The Impact of Perceived Parental Invalidation and Self-Invalidation on Suicidality in an Adolescent DBT Partial Hospitalization Program

Abstract

Background

Dialectical Behavior Therapy’s (DBT) original biosocial theory and subsequent iterations as a transactional model suggest that invalidating social and family environments can contribute to emotion dysregulation and patterns of self-invalidation that may lead to suicidal and non-suicidal self-injurious behaviors over time. To our knowledge, no studies have examined the relationship between parental and self-invalidation on suicidality in a treatment setting or longitudinally over the course of treatment from pre-to post-treatment. This study examined the relationship between youth-reported parental invalidation, self-invalidation, and suicidality over the course of treatment in a comprehensive DBT partial hospitalization program (PHP).

Methods

Two hundred sixty-four adolescents and young adults admitted to a four-week comprehensive DBT PHP that incorporated family, individual, and skills group therapy components. All patients completed surveys evaluating perceived parental-invalidation, self-invalidation, and suicidality pre- and post-treatment.

Results

Patients reported significant decreases on all outcome measures: perceived mother and father invalidation, self-invalidation, and suicidality after 4 weeks. Changes (reductions) in both self-invalidation and mother invalidation were significant predictors of reduced suicidality.

Conclusion

Comprehensive DBT is a viable treatment option for decreasing invalidation and suicidality in four weeks. These findings emphasize the importance of parent involvement in improving treatment outcomes for adolescents and young adults.

Plain Language Summary

Dialectical Behavior Therapy’s (DBT) Biosocial Theory suggests that invalidating environments (an environment where individuals feel ignored, belittled, or misunderstood) can lead to difficulties in managing emotions and the tendency to self-invalidate (mistrust, minimize or dismiss internal thoughts, feelings and experiences). These patterns may increase the risk of suicidal thoughts and behaviors. This study explores how parental and self-invalidation are related to the severity and frequency of suicidal thoughts and behaviors (suicidality) in adolescents and young adults receiving DBT treatment. A total of 264 adolescents and young adults attended a four-week DBT Partial Hospitalization Program (PHP) that included therapy with families, individual sessions, and skills groups. Participants filled out surveys on their first day of treatments and again, four weeks later to measure perceived parental invalidation, self-invalidation, and suicidality. Our patients reported a decrease in perceived parental invalidation, self-invalidation, and suicidality after four weeks of adherent DBT treatment. Further, our results showed that changes in self-invalidation and mother invalidation were the strongest predictors of change in child suicidality. Thus, greater decreases in self-invalidation and mother invalidation predicted a greater decrease in child suicidality after four weeks of treatment. These findings support the effectiveness of DBT in reducing invalidation and suicidality and highlight the importance of familial involvement in improving treatment effectiveness and outcomes for adolescents and young adults.

Keywords

invalidation DBT and suicide

The Impact of Perceived Parental and Self-Invalidation on Suicidality in an Adolescent DBT Partial Hospital Program

Adolescence, the transition from early teens to young adulthood (i.e., early 20s), is commonly characterized as a period marked by increased stress and turmoil, driven by factors such as heightened conflict with parents, academic stress, intensified emotions, ongoing brain development, and an increase in risky behaviors (Arnett, 1999; Casey et al., 2010; Spear, 2000; Yang et al., 2024). The onset of severe psychological, emotional and social problems most often begins during adolescence (Kessler et al., 2005). In addition, suicide is the second leading cause of death among youth and young adults aged 10 to 24 (Center for Disease Control [CDC], 2025). Between 2013–2023, adolescent mental health trends demonstrated an increase in suicidality (i.e., spectrum of suicidal thoughts, plans, gestures, and behaviors), with 40% of high school students reporting persistent feelings of sadness or hopelessness, 20% considering attempting suicide, and 9% attempting suicide (CDC, 2023). Parent-child interpersonal dynamics have been found to play a role in exacerbating, as well as protecting, against child suicidal thoughts and behaviors (Borowsky et al., 2001; Cero & Sifers, 2013; Fergusson et al., 2000; Hammond et al., 2025). Problematic or ineffective parenting dynamics include an authoritarian or permissive parenting style, limited involvement or structure, poor emotional support, and the use of harsh or violent disciplinary methods (McKiney et al., 2016) and invalidating one’s emotional experience (Linehan, 1993). Previous studies have found a relationship between parental invalidation and child suicidality (Adrian et al., 2018; Yen et al., 2015), and links among social invalidation, self-invalidation, and non-suicidal self-injury (NSSI) (Ruork et al., in press). Yet, research on the topic remains limited. In particular, these constructs have not been widely explored quantitatively in the context of Dialectical Behavioral Therapy (DBT) treatment research - a treatment that targets increased self-validation and emotion regulation strategies in clients and reduced invalidation (and increased validation) in parents and others (Fruzzetti, 2018; Linehan, 1993).

Invalidation and Suicidality

Invalidation is a common occurrence in everyday communication, in subtle or overt ways, and typically communicates negative emotions (e.g., disgust, anger, condescension), negative judgments and criticism (e.g., implying the person’s emotions or experiences are “wrong” or an exaggeration), and/or misses, dismisses, or ignores the person’s valid experiences (Fruzzetti, 2008). The latter of these examples may be well-intentioned (e.g., an individual shares sadness over a breakup and the friend responds with, “You’re better off without them;” an individual expresses disappointment after not getting a job and hears, “It wasn’t meant to be”); and even so, these statements still invalidate the person’s emotions by fostering doubt that the expressed emotions are justified.

Shenk and Fruzzetti (2011) examined the effects of validating and invalidating responses on college students’ emotional reactivity (including both self-report and continuous physiological measures). Subjects who received the invalidating responses had significantly higher levels of negative affect compared to those who received validating responses. Further, invalidating responses were found to be significant predictors of emotional reactivity, unlike validating responses. Repeated exposure to invalidating social and family environments may lead to increased emotional reactivity and difficulty regulating emotions, thereby leaving individuals more vulnerable, and likely, to develop ineffective coping mechanisms like NSSI or suicidal ideation (SI) (Fruzzetti, 2005; Fruzzetti et al., 2008; Linehan, 1993; Martin et al., 2016).

