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Deepening the understanding of the biosocial theory and applying dialectical behavior therapy Elizabeth A. Courtney-Seidler, Karen Burns, irene Zilber, and Alec L. Miller Cognitive & Behavioral Consultants, LLP - White Plains, NY Abstract The promise of Dialectical Behavior Therapy ( DBT ) has been substantiated by a growing body of work demonstrating its efficacy for addressing suicidal and non-suicidal self-injury as well as pervasive emotional and behavioral dysreg - ulation, among adolescents. Research elucidating the neurobiological correlates and biosocial factors contributing to the development of emotion dysregulation and self-harm is presented. A recent milestone is the completion of the first randomized controlled trial of DBT with self-harming adolescents. The results of this five-year study are presented along with an overview of the treatment as adapted for this population. Keywords Dialectical Behavioral Therapy ( DBT ), suicidal and non-suicidal self-injury, emotional and behavioral dysregulation, adolescents, self-harm, neurobiological correlates, biosocial factors, randomized controlled trial. D ialectical Behavior Therapy ( DBT) was first adapted for use with multi-problem suicidal adolescents nearly twenty years ago in response to a dearth of empirically supported psychosocial treatments for this population (Miller, Rathus & Linehan, 2007; Miller, Rathus, Linehan, Leigh & Wetzler, \f997). Miller, Rathus and colleagues retained the core principles and strategies of Linehan’s (\f993) original DBT treatment manual for suicidal women with Borderline Personality Disorder ( BPD), and made modifications based on developmental and contextual considerations for adolescents and their families. Three review articles by Groves, Backer, van den Bosch, & Miller (20\f2), MacPherson, Cheavens, & Fristad (20\f3), and Neece, Berk, & Combs-Ronto (20\f3) all found growing evidence, based on the review of over a dozen quasi-experimental and open-trial pilot studies, to suggest that DBT may be a promising treatment for adolescents with a range of problematic behaviors, including but not limited to suicidal and non-suicidal self-injury.

Ritschel, Miller & Taylor (20\f3) recently proposed DBT as transdiagnostically applicable to adoles - cents who present with more pervasive emotional and behavioral dysregulation often evidenced in mood disorders, substance use disorders, eating disorders, and disruptive behavior disorders, in addition to the more standard applications of DBT to self-harming individuals often diagnosed with BPD . More recently, Mehlum and colleagues (in press) have completed the first randomized con - trolled trial of DBT with self-harming adolescents and found DBT to be a highly effective treatment for this population.

This paper reviews adolescent suicide and self-in- jury and the neurobiological bases for some of these behaviors. Next the paper provides further support for Linehan’s (\f993) Biosocial theory of emotion dysregulation, that informs DBT treatment with adolescents. Finally, the paper briefly describes DBT treatment with adolescents along with a brief review of the results of the first adolescent DBT randomized controlled trial ( RCT). Adolescent suicide and self-injury Suicidal behavior is among the leading causes of death among adolescents (Bridge et al., 2006; Spirito & Esposito-Smythers, 2006). The estimated lifetime prevalence for suicidal ideation, planned attempts, and suicide attempts is \f2%, 4%, and 4.\f% respectively (Nock et al., 20\f3). Non-suicidal self-injury (NSSI) is often a correlate and precursor to suicidal behaviors among adolescents (Andover et al., 20\f2; Miller et al., 2007;). The lifetime prevalence of NSSI in adolescent community samples is \f5-28% (Claes, Luycks, Bijtte - bier, 20\f4; Laye-Gindhu & Schonert-Reichl, 2005; Nixon et al., 2008; Whitlock & Knox, 2007) and is found in up to 60% of adolescent clinical samples (Nock & Prinstein, 2004). The typical age of onset for NSSI is between \f2-\f4 years (Nixon, Cloutier, & Aggarwai, 2002; Nock & Prinstein, 2004; Ross & Heath, 2002) and cutting and hitting oneself are the most frequent forms of NSSI (Muehlenkamp & Gutierrez, 2004, 2007; Ross & Heath, 2002). Adoles - cents who engage in NSSI are more likely to attempt suicide (Whitlock & Knox, 2007), with 70% of adolescents who engage in NSSI reporting at least one suicide attempt and 55% reporting multiple suicide attempts (Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006; Zlotnick, Donaldson, Spirito, & Pearlstein, \f997).

