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Adolescents who self-injure: implications and strategies for school counselors.

This article explores strategies for school counselors to use in intervening and managing adolescent students who engage in self-injurious behaviors. The school counselor's roles in intervention, referral, education, advocacy, and prevention are discussed, Implications and recommendations for school counselors are addressed.

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In recent years, the media and popular literature have begun to address the issue of adolescent self-injurious behavior, and many counselors have had an increasing exposure to students who engage in these behaviors. Approximately 13% of adolescents sampled in one recent survey indicated that they engaged in self-injurious behaviors (Ross & Heath, 2002), and research has indicated that self-injury is becoming increasingly prevalent among adolescents (Hawton, Fagg, Simkin, Bale, & Bond, 1997). The incidence of self-injurious behaviors rises to 40% to 61% in adolescent inpatient settings and is ostensibly beginning earlier in the childhood and adolescent years (Conterio, Lader, & Bloom, 1998; Darche, 1990; DiClemente, Ponton, & Hartley, 1991).

Self-injurious behavior is discussed often with regard to the mentally retarded and developmentally disabled populations--people diagnosed with psychotic disorders, personality disorders, and dissociative identity disorder; however it is rarely addressed in discussions of the general adolescent population (Zila & Kiselica, 2001). This article focuses on self-injurious behaviors associated with adolescents in the non-severely mentally disabled population (e.g., mental retardation, schizophrenia, etc.). This article also is delimited to self-injurious behaviors involving self-cutting, interference with wound healing, scratching, and burning, but will not explore issues associated with hair pulling (e.g., trichotillomania), and extreme forms of self-injury (e.g., eye enucleation, amputation of body parts, breaking bones, etc.) as these are less commonly presented in school settings.

It is important to acknowledge that most cultures have forms of culturally acceptable and sanctioned self-injurious behaviors (Favazza, 1996). For example, among adolescents in Western culture, ear piercing, tattooing, and various forms of body piercing are becoming more commonplace. Deviant forms of self-injury are generally considered physically damaging and occur in response to psychological crisis. These acts demonstrate a sense of disconnection and alienation from others; the line between socially sanctioned self-injury and deviant self-injury can be hazy (Dallam, 1997).

Self-cutting is one of the most common forms of self-injury found in the non-hospitalized population, followed by burning, pinching, scratching, biting, self-hitting, and interference with wound healing (Briere & Gil, 1998; Ross & Heath, 2002; Taiminen, Kallio-Soukainen, Nokso-Koivisto, Kaljonen, & Helenius, 1998). The areas that are most typically injured are the arms and wrists, legs, abdomen, head, chest, and genitals, respectively (Conterio et al., 1998; Zila & Kiselica, 2001). In the literature, many varied definitions abound as to what constitutes self-injury. In this article, self-injury will be defined as a volitional act to harm one's body without any intention to die as a result of the behavior (Simeon & Favazza, 2001; Yarura-Tobias, Neziroglu, & Kaplan, 1995).

In many ways, the current awareness of self-injurious behaviors parallels the appreciation of eating disorders that developed in the 1970s and 1980s. At that time, anorexia and bulimia were thought to be rare and interesting conditions, but as public and professional awareness increased, many people began to seek help (Conterio et al., 1998). Despite an increasing awareness of adolescent self-injurious behavior, little is known about what treatments work best with this population (Zila & Kiselica, 2001).

The age at which people first begin to engage in self-cutting behaviors varies; however, these behaviors usually begin in middle adolescence (Herpertz, 1995), with the freshman year of high school being the average age of the first self-injurious behaviors (Ross & Heath, 2002; Favazza & Conterio, 1989). One study found that mental health professionals identified 18 as the average age their clients last engaged in self-cutting behaviors (Suyemoto & MacDonald, 1995). Thus, with regard to self-injury, school counselors are in a unique position to intervene as these behaviors typically begin, and often end, during the adolescent years.

