Ethical Issues in Rural Counseling Practice

Chapter One: Introduction

Because of the nature of rural life, it is a prerequisite for counselors to have strong self-efficacy (Bradley, Werth, & Hastings, 2012). The context of rural counseling complicates the practice of counseling because of the influence of culture and geographical issues. Supervision, consultation, continuing education and support are functions of ethics vital for professional practice in the rural areas. Counselors need to appreciate the complex nature of the challenges posed by rural practice of psychology (Daley & Hickman, 2011). Education provides the platform on which changes in psychological application, in rural settings can be instigated. This implies revision of the curriculum for continuing education to reflect the context of rural practice (Weier, & Davidson, 2005).

Knowledge of rural norms and cultural context assist in building trust with the rural residents, resulting in beneficial outcomes for the practitioner (Clopton & Knesting, 2006). Familiarity, and not professional status and credentials, is essential in building trust. Psychologists understand their clients on multiple levels because of familiarity with the community. The contexts of counseling in the rural areas differ with cultural characteristics. People who are potential subjects for mental health care services face many, diverse barriers (Helbok, Marinelli, & Walls, 2006). These barriers may introduce ethical dilemmas regarding treatment boundaries, limits of competence, multiple roles and dual relationship expectations. The application of evidence-based strategies to solve the ethical dilemmas may be beneficial to rural psychology (Smith, 2003).

Chapter Two: Statement of the Problem

Engaging a client, in counseling, outside of the conventional office settings has ethical concerns. The unique ethnical issues hamper the practice of rural psychology. In the rural setting, geographical isolation, limited counseling resources, and small populations complicates the ethical concerns for counselors (Clopton & Knesting, 2006). This study, therefore, aims to broaden the knowledge of rural counseling issues. Its purpose is to expand knowledge of issues related to practice of psychology in rural settings, necessary to ensure that the client’s needs are satisfied by the counseling therapy. The study aims to conduct a study of the practice of psychology in rural settings, and analyze the impact of the characteristics that define rural settings on clients and psychology practitioners. This will inform the development of a methodology that addresses ethical concerns related to the practice.

Chapter Three: Methodology

3.1 Study Setting

The survey will be conducted in a small rural community in Fulton County, Atlanta, Georgia. Fulton County is an urbanized area in Georgia that incorporates the cities of Atlanta, Alpharetta, Sandy Springs and neighboring communities (U.S. Census Bureau, 2010). In reference to Fulton County Census 2010 results, the area has a population of 920,581 people. School going children under the age of 10 make up 13.5% while students 10-19 years make up 13.4% of the total county population. The racial divide in the county comprises 40.8% whites, 43.5 % blacks, 5.6%Asians, 0.2% Indians and Hispanics. Approximately 27% of the citizens of the county are children attending school.

3.2 Procedure

The study uses the 2004 Economic Research Service data of the department of Agriculture to define and identify settings that qualify as rural areas. Psychologists serving schools and neighboring communities were informed about the survey and enrolled on a random, voluntary basis for participation. The study will take 28 days with 10 participants interviewed every week.

3.3 Study Design and Sampling

The study is qualitative and cross-sectional in nature. Participant psychologists will be asked to identify problems associated with the practice of counseling in the rural setting. This will use open ended questionnaires that relate to problem identification and strategy recommendations for solution. The study will use random sampling with a sample of 50 psychologists practicing, in rural settings including rural high schools and other community facilities. Participation in the study is voluntary as facilitated by administration of informed consent prior to commencement of the survey.

3.4 Instruments

The study will use open ended questionnaires to establish the ethics challenges that psychologists face in their professional practice in rural settings. The questionnaire comprises two parts: part A for challenges to adherence to the APA ethics standards and part B for recommendations for revision of education curriculum and ethics policies to accommodate the complex nature of the practice of psychology in rural contexts.

