American Journal of Orthopsychiatry

Nonsuicidal Self-Injury and Religiosity: A Meta-Analytic

Investigation
Alison M. Haney
Online First Publication, March 14, 2019. http://dx.doi.org/10.1037/ort0000395

CITATION
Haney, A. M. (2019, March 14). Nonsuicidal Self-Injury and Religiosity: A Meta-Analytic
Investigation. American Journal of Orthopsychiatry. Advance online publication.
http://dx.doi.org/10.1037/ort0000395
 American Journal of Orthopsychiatry
© 2019 Global Alliance for Behavioral Health and Social Justice 2019, Vol. 1, No. 999, 000
http://dx.doi.org/10.1037/ort0000395

Nonsuicidal Self-Injury and Religiosity:

A Meta-Analytic Investigation
Alison M. Haney
Purdue University

Nonsuicidal self-injury (NSSI) is a potentially life-threatening behavior with significant public

health implications that may potentiate suicide risk. Religiosity has been identified as a signif-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

icant protective factor against suicide attempts, and more broadly acts as a buffer against
This document is copyrighted by the American Psychological Association or one of its allied publishers.

negative mental and physical health outcomes. Whether religiosity may reduce risk for NSSI is
unclear. To understand the nature of the association between NSSI and religiosity, correlations
from 16 samples (total N ⫽ 24,767) were computed to evaluate the magnitude and direction of
the association between NSSI and religiosity. Gender, age, location, publication status, and
method of religiosity measurement were included as moderators. Results from the meta-analysis
show a small but significant negative correlation between NSSI and religiosity (r ⫽ ⫺0.101, p
⬍ .001). The role of ethnicity, identity, social support, and religious coping as contributors to this
association are also discussed. Recommendations for future research are offered based on these
findings, along with a discussion of clinical implications for assessment and treatment.

Public Policy Relevance Statement

Nonsuicidal self-injury (NSSI) can be life-threatening and places significant financial burden
on the health care system in the United States. This meta-analysis found that religiosity may
serve as a protective factor against self-harm behaviors and should thus be included in
standard risk assessment practices in medical and mental health settings.

S
elf-harm (SH) and nonsuicidal self-injury (NSSI) are poten-
tially life-threatening behaviors that also have significant
public health implications. The Center for Disease Control
(Centers for Disease Control and Prevention., 2013) reported that
self-harm injuries lead to 500,000 ER visits in 2013 and cost an
estimated $10 billion in direct and indirect costs. Although deleterious
on its own, NSSI also has been identified as a risk factor for suicide
attempts (Klonsky, May, & Glenn, 2013). Conversely, those who
endorse cultural and religious beliefs that discourage suicide and
support instincts for self-preservation have significantly fewer suicide
attempts and completions (Dervic et al., 2004, 2006; Lizardi et al.,
2008). While religion most often serves as a protective factor against
suicide (Gearing & Alonzo, 2018), the link between religious belief
and suicidal ideation and behaviors is less clear, as mixed results have
been reported in the literature. It is possible that religiosity (the degree
to which a person engages in religious or spiritual pursuits) protects
The author thanks David Rollock, Donald R. Lynam, Katherine M.
Thomas, and William G. Graziano for their feedback on earlier drafts of
this article.
Correspondence concerning this article should be addressed to Alison M.
Haney, Department of Psychological Sciences, Purdue University, 703 Third
Street, West Lafayette, IN 47907-2081. E-mail: haneyam@purdue.edu
against suicide attempts, but not against suicidal behaviors or NSSI.
The goal of this meta-analysis is to synthesize the extant research on
the link between NSSI (a risk factor for mental health problems) and
religiosity (a protective factor against mental health problems). These
findings shed light on whether religiosity may be leveraged to not
only protect against suicide but self-harm behaviors more broadly.
Religion as a Protective Factor for NSSI
Involvement in religion has been associated with positive psycho-
logical states and has been shown to buffer against stress and protect
against negative psychological states (see Hood, Hill, & Spilka,
2009). Several mechanisms have been proposed to explain how
religiosity may improve mental and physical health outcomes, includ-
ing social support through involvement in a religious community, use
of positive religious coping (PRC; e.g., turning to the divine for help)
to manage distress, reduction in existential uncertainty, and participa-
tion in religious rituals that may activate self-monitoring and regula-
tion (McCullough & Willoughby, 2009; Monteiro, 2015; Pargament,
Koenig, & Perez, 2000; Pargament, Magyar-Russell, & Murray-
Swank, 2005).
Turning to religion as a form of distress tolerance is an adaptive
strategy that may support overall well-being and buffer against mal-
adaptive behaviors and mental health difficulties (Pargament, Smith,
Koenig, & Perez, 1998). Individuals engaging in self-injurious behav-

