9

The Five Functions of

Comprehensive DBT

In addition to following assumptions about clients, therapists, and treat-

ment itself, DBT must follow five basic functions to be comprehensive
in nature. These five functions include motivating clients, teaching skills,
generalizing skills to natural environments, motivating and improving the
skills of therapists, and structuring the treatment environment (Linehan,
1993a; Koerner, 2012).

Motivate Clients

Motivation comes from understanding clients’ goals; identifying relevant

strengths, resources, and barriers; and ensuring collaboration on the meth-
ods enlisted to reach goals. It is often necessary to highlight the dialectical
discrepancies between what clients want and need, and how current emo-
tions, behaviors, or behavioral deficits interfere with accomplishing those
things.1

1
Motivational Interviewing (MI) techniques can be a helpful addition to DBT and vice
versa. Whereas MI assumes that motivated clients can then move toward goals, DBT rec-
ognizes that sometimes motivated clients still need practical skills to be successful.

Dialectical Behavior Therapy: A Contemporary Guide for Practitioners, First Edition.

Lane D. Pederson.
ch2015 John Wiley & Sons, Ltd. Published 2015 by John Wiley & Sons, Ltd.
56 Dialectical Behavior Therapy
To be motivated, clients need a responsive mix of validation, coaching,
cheerleading, skills training, and reinforcement for effort and accomplish-
ment. Deciding what to do and when requires therapists to be mindful
in the moment, responsive in the alliance, and centered on the treatment
plan. Use of commitment strategies, outlined in Chapter 15, can also be
deployed to shape and build movement toward goals.

Teach Skills

As discussed, skills training is an essential function of DBT. Unlike other

approaches, DBT does not presume that clients have the necessary behav-
iors in place to actualize their goals. Skills training addresses functional
deficits, replaces unhealthy behaviors that are self-defeating and self-
damaging, and provides the means to be more physically and psychologi-
cally healthy and functional.
Importantly, skills training without the other functions in place is not
comprehensive DBT. Many providers mistakenly assume that skills train-
ing alone is sufficient to help clients. While this may be true with lower
intensity clients who are motivated to change, it is generally not with clients
with chronic, consistent, and severe problems. These clients most often
require attention to the other functions of DBT, especially having struc-
ture and dedicated processing time within therapy, either individually or
in groups. Generally speaking, DBT skills only are not enough of a treat-
ment dose in terms of level of care to be effective for high-need clients.

Generalize the Skills with Specificity

Clients need to demonstrate skills across situations, people, and settings.

Many clients can be skillful in one area while struggling in others. To be
functional and have satisfying lives, clients need to practice skills where
they are most needed.
The good news is that any instance of skillful behavior can become an
opportunity to generalize it elsewhere. Often, clients can exhibit skills in
therapy and then the task is to assist the client to practice the skills in the
world. For example, clients who can regulate their emotions at work can
explore what skillful behaviors happen there and then transport them to
home. Or clients who accurately validate friends can then practice those
skills with a partner or spouse.
 The Five Functions of Comprehensive DBT 57
Therapists frequently make the mistake of believing that generalization
will naturally happen on its own. A complete functional assessment of
all relevant areas of life is necessary to identify where increased skill use is
indicated. This assessment with agreed-upon areas of generalization allows
us to generalize with specificity.

Motivate Therapists and Maximize Effective Therapist

Responses

To be effective, therapists must stay motivated to work with clients, espe-

cially those with challenging behaviors. Similarly, therapists need ongoing
assistance to stay centered in the approach and effective in response to
the ups and downs of therapy. Burnout and iatrogenic therapist behaviors
destroy the alliance and short-circuit the outcomes, making this function
essential to DBT. This function is met primarily through consultation, dis-
cussed in Chapter 27.

Structure the Environment

Structure refers to the treatment framework as well as clearly defined rules,

expectations, and tasks of therapy that are agreed upon by clients and ther-
apists. In short, aspects of structure include anything that results in respon-
sible attitudes and behaviors on the part of clients and therapists (Weinberg
et al., 2011), providing the parameters that create safety, containment, and
focus.
The treatment framework is the service-delivery system by which the
theoretical orientation is disseminated to clients. The original treatment
framework for DBT is the standard model, although other frameworks will
work too as long as they are matched to the level of care required by clients,
providing a high enough “dose” of DBT. In fact, differing settings and pop-
ulations require different treatment frameworks, and these adapted DBT
services have become increasingly prevalent in published research and may
be the norm in community settings.
Underlying the treatment framework, the modalities (e.g., individual
therapy, psychoeducational skills group, telephone coaching, group psy-
chotherapy, home visits) that comprise the service delivery also need to be
structured.
Treatment structure is explained in Chapter 10.