Systemic Barriers PLEASE Slides Systemic Barriers & PLEASE
Reframing Emotional Vulnerability Through a Social Determinants of Health Lens
Lesson 1: Social Determinants of PLEASE
Review: The PLEASE Skill
PL Physical iLlness Treat physical illness; take medications as prescribed.
E Eating Balanced Eat enough food; avoid foods that make you feel poorly.
A Avoid Substances Avoid non-prescribed mood-altering drugs and alcohol.
S Sleep Balanced Get the amount of sleep that is right for you.
E Exercise Get some exercise every day if possible.
Is "Balanced Living" a Choice?
Standard DBT (Dialectical Behavior Therapy) teaches PLEASE as a choice of self-care. But what if the environment makes these "choices" impossible?
"Individual skills cannot solve structural problems."
Social Determinants (SDOH)
The conditions in which people are born, grow, live, work, and age.
Economic Stability (Income, job security)
Education Access & Quality
Healthcare Access & Quality
Neighborhood & Built Environment
Social & Community Context
The Paradox
We often ask clients to practice PLEASE to reduce vulnerability, yet their environment is the primary source of their vulnerability.
Barrier Breakdown: Eating
Food Deserts
No access to fresh produce within walking distance or reliable transit.
Inflation/Cost
Healthy options are 3x-4x more expensive than ultra-processed calories.
Time Poverty
Working multiple jobs leaves zero time for meal prep or planning.
Barrier Breakdown: Sleep
Environmental Noise
"Go to a dark, quiet room."
Clients in crowded apartments, shelters, or near loud traffic cannot control their auditory environment.
Hypervigilance
"Relax your body."
If the neighborhood or home is unsafe, staying awake (hypervigilance) is a survival mechanism, not a "bad habit."
Activity: Local Landscape
Look at the 2-block radius around our clinic. How many places sell "balanced food"? How many places sell mood-altering substances? How safe is it to walk for exercise at 8:00 PM?
Access
Safety
Transit
Systemic Barriers Teacher Guide Teacher Facilitation Guide
Lesson 1: Systemic Barriers & PLEASE
Session Time 90 MIN
Lesson Overview
This lesson challenges the assumption that the PLEASE skills are accessible to everyone equally. Students will bridge the gap between clinical psychology (DBT) and sociology by applying a Social Determinants of Health (SDOH) lens to emotional regulation. The goal is to move from "blaming the client" for poor self-care to "analyzing the environment" for barriers.
Key Terminology
PLEASE Skills (DBT)
Social Determinants of Health
Food Deserts/Swamps
Time Poverty
Hypervigilance
1
The Hook: Neighborhood Audit (15 min)
Open a Google Map on the screen showing the local neighborhood (or the neighborhood where the university's community clinic is located).
Discussion Prompts:
"Find the nearest grocery store. Now, find the nearest corner store. Which is more accessible by foot?"
"If a client works shift-work (11 PM - 7 AM), what are their options for a 'balanced meal' in this area?"
"Where can someone walk safely for 20 minutes in this radius without crossing major highways or entering private property?"
2
Presentation: PLEASE vs. SDOH (25 min)
Use the Systemic Barriers PLEASE Slides . Emphasize that PLEASE is designed to "reduce emotional vulnerability" but systemic factors increase it.
Teaching Tip: Validation
When teaching PLEASE, we must validate the barrier before suggesting the skill. If we don't, we risk alienating clients from marginalized backgrounds who feel we "don't get it."
Teaching Tip: Shift of Power
Help students move from seeing themselves as "advisors" to seeing themselves as "co-strategists" with their clients.
3
Case Study Analysis (40 min)
Distribute the Barriers Audit Worksheet . Assign small groups to analyze "Marcus" or "Elena" (provided on worksheet).
Circulation Guide:
Listen for students who suggest "obvious" fixes (e.g., "He should just go to the store on the weekend"). Challenge them: "What if he doesn't have a car and the bus doesn't run on Sundays?" Push for deeper systemic analysis.
