry) to facilitate</p><p>their practice.</p><p>Lesson 2: Understanding Emotions</p><p>83</p><p>Ra</p><p>di</p><p>ca</p><p>l O</p><p>pe</p><p>nn</p><p>es</p><p>s</p><p>H</p><p>an</p><p>do</p><p>ut</p><p>2</p><p>.1</p><p>Th</p><p>e</p><p>RO</p><p>D</p><p>BT</p><p>N</p><p>eu</p><p>ro</p><p>re</p><p>gu</p><p>la</p><p>to</p><p>ry</p><p>M</p><p>od</p><p>el</p><p>o</p><p>f</p><p>Em</p><p>ot</p><p>io</p><p>ns</p><p>N</p><p>eu</p><p>ro</p><p>ce</p><p>pt</p><p>io</p><p>na o</p><p>f 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f</p><p>ac</p><p>ia</p><p>l</p><p>ex</p><p>pr</p><p>es</p><p>sio</p><p>ns</p><p>a</p><p>nd</p><p>su</p><p>bt</p><p>le</p><p>so</p><p>ci</p><p>al</p><p>c</p><p>ue</p><p>s</p><p>C</p><p>on</p><p>st</p><p>ra</p><p>in</p><p>ed</p><p>fa</p><p>ci</p><p>al</p><p>ex</p><p>pr</p><p>es</p><p>sio</p><p>ns</p><p>, t</p><p>ig</p><p>ht</p><p>g</p><p>es</p><p>tu</p><p>re</p><p>s</p><p>M</p><p>on</p><p>ot</p><p>on</p><p>ic</p><p>v</p><p>oi</p><p>ce</p><p>A</p><p>ve</p><p>rt</p><p>ed</p><p>g</p><p>az</p><p>e</p><p>or</p><p>h</p><p>os</p><p>ti</p><p>le</p><p>st</p><p>ar</p><p>e</p><p>Fi</p><p>gh</p><p>t-o</p><p>r-f</p><p>lig</p><p>ht</p><p>re</p><p>sp</p><p>on</p><p>se</p><p>Fl</p><p>at</p><p>, u</p><p>ne</p><p>xp</p><p>re</p><p>ss</p><p>iv</p><p>e</p><p>fa</p><p>ce</p><p>M</p><p>on</p><p>ot</p><p>on</p><p>ic</p><p>v</p><p>oi</p><p>ce</p><p>Sl</p><p>ow</p><p>sp</p><p>ee</p><p>ch</p><p>D</p><p>is</p><p>so</p><p>ci</p><p>at</p><p>io</p><p>n,</p><p>sw</p><p>oo</p><p>ni</p><p>ng</p><p>, f</p><p>ai</p><p>nt</p><p>in</p><p>g</p><p>a</p><p>T</p><p>he</p><p>te</p><p>rm</p><p>n</p><p>eu</p><p>ro</p><p>ce</p><p>pt</p><p>io</p><p>n</p><p>de</p><p>no</p><p>te</p><p>s h</p><p>ow</p><p>a</p><p>p</p><p>er</p><p>so</p><p>n</p><p>ap</p><p>pr</p><p>ai</p><p>se</p><p>s o</p><p>r a</p><p>ss</p><p>es</p><p>se</p><p>s e</p><p>vo</p><p>ca</p><p>tiv</p><p>e</p><p>st</p><p>im</p><p>ul</p><p>i.</p><p>Pr</p><p>im</p><p>ar</p><p>y</p><p>ap</p><p>pr</p><p>ai</p><p>sa</p><p>ls</p><p>a</p><p>re</p><p>q</p><p>ui</p><p>ck</p><p>e</p><p>va</p><p>lu</p><p>at</p><p>io</p><p>ns</p><p>, e</p><p>lic</p><p>ite</p><p>d</p><p>w</p><p>ith</p><p>ou</p><p>t c</p><p>on</p><p>sc</p><p>io</p><p>us</p><p>a</p><p>w</p><p>ar</p><p>en</p><p>es</p><p>s a</p><p>nd</p><p>o</p><p>ri</p><p>gi</p><p>na</p><p>ti</p><p>ng</p><p>a</p><p>t t</p><p>he</p><p>se</p><p>ns</p><p>or</p><p>y</p><p>re</p><p>ce</p><p>pt</p><p>or</p><p>le</p><p>ve</p><p>l.</p><p>Se</p><p>co</p><p>nd</p><p>ar</p><p>y</p><p>ap</p><p>pr</p><p>ai</p><p>sa</p><p>ls</p><p>a</p><p>re</p><p>sl</p><p>ow</p><p>er</p><p>, t</p><p>op</p><p>-d</p><p>ow</p><p>n</p><p>re</p><p>ap</p><p>pr</p><p>ai</p><p>sa</p><p>ls</p><p>o</p><p>f p</p><p>ri</p><p>m</p><p>ar</p><p>y</p><p>ev</p><p>al</p><p>ua</p><p>tio</p><p>ns</p><p>; t</p><p>he</p><p>y</p><p>in</p><p>vo</p><p>lv</p><p>e</p><p>ev</p><p>ol</p><p>ut</p><p>io</p><p>na</p><p>ri</p><p>ly</p><p>n</p><p>ew</p><p>er</p><p>c</p><p>en</p><p>tr</p><p>al</p><p>c</p><p>og</p><p>ni</p><p>tiv</p><p>e</p><p>an</p><p>d</p><p>co</p><p>ns</p><p>ci</p><p>ou</p><p>s l</p><p>ev</p><p>el</p><p>s o</p><p>f e</p><p>m</p><p>ot</p><p>io</p><p>na</p><p>l</p><p>pr</p><p>oc</p><p>es</p><p>si</p><p>ng</p><p>.</p><p>b A</p><p>c</p><p>ue</p><p>is</p><p>a</p><p>n</p><p>em</p><p>ot</p><p>io</p><p>na</p><p>lly</p><p>e</p><p>vo</p><p>ca</p><p>tiv</p><p>e</p><p>st</p><p>im</p><p>ul</p><p>us</p><p>th</p><p>at</p><p>o</p><p>cc</p><p>ur</p><p>s i</p><p>ns</p><p>id</p><p>e</p><p>th</p><p>e</p><p>bo</p><p>dy</p><p>(a</p><p>h</p><p>ap</p><p>py</p><p>m</p><p>em</p><p>or</p><p>y,</p><p>fo</p><p>r e</p><p>xa</p><p>m</p><p>pl</p><p>e)</p><p>, o</p><p>ut</p><p>sid</p><p>e</p><p>th</p><p>e</p><p>bo</p><p>dy</p><p>(a</p><p>n</p><p>un</p><p>ex</p><p>pe</p><p>ct</p><p>ed</p><p>lo</p><p>ud</p><p>n</p><p>oi</p><p>se</p><p>),</p><p>or</p><p>a</p><p>s a</p><p>fu</p><p>nc</p><p>tio</p><p>n</p><p>of</p><p>c</p><p>on</p><p>te</p><p>xt</p><p>(t</p><p>he</p><p>ti</p><p>m</p><p>e</p><p>of</p><p>d</p><p>ay</p><p>).</p><p>c</p><p>PN</p><p>S</p><p>=</p><p>p</p><p>ar</p><p>as</p><p>ym</p><p>pa</p><p>th</p><p>et</p><p>ic</p><p>n</p><p>er</p><p>vo</p><p>us</p><p>s</p><p>ys</p><p>te</p><p>m</p><p>.</p><p>d P</p><p>N</p><p>S-</p><p>V</p><p>V</p><p>C</p><p>=</p><p>v</p><p>en</p><p>tr</p><p>al</p><p>v</p><p>ag</p><p>al</p><p>c</p><p>om</p><p>pl</p><p>ex</p><p>(</p><p>“n</p><p>ew</p><p>”</p><p>va</p><p>gu</p><p>s)</p><p>o</p><p>f t</p><p>he</p><p>p</p><p>ar</p><p>as</p><p>ym</p><p>pa</p><p>th</p><p>et</p><p>ic</p><p>n</p><p>er</p><p>vo</p><p>us</p><p>s</p><p>ys</p><p>te</p><p>m</p><p>; s</p><p>oc</p><p>ia</p><p>l s</p><p>af</p><p>et</p><p>y</p><p>sy</p><p>st</p><p>em</p><p>.</p><p>e S</p><p>N</p><p>S</p><p>=</p><p>s</p><p>ym</p><p>pa</p><p>th</p><p>et</p><p>ic</p><p>n</p><p>er</p><p>vo</p><p>us</p><p>s</p><p>ys</p><p>te</p><p>m</p><p>; a</p><p>ct</p><p>iv</p><p>at</p><p>in</p><p>g</p><p>sy</p><p>st</p><p>em</p><p>.</p><p>f S</p><p>N</p><p>S-</p><p>E</p><p>=</p><p>S</p><p>N</p><p>S</p><p>ex</p><p>ci</p><p>ta</p><p>to</p><p>ry</p><p>a</p><p>pp</p><p>ro</p><p>ac</p><p>h</p><p>sy</p><p>st</p><p>em</p><p>.</p><p>g</p><p>SN</p><p>S-</p><p>D</p><p>=</p><p>S</p><p>N</p><p>S</p><p>de</p><p>fe</p><p>ns</p><p>iv</p><p>e</p><p>av</p><p>oi</p><p>da</p><p>nc</p><p>e</p><p>sy</p><p>st</p><p>em</p><p>.</p><p>h P</p><p>N</p><p>S-</p><p>D</p><p>V</p><p>C</p><p>=</p><p>d</p><p>or</p><p>sa</p><p>l v</p><p>ag</p><p>al</p><p>c</p><p>om</p><p>pl</p><p>ex</p><p>(</p><p>“o</p><p>ld</p><p>”</p><p>va</p><p>gu</p><p>s)</p><p>o</p><p>f t</p><p>he</p><p>p</p><p>ar</p><p>as</p><p>ym</p><p>pa</p><p>th</p><p>et</p><p>ic</p><p>n</p><p>er</p><p>vo</p><p>us</p><p>s</p><p>ys</p><p>te</p><p>m</p><p>; s</p><p>hu</p><p>td</p><p>ow</p><p>n</p><p>sy</p><p>st</p><p>em</p><p>.</p><p>i T</p><p>he</p><p>te</p><p>rm</p><p>in</p><p>te</p><p>ro</p><p>ce</p><p>pt</p><p>iv</p><p>e</p><p>re</p><p>fe</p><p>rs</p><p>to</p><p>e</p><p>m</p><p>ot</p><p>io</p><p>n-</p><p>ba</p><p>se</p><p>d</p><p>ph</p><p>en</p><p>om</p><p>en</p><p>a</p><p>an</p><p>d</p><p>se</p><p>ns</p><p>at</p><p>io</p><p>ns</p><p>o</p><p>cc</p><p>ur</p><p>ri</p><p>ng</p><p>in</p><p>sid</p><p>e</p><p>th</p><p>e</p><p>bo</p><p>dy</p><p>.</p><p>Lesson 2: Understanding Emotions</p><p>85</p><p>Radical Openness Handout 2.2</p><p>Main Points for Lesson 2: Understanding Emotions</p><p>1. Our neurosensory system is constantly scanning the world and ourselves for the presence of cues or</p><p>stimuli relevant to our well- being.</p><p>2. Our brains are hardwired to detect and react to five broad classes of emotionally relevant stimuli or</p><p>cues.</p><p>3. Safety cues are stimuli associated with feeling protected, secure, loved, fulfilled, cared for, and part of</p><p>a community or tribe.</p><p>4. Novel cues are discrepant or unexpected stimuli that trigger an automatic evaluative process designed</p><p>to determine whether the cue is important for our well- being.</p><p>5. Rewarding cues are cues appraised as potentially gratifying or pleasurable.</p><p>6. Threatening cues are cues appraised as potentially dangerous or damaging.</p><p>7. Overwhelming cues trigger our emergency shutdown system.</p><p>8. We are never unemotional, because we are always in one of the five emotional- mood states.</p><p>9. Broadly speaking, when one emotional system is on, the other four are off or inhibited.</p><p>10. Finally, when an emotional response tendency is ineffective, we move to another neuroregulatory</p><p>response.</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>86</p><p>Radical Openness Worksheet 2.A</p><p>Identifying the Different Neural Substrates</p><p>Instructions: During the coming week, be on the lookout for experiences and events linked to changes in</p><p>body sensations and mood states (for example, felt suddenly very hot, unexpectedly felt keyed up, without</p><p>warning was suddenly very tired, a headache rapidly came on, all of a sudden began to sweat). Use the follow-</p><p>ing skills to identify which of the five emotional response systems may have been involved and to pinpoint the</p><p>name of the emotion you may have been experiencing.</p><p>Step 1. Describe the cue that triggered your emotional response.</p><p>Use the following questions to facilitate your description.</p><p>• Did the cue occur inside your body— for example, a memory about an ex- partner?</p><p>• Did the cue occur outside your body— for example, a loud bang, a beautiful sunset?</p><p>• To what extent did contextual factors matter— for example, time of day, season of the year?</p><p>Describe other features of the emotion- eliciting cue.</p><p>Step 2. Use your body to identify the emotional system triggered by your cue.</p><p>Place a checkmark in the box next to the statement that best describes how your body felt.</p><p>� My body felt relaxed and calm (social safety cue).</p><p>� My body felt alert and focused (novelty cue).</p><p>� My body felt energized and powerful (rewarding cue).</p><p>� My body felt tense, agitated, and hot (threatening cue).</p><p>� My body felt numb and detached from reality (overwhelming cue).</p><p>Describe other body sensations.</p><p>Lesson 2: Understanding Emotions</p><p>87</p><p>Step 3. Observe how you socially signaled.</p><p>Place a checkmark in the box next to the questions that best address your experience.</p><p>� Was it easy to make eye contact or express your emotions? Was your voice tone easygoing? Did you</p><p>touch or reach out to someone? (likely the parasympathetic social safety system)</p><p>� Did you suddenly find yourself standing still and gazing intently? Or listening carefully? (likely novelty-</p><p>evaluative system)</p><p>� Were you highly expressive, talkative, or using expansive gestures? Did it require effort to listen to</p><p>others? Did it seem like you had missed something important that another person had said or done</p><p>during an interaction but you were unable to identify it? (likely SNS excitatory arousal system)</p><p>� Did you find it difficult to smile without feeling phony? Was your facial expression flat or stony? Did</p><p>you avert your eyes or stare intensely? Did your voice tone sound flat or strident? Were your gestures</p><p>tight and constrained? (likely SNS defensive arousal system)</p><p>� Were your face and body expressionless? Were your body movements slow? Was your speech rate slow</p><p>and your voice tone flat? Did you stare vacantly? (likely parasympathetic shutdown system)</p><p>Describe other social signals you observed.</p><p>Step 4. Describe if there was someone with you who experienced the same external cue or trigger but</p><p>signaled a different response to you.</p><p>Record other emotional response tendencies or reactions.</p><p>LESSON 3</p><p>Activating Social Safety</p><p>Main Points for Lesson 3</p><p>1. Overcontrolled individuals are biotemperamentally (genetically) threat- sensitive, making it more</p><p>likely for them to unintentionally carry defensive moods and behaviors (hunting dogs, shields, and</p><p>swords) with them into social situations that can lead to social ostracism.</p><p>2. One can naturally improve social connectedness by changing one’s physiology by activating</p><p>108</p><p>Radical Openness Handout 4.2 Main Points for Lesson 4: Enhancing Openness and</p><p>Social Connection via Loving Kindness 111</p><p>Radical Openness Worksheet 4.A Daily Practice of Loving Kindness Meditation 112</p><p>Radical Openness Handout 5.1 Engaging in Novel Behavior: Flexible Mind VARIEs 127</p><p>Radical Openness Handout 5.2 Using Experience to Examine Willingness to Learn 130</p><p>Radical Openness Handout 5.3 The Art of Nonproductivity and Being Just a Little Bit Silly 131</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>xviii</p><p>Radical Openness Handout 5.4 Are We Having Fun Yet? Self- Enquiry About Humor and Play 133</p><p>Radical Openness Handout 5.5 Main Points for Lesson 5: Engaging in Novel Behavior 135</p><p>Radical Openness Worksheet 5.A Engaging in Novel Behavior: Flexible Mind VARIEs 133</p><p>Radical Openness Worksheet 5.B Nonproductive and Novel Behavior Monitoring Log 139</p><p>Radical Openness Handout 6.1 Emotions Are There for a Reason 148</p><p>Radical Openness Handout 6.2 Not Everything That’s Important Is Emotional 149</p><p>Radical Openness Handout 6.3 Main Points for Lesson 6: How Do Emotions Help Us? 150</p><p>Radical Openness Worksheet 6.A Overcontrolled Myths About Emotions 151</p><p>Radical Openness Worksheet 6.B Using Neural Substrates to Label Emotions 153</p><p>Radical Openness Handout 7.1 Main Points for Lesson 7: Understanding Overcontrolled</p><p>Coping 161</p><p>Radical Openness Worksheet 7.A Overcontrol Can Become a Habit 162</p><p>Radical Openness Worksheet 7.B Finding Our Habitual Ways of Coping 163</p><p>Radical Openness Handout 8.1 Tribe Matters: Understanding Rejection and Self- Conscious</p><p>Emotions 180</p><p>Radical Openness Handout 8.2 Prototypical Emotional Expressions 182</p><p>Radical Openness Handout 8.3 Shaming Ritual 183</p><p>Radical Openness Handout 8.4 Flexible Mind SAGE: Dealing with Shame, Embarrassment,</p><p>and Feeling Rejected or Excluded 184</p><p>Radical Openness Handout 8.5 The RO DBT Self- Conscious Emotions Rating Scale 188</p><p>Radical Openness Handout 8.6 Signaling Nondominance 190</p><p>Radical Openness Handout 8.7 Main Points for Lesson 8: Tribe Matters 191</p><p>Radical Openness Worksheet 8.A Flexible Mind SAGE Skills 192</p><p>Radical Openness Handout 9.1 Open Expression = Trust = Social Connectedness 207</p><p>Radical Openness Handout 9.2 Emotions Communicate to Others 208</p><p>Radical Openness Handout 9.3 Main Points for Lesson 9: Social Signaling Matters! 209</p><p>Radical Openness Worksheet 9.A Practicing Enhancing Facial Expressions 210</p><p>Radical Openness Handout 10.1 The Three Channels of Emotion Expression 220</p><p>Radical Openness Handout 10.2 Face in the Crowd 221</p><p>Radical Openness Handout 10.3 Using Social Signaling to Live by Your Values 222</p><p>List of Radical Openness Handouts and Worksheets</p><p>xix</p><p>Radical Openness Handout 10.4 Main Points for Lesson 10: Using Social Signaling to</p><p>Live by Your Values 225</p><p>Radical Openness Worksheet 10.A Flexible Mind Is DEEP 226</p><p>Radical Openness Worksheet 10.B Flexible Mind Is DEEP 230</p><p>Radical Openness Handout 11.1 Overcontrolled States of Mind 245</p><p>Radical Openness Handout 11.2 Being Kind to Fixed Mind 246</p><p>Radical Openness Handout 11.3 Learning from Fatalistic Mind 247</p><p>Radical Openness Handout 11.4 Main Points for Lesson 11: Mindfulness Training, Part 1 249</p><p>Radical Openness Worksheet 11.A Being Kind to Fixed Mind 250</p><p>Radical Openness Worksheet 11.B Going Opposite to Fatalistic Mind 252</p><p>Radical Openness Handout 12.1 “Describe with Integrity” Skills: The Awareness Continuum 273</p><p>Radical Openness Handout 12.2 Main Points for Lesson 12: Mindfulness Training, Part 2 275</p><p>Radical Openness Worksheet 12.A “Observe Openly” Skills 276</p><p>Radical Openness Worksheet 12.B Making Participating Without Planning a Daily Habit 278</p><p>Radical Openness Worksheet 12.C The Three “What” Skills: Daily Practice Log for</p><p>the “Observe Openly,” “Describe with Integrity,”</p><p>and “Participate Without Planning” Skills 279</p><p>Radical Openness Handout 13.1 The Core Mindfulness “How” Skill: With Self- Enquiry 293</p><p>Radical Openness Handout 13.2 Cultivating Healthy Self- Doubt 294</p><p>Radical Openness Handout 13.3 Practicing Self- Enquiry and Outing Oneself 295</p><p>Radical Openness Handout 13.4 Main Points for Lesson 13: Mindfulness Training, Part 3 296</p><p>Radical Openness Worksheet 13.A Practicing the Core Mindfulness “How” Skill:</p><p>With Self- Enquiry 297</p><p>Radical Openness Handout 14.1 The Four RO “How” Skills 309</p><p>Radical Openness Handout 14.2 Using Self- Enquiry to Examine Harsh Judgments 311</p><p>Radical Openness Handout 14.3 Main Points for Lesson 14: Mindfulness Training, Part 4 312</p><p>Radical Openness Worksheet 14.A Practicing the “How” of RO Mindfulness 313</p><p>Radical Openness Handout 15.1 Main Points for Lesson 15: Interpersonal Integrity, Part 1 327</p><p>Radical Openness Worksheet 15.A Recognizing Indirect Communication 328</p><p>Radical Openness Handout 16.1 Identifying Pushbacks and “Don’t Hurt Me” Responses 341</p><p>Radical Openness Handout 16.2 Using Self- Enquiry to Explore “Pushback” and</p><p>“Don’t Hurt Me” Behaviors 343</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>xx</p><p>Radical Openness Handout 16.3 Main Points for Lesson 16: Interpersonal Integrity, Part 2 346</p><p>Radical Openness Worksheet 16.A Flexible Mind REVEALs 347</p><p>Radical Openness Worksheet 16.B Identifying Secret Desires for Control 351</p><p>Radical Openness Handout 17.1 Enhancing Interpersonal Kindness, Effectiveness, and</p><p>Connectedness, Using Flexible Mind ROCKs ON 364</p><p>Radical Openness Handout 17.2 New Year’s Resolutions 367</p><p>Radical Openness Handout 17.3 Signaling an Easy Manner 368</p><p>Radical Openness Handout 17.4 Main Points for Lesson 17: Enhancing Interpersonal</p><p>Effectiveness 369</p><p>Radical Openness Worksheet 17.A Overcontrolled Myths About Interpersonal Relationships 370</p><p>Radical Openness Worksheet 17.B Kindness First and Foremost 373</p><p>Radical Openness Worksheet 17.C Using Flexible Mind ROCKs ON to Enhance</p><p>Interpersonal Effectiveness 374</p><p>Radical Openness Handout 18.1 Self- Enquiry About Rumination After a Social Interaction 386</p><p>Radical Openness Handout 18.2 Main Points for Lesson 18: Being Assertive with an Open Mind 387</p><p>Radical Openness Worksheet 18.A Being Assertive with an Open Mind: Flexible Mind PROVEs 388</p><p>Radical Openness Handout 19.1 Main Points for Lesson 19: Using Validation to Signal</p><p>Social Inclusion 413</p><p>Radical Openness Worksheet 19.A Flexible Mind Validates: The Seven Levels 414</p><p>Radical Openness Handout 20.1 Self- Enquiry About Mistrust 423</p><p>Radical Openness Handout 20.2 The Intimacy Thermometer 425</p><p>Radical Openness Handout 20.3 What Characterizes a Genuine Friendship? 426</p><p>Radical Openness Handout 20.4 Main Points for Lesson 20, Part 1 428</p><p>Radical Openness Handout 21.1 Enhancing Social Connectedness, Using Flexible</p><p>Mind ALLOWs 440</p><p>Radical Openness Handout 21.2 Match + 1 Intimacy Rating Scale 443</p><p>Radical Openness Handout 21.3 Using Match + 1 to Establish New or Improve</p><p>Existing Relationships 444</p><p>Radical Openness Handout 21.4 Main Points for Lesson 21 445</p><p>Radical Openness Worksheet 21.A Practicing Flexible Mind ALLOWs 446</p><p>Radical Openness Handout 22.1 Being Open to Feedback from Others: Flexible</p><p>Mind ADOPTS 463</p><p>List of Radical Openness Handouts and Worksheets</p><p>xxi</p><p>Radical Openness Handout 22.2 Steps for Evaluating Feedback: Deciding Whether to</p><p>Accept or Decline 465</p><p>Radical Openness Handout 22.3 Main Points for Lesson 22: Learning from Corrective</p><p>Feedback 466</p><p>Radical Openness Worksheet 22.A Practicing Flexible Mind ADOPTS 467</p><p>Radical Openness Handout 27.1 Main Points for Lesson 27: Envy and Resentment 483</p><p>Radical Openness Worksheet 27.A Opposite Action to Unhelpful Envy: Flexible Mind</p><p>DARES (to Let Go) 484</p><p>Radical Openness Handout 28.1 Main Points for Lesson 28: Cynicism, Bitterness,</p><p>and Resignation 497</p><p>Radical Openness Worksheet 28.A Changing Bitterness: Flexible Mind Is LIGHT 498</p><p>Radical Openness Handout 29.1 What Forgiveness Is and Is Not 517</p><p>Radical Openness Handout 29.2 Forgiveness Self- Enquiry Questions 518</p><p>Radical Openness Handout 29.3 Strengthening Forgiveness Through</p><p>the brain’s</p><p>social safety system.