What is the relationship between rejection and self-harm or suicidality in adulthood?

A systematic review of interpersonal processes and their measurement within experience sampling studies of self-injurious thoughts and behaviours

Self-injurious thoughts and behaviours (SITBs) are a leading cause of death, and interpersonal processes (IPs) appear to play a role in SITBs. This systematic review synthesises the literature on IPs and SITBs in daily life and addresses four critical questions: (1) Which IPs have been assessed and how, (2) How are differences in IPs between individuals associated with SITBs?, (3) How are differences in IPs within individuals associated with SITBs? and (4) Do IPs relate differently to self-injurious thoughts than behaviours? Our review followed PRISMA guidelines and eligible literature was screened until 25 April 2024. We identified 58 Experience Sampling studies (32.76% daily-diary studies) of which most focused on IPs from major SITBs theories (e.g., thwarted belongingness) but largely used inconsistent operationalizations. Results from 39 studies investigating within-person associations were mixed. Based on 26 studies, whether differences in IPs between individuals relate to SITBs remains unclear. Three studies have investigated whether IPs relate to the transition from thoughts to behaviours, but temporal models are needed to draw firm conclusions. Studies investigating IPs and SITBs in daily life are largely inconclusive. Psychometrically validated measures are warranted, and future daily-life studies would benefit from drawing on ideation-to-action frameworks.

Do measures of social support and social distress share general factors associated with suicidal ideation and attempts?

INTRODUCTION

Aspects of social relationships have variably been associated with suicidal ideation (SI) and suicide attempts (SAs). This study assessed whether social support and social distress measures have general factors versus measure-specific factors that are associated with suicide risk.

METHODS

Adults (N = 455, 60.0% female), admitted to psychiatric inpatient units following a recent suicide attempt or active SI, completed assessments of social support (emotional support, instrumental support, friendship, perceived support from significant others, friends, family) and social distress (loneliness, perceived rejection, perceived burdensomeness, thwarted belongingness). Bifactor modeling examined general and specific factors of social support and distress in relation to SI (week prior to hospitalization, via the Beck Scale for SI) and SAs (past 30 days, via the Columbia Suicide Severity Rating Scale).

RESULTS

SI was significantly associated with the general social support (B = -1.51), the general social distress (B = 1.67), and the specific perceived burdensomeness (B = 1.57) factors. SAs were significantly associated with the specific Perceived Rejection (OR = 1.05) and Thwarted Belongingness (OR = 0.91) factors.

CONCLUSION

General social support and social distress were associated with SI but not recent SAs. Specific social distress factors were also related to SI and SAs controlling for general social distress, suggesting areas for future interventions.

A Brief Cognitive Analytic Therapy-Informed Approach for Young People That Have Self-Injured (CATCH-Y): A Case Series

BACKGROUND

Non-suicidal self-injury (NSSI) presents an increasingly prevalent problem for young people; however, there remains a scarce evidence base for effective, scalable treatments for adolescents. This study aimed to assess the feasibility and acceptability of a brief, cognitive analytic therapy (CAT)-informed intervention for young people who engage in NSSI (CATCH-Y).

METHODS

A case series design recruited 13 young people who met the inclusion and exclusion criteria to participate in the five-session intervention. Eligible participants were aged 13-17 years (M = 15.15, SD = 1.28) and had engaged in NSSI at least once in the previous 6 months. Feasibility and acceptability were measured via recruitment, retention, qualitative feedback and missing data. The secondary outcome measures of personal recovery and motivation were administered pre- and post-assessment, with measures of depressive symptoms and urges to self-injure.

RESULTS

The intervention was found to be largely feasible and acceptable with high rates of recruitment, retention and pre-/post-assessment data completeness. Measures showed preliminary support for positive change in rates of NSSI, urges to self-harm, low mood and personal recovery, although results were mixed. Completion rates for remote assessments were low.

CONCLUSIONS

The findings of this study support further evaluation of the CATCH-Y intervention on a larger scale. In-person assessments may be preferable to remote to ensure good completion rates.

Relations between discrimination, rejection sensitivity, negative affect, and decrements in problem-solving ability following social rejection: An experimental investigation

INTRODUCTION

While negative affect and problem-solving deficits have been consistently linked to suicidal thoughts and behaviors, the latter are often conceptualized and studied as time- and/or context-invariant. Though requiring additional empirical support, theory suggests that discrimination may strengthen the relation between rejection sensitivity and increases in negative affect as well as declines in problem-solving abilities following rejection. The aim of the current study was to test this claim using a social rejection paradigm (i.e., Cyberball) with young adults experiencing past-month suicidal ideation.

