School Mental Health (2022) 14:391–401

https://doi.org/10.1007/s12310-021-09472-4

ORIGINAL PAPER

Implementing Dialectical Behavior Therapy Skills Training

for Emotional Problem Solving for Adolescents (DBT STEPS‑A)
in a Low‑Income School
Carla D. Chugani1 · Courtney E. Murphy1 · Janine Talis1 · Elizabeth Miller1 · Christopher McAneny2 ·
Daniel Condosta3 · Julie Kamnikar3 · Edward Wehrer4 · James J. Mazza5

Accepted: 22 July 2021 / Published online: 5 August 2021

© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2021

Abstract
Adolescents living in low-income areas often have high need for mental health supports due to experiences of poverty
and trauma, coupled with limited access and availability of such supports. This study investigated the implementation of a
socio-emotional learning curriculum titled, “Dialectical Behavior Therapy Skills Training for Emotional Problem Solving
for Adolescents (DBT STEPS-A),” which was integrated into health classes in a low-income high school. While preliminary
evidence suggests that DBT STEPS-A can be effective in reducing mental health symptoms in high school students, this
study is the first to explore the program’s acceptability, appropriateness, and feasibility when implemented in a low-income
school. The implementation presented here also diverged from recommended training protocols due to time and cost limita-
tions. Quantitative and qualitative data were collected from 29 school stakeholders prior to implementation and from 23
school stakeholders post-implementation. Our results indicate that DBT STEPS-A is acceptable and feasible for teachers
involved in offering the program and that more work is needed to address appropriateness of the content for racially and
socio-economically diverse students, ease of implementing lessons, and support for teachers using DBT STEPS-A skills
outside of class. We conclude with a discussion of key implementation challenges and solutions generated.

Keywords Socio-emotional learning · Dialectical behavior therapy · Low-income schools · Implementation

Literature Review and poverty (Shim et al., 2018; World Health Organization
& Calouste Gulbenkian Foundation, 2014). Those attend-
Adolescents living in communities with low socioeconomic ing low-income schools have higher rates of depression,
status (SES) have higher needs for mental health support anxiety, and engagement in violence (Coley et al., 2018),
due to experiences of discrimination, violence exposure, and those who qualify for free meals are significantly more

* Carla D. Chugani Edward Wehrer

carla.chugani@chp.edu ewehrer@steelvalleysd.org
Courtney E. Murphy James J. Mazza
ceb130@pitt.edu mazza@uw.edu
Janine Talis 1
Department of Pediatrics, Division of Adolescent
Janine.talis2@chp.edu
and Young Adult Medicine, University of Pittsburgh School
Elizabeth Miller of Medicine, Pittsburgh, PA, USA
Elizabeth.miller@chp.edu 2
Homeless Children’s Education Fund, Pittsburgh, PA, USA
Christopher McAneny 3
Steel Valley High School, Munhall, PA, USA
cmcaneny@homelessfund.org
4
Steel Valley School District, Munhall, PA, USA
Daniel Condosta
5
dcondosta@steelvalleysd.org University of Washington College of Education, Seattle, WA,
USA
Julie Kamnikar
jkamnikar@steelvalleysd.org

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392 School Mental Health (2022) 14:391–401