Parental Invalidation and Suicidality

Parent-child relationships play an influential role in shaping the child’s ability to regulate their emotions (Eisenberg et al., 1998). The presence of emotional invalidation and the minimization of emotional expression within the parent-child relationship has been linked to a deficit in emotion regulation strategies for the child (Gottman & Katz, 2002; Shipman & Zeman, 2001) and the adoption of NSSI and suicidal behaviors as coping mechanisms (Hatkevich et al., 2019; Linehan, 1993; Neacsiu et al., 2018; Rathus & Miller, 2015). Previous literature examining the relationship between parental invalidation and suicidality is limited; however, in the existing findings there is a connection between parental invalidation and adolescent suicidality (Adrian et al., 2018; Crowell et al., 2008, 2013; Ojala et al., 2024; Wedig & Nock, 2007). Adrian and colleagues (2018) found within 38 teen-parent dyads, at three separate time points, that high levels of baseline parental validation and low levels of invalidation predicted infrequent NSSI and suicidality. In contrast, high levels of parental invalidation paired with high levels of parental validation were associated with the highest occurrences of NSSI and suicidal behaviors while no associations were found for SI. These findings suggest that high levels of validation did not compensate for the negative effects of low to high levels of invalidation. Further, these findings suggest that the combination of high parental invalidation and high validation may be especially distressing for adolescents, as it reflects a parent’s inconsistent use of validating responses despite their capacity to do so.

In a study examining perceived peer and family invalidation among inpatient adolescents, Yen et al. (2015) found that perceived family invalidation significantly predicted the frequency of suicidal behaviors in boys, but not girls, while perceived peer invalidation predicted NSSI for boys and girls. The authors suggested that perceived family invalidation may foster feelings of intense hopelessness, which could lead to suicidal behaviors, as family relationships are fixed compared to peer relationships (Yen et al., 2015). Few studies have examined whether parents’ gender impacts invalidation and suicidality. In a series of studies, Crowell and colleagues (2008, 2013) examined mother-teen interactions which revealed that lower positive affect, lower cohesiveness, and higher negative affect were associated with families of adolescents engaging in NSSI, but not for the control group (Crowell et al., 2008). Furthermore, mother-teen interactions of teens with NSSI were characterized by significantly greater conflict, as well as higher levels of adolescent anger and opposition when maternal invalidation was present (Crowell et al., 2013).

Under a broad scope of parental invalidation, related constructs like poor parental relationships and parental criticism have been examined in relation to child suicidality (Fotti et al., 2006; Wedig & Nock, 2007). Similarly, Wedig and Nock’s (2007) study demonstrated that parental negative expressed emotion (i.e., critical/hostile remarks and attitudes) was found to be a significant predictor of adolescent suicidality and NSSI, while parental criticism was found to increase adolescent suicidal thoughts and behaviors. Furthermore, self-criticism was a significant moderator of the relationship between parental criticism and adolescent suicidality, which shows parental criticism and adolescent suicidality have a stronger relationship when self-criticism is higher (Wedig & Nock, 2007). These results also suggest that reducing adolescent self-criticism may act as a protective factor against parental criticism.

Self-Invalidation and Suicidality

Self-invalidation results from social and family invalidation in part because individuals learn to doubt their internal experiences (Linehan, 1993). Similar constructs such as self-criticism (Sekowki et al., 2022; Wedig & Nock, 2007), self-attacking (O’Neill et al., 2021), self-stigma (Oexle et al., 2017), and low self-esteem (Collett, 2016) have been explored in previous literature regarding suicidality. Sekowki et al. (2022) found that high levels of self-criticism positively and significantly moderate the relationship between dependency (i.e., heightened sensitivity to conflict and fear of rejection) and suicidality in adolescents. Similarly, O’Neill et al. (2021) examined self-attacking (i.e., self-punishment and dissociation from the self) in a sample of adults and found it was a significant predictor of suicide probability. Although empirical support for self-invalidation is limited, a relationship between similar constructs and suicidality has been established.

Dialectical Behavior Therapy and the Biosocial Theory

DBT (Linehan, 1993) is a highly effective treatment for borderline personality disorder (BPD) that has been adapted for adolescents (DBT-A; Miller et al., 2007). DBT-A has proven to be effective in reducing adolescent suicidality (Kothgassner et al., 2021; Mehlum et al., 2014; Miller et al., 2007). DBT’s Biosocial Theory, or Transactional Model (Fruzzetti et al., 2005; Linehan, 1993), explains how emotional dysregulation (i.e., the inability to skillfully regulate emotions) can lead to the development of maladaptive or self-destructive behaviors, including NSSI and suicidal behaviors, over time. This theory hypothesizes that emotion dysregulation results from a transactional relationship between vulnerabilities (e.g., biological dispositions, temperamental factors, prior conditioning) and social and familial environmental events and processes. The temperamental aspect of the relationship considers emotional vulnerability (i.e., frequent, high intensity and reactivity to emotional cues, and a slow return to emotional baseline), as well as high impulsivity levels (i.e., difficulty restraining from self-destructive behaviors and regulating emotional responses). The social aspect focuses on interpersonal contexts, such as pervasive invalidating responses (e.g., that fail to understand, value, and instead dismiss, punish, or ignore emotions) and a regularly ineffective social and family environment (e.g., one that reinforces intense emotions and impulsive behaviors, and punishes effective behaviors).

When there is an incompatibility between the child and their caregivers, the caregivers may not meet the child’s needs adequately, therefore creating an invalidating social or family environment. Thus, emotionally sensitive children who are raised in an invalidating environment are not typically taught effective ways to identify and regulate or manage their emotions or how to tolerate emotional distress effectively (Rathus & Miller, 2015). Further, these individuals may question their own emotional reactions, leading them to rely on external cues from their surroundings and others to guide their thoughts, feelings, and responses. This ongoing mistrust of their emotions and an over-reliance on others frequently results in self-doubt and self-invalidation. Pervasive invalidating family responses contributes to pervasive emotional self-invalidation and may lead to maladaptive coping mechanisms such as NSSI or suicidality and other problem behaviors to cope with, or manage, emotion dysregulation (Rathus & Miller, 2015).

Current Study and Hypotheses

The current study investigated the association between perceived parental invalidation and self-invalidation with suicidality in a DBT partial hospitalization program (PHP) for a sample of adolescents and young adults. First, we explored changes in scores on perceived parental invalidation, self-invalidation, and suicidality after four weeks of treatment. Second, our study examined whether changes in perceived parental invalidation (i.e., biological mother and father) and self-invalidation were significant predictors of change in suicidality over that same period of time. We hypothesized that after four weeks of comprehensive DBT treatment that perceived parental invalidation, self-invalidation, and suicidality would all decrease significantly. We also hypothesized that changes in mother and father parental invalidation, as well as self-invalidation, would emerge as significant predictors of change in suicidality over the course of treatment.

