Non-suicidal self-injury (NSSI), otherwise known as deliberate self-harming behaviour without suicidal intent (American Psychiatric Association, 2022), is a global phenomenon associated with cutting, burning, scratching, hitting, stabbing, punching, or poisoning oneself to produce pain or wounds to the body (Ammerman et al., 2019). More recently, NSSI has also been found to include forms of digital self-harm causing psychological injury (Erreygers et al., 2022). Common outcomes of past self-harming injury to the body include not only the physical impacts of resulting scars (Ho et al., 2018) but also the psychosocial impacts on overall wellbeing and quality of life associated with scars in general (Ngaage & Agius, 2018; Reinholz et al., 2015). However, because NSSI scars have been self-inflicted, the psychosocial impacts are likely to have increased complexity compared with the impacts of scars resulting otherwise (Ho et al., 2018). Moreover, one of the recommendations of the National Institute for Health and Care Excellence (NICE, 2022) to support individuals who have self-harmed pertains to the management of scars. Thus, it is important to understand the impacts of NSSI scars on psychosocial functioning, quality of life, and overall recovery from self-harm to ensure this population is suitably supported.
NSSI research has predominantly focused on associated risk, protective factors, and interventions in relation to treating current self-harming behaviour (De Luca et al., 2023; McEvoy et al., 2023; Plener et al., 2015; Witt et al., 2021a, 2021b) and on surgically or cosmetically treating resulting scars (Edriss et al., 2022; Ho et al., 2018; Takaya et al., 2020). Although there has been little focus on the psychosocial, quality of life, and self-harm recovery impacts of self-harm scars, the literature indicates that most people seeking surgical or cosmetic treatment for their scars do so because of social stigma, shame, guilt, and regret (Edriss et al., 2022; Ho et al., 2018; Takaya et al., 2020). Despite the ongoing research exploring the need to improve the appearance of scars, evidence indicates no interventions are available to eradicate self-harm scars completely without any scarred remnants remaining, and hence treatment generally aims to ensure the scars look more socially acceptable (Edriss et al., 2022; Takaya et al., 2020). Therefore, being aware of the psychosocial impacts self-harm scars might have on a person’s wellbeing and quality of life is imperative for ethical counselling and psychotherapeutic practice.
A preliminary search of the self-harm scar literature revealed no recent or ongoing systematic or scoping reviews particular to the psychosocial, quality of life, and recovery impacts of NSSI scars. However, a scoping review protocol pertaining to the psychosocial impacts of scars in general was found (Ziolkowski et al., 2019). While the Ziolkowski et al. (2019) scoping review protocol focused on the impacts associated with various types of scars, the current scoping review has focused on the impacts of self-harm scars only. This scoping review addresses the research gap and assesses the extent of the published empirical literature specific to the impacts of self-harm scars on psychosocial functioning, quality of life, and recovery from self-harm tendencies, as well as examines the care and practice recommendations for individuals who have NSSI scars. Consequently, this scoping review is relevant to counsellors and psychotherapists by contributing to evidence-informed insights and awareness to support ethical client care. It also highlights opportunities for further research particular to the psychosocial, quality of life, and recovery impacts of people with self-harm scars.
Method
The scoping review was guided by the Joanna Briggs Institute (JBI; Peters et al., 2020) methodological recommendations for scoping reviews and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR; Tricco et al., 2018). Ethics approval was not required for this review.
Development of Research Question and Objectives
Following the recommendations for scoping reviews, the research question was formulated utilising the Population-Concept-Context framework (Peters et al., 2020; Tricco et al., 2018). The primary research question was formulated as follows:
- What is known about the impacts of NSSI scars on an individual’s psychosocial functioning, quality of life, and overall clinical and personal recovery from self-harm?
Key concepts in the research question were defined as follows. The term psychosocial impacts refers to the influence of physical, cognitive, emotional, behavioural, spiritual, and social domains of being on an individual’s psychological and social health, wellbeing, or quality of life (Peter et al., 2022). Clinical recovery was defined as the objective recovery outcomes as measured by a clinician or therapist, such as symptom reduction, while personal recovery was defined as the processes of subjective experience, such as being able to live a meaningful and purposeful life despite experiencing challenges or other limitations (Slade & Wallace, 2017). The objective of this scoping review was to synthesise primary empirical evidence associated with the possible psychosocial, quality of life, and overall self-harm recovery impacts experienced by people who have self-harm scars. In addition, the scoping review aimed to highlight avenues for further research by reporting on the population and scar characteristics, as well as the implications and practice recommendations noted in the studies reviewed.
