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Journal for the Education of the Gifted 34(6) 839 –859 © The Author(s) 2011 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0162353211424989 http://jeg.sagepub.com

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1The University of Iowa, Iowa City, USA 2Old Dominion University, Norfolk, VA, USA

Corresponding Author: Susannah M. Wood, PhD, Rehabilitation and Counselor Education, N348 Lindquist Center, College of Education, University of Iowa, Iowa City, IA 52245, USA Email: [email protected]

Self-Injurious Behavior in Gifted and Talented Youth: What Every Educator Should Know

Susannah M. Wood1 and Laurie M. Craigen2

Abstract

Self-injurious behaviors (SIBs) are increasing in the general adolescent population, giving rise to concerns about the impact these behaviors have on gifted and talented youth. Educators of the gifted may not have adequate understanding of these behaviors, limiting their effectiveness in supporting gifted students engaging in SIB. This article provides an overview of definitions, demographics, and influencing factors, which may enlighten teachers of gifted students about how best to work with those who are struggling with this behavior. The article concludes with a set of suggested best practices for educators of the gifted that can be implemented in schools and classrooms to support students who are self-injuring and to potentially prevent other gifted students from engaging in SIB.

Keywords

gifted, self-injury, influencing factors, best practices

We know that a portion of our young people engage in myriad behaviors that can be described as self-injurious.

Cross, 2007, p. 50

When Cross (2007) discussed self-injurious behavior (SIB) in the gifted population, he described various behaviors such as tattooing, branding, piercing, cutting, and scratching. He then explored the motivators behind these behaviors, including the

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need for group affiliation and to signal an individual’s private internal pain. The purpose of this article is to begin where Cross left off and provide educators of the gifted and talented with a thorough discussion of what self-injury is and what they can do to help students who are engaging in it. In essence, this article provides an overview of the current research on self-injury, some factors that influence it, and a series of best practices that may help guide school professionals working with gifted youth who are “revealing evidence of distress” (Cross, 2007, p. 50) through self-injury.

Definitions, Conceptualizations, and Demographics Self-injury is a broad term, encompassing a number of different behaviors in which one causes deliberate harm to him- or herself; there remains no universal definition of self-injury. Cutting is the most common and most popularized form of self-injury; however, self-burning and hitting, interference with wound healing, bone breaking, trichotillimania, and eating disorders are also considered types of self-injury (Bauman, 2008; Levenkron, 1998). There are several nomenclatures used to describe self-injury, such as deliberate self-harm (Gratz, 2001), self-mutilation (Favazza & Rosenthal, 1990; Haines & Williams, 1997; Nock & Prinstein, 2005), nonsuicidal self-harm (Laye-Gindhu & Schonert-Reichl, 2005), self-cutting (Rao, 2006), self-injurious behavior (Favaro & Santonastaso, 2002), and self-soothing (Alderman, 1997; McAllister, 2003; Strong, 1998).

Many describe self-injury as the deliberate alteration of body tissue without con- scious suicidal intent (Favazza & Rosenthal, 1990; Nock & Prinstein, 2005; Simeon et al., 1992). Others define self-injury as self-inflicting bodily harm of a socially unacceptable nature to reduce psychological distress (Craigen, Healey, Walley, Byrd, & Schuster, 2010). This is the definition that will be used in this article. Many argue that the lack of a standard definition may lead to difficulty in gaining a comprehensive understanding and assessment of the phenomenon of self-injury (Craigen et al., 2010; Muehlenkamp, 2005). The following sections will expand on the selected definition, providing gifted educators with a comprehensive understanding of self-injury.

Like the multiple conceptualizations of SIB, prevalence rates vary. Nock and Prinstein (2005) placed rates at 3% of the general adult population, and between 14% and 39% in the general adolescent population. Adolescents and traditionally college- aged students are at the highest risk for self-injury (White, Trepal-Wollenzier, & Nolan, 2002). Researchers have placed a person’s first experience with self-injury within the age range of 13 to 23 years (Favazza & Conterio, 1988), with the freshman year of college and age 18 being the most frequently cited time period in which the first experience with SIB occurs (Ross & Heath, 2002; Suyemoto & MacDonald, 1995). In the past decade, research has linked SIB to White European American women from middle- to upper- class backgrounds with average to high-average intelligence (Conterio, Lader, & Bloom, 1998).