Methods

Procedures

All participants were enrolled in a four-week (i.e., the standard requirement to be in the program) comprehensive DBT PHP between May 2019 and July 2024. Referrals came from various levels of care (e.g., outpatient, inpatient) and providers (e.g., therapists, school counselors), in addition to self-referrals. Program admission is contingent upon an interview with a staff clinician to assess clinical history, current clinical presentation, and commitment to and motivation for treatment. While most interviewed patients later admit to the PHP, some patients/families are referred elsewhere if there is current suicidality and an inability to participate in or agree to safety planning, NSSI without motivation to stop, substance use or eating disorders that require more significant medical intervention, and active psychosis.

Patients attended the program Monday through Friday, from 8:30 am to 3:00 pm. A comprehensive DBT program incorporates five treatment methods or components: (1) Group skill training to learn and practice DBT skills; (2) Individual DBT therapy sessions to address motivation to weave the skills into their “repertoire” – with support, validation, and practice in-session; (3) Skills generalization outside sessions through on-call skills coaching (e.g., via phone or in the milieu setting); (4) Incorporating family into treatment through family therapy sessions, parent DBT skill groups, and parent skills coaching; and (5) a consultation team to uphold treatment fidelity and support clinicians.

During program hours, patients participated in DBT skills groups focused on mindfulness, distress tolerance, interpersonal effectiveness, emotion regulation, and walking the middle path skills. Additional therapeutic services included two individual therapy sessions, one family therapy session, and one psychopharmacology session per week. Patients also had access to in-person skills coaching during program hours and on-call skills coaching after hours (i.e., 24/7) from a licensed PHP clinician. In addition to the weekly family therapy sessions, parents/guardians participated in a weekly two-hour online DBT parent skills group and had access to on-call parent coaching with the program director. Please refer to Batejan et al. (2022) for an extensive description of this DBT PHP.

Treatment Fidelity

All staff clinicians received specialized DBT training by experts in DBT and attended the weekly consultation team meetings. In addition to having access to mentorship and supervision opportunities through recognized DBT trainers within the McLean Hopsital treatment system, one of the authors on this manuscript is a DBT-Linehan board-certified clinician. Sessions were not recorded; therefore specific therapists’ adherence was not rated.

Inclusion and Exclusion Criteria

Included participants completed surveys at admission and after four weeks of treatment for the Self-Validation/Self-Invalidation Questionnaire (SVSI), the Validating and Invalidating Response Scale (VIRS), and the Suicide Behaviors Questionnaire (SBQ). Participants who did not complete the program and left before their planned discharge date (i.e., left voluntarily or needed a higher level of care) did not complete their four-week questionnaires and were excluded from this study. Further exclusion criteria included participants of single-parent households and those who did not rate both their biological mother and father as their parents/guardians when completing the VIRS.

Sampling Procedures and Data Collection

Participants completed online self-report questionnaires at admission and after four weeks of treatment, which was typically their discharge, as part of their routine clinical care. Questionnaires were administered and completed via the REDCap system (https://redcap.partners.org/redcap/index.php?action=myprojects). While the full battery of questionnaires included multiple clinical concerns, this study solely looked at self-invalidation, perceived parental invalidation, and suicidal behaviors. An accredited IRB (McLean Hospital Protocol 2022P000088) approved the use of data presented here for research and program evaluation purposes. The protocol is exempt, and research consent was waived by the committee.

Measures

The Suicidal Behaviors Questionaire-23

The Suicidal Behaviors Questionnaire (SBQ; Linehan, 1981) is a self-report measure that assesses the severity (e.g., “Have you thought about or attempted to kill yourself in the last three months?) and frequency (e.g., “How often have you thought about killing yourself in the last three months?”) of suicidal behaviors as well as the likelihood of a future suicide attempt (e.g., “How likely is it that you will attempt suicide today or in the next several days?”). Most items were rated on a 0 (no chance at all) to 4 (very likely) Likert scale. Two questions used a 0 to 2 scale (0 = no, 1 = yes, possible, 2 = yes, definitely). Per Linehan’s scoring instructions (Addis & Linehan, 1989; University of Washington Behavioral Research & Therapy Clinics, n d), these two questions were then re-coded (0 = 0, 1 = 2, 2 = 4). The total score was the sum of 23 items with a range of 0-88. Given skip out criteria, (e.g., consecutive no responses led to skipping questions on the rest of the measure) participants with five completed questions were included in the sample. In the current sample, 75 participants answered every question. The SBQ has demonstrated strong internal reliability with a coefficient alpha of .86 in a previous study (Tung et al., 2024), and .87 in the present study.

Self-Validation Self-Invalidation Questionnaire

The Self-Validation Self-Invalidation Questionnaire (SVSI; Davis et al., 2025) is a 24-item self-report measure that assesses self-validation (12 items) and self-invalidation (12 items). Only the self-invalidation subscale was used in the present study (see below for explanation). Example items include, “I minimize something that is important to me,” “I put someone else first at the expense of my own self-respect,” and “I tell myself I should just get over it when I am upset about something.” All items are rated on a 0 (never) to 5 (almost all the time) Likert Scale, yielding two separate total scores: self-validation (range 12–60) and self-invalidation (range 12–60). In this sample, the entire measure demonstrated strong internal reliability (α = .89), as did the invalidation subscale (α = .86).

Validating and Invalidating Response Scale

The Validating and Invalidating Response Scale (VIRS; Lee, 2012) is a 16-item self-report measure that assesses perceived parental validation (11 items) and invalidation (5 items) for any identified caregiver. In the current study, we used only the perceived parental invalidation scale (see below for explanation) and focused exclusively on biological mothers and fathers. Example items include “My [family member] tells me that I should not feel what I am feeling, think what I am thinking, or want what I am wanting-that my experiences are wrong and not legitimate.” and “My [family member] does not listen to me, ignores me, or even changes the subject when I try to express myself”). All items are rated on a 0 (Never) to 4 (Almost all the time) Likert Scale, yielding two separate total scores: validation (range 0–44) and invalidation (range 0–20). Higher scores indicate more perceived parental validation and invalidation. The VIRS has shown strong internal reliability with a coefficient alpha of .92 (Lee et al., 2012). In the current study, the invalidation subscales for both mother and father showed strong internal reliability (α = .87, .85 respectively).