likely to have mental health, social, and behavioral chal- encourages identification of coping resources (Wyman et al.,
lenges (Deighton et al., 2019). Coupled with increased 2010). Sources of Strength has been shown to be effective
mental health needs, adolescents in low-SES communities for increasing acceptability of help-seeking and perceived
have decreased access to mental health care arising from a adult support for suicidality (Wyman et al., 2010). The Signs
number of factors, including stigma, long wait times, lack of of Suicide program (MindWise Innovations, 2021), which
providers specializing in mental health care for teens (Sil- has been shown to be effective for reducing suicide attempts
berholz et al., 2017), limited finances/insurance coverage, in high school students, is designed to educate students about
and transportation. depression and suicide ideation, encourage intervention with
School-based socio-emotional learning (SEL) programs suicidal peers, and promote help-seeking among youth expe-
are a highly promising strategy for universal access to men- riencing suicide ideation (Schilling et al., 2016). Although
tal health supports, yet they typically achieve small effects SEL programs can achieve a range of important outcomes
or mixed effects for mental health outcomes (National Acad- related to mental health, a gap persists in programs provid-
emies of Sciences, 2019). Three recent meta-analyses have ing direct instruction on specific coping skills to directly
been conducted which examine the effects of SEL programs target emotional distress or behavioral dysregulation.
for a variety of standard SEL outcomes including skill build- Dialectical Behavior Therapy Skills Training for Emo-
ing, academic achievement, behavior problems, and mental tional Problem Solving for Adolescents (DBT STEPS-A) is
health (Durlak et al., 2011; Sklad et al., 2012; Taylor et al., an SEL curriculum which allows general education teach-
2017). These studies have consistently found that SEL pro- ers to teach mindfulness, emotion regulation, distress toler-
grams achieve small effect sizes for mental health outcomes ance, and interpersonal effectiveness skills from dialectical
(d = 0.16–0.24). These small effects and mixed results may behavior therapy (DBT) through 30 manualized lessons
result from challenges in implementing such programs in the designed for 50 min periods (Mazza et al., 2016). DBT
school system and issues with program fidelity. While qual- STEPS-A is based on the skills training component of DBT
ity implementation supports program effectiveness (Durlak (Linehan, 1993), an evidence-based cognitive behavioral
et al., 2011), the implementation research-related to SEL is therapy that has repeatedly been shown to be effective for
limited and focused on sub-constructs of overall implemen- improving mental health outcomes in adolescents and adults
tation success such as fidelity or dosage (Low et al., 2016). (Chen et al., 2008; Chugani et al., 2013; Linehan et al., ,
More broadly, barriers to implementation of school-based 1999, 2006, 2015; Miller et al., 2006; Perepletchikova et al.,
mental health programs include competing responsibilities, 2011). Unlike therapies that target a specific symptom (e.g.,
logistical barriers, and lack of support from school admin- depression), DBT has demonstrated transdiagnostic effec-
istrators and teachers, whereas facilitators include having a tiveness (Neacsiu et al., 2014; Ritschel et al., 2015) for a
social network among implementers, more organizational wide range of mental health challenges including depression
structure, and administrative support (Langley et al., 2010). and anxiety (Panepinto et al., 2015; Ritschel et al., 2012),
It is also noteworthy to mention that SEL programs may suicidality (Linehan et al., 2006, 2015), addiction (Dimeff
focus on many different types of skill building including & Linehan, 2008; Linehan et al., 1999; Wilks et al., 2017),
areas such as goal setting, problem solving, or in the case and eating disorders (Chen et al., 2008). Unlike many rig-
of suicide prevention, help-seeking, and gatekeeper training orously evaluated SEL programs, which show low or no
designed to help individuals learn to recognize and respond efficacy for reducing emotional distress (Collaborative for
to a person who is displaying warning signs of suicidal- Academic Social and Emotional Learning (CASEL), 2015),
ity. SEL programs that aim to improve mental health may DBT STEPS-A directly targets mental health by combining
achieve small effects if the skills taught do not directly assist mindfulness with skills for emotion regulation, distress tol-
youth in learning how to cope, regulate emotions, or modify erance, and interpersonal effectiveness and as such, was an
factors causing emotional distress. In many cases, these pro- ideal candidate for our pilot project, as our long term goal
grams may actually be targeting mental well-being rather was to improve student mental health through reductions
than emotional distress, which most rigorously evaluated in distress and mental health symptoms (e.g., depression).
SEL programs have been shown to have either low or no The program shows preliminary effectiveness for reduc-
efficacy for reducing (Collaborative for Academic Social and ing emotional symptoms and internalizing problems (e.g.,
Emotional Learning (CASEL), 2015). Even among SEL pro- depression, anxiety) in high school students (Flynn et al.,
grams designed to prevent suicide, there is a lack of focus on 2018a, 2018b) and has also shown effectiveness for social
teaching specific skills for reducing emotional arousal and resilience and difficulties with emotion regulation in racially
distress. For example, the peer-delivered Sources of Strength diverse, rural ninth-graders (Martinez Jr. et al., 2021). How-
program (LoMurray, 2005) is designed to promote identifi- ever, the present study is the only investigation to date on the
cation and engagement with “trusted adults,” encourages stu- acceptability and feasibility of DBT STEPS-A and the only
dents who identify a friend as suicidal to seek out help, and to focus on a low-income school. The focus on establishing