METHODS

The sample consisted of 50 participants. Lifetime discrimination and rejection sensitivity were assessed prior to Cyberball. Negative affect and problem-solving abilities were assessed pre- and post-Cyberball. SPSS and the PROCESS macro were used to test relations among variables of interest.

RESULTS

Rejection sensitivity predicted greater problem-solving decrements, but not negative affect, following rejection among individuals who had experienced higher (vs. lower) levels of lifetime discrimination.

CONCLUSION

Addressing rejection sensitivity and sources of discrimination within the context of treatment may reduce the impact of social rejection on problem-solving abilities among young adults at risk for suicide.

Facets of social problem-solving as moderators of the real-time relation between social rejection and negative affect in an at-risk sample

Social rejection predicts negative affect, and theoretical work suggests that problem-solving deficits strengthen this relation in real-time. Nevertheless, few studies have explicitly tested this relation, particularly in samples at risk for suicide. This may be particularly important as social rejection and negative affect are significant predictors of suicide. The aim of the current study was to examine whether cognitive (i.e., perceiving problems as threats) and behavioral (i.e., avoidance) facets of problem-solving deficits moderated the real-time relation between social rejection and negative affect. The sample consisted of 49 young adults with past-month suicidal ideation. Demographic information, social problem-solving deficits, as well as depressive/anxiety symptoms and stress levels were assessed at baseline. Social rejection and negative affect were assessed using ecological momentary assessment over the following 28 days. Dynamic structural equation modeling was used to assess relations among study variables. After accounting for depressive/anxiety symptoms, stress levels, sex, and age, only avoidance of problems bolstered the real-time positive relation between social rejection severity and negative affect (b = 0.04, 95% credibility interval [0.003, 0.072]). Individuals with suicidal ideation who possess an avoidant problem-solving style may be particularly likely to experience heightened negative affect following social rejection and may benefit from instruction in problem-solving skills.

Social stressors, emotional responses, and NSSI urges and behaviors in daily life

BACKGROUND

The defective self model of nonsuicidal self-injury (NSSI) theorizes that individuals who are highly self-critical are more likely to choose NSSI to regulate emotions. This model indirectly suggests that individuals who engage in NSSI may experience more self-conscious emotions in response to negative social feedback, increasing risk for near-term NSSI. This study examined (1) whether individuals with a history of NSSI (vs. without) display greater self-conscious and negative emotional reactions to daily social stressors, and more problematic features of these daily social stressors, and (2) whether greater-than-usual negative emotional reactions and social stressor features predict NSSI urges and behaviors in daily life.

METHODS

Participants were 134 female college students with recent, recurrent NSSI (n = 77) or no NSSI history (n = 57). Participants completed baseline measures of socioemotional functioning and a two-week daily diary protocol.

RESULTS

The NSSI (vs. no NSSI) group reported significantly greater self-conscious and negative emotional reactions to daily social stressors, and social stressors characterized by greater dysfunction. In the NSSI group, experiencing social stressors characterized by greater distress than one's average during the daily diary period was associated with same-day NSSI urges and behavior, greater confusion than one's average predicted same-day NSSI urges, and greater conflict than one's average predicted same-day NSSI behavior. Greater self-conscious and negative emotional reactions to these stressors than one's average predicted same-day NSSI urges and behavior.

LIMITATIONS

Limitations include reliance on self-report, a once-daily assessment, and lack of generalizability to other samples.

CONCLUSIONS

Interpersonal conflict and increased self-conscious emotions pose vulnerability for NSSI. Prevention and intervention efforts would benefit from including a focus on interpersonal functioning.

Interpersonal stress and nonsuicidal self-injury disorder in veterans: An ecological momentary assessment study

INTRO

Nonsuicidal self-injury (NSSI) is associated with marked functional impairment and is a robust predictor of suicide attempts. Prevalence rates of NSSI, and self-directed violence more broadly, are elevated among military veterans. Despite the inclusion of interpersonal difficulty in the diagnostic criteria for NSSI disorder, the relationship between interpersonal risk factors and NSSI is not well-characterized, especially among veterans. This ecological momentary assessment (EMA) study investigated the hypothesis that interpersonal stressors and associated distress would precede and predict NSSI urge and engagement-but not vice versa-via cross-lagged multilevel modeling.

