Skip to main content
Download PDF

Resilience revisited: a systematic review and synthesis of Non-Suicidal Self-Injury (NSSI) and its relation with resilience

BMC Psychiatry volume 25, Article number: 463 (2025) Cite this article

Abstract

Background

The aim of the current study is to examine the relationship between nonsuicidal self-injury (NSSI) and resilience. Resilience has been identified as a critical area for further investigation in the context of NSSI. Resilience has been conceptualized in different ways over the years, from psychological resilience, with a focus on the individual’s problem/deficiency, into a dynamic, cultural, interactive process in which people’s biological, psychological, social, and ecological systems work together to help them cope with challenges and maintain or improve their mental well-being.

Method

For this systematic review was searched within PubMed, PsycINFO, the Cochrane Library, and Web of Science for currently published studies on the relationship between NSSI and resilience to provide a summary, following the Preferred Reporting Items for Meta-analysis and Meta-Analysis. Second, it determines the magnitude of this relationship by calculating a random effects size, using the meta-package of R.

Results

Included were 17 studies with a total sample size of 12,273 participants (Mage = 17.56, range: 12.93–27.50, SD = 3.95; female: 59.5%) and a NSSI sample size of 4,767 (38.8%). The pooled results indicate a small to moderate relationship between resilience and NSSI, with a random effects model effect size of 0.28 (95% CI: 0.10; 0.47), with higher levels or the presence of NSSI associated with lower levels of resilience. Most studies measured psychological resilience. Several reporting the moderator and mediator function of resilience, whereby higher resilience reduces the odds of developing NSSI in the case of stressful or traumatic events. A minority of studies reported effect sizes per resilience factor. Of which problem solving/coping and emotional reactivity were predominantly reported.

Conclusions

Resilience is related to NSSI. However, it also shows that resilience is mostly measured as a psychological and individual concept. This is contrary to the multimodal perspective of resilience as well as the multimodal and non-linear nature of the recovery process of NSSI. Therefor this review highlights the need for a holistic approach with a shift in focus to a multimodal perspective. More research is needed to understand the role of resilience within the nonlinear recovery process. This research should include the voices of people with lived experience.

Peer Review reports

Introduction

Nonsuicidal self-injury (NSSI) is a significant public health concern [5, 82] that places a great burden on families and society [39] with evidence suggesting a rising prevalence [35, 47, 60, 111, 119], There are indications that the Covid period has increased the prevalence of NSSI [71, 107, 119], and there is even evidence of a lingering effect [118]. This likelihood is related to what is known: The prevalence of mental health problems such as anxiety and suicidality in general has increaed as a result of Covid and the policies surrounding it [8, 81, 103]. NSSI typically stops within a few years. However, in 20% of cases, NSSI lasts more than five years [57]. Although NSSI differs from suicidal self-injury, a history of NSSI is a risk factor for future suicidal behavior [48, 104, 112].

Given the prevalence of NSSI among adolescents and its association with suicidal behavior, the development of effective interventions for this age group is of paramount importance [92]. Although there is no gold standard for the treatment of self-injury, several interventions have shown promise in reducing or stopping NSSI [12, 94]. On the other hand, a recent meta-analysis by Fox and colleagues [25] revealed that, on average, treatment, compared to placebo, or another active treatment did not significantly reduce the incidence of or recovery from NSSI (RR = 1.11 [0.98, 1.27], p =.11). Therefore, improving our understanding of the mechanisms underlying the onset and cessation of NSSI is essential for developing effective prevention and intervention strategies.

NSSI is often used to cope with personal and social issues [15, 49, 74]. NSSI is a multifaceted behavior influenced by both proximal and distal events, suggesting a need for a multifaceted approach to recovery that addresses the individual and contextual aspects associated with the behavior [53, 115].

Resilience, defined as a dynamic process of the interplay between individual and contextual aspects [61], plays a critical role in recovery from mental health problems [79, 101] and NSSI [46, 51, 52, 115].

Consequently, resilience is a pivotal area for further investigation in the context of NSSI [58]. Therefore, the aim of the current systematic review and meta-analyses is to examine the relationship between resilience and NSSI. This is important because knowing more about resilience and its factors will help support individuals, families, and institutions in using them to heal, recover, and grow [58].

NSSI

The International Society for the Study of Self-injury [44] defines NSSI as “deliberate, self-directed damage of body tissue without suicidal intent and for purposes not socially or culturally sanctioned”. With respect to lifetime prevalence, approximately 22% of children and/or adolescents (22,6% [32], 22,1%, [56]) and 13.4% of emerging adults [88] reported having self-injured at least once in their life. In comparison, 5% of adults reported having self-injured at least once in their life [50, 88]. With respect to 12-month prevalence, approximately 19% of children and/or adolescents (19,5%, [56] 18,6%, [32]), and 3–8% of the emerging adults [87] reported having self-injured during the past year. In comparison, 0.9% of adults reported having self-injured in the year preceding the inquiry [50].

Increasing evidence suggests that NSSI is not an individual problem or individual maladaptive coping, but is embedded in interactions with the social environment [23, 83]. Feelings of marginalization or social insecurity, as in the case of LGBTIQ + people [31], and other social challenges may influence the reasons for and prevalence of NSSI [7, 114, 119]. Several explanatory models have been developed to explain the factors and processes that influence NSSI. While these models have different etiologies and emphases, difficulties with emotional regulation and social competence have been identified by most models [38, 43, 55, 72, 73, 86]. Strengthening emotion regulation and other intrapersonal factors (e.g., self-efficacy, identifying strengths) and social competence and other interpersonal factors (e.g., help-seeking skills, providing social support) are important components of a multifactorial approach to prevent, stop, and recover from NSSI [17, 21, 22, 38, 47, 53, 93]. Recovery from NSSI involves more than just the cessation of self-injurious behaviors. Recovery involves identifying alternative coping mechanisms and developing new perspectives on oneself. Individuals can cultivate personal strength, meaning, and resilience [53]. Those with first-hand experience often say that resilience is key to recovery [46, 54, 68, 80, 89, 113]. Given the central role of resilience, its meaning must be clarified.

Resilience

Resilience is considered a dynamic, cultural, interactive bio-psycho-socioecological process [61, 101, 115]. This systemic interactive conceptualization has shifted focus from the individual and his inner resources (i.e. psychological resilience) in the early resilience research to the individual and external resources and context (i.e. systemic, interactive resilience).

Over the years, there has been increasing reflection and research on what is meant by resilience and what factors and circumstances influence a perceived higher or lower level of resilience. Consequently, resilience has over the years been conceptualized in various ways, i.e., psychological or ego resilience, resilience resources, resilience as protective factors, resilience as an outcome, or resilience as a socio-ecological process [1, 24, 27, 61, 116].

Initially, the focus of resilience was the individual level; psychological or ego resilience. Psychological resilience or ego resilience consists of an internal (stable) set of individual personality traits that help us adapt to challenges [18, 62]. Instead of internal factors, resilience resources refer to external factors, such as mentors and opportunity structures [24, 121]. Both internal and external factors are referred to when considering resilience as protective factors. In this view resilience is the moderating effect of promotive factors, including assets and resources, on negative effects in predicting negative outcomes [121]. Instead of a moderator, resilience can also be seen as an outcome or so called manifested resilience. This is the positive adaptation to adversity regardless of how it is defined as resolved [61].

Over the years, the conceptualization of resilience has evolved into a process that combines psychological resilience, resilience resources, and protective factors into a biopsychosocioecological process [2, 27, 30, 62, 97, 99, 101, 106, 116]. Resilience has thereby shifted from an individual problem/deficiency to a dynamic, cultural, interactive process [61]. Ultimately, it is conceptualized as the way in which people’s biological, psychological, social, and ecological systems work together to help them deal with challenges and maintain or improve their mental well-being [101].

Interest in the relationship between NSSI and resilience is increasing [47, 91]. The relationship between resilience and self-harm is complex. Societal disruptions can have an effect on resilience at both individual and systemic level, which in its turn may decrease or increase the risk of developing self-injurious behaviors when under significant stress [115]. Either way, NSSI may indicate reduced resilience and act as a barrier to recovery [96, 100]. In any case, strengthening resilience is an important component of the recovery process [46, 53]. Therefore, the aim of the current systematic review and meta-analyses is to examine the relationship between resilience and NSSI. This is important because knowing more about resilience and its factors will help support individuals, families, and institutions in using them to heal, recover, and grow [58].