Literature Search and Selection Strategy
An initial keyword search strategy was developed from the key concepts identified in the scoping review question. Medical Subject Heading (MeSH) terms and text words identified in relevant articles were used to develop a full search strategy in PubMed and were adapted for other suitable databases. The search strategy aimed to locate published primary empirical studies.
The author searched a variety of databases to ensure a diversity of relevant sources and study designs. PubMed was searched for full text results using MeSH and text words. Adapted searches conducted in PsycINFO and CINAHL Ultimate, both located on EBSCOhost, also included full text results, but with minor differences using MeSH title, abstract, and/or keywords/subject. Titles, abstracts, and keywords were searched in Scopus using an adapted keyword strategy. All searches were limited to full text English or full text translated to English, and no limits were placed on date.
All search strategies were applied to the selected databases in alphabetical order on the same date, May 7, 2024. The search strategies for all database searches can be found in Appendix A. Results from each database search were recorded in a Microsoft Excel sheet and exported to Endnote (V.9.3.1) for duplicates to be removed. After elimination of duplicates, the remaining references were uploaded to the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; Munn et al., 2019) for title and abstract screening, followed by full text screening against inclusion and exclusion criteria.
Inclusion and Exclusion Criteria
Evidence was considered for inclusion if it met criteria based on the Population-Concept-Context framework, as recommended by the JBI (Peters et al., 2020; Tricco et al., 2018). Utilising inclusion and exclusion criteria, as presented in Table 1, two reviewers—the author and a second reviewer—independently screened the titles and abstracts of articles for potential inclusion, and the author reviewed and resolved any conflicts. When suitability of an article was unclear based on title and abstract screening, it was included for full text screening. The full texts of remaining articles were retrieved and screened by the author against the eligibility criteria. Reasons for exclusion were noted in the JBI SUMARI (Munn et al., 2019). References of included studies were then screened for potential articles.
Data Extraction Framework
Data from the selected sources were extracted and charted in numerical or narrative summary statements using a modified version of the JBI data extraction tool (Peters et al., 2020), amended by the author. The data extraction form is presented in Appendix B. Data extracted by the author comprised study citations, study design and analysis, location of studies, study aims, study measures, population and scar characteristics, impacts on psychosocial functioning and quality of life, impacts on clinical and personal recovery, relevant study findings, strengths/limitations, and recommendations for clinical practice and care. Critical appraisal of the evidence is not mandatory for scoping reviews because the purpose is to determine what is known about a topic and to provide an overview of the available evidence (Peters et al., 2020); therefore, it did not form part of this review.
Data Analysis and Synthesis
Following data extraction, each study was categorised according to author, year, and location; study design and analysis; measures utilised; population and scar characteristics; impacts on psychosocial functioning and quality of life; impacts on clinical and personal recovery; and recommendations for clinical practice and care. An overview of the synthesised and collated data is presented in Tables 2 and 3 and in textual narrative synthesis (Lucas et al., 2007). Four sub-questions were created to answer the main research question:
-
What are the possible impacts of self-harm scars on an individual’s psychosocial functioning?
-
What are the possible impacts of self-harm scars on NSSI clinical and personal recovery?
-
What population and scar characteristics were recorded in the evidence reviewed? For example, age, ethnicity, sexuality or gender, and type and location of scars.
-
What are the practice and care recommendations for counsellors and other helping professionals supporting individuals with self-harm scars?
Results
Study Selection
The searches identified 347 articles in the selected databases. After removing duplicates, 227 titles and abstracts were screened from which 170 records were excluded. The remaining 57 studies were subjected to full-text screening, of which 38 were excluded owing to irrelevant population (n = 2), irrelevant format (n = 10), and irrelevant concept (n = 26). One additional study was sourced after screening the references of included articles. A total of 20 primary studies were included in the scoping review. Figure 1 presents a PRISMA flow chart detailing the stages of article identification and selection, in line with scoping review reporting guidelines (Tricco et al., 2018).
Study, Population, and Scar Characteristics
Articles included in this scoping review were published between 2005 and 2024. The studies were conducted in the following countries: the United States of America (n = 8), the United Kingdom (n = 5), Germany (n = 3), Canada (n = 2), Turkey (n = 1), and Korea (n = 1). Eleven studies were quantitative, six qualitative, two mixed-methods, and one a case report.