METHOD

Forty veterans with NSSI disorder completed a 28-day EMA protocol with three daily prompts assessing NSSI urges, NSSI engagement, the occurrence of interpersonal stressors, and associated subjective interpersonal distress.

RESULTS

Interpersonal stressors preceded and predicted subsequent NSSI urges, but not NSSI engagement, whereas subjective interpersonal distress preceded and predicted both NSSI urges and NSSI engagement.

CONCLUSION

Results identified interpersonal stressors as a risk factor for NSSI urges, and interpersonal distress as a risk factor for both NSSI urges and NSSI engagement. Findings highlight the importance of temporally assessing interpersonal factors related to NSSI and suggest that interpersonal distress may be a modifiable risk factor for NSSI.

Sensory emotion regulation

Decades of evidence reveal intimate links between sensation and emotion. Yet, discussion of sensory experiences as tools that promote emotion regulation is largely absent from current theorizing on this topic. Here, we address this gap by integrating evidence from social-personality, clinical, cognitive-neuroscience, and animal research to highlight the role of sensation as a tool that can be harnessed to up- or downregulate emotion. Further, we review evidence implicating sensation as a rapid and relatively effortless emotion regulation modality and highlight future research directions. Notably, we emphasize the need to examine the duration of sensory emotion regulation effects, the moderating role of individual and cultural differences, and how sensory strategies interact with other strategies.

Self-harm in secure settings: Exploring the lived experiences of people who self-harm in secure hospitals

Globally, an increasing number of people who Self-Harm (SH) are being treated in mental health hospitals. Incidences of SH are common in secure hospitals, with those using the behaviour being highly dependent on staff for care and support but impacting on often limited resources. While literature related to the lived experiences of people who SH exists, this is in its infancy in African countries. The aim of this study was to explore the lived experiences of people who SH in two secure mental health hospitals in Ghana. Interpretive Phenomenological Analysis (IPA) was used to explore the experiences of people who SH in two secure mental hospitals in Ghana. A convenience sample of nine participants were recruited and face-to-face in-depth semi structured interviews were used to collect data. With the permission of each participant, all interviews were audio recorded and notes were made by the researcher (first author). Each interview was transcribed and analysed using the IPA seven-step approach, with three superordinate and 11 subordinate themes being identified. The superordinate themes were: Being let down; Living with the negative self; Forces of the supernatural and religion. Findings demonstrate that there is a need to develop a collaborative health care package if appropriate care and support is to be offered to people in secure settings who use high-risk behaviours, such as SH. To ensure care is holistic, culturally, and temporally relevant research is needed, particularly in Sub-Saharan Africa.

A systematic review of the co-occurrence of self-harm and aggression: Is dual harm a unique behavioural construct?

Introduction

Dual harm is the co-occurrence of self-harm and aggression during an individual's lifetime. It is unclear whether sufficient evidence exists for dual harm as a unique clinical entity. This systematic review aimed to examine whether there are psychological factors that are uniquely associated with dual harm when compared to those who have engaged in sole harm (self-harm alone, aggression alone) and no harmful behaviours. Our secondary aim was to conduct a critical appraisal of the literature.

Methods

The review searched PsycINFO, PubMed, CINAHL, and EThOS on September 27, 2022, resulting in 31 eligible papers that represented 15,094 individuals. An adapted version of the Agency for Healthcare Research and Quality was used to assess risk of bias and a narrative synthesis was conducted.

Results

The included studies assessed differences in mental health problems, personality, and emotion related factors between the different behavioural groups. We found weak evidence that dual harm is an independent construct with unique psychological characteristics. Rather, our review suggests that dual harm results from the interaction of psychological risk factors that are associated with self-harm and aggression.

Discussion

The critical appraisal identified numerous limitations within the dual harm literature. Clinical implications and recommendations for future research are provided.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=197323, identifier CRD42020197323.

Comparison of Lifetime Suicide Attempts and Recent Suicidal/Self-Harming Thoughts Among Sexual Minority and Heterosexual Utahns: Results from a Population-Based Survey

OBJECTIVE

We sought to be the first published article to report differences in population-representative prevalence of suicidal thoughts and attempts by sexual orientation.

