Introduction
Slowly and belatedly, psychologists are becoming part of the multi-disciplinary movement to provide services in rural and remote areas. Whereas there are established traditions of care provided by the medical and nursing professions, and to a lesser degree other health care providers, psychologists in Australia have been slow to accept the challenge, and are notable by their absence.

A survey (Farrin, Dollard and Court, 2000) of where psychologists live or work, provides an insight into their actual distribution in the provision of care. Some choose to live in a rural environment and commute to urban areas for work. Others do provide a degree of care, based on living in an urban area, and moving out on an occasional or consulting basis for brief periods of time. Such resources are of value but do not fully enter into the world of the rural consumer. Then there are psychologists who live and work in rural areas, but are not predominantly providers of services. With the growth of tertiary training institutions outside the main centres, they work primarily as academic psychologists. Hence it is hard to know just how many psychologists provide a substantial service to rural or remote communities, but we can be confident it is far fewer than any head count might suggest. Even at the most optimistic assessment of the figures, the rural community is seriously underserviced (Farrin, Dollard and Court, 2000).

In the absence of substantial rethinking about what is involved in practicing as a rural psychologist, it is highly probable that there will be a downward trend in numbers as there has been in the rural population at large for some years. Such a decline would not represent a reduced need for services, however. Rather, it would relate to a constellation of barriers to effective and satisfying work opportunities, for which many explanations have been offered (e.g. Griffiths, Dunn and Ramanathan, 1996). Behind the sociological factors there lie some significant training and professional issues that are rarely addressed at the undergraduate or graduate levels, resulting in perceptions and expectations which do not conform to reality. Without rethinking a number of widely held assumptions that pervade training programs, it may be difficult to prepare and equip those graduates who would give serious consideration to working outside the metropolitan areas.

Some moves have been made to address rural issues specifically in the training of psychologists, largely through options contained within a curriculum largely targeting traditional settings. An exception developed in the US following the devastation of Hurricane Andrew in Florida, where a Rural Psychology Program has emerged at the University of Florida, in association with many agencies in the community (Sears, Evans and Perry, 1998). In view of the need for similar developments in Australia it is worth summarising their training goals, which are identified as intraprofessional and interprofessional.

The intraprofessional developmental goals are as follows;
(a) to acquire a basic understanding about the nature of underserviced mental and behavioural health care needs of rural populations;
(b)to innovate and implement a full range of methods to increase the availability, accessibility, and acceptability of psychological services;
(c ) to engage in program development and evaluation in behavioural health areas, such plans are smoking cessation, exercise promotion, and stress management; and
(d) to learn about the benefits and obstacles associated with creating a satisfying rural practice.

Interprofessional training goals are of equal emphasis and importance. These goals include the following;
(a) to understand the role or roles of other professionals in a rural community,
(b) to expand the recognition of the importance and utility of the psychological and behavioural health services by other rural health professionals, and
(c ) to engage in coalition building with the community service delivery systems in place in rural areas. (p.505)

This is a very different agenda from that which is pursued in most Australian graduate programs. It does not represent simply an add-on to the existing curriculum but clearly involves a shift in content, style and concepts. It is clear from current writing about the difficulty in providing rural psychology services (Griffiths, Dunn and Ramanathan, 1996) that the bridge between academia and rural health needs has yet to be crossed. In order to achieve such a transition, it is suggested that the following propositions be given serious attention in the preparation of aspiring rural psychologists.

Proposals for Change

1.The fifty minute hour.
Most training in clinical psychology assumes that consultations will occur in the psychologist’s office, and are likely to last for around 50 minutes. Appointment books and plans confirm these expectations. Such an arrangement is convenient for the psychologist, but does not necessarily reflect the reality of clients' needs. Clearly these assumptions have derived from the earlier patterns of behaviour based on psychiatric practice and evolved from the work of Freud, for whom the 50 minute hour was sacrosanct (Mitchell and Lindner,1983). They appear to be powerfully perpetuated in the minds of the professionals and clients alike. Yet it happens this pattern may be far from suitable to the situation of many in the rural environment. Valuable consultations may well occur under many other conditions-some can take much less time than the hour, whilst others, especially when working with families, need to take a longer period. In the setting where clients are having to travel long distances, it is appropriate to think of ways to maximize the visit and not simply rely on a pattern which suits the urban client. Some consultations may best occur in other locations including the person’s home. Many health practitioners acknowledge the benefit of house calls, but psychologists have been slow to participate in this practice. A great deal can be accomplished also through telephone contact, thereby reducing the need for extensive travel.
In the United States, there has been some move away from the traditional training in clinical psychology to embrace more of a health psychology model, and this is beginning to appear in Australia. A strong advocate for moving in this direction was Leon Levy, who challenged many of the assumptions underlying clinical training, and responded to the needs by establishing a doctoral program in human services psychology at the University of Maryland. He commented "…many of the activities…that were once fully accepted as falling within the purview of clinical psychology are now either being shared with other specialties within psychology or with other professions or have entered the public domain" (Levy, 1984, p.486).

