The Development of a Measure to Assess Social Reactions to Self-Injury Disclosure

Abstract

Only approximately half of individuals engaging in nonsuicidal self-injury (NSSI) ever disclose their behavior. Yet there is a dearth of research aimed at understanding NSSI disclosure and the outcomes of choosing to disclose, such as social reactions to NSSI disclosure. The current study aimed to develop and validate a measure of perceived social reactions to the disclosure of NSSI, the Self-Injury Social Reactions Questionnaire (SI-SRQ). Results supported a three-factor structure of the SI-SRQ assessing positive (tangible aid, emotional support) and negative social reactions in undergraduate (n = 269), community (n = 217), and recent NSSI (n = 129) samples. The internal consistencies of the resultant subscales, in addition to the convergent validity, were also supported. The development of the SI-SRQ provides an avenue to enhance our knowledge of the relationship between social reactions to NSSI disclosure and disclosure outcomes, which may help inform educational efforts about responding to NSSI disclosures more effectively.

Keywords

NSSI disclosure disclosure reactions help-seeking behavior

Nonsuicidal self-injury (NSSI), the direct, intentional destruction of one’s own body tissue without the intent to die (Klonsky & Muehlenkamp, 2007; Nock, 2009), is linked to several adversities, including physical scarring, higher likelihood of co-occurring psychopathology (e.g., depression, anxiety, suicidal behaviors), and increased interpersonal difficulties (Adrian et al., 2011; Bentley et al., 2014; Klonsky et al., 2013; Tatnell et al., 2014). When identified, NSSI can be reduced through psychological and pharmacological interventions (Andover et al., 2017; Bentley et al., 2017; Cook & Gorraiz, 2016; Turner et al., 2014). However, for treatment to occur the NSSI behavior typically must first be disclosed.

Only half of those who engage in NSSI ever disclose their behavior (Armiento et al., 2014; Evans et al., 2005; Martin et al., 2010). This may be, in part, due to the fear that disclosing one’s NSSI will result in receiving negative and harsh judgments (e.g., being labelled “attention-seeking”; Fortune et al., 2008b; Klineberg et al., 2013), a finding that is consistent with broader concerns of help seeking for mental health difficulties (Clement et al., 2015). Research across a range of mental health symptomologies has found that individuals report apprehensions of negative reactions on disclosing their difficulties, and that these experiences predict the likelihood of help seeking from professional sources (Barney et al., 2006; Bein et al., 2019; Frey et al., 2018; Wu et al., 2017).

Unfortunately, there is support for the voiced concerns among individuals who engage in NSSI. NSSI disclosures are often met with fear, frustration, and confusion by parents (Oldershaw et al., 2008), school staff (Berger et al., 2014; Saunders et al., 2012), and even medical professionals (McAllister et al., 2002). From the theoretical perspective, such reactions may be particularly harmful as there is culminating evidence for interpersonal models of NSSI (Taylor et al., 2018). A substantial portion of individuals who engage in NSSI report doing so as a way to communicate their distress with others, potentially serving to elicit caregiving responses from others (Nock, 2008; Prinstein et al., 2009). However, if negative reactions are anticipated this may significantly impede one’s willingness to seek help, which is problematic as individuals who engage in self-injury report that disclosing their NSSI is the first step toward NSSI prevention and intervention (Fortune et al., 2008a).

On disclosing an emotional event and/or behavior (e.g., NSSI), receiving a reaction that is perceived as negative or unhelpful has been related to increased psychological distress (e.g., Ullman, 1996a) and may even serve as a hindrance to treatment engagement (Muehlenkamp et al., 2012). For example, research examining the disclosure of other distressing events (e.g., sexual assault/abuse, medical diagnoses) has found that perceived negative social reactions were associated with increased maladaptive coping, disordered eating, and posttraumatic stress symptoms (Ullman, 1996a; Ullman & Peter-Hagene, 2014; Waller & Ruddock, 1993), whereas perceived positive social reactions were associated with fewer posttraumatic stress symptoms (Ullman & Peter-Hagene, 2014), more adaptive coping (Ullman & Peter-Hagene, 2014), and better quality of life (Chandra et al., 2003).

Research on NSSI disclosure reactions has been more limited, however, as no validated assessment of perceived reactions to NSSI disclosure currently exists. Of the limited research on NSSI disclosure, it has been found that reactions perceived as negative may reduce future disclosures (Muehlenkamp et al., 2012; Toste & Heath, 2010) and hamper treatment engagement (Muehlenkamp et al., 2012), which may ultimately prolong NSSI engagement. Reactions perceived as positive would likely have the opposite effect, though this has not been tested directly.

In contrast to the NSSI literature, a measure of perceived social reactions of sexual assault disclosure (Social Reactions Questionnaire [SRQ]; Ullman, 1996a, 2000) has been essential in identifying and disentangling the impact of both positive social reactions (i.e., emotional support/belief, tangible aid/information) and negative social reactions (i.e., treated differently, distraction, others’ taking control, being blamed, and egocentric responses) to sexual assault disclosure (Ullman, 1996b; Ullman & Peter-Hagene, 2014). Many of the positive and negative reactions perceived during sexual assault disclosure are likely to also occur in response to the disclosure of NSSI. However, there may also be reactions to NSSI disclosures that are not included in the SRQ, such as those unique to NSSI stigma (e.g., “attention-seeking”; Fortune et al., 2008b; Klineberg et al., 2013), supporting the need for a scale specific to NSSI disclosure.

