Author(s), year, country	Impacts on psychosocial functioning and quality of life	Impacts on clinical and personal recovery	Recommendations for clinical practice
Acikel et al. [y@384358] Turkey	Psychosocial and quality of life—Impacts on psychology, self-confidence, and self-esteem were noted, as were reduced activity and productivity in work and social domains due to concerns about scar appearance.	Clinical—No new act of self-harm occurred postoperatively except for one client with antisocial personality disorder who presented with new scars at one year follow-up. Personal—None reported.	Medical approaches to treat self-harm scars, such as surgical interventions, can camouflage scars that appear socially unacceptable to individuals. This can improve physical appearances of the scars, self-confidence, self-esteem, and motivation to engage in more social and work aspects of life.
Bachtelle and Pepper [y@384362] USA	Psychosocial and quality of life—n = 48 (98%) endorsed significance or meaning to their non-suicidal self-injury (NSSI) scars. n = 29 (60.4%) attributed stigma and shame to their scars. Individuals with higher shame levels were more likely to engage in future self-injury, experience clinical depressive and borderline symptoms, self-disgust, scar-related regret, scar-related rumination, and attempts to avoid or reduce scar appearances. Growth interpretations (e.g., NSSI scars as markers of strength, overcoming adversity, regret over past NSSI rather than the NSSI scarring) of NSSI scars were associated with reduced levels of self-disgust, scar-related regret, and future NSSI. Growth interpretations of NSSI scars did not correlate with clinical symptoms and were associated with less overall scar-related distress.	Clinical and personal—Individuals who experience shame and stigma associated with their NSSI scars may be more clinically impacted than those who find strength or growth from their scars. Shame affected both personal and clinical recovery and was associated with increased likelihood of future NSSI and clinically depressive and borderline symptoms, especially with negative scar-related rumination present.	Exploring the significance and psychological impact of self-harm scars may increase therapist understanding to help individuals reduce future NSSI and improve scar acceptance. Utilising therapeutic strategies to address negative perceptions and shame from NSSI scars was suggested to reduce negative emotions, depressive symptoms, self-disgust, and ruminative thoughts about future NSSI. Mindfulness and acceptance strategies were suggested to promote self-compassion towards previous NSSI and scarring. Supporting clients to accept NSSI scars may be an important aspect of therapy.
A. C. Brown et al. [y@384366] UK	Psychosocial and quality of life—Participants felt the need to conceal scars owing to shame, perceiving them as socially unacceptable to others.	Clinical and personal—Shame affected both personal and clinical recovery and was associated with reoccurrence of NSSI behaviour in individuals with or without scars. Struggles with recovery were associated with difficulty accepting scars as a result of perpetuating stigma and shame.	Addressing shame was identified as a key concept to consider in therapy for individuals with NSSI and participants with self-harm scars. Compassion-focused therapy or relational therapies, such as cognitive analytic therapy, were suggested. Systemic approaches to address associated stigma may be beneficial.
Burke et al. [y@384371] USA	Psychosocial—Over 63% of individuals with NSSI scarring endorsed at least one cognition loading on the social factor associated with shame and stigma on the Non-Suicidal Self-Injury Scar Cognition Scale (NSSI-SCS; [b@384371]). Approximately 50% endorsed at least one positive cognition about their scars. 79% endorsed scar cognitions loading on reminders of past negative experiences. Feeling unique was associated with positive (e.g., attainment of a desired identity) or negative (e.g., lack of belonging) perceptions.	Clinical and personal—Individuals who endorsed items of weakness on the NSSI-SCS [@384371] may experience feeling weak regarding their ability to handle stress and be at increased risk of repeat NSSI. Individuals feeling hopeless, stuck, and suicidal because of their NSSI scarring were significantly more likely to experience suicidal ideation.	The NSSI-SCS [@384371] has the potential to enhance the ability of clinicians, therapists, and researchers to assess a range of NSSI scar-related cognitions, as well as their clinical correlates, informing both assessment and intervention.
Burke et al. [y@384368] USA	Psychosocial and quality of life—Participants concealed scars from both themselves and others at least some of the time. Frequency of scar concealment from the self and others was significantly associated with negative NSSI scar-specific beliefs, such as fear of judgement and embarrassment, and psychological distress, such as depression, anxiety, and recent NSSI urge severity.	Clinical—Frequency of scar concealment from self and others was significantly associated with recent NSSI urge severity. Personal—Frequency of scar concealment from self and others was significantly associated with negative NSSI scar-specific beliefs, such as fear of judgement and embarrassment, and psychological distress, such as depression, anxiety, and recent NSSI urge severity.	Psychological interventions targeting NSSI scarring, negative scar-specific beliefs, concealment practices, and acceptance may not only be sought by individuals with scars but also aid in NSSI remission. Acceptance and mindfulness strategies were suggested as beneficial for addressing shame, as were cognitive restructuring techniques to support more balanced beliefs about NSSI history and current scarring. Graduated exposure strategies were recommended to increase tolerance and coping.
