Mindfulness

https://doi.org/10.1007/s12671-021-01815-1

ORIGINAL PAPER

Mindfulness, Self-compassion, Self-injury, and Suicidal thoughts

and Behaviors: a Correlational Meta-analysis
Megan Per1   · Emma Schmelefske1 · Kyla Brophy1 · Sara Beth Austin2 · Bassam Khoury1

Accepted: 11 December 2021

© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2021

Abstract
Objectives  While extant research indicates an inverse association between self-compassion and mindfulness with non-
suicidal self-injury (NSSI) and suicidal thoughts and behaviors (STBs), estimates of magnitude remain unknown. The
present systematic review and meta-analysis aim to quantify the relationship between self-compassion and mindfulness
with engagement in NSSI and STBs.
Methods  Literature searches in four electronic databases (PsycINFO, MEDLINE, Scopus, ProQuest Dissertations, and The-
ses Global) were conducted. Effect sizes were estimated using pooled correlation coefficients and a random effects model.
Meta-regressions with mixed-effect models were used to determine the moderators of the associations.
Results  Sixty-eight independent samples from 62 different articles (N = 53,797) met inclusion criteria. Analyses yielded
a medium negative correlation between self-compassion and mindfulness with both NSSI and STBs. Among mindfulness
facets, the nonjudging, acting with awareness, and describing facets demonstrated the largest significant correlations with
both STBs and NSSI. The self-coldness dimension (vs self-warmth dimension) of self-compassion demonstrated the largest
correlation to STBs. There was a stronger negative correlation between self-compassion and mindfulness with engagement
in NSSI and STBs in adolescent samples (than in clinical and college student samples) and with STBs’ recency (reported
within the past 12 months vs lifetime). Associations between NSSI and STBs with self-compassion and mindfulness were
greater in lower-quality studies and studies with younger or male samples, although effect sizes remained modest.
Conclusions  Findings suggest that self-compassion and mindfulness may buffer against NSSI and STBs. Future study
regarding the efficacy and effectiveness of self-compassion and mindfulness-based interventions among NSSI and STB
populations is warranted.
Meta‑analysis registration  PROSPERO CRD42020167823.

Keywords  Suicide · Non-suicidal self-injury · Self-harm · Self-compassion · Mindfulness · Suicidal ideation · Suicide
attempt

Suicide and related behaviors are serious and often over- Age-adjusted suicide mortality has increased nearly 33%
looked worldwide public health problems (Bertolote & since 2000 (Hedegaard & Warner, 2021) and is projected
Fleischmann, 2002; World Health Organization, 2017). to rise between 3 and 9% in the coming years (McIntyre &
Annual suicide mortality exceeds 800,000 (World Health Lee, 2020a, 2020b). Suicide has remained among the top
Organization, 2018)—an alarming rate that grossly ten leading causes of death in North America for over three
underestimates the true death toll (Tøllefsen et al., 2012). decades, with rates occurring over 2.5 times that of homi-
cide (Centers for Disease Control and Prevention, 2018).
For every completed suicide, approximately 140 people
* Megan Per
megan.per@mail.mcgill.ca contemplate and 25–30 attempt to take their life (Centers
for Disease Control and Prevention, 2021; Weissman et al.,
1
Department of Educational and Counselling Psychology, 1999). Suicide-related behaviors are associated with signifi-
McGill University, Education Building, 3700 McTavish St cant morbidity and health care costs (adjusted annual US
(Room 614), QC H3A 1Y2 Montreal, Canada
rates of $93.5 billion; Shepard et al., 2016). Accurate suicide
2
The Family Institute, Northwestern University, Evanston, IL, prediction and prevention have been limited by challenges
USA

13
Vol.:(0123456789)
 Mindfulness

within spanning methodology (Carpenter & Law, 2021), 2019), optimism and hope (Chang et al., 2017), treatment
decades of inconsistent nomenclature (Goodfellow et al., compliance, and mental health service utilization (Rufino
2020; Silverman et al., 2007), and an over-focus on psycho- et al., 2021)—has been mixed. Recent investigations suggest
pathology (e.g., mental illness, loneliness, hopelessness). that cultural factors (e.g., cultural sanctions, cultural idioms
Indeed, over 50 years of focused prevention efforts have related to distress) may play an extensive role in predicting
negligibly impacted suicide rates, and significant knowledge NSSI and STBs (Tang et al., 2018) over and above tradition-
gaps remain regarding underlying mechanisms and pathways ally studied protective factors (e.g., reasons for living; Chu
to suicide (Franklin et al., 2017). et al., 2019).
Non-suicidal self-injury (NSSI), defined as the deliberate Mindfulness and self-compassion, two related culturally
and intentional destruction of one’s own bodily tissue with- adapted practices, have received increasing attention over
out suicidal intent and for reasons not socially sanctioned the past two decades for their potential to buffer against
(e.g., tattoos, body piercings; International Society for the NSSI and STBs (e.g., Bentley et al., 2017; Schmelefske
Study of Self-Injury, 2007), is distinct from but closely et al., 2020; Van Vliet & Kalnins, 2011). Within a Western
associated with suicide. Those engaging in NSSI are at sig- context, mindfulness is operationalized as the deliberate,
nificantly increased risk for suicidal thoughts and behav- non-judgmental awareness of the present moment (Kabat-
iors (STBs; Baer et al., 2020; Kiekens et al., 2018; Ribeiro Zinn, 2003). Employed widely in third wave therapies (e.g.,
et al., 2016). NSSI—a frequent precursor to STBs and co- Dialectical Behavior Therapy, and Acceptance and Commit-
occurring behavior (Hamza et al., 2012; Klonsky et al., ment Therapy) and as standalone approaches (e.g., Mindful-
2013)—is arguably the most robust predictor of attempted ness-Based Stress Reduction, Mindfulness-Based Cognitive
suicide (Taliaferro & Muehlenkamp, 2014; Victor & Klon- Therapy), mindfulness-based interventions perform as well
sky, 2014). A large, multi-site study conducted over 10 years as other evidence-based treatments for psychiatric condi-
found that individuals who self-injure were between 30 and tions (i.e., depression, substance use disorders) associated
100 times more likely to die by suicide than the general pop- with NSSI and STBs (Goldberg et al., 2018; Khoury et al.,
ulation (Hawton et al., 2015). NSSI may increase acquired 2013a).
capacity for suicide via irreversible changes in habituation In a related area, an overlapping but distinct construct to
to physiological pain and fear of death (Bender et al., 2012). mindfulness is self-compassion. While different definitions
Researchers have called for greater study and understanding of self-compassion exist in the current literature (see review
of risk and resilience factors uniquely associated with NSSI by Gilbert, 2017; Khoury, 2019; Strauss et al., 2016), self-
and STBs to better target prevention and intervention efforts compassion is broadly considered to be theoretically adja-
(Franklin et al., 2017; Hasking et al., 2019). cent to mindfulness (Khoury, 2019). A common operation-
Predominant NSSI and suicide risk models (for reviews, alization based on the Self-Compassion Scale (SCS; Neff,
see Fox et al., 2015; Klonsky et al., 2018) have failed to 2003b) involves three interconnected dimensions: holding
translate into efficacious prevention and intervention initia- painful thoughts in mindful awareness, showing kindness
tives (Fox et al., 2020; Nielssen et al., 2017), in part due to towards oneself in the face of distress, and understand-
a narrow over-focus on pathology that overlooks resilience ing difficulties as part of a larger human experience (Neff,
and other protective factors as critical moderators of the 2003a). Alternative conceptualizations of self-compassion
risk-outcome relationship. Resilience is a multidimensional include Gu et al., (2020) five-dimensional model (recogniz-
process involving transactions between intra- and interper- ing suffering; understanding the universality of suffering;
sonal resources that increase adaptive coping capacity in the feeling for the person suffering; tolerating uncomfortable
face of adversity (Gallagher & Miller, 2018; Luthar & Cic- feelings; and motivation to act/alleviate suffering), and Gil-
chetti, 2000). Incorporating resilience into suicide research bert’s dual component framework combining sensitivity to
is critical for contextualizing dynamics that underlie suicidal one’s own suffering (compassionate engagement) with a
phenomena and outcomes (Shahram et al., 2021). Resilience commitment to alleviate and prevent it (or compassionate
serves as a crucial barrier to suicidality (Brailovskaia et al., action; Gilbert & Mascaro, 2017; Gilbert et al., 2017).
2019; Sher, 2019), and preliminary evidence suggests it Substantial evidence links mindfulness and self-com-
accounts for greater variance in predicting STB remission passion to psychological health and well-being, suggest-
than do risk factors (Teismann et al., 2016). ing an inverse correlation with psychological distress and
Holistic consideration of relationships between NSSI psychopathology. Posited factors underlying these rela-
and STB risk and resilience factors add much-needed incre- tionships include facilitative effects of mindfulness and
mental validity in understanding these complex phenomena self-compassion on autonomic regulation (e.g., decreas-
(Muehlenkamp & Brausch, 2019). Research on the rela- ing sympathetic hyperarousal and dorsal vagal activation),
tionship between NSSI and STBs and traditional resilience emotion-focused coping (e.g., promoting awareness and
proxies—i.e., life satisfaction (Muehlenkamp & Brausch, identification of affective states), and distress tolerance (e.g.,