1
 2 HANEY
ior endorse using aspects of religion/spirituality as a method to resist
urges to self-harm (Klonsky & Glenn, 2008). In their study of ap-
proaches to resisting self-harm urges, Klonsky and Glenn found that
34.3% of participants with NSSI endorsed turning to religion/spiritu-
ality as a method of reducing self-harm urges, and all of those
participants endorsed that the method was perceived to be somewhat
to very helpful at reducing those urges (2008).
When considering religion as a protective factor against NSSI
and psychopathology broadly, it is important to consider how
religiosity is measured, as certain aspects of religion may be more
protective than others (Koenig, McGue, & Iacono, 2008). Some
studies measure religion simply by asking for affiliation (i.e.,
reporting which religious group a person belongs to); others de-
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termine the degree of affiliation a person feels (e.g., how strongly
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they identify with a religious group), the importance of religion to
an individual, the frequency of participation in a organized or
personal religious activity, or the degree to which a person relies
on religion to cope with life circumstances (Hill & Hood, 1999).
There is some evidence to suggest that certain aspects of religiosity
may potentiate self-harm behavior.
Religion as a Risk Factor for NSSI
Beliefs that self-harm can be used as corporal punishment for
perceived moral ineptitudes exist in the mainstream and at the
fringes of many religious groups (Favazza, 1989; Kushner, 1967).
Use of negative religious coping (e.g., feelings of persecution from
the divine) may be a risk factor for suicidal ideation and self-harm.
Negative religious coping is often contextually linked to signifi-
cant mental/physical illness, or recent trauma, though general use
and cultural understanding of persistent negative religious coping
has been identified as a risk factor for affective and somatic
symptoms of mood disorders (Haney & Rollock, 2015).
Religiosity may be a marker of emotional distress for those who
increase religious activity in response to persistent or acute stres-
sors (Nkansah-Amankra et al., 2012). Just as some individuals use
aspects of religious faith to manage feelings of distress, NSSI can
be used in an effort to manage negative emotions and decrease
rumination (Nock, Prinstein, & Sterba, 2009; Westers, Rehfuss,
Olson, & Wiemann, 2014). This may suggest that religiosity and
NSSI could increase simultaneously in response to distress such
that they appear positively associated.
Covariates of the Association Between NSSI
and Religiosity
The influence of religion on mental health varies in strength de-
pending on age, ethnicity, gender, and context (Spoerri, Zwahlen,
Bopp, Gutzwiller, & Egger, 2010). As some of the known covariates
of the association between religiosity and other mental health out-
comes are also associated with rates of NSSI, it is important to
consider how the correlation between religiosity and NSSI may vary
systematically by such potential moderators. Age may influence this
association, as younger individuals are more likely to engage in NSSI
but less likely to benefit from religious participation. Age of onset for
NSSI is typically between ages 12 and 14 (Nock, 2010), and adoles-
cents are at the highest risk for self-harm with 15–20% engaging in
self-harm at least once (Heath, Carsley, De Riggi, Mills, & Mettler,
2016; Muehlenkamp & Gutierrez, 2004). Age also is associated with
the severity of NSSI behaviors, such that earlier age of NSSI onset is
associated with greater frequency and severity of NSSI (Ammerman,
Jacobucci, Kleiman, Uyeji, & McCloskey, 2017). In the United
States, younger individuals are less likely to be religious and to be
involved in a religious community than older adults (Hackett et al.,
2012). Younger adults also report higher levels of religious doubt, an
aspect of religion associated with negative mental health outcomes
that may undermine religious coping and other beneficial spiritual
processes (Hayward & Krause, 2014; Pargament et al., 2000).
Gender and ethnic identity may also moderate the association
between NSSI and religiosity, as women and certain ethnic minority
groups (e.g., African Americans in the United States) are more likely
to be religious, use religious coping in response to stress, and may
have distinct ways of using religion to promote well-being (Chatters,
Taylor, Jackson, & Lincoln, 2008; Gholamrezaei, De Stefano, &
Heath, 2017; Hackett et al., 2012; Haney & Rollock, 2015; Pargament
et al., 2000). Rates and correlates of NSSI also vary significantly by
ethnic group and gender, with meta-analytic work indicating that
Asian men are least likely to self-harm compared to other ethnic
groups, and black women are most likely (Al-Sharifi, Krynicki, &
Upthegrove, 2015; Borrill, Fox, & Roger, 2011). Across ethnic
groups, women are 1.5 times more likely to engage in NSSI than men,
and this gender discrepancy is even larger in clinical samples (Bresin
& Schoenleber, 2015).
The context in which a person lives can also influence whether
religious faith will act as a protective factor (Panczak et al., 2013). For
example, religion is more likely to be protective if an individual is in
the majority faith group and practices their faith in a manner that is
congruent with their local community and rules of government
(Young, Sweeting, & Ellaway, 2011). This suggests there may be
variance by geographic location in the strength of the association
between NSSI and religiosity. Additionally, the measures used to
assess NSSI and religiosity in a particular sample may moderate the
strength of the association between NSSI and religiosity, as different
measures may emphasize distinct aspects or dimensions of religiosity
(e.g., religious service attendance vs. frequency of prayer) and NSSI
(e.g., frequency vs. duration).
The Present Study
The goal of this meta-analysis was to synthesize the existing
research on the association between NSSI and religiosity to deter-
mine 1) whether NSSI and religiosity are significantly associated,
2) whether the association between NSSI and religiosity is positive
or negative, and 3) whether the association between NSSI and
religiosity is moderated by relevant demographic variables and
construct measurement.
Method
Literature Search
To identify relevant research reports, a computerized litera-
ture search was conducted using PsycINFO, supplemented by
other databases including PubMed, Google Scholar, and Edu-
cational Resources Information Center. Published articles that
appeared in peer-reviewed journals published any time before
 NSSI AND RELIGIOSITY
November 2017 were collected as the primary sources of data.
Unpublished articles (i.e., doctoral dissertations) and unpub-
lished data were identified as secondary sources to mitigate the
potential bias of published studies historically reporting greater
significant means and other statistics (Rosenthal, 1979). Search
terms for religiosity were “Religioⴱ” or “Spiritualⴱ,” and search
terms for NSSI were “self-injurⴱ” or “self injurⴱ” or “self-harm”
or “self harm” or “self-mutilation” or “self-cutting” or “cutting”
or “self-burning” or “self-poisoning” or “DSH” or “nonsuicidal
self injury” or “non-suicidal self injury” or “non-suicidal self-
injury” or “nonsuicidal self-injury” or “NSSI” or “parasuicidⴱ”
or “suicidal behaviors” or “BPD” or “Borderline Personality
Disorder.” Borderline personality disorder was included as a
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search term as several measures of BPD include NSSI-relevant
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items. Additional relevant articles were identified if they had
been cited or referenced in already-identified research reports.
Emails were sent to relevant list-serves and research groups to
request unpublished data and additional research reports that
may reference the variables of interest. Two researchers re-
sponded to the request for unpublished data, and one dataset
was included in this meta-analysis.
A flowchart of the literature search process is presented in
Figure 1. Approximately 58 articles that fit the initial screening
Figure 1. Literature Search Flowchart.
3
criteria were evaluated manually for final inclusion eligibility.
These articles either were downloaded from the databases listed
above or requested through interlibrary loan. To be included,
articles needed to be printed in English or Spanish, and measure
both religiosity and NSSI. While numerous definitions and dimen-
sions of religiosity have been proposed (Hackney & Sanders,
2003), for the purposes of this meta-analysis religiosity refers
broadly to religious behaviors (e.g., participation in religious rit-
uals), religious or spiritual beliefs (e.g., ideology), religious cop-
ing, and religious affiliation (identifying as a member of a religious
group). Studies using a specific measure of NSSI were included,
along with studies that assessed individuals presenting with acute
self-harm (e.g., in an emergency room). Articles were excluded if
only suicidal ideation, attempts, or completions were measured, if
bodily harm of subjects was involuntary (e.g., Female Genital
Mutilation), and if the study measured only physician-assisted
suicide.
Fifteen published studies and one dissertation were selected for
full-text review, but four of these studies could not be used due to
insufficient statistical information presented, and one was ex-
cluded as it was determined that only suicidal behaviors and
thoughts, not NSSI, were being captured by the measure used.
Authors were contacted when information was insufficient, with a
 4 HANEY