Method

This systematic review is presented in accordance with the Preferred Reporting Items for Meta-analysis and Meta-Analysis (PRISMA) standards [66]. Appendix A provides the PRISMA checklist. The review protocol was preregistered on 22 September 2022 in PROSPERO (CRD42022362058). Amendments to the final review from the registered protocol are explained in Supplementary Content 1. The Human Ethics and Consent to Participate declarations are not applicable.

Study selection

Formulation of the research question

The population, exposure, outcome (PEO) framework was used to develop an operational strategy [67]. The following research question was posed: What is currently understood about the relationship between resilience (O) in individuals across a broad age range (P) who have experience (or experience) with NSSI (E), expressed in effect sizes?

Search strategy

The search strategy was developed in collaboration with a university librarian from Leiden University Medical Center (LUMC). It comprises a combination of key terms and MESH terms related to NSSI and resilience. Prior to the final analysis, searches were rerun following the Peer Review of Electronic Search Strategies (PRESS) guidelines for meta-analysis [64]. The initial searches for relevant literature on NSSI and related behaviors used the following keywords: self-harm, self-injury, DSH, NSSI, self-mutilation, self-injurious behaviors/behaviors, resilience, and effect. A librarian further refined and verified the searches via search equations. The searches were performed on 9 September 2022 and updated on 6 June 2023 and again on 28 February 2024 and 29 August 2024. The databases searched included PubMed, PsycINFO, the Cochrane Library, and Web of Science, using the following search string: (“Self-Injurious Behavior”[MeSH Terms] OR “deliberate self harm” OR “self$harm” OR “self-injury” OR “self injury” OR “parasuicide” OR “self-destructive behavior” OR “self mutilation” OR “zelfbeschadig*” OR “zelfverwond*” OR “automutilat*”) AND (“Resilience, Psychological”[MeSH Terms] OR “resilience” OR “resilient” OR “resiliency”) AND (“Association”[MeSH Terms] OR “relation*” Or “relatie*” OR “related” OR “gerelater*” OR “predict*” OR “voorspel*” OR “predictor*”OR “voorspeller*” OR “determinant*” OR “correlat*” OR “correlate*” OR “cause*” OR “oorza*” OR “association*” OR “link*”). Appendix B provides the full search strategies for each specific database, registers and websites, including any filters and limits used.

The search results were limited to: (i) English- and Dutch-language publications and (ii) peer-reviewed journals, including quantitative and mixed-method studies, as well as graduate-level theses, published up until August 29 th. 2024. Additional literature was identified by screening the reference lists of the included studies and consulting experts in the field. The searches were performed in both English and Dutch. Two or three members of the review team independently screened the titles and abstracts of the studies, with some use of Rayyan software [75]. Disagreements were resolved by consensus. The full texts of the remaining articles were independently assessed against the inclusion criteria. This search strategy yielded a total of 328 articles, of which 279 were unique reports. Only primary studies for which the necessary data could be obtained were included.

Inclusion and exclusion criteria

Studies were included if they met the following criteria: 1) they focused on individuals who have experienced episodes of NSSI, 2) they focused on resilience, 3) NSSI was assessed separately from other constructs (i.e., suicidality and other risky behaviors); and 4) they described effect sizes; quantitative data were presented on the association between resilience and NSSI. The exclusion criteria were as follows: 1) studies that focused on individuals with intellectual disabilities who self-harm and 2) studies that included only single episodes of NSSI.

Data extraction and quality appraisal

A data extraction form based on the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis [67] was used. The abstracted data included, among other data, citation details, country, demographic sample characteristics, NSSI definitions, resilience definitions, sampling strategies, study designs, utilized NSSI and resilience measurement instruments, and adjustments for confounding factors. Four subtypes or conceptions of resilience are predefined on the basis of the extant literature: psychological resilience [62], resilience as a protective factor [24], resilience resources [121], and resilience as an outcome [61]. Both descriptive data and effect sizes were extracted. If applicable, the measured components of resilience and the NSSI characteristics of the study populations were extracted. Additionally, since resilience is often mentioned as a mediator or moderator between an adverse event or mental health problem and NSSI, when applicable and available, these effects were extracted.

The quality of the individual studies was evaluated via standardized checklists for cross-sectional, prevalence, and cohort studies from the JBI [67]. To evaluate the described quality of the included papers, a ranking system was implemented with three categories: high quality (8–10/10 items checked), medium quality (3–7/10 checked), or low quality (< 3/10) for a checklist consisting of ten items [3]. Any discrepancies were resolved through consensus between the authors.

Data analysis

In accordance with the guidelines set forth in the Cochrane Handbook [20, 42], the findings are presented in a meticulous and systematic manner. Whenever feasible, participants with a history of suicide attempts were excluded from the analyses to facilitate the assessment of the distinctive association between NSSI and resilience. This approach was employed in studies that presented resilience data for distinct groups, including those with no NSSI history, those with NSSI history only, and those with both NSSI and suicide attempt history. In such instances, data for the former two groups were included, whereas data for the latter group were excluded.

To investigate the hypothesized low levels of resilience associated with NSSI, the effect sizes of the individual studies were collected. Thereafter, the observed effect sizes were quantified via Cohen’s d, in accordance with the effect size calculation and conversion formulas built into R via the “meta” package in R (version 4.2.3) [37, 65].

Results

Study selection and sample characteristics

A total of 279 articles were identified through database and register searches enriched with snowballing via citation searching, expert consultation, and national knowledge institutes such as the National Health Service (NHS) (k = 27). Figure 1 presents the PRISMA flowchart, which provides a summary of the search process.

Fig. 1
figure 1

Prisma flowchart [76]

Full size image

A total of 17 aggregated studies were included for further analysis, with a total sample size of 12,273 participants (Mage = 17.56, range: 12.93—27.50, SD = 3.95; female: 59.5%) and a NSSI sample size of 4,767 (38.8%). Table 1 provides the descriptive characteristics of the included studies.

Table 1 Descriptive characteristics of the included studies
Full size table

Six studies were conducted in Asia, followed by North America (5), Europe (4) and Oceania (2). Most studies (14) were cross-sectional, and three were cohort studies. Most studies were community-based (13), followed by inpatient (2) and mixed (2) study populations. Most often, NSSI is defined NSSI as damage restricted to body tissue (14); the remaining three do not make a restriction to the body tissue but generally refer to self-injury without suicidal intent. Psychological resilience was the subject of inquiry in the majority of the studies (15/17).

Quality appraisal and ethics

The majority of the papers (14/17) were appraised with a medium quality in terms of their research methodology, whereas 3 were appraised with a high-quality description of their research methodology. The primary distinction between medium- and high-quality papers was the absence of a description of the identification of confounding factors and, consequently, strategies to address them Appendix C provides the quality appraisal for each paper. All included studies provided an ethics statement. These statements are included in Table 1.

NSSI

To measure NSSI (Table 1), the most frequently used instruments were (versions of) the Deliberate Self-Harm Inventory (DSHI, 3/17; [29, 59, 109]) and (translated versions of) the Functional Assessment of Self-Mutilation (FASM, 3/17: [14, 28, 120]). Additionally, several studies (5/17) did not utilize a specific scale to assess NSSI but rather employed one or more proprietary or nonstandard questions sometimes derived from an existing instrument [9, 11, 16, 19, 63].

Resilience

A majority of the papers (15/17) employed psychological resilience, followed by resilience resources (1) and a combination of both psychological resilience and resilience resources (1).

Twelve different questionnaires were used. Three questionnaires were used most frequently: the Connor-Davidson Resilience Scale (CD-RISC), the Resilience Scale for Children and Adolescents (RSCA), and the Resilience Scale (RS) developed by Prince-Embury in 2007 (Table 1).

The instruments used consist of some overlapping and some distinct resilience factors (Table 2). Individual factors are more common than social factors. Emotional reactivity and regulation were measured most frequently, along with coping and social connections.