Gender issues may also be present with regard to rates of self-injury. It is commonly stated that females are more likely to engage in self-injury than males. In one study of self-injurious adolescents, 64% were female and 36% were males (Ross & Heath, 2002). Indeed, most studies have indicated the majority of hospitalized self-injuring patients are female (Herpertz, 1995). However, Briere and Gil (1998), using a community sample, found no gender differences with regard to self-injurious behaviors. The belief that females are more likely to engage in self-injury may be related to researchers' use of samples including help-seeking clinical populations, hospitalized patients, and sexual abuse and incest survivor populations; samples that are more likely to be comprised of females. Higher rates of male self-injury in community samples may be due to different definitions of self-injury with some researchers including deliberate recklessness and risk-taking behaviors in which males may be more likely to engage (Ross & Heath).

Many theories have been proposed concerning the etiology and function of self-injurious behaviors. Generally, theories of the etiology of sell-injury tend to be based on biological, psychological, and sociological explanations. From a biological perspective, the seratonergic system has been implicated in the pathophysiology of self-injury (Dallam, 1997; Simeon et al., 1992) as well as the idea that the endorphin rush associated with self-injury can lead to an addiction to the behavior (Pies & Popli, 1995). Among mental health professionals, one of the more popular psychological theories (Suyemoto & MacDonald, 1995) involves the ability of self-injury to regulate emotions. The psychodynamic-oriented emotional dysregulation theory holds that self-injury is the result of anger turned inward on the self (Feldman, 1988) and that the self-injury results in emotional catharsis (Crowe & Bunclark, 2000). Similarly, Linehan's (1993) biosocial emotional dysregulation theory holds that self-injury in person's diagnosed with borderline personality disorder occurs secondary to a person being highly sensitive and reactive to emotional stimuli, yet having a deficit in emotion regulation skills. In other words, people who self-injure have an inability to distract themselves from their emotional experiences; thus the person self-injures as an attempt to modulate or cope with strong emotions.

Research investigations indicate that people who self-injure have identified the following as reasons for engaging in self-injurious behaviors: (a) feeling concrete pain when psychic pain is too overwhelming; (b) reducing numbness and promoting a sense of being real; (c) keeping traumatic memories from intruding into the consciousness; (d) affect modulation; (e) receiving support and caring from others; (f) discharge of anger, anxiety, despair, and expression of disappointment; (g) gaining a sense of control; (h) self-punishment for perceptions of being bad; and (i) an enhancement of self-esteem (Himber, 1994; Shearer, 1994).

Various life factors and clinical correlates are related to self-injurious behaviors in adolescents. Self-injury is often associated with childhood sexual abuse and subsequent posttraumatic stress disorder reactions (Darche, 1990; Favazza & Rosenthal, 1993; Ghaziuddin, Tsai, Naylor, & Ghaziuddin, 1992; Langbehn & Pfohl, 1993), as well as sexual assault/rape (Greenspan & Samuel, 1989), anxiety and depression (Ross & Heath, 2002) and eating disorders (Cross, 1993).

There are many correlates and predictors that are indicative of self-injurious behavior. Conterio et al. (1998) noted that other life conditions including loss of a parent, childhood illness, physical abuse, marital violence, and familial serf-injury are related to self-injury. However, a history of sexual abuse and family violence are the best predictors of self-injury. Research also identifies adolescents' experiences that trigger self-mutilation, including the following: a recent loss, peer conflict and intimacy problems, body alienation or dissociation related to abuse, and impulse control problems (Conterio et al.; Welch, 2001). Indeed, all of these correlates can be useful in identifying at-risk adolescents for the purposes of intervention and prevention (Walsh & Rosen, 1988).

Many times, school counselors become aware of students' self-injurious behaviors prior to families and persons outside of the school setting. The school counselor's first awareness that a student is self-injuring can come from many sources: observations or physical indicators of self-injury, information reported to the counselor by the student, concerns of teachers and parents reported to counselor, or finally, other students reporting a peer's self-injury.