</p><p>3. Effective emotional expression is always context- dependent— that is, sometimes not expressing an</p><p>emotion is the most effective way to manage a given situation.</p><p>Materials Needed</p><p>• Handout 3.1 (Changing Social Interactions by Changing Physiology)</p><p>• Handout 3.2 (Closed- Mouth Cooperative Smile)</p><p>• (Optional) Handout 3.3 (Main Points for Lesson 3: Activating Social Safety)</p><p>• Worksheet 3.A (Activating Social Safety)</p><p>• Whiteboard or flipchart with marker</p><p>(Required) Discussion Point</p><p>Hunting Dogs, Shields, and Swords</p><p>“The Story of the Disliked Friend”</p><p>Read the following text aloud.</p><p>There once was a man who believed no one liked him.</p><p>His friend said, “Just go to the village and spend time in the square. You will see that none avoid you.”</p><p>The man said, “You don’t understand— people really hate me. They look at me as if something is</p><p>wrong with me. I don’t see how this would work.”</p><p>Finally his friend convinced him to try, and so he did.</p><p>The next week his friend asked, “How did it go at the village?”</p><p>The man replied, “I did just as you said. I went to the village with my three hunting dogs— restrained</p><p>of course— my shield on my back, and my sword in my belt. You never can be too cautious! What might</p><p>you think happened? The mothers in the village picked up their children and took them inside. The fathers</p><p>glared at me with contempt, and not a soul came to speak to me on the bench I sat on in the center of the</p><p>square. My dogs weren’t even barking that much! And you think people like me?”</p><p>Lesson 3: Activating Social Safety</p><p>89</p><p>> Ask: What do you think are the main points of this story?</p><p>Answer: The point is that overcontrolled individuals are likely to bring moods and behaviors</p><p>(hunting dogs, shields, and swords) into social situations that make those situations worse.</p><p>This can range from relatively subtle behaviors, such as neutral facial expressions and fake</p><p>smiles, to more obviously problematic behaviors, such as accusing others of nefarious motives.</p><p>Though these strategies are designed to protect them from harm, they damage relationships</p><p>and most importantly the reactions of others tend to reinforce their beliefs and habits.</p><p>> Ask: What types of hunting dogs, shields, and swords do you take with you when you go to the</p><p>village? For example, it is not uncommon for participants to report that they exhibit blank</p><p>facial expressions or habitually force smiles even when distressed. They may remain on the</p><p>outskirts of conversation circles, unknowingly scowl when they go to a party, or be overly</p><p>apologetic (or never apologize).</p><p>> Ask: Is it possible that your tendency to control emotions may have social consequences that you do</p><p>not intend? How has this impacted your interpersonal relationships?</p><p>Note to iNstructors: Broadly speaking, the brain system that arouses us (the sympathetic nervous</p><p>system, or SNS) and the brain system that calms us (the parasympathetic nervous system, or PNS) operate</p><p>as antagonists; when one is on, the other is off (Berntson, Cacioppo, & Quigley, 1991).</p><p>Note to iNstructors: Instructors should be aware that the SNS and PNS can also be coactivated,</p><p>with one being dominant. For example, when going to a job interview one hopes to be in one’s social safety</p><p>system yet it is likely that one will also feel somewhat anxious (see lesson 2).</p><p>(Required) Teaching Point</p><p>The Social Safety System</p><p>• When we perceive the world as unsafe our defensive- threat system goes on the alert.</p><p>• We lose our ability to flexibly interact with others and our facial expressions become</p><p>frozen because our body is preparing for action (fight/flight).</p><p>• For example, when we feel anxious or threatened, smiling is likely to feel false, inau-</p><p>thentic, or forced. This is true for everyone.</p><p>> Ask: Have you ever noticed that it is harder to sing, listen, or genuinely express positive feelings</p><p>toward others when distressed or tense?</p><p>• The good news is that we can turn off or minimize defensive arousal by activating an</p><p>area of our brain linked with social safety (Porges, 1995). For example, activating our social</p><p>safety system automatically alters frozen facial expressions because we feel naturally more easygoing</p><p>and flexibly expressive.</p><p>• When the social safety system is on, the defensive- threat system is off or minimized.</p><p>This is because our brain is hardwired such that when one emotional system is on (for example, excit-</p><p>atory reward system), the others (for example, defensive- threat system, social safety system, novelty-</p><p>orienting system) are downregulated in order to allow full expression of the emotional system being</p><p>activated (see lesson 2).</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>90</p><p>> Ask: Have you ever noticed that you cannot feel both calm and fearful at the same time? Similarly,</p><p>we cannot simultaneously experience genuine joy and real anger at the same moment in time.</p><p>• The social safety system promotes social connectedness. When activated, we experience a</p><p>sense of calm readiness and a desire to affiliate with others— we are naturally more open, playful, and</p><p>curious about the world.</p><p>• Our social safety system contains nerves that govern the muscles in our body needed</p><p>to communicate and form close social bonds.</p><p>• These social safety muscles help us to…</p><p>• Hear better what others are saying by tuning in to the higher- frequency sound vibrations</p><p>associated with human speech (middle ear muscles)</p><p>• Communicate warmth and friendliness to others via a musical tone of voice (laryngeal</p><p>and pharyngeal or voice box muscles)</p><p>• Signal authenticity and trustworthiness to others by openly revealing (rather than</p><p>hiding) our facial expressions of emotion (facial muscles)</p><p>(Required) Class Exercise</p><p>Playing with Eyebrows</p><p>Teach: An eyebrow wag involves raising both eyebrows and universally signals affection and liking. It</p><p>is our friendly signal. It most often occurs without awareness and is usually accompanied by a slight</p><p>smile and warm eye contact. Without words it says to another person “I like you” and “You are in my</p><p>tribe.” It can often be seen when friends initially greet each other. For example, when a person greets</p><p>someone they have affection for they are likely to quickly and unconsciously raise their eyebrows during</p><p>the greeting. And their friend is likely to do the same.</p><p>Instruct class members to pair up with a partner. Instructors may need to partner up with someone (it</p><p>is very important to have everyone participate).</p><p>Begin the exercise by reading the following text.</p><p>Imagine that your partner is a long- lost best friend and you happen to run into them unexpectedly</p><p>at an airport. You are delighted and ecstatic at seeing them again— it has been maybe ten years</p><p>since you last saw them! Wow, what a lucky break! So, with this in mind, turn toward you partner</p><p>and greet them as your long- lost friend, just like you would in real life. Go! Go! Greet your long-</p><p>lost friend now! [Encourage everyone to turn to their partner and practice greeting them.]</p><p>After approximately one minute, stop the exercise, and exclaim, Well done! Without discussion,</p><p>immediately begin the next practice by reading aloud the following text.</p><p>Now we are going to do the same thing— we are going to greet our long- lost friend in the airport!</p><p>Only this time, when you greet them, make sure that you do not use any eyebrow wags! Meaning,</p><p>this time greet them, just like before, but with eyebrows down. Okay, Go! Go! Greet that friend—</p><p>remember to keep those eyebrows down!</p><p>Lesson 3: Activating Social Safety</p><p>91</p><p>After approximately one minute, stop the exercise and solicit observations from the class about the</p><p>differences between the two greetings. Then use the following required teaching points to explain the</p><p>significance of the exercise.</p><p>> Ask: What were the differences between the two interactions? Which way felt more natural?</p><p>What did you notice in your body? When your eyebrows were down, did it change</p><p>your experi-</p><p>ence? Did you notice any changes in your voice tone? (Usually most people notice that they lost</p><p>their musical tone of voice, that they became monotonic.) Did you notice any differences in desires</p><p>to spend time with them or feel close or trusting toward them? How easy was it to smile with eye-</p><p>brows down? Did it influence the words you used? Did you feel more or less like touching them?</p><p>What else did you notice?</p><p>(Required) Teaching Points</p><p>Talking Eyebrows</p><p>• It’s important to know where your eyebrows are when you are talking because their</p><p>placement (up or down) matters when it comes not only to how we feel inside but</p><p>how we impact others.</p><p>• What’s amazing is that our social safety system can be turned on or turned off simply</p><p>by how we move our facial muscles and/or position our body (see lesson 2). This is because</p><p>our neuroregulatory system is bidirectional, meaning our facial expressions, the gestures we use, and</p><p>our body movements can alter how we feel about ourselves, other people, and the world.</p><p>• The bidirectional nature of our neuroregulatory systen also highlights how social</p><p>signaling impacts our desires to socially connect with each other.</p><p>• Our next set of skills will build on these observations.</p><p>(Required) Teaching Point</p><p>Activating Our Social Safety System</p><p>Refer participants to handout 3.1 (Changing Social Interactions by Changing Physiology).</p><p>Note to iNstructors: The social safety system can just as easily be switched off. We can easily</p><p>reactivate our threat system simply by thinking about something unpleasant or simply talking to someone</p><p>using a flat facial expression or by inhibiting an eyebrow wag when greeting someone (see “Playing with</p><p>Eyebrows” class exercise). Thus, instructors should remind participants that they will need to reactivate</p><p>their social safety system repeatedly, particularly when in a threatening environment.</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>92</p><p>Note to iNstructors: When teaching each of the following strategies, instructors should create</p><p>opportunities for minipractices in class using the examples provided or by creating new ones. For example,</p><p>instructors should lead participants in a progressive muscle relaxation exercise, or bring in soft furry</p><p>objects and ask participants to stroke their face with the object, and ask participants to practice hugging</p><p>themselves. Importantly, instructors should encourage everyone to participate. See “Instructor Guidelines</p><p>for ‘Participate Without Planning’ Practices,” in lesson 12, for tips on how to introduce (or not introduce—</p><p>tee hee ☺) each miniexercise.</p><p>• The Big Three + 1 skills. There are three + 1 (conditional) ways to activate our social safety</p><p>system that work almost anywhere and anytime, regardless of how stressful the situation may feel. I</p><p>call these four behaviors the Big Three + 1. When we engage them, our brain reacts as if all is well.</p><p>• If you are sitting down, start with the (+ 1)— this step involves leaning back in</p><p>your chair (rather than sitting forward). It is a bit like slouching or relaxing on a big</p><p>couch— it says to your brain, “I’m chilled out.” The + 1 can only be used when sitting, which is</p><p>why it is separated from the other three.</p><p>• Next, engage the Big Three by taking a slow deep breath, displaying a closed-</p><p>mouth cooperative smile, and using an eyebrow wag. The Big Three can be done at the</p><p>same time, whether one is sitting, standing, or lying down.</p><p>• A slow deep breath tells your brain “all is well.” It works by moving a band of muscle</p><p>beneath your lungs, known as the diaphragm muscle, that helps facilitate deep breathing</p><p>during states of rest or relaxation. The diaphragm muscle is innervated by the nerves in your</p><p>PNS-VVC social safety system. Taking a slow deep breath moves your diaphragm muscle in</p><p>such a way that it signals to your brain that “all must be well” (because when we are threat-</p><p>ened we either hold our breath or breathe faster and more shallowly). It can be likened to a</p><p>“sigh of contentment.”</p><p>• Closed- mouth cooperative smiles: A closed- mouth cooperative smile involves turning</p><p>both corners of the mouth upward, stretching the lips over the teeth but keeping the mouth</p><p>closed so that your teeth are not exposed (refer participants to handout 3.2). It almost</p><p>always is accompanied by direct eye contact, a slight constriction or narrowing of the eyes,</p><p>and crow’s- feet wrinkles that characterize genuine smiles of pleasure (that is, orbicularis oculi</p><p>muscle activation).</p><p>• An eyebrow wag involves raising both eyebrows and universally signals affec-</p><p>tion and liking. Eyebrow wags are almost always accompanied by a slight smile, eye contact,</p><p>and a musical tone of voice. They can be seen when friends initially greet each other and/or</p><p>during interactions among people who find each other attractive, or interesting.</p><p>• The social safety system comes on fast and can go off just as fast (in milliseconds).</p><p>Therefore, when stressed or in a threatening situation, it is very important to repeat the Big Three +</p><p>1 multiple times and to not be discouraged if the effects seem to go away. Repeating them will just as</p><p>quickly bring them back. Plus, the Big Three + 1 have the added advantage of signaling friendliness,</p><p>which may help reduce stress for all involved.</p><p>Lesson 3: Activating Social Safety</p><p>93</p><p>Note to iNstructors: Contrary to other consciously produced smiles, the closed- mouth coopera-</p><p>tive smile can be held static for relatively long periods of time without feeling contrived or phony. The</p><p>closed- mouth smile is more likely to be experienced by both the sender and receiver as a genuine smile of</p><p>pleasure and as a consequence trigger reciprocal smiling and/or social safety responses (for example, via</p><p>PNS- VVC activation). Often an automatic sigh of contentment accompanies or occurs immediately after</p><p>engaging a closed- mouth cooperative smile, suggesting PNS- VVC social safety activation. This can be</p><p>used to confirm successful engagement of closed- mouth cooperative smiles and can be especially helpful</p><p>when first learning how to use them. The closed- mouth cooperative smile differs from the averted gaze</p><p>and bowed head that characterizes the closed- mouth appeasement smile or smile of embarrassment (Sarra</p><p>& Otta, 2001). It also differs from what is known as the half smile (see Linehan, 1993b). The half smile is</p><p>less expressive— that is, it does not involve stretching the lips, it is less wide, and it is less likely to be asso-</p><p>ciated with crow’s- feet wrinkles around the eyes. Instead, the half smile is more physically similar to a</p><p>burglar smile and as a consequence can be easily misread. Half smiles and burglar smiles are associated</p><p>with a wide range of differing emotions and intentions, ranging from contentment to strong dislike and</p><p>feeling pleasure in another’s misfortune. The world’s best- known half smile— that is, Leonardo da Vinci’s</p><p>painting known as the Mona Lisa— is intriguing precisely because the elusive smile on the woman’s face</p><p>is so subtly shadowed that the exact nature of the smile cannot be determined, with interpretations</p><p>ranging from pleasure to disdain (see Livingstone, 2000).</p><p>(Required) Class Exercise</p><p>The Big Three + 1</p><p>Let’s practice. To start, we need to get our body into a position that normally signals to our brain that</p><p>we are anxious, tense, or uptight. To do this, everyone should adopt a very erect sitting posture that</p><p>leans forward slightly (almost as if ready to run), adopt a frozen or flat facial expression, and then</p><p>slightly tense as many muscles as you can throughout your body without making it obvious (this mimics</p><p>bodily tension).</p><p>Use the Big Three + 1 to activate your social safety system: (1) sit back in your chairs, lean away, and</p><p>adopt a relaxed sitting posture; (2) take a slow deep breath (3) while closed- mouth smiling, and (4) add</p><p>an eyebrow wag (raise your eyebrows). Instructors should demonstrate how this looks— and then have</p><p>the</p><p>class mimic it.</p><p>Play While You Teach</p><p>Instruct the class to mimic your sitting posture, gestures, and facial expressions. For example,</p><p>instructors can exaggerate chilled- out, relaxed, and loafing sitting positions, pretend to be asleep then</p><p>suddenly sit upright, then fall back again into a different relaxed pose, or pretend to be drunk or stoned,</p><p>or encourage everyone to practice while speaking with an exaggerated hippie voice: Hey man, let’s just</p><p>chill out and lay back— put those eyebrows up, sit back, and just let the world roll by. Get that closed- mouth</p><p>smile on and breathe in the love. Let it all hang out. Feeling groovy and letting it be. Yeah, this is the life.</p><p>Ask participants to adopt their best laid- back posture and then go around and adjust the posture for</p><p>those having difficulty.</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>94</p><p>Make being laid back a contest— that is, who has the most chilled- out posture? Or who has the best</p><p>eyebrow wag? Or let’s play the “Who Can Be Less Competitive?” game! The only problem is, if you win,</p><p>you lose— but when you lose, you win…hmmm. This should be fun.</p><p>• Then discuss: What did it feel like to do the Big Three + 1? What did you notice? Did you</p><p>notice anything different in your body? Which of the four actions did you find easy to do?</p><p>Which was more difficult? Remember to practice the difficult one until it becomes easy.</p><p>Note to iNstructors: Some OC clients will report feeling awkward when engaging in the preced-</p><p>ing practice. Most typically this occurs when they try to lean back in their chair. Most often this is because</p><p>they don’t normally sit like this (particularly in public) and they may have been told by parents or teachers</p><p>“Sit up straight!” or “Don’t slouch!” Instructors can play with different postures to help loosen up over-</p><p>learned inhibitions about body posture.