3.5 Analysis

The analysis will involve exploratory analysis of the needs reported by rural counselors. This will use descriptive statistics to analyze the magnitude and impact of the problem. Analysis will sort open ended responses into common themes. The number of responses per each group of theme is also noted, including non-responses. The analysis will facilitate the development of recommendations for a revised framework of ethics and education curriculum.

Chapter Four: Rationale

4.1 Need for Diverse Knowledge Base

The real problem facing rural and remote psychosocial is building a sufficient, sustainable and diversified pool of psychology professionals, who can help rural communities recognize their uniqueness and develop local solutions to local problems (Clopton & Knesting, 2006). Creating the labor force, however, is only one part of the solution. There is a need to improve the awareness of people in rural, remote communities concerning the variety of services delivered by psychologists so that people can actually seek them out. In places where people have little exposure to services, it is highly not likely that there is an understanding of the positive effect of the services (Daley & Hickman, 2011). This is evident by little or no demand of services.

The survey analyzes the need to develop a rural knowledge base and flags the dangers inherent in the rural context of the practice of psychology (Bradley, Werth, & Hastings, 2012). In reference to the nature of communities, the point remains that no two urban or rural communities are similar. Shockingly, much of the research strives to look for differences in groups, in relation to various constructs between urban and rural communities. According to Symington (2008), it may be fruitful to analyze the effect of place than exploring the broader concept of rurality. This approach can inform the development of innovative techniques of service delivery that are urgently needed.

A better integration of the private and public health system and blending of funds are some model ways of providing sustainable psychological service delivery in the rural settings (Daley & Hickman, 2011). The ultimate solution to the rural health service provision may necessitate considering ways in which psychologists work and their suitability to the context in which they work. While the traditional approach that focuses on the individual will always be required, successfully addressing the health issues of rural America is likely to require cross disciplinary approach to practice and a heightened emphasis on developing vibrant communities, as well as individuals.

4.2 Dealing with rural people: A unique population?

Initial research findings propose that people belonging to rural communities are unique. A recent study of rural adolescents in Australia found information pointing to the evidence of stoicism among rural people (Hoffman, 2011). The young people surveyed emphasized the significance of dealing with issues on one’s own. The community of the rural folks exhibited self-sufficiency; stating that one cannot be weak nor have mental illness in a country that is strong. The self-sufficiency characteristic is thought to define the strict boundaries regarding self-disclosure that rural folks display. What the community considers family becomes private business. The idea of a rural culture creates concerns about stereotyping, but the awareness of the common belief systems in rural cultures can be critical to working successfully with populations in rural areas (Daley & Hickman, 2011).

The lack of knowledge of rural cultures by outsiders expresses itself in several ways. Several programs funded by governments are developed in urban cultures but translate poorly upon implementation in rural settings (Clopton & Knesting, 2006). The rising focus on youth mental health services on co-location of programs is a perfect example of an urban system that is unlikely to translate well to the rural settings; creative, mobile, and localized solutions are functional in rural settings. There are exceptional programs that have the potential for greater health impacts. However, the programs are yet to translate to the use of technological tools such as telephone or other electronic means. This is the case despite the use of electronic technology by psychologists in delivering interventions that have an increasingly strong evidence base.

4.3 The generalist rural psychologist

There is a significant pressure on social workers working in rural areas to be generalists due to a combination of increasing demand and inadequacy of a range of skilled service providers (Smith, 2003). The demand on rural psychologists is increasing due to a lack of specialist and support services as is the case in metropolitan regions. The lack of a broad range of services in rural communities asserts pressure on psychologists to deliver adequate treatment. This challenges their ethics, which requires them to refrain from performing work beyond their professional competence capacity. For rural psychologists, several of whom may be in the early career stages; it can become an issue of arrogance whereby a psychologist does not care to observe ethics because there is no competition for their position (Daley & Hickman, 2011). Therefore, training programs should undergo review and revision so as to incorporate professionally appropriate mechanisms of managing professionals. It may sometimes not be possible in rural areas to avoid some dilemmas, but only to manage them through competent supervision and consultation.