The dynamics of adolescent self-injurious behaviors and implications and strategies for school counselors in working with this population are important to understanding these behaviors. School counselors' functions as providers of interventions, referral agents, advocates, and as educators and prevention agents of student self-injurious behavior are essential in helping these adolescents.

SCHOOL COUNSELORS' ROLE IN INTERVENING AND MANAGING SELF-INJURIOUS BEHAVIORS

According to Dahir, Sheldon, and Valiga (1998), the heart of the National Standards for school counseling programs is a focus on student success being equated with academic development, career development, and personal/social development. Therefore, in terms of facilitating student success, school counselors have an important role to play in ensuring that students are safe and that they have the resources they need to develop in all of the aforementioned areas. School counselors can help facilitate student success by providing interventions, and referrals as well as acting as advocates, educators, and prevention agents with regard to student self-injurious behaviors.

Intervention

Most adolescents who self-injure are evasive about their role in the injury, attempt to avoid attention and embarrassment, and frequently wear clothes that hide their injuries (Alderman, 2000). Physical indicators of self-injury include numerous unexplained scars, burns or cuts. The scars are often more prevalent on the arm opposite the student's dominant hand and are more likely on the forearm at an angle. Some non-threatening questions that can be helpful in eliciting information about injuries are: "What is this from?"; "Could you say more about this?"; "Have you had accidents like this before?"; "What were you thinking or feeling prior to the accident?"; "Have you found a pattern to these accidents?"; and, "How did you feel after the accident?" (Barstow, 1995; Dallam, 1997).

The primary goal for school counselors intervening with self-injuring students is to help them create a safe environment. As many students who self-injure have been physically and sexually abused and thus have a history of adults abusing their power and disregarding their needs, it may be difficult for the student to trust the counselor. Therefore, care should be taken in fostering a strong alliance with the student. An emphasis on structure, consistency, and predictability can be stressed and modeled in the counseling relationship. Developing a plan with the student that emphasizes the students' taking responsibility for behaviors and making the safest decisions possible is one method for accomplishing this goal. A detailed safety plan should be developed including identifying self-injury triggers, physical cues, and reducers related to self-injury; exploring safe people and safe places to go when wanting to self-injure; and the deliberate avoidance of objects which could be used to self-injure (e.g., paper clips, staples, erasers, sharp objects). This plan should serve to help stabilize the student and to provide structure and support until community-based counseling can begin. Techniques that can be used in helping the student manage self-injurious impulses include increasing feeling awareness and recognition, increasing coping skills to be used in managing feelings, encouraging the use of self-soothing techniques such as relaxation exercises, and encouraging the use of a safe places (Kehrberg, 1997).

Research has indicated that two important factors contribute to a cessation of self-injury (Dallam, 1997). The first factor that contributes to a cessation of self-injury is developing an ability to identify and express feelings verbally. The second factor contributing to a decrease in self-injury is learning to use behavioral alternatives to self-injury. The short-term safety plan could be used as a means of fostering the students' development of impulse control and a sense of control in managing the self-injurious behaviors (Kehrberg, 1997). Encouraging the student to be around others when wanting to injure can be helpful, as self-harm is rarely done when others are nearby (Dallam).

Safety issues should also be explored with the student including the importance of not bringing dangerous objects such as razor blades or knifes to school. Students should be instructed on the dangers of using rusty blades or sharing blades with other people who self-injure so as to prevent disease transmission (Dallam, 1997; DiClemente et al., 1991). DiClemente et al. found that 61% of a hospitalized sample of adolescents self-injured, and of that sample, 27% reported that they had shared cutting implements with other adolescents. Clearly, school counselors can play an important role in educating students about the issues associated with sharing cutting implements.

