Author Details
Elise Wilson-Barrett
Psychologist, Southern CAMHS Country Team
(Paper was presented at the SA State Psychology Conference in Adelaide on 3rd September 1999)
 

Article
Rural psychology has steadily been receiving increasing attention over recent years for a variety of reasons.  My interest in this area stems from my own experience of living and working in a rural area.

In early 1996 I began working with the Southern CAMHS Country Team.  At the same time I moved to live in the Murray Mallee with my partner on a predominantly sheep and cereal cropping farm of 1860 acres. The CAMHS office I work in is situated in the rural city of Murray Bridge, which has a population of around 13,500.  This town is the regional centre of the Murray Mallee and services a population of around 30,000.

I travel a little over 100 kms from my home to the office.  So as to reduce travel time within work hours the area has been divided into regions that different therapists are more or less responsible for.

As I live on the eastern side of our region I have the responsibility of servicing the region between Murray Bridge and the Victorian border.  I have to admit this also benefits me in that I am not required to travel the 200km round trip to the office - although some days I still manage to travel that distance just visiting several clients in the region.

For me the shift to rural living was not such a great adjustment as I had grown up on a farming property.  Although there is not a great distance between the area that I grew up and where I now live I essentially felt as though I had entered a new rural community, this time as a psychologist.  I wasn't sure what this really meant or what expectations there would be, but I did feel that "the public perceptions of what a psychologist is and does and how they should behave at times can impose certain lifestyle limitations ... having a public profile as a small town psychologist results in a general lack of personal privacy" (Lichte, 1990, p.40).

One of the other things that I was aware of was that in time some or many of the families that I encountered socially may well become clients, and that if, or when, this did occur I would have to manage the reality of multiple relationships with these families whilst maintaining confidentiality.  I had a feeling that this was not going to be an easy thing to do.

So as a result of my move to the country and my early experiences of rural psychological practice I decided that I would undertake an exploration of the dilemmas and challenges that psychologists encounter in the rural practice of psychology, specifically around the issue of dual relationships as part of my Clinical masters study.

What are dual relationships?

In the literature there are several variations on the definition of dual relationships.  Terms such as multiple or overlapping relationships are similarly used to describe dual relationships. As helping professionals, psychologists enter into dual relationships whenever they have another, significantly different relationship with their clients.  This second relationship may occur simultaneously or sequentially (Herlihy & Corey, 1992).

In my exploration of dual relationship dilemmas I am not concerned with the limited and inconsequential role that grows out of a chance encounter with clients that may occur in any setting.  I am referring specifically to situations where psychologist and client both live within the same rural community and as a result are likely to have repeated encounters.

Prevalence in rural work

"Overlapping relationships - people knowing and relating to one another in a variety of different capacities - are simply built into the rural lifestyle" (Gates & Speare, 1990; p.98).  Such relationships may be regarded simply as part of the logistics of living in smaller communities.  Such dual relationships may be almost impossible to avoid when there is no choice but to shop at a client's store or when one's children are in school with, or even friends with, a clients' children (Fenby, 1978).

For the most part, residents of such communities manage multiple levels of relationships as part of daily life.  However, as a psychologist living and working within a rural community the knowledge that is gained about the individual or families that you work with inevitably includes quite personal details about those people and the struggles they are experiencing in their lives.  This places you in quite a different position than most other community members (one that is shared by rural general medical practitioners I imagine).  "Therapists who work in rural areas inevitably confront the issue of out-of-session contact and overlapping relationships with clients ... and are more likely to know clients in other contexts, and less likely to be able to realistically refer them elsewhere, than therapists who live in larger communities" (Horst, 1989, p.7).

There have been many occasions over the past 4 years that I have been required to work with children and families that are known to me as members of the community in which I live.  The longer I work in this role and live within the community the further my knowledge expands as I discover who is related to whom and how different families interrelate.

What makes dual relationships so problematic?

In the literature various issues have been raised about the problems associated with dual relationships.  These include the potential for a conflict of interest, loss of objectivity, and exploiting those persons who have sought help (Glosoff, Corey & Herlihy, 1996, p.251).