Though some research indicates that self-injury is 3 to 4 times more common in women than men, researchers are beginning to challenge these statistics, noting that

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men may be less likely to report incidences of self-injury, and professionals may not be as adept at examining self-injury among the male population (McAllister, 2003). In fact, recent researchers have challenged this profile, suggesting that self-injury is not a “White women’s issue” (Craigen & Foster, 2009). Little research outside of studies involving hospitalized adolescents has examined self-injury among various racial and ethnic groups (Goddard, Subotsky, & Frombonne, 1996). Whitlock, Eckenrode, and Silverman (2006) suggested that there are no reliable estimates of SIB in the general adolescent and young adult population and stated that what is known, statistically speaking, is culled from clinical or hospitalized samples and from emergency room settings. The reality is that many adolescents never seek treatment for SIB in an inpa- tient, hospital, or counseling setting, precluding having the documentation needed to determine prevalence rates.

Self-injury is a behavior accompanied by a great deal of shame. The behavior itself is an extremely private act, and many individuals go to great lengths to hide their wounds from others. The secrecy and shame associated with the behavior makes it difficult to accurately assess the number of individuals engaging in the behavior. However, although it is difficult to determine exactly how many are engaging in this behavior and extrapolate to the entire population based on specific samples (Rodham, Hawton, & Evans, 2004), what is known is that the behavior is seen at increased rates in schools, homes, communities, and private practice settings. Although Cross (2007) did not posit a particular number with regard to how many gifted and talented adolescents engage in SIB, if the number is on the rise among nongifted students, one can assume that this behavior is probably also occurring in the gifted population at a similar rate.

In 2006, Whitlock et al. conducted a study of 2,875 college students at Cornell and Princeton universities. A total of 490 students reported having engaged in SIB. Both universities are Ivy League schools, known for their stringent entrance requirements and rigorous undergraduate curricula. These authors cited Greg Eels, director of coun- seling and psychological services at Cornell suggested that the stressful college envi- ronment could be a factor influencing self-injury (“Self-abuse pervasive in Ivy League”, 2006). However, Eels also stated that the incident rate among the college population reflects a national problem. Given recent demographic trends of first experi- ences with self-injury, this assertion appears valid (Favazza & Conterio, 1988, Ross & Heath, 2002; Suyemoto & MacDonald, 1995; Whitlock et al., 2006).

Some authors have reported that gifted students are less likely to ask for help from adults (e.g., school counselors) in their school building because they feel that particular professional help is “for other students,” that is, those with behavioral referrals or those considered academically at risk (Peterson, 2003, p. 64). Adolescents who self-injure also share these characteristics, and most commonly do not seek help for the emotional pain they are experiencing (Levenkron, 1998). Thus, many who engage in the behavior deal with its consequences alone and never receive treatment for their self-injury (Craigen & Foster, 2009). Although the authors here are not suggesting that gifted

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students are more likely to engage in self-injury, recent literature presents adequate foundational information for exploring linkages between attributes of individuals who engage in SIB and common gifted experiences and traits (Cross, 2007). We will dis- cuss pertinent issues specific to the gifted population in the following sections, which focus on influencing factors to provide an awareness and understanding of how SIB might manifest itself in the gifted population.

Influencing Factors of Self-Injury in Gifted Students The reasons a student may self-injure are numerous and complex. No one singular causal factor or reason exists. A review of literature conducted by White Kress, Gibson, and Reynolds (2004) suggested that individuals engage in self-injury for the following reasons: (a) to reduce the feeling of numbness and increase feelings of “being real,” (b) to feel tangible physical pain in situations where psychic pain is too overpowering, (c) to increase self-esteem and feelings of self-worth, (d) to moderate emotions and affect, (e) to prevent memories of traumatic events from entering into consciousness, (f) to elicit support and caring from others, (g) to gain a sense of self- control, (h) to punish the self for feelings and beliefs of “being bad,” and (i) to release and expunge negative emotions such as anger, anxiety, despair, and disappointment. In general, these reasons can be categorized into four main influential factors: environmen- tal, psychological, biological, and life factors.

Environmental Factors Family. Research indicates that an individual’s past or current environment, such

as family of origin, may contribute to the act of self-injury. Individuals who self- injure commonly report tumultuous, distant, or abusive relationships with family members. Studies have suggested a strong association between poor parent–adoles- cent communication and self-injury (Byrne et al., 2008; Tulloch, Blizzard, & Pinkus, 1997). Lack of support, lack of help, and isolation within the family may contribute to future SIB (Favazza & Conterio, 1988; Himber, 1994; Pattison & Kahan, 1983). Family members who also engage in SIB can be contributors (Froeschle & Moyer, 2004; Hawton, Rodham, Evans, & Weatherall, 2002). Strong correlations also have been found between childhood physical and/or sexual abuse and future acts of self- injury (Hodgson, 2004; Walsh & Rosen, 1988; Zila & Kiselica, 2001). Van der Kolk, Perry, and Herman (1991) found that 70% of adults who reported self-injury also reported a history of childhood physical abuse. Hence, a history of family violence and sexual abuse may be the best predictors of self-injury (Conterio et al., 1998; White Kress et al., 2004).