4
Debrief & Prep (10 min)
Collect initial reflections. Preview Lesson 2: The Nutrition Challenge. Ask students to bring a grocery flyer or a link to a budget store website for the next session.
Barriers Audit Worksheet Barriers Audit Worksheet
CLINICAL PRACTICE: Systemic Analysis
Name: __________________________
Date: ___________________________
Objective
Analyze the provided case study to identify systemic barriers to the PLEASE skills. Move beyond individual "willpower" and look for the environmental, socioeconomic, and structural obstacles preventing the client from achieving physiological balance.
Case Study: Marcus
Age: 28 | Occupation: Warehouse Associate (Night Shift) | Housing: Shared studio apartment
"Marcus struggles with sudden outbursts of anger and deep depressive episodes. He works the 10:00 PM to 6:00 AM shift at a fulfillment center 45 minutes away. He relies on public transit, which is limited during his commute times. His apartment is shared with two roommates who work day shifts; the space is never truly quiet or dark. He often eats at the gas station next to the bus stop because he is too exhausted to cook after his commute. He was diagnosed with hypertension but frequently forgets his medication because his 'day' is so disjointed."
Systemic Barriers Analysis
PL Physical Illness
What environmental or structural factors make treating illness or taking meds difficult for Marcus?
E Eating Balanced
Identify the "Food Swamp/Desert" factors and time constraints here.
S Sleep Balanced
How do housing density and shift work impact his sleep hygiene?
1. Beyond "Individual Responsibility"
Instead of telling Marcus to "try harder" or "prioritize sleep," what is one structural accommodation or advocacy step a counselor might suggest (e.g., transit advocacy, worker rights, housing assistance)?
2. The Privilege of PLEASE
Which part of the PLEASE acronym do you think is the most "expensive" (in time, money, or social capital) to maintain? Why?
Poverty Nutrition Planning Slides The $5 Daily Challenge
Adapting 'Eating Balanced' for Food Insecure Contexts
Lesson 2: Poverty and Nutrition Planning
Standard 'Eat Balanced' Advice
The DBT Recommendation:
Eat enough to stay healthy.
Don't eat too much or too little.
Stay away from foods that make you feel poorly or "emotional."
Avoid "bingeing" or "restricting."
The Hidden Assumption
Standard advice assumes the client has:
1. Choice of variety
Survival vs. Self-Actualization
Caloric Density
When budget is low, clients instinctively prioritize the most calories for the fewest dollars (carbs/fats/sugars).
The Crash
High-sugar, low-nutrient diets lead to blood sugar spikes and crashes, which increase emotional dysregulation.
"It is hard to regulate your emotions when your blood sugar is a roller coaster."
Harm Reduction Strategies
Protein Anchoring
Using shelf-stable, low-cost proteins (canned tuna, beans, peanut butter) to stabilize glucose.
Frozen/Canned over Fresh
Removing the "freshness" elitism. Canned veggies are better than no veggies.
Inventory Literacy
Helping clients "shop" their pantry or food bank box first to reduce stress-buying.
THE $5 CHALLENGE
You have $5.00 to provide 3 meals for a client that support mood stability (blood sugar regulation).
Context: The client only has a microwave and a shared fridge. No stove. No gourmet seasonings.
Realistic
Affordable
Accessible
Poverty Nutrition Teacher Guide Teacher Facilitation Guide
Lesson 2: Poverty and Nutrition Planning
Session Time 90 MIN
Lesson Overview
Students will grapple with the practical reality of food insecurity and its impact on emotional regulation. The "Eat Balanced" skill is often taught in a way that feels unreachable for low-income clients. This lesson focuses on "Harm Reduction Nutrition"—identifying how to stabilize blood sugar and reduce emotional vulnerability using low-cost, shelf-stable, and accessible foods.
Resource Check
Poverty Nutrition Slides
$5 Daily Challenge Worksheet
Local Grocery Store Flyers (Printed or Digital)
SNAP/WIC Eligibility Cheat Sheet
1
The "$5 Daily Challenge" Intro (15 min)
Hand each student (or group) a five-dollar bill (prop or real). Tell them: "This is your client's entire food budget for the day. They have no spices, no oil, and only a microwave."