</p><p>(Required) Teaching Point</p><p>Expansive Gestures Communicate Safety</p><p>• Expansive gestures communicate safety via the facilitative component of emotions. Recall that</p><p>humans reciprocally mimic the facial expressions of others, which triggers similar emotional experi-</p><p>ences in them. When we use expansive gestures and facial expressions, we not only trigger our own</p><p>social safety system but we send an important social signal to others— that is, that we trust them,</p><p>thereby facilitating activation of social safety in the person we are interacting with (via micromimicry</p><p>and mirror neurons). When we are defensively aroused, we tend to tighten up; our gestures and body</p><p>movements are more likely to be smaller and closer to the body (for protection). So, when feeling</p><p>tense, move your facial muscles, and use big expansive gestures with open hands rather than keeping</p><p>your arms and hands close to your body. Open your hands (rather than clenching), place your palms</p><p>upwards (rather than palms down), and practice talking with your hands. When alone and tense,</p><p>scrunch your face muscles, stick your tongue out as far as it can go while opening your eyes wide, flap</p><p>your arms and legs about, and make frequent eyebrow wags. All of these body movements will send</p><p>the message to your brain that all must be well because otherwise you wouldn’t be moving like this</p><p>(that is, we are not expansive in our gestures and facial expressions when uptight).</p><p>(Required) Class Exercise</p><p>Practice Big Gestures</p><p>Instructors should ask the class to mimic their body gestures as they teach the preceding points,</p><p>and purposely exaggerate them. For example, make your eyebrows go up and down, then scrunch your</p><p>eyes together, pucker your mouth and then stretch your lips as wide as they can go, open your mouth</p><p>and eyes as wide as they can go, stick out your tongue as far as it can go, raise your eyebrows and stretch</p><p>all of these muscles as much as you can at the same time. Now close your eyes as hard as you can and</p><p>scrunch up all of the muscles in your face— tense them all as hard as you can— then release the tension.</p><p>Lesson 3: Activating Social Safety</p><p>95</p><p>Tense and release as many different facial muscles as you can and see if you can find all of them. Rotate</p><p>your head from side to side, up and down, stretching and tensing each muscle. Use your hands to</p><p>massage the muscles in your face. Stretch your arms up to the ceiling, open your hands palms- upward,</p><p>and try to make up gestures that incorporate palms up. Be creative— pretend you are talking with</p><p>someone, and try to come up with as many new gestures as you can think of; purposefully exaggerate</p><p>your body movements. The idea is to make this fun and a communal exercise— it need only last a few</p><p>minutes, albeit ideally it is repeated multiple times, either throughout the current lesson or as an ice-</p><p>breaker at the start of teaching or prior to other RO “participate without planning” practices. Participants</p><p>should be encouraged to practice big gestures in front of a mirror at home and to incorporate these</p><p>facial and body exercises into their daily routine with as much repetition as possible throughout their</p><p>day (for example, tensing and relaxing facial muscles while driving).</p><p>(Required) Teaching Point</p><p>The “Slow Your Breath” Skill</p><p>• The “slow your breath” skill: Deliberately breathe more deeply and slowly; use long,</p><p>slow exhalations. Hyperventilation is highly associated with extreme fears when under threat.</p><p>Slowing breathing to approximately six breaths per minute (one complete breath cycle lasting ten to</p><p>twelve seconds) is effective at reducing emotional arousal. Normally most people breathe at a much</p><p>higher rate. Instructors should emphasize abdominal breathing (breathing that moves the diaphrag-</p><p>matic muscles in the abdomen) rather than shallow chest breathing.</p><p>(Required) Class Exercise</p><p>Slowing Our Breath</p><p>Instructors should conduct a brief mindfulness practice that emphasizes the importance of slow</p><p>and deep breathing. Time the practice to last one minute. Instruct participants to count one inhalation-</p><p>exhalation cycle as one breath. Encourage participants to slow down their rate of breathing to approxi-</p><p>mately six breaths per minute. Remind them the goal is not to be perfect (that is, that they must have</p><p>only six breaths) but to slow the rate down substantially. The belly should rise on the inbreath and not</p><p>the chest. Ask each participant to report the number they had during the one- minute practice, then</p><p>conduct the practice again.</p><p>(Required) Teaching Point</p><p>The Tense- and- Relax Skill</p><p>• The tense- and- relax skill: Deliberately tense and relax large muscle groups. This is one</p><p>of the most commonly used methods of relaxation. It consists of first tensing an entire limb and holding</p><p>the tension for a brief moment, then relaxing the tension. There are progressive muscle relaxation</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>96</p><p>(Optional) Class Exercise</p><p>Muscle Relaxation Exercise</p><p>Conduct a progressive muscle relaxation exercise during class. Record it and give the audiorecord-</p><p>ing to participants as a means for practice, or ask participants to record it themselves (most mobile</p><p>phones have an audiorecorder nowadays). Start with the toes and feet, asking participants to tense the</p><p>muscle, hold the tension, and slowly release. Move then to legs and torso, then to arms and neck, and</p><p>finally the facial muscles.</p><p>(Required) Teaching Point</p><p>Using Touch, Chewing, Hearing, and Vision Skills</p><p>• Using touch, deep pressure, massage, and hugs. For humans, body sensations linked to physi-</p><p>cal closeness and touch are universally experienced as comforting because they signal to our brain</p><p>that we are back in the tribe and therefore safe. You can use touch to trigger social safety, even when</p><p>others are not around. For example, practice touching or hugging soft objects (furry pets, stuffed toys,</p><p>pillows); lightly stroke your face and neck; massage the muscles of your face, scalp, and neck.</p><p>Participants should also be encouraged to stroke pets, ask for hugs from a close friend</p><p>or partner, get</p><p>a neck or back massage, buy a massaging machine, wrap themselves tightly in blankets or towels</p><p>(swaddling), hug themselves by wrapping their arms across their chests, stroke their own faces or</p><p>necks, and hold warm water bottles against their stomachs.</p><p>• Using the chewing skill. Our brains associate eating and chewing with rest and digestion. Chewing</p><p>moves the muscles of the face linked to social safety and has been shown to facilitate memory and</p><p>reduce stress (Weijenberg & Lobbezoo, 2015). Swallowing food naturally calms the body; it is difficult</p><p>to swallow when really upset. Look for your favorite calming foods and incorporate them into everyday</p><p>living. Chewing gum is another means to accomplish the same thing but without needing to actually</p><p>ingest food. (Note: Chewing gums without laxative properties should be suggested when working with</p><p>anorexia nervosa.)</p><p>• Using sounds to enhance social safety. The muscles of our inner ear that allow us to hear</p><p>human speech are linked to the brain regions of our social safety system. When we feel threatened,</p><p>our ability to hear others literally diminishes. Music can modulate brain activity in emotion- processing</p><p>areas. When stressed you can use calm, soothing music to activate your social safety system. Avoid</p><p>music that is arousing, disturbing, or exciting. Because the human voice can calm, use vocal music you</p><p>find soothing.</p><p>• Using vision to enhance social safety by gazing at pictures of loved ones, pets, or landscapes.</p><p>You can trigger your social safety system by gazing at pictures linked to warmth, expansion, or a sense</p><p>of peace. These might be pictures of a friend, your child or grandchild when young, a favorite pet, or</p><p>your partner in a place that brings back warm memories. Use pictures you can carry with you and look</p><p>at when you feel threatened or tense. As you gaze, breathe deeply and notice what happens.</p><p>scripts available on the internet. Participants should be strongly encouraged to look for commercially</p><p>produced relaxation tapes. Body- scan mindfulness practices may share some features with progressive</p><p>muscle relaxation techniques, because of their focus on the body, and may also be used.</p><p>Lesson 3: Activating Social Safety</p><p>97</p><p>(Optional) Teaching Points</p><p>Downregulating Defensive Arousal via Activation of Other</p><p>Neural Substrates</p><p>Activation of other autonomic nervous systems (such as the SNS- appetitive or SNS- excitatory and the PNS-</p><p>DVC) has been shown to operate in similar neuroinhibitory ways as activation of the social safety system (the</p><p>PNS- VVC; see lesson 2)— that is, they function to inhibit or turn off defensive arousal. Two examples:</p><p>1. The dive reflex or ice- cold water on face. A forehead cold- pressor test (for example, placing forehead</p><p>and eyes in a bowl of ice water and holding one’s breath) replicates the dive reflex and increases vagal</p><p>activity (Hughes & Stoney, 2000; Khurana, Watabiki, Hebel, Toro, & Nelson, 1980; Linehan, Bohus,</p><p>& Lynch, 2007). The dive reflex slows heart rate and produces a feeling of slowing down, and we posit</p><p>that the dive reflex likely activates the PNS- DVC (see lesson 2). The dive reflex should be used only</p><p>by those for whom there is no cardiac risk or with doctor approval for those with any history of cardiac</p><p>difficulties (Houk, Smith, & Wolf, 1999; Linehan et al., 2007). For example, the dive reflex should not</p><p>be recommended to individuals with anorexia nervosa without medical approval, since a low body</p><p>mass index (BMI) has been shown to be associated with bradycardia (slow heart rate) and electrolyte</p><p>imbalances that can influence cardiac health.</p><p>2. Intense exercise. Intense physical exercise (for example, sit- ups or running) activates the appetitive</p><p>emotional system (the excitement or pleasure part of the brain) and inhibits the defensive emotional</p><p>system. In general, intense exercise should not be recommended to severely underweight individuals</p><p>(for example, those with anorexia nervosa).</p><p>Note to iNstructors: Instructors should be aware that activation of the sympathetic nervous</p><p>system, either threat or reward, is posited to inhibit activation of the PNS- VVC- mediated social safety</p><p>system linked to contentment and desires for social engagement. Thus, when SNS activation occurs (either</p><p>positive or negative), we lose our ability to empathetically read social signals from others and prosocially</p><p>signal cooperation to others, manifested by loss of our ability to read facial affect in others, monotone</p><p>voices, reduced abilities to hear human speech accurately, and loss of facial expressivity (see Porges, 2003;</p><p>see also lesson 2).</p><p>Lesson 3 Homework</p><p>1. (Required) Worksheet 3.A (Activating Social Safety).</p><p>2. (Optional) Build a personal contentment box. Instructors should encourage participants to begin</p><p>creating their own personal contentment box that is designed to activate the social safety system. The</p><p>contentment box can be constructed over time; the idea is to start the process via a homework assign-</p><p>ment. Encourage participants to share their box with their individual therapist.</p><p>3. (Recommended) Bring an audiorecorder to the next lesson. Encourage participants to bring an</p><p>audiorecorder or mobile phone to the next lesson so they can record the loving kindness script that</p><p>will be practiced next week.</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>98</p><p>Radical Openness Handout 3.1</p><p>Changing Social Interactions by Changing Physiology</p><p>• Our bodies are hardwired with a special regulatory system for social safety. This system calms and</p><p>relaxes us.</p><p>• We have another regulatory system for defending against threats and for exciting us. This system alerts</p><p>and arouses us.</p><p>• When the social safety system is activated, we feel open, flexible, and relaxed; we are more likely to</p><p>want to explore, play, and socialize— it’s our friendly state.</p><p>• When our social safety system is on, our defensive system is off or muted. We can’t be relaxed and</p><p>angry, afraid and content, or excited and calm at the same time.</p><p>• The good news is that when stressed or anxious, we can turn our social safety system on and our</p><p>threat- emotion system off by doing certain behaviors that our brain naturally links to safety.</p><p>• Thus, we don’t have to think our way out of anxiety; we can do our way out.</p><p>• So if you want to feel less tension, let your body do the work!</p><p>Practice These Skills</p><p>• Use the Big Three + 1. Lean back in your chair, take a slow deep breath, make a closed- mouth smile,</p><p>and use an eyebrow wag.</p><p>• Use big expansive gestures with open hands rather than keeping your arms and hands close to your</p><p>body.</p><p>• Move your facial muscles. When threatened or tense, our facial muscles naturally become frozen and</p><p>we lose our ability to flexibly communicate via facial expressions. By deliberately moving our facial</p><p>muscles, we send safety signals to our brain. Facial movement tells our brain, “I must be safe because</p><p>I am not trying to mask my inner feelings.” In front of a mirror at home or elsewhere, when alone,</p><p>practice tensing, releasing, and stretching your facial muscles. Exaggerate your facial expressions.</p><p>Make your eyebrows go up and down; then scrunch your eyes together; pucker your mouth; then</p><p>stretch your lips as wide as they can go, open your mouth and eyes as wide as they can go, stick out</p><p>your tongue as far as it can go; then raise your eyebrows and stretch all of these muscles as much as</p><p>you can at the same time. Now close your eyes as hard as you can and scrunch up all of the muscles</p><p>in your face, and tense them all as hard as you can— then release the tension. Tense and release as</p><p>many different facial muscles as you can— see if you can find all of them! Repeat whenever possible</p><p>throughout your day.</p><p>• Deliberately breathe more deeply and slowly; use long, slow exhalations. Purposely exhale longer</p><p>than normal. Slow your rate of breathing to six breaths per minute; on inbreath, focus on raising the</p><p>belly,</p><p>not the chest.</p><p>• Deliberately tense and relax large muscle groups. Start with your toes and feet, then to legs and torso,</p><p>then to your arms and neck, and then to your facial muscles. Tense each set of muscles, hold the</p><p>tension, then slowly release the tension and notice the difference.</p><p>Lesson 3: Activating Social Safety</p><p>99</p><p>• Use touch, deep pressure, massage, and hugs. Practice touching or hugging soft objects (furry pets,</p><p>stuffed toys, pillows); lightly stroke your face and neck; massage the muscles of your face, scalp, and</p><p>neck. Locate the spot directly beneath the beginning of each eyebrow in the uppermost corner of each</p><p>eye socket; use both thumbs to press this spot in an upward direction, and notice what happens. Wrap</p><p>yourself tightly in blankets or towels (swaddling). Place a small heavy beanbag or sandbag over your</p><p>forehead and thighs— notice what happens. Hug yourself by crossing both arms over your upper chest</p><p>until your hands can reach your upper back, then rock your body slowly back and forth. Rub your</p><p>tummy in a clockwise direction. Wrap a hot water bottle in a towel, lie on the floor, and place a</p><p>cushion under each knee, then place the hot water bottle over your belly— notice what happens.</p><p>Gently but firmly press the space in between the webbing of your thumb and pointer finger— notice</p><p>what happens. Purchase a commercially available massaging machine or vibrating/massaging chair.</p><p>Take a warm bath or shower; use the jet sprays in hot tubs to massage your back and neck. If you have</p><p>a partner or friend to practice with, ask for a neck or foot massage; ask for a hug and squeeze firmly—</p><p>practice hugging each day, if possible. Lie down on the floor and allow your friend to gently support</p><p>your head in his or her hands; then, with your fingers, gently rub the point directly above the bridge</p><p>of your nose adjacent to each eyebrow. Experiment with using the sensation of touch— be creative—</p><p>and incorporate touch into each day.</p><p>• Chewing and eating food. When anxious, our bodies are tense and ready for action. Our brain associ-</p><p>ates eating and chewing with resting and digesting, not fleeing or fighting. Chewing moves the muscles</p><p>of the face linked to social safety. It is difficult to swallow when really upset; chewing and swallowing</p><p>food naturally calms the body. Look for your favorite calming foods (for example, milk and cookies)</p><p>and incorporate these into everyday living. Carry sugar- free chewing gum, sweets, or snack bars with</p><p>you. When stressed, rather than restricting intake, start chewing and moving those facial muscles.</p><p>• Hearing— music and the human voice. When stressed, use music that you find calming or soothing</p><p>and/or recordings of the human voice that you find calming to activate your social safety system.</p><p>Avoid listening to music that is arousing, disturbing, or exciting.</p><p>• Vision— gazing at pictures of loved ones, pets, or landscapes. You can trigger your social safety</p><p>system by gazing at pictures linked to warmth, expansion, or a sense of peace. These might be pictures</p><p>of a friend, your child or grandchild, a favorite pet, or your partner in a place that brings back warm</p><p>memories. Use pictures you can carry with you and look at when you feel threatened or tense. As you</p><p>gaze, breathe deeply and notice what happens.</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>100</p><p>Radical Openness Handout 3.2</p><p>Closed- Mouth Cooperative Smile</p><p>Lesson 3: Activating Social Safety</p><p>101</p><p>Radical Openness Handout 3.3</p><p>Main Points for Lesson 3: Activating Social Safety</p><p>1. Overcontrolled individuals are biotemperamentally (genetically) threat- sensitive, making it more</p><p>likely for them to unintentionally carry defensive moods and behaviors (hunting dogs, shields, and</p><p>swords) with them into social situations that can lead to social ostracism.</p><p>2. One can naturally improve social connectedness by changing one’s physiology by activating the brain’s</p><p>social safety system.</p><p>3. Effective emotional expression is always context- dependent— that is, sometimes not expressing an</p><p>emotion is the most effective way to manage a given situation.</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>102</p><p>Radical Openness Worksheet 3.A</p><p>Activating Social Safety</p><p>Look for opportunities to practice activating your social safety system. Describe the event you chose.