Families of gifted students can be challenged by the cognitive, affective, and behav- ioral characteristics unique to gifted children and adolescents. Family tensions can rise due to altered family roles, adaptations made in the family, and difficult relationships among and between family, the school, and the community (Hackney, 1981; Keirouz,

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1990). Family dysfunction stems from inappropriate and enmeshed boundaries, lack of parental self-efficacy and guilt in parenting a gifted child, resentment from family members, and competition of family members for needs, time, and attention (Colangelo & Dettmann, 1983; Keirouz, 1990; Ross, 1979). Family stress can have origins in a lack of practical advice or support from school and community (Alsop, 1997). Family stressors and frustrations may result in the gifted students believing they are the “problem” behind the family dynamics; some gifted students perceive counseling for family issues to be “punishment” for their perceived role in the dynamic either at home or at school (Bourdeau & Thomas, 2003). Family members may also have this perception and expect that any help they pursue would have an end goal of “fixing the child” (Bourdeau & Thomas, 2003).

Gifted students may resort to self-injury for several reasons related to family turmoil and dysfunction. First, SIBs may be one way for the gifted student to release negative emotions and tensions rooted in the family dysfunction, such as anger, anxiety, despair, and disappointment (Alderman, 1997; Himber, 1994; Zila & Kiselica, 2001). Second, self-injury may be an outcome of a gifted student’s need for support and care from fam- ily members that may not be, or may be perceived not to be, given to the gifted student (Himber, 1994; Suyemoto & MacDonald, 1995). If family tension and conflict escalate to a point at which students cannot cope with them, they may choose to divert the focus of the conflict on to themselves via self-injury (Podovoll, 1969; Suyemoto & MacDonald, 1995). Third, gifted students may blame themselves for problems at school or difficulties in the relationship between family and school and engage in self- injury to punish themselves for being a “problem” or “being bad” (Himber, 1994). Fourth, some research suggests that individuals who engage in self-injury do so to form boundaries that distinguish themselves from others (Favazza, 1989; Suyemoto & MacDonald, 1995; Walsh & Rosen, 1988). In families of gifted students in which boundaries are enmeshed or inappropriate, cutting may signal a students’ need for differentiation or the manifestation of separation from family members.

Peers. In addition to family risk factors, one’s peer group can also influence rates of self-injury. Rejection from peers can lead to increased rates of self-injury (Wester & Trepal, 2005). Bullying at school has also been found to be a significant psychosocial stressor for students who engage in self-injury (Webb, 2002).

A common challenge for many gifted students is negative experiences with their peers. Many gifted adolescents face a choice of either being smart or being popular. Although gifted students may not mind being known as academically inclined, they may not want to have that inclination highlighted in such a way that it sets them apart from their same-age peers (Brown & Steinberg, 1990; Cross, Coleman, & Terhaar- Yonkers, 1991; Kerr, Colangelo, & Gaeth, 1988; Manaster, Chan, Watt, & Wiehe, 1994). Gifted students are aware that they are different (Rimm, 2002). Gifted students also may assume that peers perceive them to be different and will treat them accordingly if gift- edness is made public or “outed” so that they are set apart from their nongifted peers (Cross, 2004; Rimm, 2002). An additional concern is the small pool of peers with

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whom gifted students can find affiliation and belonging (Rimm, 2002). Social accep- tance is a concern and challenge for gifted students, as they have a more difficult time than do others with finding peers with equivalent talents and intelligence (Austin & Draper, 1981). Gifted students may also experience being bullied at school (Peterson & Ray, 2006).

Gifted students may experience frustration, anger, and disappointment in their quest to find like-minded peers or in response to being misunderstood and rejected by the same-age peers. Self-injury can be a way for gifted students to obtain much- needed social support and care. Self-injury may be one way they choose to release these emotions and to increase their feelings of self-worth as a social being. Unfortunately, engaging in SIBs may actually increase gifted students’ acceptance by other students who self-injure.

Research has suggested that self-injury is a learned behavior; in other words, many people who self-injure learned it from a friend (Craigen & Milliken, 2010). Other stud- ies propose that there exists a contagion factor with self-injury, with the indoctrination into the behavior spreading rapidly and following epidemic-like qualities in school, hospital, and other institutional settings (Derouin & Bravender, 2004; Walsh & Rosen, 1988). Gifted students who feel the need for social acceptance, and who learn from peers to self-injure, may feel social pressure to engage in the behavior.