The current Maryland program is broadly based with emphases in behavioural medicine, clinical psychology and community-social psychology, and designed to "train psychologists for research and service in the public sector, placing special emphasis on the problems of inner city, minority and poor populations, and of children, youth, and the aged" (http://psych.umbc.edu).

He cautiously suggested "the ways in which we have thought about clinical psychology…may no longer be the most appropriate or serviceable" (Levy, 1984, p.487). More emphatically, the distinguished leader in clinical training, Don Peterson, has taken the critique further saying "The current practice of psychology…is at best a well-intentioned mistake and at worst an outright fraud." (Peterson, 1995, p. 977).

2.Extended training.
The length of psychological training has been increasing for a number of years, and the emphasis on being professional scientists is something which is prized. This has been further cultivated by the increased number of specialist groups within the Australian Psychological Society setting restrictive standards for entry, and following in the medical tradition of specialists. Certainly the growth in the knowledge base of psychology justifies increased lengths of study and the need for many to specialise, yet this is not necessarily in the best interests of clients. It is not clear that more training produces more effective practitioners. Indeed evidence to the contrary indicates that those with quite modest training can be as effective as the highly trained specialists when they stay within their areas of competence (Christensen and Jacobson, 1994). Hence the assumption that more training is a good thing must be challenged. Peterson is strong in his challenge of the view that  "extensive training is required to develop professional skills in psychotherapy, psychodiagnosis and related professional functions. This assumption is challenged by a large body of research that fails to show any relationship between training and efficacy in common forms of practice." (Peterson, 1995, p. 975). Not more, but different training is needed. It has been commented from the rural context of Montana that "…persons from the traditionally recognized professions, who are qualified for open positions by their degree title, often do not have the training or motivation to serve the populations most in need of help: persons with serious mental illness, severely emotionally disturbed children and their families, and elderly clients." (Waldo, Horswill and Brotherton, 1993).

In the rural context, the need is for generalists not specialists. In an urban area, professionals do a great deal of cross-referral to those with specialist skills, but in a rural context, the psychologist must expect to be adept in many areas, and rarely able to indulge a preference for a particular kind of work. This is the pattern seen among other rural professionals, and the psychologist is in danger of being severely handicapped by choosing to exercise skills in a limited area. Such generalising is not currently valued in the profession, but undoubtedly the client population will be better served when generalists are able to respond to a wide variety of problems with some confidence.

3.Rural parameters.
Training in an urban environment by an urban faculty can only perpetuate an urban model of practice. Those from a rural background recognise there are differences in style of living and expectations such that a cultural adjustment is needed when they visit the city. If the psychologist is to learn to be effective in the rural environment, then an acculturation process needs to be as much a part of the training as the professional knowledge base. An ideal for achieving this would be to study in a rural setting with those who also live in and understand that environment. Just as political parties readily recognise the differences in attitudes between town and country, so too must the psychologist reared in the city be ready to be culturally flexible. It will also be a significant step forward when it becomes easier for students who have grown up in country areas to continue their studies in regional Australia instead of dislocating to the metropolitan universities. Even where this is not feasible at the undergraduate level, the formative years of practitioner training at Masters or Doctoral level may be sufficient to apply theory to rural practice. Ideally, however, the whole training sequence being offered in the rural context would overcome some of the financial and relational difficulties which arise when moves are made every few years. Continuity in the training environment can contribute to a greater rural retention rate after graduation. It is widely recognised in American doctoral programs that those who move to a clinical internship for a year tend to stay on to practice in that location because they build up their professional contacts during that time of acculturation.