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Mindfulness

emotional acceptance; Basharpoor et al., 2021; Finlay-Jones and/or self-compassion; (2) assessed for NSSI and/or
et al., 2015; Inwood & Ferrari, 2018; Ogden et al., 2006). STBs; (3) included original data; (4) reported correla-
We know that there is a large body of electrophysiological, tion coefficients (or other statistics when correlation
neurobiological, and psychological evidence which indicates coefficients were not available, e.g., t-scores) between
that mindfulness and self-compassion affect mental health mindfulness or self-compassion and NSSI (defined as
outcomes by enhancing emotion regulation capacity (Inwood a deliberate non-suicidal act involving actual or poten-
& Ferrari, 2018; Lin et al., 2016; Lutz et al., 2014). We also tial tissue damage without suicidal intent) or suicidal
know NSSI and STBs are linked to emotion dysregulation outcomes; (5) were available in English or French; and
(Rajappa et al., 2012; You et al., 2018) and may function as (6) were published in a peer-reviewed journal article or
attempts to regulate and manage distressing affective expe- dissertation. Dissertations were included in an effort to
riences. Indeed, for some, NSSI and STBs (Angelakis & reduce publication bias by potentially including stud-
Gooding, 2020, 2021; Brereton & McGlinchey, 2020; Ellis ies with null or negative results, which provides a more
& Rufino, 2016) provide means of experiential avoidance— comprehensive picture of the available research (Paez,
i.e., escape behaviors aimed to attenuate the form, frequency, 2017). When information was missing, authors were
and/or contexts associated with contacting/being present contacted, and the study was included only if the neces-
with aversive internal experiences (e.g., physiological sen- sary data were obtained. Studies not explicitly differ-
sations, emotions, thoughts, memories, action urges; Hayes entiating between self-injury with and without suicidal
et al., 1996, p. 1154). Thus, experiential avoidance can be intent were excluded. There were no restrictions on
understood as an emotion regulation strategy—one way to study design or date; however, only baseline data were
manage emotions is to avoid them. used in the analyses.
Taken together, these findings suggest that mindfulness
and self-compassion may target underlying functions of
NSSI and STBs. Mindfulness and self-compassion are likely Search Strategy
to increase psychological flexibility and expand coping rep-
ertoires in ways that reduce reliance on escape via self-injury Articles were identified for inclusion via searches through
and STBs. Supporting this notion, a recent meta-analysis four electronic databases (PsycINFO, MEDLINE, Scopus,
found that mindfulness-based interventions led to moderate and ProQuest Dissertations, and Theses Global). The ini-
reductions in suicidal ideation (Schmelefske et al., 2020) tial search was conducted in PsycINFO (Ovid, 1806 to pre-
and other psychological outcomes associated with suicide sent) and was peer-reviewed by Dr. Alberto Chiesa, Uni-
(e.g., depression). versity of Bologna. The search combined keywords and
Despite growing interest in the clinical application and Boolean operators related to NSSI or suicide and mindful-
utility of mindfulness and self-compassion on NSSI and ness or self-compassion. Several studies made use of the
STBs, the relationships between these constructs remain same dataset and data was extracted when they reported
unclear. Recently, there has been a systematic review on complementary data (e.g.,Watson-Singleton et al., 2018;
self-harm, suicidal ideation, and self-compassion (Cleare Wu et al., 2019). See Fig. 1 for a flow diagram of search
et al., 2019). While laudable, this review did not quantify results.
these relationships, and examined suicidal ideation with- Data assessing (1) NSSI and STBs and (2) mindful-
out accounting for key-related constructs such as NSSI and ness and self-compassion outcomes were extracted. STBs
STBs. The present study addresses these important gaps and and NSSI were measured continuously (e.g., frequency
adds to the literature by aiming to (1) quantify the corre- of thoughts and behaviors) and/or categorically (e.g.,
lations between mindfulness, self-compassion, NSSI, and endorsement of specific thoughts and behaviors) across
STBs; (2) examine the impact of specific moderators (age, studies. Demographic information from included studies
gender, and study quality) on these relationships; and (3) was extracted and reported, and comprised of (a) publi-
compare the mean correlations between subgroups (popula- cation characteristics (e.g., year of publication and name
tion type, recency of STBs and NSSI). of authors); (b) study characteristics (e.g., sample size,
sample type, geographic region); and (c) participant char-
acteristics (e.g., mean age, percentage of female partici-
Methods pants, percentage of caucasian participants). Continuous
moderators (i.e., age, percentage of female and study qual-
Eligibility Criteria ity) were examined with meta-regressions with the goal
of investigating how outcomes were affected by the mod-
Studies were eligible for inclusion in the review if they erators. Subgroup analyses were conducted to compare
(1) reported data on completed measures of mindfulness

