Many psychologists choosing to work in a rural setting need to negotiate a delicate balance between their specialty setting and the APA ethics code, which was written within an urban context. The APA ethics code is not only important in directing professional behavior, it provides psychologists with a unified professional identity. While there has been some call to write a rural-specific ethics code, creating separate ethics codes tailored to each specialty practice within psychology has the potential to harm the profession as a whole. As such, rural psychologists must find creative ways to maintain adherence to the code of ethics, especially in most likely areas of difficulty: managing potential unavoidable dual relationships, navigating community contacts, and protecting confidentiality related to incidental exposure/contacts (such as visibility of practitioner’s office),
Part of the informed consent processes in a rural community might include discussions about how to handle unavoidable dual roles and likely community contacts. For example, it’s more likely the psychologist’s and patient’s children attend school together at the only elementary school in the area. When the psychologist is the only resource for hundreds of miles referring to another clinician may not be feasible. Patients should be aware of predictable/obvious situations in which they may encounter therapists, and some discussion of how boundaries will be managed in those situations may be necessary.
Additionally, a frank discussion about how the patient prefers community contacts to be handled would be advisable. The patient may prefer that the psychologist not interact with them in order to preserve confidentiality. Conversely, some patients may not understand that a boundary exists during community contact and therapeutic issues cannot be discussed outside of therapy. Without a proactive discussion, these issues can become ethically and therapeutically problematic.
Rural psychologists have many considerations when it comes to protecting patient confidentiality. The location of the psychologist’s office must be considered in towns where many people know one another. Patients may become leery of obtaining treatment if the office is in an easily visible area. When patients know one another, the psychologist may have to manage their own reactions when a patient discloses information about someone else the psychologist is treating, or people the psychologist knows personally and socially. This information, while confidential to the original patient most certainly could affect the psychologist’s work with additional patients, and place some burden on personal interactions as well.
There are of course many other dilemmas that may affect rural psychologists and their practices. Above all, the well-being of the patient and psychologist should guide decisions. Psychologists may consider patients first, but it is crucial they also weigh how handling ethical problems could affect their quality of life in a small community. Having a patient you know is angry with you and has an unpaid bill attending your church is certainly a possibility in a small rural town! Creativity and proactive management are likely to be the best options for management of these issues.
American Psychological Association. (2010). Ethical principles of psychologists and code of conduct. Retrieved from http://apa.org/ethics/code/index.aspx
Smalley, K. B., Rainer, J., & Warren, J. (2012). Rural Mental Health : Issues, Policies, and Best Practices. New York: Springer Publishing Company.
Rain Blohm, MS
WKPIC Doctoral Intern