Table 2 Resilient factors per instrument
Full size table

Relation resilience and NSSI

Higher levels or the presence of NSSI are associated with lower levels of resilience. The pooled results indicate a small to moderate relationship between resilience and NSSI, with a random effects model effect size of 0.28 (95% CI: 0.10; 0.47) and a fixed effect of 0.17 for the relationship between resilience and NSSI. Tables 3 and 4 summarizes both the main and additional analyses. Figure 2 provides a forest plot of the main analysis.

Table 3 Main and additional analyses
Full size table
Table 4 Distinct resilience factors
Full size table
Fig. 2
figure 2

Forest plot main analysis

Full size image

The between-study heterogeneity variance was estimated at tau2 = 0.11 (95% CI: 0.05–0.29), with an I2 value of 91.7% (95% CI: 88.2%− 94.1%). The magnitude of the I2 value indicates a considerable heterogeneity. Consequently, outlier and influence analyses were conducted to identify potential explanations for this between-study heterogeneity. No multicollinearity was found. Removing influential cases substantially lowered the heterogeneity. Subgroup analyses were performed regarding sample age, resilience type, study quality, sample type and country. Only sample age was a significant predictor of the effect size (p = 0.0067). Figure 3 provides a forest plot stratified by sample age, revealing greater effect sizes for the child/adolescent age group (0.35; 95% CI: − 0.01–0.71) and the adult age group (0.38; 95% CI: 0.05–0.71) than for studies with other age group samples. Furthermore, the type of resilience was not a significant predictor of the effect size (p = 0.067). Appendix D provides forest plots for resilience type, study quality, sample type and country. However, because of the small subgroups, it is not appropriate to draw conclusions from them, according to Harrer et al. [37], subgroup analyses are only meaningful if at least 10 studies per subgroup are available. If there is publication bias, funnel plots should display roughly symmetrical upside-down shapes. The funnel plots shown in Appendix E do not indicate publication bias. Overall, the trim-and-fill method indicates that the pooled effect of d = 0.28 is overestimated due to small-study effects. The prediction interval (0.1—0.47) indicates that small intervention effects cannot be ruled out for future studies.

Fig. 3
figure 3

Forest plot stratified by sample age

Full size image

In addition, several studies have conducted pathway analyses, reporting the moderator and mediator functions of resilience, whereby higher resilience reduces the odds of developing NSSI in the case of stressful or traumatic events. Higher levels of resilience may mitigate the effects of child abuse, other than child sexual abuse, on the prevalence, frequency, and severity of NSSI [41]. In the context of depression, resilience serves to moderate the mediating effect of depression between NSSI and distress rumination [69, 109], stressful events [109] and childhood trauma [110]. Greater resilience may also result in less suicidality in individuals who engage in NSSI [69].

A minority of the papers (4/17) presented effect sizes per resilience factor. Among these resilience factors, problem solving/coping and emotional reactivity were predominantly questioned and presented (Tables 3 and 4). Since not all data were available to calculate a shared effect size, Tables 3 and 4 presents the available mean and, if available, standard deviations per factor. The expected pattern emerged: more difficulty in the intrapersonal domain, emotion coping, and more difficulty in the interpersonal domain.

The groups also varied in size and comparison group. For example, the Nagra [69] study population consisted entirely of people who self-injured. One group suffered from suicidality, and the other did not. The study revealed that the group suffering from suicidality scored lower on intrapersonal and interpersonal factors. Additionally, the Gonçalves study [33] distinguishes three groups: no NSSI, past NSSI, and current NSSI. This shows a gradual progression. The current NSSI group has the lowest or most problematic scores. The past NSSI group had higher scores than did the current group but lower scores than did the group of participants who never self-injured.

Discussion

The aim of this study was to systematically review and synthesize what is known in the literature on the relationship between resilience and NSSI. The results indicate a significant, albeit modest, inverse relationship between resilience and NSSI, suggesting that individuals with greater resilience are less likely to engage in NSSI. This relationship also appears to have a moderating or mediating character. Higher resilience levels reduce the odds of developing NSSI when confronted with adverse events such as child abuse or when struggling with depression or suicidality.

Resilience has been linked to NSSI. Several studies argue that fostering resilience facilitates long-term recovery from and cessation of NSSI [51, 68]. Interestingly, people with lived experience explicitly mention the importance of resilience [46, 54]. Given these developments, calls have also been made to further investigate the role of resilience in the context of [58]. The current study quantifies this inverse relationship between resilience and NSSI.

First-hand experience shows that a combination of factors is necessary to promote resilience and overcome NSSI [53]. These experiences, combined with the knowledge that changes in emotion regulation capacities and cognitions appear to be unsustainable unless other social and physical systems are addressed in addition to interpersonal systems [85, 98, 99, 101], call for a more holistic approach to the treatment of NSSI. This holistic approach is also reflected in the evolution of the concept of resilience, which has shifted from an individual problem/deficiency to a dynamic, cultural, interactive process [61].

However, this holistic picture does not emerge from the present study. The included studies mostly described resilience from personal and psychological perspectives, with resilience being impaired and lower in people who self-injured. One possible explanation for this is that the most commonly used, researched, and referenced instruments were developed at a time when resilience was generally viewed as a personal and psychological concept. To do justice to the layered, multifaceted nature, and embedded within a social-ecological context, to measure resilience a personalized, tailormade instrument considering a person’s health, environment, and society is needed to understand the recovery process [101, 115]. Also, given the nonlinear character, resilience should be measured multiple times [115]. For existing resilience measures this would mean to expand their covering themes with self-efficacy, social support, meaningful life, belonging and emotional skills.

These measurements would ideally be incorporated in the clinical practice. Subsequently, these themes, being frequently mentioned among clinicians as well as people with lived experience to be important for NSSI recovery, could also be included in personalized treatment [46, 52]. To address these themes it could be helpful to include also non-verbal, creative expressions [117]. Also, as mentioned before, recovery and resilience are nonlinear processes, which may result in times where a person does not want to stop NSSI and is resistant to treatment [115]. This requires navigation and negotiation for a personalized treatment [95], addressing person-specific concerns conversationally.

Since the purpose of this study was also to provide an overview of what is understood by resilience in relation to NSSI and how strong this connection is, naming, defining and operationalizing resilience was an explicit inclusion criterion. Consequently, if, for instance, personal agency and social support were described as concepts distinct from resilience and therefore no resilience factors, they were excluded.

If distinct resilience factors were measured and described in the paper, the next step was to extract the scores for these resiliency factors. It was expected that people who self-injured would score lower on agency and social support and higher on emotion regulation. Indeed, the expected pattern emerged: more difficulty in the intrapersonal domain, more specifically emotion oriented coping, and more difficulty in the interpersonal domain. However, this picture emerged from a very small number of studies (k = 4) and from very diverse groups, both in terms of size and in terms of target populations. If future studies could publish data on their unique resilience factors, this might be helpful in the distillation of recovery-promoting resilience factors.

All included studies provided an ethics statement. These statements are included in Table 1, making explicitly how ethics are guaranteed of studies about potential vulnerable people or people who have difficulty in trusting other people. This is explicitly important not only for professionals, but even more for people with lived experience.

Limitations

Evidently this study is not without limitations. First, as the analysis proceeded, it became clear that a complete meta-analysis would not be appropriate. However, a common effect size was calculated as an indication for further research. It would help to specify the quantification direction of a relationship that is difficult to capture in a single effect size. Second, the search for relevant literature was limited to published data and articles published in English and Dutch, which may have led to the exclusion of other pertinent research. Third, it is possible that the criterion of resilience as being obligatory has led to the omission of valuable research. Studies that did not mention resilience explicitly as an indicator did not emerge in the current study. However, this study was intended to focus on whether there is also a definitional quandary regarding resilience in the context of NSSI, which was the case. Fourth, the inquiry of the presence of NSSI varied considerably, ranging from single questions to multi-item lists specifying the methods of self-injury. Single-question definitions have been demonstrated to underestimate the prevalence of self-injury [88], rendering them incompatible with validated measures of self-injury such as the DSHI [34]. Although overall, the methodological quality was medium to high, studies varied in terms of aspects of their methodological quality, including sampling procedures, and settings. Confounding factors were generally not described as accounted for, in future studies propensity score matching could be considered [4]. Fifth, the availability of gender- and age-specific data was limited, which means that these results require further research. The study samples exhibited some diversity in terms of the included age range, which is significant given that the prevalence of self-injury increases throughout childhood and adolescence [40]. This diversity in age-range as well as target populations contribute to a greater heterogeneity, but this diversity is also a reflection of the diversity of the target population.

