Abstract

Psychological services are sparse and under-developed in rural Australia. The difficulty for emerging practitioners in finding adequate supervision is an obstacle to developing accessible services. Supervision is required by State Registration Boards, who look to the Australian Psychological Society (APS) for direction regarding acceptable standards. This paper addresses the ethical issues arising from the APS adopting a position that supervision by a family member is always unacceptable. Registration Boards that might otherwise have allowed flexibility to accommodate the special needs of rural Australia are guided by this policy.  The paper questions the basis for making such a determination without scientific support, and implementing an ethical principle in an absolute manner, without support from the Society’s Code of Ethics. Evidence from other jurisdictions shows this stance is not universally supported, and the present policy is working to disadvantage individuals and rural Australians.

 

Rural supervision as a problem - the background

There has been an increased awareness of the need for improved health care in rural Australia in recent years, and a good deal of energy has been devoted, not only to finding reasons for the shortfalls, but also to finding responses that can reduce the gap between urban and rural care.  Substantial progress has been made in funding and training for the medical profession, and for some allied health groups, thanks to the initiatives of the federal government through Rural Health, Support, Education and Training programs. Psychology as a profession has been less successful than others in making the case for improved training and resources.

 

Several conferences have addressed the needs and possible solutions. Psychology received particular attention in the collection of papers, edited by Griffiths, Dunn and Ramanathan (1996), entitled Psychology Services in Rural and Remote Australia.  Among the many issues raised was that of providing adequate supervision, with Wolfenden (1996), noting that

 

“Rural training placements have also been proposed as a desirable initiative for undergraduate or recent graduates. This is an attractive idea, which would however require practical support to achieve. For this to work it should include adequate supervision and professional support, variety, no cost disincentives, and sufficient time for the person to experience the environment.” (p.26)

 

He develops the point further by suggesting that

“professional peer and mentor support are other initiatives to be encouraged. Providing rural psychologists with face-to-face access top senior to specialist psychologists, and access to regular educational and skill development opportunities is worthy of consideration.” (p.27)

 

A later event was held in Whyalla in April 2000, when the 4^th National Regional Australia Conference included a session devoted to Rural Psychology. A survey of South Australian rural and remote psychologists found that

“The importance of peer support, mentoring and local professional supervision was raised by 38% of psychologists and this is consistent with previous findings….one option suggested by a rural psychologist was for all psychologists in rural locations to be co-located with another psychologist, so that two psychologists were always based together. This would provide daily support, mentorship, peer supervision and debriefing that is currently available to most other health related disciplines.” (Farrin, Dollard & Court, 2000, p.21)

 

One outcome of that conference was a series of recommendations, with a rationale for their adoption. These included the following:

"Recommendation:   That the Commonwealth Government, State and other funding bodies assist in the provision of funding to make available incentives to secure the recruitment and retention of psychologists to rural Australia.

Rationale: The discipline of psychology is faced with the challenge of recruitment and retention of psychologists in rural communities. The rural psychologist is faced with challenges that are unique to the rural milieu, such as: personal and professional isolation; lack of peer support; inadequate resources, and dual relationship issues. These unique needs of the rural psychologist require attention." (Dollard, Farrin &  Munn, 2000, p.59).

In addition to these conferences, there has been some degree of concerted professional energy generated through the establishment of the rural psychology interest group within the Australian Psychological Society, and the formal recognition within that Society of such needs by the appointment of a Director of Branch and Regional Operations. One consequence is that we now have two sets of data seeking to establish the proportion of psychologists practicing in metropolitan areas of Australia, compared to the proportion located in non-metropolitan areas. The figures are preliminary and subject to difficulties of interpretation, but do provide a starting point for understanding the scope of the problem.

 

Griffiths and Kenardy (1996) reported APS membership figures for January 1996, across States and Territories, and found that of 5959 practitioners, 90% were identified as metropolitan based, and 10% were non-metropolitan. The range for non-metropolitan psychologists by State and Territory ranged from 36% in Tasmania down to 4% in South Australia, with 21% in the Northern Territory.

A similar enquiry was reported by Vines (2001). Once again Tasmania appeared to be high on non-metropolitan psychologists, though the classification given is Hobart vs non-Hobart (20 vs. 80%) which might suggest that many in the latter category were located in centres like Launceston, rather than truly rural or remote. South Australia had risen to 13% outside metropolitan Adelaide, but in the Northern Territory there had been a drop to 13% non-metropolitan, a total of 10 people, of whom only three belonged to any of the APS Colleges. At the same time there was an increase in membership within the Territory from 43 in 1996 to 76 in 2001.