Based on personal communication with the author of the measures and concerns about multicollinearity, we only used the invalidation subscales of the VIRS and the SVSI in our analyses. The two subscales (invalidation and validation) of the VIRS were very highly correlated (r > 0.8) in the present sample, so including both could have introduced problems of autocorrelation. In addition, past research has found high levels of validation do not compensate for invalidation (i.e., Adrian et al., 2018). To be consistent, we only used the invalidation subscales of the SVSI as well.

Analytical Strategy

This study utilized a non-experimental consecutive admission design. Completed questionnaires were defined as having submitted their questionnaires at both admission and after four weeks of treatment. However, patients would occasionally skip individual items, resulting in some missing total scores. Missing data were not able to be imputed, so the sample size for each analysis varies slightly. Data collection occurred in a real world clinical setting, where missing data occur due to patients not fully completing surveys for various reasons that were not specifically recorded at the time.

Pearson correlations, paired sample t-tests, and multiple regressions were conducted using SPSS 28.0 to assess the relationship between variables, compare admission and four-week scores, and examine predictors of change in suicidality through the use of difference scores (post-pre). Effect sizes were calculated using Cohen’s d (1988) and compared to the benchmarks of small (0.20), medium (0.50), and large (0.80) effects.

Results

Participant Characteristics

The study sample consisted of 264 adolescent and young adult participants who attended a four-week DBT PHP between May 2019 and July 2024. While there were 388 unique admissions during this period, 89 patients left the program prior to their planned discharge date or did not complete their four-week measures, and 35 patients did not rate both their biological mother and father on the VIRS. Those included in the study represented 68% of unique patients. To further characterize the participants, the 264 participants who were included were compared to the 124 who were not. Based on t-tests and two-sided p-values, the groups did not differ significantly in age, gender identity (proportion of cisgender versus not), race (proportion of White-identifying individuals), mother/father invalidation, self-invalidation, or suicidality scores at intake (all p-values were >.1).

For included patients, participants ranged from 13 to 24 years of age, with a mean age of 17.7 (SD = 2.3). Most patients identified as cisgender female (164; 62.40%), straight (112; 42.40%) or bisexual (92; 34.80%) and White/European American (177; 67.0% of the full sample). Of note, a portion of participants did not report their race. Thus, among the 242 people who did report their race, 73.0% were White/European American. Complete descriptive statistics on gender identity, sexual orientation, and race/ethnicity are presented in Table 1. The sexual orientation and race/ethnicity questions allowed for multiple selections.

Table 1.

Participant Demographics

	N	% or M (SD)
Gender
Cisgender female	164	62.40
Cisgender male	49	18.60
Nonbinary, gender fluid, or genderqueer	28	10.60
Transgender male	6	2.30
Don’t know/Questioning	10	3.80
Transgender female	4	1.50
A different gender	1	0.40
Did not disclose/Did not answer	2	0.80
Sexual orientation^a
Straight	112	42.40
Bisexual	92	34.80
Gay or lesbian	29	11.00
Queer	20	7.60
Don’t know/Questioning	26	9.80
Asexual	9	3.40
Different sexual orientation	6	2.30
Did not answer	3	1.10
Race/Ethnicity^a
White/European American	177	67.0
Latino/a/x or hispanic	19	7.20
East Asian	15	5.70
South Asian	10	3.80
Black/African American	8	3.00
Different race/ethnicity	5	1.90
American Indian/Alaska native	4	1.50
Southeast Asian	3	1.10
Native Hawaiian or Pacific Islander	1	0.40
Age	-	17.7 (2.3)

Note. N = 264.

^aSexual orientation and race/ethnicity questions allowed for multiple selections.

Mean Comparisons and Main Effect

Patients reported significant decreases on all outcome measures: perceived mother invalidation, perceived father invalidation, self-invalidation, and suicidality (p’s < .005; see Table 2). Cohen’s d indicated that all effect sizes were small to medium (≥.2), ranging from 0.20 to 0.63. Of note, based on paired t-tests, mother and father invalidation scores did not significantly differ at intake.

Table 2.

Means for Admission and Four Week Data

	Admission M (SD)	Four week M (SD)	t	df	p-value	Cohen’s d
Mother invalidation	6.79 (4.82)	6.10	3.07	253	.002	0.20
Mother invalidation	6.79 (4.82)	(4.37)	3.07	253	.002	0.20
Father invalidation	6.57 (4.97)	5.86	3.04	257	.003	0.20
Father invalidation	6.57 (4.97)	(4.67)	3.04	257	.003	0.20
Self-invalidation	41.09 (8.86)	35.56	9.99	249	<.001	0.63
Self-invalidation	41.09 (8.86)	(8.91)	9.99	249	<.001	0.63
Suicidality	28.99 (19.35)	22.04	8.74	262	<.001	0.53
Suicidality	28.99 (19.35)	(17.23)	8.74	262	<.001	0.53

Difference scores (post-pre) were computed for mother invalidation, father invalidation, self-invalidation, and suicidality using data collected at admission and at day 20 of treatment. All variables were significantly associated (p’s ≤ .05). See Table 3 for the correlation matrix between all change variables.

Table 3.

Pearson Correlation Matrix of Change Variables

	1	2	3	4
1. Mother invalidation difference	--	.38**	.28**	.22**
2. Father invalidation difference	.38**	--	.16*	.16*
3. Self-invalidation difference	.28**	.16*	--	.25**
4. Suicidality difference	.22**	.16*	.25**	--

Note. *p < .05, **p < .001.

Suicidality difference scores were entered into a regression as the dependent variable, with mother invalidation, father invalidation, and self-invalidation difference scores as predictor variables. In this regression analysis, changes in mother invalidation, as well as changes in self-invalidation, were significant predictors of changes in suicidality (B = .55, p = .03; B = .31, p = .002 respectively; see Table 4).

Table 4.

Multiple Regression of Suicidality (Post-pre) on Parent- and Self-Invalidation (Post-pre)

	B	SE B	β	t	p
Mother invalidation change	.55	.25	.15	2.18	.030
Father invalidation change	.23	.24	.06	.93	.353
Self-invalidation change	.31	0.10	0.20	3.07	.002

Discussion

This study examined the relationship between perceived or self-reported parental invalidation (i.e., biological mother and father), self-invalidation, and suicidality among adolescents and young adults in a comprehensive four-week DBT PHP. Our first aim assessed how four weeks of DBT programming impacted perceived parental invalidation, self-invalidation, and suicidality. Results showed significant reductions in mother invalidation, father invalidation, self-invalidation, and suicidality after 4 weeks of treatment. These findings align with previous research demonstrating DBT treatment’s effectiveness in reducing suicidality (Balzen et al., 2022; Tung et al., 2024). Effect sizes were small to medium, which seem like substantial improvements in a time-limited program designed to help patients increase their safety and stability sufficiently to engage in ordinary outpatient care after discharge from the PHP.

