Using DBT Skills to Assist Students Transitioning Back to School
By Gerard Barone, LCSW
The COVID-19 pandemic has taken its toll on adults and children alike, all of whom are struggling to cope with dismantled routines, and with losses both tangible and intangible. Preschool children have perhaps relished additional time with parents, but school-aged children have had their educational and social development significantly disrupted.
Since March 2020, educators across the USA have been working tirelessly to conduct remote instruction, and to provide the services mandated by Individualized Education Plans (IEP). Many districts are still uncertain about whether and how students will return to school buildings in the fall, and are scrambling to design hybrid instructional models and schedules, and to re-arrange physical space to allow for social distancing. At the same time, parents, educators and mental health professionals are all looking for strategies to help students adjust to returning to school in September.
In designing its school-based clinical services, Effective School Solutions (ESS) created a model that is both trauma and DBT-informed (Dialectical Behavior Therapy). There is no doubt that we have all experienced a shared trauma, and that a trauma-informed stance is needed now more than ever within school environments. But, we would also suggest that coaching students in DBT skills can help with the difficult transition back to the classroom in the fall. And, lest you think that DBT is entirely different from what some educators already do to assist students, consider this: every time you teach a deep breathing technique, help a student label and express an emotion, offer a self-soothing option like a music break, encourage a “seventh inning stretch” or a quick walk to clear the head, help a student adopt a balanced perspective about a stressor, or practice communication or assertiveness skills, you are teaching one aspect of DBT.
DBT is a comprehensive clinical program created by Marsha Linehan, PhD that was introduced in her groundbreaking book published in 1993. It was designed to treat chronically suicidal and self-injuring clients, many of whom met criteria for both Borderline Personality Disorder and trauma (PTSD), but since then it has been highly researched and successfully expanded to many different clinical populations. The full treatment program includes individual therapy, DBT skills educational groups, telephone coaching as needed, and weekly DBT-clinician peer consultation groups. The DBT skills component is considered an “active” ingredient of the treatment program, and has been successfully adapted to many clinical and educational settings.
The treatment model is based on the combination of Eastern philosophies that promote a dialectical stance, acceptance, and mindfulness practices, with the techniques associated with the Western psychotherapy approach known as cognitive-behavior therapy. The word “dialectical” refers to the ability to hold and integrate two seemingly opposite thoughts or feelings in one’s mind and heart at the same time. The most critical dialectic in DBT is acceptance vs. change, and a popular way of expressing this concept is “I am doing the best that I can, and I can do better.” One important aspect of dialectic thinking is the use of the word “and” rather than the words “or” or “but” as both things are considered true at the same time.
Acceptance is both a mindset and a skill, and involves the willingness to observe, acknowledge, and yes, accept, the reality of a situation over which one has no control. Cultivating a stance of acceptance allows a person to stop wasting time and energy on fighting reality, and to re-direct attention and resources to those things that one can change so as to reduce suffering and move on with life. Acceptance is not a one-time event: it requires an ongoing effort to turn one’s mind and efforts away from ultimately useless thinking and behavior in order to focus on reality and what is effective.
Mindfulness means being in the present, being aware of what is happening around you and what you are doing, thinking and feeling, without judgment of yourself or others. It means doing one thing at a time, and giving that thing your full focus and attention.
DBT skills are grouped into four training modules: Mindfulness, Distress Tolerance, Emotion Regulation and Interpersonal Effectiveness. Mindfulness and Distress Tolerance are related to the acceptance part of the acceptance vs. change dialectic, while Emotion Regulation and Interpersonal Effectiveness skills focus on changing emotions, self-defeating thoughts, and ineffective and/or damaging interpersonal behaviors. Taken together, these skills help individuals to better regulate their emotions, to recognize internal states and tolerate distress, to focus attention, and to develop and sustain satisfying interpersonal relationships. At the same time, they help individuals move away from mindlessness, inflexible thoughts and behavior patterns, extreme emotions, and impulsive behaviors.
Mindfulness is a skill that is practiced in an ongoing way throughout a formal DBT program, and has been taught and incorporated within multiple health and educational settings. There is an ever-growing body of research that demonstrates its positive effects on mood, anxiety reduction, physical health, concentration, focus, and self-regulation. DBT teaches that there are three primary states of mind: Reasonable Mind, Emotion Mind, and Wise Mind, the latter being an effective blending of the other two. Someone operating mostly from Reasonable Mind over analyzes and ignores or avoids emotions; someone operating mostly from Emotion Mind acts impulsively based on in-the-moment feelings, with little thought of outcomes or consequences. One goal of DBT is to help a person maximize time spent in Wise Mind, a place from which thoughtful analysis, experience, and emotions all play a role in decision-making and behavioral choices.