Herlihy & Corey (1992) identify that dual relationships can be problematic along a number of dimensions:
(1) they are pervasive,
(2) they can be difficult to recognize,
(3) they are sometimes unavoidable,
(4) they can be very harmful but are not always harmful, and
(5) they are the subject of conflicting advice from expert sources (p.7).

The blurring of therapeutic boundaries may occur as a result of dual relationships and may lead to inaccurate evaluations of the nature of what began as a therapeutic relationship. It is important to remind ourselves that the underlying dynamics of friendships and therapeutic relationships are not the same.

"Friendships are built on mutual disclosure and support - on sharing joys and problems and being there for each other.  Although therapeutic relationships are also based on trust, intimacy, and disclosure, they are not mutual" (Haas & Malouf, 1995; cited in Glosoff, Corey & Herlihy, 1996, p.255). In my experience it is not unusual for clients to presume a certain level of "friendship" exists as a result of a therapeutic relationship.

One of the issues that I have found most difficult is that as a psychologist you know so much personal information about the client/family as a result of the professional relationship that you have with that family.  But when you encounter each other in social situations do you acknowledge this or does acknowledgment of this reveal to others that a client/professional relationship exists? I have found that sometimes the client/family will happily acknowledge that they know me and are quite open about the fact that they have sought help, but others do not.  Some clients can be so open about having a professional relationship with you that they insist on approaching you in public and discussing how things are going.

A further issue that I find a challenge to deal with is maintenance of confidentiality that ultimately requires that my partner is unable to be informed of the existence of  other relationships that I may have with an individual client/family.  At times this may mean that in a given situation, because of the presence of a client, that I may feel uncomfortable about remaining in that situation but am unable to express the true reasons for this to my partner.  I have found that it has been important to discuss hypothetically with my partner some of the difficulties that I may encounter as well as prepare him for the possibility that clients will speak to him about my contact with them.  This has happened on several occasions and is something that my partner finds at times challenging.  Keeping your private life private can also be a challenge - even if you manage to avoid encounters when you are "off duty", the next time you see some clients they insist on discussing the fact that they saw you.

Another challenge I have found is that often conversations that take place with other community members, friends or acquaintances may touch on clients.  As many of you already know, in small communities everyone seems to know everyone’s business.  So there have been several times that I have found myself unable to participate in conversation, or attempted to carefully change the subject so as not to disclose any hint of knowledge that I may have concerning a specific client or family.

Possible Benefits of Dual Relationships

Mazer (1976) one of the early writers to explore the realities of the practice of psychiatry in a small community, alluded to some possible benefits of dual relationships.  He considered that knowledge of clients outside of the therapeutic relationship may increase one's understanding of the client and provide the opportunity to see the client in their own environment.  In addition other sources of information about the client exists in small communities.  This may however be a drawback for the client who has less control over what information the therapist is given about their background.  Gates and Speare (1990) also consider that overlapping relationships may benefit the rural practitioner who often has the opportunity to receive other information about clients and to actually observe their interactions in the larger environment.  "It is perhaps ironic that in some rural settings, it is only because of a dual relationship, i.e. considerable personal knowledge about the psychologist, that patients would seek treatment - precisely the obverse from that commonly seen in urban settings" (Jennings, 1992, p.103).

As the rural practitioner is more likely to observe the results of treatment, "a heightened sense of personal efficacy and impact can occur" (Sterling, 1992, p.121).  Sterling suggests that it is perhaps this aspect of practice that make the difficulties of working in a rural setting worthwhile - "It can be tremendously reinforcing and rewarding to experience making a positive difference in the lives of others" (p.121).

Ethical considerations

Schank and Skovholt (1997) interviewed psychologists who lived and practiced in rural areas of America about ethical dilemmas they faced in their daily practice.  Dilemmas involving professional boundaries were identified as significant concerns for each of the psychologists.  The dilemmas associated with the reality of overlapping relationships were a major theme in their findings.  Despite knowledge of ethical codes that attempt to address the issue of dual relationships the psychologists involved in the study indicated that they struggled in choosing how to apply those codes in the best interests of the client.

