Psychologists in non-urban areas face a multitude of challenges when serving rural populations. Specific challenges may include provider availability (i.e., the limited number of accessible providers), social overlap (i.e., overlapping relationships between one's professional and social life), and matched minorities (i.e., sharing the same ethnic/cultural background as the provider or belonging to the same community membership), all of which increase the likelihood of entering into a multiple relationship (Burgard, 2013). According to the United States Department of Agriculture (n.d.), 60 million Americans live in rural communities. Although there are many differing definitions of a rural community, Helbok (2003) defined it as a non-urban, heterogeneous population consisting of 5,000 or fewer people. Creativity and adaptability are necessary to offer effective services to a diverse clientele, and practices that appear ethically questionable in densely populated areas may be defensible to adequately serve clientele in remote areas with fewer available psychological services (Malone, 2012). Nevertheless, the specific challenges of rural practice often expose psychologists to ethical dilemmas and issues for which they may not be adequately prepared.
As members of small communities, rural psychologists will inevitably encounter multiple relationship dilemmas. The American Psychological Association (APA) Ethical Principles of Psychologists and Code of Conduct (2017), hereafter referred to as the Ethics Code, defines multiple relationships as follows in Standard 3.05:
A multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person.
The presence of a multiple relationship is not inherently unethical. This distinction is crucial, particularly because multiple relationships are often an inevitable aspect of rural practice (Werth et al., 2010) and multiple relationships can occur concurrently, consecutively, or sequentially to the established relationship (Lamb et al., 2004). Instead of attempting to avoid multiple relationships entirely, psychologists should strive to develop strategies to effectively evaluate and address how multiple relationships with clients may affect treatment, and remain mindful of Standard 3.06: Conflict of Interest (APA, 2017). If and when all domains of the relationship are healthy and balanced, it becomes apparent that such a relationship may be an asset, rather than a detriment, to the client’s treatment (Burgard, 2013).
While multiple relationships may occur in communities of all sizes, compelling evidence suggests that rural psychological practice is qualitatively different from urban practice in terms of its multiple relationship ethics (Helbok et al., 2006). Specifically, the interconnectedness of small and rural communities can generate a large number of overlapping local relationships, requiring further examination and careful interpretation of the ethical guidelines that apply to less densely populated areas. Helbok and colleagues (2006) noted that psychologists who practice in rural areas are often more well-known in the community, which could have a number of implications depending on their position and reputation (e.g., a trusted expert and long-time resident vs. a transplant from out of state) as well as what is known, or assumed, about the psychologist’s personal life.
Community pressure, defined as the influence of a community's distinct values and culture on professional services, is also a factor unique to rural psychological practice (Malone, 2012). This factor may stem from the specific context of a small community or the cultural and contextual differences within aboriginal communities, and may affect client experiences of confidentiality, expectations, and visibility (Malone, 2012). Additionally, individuals living in rural areas often face limited access to governmental, community, and private resources that support their ability to access essential services like healthcare (Bradley et al., 2012). While telehealth may be a viable option for some, many rural areas may not have access to technologies required for telehealth.
When considering ethical practice in rural areas where multiple relationships are routine, a number of ethical standards are relevant: competence, human relations, privacy and confidentiality, record keeping and fees, and therapy. Standard 2.01: Boundaries of Competence (APA, 2017) may be especially relevant for rural practitioners. While the standard is clear that psychologists must practice within the boundaries of their competence, there may be instances (e.g., in the case of Standard 2.02: Providing Services in Emergencies; APA, 2017) where the psychologist is one of few (or perhaps the only) licensed professional providing mental health services to a specific community. Psychologists who practice in rural areas often find themselves grappling with the dilemma of balancing the limits of their competence with the absence of referrals in the community (Werth et al., 2010). Indeed, the lack of viable referrals as well as the lack of peer consultation options within the community can produce feelings of isolation, as well as concern about practicing outside of their scope (Hastings & Cohn, 2013).
Another standard pertinent to the discussion of multiple relationships is Standard 3.04: Avoiding Harm (APA, 2017). Clients who are at risk of significant harm from an intervention should be given a referral, regardless of the temporary inconvenience this may cause (Werth et al., 2010). With respect to Principle A: Beneficence and Nonmaleficence (APA, 2017), it is crucial to assess the relative risks of nonmaleficence and beneficence, so that when the risk of harm is high and the opportunity to help is low, the clinician should refrain from intervening (Werth et al., 2010). Psychologists face the dilemma of gauging the extent to which they are practicing beyond their expertise, such as deciding not to provide services and acknowledging that working outside of their expertise can be harmful (Helbok, 2003). Conversely, if the risk of harm is low and there is a strong possibility of benefiting the client, then intervention may be the most appropriate course of action (Werth et al., 2010). Refusing treatment when there are no available referral sources may violate the principle of making every effort to ensure the wellbeing of the client (Helbok, 2003). Engaging in a multiple relationship may actually further avoid harm.
The initial and ongoing practice of obtaining informed consent (Standard 3.10 Informed Consent, as well as Standards 8.02, 9.03, and 10.01; APA, 2017), also requires specific considerations for rural practice. Simply put, information included in the informed consent can be crucial in terms of providing clarity and mitigating future risk around boundary crossings (Malone, 2012). Boundaries are frequently grouped as either structural or interpersonal boundaries. Structural boundaries are those related to the structure of the relationship, such as the time and locale of appointments (Jorgenson et al., 1997). Interpersonal boundaries are related to the interpersonal aspect of the therapeutic relationship and may involve concerns such as self-disclosure, physical touch, and gift-giving (Sawyer & Prescott, 2011). In communities where building trust may be achieved through giving gifts, sharing information freely, and other culturally specific practices, including bartering for services (Standard 6.05; APA, 2017), the psychologist must be particularly diligent about maintaining professional boundaries and act in the best interest of the client (Black, 2017).