Current Study

The aim of this study was to develop and validate a self-report measure (Self-Injury Social Reactions Questionnaire [SI-SRQ; supplementary material available online]) to assess both positive and negative social reactions to NSSI disclosures as experienced by the individual disclosing their behavior. An initial version of the SI-SRQ was assessed in a general undergraduate sample to determine a final item set and factor structure. We also aimed to replicate and extend these findings within an external, community sample and an independent sample with past-year NSSI behavior, in addition to determine the scale’s validity. Given the SI-SRQ was adapted from a measure assessing the social reactions following a sexual assault disclosure (SRQ), it was expected that the SI-SRQ would maintain several of the same positive and negative subscales, in addition to a subscale related to NSSI-specific stigma. Convergent validity was assessed by correlating the SI-SRQ positive reaction subscale(s) with perceived social support and the negative reaction subscale(s) with stigma internalization. The study also assessed the extent to which social reactions perceived as more positive would be associated with (a) increased ratings of helpfulness, (b) greater willingness to disclose again in the future, and (c) increased likelihood of NSSI discontinuation following disclosure.

Method

Participants

Undergraduate Sample

Participants included 269 undergraduate students recruited from a large urban university who reported a history (e.g., at least one lifetime act) of NSSI and had disclosed their NSSI to at least one person. Participants ranged from ages 18 to 47 years (M = 20.50, SD = 3.09), 84.80% female and identified as Caucasian (70.60%), Asian (10.00%), African American (6.30%), multiracial or another race (10.40%), or preferred not to answer (2.60%); participants predominantly identified as non-Hispanic or Latino (84.40%).

Community Sample

Participants were recruited via Amazon Mechanical Turk (MTurk). After the removal of 17 duplicate cases, the sample consisted of 217 participants who reported a history (e.g., at least one lifetime act) of NSSI and had disclosed their NSSI to at least one person. The current study was posted online as a task that can be done at the participant’s (worker’s) computer via linking to an online survey tool. Inclusion criteria for MTurk participants were as follows: 18 years of age or older, located in the United States, and had a 95% completion rate for other surveys on MTurk. Participants ranged from ages 19 to 63 years (M = 30.81, SD = 8.25) 74.07% female and identified as Caucasian (74.60%), Asian (6.00%), African American (11.10%), multiracial or another race (6.90%), or preferred not to answer (0.05%); participants predominantly identified as non-Hispanic or Latino (89.20%).

Recent NSSI Sample

Participants included 129 undergraduate students recruited from a large urban university who reported engaging in NSSI at least once in the past 1 year and had disclosed their NSSI to at least one person; this sample was independent from the first described general undergraduate sample. Participants ranged from ages 18 to 29 years (M = 19.65, SD = 1.90) 85.90% female and identified as Caucasian (66.70%), Asian (7.00%), African American (10.90%), multiracial or another race (13.20%), or preferred not to answer (2.30%); participants predominantly identified as non-Hispanic or Latino (86.70%).

Measures

Nonsuicidal Self-Injury

The Inventory of Statements About Self-injury (Klonsky & Glenn, 2009) includes 26 items assessing 13 functions of NSSI and various NSSI characteristics. The measure has demonstrated good reliability (Klonsky & Glenn, 2009), validity (Klonsky & Olino, 2008), and test–retest reliability (Glenn & Klonsky, 2011) in undergraduate samples. The current study defined lifetime NSSI frequency as the total number (frequency) of NSSI acts across the lifetime. An additional item was included at the end of the Inventory of Statements About Self-injury, which asked participants if they had ever disclosed their NSSI (i.e., “Have you ever disclosed, or told someone, about your behavior?” [Yes/No]).

Nonsuicidal Self-Injury Disclosure Reactions

The SI-SRQ was developed for this study to assess the perceptions of the social reactions an individual receives on disclosing their NSSI. This scale was adapted from the original SRQ (Ullman, 2000), which assesses social reactions on disclosure of sexual assault. In modifying this measure to assess NSSI disclosure reactions, the theoretical structure of the SRQ was considered: seven subscales characterizing positive (“tangible aid/information,” “emotional support/belief”) and negative (“victim blame,” “egocentric,” “distraction,” “take control,” “treat differently”) reactions (Ullman, 2000).