It would appear from such figures that there has been an increase in psychological resources in the NT over the five-year period (or at least in APS membership) of around 43%, and in the metropolitan area from 34 to 66 members (or 48%), while for the rural and remote part of the territory, only 11%, or one person.  Commenting on the significance of the most recent figures, Vines noted as an issue, the lack of “availability of supervisors for professional training programs in non-metropolitan areas of the different states." (Vines, 2001).

 

From rhetoric to reality

Difficulties in recruiting and retaining rural psychologist have been adequately documented, conferences have discussed the problem, and recommendations have been brought forward on how the needs of the rural community for psychological services can be addressed. It is no coincidence that the Whyalla conference of 2000 also saw the launch of the International Journal of Rural Psychology, as a vehicle for exploring concerns that exist about the quality and quantity of rural psychological services.  Among the recurrent themes that emerge is the expressed need for “Facilitating accessibility of rural psychologists to experienced practitioners for supervision and for mentorship.” (Griffiths & Kenardy, 1996, p.47).

 

This is easier said than done in a country where sparse populations outside the metropolitan areas make it difficult to locate professional opportunities such that psychologists can work in teams or even pairs as various authors propose. Many of those who try working in the rural scene find themselves isolated, and eventually find the isolation too much to maintain.  A spark of hope can be seen in a paper written by a husband and wife team, offering creative solutions to this dilemma for rural Australia, using technology and peer support (Crago & Crago, 2002). All too often, good intentions give way to disillusionment and practitioners return to the more familiar and more supportive environment of a city or rural town. Hence the rural community is likely to be exposed to the exploratory efforts of recent graduates, but miss out on experienced and specialized practitioners. There is little reason to suppose that this will improve as the universities, Registration Boards, and the APS press for higher educational standards and the maintenance of professional development programs oriented to urban practice. Admirable as such aspirations may be, they serve to disadvantage the rural practitioner selectively, creating a serious professional handicap on those who try to undertake this difficult task of serving the rural community. Indeed, such developments based on metropolitan practice effectively work against the aspirations of rural health practice. In contrast to such moves to raise the barriers for professionals, the National Rural Health Alliance published a policy report entitled Healthy Horizons, saying, inter alia,

“Achieving Goal 5" Actions required to maintain a skilled and responsive workforce in rural, regional and remote Australia are to:

5.1 Remove legal and professional barriers to practice for health professionals in rural, regional and remote Australia in order to promote flexible services and improve clinical and management capacities” (National Rural Health Alliance, 1999).

 

The rhetoric is clear and the needs are obvious, so we may ask what the reality is when it comes to seeking to implement such recommendations? The following represents one attempt to respond, together with a surprising difficulty that emerged, combining to indicate why the Northern Territory is not making the progress needed. It also highlights a more generic problem arising from an internal policy of the Australian Psychological Society that imposes the very kind of limitations that have been identified as problematic in conference papers and resolutions.

A way forward?

Many of the difficulties that have been identified as adversely affecting recruitment, retention and supervision could be overcome if the psychologist considering work in a remote area were to have close access to a more senior colleague who could offer supervision and emotional support. Ideally this would be an arrangement in which the two worked in separate organisations so that administrative and other multiple relationship issues are minimised. Ideally also, the more senior colleague would be an experienced supervisor in an area relevant to the trainee. Such an arrangement is almost impossible to engineer, with one exception. The co-location of a husband and wife team is much more feasible and stable than other arrangements that may occur fortuitously. This is something often seen in the medical profession. Stability of expectations is important if an extended period of supervision is required, since one of the problems of remote locations is that professionals stay for such short periods of time.

 

An opportunity to test out such an arrangement presented itself, and arrangements were made to work in the Northern Territory in a remote centre. The prospects looked promising, but there were more obstacles to be encountered than appear on the surface. Progress will not be made until some basic issues are addressed, taking account of the circumstances that confront those who choose rural practice as an option. Among several that have been identified, one stands out as a continuing problem that could keep arising until changes are made.

 

A first person story

I suppose the story started when my wife tried to pursue an irregular journey towards registration as a psychologist. As many women find, the conventional route is not always available at the right time to fit the neat expectations of professional and legislative bodies. She pursued a way through undergraduate and postgraduate studies relentlessly over twenty years, piecing together a very broad range of academic credentials, but lacking the magical progressive four year sequence in undergraduate psychology that forms the touchstone of professional acceptance. She did however succeed in completing a PhD in Marital and Family Therapy from an American graduate school with APA accreditation for its psychology programs, as well as American Association of Marriage and Family Therapy (AAMFT) accreditation for its marriage and family programs. The combination of a bachelor’s, a master’s and a doctoral degree, plus a couple of graduate diplomas, enabled acceptance as a full member of the American Psychological Association. Along the way she also accumulated years of professional practice experience, supervised by licensed psychologists in the USA.