Although suicidal behavior is mentioned as a symptom of Borderline Personality Disorder (BPD ) in the DSM-IV and ICD-\f0 classification systems, and research has provided ample support for this diagnostic relationship (Nock et al., 2006), suicidal and non-suicidal self-injury in adolescence is also detected in internalizing and externalizing disorders (Nock et al., 2006). There is ample research on the diagnostic correlates of suicide and NSSI in adoles- cents (See Nock et al., 2006 for review). Despite the progress in identifying psychosocial risk factors for adolescent suicidal behaviors, such as psychiatric diagnoses, the neurobiological alterations that contribute to the pathogenesis of suicide are less well understood in adolescents (Currier & Mann, 2008; Mann, 2003). Neurobiology of suicidal behaviors and non-suicidal self-injury Substantial evidence exists supporting the asso - ciation between deficits in 5-HT functioning and conditions and behaviors characterized by impul - sivity, aggression, and affective instability (Kamali, Oquendo, & Mann, 2002). A relationship between the serotoninergic system and suicidal behaviors is the most consistent finding regarding biological contributions to suicidality (Mann, 2003; Zalsman et al., 2006). Pandey and colleagues’ (\f997, 2002, 2004) post-mortem research indicates that adolescent suicide completers have increased serotonin 5-HT2 a receptors, protein, and mRNA expression in the prefrontal cortex and hippocampus compared to normal controls. More recent research from Pandey and colleagues (20\f2), found that proinflammatory cytokines, which play an important role in stress and depression, were elevated in the prefrontal cortex compared to normal controls. Brain-derived neurotrophic factor (BDNF) dysregrulation has also been associated with adolescent suicidality, independent of psychiatric diagnoses (De Leo, 20\f\f; Pandey, 2004). BDNF plays a significant role in the regulation and growth of neuronal development in children and adolescents. Research hypothesizes that the serotonin dysfunctions found in adolescents with suicidal behavior may be related to deficits in BDNF (De Leo, 20\f\f). A majority of neuroimaging studies of NSSI and suicidal behavior have been with adolescents diag- nosed with BPD . Studies have detected alterations in brain maturation with electroencephalography among adolescent females with BPD symptomatology (Ceballos, Houston, Hesselbrock, & Bauer, 2006; Houston, Ceballos, Hesselbrock, & Bauer, 2005). This research and others thus far indicate neurobiological alterations in the anterior cingulate cortex (Chanen, Jovev, et al., 2008; Chanen, Velakoulis et al., 2008; Goodman et al., 200\f; Whittle et al., 2009), pituitary gland (Jovev et al., 2008), and the dorsolateral cortex and the orbitofrontal cortex (Brunner et al., 20\f0).

Goodman and colleagues (20\f\f) found that among female adolescents diagnosed with co-morbid BPD and Major Depressive Disorder (MDD), greater BPD symptom severity and number of suicide attempts, and not depression, was associated with greater ACC abnormalities. Research findings of frontolimbic dysfunction in both male and female adolescents with BPD symptomatology and suicidal behaviors support the specific roles of emotion dysregulation and impulsivity in the development of suicidal behaviors.

There is less research on the neurodevelopmental abnormalities in adolescents with NSSI and suicidal behaviors who do not meet criteria for BPD . One neuroimaging study using a heterogeneous diagnostic sample (e.g., MDD, Dysthymia, PTSD , and BPD) compared \f8 adolescent females with and without a history of NSSI on an emotional processing task (Plener et al., 20\f2). Results indicated that adolescent females with NSSI had increased activity in the amygdala, anterior cingulate cortex ( ACC) in the inferior and middle orbitofrontal cortex, and reduced sensitivity in the cuneus and right inferior frontal cortex (Plener et al. 20\f2). Plener and colleagues (20\f2) argue that these altered neural patterns provide 2014, ALL RiGHTS RESERvEDiSSN: 155 7855 iNTERNATiONAL JOURNAL OF BEHAviORAL CONSULTATiON AND THERAPY 2014, vOL. 9, NO. 3 36 evidence for adolescents with NSSI having a reduced ability to interpret social cues and regulate emotions.