Psychological Factors Self-injury can also be viewed as an intrapsychic phenomenon. One frequently cited reason for self-injury is to end a period of depersonalization in which individuals feel detached from their bodies (Favazza & Conterio, 1988). Some who self-injure explain that harming themselves provides them with a grounding in reality and brings them back to the here and now. Those who self-injure often report feeling numb and void of any emotions, and many explain that the act of self-injury distracts them from their emotional pain. For example, some clients working with therapists on this issue have reported that “feeling something is better than feeling nothing at all,” whereas others have described their inability to express their emotions verbally and hence resorting to expressing their pain physically (Levenkron, 1998).

A second reason for self-injuring is to provide individuals with an internal sense of control. For many, self-injury is a way of regaining control over seemingly uncontrol- lable emotions and situations. Self-injury means they can control various aspects of the behavior and, consequently, the events that caused the feeling of lack of control, on their own terms (Doctors, 1999). Suyemoto and MacDonald (1995, p. 165), citing Ettinger (1992), wrote that “control is gained by cutting as the action externalizes the emotions, turning them into something concrete and specific, enabling [the individual] to distance from and predict them.”

Internal locus of control, perfectionism, and fear of failure are complex issues frequently investigated in gifted education research. Perfectionism is often discussed as a continuum of behaviors and feelings (Schuler, 2002). On one end of the continuum,

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perfectionistic behaviors can be seen as neurotic, debilitating, unhealthy, and destruc- tive; on the other end, the same behaviors can be seen as adaptive, indicating high stan- dards and a striving toward excellence and personal potential (Hamacheck, 1978; LoCicero & Ashby, 2000; Pacht, 1984; Parker & Adkins, 1995; Parker & Mills, 1996; Schuler, 2002). Roberts and Lovett (1994) found that when gifted students were exposed to failure, they demonstrated more negative reactions and irrational beliefs about that failure than did their nongifted peers. Reviews of the empirical literature are mixed, however, with some suggesting that gifted students are more perfectionistic than their nongifted age mates and others disagreeing (Schuler, 2002).

Stone and Sias (2003) cited perfectionistic thinking as a possible additional risk factor for SIB, and Conterio et al. (1998) posited that “rigid or all or none thinking” was likewise a risk factor for SIB (p. 140). These ideas echo concepts of unhealthy or neurotic perfectionism (Hamacheck, 1978; Pacht, 1984), pervasive and mixed- maladaptive perfectionism types as described by Dixon, Lapsley, and Hanchon (2004), and the “entity” theory (Robinson, 2002; Schuler, 2002) that some talented individuals may hold, resulting in these students’ increased sensitivity and vulnerability to criti- cism and avoidance of challenging or novel situations.

Some individuals who self-injure do so to feel tangible physical pain in situations where psychic pain is overpowering and to release tension (Zila & Kiselica, 2001). Conterio et al. (1998) found that individuals who demonstrated SIB were highly sensi- tive to emotions and stimuli in their environment such as odor, noise, sound, and sights. Dykes, Specian, Nelson, and Gray (2006) suggested that these individuals view these sensations as too intense and too invasive, and described the internal arousal to the stim- uli as making the individual feel out of control and overwhelmed by the associated emotions. This finding could suggest that gifted students with sensual and emotional overexcitabilities, as postulated by Dabrowski (Ackerman & Paulus, 1997; Tieso, 2007), who do not have an awareness of their excitability or healthy coping skills may be more susceptible to SIB.

Self-injury has also been categorized as a maladaptive coping strategy (Haines & Williams, 1997). For many, implementing self-injury across several problem situations indicates that they have few effective coping strategies (Haines & Williams, 1997). However, this stance is not without criticism; an alternate viewpoint suggests that it may be useful to understand self-injury as an adaptive act and as a means of survival, rather than a deficient coping strategy (Solomon & Farrand, 1996). Solomon and Farrand (1996) suggested that individuals who harm themselves do so to stay alive and to prevent themselves from suicidal gesturing.

Biological Factors In addition to the environmental and psychological motivations for self-injury, research is now beginning to investigate biological explanations for self-injury. Recent neurobio- logical research demonstrated self-injury has physiological antecedents and consequences which may instigate the behavior, making it difficult for individuals who self-injure to

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stop (Shaw, 2002; Winchel & Stanley, 1991). Neurotransmitters such as serotonin and enkephalins have been investigated to determine their potential links to self-injury.

The two major tasks of these neurotransmitters are to suppress pain and to regulate emotions. Simeon et al. (1992) examined serotonin activity in a study of self-injurers and non-self-injurers with personality disorders, finding that self-injurers had significantly lower levels of serotonin activity. These results speak to the efficacy of using psychotropic medications to increase brain serotonin levels, and consequently reduce incidence of self-injury (Favazza, 1998).