 

Even with the special provisions of the Australian Psychological Society for granting membership with unusual combinations of training, and the general assumption that APA membership is a good indicator of professional credibility, her credentials were initially rejected. Ultimately, the APS indicated that the academic credentials were satisfactory after all, and full membership could be granted after a further six months of supervision. After literally years of frustration trying to achieve a solution, she decided she would accept a position in the Northern Territory, where the regulations appeared straightforward, and where the Board was not constrained to conform to APS membership criteria. She applied for a remote area position that called for psychological registration, and advised the agency that she would either be registerable immediately or after a short period of supervision.

 

As a husband, I supported her decision, and rearranged my life to go the same location and work as a part time psychologist in private practice. I not only supported the idea of doing something worth while for rural Australia, but wanted to reciprocate for the many times that she had moved house in order to accommodate my professional priorities.

 

It was our expectation that she would be able to function as an independent practitioner without needing further supervision, but the fall back position assumed that if she should need a brief period of supervision, there was someone in town who could provide it.  My own background had included supervising psychology students for over 30 years, with recognition of this by the SA State Board, and by several universities. In addition I had just finished a spell as supervisor of trainee psychologists undertaking a university placement in rural psychology. Under ideal circumstances, we would not have entertained the idea of partner supervision, but, with the nearest other potential supervisor over 3½ hrs drive away, it appeared to be the kind of practical solution that rural work calls for.

 

We decided to try and establish the ethical grounds on which the N.T. Board might decide whether a family member may supervise. The Registrar stated in a letter that “The Board has adopted the Australian Psychological Society’s Code of Professional Conduct as its guidelines on ethical and professional standards.” That letter, dated in 2001, refers to a document that was superceded in 1997 by the introduction of new Code of Ethics by the APS. Codes of Ethics necessarily change as prevailing circumstances change, and clearly there are problems in dealing with an ethical issue when Board decisions are based on an outdated code. 

 

When the Board refused to endorse a supervision program at all but agreed to accept an APS-approved plan, we then became aware for the first time that the wording on the APS proposal form states not just that dual relationships should be avoided if possible, or that supervision by a family member would need to be addressed carefully, but that supervision by an immediate family member is not allowable under any circumstances (APS Supervision Manual, 1999).  Subsequent events have confirmed that this position is held to strongly by the Membership Committee and, in spelling out a supervision arrangement to my wife it was stated explicitly that a period of supervision should be undertaken with a supervisor who was not her husband. This position even negated a proposal that was put forward for a primary and secondary supervisor, as allowed by several State Psychology Boards to accommodate some of the difficulties encountered in rural locations.

 

Implications

This experience is only illustrative of the problems that create hidden but powerful obstacles to working in rural Australia. It may go some way to explaining why the number of practitioners has not grown in recent years. (Even the small increase of 3% of clinical membership in the NT has been lost as I was that one member of the Clinical Board, and found these disincentives too great).

 

Of course there can be reasons why close relationships are best avoided in supervision, but one can also argue that the benefits of proximity and collegiality that exist can far outweigh such considerations. In this case, the requirement was only for six months, with 18 months already credited and carried out elsewhere. To overrule the intentions of both the trainee and the supervisor is both arbitrary and paternalistic. In the rural setting where few alternatives exist, there is everything to be said for making possibilities work.

While the primary argument is one concerning practice in rural and remote areas, there is also a broader significant professional issue that this story illustrates. This relates to the powers of the professional bodies and how they interact with each other. It raises the question whether the one part of the APS should introduce an absolute prohibition in an area that surely represents an ethical dilemma. It questions whether the APS should apply ethical principles that are not themselves approved by the membership and enshrined in the Code of Ethics. And it raises the significant psychological question whether a dual relationship involving a family member is intrinsically so dangerous as to call for complete prohibition. That, one might suppose, should be established by scientific evidence rather than mere opinion.

 

Who is family?

Both the Australian Psychological Society and the Northern Territory Psychologists Board adhere to the principle that supervision must not be provided by one family member to another. The Board takes its lead from the APS proscription in this even though, as noted above, individual members express other positions. In addition, it should be reiterated that the NT Board is no longer required to do this since, in his annual report to the NT Government, the Chair, John Montz (2000), notes that

"In 2001, the Board, rather than the APS, is responsible for monitoring     

the supervised practice required for full registration".