To develop the items for the SI-SRQ, the following steps were taken. First, seven items from the SRQ that were specific to the experience of sexual assault were removed (e.g., “reframed the experience as a clear case of victimization,” “took you to the police,” “wanted to seek revenge on the perpetrator”). Next, nine items were modified to better reflect NSSI behaviors as opposed to the experience of sexual assault. The main change was revising the wording “your experience” to “your behavior.” Finally, five items were added to the SI-SRQ that reflect reactions that are specific to NSSI disclosure. These items were developed through a review of the literature (e.g., Klineberg et al., 2013) and a focus group of six psychology researchers who have expertise in self-injurious behaviors (experience ranged from 2 to 20 years). The content of these items included misconceptions of NSSI (i.e., “told you that you are just trying to get attention,” “told you that you are just trying to manipulate others,” “told you that you were acting irresponsibly”); attempts to control the NSSI behavior (i.e., “made you promise to stop engaging in the behavior”); and emotional support surrounding NSSI (i.e., “believed you were trying your best”). Item development resulted in a total of 46 items. The instructions from the SRQ were modified to address disclosures of NSSI; however, the same 5-point Likert-type scale response set was maintained, where 0 = never, 1 = rarely, 2 = sometimes, 3 = frequently, and 4 = always. The SI-SRQ was tested in a small pilot study (i.e., review by several independent parties) prior to use in the study.

Outcomes of NSSI Disclosure

Participants were asked three questions about their perceptions of the social reactions they received during their NSSI disclosure and their behavior following the disclosure: how helpful the disclosure reactions were (1 [not at all helpful] to 10 [very helpful]) if they would disclose the behavior again in the future (Yes/No), and if they continued hurting themselves following the disclosure (Yes/No).

Perceived Social Support

The Multidimensional Scale of Perceived Social Support (Zimet et al., 1988) is a 12-item self-report measure that assesses perceived social support from one’s family, friends, and significant other (e.g., “I get the emotional help and support I need from family”). Responses are provided on a 7-point Likert-type scale (1 = very strongly disagree to 7 = very strongly agree). The Multidimensional Scale of Perceived Social Support has demonstrated good reliability, validity, and test–retest reliability (Zimet et al., 1988) in an undergraduate sample. This scale demonstrated excellent reliability in the community sample, α = .91.

Mental Health Stigma Internalization

The Internalized Stigma of Mental Illness Inventory–10-item version (Boyd et al., 2014; Ritsher et al., 2003) is a 10-item self-report measure that assesses individual’s internalization of stigma toward mental illness (e.g., “People ignore me or take me less seriously just because I have a mental illness”). Responses are provided on a 4-point Likert-type scale (1 = strongly disagree to 4 = strongly agree). The psychometrics (e.g., reliability, validity, test–retest reliability) of this measure have been supported (Boyd et al., 2014) in a variety of psychiatric and community samples. This scale demonstrated adequate reliability in the community sample, α = .82.

Procedures

All participants completed all study questionnaires online as part of a larger study. Participants recruited from undergraduate samples (i.e., general undergraduate sample; recent NSSI sample) were offered course research credit for their participation, whereas participants from the community sample were offered monetary compensation for their participation. Participants from all three samples were offered referral information for local resources and national crisis services at the beginning and end of the study, as well as throughout the study procedures. Resources were also available after the completion of the study via a website. All study procedures received approval from the institutional review board.

Data Analytic Plan

SI-SRQ items demonstrated the following distribution ranges; undergraduate sample: skewness = −1.06 to 2.23 (z scores: 0.33-.15.07; Kim, 2013), kurtosis = 0.26 to 4.62 (z scores: 0.01-15.93); community sample: skewness = −0.34-1.42 (z scores: 0.08-8.50), kurtosis = −1.06 to 0.71 (z scores: 0.59-2.15); recent NSSI sample: skewness = −0.95 to 2.00 (z scores: 0.02-9.52), kurtosis = −1.31 to 3.33 (z scores: 0.25-7.93). The range of each item (0-4) reflects the minimum and maximum values possible. Five cases from the community sample were removed from all analyses due to having missing data on all SI-SRQ items, resulting in a final sample of 211.

Given the current study’s aim was to examine the initial factor structure of the SI-SRQ, an exploratory factor analysis (EFA) was first run utilizing the undergraduate sample (Worthington & Whittaker, 2006; Yong & Pearce, 2013). Oblique promax rotation was used (Floyd & Widaman, 1995). Multiple indices were evaluated to determine the appropriate number of factors: scree plot, factor interpretability, and parallel analysis (principal axis factor with 99% confidence interval and 1,000 random generated data sets; O’Connor, 2000). On arriving at the best fitting factor solution, factor correlations and item loadings were examined. Items that demonstrated poor loadings (<.40) and/or had high cross-loadings (>.40) were removed (Tabachnick & Fidell, 2001).

The factor structure of the revised SI-SRQ was also examined in an external, community (MTurk) sample and a sample of individuals with recent NSSI history via confirmatory factor analysis (CFA). Model fit was determined based on a root mean square error of approximation (RMSEA) below 0.08, standardized root mean square residual (SRMR) below 0.08, a comparative fit index (CFI) greater than 0.90, and Tucker–Lewis index (TLI) greater than 0.90 (Hu & Bentler, 1999; Kline, 2005; Steiger, 2007). Internal consistency of the SI-SRQ was measured via Cronbach’s alpha and omega of the derived subscales. Analyses to determine convergent validity (i.e., perceived social support, stigma internalization) were conducted using bivariate correlations. Finally, relationships between perceived disclosure reactions and disclosure characteristics were examined through bivariate correlations (i.e., perceived helpfulness) and t tests (i.e., future willingness to disclose, NSSI discontinuation) in the community sample and recent NSSI sample.