</p><p>Observe and describe any hunting dogs, shields, or swords that you may have wanted to bring into a social</p><p>situation— for example, frowning when entering a room, pretending to feel okay when not, and so forth.</p><p>Place a checkmark in the box next to each strategy you practiced, and in the spaces following each strat-</p><p>egy, briefly describe your emotional experience, and rate the intensity of the emotion or body tension</p><p>before and after trying the strategy (using a scale from 1 to 10, with 1 signifying low intensity, 5 moderate</p><p>intensity, and 9 or 10 extremely intense).</p><p>� Adjusted my body posture by using the Big Three + 1— leaned back, took a deep breath, made</p><p>a closed- mouth smile, and used an eyebrow wag.</p><p>Intensity before Intensity after</p><p>� Used big gestures with open hands rather than keeping my arms and hands close to my body.</p><p>Intensity before Intensity after</p><p>� Deliberately practiced exaggerating facial expressions and moving facial muscles.</p><p>Intensity before Intensity after</p><p>Lesson 3: Activating Social Safety</p><p>103</p><p>� Deliberately slowed my breath and used long slow exhalations.</p><p>Intensity before Intensity after</p><p>� Deliberately tensed and relaxed large muscle groups in my body.</p><p>Intensity before Intensity after</p><p>� Used touch, deep pressure, hugs, and massage.</p><p>Intensity before Intensity after</p><p>� Ate calming food(s) or chewed gum.</p><p>Intensity before Intensity after</p><p>� Used hearing by listening to soothing music and soothing voices.</p><p>Intensity before Intensity after</p><p>� Used vision by gazing at pictures of loved ones, pets, or landscapes.</p><p>Intensity before Intensity after</p><p>Describe other social safety activation skills you used.</p><p>LESSON 4</p><p>Enhancing Openness and Social</p><p>Connection via Loving Kindness</p><p>Note to iNstructors: Loving kindness meditation (LKM), when taught in skills class, will often</p><p>be a review for the majority of participants, since it is also taught in RO DBT individual therapy (ideally,</p><p>about the seventh individual therapy session). This allows for some flexibility in teaching; for example, if</p><p>all class members are already using LKM, then instructors can quickly review the main principles, conduct</p><p>an LKM practice, and then troubleshoot problems that participants may be experiencing applying LKM</p><p>in their lives. If there is additional class time available, instructors should use the time to ask how overall</p><p>use of RO DBT skills is going and address problems, ask for any questions about material covered in prior</p><p>lessons, conduct one of the optional class exercises, or teach other optional material that had not been</p><p>covered.</p><p>Main Points for Lesson 4</p><p>1. Loving kindness meditation (LKM) is a type of mood induction that activates our brain’s social safety</p><p>system.</p><p>2. LKM practices in RO DBT are designed to be used prior to social encounters (social safety effects</p><p>have been reported to last from twenty minutes up to four hours).</p><p>3. Importantly, the overarching goal of LKM practices in RO DBT is not to improve a person’s ability to</p><p>experience love or kindness toward themselves or other people but instead to trigger a mood state</p><p>associated with contentment, curiosity, and desires for social engagement by activating an area of the</p><p>brain linked with social safety responses.</p><p>4. RO DBT LKM differs from other LKM practices. Since many OC clients can find it difficult or even</p><p>distressing to consider extending feelings of warmth, kindness, or love toward themselves, LKM prac-</p><p>tices in RO DBT involve only three steps: (1) creating an experience</p><p>of warmth/love/kindness, (2)</p><p>extending warm feelings toward someone the client already cares about, and (3) extending warm feel-</p><p>ings toward a neutral person.</p><p>Materials Needed</p><p>• Handout 4.1 (A Script for Loving Kindness Meditation)</p><p>• (Optional) Handout 4.2 (Main Points for Lesson 4: Enhancing Openness and Social Connection via</p><p>Loving Kindness)</p><p>Lesson 4: Enhancing Openness and Social Connection via Loving Kindness</p><p>105</p><p>Note to iNstructors: Instructors should be alert for participant responses that may be judgmen-</p><p>tal, dismissive, or uncomfortable with concepts related to love, kindness, or compassion. For some OC</p><p>participants, the idea of love is fake or phony or they may believe that those who desire love are naive or</p><p>childish. Since LKM is derived from Buddhist traditions, many may find this off- putting because it may</p><p>imply that we are pushing religion or trying to make them spiritual. Instructors should remind participants</p><p>that the overall aim of LKM practices in RO DBT is to reduce SNS- mediated defensive arousal by induc-</p><p>ing a positive mood state linked to the social safety system.</p><p>(Required) Teaching Points</p><p>Loving Kindness Meditation</p><p>• Loving kindness meditation is a way of enhancing kindness and positive mood states</p><p>as well as social connectedness. LKM has been shown to increase feelings of warmth and care</p><p>for self and others (Hofmann, Grossman, & Hinton, 2011; Salzberg, 1995). The practice of LKM has</p><p>led to shifts in people’s daily experiences of a wide range of positive emotions, including love, joy, grati-</p><p>tude, contentment, hope, pride, interest, amusement, and awe. Loving kindness has been beneficial in</p><p>reducing pain, anger, and psychological distress in participants (Carson et al., 2005). Positive effects</p><p>can occur even if the practitioner has little prior experience and with only a few minutes of training.</p><p>Short practices of LKM (about seven minutes) have been shown in experimental studies to signifi-</p><p>cantly increase positivity and social connectedness toward others (Hutcherson, Seppala, & Gross,</p><p>2008).</p><p>• RO DBT practices of LKM are designed to activate the neurobiological social safety</p><p>system (PNS- VVC; see lesson 2). Changing physiology prior to social interactions is essential for</p><p>threat- sensitive OC individuals in order to enhance social bonds. The goal is to develop a new habit</p><p>that will allow one to induce a mood state associated with safety and contentment prior to social</p><p>interactions. A minipractice can take four minutes or less and may simply involve repeating a few</p><p>phrases that generate feelings of safety, kindness, or warmth while closed- mouth smiling and breath-</p><p>ing slowly.</p><p>• Even small amounts of generated love, warmth, kindness, or tenderness appear to be</p><p>all that is needed to begin this work. Research suggests that with continued practice one devel-</p><p>ops the ability to more easily generate these feelings (Carson et al., 2005).</p><p>• Worksheet 4.A (Daily Practice of Loving Kindness Meditation)</p><p>• Digital audiorecorder: Ideally, each participant has brought with them some type of audiorecording</p><p>device (for example, a mobile phone) to record the instructor’s voice during the upcoming loving</p><p>kindness practice.</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>106</p><p>Note to iNstructors: Unlike many traditional LKM practices, RO DBT has purposely removed</p><p>LKM steps that involve extending love or kindness toward oneself, a difficult person, or the world. Our</p><p>reasoning is simple. The primary goal of LKM is to activate the social safety system in order to enhance</p><p>social connectedness. Many OC clients find LKM practices that involve extending kindness or warmth</p><p>toward themselves (or problematic individuals) to be difficult, thereby activating SNS- mediated defensive</p><p>arousal rather than social safety. Therefore, we have purposefully removed three of the steps common</p><p>among traditional LKM practices as a means of preventing this. In addition, some participants may ask</p><p>why the words “love” and “kindness” are used if the primary goal of RO DBT LKM is to activate a mood</p><p>state linked to the neurobiologically based social safety system. Instructors can explain that the words used</p><p>in RO DBT LKM are those that have been researched and shown to most reliably activate social safety</p><p>(that is, if saying “bloop” activated social safety, then it could be used, too). Thus, if someone strongly</p><p>objects to certain words used in the LKM script (see handout 4.1), then participants should be encouraged</p><p>to work with their individual therapist on finding wording that works for them (see phrases suggested later</p><p>to help facilitate this). Lastly, instructors should encourage participants to establish a daily LKM practice.</p><p>With repeated practice over time, many participants are able to trigger their social safety system whenever</p><p>and wherever they are by simply repeating a few of the core LKM phrases (for example, “May they feel a</p><p>sense of peace,” “May they feel safe and secure”).</p><p>(Required) Class Exercise</p><p>Loving Kindness Meditation Practice</p><p>Refer participants to handout 4.1 (A Script for Loving Kindness Meditation).</p><p>Note to iNstructors: Prior to the start of reading the LKM script, instructors should ask those</p><p>participants who have brought an audiorecorder (see lesson 3 homework assignments) to start their record-</p><p>ing. Alternatively, instructors should digitally record the LKM practice (not the discussion afterward) and</p><p>make this recording available to the participants. This recording can then be used by the client as a means</p><p>to augment their LKM work.</p><p>Use the script provided in handout 4.1 to guide the practice. Since LKM in RO DBT is designed to</p><p>generate warm feelings and activate the social safety system (PNS- VVC), instructors should feel free to</p><p>adopt a calm and relaxed tone of voice while conducting the practice. Indeed, research shows that</p><p>warm human voice tones can activate the PNS- VVC (Porges, 2007). The book comes with several ver-</p><p>sions of LKM audiorecordings. Participants can use these, too. However, the recordings that come with</p><p>the book should not replace an in- class LKM practice (that is, do not play the book audiorecording as</p><p>a replacement for a live practice).</p><p>Lesson 4: Enhancing Openness and Social Connection via Loving Kindness</p><p>107</p><p>(Required) Discussion Points</p><p>LKM Practice</p><p>After completing the loving kindness meditation, instructors should ask for observations and discuss</p><p>experiences. Use the following questions as a guide. Instructors should be familiar with the obstacles outlined</p><p>here and use these to facilitate teaching around any difficulties with the practice.</p><p>> Ask: What did you experience during this practice?</p><p>> Ask: Were there any difficulties locating a memory or prior experience linked to loving kindness?</p><p>(Instructors should validate this as normal and use the teaching points under common obstacles to</p><p>help participants make sense of their experience.)</p><p>> Ask: Were you able to generate a feeling of warmth or kindness during the practice? Are you feeling</p><p>more peaceful or content following this practice? If not, what was your experience?</p><p>> Ask: Did anyone experience a sense of sadness in addition to or instead of warmth?</p><p>> Ask: What are the steps you need to take to make this practice more alive for you and/or more</p><p>beneficial?</p><p>Lesson 4 Homework</p><p>1. (Required) Handout 4.1 (A Script for Loving Kindness Meditation).</p><p>2. (Required) Worksheet 4.A (Daily Practice of Loving Kindness Meditation). During</p><p>the next lesson (and for the remainder of RO DBT treatment), participants should develop a daily</p><p>practice of LKM (if they do not already have one). LKM can be most beneficial when practiced prior</p><p>to social interactions. Participants should record their observations using worksheet 4.A. Participants</p><p>can use handout 4.1 as a script or guide during their practices. However, ideally, they will use an audio-</p><p>recording from either the practice done during lesson 4, an LKM practice</p><p>conducted and recorded</p><p>during individual therapy, or one of the several audio versions of LKM that came with the book.</p><p>Importantly, LKM practices, scripts, or audiorecordings from other sources should not be used. The</p><p>script provided in handout 4.1 is purposefully designed to promote social safety, and non– RO DBT</p><p>LKM practices often have different goals and wording. Finally, participants should be encouraged to</p><p>make personal audiorecordings and to involve their individual therapists in creating an LKM practice</p><p>that suits them.</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>108</p><p>Radical Openness Handout 4.1</p><p>A Script for Loving Kindness Meditation</p><p>Remember, the goals of LKM practices are to induce a positive mood state associated with social safety.</p><p>• Use the following script to make an audiorecording. It is designed to be read aloud. We recommend</p><p>that you do not change the wording. Practice using the script as it is currently written first. Research</p><p>has demonstrated this script to be the most useful for people in RO DBT skills classes. If you decide</p><p>you would like to make changes to the script, work with your individual therapist or skills instructor</p><p>before doing so.</p><p>• Commit to a daily practice.</p><p>Getting seated</p><p>Find a comfortable seated position in a chair, on the floor, on the sofa. The most important thing is that you</p><p>find a position in which you feel alert and the chances of you drifting off to sleep are minimal. For the</p><p>practice of loving kindness you can keep your eyes open or closed— the choice is yours— with the</p><p>understanding that our goal is to remain awake, as best we can.</p><p>Noticing the breath</p><p>Once you find that position, begin by simply taking a breath— with awareness. Not trying to change the</p><p>breath or fix it in some way, just being fully present with the full duration of the inbreath and the full</p><p>duration of the outbreath. You may notice it most strongly in the nose and the throat. Some people notice</p><p>the breath in the chest or the belly. Wherever the breath is most alive for you, just allow yourself to rest your</p><p>awareness there. If your mind wanders away from the breath, which it is prone to do, then, without</p><p>judgment, just simply bring yourself back to the next natural inhalation or exhalation.</p><p>Finding our heart center</p><p>And now, very gently, allow your awareness to move from your breath to your heart center. Into that place,</p><p>right there, in the middle of the chest. Not as much the physical heart but that place where we tend to feel</p><p>warm emotions. If you would like to do so, sometimes people find it helpful to gently place their open hand</p><p>over the location of their physical heart as this can help facilitate the practice.</p><p>As best you can, try and find a memory or feeling sense of a time when you experienced a strong sense</p><p>of loving kindness, either from someone or toward someone. It might have been the first day you met your</p><p>life partner; the day a child or grandchild was born; it might have even been a particular afternoon with</p><p>your favorite pet, or a time when you felt warm appreciation after helping or being helped by someone. The</p><p>idea is not to find the perfect experience or image, nor should you be concerned if you find yourself thinking</p><p>of many different events or experiences. The idea is— as best you can— to re- create the warm, tender, or</p><p>positive feelings associated with prior experiences of loving kindness, and to allow these feelings to grow in</p><p>your heart center. For just a moment, allow these feelings to grow.</p><p>Sending loving kindness to a person we care about</p><p>And now, in your mind’s eye, gently bring into focus an image of someone you care about, a person you</p><p>already have existing warm feelings for, may feel love toward, or may feel a sense of positive connection</p><p>with. It doesn’t have to be a perfect relationship or one without conflict— the idea is to find an image or</p><p>feeling sense of someone you know whom you already have warm feelings for. As best you can, hold this</p><p>Lesson 4: Enhancing Openness and Social Connection via Loving Kindness</p><p>109</p><p>image or a feeling sense of this person in your heart center. And now, from the feelings of loving kindness in</p><p>the center of your chest, extend warm wishes to this person you care about. Using these phrases, silently</p><p>repeat to yourself…</p><p>May this person be at ease.</p><p>May they be content with their life.</p><p>May they be joyful.</p><p>May they feel safe and secure.</p><p>Again, extending warm wishes of loving kindness to this person you care about…</p><p>May they be at ease.</p><p>May they be content with their life.</p><p>May they be joyful.</p><p>May they feel safe and secure.</p><p>And again, from the source of loving kindness in your own heart, extending well wishes to this person you</p><p>already care for…</p><p>May this person be at ease.</p><p>May they be content with their life.</p><p>May they experience joy.</p><p>And may they feel safe and secure.</p><p>And now, gradually allow the image or feeling sense of this person you care for to gently dissolve from your</p><p>mind’s eye, resting your attention back in your heart center, back into those feelings of warm loving</p><p>kindness— as best you can.</p><p>Sending loving kindness to a person we feel neutral about</p><p>Bring to mind an image of someone who you don’t really know, who you’ve at least seen once but don’t feel</p><p>any connection with one way or another. It could be your postman, or a supermarket clerk you’ve seen, or</p><p>someone else of that sort. And again, as best you can, from your own heart, extending warm wishes of</p><p>loving kindness toward this person you hardly know about, saying silently…</p><p>May this person be at ease.</p><p>May they be content with their life.</p><p>May they be joyful.</p><p>May they feel safe and secure.</p><p>Again, extending warm wishes of loving kindness to this person you hardly know at all…</p><p>May they be at ease.</p><p>May they be content with their life.</p><p>May they be joyful.</p><p>May they feel safe and secure.</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>110</p><p>And again, from the source of loving kindness in your own heart, extending well wishes to this person you</p><p>barely know…</p><p>May this person be at ease.</p><p>That they be content with their life.</p><p>That they be joyful.</p><p>That they feel safe and secure.</p><p>And now, with warm loving care, gently turn your attention back to the sensations of your breath and your</p><p>heart center, allowing the image or feeling sense of this person you hardly know to be released— allowing</p><p>yourself to rest here, in this moment, with your feelings of warmth and kindness. Remembering that you can</p><p>carry with you throughout your day these warm feelings of love and kindness that you were able to</p><p>generate, knowing that you can always find your heart center when needed and making a kindhearted</p><p>commitment to integrate this practice of loving kindness into your life, as best you can. And when you are</p><p>ready, you can open your eyes and bring your attention back into the room.