While past research has found parental invalidation, self-invalidation, and suicidality to be related constructs, parental invalidation, and self-invalidation have not been looked at together or examined longitudinally in a DBT PHP or other treatment setting. Our findings suggest that, over the course of participation in the current DBT PHP, patients reported reductions in suicidality, as well as decreases in perceived parental and self-invalidation. This reduction in invalidation may stem from DBT therapists’ emphasis on teaching and modeling effective validation during family sessions, parent skills groups, and parent skills coaching calls, in addition to the reinforcement of mindful awareness to help the client build trust in their internal experiences (Fruzzetti et al., 2005; Linehan, 1993; Miller et al., 2007).

Our second aim examined whether changes in mother invalidation, father invalidation, and self-invalidation predicted changes in suicidality over the course of treatment (from pre-to post-treatment) in the PHP. Results indicated that changes in self-invalidation were the strongest predictors of change in suicidality after 4 weeks of treatment. Thus, greater decreases in self-invalidation predicted a greater decrease in the severity of suicidal thoughts and behaviors. This finding aligns with Linehan’s ideas that self-invalidation contributes to emotion dysregulation and the adoption of ineffective coping mechanisms such as NSSI and suicidality (Linehan, 1993). Therefore, targeting reduced self-invalidation consistently in treatment may contribute to decreased NSSI and suicidality. This extends findings from Ruork et al. (in press) to adolescents and young adults living with their parents. They showed that social invalidation for adults was significantly associated with subsequent self-invalidation and shame. Further, they found that social invalidation, self-invalidation, and shame were also significantly associated with NSSI.

Additionally, changes in perceived invalidation from the youth’s mother was also a significant predictor of changes in suicidality after 4 weeks of treatment, while changes in the father’s invalidation was not. Therefore, greater decreases in the mother’s invalidation predicted a greater decrease in child suicidality. Although previous research has reported heightened conflict in mother-teen interactions among adolescents who engage in NSSI (Crowell et al., 2013), there are no previous studies to our knowledge that have looked at the relationship between parents’ gender, invalidation, and suicidality. Our findings may be explained in part by prior research showing that mothers are often the primary caregivers (Bornstein et al., 2025) and likely spend more time with their child, thereby having more opportunities to invalidate (or validate) their child. Improvements developed through treatment with mothers may thus have a bigger impact on their children, particularly when the mother’s own mental health is considered (Coles et al., 2022; Pilowsky et al., 2008). Pilowsky and colleagues (2008) examined a targeted intervention for maternal depression among 151 women with major depressive disorder and their children, assessing outcomes at three-month intervals over one year. Reductions in children’s psychiatric symptoms were significantly associated with decreases in maternal depression severity. Conversely, poorer maternal mental health has been linked to worse child mental health outcomes (Kahn et al., 2004; Riley et al., 2009).

While changes in self-invalidation were the strongest predictor, changes in mother invalidation also predicted change in suicidality after four weeks of treatment. Our results suggest that DBT treatment in a 4-week PHP setting that incorporates parent/family involvement can be a viable treatment option for reducing both perceived parental and self-invalidation by modeling and teaching parents’ skills to reduce invalidating responses and increase validating ones (Fruzzetti, 2018; Fruzzetti et al., 2005; Linehan, 1993; Miller et al., 2007).

Strengths and Limitations

Although previous research has explored the relationship between parental invalidation and suicidality as well as self-invalidation and suicidality, this study took a novel approach and expanded on previous literature by examining them together within a comprehensive DBT PHP. Given the rather intense level of care and extended program structure, patients had access and support to practice and generalize skills, both during program hours and at home after hours, when they might have been experiencing intense emotions and stressors. This suggests that patients improved their abilities to manage their emotion dysregulation and thus decrease suicidality, self-invalidation, and this in turn may have facilitated reductions in parental invalidation, even when confronted with difficulties in their daily lives (i.e., as opposed to when patients are solely treated in an inpatient setting, or when parents are not intensively included in treatment).

Another notable strength of this study is the integration of parent involvement into treatment within the DBT PHP. In this specific program, parents participated in weekly family therapy sessions, had weekly parent DBT skills groups, and had access to on-call parent skills coaching. Family sessions typically focused on improving communication (e.g., increasing youth’s accurate expression and increasing validation/reducing invalidation; Fruzzetti, 2018), increasing connection, increasing more collaborative problem solving, implementing contingency management strategies that focus more on positive consequences, and supporting the generalization of DBT skills across settings. Therefore, both patients and parents received ongoing feedback and coaching from clinicians, allowing them to troubleshoot and refine their skill use. An additional strength of this study is the diversity of the adolescents regarding their sexual orientation and gender identity. Sixty-one percent of the patients identified as a sexual minority and 19% identified as a gender identity other than cisgender.

Of course, this study has several limitations, including the absence of a control group. Given its within-subject design, it is uncertain whether decreases in suicidality and invalidation were solely due to DBT treatment as we cannot rule out other factors (e.g., time passing, improvements in life circumstances, regression toward the mean). It is possible that patients might have shown some improvement over 20 days of treatment-as-usual or remaining on a waitlist. However, because patients were referred by outpatient providers (suggesting this was not the right level of care) after extensive treatment without much improvement, we believe that the adolescents in the current study would not have improved to the same extent without active intervention. Additionally, Tung et al. (2024), using a similar patient population in this PHP, found that about one third of the patients made clinically significant and reliable change on a measure of emotion regulation (i.e., recovery or scores in the “normal” range). This further suggests that, DBT remains a highly effective treatment for emotionally dysregulated and suicidal adolescents, that has been shown to increase validation and decrease suicidality within adolescent samples (e.g., Balzen et al., 2022; Kothgassner et al., 2021; Mehlum et al., 2014; Miller et al., 2007; Tung et al., 2024).

Another notable limitation of this study is the exclusive reliance on self-report measures, which are vulnerable to potential biases, such as mood-dependent responses, and the minimization or exaggeration of problems or complaints about others. However, because patients completed these measures on their personal devices independently, they may have been more forthcoming. Also, it is a limitation that parent assessments were not included. Therefore, we only have the child’s perception or report about their parental invalidation, and not the parent’s own reports of their invalidation or observer/objective ratings or measures. Additionally, our inclusion criteria of rating biological mother and father dyads only on the VIRS measure is also a limitation as it excluded other types of caregiver dyads. The relative lack of diversity in our sample also poses a challenge, as this study predominantly included White and higher-income participants. Consequently, the sample is not entirely representative, which may limit generalizability to broader samples.

