Uses behavioral principles Uses behavioral principles

Uses dialectical philosophy Uses dialectical philosophy

Developed for undercontrolled clients Cluster B “dramatic erratic” personality styles, mainly borderline and antisocial PD Developed for overcontrolled clients Clusters A and C “overcontrolled” personality styles (e.g., avoidant, obsessive compulsive, paranoid and schizoid PDs, but also chronic depression and anorexia nervosa)

Client has anxious attachment style Seeks attachment with therapist and fears abandonment Client has avoidant attachment style Does not seek attachment with therapist and abandons relationship easily, especially when there is conflict

Core problem Emotion dysregulation, poor impulse control Core problem Social signaling deficits, low openness, and aloofness

Suicide and self-harm Undercontrolled (UC) clients engage in self-harm and suicide at high rates UC client suicide and self-harm is usually mood-dependent and unplanned

UC clients do not keep their self-harming behavior a secret

UC self-harm and/or suicidal behavior is mood-dependent and impulsive Suicide and self-harm Overcontrolled (OC) clients engage in self-harm and suicide at high rates OC client suicide and self-harm is usually planned

OC self-harming behavior is usually a well-kept secret

OC self-harm and/or suicidal behavior is more likely to be rule-governed rather than mood-governed—e.g., to restore their faith in a just world by punishing themselves for perceived wrongs

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

Therapeutic stance Therapist uses external contingencies, including mild aversives, takes a direct stance in order to stop dangerous, impulsive behavior Therapeutic stance Therapist is less directive, encourages independence of action and opinion, emphasizes self-enquiry and self-discovery

Teaches the therapist How to use external contingencies to help the client gain control and discover the reinforcing consequences of impulse control Teaches the therapist How to use social signaling to enhance client engagement and model vulnerability and connectedness

Primary therapeutic focus Internal: emotion regulation skills, gaining behavioral control, and distress tolerance Primary therapeutic focus External: social-signaling, openness, and social connectedness skills

Teaches How to avoid conflict, be more organized, restrain impulses, delay gratification and tolerate distress (skills already over learned or engaged in compulsively by most OC individuals) Teaches Clients to increase openness, flexible responding, enhance social connectedness, and vulnerable expression of emotion

External contingencies, including mild aversives, help the client gain control and discover the reinforcing consequences of impulse control Emphasis is on self-enquiry and self-discovery rather than impulse control

Therapist may encourage brief disengagement from conflict to reduce/avoid escalation Therapist encourages engagement if a conflict exists rather than automatic abandonment or avoidance

Therapist rewards regulated and measured expression of emotions and thoughts Therapist rewards candid disclosure and uninhibited expression of emotion

Treatment target hierarchy Life-threatening behavior—e.g., suicide and self-harm behaviors Therapy-interfering behaviors Quality-of-Life interfering behaviors Mental health related dysfunctional response pattern (e.g., other severe DSM Axis I & IV Disorders)

High risk or unprotected sexual behavior

Extreme financial difficulties

Criminal behaviors that may lead to jail

Seriously dysfunctional interpersonal behaviors

Employment or school related dysfunctional behaviors

Physical health dysfunctional behaviors

Housing related dysfunctional behaviors Treatment target hierarchy Life-threatening behavior—e.g., suicide and self-harm behaviors Therapeutic-alliance ruptures Maladaptive OC social signaling stemming from over control Inhibited and disingenuous emotional expression

Hyper detailed focus and overly cautious behavior

Rigid and rule governed behavior

Aloof and distant style of relating

High social comparisons, envy, and bitterness

Prioritizes therapy interfering behaviors Positioned second in the treatment hierarchy, therapy interfering behaviors are seen as problems necessitating change Prioritizes therapeutic alliance ruptures Positioned second in the treatment hierarchy, alliance ruptures are seen as opportunities for growth – thus are welcomed

Mindfulness practices informed by Zen Buddhism Mindfulness practices informed by Malamati Sufism

Mindfulness Emphasis on non-judgmental awareness of “what is” and intuitive knowing

Encourages cultivation of Wise Mind responses that focus on reducing mood-dependent impulsive responding and increasing abilities to delay immediate gratification in order to pursue distal goals Mindfulness Emphasis on self-enquiry, “outing-oneself,” participating without planning, and the cultivation of healthy self-doubt

Encourages cultivation of Flexible Mind responses that promote relaxation of rigid, rule-governed control efforts and an increase in context-appropriate disinhibition and/or emotional expression

Emphasizes and prioritizes Radical Acceptance Radical Acceptance is “letting go of fighting reality” “It is the way to turn suffering that cannot be tolerated into pain that can be tolerated” (Linehan 1993). Emphasizes and prioritizes Radical Openness Radical Openness is actively seeking the things one wants to avoid in order to learn—challenging our perceptions of reality, modelling humility, and a willingness to learn “We don’t see things as they are—we see things as we are” (Lynch 2017).

Emphasizes internal emotion regulation and non-mood dependent actions Emphasizes our tribal nature and social-connectedness

Does not take temperament into account Prioritizes interventions designed to take temperament into account Temperament (genetics for emotion) influences the perceptual and regulatory biases clients bring into social situations and needs to be accounted for when treating clients