</p><p>End of practice</p><p>Lesson 4: Enhancing Openness and Social Connection via Loving Kindness</p><p>111</p><p>Radical Openness Handout 4.2</p><p>Main Points for Lesson 4: Enhancing Openness and</p><p>Social Connection via Loving Kindness</p><p>1. Loving kindness meditation is a type of mood induction that activates our brain’s social safety system.</p><p>2. LKM practices in RO DBT are designed to be used prior to social encounters (social safety effects</p><p>have been reported to last from twenty minutes to up to four hours).</p><p>3. Importantly, the overarching goal of LKM practices in RO DBT is not to improve a person’s ability to</p><p>experience love or kindness toward themselves or other people but instead to trigger a mood state</p><p>associated with contentment, curiosity, and desires for social engagement by activating an area of the</p><p>brain linked with social safety responses.</p><p>4. RO DBT LKM differs from other LKM practices. Since many OC clients can find it difficult or even</p><p>distressing to consider extending feelings of warmth, kindness, or love toward themselves, LKM prac-</p><p>tices in RO DBT involve only</p><p>three steps: (1) creating an experience of warmth/love/kindness, (2)</p><p>extending warm feelings toward someone the client already cares about, and (3) extending warm feel-</p><p>ings toward a neutral person.</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>112</p><p>Radical Openness Worksheet 4.A</p><p>Daily Practice of Loving Kindness Meditation</p><p>• Loving kindness meditation is a type of positive mood induction that activates our brain’s social safety</p><p>system, our “friendly system” that is linked to feelings of calmness, contentment, and an easy social</p><p>manner.</p><p>• Use LKM practices before social interactions to increase positivity and social connectedness toward</p><p>others.</p><p>• A short six- minute exercise is all that is needed; research shows that the more you practice, the stron-</p><p>ger the effects. Make it part of your daily ritual.</p><p>• Remember, LKM in RO DBT involves only three steps: (1) creating an experience of warmth/love/</p><p>kindness, (2) extending warm feelings toward someone you already care about, and (3) extending</p><p>warm feelings toward a neutral person.</p><p>• Remember, LKM in RO DBT is less about extending love or kindness and more about activating our</p><p>social safety system.</p><p>• Use the script in handout 4.1 as a guide for practice or in making a digital recording of a loving kind-</p><p>ness practice to use on a daily basis. Practice each day prior to leaving your house. Record your experi-</p><p>ences using the following daily practice log.</p><p>Lesson 4: Enhancing Openness and Social Connection via Loving Kindness</p><p>113</p><p>Day What did I notice during the practice? How long did the social</p><p>safety experience last? How did it impact my day?</p><p>Sunday</p><p>Monday</p><p>Tuesday</p><p>Wednesday</p><p>Thursday</p><p>Friday</p><p>Saturday</p><p>Were there any obstacles that arose while practicing loving kindness meditation? Describe these and how you</p><p>used radical openness skills to deal with them.</p><p>LESSON 5</p><p>Engaging in Novel Behavior</p><p> If it’s not fun, then it’s not play. </p><p>Main Points for Lesson 5</p><p>1. Discovery requires openness and willingness not to always have an answer. The most effective people</p><p>in the world learn something new every day!</p><p>2. Learning new things usually involves making a mistake.</p><p>3. There are four stages we all go through when learning something new: unconscious incompetence,</p><p>conscious incompetence, conscious competence, and unconscious competence.</p><p>4. Use Flexible Mind VARIEs skills to try new things.</p><p>5. OC clients need to let go of always trying to perform better or try harder. Relaxing, playing, and being</p><p>nonproductive are skills that OC individuals need to practice.</p><p>6. Doing something new or different every day helps break down old habits and encourages spontaneity.</p><p>New behavior often opens up new horizons. It teaches our brain that it’s okay to not have everything</p><p>planned.</p><p>Materials Needed</p><p>• Handout 5.1 (Engaging in Novel Behavior: Flexible Mind VARIEs)</p><p>• Handout 5.2 (Using Experience to Examine Willingness to Learn)</p><p>• Handout 5.3 (The Art of Nonproductivity and Being Just a Little Bit Silly)</p><p>• Handout 5.4 (Are We Having Fun Yet? Self- Enquiry About Humor and Play)</p><p>• (Optional) Handout 5.5 (Main Points for Lesson 5: Engaging in Novel Behavior)</p><p>• Worksheet 5.A (Engaging in Novel Behavior: Flexible Mind VARIEs)</p><p>• Worksheet 5.B (Nonproductive and Novel Behavior Monitoring Log)</p><p>• Whiteboard or flipchart with marker</p><p>(Recommended) Mindfulness Practice</p><p>The Oompa- Loompa</p><p>Lesson 5: Engaging in Novel Behavior</p><p>115</p><p>Note to iNstructors: The Oompa- Loompa chant or dance is a “participate without planning”</p><p>mindfulness practice. In RO DBT, “participate without planning” practices do not begin with an orienta-</p><p>tion or forewarning of the upcoming practice. This is because talking about what is going to happen</p><p>usually triggers anticipatory anxiety and rumination, resulting in a greater chance for a client to refuse to</p><p>participate (see “Instructor Guidelines for ‘Participate Without Planning’ Practices,” in lesson 12).</p><p>Participating without planning is an essential skill for OC clients to learn how to join in with the com-</p><p>munity and feel like part of a tribe. Importantly, the Oompa- Loompa chant should be time- limited—</p><p>ideally it should last no longer than one minute. Use the following instructions as a guide.</p><p>• Begin the Oompa- Loompa by saying to the class (without any warning): OKAY…EVERYONE</p><p>STAND UP! NOW, DO WHAT I DO! NOW, BEND YOUR ARMS AND PUT ONE</p><p>FORWARD AND ONE BACK. Like this! Now start to move them back and forth!</p><p>• The instructor should then start to gently rock their arms from side to side and say: Now repeat</p><p>what I say next! The instructor should chant Just because you think it, doesn’t mean it’s true while</p><p>continuing to signal for everyone to join in.</p><p>• The coinstructor can demonstrate what is meant by immediately joining in with the movements</p><p>and chant.</p><p>• The instructor should continue to repeat the chant— Just because you think it, doesn’t mean it’s</p><p>true— while continually changing their body movements (for example, raising their hands above</p><p>their head, shaking them about, waving arms side to side like seaweed swaying in the ocean current,</p><p>slowing the speed and then speeding up). Pat the table lightly, then harder and louder while increasing</p><p>the volume of the chant, then slow everything down and slowly lower the volume to a whisper.</p><p>• Keep the chant and movement going the entire practice, with eyebrow wags and a warm smile.</p><p>• End the practice by raising your arms above your head and shouting Just because you think it,</p><p>doesn’t mean it’s TRUE!</p><p>• Celebrate with the class: Well done! Applause to all! Let’s give ourselves a hand! That is, encourage</p><p>class members to applaud their practice.</p><p>• Then say: Okay, everyone can sit down.</p><p>• Solicit observations and teach.</p><p>After the practice, ask participants to share what they observed, with a focus on thoughts they may have</p><p>had or predictions they may have made. For example, instructors can say, “Raise your hand if you had a</p><p>thought before or during the practice that said something like ‘I just won’t or I just can’t do this!’” Invariably,</p><p>several hands will be raised. The instructor should smile warmly and gently whisper, “Just because you think</p><p>it, doesn’t mean it’s true.” (Note: This highlights the importance of everyone in the class participating, at least</p><p>to some degree; otherwise, for those who did not participate, their prediction was actually accurate.) Instructors</p><p>can continue by saying, “What other thoughts did people have during the practice?” Examples might include</p><p>“I thought you were going to have us sing” or “I thought that I was going to die of embarrassment” or “I</p><p>thought someone would walk by outside and call the police.” After each inaccurate prediction or unwarranted</p><p>thought, instructors should simply repeat with a warm smile, “Just because you think it, doesn’t mean it’s true.”</p><p>Instructors should be prepared to share examples of their own inaccurate or unwarranted thoughts (for</p><p>example, “I had a fleeting thought of my boss walking in and wondering what I was up to”) and to then</p><p>encourage the class to reply by repeating the chant. Instructors should highlight that despite everyone think-</p><p>ing a wide range of things (for example, bad things), most predictions did not actually occur (for example,</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>116</p><p>despite thinking I would die, amazingly I am still alive). The phrase Just because you think it, doesn’t mean it’s</p><p>true should be remembered and used as a cue to remind participants that internal experiences (that is, thoughts,</p><p>sensations, images, or emotions) are not facts or truths.</p><p>(Required) Teaching Point</p><p>Why Engage in Novel Behavior?</p><p> We learn the most when approach what we fear the most. </p><p>> Ask: What are the advantages of trying out new things? What are the disadvantages?</p><p>• You can never learn anything new if you don’t take a risk.</p><p>• Novelty is the spice of life. For example, eating porridge every breakfast,</p><p>doing laundry on</p><p>Sunday, driving the same way to work, wearing the same clothes, walking the same speed on the</p><p>treadmill can sometimes get a little monotonous!</p><p>> Ask: What type of behaviors do you always do the same? How many of the behaviors are based on</p><p>rules? What are the consequences of always doing the same thing repeatedly?</p><p>• Discovery requires openness and willingness not to always have an answer. The most</p><p>effective people in the world learn something new every day!</p><p>• Learning new things usually involves making a mistake.</p><p>(Required) Teaching Point</p><p>How Do We Learn Something New?</p><p>• There are four stages we all go through when learning something new:</p><p>1. Unconscious incompetence, or not knowing that we don’t know. For example, all</p><p>of us, at one time in our life, did not know that we did not know how to tie our shoes. This is</p><p>unconscious incompetence.</p><p>2. Conscious incompetence, or knowing what it was that we didn’t know but not</p><p>knowing what to do about it. Eventually we became aware of the fact that shoes have bits</p><p>known as laces and, when tied together in what your big sister keeps referring to as a “knot” (not</p><p>to be confused with “snot,” tee hee ☺), they keep our shoes firmly attached to our feet! An</p><p>amazing discovery that has moved us to the second stage of learning a new skill: conscious incom-</p><p>petence, or becoming aware of one’s lack of knowledge.</p><p>3. Conscious competence, or knowing what to do but not being very proficient at</p><p>it when we do it. We can now tie our shoes! All by ourselves! But we are really slow. We have</p><p>to concentrate really hard on the steps involved, and sometimes we get it wrong. Plus, our big</p><p>sister’s smirk upon seeing one of our more creative knot- tying attempts is not particularly helpful.</p><p>4. Unconscious competence, or “We are so proficient, we don’t have to think about</p><p>it,” also known as “the expert.” Our hard work has paid off: we can tie our shoes like an</p><p>expert without ever having to think about it! We can tie our shoes in our sleep, in the dark, when</p><p>upside down, or even when talking to our big sister about how big her nose is (tee hee ☺)—</p><p>without ever missing a step! We are on top of the world!</p><p>Lesson 5: Engaging in Novel Behavior</p><p>117</p><p>• For many adults, the only stage they ever desire to experience or acknowledge being</p><p>in is the fourth stage— that is, the stage where it is often assumed that new learning is no longer</p><p>necessary.</p><p>> Ask: What are the downsides of being an expert? (Hint: Experts may be more closed- minded</p><p>because they assume they already know what the correct answer is when their knowledge is</p><p>challenged.)</p><p>> Ask: To what extent are you okay with the earlier stages of learning? What might this mean?</p><p>> Ask: What behaviors do you always do the same? How often do you think you keep things the same</p><p>in order to minimize the stress of not knowing? What is it that you might need to learn?</p><p>> Ask: How often have you thought that trying something new would be an awful experience, only to</p><p>discover that it wasn’t as bad as you had expected and/or that you might have even liked it (Oh my!</p><p>☺)— for example, eating oysters, riding a horse, going for a walk at night with your partner, giving a</p><p>toast, saying hi to someone?</p><p>• Remember, the goal of doing something you are not used to doing is to do something</p><p>you are not used to doing (tee hee ☺).</p><p>• Plus, “There’s nobody here but us chickens!” We are all scared when we try some-</p><p>thing new, but we are also scared when we don’t. Not doing impacts our well- being just as</p><p>much as doing. We can’t escape being affected by our own actions.</p><p>• Doing something new requires a willingness to tolerate uncertainty.</p><p>> Ask: How comfortable are you with uncertainty? With chaos? With disorder? What might your</p><p>answer tell you about what you need to learn?</p><p>• The good news is that we naturally feel more solid when we take on those things we</p><p>fear the most, and then learn from them.</p><p>• Practice Flexible Mind VARIEs to learn how to learn from novelty and reap the</p><p>benefits from behaving courageously (albeit without getting too uptight about it— tee hee ☺).</p><p>(Required) Teaching Point</p><p>Engaging in Novel Behavior: Flexible Mind VARIEs</p><p>Refer participants to handout 5.1 (Engaging in Novel Behavior: Flexible Mind VARIEs).</p><p>Note to iNstructors: Write out the acronym (VARIE) on a flipchart or whiteboard, with each</p><p>letter arranged vertically in a column, but without teaching or naming the specific skill that each letter</p><p>signifies. Next, starting with the first letter in the acronym (V in VARIE), teach the skills associated with</p><p>that letter, using the key points outlined in the following sections until you have covered all of the skills</p><p>associated with each individual letter. Importantly, only write out on the whiteboard or flipchart the</p><p>global description of what each letter actually stands for when you are teaching the skills associated with</p><p>it. This teaching method avoids long explanations about the use of certain words in the acronym and/or</p><p>premature teaching of concepts. The meaning of each letter is only revealed during the formal teaching of</p><p>the skills associated with it.</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>118</p><p>Flexible Mind VARIEs</p><p>V Verify one’s willingness to experience something new</p><p>A Check the Accuracy of hesitancy, aversion, or avoidance</p><p>r Relinquish compulsive planning, rehearsal, or preparation</p><p>i Activate one’s social safety system and then Initiate the new behavior</p><p>e Nonjudgmentally Evaluate the outcome</p><p>V Verify one’s willingness to experience something new.</p><p>• The most effective people in the world learn something new every day! They learn by</p><p>being open to change and trying out new things. Successful people are adaptive; they learn to adjust</p><p>to changing circumstances. (Instructors can use examples from competition TV, like American Idol or</p><p>Dancing with the Stars. For example, sometimes the judges with the toughest feedback are those who</p><p>the contestants can learn the most from, whereas the judges who say nice things to everyone don’t</p><p>really give contestants anything to go on.)</p><p>• Trying out new things involves active learning and practice. After falling off a horse, one</p><p>must ride again multiple times before feeling comfortable again. Similarly, to learn that new things can</p><p>be interesting, educational, or even fun, one must try them out first.</p><p>• To learn from something new, a person must be willing to open- mindedly experience</p><p>it. A genuine commitment for change represents the core difference between engaging in a new</p><p>behavior and simply thinking about it.</p><p>• Practice self- enquiry of willingness by asking…</p><p>¾ Will trying out this new behavior get me closer or farther away from my valued goals? What are my</p><p>expectations or predictions of what might happen if I tried out the new behavior? What do I fear might</p><p>happen if I did something different?</p><p>¾ To what extent do I really want to change or try something new? If low, what might this mean?</p><p>• With a closed- mouth smile, eyebrows raised, and slow deep breath, open and soften</p><p>while you imagine engaging in the new behavior, rather than tensing and resisting.</p><p>A Check the Accuracy of hesitancy, aversion, or urges to avoid engaging in the</p><p>new behavior in order to determine whether your emotions are warranted.</p><p>• Remember that self- discovery requires a willingness not to always have an answer.</p><p>• Remember that taking risks and making mistakes is how one learns. Learning new</p><p>things usually involves making a mistake; otherwise, you would already know how to do it! For</p><p>example, when truly engaged in learning how to play the violin, dance, or do calculus, one constantly</p><p>discovers new or better ways to perform the new behavior.</p><p>• Practice self- enquiry by asking…</p><p>¾ Do I believe that I already know the outcome of what might happen if I tried the new behavior?</p><p>Lesson 5: Engaging in Novel Behavior</p><p>119</p><p>¾ Do I believe that I know all of the facts in the situation</p><p>I am in? Do I find myself wanting to automatically</p><p>explain or defend my perceptions of the facts or discount the other person’s perceptions of the facts? If yes</p><p>or maybe, then is this a sign that I am in Fixed Mind?</p><p>¾ Am I saying to myself that I have already tried out the new behavior in the past and believe it useless to</p><p>try again? Do I believe it is unfair that I must do something different? If yes or maybe, then, what might</p><p>this mean? Is it possible I am operating from Fatalistic Mind?</p><p>¾ Is there a possibility that I may not really want to change how I behave or think? Do I secretly hope I will</p><p>fail when trying the new behavior? If so, how might this influence my ability to achieve my valued goals?</p><p>¾ Is it possible I am minimizing the positive consequences?</p><p>R Relinquish compulsive planning, rehearsal, or preparation prior to trying out</p><p>the new behavior.</p><p>Note to iNstructors: Most OC clients obsess about social events before they occur, especially</p><p>those that may require spontaneity or intimate exchanges (for example, a date, a party). Excessive plan-</p><p>ning and rehearsal when unneeded is energy- consuming; it can lead to burnout and exhaustion.