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Students who self-injure: school counselor ethical and legal considerations.

This article explores ethical considerations that school counselors may need to address when providing counseling services to self-injurious students. Ethical issues related to student confidentiality, responsibilities to parents and to the school, and professional competence are discussed in relation to the American School Counselor Association's (2004) Ethical Standards for School Counselors. Implications and recommendations for school counselors working with self-injurious students are provided.

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Self-injury is an issue that has received increased attention in the recent literature (Austin & Kortum, 2004; Froeschle & Moyer, 2004; Kress, 2003; Kress, Gibson, & Reynolds, 2004; White, McCormick, & Kelly, 2003) and has become more visible in the school setting with many educators and school counselors feeling frustration and confusion as to how to best address student self-injurious behaviors (Austin & Kortum). Estimates of self-injury vary depending on the population sampled and the definition of self-injury (Suyemoto & Kountz, 2000), but current estimates of self-injury range from 1 percent to 4 percent (Briere & Gil, 1998) of the general population. With regard to the adolescent population, a recent study indicated that 13% of surveyed adolescents reported engaging in self-injurious behavior (Ross & Heath, 2002).

With an ostensible recent increase in self-injury prevalence in the adolescent population, it is important that school counselors recognize the signs and symptoms of self-injury and have the knowledge needed to appropriately intervene and best help these students (Kress et al., 2004). On average, people who self-injure typically begin this behavior during middle adolescence (i.e., about age 14 or the freshman year of high school) and will continue the behavior into their late twenties (Austin & Kortum, 2004; Favazza & Conterio, 1989; Herpertz, 1995; Ross & Heath, 2002); thus school counselors are in a position to provide early identification, intervention, prevention, and advocacy for students who self-injure (Kress et al, 2004).

As student self-injurious behavior is complex and multifaceted, school counselors should be aware of the many ethical issues associated with counseling self-injurious students. The purpose of this article is to first provide a brief overview of self-injurious behavior, and to then address the ethical considerations, as defined by the American School Counselor Association's (ASCA) Ethical Standards for School Counselors (2004), that school counselors should be aware of when working with students who self-injure. More specifically, ethical issues associated with student confidentiality, responsibilities to parents and to the school, and professional competence will be addressed and practical suggestions for how school counselors can best manage these issues will be provided. As many school counselors have had little, if any, training in managing issues associated with student self-injury, this article is an attempt to increase school counselors' ability to integrate the ASCA Ethical Standards for School Counselors into their work with the growing self-injurious population.

OVERVIEW OF SELF-INJURIOUS BEHAVIOR

Before addressing the ethical issues involved in counseling self-injurious students, it is first important that school counselors have an awareness of self-injurious behavior, and an ability to recognize these behaviors. More specifically, school counselors should be aware of what defines self-injury, and the correlates/risk factors associated with self-injury. This section provides a brief overview of the aforementioned issues (readers are encouraged to review additional sources for more in-depth information about self-injury, e.g., Conterio, Lader, & Bloom, 1998; Favazza, 1996; Kress, 2003; Simeon & Hollander, 2001).

Definitions of self-injurious behavior vary, but in general self-injury has been defined as an intentional act with the objective to do harm to the body without leading to a result of death (Simeon & Favazza, 2001; Yarura-Tobias, Neziroglu, & Kaplan, 1995). Self-injury can include, but is not limited to, scratching, branding, cutting, self-hitting, burning, and biting (Patterson & Kahan, 1983). Despite the various methods of self-injury, cutting is the most prevalent method (Briere & Gil, 1998; Gallop, 2002; Ross & Health, 2002; Taiminen, Kallio-Soukainen, Nokso-Koivisto, Kaljonen, & Helenius, 1998). Self-cutting is usually done with instruments such as razor blades, or knives (Austin & Kortum, 2004), and the severity of the cuts can range from superficial scratches to deep gouges (Conterio et al., 1998).