These findings are consistent with a model proposed by Nock (20\f0) that proposes that increased negative emotions coupled with social problem solving and communication deficits, leads to increased risk for engaging in maladaptive emotion regulation strategies such as NSSI.

Neuroimaging research has found differential patterns of neural activity during emotional pro - cessing tasks of mild and ‘protypical’ angry, happy, and neutral facial expressions in adolescents with and without a history of a suicide attempt (Pan et al., 20\f3). Pan and colleagues (20\f3) found that adolescent suicide attempters of both genders had elevated activity in attention control circuitry and reduced anterior cingulate gyrus connectivity, an area that supports emotional processing, and the regulation of emotional responses (Etkin et al., 20\f\f), compared to non-attempters when processing mild intensity angry faces. Neuroimaging findings of al- tered activity with only mild angry facial expressions is consistent with research finding milder intensity facial expressions to be more indicative of social displays of emotion compared to \f00% prototypical intensity facial expressions (Surguladze et al., 2005).

Pan and colleagues (20\f3) propose that adolescent suicide attempters increased attention and processing of mild social displays of disapproval may contribute to a vulnerability to suicidal behavior. Taken together, the neuroimaging findings of altered neural activity in the brain structures mentioned above support theoretical models that implicate poor emotional processing in social situations and affective dysreg- ulation in NSSI and suicidal behaviors (Nock, 20\f0; Nock & Prinstein, 2005).

Physical pain processing. Research suggests that adolescents who engage in NSSI experience emotional dysregulation and higher physiological reactivity (e.g., skin conductance measures) in response to stressful situations (Deliberto & Nock, 2008; Nock & Mendes, 2008). Nock and Mendes (2008) compared skin conductance measures during a distressing task for 62 adolescents with a history of NSSI to 30 matched controls without a history of NSSI. Increased physiological arousal was found among adolescents with NSSI. Physical pain processing is also different in adolescents who self-harm. Nock & Prinstein (2005) found that adolescent psychiatric inpatients with a history of self-injury reported little to no pain when engaging in NSSI behaviors. These findings are consistent with experimental studies showing that individuals who self-injure have a lower pain sensitivity and greater ability to tolerate pain for a longer period of time compared to those without a history of self-injury (Bohus et al., 2000; Russ et al., \f999). Elevated levels of endogenous opiates in individuals who self-injure has been hypothesized to account for the presence of this lower pain sensitivity (Nock, 2009). Neurological structural and hormonal changes in the processing of emotional distress and pain put adolescents at greater risk for making impulsive decisions and affective instability, which contribute to a greater vulnerability to NSSI (Ballard, Bosk, & Pao, 20\f0).  Association of NSSI and suicidal thoughts and behaviors As previously mentioned, chronic NSSI in and of itself is an important risk factor for suicidal behavior in adolescents (Joiner, 2005; Wichstrom, 2009). In a recent longitudinal study examining the temporal relationship between NSSI and suicidal behaviors, college aged students who had any history of NSSI were three times more at risk for concurrent or later suicidal thoughts or behaviors (Whitlock et al., 20\f3). These findings are consistent with the most widely supported theory of suicide, the Interpersonal Theory of Suicide (IPTS ; Joiner, 2005; Van Orden et al., 20\f0). The IPTS posits that acquired capability, which is defined as the capacity one has to perform a lethal suicide attempt, is a necessary component for suicidal desire (encompassed by thwarted be - longingness and perceived burdensomeness) to develop into suicidal behavior. Joiner and colleagues (Joiner, 2005; Van Orden et al., 20\f0) hypothesize that acquired capability develops from a reduced fear of death and increased pain tolerance, which often occurs through repeated exposure to painful experiences (e.g., trauma, NSSI ). Recent research supports IPTS’s proposed relationship between NSSI and suicidal behavior, with repeated experience with NSSI mediating the relationship between low distress tolerance and suicide attempts (Anestis et al., 20\f3).