Sample size ranged from 6 to 368 participants. Generally, age ranged between 14 years and 80 years; however, included studies focused mostly on young adults in their 20s (n = 19), except for one whose participants were 14–17 years. Population characteristics included undergraduate students (n = 5), women in prison (n = 1), young people with depression (n = 1), people identifying as heterosexual, homosexual, lesbian, gay, bisexual, questioning, asexual, or not disclosing sexuality, as well as various nationalities. Overall, most participants identified as white and heterosexual. Genders, as reported in most of the studies, were mainly distinguished as female and male. However, one study reported a female participant identifying as transgender. Additionally, one study comprised five female and one non-binary participants, while another comprised male, female, and non-binary genders without specifying the number for each. Furthermore, one study represented only males, three only females, two did not identify gender, and some studies only reported the predominant gender. Overall, as reported in the studies, females were predominantly represented. Most studies comprised participants with NSSI scars (n = 19), except one which focused on the perceptions of participants without NSSI histories towards people with NSSI scars (Burke et al., 2019), making it relevant for this review. Scar characteristics were stated in 12 studies, mainly detailing the number of scars, which varied from one to over 50, and their locations—most often on the arms but also other parts of the body, such as the chest. Five studies reported methods of obtaining scars, with skin cutting most frequently mentioned. An overview of the reported study, population, and scar characteristics is presented in Table 2.
Psychosocial and Quality of Life Impacts of Self-Harm Scars
The psychosocial and quality of life impacts identified in this review were diverse, and participants predominantly experienced them as challenging, although some experienced them more positively or a combination of both. Feelings of stigma and shame attributable to NSSI scars were identified as a prominent theme adversely affecting psychosocial wellbeing and quality of life by 10 of the included studies (Bachtelle & Pepper, 2015; A. C. Brown et al., 2022; Burke et al., 2017, 2019; Kendall et al., 2021; Kristen et al., 2024; Lewis & Mehrabkhani, 2016; Piccirillo et al., 2020; Reinholz et al., 2015; Stacy et al., 2017). Additionally, NSSI scars were identified as contributing to psychological distress (Acikel et al., 2005; Bachtelle & Pepper, 2015; Burke et al., 2020); feeling a lack of belonging (Burke et al., 2017; Mutamba et al., 2023); struggles with unpleasant memories, self-acceptance, mental health, personal recovery, and emotional wellbeing (Kendall et al., 2021); emotional and clinical difficulties (Bachtelle & Pepper, 2015; Myung et al., 2024), such as anger, grief (Mutamba et al., 2023), depressive or borderline symptoms, self-disgust, scar-related regret, scar-related rumination (Bachtelle & Pepper, 2015) or increased propensity to engage in future NSSI (Bachtelle & Pepper, 2015; Burke et al., 2017; Chandler, 2014; Dyer et al., 2013; Gutridge et al., 2019; Stacy et al., 2017); and increased risk of suicide (Burke et al., 2016, 2018). NSSI scars might also adversely affect an individual’s confidence (Gutridge et al., 2019) and self-esteem (Acikel et al., 2005; Kristen et al., 2024). For example, some participants felt self-conscious (Mutamba et al., 2023) or embarrassed and concerned about judgement (Burke et al., 2020; Gutridge et al., 2019) and negative perceptions or assumptions of others (Chandler, 2014; Gutridge et al., 2019; Lewis & Mehrabkhani, 2016; Mutamba et al., 2023) or themselves held negative perceptions, attitudes, and cognitions about their scars (Burke et al., 2017; Lewis & Mehrabkhani, 2016; Myung et al., 2024; Piccirillo et al., 2020). An overview of identified psychosocial and quality of life impacts of NSSI scars is presented in Table 3.
Additionally, the studies reviewed identified that NSSI scars can have a negative impact on body image—for example, dissatisfaction, unhappiness, and preoccupation with physical appearance—that may be greater than the negative impact of scars caused by accident or surgery (Dyer et al., 2013, 2015). Studies indicated that individuals with NSSI scars tended to be concerned with the presence of scars and desired to conceal, hide, or reduce scar appearance (Acikel et al., 2005; Bachtelle & Pepper, 2015; Chandler, 2014; Kristen et al., 2024; Stacy et al., 2017). Increased concerns with scar appearance and fear of stigma or negative views of others tended to contribute to avoidance behaviour, such as avoiding relationships (Burke et al., 2019; Kendall et al., 2021) or avoiding social activities and clothing that might expose scarring (Kendall et al., 2021; Mutamba et al., 2023). Other avoidant behaviours included reducing workload, altering career choices, or reducing involvement in certain social domains that might require individuals to reveal their scars (Acikel et al., 2005; Kendall et al., 2021).