Implications

To provide adequate mental health care for people who self-injure and their loved ones, a clear picture of the factors involved is needed. Such a picture contributes to a holistic approach to healthcare, which is needed to help individuals cultivate personal strength and meaning during the recovery process [79]. This holistic approach includes a support system that quickly identifies biopsychosocial and cultural factors and better supports people who self-injure. This seems even more relevant since changes in emotion regulation skills and cognitions are unlikely to be sustained unless other physical, interpersonal and social factors are considered [85, 97, 101, 102].

The need from clinical practice for tools to strengthen resilience in the case of NSSI is understandable, but given the individual process, it is merely a process of navigation and negotiation [101] about which factors to target and when to do so. However, there are some important factors that emerge from the findings of people with lived experience who have recovered from NSSI, such as emotion regulation, self-efficacy, identifying strengths, help-seeking skills, providing social support, sense of belonging, meaningful life [17, 21, 22, 38, 47, 53, 93]. To gain insight into which resilience factors are most protective against NSSI or act as mediators in recovery, it is recommended that future research publish data on their unique resilience factors. This could be helpful in distilling recovery-promoting resilience factors.

Recovery from NSSI is a nonlinear, multifaceted process. Fostering resilience facilitates long-term cessation and recovery. To achieve this, one must understand resilience in the context of NSSI and have the tools to facilitate personal definitions and treatment for those who self-injure and their environment [115]. In other words, instruments to assess resilience in a multidimensional way are needed. It follows that for a person to achieve recovery and to increase resilience, practitioners should not focus merely on symptoms and the cessation of NSSI. Instead, it is necessary for them to consider how symptoms interact with the various areas of life of the person who self-injures [6, 53], recognizing that these interactions can vary and may not always follow a predictable pattern. To obtain a clear holistic picture of the factors involved and how these factors interact, personalized, conversation-based approaches to treatment are recommended [6]. Additionally, as NSSI is considered a non-verbal way of expressing what someone is struggling with [78, 117], it is recommended tofacilitate opportunities for creative, non-verbal expressions of distress and strength to come to understand symptoms and their interactions.

Additionally, more research is needed to understand the role of resilience in the nonlinear recovery process. To do justice to the biopsychosocial model, taking into account cultural differences and personal adaptations, follow-up research should draw on a variety of sources and knowledge including both theoretical knowledge from different disciplines [102] and practical and experiential knowledge. This research should explicitly include the voices of people with lived experience in the quest to develop tools and guides to support people who self-injure to express their needs and struggles, as well as to discover their own strengths and the strengths and sources of help around them.

Conclusion

This review is the first to systematically explore, describe and quantify the rel

ationship between resilience and NSSI. NSSI and resilience are negatively related, and people exhibiting greater resilience are less prone to self-injurious behavior. Following developments in both resilience and NSSI research, this review suggests shifting the focus to a holistic approach that includes both personal, environmental and societal factors. This perspective would do more justice to the multimodal and nonlineair character of the recovery process.

To achieve a holistic understanding of symptoms and their interactions, the development of tools to support professionals in personalized, conversation-based approaches, including nonverbal expressions, to treatment is recommended.

To do justice to this holistic biopsychosocial model, taking into account cultural and personal differences, follow-up research should draw on a variety of sources and knowledge. This research should explicitly include the voices of people with lived experience.

Data availability

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

ASES:

Academic Self-Efficacy Scale

BCE:

Benevolent Childhood Experiences Scale

BRS:

Brief Resilience Scale

CD-RISC:

Connor-Davidson Resilience Scale

CD-RISC- 10f:

10-Item Connor-Davidson Resilience Scale

C-FASM:

Chinese version of the Functional Assessment of Self-Mutilation

DSHBQ:

Deliberate Self-harm Behaviors Questionnaire

DSHI:

Deliberate self-harm inventory

DSHI-s:

Deliberate Self-Harm Inventory – Short form

FASM:

Functional Assessment of Self-Mutilation

GMSR:

Gender Minority Stress and Resilience measure

ISAS:

Inventory of Statements about Self-Injury

ISSS:

International Society for the Study of Self-injury

LOT-R:

Life Orientation Test-Revised

MAAS-A:

Mindful Attention Awareness Scale-Adolescents

NHS:

National Health Service

NSSI:

Nonsuicidal self-injury

Osi:

Ottawa self-injury inventory

Osic:

Ottawa self-injury inventory Chinese revised edition PEO: population, exposure, outcome

PRESS:

Peer Review of Electronic Search Strategies

PRISMA:

Reporting Items for Meta-analysis and Meta-Analysis

RAS:

Resilience Appraisal Scale

RS:

Resilience Scale for College Students

RS:

Resilience Scale

RSA:

Resilience Scale for Adults

RSCA:

Resilience Scale for Children and Adolescents

SIQ‑TR‑SF:

Self‑Injury Questionnaire ‑ Treatment Related – Short Form

TALCS:

Trice Academic Locus of Control Scale

References

  1. Aburn G, Gott M, Hoare K. What is resilience? An integrative review of the empirical literature. J Adv Nurs. 2016;72(5):980–1000.

    Article  PubMed  Google Scholar 

  2. Alessa L, Kliskey A. People, perceptions, and process. In: Ungar M, editor. multisystemic resilience: adaptation and transformation in contexts of change. Oxford: Oxford University Press; 2021. p 165.

  3. Aromataris E, Munn Z, editor. JBI manual for evidence synthesis. JBI; 2020.

  4. Austin PC. An introduction to propensity score methods for reducing the effects of confounding in observational studies. Multivariate Behav Res. 2011;46(3):399–424. https://doiorg.publicaciones.saludcastillayleon.es/10.1080/00273171.2011.568786.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Balazs J, Brunner R. Nonsuicidal Self-Injury in Adolescents: Research and Clinical Practice. In Fiorillo A, Falkai P, Gorwood P, editors. Mental Health Research and Practice: From Evidence to Experience. Cambridge University Press; 2024. p. 19–26. https://doiorg.publicaciones.saludcastillayleon.es/10.1017/9781009067287.003.

  6.  Bansema CH, Vermeiren RRJM, de Soet R, et al. A systematic review exploring characteristics of youth with severe and enduring mental health problems (SEMHP). Eur Child Adolesc Psychiatry. 2024;33:1313–25. https://doiorg.publicaciones.saludcastillayleon.es/10.1007/s00787-023-02216-6.

  7. Barlattani T, Celenza G, Cavatassi A, Minutillo F, Socci V, Pinci C, Santini R, Pacitti F. Neuropsychiatric Manifestations of COVID-19 Disease and Post COVID Syndrome: The Role of N-acetylcysteine and Acetyl-L-carnitine. Curr Neuropharmacol. 2025;23(6):686–704. https://doiorg.publicaciones.saludcastillayleon.es/10.2174/011570159X343115241030094848.

  8. Barlattani T, D’Amelio C, Capelli F, Mantenuto S, Rossi R, Socci V, Stratta P, Di Stefano R, Rossi A, Pacitti F. Suicide and COVID-19: a rapid scoping review. Ann Gen Psychiatry. 2023;22(1):10.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Brennan SL, Irwin J, Drincic A, Amoura NJ, Randall A, Smith-Sallans M. Relationship among gender-related stress, resilience factors, and mental health in a Midwestern US transgender and gender-nonconforming population. Int J Transgend. 2017;18(4):433–45. https://doiorg.publicaciones.saludcastillayleon.es/10.1080/15532739.2017.1365034.

    Article  Google Scholar 

  10. Brown KW, West AM, Loverich TM, Biegel GM. Assessing adolescent mindfulness: validation of an adapted mindful attention awareness scale in adolescent normative and psychiatric populations. Psychol Assess. 2011;23(4):1023.

    Article  PubMed  Google Scholar 

  11. Bunting L, McCartan C, Davidson G, Grant A, Mulholland C, Schubotz D, Hamill R, McBride O, Murphy J, Nolan E, Shevlin M. The influence of adverse and positive childhood experiences on young people’s mental health and experiences of self-harm and suicidal ideation. Child Abuse Negl. 2023;140:1–12. https://doiorg.publicaciones.saludcastillayleon.es/10.1016/j.chiabu.2023.106159.