Distress Tolerance is the module that emphasizes learning to bear pain skillfully. The ability to tolerate and accept distress is an essential mental health goal for at least two reasons. First, pain and distress are a part of life; they cannot be entirely avoided or removed. The unwillingness to accept this fact in and of itself leads to increased suffering. Second, distress tolerance, at least over the short run, is part and parcel of any attempt to change oneself since impulsive actions will interfere with efforts to establish desired changes. Distress tolerance skills are concerned with tolerating and surviving crises, coping with things over which we have no control, and accepting life as it is in the moment. Some important distress tolerance skills are radical acceptance, distracting, and self-soothing using the 5 senses.
The Emotion Regulation module addresses the biology and function of emotions, including how to recognize and label one’s emotions, and teaches the skills needed to manage emotions instead of being managed by them. This module aims at decreasing emotional vulnerability and suffering, and includes important skills such as accumulating positive emotions, taking care of the body, checking the facts, and opposite action.
The fourth DBT module is Interpersonal Effectiveness, the goals of which are to be skillful in getting what one wants and needs from others; to build, nurture and repair healthy relationships and to end destructive ones; and to develop and maintain self-respect within the context of one’s relationships. This module includes such skills as DEAR MAN which offers a step-by-step approach for assertive interactions with others (Describe, Express, Assert, Reinforce, stay Mindful, Appear confident, Negotiate) and FAST, which offers a model for maintaining self-respect in relation to others (be Fair, no Apologizing for having an opinion or request, Stick to your own values, be Truthful).
Students returning to school this fall in the midst of the ongoing COVID-19 crisis can use all the support that parents and school professionals can offer. Teaching students select DBT skills from each of the four modules can help them navigate the significant stressors that they will face, including uncertainty, a return to routine, and the re-acclimation to social structure.
The uncertainty caused by the COVID-19 pandemic relates to its being a scary reality over which we have no control. If infection rates ebb and flow, we may be confronted with additional rounds of school and business closings, and we will need to alter our behavior to match changing conditions. So, perhaps an obvious place to start helping students with uncertainty is by teaching the Distress Tolerance (DT) skill known as Radical Acceptance.
Non-acceptance of the reality of COVID might sound something like this: “This is not fair”, “I can’t miss my sports competitions”, “Why is this happening to me?”, “They’re making a big deal of this, the virus can’t hurt kids.” This stance of non-acceptance interferes with effective problem solving and coping, and increases both mental and emotional distress.
People often hear the word “acceptance” and equate it with approving of or liking a particular situation, but this is not the case. It is important to recognize and own one’s sadness, anger, disappointment, etc., while at the same time fully embracing “what is”. Acceptance is about letting go of one’s attachment to a desired outcome and accepting life as it is in this moment in order to focus on what is under your control. And, what students can currently control are safety behaviors (e.g. masks, hand washing, social distancing), creating a daily schedule that balances school work and pleasurable activities, taking care of one’s physical well-being, and finding creative ways to connect with family and friends. It is important to note that acceptance is a constant journey, not a final destination. You can start in a place of non-acceptance, experience acceptance, and then periodically revert back to a state of non-acceptance. Acceptance is an active process that requires a constant effort to turn one’s mind toward “what is”.
Another DT skill that can help with uncertainty is Distracting. Students can create lists of activities to engage in when worry thoughts or painful emotions seem to take over. Activities at home might include watching a funny video, doing some jumping jacks, texting a friend, taking a bubble bath, dancing to a favorite song, listening to loud music, or walking the dog. Classroom activities might include drawing, playing with a fidget toy or squeezing a stress ball, doing a puzzle, helping the teacher, moving to the back of the room to do some stretches, etc.
Self-Soothing is a DT skill that uses the 5 senses to calm and soothe oneself when experiencing distress. It can be used successfully for coping with uncertainty, and also for the other major stressors that children will face. Parents can help their children create portable self-soothing kits that can be accessed as needed over the course of the day. A school kit can include a photo of a parent or a beloved pet or a favorite place, a small scented soap or hand lotion, a small tasty treat, a soft or fuzzy piece of fabric, a cooling facial wipe, a calming song or recorded message from a parent on a cell phone. A teacher can also create a self-soothing bin in a corner of the classroom that contains a variety of such objects, and perhaps also headphones that give students access to favorite songs or encouraging recorded messages.