Psychiatric disorders characterized by low levels of distress tolerance and emotion dysregulation such as Borderline Personality Disorder (Linehan, \f993) and Substance Abuse Disorders (Howell et al., 20\f\f) have been found to have higher rates of suicidal behavior and death by suicide (Bornovalova et al., 20\f\f; Skodol et al. 2002).

Clinically these findings highlight the importance for therapeutic interventions aimed at reducing sui- cidal behavior to increase emotionally dysregulated individuals’ abilities to tolerate distress and not engage in maladaptive emotion regulation strategies such as NSSI.

 The biosocial model Providing the theoretical framework for DBT , Linehan’s Biosocial Theory (\f993) posits that a problematic and pervasive transaction between a biologically vulnerable individual and an invalidating environment yields emotional dysregulation in individuals, many of whom present with suicid - al behavior and borderline personality disorder.

Along with a biological vulnerability described earlier in the paper as it relates to suicide, self-in - jury and BPD, an invalidating environment is the other key component of this theory. While the research reviewed previously in this paper has indirectly emphasized the neurobiology aspect of the biosocial theory, less is understood about the components of the invalidating environment. Thus, the remainder of this section explores different etiological pathways and expressions of invalidation that should be considered when working with suicidal multi-problem youth.

Broadly speaking, an invalidating environment is one that responds to the individual’s communi- cations of his/her internal emotional experiences with skepticism, derision, or punishment (Linehan, \f993). According to Linehan (\f993), invalidation questions the accuracy of the individual’s experience and representation of his/her emotions, either overtly or in more subtle ways, and may even suggest that the emotional responses of the individual – positive or negative – result from undesirable personality traits, such as being manipulative, overly sensitive, dramatic, or paranoid. This is especially true when events in the environment don’t appear to support the validity of an emotional response, or one of such intensity or duration.

While any environment can be invalidating at times, the characteristics of an emotionally dysreg- ulated individual – sensitivity, reactivity, and slower return to emotional baseline – make it more likely that the environment will respond to the expression of emotion with invalidation more chronically.

Additionally, while such pervasive invalidation may be distressing for those with normative capabilities to regulate emotions, it is even more challenging for individuals who experience their emotional states as highly intense and difficult to manage, and can exacerbate their disposition toward dysregulation.

The view of one’s emotional experiences as generally “wrong” in some way can become internalized by some individuals, leading to mistrust in the accuracy of emotional responses and shame in the face of their inability to easily resolve problems. Over time, the individual seeks out external cues for appropriate emotional responses to events and punishes him/ herself for failures to navigate difficulties more skillfully, leading to the development of maladaptive behaviors including but not limited to suicidal and non-suicidal self-injurious behaviors.

Caregiver emotion socialization and invalidation The prevailing DBT theory posits borderline symp- tomatology as, fundamentally, a deficit in emotion regulation skills. According to Gross (20\f3), emotion regulation is a process involving both the up-reg - ulation and down-regulation of the intensity or duration of emotions, occurring either intrinsically or extrinsically. Gross’s information-processing model proposes that the process involves situation selection, situation modification, attention deployment, cog- nitive change (i.e. such strategies as suppression or reappraisal), and response modulation. Disturbances in emotion regulation may therefore result from poor awareness of emotional responses or poor selection of goals or strategies for managing responses. Addi- tionally, Gross (20\f3) believes regulation is primarily achieved via extrinsic means in infancy but changes throughout the lifespan.

Undoubtedly, the environment exerts powerful influence on the development of such skills. Yet it has proven difficult to quantify the exact nature of such invalidating environments. The existing conceptualization characterizes the invalidating environment as one in which the caregiver rejects or punishes emotional expression, thereby leading to escalation of affect by the dysregulated individual, which is subsequently intermittently reinforced by the caregiver providing support or removing an aversive stimulus in response to the extreme expression.