Future Directions

Future research should also measure validation to understand whether the construct mitigates the effects of invalidation (from both parents and self) on suicidality. The current study did not examine self-validation and perceived parent validation as the VIRS perceived parent-validation/invalidation subscales were too highly correlated; therefore, only the invalidation subscale was used. Additionally, future studies can expand upon this study by including multi-informant measures, such as parental perceptions of their own validating and invalidating responses to mitigate the limitations that come with self-report data as well as to corroborate the child’s report about their parent’s tendency to validate and/or invalidate. Furthermore, future studies should include all types of caregivers (e.g., LGBT + parents, single parents, stepparents, grandparents) to obtain a more comprehensive understanding of how invalidation from different types of caregivers and family constellations may impact a child’s emotion dysregulation and suicidality. Finally, it will be important to look at these constructs in a more racially-, ethnically- and income-diverse sample as families and cultural practices may look different in the ways that they validate or invalidate.

Conclusion

In summary, the current study found that adolescents and young adults treated in a four-week DBT PHP reported decreased perceived parental invalidation (i.e., biological mother and father), self-invalidation, and suicidality. The study found that changes in self-invalidation and perceived mother’s invalidation predicted changes in suicidality after four weeks of comprehensive DBT treatment. These findings highlight the importance of parent involvement, especially around decreasing invalidation and building connections, to support better treatment outcomes for adolescents and young adults.

Footnotes

ORCID iDs

Genesis A. Vergara

Kristen L. Batejan

Ethical Considerations

An accredited IRB (McLean Hospital Protocol 2022P000088, United States) approved the use of data presented here for research and program evaluation purposes.

Consent to Participate

This research was conducted on humans by the Helsinki Declaration of 1975, as revised in 2013.

Author Contributions

The authors confirm their contribution to the paper. Data collection: Katherine J. Brown, Daniella H. Levy, Allison P. Falls, Nicole M. Antkiewicz. All authors reviewed the results and approved the final version of the manuscript.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was financially supported by the employer, McLean Hospital. The funder was involved in the writing, editing, approval, and decision to publish this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Please contact the corresponding author for more information.*

Standards of Reporting

STROBE guidelines were followed.

Author Biographies

Katherine J. Brown is a first-year student in the combined Counseling and School Psychology doctoral program at the University of Buffalo. Prior to beginning her graduate studies, she completed a two-year Post-Baccalaurete Clinical Fellowship at McLean Hospital, where she worked in the 3East Partial Hospital Program.

Esther S. Tung, PhD, is a staff psychologist at the McLean Anxiety Mastery Program and an instructor in psychology in the Department of Psychiatry at Harvard Medical School. Her clinical and research areas of expertise are in cognitive behavioral therapy, dialectical behavior therapy, treating anxiety disorders, mood disorders, borderline personality disorder, and suicidal ideation, as well as Asian-American mental health.

Genesis A. Vergara, PhD is a licensed clinical psychologist and Researcher specializing in suicide, self-injury, and related interpersonal processes. She completed her predoctoral APA-accredited internship at McLean Hospital/Harvard Medical School and earned her PhD in Clinical Psychology at the Catholic University of America.

Alan E. Fruzzetti is a Research Fellow at the National Suicide Research Foundation/ University College Cork, Lead for supervision & implementation for the HSE DBT Team and professor emeritus at the University of Nevada-Reno and was on the faculty at Harvard Medical School. He is co-founder of the Center for DBT and Families and the World DBT Association, a past-president of the National Education Alliance for Borderline Personality Disorder (NEA-BPD), and on the board of directors of the DBT Board of Certification. His research focuses on the connections between emotion dysregulation and interpersonal or family processes and the development and evaluation of interventions to help both individuals and relationships. He received his BA from Brown University and MS and PhD from the University of Washington in Seattle and has received numerous awards for research, teaching and community service.

Peg M. Worden, PsyD is a senior child and adolescent psychologist with 25 years of experience treating adolescents, children, and familes at McLean Hospital and an instructor in psychology in the Dapartment of psychiatry at Harvard Medical School. In 2009, she partnered with Dr. Michael Hollander and created the 3East DBT Partial Hospital Program. She has extensive experience diagnosing and treating adolescents who engage in self-harm and struggle with suicidal ideation, as well as those with depression, anxiety, PTSD, substance use, and personality disorders. She is skilled in a wide range of therapeutic techniques, including cognitive behavior therapy.

Kristen L. Batejan, PhD is a licensed clinical psychologist at the McLean Hospital 3East DBT Partial Hospital Program and an instructor in psychology in the Department of psychiatry at Harvard Medical School. She is experienced in treating adolescents and young adults struggling with emotion dysregulation, self-harm, and suicidality. She specializes in the use of dialectical behavior therapy (DBT). Her research has focused on the phenomenology of suicidal and self-injurious behaviors.

References

Addis

Linehan

M. M.

(1989 November 2-5). Predicting suicidal behavior: Psychometirc properties of the suicidal behaviors questionnaire [Poster presentation]. Association for the Advancement of Behavior Therapy. Washington, DC.

Adrian

Berk

M. S.

Korslund

Whitlock

McCauley

Linehan

(2018). Parental validation and invalidation predict adolescent self-harm. Professional Psychology: Research and Practice, 49(4), 274–281. https://doi.org/10.1037/pro0000200

Arnett

J. J.

(1999). Adolescent storm and stress, reconsidered. American Psychologist, 54(5), 317–326. https://doi.org/10.1037/0003-066x.54.5.317

Balzen

K. M.

Goette

W. F.

Sachs

Krantz

S. M.

Heerschap

Kennard

B. D.

Emslie

G. J.

Stewart

S. M.

(2022). Borderline personality feature influence treatment response to suicide prevention. Journal of Affective Disorders, 311(1), 515–522. https://doi.org/10.1016/j.jad.2022.05.083

Batejan

K. L

Van der Feen

Worden

(2022). Dialectical behavior therapy. In Leffler

J. M.

Frazier

E.E.

(Eds.), Handbook of Evidence—Based Day Treatment Programs for Children and Adolescents (pp. 157–173). Switzerland: Springer Nature.