response from one author (25% response rate), who no longer had
access to the data used in the study. After manually evaluating each
article, 15 samples were identified from 10 published articles, one
dissertation, and one unpublished dataset. The range of published
sample sizes was 159 –14,385 (unpublished samples ranged 33–151)
with the total sample size yielding 24,996 adolescents and adults.
Coding Procedures
Coding and reporting procedures were conducted using the
Preferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA; Moher, Liberati, Tetzlaff, & Altman, 2009)
guidelines. All articles eligible for final inclusion in analyses were
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in each study and their psychometric properties can be found in
Table 1 (NSSI) and Table 2 (Religiosity).
Moderator Analyses
Several moderators were coded and analyzed in this study: age
(mean for sample), gender (% of women in sample), publication
status (published vs. unpublished), and location. Location, coded
as the country from which the sample was drawn, was collapsed
into two categories: United States sample or International sample.
Due to inconsistent reporting, ethnic and religious composition of
the samples were not run as moderators (implications reviewed in

coded for general demographic characteristics (publication year, Discussion). Additionally, religious affiliation was used as the sole
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country, sample size, gender, ethnicity, age group, sample charac-
teristics), measure of religiosity used, measure of NSSI used,
reported statistics related to the association between religiosity and
NSSI, and any other additional relevant information provided by
the article. Additional important psychometric properties such as
the internal consistency of each study also were coded, though not
included in analyses due to inconsistencies in data reporting of
these characteristics and the number of unique, single items used
rather than validated measures. A summary of the measures used
measure of religiosity in some studies and therefore would not be
a suitable moderator for these analyses. When possible, method of
measurement (e.g., instrument used) of NSSI and religiosity for
each sample was included as a moderator to examine how the
association may vary based on construct measurement. While
measures of NSSI used were too varied for such analyses, religi-
osity measures could be broadly separated into dichotomous mea-
sures (religious vs. nonreligious) and continuous measures (degree
of religiosity).