The Shock Factor:
Most students will realize they can't even buy a "healthy" salad for $5. This immediate barrier sets the stage for the presentation.
2
Presentation: Blood Sugar & Emotion (20 min)
Use the Poverty Nutrition Planning Slides . Focus on the physiological link between glucose spikes/crashes and the "Vulnerability" part of PLEASE.
Key Concept: Protein Anchoring
Teach students to look for the "Anchor" in every meal. An anchor is a protein/fat that slows digestion. Example: Adding peanut butter (anchor) to a cheap cracker.
3
Workshop: Meal Planning for Vulnerability (45 min)
Students use the $5 Daily Challenge Worksheet . They must use real prices from local budget grocery stores (Aldi, Dollar General, etc.).
Challenge: "My client only has a microwave." (Forces students away from dried beans/rice which require stove-time).
Challenge: "My client doesn't have a fridge." (Forces students toward shelf-stable items).
4
Gallery Walk & Debrief (10 min)
Students hang their meal plans. Debrief: "What was the hardest thing to give up? (Freshness? Flavor? Variety?)" Connect this back to the client's emotional state.
Five Dollar Challenge Worksheet The $5 Daily Challenge
Practical Nutrition for High-Stress, Low-Budget Contexts
$5.00
Total Daily Budget
The Mission
Design a 1-day meal plan for a client that optimizes emotional stability by regulating blood sugar. The plan must cost no more than $5.00 total.
The Client Context (Barriers)
No Stove (Microwave only)
Small shared fridge shelf
10 min prep time per meal
Neighborhood: Dollar General only
Goal Indicator
Protein Anchor
Fiber Component
Low Glycemic
Meal Items & Quantity Cost ($) Breakfast $ ____.__ Lunch $ ____.__ Dinner $ ____.__ Snack (Optional) $ ____.__ Total Calculated Cost: $ ________
Clinical Rationale
1. Vulnerability Reduction: How does this menu specifically prevent "hanger" or blood sugar crashes?
2. Realistic Feedback: If you were the client, how "satisfying" or "humiliating" would this diet feel? How do you handle that in a session?
Rest in Restless Spaces Slides Rest in Restless Spaces
Environmental Adaptation for 'Sleep Balanced' (S)
Lesson 3: Sleep Hygiene in Shared Spaces
The Paradox of Sleep Hygiene
Standard Advice
Keep the room cool, dark, and quiet.
Use the bed only for sleep/sex.
Go to bed at the same time every night.
Avoid screens 1 hour before bed.
The Systemic Reality
"How do I keep it quiet when my roommate is playing video games 3 feet away?"
"How do I avoid screens when I live in a studio and the TV is the only light?"
"How do I use the bed only for sleep when I don't have a chair or a desk?"
Safety First, Sleep Second
For clients in unsafe environments (shelters, high-crime areas, volatile homes), Staying Awake is an adaptive survival skill.
If we focus on "hygiene" without addressing "safety," we are asking the client to ignore their nervous system's warning signals.
Low-Cost Environmental "Hacks"
Auditory Masking
Brown noise vs. White noise (Brown is better for masking thick thuds/voices). Free apps or YouTube on a loop.
Visual Shielding
"Sleep hoods," $1 eye masks, or a t-shirt over the eyes to simulate "darkness" in a lit room.
The "Work" Blanket
If using the bed for everything, use a specific "day blanket" and remove it only at bedtime to signal the brain.
Temperature Proxy
Can't control the thermostat? A cold wet cloth on the wrists or back of the neck can mimic the drop in core temp needed for sleep.
Micro-Routines
When a 60-minute "wind-down" is impossible due to life chaos, we teach Micro-Routines (3-5 minutes) that trigger the parasympathetic nervous system.
Scent
A specific cheap lotion or soap used only at bedtime.
Breath
4-7-8 breathing (1 minute) while still fully clothed.
