Self-Injurious Behavior and 
Ethical Considerations
Cheryl Kempinsky, Ph.D.
Non-suicidal self-injury (NSSI) has become a common presentation at hospital emergency departments.  An estimated 9% of those "repeating” for emergency psychiatric care have harmed themselves: 1 to 4% of adults and 13 to 23% of adolescents presenting in ERs have self-inflicted wounds.  In 2010, a Canadian school-based study revealed that 9.1% had engaged in NSSI (2.3% boys and 6.8% girls) yet only 13.5% of these students were willing to seek help from school counselors.  Among college-aged adults in the U.S. surveyed in 2006, the percentage of those having exhibited a self-injurious behavior one or more times was 17 with 75% of these students engaging more than once. Thirty-six percent reported that no one knew of their self-injurious behavior and only 3% indicated that a physician knew.  Because of prevalence, likelihood of referral for aftercare, and extent of undisclosed behavior, clinicians need to be aware of treatment practices and ethical considerations involved in the treatment of NSSI.
NSSI is defined as "the deliberate and intentional destruction of body tissue without suicide intent and for purposes not socially sanctioned.”  Examples of such behaviors include cutting, burning, stabbing, hitting, scratching, and excessive rubbing.  Reflecting current trends, tattoos and piercings are excluded from this definition which renders the distinction between "socially sanctioned” self-injury and "non-socially sanctioned” self-injury an important one. Evidence of increased attention include the proposed DSM-V nosology and diagnostic criteria for NSSI, but the history of documented self-injury has been traced to ancient texts.  Diagnostically, in DSM-IV, the only mention of self-injury is among criteria for Borderline Personality Disorder (BPD), and it is held that over 70% of BPD patients engage in suicide attempts and/or NSSI.
Clinicians must be alert to the possibility of NSSI among clinic populations and be educated in the assessment for self-harm behaviors. From a perspective of risk management, clinicians prioritize suicide risk assessments.   Now, we need to query regarding the presence of self-inflicted harm. Similar to the process of a suicide risk assessment (SRA), an injury risk assessment (IRA) addresses thoughts, urges, actions, function, intentionality, history, and both the situational and diagnostic contexts of the occurrence of this behavior.
Ethical considerations include competence, consultation, and referral (APA, 2.01, 2.03, 2.04), countertransference (APA Ethics Code 2002, Principle E: Respect for People’s Rights and Dignity), informed consent, particularly with regard to adolescent treatment (APA 3.10), and limits of confidentiality (APA 4.02a, 4.05b). Ethical practice and standard of care suggest that when accepting such referrals, consider the extent to which your training and experience in evidence-based treatments define your practice to a level of competence, seek regular consultation, and document your work.
Klonsky, E.D., Muehlenkamp, J.J., Lewis, S.P., & Walsh, B. (2011). Nonsuicidal Self-Injury. 92pp. Hogrefe Publishing, Cambridge, MA.

Nixon, M.K. & Heath, N.L. (2009).  Self-injury in Youth: the essential guide to assessment and intervention.  339 pp. Routledge/Taylore & Francis Group, New York, NY.

Perepletchikova, F., Axelrod, S.R., Kaufman, J., Rounsaville, B.J., Douglas-Palumberi, H., & Miller, A.L (2011).  Adapting Dialectical Behavior Therapy for Children: Towards a new research agenda for paedriatric suicidal and non-suicidal self-injurious behaviors.  Child and Adolescent Mental Health, vol. 16, No. 2, pp. 116-121