</p><p>Discuss the pros and cons of planning and rehearsing beforehand.</p><p>> Ask: What types of behaviors or events is it best to plan or rehearse beforehand (for example, sky-</p><p>diving, horseback riding, a major speech, a presentation at a meeting)? What types of behaviors or</p><p>events is it best to not rehearse or plan beforehand (for example, a date, a party, lunch with a</p><p>friend)?</p><p>> Ask: Is preparation really needed for me to engage in this new behavior?</p><p>> If so: Mindfully research the steps needed to engage in the new behavior and prepare, with</p><p>an aim of not getting it perfect.</p><p>> If not: Purposefully decide to let go of planning and rehearsal. Practice turning your mind to</p><p>unrelated activities (for example, read an amusing book, take a soothing bath or nap, practice</p><p>mindful breathing, conduct a loving kindness meditation) and use the following skills.</p><p>• Remind yourself that compulsive planning or rehearsal may feel like wisdom but in</p><p>reality may masquerade as avoidance (for example, “I just need to read one more article, and</p><p>then I will be ready”).</p><p>• Practice loving your perfectionist tendencies rather than trying fix them or get rid of</p><p>them. Trying to rid oneself of perfectionistic thinking is like using mud to wash mud off your car— it</p><p>just makes matters worse. Be kind to yourself.</p><p>• Extend feelings of loving kindness toward the part of you that wants to rehearse or</p><p>plan ahead, rather than berating yourself. Repeat silently to yourself: May my perfectionistic</p><p>mind be at ease, may my perfectionistic mind be content, may my perfectionistic mind be safe and secure.</p><p>• Practice mindfully urge- surfing desires to rehearse what to say or do (see the material on</p><p>urge- surfing in lesson 12). Outside of formal lectures or speeches, rehearsing what you will say before-</p><p>hand often backfires— we stop listening to the people we are interacting with and become focused on</p><p>remembering our lines.</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>120</p><p>I Activate one’s social safety system and then Initiate the new behavior.</p><p>• Activate your social safety system before you engage in the new behavior. Use skills</p><p>from lesson 3; see handout 3.1 (Changing Social Interactions by Changing Physiology). Use a loving</p><p>kindness mediation to induce a long- lasting social safety mood state (see lesson 4).</p><p>• “Don’t think— just do!” Passionately participate by throwing yourself fully into the experience,</p><p>and keep turning your mind back to the experience. Remind yourself that you are learning how to</p><p>participate in life without always having to have everything planned. Turn your mind away from judg-</p><p>mental or worry thoughts.</p><p>• When engaging in the new behavior, repeatedly use the Big Three + 1 skills to keep</p><p>yourself in your social safety system (that is, lean back, deep breath, closed- mouth smile,</p><p>eyebrow wag).</p><p>• Feeling awkward when trying something new means you are learning, not that you</p><p>are doing something wrong or failing. New experience is the only way to grow— it is the oppo-</p><p>site of complacency.</p><p>• When experiencing discomfort, use this as an opportunity to practice self-enquiry by</p><p>asking How might I learn from this? rather than automatically falling apart or blaming the</p><p>world.</p><p>• If possible, repeat the new behavior, again and again, before you evaluate your</p><p>performance.</p><p>E Look back over what happened, and nonjudgmentally Evaluate the outcome.</p><p>• After initiating the new behavior, allow time to nonjudgmentally examine how things</p><p>went and what you learned from the experience. Use the Awareness Continuum (see lesson</p><p>12) to describe what happened, including the emotions, thoughts, or sensations you experienced</p><p>during the event.</p><p>• Practice noticing what went well and how you benefited from the experience, rather</p><p>than what you could have done better or what went wrong.</p><p>• Focus on the objective evidence supporting your observations when evaluating the</p><p>reactions of others. Remember that we can only imagine what another person is thinking or</p><p>feeling inside (if they have not revealed them to us).</p><p>• Practice self- enquiry by asking…</p><p>¾ What objective evidence do I have to support my conclusions about the event or the other person, other</p><p>than gut feeling or opinion?</p><p>¾ Is there a chance that I might be mistaken?</p><p>¾ To what extent am I willing to question my personal perceptions?</p><p>¾ What do I need to learn?</p><p>Lesson 5: Engaging in Novel Behavior</p><p>121</p><p>• Loosen Fixed Mind thinking by recalling “We don’t see the world as it is— we see the</p><p>world as we are.”</p><p>• Block automatic tendencies to blame others or the world. This means taking responsibility</p><p>for our personal reactions and responses instead of automatically expecting the world to conform to</p><p>our wishes.</p><p>• Block Fatalistic Mind thinking by reminding yourself, without falling apart or harsh</p><p>self- blame, that you choose how you respond to the world. RO recognizes that for the most</p><p>part we choose how we feel (that is, no one can force me to feel a particular emotion).</p><p>• Remember to practice frequently. Doing something new every day for overcontrolled</p><p>individuals is like brushing one’s teeth— it represents good mental health hygiene.</p><p>Whenever we do something new or different, we acquire new learning (for example, that it is okay not</p><p>to have everything planned, that making mistakes or embracing uncertainty is how we learn).</p><p>• Practice self- enquiry to examine how open you are to trying out new things, and dis-</p><p>cover any potential obstacles for growth.</p><p>Refer participants to handout 5.2 (Using Experience to Examine Willingness to Learn).</p><p>Instructors should randomly pick class members to read aloud a self- enquiry question (of their choosing)</p><p>from this handout and then briefly discuss the question. Then pick another class member to read aloud</p><p>another question, and so forth. Importantly, it is not necessary to cover (that is, read aloud) all of the ques-</p><p>tions; a few are usually sufficient to help expose participants to the handout (which is the point of reviewing</p><p>it). Encourage participants to get into the habit of using this handout after they practice Flexible Mind VARIEs</p><p>to further enhance their growth.</p><p>• Make time to reward yourself for trying something new, regardless of how you evalu-</p><p>ated your performance. Get into the habit of rewarding yourself every time you do something new</p><p>or different, whether you feel like you deserve a reward or not. The goal of Flexible Mind VARIEs is</p><p>not to be perfect but to learn.</p><p>• Experiment with new rewards rather than doing the same thing over and over again.</p><p>Examples include curling up for half an hour with a nonserious book, having a glass of wine, eating</p><p>one of your favorite chocolates, taking a long hot bath with aromatic candles, taking a nap, listening</p><p>to your favorite music while enjoying your</p><p>Grief Work:</p><p>Examples of Common Beliefs or Expectations 520</p><p>Radical Openness Handout 29.4 Main Points for Lesson 29: Learning to Forgive 522</p><p>Radical Openness Worksheet 29.A Flexible Mind Has HEART 523</p><p>Handout 30.1 The Asch Experiment 540</p><p>CHAPTER 1</p><p>Basic Principles, Treatment Overview, and</p><p>Global Structure of Skills Training Classes</p><p>Radically open dialectical behavior therapy (RO DBT) is an evidence- based treatment targeting a spectrum</p><p>of disorders characterized by excessive inhibitory control, or overcontrol (OC). It is intended for clinicians</p><p>treating clients with chronic problems such as refractory depression, anorexia nervosa, and obsessive- compulsive</p><p>personality disorder. Radical openness (RO) is the core philosophical principle and core skill in RO DBT. The</p><p>feasibility, acceptability, and efficacy of RO DBT are evidence- based, supported by more than twenty years of</p><p>clinical translational research experience as well as by five published trials and one large multicenter random-</p><p>ized controlled trial; for an overview, see Radically Open Dialectical Behavior Therapy: Theory and Practice for</p><p>Treating Disorders of Overcontrol (T. R. Lynch, 2018; this core source, to which the manual you are reading is</p><p>the companion, will be cited frequently throughout the manual, and so I will refer to it simply as “the RO DBT</p><p>textbook”). RO DBT research, training, and clinical work have been extended to differing age groups (adoles-</p><p>cents, older adults, young adults), differing disorders (anorexia nervosa, chronic depression, autism, OC per-</p><p>sonality disorders, treatment- resistant anxiety), differing cultures and countries (Europe, North America),</p><p>differing settings (forensic, inpatient, outpatient), and a wide range of differing providers (psychologists, nurses,</p><p>social workers, psychiatrists, family therapists, occupational therapists); a range of differing modalities has also</p><p>been developed and applied (skills alone, multifamily training, RO couples therapy). The primary aims of this</p><p>manual, in contrast to those of the RO DBT textbook, are to provide a detailed overview of underlying treat-</p><p>ment principles and clinical guidelines for assessing, targeting, and intervening with problems of overcontrol</p><p>and to provide a hands- on practical guide and the supporting materials needed to teach RO skills (referred to</p><p>throughout this manual simply as “RO skills”). The manual includes step- by- step teaching instructions, class</p><p>exercises, and clinical tips on how to manage maladaptive behavior in class, with a brief overview of the under-</p><p>lying theory and interventions that are detailed more fully in the RO DBT textbook. The client handouts and</p><p>worksheets for each RO skills lesson plan, available at http://www.newharbinger.com/39317, can be printed for</p><p>distribution to clients and/or modified as needed for a particular setting.</p><p>This chapter begins with a definition of overcontrolled coping, followed by a description of the RO DBT</p><p>therapeutic stance used when teaching RO skills. Next, principles for gaining commitment to attend RO skills</p><p>training classes are described, followed by a description of the overall structure for each RO lesson plan and an</p><p>overview of RO skills.</p><p>What Is Overcontrol?</p><p>Self- control— the ability to inhibit competing urges, impulses, behaviors, or desires and delay gratification in</p><p>order to pursue distal goals— is often equated with success and happiness. Indeed, inhibitory control is highly</p><p>valued by most societies, and failures in self- control characterize many of the personal and social problems</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>2</p><p>afflicting modern civilization. However, too much self- control can be equally problematic. Overcontrol has</p><p>been linked to social isolation, poor interpersonal functioning, hyperperfectionism, rigidity, risk aversion, lack</p><p>of emotional expression, and the development of severe and difficult- to- treat mental health problems, such as</p><p>chronic depression, anorexia nervosa, and obsessive- compulsive personality disorder.</p><p>Maladaptive overcontrol is posited to represent a personality style that results from transactions between</p><p>temperamental predispositions (nature) and family/environmental/cultural influences (nurture) that create a</p><p>style of coping characterized by excessive inhibitory control and aloof relationships (OC coping) that func-</p><p>tions to limit new learning, flexible responding, and the development of close social bonds. There are four</p><p>dimensions of infant temperament relevant to the “nature” component of this model:</p><p>1. Negative affectivity (threat sensitivity)</p><p>2. Positive affectivity (reward sensitivity)</p><p>3. Effortful control (self- control capacity)</p><p>4. Detail- focused (versus global) processing of stimuli</p><p>Children at risk for overcontrolled coping and social isolation are likely to have high threat sensitivity, low</p><p>reward sensitivity, high detail- focused processing, and high effortful control and are characterized by being</p><p>behaviorally inhibited, shy, timid, risk- avoidant, emotionally constrained; by having hyper- detail- focused pro-</p><p>cessing; and by and showing aloof/socially withdrawn behavior. By contrast, children at risk for pervasive</p><p>emotion dysregulation and behavioral dyscontrol (that is, undercontrolled coping) are likely to have high</p><p>threat sensitivity, low effortful control (Linehan, 2015a), and high reward sensitivity (T. R. Lynch, Hempel, &</p><p>Clark, 2015).</p><p>Yet, despite these inherent difficulties, overcontrolled coping is not always problematic. For example,</p><p>innate capacities to inhibit impulses, plan ahead, and delay gratification make OC clients the doers, savers,</p><p>planners, and fixers of the world. They are the guests who help clean up after the party and the people who</p><p>save for their retirement so as not to burden others. They strive for moderation in all aspects of their lives and</p><p>value honesty, fairness, and doing the right thing. They are the people you see working late at night and then</p><p>rising early to ensure that things work properly; they are the reason why trains run on time (see table 1.1). The</p><p>problem is that overcontrolled coping works well when it comes to sitting quietly in a monastery or building a</p><p>rocket, but it creates problems when it comes to social connectedness.</p><p>Table 1.1. Overcontrol Is Fundamentally Prosocial</p><p>OC Characteristic Prosocial Attribute</p><p>Ability to delay gratification Enables resources to be saved for times of less abundance</p><p>Desire to be correct, exceed expectations, and perform</p><p>well</p><p>Essential to communities’ ability to thrive and grow</p><p>Valuing of duty, obligation, and self- sacrifice Helps societies flourish and ensures that people in need</p><p>are cared for</p><p>Valuing of rules and fairness Helps societies remain balanced and enables resistance</p><p>to powerful but unethical individuals and harmful</p><p>societal pressures</p><p>Detail- focused processing and quick pattern recognition Increases precision and thus the likelihood that problems</p><p>will be detected and solved so that everything functions</p><p>properly</p><p>Basic Principles, Treatment Overview, and Global Structure of Skills Training Classes</p><p>3</p><p>For OC clients, their greatest strength is their greatest weakness. Too much self- control depletes the very</p><p>resources needed to override habitual self- control when doing so would be adaptive. A type of catch- 22</p><p>emerges: excessive self- control exhausts the resources needed to control excessive self- control, making it harder</p><p>for alternative ways of coping (such as taking a nap or asking for help) to emerge. Internally, OC clients may</p><p>feel like prisoners of self- control, and their natural tendency to inhibit (control) their expressions of emotion</p><p>makes it harder for others to know they are distressed and to offer assistance. Plus, maladaptive OC coping is</p><p>expressed discreetly. For example, an overcontrolled client is likely to downplay personal distress when queried,</p><p>making identification of the problem more difficult</p><p>favorite beverage, watching your favorite TV show, sitting</p><p>out in your garden and enjoying the sunshine. Of course, now that you have rewarded yourself for</p><p>doing something different, you need to reward yourself for rewarding yourself! (☺)</p><p>(Required) Teaching Point</p><p>Remembering How to Play: The Art of Nonproductivity and</p><p>Being Just a Little Bit Silly</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>122</p><p> Fun Facts: Born to Be Wild!</p><p>Humans are born with an innate capacity for play, and family/environmental/cultural experiences</p><p>shape how it is expressed over time. Indeed, play is a natural behavior among mammals (think of a</p><p>small kitten playing with a ball of yarn). Many OC clients consider play or having fun childish or</p><p>selfish. Archaeological records have shown that play and games have been a core part of human</p><p>experience since prehistoric times, supported by the existence of dice, gaming sticks, gaming boards</p><p>and various forms of ball- play material made of stones, sticks, and bones [S. J. Fox, 1977; Schaefer</p><p>& Reid. 2001]. Play allows us to focus on the means (that is, what we are doing) rather than the</p><p>ends (where we want to go) [Pellegrini, 2009]. It allows us a chance to repeat, practice, rehearse,</p><p>exaggerate, or experiment with a new behavior before it really matters (for example, war games).</p><p>Thus, play subsumes a vital role in the development of problem- solving skills in primates, and for</p><p>humans it also provides the practice grounds for a range of higher- order cognitive and social-</p><p>emotional skills essential for our success. One important caveat: If it’s not fun, then it’s not play. Be</p><p>careful to not take your play too seriously.</p><p>Note to iNstructors: OC clients are unlikely to genuinely believe it is socially acceptable for an</p><p>adult to play, relax, or openly express emotions unless they see their therapist model it first. Thus, therapists</p><p>(especially those leaning toward OC) may need to practice the skills outlined in the following section first</p><p>if they are going to effectively teach them.</p><p>Refer participants to handout 5.3 (The Art of Nonproductivity and Being Just a Little Bit Silly).</p><p>• “All work and no play makes Jack a dull boy!” Overcontrolled individuals don’t need to learn</p><p>to be more serious, try harder, or strive to do better! They are experts at this.</p><p>• If you are overcontrolled, you need to learn how to chill out and have a little fun!</p><p>• Being able to nonjudgmentally chuckle at our foibles is a sign of mental health and</p><p>essential for healthy relationships. It signals to the world that we don’t take ourselves too seri-</p><p>ously and that we will likely be open to feedback.</p><p>• Yet relaxing and playing can feel like hard work for an overcontrolled person!</p><p>> Ask: When was the last time you remember having fun, laughing freely, or being silly? What are the</p><p>benefits of play, laughter, or relaxing? How might playfulness benefit relationships? What do you</p><p>find amusing in life?</p><p>> Ask: What are the signs that tell you that you may need to take a break? What changes occur in</p><p>your body (for example, headaches)? Are there changes in how you relate to others (for example,</p><p>more aloof, isolation)?</p><p>> Ask: What does taking a break mean to you? Do you always do the same thing to reward yourself?</p><p>How much time do you allocate in your life for nonproductive activity (for example, taking a nap,</p><p>reading a novel, enjoying a walk)?