It has become even more important than before the pandemic to incorporate mindfulness skills into a child’s day to cope with uncertainty and other stressors. For example, parents and teachers can help students do paced breathing exercises (e.g., inhaling to the count of 3, exhaling to the count of 5) while paying attention to the sensations associated with breathing. Children and teens can learn how to close their eyes for 60 seconds and pay attention to all the sounds they hear. Students can learn body scan exercises, noticing body parts from head to toe, while allowing oneself to let go of tension. Any activity can be turned into a mindfulness practice — walking, washing one’s hands, stretching, eating a grape — as long as the individual turns all attention to the sensations and movements associated with that activity.
After 6 months of more flexible and less demanding daily routines, students may find it very stressful to return to a typical school day. A return to getting up early, hectic morning routines, long and highly structured school days, earlier bedtimes, and more restricted play and screen time — all of this will create stress for even the most motivated students.
Emotion Regulation (ER) skills, however, can help students adapt to the resumption of a more rigorous schedule. One ER skill, known as PLEASE, focuses on taking care of the body. This skill involves noticing and treating physical illness, balancing one’s eating and getting enough sleep, getting exercise, and avoiding mood-altering substances. Taking care of one’s physical being is critically important since poor health habits make one more vulnerable to extreme emotions. Parents can begin preparing students for a return to school by working on improving these health habits as the summer progresses, ensuring that sleep schedules start to shift at least two weeks before the start of school. Teachers can incorporate movement breaks throughout the day (stretching, shaking, marching or jumping in place, reaching for the ceiling followed by touching the toes) and can discuss with students the importance of good health habits.
The ability to recognize, observe and describe one’s emotions, without judgment, is the foundation of ER. Teachers can post emotion words and descriptors around the classroom and encourage students to verbalize their feelings and associated physical sensations. Once students recognize, own, and validate their own emotions, they can then take positive actions to alter emotions to reduce distress in the moment. One ER skill is known as Accumulating Positive Emotions and involves students generating lists of things that boost their mood, even if only for a few moments at a time — listening to music, talking to a friend, taking a walk, hugging their parents, watching funny videos, playing video games, doing yoga, writing in a journal, drinking a cup of tea — and then selecting things off the list when they want to improve their mood. Teachers can help each student develop a list of appropriate in-school mood-boosting actions.
Re-acclimation to the social structure of school is yet another major stressor for students returning in the fall. Students who are extroverted and typically are highly integrated into peer and faculty networks may be brimming with excitement to return to friends and shared activities. They may be overstimulated by the sudden shift to a social environment, and have difficulty observing social distance and settling down into work routines. Shy or socially anxious students, or those on the autism spectrum, on the other hand, may experience spikes in anxiety and behavior problems as they feel the dread of returning to social situations.
The DT and ER skills already described above can be useful in helping students deal with these stressors, but there are other ER skills that can help students change unwanted emotions. Check the Facts involves a process by which the individual examines whether the problem is actually as they view it. Often emotions fuel our thoughts, and the “problem” actually turns out to be much smaller or non-existent. For example, a teen may be upset because he feels that a friend is angry with him. The teen can be coached to check the facts — e.g., speak with the friend in question — to determine whether that belief is true. He may find that the belief is unfounded, or he can be coached through interpersonal skills to problem solve and repair the relationship.
Students can also be taught the skill known as acting opposite to the current emotion. For example, when one feels fear, the urge is to avoid the situation. Acting opposite would involve approaching the feared situation (e.g. volunteering to present in class, opening a conversation with a peer who the youngster finds intimidating), noticing one’s painful emotions, and yet acting in spite of them.
Finally, Interpersonal Effectiveness (IE) skills can help students navigate the complex set of school relationships. The DEAR MAN and FAST skills described above are designed to help individuals develop assertive behaviors from a stance of self-kindness and self-validation. Students can also be coached to develop a “crisis survival network”, 3–5 trusted adults and peers who can provide support during tough times. Dr. Marsha Linehan’s website (behavioraltech.org), as well as the books mentioned below, have numerous worksheets available to help students develop or strengthen these important skills.
This article highlights only a handful of the DBT skills that are described in the various work of Dr. Linehan and her associates. Some are more easily adapted to educational settings than others, but there are numerous resources available to access more detailed descriptions and lesson plans (see below). In addition, ESS staff are committed to professional development activities, and can help support school professionals as they prepare for the re-opening of school in September.
Resources:
Linehan, Marsha, M. (2015) DBT Skills Training Handouts and Worksheets, second edition.
Rathus, J. H. and Miller, A. L. (2015) DBT Skills Manual for Adolescents.
Mazza, J. J., Dexter-Mazza, E. T., Miller, A. L., Rathus, J. H., Murphy, H. E. (2016) DBT Skills in Schools.
Dr. Linehan’s website www.behavioraltech.org
