Just cut it out: legal and ethical challenges in counseling students who self-mutilate.

This article reviews current literature on self-mutilation, comprises a definition, examines gender differences, and describes the profile of the self-mutilator in order that school counselors and other personnel may make accurate risk assessments. Precipitating events are described to aid school counselors in anticipating a harmful event. Information is included to assist with prevention and confidentiality issues as appropriate.

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It is estimated that 700 of every 100,000 individuals self-mutilate (Dunkle, 1990). Researchers indicate that 53% of a social worker's teen case load includes some form of self-destructive behavior, with 14 to 16 year olds comprising the largest group (Neagle, 1991). Dihiino (1998) states that non-lethal self-mutilation is becoming a common adolescent problem. Lloyd (1997) sampled 143 high school students and found that 39% had participated in some form of self-mutilation within a year's time. Consequently, self-mutilation is a phenomenon addressed daily by school counselors.

Ethical dilemmas arise when counselors must determine the difference between cases of normal identity and those constituting inappropriate behaviors. School counselors must use laws and codes of ethics to determine when confidentiality must be breached as well as implement strategies to assist self-mutilating students. This article describes types of non-suicidal self-mutilation, examines the profile of self-mutilators, reviews laws and codes of ethics as related to confidentiality, distinguishes between suicide and self-mutilation, and suggests best practices school counselors can implement to help such students.

BACKGROUND

In order to effectively handle the legal and ethical complications presented to counselors, awareness of problem behaviors, background information and other data on self-mutilation is necessary. A definition of self-mutilation, gender differences, profiles, and risk factors is presented to aid counselors in developing plans of action. References cited may be used for additional study.

Definition

Boundaries established by previous generations have been crossed and consequently, difficulties arise when attempting to distinguish between society's norms and perverse self-mutilation. Piercings and tattoos once thought barbaric have recently become common place. In a society full of accepted mutilations, a distinction between accepted body adornments and psychotic mutilations can become blurred. Simeon et al. (1992) refers to self mutilation as "deliberate harm to one's own body resulting in tissue damage, without a conscious intent to die" (p. 221). Stone and Sias (2003) state that self-mutilation refers to a complex group of behaviors in which there is "deliberate destruction or alteration of body tissue without conscious suicidal intent" (p. 113). Levenkron (1998) states that "the current trend of piercing the skin on various parts of the face and body ... is not self-mutilation. This behavior, although repugnant to some of us, falls into the category of adolescent trendiness (which also includes larger and more outrageous tattoos)" (p. 23). Self-mutilation for the purpose of this article refers to those who seek out pain and blood in order to relieve emotional pain. Students who tolerate self inflicted pain to achieve a certain look need a different plan of action than the aforementioned self-mutilator. This leaves school counselors with an ethical concern of determining a student's intent before devising a plan of action.

Gender Differences

More is known about self-mutilation with girls than with boys (Zila & Kiselica, 2001). Michelman and Eicher (1991) state that dress and body markings reflect social culture for both sexes. Boys may use wounding as a passage into manhood and as an attempt to establish self and cultural acceptance. Girls may injure themselves to privately overcome issues associated with the onset of menstruation and previous sexual abuse (Zila & Kiselica). Male and female self-mutilators demonstrate poor relationships with the opposite sex. Michelman & Eicher found that females who carved a male's initials on their skin did so as a symbolic method of separating from their families. Boys who mutilated rarely achieved any form of emotional stability with a girlfriend.

Methods and Types of Mutilation

Self-mutilation can range from severe tissue damage to surface skin damage. Favazza and Rosenthal (1993) identify three types of mutilation: stereotypic, major, and moderate. Stereotypic self-mutilation is most often seen in the mentally retarded institutionalized individual. Psychotic patients often perform major self-mutilations or those that destroy a large portion of the body. One such example might be an amputation. Moderate self-mutilation is the most common type, is non life threatening, occurs in many forms, and is intermittent. This type of self-mutilation is seen most often with adolescents and is the type discussed in this article. Examples might include skin carving, scratching or scraping, needle piercing, and minor burns.