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acceptability and feasibility specifically with low-income graduation. The standard training protocol for implementing
schools is particularly important, as SEL programs like DBT DBT STEPS-A is attendance at a three-day training event led
STEPS-A will not likely reach these schools and students by the curriculum developers. Typically, school districts or
unless they are optimized to fit with available resources and collaborating community agencies contract with the program
to be culturally responsive to the needs and experiences of developers to offer the training, allowing teachers and behav-
students. While larger, more rigorous trials of DBT STEPS- ioral health specialists from across the district to attend. It is
A are needed to investigate efficacy, a first step in this area of also strongly recommended that a half-day training specifi-
inquiry is to establish the acceptability, appropriateness, and cally geared toward school administrators be offered dur-
feasibility of the model to inform strategic adjustments prior ing initial training. Finally, it is recommended that schools
to large-scale studies. In this study, we aimed to address this implementing the program receive ongoing expert consulta-
gap by: (1) evaluating an implementation of DBT STEPS-A tion during at least the first year of implementation at a rate
integrated into required high school health classes, and (2) of one hour per month.
partnering with a low-income high school situated within a When this ideal training scenario was presented to the
low-SES community to evaluate the potential for dissemina- district superintendent, it became clear that this would not
tion of the program into such communities. be feasible for several reasons. First, the district would not be
able to afford the cost of the training as it is a small district
(two elementary, one middle, and one high school). Second,
Background and Community Context the time needed to send teachers to three consecutive days
of training was not available. Third, the teacher’s collec-
The superintendent of a Southwestern Pennsylvania pub- tive bargaining agreement mandates that any work they do
lic school district assembled a coalition of community and outside of regular school hours (e.g., summer months) will
school stakeholders to address a recently received desig- result in additional hourly compensation. Fourth and per-
nation for Additional Targeted Support and Improvement haps most challenging to address, asking teachers to learn
(A-TSI) by the Pennsylvania Department of Education due a completely new curriculum from a content area outside
to racial disparities in academic achievement and school of their typical health class expertise was potentially over-
attendance (Pennsylvania Department of Education, 2019). whelming and could diminish teacher willingness and enthu-
Investigators from the University of University of Pittsburgh siasm for the program. Instead of attempting the traditional
with expertise in school-based health initiatives were invited training and implementation strategy for DBT STEPS-A,
to attend. At this time, the superintendent expressed a desire the superintendent recommended we explore the option of
to include an initiative to support the mental health of stu- using a co-teaching model in which a fully trained individual
dents in the district. Supporting student mental health within would co-teach with high school health teachers, allowing
this district has been an ongoing challenge on several fronts. them to learn the content and curriculum delivery over time.
First, the district is located in a low-SES community with Given the clear barriers with the traditional training model
high rates of community violence. Within the high school, and high need for mental health support in the school dis-
67.3% of students are economically disadvantaged, 21.5% trict, we agreed to develop a co-teaching model for program
receive special education, and the racial demographics are implementation.
as follows: 56.3% White, 34.3% Black, 1.8% Hispanic, 1.1% The next challenge was to locate an appropriate co-
Asian, and 6.4% two or more races. Within the school dis- teacher to partner in the project. In our community, we are
trict overall, 27% of children live below the poverty line. fortunate to have a community-based organization called
Second, few mental health providers are available in the the Homeless Children’s Education Fund (HCEF), whose
local community. Third, even when students are referred to mission is to support the educational needs of children
the school’s program for addressing mental health problems, experiencing homelessness in Allegheny County. HCEF
parents often do not provide their consent for students to has found that it can often be most effective to reach these
participate. youth via schools, as they can be difficult to access outside
of school hours due to parentification (having to take on a
parent role for siblings), the need to work, housing instabil-
Planning and Development ity, or difficulties accessing transportation. Three years ago,
HCEF’s teen program manager began offering college and
Given the challenges in addressing student mental health career readiness programming in local public schools. Given
outside of the school context, we devised a plan for bringing that children experiencing homelessness have high rates of
more mental health support into the school by implementing mental health symptoms and HCEF providers were already
the DBT STEPS-A curriculum as an upstream approach to embedded within public school classrooms, it was a natural
be integrated within high school health classes required for fit to invite HCEF’s teen program manager to partner with us