Some studies reported positive psychosocial and quality of life impacts for individuals with NSSI scars. For example, some individuals reported more positive cognitions (Burke et al., 2017; Lewis & Mehrabkhani, 2016), such as associating their scars with reminders not to engage in NSSI behaviour again, or with strength because the scars indicated they had managed and overcome challenging times in their lives, thereby reflecting greater acceptance (Bachtelle & Pepper, 2015; Chandler, 2014; Lewis & Mehrabkhani, 2016).
Clinical and Personal Recovery Impacts of Self-Harm Scars
The impacts of self-harm scars on clinical and personal recovery identified in the studies are provided in Table 3 above. While some studies did not report clinical or personal recovery outcomes, those that did were associated with adverse psychosocial and quality of life impacts (Acikel et al., 2005; Bachtelle & Pepper, 2015; A. C. Brown et al., 2022; Burke et al., 2016, 2017, 2020; Chandler, 2014; Dyer et al., 2013; Gutridge et al., 2019; Kristen et al., 2024; Mutamba et al., 2023; Piccirillo et al., 2020; Stacy et al., 2017). Stigma and shame were identified as adversely affecting clinical and personal recovery generally (Bachtelle & Pepper, 2015; A. C. Brown et al., 2022; Kendall et al., 2021; Kristen et al., 2024; Piccirillo et al., 2020), as well as more specifically leading to non-acceptance or concealment of scars (Bachtelle & Pepper, 2015; Kendall et al., 2021; Lewis & Mehrabkhani, 2016), self-disgust, scar-related regret, and scar-related rumination (Bachtelle & Pepper, 2015). NSSI scars were also shown to influence clinical recovery adversely by increasing the risk of repeat NSSI behaviour (Bachtelle & Pepper, 2015; A. C. Brown et al., 2022; Burke et al., 2017, 2020; Chandler, 2014; Dyer et al., 2013; Gutridge et al., 2019; Stacy et al., 2017) and contributing to clinically depressive and borderline symptoms (Bachtelle & Pepper, 2015) and suicide (Burke et al., 2016, 2018). Moreover, increased scar-related ruminative brooding was found to correlate with a higher likelihood of future NSSI behaviour in one study (Bachtelle & Pepper, 2015) and suicidal ideation in another, which also suggested that levels of brooding were important to consider in terms of evaluating suicidal risk (Burke et al., 2016).
Some studies reported positive clinical and personal recovery outcomes for individuals with NSSI scars (Bachtelle & Pepper, 2015; Chandler, 2014; Kendall et al., 2021; Kristen et al., 2024; Lewis & Mehrabkhani, 2016). Positive outcomes related to increased growth interpretations, such as viewing NSSI scars as markers of strength or overcoming adversity, or associating regret over past NSSI behaviour rather than the NSSI scarring itself, were found to reduce levels of self-disgust, scar-related regret, and future NSSI (Bachtelle & Pepper, 2015). Positive associations attributed to NSSI scars were also found to increase hope and scar acceptance (Chandler, 2014). Additionally, some individuals associated revealing their NSSI scars as validating of the distress they had experienced (Kristen et al., 2024) or resisting shame and dismantling stigma (Kendall et al., 2021). One study found growth interpretations of NSSI scars were associated with less overall scar-related distress and did not correlate with clinical symptoms (Bachtelle & Pepper, 2015).
Recommendations for Clinical Practice and Care
Recommendations for clinical practice and care comprised varieties of biological, psychological, and social approaches, as presented in Table 3 above. Biological approaches identified in the studies included the use of medical interventions to improve the appearance of scars (Acikel et al., 2005). It was noted that such approaches may not only improve scars to appear more socially acceptable to individuals but also have beneficial psychosocial impacts on self-confidence, self-esteem, and increased work and social engagements (Acikel et al., 2005). Moreover, methods of camouflaging or treating NSSI scars—such as using tattoos—to reduce their appearance may aid recovery and wellbeing (Gutridge et al., 2019; Kendall et al., 2021; Reinholz et al., 2015).
