You have a client who shows up on time, follows every recommendation, never floods in session, and still isn’t getting better. Their presenting concern might be chronic depression, a restrictive eating disorder, or persistent anxiety. On paper, they look like a good therapy candidate. In practice, something keeps not landing.
Radically Open DBT was developed for exactly that client.
In Episode 35 of Self Careapist Therapist, I sat down with Dr. Ellen Astrachan-Fletcher, Senior Clinician in RO-DBT, lecturer at Northwestern University’s Feinberg School of Medicine, and Associate Professor of Psychiatry at UIC. She brings over 30 years of clinical and teaching experience to both DBT and RO-DBT, and she is among the most knowledgeable clinicians in the country on this treatment approach. This post pulls the key clinical concepts from that conversation.
What Is Radically Open DBT (RO-DBT)
Dr. Thomas Lynch developed Radically Open DBT after observing that a significant subset of clients were not responding to standard DBT. He had trained closely with Marsha Linehan and understood the model well. Even so, he kept encountering clients for whom the core DBT interventions (learning to contain, regulate, and tolerate distress) were not only unhelpful. For these clients, those interventions were simply wrong for the problem.
Standard DBT targets emotional dysregulation: the pattern of showing intense emotion across contexts and struggling to manage it. RO-DBT, by contrast, targets the opposite: emotional overcontrol.
Importantly, emotional overcontrol is not the same as being a controlling person. It describes someone who controls their emotions, holding internal experience tightly while presenting a contained exterior to the world.
Who Is RO-DBT Designed For?
RO-DBT is transdiagnostic, meaning it targets what underlies several diagnostic presentations rather than the diagnosis itself. In practice, research and clinical application have found it well-suited for:
Chronic, treatment-resistant depression. Depression was actually the first condition studied with this model, in a geriatric population. Treatment that had not responded to medication or traditional therapy was often rooted in deep emotional loneliness.
Restrictive eating disorders. Dr. Astrachan-Fletcher co-authored a clinical workbook specifically on RO-DBT for eating disorders, and her forthcoming book addresses RO-DBT for anxiety (August 2026).
OCD and OCPD. Obsessive-compulsive personality disorder in particular skews heavily toward emotional overcontrol.
Personality disorder presentations. Notably, Dr. Astrachan-Fletcher pointed out that the majority of personality disorders cluster on the overcontrolled rather than undercontrolled end.
Chronic anxiety that has not responded to CBT or standard treatment approaches.
Overall, clients who appear to be doing well but report persistent emptiness, difficulty feeling close to others, or a sense of not quite belonging in their own life may be worth exploring through an overcontrol lens.
The Core Problem RO-DBT Addresses: Emotional Loneliness
Tom Lynch uses the term emotional loneliness to describe feeling completely alone in a room full of people who love you.
The internal logic driving this experience goes something like: if they really knew me, if they knew what I actually thought and felt, they would not love me and they would not stay. As a result, the overcontrolled person holds back. Real experience stays concealed, even from people who are genuinely safe. The surface presentation is fine. The stated answer is fine. Then, privately, that same person goes home and cries alone in the bathroom because no one knew they needed anything.
This is not depression in the traditional cognitive-behavioral sense. Rather than a distorted thought pattern that needs challenging, the problem is a learned, reinforced behavioral pattern of emotional concealment that cuts a person off from the very relationships that could help.
What Is Emotional Leakage?
Overcontrolled clients do express emotion, but it surfaces differently than you might expect. RO-DBT uses the term emotional leakage for the moments when controlled emotion comes out in unexpected or indirect ways.
Dr. Astrachan-Fletcher offered a particularly useful example: an overcontrolled person on a bus holds a firm belief that young people should give up their seats for elderly riders. An elderly person boards. A teenager does not move. Having been containing everything for days, the overcontrolled person walks over and confronts the teenager directly. The outburst feels completely justified because it involves right and wrong, not personal feelings.
That is emotional leakage through moral certitude. The content concerns a rule violation. The energy behind it, however, belongs somewhere else entirely.
Recognizing this pattern therefore shifts how a clinician responds to clients who erupt occasionally but remain extremely controlled otherwise. The eruption is not the problem. It is a signal about what someone has been holding.