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as the trained co-teacher. It is important to note that HCEF’s and Thursdays. The curriculum delivery was structured this
teen program manager does not have any formal training or way for two primary reasons: (1) giving a few days between
experience in the provision of mental health services, nor each lesson allows students some time to apply skills outside
is such training required to teach DBT STEPS-A lessons. of the classroom in their lives before learning the next skill,
Though in this specific case, we leveraged a relationship and (2) it allows for some integration of skills training with
with a community-based organization to partner with the other health content (e.g., discussion of how the skills apply
school, we assert that the co-teaching model could be imple- to other health topics such as setting limits in an intimate
mented with anyone meeting the following criteria: relationship, having a discussion about consent, or saying
no when offered drugs or alcohol). The high school health
1. Highly enthusiastic about bringing DBT STEPS-A to the teachers (n = 2) considered their current health curriculum
local school district and found that they could dedicate 33 class periods to DBT
2. Has access to classrooms and resources to do so (i.e., STEPS-A while still adequately covering the remaining
has time and ability to travel to school classrooms, able needed content to adhere to educational standards for high
to pass all required background checks) school health class. Though this would allow for delivery of
3. Willing to participate in a three-day DBT STEPS-A the full 30-lesson curriculum, challenges related to length
training of class periods emerged early in the semester and it became
4. Committed to working as a co-teacher until health teach- necessary to switch to a 19-lesson version of the curriculum
ers are able to teach the lessons independently (we antic- that would allow for DBT STEPS-A lessons to be delivered
ipate this process will take approximately 2 years) only once per week, with a few exceptions where lessons
occurred twice per week. Time issues included in-class chal-
lenges such as needing to take more time than planned to
Methods explain certain concepts and the need to review homework
assignments in class due to low completion rates, as well
Training Protocol and Participants as logistical challenges that interfered with delivery of the
program as originally planned (e.g., senior skip days or other
Our co-teaching model of implementation is based on the school events that cut into health class periods). The team
premise that when time and resources are scarce (such as received expert consultation from one of the DBT STEPS-A
in the case of many low-income schools), available support program developers to address these challenges, including
and resources should be directed most heavily onto key pro- guidance on which parts of each lesson to shorten as well
gram implementers. We obtained an internal grant (Clini- as recommendations on which lessons to completely omit.
cal and Translational Science Award) to support the pro- The 19-lesson curriculum was designed to cover key skills
ject. The first step in this process was to send a community from all four core skills training modules and is consistent
partner who agreed to serve as the co-teacher to a standard with other DBT skills training protocols adapted due to time
three-day DBT STEPS-A training event led by the program constraints (Chugani et al., 2013). Figure 1 provides a flow-
developers. Following this, one of the program developers chart of the overall implementation process (establishing
provided a one-day presentation on DBT STEPS-A designed partnerships, training, and program implementation).
to enhance interest among key school stakeholders includ-
ing 21 general education teachers, two special education Role of Health Teachers and Co‑Teacher
teachers, two school counselors/psychologists, and three
administrators. The one-day presentation was held during Given that the health teachers had not received the standard
the summer months, and all teachers in attendance were 3-day training to deliver DBT STEPS-A, the co-teacher’s
compensated at their union-negotiated hourly rate hour for role was to lead classes on days that program lessons were
six training hours plus one hour for lunch. Lunch and a copy being delivered. Meanwhile, the health teachers added any
of the DBT STEPS-A manual were provided to all attendees. additional information as needed, supported students in their
work during these lessons, and related to content to other
Program Launch health topics taught on days when the co-teacher wasn’t pre-
sent (note that the co-teacher only joined health classes to
In the high school, health class is a one-semester course, teach DBT STEPS-A lessons twice per week). Since health
which meets five days per week, 42 minutes per class period. teachers knew their students better than the co-teacher, they
Thus, we decided (with input from one of the program devel-
opers) that DBT STEPS-A lessons would occur on Mondays

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School Mental Health (2022) 14:391–401 395