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 Mindfulness

Fig. 1  PRISMA flow diagram

of screening process

Identification
Records idenfied through database
searching
(n = 1,296)

Records aer duplicates removed

(n = 841) original

Screening
Records screened Records excluded
(n = 841) (n = 641)

Full-text arcles assessed for Full-text arcles excluded: (n

eligibility = 138)
Eligibility

(n = 200) Did not report outcomes (n =

74)
Did not provide correlaons
(n = 38)
Duplicate sample (n = 21)
Cannot locate (n = 2)

Studies included in
Included

quantave synthesis (meta-

analysis)
(n = 68 studies; 62 arcles)

the correlations of the different samples (e.g., clinical vs Statistical Analyses

community).
Data were analyzed with Comprehensive Meta-Analysis, Ver-
Study Selection sion 3.070 (Borenstein & Rothstein, 1999). Pearson correla-
tion coefficients of each sample were weighted by the inverse
Duplicates were removed using Endnote X8.2 and exported of the corresponding sampling variance and converted into
to Rayyan, an online screening tool for systematic reviews Fisher’s transformation to account for sampling error (Hedges
(Ouzzani et al., 2016). A non-blinded, standardized pro- & Olkin, 2014; Rosenthal & Rubin, 1988). A random effect
tocol was used to determine inclusion eligibility using the model more resilient to heterogeneity (Khoury et al., 2013b)
aforementioned criteria by the first M. P. and second E. S. was used for aggregated r values and moderation analyses.
authors. M. P. and E. S. separately assessed 15% (k = 129) Classic fail-safe N analysis and funnel plots were computed to
of the same articles following duplication removal. An inter- assess publication bias across studies. These analyses estimate
rater agreement of 97.42% was achieved initially. Follow- the number of studies needed to cause significant aggregated
ing consideration of rationales for inclusion or exclusion, r values to be insignificant. Study quality was assessed using
consensus was reached through discussion. Thereafter, M. the standardized critical appraisal tool (AXIS tool; Downes
P. and E. S. each independently assessed half of the remain- et al., 2016) designed for non-experimental research. Risk of
ing articles. Any disagreements between reviewers about bias was assessed by two independent reviewers (E. S. and M.
whether a study should be included were resolved through P.), who resolved disagreement by discussion or by involving
consultation with the last author, B. K. a third reviewer (B. K.).

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Mindfulness

Results and NSSI outcomes had a medium negative correlation (r

= −.267) with self-compassion and mindfulness combined
Study Selection and Characteristics (k = 18; 95% CI [−.336, −.194], p < .001), with high het-
erogeneity. Mindfulness and self-compassion combined
One thousand two hundred and ninety-six articles were had a medium negative correlation and high heterogene-
retrieved from the initial search on June 30, 2021. Removal ity for NSSI frequency (r = −.285; k = 9; 95% CI [−.395,
of duplicates resulted in 841 articles. A total of 68 samples −.167], p < .001). NSSI versatility had a small negative
(62 different articles) were included in the meta-analysis. correlation (r = −.176) with self-compassion and mindful-
The combined number of participants was 53,797 and the ness combined (k = 3; 95% CI [−.250, −.100], p < .001),
mean size of the sample was 791.13 (SD = 3,168.35; range with small heterogeneity. Table 2 presents the combined
= 8–26,292). The mean age of the sample was 26.97 and random effects model, examining the relationship between
58.09% of the sample was female. The majority of the NSSI and suicide outcomes with self-compassion and
studies were conducted in North America (64.71%) and mindfulness. See Table 3 for the effect sizes for the self-
the majority of participants were Caucasian (58.93%). Of compassion dimensions with suicide and NSSI outcomes.
the included studies, the majority were college students The mindfulness facets and self-compassion dimensions
(e.g., undergraduate students; 39.71%), followed by com- were also analyzed in relationship to NSSI outcomes in four
munity/non-clinical samples (23.53%), clinical samples studies. Similar to suicide outcomes, only the describing
(17.65%), then adolescents (16.18%). Risk of bias scores (r = −.250; 95% CI [−.451, −.024], p = .030; small-to-
ranged from 6 to 15 (mean = 11.77, SD = 1.86). See medium effect), acting with awareness (r = −.347; 95% CI
Table 1 for detailed characteristics of individual studies. [−.548, −.108], p = .005; medium effect), and nonjudging
(r = −.399; 95% CI [−.633, −.098], p = .011; medium-to-
large effect) facets of mindfulness had a significant negative
Synthesis of Results effect, and high heterogeneity, with NSSI outcomes. The
non-reacting and observing facets were not significant. The
STBs showed a medium negative correlation (r = −.269) self-warmth and self-coldness dimensions of self-compas-
with combined self-compassion and mindfulness (k = 55; sion were not analyzed, as only two studies reported on these
95% CI [−.302, −.236], p < .001), with high heterogene- subscales.
ity. Suicidal ideation had a medium negative correlation
(r = −.302; k = 34; 95% CI [−.357, −.244], p < .001) Subgroup Analyses
with self-compassion and mindfulness combined and high
heterogeneity. Suicide attempts had a small-to-medium Subgroup analyses of both STBs reported within the last
negative correlation (r = −.209; k = 10; 95% CI [−.236, 12 months (r = −.278; k = 31; 95% CI [−.320, −.235], p
−.183], p < .001), with mindfulness and self-compassion < .001) and lifetime history (r = −.256; k = 21; 95% CI
combined and low heterogeneity. [−.312, −.198], p < .001) of STBs had a medium negative
The mindfulness facets and self-compassion dimensions correlation with self-compassion and mindfulness com-
were also analyzed in relationship to STBs. Of the 11 studies bined, with high heterogeneity. STBs within clinical sam-
that analyzed the mindfulness facets and STBs, the nonjudg- ples had a medium negative correlation with mindfulness
ing (r = −.270; 95% CI [−.327, −.212], p < .001) and the and self-compassion (r = −.247; k = 11; 95% CI [−.350,
acting with awareness facet (r = −.277; CI [−.329, −.0.223], −.139], p < .001), with medium heterogeneity. A small-to-
p < .001) had a medium negative correlation, and moderate medium negative correlation was found in community sam-
heterogeneity, with STBs. The describing facet had a small ples (r = −.233; k = 13; 95% CI [−.293, −.171], p < .001),
negative effect (r = −.137; 95% CI [−.194, −.080], p < .001) with high heterogeneity to self-compassion and mindfulness
with STBs and moderate heterogeneity. The non-reacting combined. College student samples had a medium negative
and observing facets were not significant. Regarding the correlation (r = −.287; k = 21; 95% CI [−.337, −.235], p <
self-compassion dimensions, the self-warmth dimension had .001), with high heterogeneity, and adolescent samples had
a small negative effect (r = −.166) and moderate heteroge- a medium negative correlation (r = −.335; k = 8; 95% CI
neity with STBs (k = 8; 95% CI [−.237, −.093], p < .001). [−.370, −.300], p < .001), with low heterogeneity, to self-
The self-coldness dimension had a small-to-moderate effect compassion and mindfulness combined.
(r = .239) and large heterogeneity with STBs (k = 7; 95% CI Subgroup analyses of combined NSSI outcomes reported
[−.427, −.031], p = .025). within the last 12 months had a medium negative correla-
The aggregated random effects model for the relation- tion (r = −.257; k = 8; 95% CI [−.352, −.156], p < .001),
ship between mindfulness and self-compassion outcomes, and lifetime NSSI history had medium negative correla-
tion (r = −.260; k = 12; 95% CI [−.350, −.165], p < .001),

