Steps to Containing a Mental Health Crisis Printable- RO-DBT Model

Traditional DBT helps develop emotion regulation and impulse control for people who struggle in these areas. Radically Open (RO) DBT is an adaptation of DBT targeted towards people struggling in the opposite way:  those with an overabundance of self-control and who struggle to express emotion.

I encountered the text version of this crisis response list in the RO-DBT Manual by Thomas Lynch and decided to turn it into this visual reference sheet.

In accordance with this website’s terms of use, this data is presented as an educational resource and artistic creation. The resources posted on Instagram and my website are not therapy and do not construe a therapeutic relationship.  

Talking about a mental health crisis is the first step, but the nature of crisis is that many of us “go blank” under pressure. What we’ve learned about mental health crisis response in the past may fly out the window when an actual crisis occurs. This visual alternative to an RO-DBT* crisis checklist is designed to be fun to review and easy-to-remember (when we use more parts of our brains to study- like do when we engage visual information- we are more likely to remember).

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NOTE: Price paid is compensation for art/ illustration services only. For clinical resources see the RO-DBT Manual.

*One very important note:

This Mental Health Crisis response model was developed specifically for individuals with high self-control and low impulsivity. All items on the list may not be safe or applicable to everyone experiencing a mental health crisis. Call local emergency services if you are concerned someone is in imminent danger of harming themselves.

RO-DBT Approach to Responding to Crisis:

This list is an extremely condensed version of the instructions for practitioners for crisis response that are described in the RO-DBT manual. Please refer to the manual for any clarification, this visual is meant to be a sort of artistic “cheat sheet” for refreshing information already learned.

1. Thank you for telling me.

Expressing gratitude acknowledges that the person has put in an enormous effort to share their distress. This simple phrase builds trust and safety.

2. Ask: “What set this off?”

Identifying the triggers helps us understand context and what specific events led to the crisis. A good understanding of why someone has reached crisis mode can help de-escalation.

3. Seek what they are trying to communicate.

All behavior communicates. Actively seek to understand what’s going on and what the conversation might be communicating in a wider lens.

4. Check-in and invite criticism, “Did I miss something?”

Acknowledging that your actions (or not acting when you should have) might be contributing to the crisis can feel incredibly vulnerable, but it is a powerful tool. Asking openly invites frank conversation and repair of a potential rupture that might be at the root of the current crisis.

5. Validate: “No wonder you feel…”

Validation acknowledges someone feelings as legitimate, which itself can reduce feelings of isolation and distress.

6. Show concern. Don’t force yourself not to react.

In most therapist’s training, they’re taught to engage clients in crisis with a calm, unflappable attitude (for impulsive individuals, this can be soothing). But this method for crisis response with people who have high control and low impulsivity, researchers have determined that having an appropriate emotional response can strengthen your connection and help resolve crisis.

7. Signal openness. Balance concern with signals of openness.

Showing too much concern, even for someone for whom RO-DBT was designed, can cause someone to feel the need to reign in their crisis to make us feel better. Balancing our concern with signals of openness to hear more encourages a person to share more freely without fearing they’ll overwhelm us.

8. Take a break together, go for a walk or make a snack.

Conversations about crisis are intense. Diffusing the intensity can help diffuse crisis. Physical activity or a shared task can provide a distraction and reduce emotional intensity. It also offers a moment of normalcy and connection.

9. Remove access to the method or make a plan to remove access to the method and follow up on the plan.

Ensuring safety by removing means of harm is a critical intervention- and it’s best done collaboratively. For example, as it’s phrased on my crisis plan, asking “How can we help you and your place to be safe?”

10. Self-examine. Be radically open to your own experience of what is happening.

Practitioners need to be aware of their own emotional responses and biases. This self-awareness often informs what the next, best step is.

11. Ask what social signal is being sent in the interaction.

Social signals are an important concept in RO-DBT. Social signals are the actions or behaviors we take when we’re around other people that communicate how we’re feeling or what we’re thinking without using words.¹. Understanding someone’s social signals can help you understand unspoken needs and motivations. It helps in tailoring your response to better meet their emotional and social needs.

12. Show your care with an emotional appeal such as “Please stay.”

Honest, emotional appeals can strengthen the personal connection and provide a compelling reason for the person to consider alternative actions.

13. Show trust: “I believe in you and your recovery.”

Expressing belief in someone’s ability to recover can boost their confidence and hope- when we can’t locate our own hope, sometimes borrowing someone else’s can get us through.

14. Say, “I don’t want you to do this.”

Directly expressing your wish for their safety can be a powerful deterrent. It clearly communicates your concern and underlines the impact their actions would have on others.

15. Encourage the use of self-control.

Although people being treated with RO-DBT are often in therapy to deal with the problems caused by overcontrol, this can be a tool in crisis response. Reminding them of their capacity for self-control can empower them to manage their impulses by shifting focus from a problem to their strengths.

16. Introduce self-inquiry: Invite them to use crisis as discovery about themselves.

Encouraging self-inquiry can help the person see the crisis as an opportunity for growth. It promotes a proactive and reflective approach to their emotions and behaviors.

17. Remind the person of their commitments, agreements, and promises – and emphasize their integrity.

Highlighting someone’s commitments can anchor them to their values and responsibilities. For people with high self-control and low impulse, integrity is often a driving factor, which can be used in crisis response.

18. Get back-up.

Everyone needs a support network– people in crisis and the people who care for them. Make sure the person has more crisis resources. Don’t try to carry the burden alone and push yourself past your own self-care boundaries.

19. Ask them to agree to a safety plan. If appropriate, have them call a friend to be present.

A good safety plan provides a safe, structured gameplan for very bad days. Good safety plans empower, teach, and support us in caring for each other. Download my free printable safety plan.

20. Connect and get contact information for the person’s other support people.

Establishing connections with other supportive people can help share the burden of care with a network large enough to tolerate the strain without burning out a single individual.

21. If suicidality cannot be reduced, go with the person to emergency services.

When crisis intervention fails and a higher level of care is necessary to prevent a suicide, stay with the individual until another caring, responsible party can stand in. This may look like going to the ER, waiting together for an ambulance or mental health response team, or staying with them while a family member packs a bag and comes to take them to a higher level of care facility.

Cultural Considerations

The origin of crisis response guidelines (i.e., Mental Health First Aid) is rooted in Western, predominately White, and English-speaking countries. Because of this, it is especially important to keep cultural sensitivity and flexibility in mind when discussing mental health crisis responses. As we learn more about crisis response and how best to support people experiencing a mental health crisis, crisis workers need to adapt these strategies based on cultural context, consider cultural differences in emotional language, rethink how health systems function, and grow awareness of how different cultures view suicide. Researchers and first responders are working to address these questions, including different intervention methods and how risk assessment can be helpfully adapted for non-white, non-English speaking populations and other marginalized groups. (See this research article by Lu, Li, Oldenburg, Wang, Jorm, He, and Reavley, 2020).

1. Gilbert, K., Hall, K., & Codd, R. T. (2020). Radically open dialectical behavior therapy: Social signaling, transdiagnostic utility and current evidence. Psychology research and behavior management, 19-28. [↩]