COURTNEY-SEiDLER, BURNS, ZiLBER, & MiLLER 37 Citing the work of Chess and Thomas, Linehan (\f993) points to “poorness of fit” between child and environment, wherein the child’s temperament or expressions of mood are ill-suited to the expec- tations or resources/abilities of the environment to effectively manage, as an early manifestation of an invalidating environment. It would follow that characteristics of the caregiver, as well as of the infant and the environment, play a role in the invalidating dynamic. In terms of individual qualities of the caregiver that would result in such mismatch, Keenan (2000) identified caregiver responsiveness and supportiveness as factors that were negatively correlated with infant cortisol level and negative affect – indicators of dysregulation – exclusive of infant temperament. An investigation of familial emotion socialization among parent-teen dyads by Buckholdt, Parra, and Jobe-Shields (20\f4) found that self-reported dysregulation in parents was correlated with higher rates of invalidation of their adolescents’ emotional expression, which predicted adolescent emotion dysregulation. This finding suggests that dysregulation may be transmitted from parent to child not just via biological processes but also by way of modeling and transactional processes. Research focusing on interactions between care- givers and children in early childhood has provided clarification of the processes by which emotion reg- ulation is facilitated or hindered by parental emotion socialization. Krause, Mendelson, and Lynch (2003) examined the effect of invalidation in childhood – as recalled by subjects – on subsequent mental health outcomes in a community sample of individuals between the ages of \f8 and 30 years old. Defining invalidation as parental reactions to emotional expressions characterized by minimization, criticism, punishment, or distress, the authors found that such negative emotion socialization was associated with poorer mental health outcomes in adulthood, as reflected by Beck Depression Inventory and Beck Anxiety Inventory scores. However, this result was mediated by the subjects’ emotional inhibition – a style of responding to emotionally-arousing expe - riences with ambivalence, conscious suppression, or situational and/or chronic avoidance. Eisenberg and colleagues (200\f, \f996, \f994, as cited by Krause et al., 2003) concluded via multiple studies that punitive, dismissive, or dysregulated caregiver responses to children’s emotional expressions (as reported retrospectively) predicted emotional inhibition and avoidance. Krause et al. theorize that the develop- ment of an inhibited style of emotion regulation serves adaptive function in an environment where more demonstrative and expressive styles evoke aversive responses. It must be noted that this line of research is limited by the fact that it relies primarily on retrospective reports of communication around emotional expression. Applying a methodology less vulnerable to recall biases, Crowell et al. (20\f3) looked at patterns of verbal escalation in interactions between mothers and teens (using a primarily female sample) in real-time discussions of conflict areas. Compared to non-self-injuring controls, dyads with self-in - juring teens had greater frequency of utterances coded high-aversiveness (as opposed to low- and intermediate-aversiveness). These dyads also exhibit - ed patterns in which maternal de-escalation occurred most frequently in response to high-aversiveness communication by teens and with reduction to intermediate-level aversiveness, supporting one hypothesis that dysregulated communication and be - havior is maintained via caregiver reinforcement. In contrast, control dyads exhibited patterns of maternal matching at low- and intermediate-aversiveness levels and most frequent de-escalation to low-aversiveness.

Put more simply, mothers in self-injurious dyads did not de-escalate conflict until it was highly aversive, and then de-escalated to a smaller degree than mothers in control dyads, who de-escalated more readily and to a more significant degree. While teens in both conditions exhibited a pattern of de-escalating from high- to intermediate-aversiveness, self-in - juring teens were more likely to escalate low and intermediate-level interactions while control teens matched aversiveness at low and intermediate levels.

Additionally, critical (invalidating and/or coercive) maternal statements were associated with higher teen anger and oppositionality across groups, and lower respiratory sinus arrhythmia (RSA), a commonly used marker of psychophysiological dysregulation. Wedig and Nock (2007) examined the relationship between the related construct of parental expressed emotion – operationalized as parental over-involvement and criticism – and self-injurious thoughts and actions in subjects between the ages of \f2 and \f7 years old.

They found that high parental criticism, but not over-involvement, was correlated with self-injurious behaviors and suicidal ideation, plans, and attempts, but was moderated by self-critical cognitive styles among the teen subjects.