From my reading about the issue of dual relationships opinion seems divided over whether dual relationships should be avoided at all costs, or if, that in some circumstances they can be condoned provided proper steps are taken to minimize risk and harm.  My experience is that in rural areas not all dual relationships can be avoided.

What guidelines exist around how to handle dual relationships?

Glosoff, Corey and Herlihy (1996) articulate clearly that "there are few simple and absolute answers that neatly resolve dual relationship dilemmas" (p.254).  One of the first places to look however for guidance around dual relationship issues is to the Code of Ethics (1997) of The Australian Psychological Society.  The general principles of the Code of Ethics include responsibility, competence and propriety, which operate in all situations.  Furthermore, the only section of the code that addresses the issue of dual relationships, Section B7, states:
 

The American Psychological Association (1992) Ethical Principles of Psychologists and Code of Conduct provides psychologists with the general proscription against multiple or dual relationships and acknowledges the special potential problems for psychologists practicing in small communities, stating that it may not be feasible or reasonable for those psychologists to avoid social or other non-professional contacts with clients (Sonne, 1994).  In Standards 1.17 (a) the code states:
 

Rich (1990) in his paper on the myths and realities of rural practice states that in urban practice there is a clear expectation by both client and psychologist for a separation between personal and professional roles.  What constitutes an ethical violation is therefore usually quite clear (Schanck & Skovholt, 1997).  In rural settings there may be the same expectation, however it is highly likely that the client and psychologist will find themselves in more than one relationship and maintaining such separation becomes far more difficult.  As a result "in rural settings, prevailing standards and codes of ethics cannot be applied in automatic ways" (Schank & Skovholt, 1997, p.45).

Sobel (1992) suggests that a rural or small community practitioner must be "willing to make compromises in professional standards and ethical guidelines" (p.62).  Situations arise "that often require therapists to rely upon their best logical, professional and ethical behaviour, for sometimes one has to walk within the 'gray' areas in order to be successful as a professional as well as an individual living within the community" (Sobel, 1992, p.62).

Glosoff, Corey and Herlihy (1996) write that regardless of the avoidability of dual relationships, the ethical professional takes "appropriate professional precautions such as informed consent, consultation, supervision, and documentation" (p.256) to ensure that clients are not harmed.  Being able to compartmentalize relationships within the context of the community and maintain a balance between professional and community identification is necessary according to Schank & Skovholt (1997) because it is impossible for psychologists to isolate themselves from their clients and former clients.  Lichte (1996) suggests that another important strategy is to keep detailed case notes as a reminder of where information originated - from therapy sessions or community contact.

Training and preparation for rural work

From my own experience and what I have read in the literature very little, if any, training is provided to psychologists who may end up working in rural or remote areas. Kenardy and Griffiths (1996) state that very few of the university psychology courses in Australia have curriculum components that address the issues of rural practice or the unique issues that the small town practitioner faces.

Kenardy and Griffiths (1996) acknowledge that psychologists working in rural and remote areas are faced with a unique challenge.  "Psychologists in rural areas must function more autonomously with more professional isolation, have a broad skills base, be able to attend to the specific needs of groups such as the elderly, adolescents and Aborigines, and be able to deal with the special practice issues associated with dealing with psychological and health problems in rural communities such as confidentiality and lack of access to professional development and supervision" (p.31).  Kenardy and Griffiths (1996) write, these dimensions have, in the past, been dealt with by rural psychologists with very little preparation or support, and as a result have lead to high job attrition.  They clearly state that one of the tasks of those involved with planning and implementing education and training of psychologists will be to prepare them for rural settings, train them sufficiently and retain them in their positions.

According to Sterling (1992) "therapists in small communities have to create their own rules and guidelines and develop their own means of managing these issues.  The principles of practice learned in training are not always directly applicable to the small community context, and only serve as a rough foundation.  Thus, for each therapist, the formation of guiding principles of boundaries and confidentiality is done in relative isolation" (p.113).