Table 1. Summary of Instruments Used to Measure Nonsuicidal Self-Injury

Instrument
Non-Suicidal Self-Injury Assessment
Tool (NSSI-AT; Whitlock &
Purington, 2011)
Self-Harm Behavior Questionnaire
(SHBQ; Gutierrez, Osman,
Barrios, & Kopper, 2001)
Self Harm Inventory; (SHI; Sansone
& Wiederman, 2015)
Deliberate Self-Harm Inventory
(DSHI; Gratz, 2007)
Functional Assessment of Self-Injury
(FASM; Lloyd-Richardson,
Perrine, Dierker, & Kelley, 2007)
Other
a b
Authors of the NSSI-AT note that this is not meant to be a unitary scale, thus internal consistency is expected to be low.
psychometric properties (Latimer, Covic, Cumming, & Tennant, 2009)
Internal
Description Consistency Studies
a
Likert scale; NSSI characteristics, functions, .38–.66 Kress, Newgent, Whitlock, &
recency, frequency, patterns, and treatment- Mease, 2015
seeking behaviors.
Open-ended interview; NSSI method, .89–.96 Andrews, Martin, Hasking, &
frequency, and severity. Page, 2014
List of self-harm behaviors; subset of behaviors .83b Sansone & Wiederman, 2015
ask respondents to specify number of times Haney & Griffin (2019)
engaged in the target behavior.
List of self-harm behaviors; if endorsed: onset, .82 Kuentzel, Arble, Boutros, Chugani,
frequency, latency, and severity (medical & Barnett, 2012; Wagner, 2008
treatment required).
List of self-harm behaviors; if endorsed: .81 Buser, Buser, & Rutt, 2017
number of times, severity (medical treatment
required).
Patients brought to an emergency room for self- Grover, Sarkar, Bhalla,
harm; included unless they refused consent, Chakrabarti, & Avasthi, 2016
were too sick, or had psychiatric disorders
other than depressive disorders.
Checklist of self-harm behaviors: cutting, Borrill, Fox, & Roger, 2011
scratching/biting skin, overdose, swallowing
objects, burning, self-poisoning or “other.”
“Which of the following best describes how Longo, Walls, & Wisneski, 2013
often you have engaged in the following
behaviors?”
“Have you ever purposely injured yourself Polanco-Roman, Tsypes, Soffer, &
without suicidal intent?” Miranda, 2014
“Have you ever engaged in deliberate Rotolone & Martin, 2012
self-injury?”; if endorsed: frequency, purpose,
types of behavior, and cessation.
From separate paper on
 NSSI AND RELIGIOSITY 5

Table 2. Summary of Instruments Used to Measure Religiosity

Instrument Description Internal Consistency Studies

Multidimensional Measurement of
Religiousness/Spiritualit1y
(Traphagan, 2005)
Brief RCOPE (Pargament, Feuille, &
Burdzy, 2011)
Standardized Data Set (SDS;
CCMH, 2012)
The Functional Assessment of
Chronic Illness Therapy (FACIT-
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Assess several domains of R/S. Study
authors adapted items related to
belief in the afterlife and importance
of R/S.
Assess positive religious coping (PRC)
and negative religious coping
(NRC).
Assess degree to which spiritual
connections are central to life.
Assess meaning in life, harmony,
peacefulness, and sense of strength
Meaning: .96
Spirituality: .92
Religious Practices: .91
PRC: Median alpha .92 (.67–.94)
NRC: Median alpha .81 (.60–.90)
.81–.88
Kress et al., 2015
Buser et al., 2017; Grover et al.,
2016
Polanco-Roman et al., 2014
Sansone & Wiederman, 2015

Sp-12; Webster, Cella, & Yost, and comfort from faith.

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2003)
Faith Development Scale (Leak, Assess overall current faith .71 Wagner, 2008
Loucks, & Bowlin, 1999) development.
Other “Are you a religious or spiritual Andrews et al., 2014; Haney &
person?”: “yes” or “no.” Griffin (2019)
Participants select from list of religious Borrill et al., 2011; Kuentzel et
affiliations; study authors then al., 2012; Longo et al., 2013;
dichotomize religious from non- Rotolone, & Martin, 2012
religious.

