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This paper has been written following an influential therapeutic encounter that we experienced while working with an emotionally distressed woman. The barriers that can get in the way of providing a structured therapeutic approach are discussed. The paper focuses on dialectical behaviour therapy as a treatment model, and discusses how the concept of ‘dialectics’ provide an over‐riding context for case conceptualisation (Linehan, 1993). The dialectical dilemmas and powerful dynamics that can be enacted between individuals, teams and patients in their endeavours to cope with distress will be illustrated. The dialectical philosophy is described and elaborated upon, providing a framework for the synthesis of clinical interpersonal encounters and metaphorical concepts of a therapy seesaw. The paper discusses how these ideas can guide us in our work with emotionally distressed individuals.