Horst (1989) presents evidence to suggest that "while psychologists who practice in rural areas do experience more outside contact with clients, they manage to differentiate between true dual (i.e. harmful, conflictual) relationships and relationships which overlap in less harmful ways.  Rural psychologists are more likely to have as clients individuals whom they know in some other way" (p.23).  Furthermore Horst states that "while it may be difficult for rural psychologists to control the amount of outside contact they have with clients, they do seem to manage to exert control over the form the outside contact will take" (p.23).

What do people working in rural & remote areas currently do to address this issue?

This point brings me to the focus of my research, which involves a qualitative exploration of what rural Australian psychologists currently do when faced with the dilemma of dual relationships.  I hope to use the findings of my research to produce guidelines that can be used to assist psychologists when they are faced with the issue of dual relationships.  It is my belief that such guidelines will be especially useful for psychologists in training that may contemplate rural psychological practice as a career option.

One which, despite the challenges I have outlined, is one that I can thoroughly recommend.
 

References

Fenby, B.L. (1978) Social Work in a Rural Setting.  In Johnson, H.W. (Ed) Rural Human Services: A Book of Readings; Peacock; Itasca (pp 149-153)

Gates, K.P. & Speare, K.H. (1990) Overlapping Relationships in Rural Communities; In Lerman, H. & Porter, N. (Eds) Feminist Ethics in Psychotherapy; Springer; New York (pp 97-101)

Glosoff, H., Corey, G. & Herlihy, B. (1996) Dual Relationships. In Herlihy, B. & Corey, G. (Eds) ACA Ethical Standards Casebook (Fifth Edition); American Counseling Association; Alexandria VA; USA (pp251-266)

Herlihy, B. & Corey, G. (1992) Dual Relationships In Counseling; American Association for Counseling and Development; USA
 (Chapter 1: Dual Relationships in Perspective; pp3-18)
 (Chapter 12: Key Themes, Questions, and Decision Making; pp223-234)

Horst, E.A. (1989) Dual Relationships Between Psychologists and Clients in Rural and Urban Areas; Journal of Rural Community Psychology; 10(2); 15-24

Jennings, F.L. (1992) Ethics of Rural Practice; Psychotherapy in Private Practice (Special Issue: Psychological Practice in Small Towns and Rural Areas); 10(3); 85-104

Kenardy, J. & Griffiths, R. (1996) Education and Training for Rural Psychologists.  In Griffiths, R., Dunn, P. & Ramanathan, S. (Eds) Psychology Services in Rural and Remote Australia: Issues Paper; Australian Rural Health Research Institute; Charles Sturt University; NSW

Lichte, C. (1996) The Delivery of Psychology Services in Rural and Remote Australia.  In Griffiths, R., Dunn, P. & Ramanathan, S. (Eds) Psychology Services in Rural and Remote Australia: Issues Paper; Australian Rural Health Research Institute; Charles Sturt University; NSW

Mazer, M. (1976) People and Predicaments; Harvard University Press; USA (Chapter 19: The Therapist in the Community; 212-227)

Rich, R.O. (1990) The American Rural Metaphor: Myths and Realities in Rural Practice; Human Services in the Rural Environment; 14(1); 31-34

Schank, J.A. & Skovholt, T.M. (1997) Dual-Relationship Dilemmas of Rural and Small-Community Psychologists; Professional Psychology: Research and Practice; 28(1); 44-49

Sobel, S.B. (1992) Small Town Practice of Psychotherapy: Ethical and Personal Dilemmas; Psychotherapy in Private Practice; 10(3); 61-69

Sonne, J.L. (1994) Multiple Relationships: Does the New Ethics Code Answer the Right Questions? Professional Psychology: Research and Practice; 25(40; 336-343

Sterling, D.L. (1992) Practicing Rural Psychotherapy: Complexity of Role and Boundary; Psychotherapy in Private Practice (Special Issue: Psychological Practice in Small Towns and Rural Areas); 10(3); 105-127.