Self-injury is usually performed on the arms, wrists, and legs, but the breasts, thighs, stomach, and genitals are also sites where people self-injure (Conterio et al., 1998). Most people who self-injure hide their injuries (e.g., wearing long-sleeved pants or shirts even on a warm day; Conterio et al.), and they will avoid injuring themselves in the presence of other people (Gallop, 2002).

Self-injury can serve a variety of functions or purposes. People who self-injure typically have difficulty expressing strong negative emotional experiences such as pain, hurt, or anger and self-injury is often considered a form of emotional regulation (Favazza, 1996). The adolescent's self-injury may be a way to avoid overwhelming emotions through a focus on physical pain (Austin & Kortum, 2004; Dallam, 1997; Levenkron, 1998). Self-injury may be a method of gaining control over a situation in which the adolescent feels he or she does not have any control (Austin & Kortum; Dallam). In addition to the expression of emotions, adolescents may use self-injury in order to decrease dissociation, depersonalization, and derealization, and relieve feelings of emptiness and numbness (Dallam; Simeon & Favazza, 2001).

There are several life experiences that correlate with self-injurious behavior including losing a parent, family violence, childhood sexual abuse or rape, a childhood illness, and a history of self-injury in the family (Conterio et al., 1998; Deiter, Nicholls, & Pearlman, 2000). Two of the best predictors of self-injury are childhood sexual abuse and/or family violence (Deiter et al.). As children who experience sexual or physical abuse are in a state of constant emotional dysregulation, and they do not yet have the skills necessary to regulate these intense emotional experiences, they may engage in self-injury in an attempt to regulate strong emotions (Levenkron, 1998).

ETHICAL CONSIDERATIONS AND PRACTICE RECOMMENDATIONS

School counselors have an important role to play in ensuring that students are safe, and that they have the resources they need to develop both academically and personally (Dahir, Sheldon, & Valiga, 1998). As school counselors are often among the first to be made aware of students' self-injurious behaviors, they are in a position to effectively intervene with self-injurious students (Kress et al., 2004). However, in the process of intervening, providing referrals, and advocating for self-injurious students, school counselors may be faced with many complicated ethical issues. In the following sections, some of these ethical issues are reviewed, and suggestions for how school counselors might handle these situations are provided.

Confidentiality and Responsibilities to Students

School counselors are ethically obligated to keep student-reported information confidential unless disclosure is required to prevent clear and imminent danger to the counselee or others (ASCA, 2004). The following vignette provides an example of the challenges that school counselors must address with regard to self-injury and students' confidentiality rights.
 Vignette 1. A teacher noticed that despite the
 warm weather, Jennifer was wearing long-sleeve
 shirts and pants. The teacher became
 concerned, and later overheard Jennifer telling
 her friends that she wore these clothes so that
 her parents and teachers would not see the
 cuts that she made on her arms and legs. The
 teacher referred Jennifer to the school counselor.
 The counselor told Jennifer that their
 conversation would be kept confidential
 unless she was at risk of harming herself or
 others. After initial introductions, the counselor
 stated that she was concerned that
 Jennifer was engaging in self-injurious behavior.
 Jennifer quickly replied that she was not
 suicidal. Jennifer disclosed that she has been
 cutting delicate marks into her arm and legs
 with a razor blade. Jennifer told the counselor
 that the self-injury helps her to relieve the tension
 and stress accompanied with her full
 schedule of Advanced Placement classes.

 The counselor, who was unfamiliar with
 self-injurious behaviors, immediately considered
 the self-cutting to be a suicidal action. At
 the end of the counseling appointment, the
 counselor told Jennifer that she felt she was at
 risk of seriously harming herself and that she
 had to report this behavior to her parents.
 After contacting Jennifer's parents, the counselor
 documented the nature of the counseling
 session and placed the documentation in
 Jennifer's student file.