Muscle
Progressive relaxation of only the jaw and hands.
Rest in Restless Spaces Teacher Guide Teacher Facilitation Guide
Lesson 3: Rest in Restless Environments
Session Time 90 MIN
Lesson Overview
Students will explore how to teach sleep hygiene (the 'S' in PLEASE) to clients who lack a private, quiet bedroom. This lesson emphasizes the distinction between ideal sleep hygiene and survival sleep hygiene. Students will practice adapting interventions for shared apartments, shelters, and environments where hypervigilance is a safety requirement.
Required Tech
Audio Speakers (for simulation)
"City Chaos" audio loop (YouTube/Spotify)
White/Brown/Pink noise samples
Sleep Spaces Slides
1
Audio Simulation: The Focus Challenge (20 min)
Play a recording of loud city noise (sirens, arguments, construction) at a medium-high volume. Ask students to close their eyes and follow a 5-minute guided mindfulness meditation.
Debrief Questions:
"How many times did your heart rate spike when a siren went off?"
"Did you feel safe closing your eyes? Why or why not?"
"How much 'willpower' did it take to stay in the exercise vs. reacting to the noise?"
2
Presentation: Safety & Sleep (25 min)
Use the Rest in Restless Spaces Slides . Key takeaway: Hypervigilance is not a "clinical symptom" if the environment is actually dangerous. It is an adaptation.
Teaching Tip: Auditory Colors
Explain the difference between White Noise (high frequency, like static) and Brown Noise (low frequency, like a deep rumble). Brown noise is significantly more effective at masking the "thumps" and "shouts" found in crowded housing.
3
Workshop: Shared Space Sleep Plan (35 min)
Students work on the Shared Space Sleep Plan worksheet. Assign different "Roommate Personas" (e.g., The Gamer, The Night-Worker, The Argumentative Couple next door).
Circulation Guide:
Watch for students suggesting "Buy noise-canceling headphones." Remind them: "Your client is on a fixed income. They can afford a $3 box of earplugs from the pharmacy. How do we make that work?"
4
Exit Ticket (10 min)
"One sleep hack that costs $0 and takes less than 5 minutes." (Example: Using a rolled-up towel to block light/noise from under a door).
Shared Space Sleep Plan Worksheet Shared Space Sleep Plan
"S" Skill Adaptation: Sleep Balanced
Student Name: __________________________
The Clinical Challenge
Your client, Elena , lives in a two-bedroom apartment with four other adults and two toddlers. She sleeps on the couch in the living room. The TV is often on until midnight, and the toddlers wake up at 6:00 AM. Elena feels "constantly on edge" and "angry for no reason" in the afternoons.
Phase 1: Environmental Triage
A. Light Control ($0 - $5 options)
How can Elena simulate a dark room in a shared living room?
B. Noise Control ($0 - $5 options)
Think beyond headphones. What can Elena do about TV noise and voices?
C. Privacy/Boundaries
How can she create a "mental" bedroom when she has no physical one?
D. Temperature Adaptation
Shared living rooms are often drafty or overly hot. Ideas?
Phase 2: The "Safe to Sleep" Script
Elena feels guilty asking her roommates to turn down the TV. She also feels "dangerous" when she closes her eyes because she's responsible for the toddlers' safety during the day. Draft a short script (3-4 sentences) you would use in a session to validate her need for sleep while respecting her environmental reality.
Phase 3: Micro-Routine (3 Minutes)
Create a 3-step ritual Elena can do in her "sleeping spot" to signal her body it is time to rest.
Step 1: Physical
Step 2: Sensory
Step 3: Cognitive
Movement Mastery Slides Movement Mastery
Inclusive Exercise (E) for All Bodies and Abilities
Lesson 4: Accessible Movement and Physical Ability
Redefining "Exercise"
The Standard Prompt:
"Get some exercise every day... help your heart and your mood."