METHOD

Data from Utah's Behavioral Risk Factor Surveillance System (BRFSS) collected for 2016 (N = 10,988) and 2017 (N = 10,251) were examined to determine differences in the prevalence of suicidal thoughts in the past 2 weeks and the lifetime prevalence of suicide attempts (i.e., any, single, and multiple) by sexual orientation.

RESULTS

3.5% of heterosexuals Utahns reported recent suicidal/self-harming thoughts in the last 2 weeks compared to 14.7% of LGB Utahns (OR = 4.73 95% CI [2.67, 8.36]). 5.8% of heterosexuals reported a lifetime prevalence of any suicidal attempts compared to 37.2% of LGB folx (OR = 9.58 95% CI [7.16, 12.81]) with similar differences occurring for single and multiple attempts. Comparing LG versus B, there was no difference in ideation or prevalence of any attempt, but bisexuals reported higher rates of multiple suicide attempts.

CONCLUSION

LGB folx in Utah are drastically more likely to have thought about suicide/self-harming in the last 2 weeks and to have attempted suicide in their lifetime when compared to heterosexuals in Utah.

The relevance of the interpersonal theory of suicide for predicting past-year and lifetime suicidality in autistic adults

Background

While there are known risk factors for suicidality in autistic adults, these are often unconnected from theoretical frameworks that might explain why risk is elevated and guide clinical interventions. The present study investigated the relevance of constructs from the Interpersonal Theory of Suicide (ITS), including perceived burdensomeness, thwarted belongingness and acquired capability for suicide, and explored mechanisms through which certain risk factors (relationship status, age at diagnosis) might elevate suicide risk.

Methods

Autistic adults (n = 314) completed an online study including measures of depression, anxiety and constructs from the ITS. Linear and multinomial regression analysis disentangled contributions of ITS variables from effects of depression and anxiety for past-year suicide ideation, past-year and lifetime suicide attempts. Mediation analyses examined associations between risk factors and these suicide outcomes via mechanisms proposed by the ITS.

Results

Past-year suicide ideation was associated with burdensomeness, mental rehearsal of suicide plans (a facet of acquired capability), and depression. Greater feelings of burdensomeness, and reduced fear of death, marked out participants who had attempted suicide in comparison to those who had experienced suicide ideation in the past year. Relationship status was indirectly associated with past-year suicide ideation via the mediators of depression and burdensomeness, and was associated with past-year attempts via its effect on ideation. Age at diagnosis was unrelated to any variables.

Limitations

Cross-sectional research is insensitive to causality and temporal dynamics, which is likely why interaction hypotheses from the ITS were unsupported. Normative measures may be invalid in autistic samples. There was no control group. The autistic sample was unrepresentative of the whole population, particularly autistic people with intellectual disabilities, ethnic/racial minorities, and gender minorities.

Conclusions

Perceived burdensomeness and acquired capability appear potentially important to suicide in autistic people, and may mediate the effects of some risk factors. Future research should explore the temporal dynamics of suicide trajectories in longitudinal, prospective designs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13229-022-00495-5.

Psychological pain and suicidal behavior: A review

Despite accumulation of clinical research on risk factors for suicidal process, understanding of the mechanisms and pathways underlying the emergence of suicidal thoughts and their progression to acts is insufficient. The suicidal process has been conceptualized in multiple psychological theories that have aimed to shed light on the interplay of contributing factors. One of the central concepts included in both the cubic model of suicide and the three-step theory of suicide is psychological pain (mental pain or psychache). Over the two last decades, interest in psychological pain has increased considerably, particularly since the discovery of the complex link between the pain processing system and the neurobiology of suicide, and the putative antisuicidal effect of buprenorphine. Growing evidence supports the association between experiencing psychological pain and suicidal ideation and acts in both clinical and non-clinical samples. However, many questions related to the concept of psychological pain and its role in prediction of suicidal behavior remain to be answered in future research. In this narrative review, we have outlined the history of the concept, the definition of psychological pain, and the tools developed for its measurement, summarized the empirical research on psychological pain in relation to suicidal behavior, and suggested future directions for clinical research on psychological pain and suicidal behavior.