One serious complication of self-injury is the possibility of accidental death as a result of damage inflicted on the body. Thus, in assessing a student's self-injury, it is important to consider the severity of the behaviors as well as possible medical complications. If there is any concern that the student has infections or is engaging in self-injury of a severe and chronic nature (e.g., infections secondary to recurrent cutting, etc.) that could cause severe medical complications, the student should be referred to a physician for an assessment.

To facilitate student safety, Issues related to suicide should be assessed, Counselors should consider (a) an assessment of depression, helplessness, and hopelessness; (b) suicidal ideation, plan and intent, preparation and access to a means of suicide, and past attempts; (c) social support; (d) family history of suicide; and (e) recent stressors. It is important to note that suicide and self-injury are not necessarily related. Indeed, self-injury should only be thought of as suicidal if the student indicates intent to die. It should be noted however, that the link between suicide and self-injury is complicated; one can have suicidal ideation and self-injure and not be considered suicidal (Simeon & Favazza, 2001). An over-reactive stance could alienate students and fracture a developing student/counselor alliance.

The school counselor could provide support during aftercare and could be involved in helping to arrange home tutoring if needed. School counselors might also suggest modifications of the students schedule if needed through the use of a 504 plan. This type of plan allows students identified with a physical or mental impairment, yet not qualified for specialized education, to receive accommodations in their school schedule to receive help for the impairment. For example, the self-injuring student may need to leave class for counseling sessions, follow-up medical care, behavior modification scheduled checks, and time-out sessions to practice cognitive-behavioral intervention techniques. The 504 plan is an agreed upon arrangement between school, parent, and student.

Finally, an important part of a school counselor's intervention plan for self-injurious students is to follow their ethical duty in assessing and, if necessary, reporting the situation. School counselors are obligated to assess the student's behavior in doing harm to him or herself. Legally, school counselors are obligated to contact the student's parents or local authorities in helping the student. Although this task may appear clear, it is often difficult to decipher the severity of behavior and the intent of the self-injury. Part of the process should include assessing the family situation and determining if the student is safe in his or her home environment. If appropriate, parents should be called to the school and appropriate referral information should be given. However, parents should not be the first contacted if issues of abuse are part of the student's report. Following school protocol, the local social

service agency or police should be contacted if abuse is suspected.

Referral Issues

In discussing the role of school counselors, Baker (2001) stated that their scope of practice primarily includes the intervention and prevention of mental and emotional disorders, but not the diagnosis and treatment of disorders. Thus, school counselors play an important role in the referral of students to qualified professionals. School counselors can make either a partial or a complete referral (Baker). A complete referral would involve dissociating from the student's case, and a partial referral would involve some continued involvement with the student while he or she works with outside mental health professionals. A referral for inpatient or out-patient treatment would be appropriate, and should be done in a sensitive manner so that the student does not feel abandoned or refuses to go. School counselors need to be knowledgeable of the practitioners and treatment centers that have specific training in the management of self-injury. If possible, the school counselor might use an in-service day to visit local treatment facilities and determine the steps a student would go through in receiving treatment. When counselors are aware of what the treatment process is like, they can better help students and their families in making decisions and developing intervention plans.

Once the student begins work with a community mental health professional, the counselor can collaborate with the community professional and can continue to play a role in the student's treatment process (e.g., being a safe person the student can talk to when wanting to injure). If the student goes for inpatient treatment, the school counselor could be involved in continuing the educational process through arranging in home tutoring or collaborating with the educational tutor at the residential center or hospital.

Advocacy and Education

Advocating for students, and educating school personnel are important roles of school counselors (Baker, 2001). Through advocacy and education, school counselors can help to dispel myths and break down stereotypes regarding self-injury.

