Non-Suicidal Self-injury

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Legal and Ethical Concerns. Presented by. Amanda C. La Guardia, PhD, LPC-S, NCC. Typical concerns. General Issues:. How can I tell the difference between NSSI and a suicide attempt?. ID: 545724 Download Presentation

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Non-Suicidal Self-injury

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Presentations text content in Non-Suicidal Self-injury


Non-Suicidal Self-injury

Legal and Ethical Concerns

Presented by

Amanda C. La Guardia, PhD, LPC-S, NCC


Typical concerns

General Issues:

How can I tell the difference between NSSI and a suicide attempt?

What if the client is self injuring and also states active suicidal ideation?

Should I advocate my client stop the behavior in order to get treatment?

Is the behavior psychologically addictive and if so, do I treat it as an addiction?

Should I use a no-harm contract?

Working with children:

How much do I have to tell the parents?

When should I tell the parents?

What issues must I consider when working in the schools?

How do I assess for severity and risk?


Defining self injury

Self Harm is an umbrella



Self Injury and Self Mutilation

Self Injury: A kind of self harm that leads to visible and direct bodily injury including cutting and burning (McAllister, 2003)

Research shows there is no association between suicidal intent and the act of self injury

Attempt at self soothing/coping

Harm done in the belief they will survive



Whisenhunt & Chang, 2013


Adolescent concerns

Some statistics:


% of adolescents have suicidal thoughts

7% of pre-adolescents & 12-40% of adolescents engage in NSSI

4% attempt suicide

18% have engaged in NSSI

Issues of Belonging


2 - 4 times more likely to self-injure


, ethnic minorities, and youth subcultures also at heightened risk



A form of communication

Tied to shame

Research suggests that some adolescents become addicted to the emotional relief-seeking due to the high they experienced with the associated endorphin release (




, 2004


Can become ritualistic and associated with triggering events

NSSI is the strongest predictor of eventual death by suicide in adolescence

Suicide risk increases up to 10-fold for adolescents displaying NSSI (




, 2007)


Purpose of self injury

Need for Emotional Regulation

"NSSI performs a clear social and communicative function among teenagers which is arguably linked to their social identity"


who engage in self-injure also find a sense of community with others who self-injure.

Peer-pressure, want to emulate celebrities or fictional role-models = seeking sense of belonging (


& Whitlock, 2010)


Emotional regulation

Teach adolescents:

(a) awareness, understanding, and acceptance of emotions

(b) ability to engage in goal-directed behaviors and inhibit impulsive behaviors when experiencing negative emotions

(c) flexible use of situationally appropriate strategies to modulate the intensity and/or duration of emotional responses rather than to eliminate emotions

(d) willingness to experience negative emotions as part of pursuing meaningful activities in life


Purpose of self injury

Intrapersonal negative reinforcement

reduction of emotions like anxiety or anger


positive reinforcement

relieve numbness or feeling empty

Interpersonal negative reinforcement

reduction in victimization

Interpersonal positive reinforcement

gaining attention/emotional support from peers



Social Identity Theory

"... even minimal identification with a 'fictional' social group leads to increased in-group influence and adoption of stereotypical in-group behaviors, particularly among newer members..."


% of females and 57% of males who self injure also have a friend who does

NSSI Social Contagion Theory:




Relations (predisposition leads to attraction)

2. Direct Imitation

3. Indirect Imitation/Media Influence


Social identity

Low family support, high family dysfunction, and low family cohesion are associated with


NSSI and Suicide


Peer support has been shown to exert a strong influence on suicidal ideation and NSSI

Meaning of NSSI is socially constructed and how individuals make the choice to engage and communicate to others about self-injury is influenced by social context and psychological


The choice to engage in NSSI for social purposes involves perceiving, evaluating, and acting within an environment based on social cues, symbolic meaning, and perceived role expectations.


Assessment of severity and risk


Assessment of severity and risk

If a mild to moderate risk is determined, students may not pose a threat to self and thus can be reintegrated back into the school environment. A strengths assessment will be conducted with the following goals:

Determine how students and their families are meeting the student’s needs (e.g. nurturance, safety) and family needs (e.g. food, medical, etc.)

Identify ways professionals can be helpful to the family and the student (prevention)

Provide student and family with encouragement and supportive feedback for implementation of effective behaviors and strategies



Important for at least one trusted caregiver to be aware of an child or adolescent’s self injurious behavior

Caregiver education is essential to prevent shaming (Cornell Institute)

Understanding the family environment prior to creating a plan for caregiver inclusion is essential

What caregiver does the client feel emotionally safest with?

What aspects of the self injury would they like to share and what aspects would they like the counselor to discuss?

How would they like to see caregivers involved in the safety plan?



Is the client actively considering suicide?

What purpose does the self injury serve in relation to the client’s suicidal ideation?

What is the potential lethality of the self injurious behaviors?

Does the client disassociate?

What is the location and typical depth of the wounds?

How are they cared for?

Have there been previous suicide attempts?



