Table 2.

RO-DBT treatment goals and target hierarchy for over-controlled disorders

Primary targets and goals DECREASE severe behavioural over-control, emotional loneliness and aloofness/distance INCREASE openness, flexibility, prosocial signalling and vulnerable expression of emotion
Treatment target hierarchy for over-control
1. Life-threatening behaviours	Suicidal ideation and non-suicidal self-injury Over-controlled self-injurious behaviour tends to be planned in advance, occurs in private and rarely requires immediate medical attention
2. Therapeutic alliance ruptures	Patient feels misunderstood or perceives therapy as not relevant to their problems Signals of non-engagement by over-controlled patients tend to be understated, for example saying “hmm”, “maybe” or “I guess so” when disagreeing, or by avoiding eye contact or changing the topic when feeling misunderstood
3. Over-controlled Behavioural themes	Constrained expressions of emotion Over-controlled patients tend to display inhibited, flattened or insincere facial expressions (eg, smiling when distressed, showing concern when not feeling it), have a monotonic voice tone and tight and non-expansive gestures or body movements. They will work hard to avoid public displays of emotion Overly cautious and hyper-vigilant Over-controlled patients are not necessarily avoidant but guarded, wary and suspicious. They exhibit superior detailed-focused processing Rigid and rule-governed behaviours The actions of over-controlled patients tend to be non-mood dependent and instead follow certain self-imposed rules. They are motivated by social obligation and exhibit high moral certitude; they often make self-sacrifices to care for others or to do the ‘right’ thing. They tend to be hyper-perfectionistic and have compulsive needs for order and structure Aloof and distant relationships Over-controlled patients do not necessarily lack contact but lack social connectedness with others. They are slow to warm-up and will walk away or abandon a relationship when in conflict. They are likely to feel like an outsider, different or detached from others Envy, Resentment, Bitterness and Revenge Over-controlled patients tend to be performance-focused, engage in social comparisons, are secretly competitive, tend to hold grudges and may have secret pride in superior capacities for self-control. They may take pleasure in a rival failing or feel unappreciated for personal self-sacrifices or efforts on their part to meet or exceed expectations

Targets higher in the treatment hierarchy take priority over lower ones. Thus, life-threatening behaviors and therapeutic alliance-ruptures take precedence over behavioral themes when these are present. Therapists use the behavioral themes to facilitate treatment planning.