Qualitative Research Report

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Ethical guidelines for psychological practice in rural and remote settings

1. Introduction ..................................................................................................................... 164

2. Living and working in rural and remote areas ........................................................ 164

3. Competence and professional responsibility ......................................................... 165

4. Boundary management and multiple relationships ............................................. 166

5. Confidentiality and informed consent ...................................................................... 167

6. Professional and personal isolation .......................................................................... 167

7. Summary ......................................................................................................................... 167

8. References ........................................................................................................................ 168

164 Ethical guidelines for psychological practice in rural and remote settings Ethical guidelines for psychological practice in rural and remote settings

1. Introduction

1.1. The following Guidelines recognise the benefits and challenges of psychological practice in rural and remote settings of Australia. The social connectedness in rural and remote settings has on the one hand the potential to enhance the provision of psychological services, and on the other hand the potential to challenge professional boundaries. These Guidelines reinforce the particular responsibilities of psychologists working with and within a local community, and show how the standards of the APS Code of Ethics (2007) can be applied to the work undertaken by psychologists in rural and remote Australia.

1.2. Psychological services are provided to rural and remote communities in several ways, which can include: • a psychologist residing in or near the rural or remote community; • a visiting psychologist (e.g., fly-in-fly-out); or • a non-resident psychologist via internet or telephone.

Refer to Ethical guidelines for providing psychological services and products using the internet and telecommunication technologies (2011).

1.3. The practice of psychology in rural and remote settings differs from urban/ metropolitan areas in several ways (Campbell & Gordon, 2003; Helbok, 2010; Schank et al., 2010). Common ethical issues identified as having particular relevance to the provision of psychological services in rural and remote settings are:

• confidentiality; • boundary management; • limits to competence; • professional collaborations; • limited professional resources; • professional and personal isolation; and • self-care and burnout (Schank et al., 2010).

Refer to Ethical guidelines for managing professional boundaries and multiple relationships (2016).

1.4. The lack of anonymity in small communities where everyone may know, or know of, everyone else, can challenge professional practice in ways not commonly encountered in urban settings. However, maintaining a professional profile and a sense of social connectedness can contribute to effective psychological services. While regional centres are not the same as rural and remote communities, psychologists in such centres may identify with some or all of the matters referred to in these Guidelines (Conomos, Griffin, & Baunin, 2013).

2. Living and working in rural and remote areas

2.1. Psychologists who practise in rural and remote areas, whether they reside in the actual areas or are visiting psychologists, are aware of the time required to build trust and respect within a community.

Refer to Ethical guidelines for the provision of psychological services for, and the conduct of psychological research with, Aboriginal and Torres Strait Islander peoples (2015).

2.2. Psychologists in rural and remote areas are more likely to share the same community experiences as clients. Psychologists are aware of the potential effect that such greater social connectedness with their clients may have on their professional judgement and objectivity.

2.3. When psychologists live and practise in small community settings, the lack of anonymity and greater community awareness of psychologists’ (and their families’) social and personal life may lead to more frequent boundary issues and multiple relationships. Psychologists adopt a continuous and systematic ethical decision-making process (Australian Psychological Society, 2013) in order to anticipate and manage these complex situations.

2.4. Psychologists who live and practise in rural and remote areas carefully consider how much weight they give to “common knowledge” about their clients.

165Ethical guidelines for psychological practice in rural and remote settings Ethical guidelines for psychological practice in rural and remote settings

3. Competence and professional responsibility

Refer to the Code, standard B.1. Competence.

B.1.1. Psychologists bring and maintain appropriate skills and learning to their areas of professional practice.

B.1.2. Psychologists only provide psychological services within the boundaries of their professional competence. This includes, but is not restricted to:

(a) working within the limits of their education, training, supervised experience and appropriate professional experience.

3.1. Psychologists are aware that greater public visibility and lack of anonymity of psychologists who practise in rural and remote areas can have implications for them, their clients and community perceptions of the profession of psychology.

3.2. While being conscious of the limits to their capacity to deal with the range of client needs when alternative or supporting resources are not readily available, psychologists who practise in rural and remote areas consider the respective implications of providing a psychological service themselves, or making an appropriate referral, which might mean a delay.

Refer to Ethical guidelines relating to clients at risk of suicide (2014); Ethical guidelines for working with clients when there is a risk of serious harm to others (2013); Professional Practice Management Standards (2011); and Setting up a private practice: Issues to consider (2014).

3.3. If psychologists consider they are not sufficiently competent or experienced to provide the appropriate psychological service needed to address the client’s problem, they explain this situation to the client and then assist in identifying alternative professional services for the client. Where no other psychological services are available, in consultation with their client and with their clients’ consent, psychologists may provide psychological services to the client. If psychologists decide this latter course of action is the most appropriate available option, the steps taken to obtain the necessary information and resources are documented. If appropriate and available, psychologists also arrange supervision in such circumstances.