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 Table 1  Characteristics of included studies
Study Study design Publication type Participants (N) Country Mean age (SD) % female % Caucasian Study quality Outcomes Measures

13
Aalsma et al., Pilot study Journal article 10th–12th grade USA 15.2 (1.3) 79.1 37.2 13 Mindfulness MAAS-A and
(2020)a adolescents and suicidal SIQ
(18) ideation (SI)
8th–9th grade
adolescents
(25)
Ali (2014) Cross-sectional Dissertation Students with USA 16 (1.28) 50 66.7 13 Self-compas- SCS and subset
a behavioral sion (SC) and questions from
or emotional suicidality the YRBSS
disorder (12)
Anastasiades Cross-sectional Journal article Female under- USA 19.92 (1.58) 100 76.7 12 Mindfulness MAAS and BSS
et al., (2017) graduate and SI
students (928)
Argento et al., Brief mindful- Journal article University stu- Canada 20.17 (1.98) 100 54.9 13 Mindfulness SMS and ISAS
(2020) ness induction dents (144) and NSSI
Basharpoor Cross-sectional Journal article University stu- Iran 21.25 (2.76) 57.33 N/A 8 SC and SI SCS and BSS
et al., (2016) dents (150)
Bock et al., Cross-sectional Journal article University stu- USA 20.26 (2.55) 76.4 61.9 11 Mindfulness FFMQ and DSHI
(2021) dents (339) and NSSI
Bravo et al., Cross-sectional Journal article Military person- USA 32.74 (7.5) 44.5 62.4 12 Mindfulness FFMQ and IDAS:
(2018)a nel (407) and suicidality suicidality
College students 24.46 (8.66) 41.30 47.8 subscale
(310)
Brooks et al., Cross-sectional Journal article Black college USA 22.4 (5.6) 79.2 0 13 Mindfulness, FFMQ, BSS and
(2021) students (307) suicidality SBQ-R
and SI
Buitron et al., Cross-sectional Journal article Undergraduates USA 20.81 (3.96) 78.00 63.8 11 Mindfulness FFMQ and ASIQ
(2017) with moder- and SI
ate to severe
depressive
symptoms
(218)
Chassagne et al., Cross-sectional Journal article Students (1034) France Females: 20.1 79.11 N/A 9 Mindfulness French version of
(2020) (2) and SI the FFMQ and
Males: 20.6 3 items assess-
(2.2) ing suicide
ideation
Cheng et al., Cross-sectional Journal article Psychiatric USA 33.3 (11) 42.9 44.5 12 Mindfulness, FFMQ, BSS and
(2018) inpatients with SI, and sui- medical records
a history of cide attempts assessing
trauma expo- (SA) previous suicide
sure (119) attempts
Mindfulness
 Table 1  (continued)
Study Study design Publication type Participants (N) Country Mean age (SD) % female % Caucasian Study quality Outcomes Measures
Mindfulness

Chesin et al., A quasi-exper- Journal article High–suicide USA 41.7 (16.3) 80 N/A 11 Mindfulness, FFMQ, SCS-SF
(2016) imental pre– risk outpa- SC, and suici- and LEIDS-R:
post study tients (10) dality hopelessness/
suicidality
subscale
Chesin and Cas- Cross-sectional Journal article Undergraduate USA 19.7 (2.9) 63.5 42.8 12 Mindfulness, MAAS, BSS and
cardi (2019) students (780) SI, and SA 1 item assessing
previous suicide
attempts
Cladder-Micus Intervention Journal article Patients with The Netherlands 47.53 (11.67) 70.4 N/A 13 Mindfulness KIMS and
et al., (2018) three or more and suicidality LEIDS-R:
previous hopelessness/
depressive epi- suicidality
sodes (115) subscale
Cleare (2019)a Cross-sectional Dissertation Community (61) Scotland 28.4 (9.5) 49.2 80.3 13 Mindfulness, SCS, FFMQ-SF,
Longitudinal University stu- 22.9 (5.76) 75.7 93 13 SC, and SI and BPMS
survey study dents (514)
Exploratory/ Individuals with Range = 20–40 50 100 12
pilot qualita- and without
tive research a history of
NSSI
Collett et al., Cross-sectional Journal article Patients with UK 45.6 (12.1) 52 N/A 12 SC and SI SCS and BSS
(2016) persecutory
beliefs (21)
Collins et al., Cross-sectional Journal article University stu- Australia 25.98 (10.47) 69.96 77 11 Mindfulness, MAAS, SITBI
(2018) dents (233) SI, and sui- and 1 item
cidal intention assessing sui-
cidal intention
Dixon-Gordon Pilot study Journal article Women with North America 34.47 (11.83) 100 63.2 13 Mindfulness FFMQ and DSHI
et al., (2015) BPD (19) and NSSI
Dobbins (2014) Cross-sectional Dissertation Older adoles- USA 18.41 (.50) 59.6 57 13 Mindfulness FFMQ and DSHI
cents (111) and NSSI
Fang et al., Cross-sectional Journal article Undergraduate China N/A 60.9 N/A 15 Mindfulness MAAS and
(2019) medical stu- and suicidality SBQ-R
dents (2633)
Fang (2020) Cross-sectional Dissertation Undergraduate USA 19.37 (2.41) 76 88 14 SC and SI SCS and ASIQ
students (417)
Forkus et al., Cross-sectional Journal article Military veter- N/A 35.08 22.7 70.4 10 SC and NSSI SCS and DSHI
(2019) ans (203)

13
 Table 1  (continued)
Study Study design Publication type Participants (N) Country Mean age (SD) % female % Caucasian Study quality Outcomes Measures