Bornstein

M. H.

Rothenberg

W. A.

Putnick

D. L

Lasnford

J. E.

(2025) (In press). Multiple child caregivers and multiple cognitive caregiving practices: Associations with early childhood development in 51 low- and middle-income countries. International Journal of Behavioral Development. https://doi.org/10.1177/01650254251336145

Borowsky

I. W.

Ireland

Resnick

M. D.

(2001). Adolescent suicide attempts: Risks and protectors. Pediatrics, 107(3), 485–493. https://doi.org/10.1542/peds.107.3.485

Casey

B. J.

Jones

R. M.

Levita

Libby

Pattwell

S. S.

Ruberry

E. J.

Soliman

Somerville

L. H.

(2010). The storm and stress of adolescence: Insights from human imaging and mouse genetics. Developmental Psychobiology, 52(3), 225–235. https://doi.org/10.1002/dev.20447

Center for Disease Control and Prevention . (2023). Youth risk behavior survey data summary & trends report: 2013–2023. U.S. Department of Health and Human Services (Accessed 30 January 2025).

10.

Center for Disease Control and Prevention . (2025). Health disparities in suicide. Available at:. https://www.cdc.gov/suicide/disparities/index.html#:∼:text=Youthandyoungadultsages,group%2Caccountingfor7%2C126deaths (Accessed 30 January 2025).

11.

Cero

Sifers

(2013). Parenting behavior and the interpersonal-psychological theory of suicide: A mediated moderation analysis with adolescents. Journal of Affective Disorders, 150(3), 987–992. https://doi.org/10.1016/j.jad.2013.05.025

12.

Cohen

(1988). Statistical power analysis for the behavioral sciences (2nd ed.). Lawrence Erlbaum Associates, Publishers.

13.

Coles

D. C.

Cage

(2022). Mothers and their children: An exploration of the relationship between maternal mental health and child well-being. Maternal and child health, 26(5), 1015–1021. https://doi.org/10.1007/s10995-022-03400-x

14.

Collett

Pugh

Waite

Freeman

(2016). Negative cognitions about the self in patients with persecutory delusions: An empirical study of self-compassion, self-stigma, schematic beliefs, self-esteem, fear of madness and suicidal ideation. Psychiatry Research, 239(0), 79–84. https://doi.org/10.1016/j.psychres.2016.02.043

15.

Crowell

S. E.

Baucom

B. R.

McCauley

Potapova

N. V.

Fitelson

Barth

Smith

C. J.

Beauchaine

T. P.

(2013). Mechanisms of contextual risk for adolescent self-injury: Invalidation and conflict escalation in mother-child interactions. Journal of Clinical Child and Adolescent Psychology, 42(4), 476–480. https://doi.org/10.1080/15374416.2013.785360

16.

Crowell

S. E.

Beauchaine

T. P.

McCauley

Smith

C. J.

Vasilev

C. A.

Stevens

A. L.

(2008). Parent-child interactions, peripheral serotonin, and self-inflicted injury in adolescents. Journal of Consulting and Clinical Psychology, 76(1), 15–21. https://doi.org/10.1037/0022-006X.76.1.15

17.

Davis

R. W.

McLean

C. L.

Fruzzetti

A. E.

(2025). Development, reliability and validity of the self-validation and self-invalidation questionnaire. Manuscript Submitted for Publication.

18.

Eisenberg

Cumberland

Spinrad

T. L.

(1998). Parental socialization of emotion. Psychological Inquiry, 9(4), 241–273. https://doi.org/10.1207/s15327965pli0904_1

19.

Fergusson

D. M.

Woodward

L. J.

Horwood

L. J.

(2000). Risk factors and life processes associated with the onset of suicidal behavior during adolescence and early adulthood. Psychological Medicine, 30(1), 23–39. https://doi.org/10.1017/s003329179900135x

20.

Fotti

S. A.

Katz

L. Y.

Afifi

T. O.

Cox

B. J.

(2006). The associations between peer and parental relationships and suicidal behaviors in early adolescents. Canadian Journal of Psychiatry, 51(11), 698–703. https://doi.org/10.1177/070674370605101106

21.

Fruzzetti

A. E.

(2018). DBT with parents, couples and families to augment stage 1 outcomes. In Swales

(Ed.), Oxford handbook of dialectical behaviour therapy (p. 389). Oxford University Press. https://doi.org/10.1093/oxfordhb/9780198758723.013.19

22.

Fruzzetti

A. E.

Shenk

(2008). Fostering validating responses in families. Social Work in Mental Health, 6(1–2), 215–227. https://doi.org/10.1300/J200v06n01_17

23.

Fruzzetti

A. E.

Shenk

Hoffman

P. D.

(2005). Family interaction and the development of borderline personality disorder: A transactional model. Development and Psychopathology, 17(4), 1007–1030. https://doi.org/10.17/s0954579405050479

24.

Gottman

J. M.

Katz

L. F.

(2002). Children's emotional reactions to stressful parent-child interactions: The link between emotion regulation and vagal tone. Marriage & Family Review, 34(3–4), 265–283. https://doi.org/10.1300/J002v34n03_04

25.

Hammond

N. G.

Semchishen

S. N.

Geoffroy

M. C.

Sikora

Wafy

Hsueh

Khan

Edwards

Gravel

Ferro

M. A.

Colman

(2025). Family dynamics and self-harm and suicidality in children and adolescents: A systematic review and meta-analysis. The Lancet Psychiatry, 12(9), 660–672. https://doi.org/10.1016/S2215-0366(25)00217-2

26.

Hatkevich

Penner

Sharp

(2019). Difficulties in emotion regulation and suicide ideation and attempt in adolescent inpatients. Psychiatry Research, 271(2), 230–238. https://doi.org/10.1016/j.psychres.2018.11.038

27.

Kahn

R. S.

Brandt

Whitaker

R. C.

(2004). Combined effect of mothers' and fathers' mental health symptoms on children's behavioral and emotional well-being. Archives of Pediatrics and Adolescent Medicine, 158(8), 721–729. https://doi.org/10.1001/archpedi.158.8.721

28.

Kessler

R. C.

Berglund

Demler

Jin

Merikangas

K. R.

Walters

E. E.

(2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. Archives of General Psychiatry, 62(6), 593–602. https://doi.org/10.1001/archpsyc.62.6.593

29.

Kothgassner

O. D.

Goreis

Robinson

Huscasava

M. M.

Schmahl

Plener

P. L.

(2021). Efficacy of dialectical behavior therapy for adolescent self-harm and suicidal ideation: A systematic review and meta-analysis. Psychological Medicine, 51(7), 1057–1067. https://doi.org/10.1017/S0033291721001355

30.