Vignette 1 brings to the forefront various ethics-related questions and ethical standards for school counselors to consider: Did the counselor break confidentiality (ASCA, 2004, Standard, A.2f), or did the counselor have a duty to warn others because the student was a danger to herself (ASCA, Standard A.2b)? What additional information might the school counselor have gathered to more adequately assess the situation, and to have engaged in appropriate ethical decision-making? Suppose the counselor decided that Jennifer was not in danger of seriously harming herself, does the school counselor still have a responsibility to contact the student's parents (ASCA, Standard B. 1a)?

Remley, Hermann, and Huey (2003) stated that the extension of privacy rights belongs to the parent (even in cases when the child requests confidentiality), and judicial decisions have historically protected parental rights (Isaacs & Stone, 1999). Thus, the school counselor should consider reporting self-injurious behavior even in cases where the counselor does not perceive the student is in imminent danger. Counselors' interpretations of the kind of circumstances worthy of breaching confidentiality are varied (Isaacs & Stone), and the Vignette 1 example provides an instance where there may be considerable variability in decisions or judgments related to breaking confidentiality. Despite this, in a situation such as Vignette 1 where the counselor is not clear as to the need to break student confidentiality and report student self-injury to parents, it is recommended that school counselors seek legal consult with the school district attorney.

Favazza (1996) stated that by definition, the intent of the person who is engaging in self-injurious behavior is not of a suicidal nature. Some even have stated that self-injury may prevent suicide by serving as a coping strategy (Austin & Kortum, 2004). While it is important for school counselors to be aware that most people who engage in self-injurious behavior make a clear distinction between suicidal ideation and intention, and deliberate self-injurious behaviors without the intention to die (Allen, 1995), the school counselor must consider the serious consequences and liability that may occur by withholding this information from parents. As previously mentioned, school counselors should consider consulting with the school administration and their district's attorney about these types of issues.

As self-injurious behavior has been found to be one of the most disturbing behaviors encountered by helpers (Gamble, Pearlman, Lucca, & Allen, 1994), it is important that school counselors monitor their personal reactions to disclosures of self-injury and make decisions based on student-reported experiences and intentions rather than transference reactions such as fear or a desire to control the student's behavior (White et al., 2003).

It is also recommended that school counselors complete a thorough assessment of the student's self-injurious behaviors. This will help the counselor in assessing the severity of the self-injury (Kress, 2003). Some of the issues to consider inquiring about, when a student discloses self-injury (Kress; Simeon & Favazza, 2001), are the age of onset of the self-injury, course of the behavior (i.e., has it been steady or has it decreased or increased in frequency), current frequency of self-injury, change in self-injurious behaviors over time, medical complications (e.g., stitches, surgeries, infections, corrective surgeries), what types of tools does the student use to self-injure, does the student engage in appropriate wound care, does the student share self-injury apparatuses with other people or use dirty or rusty tools, emotional states when injuring, triggers leading to the self-injury, immediate and more long-term aftermath of injuring, does the student's family or friends know about the self-injury, and finally, recent life experiences, past traumas, or current life stressors that may be relevant to understanding the student's context and situation.

A thorough suicide assessment and self-injury assessment will help the counselor determine if the student is in imminent danger, assess for any additional risk-management issues, and ultimately determine what actions should be taken.

Finally, the counselor in Vignette 1 documented the nature of the counseling session and placed the client notes in her student file. Since student files are generally available to almost all school personnel, it is likely that the counselor, by including her case notes in the student's file, did not secure records necessary for rendering professional services to the counselee as required by confidentiality guidelines (ASCA, 2004, Standard A.8). In addition, Isaacs and Stone (1999) pointed out that counselors are in a precarious position because they work with other educators who do not have the same obligations to protect a student's privacy as a counselor. Thus, another suggestion related to confidentiality and self-injury is for school counselors to follow all ethical guidelines when sharing information about a student's self-injurious behavior through written or verbal communications.