13
Garisch and Longitudinal Journal Article Secondary stu- New Zealand 16.35 (0.62) 43 71.1 identified 13 Mindfulness CAMS-R and
Wilson (2015) survey dents (1162) as NZ Euro- and NSSI DSHI
pean
Hashemi et al., Cross-sectional Journal article Cardiovascular Iran 46.62 (15.45) 42.2 N/A 9 Mindfulness FFMQ and 3
(2018) patients (110) and SI items assessing
suicide ideation
Hasking et al., Cross-sectional Journal article Undergraduate Australia 20.99 (5.33) 76.8 N/A 11 SC, NSSI, and SCS-SF, ISAS
(2019) psychology SI and 2 items
students (415) assessing sui-
cidal ideation
Hatchel et al., Cross-sectional Journal article LGBTQ youth USA 15.91 (1.18) 70.2 74.3 12 SC and SI SCS-SF and 2
(2019) (934) items assessing
suicidal ideation
Jiang et al., Cross-sectional Journal article High school China 13.58 (1.04) 40.1 N/A 12 SC and NSSI SCS and 1 item
(2017) students (658) assessing NSSI
Kaniuka et al., Cross-sectional Journal article Undergraduate USA 21.81 (5.33) 67 87 9 SC and suici- SCS and SBQ-R
(2020b) students (338) dality
Kaniuka et al., Cross-sectional Journal article Sexual minority North America 26.25 (7.73) 46.2 79.6 13 SC and SI SCS-SF and
(2020a, b) adults (651) SIDAS
Kelley et al., Cross-sectional Journal article Military veter- USA 43.14 (12.23) 3.2 74.1 11 SC and suici- SCS-SF and
(2019) ans (189) dality IDAS: suicidal-
ity subscale
Kelliher-Rabon Cross-sectional Journal article Community USA 35.91 (11.77) 52 79.5 11 SC and suici- SCS and SBQ-R
et al. (2021)a (623) dality
Persons with 47.66 (13.19) 95.7 91.7 12
fibromyalgia
(419)
Persons with 61.28 (27.63) 64.3 91.9 12
or recovering
from cancer
(235)
Lamis and Cross-sectional Journal article Undergraduate USA 19.85 (1.66) 77.2 79.2 9 Mindfulness MAAS and
Dvorak (2014) students (552) and SI SAEI-28
Liu et al., Cross-sectional Journal article Adolescents’ China 14.94 (1.58) 52.9 0 14 SC and suicide SCS and Chinese
(2020) post-earth- risk version of the
quake (499) YRBSQ
Lu et al., (2019) RCT​ Journal article Left behind pri- China 11.86 (.71) 22.45 N/A 13 Mindfulness MAAS and
mary school and SI risk PANSI
students (49)
Mindfulness
 Table 1  (continued)
Study Study design Publication type Participants (N) Country Mean age (SD) % female % Caucasian Study quality Outcomes Measures
Mindfulness

MacIsaac Cross-sectional Dissertation No history of Canada No NSSI: 21.61 No NSSI: No NSSI: 52.06 12 Mindfulness, MAAS, DSHI,
(2019) NSSI (194) (5.85) 82.47 NSSI-Distal: SC, and NSSI ISAS and SCS-
History NSSI NSSI-Distal NSSI- 63.63 SF
(83) 20.43 (1.89) Distal: NSSI-Proximal:
NSSI-Proximal: 86.36 82.05
20.92 (2.91) NSSI-
Prox-
imal:
94.87
McMain et al., Randomized Journal article High suicide Canada 29.67 (8.62) 66 N/A 14 Mindfulness, KIMS, DSHI and
(2017) b trial risk in patients NSSI and SA LSASI
with BPD (84)
Mohammad- Cross-sectional Journal article Males with sub- Iran N/A 0 0 6 Mindfulness MAAS and SPS
khani et al., stance abuse and suicide
(2015) or dependence risk
in outpatient
setting and
prison (348)
Nagy (2017) Experimental Dissertation Undergraduate USA 19.37 (2.12) 74.2 73.8 14 SC and NSSI SCS and ISAS
psychology
students (233)
Paulus et al., Cross-sectional Journal article Latinos attend- USA 38.8 (11.4) 86.7 0 10 Mindfulness MAAS and
(2018) ing commu- and suicidality IDAS: suicidal-
nity-based ity subscale
primary health
care clinic
(391)
Per et al., (2021) Cross-sectional Journal article University Canada 23.98 (7.44) 82.2 49.01 13 SC, mindful- SCS, FFMQ, and
students and ness, and DSHI
community NSSI fre-
(343) quency
Possemato et al., RCT​ Journal article Veterans with USA 46.4 (16.3) 12.9 82.3 15 Mindfulness MAAS and
(2016) PTSD in and SI PHQ-9
primary care
(62)
Rabon et al., Cross-sectional Journal article Military veter- USA 49.9 (16.78) 30.9 85.2 13 SC and suici- SCS-SF and
(2019) ans (541) dality SBQ-R
Riquino (2019) Performance- Dissertation Individuals with USA 20.83 (2.07) 63.3 73.3 12 Mindfulness, FFMQ and SITBI
based task a history of SI, SA, and
engaging in frequency of
NSSI (30) NSSI

13
 Table 1  (continued)
Study Study design Publication type Participants (N) Country Mean age (SD) % female % Caucasian Study quality Outcomes Measures

13
Roush et al., Cross-sectional Journal article Psychiatric USA 36.17 (15.3) 46.6 80.5 14 Mindfulness FFMQ and BSS
(2018) inpatients and SI
(118)
Serrano et al., Cross-sectional Journal article Firefighters USA 38.5 (8.55) 5.3 75.1 12 Mindfulness FFMQ and
(2020) (865) and suicidality SBQ-R
Servaty-Seib Cross-sectional Journal article First-year USA 18.47 (.5) 63.9 72.2 11 SC, SI, and sui- SCS-SF and SIS
et al., (2021) university stu- cide actions
dents (665)
Shorey et al., Cross-sectional Journal article Women in a USA 32.3 (13.95) 100 96.3 13 Mindfulness MAAS and PAI
(2016) substance and SI
use treatment
facility (81)
Song and Bae Cross-sectional Journal article Korean college Korea 21.59 (2.07) 55.8 0 12 Mindfulness, Korean version of
(2020) students (355) SA and SI the FFMQ and
SSI
Stanley et al., Cross-sectional Journal article Firefighters USA 38.37 (8.53) 5.5 75.2 11 Mindfulness FFMQ and
(2019) (831) and suicidality SBQ-R
Tanaka et al., Cross-sectional Journal article Adolescents Canada 18.1 (1) N/A 27 13 SC and SA SCS and 1 item
(2011) receiving child assessing sui-
protection ser- cide attempts
vices (117)
Tucker et al., Cross-sectional Journal article Undergraduate USA 19.34 64.8 81 7 Mindfulness FFMQ and
(2014) psychology and SI HDSQ-SS
students (315)
Tuna and Gen- Multi-method, Journal article Undergraduate Turkey 21.07 (1.58) 60.0 0 10 SC and NSSI SCS (Turkish
çöz (2021) laboratory- students with translation) and
based design and without ISAS
a history of
NSSI (70)
Umphrey et al., Cross-sectional Dissertation College students USA 29 71 60.7 10 SC and SI SCS and CHRTS
(2021) (481)
Vigna (2016) Cross-sectional Dissertation High school stu- USA N/A 50.1 68.9 8 SC, SI, SA, and SCS-SF, 3
dents (1,882) NSSI items assess-
ing suicide
ideation, suicide
attempts, and
NSSI
Wang et al., Cross-sectional Journal article Gay men (445) Switzerland N/A 0 N/A 13 Mindfulness, MAAS and PSS
(2018) SI, suicide (3-items)
plans, and SA
Mindfulness
 Table 1  (continued)
Study Study design Publication type Participants (N) Country Mean age (SD) % female % Caucasian Study quality Outcomes Measures
Mindfulness