The Three Treatment Targets in RO-DBT
Rather than building emotional regulation skills the way standard DBT does, RO-DBT develops three distinct capacities:
Flexibility is the ability to respond differently across different situations and contexts, rather than applying a fixed, rule-governed approach to every interaction.
Receptivity and openness addresses the ability to take in feedback. Overcontrolled clients often struggle here, not because they are arrogant, but because receiving feedback feels threatening when someone already believes they are never good enough.
True connection requires careful definition. Dr. Astrachan-Fletcher was explicit on this point: true connection is not a large network or many acquaintances. Instead, it is the felt experience of being fully known by someone and loved anyway. Toward that end, RO-DBT teaches clients to practice vulnerability and authentic self-disclosure, the very behaviors that feel most dangerous to someone with overcontrolled coping.
The Three Mind States in RO-DBT
RO-DBT introduces three mind states that both clinicians and clients work with throughout treatment.
Fixed mind shows up as certainty, rigidity, and resistance to input. Someone in fixed mind believes they already have the answers and do not need feedback.
Fatalistic mind, by contrast, shows up as hopelessness, disengagement, and resigned withdrawal. Here, the belief is that there are no answers and nothing can change.
Flexible mind is what treatment works toward. It is the capacity to ask: given this feedback, or given my reaction, is there something for me to learn here? In essence, flexible mind is openness without capitulation, willingness without self-abandonment.
Where Does Overcontrol Come From?
Temperament is genetic. Dr. Astrachan-Fletcher explained that overcontrolled coping tends to develop from a combination of biological factors, particularly high threat sensitivity and high detail focus, shaped by early life experience.
The highly threat-sensitive, detail-focused child already notices danger and errors everywhere. When that child’s early environment sends repeated messages, whether explicit or implicit, that containing emotion is safer than expressing it, the pattern gets reinforced. Over time, it becomes a deeply grooved way of moving through the world.
By adulthood, these clients have often received praise for exactly the traits that are isolating them. They are reliable, thorough, hardworking, and responsible. Consequently, the overcontrol does not feel like a problem from the inside. It feels like identity.
How RO-DBT Treatment Is Structured
Like standard DBT, RO-DBT pairs individual therapy with a skills component. That skills component is deliberately called a class rather than a group, and the distinction matters clinically.
Overcontrolled clients tend to engage much more comfortably in a classroom setting (a table, paper, pens, and a clear educational frame) than in a process group where emotional sharing is expected. The class format signals that participants are there to learn, not to perform vulnerability in front of strangers. For many overcontrolled clients, that reframe makes the difference between engaging with treatment and finding a reason to avoid it.
How to Train in RO-DBT
Dr. Astrachan-Fletcher recommends starting at radicallyopendbt.net, the official site for all sanctioned RO-DBT training.
The pathway moves through three levels. Level 1 offers an introductory overview, useful for orientation but not sufficient for practicing as an RO-DBT therapist. Level 2 is a full online training taught directly by Tom Lynch, covering all theory and skills in depth. After completing Level 2, Level 3 is an in-person intensive where clinicians practice the nuances of the treatment with colleagues. Beyond Level 3, clinicians can pursue RO-DBT Scholar and Senior Clinician designations.
Dr. Astrachan-Fletcher holds the Senior Clinician designation and offers organizational trainings for groups and treatment programs. Her practice, EAF ReCenter, can be reached at eaf-recenter.com.
Clinical Takeaways
When a client has tried multiple treatments and continues to report emptiness or relational disconnection, overcontrol may be the organizing mechanism rather than the presenting diagnosis.
Furthermore, emotional loneliness is a specific and treatable clinical target. The intervention is not more socialization. Rather, it is helping the client learn to show up in the connections they already have.
It is also worth noting that the skills in RO-DBT are not similar to DBT skills. They address different underlying problems and require separate training. Familiarity with DBT, in other words, does not translate to competence in RO-DBT.
Finally, the classroom format of the skills component is a clinical decision, not an administrative convenience. It was designed specifically with the overcontrolled client’s experience in mind.
Listen to the Full Episode
This post covers the core framework. The conversation with Dr. Astrachan-Fletcher goes much deeper, including specific skill examples, the clinical presentation differences between overcontrolled and undercontrolled clients, and a candid discussion of how self-report assessments can fail with this population.
You can listen to Episode 35 on all major podcast platforms or watch the full conversation on YouTube at @selfcareapist.