Fig. 1  Flowchart of partner-

ships, training, and implementa-
tion. PI = Principal investigator

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396 School Mental Health (2022) 14:391–401

also found that it was easier for them to tell when a student other notes about the class including successes, challenges,
needed something to be re-worded or explained differently or other interesting things that happened. In vivo or video-
to better grasp the content. recorded fidelity ratings were outside of the scope of the
current project.
Measures Finally, the 29 teachers and administrators (including the
health teachers and our trained co-teacher) who participated
Pre‑Implementation Measures in the one-day presentation were invited to complete the
AIM, IAM, and FIM at the end of the first semester dur-
To assess how well the one-day presentation was received by ing which the DBT STEPS-A was offered. In addition to
high school teachers and administrators, an internally devel- these measures, four qualitative items gathered feedback
oped training evaluation was administered that included five on what else can be done to support program implementa-
quantitative items (e.g., “How valuable did you find today’s tion, what participants would suggest if the implementation
training?”) and four qualitative items (e.g., “What would was done again, additional feedback about any part of the
have made this training more valuable/useful for you?”). The DBT STEPS-A curriculum or training, and feedback for the
five quantitative items were investigator-developed items research team about how to improve the partnership with
typically used in educational training events, and all were the school or district.
rated on a five-point Likert scale ranging from “not at all”
(1) to “extremely” (5). Analyses
Participants in the one-day presentation also completed
the Acceptability of Intervention Measure (AIM), Inter- Quantitative items were analyzed descriptively (mean, stand-
vention Appropriateness Measure (IAM), and Feasibility ard deviation, range). Qualitative data were transcribed elec-
of Intervention Measure (FIM), which are brief, validated tronically and uploaded to Dedoose, a secure online platform
scales of the acceptability, appropriateness, and feasibility for qualitative data analysis (Sociocultural Research Con-
of interventions (Weiner et al., 2017). Each scale has four sultants LLC, 2018). We set our benchmark for adequate
items, and all three scales have demonstrated good discrimi- acceptability, appropriateness, and feasibility as a mean rat-
nant and structural validity, test–retest reliability, and good ing of 4 (on a Likert scale of 1–5). Qualitative data were
internal consistency (α range = 0.85–0.91). Items are rated coded by a research assistant under the supervision of the
on a five-point Likert scale ranging from “completely disa- first author using a descriptive qualitative coding method
gree” (1) to “completely agree” (5). aiming to capture common patterns or themes in responses
among participants (Sandelowski, 2000). The University
Post‑Implementation Measures of Pittsburgh Human Subjects Research Protections Office
(HRPO) approved this study as an exempt protocol for evalu-
To examine fidelity and ease of use on a lesson-by-lesson ation of educational curricula.
basis, a brief, electronic fidelity form was created which the
co-teacher completed after each lesson (one rating per class
period). The fidelity form captures the rater, lesson number, Results
class period number, whether the lesson content was fully
delivered (if not, what percentage was delivered on a slid- Pre‑Implementation Findings
ing scale of 0 to 100%), how easy it was to teach the lesson
(rated on a five-point Likert Scale from “extremely difficult” Overall, participants in the one-day presentation found the
(1) to “extremely easy” (5)), how well the students seemed event to be valuable and agreed that DBT STEPS-A was
to like the lesson (rated on a five-point Likert Scale from important for high school students. Table 1 presents partici-
“dislike a great deal” (1) to “like a great deal” (5)), and any pants ratings on our internally developed training evaluation

Table 1  Participant ratings on Item (n = 29) M SD Range

training evaluation items
1. How valuable did you find today’s training? 3.93 0.75 2–5
2. How important do you think it is for high school students to learn STEPS-A skills? 4.62 0.49 4–5
3. How important you do think it is to include skills for emotional well-being and 4.59 0.69 2–5
problem solving in high school health curricula?
4. How likely are you to use information you learned today in your teaching? 3.93 0.70 2–5
5. How likely are you to use information you learned today in your personal life? 3.90 0.77 2–5

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School Mental Health (2022) 14:391–401 397