</p><p>• The good news is that it is possible to relearn how to not always take life so seriously,</p><p>and to laugh and play!</p><p>Lesson 5: Engaging in Novel Behavior</p><p>123</p><p>• In the meantime, our motto can be “Fake it until you make it!” (tee hee ☺)</p><p>> Ask: Why do you think I said that?</p><p>Answer: Because doing some new or different may feel phony or fake at first, but it is the only</p><p>way to learn.</p><p>• Practicing new ways of expressing ourselves and moving our bodies helps break down</p><p>overlearned inhibitory barriers that impair social connectedness. Recall that research</p><p>shows that we become anxiously aroused when interacting with a nonexpressive person and we prefer</p><p>not to affiliate with them, whereas open expression of emotion— even when the emotion is negative—</p><p>signals genuineness and trustworthiness, and research shows that people prefer to spend time with</p><p>people who reveal their inner feelings to others.</p><p>• Plus, joining in communal activities sends a powerful message to our brain— namely,</p><p>that we are part of a tribe and have done nothing to be ashamed about, even when it</p><p>feels scary inside.</p><p>Note to iNstructors: After reviewing handout 5.3 (The Art of Nonproductivity and Being Just</p><p>a Little Bit Silly), instructors should immediately begin the following exercise, without any forewarning or</p><p>orientation.</p><p>(Required) Class Exercise</p><p>The Extremely Fun Extreme Expression Workshop</p><p>Note to iNstructors: Unless absolutely necessary, it is essential not to orient OC clients to this</p><p>exercise or forewarn them about it (see “Instructor Guidelines for ‘Participate Without Planning’ Practices,”</p><p>in lesson 12). If they are forewarned, they will be more likely to worry, focus on their anticipatory anxiety,</p><p>or go numb than listen to instructions, and their genuine participation will be less likely.</p><p>Note to iNstructors: Instructors should plan for five brief “participate without planning” prac-</p><p>tices, distributed randomly, during lesson 5. Each practice should last only thirty seconds to one minute,</p><p>ending with applause to celebrate tribal participation; see “Instructor Guidelines for ‘Participate Without</p><p>Planning’ Practices,” in lesson 12. Importantly, the practices used in the Extremely Fun Extreme Expression</p><p>Workshop should be randomly distributed throughout the lesson, not bunched together. The idea is to provide</p><p>multiple brief exposures to participating with others and being part of a tribe without thinking much</p><p>about it beforehand.</p><p>Extremely Fun Extreme Expression Practices</p><p>• With a warm smile say to the class: Okay…EVERYONE STAND UP! NOW, LET’S</p><p>CLAP OUR HANDS AND SAY HA HA…HO HO HO! Rhythmically clap your hands in</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>124</p><p>time with each sound of laughter: Ha ha…ho, ho, ha…ha ha…ho, ho, ho…ha, ha…ho, ho, ho…</p><p>ha, ha…ho, ho, ho! Repeat once. Encourage eye contact, use large gestures, and move with your</p><p>clapping sounds while encouraging the class to join you. Smile and use an eyebrow wag while</p><p>you look briefly into the eyes of every participant. Stop after thirty seconds to one minute and</p><p>say: Well done! Applause to all! Encourage all class members to give each other a round of</p><p>applause. Then quickly move to the next minipractice, before anyone has a chance to comment</p><p>or evaluate.</p><p>• Say to the class: Ohhhh, I’m a balloon! (Mimic blowing air into a balloon.) Phoof…phoof…</p><p>phoof… Say: Come on, blow up your balloon! Phoof…phoof…no, make it bigger…phoof…phoof…</p><p>phoof…OH NO…I’m deflating! Make movements of a balloon deflating… run around the room</p><p>in random ways…Phmmmm…blmmmm…ssssssss.…Ha ha ha ha ho ho ho ho…ha ha ha ho ho ho.</p><p>Be sure to make eye contact with every member of the class as you encourage them to blow</p><p>themselves up and then deflate. Then stop, have class members give themselves a round of</p><p>applause, and quickly move on to the next exercise, before anyone has a chance to comment</p><p>or evaluate.</p><p>• Practice “I’m NOT arrogant, I’m just better than you!” Say to the class: Okay…EVERYONE</p><p>STAND UP! NOW, DO WHAT I DO! Put your chin up in the air, shoulders back, and hold your</p><p>head high! Put a swagger in your gait! Instructors should start swaggering about and say: Now</p><p>shout Out of my way! Don’t you know who I am? I am a very important person! Just who</p><p>do you think you are? Hrrmmph! Keep marching about and hrrmmphing for another ten to</p><p>fifteen seconds. Instructors should end by clapping their hands in celebration, encouraging</p><p>class members to give themselves a round of applause, and saying: Well done! Okay, sit down,</p><p>and let’s</p><p>for clinicians (see the material about the “I am fine” phe-</p><p>nomenon in chapter 6 of the RO DBT textbook). The OC client feels like a stranger in a strange land, always</p><p>watching yet rarely participating.</p><p>Four Core Deficits</p><p>Maladaptive overcontrol is characterized by four core deficits:</p><p>1. Low receptivity and openness, manifested by low openness to novel, unexpected, or disconfirming feed-</p><p>back, avoidance of uncertainty or unplanned risks, suspiciousness, hypervigilance for potential threat,</p><p>and marked tendencies to discount or dismiss critical feedback</p><p>2. Low flexible control, manifested by compulsive needs for structure and order, hyperperfectionism, high</p><p>social obligation and dutifulness, compulsive rehearsal, high premeditation and planning, compulsive</p><p>fixing and approach coping, rigid rule- governed behavior, and high moral certitude (that is, the belief</p><p>that there is only one right way of doing something)</p><p>3. Pervasive inhibited emotional expression and low emotional awareness, manifested by context- inappropriate</p><p>inhibition of emotional expression (for example, exhibiting a flat face when complimented) and/or</p><p>insincere or incongruent expressions of emotion (for example, smiling when distressed, showing</p><p>concern when not feeling it), consistent underreporting of distress, and low awareness of body</p><p>sensations</p><p>4. Low social connectedness and intimacy with others, manifested by aloof and distant relationships, feeling</p><p>different from other people, frequent social comparisons, high envy and bitterness, and reduced</p><p>empathy</p><p>RO DBT Therapeutic Stance</p><p>Rather than focusing on what’s wrong with hyper- detail- focused perfectionists who tend to see mistakes every-</p><p>where (that is, OC clients), radically open dialectical behavior therapy begins by observing what’s healthy</p><p>(about all of us) and uses this to guide treatment interventions. Psychological health or well- being in RO DBT</p><p>is hypothesized to involve three core transacting features:</p><p>1. Receptivity and openness to new experience and disconfirming feedback, in order to learn</p><p>2. Flexible control, in order to adapt to changing environmental conditions</p><p>3. Intimacy and social connectedness (with at least one other person), based on premises that species</p><p>survival required capacities to form long- lasting bonds and to work in groups or tribes</p><p>The core idea is that OC clients are more likely to benefit from treatment approaches that prioritize the</p><p>value of seeking pleasure, relaxing control, and joining with others over approaches prioritizing emotion regu-</p><p>lation, nonavoidance, correcting deficits, and tolerating distress in order to achieve long- term goals.</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>4</p><p>Plus, the primary downsides of maladaptive overcontrol are social in nature. For example, both low open-</p><p>ness and pervasive constraint of emotional expression have been repeatedly shown to exert a negative impact</p><p>on the formation of close social bonds, leading to an increasing sense of isolation from others. OC clients suffer</p><p>from emotional loneliness— not lack of contact but lack of connection with others. Rather than focusing on how</p><p>to do better or try harder, the primary aim in RO DBT is to help OC clients learn how to rejoin their tribe and</p><p>establish strong social bonds with others. Consequently, the role of the therapist in RO DBT can be likened to</p><p>that of a tribal ambassador who metaphorically encourages socially isolated OC clients to rejoin their tribe by</p><p>communicating, “Welcome home. We appreciate your desire to meet or exceed expectations and the self-</p><p>sacrifices you have made. You have worked hard and deserve a rest” (see “The Therapist as Tribal Ambassador,”</p><p>in chapter 6 of the RO DBT textbook).</p><p>As ambassador, the RO skills instructor adopts a stance that models kindness, cooperation, and playful-</p><p>ness rather than fixing, correcting, restricting, or improving. Plus, ambassadors don’t expect people they inter-</p><p>act with in other countries to think, feel, or act the way they do, or to speak the same language. Ambassadors</p><p>reach out toward those who are different and learn their customs and language, without expecting anything</p><p>in return. Thus, RO skills training instructors are humble, working hard to find a common language with their</p><p>clients, without assuming that their perspective as instructors is necessarily the correct one. Ambassadors are</p><p>also face savers: they allow other people (or countries) to admit to some fault, without rubbing their noses in</p><p>it. They take the heat off when things get extremely tense during negotiations by allowing others (and them-</p><p>selves) the grace of not having to understand, resolve, or fix a problem or issue immediately. Yet ambassadors</p><p>also recognize that sometimes kindness means telling good friends painful truths in order to help them achieve</p><p>their valued goals in a manner that acknowledges the ambassador’s own potential for fallibility. “Therapist as</p><p>tribal ambassador” principles are represented throughout the RO DBT treatment assumptions, described next.</p><p>Basic Assumptions</p><p>Broadly speaking, treatments differ by what is targeted for change (for example, neurochemical deficiencies,</p><p>maladaptive schemas, lack of metacognitive awareness, dysregulated emotion, avoidant coping, childhood</p><p>trauma, or, in the case of RO DBT, social signaling deficits). Yet treatments also differ philosophically (in terms</p><p>of assumptions about the nature of reality, truth, free will, personal responsibility, optimal health, illness,</p><p>morality, social responsibility, and the role of health care providers). Importantly, from an RO DBT perspec-</p><p>tive, assumptions about treatment are not truths but guiding principles of behavior. The following assumptions</p><p>are most relevant to RO skills training.</p><p>• RO DBT defines psychological well- being as involving the confluence of three factors: receptivity, flex-</p><p>ibility, and social connectedness.</p><p>• RO DBT highlights our tribal nature; it prioritizes the importance of social connectedness as essential</p><p>for individual well- being and species survival.</p><p>• Social signaling matters! Deficits (not excesses) in genuine prosocial signaling represent the core</p><p>problem for disorders of overcontrol and are posited to be the source of OC clients’ emotional</p><p>loneliness.</p><p>• Radical openness assumes that we don’t see things as they are but that we see things as we are.</p><p>• Radical openness involves a willingness to question ourselves when challenged, in order to learn, by</p><p>asking What is it that I might need to learn?</p><p>• RO skills instructors recognize that radical openness is not something that can be grasped solely via</p><p>intellectual means, and they practice RO skills and self- enquiry themselves in order to model and</p><p>teach key principles more effectively to their clients.</p><p>Basic Principles, Treatment Overview, and Global Structure of Skills Training Classes</p><p>5</p><p>• RO skills instructors take responsibility for their emotional reactions, personal perceptions, and overt</p><p>behavioral responses, without falling apart or automatically blaming themselves or others, in order to</p><p>encourage their OC clients to practice similarly.</p><p>• RO DBT encourages clients to celebrate problems as opportunities for growth rather than obstacles</p><p>that block personal well- being.</p><p>• RO skills instructors recognize that it is arrogant to assume that they can ever fully understand their</p><p>clients, and yet they continue to strive to do so anyway.</p><p>• RO skills instructors recognize that OC clients are often suffering, even though they may not always</p><p>show it.</p><p>• RO skills instructors recognize that OC clients take life too seriously and that, rather than needing to</p><p>learn how to be better or work harder, they need to learn how to relax, play, and laugh at their mis-</p><p>takes, with kindness.</p><p>• RO skills instructors recognize that OC clients will not believe it is socially acceptable for someone to</p><p>openly play, relax, or disinhibit unless they see their therapists model</p><p>this behavior first.</p><p>• RO skills instructors recognize that alliance rupture repairs are best done outside of class— for</p><p>example, during break or after class.</p><p>• RO skills instructors encourage class members to practice celebrating obstacles as opportunities for</p><p>self- discovery and self- enquiry.</p><p>• RO skills instructors encourage engagement in conflict rather than automatic abandonment, and</p><p>candid disclosure and uninhibited expression of emotion rather than constrained or carefully regu-</p><p>lated expressions.</p><p>The Primary Mechanism of Change: Social Signaling</p><p>RO DBT introduces a unique thesis regarding the mechanism by which overcontrolled behavior leads to psy-</p><p>chological distress by linking neuroregulatory theory and the communicative functions of emotional expres-</p><p>sion to the formation of close social bonds. A central component of this mechanism is that heightened</p><p>biotemperamental threat sensitivity makes it more difficult for individuals with overcontrol to enter into their</p><p>neurobiologically based social safety system (T. R. Lynch et al., 2013; T. R. Lynch, Hempel, & Dunkley, 2015).</p><p>Feeling safe activates an area of the brain (the ventral vagal complex of the parasympathetic nervous system)</p><p>associated with contentment, friendliness, and social engagement via innervation of muscles involved with</p><p>modulating voice tone, making appropriate facial expressions, listening to human speech, and maintaining eye</p><p>contact (Porges, 1995, 2001). When an organism feels safe, it naturally experiences a desire to affiliate with</p><p>others and finds it easy to socially signal inner experience and empathically engage with others. However,</p><p>when the environment is perceived to be threatening, defensive arousal and fight- or- flight responses become</p><p>dominant, and social safety responses and capacities for signaling genuine cooperation become impaired (for</p><p>example, when stressed out, we can only fake a genuine smile). Thus, overcontrolled biotemperamental threat</p><p>sensitivity and sympathetic nervous system– mediated withdrawal of social safety responses, combined with</p><p>overlearned tendencies to mask inner feelings, are hypothesized to engender social ostracism and loneliness,</p><p>thereby exacerbating psychological distress. These observations help articulate the unique suffering associated</p><p>with OC coping: natural tendencies to mask inner feelings lead to the very problem they were developed to</p><p>prevent (that is, people prefer to not interact with OC individuals and see them as inauthentic). Thus, for OC</p><p>clients, superior capacities for self- control represent both a blessing and a curse. OC clients’ capacity for inhibi-</p><p>tory control allows them to delay gratification and work harder than most others, yet compulsive self- control</p><p>and hyper- detail- focused processing often negatively impact their relationships and their sense of well- being.</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>6</p><p>Importantly, RO skills instructors are no less susceptible to these reciprocal inhibitory influences than</p><p>other people. Consequently, instructors must learn to go opposite to automatic urges to shut down, freeze, or</p><p>mimic the inhibited expressions that can sometimes be exhibited by an OC client class. In my experience, the</p><p>emotion most likely experienced by therapists in these situations is humiliation (that is, low- level shame),</p><p>which triggers automatic action urges to hide and thoughts that one is behaving inappropriately (for example,</p><p>when requesting group participation). Therapists should block automatic response tendencies to inhibit or</p><p>constrict expressions when this occurs by freely revealing their emotions/thoughts to the group in a manner</p><p>that signals to themselves and others that there is nothing to be ashamed of (for example, eyebrow wags, large</p><p>gestures, half smiles, relaxed posture, use of humor). This approach, when used repeatedly by a skills instructor,</p><p>is posited to reduce unjustified shame, signal to the group that emotional expression is not dangerous, and</p><p>promote social safety via micromimicry.</p><p>Moreover, instructors are encouraged to practice outing themselves by demonstrating their willingness to</p><p>not take themselves too seriously, via humorous or self- effacing revelations of personal quirks or fallibilities.</p><p>Skills instructors should be mindful that biotemperamental predispositions make it harder for an OC client to</p><p>benefit from the potentially rewarding experience of social interactions (see chapter 2). Thus, it is essential for</p><p>instructors to encourage OC clients to use RO skills designed to activate the social safety system prior to prac-</p><p>ticing interpersonal skills (see Radical Openness Handout 3.1: Changing Social Interactions by Changing</p><p>Physiology). Finally, instructors should be prepared to reference and encourage the use of other RO skills that</p><p>are interpersonally focused when teaching interpersonal skills— for example, being open to critical feedback</p><p>(Flexible Mind ADOPTS), revealing rather than masking inner feelings (Flexible Mind ALLOWs), forgive-</p><p>ness of self and others (Flexible Mind Has HEART), and learning how to validate others (Flexible Mind</p><p>Validates). The vast majority of RO skills outlined in this manual have been derived from these core theoreti-</p><p>cal perspectives.