School counselors can advocate for students through faculty in-services and parenting groups, and speaking in health classes to students regarding self-injury. It is important to inform staff, parents, and students that self-injury does not mean someone is crazy, but can be understood as a means of attempting to help one's self. In particular, educating school faculty regarding the etiology and function of self-injury can help in dispelling the myth that people who self-mutilate are attention seeking. Dispelling myths can help students gain access to support and needed services both within the school and in the outside community. For example, a teacher who is aware a student is self-injuring may not report self-injury as he or she may perceive it as trivial or as a way for the student to receive attention. With education, the teacher may be more likely to seek help for the student and to make the school counselor aware of the situation.

Education of staff and teachers is one manner in which school counselors can advocate for students who self-injure. By educating faculty about self-injury, they should feel more comfortable in managing the issue of self-injury. Also, educating faculty on ways to approach or manage student self-disclosure of self-injury can be helpful. In particular, the physical education teacher and the school nurse may be of critical importance in identifying and monitoring students who self-injure.

Advocating for students by educating faculty about the fact that self-injury is not equated with suicidality is also very important. Strong personal reactions to self-injury can lead to reactionary stances and extreme measures such as unnecessary hospitalizations, pulling students out of school, or suspending students. Educating faculty and administrators on the differences between self-injury and suicide attempts can help in avoiding unnecessarily restrictive actions.

Prevention

Conterio et al. (1998) and Welch (2001) have noted that loss, childhood illness, physical and sexual abuse, marital violence, familial self-injury, peer conflict and intimacy problems, and impulse control problems are all related to self-injury. Thus, for the purposes of prevention, school counselors should consider these variables when targeting at-risk students. As with the issue of intervention, prevention efforts can include helping students to express and identify their feelings, while also developing healthy behavioral coping skills. Group counseling and counselor outreach activities that encourage at-risk students' development of these aforementioned skills may be helpful in preventing self-injury. Prevention efforts can also occur by providing pamphlets and handouts to students. Materials concerning self-injury can be distributed through health classes or directly through the school counseling office.

A sequence of events in which a person inflicts self-injurious behaviors and is imitated by others in the environment is referred to as contagion of self-injurious behaviors (Walsh & Rosen, 1985). The issue of contagion has received some attention in the research literature (Rosen & Walsh, 1989; Ross & McKay, 1979; Taiminen et al., 1998; Walsh & Rosen) Initial research indicated that in hospital and residential treatment settings, adolescents tend to imitate self-injurious behaviors. Self-injurious acts followed in 25 residents at a residential facility indicted that these acts are bunched or clustered in time across subjects, suggesting that adolescents in a residential setting trigger the self-injurious behaviors in each other (Walsh & Rosen). These findings suggest that a group process variable or social factors may contribute to the behavior in participants who already self-injure or are at risk for self-injuring. Walsh and Rosen noted that labeling self-injury as a behavior that is likely to be imitated actually decreases self-injury as many adolescents, for developmental reasons, do not want to be perceived as being imitative or be labeled as followers.

Similar to Walsh and Rosen (1985), Talminen et al. (1998) have suggested adolescents' weak egos and diffuse identities make them susceptible to various forms of identification including self-injuring and refer to this phenomena as "rites of togetherness" (p. 215). Through intensive study (i.e., interviewing methods and empirical observation), Rosen and Walsh (1989) came to similar conclusions. They stated that adolescents in a residential setting engaged in contagious self-injury as a "concrete display of affinity between two people" (p. 657). Rosen and Walsh observed the following: (a) individuals involved in contagious self-injury are highly enmeshed; (b) they have difficulty with conventional forms of intimacy; (c) they find deviate acts (e.g., shared self-injury) to be compelling and exciting. Rosen and Walsh concluded that when contagious self-injury occurs, it is important to use interventions that target specific dyads. It is important to help the adolescents express emotions and negotiate intimacy in more normative ways. When this is not possible, it may be necessary to isolate the person being modeled from the rest of the group.