An additional group of neurotransmitters called enkephalins have also been shown to demonstrate a potential link to self-injury. Favazza (1998) proposed that self-injury may produce enkephalins, inducing a pleasurable effect, and thus indi- viduals who self-injure may harm themselves to induce their production. If this is the case, individuals may link their harming behaviors with positive feelings and plea- sure. This, in turn, may motivate the individuals, when they feel depressed or unhappy, to harm themselves to feel better. Empirical studies examining the role of neurotransmitters in self-injury are limited, and future research, which may ulti- mately guide treatment, is needed.

Whereas neuropsychology and cognitive psychology seem to be complementary fields to gifted research, brain research is just now making its way into the professional gifted literature (Kalbfleisch, 2008). Although this body of research is growing, not much is known precisely about the roles of neurotransmitters and neural structures with regard to intelligence, creativity, ability, and the experiences of the gifted students. However, a student’s thinking and learning styles have both biological and cognitive underpinnings. Dai (2008) defined “style” as the self-organization of cognitive resources in managing academic or other challenges (p. 698). Obviously, learning and thinking styles have implications for how gifted students manage emotions and motivation and how they adapt when confronted with challenge, success, and failure (Dai, 2008).

Several researchers have suggested that if individuals do not have a way to moderate or regulate their emotions or cope with stressful events, self-injury could be a way of coping with them (Nock & Prinstein, 2005; Suyemoto & MacDonald, 1995; Walsh & Rosen, 1988). Hence, a gifted student with less ability to manage emotions or fewer cognitive resources with which to adapt to new challenges or failures (inherent in new curriculum, academic expectations, or interpersonal relationships) may choose to express those emotions or adapt physically to internal turmoil by engaging in SIB.

Life Factors A last factor that may influence individuals to self-injure includes stressors that come with life situations. Conterio et al. (1998) and Welsch (2001) cited recent losses, peer conflict, and family-related illnesses as possible predictors of self-injury. Students who have experienced these life events may be at greater risk for engaging in SIBs than those who have not experienced them (Walsh & Rosen, 1988). Like all other students, gifted students face challenging life situations. To some extent, biology,

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home, and school environments can mediate students’ experiences of issues and chal- lenges such as the death of a family member or divorce and relocation. But there can be negative consequences to these experiences (Clemons, 2008), and as Peterson (2006) stated, gifted students, like all students, are not immune to them. In fact, the presence of gifted characteristics (e.g., overexcitabilities) and academic pressures may make these life situations even more difficult to manage effectively, leaving SIB as a possible coping strategy (Peterson, 2006).

Self-Injury, Mental Health, and Suicide Teachers and others who work with the gifted should be aware that self-injury is rarely an isolated issue. Students who self-injure may be experiencing additional psychological or emotional problems. Early conceptualizations viewed self-injury as a behavior associated solely with schizophrenia or borderline personality disorder; however, contemporary research has rejected these viewpoints and adopted a broader conceptualization of self-injury (Favazza, 1998; Favazza & Rosenthal, 1990; Muehlenkamp, 2005). For example, individuals who self-injure may also have higher rates of depression, obsessive-compulsive disorder, and anxiety disorders such as those specific to eating and body image (Paul, Schroeter, Dahme, & Nutzinger, 2002; Suyemoto, 1998).

However, educators are probably most concerned about the possibility of suicidal behavior in students who engage in SIB. As discussed above, definitions of self-injury often view self-injury and suicide as separate and distinct phenomena. Proponents of this viewpoint argue that the intent behind each behavior is remarkably different. For individuals who self-injure, the intent may be to release tension, and many individuals report a sense of relief after the act of self-harm. However, the suicide attempter expe- riences overwhelming feelings of helplessness, and the goal for the suicide attempter is to end his or her life (Fawcett et al., 1987).

In spite of the perceived differences between suicide and self-injury, parallels exist between the two, and self-injury can coexist with suicidality (Vivekananda, 2000). Research indicates that an individual who self-injures is 18 times more likely than the rest of the population to eventually complete suicide (Ryan, Clemmett, & Snelson, 1997). Furthermore, approximately 55% to 85% of individuals who self-injure have made at least one suicide attempt (Favazza & Conterio, 1988; Stanley, Gameroff, Michalsen, & Mann, 2001). In addition, newer conceptualizations imply that self- injury and suicide are both types of self-harming behaviors and exist on opposite extremes of the same continuum (Craigen et al., 2010).

Suggested Best Practices for Educators Working With Talented Youth The authors of this article are not suggesting that gifted and talented youth are any more likely to engage in self-injury than their nongifted peers; however, there is

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enough research to support the need for educator awareness about these behaviors as they may manifest in the gifted population. Educators should avoid placing all indi- viduals who self-injure in a particular category; despite their commonalities, it is impor- tant to remember that adolescents who self-injure are unique individuals who should be treated as such. Hence, educators of the gifted should familiarize themselves with infor- mation about SIB to best help their students.