Data Analytic Steps
All statistical analyses were computed in Comprehensive Meta-
Analysis 3 (CMA 3; Biostat, Englewood, NJ). All studies were
coded by the author and a second independent rater. Cohen’s
kappa statistic (K; Cohen, 1960), a measure of agreement between
raters, was K ⫽ 0.83. Any disagreements or differences were
resolved by discussion.
The Pearson product–moment correlation coefficient between
religiosity and NSSI for each sample was computed using a bias
correction function, included in the analytic software, to adjust for
any population-related bias from the studies that had relatively
smaller samples. Odds ratios were converted to Cohen’s ds, then
converted to Pearson’s rs (see Borenstein, Hedges, Higgins, &
Rothstein, 2009). To standardize effect sizes, rs were trans-
formed to zs using Fisher’s Zr-transformation. These mean
standardized effect sizes (zs) were then transformed back to rs
at the end of all statistical analyses to ensure uniform compar-
isons and to ease interpretability. All effect-size analyses were
weighted using the reciprocal of their variances, such that
studies with larger sample sizes were weighted more heavily.
The weighted mean effect size estimates and their 95% confi-
dence intervals (CIs) around the means were calculated in a
random-effects model.
Tests of homogeneity were conducted to determine sources of
variance and to inform which model (random vs. fixed vs. mixed
effects) to use for moderator analyses. Cochran’s Q was calculated
as the weighted sum of squared differences between individual
study effects and the pooled effect across studies. Q has a chi-
square distribution and can be overpowered as a test of heteroge-
neity if the number of studies is small. The I2 statistic was also
calculated as it is less dependent on study number. The I2 statistic,
where I2 ⫽ 100% x (Q-df)/Q, describes the percentage of variation
across studies that is due to heterogeneity rather than chance
(Higgins et al., 2002).
Moderator effects of gender, mean age, location, publication
status, and religiosity measure were also analyzed. Categorical
moderators included location (I ⫽ International vs. US ⫽ United
States), publication status (Y ⫽ published, N ⫽ unpublished), and
type of religiosity measurement (D ⫽ dichotomous, C ⫽ contin-
uous). Continuous moderators included mean age (range 14.9 –
43.1) and gender, represented by the percentage of women in each
sample (range 36 –100%).
Results
Description of Studies in Analysis
Study characteristics are summarized in Table 3. Combining
across samples, the total number of participants is 24,996. Of the
15 samples used in this meta-analysis, one was composed of
adolescents (mean age 14.9), eight were composed primarily of
young adults (M ⫽ 18.1–22.8 years), and five were samples with
most participants over the age of 30 (M ⫽ 30.3– 43.1 years).
Eleven samples (73%) were from studies conducted in the United
States, and four were conducted outside of the U.S. in Australia,
the United Kingdom, and India. Thirteen samples (87%) were
more than half women (range 36 –100%), such that the total
sample is composed of approximately 62.4% women. All but one
study (Borrill et al., 2011) was cross-sectional in design.
Analysis of Effect Sizes
Table 4 presents a summary of effect size information for each
sample. The aggregated effect size (using a random effects model)
across all samples was ⫺0.101 (p ⬍ .001), indicating that there is
a small but significant correlation such that higher levels of reli-
giosity are associated with lower levels of NSSI engagement (and
vice versa). Figure 2 includes a forest plot providing a visual
 6 HANEY

Table 3. Key Descriptive Characteristics of Studies for Inclusion

Study name Subset N Publisheda % Women Locationb Mean age Designc % White

Andrews et al. (2014) All 1973 Y 71.6 I 14.9 CS

Borrill et al. (2011) All 617 Y 77.0 I L 39.0
Buser et al. (2017) All 297 Y 76.1 U 21.06 CS 72.7
Grover et al. (2016) All 159 Y 47.1 I 30.3 CS
Haney & Griffin (2019) Clinical 160 N 56.3 U 34.8 CS 86.1
Haney & Griffin (2019) Community 96 N 52.0 U 35 CS 90.3
Haney & Griffin (2019) Legal System 195 N 36.0 U 34.2 CS 89.3
Kress et al. (2015) All 14385 Y 57.0 U 21.76 CS 69.9
Kuentzel et al. (2012) Religious 5059 Y 70.0 U 22.2 CS
Longo et al. (2013) All 250 Y 46.4 U 18.05 CS 60.0
Polanco-Roman et al. (2014) Minority 642 Y 75.4 U 21.96 CS
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Polanco-Roman et al. (2014) White 514 Y 75.7 U 22.67 CS 100.0

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Rotolone & Martin (2012) All 312 Y 69.8 I 20.8 CS

Sansone & Wiederman (2015) All 306 Y 74.5 U 43.11 CS 85.9
Wagner (2008) Women 33 N 100 U 20.36 CS 84.8
Total sample size: 24994
a
Y ⫽ Published; N ⫽ Unpublished b
US ⫽ United States; I ⫽ International c
CS ⫽ Cross Sectional; L ⫽ Longitudinal.