Based on a similar pathway in the development of conduct disorder among impulsive youth, Crowell, Beauchaine, and Linehan (2009) looked at trait impulsivity as a vulnerability factor distinct from emotion dysregulation that transacts with the envi- ronment in early childhood to produce maladaptive coping traits and behavior. According to Crowell and colleagues (2009) a resurgence of risk occurs in mid- to late-adolescence when the established dysregulated coping patterns undermine the individual’s ability to effectively navigate the social environment.

Abuse and invalidation Many studies have examined the impact of more extreme forms of invalidation: physical, emotional, and sexual abuse. Trull (200\f) established that childhood physical or sexual abuse was directly correlated with borderline features and the rela - tionship partially mediated by trait disinhibition and negative affectivity in a sample of \f8-year-old male and female college students, while Westphal et al. (20\f3) found that among an urban primary care sample made up mostly of women, a history of interpersonal trauma (physical/sexual abuse or assault) conferred eight times more risk of also having BPD. Shields and Cicchetti (\f998) established that the relationship between various forms of abuse and adolescent behavioral dysregulation is mediated by emotion dysregulation. A similar conclusion was reached by van Dijke, Ford, van Son, Frank, and van der Hart (20\f3), who found that underregulation of emotion – characterized by higher frequency and intensity and slower recovery from negative emotions, as well as the use of maladaptive coping skills – par - tially mediated the relationship between childhood trauma by a primary caregiver (emotional, physical, or sexual) and future development of borderline personality disorder in a clinical sample, whereas overregulation did not. However, a more inhibited emotional regulation strategy was implicated in the relationship between trauma and borderline features in the work of Gaher, Hofman, Simons, and Hunsaker (20\f3), who established that the positive correlation between exposure to traumatic events and subsequent borderline symptoms was mediated by alexithymia in a college-aged sample. According to Horwitz, Widom, McLaughlin, and White (200\f), the relationship between abuse and negative outcomes is mediated by environmental responses to disclosures of abuse, a finding that substantiates the theory that invalidation of emotional responses is a catalyst for subsequent dysfunction. Childhood sexual abuse (CSA) and its role in the acquisition of borderline pathology and emotion dysregulation have received special attention. CSA differentiated between individuals with BPD and those with depression in Horesh, Sever, and Apter’s (2003) sample of adolescents and adults. In a prospec - tive study by Yen et al. (2004), the correlation between a history of CSA and suicidal behavior was mediated by emotion dysregulation. Similarly, Brodsky et al.

(\f997) found that the relationship between CSA and number of future suicide attempts was mediated by impulsivity, corroborating the aforementioned work by Crowell, Beauchaine, and Linehan (2009) that identified impulsivity as another potential pathway between life experiences and negative outcomes. While these studies suggest that abuse has lasting detrimental effects on the individual’s ability to regulate emotions, Fruzzetti, Shenk, and Hoffman (2005) point out that although victims of abuse are more likely to develop personality pathology, the vast majority of abuse victims do not develop such difficulties. Clearly, more work is needed in order for specific mechanisms governing the relationship between abuse and BPD to be clearly understood.

Sociocultural invalidation Crowell, Beauchaine, and Linehan (2009) point out that in addition to the strong role of family in the transactions governing the development of emotion regulation capabilities, sociocultural factors exert a strong impact, particularly during adolescence.

According to Gross (20\f3), while adolescence is a developmental period marked by emotional changes, as well as significant changes in social and educational landscape, it is also a time when the desire for au- tonomy may lead to rejection of extrinsic regulation.

Silk et al. (2009) established that subjects in mid- to late-stage puberty demonstrated greater emotional reactivity – as measured by pupil dilation, an index of brain activation – during an emotional word identifi - cation task than their pre- to early-stage counterparts.