RISK FACTORS

Are other behaviors linked to self-mutilation? Research indicates that those who have been repeatedly abused are the most likely to inflict self injury (Favazza & Rosenthal, 1993; Kehrberg, 1997; McLane, 1996; Simpson, 1981; Zila & Kiselica, 2001). Additionally, self-mutilators are more likely to have eating disorders, abuse drugs and alcohol, have above average intelligence, and more often than not are employed in the medical field (Simpson). Walsh and Rosen (1988) found other variables determining risk of self-mutilation. These include loss of a parent, peer conflicts, sexual abuse, having another self-mutilating family member, and observing family violence. The most common events leading to self injurious behaviors in teenagers are recent loss or death, peer conflict, intimacy problems, impulse disorder, and a rejection of human interconnection (Kehrberg). Cutting is an out of body experience in which the person bypasses the body's defenses and desires pain (Levenkron, 1998).

Precipitants

Feelings of shame, humiliation, and rage may preempt self-injurious behaviors in these individuals. Failure (accompanied by feelings of low self-worth; Richards, 1999) and pent up rage often precede cutting with these subjects (Prescott, 2000). Mutilation is a way to alleviate stress, depression, rejection, hyperactivity, numbness, and feelings of alienation. The onset of menstruation and inability to handle emerging sexuality has been linked to self-mutilating behaviors particularly with rape or incest victims (Zila & Kiselica, 2001). Cutting becomes a re-enactment of childhood trauma, a method of communicating the unspoken, and a way to manage the psyche (Levenkron, 1998). The use of alcohol or drugs may be another method of inflicting self-harm and has been shown to induce self-mutilating behavior. A romantic breakup, conflict with a parent, or any other incident leading to feelings of alienation may bring about the onset of self-mutilation (Zila & Kiselica). It seems all self-mutilations are precipitated by a need to regain control by injuring the body.

MYTHS

A huge dilemma for counselors and self-abusers arises as a result of the lack of knowledge people have about the issue. Since discussion follows concerning legal and ethical issues as well as best practices, information on myths is included to help heighten awareness.

Myth #1. Self-mutilators use this behavior to manipulate other people. Physical pain is inflicted in an attempt to replace emotional rage. The victim's attempts to conform to expectations of normal behavior lead to silence about the event. Victims go to great lengths to present themselves as uninjured and normal and rarely seek to manipulate others through mutilation (McLane, 1996).

Myth #2. Self-mutilation is synonymous with suicide. Self-mutilation is a ritual performed for different reasons than suicide and should not be compared or confused with the latter. The self-mutilator uses pain to mask emotional pain but does not intend to destroy the entire body (Levenkron, 1998; Zila & Kiselica, 2001).

Myth #3. Self-mutilators are dangerous and will probably harm others. Self-mutilation is usually secretive and is most often performed in isolation. The behavior is not performed in an attempt to harm but rather to vanquish emotional pain. Violence is not directed toward others (McLane, 1996).

Myth #4. Self-mutilators just want attention. Most self-mutilators perform their ritual and symbolic acts in private. They are often humiliated about their scars and keep them private (Levenkron, 1998).

THE PROFILE

The profile of a self-mutilator has been researched by counselors, those in the medical field, educators, and psychiatrists. School counselors and other personnel need to become acquainted with typical responses in order to make accurate risk assessments. Presented below are some of the typical behaviors, thinking patterns and motivations, and personality traits to aid the counselor with awareness.

Behavior and Personality Traits

Self-mutilating behavior generally begins in adolescence (Kehrberg, 1997) and may be accompanied by distinguishing behaviors. Girls who mutilate often do it to determine if somebody does actually care. Smith (1989) found that incest survivors who self-mutilate are more likely to be shy, have lower self-esteem, and may feel less bound by societal rules. Accepting help from others may be difficult for these subjects since they are unfamiliar with bonding. They rely only upon themselves and have few friends (Zila & Kiselica, 2001).