Unfortunately, many school professionals adopt the stance that self-injury is a men- tal health issue and not a “school issue.” Because self-injury affects the school and the school environment on many levels, this stance is unrealistic. First, research supports the fact that SIB can be taught, and the school environment can facilitate the contagion factor associated with this behavior (Trepal & Wester, 2006). Second, self-injury does not exist in isolation, and it is often accompanied by other behaviors that may directly affect the school environment (e.g., substance abuse, aggression). Hence, it is benefi- cial for educators to take a close look at self-injury among gifted adolescents. The fol- lowing section outlines suggested best practices for educators working with talented youth who self-injure. These suggestions include information related to assessment and intervention, referrals and resources, and professional development and training.

Assessment and Intervention Protocols All educators must know whether their school has a self-injury protocol. Self-injury protocols can guide school professionals in how they communicate and make refer- rals for students who are self-injuring (Shapiro, 2008; Walsh, 2006). School protocols should also communicate the school’s stance on confidentiality with minors who self-injure. If a self-injury protocol is not in place, it would be beneficial to create a multidisciplinary team (consisting of school nurses, teachers, school psychologists, school social workers, school counselors, and administrators) to create a school- based protocol (Shapiro, 2008). A primary goal in the development of a self-injury protocol/written policy is to ensure that all staff members are in agreement about definition and procedures and therefore approach and conduct interventions in a similar manner. Self-injury protocols and/or written policies may include, but are not limited to, the following:

• Recognizing warning signs related to self-injury • Learning how to distinguish between an act of self-injury and a suicidal act • Understanding who should be contacted when reporting incidences of self-

injury and how to protect privacy • Making appropriate psychological, psychiatric, or medical referrals for self-

injury • Knowing appropriate steps to follow when an individual requires immediate

attention (Walsh, 2006)

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We suggest that school personnel examine Onacki’s (2005) sample protocol as a start- ing point. Once a self-injury protocol is created, it should only be implemented with adequate and advance training of all staff members (Walsh, 2006).

Recognizing and Working With the Student Who Self-Injures Teachers of the gifted are often informal providers of counseling for their students and, frequently, when there is a good relationship, the first person whom gifted students come to when in need of help (Croft, 2003). Hence, educators should be prepared if gifted stu- dents reveal that they are self-injuring and must be able to recognize warning signs as well as be able to communicate effectively and compassionately with students who self-injure. The following are common warning signs in students who self-injure (Levenkron, 1998):

• Unexplained cuts, scratches, or scars • Excuses for new cuts, scratches, or scars • Mood changes, including increases in depression, anxiety, and/or aggression • Wearing long sleeves, long pants in warm weather • The appearance of razors or sharp objects that one would not expect among

a person’s belongings • Defensiveness when asked about the topic of self-injury • Increase in isolating or detached behaviors • Increase in substance use and/or abuse

Given the secrecy and privacy associated with the behavior, it is likely that a student will be extremely hesitant to reveal their self-injury in a school environment. Thus, it is critical that educators work diligently to establish a trusting and supportive relationship with their students. Building trust will take time, patience, and effort. In fact, adolescents who self-injure indicate that trust is one of the most important factors in a helping relation- ship (Craigen & Foster, 2009).

When communicating with a student who self-injures, educators should begin by making nonjudgmental responses and empathic statements that demonstrate a willing- ness to learn about who the student is, beyond their self-injuring behaviors (Moyer & Nelson, 2007). For example, it can be beneficial to ask about the student’s hobbies, family life, significant life events, accomplishments, and the like. The following repre- sents a list of statements that educators can make when they discover their student is deliberately harming themselves.

• “I see your wounds and I can tell that you are in a great deal of pain.” • “You must really be hurting and I want to help you.” • “I see you are having a difficult time and I am sorry you feel like you need to

hurt yourself in order to feel better.” • “Thank you for sharing this with me. I know how personal and private this

is to you.”

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Above all, we recommend that the first and best thing a teacher can do is listen to the student when he or she reveals the struggle with self-injury. In their qualitative study, Moyer and Nelson (2007) found that individuals engaging in SIB reported that the need to be heard without judgment or condemnation was of primary importance to them. Yet, when the words “cutting” or “hurting myself” are uttered, teachers may feel an almost immediate physical and emotional reaction. These reactions are normal and have been documented, but teachers need to be aware of their own reactions and what they are “telling” the student via their nonverbal behaviors.