Other studies noted the importance of applying early intervention approaches to support individuals who self-harm as a method of reducing the possibility of future scarring (Dyer et al., 2013, 2015; Lewis & Mehrabkhani, 2016). It was suggested that therapists assess the presence and number of scars when evaluating suicide risk (Burke et al., 2016, 2018) and a range of scar-related cognitions in individuals with NSSI scars to better inform their practice (Burke et al., 2017; Lewis & Mehrabkhani, 2016; Myung et al., 2024). Awareness of how individuals depict their experiences of NSSI scarring (Bachtelle & Pepper, 2015; Chandler, 2014; Kristen et al., 2024; Reinholz et al., 2015), how the scars might be discussed or perceived in the broader social context, and how this could affect individuals (Kristen et al., 2024; Mutamba et al., 2023) were also identified as important aspects of practice. Other individual impacts identified as important to explore in therapy included concern about the perceptions of others, disgust (Chandler, 2014; Lewis & Mehrabkhani, 2016), and concern about negatively influencing youth (Gutridge et al., 2019). While an overarching compassionate approach to care was suggested (Chandler, 2014), utilisation of therapeutic interventions to support individuals with the impacts of stigma and shame (Bachtelle & Pepper, 2015; A. C. Brown et al., 2022; Piccirillo et al., 2020), brooding (Bachtelle & Pepper, 2015; Burke et al., 2016), negative scar-specific beliefs, concealment practices (Bachtelle & Pepper, 2015; Burke et al., 2020), negative emotions, depressive symptoms, and self-disgust (Bachtelle & Pepper, 2015) were also recommended. For instance, using compassion-focused therapy, relational therapies such as cognitive analytic therapy (A. C. Brown et al., 2022), or acceptance and mindfulness strategies were suggested as potentially beneficial for addressing shame (Bachtelle & Pepper, 2015; Burke et al., 2020) and promoting self-compassion towards previous NSSI behaviour and scarring (Bachtelle & Pepper, 2015). Additionally, rumination-focused cognitive behavioural therapy was suggested to assist with brooding (Burke et al., 2016), as were cognitive restructuring techniques to support more balanced beliefs about NSSI history and current scarring (Burke et al., 2020). NSSI scars were associated with evoking unpleasant memories for some, and had implications for self-acceptance, mental health, personal recovery, and emotional wellbeing (Kendall et al., 2021). However, utilising graduated exposure strategies to increase tolerance and coping was suggested for individuals who may conceal their scars as a means of avoiding memories triggered by their scars (Burke et al., 2020). Bachtelle and Pepper (2015) also highlighted that supporting clients to accept NSSI scars may be an important aspect of therapy, and that increased understanding of the impacts of scars may aid therapists in guiding treatment.
Furthermore, studies highlighted that broader systemic (A. C. Brown et al., 2022) or public health approaches, such as the use of psychoeducational or early intervention programs (Burke et al., 2019; Piccirillo et al., 2020), may be beneficial in addressing the stigma associated with NSSI scars. An example identified was facilitating psychoeducational programs in school settings that can provide non-judgemental information about NSSI and the associated risk and consequences (Piccirillo et al., 2020). It was also recommended that therapists utilise social media and the internet to provide psychoeducation and address stigma in the broader public domain (Piccirillo et al., 2020).
Discussion
Interpretations and Implications
The aim of this scoping review was to synthesise the existing empirical evidence reporting psychosocial, quality of life, and recovery impacts, and the associated practice recommendations particular to individuals with NSSI scars. Regarding the possible psychosocial and quality-of-life impacts NSSI scars might have on an individual, this scoping review confirms diverse psychosocial and quality of life impacts. As noted in the studies reviewed, the psychosocial and quality of life impacts associated with the stigma and shame experienced were prominent for individuals with NSSI scars (Bachtelle & Pepper, 2015; A. C. Brown et al., 2022; Burke et al., 2017, 2019; Kendall et al., 2021; Kristen et al., 2024; Lewis & Mehrabkhani, 2016; Piccirillo et al., 2020; Reinholz et al., 2015; Stacy et al., 2017). NSSI scars tended to contribute to avoidance behaviour, such as reducing social engagements, as well as scar concealment behaviour, such as wearing clothes to hide scars in various social contexts (Kendall et al., 2021; Mutamba et al., 2023). Avoidance and scar concealment behaviour tended to be associated with social domains, such as work (Acikel et al., 2005; Kendall et al., 2021) and relationships (Burke et al., 2019; Kendall et al., 2021). Psychosocial and quality of life impacts were likely to be intertwined and reciprocal, such that stigma and shame could perpetuate negative scar beliefs and cognitions, including self-stigma, which perpetuated avoidance behaviour and contributed to ongoing stigma (Bachtelle & Pepper, 2015; Burke et al., 2017; Lewis & Mehrabkhani, 2016; Myung et al., 2024; Piccirillo et al., 2020). It was observed that people with NSSI scars were more inclined to experience stigma and shame than those with naturally occurring scars, who tended to perceive their scars as more socially acceptable (Piccirillo et al., 2020; Reinholz et al., 2015; Stacy et al., 2017).