summary of effects retrieved. While correlation estimates ranged
⫺0.34 – 0.42, only one study (Wagner, 2008) reported a positive
correlation. This study was unique in several ways: it had the
smallest sample size (n ⫽ 33), it was the only sample comprised
only of women, it was the only unpublished article (not dataset)
included in the analysis, and it was the only study to use a
developmental scale of religiosity. All other correlations were
negative, with four falling between 0 and ⫺0.11, five falling
between ⫺0.1 and ⫺0.2, four falling between ⫺0.2 and ⫺0.3, and
one between ⫺0.3 and ⫺0.4.
Heterogeneity
The between-studies variance (T2) is estimated as 0.063. The
Q-value, which reflects the distance of each study from the mean
effect, is 94.24 (df ⫽ 14, p ⬍ .001). If all studies shared the same
true effect size, the expected value of Q would be equal to the
degrees of freedom (which is 14). Here, Q is greater than that
value, so there is some evidence of variance in true effects. As Q
is statistically significant (p ⬍ .05), this excess variance falls
outside the range that could be attributed to random sampling error
in effect sizes. I2 ⫽ 85.14, meaning that 85.1% of variation across
studies that is due to heterogeneity rather than chance. As signif-
icant heterogeneity was found across samples, a random-effects
model was employed for all subsequent models.
Moderators
Significant heterogeneity among samples supports the appropriate-
ness of moderator analyses. When analyzed, none of the proposed
moderators (measurement, age, gender, location, and publication sta-
tus) were significant (see Table 5). Additionally, none of the moder-
ators tested significantly improved model fit (change in Q, R2, and T2
not significant). As there was significant heterogeneity identified in
this sample and no significant moderator identified, there may be
systematic variance due to variables not captured in this moderator
analysis, such as religious or ethnic composition.
Additional Results
The Role of Religious Coping and Social Support
Religious coping. Studies were coded to identify con-
structs in addition to demographics that were measured in multiple
samples. Religious coping was measured in two studies. When
examining four dimensions of religious coping, Buser and col-
leagues (2017) found that dimensions of negative religious coping
(spiritual discontentment and punishment) were significantly and
positively associated with NSSI, while aspects of positive religious
coping (spiritual surrender and collaborative coping) were nega-
tively associated with self-harm. Grover and colleagues (2016)
found that those who engaged in self-harm behavior used higher
levels of negative religious coping and controls used higher levels
of positive religious coping.
Social support. Three studies measured social support in
addition to religiosity and NSSI. Andrews and colleagues (2014)
found that low family support (OR ⫽ 0.88, 95% CI: [0.84 – 0.91],
p ⬍ .001), but not low support from friends or significant others,
was associated with onset of NSSI. Rotolone and Martin (2012)
found that social support was associated with NSSI, such that
perceived social support explained 37% of the between groups
variance (no NSSI vs. NSSI). Rotolone and Martin also found that
family and friend support, but not significant other support, were
significantly associated with NSSI such that those who perceived
low levels of support from family and friends were more likely to
have engaged in self-harm (2012). Polanco-Roman and colleagues
(2014) examined these associations further in white and minority
1
When rounded to one decimal place.
 NSSI AND RELIGIOSITY 7

Table 4. Summary of Correlations and Related Statistics

Statistics for each study

Subgroup Lower Upper Relative
Model Study name within study Correlation limit limit Z p weight

Andrews et al. (2014) All ⴚ.170 ⫺.213 ⫺.127 ⫺7.619 .000 10.226
Borrill et al. (2011) All ⫺.068 ⫺.146 .011 ⫺1.688 .091 8.181
Buser et al. (2017) All ⴚ.140 ⫺.250 ⫺.027 ⫺2.416 .016 6.216
Grover et al. (2016) All ⫺.112 ⫺.263 .044 ⫺1.407 .160 4.415
Haney & Griffin (2019) Clinical ⫺.096 ⫺.252 .065 ⫺1.171 .241 4.273
Haney & Griffin (2019) Community ⴚ.174 ⫺.326 ⫺.014 ⫺2.124 .034 4.236
Haney & Griffin (2019) Legal ⫺.084 ⫺.242 .078 ⫺1.017 .309 4.236
Kress et al. (2015) All ⴚ.030 ⫺.046 ⫺.014 ⫺3.599 .000 11.333
Kuentzel et al. (2012) Religious ⴚ.032 ⫺.051 ⫺.014 ⫺3.384 .001 11.276
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Longo et al. (2013) All ⴚ.343 ⫺.448 ⫺.229 ⫺5.618 .000 5.714
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Polanco-Roman et al. (2014) Minority ⫺.006 ⫺.083 .071 ⫺.152 .879 8.275
Polanco-Roman et al. (2014) White ⫺.003 ⫺.089 .084 ⫺.068 .946 7.729
Rotolone & Martin (2012) All ⴚ.189 ⫺.294 ⫺.080 ⫺3.363 .001 6.358
Sansone & Wiederman (2015) All ⴚ.230 ⫺.334 ⫺.121 ⫺4.077 .000 6.302
Wagner (2008) Women .427 .098 .672 2.499 .012 1.229
Random ⴚ.101 ⫺.142 ⫺.059 ⫺4.739 .000

Note. Bolded values indicate statistical significance at p ⬍ .05.

emerging adults and found that family support (but not friend
support) was negatively associated with NSSI for white partici-
pants before controlling for other risk and protective factors.
Neither family nor friend support was significantly associated with
NSSI in minority participants.
Publication Bias
Publication bias was assessed using classic fail-safe N, which
estimates the number of unpublished studies that would nullify the
results found in the reviewed published literature. In this case,
fail-safe N is 308, meaning that there would need to be 308 “null”
studies in order for the combined 2-tailed p value to exceed 0.050.
In other words, there would need to be 15 unpublished missing
studies for every one study in this meta-analysis for the effect to be
nullified. A funnel plot (see Figure 3) also was created to show
standard error on the vertical axis as a function of effect size on the
horizontal. Larger studies tend to cluster near the top of the graph
near the mean effect size, and smaller studies are dispersed across
a range of values toward the bottom of the graph, as there is more
sampling variation. This funnel plot is distributed reasonably sym-
metrically around the combined effect size. This, in conjunction
with fail-safe N results, suggests that the effect found is not a
product of publication bias.
nificant but small; however, other meta-analytic work looking at
NSSI and its putative correlates has found effect sizes of similar
magnitude. For example, a meta-analysis of the association be-
tween NSSI and life stress found a significant positive association
of approximately the same magnitude2 reported here (Liu, Cheek,
& Nestor, 2016). The association between religiosity and com-
pleted suicide, as reported in a recent meta-analysis (where r ⫽
.263; Wu, Wang, & Jia, 2015), is somewhat larger in magnitude
than the association between NSSI and religiosity found here.
These results support the growing body of evidence indicating
that religiosity is associated with positive mental and physical
health outcomes by demonstrating that religiosity is associated
with lower risk of self-harming behaviors. However, these findings
do not disentangle how various aspects of religion may differen-
tially impact NSSI over time. As most of the studies included were
cross-sectional in design, these data cannot fully assess whether an
increase in religiosity (perhaps in response to distress) may predict
increased NSSI or vice versa. In a longitudinal study, religious
doubt, but not general religiosity, had a bidirectional association
with NSSI such that religious doubt predicted an increase in NSSI
and vice versa (Good, Hamza, & Willoughby, 2017).4 Evidence
from this meta-analysis suggests that religion is protective against
NSSI, but additional longitudinal research is needed to differenti-
ate between concurrent and cross-lagged associations among these
variables.