Table 2  Descriptive Statistics by Item for the Feasibility of Interven- including a troubleshooting portion with time for questions
tion Measure (FIM) and answers. Participants also requested the addition of case
Item (n = 29) M SD Range examples or role-play scenarios to enrich the learning expe-
rience and to better illustrate implementation.
1. DBT STEPS-A seems implementable 4.17 0.60 3–5
2. DBT STEPS-A seems possible 4.24 0.58 3–5
Post‑Implementation Findings
3. DBT STEPS-A seems doable 4.17 0.54 3–5
4. DBT STEPS-A seems easy to use 3.83 0.89 2–5
Acceptability, appropriateness, and feasibility were re-
assessed at the end of the first semester of implementation
with the same 29 participants who attended the training
items (n = 29). Participant ratings also indicate that par- event being invited to complete the post-semester evalua-
ticipants found DBT STEPS-A to be highly acceptable tion. All original training participants were included in this
(M = 4.47, SD = 0.57, α = 0.96) and appropriate (M = 4.55, evaluation regardless of their role in implementing the pro-
SD = 0.53, α = 0.94) for their school and students. In com- gram with the focus on examining how the program was
parison, the scores for feasibility of the program were lower, perceived by a variety of school stakeholders. Overall, 23
though the overall mean score remained supportive (M = 4.1, participants responded to the post-semester survey for a fol-
SD = 0.57, α = 0.88). Given this, each individual feasibility low-up response rate of 79%. Respondents included three
item was examined and results revealed that “ease of use” health teachers (including the trained co-teacher), four high
as a particular area was perceived as a relative weakness school/district administrators, 15 general education teachers
(see Table 2). It is important to note that these ratings were not directly involved in teaching DBT STEPS-A lessons as
provided prior to program implementation, at the end of the part of health class, and one respondent who did not indicate
one-day presentation. their job role. Table 3 presents post-implementation ratings
of program acceptability, appropriateness, and feasibility for
Qualitative Feedback on the One‑day Presentation the overall group of respondents, health teachers/co-teacher

Participants almost unanimously felt the topics covered dur-

ing the one-day DBT STEPS-A presentation were important,
needed, and valuable. Overall, well-being, coping strategies, Table 3  Post-Implementation Ratings of Acceptability, Appropri-
and mental health were highlighted as areas where strate- ateness, and Feasibility Overall, Among Those who Delivered DBT
STEPS-A Lessons, and Among Teachers, Staff, and Administrators
gic improvements were wanted and necessary. Participants
generally enjoyed the introduction to the DBT STEPS-A Construct M SD Range
curriculum, though some also expressed interest in being
Acceptability (n = 23) 3.87 0.57 2.75–4.75
able to see what the program was like once implemented.
Health Teachers/Co-Teacher (n = 3) 4.33 0.14 4.25–4.5
However, about one quarter of participants said they simply
Teachers/Staff/Administrators (n = 19) 3.84 0.56 2.75–4.75
felt the presentation was too long or that there was too much
Appropriateness (n = 23) 3.95 0.62 3–5
information presented at once for them to feel comfortable
Health Teachers/Co-Teacher (n = 3) 3.75 0.66 3–4.25
putting it to use. This left some participants feeling over-
Teachers/Staff/Administrators (n = 19) 4.03 0.60 3–5
whelmed after the presentation concluded.
Feasibility (n = 21) 3.74 0.65 2.25–5
Nearly all participants requested more information on
Health Teachers/Co-Teacher (n = 3) 4.25 0.50 3.75–4.75
how to implement the program and apply DBT STEPS-A
Teachers/Staff/Administrators (n = 17) 3.69 0.63 2.25–5
techniques in real-life situations, with a few voicing logisti-
cal concerns. Among the suggestions related to what infor-
mation would be desired should another training event occur
were: (1) more time for training, (2) more engagement with
trainees, and (3) more details on how to apply the program Table 4  Post-Implementation Feasibility Ratings by Item Among
in their specific setting. Those who made these suggestions Those Who Delivered DBT STEPS-A Lessons (Health Teachers and
were interested in reviewing specific materials (e.g., les- Co-Teacher; n = 3)
son plans) and obtaining a more in-depth understanding Item M SD Range
of the skills and strategies than what was introduced. Most
1. DBT STEPS-A seems implementable 4.33 0.58 4–5
participants also suggested a more “hands on” approach,
2. DBT STEPS-A seems possible 4.33 0.58 4–5
3. DBT STEPS-A seems doable 4.33 0.58 4–5
4. DBT STEPS-A seems easy to use 4 1 3–5