While the majority of studies included in this scoping review indicated most people experienced challenges associated with NSSI scars, a few reported more positive, or both positive and negative experiences (Bachtelle & Pepper, 2015; Chandler, 2014; Kendall et al., 2021; Kristen et al., 2024; Lewis & Mehrabkhani, 2016). For example, some individuals tended to resist stigma and find greater self-acceptance of their NSSI scars (Bachtelle & Pepper, 2015; Chandler, 2014; Kendall et al., 2021; Kristen et al., 2024), while others exhibited ambivalence about accepting or rejecting their scars, feeling confident to reveal them in certain situations but not in others (Lewis & Mehrabkhani, 2016). These results reveal that experiences are unique and that it is important to ensure a compassionate (Chandler, 2014) and person-centred approach is applied in counselling or psychotherapeutic contexts, as suggested by Lewis and Hasking (2021).
This scoping review additionally sought to identify possible impacts of NSSI scars on clinical and personal recovery; however, not all the studies reported clinical and personal recovery outcomes. Nonetheless, the review found the impacts of NSSI scars on recovery tended to be associated with psychosocial experiences and quality of life (Bachtell & Pepper, 2015; Kendall et al., 2021; Kristen et al., 2024; Piccirillo et al., 2020; Reinholz et al., 2015). For example, a prominent concern held by people with NSSI scars related to how they would be perceived by their broader community, and while some struggled with associated stigma and shame, others were more resilient to this (Chandler, 2014; Kendall et al., 2021; Kristen et al., 2024; Lewis & Mehrabkhani, 2016). The scoping review revealed that individuals who struggle with navigating the impacts of stigma and shame on their lives, or who experience difficulty accepting their scars, could lose hope and become vulnerable to repeat NSSI behaviour (Bachtelle & Pepper, 2015; Stacy et al., 2017) or even be at increased risk of suicide (Burke et al., 2016, 2017). Thus, NSSI scars are an important factor to consider with regard to suicidal ideation (Burke et al., 2016). The results place increased weight on the importance of therapists fostering a compassionate approach to support the unique experiences of people with NSSI scars (Chandler, 2014). These suggestions are further supported by a relevant commentary (Lewis, 2016) and recent review (Lewis & Hasking, 2021) advocating for a person-centred framework when working with individuals with histories of NSSI.
Scar and population characteristics recorded in the studies were also explored by this scoping review. Although various ages, ethnicities, sexualities, and genders were considered in different studies, the majority of participants identified in this scoping review were white, young adults in their 20s, female, and from Western backgrounds; therefore, the results of the review cannot be generalised to all populations. Additionally, NSSI scar characteristics were either unrecorded or inconsistently recorded across the studies. However, evidence indicated self-harm cuts to the arms were most frequently associated with scars (Acikel et al., 2005; Burke et al., 2017) and that a greater number of scars might correlate with a greater risk of suicide (Burke et al., 2016). While Chandler (2014) did not report specifically on scar characteristics, the author noted that presence of scars increased the risk of repeat self-harm. The results of this review indicate awareness of scar characteristics is therefore an important factor to consider in terms of supporting individuals in their recovery.
This scoping review also sought to identify practice and care recommendations for therapists supporting individuals with NSSI scars. Most studies reviewed provided biological, psychological, and social recommendations associated with clinical practice and care. While medical interventions cannot eliminate NSSI scars completely, the scoping review results indicate that improving the appearance of NSSI scars, whether through surgery, medical tattooing, or other cosmetic procedures, may benefit individuals’ psychosocial functioning and quality of life (Acikel et al., 2005; Gutridge et al., 2019; Kendall et al., 2021; Reinholz et al., 2015). These results are supported by other reviews particular to the medical treatment of NSSI scars (Edriss et al., 2022; Ho et al., 2018; Takaya et al., 2020).