An experimental examination of interpersonal problem-solving in nonsuicidal self-injury: A pilot study

Nonsuicidal self-injury (NSSI) typically occurs in the presence of negative emotions. Prior research has emphasized interpersonal stress as a specific context that may elevate negative emotions in this population and even increase the likelihood of NSSI behavior. However, the factors that contribute to the relationship between interpersonal stress and NSSI have received relatively limited attention. The current pilot study aimed to experimentally examine interpersonal problem-solving as a potential moderator of the interpersonal stress - NSSI risk relationship among those with a NSSI history. Eighty-six participants (52.3% with NSSI history) were randomly assigned to one of three mood induction conditions (interpersonal negative, general negative, interpersonal neutral), after which they completed an interpersonal problem-solving task and a laboratory analogue of self-injurious behavior. Results indicated that NSSI history was associated with poorer interpersonal effectiveness. Further, individuals with a history of NSSI who experienced an interpersonally-focused negative mood and produced less effective interpersonal solutions were more self-harming on a laboratory analogue of self-injurious behavior. While the present findings are preliminary in nature, they offer guidance for research moving forward and, if replicated, suggest interpersonal problem-solving as a potential treatment target among individuals engaging in NSSI.

The interpersonal processes of non-suicidal self-injury: A systematic review and meta-synthesis

BACKGROUND

Understanding the processes underlying non-suicidal self-injury (NSSI) is important given the negative consequences of this behaviour. Qualitative research has the potential to provide an in-depth exploration of this. There has been limited research regarding the interpersonal processes associated with NSSI; therefore, a meta-synthesis was conducted to investigate this.

METHODS

A search of PsycINFO, MEDLINE, Web of Science, and CINAHL electronic databases from date of inception to November 2020 was conducted. In total, 30 papers were included in the final review. A meta-ethnographic approach was utilized to synthesize the data.

RESULTS

Two overarching themes were found. Within 'Powerful relational dynamics', NSSI was cited as a response to participants becoming stuck in aversive or disempowering relational positions with others. Within the 'Taking matters into their own hands' subtheme, NSSI was reported as a way for participants to get interpersonal and emotional needs met.

LIMITATIONS

Several included papers did not comment on the researcher-participant relationship, which may have affected qualitative results. A small number of potentially eligible papers were unavailable for synthesizing.

CONCLUSION

Findings provide a more nuanced investigation of the interpersonal processes underlying NSSI. Consistent with relevant theories, NSSI appears to be a way of mitigating difficult interpersonal experiences or getting interpersonal needs met. NSSI may be engaged in as a substitute to other, less damaging ways to cope. An argument is made for a more empathetic understanding of NSSI and the use of relational interventions.

PRACTITIONER POINTS

Self-injury may occur in response to interpersonal stressors Self-injury can be a means to get interpersonal needs met Self-injury may replace other means of coping that become blocked or thwarted Emotional distress can be closely linked with interpersonal factors for this group Relational therapies may be beneficial where interpersonal processes are linked to NSSI.

Does neighbourhood identification buffer against the effects of socioeconomic disadvantage on self-harm?

BACKGROUND

Socioeconomic disadvantage and lack of group belonging (i.e., social identity) have been linked to poor mental health. However, no research has investigated the relationship between neighbourhood identity and self-harm, nor whether identifying with one's neighbourhood can mitigate the effects of economic stress on self-harm.

METHODS

Pre-registered secondary data analysis of a large (N = 3412) community health survey conducted in disadvantaged areas of North West England.

RESULTS

Despite the sample having a relatively high and therefore restricted level of disadvantage, individual and geographic indicators of disadvantage, as well as neighbourhood identification, were unique and strong predictors of self-harm thoughts and behaviours across several analyses. Specifically, experiencing disadvantage and disidentification predicted significantly higher odds of self-harm and self-harm thoughts. No consistent interactive effects emerged.

LIMITATIONS

The cross-sectional design limits firm conclusions regarding causal effects of neighbourhood identity and disadvantage on self-harm. However, causal direction is supported by past research and theory. The data is self-report, which is subject to response bias. The sample was also recruited from a region of the UK with low numbers of residents from ethnic minority backgrounds.

CONCLUSIONS

The results are consistent with past research indicating an association between social identity and better mental health, but for the first time extend these effects to self-harm. The findings demonstrate the importance of considering social and economic factors when attempting to prevent suicide and understand and treat self-harm thoughts.