Although teachers may feel frightened, dismayed, or disgusted by what they may see as the bizarreness of the behavior, displaying these emotions can result in the emo- tional shutdown, withdrawal, and disengagement of the student from the conversation. By communicating these reactionary emotions, a teacher risks forfeiting a safe and trusting relationship with the student, which is precisely what the student needs for recovery. We recommend teachers focus on the student, not on the evidence or specific SIB behaviors, and demonstrate both verbally and nonverbally that they care about the student and are willing to listen and help without judging the student or the behavior. The empathic responses suggested above convey nonjudgment, support, and an uncon- ditional positive regard for the student, which can allow for the development of a strong and trusting relationship.

Referrals and Ethical Considerations Froeschle and Moyer (2004) discussed the importance of weighing legal responsibili- ties with ethical decisions when working with individuals who self-injure. Typically, teachers are mandatory reporters. When confronted by a student who appears to be in danger, we suggest teachers should choose to discuss with the student their duty to warn, their desire to help, and their responsibility to take appropriate action, as educa- tors may be in legal jeopardy for nondisclosure if students reveal that they are self- injuring and later seriously injure themselves. Teachers may be unclear as to when self-injury becomes dangerous and warrants breaching confidentiality. Unfortunately, there is no clear-cut answer to these complex ethical dilemmas, making it difficult for gifted educators to navigate issues related to confidentiality and self-injury. There are many challenges to managing confidentiality with clients who self-injure (White Kress, Drouhard, & Costin, 2006). It is important for gifted educators to be transparent with students and state their stance on confidentiality at the outset of requested or other seri- ous conversations. We suggest teachers go with the student to the school counselor or other helping professional in the building so that the student does not feel alone and understands that the teacher is willing to help, including collaborating with another professional in the building. We recommend educators to not only be familiar with SIB protocols but also seek consultation with a professional in their building who has the preferred training, such as the school counselor, school psychologist, social worker, or other helping professional.

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Once this contact ensues, the helping professional should ask themselves the following questions when considering how to provide the best possible care for the student:

• The frequency and duration of the SIB: How long has the student been engaging in the behavior? How many times in a week/day?

• The type of SIB: Is it scratching, bruising, superficial, or deep cutting? • The severity of the SIB: Is it life threatening? How old are the marks? • The influencing factors of the behavior: Are there medical/physiological con-

cerns? What role does the family play? Are there instances of bullying? What stressors are the students experiencing?

• The level of rapport and depth of relationship with the student: How well do I know this student? Will the student trust me enough to self-disclose?

• The self-disclosure: Is this the first time the student has self-disclosed? If this is not the first time, to whom has the student disclosed and what is the other person’s relationship with the student?

• The student’s desire and ability to receive help: Does the student want help? Will he or she be willing to receive it from me? From an outside source? Will he or she accept help from family members?

• The time it may take to develop a working relationship in light of the helping professional’s caseload: Given the degree, the severity, the frequency, and any other factors, is time of the essence?

• Any supports and resources already established or easily available to the student: Is the student already receiving support? Is the family already engaged?

• The current availability and capabilities of local community mental health professionals: Who can I contact to get the student the help she or he needs? Is that professional qualified? What is the professional’s degree of experience with SIB? Does she or he understand the needs of a gifted student?

We believe that any helping professional must carefully weigh the student’s need, the severity of the SIB, and the professional’s ability to help. If the helping profes- sional’s caseload precludes the opportunities and time building a therapeutic relation- ship would require for the student to develop trust and the safety warranted to self-disclose, the professional should make a referral.

If the SIB has been identified and assessed in the school environment by a helping professional as critical or life threatening, a referral to a community mental health professional is warranted. Unfortunately, many community counselors and psychologists are still not comfortable with SIB nor do they have the experience of working with self-injury (Craigen & Foster, 2009; Trepal & Wester, 2007). Thus, it is vital that the school helping professional connects students with a professional in the community who is capable of working with the behavior and should call and speak to the profes- sional directly.

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In the information age, many mental health professionals post their vitae or treatment philosophy on their agency’s website, whereas some professionals have advertise- ments on sites such as psychologytoday.com (Psychology Today, 2009). Included in these advertisements are the professional’s treatment philosophy and the types of clients and behaviors with which they have the most experience. In sum, creating a resource list of qualified mental health professionals could be extremely useful for the school and the student.

Support and Intervention Once an appropriate community service provider is determined, it is possible, with the help of the student and parent, that school-based helping professionals may be able to receive a release of information that enables them to best support the interventions at school and support the community counselor who is working with the student. From that point forward, the family, student, and helpers should discuss and advocate for the teacher to be a part of the support systems that the student needs. Working together, the school-based helper and teacher can discuss and implement various supports and strategies in the classroom, in a small group, or one-to-one with the student—the goal being to support the interventions of the community-based counselor with the student.