Verbal Cues

Verbal cues can provide hints that self-destructive behaviors are occurring (Schneidman, Farbverow, & Litman, 1976). Girls will voice concerns that they are patronized and others do not listen. This perception may lead girls to violate themselves in order to feel heard (Machoian, 1998). They rarely discuss their violations because of shame, and in order to maintain the secret, distance themselves from others (Zila & Kiselica, 2001). These verbal cues should be evaluated in conjunction with behaviors and personality traits to assess a course of action.

Thinking Patterns and Motivations

When a subject recalls a painful event from the past, feelings of rejection, anger, shame, and low self-worth arise. Previous efforts to communicate this pain have been kept secret due to embarrassment and the unspoken familial code of silence. Pain becomes hard to communicate and victims use mutilation as a way to express overwhelming emotions. Cutting becomes a desperate ploy to obtain empowerment, control, and self healing. After cutting, mutilators feel a sense of calm having found a unique method of organizing the psyche. An all encompassing pain is ended in one moment allowing the victim this feeling of control (McLane, 1996).

BEST PRACTICES

School counselors must be prepared to handle situations appropriately before, during, and after self-injury. School counselors may be the first professional seen by a self-mutilating student. The actions taken by the school counselor may determine if and when students receive additional help from other professionals and must coincide with laws and ethical codes. Following are descriptions of best practices to be implemented by schools in handling cases of self-mutilation.

Prevention

Consult with other professionals and refer students out when appropriate. Become familiar with community agencies and private practitioners who treat self-mutilators before the information becomes needed. Provide these resources to parents.

Collaborate with another professional since hospitalization may be considered.

Individual and group counseling strategies should be implemented to assist students with self-mutilation along with the accompanying issues of self-esteem, grief, loss, divorce, assertiveness training, and anger. Cognitive counseling and behavior modification have been shown to be affective in helping self-mutilators. Asking about the behavior demonstrates a willingness to listen and offers needed empathy (Zila & Kiselica, 2001). Counselors should instill alternative methods of empowerment while supporting the self-mutilating person's dignity (Prescott, 2000).

Create a supportive environment. Become a safe haven when negative emotions become too encompassing.

Educate teachers and other staff on the importance of listening and empathizing with students. Information in this article should be shared with staff so they can both help students and determine differences between suicidal and non-lethal self-mutilation.

Encourage staff" to release students from class to visit with the building counselor when negative emotions surface.

Encourage verbalization. Self-mutilators need a method of communicating pain in lieu of cutting (Levenkron, 1998).

Involve the family in counseling when possible. Improved communication and attachment issues are best resolved within the entire system (Kehrberg, 1997). Parents should be educated on self-mutilation in order to assess dangerous behavior at home.

Classroom presentations should include related issues such as drug and alcohol abuse, violence, self-esteem, and possible exposure to diseases. Modeling, assertiveness training, and showing appropriate ways to voice negative emotions have all proven effective in handling those who self-mutilate (Zila & Kiselica, 2001).

As required by law, report suspected child abuse.

Notify parents and other appropriate personnel when a student is inflicting bodily harm. Following is a discussion to help determine when confidentiality must be broken.

Legal and Ethical Considerations

At what point should a self-mutilating student's confidentiality be breached? Counselors must often weigh legal responsibilities with ethical decisions when dealing with self-mutilators. Once the self-mutilator has disclosed painful events, breach of confidentiality can mean further harm for an already alienated student. As stated in the definition of self-mutilation, many injuries are inflicted for non-psychotic reasons such as body adornment. Should counselors risk student trust by reporting these injuries?

The expectation that what is communicated in counseling will remain private or confidential seems to be crucial to both the client's willingness and ability to self-disclose. Research by McGuire, Parnell, Blau, & Abbot (1994) indicated that adolescents understand and desire confidentiality. A study of 235 high school seniors in Illinois by West & Kayser (1991) revealed that the second highest reason students did not approach counselors was fear of inappropriate disclosure. School counselors must remember that, "Confidentiality belongs to the client ..." (Glosoff, Herlihy, & Spence, 2000, p. 454). ACA says that, "counselors respect their clients' right to privacy and avoid illegal and unwarranted disclosures of confidential information" (Ledyard, 1998). Thus, school counselors must make every effort to disclose information only when ethically feasible.