With respect to privacy and confidentiality, Standard 4.01: Maintaining Confidentiality (APA, 2017) states:
Psychologists have a primary obligation and take reasonable precautions to protect confidential information obtained through or stored in any medium, recognizing that the extent and limits of confidentiality may be regulated by law or established by institutional rules or professional or scientific relationship.
Standard 4.02: Discussing the Limits of Confidentiality states that psychologists should discuss the relevant limits at the outset of the therapeutic relationship, to include a discussion of limits and how information gathered through the course of treatment may be utilized (APA, 2017). Standard 4.04: Minimizing Intrusions on Privacy reminds us that discussion of confidential information obtained through one’s work must be limited to persons concerned with such matters (APA, 2017). As a consequence, additional caution should be considered when sharing confidential information with relevant parties, as these individuals may have personal connections to the client.
To conclude, the practice of psychology within rural areas presents distinctive hurdles for psychologists striving to deliver optimal care, often with limited resources. There are several circumstances that generate multiple relationships, many of which are nearly impossible to avoid. Developing effective and tailored strategies for enhancing access to behavioral health services among underserved populations is crucial and aligns with Principle D: Justice (APA, 2017). There is considerable gray area within multiple relationships, but when appropriately monitored through setting clear expectations and maintaining boundaries, there is potential for increased therapeutic value. However, setting boundaries and managing those potential blurred lines should be a primary focus in rural psychological practice. Engaging with the client in more than one setting may be more tenable and beneficent than barring all rural clients who may be personally connected to the psychologist. Due to the complicated nature of this topic and its layered complexity, here are some questions to consider when a dilemma of multiple relationships emerges:
1. Is it necessary for such a relationship to exist, specific to this community?
2. By engaging in this multiple relationship, am I further avoiding harm?
3. Is there risk that the multiple relationship could harm the client?
4. Is there risk of the multiple relationship disrupting rapport or the therapeutic relationship?
5. Am I appropriately documenting my clinical activities?
6. Does my informed consent include a clear discussion of how multiple relationships are handled in the practice?
Finally, the OPA Ethics Committee is an available resource for OPA members seeking consultation around ethical practice. We encourage members to reach out to the committee when navigating ethical issues of concern.
References
American Psychological Association. (2017). Ethical principles of psychologists and code of conduct. http://www.apa.org/ethics/code/
Black, S. C. (2017). To cross or not to cross: Ethical boundaries in psychological practice. Journal of the Australian and New Zealand Student Services Association, 25(1). https://janzssa.scholasticahq.com/article/1339-to-cross-or-not-to-cross-ethical-boundaries-in-psychological-practice
Bradley, J. M., Werth, J. L., Jr., & Hastings, S. L. (2012). Social justice advocacy in rural communities: Practical issues and implications. The Counseling Psychologist, 40(3), 363–384. https://doi.org/10.1177/0011000011415697
Burgard, E. L. (2013). Ethical concerns about dual relationships in small and rural communities: A review. Journal of European Psychology Students, 4(1), 69-77. https://doi.org/10.5334/jeps.az
Hastings, S. L., & Cohn, T. J. (2013). Challenges and opportunities associated with rural mental health practice. Journal of Rural Mental Health, 37(1), 37–49. https://doi.org/10.1037/rmh0000002
Helbok, C. M. (2003). The practice of psychology in rural communities: Potential ethical dilemmas. Ethics & Behavior, 13(4), 367–384. https://doi.org/10.1207/S15327019EB1304_5
Helbok, C. M., Marinelli, R. P., & Walls, R. T. (2006). National survey of ethical practices across rural and urban communities. Professional Psychology: Research and Practice, 37, 36-44.
Jorgenson, L. M., Hirsch, A. B., & Wahl, K. M. (1997). Fiduciary duty and boundaries: Acting in the client’s best interest. Behavioral Sciences & the Law, 15(1), 49–62. https://doi.org/10.1002/(SICI)1099-0798(199724)15:1<49::AID-BSL253>3.0.CO;2-X
Lamb, D. H., Catanzaro, S. J., & Moorman, A. S. (2004). A preliminary look at how psychologists identify, evaluate, and proceed when faced with possible multiple relationship dilemmas. Professional Psychology: Research and Practice, 35(3), 248-254. https://doi.org/10.1037/0735-7028.35.3.248
Malone, J. (2012). Ethical professional practice: Exploring the issues for health services to rural Aboriginal communities. Rural and Remote Health, 12(1), 1891–1891. https://doi.org/10.22605/RRH1891
Sawyer, S., & Prescott, D. (2011). Boundaries and dual relationships. Sexual Abuse: A Journal of Research and Treatment, 23(3), 365-380. https://doi.org/10.1177/1079063210381411
U.S. Department of Agriculture. (n.d.). Rural. https://www.usda.gov/topics/rural
Werth, J. L., Jr., Hastings, S. L., & Riding-Malon, R. (2010). Ethical challenges of practicing in rural areas. Journal of Clinical Psychology, 66(5), 537–548. https://doi.org/10.1002/jclp.20681