Research supports several interventions that could be implemented in the school for gifted students who are self-injuring. These include the following:

• Developing a detailed safety plan, including defined safe people and safe places a student can utilize (White Kress et al., 2004)

• Implementing activities that help the student identify and express feelings orally and through writing (White Kress et al., 2004)

• Developing a 504 plan that allows for counseling sessions, medical care, and time-out sessions as needed (White Kress et al., 2004)

• Teaching healthy problem-solving coping skills to all students via classroom guidance or class activities (Moyer & Nelson, 2007; Trepal & Wester, 2006)

• Working with the student to develop and utilize an impulse-control log that allows the student to communicate the impulse to self-injure and hypothesize what the impulse is communicating (Conterio et al., 1998; Dykes et al., 2006)

• Utilizing sequential writing assignments regarding body, gender, family and relationship issues, autobiographies, and feeling identification (Conterio et al., 1998; Dykes et al., 2006)

• Planning educational and career paths with support in mind, including intern- ships, college, and future vocations (Trepal & Wester, 2006)

• Using art or other visual or physical manipulatives that allow the students to describe feelings when they feel the need to self-injure (Wester & Trepal, 2005)

Small groups focusing on grief, loss, anger, and self-esteem may also be beneficial to students who self-injure (Froeschle & Moyer, 2004).Gifted students may especially

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benefit from group counseling experiences with other gifted students, because they may have had similar experiences related to being gifted (Colangelo, 2003)

Professional Development and Training Self-injury is prevalent in schools, and the behavior is emerging among the gifted population (Grobman, 2006). Thus, educators should receive specific training to meet the needs of gifted adolescents who self-injure. Research points to the fact that school and mental health professionals lack knowledge and awareness related to self-injury (Craigen & Foster, 2009). What is known is that both parties want more information and training about self-injury (Craigen & Foster, 2009; Shapiro, 2008). Thus, it would behoove gifted educators to partner with the school counselor or school psychologist to develop a comprehensive training program for all school professionals. Specifically, the training should target the unique needs of gifted adolescents and the nature of self- injury. Collaborators can also extend training to the parents in the community in conjunction with neighborhood resources (Roberts-Dobie & Donatelle, 2007). Both parties might attend conferences or other professional development opportunities on SIB and present the information to their school staff.

Self-Care for the Educator Counselors and other helping professionals have reported feeling intimidated, distressed, guilty, disgusted, sad, traumatized, and incompetent or powerless to help when clients disclose their struggles with SIB (White, McCormick, & Kelly, 2003; Zila & Kiselica, 2001). A student’s disclosure may generate these same emotions in teachers as well as introduce teachers’ past experiences, memories of similar struggles, or family of origin concerns. These emotions and experiences can cause educators and helping profes- sions alike to engage in countertransference or may prevent them from providing adequate help to the student (White Kress, 2003). Hence, we recommend both parties to be aware of what their potential reactions may be if they have never had a student disclose an issue related to SIB before and make a plan for that event. Regardless of whether teachers have or have not had experiences similar to their students’, we also recommend the following self-care practices:

• Consultation with a trusted professional • Seeking counseling for themselves • Journaling their experiences and reactions • Taking necessary time away from the building to process the experience • Learning more about SIB to gain greater understanding of the student experi-

ence and their reactions to the disclosure of that experience

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Conclusion

Some educators may adopt the viewpoint that the topic of self-injury is not a “school issue,” whereas others may take the stance that self-injury is not relevant to the gifted population. Ultimately, both statements are flawed. Regrettably, SIB is inextricably linked with our gifted youth. As a profession, we must respond to this reality with an informed knowledge base and a motivation to learn more about this complex behavior to better work with gifted youth.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research and/or authorship of this article.

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Bios

Susannah M. Wood is an assistant professor at the University of Iowa where she teaches both doctoral students and students who are pursuing their master’s in school counseling with an emphasis in gifted education in partnership with The Connie Belin and Jacqueline N. Blank International Center for Gifted Education and Talented Development. She received her MEd in school counseling and PhD in counselor education from The College of William and Mary. Her research interests encompass preparing school counselors for their practice with a focus on serving the gifted population in collaboration with other educators and professionals.

Laurie M. Craigen is an assistant professor in the Department of Counseling and Human Services at Old Dominion University in Norfolk, Virginia. She is also a licensed professional counselor and actively sees clients at Southside Counseling Center in Suffolk, Virginia. Recently, Laurie was accepted as a summer research fellow at the Eunice Kennedy Shriver National Institute of Child, Health, and Human Development. She has a number of peer- reviewed self-injury articles published; speaks about the topic at local, regional, and national conferences; and is actively involved with self-injury research.

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