CBT and DBT: A Practical Comparison

Supporting people with mental health concerns requires counsellors to have a diverse toolkit.  There are many things we all have in common, such as patterns we form in our thinking, our behaviour and our struggles. At the same time, we’re highly diverse in our strengths, choices and perspectives.  Some modalities guide and support counselling work across many different issues and are relevant for working with a wide range people. It is helpful to become familiar with multiple common frameworks that we can draw on to support as many people as possible.

Cognitive behavioural therapy (CBT) is a well-researched modality for providing time-sensitive, present-focused psychotherapy. It was originally developed through the work of Dr. Aaron T. Beck.

Dialectical behaviour therapy (DBT) was developed by Marsha Linehan, who further built on CBT ideas to focus specifically on supporting people experiencing intense emotional pain, such as those with chronic suicidality and those diagnosed with borderline personality disorder.

It is helpful to become familiar with multiple common frameworks that we can draw on to support as many people as possible.

Both theories provide counsellors with a strong set of strategies and resources. Understanding where CBT and DBT overlap and how they differ will help counsellors make more informed choices.

Core Ideas Differentiating CBT and DBT

CBT primarily focuses on the influence our thoughts have on our emotions and behaviours. It helps people identify irrational or unhelpful thoughts and beliefs, so they can modify them to improve emotional well-being and behavioural patterns.

DBT builds on this interest in cognitive and behavioural change by placing equal emphasis on acceptance and validation of the inner emotional experience. The concept of a “dialectic” refers to the combination of opposite ideas. DBT supports people to both accept the reality of their lives and experience as well as learn to change their lives by adjusting their less helpful behaviours.

A Quick Comparison

CBT and DBT share a common foundation, making them complementary approaches that can be used together. However, focusing in on where they diverge can help differentiate when one may be a more helpful resource than the other:

CBT	DBT
Focuses on changing maladaptive thoughts to foster change in behaviour	Balances acceptance and change first before striving to change thoughts or behaviour.
Emphasizes cognitive and thought restructuring.	Emphasizes emotion regulation and distress tolerance.
Often shorter-term and follows a set structured list of steps.	Often longer and skills-based, also following structure with lots of support for practicing the skills.
Most commonly offered in individual counselling format.	Often combines individual counselling with group counselling.
Treatment plans are usually symptom-focused, more linear, and measurable.	Includes highly structured plans but tends to involve multiple treatment components, simultaneously covering both cognitive, emotional, and social skills.

The Differences in Practice

Here is a possible illustration of some steps in a counselling process using the two methods. A person who is struggling with social anxiety may state: “If I say something awkward, everyone will judge me. This makes me highly anxious, so I prefer to stay at home and not join social events.”

A CBT-Oriented Process

This would focus on the initial thought/belief, exploring the evidence for and against this belief to determine if it is distorted or realistic. Then using cognitive exercises, the counsellor might develop homework steps to adjust the thinking pattern when it is maladaptive.

A CBT session may follow a structure such as:

• Mood check-in.
• Review the homework set from the last session.
• Identification of target problems or troubling thoughts.
• Cognitive restructuring practice, such as identifying cognitive distortions like catastrophizing, black-and-white thinking, overgeneralization, and the worry of being judged.
• Behavioural interventions and experiments, such as identifying a small-risk social event so the person can practice noticing their thoughts and emotional reactions.
• New homework assignments.

In this way, the person can work on gradually confronting feared situations to reduce anxiety and avoidance behaviours.

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A DBT-Oriented Process

While still interested in behavioural change, DBT places equal emphasis on acceptance and encourages validation of the client’s internal experience first. This may be particularly helpful if the emotional and internal experience is especially overwhelming and intense.

A DBT therapist might respond: “Given what you’ve experienced, it makes sense that social situations feel threatening.”

Only after validation would the counsellor begin exploring behavioural or cognitive change strategies. This may involve more in-depth understanding of the person’s history and overall mental health.

This balance between acceptance and change forms the “dialectic” at the centre of DBT.

A DBT process may follow a structure such as:

• Mindfulness practice to notice and accept experience without immediate reaction.
• Distress tolerance skills practice such as grounding, distraction, and radical acceptance when feeling anxious and judged.
• Emotion regulation practices to manage the intensity of anxiety when it shows up.
• Group attendance learning skills together with others to experience validation and social practice.
• Individual coaching through challenging experiences
• Homework for tracking emotional patterns, practicing skills from the group, and applying interpersonal effectiveness scripts in social settings such as boundary-setting.

Which One to Use

There is a large body of research consistently demonstrating strong evidence for both CBT and DBT. However, each one is shown to be more effective for particular concerns and populations.

CBT is considered highly effective for anxiety, panic disorder, phobias, depression, addictions, eating disorders, and anger in particular, and can be applied for a wide range of concerns.

Importantly, CBT and DBT don’t need to be understood as competing modalities…a counsellor may use CBT cognitive restructuring with a client who also benefits from DBT mindfulness and distress tolerance skills.

DBT has substantial evidence supporting its effectiveness for issues driven by emotional reactivity. For example, it is particularly recommended when a person is struggling with self-harming behaviour, suicidality, chronic emotion dysregulation related to trauma or violence, a diagnosis of borderline personality disorder, or ongoing and intense interpersonal instability.

Importantly, CBT and DBT don’t need to be understood as competing modalities. Instead, they are often integrated and useful together. For example, a counsellor may use CBT cognitive restructuring with a client who also benefits from DBT mindfulness and distress tolerance skills.

The setting in which someone is accessing help may also determine what is most appropriate. Because CBT is highly teachable and manualized, it is frequently used in brief therapy settings and integrated health care systems. The comprehensive nature of DBT reflects the complexity of the populations it was originally designed to treat. For counsellors working in community mental health, inpatient care, or high-risk environments, the layered support model of DBT can be particularly useful.

Finishing Thoughts

Both CBT and DBT offer powerful and effective strategies for mental health counselling. CBT provides a strong foundation of tools to help people identify and modify maladaptive thoughts and behaviours. It is structured and a practical approach for many common mental health concerns. DBT builds on this foundation by addressing the complexity of intense emotionality and interpersonal struggles.

A counsellor considering each of these modalities may benefit the most from understanding and learning about each one, so that the models can be used to complement one another in an evidence-based and compassionately attuned counselling practice.

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