Robust weighted least squares estimator was utilized for EFA and CFA analyses as this estimator has been shown to possess strong convergence properties within small samples and in the presence of nonnormality (Flora & Curran, 2004; Forero-Garcia et al., 2009; Lei, 2009; Muthén et al., 1997). Following the CFA analyses, SI-SRQ factor scores were not found to be significantly skewed or kurtotic as suggested by the following: community sample skewness statistics, 0.07 to 0.69 (z scores: 0.41-4.06); community sample kurtosis statistics, −0.36 to 0.68 (z scores: −1.03-2.00); recent NSSI sample skewness statistics, −0.31 to 0.79 (z scores: −3.10-7.90); recent NSSI sample kurtosis statistics, −0.59 to −0.03 (z scores: −2.95 to −0.14). Given that each concept for the validity analyses were measured by one scale in both samples (community and recent NSSI) and related to the three SI-SRQ factor scores, a Bonferroni corrected p .008 (.05/2*3) was used.

Results

Preliminary Analyses

Undergraduate Sample

The median number of lifetime NSSI acts was 58.00 (range = 1-4962). The most common NSSI method endorsed was cutting (62.40%) and the mean number of lifetime NSSI methods was 3.64 (SD = 2.26). The majority of participants reported most recently engaging in NSSI 1 or more years ago (58.70%, n = 158), followed by 12.30% (n = 33), who reported their most recent NSSI act was 6 months to less than 1 year ago; 9.30% (n = 25), who reported 3 months to less than 6 months ago; 7.40% (n = 20), who reported 1 month to less than 3 months ago; 6.70% (n = 18), who reported less than 1 week ago; and 5.60% (n = 15), who reported 1 week to less than 1 month ago.

Community Sample

The median number of lifetime NSSI acts was 100.00 (range = 1-2535). The most common NSSI method endorsed was cutting (65.70%) and the mean number of lifetime NSSI methods was 3.87 (SD = 2.89). The majority of participants reported most recently engaging in NSSI 1 or more years ago (58.50%, n = 127), followed by 11.50% (n = 25), who reported less than 1 week ago; 11.10% (n = 24), who reported 1 month to less than 3 months ago; 7.40% (n = 16), who reported 1 week to less than 1 month ago; 6.0% (n = 13), who reported 3 months to less than 6 months ago; and 5.50% (n = 12), who reported 6 months to less than 1 year ago.

Recent NSSI Sample

The median number of lifetime NSSI acts was 101 (range = 1-10350). The most common NSSI method endorse was cutting (60.30%) and the mean number of lifetime NSSI methods was 3.00 (SD = 2.33). All participants reported past-year NSSI, with the median number of past-year NSSI acts being 18 (range = 1-367). The majority of participants reported most recently engaging in NSSI 6 months to 1 year ago (45.80%; n = 59), followed by 16.30% (n = 21), who reported 1 week to less than 1 month ago; 14.70% (n = 19), who reported 3 to 6 months ago; 11.60% (n = 15), who reported less than 1 week ago; and 11.60% (n = 15), who reported 1 month to less than 3 months ago.

See Table 1 for descriptive information and comparison of study variables across samples.

Table 1.

Descriptive Information for Study Variables.

	Undergraduate sample (n = 269);	Community sample (n = 217);	Recent NSSI sample (n = 129);	Test statistic	Effect size
	M (SD)	M (SD)	M (SD)	Test statistic	Effect size
Negative reactions factor	0.98 (0.79)	1.18 (0.93)	0.86 (0.76)	6.27**	.022
Tangible aid factor	1.95 (0.90)	1.85 (0.91)	1.81 (0.88)	1.26	.004
Emotional support factor	2.27 (0.922)	1.93 (1.06)	2.33 (0.98)	9.58***	.031
Perceived helpfulness	5.49 (2.4)	5.41 (2.71)	5.60 (2.28)	0.320	.001
Future disclosure willingness ^a	74.20	76.10	80.50	1.75	.05
Discontinued NSSI ^a	44.20	40.20	37.20	2.52	.06
Social support	5.22 (1.35)	5.11 (1.24)	5.37 (1.12)	1.42	.01
Internalized stigma	1.88 (0.43)	2.01 (0.56)	1.87 (0.50)	3.08*	.01

Note. NSSI = nonsuicidal self-injury.

Percentage endorsement, chi-square, and Cramer’s V reported.

p < .05. **p < .01. ***p < .001.

Exploratory Factor Analysis

Multiple indices were evaluated to determine the appropriate number of factors: scree plot, factor interpretability, and parallel analysis (principal axis factor with 99% confidence interval and 1,000 random generated data sets; O’Connor, 2000). Parallel analyses of the EFA showed five factors with eigenvalues that fell above the corresponding eigenvalues generated from the randomly ordered data (raw data eigenvalues [percentile random data eigenvalue]: 15.10 [1.33], 6.79 [1.29], 1.53 [1.08], 1.33 [1.00], 1.06 [0.93]). However, the scree plot suggested a three-factor solution. The factor pattern, factor structure matrices, and correlations among the factors, in addition to model fit and item content, were then also considered in interpretation of the factor structure. Most important, when examining all factor solutions, there were only three factors that consisted of at least three items that loaded greater than .40 onto a single factor (and did not have high cross-loadings). After considering all of these indices, in addition to factor interpretability, a three-factor solution was determined to be the best fitting solution.

