Self-harm has been gaining increasing scientific interest in the past decade. It is associated with considerable suffering and can lead to significant costs for the health care system. Accordingly, increased knowledge and treatment development are important [1, 2]. Self-harm is often inflicted with a knife, needle or razor on areas such as arms, legs or abdomen [3–5]. The prevalence of self-harm in adolescence varies between different studies, depending in part upon how it is measured. In this paper, the broader definition used in the NICE guidelines will be used: “Self-poisoning or self-injury, irrespective of the apparent purpose of the act”. A large community-based study in Sweden found that 35.6 % of adolescents (15–17 y) reported at least one episode of self-harm during the past year [6]. Self-harm has proven to be a stronger predictor of suicide attempts than a past history suicidal behavior [7, 8] and is a serious threat to physical health and psychological functioning [4].
Self-harm is increasingly understood as a reflection of a person’s emotional distress [9, 10]. Family processes linked to the onset and maintenance of self-harm have also attracted attention [11–13]. Young people's reported experiences of having been maltreated in the form of physical or sexual abuse during childhood increases the likelihood of developing self-harm behavior, especially if they have been maltreated by primary caregivers [14, 15]. A systematic review by Liu and colleagues found that childhood maltreatment including emotional abuse and neglect were associated with self-harm, even in non-clinical samples [15].
During the transition into adulthood, peer and partner relationships become increasingly important for emotional development [16]. A longitudinal study by Yen and colleagues showed that perceived peer invalidation predicted self-harm in a high-risk sample [17]. In another longitudinal cohort study 2127 adolescent girls were assessed for interpersonal risk factors and self-harm onset from age 13 to 17. Frequency of peer victimization and negative beliefs about peers were both predictive of later onset of self-harm [13].
It is of high importance to clarify the etiology and underlying factors that lead to self-harm, as these can inform prevention and intervention strategies [18]. Researchers have become increasingly interested in young people’s subjective psychological and emotional experiences of invalidation such as feeling misunderstood, questioned and alienated, and the association of these experiences to self-harm. A total of 38 adolescents enrolled in a DBT program were assessed for treatment outcome during a six-months treatment period. Robust associations between parental invalidation/validation and self-harm were found at baseline [19].
Emotion dysregulation is understood to play a critical role in the development of psychopathology generally and in the onset and maintenance of self-harm in particular [9]. Persistent and severe difficulty in regulating emotions is seen as the primary contributor to self-harm and suicide attempts [9, 10]. These behaviors are developed as means to manage pervasive emotion dysregulation in the absence of other coping strategies [9, 10]. Evidence for the regulatory properties of self-harm have been summarized by a systematic review [3]. Acute negative affect often precedes self-harm and reduced negative affect is a common consequence immediately after an episode. Also, those who regularly self-harm often anticipate reduced emotional distress as an immediate outcome [3] although shame and other negative emotions relating to having self-harmed may be longer-term emotional consequences [17].
The experience of validation and subsequent emotional dysregulation: The Biosocial Theory
The Biosocial Theory developed by Linehan [20] is the core etiological theory of Borderline Personality Disorder (BPD) in its leading evidence-based treatment, Dialectical Behavior Therapy (DBT) [21]. As such, it explains the emergence and maintenance of BPD sypmtoms, including emotion dysregulation at the core of BPD [20]. The Biosocial Theory is transactional, wherein a biological predisposition to emotional vulnerability (a sensitive temperament) is uniquely and adversely affected by an invalidating environment [20]. Emotional vulnerability is assumed to be present at birth (temperament) with neurological correlates therein [20, 22]. The experience of emotional sensitivity means that these individuals’ affective arousal is heightened more quickly than less sensitive individuals. Once elevated it also takes a longer time to return to emotional baseline [20, 22]. Accordingly, in the presence of invalidation, remaining emotionally regulated is more challenging for emotionally sensitive individuals.
The other key component of the Biosocial Theory is an invalidating environment, characterized by intolerance towards expression of private emotional experiences; the person is met with unpredictable, inappropriate or extreme responses. Emotional expressions can also be punished or trivialized, and it is not uncommon for the individual to be blamed [17]. Such an environment signals to the person that they are not acceptable or important and that there is no support from key others in the home environment or different contexts such as school or peer groups[20, 22, 23]. Linehan states that the consequences of growing up in such an environment, among other things, is that the person does not develop the ability to recognize, name, regulate and tolerate strong emotional reactions. Coupled with distress in the form of elevated emotional arousal the individual is trapped between emotional inhibition and emotional outbursts that are ineffective and “self-invalidating” [20]. After periods of unmodulated strong negative affect akin to “emotional hell” [20] compounded by environmental invalidation, dysfunctional emotion regulation efforts such as self-harm are utilized as a form of escape. This effectively redirects negative affect in the short term, which is why self-harming behaviors tend to persist [20].