3.4. Psychologists who practise in rural and remote areas, whether local, visiting or via other media (e.g., telephone or skype), develop a sound knowledge of the professional and community networks, resources, and services available in the region, whether local, neighbouring or at some distance from the client’s community.

3.5. Psychologists who practise in rural and remote areas routinely ask if their clients identify as Aboriginal or Torres Strait Islander, and develop culturally competent interventions for work with Indigenous clients and communities. Psychologists are aware of the historical bases for some Indigenous clients’ mistrust or scepticism of mainstream health services in terms of assessment, intervention, stereotyping and prejudice (Dudgeon, Rickwood, Garvey & Gridley, 2014).

Refer to Ethical guidelines for the provision of psychological services for, and the conduct of psychological research with, Aboriginal and Torres Strait Islander peoples (2015).

3.6. Psychologists understand that undertaking psychological practice with Aboriginal and Torres Strait Islander people and communities without awareness of the protocols of local communities can cause harm to clients. Psychologists therefore recognise the importance of engaging with the local community, undertaking local cultural awareness training and identifying a cultural mentor to support them, prior to embarking on such practice.

166 Ethical guidelines for psychological practice in rural and remote settings Ethical guidelines for psychological practice in rural and remote settings

4. Boundary management and multiple relationships

Refer to the Code, standard B.3. Professional responsibility.

B.3. Psychologists provide psychological services in a responsible manner. Having regard to the nature of the psychological services they are providing, psychologists: ... (g) are aware of, and take steps to establish and maintain proper professional boundaries with clients and

colleagues. ...

4.1. Multiple relationships are often unavoidable in rural and remote communities. Psychologists who practise in these communities may encounter situations where people with whom they have existing relationships seek their psychological service. Psychologists establish and maintain appropriate professional boundaries when dealing with potential clients and clients with whom they may have multiple relationships.

Refer to Ethical guidelines for managing professional boundaries and multiple relationships (2016); and Ethical guidelines on the prohibition of sexual relationships with clients (2007).

Refer to the Code, standard C.3. Conflict of interest.

C.3.1. Psychologists refrain from engaging in multiple relationships that may: (a) impair their competence, effectiveness, objectivity, or ability to render a psychological service; (b) harm clients or other parties to a psychological service; or (c) lead to the exploitation of clients or other parties to a psychological service.

4.2. Multiple relationships can also emerge subsequent to the initial engagement with a client. Consequently, at the outset psychologists who practise in rural and remote areas discuss with clients the possibility of multiple relationships emerging. Psychologists discuss with new clients strategies for monitoring and dealing with boundary issues should they arise. For example, psychologists mention the possibility that they will encounter clients in other settings and contexts, and discuss in advance the mutually acceptable ways of handling such encounters.

4.3. Psychologists who practise in rural and remote areas establish reasonable limits and clear parameters for any informal ‘consultation’ outside of the professional relationship.

4.4. Where a psychologist determines that the potential risks associated with a person receiving no service are greater than the potential risks of providing a psychological service to a person with whom the psychologist has or has had a previous connection, psychologists document:

• informed consent from the client; • the reasons for the decision to provide a psychological service to the person with whom they have or have

had a previous connection; • advice they have received from a senior colleague or peer, ideally someone who has an understanding of

rural and remote contexts, before making the decision to provide a psychological service; • the lack of alternative service providers; and • any other issues of concern. Refer to Ethical guidelines on record keeping (2011).

4.5. Subject to 4.4 of these Guidelines, psychologists avoid providing psychological services to family and close friends because the personal relationship has the potential to impair their professional judgment (Schank et al, 2010).

4.6. When assessing for conflict of interest in multiple relationships, psychologists carefully evaluate any financial relationships with existing clients and/or community members where there is a potential for adversely affecting the psychologist-client relationship. For example, having a local trader as a client may be unavoidable and is unlikely to affect psychologists’ professional judgement; whereas accepting a client who is one’s tenant, landlord or employee may adversely affect psychologists’ professional judgement. Where potential for conflict of interest or multiple relationships exists, psychologists seek consultation with colleagues.

Refer to Ethical guidelines regarding financial dealings and fair trading (2012).

167Ethical guidelines for psychological practice in rural and remote settings Ethical guidelines for psychological practice in rural and remote settings

5. Confidentiality and informed consent

Refer to the Code, standard A.5. Confidentiality.

A.5.2. Psychologists disclose confidential information obtained in the course of their provision of psychological services only under any one or more of the following circumstances:

(a) with the consent of the relevant client or a person with legal authority to act on behalf of the client; (b) where there is a legal obligation to do so; (c) if there is an immediate and specified risk of harm to an identifiable person or persons that can be averted

only by disclosing information; or (d) when consulting colleagues, or in the course of supervision or professional training, provided the

psychologist: (i) conceals the identity of clients and associated parties involved; or (ii) obtains the client’s consent, and gives prior notice to the recipients of the information that they

are required to preserve the client’s privacy, and obtains an undertaking from the recipients of the information that they will preserve the client’s privacy.