</p><p>Treatment Structure and Targets</p><p>Although RO DBT has been researched and applied clinically in a wide range of settings (inpatient, day hos-</p><p>pital, and skills alone), the approaches outlined in this manual are derived primarily from an outpatient model</p><p>of treatment delivery. The RO DBT outpatient treatment protocol consists of weekly one- hour individual</p><p>therapy sessions and weekly two- and- a- half- hour skills training classes occurring over a period of approxi-</p><p>mately thirty weeks. Telephone coaching of skills and/or availability of therapists outside of individual therapy</p><p>and weekly therapist consultation/supervision meetings are recommended but not required. RO DBT recog-</p><p>nizes that clinicians and treatment settings may need to adjust this recommended structure as a function of an</p><p>individual client’s needs and/or environmental constraints— for example, by adding individual therapy ses-</p><p>sions, allowing clients to repeat skills training classes, or pragmatically adjusting to environmental/financial</p><p>constraints.</p><p>The key for effective treatment targeting when treating problems of overcontrol is not to focus solely on</p><p>inner experience (such as dysregulated emotion, maladaptive cognition, lack of metacognitive awareness, or</p><p>past traumatic memories) as the source of OC suffering. Instead, RO DBT targets indirect, masked, and con-</p><p>strained social signaling as the primary source of OC clients’ emotional loneliness, isolation, and misery.</p><p>Robust research shows that context- inappropriate suppression of emotional expression or incongruent expres-</p><p>sion of emotion (that is, what is expressed outwardly does not match inner experience) is more likely to be</p><p>perceived as untrustworthy or inauthentic (Boone & Buck, 2003; English & John, 2013; Kernis & Goldman,</p><p>2006) and to be associated with reduced social connectedness (Mauss et al., 2011). Indirect social signals</p><p>interfere with social connectedness because they make it harder to know the sender’s true intentions (for</p><p>example, a furrowed brow can reflect intense interest or disagreement). Crucially, in comparison to nonsup-</p><p>pressors, chronic inhibitors of emotional expression report experiencing themselves as inauthentic and as</p><p>misleading others about their true selves (Gross & John, 2003). Yet indirect or disguised social signals are</p><p>Basic Principles, Treatment Overview, and Global Structure of Skills Training Classes</p><p>7</p><p>powerful because they allow the sender to influence others without having to admit it— that is, they contain</p><p>plausible deniability: “What? Me, angry? No, I’m just being quiet” or “Don’t worry— I like you. The reason I</p><p>never laugh at your jokes is simply because I don’t find them funny.”</p><p>RO</p><p>DBT uses a three- step process to address indirect communication and disguised demands. First, the</p><p>individual therapist introduces the problem of masking inner feelings during the orientation and commitment</p><p>phase of treatment (ideally, in the third session; see the RO DBT textbook), thereby setting the stage for future</p><p>targeting. Second, to facilitate the identification of indirect social signaling targets, therapists are encouraged</p><p>to repeatedly ask themselves, throughout the course of treatment, How might my OC client’s social signaling</p><p>impact social connectedness? In addition, OC clients are encouraged to collaboratively join with their therapists</p><p>(or skills trainers) in developing a sense of curiosity about their style of social signaling, using self- enquiry.</p><p>Examples of self- enquiry questions relevant for OC clients include those that follow:</p><p>• To what extent am I proud of the way I communicate my emotions, intentions, and beliefs? Would I</p><p>encourage another person or a young child to behave similarly? What might this tell me about my</p><p>valued goals?</p><p>• What is it that I need to learn from how I communicate my needs, wants, and desires to others? To</p><p>what extent am I willing to truly examine my social signaling behaviors? What might this tell me?</p><p>• What prevents me from directly asking the other person for what I need or want? What might this tell</p><p>me about my relationship with this person or how I perceive myself? What is it that I might need to</p><p>do differently, change, or learn?</p><p>Third, RO skills training classes explicitly address maladaptive indirect social signaling by teaching skills</p><p>designed to specifically modify them (for example, Flexible Mind REVEALs skills; see lesson 16). Candid</p><p>labeling and skills training publicly expose what is often a well- kept secret, making it harder for socially con-</p><p>scientious OC clients to continue pretending (to others and themselves) that their indirect style of social sig-</p><p>naling is nonexistent or not a problem (or perhaps an appropriate way to behave). Essentially, by naming the</p><p>problem aloud, OC clients lose their shield of plausible deniability, prompting prosocial behaviors linked to</p><p>values for truthfulness, fairness, and doing the right thing and motivating the practice of new RO skills linked</p><p>to direct and candid expression of emotion.</p><p>Individual Therapy Treatment Target Hierarchy</p><p>Individual therapy treatment targets are organized hierarchically into three broad categories:</p><p>1. Severe and imminent life- threatening behaviors</p><p>2. Therapeutic alliance ruptures</p><p>3. Maladaptive OC social signaling linked to five OC behavioral themes (see figure 1.1)</p><p>The RO DBT textbook describes in detail treatment interventions for each level of this hierarchy.</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>8</p><p>Life-Threatening</p><p>Behavior</p><p>Suicidal ideation and/or</p><p>behavior</p><p>Self-injury</p><p>Alliance Ruptures</p><p>Client feels misunderstood</p><p>Client perceives therapy as</p><p>irrelevant to problems</p><p>Client not engaged</p><p>Changes in movement, speed, or</p><p>flow of client's in-session behavior</p><p>OC Behavioral Themes</p><p>Inhibited and disingenuous emotional expression</p><p>Hyper-detail-focused and overly cautious behavior</p><p>Rigid and rule-governed behavior</p><p>Aloof and distant style of relating</p><p>High social comparisons, envy, and/or bitterness</p><p>Figure 1.1. Individual Treatment Target Hierarchy for Disorders of Overcontrol</p><p>RO Skills Training: Global Aims and Targets</p><p>The primary aim of RO skills training is to impart new knowledge and encourage self- discovery (that is, to</p><p>educate rather than heal). RO skills training instructors are encouraged to adopt a teaching style that parallels</p><p>the enthusiasm, passion, and curiosity exhibited by the best teachers around the world. The best teachers love</p><p>to learn! They are both highly knowledgeable and humble about the subjects they teach. They encourage the</p><p>student to challenge what they expound, and they are delighted when the student surpasses their personal</p><p>understanding. From an RO DBT perspective, this requires RO skills trainers to practice what they preach</p><p>(that is, to have direct experience with applying the RO skills in their own lives).</p><p>Since the primary aim of RO skills training is to teach skills, it occurs in a classroom, and the skills train-</p><p>ing component of the treatment is referred to as an RO skills training class, in order to differentiate it from</p><p>group therapy or process groups. This use of language is purposeful. It helps remind reluctant OC clients of</p><p>their prior success in educational settings (see “Orientation and Commitment,” in chapter 4 of the RO DBT</p><p>textbook, and “Enhancing Client Engagement via Orientation and Commitment,” in chapter 5 of the RO</p><p>DBT textbook).</p><p>Similar to individual RO DBT, treatment targets and aims in RO skills training classes can be arranged</p><p>according to a hierarchy (see figure 1.2). The hierarchy helps guide instructors’ behavior and attention, both</p><p>during actual classroom teaching and outside of class. The hierarchy also discriminates among (maladaptive)</p><p>behaviors that can be ignored, those that should be ignored in class but addressed in private, and those that</p><p>must be addressed in class. For example, rather than publicly admonishing a late- arriving client or automati-</p><p>cally assuming nonparticipation to mean nonengagement, an RO skills instructor is likely to give the client the</p><p>benefit of the doubt in class while addressing the client’s nonparticipation directly in private. In addition, RO</p><p>DBT skills classes are not intended to provide a forum for class members to practice giving each other critical</p><p>or interpersonal feedback, share unrelated stories, reminisce about the past, or tell others how they should cope</p><p>Basic Principles, Treatment Overview, and Global Structure of Skills Training Classes</p><p>9</p><p>with a problem (see chapter 3 for detailed strategies). Finally, in RO DBT there is not a formal list of class rules;</p><p>indeed, it is considered unnecessary or even iatrogenic to formally review a list of rules regarding classroom</p><p>behavior (see chapter 3 for a clinical example of how class rules can become a problem).</p><p>Teach Radical</p><p>Openness Skills</p><p>Social signaling</p><p>Openness</p><p>Flexible responding</p><p>Social connectedness</p><p>Attend to "Big" Maladaptive</p><p>Social Signals in Class</p><p>"Don't hurt me" responses</p><p>Personal attacks</p><p>Noncompletion of homework</p><p>Target All Other Maladaptive Behaviors in Private</p><p>via Therapeutic Induction of Social Responsibility</p><p>Lateness</p><p>Nonparticipation</p><p>Therapeutic alliance ruptures</p><p>Figure 1.2. RO Skills Training Target Hierarchy</p><p>Orienting OC Clients to RO Skills Training</p><p>Clients should, ideally, begin attending RO skills training class in the third week of individual RO DBT</p><p>therapy. Thus, during the second session, individual therapists should briefly outline the rationale and struc-</p><p>ture of RO skills training classes and obtain commitment to attend the very next scheduled class (see</p><p>“Orientation and Commitment,” in chapter 4 of the RO DBT textbook). Therapists should emphasize that the</p><p>primary purpose of RO skills training is to learn new skills, not to process inner feelings, practice giving others</p><p>feedback, or disclose highly personal information. It is important for therapists to refer to RO skills training as</p><p>a class, not a group. Referring to RO skills training as a class not only more accurately reflects its primary func-</p><p>tion (that is, learning new skills) but also helps reduce automatic avoidance by an OC client who has negative</p><p>memories of group activities and/or failed group therapy experiences.</p><p>Class attendance should be discussed in a manner that suggests that doing anything else would be irratio-</p><p>nal, since learning new skills and new ways of coping is the essence of the treatment. Therapists should adopt</p><p>a stance that assumes class attendance rather than one that assumes they will need to convince or persuade</p><p>the OC client to attend. The attitude needed is similar to one adopted by a nurse</p><p>in a hospital who asks a</p><p>client to undress and put on a hospital gown before surgery; despite the fact that most people experience</p><p>anxiety or mild embarrassment when asked to do this, the nurse, via a relaxed and matter- of- fact tone, com-</p><p>municates that the request is a routine part of treatment, not a problem.</p><p>Well- intentioned attempts by a therapist to prepare an OC client who reports social anxiety at the thought</p><p>of attending an RO skills training class (for example, by teaching emotion regulation or relaxation skills</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>10</p><p>beforehand) can inadvertently signal that the client’s fear is justified and can unnecessarily lengthen the com-</p><p>mitment process, sometimes by months. It’s like telling someone who has arrived for horseback riding lessons</p><p>that horses aren’t dangerous while placing full- body armor and a helmet on this person just prior to the first</p><p>ride. Therapists’ fears and concerns can be exacerbated by the opinions of other professionals, or by stories</p><p>from family members pertaining to clients’ past negative reactions to requests for change.</p><p>Rather than assuming resistance, RO DBT therapists should adopt a nondefensive, noncoercive, and non-</p><p>apologetic stance, similar to the positive yet firm attitude displayed by the character Mary Poppins in the 1964</p><p>Disney film of the same name, that signals confidence in OC clients’ innate ability to attend skills training</p><p>classes. The core idea when working with an OC client is to remember that presuming the client’s competence</p><p>engenders competent behavior in the client. It works because it signals positive belief (“a spoonful of sugar”)</p><p>in the OC client’s innate competencies and assumes class attendance (“the medicine”) as irrefutable while</p><p>ignoring (placing on an extinction schedule) any indirect social signals from the OC client suggesting other-</p><p>wise (see the material about “pushback” and “don’t hurt me” responses in lesson 16). Indeed, most OC clients</p><p>are highly aware of their superior capacities for self- control— they already know that they can endure distress</p><p>or physical pain without complaint, if they decide to, and they are highly aware of their innate capacities to</p><p>resist impulses (such as desires to eat), delay gratification, or not to speak to someone they live with for hours,</p><p>days, weeks, or even years, simply because they have decided to do so. Their innate capacity for control is what</p><p>makes them difficult to treat and interpersonally powerful (albeit this may be a carefully guarded secret). In</p><p>order to help reluctant OC clients achieve their full potential, RO DBT embraces OC clients’ innate capacity</p><p>for superior self- control while simultaneously noting their core values linked to doing the right thing, behaving</p><p>with integrity, and honoring their prior commitments.</p><p>However, successful implementation of these principles can sometimes require therapists to practice self-</p><p>enquiry regarding their personal reactions or the beliefs they may hold about their role as therapist, their beliefs</p><p>about what comprises effective therapy, and/or the beliefs and attitudes they may have regarding their clients.</p><p>Therapists should be alert for strong desires to prepare, soothe, or behave cautiously when introducing the</p><p>necessity of attending RO skills classes to an OC client and should use this as an opportunity for self- growth.</p><p>Examples of self- enquiry questions include those that follow:</p><p>• What do I fear may happen if I do not behave cautiously with this client?</p><p>• Is it possible that I am assuming the client is fragile or incompetent?</p><p>• Why do I believe it to be so important to prepare this client for class participation?</p><p>• Is it possible that I have been subtly shaped by my prior experiences or by this client to assume that</p><p>skills classes will prove extremely difficult for the client?</p><p>In summary, rather than assuming incapability, therapists should remind OC clients that they already</p><p>have a great deal of experience in similar situations (that is, they have attended school and participated in</p><p>structured classroom activities). Attending an RO skills training class is like going back to school— the focus</p><p>will be on the material being taught, not on the individual being taught. OC clients’ superior capacities for</p><p>self- control and their prior experiences in classroom settings function as proof of their ability to attend an RO</p><p>class as well.</p><p>Finally, the structure of this manual assumes an outpatient setup, with either open or closed groups. In an</p><p>open group setup, a client can join the skills group at any time (with the exception of RO Integration Week,</p><p>lesson 30; see also chapter 4 for instructions on using this manual). In a closed group, all clients start with</p><p>lesson 1 at the same time, and new clients wait until a new group starts. However, it should be noted that RO</p><p>skills training lessons can be used flexibly to suit treatment providers’ needs and/or limitations. For example,</p><p>RO skills have been successfully applied in inpatient, day hospital, and forensic settings (T. R. Lynch et al.,</p><p>2013; Keogh, Booth, Baird, & Davenport, 2016) as well as with adolescents and families (Simic, Stewart,</p><p>Hunt, Konstantellou, & Underdown, 2016) and as an augmentation strategy (Chen et al., 2015).</p><p>Basic Principles, Treatment Overview, and Global Structure of Skills Training Classes</p><p>11</p><p>Structuring RO Skills Training Classes</p><p>This manual contains twenty new skills compressed into thirty lessons (or weeks), with RO mindfulness skills</p><p>repeated once (see table 1.2). Whenever possible, instructors should look for opportunities to link each new</p><p>skill with clients’ valued goals linked to social connectedness. For example, when reviewing homework, an</p><p>instructor might ask a client the extent to which a new skill impacted the client’s relationships.</p><p>Table 1.2. RO Skills Training, Weeks 1– 30</p><p>Week/</p><p>Lesson</p><p>Title of Lesson</p><p>1 Radical Openness</p><p>2 Understanding Emotions</p><p>3 Activating Social Safety</p><p>4 Enhancing Openness and Social Connection via Loving Kindness</p><p>5 Engaging in Novel Behavior</p><p>6 How Do Emotions Help Us?</p><p>7 Understanding Overcontrolled Coping</p><p>8 Tribe Matters: Understanding Rejection and Self- Conscious Emotions</p><p>9 Social Signaling Matters!</p><p>10 Using Social Signaling to Live by Your Values: Flexible Mind Is DEEP</p><p>11 Mindfulness Training, Part 1: Overcontrolled States of Mind</p><p>12 Mindfulness Training, Part 2: The “What” Skills</p><p>13 Mindfulness Training, Part 3: The Core Mindfulness “How” Skill: With Self- Enquiry</p><p>14 Mindfulness Training, Part 4: The “How” Skills</p><p>15 Interpersonal Integrity, Part 1: Saying What We Really Mean</p><p>16 Interpersonal Integrity, Part 2: Flexible Mind REVEALs</p><p>17 Interpersonal Effectiveness: Kindness First and Foremost</p><p>18 Being Assertive with an Open Mind</p><p>19 Using Validation to Signal Social Inclusion</p><p>20 Enhancing Social Connectedness, Part 1</p><p>21 Enhancing Social Connectedness, Part 2</p><p>22 Learning from Corrective Feedback</p><p>23 Mindfulness Training, Part 1: Overcontrolled States of Mind (Repeated from Lesson 11)</p><p>24 Mindfulness Training, Part 2: The “What” Skills (Repeated from Lesson 12)</p><p>25 Mindfulness Training, Part 3: The Core Mindfulness “How” Skill: With Self- Enquiry (Repeated from</p><p>Lesson 13)</p><p>26 Mindfulness Training, Part 4: The “How” Skills (Repeated from Lesson 14)</p><p>The Skills Training Manual for Radically Open Dialectical Behavior Therapy</p><p>12</p><p>27 Envy and Resentment</p><p>28 Cynicism, Bitterness, and Resignation</p><p>29 Learning to Forgive</p><p>30 RO Integration Week</p><p>Each skills training session is designed to occur within a two- and- a- half- hour time frame, including home-</p><p>work review, a brief break, and new teaching. Paper copies of handouts and worksheets are considered essential</p><p>to the learning process and should be made available during skills training classes. No later than the day of the</p><p>first class, each participant should be provided with an RO skills training folder containing copies of all</p>
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