While the aforementioned studies all involved adolescents in residential treatment settings, Fennig, Carlson, and Fennig (1995) described their experiences consulting in a public school setting regarding a situation where an outbreak of self-mutilation occurred. They expressed concerns that this phenomenon may be more frequent in educational systems than reported. In describing their experiences they made the following observations: (a) the majority of students involved in the outbreak did not demonstrate any overt psychopathology and were not identified as emotionally disturbed; (b) the only overt sign of problems associated with self-injury was a drop in grades; (c) several initiators with more severe psychopathology seemingly induced the behavior in more passive students and all had anxiety and depressive related traits; (d) isolation of the more severely disturbed initiators was most effective in lowering the severity and frequency of the phenomenon.

While these suggestions are narrative and have not been empirically scrutinized, school counselors facing similar situations can use this information. Combined, the research related to contagion implies that social factors may contribute to the development and maintenance of self-injurious behavior. A related issue is to differentiate initiation self-mutilating behaviors of gangs or cliques from self-injuring behaviors related to psychopathology. Although both types of behaviors are significant, intervention and referral can take different directions. If an ostensible contagion situation occurs, consultation with other professionals may be necessary.

PERSONAL REACTIONS

Counselors may have many strong feelings when faced with student self-injurious behaviors. Alderman (2000) stated that the typical clinician treating a client who self-mutilates is often left feeling a combination of helplessness, guilt, anger, betrayal, disgust, and sadness. Self-injury has been identified as the most distressing client behavior encountered in clinical practice and the behavior that many professionals find most traumatizing to encounter (Gamble, Pearlman, Lucca, & Allen as cited in Deiter & Peralman, 1998).

Writers on self-injury frequently address the issue of counselors' need to manage their personal reactions towards clients who self-injure. Issues such as the time and emotional investment required in working with this population, the strong reactions of counselors to self-injury, and the limits these reactions place on counselors' ability to work with clients have been noted (Levenkron, 1998; Zila & Kiselica, 2001). Self-injury is sometimes viewed as being manipulative or "attention seeking" (Simeon & Favazza, 2001). Counselors may sometimes feel frustrated with self-injury and may want to attempt to control the student by forcing him or her to stop engaging in the self-destructive behavior, or by lecturing or debating the problems associated with self-injury. A personal awareness and understanding of one's intentions when working with students who self-injure can be helpful in facilitating successful interventions. Avoiding attempts to control the student or tell him or her to stop the behavior can facilitate student empowerment as well as prevent potential power struggles. A constant monitoring of personal reactions combined with ongoing consultation and supervision can help in ensuring that counselors maintain an objective perspective when working with this population (Deiter & Pearlman, 1998).

CONCLUSIONS

Self-injury is an increasing trend that has not been adequately addressed in the literature. Preliminary research indicates that the etiology, function, and interventions associated with self-injury are diverse and varied; counselors know little and must be careful, deliberate, and thoughtful in working with this population.

Counselors can serve as powerful advocates to students who self-injure through challenging a culture that may contribute to adolescents' challenges and by hearing adolescents stories, validating their experiences, and providing a safe refuge. Counselors can also play a role in intervening and preventing self-injury; educating teachers, parents, and students; and making referrals to specialists who can help the self-injuring student. On a more macro-cultural level, counselors can serve to fight oppressive cultural systems that serve to disempower adolescents and hamper their voices by providing an environment that fosters self-expression and the use of positive coping skills (Conterio et al., 1998; Zila & Kiselica, 2001).

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Victoria E. White Kress, Ph.D., is an assistant professor, Department of Counseling, Youngstown State University, Youngstown, OH. E-mail: vewhite@ysu.edu.

Donna M. Gibson, Ph.D., is an assistant professor, School of Education, The Citadel, Charleston, SC.

Cynthia A. Reynolds, Ph.D., is an assistant professor, Counseling and Special Education, University of Akron, OH.
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Author:Reynolds, Cynthia A.
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Date:Feb 1, 2004
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Students who self-injure: school counselor ethical and legal considerations.

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