At the same time, counselors have a duty to warn or protect others in society from harmful behavior. Vernon (1993) believes the student's age and capability, the possible consequences of disclosures on therapeutic progress, and the legal and ethical policies within a particular school district should govern the decision regarding violation of confidentiality.

Research is unclear about parents' legal rights to access of information shared by students in private school counseling sessions. Huey and Remley (1988) contend that parents have a right to information shared in a confidential counseling session while Fischer and Sorenson (1996) believe that school counselors have a tight to secure the content of counseling sessions. Ritchie & Norris Huss (2000) believe that ethically the child is the client but legally the parent is the client. Ledyard (1998) indicates there is a lack of agreement regarding confidentiality when counseling minors, specifically when sharing information with parents. Although parents may have the legal right to know what is going on, it is an ethical responsibility to get the minor's permission before sharing anything. The minor should be included in as much of the decision making as possible (Ledyard). As a result, school counselors must clarify the limits of confidentiality with both parents and students.

The Tarasoff rulings in California found a psychologist liable for damages after he failed to warn a woman of impending harm. The client confided the premeditated murder to the therapist and eventually carried out the act. Despite the fact that the psychologist notified campus police, the judge found him negligent for failure to warn the potential victim. This mandated reporting extends "to those foreseeably endangered" (McCarthy & Sorenson, 1993, p. 162). A counselor may be in legal jeopardy for non-disclosure if a student shares mutilating behavior with a counselor and is later seriously injured.

Disclosures may be appropriate if counselors are aware a student poses a risk to self or others. Psychotic forms of self-mutilation meet this category, yet it may be difficult to determine which injuries are threats to self and which are simply one time rites of passage. A method of handling this dilemma includes encouraging students to share vital information with parents. The therapeutic alliance formed as a result of prior confidentiality can help facilitate appropriate disclosure. Counselors must teach students the benefits of appropriate communication with parents. Parents, as collaborators, can learn appropriate ways to reinforce such sharing. Self-sharing by students removes the ethical and legal burden from the shoulders of the counselor. Should students refuse to disclose, counselors may need to inform parents or others. Lawrence and Robinson Kurpius (2000) list ways counselors can protect themselves when students are wary of disclosing to parents. These include practicing within the limits of abilities, familiarizing oneself with state laws and statutes, clarifying policies about confidentiality, keeping accurate and objective records, maintaining liability coverage, and conferring with colleagues.

CONCLUDING COMMENTS

School counselors may be the first professionals to encounter the student self-mutilator. Plans implemented to assist these students may have lasting positive or negative effects depending upon the response. Counselors have an ethical and legal obligation to educate themselves about self-mutilation and implement appropriate plans of action. Collaboration with other professionals, education of all staff and parents, classroom guidance, and counseling strategies can make a difference for self mutilating students. Counselors should take responsibility for clarifying confidentiality with students and other parties prior to counseling sessions since a threat of harm may require disclosure.

References

Dibrino, C. I. (1998). Self-mutilation in adolescence (Doctoral dissertation, Adler School of Professional Psychology, 1998). Dissertation Abstracts International, 59, 5077.

Dunkle, T. (1990). Health: Dissecting causes of self-mutilation. Insight, 6(22), p. 48-51.

Favazza, A. R., & Rosenthal, R.J. (1993). Diagnostic issues in self-mutilation. Hospital and Community Psychiatry, 44, 134-140.

Fischer, G. P., & Sorenson, L. (1996). School law for counselors, psychologists and social workers (3rd ed.).White Plains, NY: Longman.

Huey, W. C., & Remley, T. P., Jr. (1988). Ethical and legal issues in school counseling. Alexandria, VA: American School Counselor Association.

Glosoff, H. L., Herlihy, B., & Spence, E. B. (2000). Privileged communication in the counselor-client relationship. Journal of Counseling and Development, 78, 454-462.

Kehrberg, C. K. (1997). Self-mutilating behavior. Journal of Child and Adolescent Psychiatric Nursing, 10(3), 35-40.