 

It therefore becomes important to ask how the term family is to be defined for legal purposes. The term has changed significantly in recent years in the area of family law, and has become increasingly broadly defined in mainstream society in Australia. In the Northern Territory especially, the definition needs to embrace the familial relationships found among aboriginal groups, which have quite different patterns from those in Western culture.

 

In an attempt to determine both the established meaning of the term family for the purpose of administering supervision arrangements, and to discover what underlying principle might guide the prohibition against supervision by a family member, I sought clarification from the NT Board in the following terms -

"If there is a total injunction against close members of the family, does the principle also apply to supervision where a couple lives in a de facto relationship?

Does the principle apply to a couple engaged to be married?

Does the principle apply to a gay or lesbian couple?

Clearly it does apply if I seek to supervise my son. Does it apply to stepchildren also?" (J.H.Court, personal communication,  March 23, 2001)

 

The response from the Registrar on behalf of the NT Psychologists Board was that all these categories would be included.  A similar enquiry to the APS produced a more guarded response

 

“It is arguable that the term 'immediate family' is imprecise - indeed, it could be applied to a gay partner or a member of an Aboriginal person's extended kinship network."

       

What is not clear is that there is any administrative machinery or advice to practitioners that such relationships would not be acceptable if known. If the principle is so important, there needs to be clear expression of this for those who need to know, and clear administrative arrangements for dealing with these issues equitably. In their absence, this proscription against some relationships but not others, without a clear rationale, is essentially discriminatory.

Official positions on multiple relationships

 

The APS Code of Ethics (Section D: Supervision and Training) does not carry an absolute injunction against supervision by a close family member. Indeed, this section makes no mention of a dual relationship problem in the area of supervision.   In Section B7 of the APS Code it is noted that “psychologists must avoid dual relationships that could impair their professional judgement or increase the risk of sexual exploitation” (APS Code of Ethics, 1999).

 

Examples are offered that include reference to close friends and relatives. There is no specific injunction carrying special force in relation to immediate family. Nor does the sentence convey that all such interactions are by definition prohibited, but the caution is there regarding possible hazards.

Clearly there is a discrepancy between this official position of the Society and the administrative guideline of the Membership Committee that insists on an absolute prohibition. This is surprising, since it is also at odds with the supervision manual provided by that Committee to supervisees and supervisors, which favours a developmental model of supervision, and draws support for this from the textbook Fundamentals of Clinical Supervision (Bernard & Goodyear, 1998). Those authors outline various developmental models, making very clear that supervision early in a person’s professional career should be quite different from that which is required at a later stage. Littrel et al. (1979) have a four stage model in which the “final stage is for the trainee to become a self-supervisor and take responsibility as the ‘principle designer of his or her learning’. The supervisor, we assume, becomes a more distant consultant at that time.” The Stoltenberg Model also offers a four stage development, the last stage of which is described as

"the master counsellor, who is not only skilled interpersonally and cognitively, but professionally. At this point, supervision, if continued, is collegial” (Bernard & Goodyear, 1998, p.24)

 

These models might suggest that the constraints regarding supervision which are appropriate to a new graduate could be different from those for someone who is mature and experienced, perhaps coming in from a related profession and seeking to meet Society criteria. Similarly if several supervisors are involved throughout a supervision program, the criteria in this area might be different at the end of the process from those applying in the neophyte context.

 

Bernard and Goodyear (1998) do also address the question of possible complications in the supervisory relationship, and specifically under a heading ‘sexual or romantic attraction’ . They draw on a paper by Hall (1988) who refers to ‘pre-existing supervisor-supervisee sociosexual relationships (e.g. in spousal relationships)’, and argues that transference issues are ‘sufficient reason to avoid them’ (Bernard & Goodyear, 1998, p.86). This sweeping statement is extraordinary, and if pursued would lead to some strange consequences. The paper itself appeared in a remote journal, is only two pages long, and, from the text, it is clear that it is anecdotal and speculative. A  case vignette is offered by Hall, from which Bernard and Goodyear infer that the author surmises that ‘the wife might be inclined .......’    and secondly ‘the wife very likely would be reluctant....’ (Emphases added). If this is the extent of evidence for caution, it is slight indeed, and certainly cannot be compared to the substantial evidence relating to the harmful implications of sexual involvement with clients that leads to firm ethical constraints.