    Article  Google Scholar 

  12. Calvo N, García-González S, Perez-Galbarro C, Regales-Peco C, Lugo-Marin J, Ramos-Quiroga J-A, Ferrer M. Psychotherapeutic interventions specifically developed for NSSI in adolescence: a systematic review. Eur Neuropsychopharmacol. 2022;58:86–98. https://doiorg.publicaciones.saludcastillayleon.es/10.1016/j.euroneuro.2022.02.009.

    Article  CAS  PubMed  Google Scholar 

  13. Campbell-Sills L, Stein MB. Psychometric analysis and refinement of the connor–davidson resilience scale (CD-RISC): validation of a 10-item measure of resilience. J Trauma Stress. 2007;20(6):1019–28.

    Article  PubMed  Google Scholar 

  14. Calvete E, Orue I, Sampedro A. Does the acting with awareness trait of mindfulness buffer the predictive association between stressors and psychological symptoms in adolescents? Pers Individ Differ. 2017;105:158–63. https://doiorg.publicaciones.saludcastillayleon.es/10.1016/j.paid.2016.09.055.

    Article  Google Scholar 

  15. Chapman AL, Gratz KL, Brown MZ. Solving the puzzle of deliberate self-harm: The experiential avoidance model. Behav Res Ther. 2006;44(3):371–94. https://doiorg.publicaciones.saludcastillayleon.es/10.1016/j.brat.2005.03.005.

  16. Cheng J, Zhao J, Song B, Han H, Liu N, Chen Y, Liu X, Dong Y, Bian W, Liu Z, Han S. Positive effects of parent-child group emotional regulation and resilience training on nonsuicidal self-injury behavior in adolescents: a quasi-experimental study. Front Psychiatry. 2024;15:1343792. https://doiorg.publicaciones.saludcastillayleon.es/10.3389/fpsyt.2024.1343792.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Christoffersen MN, Møhl B, DePanfilis D, Vammen KS. Non-suicidal self-injury—does social support make a difference? An epidemiological investigation of a Danish national sample. Child Abuse Negl. 2015;44:106–16.

    Article  PubMed  Google Scholar 

  18. Connor KM, Davidson JR. Development of a new resilience scale: the Connor-Davidson resilience scale (CD-RISC). Depress Anxiety. 2003;18(2):76–82.

    Article  PubMed  Google Scholar 

  19. Covello C. Uncovering risks, strengths, & resiliency factors of self-injuring and non-self-injuring youth in residential treatment ProQuest Information & Learning. psyh. 2013.

  20. Cumpston MS, McKenzie JE, Welch VA, Brennan SE. Strengthening systematic reviews in public health: guidance in the cochrane handbook for systematic reviews of interventions, 2nd edition. J Public Health. 2022;44(4):e588–92. https://doiorg.publicaciones.saludcastillayleon.es/10.1093/pubmed/fdac036.

    Article  Google Scholar 

  21. Deliberto TL, Nock MK. An exploratory study of correlates, onset, and offset of non-suicidal self-injury. Arch Suicide Res. 2008;12(3):219–31.

    Article  PubMed  Google Scholar 

  22. Evans E, Hawton K, Rodham K. In what ways are adolescents who engage in self-harm or experience thoughts of self-harm different in terms of help-seeking, communication and coping strategies? J Adolesc. 2005;28(4):573–87.

    Article  PubMed  Google Scholar 

  23. Favazza AR. A cultural understanding of nonsuicidal self-injury; 2009.

  24.  Fletcher D, Sarkar M. Psychological Resilience: A Review And Critique Of Definitions. Concepts Theory. 2013;18(1):12–23.

  25. Fox KR, Huang X, Guzmán EM, Funsch KM, Cha CB, Ribeiro JD, Franklin JC. Interventions for Suicide and self-injury: a meta-analysis of randomized controlled trials across nearly 50 years of research. Psychol Bull. 2020;146(12):1117–45. https://doiorg.publicaciones.saludcastillayleon.es/10.1037/bul0000305.

    Article  PubMed  Google Scholar 

  26. Friborg O, Hjemdal O, Rosenvinge JH, Martinussen M. A new rating scale for adult resilience: what are the central protective resources behind healthy adjustment? Int J Methods Psychiatr Res. 2003;12(2):65–76.

    Article  PubMed  Google Scholar 

  27. Fullerton DJ, Zhang LM, Kleitman S. An integrative process model of resilience in an academic context: resilience resources, coping strategies, and positive adaptation. PLoS One. 2021;16(2):e0246000.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Gao Y, Wang Y, Wang Z, Ma M, Li H, Wang J, Liu J, Qian H, Zhu P, Xu X. Family intimacy and adaptability and non-suicidal self-injury: a mediation analysis. BMC Psychiatry. 2024;24(1):210. https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12888-024-05642-1.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Garisch JA, Wilson MS. Prevalence, correlates, and prospective predictors of non-suicidal self-injury among New Zealand adolescents: cross-sectional and longitudinal survey data. Child Adolesc Psychiatry Ment Health. 2015;9:1–11.

    Article  Google Scholar 

  30. Gartland D, Bond L, Olsson CA, Buzwell S, Sawyer SM. Development of a multi-dimensional measure of resilience in adolescents: the adolescent resilience questionnaire. BMC Med Res Methodol. 2011;11:1–10.

    Article  Google Scholar 

  31. Gillett RM. Significant Social Others Influence on NSSI in the LGBTQIA+ Community: An Exploratory Analysis. In: SUNY Brockport, Honors College; 2021.

  32. Gillies D, Christou MA, Dixon AC, Featherston OJ, Rapti I, Garcia-Anguita A, Villasis-Keever M, Reebye P, Christou E, Al Kabir N. Prevalence and characteristics of self-harm in adolescents: meta-analyses of community-based studies 1990–2015. J Am Acad Child Adolesc Psychiatry. 2018;57(10):733–41.

    Article  PubMed  Google Scholar 

  33. Gonçalves S, Vieira AI, Machado BC, Bessa C. Non-suicidal self-injury in Portuguese college students: relationship with emotion regulation, resilience and self-compassion. Curr Psychol. 2023;10. https://doiorg.publicaciones.saludcastillayleon.es/10.1007/s12144-023-04985-4.

  34. Gratz KL. Measurement of deliberate self-harm: preliminary data on the deliberate self-harm inventory. J Psychopathol Behav Assess. 2001;23:253–63.

    Article  Google Scholar 

  35. Griffin E, McMahon E, McNicholas F, Corcoran P, Perry IJ, Arensman E. Increasing rates of self-harm among children, adolescents and young adults: a 10-year national registry study 2007–2016. Soc Psychiatry Psychiatr Epidemiol. 2018;53:663–71.

    Article  PubMed  Google Scholar 

  36. Guérin-Marion C, Bureau JF, Lafontaine MF, Gaudreau P. Low self-perceived resilience mediates the link between limited access to emotion regulation strategies and non-suicidal self-injury. Cogent Psychol. 2023;10(1):7. https://doiorg.publicaciones.saludcastillayleon.es/10.1080/23311908.2023.2276862.

    Article  Google Scholar 

  37. Harrer M, Cuijpers P, Furukawa T, Ebert D. Doing meta-analysis with R: a hands-on guide. Boca Raton and Oxon: Chapman and Hall/CRC; 2021.

  38. Hasking P, Whitlock J, Voon D, Rose A. A cognitive-emotional model of NSSI: using emotion regulation and cognitive processes to explain why people self-injure. Cogn Emot. 2017;31(8):1543–56. https://doiorg.publicaciones.saludcastillayleon.es/10.1080/02699931.2016.1241219.

    Article  PubMed  Google Scholar 

  39. Hauber K, Boon A, Vermeiren R. Non-suicidal self-injury in clinical practice. Front Psychol. 2019;10:502.

  40. Hawton K, Saunders KE, O’Connor RC. Self-harm and suicide in adolescents. Lancet. 2012;379(9834):2373–82.

    Article  PubMed  Google Scholar 

  41. He NN, Xiang YH. Child maltreatment and nonsuicidal self-injury among Chinese adolescents: the mediating effect of psychological resilience and loneliness. Child Youth Serv Rev. 2022;133:8. https://doiorg.publicaciones.saludcastillayleon.es/10.1016/j.childyouth.2021.106335.