The initial EFA resulted in three items that demonstrated low factor loadings on any factor (e.g., below .40; “Told you that it was not your fault,” “Tried to comfort you by telling you it would be okay,” “Told you he/she felt sorry for you”) and four items with high cross-loadings on at least two factors (e.g., above .40; “Told you that you are loved,” “Reassured you that you are a good person,” “Helped you get information of any kind about coping with your behavior,” “Shared his/her own experience with you”). These seven items were removed and an EFA was conducted on the remaining 39 items.

The final three-factor solution consisted of 39 items, χ²(592) = 1087.58, p < .001; RMSEA = 0.055; SRMR = 0.086; CFI = 0.962, TLI = 0.955. All items loaded positively on their respective factor. Interpretation of the factors suggested that the items on the first factor assessed negative reactions to NSSI disclosure (“negative reactions,” n = 27 items); the second factor assessed reactions offering tangible aid or support (“tangible aid,” n = 5 items); and the third factor assessed reactions offering emotional support (“emotional support,” n = 7 items). See Table 2 for factor loadings and item specification. The negative reactions factor was significantly (p < .05) correlated with the tangible aid (r = .38) and emotional support factor (r = −.34). The tangible aid factor was significantly (p < .05) correlated with the emotional support factor (r = .12).

Table 2.

Exploratory Factor Analysis Results of the Final Model in the Undergraduate Sample (n = 269).

Item	Rotated factor loading			Item statistics
Item	Factor 1: Negative reactions	Factor 2: Tangible aid	Factor 3: Emotional support	M (SD)
Pulled away from you	.69	.19	−.05	1.25 (1.20)
Told you that you were just trying to get attention	.66	.20	−.11	1.05 (1.19)
Told others about your behavior without permission	.55	.27	−.16	1.14 (1.26)
Treated you differently in some way that made you uncomfortable	.59	.24	−.21	1.08 (1.26)
Tried to take control of what you did/decision you made	.60	.27	−.02	1.12 (1.17)
Focused on his/her own needs and neglected yours	.78	−.06	−.06	1.13 (1.21)
Told you to go on with your life	.69	.03	.17	1.24 (1.23)
Told you that you should feel ashamed because of your behavior	.88	−.03	−.01	0.66 (1.02)
Avoided talking to you or spending time with your	.84	.02	−.03	0.74 (1.02)
Made decisions or did things for your	.72	.13	−.01	1.03 (1.17)
Said they feel personally wronged by your behavior	.79	.01	.02	0.70 (1.11)
Told you to stop thinking about it	.46	.33	.04	1.77 (1.26)
Told you that you could have done more to prevent your behavior	.55	.28	.01	1.11 (1.17)
Acted as if you were damaged goods or somehow different now	.84	−.01	−.10	0.91 (1.16)
Treated you as if you were a child or somehow incompetent	.83	−.02	−.12	0.98 (1.19)
Expressed so much anger about your behavior that you had to calm them down	.86	−.07	−.01	0.68 (1.05)
Told you to stop talking about it	.83	.01	.02	0.78 (1.11)
Told you that you are just trying to manipulate others	.76	.07	.15	0.58 (0.94)
Told you that you were acting irresponsibly	.73	.02	−.09	1.11 (1.17)
Minimized the importance or seriousness of your experience	.79	−.07	−.14	1.16 (1.19)
Said he/she knew how you felt when he/she really did not	.60	.17	.09	1.51 (1.23)
Had been so upset that he/she needed reassurance from you	.74	.09	.16	1.13 (1.18)
Tried to discourage you from thinking about your behavior	.53	.28	.16	1.44 (1.30)
Made a joke or sarcastic comment about this type of experience	.81	.29	.01	0.89 (1.15)
Made you feel like you didn’t know how to take care of yourself	.90	−.08	−.04	0.87 (1.13)
Said they feel you’re tainted by your behavior	.96	−.22	.10	0.45 (0.91)
Encouraged you to keep your behavior as a secret	.85	−.09	.04	0.70 (1.09)
Distracted you with other things	.16	.46	.18	1.76 (1.29)
Offered to help you get medical care	.02	.71	.12	1.58 (1.31)
Made you promise to stop engaging in the behavior	−.10	.68	−.03	2.24 (1.46)
Encouraged you to seek counseling	−.12	.71	.03	2.44 (1.30)
Provided information and discussed options	.06	.54	.35	1.72 (1.29)
Listened to your thoughts and feelings	−.16	.02	.78	2.82 (1.03)
Saw your side of things and did not make judgments	−.19	−.06	.83	2.44 (1.18)
Showed understanding of your experience and feelings	−.13	.01	.80	2.41 (1.13)
Was able to really accept your experience	−.02	−.09	.83	2.12 (1.22)
Spent time with your	−.13	.20	.77	2.61 (1.15)
Told you that you did not do anything wrong	.23	−.05	.73	1.75 (1.35)
Believed you were trying your best	.15	.05	.70	1.80 (1.18)
Factor correlations
Factor 1	—
Factor 2	.38	—
Factor 3	−.34	.12	—

Note. Bolded loadings represent the items’ designated derived factor.