The Barriers
Physical Disability (Mobility aids, limb loss)
Chronic Pain / Fibromyalgia
Chronic Illness / Fatigue (CFS/ME)
Age-related limitations
The Shift
Move away from Fitness (weight loss, cardio, aesthetics).
Move toward Mastery (feeling capable in one's body, mood regulation).
How Movement Reduces Vulnerability
Chemical Release
Increases endorphins and serotonin, which act as natural "buffers" against stress triggers.
Build Mastery
Accomplishing a physical task (even small) fights the "hopelessness" associated with depression.
Grounding
Movement pulls the focus out of ruminative thoughts and into the physical sensation of the present moment.
The "Pacing" Framework
For clients with chronic pain, "pushing through" can cause a multi-day "crash."
Micro-movements: Finger stretches, neck rolls, ankle circles.Iso-metrics: Tensing and releasing muscles while sitting or lying down.Gentle Resistance: Using a towel or light band.
Golden Rule
"2 minutes of movement you can sustain is better than 20 minutes of exercise that causes a flare-up."
Scenario: Wheelchair User
Your client has a T10 spinal cord injury (uses a manual wheelchair). They report high "vulnerability" to rejection and anger. How do we adapt the 'E' in PLEASE for mood regulation?
Upper Body Mastery
Specific chair-based strength moves.
Rhythmic Movement
Wheeling in a safe park or mall at a steady pace.
Mind-Body
Adapted yoga or stretching for upper extremities.
Movement Mastery Teacher Guide Teacher Facilitation Guide
Lesson 4: Inclusive Movement Mastery
Session Time 90 MIN
Lesson Overview
Students will learn to adapt the 'E' (Exercise) in PLEASE for clients who may find traditional exercise physically impossible or harmful. This lesson shifts the focus from "fitness" to "mood regulation and mastery." Students will analyze case studies of clients with chronic pain and physical disabilities to develop inclusive, sustainable movement recommendations.
Concepts
Build Mastery vs. High-Intensity
Pacing for Chronic Pain
Adaptive Equipment
Grounding through Sensation
1
Hook: The "2-Minute Mastery" (15 min)
Ask students to perform a very simple movement (e.g., rotating their wrists or doing seated calf raises) for 2 minutes straight while focusing solely on the sensation.
Facilitation Note:
"How did your focus change from Minute 1 to Minute 2? Did anyone feel bored? Did anyone feel more 'present' in their body? That's the mood-regulation benefit we're after, regardless of intensity."
2
Presentation: Redefining the 'E' (20 min)
Use the Movement Mastery Slides . Emphasize that for many clients, "Exercise" is a loaded word associated with failure, pain, or exclusion. Introduce the term "Movement for Mastery."
3
Workshop: Modification Matrix (45 min)
Students work in pairs on the Movement Modification Matrix . Each pair is assigned a specific case (e.g., fibromyalgia, wheelchair user, elderly client with osteoarthritis).
Key Question for Students:
"How can this client feel 'successful' in their body today without causing themselves pain tomorrow?"
4
Debrief (10 min)
Discuss the psychological impact of being told to "just exercise" when you physically cannot. How do we repair that clinical rupture?
Movement Modification Matrix Worksheet Movement Modification Matrix
Adapting 'E' for Inclusive Clinical Practice
Goal Build Mastery
Instructions
Clinical PLEASE skill (Exercise) often fails because recommendations are not inclusive. For each case study below, identify the primary barriers and propose three adapted movement options that prioritize mood regulation over physical fitness.
Case 1: Sarah
Fibromyalgia & Chronic Fatigue
"Sarah feels like she's 'failing' at PLEASE because every time she tries to walk for 20 mins, she is bedbound for two days after."
Environmental/Physical Barriers
Proposed 'Mastery' Movements (Low Intensity/High Regulation)
1. ____________
2. ____________
3. ____________
Case 2: James
Ambulatory Wheelchair User
"James has limited use of his legs and uses a chair for long distances. He misses the 'adrenaline' of sports and feels emotionally stagnant."
