CBT, ACT, DBT, and EMDR: How Different Therapies Understand Distress
When people start looking for a therapist, it’s common to feel overwhelmed by the alphabet soup: CBT, ACT, DBT, EMDR. These approaches can sound like competing “brands” of therapy, each claiming to work in a different way.
A more helpful question is this:
What does each therapy believe is keeping distress going?
Because the way a therapy understands distress shapes the tools it uses to help.
Below is a practical, evidence-informed guide to how four commonly used therapies understand psychological distress, and what you might expect when working with a therapist trained in these approaches.
Why Safety Is the Foundation of All Effective Therapy
Across approaches, therapy typically begins by building a sense of safety: emotional, relational, and physiological safety. This foundation matters because we can’t shift patterns we can’t notice, and it’s much harder to notice clearly when we feel threatened or overwhelmed.
This is also why mindfulness shows up across many evidence-based therapies. Mindfulness refers to the ability to notice internal experiences and the environment with less judgment, allowing for more choice in how we respond. It is a transdiagnostic skill used across CBT, ACT, and DBT, among others.
Many people worry that choosing the “wrong” type of therapy will waste time or mean they’re doing therapy incorrectly. In practice, therapy is rarely about committing to a single approach upfront. Therapy is about understanding what’s maintaining distress and responding flexibly over time.
Read more: 10 Misconceptions about Therapy
CBT: How Thoughts and Beliefs Shape Emotional Distress
CBT (Cognitive Behavioural Therapy) proposes that distress is influenced by how we interpret ourselves, others, and the world and how these interpretations shape emotion and behaviour (Chand et al., 2023).
CBT describes layers of cognition that often operate automatically:
Core beliefs / schemas: deeply held beliefs about self and the world
Intermediate beliefs / rules: assumptions like “I must…” or “If I don’t…, then…”
Automatic thoughts: situation-linked thoughts that pop up quickly and feel true
A CBT example
A core belief about the self:
“I’m unlovable.”
Intermediate rule about navigating the world:
“I must be perfect or extra good to be accepted.”
In daily life, this can show up as hypervigilance around mistakes, people-pleasing, anxiety around feedback, and difficulty resting.
These beliefs aren’t always fully conscious but they often feel like “just reality.”
What CBT Focuses On in Therapy
CBT helps you:
notice patterns in thoughts, emotions, and behaviours
examine whether interpretations are accurate or helpful
develop more flexible ways of responding
CBT often suits people who want a clearer structure for understanding anxiety, self-criticism, or overthinking loops in everyday life.
Want to understand how anxiety works? Read more here.
ACT: How Getting Caught in Thoughts Increases Suffering
ACT (Acceptance and Commitment Therapy) grew from behavioural science and is often described as part of the “third wave” of CBT approaches. It is grounded in Relational Frame Theory (RFT), a model of human language and cognition (Hayes, 2016)
ACT’s key idea isn’t that thoughts are “wrong.” It’s that suffering increases when we become overly entangled with thoughts, treating them as literal truths that must be obeyed. This is a process known as cognitive fusion.
An ACT Example
If your mind says:
“I’m going to fail.”
Fusion can look like:
“This is true. I can’t cope. I should avoid.”
ACT works toward cognitive defusion:
“I’m having the thought that I’m going to fail.”
The thought can be present without defining who are you or dictating what you do next.
What ACT Aims to Change
ACT helps you:
notice thoughts as mental events rather than facts
make room for uncomfortable internal experiences without escalating into avoidance
take values-aligned action even with anxiety present
ACT can be particularly helpful when distress persists despite insight, or when attempts to control thoughts and feelings have become exhausting.
DBT: When Emotional Distress Is a Skills Problem
DBT (Dialectical Behaviour Therapy) is a highly structured, skills-based therapy developed by Marsha Linehan. It integrates behavioural change strategies with acceptance- and mindfulness-based approaches (Kelly & Robinson, 2017).
DBT is often used when emotions feel intense, fast, and hard to regulate — especially when distress leads to impulsive reactions, relationship ruptures, or self-destructive coping.
DBT’s working assumption is practical:
Sometimes suffering persists because you don’t yet have the skills to respond differently under stress.
The Four Core Skills Taught in DBT
DBT teaches skills across four pillars:
Mindfulness
Emotion Regulation
Distress Tolerance
Interpersonal Effectiveness
What DBT Helps You Build
DBT equips you with tools to:
understand emotions (instead of fearing them)
ride out urges without making things worse
communicate needs and boundaries effectively
tolerate distress while staying aligned with your goals
DBT skills are widely used beyond BPD and can be helpful whenever emotions feel overwhelming or destabilising.
