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Cutting, Eating Disorders and Confidentiality
Carolyn Stone, Ed.D.
Tuesday November 22, 2005
by: Carolyn Stone, Ed.D.

Section: Inside Insight

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A teacher reports to you that Donnell, one of her eighth-grade students, had a bandaged wrist and that she overheard her telling someone she decided to experiment with cutting just “to see what it would feel like.” At the teacher’s request you talk to Donnell, who admits the cutting but says she was only experimenting and that it was horrible and she never plans to do it again. She explains that her friend Catherine, another eighth-grader in your school, cuts all the time. Do you call Donnell’s parents? Catherine’s parents?

Randy is on the wrestling team, and Coach Gilbert is convinced Randy is bulimic. Gilbert says he has first-hand knowledge of bulimia since he suffered from this during his own years as a wrestler and has confronted Randy who denies purging. When you call Randy in, you notice his teeth appear pitted and his skin is sallow, but he denies having a problem. He begs you not to call his mother as he fears she will “ship me off to live with my dad.” Randy believes a call from you will give his mother the ammunition she needs to “finally have an excuse to get rid of me.” Do you call Randy’s mother?

School counselors know all too well how the trust established between a counselor and student can enhance the their effectiveness and widen opportunities to intervene for the student population. Conversely, for some students a breach in trust can create a chasm that can render the counselor inconsequential in a student’s view. Consequently, breaching confidentiality, even when we know it is imperative to protect a student, creates anxiety. Our profession takes the confidentiality imperative very seriously.

Self-harm is being played out in schools across America with many students suffering from eating disorders or cutting behavior. This unfortunate reality of a school counselor’s life, especially for middle school counselors, is a weighty burden because of the ambiguity of protecting students’ trust in the school counselor as a confidant and the need to protect the students from harm. The struggle is compounded by the student’s age and developmental levels. In other words, the younger the child, the greater our responsibility is to parents. Additionally, we have the added burden of functioning in an academic setting in which students are required by law to be there, and the setting is designed for academic instruction rather than counseling. This adds to our obligation to involve parents when their children are in danger. Eating disorders and cutting behavior underscore the conflict counselors face in trying to behave legally and ethically toward students and their parents.

Do these behaviors represent clear, imminent danger? Granted, it’s not paramount to holding guns to their heads, but for many students these behaviors represent serious physical and mental health issues that can result in death or permanent harm. Coach Gilbert, based on a real person, still suffers from bulimia today, years after beginning this practice as a teen. The potential lethality of cutting and eating disorders is not necessarily as direct or strong as suicide but there are parallels between our obligations to suicidal students and those who self-injure.

The Letter of the Law
Where do school counselors stand legally? The law of negligence involves injury or damage to another through a breach of duty owed to that person. Duty owed is a legal responsibility. Negligence requires the presence of four elements:
• A duty is owed.
• The duty owed was breached
• There is a causal connection between breach of duty and injury.
• An injury has occurred.

There have been a number of cases against school counselors involving suicide and one in which the court stated that the counselor had a legal duty to try to prevent a possible suicide (Eisel vs. Montgomery County Board of Education, 1991). Although cutting and eating disorders are not as imminently lethal as suicide, both can lead to death. To date, however, there are no cases against a school counselor for failure to report these two types of self-harm.

The court in the Eisel case cited as critical the in loco parentis doctrine, which means educators, including school counselors, are legally standing in for parents and owe a special duty to exercise reasonable care to protect a student from harm. The court concluded school counselors have a duty to use reasonable means to attempt to prevent a suicide when they are placed on notice of a student’s suicidal intent. With the Eisel ruling, the court redefined the school counselor/student relationship and declared that school counselors have a duty of care when placed on notice of a possible suicide. Are the principles established in the Eisel case are applicable to future cases in which a school counselor learns a student is cutting or might have an eating disorder? Yes, a court of law could argue that we also owe a duty to try to prevent a student’s death due to eating disorders and/or complications from cutting.

The Eisel ruling, although of considerable importance to our profession, does not take away a counselor’s ability to make judgment calls in situations of possible self-harm. Every time a school counselor decides not to inform parents or guardians after students have disclosed something in a session that could possibly lead to the student or others being harmed, counselors take a legal risk. However, if they refuse to take such risks from time to time, they could not possibly be effective counselors.

The duty to care is critical, as is the enormity of breaching confidentiality. Making the decision whether or not to breach confidentiality shouldn’t be an easy one; it should cause the professional school counselor considerable discomfort. Exercising the least intrusive way to breach can both protect our students and many times protect our trusting relationship. The least intrusive approach to breaching might be simply to encourage students to tell their parents or giving them the option of calling or having you call. The most intrusive approach would be to call parents without forewarning the students. In all breaching situations, each degree along the continuum is appropriate at times. Only the school counselor, in consultation with others, considering the specific circumstances of the self-harm case can determine the most appropriate way to breach.

Typically, there is no way to know with certainty if a student really has an eating disorder short of a doctor’s diagnosis. Cutting, while at times obvious, can even be well-hidden. Even though our information may be limited, we have to try to connect the dots on the information we have, consider the warning signs, the child’s age, his or her problem-solving ability and the child’s family support system. Only then can we determine if a breach is the right decision. In the case of Donnell and especially with Catherine and Randy, get additional information before makin a decision. When you’ve determined a breach of confidentiality is needed, work with the students to make the breach less intrusive.

The only way to ensure you never get sued is by always telling parents or guardians everything students tell them in counseling sessions. This flies in the face of the ethical imperative to respect our students’ confidences and to wrestle with each situation in context. Seek supervision and consultation to reach the decision that a “reasonably competent professional” would make, as this will help satisfy the legal test if your decision is questioned.

In some cases, such as worry about Randy’s mother’s reaction, the reasonably competent professional would consult with other professionals, and it could be that a call is delayed or never made. It is ultimately the school counselor’s responsibility to negotiate the complex nature of self-harm situations and avoid the easy, fixed solutions of always breaching or never breaching. The legal and ethical complications of any human service profession are daunting. Working with clients who are minors in a setting designed for academics adds considerably to the difficulty of respecting confidentiality in these complex self-harm cases. Err on the side of caution.