Discussion
Magnitude of Effect Size
Overall, this meta-analysis found that there is a small but sig-
nificant negative association between NSSI and religiosity, such
that being religious is associated with less engagement in NSSI.
This association did not vary by sample age, gender composition,
location, or publication status, but did vary based on how religi-
osity was measured. The overall correlation was statistically sig-
Heterogeneity and Moderators
There was significant heterogeneity among the included sam-
ples, suggesting that there may be moderators systematically in-
2
Reported OR ⫽ 1.81 [95% CI ⫽ 1.49 –2.21]; converted to r ⫽ 0.16.
3
Reported OR ⫽ 0.38 (95% CI: 0.21– 0.71).
4
This study was not included in the meta-analysis.
 8 HANEY
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This document is copyrighted by the American Psychological Association or one of its allied publishers.

Figure 2. Forest plot of effect sizes. See the online article for the color version of this figure.

fluencing the association between NSSI and religiosity. However,
none of the covariates assessed significantly moderated the asso-
ciation between NSSI and religiosity. The moderators may be
nonsignificant because of a restricted range within the included
samples (e.g., most studies did not include older adult partici-
pants, resulting in a limited range for mean age). However, a
number of potential moderators known to be associated with
both NSSI and religiosity, such as ethnicity, could not be
included in these analyses due to inconsistent reporting (see
Table 3 “% White”).
Although a significant difference was not identified between
dichotomous measures of religiosity (e.g., affiliation) and con-
tinuous measures (e.g., degree of religious commitment or
centrality), the continuous measures used were varied and some
emphasized particular facets of religiosity not captured in oth-
ers (see Table 2), as distinct aspects of religion can be differ-
entially associated with mental health outcomes. For example,
previous research has found that personal importance of reli-
gion has a stronger association with decreased odds of depres-
sion, while religious attendance is more protective against
substance use behaviors (Rasic, Robinson, Bolton, Bienvenu, &
Sareen, 2011).
Importantly, religious composition of each sample could not be
used as a moderator in these analyses, though faith traditions
emphasize distinct principles for self-regulation that are relevant to
NSSI (McCullough & Willoughby, 2009). For example, the med-
itative practices of Buddhism bear some similarity to the
mindfulness-based approaches to promote self-regulation in clin-
ical settings (Gratz, 2007; Grossman, Niemann, Schmidt, &
Walach, 2004; Monteiro, 2015). As more research is conducted in
diverse settings, examining these associations in populations from
additional religious traditions will allow for a better understanding
of circumstances under which religiosity may be protective against
NSSI, and for whom.

Table 5. Moderator Analyses

95% CI
n Correlation SE Lower Upper Z p Q

Gender
Intercept ⴚ.359 .139 ⫺.632 ⫺.086 ⫺2.570 .010
% Women 15 .390 .211 ⫺.024 .805 1.850 .065 3.41
Age
Intercept ⫺.061 .078 ⫺.215 .092 ⫺.780 .434
Mean age 14 ⫺.002 .003 ⫺.008 .004 ⫺.590 .558 .34
Location
Intercept ⴚ.139 .035 ⫺.206 ⫺.071 ⫺4.020 .000
Location: (U.S) 15 .057 .041 ⫺.024 .137 1.380 .168 1.90
Publication status
Intercept ⫺.068 .058 ⫺.181 .045 ⫺1.180 .238
Published (Yes) 15 ⫺.039 .062 ⫺.161 .082 ⫺.630 .527 .40
Measure of religiosity
Intercept ⫺.051 .043 ⫺.135 .033 ⫺1.180 .237
Measure (Dichotomous) 15 ⫺.088 .056 ⫺.197 .020 ⫺1.590 .111 2.53

Note. Bolded values indicate statistical significance at p ⬍ .05.