    Article  Google Scholar 

  42. Higgins J. Cochrane handbook for systematic reviews of interventions. Cochrane Collaboration and Wiley; 2008.

  43. Hooley JM, Franklin JC. Why do people hurt themselves? A new conceptual model of nonsuicidal self-injury. Clin Psychol Sci. 2018;6(3):428–51.

    Article  Google Scholar 

  44. ISSS. Treatments for self-injury. 2024. Retrieved 29–07–2024 from https://www.itriples.org/aboutnssi/treatments-for-self-injury.

  45. Johnson J, Gooding PA, Wood AM, Tarrier N. Resilience as positive coping appraisals: testing the schematic appraisals model of suicide (SAMS). Behav Res Ther. 2010;48(3):179–86.

    Article  CAS  PubMed  Google Scholar 

  46. Kelada L, Hasking P, Melvin G, Whitlock J, Baetens I. “I do want to stop, at least I think I do”: an international comparison of recovery from nonsuicidal self-injury among young people. J Adolesc Res. 2018;33(4):416–41.

    Article  Google Scholar 

  47. Khan A, Ungar M. Resilience to self-harm a scoping review of protective factors that aid in recovery among marginalized young people [review; early access]. Crisis. 2021;9. https://doiorg.publicaciones.saludcastillayleon.es/10.1027/0227-5910/a000831.

  48. Kiekens G, Hasking P, Boyes M, Claes L, Mortier P, Auerbach R, Cuijpers P, Demyttenaere K, Green J, Kessler R. The associations between non-suicidal self-injury and first onset suicidal thoughts and behaviors. J Affect Disord. 2018;239:171–9.

    Article  CAS  PubMed  Google Scholar 

  49. Klonsky ED. The functions of deliberate self-injury: A review of the evidence. Clin Psychol Rev. 2007;27(2):226–39. 

  50. Klonsky ED. Non-suicidal self-injury in United States adults: Prevalence, sociodemographics, topography and functions. Psychol Med. 2011;41:1981–86. https://doiorg.publicaciones.saludcastillayleon.es/10.1017/S0033291710002497.

  51. Lewis SP, Hasking P. Putting the “self” in self-injury research: Inclusion of people with lived experience in the research process. Psychiatr Serv. 2019;70(11):1058–60.

    Article  PubMed  Google Scholar 

  52. Lewis SP, Hasking PA. Rethinking self-injury recovery: a commentary and conceptual reframing. BJPsych Bull. 2020;44(2):44–6.

    Article  PubMed  Google Scholar 

  53. Lewis SP, Hasking PA. Self-injury recovery: a person-centered framework. J Clin Psychol. 2021;77(4):884–95. https://doiorg.publicaciones.saludcastillayleon.es/10.1002/jclp.23094.

    Article  PubMed  Google Scholar 

  54. Lewis SP, Kenny TE, Whitfield K, Gomez J. Understanding self-injury recovery: views from individuals with lived experience. J Clin Psychol. 2019;75(12):2119–39.

    Article  PubMed  Google Scholar 

  55. Li M, Li Q, Wu C. Mechanisms and intervention strategies of emotional dysregulation in individuals with nonsuicidal self-injury. Interdiscip Nurs Res. 2023;2(4):257–63. https://doiorg.publicaciones.saludcastillayleon.es/10.1097/nr9.0000000000000041.

    Article  Google Scholar 

  56. Lim KS, Wong CH, McIntyre RS, Wang J, Zhang Z, Tran BX, Tan W, Ho CS, Ho RC. Global Lifetime and 12-Month Prevalence of Suicidal Behavior, Deliberate Self-Harm and Non-Suicidal Self-Injury in Children and Adolescents between 1989 and 2018: A Meta-Analysis. Int J Environ Res Public Health. 2019;16(22):4581. https://doiorg.publicaciones.saludcastillayleon.es/10.3390/ijerph16224581. 

  57. Liu RT, Scopelliti KM, Pittman SK, Zamora AS. Childhood maltreatment and non-suicidal self-injury: a systematic review and meta-analysis. Lancet Psychiatry. 2018;5(1):51–64. https://doiorg.publicaciones.saludcastillayleon.es/10.1016/S2215-0366(17)30469-8.

  58. Lloyd-Richardson EE, Baetens I, Whitlock JL. Conclusion and future directions. In: The Oxford handbook of nonsuicidal self-injury. Oxford University Press; 2024. https://doiorg.publicaciones.saludcastillayleon.es/10.1093/oxfordhb/9780197611272.013.60.

  59. Madden SC. The relationship between psychological maltreatment and deliberate self-harm and the moderating role of resilience in an undergraduate residence hall population. Colorado: University of Northern Colorado; 2008.

  60. Madge N, Hewitt A, Hawton K, Wilde EJD, Corcoran P, Fekete S, Heeringen KV, Leo DD, Ystgaard M. Deliberate self-harm within an international community sample of young people: comparative findings from the Child & Adolescent Self-harm in Europe (CASE) study. J Child Psychol Psychiatry. 2008;49(6):667–77.

    Article  PubMed  Google Scholar 

  61. Masten AS. resilience in developmental systems. In: Ungar M, editor. multisystemic resilience. Oxford: Oxford University Press; 2021. https://doiorg.publicaciones.saludcastillayleon.es/10.1093/oso/9780190095888.003.0007.

  62. Masten AS, Cicchetti D. Resilience in development: progress and transformation. Dev Psychopathol. 2016;4(3):271–333.

    Google Scholar 

  63. McDowell MJ, Hughto JMW, Reisner SL. Risk and protective factors for mental health morbidity in a community sample of female-to-male trans-masculine adults: correction. BMC Psychiatry. 2019;19:16.

    Article  PubMed  PubMed Central  Google Scholar 

  64. McGowan J, Sampson M, Salzwedel DM, Cogo E, Foerster V, Lefebvre C. PRESS peer review of electronic search strategies: 2015 guideline statement. J Clin Epidemiol. 2016;75:40–6.

    Article  PubMed  Google Scholar 

  65. McKenzie JE, Brennan SE. Synthesizing and presenting findings using other methods. In: Cochrane handbook for systematic reviews of interventions. 2019. p. 321–347.

  66. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339:b2535. https://doiorg.publicaciones.saludcastillayleon.es/10.1136/bmj.b2535.

    Article  PubMed  PubMed Central  Google Scholar 

  67. Moola S, Munn Z, Sears K, Sfetcu R, Currie M, Lisy K, Tufanaru C, Qureshi R, Mattis P, Mu P. Conducting systematic reviews of association (etiology): the Joanna Briggs Institute’s approach. JBI Evid Implement. 2015;13:163–9.

    Google Scholar 

  68. Morris C, Simpson J, Sampson M, Beesley F. Cultivating positive emotions: a useful adjunct when working with people who self-harm? Clin Psychol Psychother. 2014;21(4):352–62. https://doiorg.publicaciones.saludcastillayleon.es/10.1002/cpp.1836.

    Article  PubMed  Google Scholar 

  69. Nagra GS, Lin A, Upthegrove R. What bridges the gap between self-harm and suicidality? The role of forgiveness, resilience and attachment. Psychiatry Res. 2016;241:78–82. https://doiorg.publicaciones.saludcastillayleon.es/10.1016/j.psychres.2016.04.103.

    Article  PubMed  Google Scholar 

  70. Narayan AJ, Rivera LM, Bernstein RE, Harris WW, Lieberman AF. Positive childhood experiences predict less psychopathology and stress in pregnant women with childhood adversity: a pilot study of the benevolent childhood experiences (BCEs) scale. Child Abuse Neglect. 2018;78:19–30. https://doiorg.publicaciones.saludcastillayleon.es/10.1016/j.chiabu.2017.09.022.

    Article  PubMed  Google Scholar 

  71. Nearchou F. Self-harm in young people: investigating the role of resilience and posttraumatic stress related to the COVID-19 pandemic. J Child Adolesc Trauma. 2022. https://doiorg.publicaciones.saludcastillayleon.es/10.1007/s40653-022-00511-z.