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398 School Mental Health (2022) 14:391–401

alone (i.e., those who actually delivered the program), and Fidelity Ratings
teachers, school staff, and administrators who were trained
during the summer but do not have direct responsibility for The co-teacher, who received the standard three-day training
program delivery. The overall mean scores were 3.87 for in DBT STEPS-A, provided fidelity ratings throughout the
program acceptability (4.33 among those who delivered the first semester of implementation. Of the 69 DBT STEPS-A
program), 3.95 for program appropriateness (3.75 among classes taught during the fall 2019 semester (23 lessons per
those who delivered the program), and 3.74 for feasibility class section with 3 sections total), teachers were able to
(4.25 among those who delivered the program). Table 4 deliver the full lesson content 71% of the time. When lesson
presents the mean ratings for program feasibility by item content was not fully delivered, the co-teacher estimated that
among health teachers and the co-teacher (n = 3; i.e., those the amount of content that was delivered ranged from 15 to
who directly delivered the program). 94%. The average rating for ease of use for the lessons was
3.30 (SD = 0.086). The average rating for how well students
Qualitative Program Feedback seemed to like the lesson was 3.52 (SD = 0.093). Thus, while
the overall ratings for ease of use of the program indicate an
Of the 23 follow-up survey participants, 12 provided quali- acceptable degree of program feasibility (see Table 4), these
tative feedback about the program through four open-ended lesson-by-lesson ratings indicate that ease of use of certain
questions. Overall, respondents shared a desire for more lessons and student responsiveness to specific lessons could
time to implement the program and more post-training col- be improved.
laboration and contact with the trainer, which if available,
would have improved the programming experience. While
there was no negative feedback about DBT STEPS-A as a Discussion
program, participants who did not have direct involvement
with teaching DBT STEPS-A lessons lacked understanding The data presented here are the first to explore acceptabil-
of how to support students in using the skills, though they ity, appropriateness, and feasibility of the DBT STEPS-A
expressed a strong desire to be able to do so. Some partici- program in a low-income school, as well as to present a
pants also expressed a desire to be evaluated, reporting that detailed account of program implementation and on-the-
they would like to know how well they are doing in imple- ground adaptations. While DBT STEPS-A was rated as
menting the program. adequately acceptable, appropriate, and feasible by school
When asked about what changes they would like to see, stakeholders immediately after training and prior to imple-
participants were concerned with logistical and adminis- mentation, these ratings dropped below the benchmark of
trative details, such as a desire for more communication an average rating of 4 post-implementation. Additionally,
between those who did vs. did not have direct responsibility these ratings varied among those who did vs. did not directly
for delivering the program, limited accessibility to the pro- deliver DBT STEPS-A lessons. Among those with direct
gram for all students (e.g., lack of opportunity for those who involvement in teaching the program, acceptability and fea-
have already taken health class prior to implementation) and sibility were adequate, while appropriateness fell below the
tailoring teaching strategies based on student needs (e.g., benchmark. Interestingly, while program ease of use was
age-based content for younger vs. older students, material adequate among those with direct involvement, lesson-by-
for at-risk students, etc.). Overall, participant responses were lesson ratings for ease of use (provided by the co-teacher,
less focused on changing the content of the program itself as who received the standard 3-day training to deliver DBT
they were on increasing the level of support and implemen- STEPS-A) fell well below the benchmark. One explanation
tation adaptation for their setting and student needs, includ- for this lower rating may be due to the fact that this was the
ing a desire for follow-up training and consistent, situational first time the co-teacher had implemented the DBT STEPS-
guidance from their trainer(s). A curriculum and that ease of use may increase with greater
Among the three participants who had direct involvement familiarity. In addition, although the co-teacher had experi-
in teaching DBT STEPS-A lessons, two provided qualita- ence providing programming in high schools, he is not a
tive feedback. The responses indicate that they felt poorly high school teacher, and this may have impacted ease of
prepared to implement the program, wanted to consult with use of the program. Post-implementation qualitative feed-
other teachers delivering the program, and desired a better back further indicated that school stakeholders had ques-
understanding of the practical application of the skills. They tions about how to support students in using DBT STEPS-A
also emphasized needing more training overall, continued skills outside of health class, how students who had already
support, and opportunities for personalized consultation. taken health could be exposed to the program, and a desire
for more ongoing training and contact with trainers. Addi-
tionally, it is important to note that the implementation at