Rejection sensitivity and adolescent non-suicidal self-injury: Mediation through depressive symptoms and moderation by fear of self-compassion

OBJECTIVES

Rejection sensitivity is a risk trait that contributes to the relationships between rejection experiences in various domains and non-suicidal self-injury (NSSI). However, research about the association between rejection sensitivity and NSSI has still been understudied. This study sought to examine the mediating role of depressive symptoms and the moderating role of fear of self-compassion in the association between rejection sensitivity and adolescent NSSI.

DESIGN

A cross-sectional correlational design was employed through which rejection sensitivity, depressive symptoms, fear of self-compassion, and NSSI experiences in the past year were measured.

METHODS

Seven-hundred twenty-eight Chinese secondary school students (51.1% females; mean age = 14.07, SD = 0.75) were included by convenient sampling.

RESULTS

Regression analyses revealed that depressive symptoms worked as a mediator in the association between rejection sensitivity and NSSI. It was also found that fear of self-compassion acted as a moderator, such that a higher level of fear of self-compassion strengthened the link between rejection sensitivity and depressive symptoms and the direct link between rejection sensitivity and NSSI.

CONCLUSIONS

These findings highlight the need to address adolescents' rejection sensitivity, depressive symptoms, and fear of self-compassion in preventing and intervening NSSI.

PRACTITIONER POINTS

Focusing on rejection sensitivity might help understand the relationships between intra- and interpersonal distress and NSSI. The findings of this study evidenced the risk effect of adolescents' rejection sensitivity on NSSI and the partial mediation of depressive symptoms in the link. Targeting adolescents' rejection sensitivity will be beneficial in developing NSSI-related prevention and intervention programs. This study also found that adolescents' fear of self-compassion magnified the associations between rejection sensitivity, depressive symptoms, and NSSI. It suggests that targeting adolescent's fear of self-compassion will also be beneficial.

Pilot service evaluation of a brief psychological therapy for self-harm in an emergency department: Hospital Outpatient Psychotherapy Engagement Service

BACKGROUND

Brief psychological therapies may be helpful for people who have recently self-harmed. The current paper reports on a service evaluation of a novel brief therapy service based within an Emergency Department, Hospital Outpatient Psychotherapy Engagement (HOPE) Service. This service combines elements of psychodynamic interpersonal and cognitive analytic therapy to help people who present with self-harm-related difficulties. The primary aim of this service evaluation was to ascertain the feasibility of HOPE in terms of attendance rates. The study also examined variables associated with engagement, and change over time in psychological distress for those attending the service.

METHOD

The HOPE service was evaluated over a ten-month period. Consenting patients completed measures of psychological distress and working alliance across four therapy sessions and one follow-up session. Measures of emotion regulation style and self-harm function were also completed at the point of referral.

RESULTS

Eight-nine patients were referred to the service (83 eligible referrals). Fifty-three (64%) attended at least one therapy session. Baseline variables did not distinguish people who attended and people who did not. Psychological distress decreased significantly across the sessions. Most people reported a good working alliance with their therapist.

CONCLUSIONS

The results of this service evaluation support the feasibility of the HOPE service, demonstrating good engagement rates given the complexity of the population and context. Whilst there was evidence of reductions in distress, randomized controlled trials are needed to determine if HOPE has clinical efficacy.

PRACTITIONER POINTS

Rates of engagement with HOPE suggest the service is feasible in an Emergency Department context Working alliance scores were positive for the majority of patients The HOPE service shows promise as a brief intervention for people who self-harm but requires further evaluation Randomized controlled trials are needed to determine the clinical efficacy of the HOPE service.

Suicidality: An Evolutionary Concept Analysis

Suicide is a preventable health problem. Multiple definitions and inconsistent use of the term suicidality can result in failure to properly recognize suicide risk and behavior and confuses suicide research. Clarification of the suicidality concept is needed to facilitate the care for individuals at risk for suicide. Using Rodgers' evolutionary concept analysis method, this analysis describes the breadth and scope of the suicidality concept. Findings indicate suicidality covers a spectrum of suicidal risk and levels of emotional suffering and intent. The analysis does not draw definite conclusions, but outlines a direction for further research.