Student Confidentiality and Responsibilities to Parents and School Systems

School counselors are in a unique and challenging position in that not only do they have responsibilities to students, but they also have responsibilities to parents and the school (ASCA, 2004; Glosoff & Pate, 2002). In addition, "unless privilege or confidentiality law exists in a state, confidentiality based on adherence to an ethical code is legally subordinate to employer policy" (Tompkins & Mehring, 1993, p. 3). The school counselor must consider at what point parents and school administrators have the right to demand access to confidential information. The following vignette exemplifies the challenge of managing confidential student information with the responsibilities school counselors have to parents and school administrators.
 Vignette 2. Three of Rebecca's friends came to
 the school counselor's office because they
 were concerned by her recent strange behavior.
 They reported to the counselor that
 Rebecca picks the skin on her arms until it
 bleeds. Rebecca's friends said that this behavior
 has been occurring for the past 3 months.
 When the counselor met with Rebecca, she
 admitted to picking her skin and said it helps
 her deal with the stress of her parents' divorce.
 The counselor did not see any visible scarring
 on Rebecca's arms; however, she told Rebecca
 that she needed to contact her parents to
 inform them of this issue. The counselor
 informed Rebecca that school policy states
 that parents/guardians must be called if a student
 is at risk of harming himself or herself.
 The school counselor called Rebecca's mother
 with the intention of setting up an appointment
 to meet and discuss Rebecca's self-injury.

 When Rebecca's mother stated she was
 unable to come in for a meeting and that
 Rebecca was hurting herself for "attention,"
 the counselor felt she had no choice but to
 report Rebecca's behavior to the school principal.
 The counselor told the principal of
 Rebecca's alleged self-injurious behavior and
 her mother's unwillingness to attend a meeting
 with her daughter. The principal immediately
 called Rebecca into his office for a meeting
 with the counselor at which time the principal
 called Rebecca's mother.


Rebecca's case provides an example of the difficulties in balancing the confidentiality rights of minors, the counselor's responsibility, to act in a minor's best interest, and the legitimate rights and concerns of parents and the school (Isaacs & Stone, 1999).

In considering this vignette, the following question is pertinent: Was it necessary to break Rebecca's confidentiality (by informing the school principal of Rebecca's self-injurious behavior)? While ASCA (2004) states that the professional school counselor "informs appropriate officials in accordance with school policy of conditions that may be potentially damaging to the school's mission, personnel and property while honoring the confidentiality between student and counselor" (Standard D.1b, p. 2), this case does not fall into that category. Rather, the counselor in this vignette might have consulted another counselor and/or the principal (without revealing the student's name) to get objective perspectives on this case before breaking the student's confidentiality. In other words, the counselor could have provided the principal with "accurate, objective, concise and meaningful data necessary to adequately evaluate, counsel and assist the student" (ASCA, Standard C.2b, p. 2) without violating her confidentiality rights.

The counselor in this vignette believed that it was the parents' right to be aware of Rebecca's self-injurious behavior and attempted to establish a collaborative relationship with Rebecca's mother (ASCA, 2004, Standard B.1a). The counselor in this vignette did not contact Rebecca's father, which did not follow ASCA's ethical standards that state that a good-faith effort should be made to keep both parents informed with regard to information about children (Standard B.2d).

Professional Competence

The Ethical Standards for School Counselors (ASCA, 2004) states that the professional school counselor functions within the boundaries of individual professional competence and accepts responsibility for the consequences of his or her actions (Standard E.1a). According to the American Counseling Association (ACA) and ASCA ethical codes, counselors are to practice only within the boundaries of their competence, based on their education, training, and experience (ACA, 1995, Standards C.1 & C.2; ASCA, Standard E.1b). The following vignette describes the complexity involved in understanding professional competence.
 Vignette 3. Ms. Williams, a first-year high
 school counselor in a suburb of Chicago,
 believed that her graduate school training prepared
 her well for her new position. When the
 director of school counseling asked her if she
 would be wilting to run a support group for
 students who self-injure, she eagerly complied.
 Although Ms. Williams had no experience
 with this population, she recalled learning in
 her graduate work that self-injurious behavior
 was increasing in prevalence among high
 school students. She spent a month doing
 research on working with this population, and
 she developed a group counseling plan.