While this scoping review indicates an overarching compassionate approach to therapy would support individuals with self-harm scars (Chandler, 2014), it also notes the benefits of utilising various psychological therapies to address shame, stigma (Bachtell & Pepper, 2015; A. C. Brown et al., 2022; Piccirillo et al., 2020), and unhelpful cognitions in order to support increased scar acceptance (Bachtelle & Pepper, 2015; Burke et al., 2020). Additionally, utilising rumination-focused cognitive behavioural therapy to evaluate and address ruminative brooding was highlighted as an important aspect to consider in terms of suicidal risk (Burke et al., 2016). Although studies suggested the use of psychological therapies, the psychosocial challenges faced by individuals with NSSI scars often stemmed from the stigma and shame perpetuated by negative perspectives in broader social contexts and communities (A. C. Brown et al., 2022; Piccirillo et al., 2020). Evidence indicated this affected individuals’ negative bias and self-stigma associated with their scars (Piccirillo et al., 2020). Therefore, unsurprisingly, evidence highlighted the importance of evaluating the unique meaning, beliefs, or cognitions people with NSSI scars might hold (Burke et al., 2017). Moreover, the review found that therapists should not only consider how broader sociocultural perspectives towards NSSI scarring might be influencing individuals (Kristen et al., 2024) but also advocate for public health or systemic approaches to address stigma (A. C. Brown et al., 2022; Burke et al., 2019).
From a public health perspective, social media and the internet may be useful avenues for therapists to address broader perspectives and reduce the stigma associated with NSSI and subsequent scarring (Piccirillo et al., 2020). Evidence also suggests that educational or early intervention programs about NSSI and its consequences could target individuals who either do or do not self-harm as a means of reducing the risks of NSSI, future scarring, stigma, and shame (Burke et al., 2019; Piccirillo et al., 2020). One potential strategy to address stigmatising perceptions and behaviours is facilitating non-judgemental psychoeducational programs in school settings that can provide information about NSSI and the associated risk factors (Piccirillo et al., 2020). Moreover, psychoeducational programs with the potential to reduce stigma may subsequently promote help-seeking behaviour among those with histories of self-harm who may, or may not yet, have scars (Piccirillo et al., 2020). The results are supported by two commentaries, one particular to the overlooked role of NSSI scarring (Lewis, 2016) and another particular to stigma and the lived experience of NSSI (Hasking et al., 2022), as well as a recent review endorsing the use of a person-centred framework with individuals presenting with NSSI histories (Lewis & Hasking, 2021).
Literature Limitations and Directions for Future Research
This scoping review identified several limitations of the studies and gaps in the research, which may provide directions for future research. Although the evidence provides useful information particular to the psychosocial, quality of life, and recovery outcomes, as well as practice and care recommendations for individuals with NSSI scars, the studies did not tend to focus on this specifically; therefore, conducting future studies particular to the topics in question may strengthen the results of this scoping review. In particular, few studies reported the impacts on clinical and personal recovery, or discerned their differences, and the results from this scoping review indicate these are important aspects to consider given the unique nature of NSSI scar experiences, whether positive, negative (Bachtelle & Pepper, 2015; Chandler, 2014; Kristen et al., 2024), or at times ambivalent (Lewis & Mehrabkhani, 2016). Lewis’s (2016) commentary on the overlooked role of NSSI scarring and Lewis and Hasking’s (2021) recent review endorsing the use of a person-centred framework for individuals with histories of NSSI support the results and suggestions of this scoping review.
Furthermore, although population and scar characteristics were recorded in the studies, some studies did not report some of these characteristics. In general, the participants in the studies reviewed were predominantly white, heterosexual females. Therefore, this scoping review indicates the results are limited and cannot be generalised to all populations. The scoping review indicates that additional research to evaluate any similarities or differences associated with various demographics and aspects of culture is recommended. Additionally, owing to the lack of scar characteristics captured in most of the studies, which may hold implications for identifying risk to improve recovery support (Burke et al., 2016; Chandler, 2014), future research should include detailed reports on scar locations, the extent of scarring, and the methods of self-injury. This will enhance understanding of NSSI scarring and strengthen the results of this scoping review.