Warner (2015) Cross-sectional Dissertation College students USA 25.5 (7.8) 62.8 69.9 14 Mindfulness CAMS-R and 1
(26,292) and NSSI item assessing
NSSI
Watson-Sin- Analyzing scale Journal article African Ameri- USA 37.24 (12.24) 52 0 14 SC, mindful- SCS, FFMQ BSS
gleton et al., psychometric can clinical ness, and SI
(2018)b properties, sample (283)
cross-sectional
Wu et al., Longitudinal Journal article Secondary China 13.15 (1.1) 43.29 N/A 11 SC, NSSI, SI, SCS, 12 items
(2019)b survey school stu- and SA assessing
dents (813) NSSI and 2
items assessing
suicide ideation
and attempt
Xavier et al., Cross-sectional Journal article Adolescents Portugal 15.24 (1.64) 51.6 N/A 12 SC and NSSI SCS and RTSHIA
(2016) (643) (excluded
suicidal intent
responses)
Zeifman et al., Cross-sectional Journal article Ethnically Canada 21.04 (6.3) 83.1 36.9 13 SC and suici- SCS and SBQ-R
(2021) diverse dality
undergraduate
students (130)
Zeng et al., Cross-sectional Journal article Older adults China 51.72 (2.73) 46 0 8 Mindfulness MAAS and
(2017) (213) and SI SBQ-R
Zhang et al., Cross-sectional Journal article Students grade China 13.34 (.95) 47.8 0 11 SC and SI SCS and short
(2021) 7–9 (1,167) Chinese version
of the ASIQ
a
 Separate samples reported in one study
b
 Data received from two articles with the same sample
Abbreviations: ASIQ The Adult Suicide Ideation Questionnaire, BPMS The British Psychiatric Morbidity Survey, BSS Beck Suicide Ideation Scale, CAMS-R Cognitive and Affective Mindful-
ness Scale–Revised, CHRTS Concise Health Risk Tracking Scale, DSHI Deliberate Self-Harm Inventory, FFMQ Five Facet Mindfulness Scale, FASM The Functional Assessment of Self-
Mutilation Scale, HDSQ-SS Hopelessness Depression Symptom Questionnaire–Suicidality Subscale, IDAS Inventory of Depression and Anxiety Symptoms, ISAS Inventory of Statements about
Self-Injury, KIMS The Kentucky Inventory of Mindfulness Skills, LEIDS-R Leiden Index of Depression Sensitivity-Revised, LSASI Lifetime Suicide Attempt Self-Injury Interview, L-SASII
Lifetime Parasuicide Count, MAAS The Mindfulness Attention Awareness Scale, MAAS-A The Mindfulness Attention Awareness Scale-Adolescents, PAI The Personality Assessment Inventory,
PANSI The Positive and Negative Suicide Ideation, PSS Paykel Suicide Scale, RTSHIA Risk-Taking and Self-harm Inventory for Adolescents, SAEI-28 The Suicide Anger Expression Inven-
tory-28, SBQ-R Suicidal Behaviors Questionnaire-Revised, SCS Self-Compassion Scale, SHI Self-harm Inventory, SIDAS The Suicidal Ideation Attributes Scale, SIQ Suicide Ideation Question-
naire, SIQ-JR Suicide Ideation Questionnaire-Junior High School Version, SIS Suicidal Ideation Scale, SMS State Mindfulness Scale, SPS Suicide Probability Scale, SSI The Scale for Suicide
Ideation, YRBSQ Youth Risk Behavior Survey Questionnaire, YRBSS Youth Risk Behavior Surveillance Survey

13
13
Table 2  Effect sizes for the relationship between mindfulness and self-compassion with suicide and NSSI outcomes
Mindfulness Self-compassion
2
k r Z 95% C.I. Q I k r Z 95% C.I. Q I2

Combined suicide outcomes 35 −.230* −12.708 [−.264, −.196] 121.149 71.935 25 −.323* −10.794 [−.376, −.267] 175.726 86.342
Suicide ideation 23 −.255* −7.230 [−.320, −.188] 188.980 88.359 15 −.364* −8.036 [−.442, −.281] 154.326 90.928
Suicide attempts 6 −.201* −10.835 [−.236, −.165] 5.410 7.584 4 −.223* −8.986 [−.269, −.175] 1.659 0.000
Combined NSSI ­outcomesa 11 −.228* −4.399 [−.324, −.128] 184.981 94.594 9 −.369* −5.254 [−.487, −.238] 140.012 94.286

*indicates p < .001

a
 Outcomes include: frequency, versatility, and history. Column names: k = number of studies, r = average Pearson Correlation, Z = Wald test, CI = confidence interval of 95%, Q = Hedges’ Q
test for homogeneity; I2 = heterogeneity analysis in percentile

Table 3  Effect sizes for the relationship between mindfulness facets and self-compassion dimensions with suicide and NSSI outcomes
Suicide outcomes NSSI outcomes
2
k r Z 95% C.I. Q I k r Z 95% C.I. Q I2

FFMQ
  Acting with awareness 11 −.277*** −9.713 [−.329, −.223] 25.756 61.173 4 −.347** −2.793 [−.548, −.108] 30.163 90.054
  Describing 11 −.137*** −4.631 [−.194, −.080] 26.828 62.725 4 −.250* −2.166 [−.451, −.024] 24.696 87.852
  Nonjudging 11 −.270*** −8.759 [−.327, −.212] 30.072 66.747 4 −.399* −2.556 [−.633, −.098] 50.384 94.046
  Non-reacting 11 −.050 −1.115 [−.138, .038] 62.493 83.998 4 −.285 −1.410 [−.605, .114] 81.942 96.339
  Observing 11 −.006 −.090 [−.131, .119] 130.045 92.310 4 −.026 −.236 [−.235, .186] 20.924 85.662
SCS
Self-warmth 8 −.166*** −.166 [−.237, −.093] 15.679 55.353
Self-coldness 7 .239* −2.247 [−.427, −.031] 89.743 93.314

The self-warmth and self-coldness dimension of the SCS were not analyzed as only two studies reported subscales with NSSI outcomes
FFMQ Five Facet Mindfulness Scale, SCS Self-Compassion Scale
***p > .001; **p >.01; *p >.05
Mindfulness
Mindfulness

self-compassion and mindfulness combined, both with high

94.067
87.761
82.367
80.178
94.087
11.811
heterogeneity. Combined NSSI outcomes in community

I2
samples had a medium negative correlation (r = −.336)
with self-compassion and mindfulness combined (k = 3;

117.980
95% CI [−.594, −.016], p = .04), with high heterogeneity.