 During her first group, four female students
 attended and shared their history with self-injurious
 behavior. Each girl had a different
 way of self-injuring--cutting, biting, bruising,
 and burning. Each of the girls appeared to
 have numerous complex issues, and after several
 sessions, Ms. Williams noted that each of
 the girls had experienced, or were currently
 experiencing, some sort of physical, emotional,
 or sexual abuse. The intensity of the group,
 and the issues surrounding the group members'
 abuse, started to overwhelm Ms.
 Williams. With little direct supervision, Ms.
 Williams turned to a veteran school counselor
 for consultation. The counselor suggested that,
 in addition to the group counseling, Ms.
 Williams meet with each of the girls for individual
 counseling. Ms. Williams wondered if
 she was able to provide this level of service,
 and she became fearful that she had overcommitted
 herself.


One of the primary roles of school counselors is to facilitate the personal and social development of all students (Schmidt, 1999). School counselors cannot be competent in all areas or all student-presented issues. School counselors thus have an ethical responsibility to assess whether they have the knowledge and skills to help the student explore concerns, examine alternatives, make appropriate decisions, and act accordingly (Schmidt). Students who self-injure require skilled counselors who are educated on the etiology and functions of self-injury, as well as appropriate interventions (White et al., 2003). White et al. stated that it is important for counselors working with self-injurious students to achieve competency in this area, or to refer clients to counselors who are competent to work with this population. The counselor in Vignette 3 did seek out consultation from another counselor, which is consistent with the ASCA standard of Sharing Information with Other Professionals (ASCA, 2004, Standard C.2a).

Another recommendation related to competence is to have a specified person knowledgeable about self-injurious behavior who can be consulted when student self-injury issues arise. Also, as education of school faculty on the topic of self-injury is an important charge of school counselors (Kress et al., 2004), school counselors who believe they are not competent in this area might invite knowledgeable guest speakers to talk to the school community about this topic.

A final recommendation is that school counselors be aware of several community mental health professionals who specialize in self-injury and use these processionals as a student referral source. It is suggested that the school counselor maintain regular contact with the student's mental health professional, and work closely with this person. Some of the issues that the school counselor may want to collaboratively work with the student's mental health professional on are developing a safety plan or a list of alternatives to self-injury that the student can use when wanting to self-injure while at school, and developing a no-harm contract (Conterio et al., 1998). Regular communication with the student's mental health professional also can serve to help the school counselor stay abreast of the student's progress and the status of the self-injury.

ADDITIONAL RECOMMENDATIONS FOR PRACTICE

No-Harm Contracts

Ethical standards require school counselors to inform appropriate authorities when a student's behavior is indicative of clear and imminent danger to the student or others (ASCA, 2004, Standard A.7a). It is recommended that counselors assess this danger with careful deliberation, and consult with other school counselors with regard to ethical decision making (ASCA).

As school counselors have a duty to protect their clients and other students, the development of a no-harm contract (Conterio et al., 1998) that clearly specifies what behaviors will require the school counselor/faculty/staff to take what actions may be helpful in clarifying to the student, parents, and school personnel the boundaries associated with the self-injurious behavior. For example, in a no-harm contract, a school counselor might specify that a student cannot bring sharp objects/cutting implements to school and if he or she does, certain actions will be taken by the school faculty/staff. Besides the issue of bringing sharp or dangerous objects to school, other possible issues that may be addressed in a no-harm contract are discussing the limits of self-injuring while on school property, the sharing of self-injurious objects/implements while at school, and wound care while at school. The no-harm contract might also address acceptable alternative behaviors that the student will engage in when having impulses to self-injure while at school.

