Effectiveness of Dialectical Behavior Therapy in Schools and Barriers and Facilitators to Implementation: A Rapid Scoping Review

Background and Purpose: Youth are experiencing an unprecedented mental health crisis, with increasing rates of suicide, self-harm, anxiety, and depression. Abrupt changes, such as social isolation during the COVID-19 pandemic, have caused increased loneliness and depression. According to CDC data, 22% of high school students seriously considered suicide, 18% made a suicide plan and 10% attempted suicide in the US in 2021. Exacerbating this crisis are persistent barriers to behavioral health care access including provider shortage, transportation, cost, and stigma. One solution is increasing school based mental health supports. Embedding services within schools avoids many barriers. One promising approach is Dialectical Behavior Therapy. DBT was originally developed for treating highly suicidal patients with borderline personality disorder but has since been used to target multiple mental health conditions. DBT skills in schools include tiered approaches across a continuum of care, ranging from teaching DBT skills to ALL students in the general classroom curriculum to integrating DBT strategies in individual counseling. Despite the effectiveness of DBT, research evaluating DBT and its adaptations in schools remains limited. Research has focused largely on pilot feasibility studies with limited data on student and school outcomes. This highlights a critical need to assess evidence for DBT interventions in school settings. This review supports future research on DBT interventions in schools with the goal of establishing DBT informed approaches in schools as an evidence-based intervention to improve youth mental health.

Methods: A systematic literature search was conducted identifying studies for a DBT scoping review. Databases searched included: PubMed, Scopus, Web of Science, APA PsycINFO via EBSCOhost, and Applied Social Sciences Index & Abstracts (ASSIA) via ProQuest. Authors also searched reference lists of included publications, contacted DBT developers for missing articles, and hand searched Discover Psychology and Google Scholar. Quantitative, qualitative and mixed methods designs were included with no date restriction. Search results were imported into a joint EndNote Library and duplicates deleted. Results were then imported into Covidence, a systematic review screening tool. Titles and abstracts were independently screened by six reviewers. Eligible articles for full-text review were screened by three reviewers. At each step reviewers discussed incongruent results until a conclusion was reached. Results were tabulated with information included about title, authors, date, study design, population, sample size, intervention, comparison condition, main outcome, and secondary outcomes for each article reviewed.

Results: Results demonstrate the state of the evidence for the use of DBT skills in all school settings from universal to targeted interventions, from elementary through higher education. Specifically, results illustrate use of DBT skills in schools and effect on mental health and academic outcomes. Results describe acceptability, feasibility, barriers and facilitators to implementation, and needed adaptations.

Conclusions and Implications: DBT skills when used in school-based settings have the potential to address a variety of mental health problems and promote overall wellness and resilience for all students. Future research should continue to explore efficacy and effectiveness, and feasible methods for implementation of DBT skills in schools, especially in under-resourced areas with high risk and health disparities.