Replication and Extension

Confirmatory Factor Analysis in Community Sample

The three-factor structure determined in the EFA was tested on the external, community sample. The model demonstrated adequate fit, χ²(741) = 1570.28.50, p < .001; RMSEA = 0.077; SRMR = 0.090; CFI = 0.921; TLI = 0.916. Item loadings on each factor were appropriate (greater than .40 on their respective factors). See Figure 1 for factor loadings. Additional analyses showed that age was not significantly related to SI-SRQ negative reactions (r = −.08, p = .36), tangible aid (r = −.05, p = .53), or emotional support (r = −.11, p = .18) factors. Likewise, mean factor scores did not differ based on gender: negative reactions, t(215) = 0.21, p = .84, d = .20; tangible aid, t(215) = −0.60, p = .55, d = .01; emotional support, t(215) = 0.64, p = .52, d = .23; or race, F(9, 511) = .63, p = .77, η² = .02.

Figure 1.

Confirmatory factor analysis in the community sample (n = 217).

Confirmatory Factor Analysis in Sample With Recent NSSI History

The three-factor structure determined in the EFA was also tested on an independent, undergraduate sample who reported a past-year history of NSSI. The demonstrated adequate fit, χ²(741) = 1235.45 p < .001; RMSEA = 0.077; SRMR = 0.099; CFI = 0.935; TLI = 0.932. Item loadings on each factor were appropriate (greater than .40 on their respective factors). See Figure 2 for factor loadings. Additional analyses showed that age was not significantly related to SI-SRQ negative reactions (r = −.04, p = .68), tangible aid (r = −.07, p = .42), or emotional support (r = −.01, p = .89) factors. Likewise, mean factor scores did not differ based on gender: negative reactions, t(127) = 0.41, p = .69, d = .11; tangible aid, t(127) = −1.26, p = .21, d = .36; emotional support, t(127) = −0.32, p = .78, d = .11; or race, F(9, 270) = .60, p = .79, η² = .02.

Figure 2.

Confirmatory factor analysis in the recent nonsuicidal self-injury sample (n = 129).

Reliability Analyses

Internal reliability for each factor was good to excellent in both samples. In the community sample, the following reliability statistics were demonstrated: negative reactions (α = .97; Ω = .97), tangible aid (α = .72; Ω = .74), and emotional support (α = .92; Ω = .92). In the recent NSSI sample, the following reliability statistics were demonstrated: negative reactions (α = .96; Ω = .97), tangible aid (α = .69; Ω = .72), and emotional support (α = .91; Ω = .92).

Validity Analyses

In the community sample, the tangible aid (r = .23, p = .002) and emotional support (r = .32, p < .001) factors were both significantly positively related to perceived social support, whereas the negative reactions factor (r = −.20, p = .006) demonstrated a negative relationship to perceived social support. In the recent NSSI sample, the tangible aid factor was not significantly related to perceived social support (r = .01, p = .90) nor was the emotional support factor (r = .20, p = .03). The negative reactions factor was significantly negatively related (r = −.27, p = .003) to perceived social support.

In the community sample, stigma internalization was not significantly correlated with the tangible aid (r = .01, p = .89) or emotional support (r = −.06, p = .82) factors, but was significantly positively related to the negative reactions factor (r = .31, p < .001). In the recent NSSI sample, stigma internalization demonstrated a significantly positive relationship with the tangible aid factor (r = .25, p = .005), a significantly negative relationship with the emotional support factor (r = −.26, p = .003), and a significantly positive relationship with the negative reactions factor (r = .40, p < .001).

Perceived Helpfulness

In the community sample, helpfulness ratings were positively correlated with the tangible aid (r = .44, p < .001) and emotional support (r = .68, p < .001) factors. There was a nonsignificant relationship between helpfulness ratings and the negative reactions factor (r = −.16, p = .04). In the recent NSSI sample, helpfulness ratings were positively correlated with the tangible aid (r = .27, p = .002) and emotional support (r = .63, p < .001) factors, and negatively correlated with the negative reactions factor (r = −.30, p = .001).

Future Disclosure

In the community sample, participants who reported they would disclose their behavior again in the future, compared with those who stated they would not, reported higher levels of the emotional support factor, t(204) = −3.69, p < .001, d = .59. There were no differences on reported levels of the negative reactions, t(194) = 1.51, p = .13, d = .24, and tangible aid, t(204) = −1.79, p = .08, d = .29, factors. In the recent NSSI sample, participants who reported they would disclose their behavior again in the future reported higher levels of the emotional support factor, t(125) = −3.66, p < .001, d = .81; however, among these individuals, there were no differences on reported levels of the negative reactions, t(119) = 0.42, p = .68, d = .09, and tangible aid, t(125) = −0.94 p = .35, d = .22, factors. See Table 3 for means and standard deviations.

Table 3.

Means and Standard Deviations on Perceived Social Reactions by Disclosure Outcomes.