Lee

Hyun

Lee

Fruzzetti

A. E.

(2012). Validity study of the validation and invalidation scale (VIRS) among college women with dating violence. Stress Research, 20(3), 2012.

31.

Linehan

M. M.

(1981). The suicidal behaviors questionnaire (SBQ). University of Washington. Unpublished instrument.

32.

Linehan

M. M.

(1993). Cognitive-behavioral treatment of borderline personality disorder. NY Guilford Press.

33.

Martin

Bureau

J. F.

Yurkowski

Fournier

T. R.

Lafontaine

M. F.

Cloutier

(2016). Family-based risk factors for non-suicidal self-injury: Considering influences of maltreatment, adverse family-life experiences, and parent-child relational risk. Journal of Adolescence, 49(1), 170–180. https://doi.org/10.1016/j.adolescence.2016.03.015

34.

McKiney

Morse

Pastuszak

(2014). Effective and ineffective parenting: Associations with psychological adjustment in emerging adults. Journal of Family Issues, 37(9), 1203–1225. https://doi.org/10.1177/0192513X14537480

35.

Mehlum

Tørmoen

A. J.

Ramber

Haga

Diep

L. M.

Laberg

Larsson

B. S.

Stanley

B. H.

Miller

A. L.

Sund

A. M.

Grøholt

(2014). Dialectical behavior therapy for adolescents with repeated suicidal and self-harming behavior: A randomized trial. Journal of the American Academy of Child & Adolescent Psychiatry, 53(10), 1082–1091. https://doi.org/10.1016/j.jaac.2014.07.003

36.

Miller

A. L.

Rathus

J. H.

Linehan

M. M.

(2007). Dialectical behavior therapy with suicidal adolescents. Guilford.

37.

Neacsiu

A. D.

Fang

C. M.

Rodriguez

Rosenthal

M. Z.

(2018). Suicidal behavior and problems with emotion regulation. Suicide and Life-Threatening Behavior, 48(1), 52–74. https://doi.org/10.1111/sltb.12335

38.

Oexle

Rüsch

Viering

Wyss

Seifritz

Kawohl

(2017). Self-stigma and suicidality: A longitudinal study. European Archives of Psychiatry and Clinical Neuroscience, 267(4), 359–361. https://doi.org/10.1007/s00406-016-0698-1

39.

Ojala

Garke

M. A.

Ei Alaoui

Forsström

Hedman-Lagerlöf

(2024). The trajectory of anxiety and depressive symptoms and the impact of self-injury: A longitudinal 12-month cohort study of individuals with psychiatric symptoms. PLoS One, 19(11), 13961. https://doi.org/10.1371/journal.pone.0313961

40.

O’Neill

Pratt

Kilshaw

Ward

K. J.

Haddock

(2021). The relationship between self-criticism and suicide probability. Clinical Psychology & Psychotherapy, 28(6), 1445–1456. https://doi.org/10.1002/cpp.2593

41.

Pilowsky

D. J.

Wickramaratne

Talati

Tang

Hughes

C. W.

Garber

Malloy

King

Cerda

Sood

Alpert

Trivedi

Murizio

Rush

Wisniewski

Weissman

(2008). Children of depressed mothers 1 year after initiation of maternal treatment: Findings from the STAR*D-Child study. American Journal of Psychiatry, 165(9), 2–12. https://doi.org/10.1176/appi.ajp.2008.07081286

42.

Rathus

J. H.

Miller

A. L.

(2015). DBT skills manual for adolescents. Guilford Press.

43.

Riley

A. W.

Coiro

M. J.

Broitman

Colantuoni

Hurley

K. M.

Bandeen-Roche

Miranda

(2009). Mental health of children of low-income depressed mothers: Influences of parenting, family environment, and raters. Psychiatric Services, 60(3), 329–336. https://doi.org/10.1176/ps.2009.60.3.329

44.

Ruork

A. K.

Hazlett-Stevens

Fruzzetti

A. E.

(In press). Evaluating the role of social interactions and shame in self-injurious behaviors using ecological momentary assessment: Feasibility and preliminary evaluation. Journal of Emotion and Psychopathology.

45.

Sekowki

Lengiewicz

Lester

(2022). The complex relationships between dependency and self-criticism and suicidal behavior and ideation in early adulthood. Personality and Individual Differences, 198, 111806. https://doi.org/10.1016/j.paid.2022.111806

46.

Shenk

C. E.

Fruzzetti

A. E.

(2011). The impact of validating and invalidating responses on emotional reactivity. Journal of Social and Clinical Psychology, 30(2), 163–183. https://doi.org/10.1521/jscp.2011.30.2.163

47.

Shipman

K. L.

Zeman

(2001). Socialization of children’s emotion regulation in mother-child dyads: A developmental psychopathology perspective. Development and Psychopathology, 13(2), 317–366. https://doi.org/10.1017/S0954579401002073

48.

Spear

L. P.

(2000). The adolescent brain and age-related behavioral manifestations. Neuroscience & Biobehavioral Reviews, 24(4), 417–463. https://doi.org/10.1016/s0149-7634(00)00014-2

49.

Tung

E. S.

Batejan

K. L.

Johnson

Worden

P. M.

Fruzzetti

A. E.

(2024). Effectiveness of DBT partial hospitalization program for adolescents and young adults. Counseling Outcome Research and Evaluation, 15(2), 1–20. https://doi.org/10.1080/21501378.2024.2342590

50.

University of Washington Behavioral Research & Therapy Clinics . (n.d.). Assessment instructions. Available at:. https://depts.washington.edu/uwbrtc/resources/assessment-instruments/ (Accessed 22 Oct 2025).

51.

Wedig

M. M.

Nock

M. K.

(2007). Parental expressed emotion and adolescent self-injury. Journal of the American Academy of Child & Adolescent Psychiatry, 46(9), 1171–1178. https://doi.org/10.1097/chi.0b013e3180ca9aaf

52.

Yang

Yuan

Wang

Liu

Jimin

Chen

(2024). Multidimensional stressors and depressive and anxiety symptoms in adolescents: A network analysis through simulations. Journal of Affective Disorders, 347(1), 364–374. https://doi.org/10.1016/j.jad.2023.11.057

53.

Yen

Kuehn

Tezanos

Weinstock

L. M.

Solomon

Spirito

(2015). Perceived family and peer invalidation as predictors of adolescent suicidal behaviors and self-mutilation. Journal of Child and Adolescent Psychopharmacology, 25(2), 124–130. https://doi.org/10.1089/cap.2013.0132