A validating approach means that the person’s expression about emotional experience is met with interest, attention, understanding, acceptance and authenticity [17]. A validating approach does not aim to prove or to disprove validity of experience. A validating response gives present and authentic attention to emotional experience in order to facilitate acceptance of the emotion and importance of the person. Linehan has identified six levels of validation; 1) paying attention. That is, being present, staying “awake” and disengaging from judgmental communications, 2) accurate reflection, by summarizing what a person is sharing and taking a non-judgmental stance 3) Mind-reading. That is, stating the unarticulated, reading a person’s behavior and summarizing what they might be thinking or feeling, 4) Understanding a person’s behavior in terms of their history or biology, and reflecting it as such 5) Normalizing and recognizing an emotional reaction that is logical and that anyone would have given the circumstances, 6) Showing radical authenticity [20].
In DBT validation is a core therapeutic component which is regarded as being very potent, as it strengthens relationships, helps with managing emotions, and assists the person in therapy to feel understood and accepted, rather than being solely encouraged to change [20]. Validations level one and two corresponds to what we usually call empathy, levels three and four resembles empathic approach as it is used in general psychotherapy, and levels five and six are distinctive to DBT. The different levels of validation are important to separate as not every behavior can be validated on all levels but most behaviors can be validated at some level. Moreover, the levels of validation are hierarchically organized and each level depends to a certain extent upon one of the previous ones. Validation is implicit in many therapies, however in DBT there is a an explicit focus on validation as a treatment strategy, as well as how and what to validate [24].
To date the use of the specific levels of validation and their impact on emotion regulation has been empirically examined to a limited extent. The Dialectical Behavior Therapy- Validation Level Coding Scale, DBT-VLCS [25] has been used to examine how the patients positive and negative affects changed over the treatment course as a result of therapists’ use of different validation levels. An increased frequency of therapists’ use of high levels of validation was associated with a reduced level of negative affect reported by the clients. Also, an increase in frequency of therapists’ use of higher levels of validation increased the client’s positive affects, whereas a higher frequency of lower levels of validation were associated with clients reporting a decrease of positive affect. The authors argue that in light of these findings it is reasonable that higher levels of validation are a prerequisite for emotional change at least in a psychotherapy setting [26].
Emotion dysregulation has been described as a state of high negative/ aversive arousal that potentially can disrupt cognitive and behavioral self-management [23]. This in turn causes the person to lose track of long-term goals [23]. Difficulties in managing the intensity and duration of negative emotions such as sadness, anger or fear, increases the likelihood of the person using maladaptive strategies like escape, avoidance or impulsive behaviors [22]. The different systems or components that are included in emotion regulation are physical arousal, facial expression, behavior, cognitive evaluation, motivation, goal orientation, and subjective experiences [9, 27, 28].
Given the support for various aspects of the Biosocial Theory, it is logical to assume an indirect link between the experience of invalidation and self-harm via emotion dysregulation. Similar relationships have been examined empirically in different studies, however instead of validation/invalidation, concepts like family climate, emotional abuse and neglect, alienation and maltreatment have been utilized. Guérin-Marion and colleagues studied 57 individuals who self-harmed and a matched control-group. They explored the pathway between parental maltreatment/ perceived alienation and self-harm and found poor emotional clarity to be a significant mediator [14]. Another study with 99 adolescent girls admitted to a psychiatric ward showed that relational problems within the family were directly associated with self-harm and indirectly related to self-harm through emotion dysregulation [16].
The relation between invalidation and self-harm and the assumed mediating role of emotion dysregulation has commonly been studied in clinical samples with observational data assessed by clinicians. To the best of our knowledge there is no self-report instrument that captures respondents experienced validation/invalidation within multiple relationships in a non-clinical sample.
The general aim of the present study was to examine and strengthen the knowledge about the pathway between experienced validation/ invalidation and self-harm, taking emotion dysregulation into account and using the novel self-assessment “Responses to My Emotions, Thoughts and Actions” to assess perceived validation/invalidation.
The specific research questions were:
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What is the nature of the relation between perceived validation/invalidation, emotion dysregulation and self-harm?
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Does the relation between perceived validation/invalidation, emotion dysregulation and self-harm vary across the different relationships, such as relation with parents, siblings and friends?
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Is there any level of validation/invalidation that seems to be have a clearer impact on self-harm and emotional dysregulation?