RURAL Skills (School Kids Invested in Learning Life Skills): A Dialectical Behavior Therapy Skills Early Depression Intervention In Rural Schools

Background: Early intervention for depression is critical to reducing the mental health burden across the lifespan. Rural Appalachian youth face heightened risk of depression, suicide, and social determinants of health, including limited access to care, fewer resources, transportation barriers, poverty, provider shortages, out-of-home placements, parental substance use or death, and trauma exposure. School-based interventions are critical to expanding access to evidence-based care. Dialectical Behavior Therapy (DBT) effectively treats adolescent depression and suicide risk; however, my community-engaged research shows that existing school-based adaptations of DBT are not feasible in rural Appalachian schools due to competing demands, time constraints, limited resources, lack of funding, and stigma of mental health services. Yet DBT skills are perceived as highly appropriate and acceptable by rural community partners, school counselors, and students, aligning with rural values. My adapted program, RURAL SKILLS (School Kids Invested in Learning Life Skills), addresses common barriers through an abbreviated 9-session, small-group for middle schoolers at risk of depression. Unlike other DBT skills-based programs, SKILLS uses activity-based learning and videos to teach and generalize skills. A train-the-trainer model reduces costs and increases feasibility in low-resourced rural settings. The objective of this study was to examine Appalachian school mental health professionals' perception of the appropriateness, acceptability, and feasibility of RURAL SKILLS. The secondary aim was to assess if RURAL SKILLS training increased knowledge in DBT skills.

Methods: This study was one part of a community-based participatory study to adapt, refine, and test the RURAL SKILLS intervention. We used a pre-post online survey of a convenience sample of Appalachian school mental health professionals attending one of six regional RURAL SKILLS trainings (N = 81) from May 6^th to September 30^th 2025. The trainer, developer of RURAL SKILLS, has intensive training in DBT, and training and consultation with DBT in Schools. Appropriateness, acceptability, and feasibility were measured only at post-test with the Acceptability of Intervention Measure (AIM), Interventon Appropriateness Measure (IAM), and Feasibility of Intervention Measure (FIM), validated measures with strong psychometric properties and a 4/5 benchmark in prior DBT in Schools research. DBT knowledge was measured pre-post through a knowledge test created by DBT in schools, independently validated by DBT experts, and tested with college students. Analysis included descriptive statistics for benchmarks and a paired samples t-test for change in knowledge.

Results: RURAL SKILLS showed high perceived appropriateness (M=4.54/5, SD=0.71), acceptability (M=4.44/5, SD =0.69), and feasibility (M=4.08/5, SD=1.02). The participants reported significant DBT knowledge gain pre-post-training (t=12.37, p<0.001). Across trainings participants’ averaged a 42% on the DBT knowledge test pre-training and 71% post-training.

Conclusions: The abbreviated and applied model RURAL SKILLS shows high appropriateness, acceptability, and feasibility with Appalachian school based mental health professionals. This aligns with previous research of DBT in Schools showing high acceptability, yet lower feasibility, especially in lower-resourced settings. The RURAL SKILLS training is effective in increasing DBT knowledge, yet should be refined to reach a benchmark of 80% post-test. Future research proposes partnering with Appalachian schools in a feasibility study, testing RURAL SKILLS using community-engaged and implementation science methodology.