EMDR: How Unprocessed Memories Keep Distress Alive
EMDR (Eye Movement Desensitization and Reprocessing) is often less “talk-focused” and more “processing-focused.” It is based on the Adaptive Information Processing (AIP) model, which proposes that many symptoms are linked to distressing memories that were not fully processed and integrated.
When an experience is overwhelming, it can remain “stuck” in a vivid, sensory form — images, emotions, body sensations, or beliefs — instead of being stored as a resolved past event.
What Happens in EMDR Therapy
EMDR uses bilateral stimulation (such as eye movements or tapping) during parts of therapy to support processing while keeping the person within a tolerable window of arousal. EMDR is typically described as an eight-phase approach, and good practice emphasises preparation and safety before reprocessing (Gainer et al., 2020)
A common misconception is that EMDR is always fast. For some people it can be efficient, but for others (especially those with complex trauma histories) it can be a slower, more resourced process. This is something to discuss carefully with your therapist.
Do Therapists Use Only One Therapy Approach?
Often, no.
Many psychologists train in multiple approaches and integrate them thoughtfully. For example, a therapist might:
teach DBT skills to stabilise emotion and build coping capacity
use ACT to reduce fusion and avoidance
use CBT to work with unhelpful beliefs and behavioural loops
use EMDR-based strategies to support memory processing (when appropriate)
The question isn’t “which therapy is best?”
Rather ask, “What do you need most right now? Insight, skills, processing, or a combination?”
How to Choose a Therapist That’s Right for You
If you’re unsure where to start, two helpful anchors are:
Do you feel understood?
Feeling heard is a proxy for safety — and safety is foundational for change.Do their approaches fit what you’re seeking?
If you resonate with a particular framework (skills-focused, values-focused, trauma-processing), look for therapists trained in that area.
You don’t need to decide on a “perfect” approach before beginning. Therapy is a collaborative process that adapts as understanding deepens and needs change.
Note: The therapeutic approaches discussed above are supported by established clinical guidelines and peer-reviewed research.
References
Chand, S. P., Kuckel, D. P., & Huecker, M. R. (2023). Cognitive behavior therapy. In StatPearls. StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK470241/
EMDR International Association. (n.d.). What is EMDR therapy? (A layperson’s guide).
https://www.emdr.com/what-is-emdr-therapy-layperson/
Gainer, D., Alam, S., Alam, H., & Redding, H. (2020). A FLASH OF HOPE: Eye Movement Desensitization and Reprocessing (EMDR) Therapy. Innovations in clinical neuroscience, 17(7-9), 12–20.
Hayes S. C. (2016). Acceptance and Commitment Therapy, Relational Frame Theory, and the Third Wave of Behavioral and Cognitive Therapies - Republished Article. Behavior Therapy, 47(6), 869–885. https://doi.org/10.1016/j.beth.2016.11.006
Kelly, C., & Robinson, D. M. (2018). Dialectical behavior therapy (N. Gerardi, Contributor). In A. Vernon & K. A. Doyle (Eds.), Cognitive behavior therapies: A guidebook for practitioners (pp. 209–245). American Counseling Association.
Frequently Asked Questions
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They differ in what they see as maintaining distress. CBT focuses on beliefs and behaviour patterns, ACT on how we relate to thoughts and emotions, DBT on skills for managing emotional intensity, and EMDR on processing unintegrated memories. In practice, these approaches often overlap.
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There isn’t a single best approach. Anxiety can be maintained by overthinking, avoidance, emotional intensity, or unresolved experiences. A therapist will usually help clarify what’s driving your anxiety before deciding how to work with it.
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No. CBT is not about forcing positivity. It focuses on examining whether certain interpretations are accurate, balanced, and helpful, while acknowledging that emotions often make sense given past experiences.
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Yes. ACT views thoughts as meaningful experiences, but not always reliable guides for action. The goal is to reduce how much control thoughts have over behaviour, not to eliminate them.
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No. While DBT was originally developed for BPD, its skills are widely used for emotional regulation, impulsivity, and interpersonal stress across many presentations.
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No. EMDR emphasises preparation, pacing, and safety. It does not require detailed verbal recounting or prolonged exposure, and reprocessing only occurs when sufficient coping resources are in place.
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Often, yes. Many therapists integrate approaches based on what is most helpful at different stages of therapy.
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You don’t need to have this figured out upfront. Feeling understood and working collaboratively to clarify what’s driving distress are often more important than choosing a specific model at the start.