The rural differences can be quite pronounced and unexpected for the city trained psychologist if they have not been anticipated during training. Conservative values are more widespread, and many of the changes associated with a fast changing urban environment are not embraced or even recognised in the bush, where the pace of life and the priorities are so different (Harvey and Hodgson, 1995). Some problems present differently so that "the socio-cultural environment in which family violence and other maladaptive patterns occur differs tremendously from urban to rural settings" (Mulder and Chang 1997, http://we.marshall.edu/jrcp/vole1/vol_e1/Mulder_Chang.html ), calling for perceptive responses. Perhaps even more significantly, the question of dual and multiple relationships has to be handled differently in small communities, so that there needs to be an appreciation of how the ethical codes of the profession can apply.
Recent good writing in this area has brought such differences into focus, identifying the challenges both professionally and socially for psychologists and their clients. (Faulkner and Faulkner, 1997, http://www.cornerstonebh.com/mangrel.htm ; Schank and Skovholt, 1997; Sonne, 1994; Wilson-Barrett, 1999).

4.Rurally attuned faculty.
Finding rural academic staff will be a challenge since the heavily competitive nature of academic life is often at odds with the more cooperative style of rural life. Expectations for faculty to undertake quality research and to publish can present a conflict for those who are committed to a pioneering service for rural settings. These conflicts are common obstacles to academics who seek to undertake clinical training in universities, but even more pronounced for those interested in rural issues since funding for research work has not been well supported in the past, and resources are few.

A subset of this concern is the need for adequate training in relation to work with indigenous populations. While the APS has developed substantial guidelines on what should be included (Australian Psychological Society, 1999), it is questionable whether the detail which is called for is adhered to by academics without a background or experience of working in such settings. This is an area where it is obvious that European middle-class assumptions do not apply, and should not be imposed on practice.

5. Robust psychological assessment.
Psychological assessment has been a mainstay in the standardisation of instruments and the way they are administered has been well defined. The demands that they shall be reliable and valid have resulted in great care with test construction. This emphasis works well in the urban, middle class, educated environment where such tests were developed, but they do not necessarily work equally well in diverse settings quite different from the place where such instruments were originally developed. Hence the real challenge for rural psychology is to use and apply instruments which are contextually valid, and robust enough to be used in varied situations. This might sound like an impossibility, but the success of the classic measure of cognitive functioning, Raven's Progressive Matrices (Raven, Raven &Court, 1998) designed for such purposes and now the second most widely used psychological test in the world, is testimony to the value of well-constructed, easily administered tests which can provide useful information under less than ideal circumstances. In rural and remote settings, where the standard arrangements are not available, it may be legitimate to discard normative information in favour of qualitative information about behaviour. There is still a great need to develop assessment strategies suitable for indigenous populations.

6.Flexible approaches to therapy.
The pressure to use only well-validated procedures in therapy is one that has come in response to the economic demands of health funds which seek to rationalise health care using objective criteria. While this has led to some significant advances in defining approaches to the more common disorders and has been shown to be efficacious, the danger in this process is that other approaches which have not been subjected to rigorous studies will be discarded. Even those involved in the evaluation process have expressed serious misgivings about disregarding techniques that have not been fully evaluated (DeRubeis and Crits-Cristoph, 1998), while Ron Fox is very clear about his concerns – "…the proposed solution that some zealots would impose on practice is tied to a narrow definition of science that most clinicians, and most scientists for that matter, would reject…to propose that clinicians restrict themselves to applying only what is ‘known’ is to guarantee that professional psychologists will never be of much use to society" (Fox, 1996, pp.780-781).

7.Constraints – time, distance, resources.
The urban psychologist may practice knowing that clients will come from the immediate area in sufficient numbers to make the work viable. Travel time and distance are minor irritations rather than major obstacles. Access to resources like libraries, bookshops, and the wisdom of colleagues as needed, form basic assumptions of urban practice. For the private practitioner, these assumptions are vital for financial survival. There needs to be a critical population mass from which to draw clients, they need to be able to travel to appointments, and they need to be able to afford the fees for service. All these considerations are, of course, from the standpoint of the psychologist and do not fully acknowledge the needs of potential clients. There are, even in urban settings, many clients who could benefit from psychological care, but who are debarred from access by virtue of their disability or social circumstances, who do not have adequate transport, and lack the money or health fund cover to consider an appointment.

Such concerns are amplified in rural and remote settings. Distance becomes a matter of hours or longer of travel, making the freedom to seek help much more restricted. The critical mass of population is scattered very widely. Financial considerations weigh heavily in rural Australia, and the added burden of travel and time costs multiplies this. The last thing needed is a highly qualified psychologist who has acquired such a high level of indebtedness while training that she or he cannot afford to charge less than the recommended standard fee. The professional push to ever higher qualifications is not solving problems, but increasing them. Targeted, broad competence at modest cost will be of much greater benefit to rural Australians.