Burke et al. [y@384369] USA	Psychosocial and quality of life—Presence and number of NSSI scars predicted current suicidal ideation and suicide attempt history, which was more strongly associated with greater levels of brooding. Individuals with NSSI scars reporting lower levels of brooding were at reduced risk of suicidal ideation.	Clinical and personal—Presence and number of NSSI scars predicted current suicidal ideation and a history of suicide attempts, which were linked to higher levels of brooding. Individuals with NSSI scars reporting lower levels of brooding were at reduced risk of experiencing current suicidal ideation.	Assessing presence and number of scars is important to evaluate suicide-related risk. Therapy interventions to address ruminative brooding may increase resilience to suicidal ideation and behaviour. Rumination-focused cognitive behavioural therapy was suggested to assist with brooding.
Burke et al. [y@384370] USA	Psychosocial and quality of life—NSSI scars may be associated with increased suicide risk.	Clinical—NSSI scars may be associated with increased suicide risk.	NSSI functions, scarring, and medical lethality may be more important to assess than NSSI severity indices when evaluating suicide risk.
Burke et al. [y@384372] USA	Psychosocial and quality of life—Overall acceptance of unintentional disfigurement or tattoos and rejection of NSSI scars by individuals without NSSI history was noted. There was a greater perception of NSSI scars being bad than good, being dangerous than safe, and being rejected than accepted in individuals without NSSI history. Participants without scars were less likely to engage in sexual or non-sexual interactions with people with NSSI histories and scars. Women without NSSI histories tended to be more accepting of sexual or non-sexual interactions with people with NSSI histories and scars.	Not reported.	Educational programs about NSSI and impacts may be helpful for populations with and without NSSI history/scars in reducing implicit and explicit bias associated with perpetuating stigma and shame.
Chandler [y@384374] UK	Psychosocial and quality of life—All participants were concerned about the perceptions of others. Some associated NSSI scars with disgust, hopelessness, social anxiety, and a desire to hide them, noting that they may increase the likelihood of re-engaging in NSSI.	Clinical and personal—Some participants associated NSSI scars with disgust, hopelessness, social anxiety, and a desire to hide them, noting that they may increase the likelihood of re-engaging in NSSI. Others associated their scars with hope and acceptance, viewing them as reminders of having overcome challenges and the need to avoid re-engaging in NSSI.	Attending to the diverse ways in which scars are experienced was highlighted as an important aspect of compassionate clinical practice.
Dyer et al. [y@384379] Germany	Psychosocial—NSSI scars led to negative body image.	Not specifically reported; however, scars were found to lead to negative body image, which may increase risk of further harm.	Addressing NSSI early in treatment may help reduce scarring that might otherwise exacerbate existing negative body image.
Dyer et al. [y@384380] Germany	Psychosocial—Women with scars tended to experience greater negative body image than men; men with NSSI scars also experienced negative body image.	Not reported.	Assessment of body image disturbances among individuals with NSSI and support to reduce NSSI behaviour and possible scarring was recommended.
Gutridge et al. [y@384386] UK	Psychosocial and quality of life—Women reported embarrassment and lack of confidence, especially around unknown people, wished scars would go away, and noted that scars were reminders of bad times in life. Women felt less embarrassed in prison settings since many other women had NSSI scarring. Women were concerned about negative judgement and the perceptions of others; they wanted to cover scars in most social situations. Negatively influencing youth was also of concern. Covering scars was functional for reducing concerns.	Clinical and personal—NSSI scars increased risk of re-engaging in NSSI. Women expressed that less noticeable scars would aid NSSI recovery.	Medical skin camouflage may help female prisoners with NSSI recovery and wellbeing.
Kendall et al. [y@384393] UK	Psychosocial and quality of life—Two prevalent themes were identified: temporal aspects of identity, and social stigma and scars. The impact of scarring was prevalent in social and personal life and affected self-perspectives. Experienced stigma was prominent. Scars commonly evoked unpleasant memories, emotional pain, and struggles with self-acceptance, mental illness, healing, and surviving. To avoid stigma and shame and support wellbeing, social functioning, clothing, relationships, and careers were altered.	Clinical and personal —Some narratives were associated with resisting shame and allowing scars to be visible as a means of dismantling stigma. Others reported scars evoked unpleasant memories, emotional pain, and struggles with self-acceptance, mental illness, healing, and surviving. Experiencing stigma was prominent.	Tattoos may change the narrative associated with scars and help recovery. Addressing stigma and supporting individuals towards self-acceptance was suggested.