    Article  PubMed  PubMed Central  Google Scholar 

  72. Nock MK, Prinstein MJ. A Functional approach to the assessment of self-mutilative behavior. J Consult Clin Psychol. 2004;72(5):885–90. https://doiorg.publicaciones.saludcastillayleon.es/10.1037/0022-006X.72.5.885.

    Article  PubMed  Google Scholar 

  73. Nock MK, Prinstein MJ. Contextual features and behavioral functions of self-mutilation among adolescents. J Abnorm Psychol. 2005;114(1):140.

    Article  PubMed  Google Scholar 

  74. Nock MK. Why Do People Hurt Themselves? New Insights Into the Nature and Functions of Self-Injury. Curr Dir Psychol Sci. 2009;18(2):78–83. https://doiorg.publicaciones.saludcastillayleon.es/10.1111/j.1467-8721.2009.01613.x.

  75. Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan—a web and mobile app for systematic reviews. Syst Rev. 2016;5(1):210. https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13643-016-0384-4.

    Article  PubMed  PubMed Central  Google Scholar 

  76. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71.

    Article  PubMed  PubMed Central  Google Scholar 

  77. Prince-Embury S, Courville T. Comparison of one-, two-, and three-factor models of personal resiliency using the resiliency scales for children and adolescents. Can J Sch Psychol. 2008;23(1):11–25.

    Article  Google Scholar 

  78. Raffagnato A, Angelico C, Valentini P, Miscioscia M, Gatta M. Using the body when there are no words for feelings: alexithymia and somatization in self-harming adolescents. Front Psych. 2020;11:262.

    Article  Google Scholar 

  79. Ribeiro S, Pimentel AP, Fernandes VR, Deslandes AC, Amarante P. It is time for more holistic practices in mental health. PLOS Ment Health. 2024;1(1):e0000028.

    Article  Google Scholar 

  80. Rotolone C, Martin G. Giving up self-injury: a comparison of everyday social and personal resources in past versus current self-injurers [ref in]. Arch Suicide Res. 2012;16(2):147–58.

    Article  PubMed  Google Scholar 

  81. Santomauro DF, Mantilla Herrera AM, Shadid J, Zheng P, Ashbaugh C, Pigott DM, Abbafati C, Adolph C, Amlag JO, Aravkin AY, Bang-Jensen BL, Bertolacci GJ, Bloom SS, Castellano R, Castro E, Chakrabarti S, Chattopadhyay J, Cogen RM, Collins JK, et al. Global prevalence and burden of depressive and anxiety disorders in 204 countries and territories in 2020 due to the COVID-19 pandemic. Lancet. 2021;398(10312):1700–12. https://doiorg.publicaciones.saludcastillayleon.es/10.1016/S0140-6736(21)02143-7.

    Article  Google Scholar 

  82. Skegg K. Self-harm. Lancet. 2005;366(9495):1471–83. https://doiorg.publicaciones.saludcastillayleon.es/10.1016/S0140-6736(05)67600-3.

  83. Slavich GM. Social safety theory: a biologically based evolutionary perspective on life stress, health, and behavior. Ann Rev Clin Psychol. 2020;16:265–95. https://doiorg.publicaciones.saludcastillayleon.es/10.1146/annurev-clinpsy-032816-045159.

    Article  Google Scholar 

  84. Smith BW, Dalen J, Wiggins K, Tooley E, Christopher P, Bernard J. The brief resilience scale: assessing the ability to bounce back. Int J Behav Med. 2008;15:194–200.

    Article  PubMed  Google Scholar 

  85. Stainton A, Chisholm K, Kaiser N, Rosen M, Upthegrove R, Ruhrmann S, Wood SJ. Resilience as a multimodal dynamic process. Early Interv Psychiatry. 2019;13(4):725–32. https://doiorg.publicaciones.saludcastillayleon.es/10.1111/eip.12726.

    Article  PubMed  Google Scholar 

  86. Stanley B, Sher L, Wilson S, Ekman R, Huang YY, Mann JJ. Non-suicidal self-injurious behavior, endogenous opioids and monoamine neurotransmitters. J Affect Disord. 2010;124(1–2):134–40.

    Article  CAS  PubMed  Google Scholar 

  87. Staring L, Kiekens G, Kirtley OJ. The Epidemiology of nonsuicidal self-injury and self-harm in nonclinical samples: population-level trends. In: Lloyd-Richardson EE, Baetens I, Whitlock JL, editors. The Oxford handbook of nonsuicidal self-injury. Oxford: Oxford University Press; 2024. https://doiorg.publicaciones.saludcastillayleon.es/10.1093/oxfordhb/9780197611272.013.7.

  88. Swannell SV, Martin GE, Page A, Hasking P, St John NJ. Prevalence of nonsuicidal self-injury in nonclinical samples: systematic review, meta-analysis and meta-regression. Suicide Life Threat Behav. 2014;44(3):273–303.

    Article  PubMed  Google Scholar 

  89. Tatnell R, Kelada L, Hasking P, Martin G. Longitudinal analysis of adolescent NSSI: the role of intrapersonal and interpersonal factors. J Abnorm Child Psychol. 2014;42(6):885–96. https://doiorg.publicaciones.saludcastillayleon.es/10.1007/s10802-013-9837-6.

    Article  PubMed  Google Scholar 

  90. Testa RJ, Habarth J, Peta J, Balsam K, Bockting W. Development of the gender minority stress and resilience measure. Psychol Sex Orientat Gend Divers. 2015;2(1):65.

    Article  Google Scholar 

  91. Tian X, Chang W, Meng Q, Chen Y, Yu Z, He LM, Xiao YY. Resilience and self-harm among left-behind children in Yunnan, China: a community-based survey. BMC Public Health. 2019;19(1):8, Article 1728. https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12889-019-8075-4.

    Article  PubMed  Google Scholar 

  92. Tian X, Yang GY, Jiang LL, Yang RX, Ran HL, Xie FJ, Xu XF, Lu J, Xiao YY. Resilience is inversely associated with self-harm behaviors among Chinese adolescents with childhood maltreatment. PeerJ. 2020;8:e9800. https://doiorg.publicaciones.saludcastillayleon.es/10.7717/peerj.9800. 

  93. Trujillo NP, Servaty-Seib H. Parental absence and non-suicidal self-injury: social support, social constraints and sense-making. J Child Fam Stud. 2018;27(5):1449–59. https://doiorg.publicaciones.saludcastillayleon.es/10.1007/s10826-017-0976-1.

    Article  Google Scholar 

  94. Turner BJ, Austin SB, Chapman AL. Treating nonsuicidal self-injury: a systematic review of psychological and pharmacological interventions. Can J Psychiatry. 2014;59(11):576–85.

    Article  PubMed  PubMed Central  Google Scholar 

  95. Ungar M. R2 program. 2025. Retrieved 24 March 2025 from https://resilienceresearch.org/welcome-r2/.

  96. Ungar M. Nurturing hidden resilience in troubled youth. Toronto: University of Toronto Press; 2004.

  97. Ungar M. Multisystemic resilience: adaptation and transformation in contexts of change. Oxford: Oxford University Press; 2021.

  98. Ungar M, Jefferies P. Becoming more rugged and better resourced: the R2 resilience program’s(c) psychosocial approach to thriving. Front Psychol. 2021;12:745283. https://doiorg.publicaciones.saludcastillayleon.es/10.3389/fpsyg.2021.745283.

    Article  PubMed  PubMed Central  Google Scholar 

  99. Ungar M, Liebenberg L. Assessing resilience across cultures using mixed methods: construction of the child and youth resilience measure. J Mixed Methods Res. 2011;5(2):126–49. https://doiorg.publicaciones.saludcastillayleon.es/10.1177/1558689811400607.

    Article  Google Scholar 

  100. Ungar M, Teram E, Picketts J. Young offenders and their communities: reframing the institution as an extension of the community. Can J Commun Ment Health. 2001;20(2):29–43 https://doiorg.publicaciones.saludcastillayleon.es/10.7870/cjcmh-2001-0014%M12051027.

    Article  CAS  PubMed  Google Scholar 

  101. Ungar M, Theron L. Resilience and mental health: how multisystemic processes contribute to positive outcomes. Lancet Psychiatry. 2020;7(5):441–8. https://doiorg.publicaciones.saludcastillayleon.es/10.1016/S2215-0366(19)30434-1.