89.877
17.014
35.314
33.823
2.268
College samples had a small-to-medium negative correla-

Q
tion (r = −.220; k = 8; 95% CI [−.287, −.151], p < .001)
and adolescent samples had a medium negative correlation

[−.352, −.156]
[−.350, −.165]
[−.397, −.262]
[−.287, −.151]
[−.594, −.016]
[−.231, .168]
(r = −.331; k = 4; 95% CI [−.397, −.262], p < .001), with
self-compassion and mindfulness combined, both with high

95% C.I.
heterogeneity. Combined NSSI outcomes within clinical
samples were non-significant. See Table 4.

Moderation Analyses

−4.877
−5.240
−8.929
−6.120
−2.052
−.314
Z
The relationship between STBs and mindfulness and self-

Table 4  Sub-group analysis for sample type and recency of suicide and NSSI outcomes with mindfulness and self-compassion combined
compassion were negatively and weakly moderated by par-

−.257**
−.260**
−.331**
−.220**
NSSI outcomes

−.336*
ticipants’ mean age (k = 48; β = −.009, SE = 0.0009, p <

−.032
.001), gender (percentage of females in the sample; k = 51; β

r
= −.004, SE = 0.0003, p < .001), and study quality (k = 55;
β = −.024, SE = 0.002, p < .001). The relationship between

12
8
4
8
3
3
k
NSSI outcomes and mindfulness and self-compassion was
negatively moderated by mean age (k = 17; β = −.011, SE =

81.282
86.649
16.489
88.502
83.094
68.297
0.002, p < .001), gender (k = 17; β = −.004, SE = 0.0007, p
< .001), and study quality (k = 18; β = −.022, SE = 0.004,

2
I
p < .001).

160.275
149.805
173.951
70.982
31.543

8.382
Publication Bias Analysis
Q

The effect size for all analyses corresponded to a z-value

[−.320, −.235]
[−.312, −.198]
[−.370, −.300]
[−.337, −.235]
[−.293, −.171]
[−.350, −.139]

of −43.411 (p < .001); signifying at least 3,3291 studies

with null effect would be needed to invalidate our findings.
95% C.I.

A funnel plot was generated showing that 5 studies would

need to be added below the mean of the plot to achieve sym-
metry, suggesting that present results may represent slight
overrepresentation of the true relationship. Based on a ran-
−.10.348

−12.111
−17.238
−8.358
−7.238
−4.407

dom effects model, the new imputed mean would be −.286

(95% CI [−.318, −.253]). Although the imputed effect size
Z

is smaller than the original effect sizes, these results still

suggest the effect sizes are valid and robust.
Suicide outcomes

−.335**
−.287**
−.233**
−.247**

−.278*
−.256*
r

** indicates p < .001; * indicates p < .05

Discussion
31
21
21
13
11

8
k

Aggregating findings from 53,797 participants across 68

samples, this meta-analysis rigorously quantified rela-
Within 12-month outcomes

tionships between mindfulness, self-compassion, and

suicide-related outcomes (NSSI and STBs) in the extant
Adolescent sample
Lifetime outcomes

literature, and statistically evaluated important moderat-

College students
Clinical sample

ing factors of these relationships. Our methodology and

Community

findings provide necessary clarification regarding the role

of culturally adapted, resilience-based practices that may
have clinical importance for preventing and treating NSSI

13
 Mindfulness

and STBs. As expected, we found a negative association behaviors (Karyadi et al., 2014), and neuroticism (Hanley
between NSSI (r = −.267) and STB (r = −.269) out- & Garland, 2017).
comes with mindfulness and self-compassion combined. In terms of self-compassion, weighted mean correlations
These results parallel findings from recent meta-analyses on SCS dimensions revealed that greater self-coldness (r =
on experiential avoidance (Angelakis & Gooding, 2021) .239) and lower levels of self-warmth (r = −.166) were sig-
and self-criticism (Zelkowitz & Cole, 2019)—constructs nificantly linked to STBs. An insufficient number of studies
often operationalized as inverse to mindfulness and self- reporting subscale data (i.e., two) prevented us from ana-
compassion. Both studies found positive relationships and lyzing self-warmth and self-coldness dimensions for NSSI
effect size estimates between experiential avoidance with outcomes; this paucity highlights an important avenue for
STBs (moderate to large effect) and NSSI (small effect) future research. Given the mixed evidence pertaining to the
and self-criticism with NSSI (moderate-to-large effect), validity of the SCS total score (Brenner et al., 2017; Brenner
providing convergent validation that mindfulness and self- et al., 2018; Muris & Otgaar, 2020), our dimension-specific
compassion may serve key functions in the etiology and investigation provides a crucial and nuanced picture regard-
maintenance of suicide and engagement in NSSI. ing the relationship between orthogonal dimensions of self-
Importantly, the significant negative relationships emerg- compassion important for suicide outcomes. The particularly
ing between mindfulness and self-compassion with suicide robust relationship between self-coldness and STBs suggests
attempt history (r = −.209) and ideation (r = −.302) in the that those reporting high levels of self-criticism, feelings of
present study align with previous research demonstrating isolation, and identification with negatively labeled emotions
that mindfulness and self-compassion significantly lower (self-coldness) may be especially susceptible to STBs.
the risk of STBs (Chesin & Jeglic, 2016; Lamis & Dvorak, A third objective of this meta-analysis was to examine
2014). Indeed, frequency of NSSI engagement (i.e., how personal and temporal moderators by comparing mean
often individuals report engaging in NSSI) had a medium correlations between sample characteristics and outcome
negative effect (r = −.285) on mindfulness and self-com- recency, given evidence linking these with depressive symp-
passion. This finding suggests that those reporting NSSI his- toms and suicide (Kelliher-Rabon et al., 2018). Results from
tories tend to be less mindful and self-compassionate than the subgroup analyses revealed that individuals with a recent
those with no history. Similarly, NSSI versatility (i.e., how history (i.e., within the past 12 months) of STBs (r = −.278)
many methods one uses to engage in NSSI) had a small scored slightly lower on measures of mindfulness and self-
(r = −.176), negative relationship with mindfulness and compassion than those with any STBs’ lifetime history (r =
self-compassion combined, denoting that those employing −.256). These findings may indicate that levels of mindful-
a greater diversity of NSSI methods endorse lower levels ness and self-compassion may be lower among those cur-
of mindfulness and self-compassion than those using fewer rently experiencing STBs. Surprisingly, NSSI lifetime (r =
methods. While the importance of assessing NSSI frequency −.260) and within 12 months (r = −.257) revealed mini-
and methods has been well-documented (given their asso- mal differences among the correlations. Additional work is
ciation with suicide risk; see Paul et al., 2015; Turner et al., needed to establish causal relationships between mindful-
2013), relationships between NSSI frequency and versatility ness and self-compassion on STBs and NSSI onset, mainte-
have been largely ignored in meta-analyses (e.g., Batejan nance, and recovery.
et al., 2015) prior to this study. Regarding cohort age, both NSSI (r = −.331) and STBs
We also sought to systematically quantify the relation- (r = −.335) were negatively associated with self-compas-
ship between mindfulness facets and STBs. Nonjudging (r sion and mindfulness in studies utilizing adolescent sam-
= −.270), acting with awareness (r = −.277), and describ- ples. Adolescence, a stressful developmental stage associ-
ing (r = −.137) were significantly negatively correlated ated with notable increases in NSSI and STBs prevalence
with STBs, while observing and non-reacting facets were (Andover et al., 2012; Brown & Plener, 2017), has been
unrelated. Results between mindfulness facets and NSSI understudied within literature on NSSI/suicide and mind-
outcomes paralleled suicide findings, showing significant fulness/self-compassion to date. Reflecting this dearth of
negative associations between NSSI and nonjudging (r = research, only 16.18% (k = 11) of studies in our meta-analy-
−.399), acting with awareness (r = −.347), and describing sis included adolescent samples. Nevertheless, our results—
(r = −.250). Together, these results align with research to the observed medium effect size among younger samples
date demonstrating that, of the mindfulness facets, levels and meta-regression on age—align with established links
of non-judging and acting with awareness tend to be sig- between both self-compassion and mindfulness with risk
nificantly lower among those with histories of self-injurious (mental illness, depression) and protective (secure attach-
and STBs. These two facets have strong, negative associa- ment, connectedness) factors for NSSI and STBs in adoles-
tions with other psychological health indicators, including cents (Bluth & Blanton, 2014, 2015; Cunha et al., 2014; Neff
affective symptoms (Carpenter et al., 2019), substance use & McGehee, 2010). We obtained similar results for STBs (r