Lawrence, G., & Robinson Kurpius, S. E. (2000). Legal and ethical issues involved when counseling minors in nonschool settings. Journal of Counseling and Development, 78, 130-136.

Ledyard, P. (1998). Counseling minors: Ethical and legal issues. Counseling and Values, 42, 171.

Levenkron, S. (1998). Cutting. New York: W. W. Norton.

Lloyd, E. E. (1997). Self-mutilation in a community sample of adolescents (suicide ideation) (Doctoral dissertation, The Louisiana State University and Agricultural and Mechanical College, 1997). Dissertation Abstracts International, 58, 1886.

Machoian, L. (1998).The possibility of love: A psychological study of adolescent girls' suicidal acts and self-mutilation (Doctoral dissertation, Harvard University, 1998). Dissertation Abstracts International, 59, 1886.

McCarthy, M. M., & Sorenson, G. P. (1993). School counselors and consultants: Legal duties and liabilities. Journal of Counseling and Development, 72, 159-174.

McLane, J. (1996).The voice on the skin: Self-mutilation and Merleau-Ponty's theory of language. Hypatia, 11(4), pp. 107-121.

McGuire, J. M., Parnell, T., Blau, B. I., & Abbot, D.W. (1994). Demands for privacy among adolescents in multi-modal alcohol and other drug abuse treatment. Journal of Counseling and Development, 73, 74-78.

Michelman, J. D., & Eicher, J. B. (1991). Adolescent dress, part 1: Dress and body marking of psychiatric outpatients and inpatients. Adolescence, 26(102), 375-385.

Neagle, R. (1991). Self-destructive behavior among adolescents: Views of social workers and other health care professionals regarding prevalence and causes (Master's thesis, California State University 1991). Master's Abstract International, 29, 0588.

Prescott, L. (2000). Veterans of abuse and daughters of the dark: The politics and naming and risk of transformation in building partnerships for change. Perspectives in Psychiatric Care, 36(3), p. 95-100.

Richards, M. V. (1999).The phenomenon of self-mutilation: An empirical phenomenological investigation (guilt, worthlessness) (Doctoral dissertation, Duquesne University, 1999). Dissertation Abstracts International, 60, 2958.

Ritchie, M., & Norris Huss, S. (2000). Recruitment and screening of minors for group counseling. Journal of Specialists in Group Work, 25, 146-156.

Schneidman, E., Farbverow, N., & Litman, R. (1976). The psychology of suicide. New York: Jason Aronson.

Simeon, D., Stanley, B., Frances, A., Mann, J. J., Winchel, R., & Stanley, M. (1992). Self-mutilation in personality disorders: Psychological and biological correlates. American Journal of Psychiatry, 149, 221-226.

Simpson, C. A. (1981). An exploratory study of self-mutilation (Doctoral dissertation, University of Kansas, 1981). Dissertation Abstracts International, 42, 3003.

Smith, J. E. (1989). A study of the relationship between delicate self-cutting, ability to express emotion, locus-of-control, impaired relationships, anxiety, and depression (self-mutilation) (Doctoral dissertation, California Institute of Integral Studies, 1989). Dissertation Abstracts International, 50, 3716.

Stone, J. A., & Sias, S. M. (2003). Self-injurious behavior: A bimodal treatment approach to working with adolescent females. Health Source: Nursing/Academic Edition, 25(2), 112-125.

Vernon, A. (1993). Counseling children and adolescents. Denver, CO: Love.

Walsh, B.W., & Rosen, P. M. (1988). Self-mutilation: Theory, research, and treatment. New York: Guilford.

West, J. S., Kayser, L. (1991, November). Student perceptions that inhibit the initiation of counseling. School Counselor, 39(2), 77-82.

Zila, L. M., & Kiselica, M. S. (2001). Understanding and counseling self-mutilation in female adolescents and young adults. Journal of Counseling an Development, 79(1), 46-52.

Janet Froeschle is a school counselor at Harold C. Kaffie Middle School, and Mike Moyer is Communities-in-Schools case manager at Richard King High School. Both are doctoral students, Department of Counseling and Educational Psychology, Texas A&M University-Corpus Christi.