You have a client who shows up on time, follows every recommendation, never floods in session, and still isn’t getting better. Their presenting concern might be chronic depression, a restrictive eating disorder, or persistent anxiety. On paper, they look like a good therapy candidate. In practice, something keeps not landing.
Radically Open DBT was developed for exactly that client.
In Episode 35 of Self Careapist Therapist, I sat down with Dr. Ellen Astrachan-Fletcher, Senior Clinician in RO-DBT, lecturer at Northwestern University’s Feinberg School of Medicine, and Associate Professor of Psychiatry at UIC. She brings over 30 years of clinical and teaching experience to both DBT and RO-DBT, and she is among the most knowledgeable clinicians in the country on this treatment approach. This post pulls the key clinical concepts from that conversation.
What Is Radically Open DBT (RO-DBT)?
Dr. Thomas Lynch developed Radically Open DBT after observing that a significant subset of clients were not responding to standard DBT. He had trained closely with Marsha Linehan and understood the model well. He kept encountering clients for whom the core DBT interventions (learning to contain, regulate, and tolerate distress) were not only unhelpful. They were wrong for the problem.
Standard DBT targets emotional dysregulation: the pattern of showing intense emotion across contexts and struggling to manage it. RO-DBT targets the opposite: emotional overcontrol.
Emotional overcontrol is not the same as being a controlling person. It describes a person who controls their emotions, holding internal experience tightly while presenting a contained exterior to the world.
Who Is RO-DBT Designed For?
RO-DBT is transdiagnostic, meaning it targets what underlies several diagnostic presentations rather than the diagnosis itself. Research and clinical application have found it well-suited for:
Chronic, treatment-resistant depression. Depression was the first condition studied with this model, in a geriatric population. Treatment that had not responded to medication or traditional therapy was often rooted in deep emotional loneliness.
Restrictive eating disorders. Dr. Astrachan-Fletcher co-authored a clinical workbook specifically on RO-DBT for eating disorders, and her forthcoming book addresses RO-DBT for anxiety (August 2026).
OCD and OCPD. Obsessive-compulsive personality disorder skews heavily toward emotional overcontrol.
Personality disorder presentations. Dr. Astrachan-Fletcher noted that the majority of personality disorders cluster on the overcontrolled rather than undercontrolled end.
Chronic anxiety that has not responded to CBT or standard treatment approaches.
Clients who appear to be doing well but report persistent emptiness, difficulty feeling close to others, or a sense of not quite belonging in their own life may be worth exploring through an overcontrol lens.
The Core Problem RO-DBT Addresses: Emotional Loneliness
Tom Lynch uses the term emotional loneliness to describe feeling completely alone in a room full of people who love you.
The internal logic driving this experience goes something like: if they really knew me, if they knew what I actually thought and felt, they would not love me and they would not stay. So the overcontrolled person holds back. They keep their real experience concealed, even from people who are genuinely safe. They appear fine. They say they are fine. Then they go home and cry alone in the bathroom because no one knew they needed anything.
This is not depression in the traditional cognitive-behavioral sense. The problem here is not a distorted thought pattern that needs challenging. It is a learned, reinforced behavioral pattern of emotional concealment that cuts a person off from the very relationships that could help.
What Is Emotional Leakage?
Overcontrolled clients do express emotion, but it surfaces differently. RO-DBT uses the term emotional leakage for the moments when controlled emotion comes out in unexpected or indirect ways.
Dr. Astrachan-Fletcher offered a particularly useful example: an overcontrolled person on a bus who holds a firm belief that young people should give up their seats for elderly riders. An elderly person boards. A teenager does not move. The overcontrolled person, who has been containing everything for days, walks over and confronts the teenager directly. The outburst feels completely justified because it involves right and wrong, not personal feelings.
That is emotional leakage through moral certitude. The content concerns a rule violation. The energy behind it belongs somewhere else entirely.
Recognizing this pattern shifts how a clinician responds to clients who erupt occasionally but remain extremely controlled otherwise. The eruption is not the problem. It is a signal about what someone has been holding.
The Three Treatment Targets in RO-DBT
Rather than building emotional regulation skills the way standard DBT does, RO-DBT develops three capacities:
Flexibility is the ability to respond differently across different situations and contexts, rather than applying a fixed, rule-governed approach to every interaction.