 

In the face of this caution it is also noteworthy that Hall, writing as executive secretary to the New York Board of Psychology, offers a more general comment in her paper

 “In the sample of regulations I reviewed there was no mention of experience supervised by a relative, friend or lover being viewed as unacceptable…the licensure boards/organizations have a published set of rules which determine acceptable experience, and whatever is left out cannot be used to deny experience. A hidden rule stating that relatives cannot supervise applicants for licensure would probably be ruled arbitrary and capricious. In order to apply the dual relationship provision to the review of experience, licensure bodies would have to give notice of the adoption of such a rule and be prepared to demonstrate the relationship between the intended rule and the protection of the public.”  (Hall, 1988, pp.5-6)

"charged that some professional writings have created ‘dual relationship phobia’...He was critical of those who have elevated their hypervigilance to the status of ethical standards rather than charging educators and supervisors to exercise t heir responsibility as decision makers and resolvers of conflict” (Bernard & Goodyear, 1998, p.191).

 

The Guidelines to the current APS Code of Ethics in relation to multiple relationships offer a balanced and helpful commentary on the topic. Far from being absolute, they note that there are differences of opinion within the profession. The guidelines recognise as a reality that "the psychologist may have a client with whom he/she also has another personal, scientific, professional, financial or other relationship” (APS Guidelines, 1999) and proceed to offer ways of handling these rather than saying they must not exist. There is no mention of supervision at this point and indeed most of the discussion on multiple relationships addresses client relationships. This relative silence might even suggest that multiple professional relationships are less hazardous. Indeed they should be if potential supervisees have been thoroughly taught and have read the Code, since both parties will then have a shared understanding of what is appropriate.

 

The APS guidelines to the Code also state:

"Furthermore, multiple relationships may be unavoidable in certain settings, for example where psychologists practice in small communities" (APS Guidelines,1999).

 

If the matter of multiple relationships in supervision is so serious as to call for a total ban, surely this should be clearly expressed in the APS Code. It is not. The matter receives scant attention. However, the hazards are much better expressed in the Code of Ethics of the British Psychological Society. It is clear that, as with the APS and the APA, the major concerns are over the abuse of power and the potential for sexual harassment. In addressing those potential problems, the BPS explicitly allows that a supervisory relationship between close family members could occur:

".....for example, the psychologist is supervising a student to whom s/he is married or the psychologist is teaching a student s/he is dating.”  (BPS Code,Section 1.3, p.36).

 

In the briefing paper attached to the BPS Code, which corresponds to the APS Guidelines, it is noted under Section 1.2 (p.41) that:

 "whilst many dual relationships do not cause harm, however, it is certain they carry  a risk of exploitation or of impaired judgement. The question of the degree to which such relationships may therefore be regarded as unethical is raised.”

 

The briefing paper continues with a section headed The Legal Position, and there states:

"Despite the typical power imbalances, however, it seems unwise to assume that dual relationships are exploitative or to assume that they always lead to negative consequences....such relationships may present difficulties, third parties may complain and psychologists should be prepared for these eventualities.” (pp. 41-42.)

 

Based on my earlier experience as a rural supervisor, I wrote that:

“Professional ethics is typically taught in graduate programs....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 frequently in rural practice from multiple relationships (Sobel, 1992; Sonne, 1994; Wilson-Barrett and Dollard, 2000). 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” (Court, 2000).

 

While these comments were particularly addressed to the psychologist/client relationship, the same is true between professional colleagues.

 

One might also consider the argument from silence in this context. In an excellent resource on supervision, written primarily for the Australian scene, and covering a wide variety of supervision models, there is no indication that spousal supervision is considered a taboo in any of the wide range of helping professions that are considered (McMahon & Patton, 2002).

 

A distinction has been made here between ethical codes and ethical guidelines. It is customary to work professionally on the basis that codes are mandatory and enforceable, whereas guidelines are educative. This distinction is made clearly by the APA in its Ethical Principles of Psychologists and Code of Conduct, stating that "The ethical Standards set forth enforceable rules for conduct and psychologists" and with a Footnote 1 stating that "guidelines and standards, whether adopted by the American Psychological Association (APA) or its Divisions, are not enforceable as such by this Ethics Code, but are of educative value" (APA, 1992).

 

The situation in Australia is that neither the APS Code nor the APS Guidelines refer to the matter of supervision by a family member. The supervision manual referred to here is based on the Membership Committee's internal deliberations, without consultation with the wider membership. These are then followed unquestioningly by the NT Registration Board. A useful general principle is that "ethical practices must be conducted on the basis of a consideration of competing ethical consideration".