C.2.b. New Specialty

Areas of


Counselors practice in specialty

areas new

to them only after

appropriate education

, training, and

supervised experience

. While developing

skills in

new specialty areas,

counselors take

steps to ensure the

competence of

their work and protect others

from possible




. Cultural Sensitivity

Counselors recognize that

culture affects

the manner in which

clients’ problems

are defined and

experienced. Clients

’ socioeconomic and

cultural experiences

are considered when

diagnosing mental



ETHICAL ISSUES: confidentiality

A.2.e. Mandated Clients

Counselors discuss the

required limitations

to confidentiality

when working

with clients who have

been mandated

for counseling

services. Counselors

also explain what

type of

information and with whom

that information

is shared prior to

the beginning

of counseling


B.1.d. Explanation

of Limitations

At initiation and throughout the

counseling process

, counselors inform clients

of the

limitations of confidentiality and

seek to

identify situations in which

confidentiality must

be breached


B.2.e. Minimal Disclosure

To the extent possible, clients

are informed

before confidential

information is

disclosed and are

involved in

the disclosure

decision-making process

. When circumstances

require the

disclosure of confidential

information, only


information is



Ethical issues: confidentiality

B.5.b. Responsibility to

Parents and

Legal Guardians

Counselors inform parents and

legal guardians

about the role of

counselors and

the confidential nature of the

counseling relationship

, consistent with

current legal

and custodial

arrangements. Counselors

are sensitive to the

cultural diversity

of families and respect

the inherent

rights and responsibilities

of parents/guardians

regarding the

welfare of

their children/charges

according to

law. Counselors work to

establish, as

appropriate, collaborative



parents/guardians to

best serve


B.5.c. Release of

Confidential Information

When counseling minor clients

or adult

clients who lack the

capacity to

give voluntary consent to

release confidential


counselors seek

permission from an

appropriate third

party to disclose

information. In

such instances, counselors

inform clients

consistent with their level

of understanding

and take

appropriate measures to safeguard the client’s confidentiality



In order to provide effective intervention, a counselor must understand the client’s readiness or willingness to change her or his behavior

Consider this question, how much do you want to stop using self injury? Think about your response on a scale from 1 to 10, 1 being “not at all” and 10 being “I definitely what to try something different.” Where are you right now on a scale from 1 to 10?

Awareness-oriented approaches


1-3 (pre-contemplation, contemplation, preparation)

Action-oriented approaches

Stages 3-5

(preparation, action, maintenance)

For real change to happen, one needs to possess:

hope for a future that does not include self-injury,

confidence that change is possible,

intention to put time and effort into making changes,

ability to identify and practice the skills needed to stop the behavior, and

resoluteness – the ability to be disciplined in applying the skills needed to stop the behavior and use other methods instead.



Privacy Rule generally allows a parent to have access to the medical records about his or her child, as his or her minor child’s personal representative when such access is not inconsistent with State or other law


There are three situations when the parent would not be the minor’s personal representative under the Privacy Rule. These exceptions are:


the minor is the one who consents to care and the consent of the parent is not required under State or other applicable law;

When the minor obtains care at the direction of a court or a person appointed by the court; and

When, and to the extent that, the parent agrees that the minor and the health care provider may have a confidential relationship.

However, even in these exceptional situations, the parent may have access to the medical records of the minor related to this treatment when State or other applicable law requires or permits such parental access. Parental access would be denied when State or other law prohibits such access. If State or other applicable law is silent on a parent’s right of access in these cases, the licensed health care provider may exercise his or her professional judgment to the extent allowed by law to grant or deny parental access to the minor’s medical information.

Finally, as is the case with respect to all personal representatives under the Privacy Rule, a provider may choose not to treat a parent as a personal representative when the provider reasonably believes, in his or her professional judgment, that the child has been or may be subjected to domestic violence, abuse or neglect, or that treating the parent as the child’s personal representative could endanger the child.


Legal factors

Imperative you understand

your state’s


consent, medical records and health privacy

laws as the HIPAA privacy rule defers to these laws

Adolescents and the professionals who provide their health care have long expected that when an adolescent is allowed to give consent for health care, information pertaining to it will usually be considered


For minors, on the question of parental access to information, the rule defers to state laws unless they are silent or unclear. Many states have enacted laws concerning privacy of health information and medical records, although not all address disclosure of information to parents when minors have consented to the

care. When this is the case, the federal rule applies

English, A., & Ford, C. A. (2014). The HIPAA privacy rule and adolescents: Legal questions and clinical challenges,

Perspectives on Sexual and Reproductive Health, 36

(2), 80-86.



No harm contracts are not effective and can create liability for the counselor

Focus on developing safety plans:


background information in order to better understand the perspective of the client

Contributing Factors

Defining the problem

Perspectives on their contribution to friends/family

Focus on how NSSI is serving a purpose in the client’s life:

What does the behavior help them to cope with?

Connection to Trauma and/or need for control

Triggering events: Impulsivity

, ritual behaviors, episodic


on empathy, resiliency, encouragement, understanding, and connection rather than conflict



Use multiple means of assessing suicidal risk (Janis & Nock, 2008)

People who self-injure and have a history of suicide attempts may underestimate the lethality of their suicide attempts (


et. al. , 2011)

Use past self-injurious thoughts and behavior to help gauge risk (Janis & Nock, 2008)

Pay attention to frequency of SI, because repeated SI is more closely related to suicidal ideation (


et al., 2010)

Monitor for substance use/abuse because these clients may be at higher risk for suicide (


, Cetin,


, Can, &


, 2011)


In summary

Focus on…


Building (therapeutic alliance)

Communication skill building (expression of needs)

Affective Expression (identify feelings & appropriate expression of feelings)

Behavioral Intervention (coping with difficult emotions – appropriate self-soothing)

Cognitive Intervention (problem solving & addressing self-defeating thoughts)

Safety Plans (specify health strategies for coping with intrusive thoughts and overwhelming emotions – activities, suggestions for communication, and contact


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