Victoria E.
White Kress
and Nicole Drouhard
are with the
Department of
Counseling, Youngstown
State University,
Youngstown, OH.
E-mail:
Students Who Self-Injure:
vewhite@ysu.edu
Amanda Costin is with
School Counselor Ethical
the School of Human
Services, Capella
University, Florence,
and Legal Considerations
MA. This article explores ethical considerations that school
counselors may need to address when providing coun-
seling 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 Associations (2004) Ethical Standards for
School Counselors. Implications and recommendations
for school counselors working with self-injurious stu-
dents are provided.
elf-injury is an issue that has received increased
S 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 educa-
tors 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 sam-
pled 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 impor-
tant 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, peo-
ple who self-injure typically begin this behavior dur-
ing 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, interven-
tion, 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 considera-
tions, as defined by the American School Counselor
Associations (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 compe-
tence 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 associ-
ated with student self-injury, this article is an
attempt to increase school counselors ability to inte-
grate 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 impor-
tant 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 afore-
mentioned 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 intention-
al act with the objective to do harm to the body
without leading to a result of death (Simeon &
10:2 DECEMBER 2006 | ASCA 203
 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).
A recent study Self-injury can serve a variety of functions or pur-
poses. People who self-injure typically have difficul-
indicated that 13% ty expressing strong negative emotional experiences
such as pain, hurt, or anger and self-injury is often
of surveyed considered a form of emotional regulation (Favazza,
1996). The adolescents self-injury may be a way to
adolescents avoid overwhelming emotions through a focus on
physical pain (Austin & Kortum, 2004; Dallam,
reported engaging 1997; Levenkron, 1998). Self-injury may be a
method of gaining control over a situation in which
in self-injurious the adolescent feels he or she does not have any con-
trol (Austin & Kortum; Dallam). In addition to the
behavior. expression of emotions, adolescents may use self-
injury in order to decrease dissociation, depersonal-
ization, 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 par-
ent, 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 vio-
lence (Deiter et al.). As children who experience sex-
ual or physical abuse are in a state of constant emo-
tional 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
204 ASCA | PROFESSIONAL SCHOOL COUNSELING
ensuring that students are safe, and that they have
the resources they need to develop both academical-
ly 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 coun-
selors may be faced with many complicated ethical
issues. In the following sections, some of these ethi-
cal 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 coun-
selor. 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 coun-
selor stated that she was concerned that
Jennifer was engaging in self-injurious behav-
ior. 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 ten-
sion and stress accompanied with her full
schedule of Advanced Placement classes.
The counselor, who was unfamiliar with
self-injurious behaviors, immediately consid-
ered 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 Jennifers parents, the coun-
selor documented the nature of the counsel-
ing session and placed the documentation in
Jennifers 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 appro-
priate ethical decision-making? Suppose the coun-
selor decided that Jennifer was not in danger of seri-
ously harming herself, does the school counselor still
have a responsibility to contact the students 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 confidentiali-
ty), 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 circum-
stances worthy of breaching confidentiality are var-
ied (Isaacs & Stone), and the Vignette 1 example
provides an instance where there may be consider-
able 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 recom-
mended 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 seri-
ous consequences and liability that may occur by
withholding this information from parents. As previ-
ously mentioned, school counselors should consider
consulting with the school administration and their
districts 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 moni-
tor their personal reactions to disclosures of self-
injury and make decisions based on student-report-
ed experiences and intentions rather than transfer-
ence reactions such as fear or a desire to control the
students behavior (White et al., 2003).
It is also recommended that school counselors
complete a thorough assessment of the students
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 fre-
quency), current frequency of self-injury, change in
self-injurious behaviors over time, medical complica-
tions (e.g., stitches, surgeries, infections, corrective
surgeries), what types of tools does the student use
to self-injure, does the student engage in appropri-
ate wound care, does the student share self-injury
apparatuses with other people or use dirty or rusty
tools, emotional states when injuring, triggers lead-
ing to the self-injury, immediate and more long- As student self-
term aftermath of injuring, does the students fami-
ly or friends know about the self-injury, and finally, injurious behavior is
recent life experiences, past traumas, or current life
stressors that may be relevant to understanding the complex and
students context and situation.
A thorough suicide assessment and self-injury multifaceted,
assessment will help the counselor determine if the
student is in imminent danger, assess for any addi- school counselors
tional risk-management issues, and ultimately deter-
mine what actions should be taken. should be aware of
Finally, the counselor in Vignette 1 documented
the nature of the counseling session and placed the the many ethical
client notes in her student file. Since student files are
generally available to almost all school personnel, it issues associated
is likely that the counselor, by including her case
notes in the students file, did not secure records with counseling
necessary for rendering professional services to the
counselee as required by confidentiality guidelines self-injurious
(ASCA, 2004, Standard A.8). In addition, Isaacs
and Stone (1999) pointed out that counselors are in students.
a precarious position because they work with other
educators who do not have the same obligations to
protect a students privacy as a counselor. Thus,
another suggestion related to confidentiality and
self-injury is for school counselors to follow all ethi-
cal guidelines when sharing information about a stu-
dents 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 responsibili-
ties to students, but they also have responsibilities to
parents and the school (ASCA, 2004; Glosoff &
Pate, 2002). In addition, unless privilege or confi-
dentiality law exists in a state, confidentiality based
on adherence to an ethical code is legally subordi-
10:2 DECEMBER 2006 | ASCA 205
 nate 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 informa-
tion. The following vignette exemplifies the chal-
lenge of managing confidential student information
with the responsibilities school counselors have to
parents and school administrators.