Environmental/Physical Barriers
Proposed 'Mastery' Movements (Adaptive/High Sensory)
1. ____________
2. ____________
3. ____________
Reframing the Dialogue
Standard Prompt: "You need to get active to feel better."
How would you re-word this for Sarah or James to avoid clinical shaming?
Community Resource Mapping Slides Community Asset Mapping
Beyond the Clinic: Scaling PLEASE Skills via Community Resources
Lesson 5: Community Resource Mapping
The Social Ecology of PLEASE
An individual's ability to practice PLEASE is dependent on the Community Assets available to them.
"A skill is only a skill if the environment supports its use."
The Counselor's New Role
You are not just a therapist. You are a Resource Navigator and a Systems Map.
What is a Community Asset?
PL
Free clinics, mobile health units, needle exchanges.
E (Eat)
Food banks, community gardens, WIC offices.
A (Substances)
Peer support (AA/NA), harm reduction centers.
E (Exercise)
Safe parks, community centers, library passes.
Today's Scavenger Hunt
In teams, you have 45 minutes to find three free local resources that directly support a specific PLEASE skill for a low-income client.
Step 1: Locate
Find the physical address and hours.
Step 2: Verify
Identify the eligibility requirements (ID? Income?).
Step 3: Access
Which bus route goes there? Is it walkable?
The Equity PLEASE Mindset
"True clinical mastery is not just knowing the acronym. It is knowing how to make the acronym work for the person in front of you, regardless of their zip code."
Systemic Analysis Cultural Humility Practical Advocacy
Community Resource Mapping Teacher Guide Teacher Facilitation Guide
Lesson 5: Community Resource Mapping
Session Time 90 MIN
Lesson Overview
This final lesson synthesizes the entire sequence by moving from analysis of barriers to actionable resource navigation . Students will conduct a "Digital Scavenger Hunt" to find real local resources that support the PLEASE skills for low-income or marginalized clients. The goal is for each student to leave with a physical "Community Asset Map" they could actually use in a clinic.
Required Tech
Student Laptops/Tablets
Local Map Access
Community Assets Slides
Asset Map Worksheet
1
Hook: The "2-1-1" Test (10 min)
Ask students to take out their phones. "You have 60 seconds to find the nearest food pantry that is open right now . Go."
Facilitation Note:
Most will struggle or find out-of-date info. This demonstrates why the "Resource Navigator" role is vital—generic info is often useless for a client in crisis.
2
Presentation: Systems Thinking (15 min)
Use the Community Resource Mapping Slides . Focus on the "Counselor as Navigator" slide. Discuss how providing a resource is a therapeutic intervention, not "just paperwork."
3
The Great Asset Scavenger Hunt (50 min)
Divide students into groups. Each group is assigned one PLEASE letter (or two). They must fill out their section of the Community Asset Map for the local area.
Look for:
Non-traditional assets (e.g., libraries as cooling centers, barbershops as health hubs, parks with free fitness equipment).
Verify:
Is it accessible via the 'Main St' bus line? Does it require a Social Security Number or ID? (Barriers for undocumented or unhoused clients).
4
Presentation & Sequence Wrap (15 min)
Groups present their "Top 3 Picks." Final reflection: "How has your view of PLEASE changed since Lesson 1?"
Community Asset Map Worksheet Community Asset Map
Sequence Capstone: Systemic Resource Navigation
Target Neighborhood: ______________________
PL: Health Assets
Free/Sliding Scale Clinic
Pharmacy/Medication Assistance
E: Nutritional Assets
Food Pantry / Community Fridge
WIC/SNAP Support Office
S: Environmental Assets
Safe Respite / Cooling Centers
Housing Advocacy / Tenants' Rights
E: Movement Assets
Safe Parks / Free Rec Center
Community Center / Library Mastery Classes
Accessibility Audit
Choose ONE resource above. Is it truly accessible for a client with zero income and no car? Check all that apply:
Bus/Rail Access
No ID Required
Open After 5 PM
ADA Accessible
No SSN Required
Walkable Radius
Final Reflection: How does providing this resource reduce the client's emotional vulnerability?