4.4 Privacy issues

In rural areas, the absence of anonymity is the order of life (Clopton & Knesting, 2006). The population size in rural villages and centers negatively impact on client privacy and may create boundary issues for the psychologist. The concern for keeping confidentiality in such settings is not exclusive to psychologists. There is a lot of stigma attached to an event of a visit by a psychologist. People are more likely to know each other in small communities. Psychologists are more likely to meet and provide services to their clients in a non-professional way. The guidelines provided by APA for the practice of psychology in rural areas are to ensure that the counseling environment encourages participation by people in seeking treatment. Otherwise, psychologists may experience a situation where clients are reluctant to come forward for treatment for fear of a breach of the rights of confidentiality and the resulting stigma.

4.5 Training, professional development and supervision

In the recent past, there has been significant State and Federal Government response to the rural health workforce shortage (Bradley, Werth, & Hastings, 2012). This focus includes addressing issues related to curriculum development and educational incentives. However, significant enhancements in incentives have occurred largely for the doctors, nurses and allied health professionals, but not psychologists. In the same way that doctors and nurses get incentives, the governments should implement similar reforms for the psychologists (Daley & Hickman, 2011). The trend requires continuing education necessary to better equip psychologists in matters of ethics.

It is encouraging that some institutions offer postgraduate courses by distance education. It is a positive development for rural-based psychologists. However, authorities often overlook hardships associated with such study program. For instance, attending residential learning centers often takes up all holiday leave; there are high costs related to organizing child care and time off work for boarding schools; placement close to home is unlikely and further cost is incurred in temporarily transferring to other locations to complete placements. Many psychologists working in rural regions are involved in outreach work. Therefore, they have long professional days alongside extensive travel commitments; a situation not suited for distance learning and often a situation poorly understood by the inflexible academic system.

4.6 Professional Development

In addition to the requirement for formal education, rural psychologists find it hard to access professional development, professional networking, and supervision (Daley & Hickman, 2011). The advent of electronic and digital technologies supports easy access to education. However, the opportunity to participate in local, quality professional development is not available to many of psychologists working in the rural areas. Finding opportunities to access a suitable supervisor are negligible, and dependence on the telephone can be critical. Rural psychology education institutions need to give considerations to their role of developing a quality rural psychology knowledge base. There is negligible interest from researchers regarding issues of rural psychology. Universities need to perceive this gap as an opportunity for business. These institutions should provide support to the research initiatives of rural psychologists.

Differences related to cultural settings and geographical location is the main obstacles to the provision of standardized quality counseling services (Smith, 2003). Limited resources, geographical isolation, and rural values contribute to the challenges in the practice of rural counseling. Out of the issues identified as obstacles to the process of the practice of psychology, four issues have been identified as the most challenging. These are dual relationships, engagement in general counseling, lack of privacy, and professional isolation. These are issues that cause ethical dilemmas to the counselors. They cause difficulty in making professional judgments and complications related to conflict of values, obligations, and principles. Boundaries and Dual relationship issues are the most common problem that counselors encounter. Dual relationships can also qualify as overlapping relationships, which is defined as those relationships in which an individual has a professional role and another role as a student, partner, or friend with another individual simultaneously.

4.7 Dual Relationships

Counselors participate in community, social interactions and business ventures with other members of the community (Gottlieb, 1993). The interactions create ethical challenges for both the counselor and his clients in equal measure. In a bid to avoid dual relationships, counselors stay away from social relationships and friendships (Smith, 2003). However, in some instances, avoiding social relationships and friendships is not possible. This creates the dilemma in the provision of services due to lack of counseling alternatives. Another form of dual relationships occurs when interests of two professionals connect. This could involve a medical professional and an educational service provider. In the process of professional interaction and guidance between the professionals, information sharing may occur without the consent of the client. Dual relationships have broken the boundaries that guide confidentiality of client’s information. In this respect, researchers and other psychology professionals should administer informed consent in all counseling practices.