	Community sample (n = 217)			Recent NSSI sample (n = 129)
	Tangible aid	Emotional support	Negative reactions	Tangible aid	Emotional support	Negative reactions
Future disclosure willingness	1.13 (0.88)	1.91 (0.89)*	2.08 (1.00)	1.85 (0.88)	2.49 (0.91)*	0.84 (0.78)
Future disclosure unwillingness	1.36 (1.04)	1.65 (0.91)*	1.46 (1.10)	1.66 (0.85)	1.72 (1.00)*	0.92 (0.66)
Discontinued NSSI	1.06 (0.90)	1.87 (0.96)	2.11 (1.09)	1.61 (0.84)	2.48 (1.08)	0.62 (0.72)
Continued NSSI	1.26 (0.94)	1.83 (0.86)	1.80 (1.02)	1.93 (0.88)	2.25 (0.91)	0.99 (0.75)

Note. NSSI = nonsuicidal self-injury.

p ≤ .008.

NSSI Discontinuation

In the community sample, there were no differences between those who discontinued versus continued engaging in NSSI following their disclosure on reported levels of the emotional support, t(204) = 2.05, p = .04, d = .28; negative reactions, t(194) = −1.48, p = .14, d = .22; or tangible aid, t(204) = 0.32, p = .75, d = .04, factors. In the recent NSSI sample, there were no differences between those who discontinued versus continued engaging in NSSI following their disclosure on reported levels of the emotional support, t(125) = 1.34, p = .18, d = .24; negative reactions, t(119) = −2.65, p = .009, d = .50; or tangible aid, t(125) = −2.02, p = .04, d = .37, factors. See Table 3 for means and standard deviations.

Discussion

The primary aim of the current study was to develop and validate a new measure of perceived social reactions on disclosure of NSSI, the SI-SRQ. It was anticipated that the SI-SRQ would consist of both positive and negative social reaction factors, similar to the SRQ, and that this structure would be supported in both an undergraduate and community sample. Measure validity was expected to be demonstrated through significant associations between perceived social support and positive social reactions as well between as stigma internalization and negative social reactions. The study also explored associations between social reactions to disclosure and participant perception (i.e., helpfulness) and behavior (i.e., willingness to disclose again, discontinuation of NSSI) following NSSI disclosures. Positive social reactions were anticipated to be related to greater perceived helpfulness, increased willingness to disclose NSSI in the future, and a higher rate of NSSI discontinuation. Overall, the initial psychometric properties of the SI-SRQ were supported, resulting in three subscales assessing positive and negative social reactions. There was also evidence of reliability within the subscales and modest support for the convergent validity for the SI-SRQ. Furthermore, (positive) emotional support had the hypothesized effects on individual perceptions and behavior following disclosure.

Results from the current study demonstrated that a three-factor solution for the SI-SRQ was the best-fitting model, which was replicated across samples. The final scale consisted of 38 items that fell onto three different factors: tangible aid, emotional support, and negative reactions. These factors, or subscales, corresponded with the current study hypotheses in that they represented both positive (tangible aid, emotional support) and negative (negative reactions) perceived social reactions. The finding of a single negative reactions factor contrasts with the factor structure of the SRQ, the scale from which the SI-SRQ was adapted, which consists of five different negative social reaction factors (e.g., victim blame, egocentric, take control). Though speculative, this discrepancy is likely due to the fact that the clear and self-directed nature of NSSI allows for more homogenous, less nuanced, negative responses relative to the complexity, ambiguity, and involuntary nature of sexual assault (e.g., Ullman, 2007). It is also important to note that, while the emotional support and tangible aid subscales are conceptualized as positive social reactions, there was a small but significant positive correlation between the tangible aid and negative reactions subscales. As discussed below, despite tangible aid being perceived as helpful to individuals disclosing their behavior, this factor was not associated with other positive disclosure outcomes. This may suggest that not all aspects, or all occurrences, of receiving social reactions of tangible aid are positive, accounting for this factor’s correlation with the negative reactions subscale. However, there is a need for further exploration of this association.

Convergent validity of the SI-SRQ was supported through positive associations between perceived social support and perceived positive (tangible aid and emotional support) reactions and a negative association between perceived social support and perceived negative reactions. Furthermore, stigma internalization was positively related to perceived negative reactions. The associations between perceived social support and the two positive reaction factors are important, as the former assesses the availability of general support (e.g., “ . . . when in need,” “ . . . when things go wrong”), whereas the latter—the positive reaction factors—assess actually receiving support in the context of disclosing NSSI. Thus, the positive reaction factors are tapping into a construct similar to perceived social support, but specific to NSSI disclosure and unpacking emotional and tangible aspects of that social support. A similar relationship exists between stigma internalization and the negative reactions factor, where the measure of stigma internalization used in the current study assesses the broader impact of mental illness (e.g., “People ignore me or take me less seriously just because I have a mental illness”). On the other hand, the SI-SRQ negative social reaction items assess similar interactions (e.g., “Pulled away from you”), but in direct response to NSSI (which, when recurrent and problematic, often represent a mental illness) disclosures. To our knowledge, no measure currently exists to assess NSSI-related stigma, but our results suggest NSSI stigma may be part of a general negative response to NSSI disclosure. Finally, providing further support for the validity of SI-SRQ, the two positive reactions subscales were positively associated with perceived helpfulness of responses in both the community and recent NSSI samples. Additionally, in the recent NSSI sample, the negative reactions subscale was negatively associated with perceived helpfulness. Taken together, along with the use of a conservative correction for multiple analyses, the current findings provide support for the psychometric properties of the SI-SRQ.