ADOLESCENT SUiCiDE AND SELF-iNJURY 38 Adolescents also exhibited greater stress responses (as indicated by neuroendocrine and cardiovascular responses such as cortisol, blood pressure, and heart rate) than younger subjects when faced with situations simulating performance evaluation and social rejection (Stroud et al., 2009). While these studies were conducted with non-clinical samples rather than multi-problem youth, they highlight the existence of increased emotional and stress reactivity related to the normative neurobiological changes of puberty, distinct from any pre-existing biological vul - nerability, which dovetails with increased risk-taking also seen during this stage (Silk et al.). As a result, invalidation in the peer environment at this time of myriad biological and environmental shifts presents an even greater challenge for adolescents prone to dysregulation and lacking in effective self-regulatory skills. The impact of difficulties in peer and parental relationships on NSSI in a female adolescent clinical sample was studied by Adrian, Zeman, Erdley, Lisa, and Sim (20\f\f). These investigators found that the effect of problematic peer and family relationships on increased NSSI was mediated by emotion dysreg - ulation and that the direct effects of peer and family difficulties on NSSI were only marginally significant.

Similar results were observed in a community sample of girls aged \f0- to \f4-years-old, in which the quality of communication with peers moderated the rela- tionship between peer victimization and NSSI (Hilt, Cha, & Nolen-Hoeksema, 2008). These findings underscore the pivotal role of social invalidation in potentiating existing risk factors of the emotionally dysregulated individual.

Applying the rejection sensitivity model to the BPD population, Berenson, Downey, Rafaeli, Coifman, and Paquin (20\f\f) found that individuals with BPD reported higher levels rejection sensitivity compared to control subjects, meaning that cues associated with rejection, as well as neutral and ambiguous cues, more easily trigger processing biases and maladaptive behavioral responses. The BPD subjects were also more likely to experience rage in response to rejection cues than non-BPD controls. While these studies support the hypothesis that characteristics of the individual transact with aspects of the environment to produce increased emotional and behavioral dys- regulation, and pinpoint rejection as one particularly salient event in the interpersonal domain, it is unclear whether such rejection is perceived as invalidating or simply aversive. A potentially clarifying line of inquiry would be to further assess cognitions of individuals in situations of social rejection about their emotional experiences.

The aforementioned concept of poorness of fit raises the question of what other types of environ- ments may become chronically invalidating to the emotionally vulnerable individual. Mismatches between an individual’s values or sense of identity and those of the prevailing environment could occur around any number of issues. For example, sexual minority status was identified as one of several independent predictors of past-year and lifetime NSSI in a college-aged sample (Wilcox et al., 20\f2), while harassment on the basis of gender identity or sexual orientation conferred greater risk for NSSI in a nonclinical sample of sexual minority subjects aged \f3 to 22 years old (Walls, Laser, Nickels, & Wisneski, 20\f0). Interestingly, Walls et al. (20\f0) found that degree of “outness” about sexuality was positively correlated with NSSI, while having an adult confidant with whom the subject felt safe discussing issues related to sexuality decreased risk for NSSI, which led the investigators to surmise that sexual minority youths who are more “out” experience greater environmental invalidation, thereby putting them at greater risk for self-harm. Additionally, it would seem that having a source of emotional support was protective. Clearly, the emotional experiences of socially marginalized groups have a bearing on the understanding of the different contexts in which chronic invalidation may occur.

Linehan’s Biosocial Theory has gained further support from the past twenty years of research examining the biological and environmental factors that may contribute to emotional dysregulation, suicide, and self-harm. Emotion dysregulation has been identified as one of the primary routes by which early experiences of invalidation yield outcomes such as deliberate self-harm, suicidal behavior, and poor interpersonal functioning. This theory directly informs the treatment. Teaching teens emotion regulation skills acknowledges their biological makeup and subsequent skills deficits in this domain.

Teaching teens (and their families) validation skills in DBT honors their reality of experiencing pervasive invalidation in their day-to-day lives.

 Adolescent dialectical behavior therapy Dialectical Behavior Therapy (DBT ) for adolescents is a comprehensive, multi-modal intervention that uses individual psychotherapy, multifamily skills training groups, family therapy, telephone coaching for patients and family members, and therapist consultation meetings to simultaneously address both suicide risk factors and a multitude of other problems (Miller, Rathus, & Linehan, 2007). DBT is comprised of four treatment stages and an additional pretreatment stage, each of which matches the level of severity and complexity of the patient’s problems.