Lack of privacy is the other issue that creates challenges in the practicing psychology in their home communities (Gottlieb, 1993). Psychology has been termed an urban-centric practice. The vast majority of the population resides in large cities and centers where the bulk of universities, hospitals, research centers, and large organizations are found. Both the education and field practice of psychology highly occur in cities and to a less extent in sizeable rural centers. In addition, the level of our knowledge base derives from research information with sampling of people who are residents in urban locations. The focus on urban centers is beginning to change and the rural crisis that began and developed over the last decade destroying the economic foundations of the country and many rural communities. The result has been an increase in attention being shown to rural concerns by policy makers and governments.

The impact of geographical aspects on the mental health of people residing in rural, remote communities focuses popular attention on the plight of the residents of the rural areas resulting in the implementation of useful social support programs by Federal and State Governments (Helbok, Marinelli, & Walls, 2006). Social workers also are showing great attention to concerns of the rural areas, although the insufficient amount of psychosocial services provided in rural, remote areas remains a principle issue requiring detailed exploration as explored in this proposal.

The growing interest of Psychology in rural issues is a welcome development considering the fact that while Americans are overwhelmingly urban inhabitants, an unusually high percentage of the population live in rural, remote regions (Schank, & Skovholt, 2005). The Economic Research Services of the Department of Agriculture has categorizations. The department’s description places the number of people living in rural areas to be greater than a million, although there are many ways of definitions and procedures of categorizing rurality. The crucial fact is that while some overall patterns are visible in rural communities, in relation to proximity to services, there is significant variation within each greater geographical area. In this study, I am set out to explore the problems and stumbling blocks, in the provision of psychology services in rural, remote America.

Despite the intimate knowledge of service provision in the mental health services sector in rural areas of the United States, the goal of the survey is to examine all domains of psychological services. However, the research information remains scant outside the psychology arena, although the rural psychology workers also provide extensive and valued services in the education, occupational and rehabilitation health sectors. In comparison with like the mental health sector, these services generally have a focus on some form of the psychological wellbeing or distress of individual clients. There is minimal or very little utilization of organizational psychology in special specialized sectors such as forensic or neuropsychology (Helbok, Marinelli, & Walls, 2006). The argument is that many of the issues we raise have some relevance to the domains of psychological practice provided that many of the issues of rural practice of psychology are clearly related to obvious isolation issues.

5.0 References

Bradley, J., Werth, J., & Hastings, S. (2012). “Social Justice Advocacy in Rural Communities: Practical Issues and Implications”. The Counseling Psychologist, 40(3): 363-384.

Clopton, K. & Knesting, K. (2006). “Rural School Psychology: Re-opening the Discussion”. Journal of Research in Rural Education, 21(5)

Daley, M. & Hickman, S. (2011). “Dual Relationships and Beyond: Understanding and Addressing Ethical Challenges for rural Social Work”. Journal of Social Work and Ethics, 8(1)

Gottlieb, C. (1993). “Avoiding exploitative dual relationships”. Psychotherapy, 30(1): 41-48.

Helbok, C.M., Marinelli, R., & Walls, R.T. (2006). “National survey of ethical policies across rural and urban communities”. Professional Psychology: research & Practice, 37(1): 36-44.

Hoffman, T.D. (2011). “Rural Ethics: Culture, Dilemmas, and Strengths-Based Resolutions”. Journal of Rural Community Psychology, E14 (1)

Schank, J.A. & Skovholt, T.M. (2005). “Ethical Practice in Small Communities: Challenges and Rewards for Psychologists”. Washington, DC: American Psychological Association.

Smith, D. (2003). “10 ways practitioners can avoid frequent ethical pitfalls”. Monitor on Psychology, 34(1): 50.

Symington, A. (2008). “Rural Counselor Competency Manual”. Lethbdridge, Alberta: University of Calgary.

Weier, J. & Davidson, G. (2005). “Remote rural community perceptions of ethical psychological practice”. South Journal of Psychology, 11(2): 24-47.

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