Moreover, considering the evidence indicates that some individuals struggle more with the stigma and shame associated with NSSI scars, while others may be more resilient (Bachtelle & Pepper, 2015; Chandler, 2014; Kendall et al., 2021; Kristen et al., 2024; Lewis & Mehrabkhani, 2016), future research exploring the intersections of population, scar characteristics, and the impacts of scarring may provide greater insight into the differing experiences. Incorporating an intersectional approach within therapeutic practice is essential for culturally appropriate and person-centred care (Ratts, 2017), which future research could consider. Additionally, while various methodologies were utilised in the studies reviewed, most were quantitative by design. Therefore, the results of this scoping review may be strengthened by additional qualitative or mixed methods research that further explores the unique experiences and impacts of NSSI scars on people who live with them.
Strengths and Limitations
To the author’s knowledge, this is the first scoping review to explore what is known about the psychosocial, quality of life, and recovery impacts, as well as care and practice recommendations, associated with self-harm scars. The results are therefore relevant for therapists supporting people with histories of self-harm who may have scars, as well as those currently self-harming who may be at increased risk of developing scars. Additionally, the results from this review can inform therapist education and practice, as well as provide avenues for future research particular to the experiences and needs of those with NSSI scars. Furthermore, this scoping review was guided by the methodological recommendations for scoping reviews outlined by the JBI (Peters et al., 2020) and PRISMA-ScR (Tricco et al., 2018), and thorough search strategies were developed and conducted in several databases to ensure the review captured relevant studies for screening and analysis. The scoping review presented empirical evidence on the possible psychosocial, quality of life, and recovery impacts on individuals with NSSI scars, which may have implications for practice, policy, and future research.
While this scoping review was limited to exploring empirical evidence, it is expected that future results gained from exploring the grey literature will support the current results. Additionally, while critical appraisal of the evidence was not performed for this review since it is not required for scoping reviews (Peters et al., 2020), it may be considered a limitation. This review may also have been limited by excluding papers for which there was no English version available. Given these limitations, the author notes that the results of this scoping review should be considered with caution, and that further research to validate the results is recommended.
Conclusion
While empirical research specifically associated with the psychosocial, quality of life, and recovery impacts of NSSI scars is limited, this scoping review provides insights into the potential experiences of individuals with NSSI scars that have implications for future practice and research. Psychosocial, quality of life, and recovery impacts, as found by this scoping review, tended to be bidirectional and reciprocal, whether positively or negatively experienced. Thus, it is suggested that therapists evaluate the unique psychosocial and quality of life experiences of individuals presenting with NSSI scars to better guide practice, while also being mindful of broader social discourses and personal biases that may affect the individual and therapeutic relationship.
Additionally, the needs of individuals with NSSI scars may vary, and many people with NSSI scars may not seek support specifically for scarring owing to adverse consequences such as stigma and shame. However, therapists could enhance person-centred care for individuals presenting with current or historical self-harm by assessing for NSSI scars and evaluating the intersecting psychosocial, quality of life, population, and scar characteristics that may perpetuate distress and affect personal or clinical recovery.
Besides being adept at applying psychological approaches to support individual needs—for example, utilising cognitive restructuring for unhelpful beliefs, graduated exposure for unpleasant memories, or compassion-focused acceptance and mindfulness approaches for struggles with shame and stigma—therapists may improve their practice by offering access to available medical or cosmetic scar interventions. Moreover, at a systemic level, it becomes an ethical responsibility of therapists to promote acceptance narratives, such as through online platforms, by facilitating psychoeducational and early intervention programs in settings like schools, for example, which may aid in deconstructing stigma and shame.
This scoping review highlighted possibilities for further research, such as exploring possible differences in the experienced impacts of NSSI scars within different cultural demographics and improving the evaluation of population and scar characteristics. Furthermore, future research could consider the intersecting impacts of population and scar characteristics on psychosocial experiences, quality of life, and outcomes of personal and clinical recovery. Exploring clinical and recovery outcomes for those who may have engaged support for NSSI scars may also be beneficial. This review also highlighted that additional qualitative or mixed methods research may strengthen the results.
Finally, this scoping review has presented the available published empirical evidence associated with the impacts of NSSI scars on psychosocial functioning, quality of life, and recovery. It is hoped this review might promote awareness and insight to support therapeutic practice and the implementation of public health or systemic interventions. It is also hoped this scoping review encourages avenues for further research to improve understanding and address the unique support and wellbeing needs of individuals who may be living with self-harm scars.