School Policies on Self-Injurious Behaviors

A final recommendation related to students and self-injurious behavior is for school counselors to develop a school policy that addresses this topic. School polices related to student self-injurious behavior might address some or all of the following issues: when should school faculty/staff report suspected student self-injurious behaviors, to whom should faculty/staff report these behaviors, to what extent is the school administration involved with students who self-injure, to what extent are the school counselors involved, what is the school nurse's involvement, and finally what is the policy on parental notification and involvement. A cautionary suggestion is that the school policy should have built-in flexibility as there is a great deal of variability in the underlying dynamics, issues, and needs of students who self-injure. An overly strict or rigid policy may not serve the best interests of some students. For example, a help-seeking 17-year-old senior student who engages in delicate self-cutting, is from an emotionally neglectful and disengaged family, has appropriate wound care, and denies any history of suicidal ideation or intention to seriously harm herself will have different needs than a 12-year-old student who engages in severe self-injury (including burning and head banging), does not utilize appropriate wound care, and is not help-seeking.

CONCLUSIONS

This article has provided a brief overview of self-injurious behavior, and ethical issues in relation to ASCA's Ethical Standards for School Counselors (2004). General practice recommendations for school counselors are to be aware of the self-injury-related literature, monitor possible reactions to control students or to force them to stop injuring, become familiar with the relationship between suicide and self-injury and implement and document a thorough suicide assessment when working with this population to avoid overreaction or underreaction to self-injury, implement no-harm contracts that clearly specify what behaviors are and are not acceptable while on school property, and develop a school policy that addresses self-injurious behavior. School counselors also are advised to seek supervision and/or consultation concerning self-injury-related issues, and to have referral sources that are knowledgeable about self-injury.

Anticipating ethics-related concerns will help prevent ethical problems when working with self-injurious students. ACA's (1995) Code of Ethics and Standards of Practice and ASCA's (2004) Ethical Standards for School Counselors are two resources available to help school counselors manage ethical issues in their counseling relationships (Glosoff & Pate, 2002). To be effective advocates for their students' rights, school counselors must have knowledge about the legal status of minors and their parents, and the ethics of privacy, confidentiality, privileged communication, and informed consent (Glosoff & Pate).

School counselors, to a greater degree than counselors who practice in other settings, are continually challenged with legal and ethical problems because their clients are of a minor status, they have responsibilities to numerous constituents (e.g., school administrators, parents), they have a large number of students to counsel, and they work in a setting that requires compliance with many federal and state statues (Remley, 2002). Isaacs and Stone (1999) suggested that school counselors be prepared to deal with the many ambiguous ethical scenarios that may occur prior to their occurrence, by being aware of current laws as well as district policies pertaining to breaching confidentiality; establishing in advance the kinds of behaviors that might warrant breach of confidentiality; establishing a network of peers who can be consulted when situations arise; and educating stakeholders concerning the rationale for confidentiality.

In this article, ethical issues related to student confidentiality, responsibilities to parents and to the school, and professional competence were discussed in relation to ASCA's (2004) Ethical Standards for School Counselors. This article has provided a brief overview of and orientation to this topic. Future researchers might further explore additional ethical issues associated with students who engage in self-injurious behavior.

References

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Simeon, D., & Favazza, A. R. (2001). Self-injurious behaviors: Phenomenology and assessment. In D. Simeon & E. Hollander (Eds.), Self-injurious behaviors: Assessment and treatment (pp. 1-28).Washington, DC: American Psychiatric Press.

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Taiminen, T. J., Kallio-Soukainen, K., Nokso-Koivisto, H., Kaljonen, A., & Helenius, H. (1998). Contagion of deliberate self-harm among adolescent inpatients. Journal of the American Academy of Child and Adolescent Psychiatry, 37(2), 211-217.

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White, V. E., McCormick, L., & Kelly, B. (2003). Counseling self-injurious clients: Ethical considerations. Counseling and Values, 47, 220-229.

Yarura-Tobias, J. A., Neziroglu, F. A., & Kaplan, S. (1995). Self-mutilation, anorexia, and dysmenorrhea in obsessive compulsive disorder. International Journal of Eating Disorders, 17, 33-38.

Victoria E. White Kress and Nicole Drouhard are with the Department of Counseling, Youngstown State University, Youngstown, OH. E-mail: vewhite@ysu.edu Amanda Costin is with the School of Human Services, Capella University, Florence, MA.
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