13
Mindfulness

= −.287) and NSSI (r = −.220) outcomes for studies using while other researchers report negligible gender differences
college student samples. The college transition, marked by (e.g., Garisch & Wilson, 2015; Heath et al., 2008; Serras
a unique confluence of academic, social, developmental et al., 2010). Despite the mixed evidence regarding gender
stressors (Bewick et al., 2010; Morgan, 2017), is a time of differences in prevalence, research has suggested gender
heightened risk for STBs and NSSI (for review, see Swan- differences may be found among the methods used and fre-
nell et al., 2014). Our findings supplement existing research quency of engagement in NSSI. There is evidence suggest-
indicating that mindfulness and self-compassion may serve ing that women engage in NSSI more frequently (Garisch
as adaptive emotion regulation skills that help buffer col- & Wilson, 2015; Hawton & Harriss, 2008) and are more
lege students from STBs and NSSI (John & Gross, 2004; likely to cut, whereas men are more likely to burn or self-
Vujanovic et al., 2010). hit (Kuentzel et al., 2012). Gender differences have been
Negative correlations between mindfulness and self- identified in STBs, with females exhibiting higher rates of
compassion with NSSI (r = −.336) and STBs (r = −.233) suicidal ideation and attempts than their male peers, who are
emerged for studies on community samples. Among clini- more than twice as likely to die by suicide (Cha et al., 2018;
cal samples, we only found a similar inverse relationship (r May & Klonsky, 2016; Miranda-Mendizabal et al., 2019).
= −.247) between mindfulness/self-compassion and STB Recent evidence, however, indicates that the gender dispar-
outcomes. Notably, the three included studies examining ity in suicide mortality has narrowed over the past 40 years,
NSSI in clinical samples only assessed mindfulness (i.e., especially among younger age groups (Ruch et al., 2019).
not self-compassion) and were nonsignificant. These find- Given the established gender differences for specific STBs
ings—particularly the magnitude of effect for our pooled and NSSI outcomes, our gender moderator may reflect meta-
clinical sample—were surprising for several reasons. STBs analysis pooling outcomes (i.e., pooling NSSI frequency,
and NSSI are more prevalent in clinical populations (Fox NSSI as a dichotomous outcome, and NSSI versatility). It
et al., 2015; Franklin et al., 2017; Horváth et al., 2020). would be interesting to look at the extent to which gender
Data suggest that those receiving mental health treatment influences the relationship between mindfulness and self-
experience more complex fears, blocks, and resistances to compassion with specific suicidal (i.e., ideation, attempts)
self-compassion than their non-treated peers (Gilbert & and non-suicidal outcomes (frequency, methods used).
Mascaro, 2017; Kirby & Gilbert, 2019). Individuals with
several psychiatric diagnoses also have lower levels of self- Limitations and Future Research
compassion compared with community samples (Castilho
et al., 2015; MacBeth & Gumley, 2012). Similarly, mind- Important limitations must be considered when examining
fulness is inversely related to psychopathology, including the results of this meta-analysis. While correlational research
depression (Tomlinson et al., 2018). Future studies should is an important first step in understanding the intersection
continue to investigate the potential differences between of mindfulness and self-compassion with NSSI and STBs,
mindfulness and self-compassion with NSSI within clini- replication, experimental study, and longitudinal research
cal and community samples given that mindfulness and are needed to establish causality. Another major limitation
compassion-based interventions are administered differ- of this meta-analysis pertains to the broad outcomes. For
ently between these clinical vs non-clinical groups (Kirby example, suicidal phenomena encompass a wide range of
& Gilbert, 2019). behaviors, from passive ideation, planning, and intent, to
We identified two additional moderating variables: study (fatal and non-fatal) attempts. Given a high degree of vari-
quality and gender. Study quality score negatively moderated ability in measures used, we pooled outcomes. Such hetero-
outcomes, with lower quality studies showing higher effect geneity among measures has been highlighted in prior NSSI
sizes (although this effect was weak). This methodologi- and STB reviews (Turner et al., 2014; Van Geel et al., 2014).
cal caveat limits interpretations of the relationship between A majority of the studies (64.71%) included in this meta-
mindfulness and self-compassion with STBs and NSSI and analysis were conducted in North America, female (58.09%),
signals a need for higher quality, more rigorously designed and utilized Caucasian samples (58.93%) which limits the
investigations. For gender, there was a more robust relation- generalizability of our findings to other countries, ethnic
ship between mindfulness and self-compassion with STB groups, and gender identities. Important differences in NSSI
and NSSI outcomes for males. Males tend to show mar- and STBs have been documented for different countries and
ginally higher levels of self-compassion than females, an regions, racial/ethnic populations (Nock et al., 2008), and
effect qualified by ethnicity and gender role orientation gender identities (Di Giacomo et al., 2018; Liu et al., 2019).
(Yarnell et al., 2019). The evidence regarding gender dif- This review underscores the overrepresentation of white,
ferences in NSSI prevalence is mixed. Some researchers CIS-gendered, North American participants in the current
have found that females are more likely to engage in NSSI literature. We encourage research in non-Western countries
than males (e.g., Cheng et al., 2010; Whitlock et al., 2006), and among other underrepresented minority groups.

13
 Mindfulness

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