Kristen et al. [y@384396] UK	Psychosocial and quality of life—Two paradoxical impacts of scars were identified as being shameful and stigmatising, or as validating suffering. Participants expressed self-hate, negative body image, low self-esteem, and lack of self-efficacy due to the stigma and shame of their scars. Participants tended to navigate unpleasant impacts by concealing scars, or by associating validation of their mental health difficulties with the meaning of their scars.	Clinical and personal—Challenges were associated with the impact of stigma and shame on recovery. Some participants described their scars positively as validating their distress.	Therapist awareness of adolescent use of descriptions of self-harm behaviours and scars (shameful and stigmatising or validating of suffering) within therapy may support treatment and recovery. Therapists should consider the broader social context of NSSI scars when supporting clients.
Lewis and Mehrabkhani [y@384402] Canada	Psychosocial and quality of life—Four dominant themes were associated with perceptions of scars: as part of positive or negative self-narratives (either shame or strength of overcoming challenges), non-acceptance of scars (disgust and shame), accepting scars as a process, and ambivalence towards scars (okay if concealed or when alone, and concern about perceptions of others). Shame tended to hinder scar acceptance and recovery and also contributed to ambivalence about perceptions of scars.	Clinical and personal—Shame hindered scar acceptance and recovery. It also contributed to ambivalence about perceptions of scars.	Discussing the role of scars in NSSI assessment and intervention is important. For clients with visible or noticeable scars, supporting the processing of scar-related emotions and thoughts is necessary. Shame was identified as a barrier to NSSI scar acceptance; therefore, it may be important to address shame in therapy.
Mutamba et al. [y@384406] Canada	Psychosocial and quality of life—Participants identified feelings of discomfort and a sense of unbelonging, as well as anger, grief, and numbness; self-consciousness of scars, concerns about assumptions of others, avoiding activities due to concerns about exposing scars; and concerns about how NSSI scars would affect careers, relationships, and other areas of life.	Clinical—Not reported. Personal—Scars tended to affect personal recovery, as noted in the reported psychosocial and quality of life impacts; however, this was not explicitly noted in the study.	To improve personalisation of care, therapists should consider how the social circumstances of youth presenting with embodied expression (self-harm) might be affected.
Myung et al. [y@384407] Korea	Psychosocial and quality of life—The study suggested that the Korean sample may experience more negative cognitions related to NSSI scars, which could contribute to emotional and clinical difficulties, compared with the Burke et al. [y@384371] study.	Not reported.	The Korean version of the Multidimensional Non-Suicidal Self-Injury Scar Scale [@384407] will be useful for understanding cognitive and psychosocial impacts in future research in relation to clinical practice.
Piccirillo et al. [y@384417] USA	Psychosocial and quality of life—Individuals with and without prior NSSI both associated NSSI behaviour with negative attributes compared with positive attributes in both implicit and explicit tests. Individuals with NSSI history had fewer negative associations than those without NSSI. Lower explicit bias correlated with history of more severe NSSI, but not implicit bias. Participants with history of NSSI had more negative attitudes towards NSSI and were less likely to engage in relationships than those without NSSI history.	Clinical and personal—Stigma is associated with adverse impacts on clinical and personal recovery.	The researchers suggested addressing the stigma of NSSI and scars to improve support, recovery, and disclosure for individuals with NSSI or NSSI scars. Public health approaches, such as psychoeducation, may be useful to address stigma associated with NSSI scars.
Reinholz et al. [y@384420] Germany	Quality of life—Differences in the impact on quality of life between different scar types were identified. The strongest impacts were attributed to self-harm scars and associated stigma.	Not reported.	Knowledge of the impact on quality of life of different scar types may be crucial for treatment and prevention, and treating scars may improve quality of life.
Stacy et al. [y@384425] USA	Psychosocial and quality of life—Compared with the environmentally inflicted scar group, participants in the NSSI scar group were more likely to interpret scars as reminders of having overcome adversity and avoided foolish choices; they were also more likely to associate stigma or shame with scars. The NSSI group showed greater attention to their scars than did the environmental group, engaged in more scar-related behaviours, and used their scars for specific purposes. Individuals in the NSSI group prioritised observing, thinking about, noticing, touching, rubbing, or reducing the appearance of their scars, and concealing their scars from others. The NSSI group focused on their scars more when stressed than did the environmental group and reported scars may increase risk of re-engaging in self-harm.	Clinical—Compared with the environmental scar group, the NSSI scar group reported actively attending to scars more when stressed and that scars may increase risk of re-engaging in self-harm. Personal—Compared with the environmental scar group, individuals in the NSSI group were more likely to interpret their scars as reminders of having overcome adversity and avoided foolish choices; they were also more likely to associate stigma or shame with scars.	Implications for practice were not specifically reported.