    Article  PubMed  Google Scholar 

  102. Ungar M, Theron L, Murphy K, Jefferies P. Researching multisystemic resilience: a sample methodology. Front Psychol. 2021;11:607994.

    Article  PubMed  PubMed Central  Google Scholar 

  103. van Oers HA, Alrouh H, Tieskens JM, Luijten MAJ, de Groot R, Broek E, van der Doelen D, Klip H, De Meyer R, van der Mheen M, Ruisch IH, van den Berg G, Bruining H, Buitelaar J, van der Rijken R, Hoekstra PJ, Kleinjan M, Lindauer R, Oostrom KJ, et al. Changes in child and adolescent mental health across the COVID-19 pandemic (2018–2023): insights from general population and clinical samples in the Netherlands. JCPP Adv. 2024;4(3):e12213. https://doiorg.publicaciones.saludcastillayleon.es/10.1002/jcv2.12213.

    Article  PubMed  Google Scholar 

  104. Victor SE, Klonsky ED. Correlates of suicide attempts among self-injurers: a meta-analysis. Clin Psychol Rev. 2014;34(4):282–97.

    Article  PubMed  Google Scholar 

  105. Wagnild GM, Young HM. Development and psychometric evaluation of the resilience scale. J Nurs Meas. 1993;1(2):165–17847.

    CAS  PubMed  Google Scholar 

  106. Wang JL, Zhang DJ, Zimmerman MA. Resilience theory and its implications for Chinese adolescents. Psychol Rep. 2015;117(2):354–75.

    Article  PubMed  Google Scholar 

  107. Wang LJZ, Lan Y, Liu SJ, Yan WS. Impact of the COVID-19 and psychological risk factors on non-suicidal self-injury behavior among high school students: a one-year follow-up study. BMC Psychiatry. 2023;23(1):512. https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12888-023-05021-2.

    Article  PubMed  PubMed Central  Google Scholar 

  108. Watson C, Tatnell R. Resilience and non-suicidal self-injury in LGBTQIA plus people: targets for prevention and intervention. Curr Psychol. 2022;41(1):307–14. https://doiorg.publicaciones.saludcastillayleon.es/10.1007/s12144-019-00573-7.

    Article  Google Scholar 

  109. Wei C, Li ZY, Ma T, Jiang XX, Yu CF, Xu Q. Stressful life events and non-suicidal self-injury among Chinese adolescents: a moderated mediation model of depression and resilience. Front Public Health. 2022;10:9, Article 944726. https://doiorg.publicaciones.saludcastillayleon.es/10.3389/fpubh.2022.944726.

    Article  Google Scholar 

  110. Weng XJ, Tang RR, Chen LX, Weng XR, Wang DD, Wu ZN, Yu LF, Fang XY, Zhang C. Pathway from childhood trauma to nonsuicidal self-injury in adolescents with major depressive disorder: the chain-mediated role of psychological resilience and depressive severity. Eur Arch Psychiatry Clin Neurosci. 2024;9. https://doiorg.publicaciones.saludcastillayleon.es/10.1007/s00406-023-01746-z.

  111. Wester K, Trepal H, King K. Nonsuicidal self-injury: Increased prevalence in engagement. Suicide Life Threat Behav. 2018;48(6):690–8.

    Article  PubMed  Google Scholar 

  112. Whitlock J, Muehlenkamp J, Eckenrode J, Purington A, Abrams GB, Barreira P, Kress V. Nonsuicidal self-injury as a gateway to suicide in young adults. J Adolesc Health. 2013;52(4):486–92.

    Article  PubMed  Google Scholar 

  113. Whitlock J, Prussien K, Pietrusza C. Predictors of self-injury cessation and subsequent psychological growth: results of a probability sample survey of students in eight universities and colleges. Child Adolesc Psychiatry Ment Health. 2015;9(1):19. https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13034-015-0048-5.

    Article  PubMed  PubMed Central  Google Scholar 

  114. Williamson P. Refugee and asylum seeker self harm with implications for transition to employment participation -a review introduction. Suicidologi. 2011;16:30–8.

    Google Scholar 

  115. Wilson E. Exploring The Role Of Resilience In Rates Of Self-Harm And Suicide During The Covid-19 Pandemic And Beyond. Sentio J. 2022:92–103.

  116. Windle G. What is resilience? A review and concept analysis. Rev Clin Gerontol. 2011;21(2):152–69.

    Article  Google Scholar 

  117. WuIandari B, Ediati A. The use of art therapy for reducing self-injury behavior: a systematic review. In: Proceedings of International Conference on Psychological Studies (ICPsyche). 2023.

  118. Zavaleta-Ramírez P, Rosetti M, Albores-Gallo L, Sarmiento-Hernández E. Clinical characteristics and prevalence of adolescent self-harm before, during and after the COVID-19 pandemic: retrospective cross-sectional database study. Bjpsych Open. 2025;11(2):e41, Article e41. https://doiorg.publicaciones.saludcastillayleon.es/10.1192/bjo.2025.4.

    Article  PubMed  Google Scholar 

  119. Zetterqvist M, Jonsson LS, Landberg Å, Svedin CG. A potential increase in adolescent nonsuicidal self-injury during covid-19: a comparison of data from three different time points during 2011–2021. Psychiatry Res. 2021;305:114208.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  120. Zhang B, Zhang W, Sun LM, Jiang C, Zhou YJ, He KL. Relationship between alexithymia, loneliness, resilience and non-suicidal self-injury in adolescents with depression: a multi-center study. BMC Psychiatry. 2023;23(1):11, Article 445. https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12888-023-04938-y.

    Article  Google Scholar 

  121. Zimmerman MA, Stoddard SA, Eisman AB, Caldwell CH, Aiyer SM, Miller A. Adolescent resilience: promotive factors that inform prevention. Child Dev Perspect. 2013;7(4):215–20. https://doiorg.publicaciones.saludcastillayleon.es/10.1111/cdep.12042.

    Article  Google Scholar 

Download references

Acknowledgements

The authors wish to thank Ms. Plevier, a university librarian from Leiden University Medical Center, who assisted in developing the right search strategy, Dr. sc. med. Delfine d'Huart for sharing her knowledge in performing meta-analyses in R, and Dr. Laura Nooteboom for her contribution to the initial inception and drafting of this study.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author information

Authors and Affiliations

  1. Department of Child and Adolescent Psychiatry (LUMC Curium), Leiden University Medical Center, Endegeesterstraatweg 27, 2342 AK Oegstgeest, Postbus 15 – 2300 AA, Leiden, The Netherlands

    Daphne Weedage, Robert R. J. M. Vermeiren & Cyril Boonmann

  2. Intensive Treatment Centre and Parnassia Academy, Parnassia Groep, The Hague, The Netherlands

    Nienke Kool-Goudzwaard

  3. Stichting Zelfbeschadiging (National Self-harm Foundation), Utrecht, the Netherlands

    Dwayne Meijnckens

  4. Department of Psychology, University of Basel, Basel, Switzerland

    Cyril Boonmann

Authors
  1. Daphne Weedage
    View author publications

    You can also search for this author inPubMed Google Scholar

  2. Nienke Kool-Goudzwaard
    View author publications

    You can also search for this author inPubMed Google Scholar

  3. Dwayne Meijnckens
    View author publications

    You can also search for this author inPubMed Google Scholar

  4. Robert R. J. M. Vermeiren
    View author publications

    You can also search for this author inPubMed Google Scholar

  5. Cyril Boonmann
    View author publications

    You can also search for this author inPubMed Google Scholar

Contributions

DW, NK-G, CB and RRJM contributed to the conceptualization of this paper. DW and CB designed the methodology of the study, DW performed the data collection and data curation. NK-G, DM and CB contributed to the validation of this paper. DW wrote and prepared the original draft, and all five authors (DW, NK-G, DM, RRJM and CB) contributed to the reviewing and editing process. This paper was written under supervision of CB and RRJM. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Daphne Weedage.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Weedage, D., Kool-Goudzwaard, N., Meijnckens, D. et al. Resilience revisited: a systematic review and synthesis of Non-Suicidal Self-Injury (NSSI) and its relation with resilience. BMC Psychiatry 25, 463 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12888-025-06868-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12888-025-06868-3

Keywords

BMC Psychiatry

ISSN: 1471-244X

Contact us