Ethics Rounds

One of the great pleasures of directing APA's Ethics Office is having the opportunity to speak with psychologists across our entire association about the ethical challenges they encounter in their work. Over the past many months, a growing focus of my discussions has been ethics in rural settings. Last year, in a workshop with the South Dakota Psychological Association, I presented a vignette with numerous overlapping and seemingly unavoidable multiple relationships. The first comment on the vignette was a wry, "Welcome to my life." Last spring, members of the Hawaii Psychological Association told me about the "coconut wireless," a reference to how quickly information is gathered and disseminated in the island communities and how this high level of scrutiny affects both their professional and personal lives. Members of the Minnesota Psychological Association shared their experiences working in rural settings in a September workshop where we had the benefit of speaking with Janet Schank, whose excellent book "Ethical Practice in Small Communities" (APA, 2006, co-author Thomas Skovholt) has been central to my thinking about these issues. On a beautiful fall weekend in Northern Michigan, I spent a day with members of the Michigan Psychological Association elaborating the contours of a rural ethic based on the concept of culture. Each of these discussions introduced me to new ways of thinking about the ethical dimensions of rural practice.

Unique rewards

Participants in our Michigan workshop articulated a shift in thinking about rural ethics, from a deficit-oriented perspective to an orientation based upon the richness and complexity of life in a rural setting, a shift that resonates well with "Ethical Practice in Small Communities," especially the chapter "The Challenge and Hope of Small-Community Psychology." Over the course of our day together, the group in Michigan tied this shift explicitly to APA's Ethics Code and the concept of cultural competence. Workshop participants portrayed professional life in rural culture as offering unique rewards for psychologists who embrace the setting's circumstances and challenges.

What I found particularly interesting about the Michigan workshop was that the shift in our thinking could be tied to a particular moment in the workshop when a participant shared an anecdote from her graduate training, which she had received in an urban environment. During an ethics course, she explained, her professor said that a certain multiple relationship should be avoided, noting, however (with little further comment from the professor at this or at any other point in the course), that a psychologist might not be able to avoid this kind of multiple relationship in a rural setting. When another workshop participant responded that the professor's comment pathologized and considerably oversimplified rural practice, the group began to elaborate the features of rural practice as those of a unique and identifiable culture. We framed our discussion in terms of ethical standard 2.01(b):

2.01 Boundaries of Competence

(b) Where scientific or professional knowledge in the discipline of psychology establishes that an understanding of factors associated with age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, or socioeconomic status is essential for effective implementation of their services or research, psychologists have or obtain the training, experience, consultation, or supervision necessary to ensure the competence of their services.

As a starting point for our discussion, we asked what a graduate school course on cultural competence in rural practice would teach. No one in the group reported having received any such training in a graduate program.

Central to the group's thinking was the relationship between the individual psychologist and the community. Becoming an active member of the community through involvement in community activities will likely be an expectation that will be closely tied to the psychologist's success. Accepting requests to participate in a range of activities, from serving on boards to organizing local events such as festivals and parades, can be an important vehicle for establishing one's bona fides as a good and supportive citizen of the community. Such involvement can also show one's respect for the community's values and traditions.

The workshop participants elaborated several ethical complexities of these relationships. One participant talked about the ability to be "simultaneously engaged and disengaged." He explained that a psychologist is likely to encounter patients and clients in multiple venues. An important skill is for the psychologist to be present in an interaction as a good neighbor but also as the individual's psychologist; to be engaged on both levels but to be comfortable and flexible in engaging and disengaging from one or the other as is appropriate to the situation. I pointed out that psychologists in urban settings sometimes encounter clients outside of work as well, to which the participants responded that such encounters are part of the very fabric of life in a rural setting. Another participant explained that the monitoring must therefore be constant. A third participant pointed out that psychologists become "participant/observers" in the local culture, which allows the psychologist to view the reciprocal influence of the psychologist on the community and the community on the psychologist.

Private time

I asked the participants to share their ideas about self-care, given what I reflected must be the strains of this high level of scrutiny and of always being in a professional role, at least in some measure. The group had clearly given self-care a great deal of thought; there was universal agreement that planning private time or time away from the community was essential, as was developing supportive networks. When I asked about supportive networks, the group had a collective twinkle in its eye and responded, "That's what we're here for." I was curious about private time, especially after one participant mentioned it was not unusual in her community for individuals to enter another's house without an invitation or announcing a visit, and was treated to a discussion of "camp," a concept with which I was not familiar and comes from the culture of deer hunting. Camp refers to time away from professional demands. Everyone here, I was told, creates their own version of camp.

A theme ran across several vignettes that the group had generated for discussion, that of having information about a client from outside the professional relationship, a universal experience for workshop participants. One participant noted that here there are not six degrees of separation, there are two—at most. For this reason, psychologists must be able to integrate their personal and professional lives, which requires the ability to "dual process" information by staying mindful of whether information the psychologist has came from within or outside of the professional relationship. One participant explained that this aspect of rural practice helps her to stay present during sessions by necessitating that she set aside thoughts of anything other than what her client is discussing. Other participants noted that outside information can sometimes be helpful in understanding a client's situation more fully.

Several other themes emerged in our workshop. Participants talked about teenage children developing relationships with clients and spouses unwittingly sharing information with clients. Of particular poignancy, one participant told of a client asking whether he might use the psychologist's state hunting permit; hunting was one of the few means available for this unemployed client to feed his family. As I listened to our discussion, I found myself keenly aware of how fully these psychologists had embraced life in their communities and how respectfully they had acclimated to the cultures in which they work. Our discussion touched upon the "goodness of fit" between a psychologist and rural culture, and the value of reflecting on whether this type of setting best matches a psychologist's interests and temperament.

I felt honored by the psychologists at our workshop in Roscommon, Mich., for sharing their experiences with me in such an open and thoughtful way. I hope that we will continue our discussion of ethics in a way that allows us to share with our colleagues the rich and rewarding aspects of professional life in rural settings. I was especially aware of the rewards as I returned to my office in Washington, D.C., and peered out my office window into the parking lot at Union Station. Our workshop in Roscommon took place on what National Geographic Magazine described as one of the six most beautiful lakes in the world.

Stephen Behnke, PhD, JD, directs APA's Ethics Office.