Receptivity and openness addresses the ability to take in feedback. Overcontrolled clients often struggle here, not because they are arrogant, but because receiving feedback feels threatening when someone already believes they are never good enough.
True connection requires careful definition. Dr. Astrachan-Fletcher was explicit: true connection is not a large network or many acquaintances. It is the felt experience of being fully known by someone and loved anyway. RO-DBT teaches clients to work toward this through vulnerability and authentic self-disclosure, the very behaviors that feel most dangerous to someone with overcontrolled coping.
The Three Mind States in RO-DBT
RO-DBT introduces three mind states that both clinicians and clients work with throughout treatment.
Fixed mind shows up as certainty, rigidity, and resistance to input. A person in fixed mind believes they already have the answers and does not need feedback.
Fatalistic mind shows up as hopelessness, disengagement, and resigned withdrawal. A person in fatalistic mind believes there are no answers and nothing can change.
Flexible mind is what treatment works toward. It is the capacity to ask: given this feedback, or given my reaction, is there something for me to learn here? Flexible mind is openness without capitulation, willingness without self-abandonment.
Where Does Overcontrol Come From?
Temperament is genetic. Dr. Astrachan-Fletcher explained that overcontrolled coping tends to develop from a combination of biological factors, particularly high threat sensitivity and high detail focus, shaped by early life experience.
The highly threat-sensitive, detail-focused child already notices danger and errors everywhere. When that child’s early environment sends repeated messages, whether explicit or implicit, that containing emotion is safer than expressing it, the pattern gets reinforced. Over time it becomes a deeply grooved way of moving through the world.
By adulthood, these clients have often received praise for exactly the traits that are isolating them. They are reliable, thorough, hardworking, and responsible. The overcontrol does not feel like a problem from the inside. It feels like identity.
How RO-DBT Treatment Is Structured
Like standard DBT, RO-DBT pairs individual therapy with a skills component. That skills component is deliberately called a class rather than a group, and the distinction matters clinically.
Overcontrolled clients tend to engage much more comfortably in a classroom setting (a table, paper, pens, and a clear educational frame) than in a process group where emotional sharing is expected. The class format signals that participants are there to learn, not to perform vulnerability in front of strangers. For many overcontrolled clients, that reframe makes the difference between engaging with treatment and finding a reason to avoid it.
How to Train in RO-DBT
Dr. Astrachan-Fletcher recommends starting at radicallyopendbt.net, the official site for all sanctioned RO-DBT training.
The pathway moves through three levels. Level 1 offers an introductory overview, useful for orientation but not sufficient for practicing as an RO-DBT therapist. Level 2 is a full online training taught directly by Tom Lynch, covering all theory and skills in depth. Level 3 is an in-person intensive where clinicians practice the nuances of the treatment with colleagues. Beyond Level 3, clinicians can pursue RO-DBT Scholar and Senior Clinician designations.
Dr. Astrachan-Fletcher holds the Senior Clinician designation and offers organizational trainings for groups and treatment programs. Her practice, EAF ReCenter, can be reached at eaf-recenter.com.
Clinical Takeaways
When a client has tried multiple treatments and continues to report emptiness or relational disconnection, overcontrol may be the organizing mechanism rather than the presenting diagnosis.
Emotional loneliness is a specific and treatable clinical target. The intervention is not more socialization. It is helping the client learn to show up in the connections they already have.
The skills in RO-DBT are not similar to DBT skills. They address different underlying problems and require separate training. Familiarity with DBT does not translate to competence in RO-DBT.
The classroom format of the skills component is a clinical decision, not an administrative convenience. It was designed with the overcontrolled client’s experience in mind.
Listen to the Full Episode
This post covers the core framework. The conversation with Dr. Astrachan-Fletcher goes much deeper, including specific skill examples, the clinical presentation differences between overcontrolled and undercontrolled clients, and a candid discussion of how self-report assessments can fail with this population.
You can listen to Episode 35 on all major podcast platforms or watch the full conversation on YouTube at @selfcareapist.
Lorain Moorehead, LCSW, is an EMDR Certified Therapist and host of Self Careapist Therapist, a podcast for licensed mental health clinicians. Select episodes are CE-eligible through the Arizona Board of Behavioral Health Examiners. Learn more at lorainmoorehead.com.
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