 NSSI AND RELIGIOSITY
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This document is copyrighted by the American Psychological Association or one of its allied publishers.
Figure 3. Funnel plot of standard error for publication bias assessment.
Religious Coping and Social Support
The mechanisms by which religiosity may influence NSSI re-
main unclear, though extant literature examining other mental
health indicators has identified religious coping and social support
from other believers as important salutary components of religion.
Studies included in this meta-analysis that looked at aspects of
religious coping found that the type of coping that an individual
uses is clinically relevant. Higher levels of positive religious
coping were associated with lower risk of NSSI, and higher levels
of negative religious coping were associated with increased risk of
NSSI (Buser et al., 2017; Grover et al., 2016). This indicates that
the way an adherent functionally uses religion has important
implications for the level of risk for NSSI.
In the subset of studies that included measures of social support,
higher levels of perceived family support were found to be pro-
tective against NSSI (Andrews, Martin, Hasking, & Page, 2014;
Polanco-Roman et al., 2014; Rotolone & Martin, 2012). Associa-
tions with support from friends and significant others were more
variable across studies, with evidence of significant variance by
ethnicity and gender as well. It is important to note that these three
studies had participants from adolescence to emerging adulthood
(M ⫽ 14.9 –22.7), and these associations may vary in older sam-
ples. While the protective capacity of religion often is thought to
be a function of the wider social network it provides, these studies
suggest that the family plays an important role that may or may not
be associated with religion.
Limitations
There are several important limitations to this meta-analysis.
First, the number of studies included is relatively small, and
studies were only reviewed if they were available in English or
Spanish. While some studies could not be included due to
insufficient information, this is an area of research that has only
been considered empirically in recent years (the oldest sample
included was collected in 2008). While this review seeks to
9
clarify the association between NSSI and religiosity, some
studies included used measures that do not specifically distin-
guish between NSSI and self-injury that may have concurrent
suicidal ideation or intent. Therefore, some of the study esti-
mates may conflate these related but distinct phenomena
(Brown, Comtois, & Linehan, 2002).
There was inconsistency in data reporting across studies, with
several studies not reporting zero-order correlations among the
study variables or demographic information. Although such incon-
sistency is a common concern across meta-analytic studies (Van-
paemel, Vermorgen, Deriemaecker, & Storms, 2015), lack of
information about demographic composition and reporting of basic
statistics by demographic groups prevented potentially significant
associations from being considered in analyses. For example, in
the only included study with a significant positive association
between NSSI and religiosity was from a sample with over 20% of
participants identifying as bisexual or homosexual, and religiosity
was identified as a potential contributor to self-injury by eliciting
feelings of guilt or cynicism in participants (Wagner, 2008). As-
pects of identity that may be perceived by an individual as incon-
gruous with their religious beliefs or community may result in
increased levels of religiosity being associated with increased
engagement in NSSI, and additional work is needed to clarify what
individual characteristics may undermine the protective influence
of religiosity.
Despite significant heterogeneity among samples, these results
must be generalized with caution, as much of the data was col-
lected from young, female, European American Christians living
in the contiguous United States. While four studies were from
international samples (Australia, the United Kingdom, India) fu-
ture work sampling from diverse ethnocultural groups and reli-
gious backgrounds is needed.
Future Directions
Although such limitations must be considered, this meta-
analysis provides important information about the association be-
 10
tween religiosity and a specific mental health outcome with sig-
nificant public health implications. As religion has been identified
as a protective factor against NSSI, future work should consider
how to leverage aspects of religion in a therapeutic context to
support alternate, adaptive regulatory strategies in those who self-
injure (cf. Grossman et al., 2004; McCullough & Willoughby,
2009). As religion and self-harm behaviors are commonly ad-
dressed in suicide risk assessment (American Psychiatric Associ-
ation, 2015), understanding the mechanisms driving this associa-
tion may inform improved risk assessment strategies.
This meta-analysis also highlights the value of including mea-
sures of religiosity in future research on NSSI. While some re-
search includes religious affiliation as a demographic variable,
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
nominal affiliation of an individual does not provide information
This document is copyrighted by the American Psychological Association or one of its allied publishers.
about the importance of religion in his or her life, or frequency of
participation in private or public religious ritual. Dimensional
measures of religiosity did not converge on a common set of
meaningfully comparable referents in this meta-analysis, but in-
cluding a dimensional measure of religiosity in future work on
NSSI (e.g., the Duke Religion Index, a five-item measure of
religiosity commonly used in epidemiological studies; Koenig &
Büssing, 2010) will allow researchers to clarify aspects of religious
faith that may be most protective against self-harm behaviors.
Conclusion
Overall, results show that religion appears to be protective
against NSSI, with religious affiliation and degree of religiosity
significantly and negatively correlated with self-harm. Specific
aspects of religion, such as engaging in positive religious coping,
may be particularly relevant to this association. However, there
may be aspects of religion that place a religious adherent at greater
risk for NSSI, including negative religious coping and doubt.
There is not yet sufficient literature to determine how differenti-
ating among these aspects of religiosity may influence the magni-
tude of this association, or how it may vary within diverse popu-
lations. As risk and protective factors for NSSI and suicidal
behaviors continue to be clarified, there is empirical evidence that
dimensions of religiosity warrant continued research and clinical
attention.
Keywords: NSSI; self-harm; religion; coping; social support
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