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

Professional School Counseling, April, 2004 by Janet Froeschle, Mike Moyer

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.

*********

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.