Social rejection, popularity, peer victimization, and self-injurious thoughts and behaviors among adolescents: A systematic review and meta-analysis

Self-injurious thoughts and behaviors (SITBs) are significant public health problems in adolescence. The current article provides a comprehensive systematic review examining the relationship between events leading to perceived low relational evaluation (e.g. social rejection) and SITBs among adolescents. Theoretical work posits that low relational evaluation is experienced as psychologically painful, a known correlate of SITBs. Therefore, events leading to low relational evaluation may be particularly informative in understanding the context of SITBs. The current review examines how experiences of low relational evaluation that are hypothesized to elicit psychological pain, such as social rejection, low popularity, and peer victimization are related to engagement in SITBs in adolescence. A total of 56 articles meeting inclusion criteria were identified. The hypothesis of an association between indicators of low relational evaluation and SITBs was generally supported throughout the literature, with more consistency found among studies examining suicidal ideation specifically. However, interpretation of the findings is constrained by various methodological limitations of studies. The present review concludes with a theoretical conceptualization of the relationship between perceived relational value and SITBs, leveraging social and evolutionary psychological theory, to guide future research into this topic.

An examination of the relationship between shame, guilt and self-harm: A systematic review and meta-analysis

Self-harm is a major public health concern associated with suicide risk and significant psychological distress. Theories suggest that aversive emotional states are an important process that drives self-harm. Shame and guilt may, in particular, be important emotions in self-harm. This review therefore sought to provide a systematic review and meta-analysis of the relationship between shame, guilt, and self-harm. A systematic search of electronic databases (PsycINFO; Medline; CINAHL Plus; Web of Science and ProQuest) was undertaken to identify studies measuring shame, guilt and self-harm (including suicidal and non-suicidal behaviour). Meta-analysis was undertaken where papers focused on the same subtype of shame or guilt and shared a common outcome. Thirty studies were identified for inclusion. Most forms of shame were associated with non-suicidal self-injury (NSSI), but research was sparse concerning suicidal behaviour. Fewer studies examined guilt and findings were more varied. Methodological issues included a paucity of longitudinal designs and lack of justification for sample sizes. Results of this review support the link between shame and self-harm, particularly NSSI. The direction of this relationship is yet to be established. Clinically, consideration should be given to the role of shame amongst individuals who present with NSSI. This review was pre-registered on PROSPERO (CRD42017056165).

Patient perspectives of helpful risk management practices within mental health services. A mixed studies systematic review of primary research

WHAT IS KNOWN ABOUT THE SUBJECT?: Risk in psychiatry involves harm to self or others owing to mental health difficulties, for example iatrogenic effects of treatment, self-harm, suicide and violence. Risk management is a framework to minimize risks, comprising of risk assessment, generation of risk management plans and evaluation of interventions. Literature has extensively explored risk management and presented a critique that its practices can lead to patient harm. However, there is a paucity of literature about what patients identify as helpful risk management practices, despite the potential for such patient views to ameliorate harm and improve mental health care. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE: Interpersonal relationships with clinicians, and communication that keeps patients involved and informed of management processes, were found to be central to beneficial risk management practices, while patients having agency and autonomy to influence their participation was also important. Beneficial interpersonal relationships and connectivity in the form of patients' wider community of support were found to be influential in aiding risk management. Meaningful relationships, and particularly peer support, that maintained personal and collective identities were prevalent in the literature. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Rendering risk management more visible and accessible in practice might cultivate an openness that promotes patient participation. This includes drawing on a wider network of support, for example the patient's friends and family, as well as having advocacy utilizing peer support. Abstract Introduction Minimizing the harm that patients pose to themselves and others, due to mental health difficulties, is a central component of risk management in psychiatry. However, risk management itself can cause patient harm, but despite this and the potentially informative value of lived experience, little is known about what patients want or expect from risk management. Aim To review research and explore what patients consider beneficial in risk management practice. Method A mixed studies systematic review utilizing PRISMA guidelines, alongside a convergent qualitative design to categorize findings. Results Twelve papers were identified, generating two categories of beneficial practices: interpersonal relationships and communication with clinicians; coupled with patient agency in their own risk management. Discussion Connectivity appears important. Particularly patients feeling involved, and their voices being heard in both the identification of risks and then shaping risk management practice. Moreover, this included involvement of friends, family and peers to widen input and supportive networks beyond clinical relationships. Implications for Practice Risk management needs to be an accessible part of care, which is more inclusive of patient views and needs. The latter might also be aided by drawing on the patient's wider community in order to provide more effective support and risk management.