Psychologists who practise in rural and remote areas are particularly mindful of not making any inadvertent disclosures of their clients’ personal information.

6. Professional and personal isolation

6.1 Whether in private practice or as a psychologist in a multi-disciplinary team, many psychologists who practise in rural and remote Australia are the only psychologist in that area. To offset their professional isolation, such psychologists seek ongoing professional supervision and/or peer consultation to attend, address and monitor any emerging issues. If no supervision is available locally, psychologists seek supervision by telephone, videoconferencing or internet, from a suitably experienced colleague. Alternatively, psychologists may approach other rural practitioners for professional consultation.

Refer to the Code, standard B.1. Competence.

B.1.4. Psychologists continuously monitor their professional functioning. If they become aware of problems that may impair their ability to provide competent psychological services, they take appropriate measures to address the problem by:

(a) obtaining professional advice about whether they should limit, suspend or terminate the provision of psychological services;

... (c) refraining, if necessary, from undertaking that psychological service.

6.2. Psychologists who practise in rural and remote areas frequently face multiple professional and sometimes personal stressors. They may work with people known to them, and may therefore be at increased risk of psychological distress in response to adverse client outcomes. To maintain effectiveness in their professional role psychologists monitor their own self-care and levels of resilience in relation to such stressors.

Refer to Ethical guidelines for managing professional boundaries and multiple relationships (2016).

7. Summary

Psychologists who work in rural and remote areas are aware of the need and time required to build trust and respect within a community as well as with individual clients. They familiarise themselves with and develop a sound knowledge of the professional and community networks, resources, and services available in the region. Psychologists are aware of the limits to their competence in psychological practice and, if a psychologist with the necessary experience is not available, seek supervision or peer support if it is appropriate to offer the psychological service themselves. They carefully monitor their professional boundaries and develop strategies to anticipate and manage any multiple relationships that may emerge. Psychologists protect their clients’ confidentiality from inadvertent disclosures and proactively discuss with their clients mutually acceptable ways of handling everyday encounters outside of the consultation room.

168 Ethical guidelines for psychological practice in rural and remote settings Ethical guidelines for psychological practice in rural and remote settings

8. References

Australian Psychological Society. (2007). Code of ethics. Melbourne: Author. Australian Psychological Society. (2007). Ethical guidelines on the prohibition of sexual relationships with clients.

Melbourne: Author. Australian Psychological Society. (2011). Ethical guidelines for providing psychological services and products using

the internet and telecommunications technologies. Melbourne: Author. Australian Psychological Society. (2011). Ethical guidelines on record keeping. Melbourne: Author. Australian Psychological Society. (2011). Professional Practice Management Standards. Melbourne Author. Australian Psychological Society. (2012). Ethical guidelines regarding financial dealings and fair trading.

Melbourne: Author. Australian Psychological Society. (2013). How to: Make a sound ethical decision. InPsych, 35, 38-39. Australian Psychological Society. (2013). Ethical guidelines for working with clients when there is a risk of serious

harm to others. Melbourne: Author. Australian Psychological Society. (2014). Ethical guidelines relating to clients at risk of suicide. Melbourne:

Author. Australian Psychological Society. (2014). Setting up a private practice: Issues to consider. Melbourne: Author. Australian Psychological Society. (2015). Ethical guidelines for the provision of psychological services for and the

conduct of psychological research with Aboriginal and Torres Strait Islander peoples. Melbourne: Author. Australian Psychological Society. (2016). Ethical guidelines for managing professional boundaries and multiple

relationships. Melbourne: Author. Campbell, C. D., & Gordon, M. C. (2003). Acknowledging the inevitable: Understanding multiple relationships in

rural practice. Professional Psychology: Research and Practice, 34, 430-434. Conomos, A. M., Griffin, B., & Baunin, N. (2013). Attracting psychologists to practice in rural Australia: The role of

work values and perceptions of the rural work environment. Australian Journal of Rural Health, 21, 105-111. Dudgeon, P., Rickwood, D., Garvey, D., & Gridley, H. (2014). A History of Indigenous Psychology. In Dudgeon,

P., Milroy, H., & Walker, R. (Eds.), Working Together: Aboriginal and Torres Strait Islander Mental Health and Wellbeing Principles and Practice (pp. 39-54), Commonwealth of Australia.

Helbok, C. M. (2010). Living and working in a rural community. Professional Psychology: Research and Practice, 34, 505-507.

Schank, J. A., Helbok, C. M., Haldeman, D. C., & Gallardo, M. E. (2010). Challenges and benefits of ethical small-community practice. Professional Psychology: Research and Practice, 41, 502-505.

Revised version approved by the APS Board of Directors, March 2016