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this school represents a substantial departure from the rec- lesson introduction, then teaching about half the lesson, and
ommended training protocols, which were not financially then teaching the lesson independently with the co-teacher
feasible for this school district. Given that the training pro- observing and supporting as needed. This transition plan
vided to this group of stakeholders was so limited, it is not was developed in consultation with the health teachers, who
surprising that some felt ill-prepared to use the program. agreed that the timing of the plan was reasonable and that
Additional grant funding to support the cost of the stand- they were comfortable with the program material, although
ard 3-day DBT STEPS-A training for the health teachers as no additional learning opportunities beyond the 1-day train-
well as dedicated financial resources (e.g., substitute teacher ing related to DBT STEPS-A were provided.
coverage) to protect health teachers’ time to participate in The co-teacher also found that it was difficult to ade-
training and prepare to deliver DBT STEPS-A lessons may quately deliver the DBT STEPS-A lessons as written given
have led to better confidence for teachers tasked with learn- the lessons are designed for 50 min and class periods in this
ing and delivering the program. Interestingly, the two health high school are 42 min. While the co-teacher received expert
teachers, neither of whom received the standard three-day consultation from the program developers about where to
training to deliver the program, rated it as both adequately trim down lesson content, they found that this was not suf-
acceptable and feasible. Further, while the stakeholder rat- ficient and decided that it would be more feasible to switch
ings overall fell below our a priori benchmark of 4, the rat- to a 19-lesson version of the curriculum which was devel-
ings were just slightly below the benchmark. Given that this oped in consultation with one of the DBT STEPS-A program
implementation took place in a low-income school, it is pos- developers and the health teachers. Finally, students did not
sible that the program may not fully attend to the needs of complete their assigned DBT STEPS-A homework as they
students living in areas with high rates of poverty and com- were unaccustomed to receiving homework in health class.
munity violence or may need further adaptation to meet the The co-teacher found that the most effective way to handle
needs of a racially and ethnically diverse student population. this was to encourage students to complete the homework
Further program refinement based on more in-depth qualita- sheets during the next lesson review, as well as to start com-
tive interviews, including student feedback, would likely be pleting them during the end of each class period. For the
of substantial benefit in informing next steps, especially as following semester, health teachers agreed to make DBT
the curriculum adaptations did not directly assess cultural STEPS-A homework completion a graded journal entry that
responsiveness or mismatch in the present study. all students would complete during the day after the DBT
Several major challenges in implementation were also STEPS-A lesson was delivered. Health teachers also agreed
observed during the first semester of implementation, and to facilitate one additional mindfulness activity per week on
these were largely consistent with barriers to implementa- a non-DBT STEPS-A lesson day to further integrate these
tion of other school-based programs (Langley et al., 2010). skills into the overall health curriculum and reinforce the
First, health teachers were extremely busy and there were materials.
no opportunities other than in-service days for them to meet
with the trained co-teacher to discuss progress and planning
for transitioning them toward independent delivery of the Limitations
curriculum. In essence, though our data indicate that more
training, contact with trainers, and personal consultation This study is limited by a small sample within a single high
was desired, the reality was that there was little time dur- school. The data are limited to pre- and post-implementation
ing which this could occur. While the co-teacher received ratings of intervention acceptability, appropriateness, feasi-
monthly expert consultation throughout the semester (hour- bility, qualitative feedback, and basic lesson fidelity ratings,
long phone calls) and emailed for further assistance as and do not include preliminary effectiveness data. An impor-
needed, the health teachers were unable to participate in this tant limitation of the present work is that it does not include
support because they did not have time to participate dur- direct feedback from students, which would aid in strategic
ing their workday and could not participate outside of their adaptations for cultural responsiveness and relevance. A
workday. This situation was partially remedied by arranging second limitation is that the fidelity ratings reported here
for the health teachers and co-teachers to meet once weekly are self-reported, as a validated fidelity measure for DBT
during their early morning planning period to review the STEPS-A is not available and neither in vivo nor recorded
contents of each lesson prior to delivering the lesson in observations were possible for the present study. Constructs
class later the same day. To address the issue of supporting such as acceptability, appropriateness, and feasibility may
health teachers in their transition to teaching DBT STEPS- vary according to quality of implementation, and as such,
A independently, the research team, co-teacher, and health our findings should be interpreted with this limitation in
teachers met and made a plan for gradual transition over mind. Despite these limitations, this pilot study is the first to
the following three semesters including first teaching the explore key implementation variables in the delivery of DBT

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STEPS-A and to focus specifically on collaborating with ing fees related to its use. Dr. Chugani receives consulting fees from
school stakeholders to adapt programs to enhance feasibility the Citrone 33 Foundation.
for low-resource schools. This pilot work has revealed that
despite many implementation challenges, DBT STEPS-A
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