The private practitioner who cares to recognise how many people are excluded from psychological services may sleep at nights by rationalising that there are State supported facilities for the less advantaged to fall back on. If there is a tenuous truth in that in urban settings, it would be very hard to sustain in the rural context. The reality is that many major problems go unrecognised, and untreated, when early intervention and primary health strategies could make a real difference.

8.Embrace technology.
Most psychologists in Australia are still committed to personal contact with clients, assuming that service is best delivered through the establishment of face -to-face encounters. Training largely assumes this paradigm. Training placements are locations where service delivery occurs, and such work can be supervised. It follows that graduates will continue to think within this model and have difficulty in embracing service delivery in other modes. Yet in the rural environment, one major obstacle to care is the inability of clients to get to the practitioner for reasons of distance, cost, disability, etc. There is now a body of evidence from the rural experience in North America, that a great deal of effective work can be undertaken using the new technologies that include email and videoconferencing. The whole movement towards the delivery of telehealth (Barak, 1999: http://construct.haifa.ac.il/~azy/app-r.htm) is one that rural psychologists need to understand and apply, even though it may run counter to many training assumptions.

9. Ethical considerations.
Professional ethics is typically taught in graduate programs using the professional codes of the American and Australian Psychological Societies. While they provide an excellent base for understanding professional responsibilities, it has been noted that they do not always do justice to the dilemmas that arise very frequently in rural practice that arise from multiple relationships (Sobel, 1992; Sonne, 1994; Wilson-Barrett, 1999). Essentially the codes are written for the urban environment. Those preparing for rural practice need to reflect on how the principles work out in settings where it is not always possible to be so carefully, professionally antiseptic in one’s relationships without depriving people of care.

10.Generalist training.
Training at graduate level is typically constrained by the requirements to fit the current College structures of the APS. Hence it is difficult to move beyond such categories as clinical, educational, forensic etc. Yet a rural psychologist needs to be trained as a generalist, even at the risk of being less specific in one of those areas. An alternative would be a structured experience in addition to the current training, rather than a simple nod to rural issues during courses. Without the incorporation of directly relevant training during the graduate years, the result will be psychologists who go out and prove ill-equipped to cope. This will all too easily perpetuate the belief that psychologists have little to offer in rural health settings.

Of those alternatives, a focussed generalist training, or an addition to current offerings, the former is the better choice since extra training means extra costs. Already, psychologists are seen by many employers as too expensive when positions are being filled. Increasing the length of training exacerbates the problem. In the rural context, financial considerations are even more acute than in the urban setting. Those who do attempt private work in rural locations have to work very hard to make a living, and rarely manage to do this without including other sources of income. Training to enable practitioners to work not harder but smarter is one way of resolving the dilemma. Including rural placements among clinical options would be a modest move in the right direction, provided course teaching supports and informs students by way of preparation.

A useful parallel from the medical profession arises from a similar recognition of training needs distinct from those for urban practice, so that the Rural Doctors Association of Australia has moved towards the establishment of a Rural College (ACRRM) alongside the other specialist Colleges. (http://www.medeserv.com.au/acrrm/open/fore.htm)

11. Three summary recommendations.
Three other ways forward would assist potential rural psychologists. One is through more training in group work, to expand the traditional psychological emphasis on the individual; a second is to offer more training in the use of distance technology (Court, 2000). Both have been shown to have efficacy (DeRubeis and Crits-Cristoph, 1998; Kirby, Hardesty, and Nickelson, D. W. (1999) and both show potential for reducing costs without diluting the service that can be offered. Thirdly, it is clear that rural health workers need to be well equipped to understand medications and to work more closely with colleagues in determining appropriate prescribing. The response in the US by the APA has been to provide intensive training in psycho-pharmacology for psychologists (http://www.apa.org/ed/psypharm.html) to enable them to function effectively in rural areas, and with the military (http://www.apa.org/practice/gaoreport.html). Success in that has now led the College of Professional Psychology of the APA to pioneer a certification examination in psychopharmacology. (Foxhall, 1999; http://www.apa.org/monitor/dec99/pr2.html)That might well become a longer term objective in Australia. In the short term, more detailed teaching on current psychotropic medications would facilitate communication with medical practitioners and other mental health practitioners.

Conclusions
Current training practices have resulted in graduates being poorly prepared for rural practice. This fact has combined with many other obstacles to rural recruitment and retention to the point where the professional identity of psychology is largely absent from the health care scene in rural Australia. Changes are needed on several fronts, and a range of suggestions for improvement is proposed, which relate to philosophy of practice, training methods, and sensitivity to the special qualities of rural and remote Australia.

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