Each Stage includes a hierarchy of specific treatment targets (i.e., behaviors to increase or decrease). The responsibility for meeting these behavioral targets is spread among the various treatment modes. The pretreatment stage aims to orient patients and their families to DBT , obtain their commitment to participate in treatment, and establish agreement on treatment goals, including the reduction of suicidal and non-suicidal self-injurious behavior. Patients initiate treatment in this stage, and return to it if their commitment or engagement declines.

Stage \f of treatment, which has been the focus of treatment studies to date, aims to increase safety and establish behavioral control by addressing four primary behavioral targets that are prioritized in the following order: decreasing life-threatening behaviors; decreasing therapy-interfering behaviors; decreasing quality-of-life interfering behaviors; and increasing behavioral skills. During this treatment stage, the targets are addressed hierarchically and recursively as higher-priority behaviors reappear. Within Stage \f, life-threatening behaviors refer to suicide-related behaviors, including suicidal ideation, intention, plan and non-suicidal self-injury. These behaviors are addressed before all other treatment targets, based on the rationale that the patient must be alive for therapy to be helpful. Stages 2 thru 4 of treatment are characterized by patient’s being in good behavioral control and increased functioning. Stage 2 aims to increase emotional experiencing of past traumatic experiences. This is the stage that Post Traumatic Stress Disorders (PTSD ) would be treated. Stage 3 DBT focuses on achieving individual goals associated with problems of living. Lastly, Stage 4 aims to increase a feeling of completeness, and finding increased freedom and joy in one’s life. A more detailed description of DBT stages of treatment with adolescents can be found elsewhere (Miller, Rathus & Linehan, 2007; Rathus & Miller, in press).

Mehlum and colleagues (in press) recently com- pleted a five-year randomized controlled trial to determine whether a \f6-week version of DBT is more effective than enhanced usual care (E\bC) to reduce self-harm, suicidal ideation, depression, hopelessness, and symptoms of borderline personality disorder in adolescents. The sample was comprised of 77 teens with recent and repetitive self-harm treated at community clinics in Oslo, Norway. Results of the study found DBT was superior to E\bC in reducing self-harm episodes, suicidal ideation, depression, and borderline symptoms. Total number of treatment contacts was found to be a partial mediator of the association between treatment and changes in the severity of suicidal ideation, although no mediation effects were found on the other outcomes or for total treatment time.

 Conclusions and future directions Despite the increasing body of research and un - derstanding regarding adolescent suicide and non-suicidal self-injurious behaviors, much remains to be learned about the neurobiology, associations between suicidality and NSSI, as well as the invali- dating environments beyond those involving care- givers and peers. In particular, future neurobiology research may establish biological markers that place some individuals at risk for suicide and NSSI behaviors. Psychological research may elucidate how some of the environments outside the home (e.g., school, afterschool programs, social clubs, religious events) may be invalidating and the potential ad- verse pervasive effects on emotionally vulnerable students. DBT with adolescents has begun to be applied to schools (Mazza, Mazza, Murphy, Miller, & Rathus, in press; Rathus & Miller, in press), and research on the efficacy of DBT across settings may help to understand the increased precision of the treatment targets and delivery of its components.

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 Author contact Elizabeth Courtney-Seidler, Ph.D. Cognitive & Behavioral Consultants, LLP (Westchester and Manhattan) 1 North Broadway, Suite 704 White Plains, NY 10601Email: ecourtney-seidler@cognitivebehavioralconsul- tants.com Karen Burns, Psy.D. Cognitive & Behavioral Consultants, LLP (Westchester and Manhattan) 1 North Broadway, Suite 704 White Plains, NY 10601Email: [email protected] Irene Zilber, Ed.M., M.S. Cognitive & Behavioral Consultants, LLP (Westchester and Manhattan) 1 North Broadway, Suite 704 White Plains, NY 10601Email: [email protected] Alec L. Miller, Psy.D. Cognitive & Behavioral Consultants, LLP (Westchester and Manhattan) 1 North Broadway, Suite 704 White Plains, NY 10601Email: [email protected] COURTNEY-SEiDLER, BURNS, ZiLBER, & MiLLER