In examining individual perceptions and behavioral outcomes following NSSI disclosures, the emotional support subscale was associated with the greatest number of positive outcomes, including perceived helpfulness and increased willingness to disclose again. Results are in line with literature supporting social support as a potential protective factor against negative outcomes, such as suicide attempts, among those who engage in NSSI (e.g., Brausch & Gutierrez, 2010). Moreover, similar research among sexual assault victims supports a similar pattern: emotional support was associated with better recovery (Ullman, 1996a). However, this was not the case with tangible aid reaction (Ullman, 1996a), which is in line with current findings. Though tangible aid social reactions to NSSI disclosure were perceived as helpful in this study, they were not associated with willingness to disclose in the future or likelihood of discontinuing NSSI. It is possible that providing resources (i.e., offering to help get medical care), as opposed to providing nonjudgmental listening, may not be sufficient to promote positive behavioral outcomes. Likewise, negative social reactions adversely affected perceived helpfulness of the disclosure experience, but were not significantly associated with future willingness to disclose one’s behavior or NSSI discontinuation. It is possible, however, that perceived positive reactions were endorsed at a higher level (item range for tangible aid and emotional support factors, 1.58-2.82) than perceived negative reactions (item range, 0.58-1.77), which may have mitigated the effects of negative reactions on behavior outcomes. While no significant relationships between social reactions and discontinuation of NSSI following the disclosure experience were found, many of these analyses produced small to medium effect sizes, highlighting the potential importance of further studying these relationships.

Research in the area of NSSI disclosure has been limited due to a lack of assessment tools. This study provides preliminary support for the SI-SRQ as a self-report measure of perceived social reactions on NSSI disclosure. The development of SI-SRQ fills a significant gap in the literature and will allow future research to address important questions about NSSI disclosure. The initial use of the SI-SRQ suggests that, when disclosing NSSI, individuals typically receive reactions that fall into one of three categories: negative reactions, reactions providing tangible aid, and reactions providing emotional support. The current study has helped provide foundational knowledge on social reactions to NSSI disclosure. However, more research is needed to better understand the nuances of reactions to disclosure, and how these reactions influence interpersonal and intrapersonal distress, disclosure patterns, and treatment seeking.

The current project has provided valuable information about NSSI disclosure; however, findings must be interpreted within the context of study limitations. To our knowledge, this is the first comprehensive study of the NSSI disclosure experience and, as such, has only provided cross-sectional, preliminary data. It will be important for future research to examine the nuanced impact of NSSI disclosures and these relationships over time. For example, the current study was not able to examine social reactions from specific disclosure recipients, nor the influence of social reactions received from a peer or family member on that specific relationship. Furthermore, we were we not able to investigate the influence of perceived social reactions on treatment engagement, a relationship documented in previous research (Muehlenkamp et al., 2012). A longitudinal study design would help elucidate the temporal relationships among disclosure experiences, NSSI behavior, and subsequent psychological distress and treatment seeking. The current project elected to focus on the perceptions of the individual disclosing their NSSI; while their experience of disclosing is necessary in understanding the disclosure experience, the extent to which these perceptions are consistent with the intentions of the disclosure recipient will be an area for future research to explore. Finally, it will be important to validate the use of the SI-SRQ, as well as to further disentangle nuanced aspects of the disclosure experience, among clinical populations (e.g., individuals meeting criteria for NSSI disorder) and individuals of various age ranges and ethnic identities, particularly through in-person (vs. online) research methodologies. Of particular note is the use of a sample from MTurk. While this sample has been found to be reliable (Buhrmester et al., 2011) and attentive (Hauser & Schwarz, 2016), replication for increased generalizability is necessary.

Despite these limitations, results from the present project have direct implications for clinical prevention and intervention efforts. The current study provides a measure to assess perceived social reactions to NSSI disclosure and highlights the distinction and potential significance of reactions an individual may receive on disclosing his or her NSSI. Findings highlight two important avenues of clinical implications. First, there is the potential opportunity for clinical interventions to address perceptions and attributions of tangible aid and negative reactions among individuals who have disclosed their NSSI. This may promote more effective interpersonal communication in the future which, when perceived to go poorly, may trigger future NSSI behaviors (e.g., Turner et al., 2016). Current findings also highlight the importance of increasing educational efforts about specific responses to NSSI disclosures among both providers and members of the broader community. Enhancing potential disclosure recipients’ preparedness to provide general, emotional support toward the NSSI disclosure, as opposed to immediate information about counseling or other services, may be beneficial to promote future NSSI disclosures and discontinuation of NSSI behavior.

Supplemental Material

Supplement_material – Supplemental material for The Development of a Measure to Assess Social Reactions to Self-Injury Disclosure

Supplemental material, Supplement_material for The Development of a Measure to Assess Social Reactions to Self-Injury Disclosure by Brooke A. Ammerman and Michael S. McCloskey in Assessment

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Brooke A. Ammerman

Supplementary Material

Supplemental material for this article is available online.

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