Vignette 2. Three of Rebeccas friends came to
the school counselors office because they
were concerned by her recent strange behav-
ior. They reported to the counselor that
Rebecca picks the skin on her arms until it
bleeds. Rebeccas friends said that this behav-
ior 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
People who self- on Rebeccas arms; however, she told Rebecca
that she needed to contact her parents to
injure typically inform them of this issue. The counselor
informed Rebecca that school policy states
have difficulty that parents/guardians must be called if a stu-
dent is at risk of harming himself or herself.
expressing strong The school counselor called Rebeccas mother
with the intention of setting up an appoint-
negative emotional ment to meet and discuss Rebeccas self-
injury.
experiences such as When Rebeccas mother stated she was
unable to come in for a meeting and that
pain, hurt, or anger. Rebecca was hurting herself for attention,
the counselor felt she had no choice but to
report Rebeccas behavior to the school prin-
cipal. The counselor told the principal of
Rebeccas alleged self-injurious behavior and
her mothers unwillingness to attend a meet-
ing with her daughter. The principal immedi-
ately called Rebecca into his office for a meet-
ing with the counselor at which time the prin-
cipal called Rebeccas mother.
Rebeccas case provides an example of the diffi-
culties in balancing the confidentiality rights of
minors, the counselors responsibility to act in a
minors best interest, and the legitimate rights and
concerns of parents and the school (Isaacs & Stone,
1999).
In considering this vignette, the following ques-
tion is pertinent: Was it necessary to break Rebeccas
confidentiality (by informing the school principal of
Rebeccas 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 schools mission, personnel and
206 ASCA | PROFESSIONAL SCHOOL COUNSELING
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 re-
vealing the students name) to get objective perspec-
tives on this case before breaking the students con-
fidentiality. In other words, the counselor could
have provided the principal with accurate, objec-
tive, concise and meaningful data necessary to ade-
quately 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 Rebeccas self-
injurious behavior and attempted to establish a col-
laborative relationship with Rebeccas mother
(ASCA, 2004, Standard B.1a). The counselor in this
vignette did not contact Rebeccas father, which did
not follow ASCAs ethical standards that state that a
good-faith effort should be made to keep both par-
ents 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 indi-
vidual professional competence and accepts respon-
sibility 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 edu-
cation, 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 pre-
pared her well for her new position. When the
director of school counseling asked her if she
would be willing 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-injuringcutting, biting, bruising,
 and burning. Each of the girls appeared to
have numerous complex issues, and after sev-
eral sessions, Ms. Williams noted that each of
the girls had experienced, or were currently
experiencing, some sort of physical, emotion-
al, or sexual abuse. The intensity of the group,
and the issues surrounding the group mem-
bers 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 indi-
vidual counseling. Ms. Williams wondered if
she was able to provide this level of service,
and she became fearful that she had overcom-
mitted 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 re-
sponsibility to assess whether they have the knowl-
edge 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 com-
petency 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 consulta-
tion 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 impor-
tant charge of school counselors (Kress et al., 2004),
school counselors who believe they are not compe-
tent 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 pro-
fessionals who specialize in self-injury and use these
processionals as a student referral source. It is sug-
gested that the school counselor maintain regular
contact with the students mental health profession-
al, and work closely with this person. Some of the
issues that the school counselor may want to collab-
oratively work with the students mental health pro-
fessional 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 students
mental health professional also can serve to help the
school counselor stay abreast of the students
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 students
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 Students who self-
danger with careful deliberation, and consult with
other school counselors with regard to ethical deci- injure require
sion making (ASCA).
As school counselors have a duty to protect their skilled counselors
clients and other students, the development of a no-
harm contract (Conterio et al., 1998) that clearly who are educated
specifies what behaviors will require the school
counselor/faculty/staff to take what actions may be on the etiology and
helpful in clarifying to the student, parents, and
school personnel the boundaries associated with the functions of self-
self-injurious behavior. For example, in a no-harm
contract, a school counselor might specify that a stu- injury, as well as
dent cannot bring sharp objects/cutting implements
to school and if he or she does, certain actions will appropriate
be taken by the school faculty/staff. Besides the
issue of bringing sharp or dangerous objects to interventions.
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 con-
tract might also address acceptable alternative be-
haviors 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 devel-
op 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 coun-
selors involved, what is the school nurses involve-
ment, and finally what is the policy on parental noti-
10:2 DECEMBER 2006 | ASCA 207
 fication 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 underly-
ing 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 engag-
es in delicate self-cutting, is from an emotionally neg-
lectful and disengaged family, has appropriate
wound care, and denies any history of suicidal idea-
tion 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
ASCAs 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 con-
trol students or to force them to stop injuring,
become familiar with the relationship between sui-
cide 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 accept-
able 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 knowl-
edgeable about self-injury.
Anticipating ethics-related concerns will help pre-
vent ethical problems when working with self-injuri-
ous students. ACAs (1995) Code of Ethics and
Standards of Practice and ASCAs (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 stu-
dents rights, school counselors must have knowl-
edge about the legal status of minors and their par-
ents, and the ethics of privacy, confidentiality, privi-
leged communication, and informed consent
(Glosoff & Pate).
School counselors, to a greater degree than coun-
selors who practice in other settings, are continually
challenged with legal and ethical problems because
their clients are of a minor status, they have respon-
sibilities to numerous constituents (e.g., school
administrators, parents), they have a large number of
students to counsel, and they work in a setting that
208 ASCA | PROFESSIONAL SCHOOL COUNSELING
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 edu-
cating 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 ASCAs (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.
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