Professional Ethics in Rural and Northern Canadian Psychology
Malone, Judi L., Dyck, Karen G., Canadian Psychology
Although the literature in rural, northern, and remote (R&N) psychology and professional ethics for this setting is limited, it is clear that this area of psychological practice presents a specific context which must be considered for ethical decision-making. Existing literature suggests that overlapping relationships, community pressure, generalist practice, interdisciplinary collaboration, and professional development concerns are aspects of R&N practice that may be more prevalent. When they are, they pose risks by complicating professional practice and the resolution of related ethical issues. This article highlights the ways that demographic and practice characteristics may instigate ethical issues in R&N professional practice. We briefly review these considerations in relation to the literature, professional ethics, the Canadian Code of Ethics for Psychologists (Code), and case examples from our own practices. More specifically, we discuss how the Code provides guidance in applying the ethical principles to decisionmaking in R&N communities. Further, we suggest practical applications for ethical decision-making acumen inherent in the Code.
Keywords: rural, northern, remote, professional ethics, Canadian
Si la littérature sur l'exercice de la psychologie dans les régions rurales, nordiques et éloignées (R et N) et sur l'éthique propre à ce milieu est restreinte, il est clair que le psychologue évolue dans un contexte précis dont il faut tenir compte dans la prise de décisions éthiques. La littérature suggère que les relations interdépendantes, la pression de la communauté, la pratique de généraliste, la collaboration interdisciplinaire et les préoccupations relatives au perfectionnement professionnel sont des aspects parfois prédominants en régions R et N. Et lorsqu'ils le sont, ils constituent des risques puisqu'ils compliquent l'exercice de la profession et la résolution des problèmes éthiques connexes. Cet article met en relief les façons dont les caractéristiques démographiques et de la profession dans les régions R et N peuvent donner lieu à des problèmes édiiques. L'article présente ces éléments au moyen de la littérature existante, la déontologie, le Code canathen de déontologie professionnelle des psychologues et d'exemples de cas. Il explique en quoi le Code constitue un guide pour l'application de principes édiiques dans la prise de décisions concernant des collectivités R et N. Des applications pratiques sont ensuite suggérées pour la prise de décisions éthiques selon le Code.
Mots-clés : rural, nordique, éloigné, éthique professionnelle, canadien.
Psychologists are in the business of relationships and are continually immersed in the complexity of human interaction (Bauman, 1999). This dynamic is intensified for rural, northern, and remote (R&N) psychologists where intricate relational matrices, together with demographic considerations, have the potential to create ethical challenges that are more prevalent, complicated, or perhaps even less easily resolved. Practice characteristics, such as overlapping relationships, community pressure, generalist practice, interdisciplinary practice, professional isolation, and limited opportunities for professional development may foster ethical dilemmas that require a nuanced understanding of the Canadian Code of Ethics for Psychologists (Code), (Canadian Psychological Association [CPA], 2000).
In this article we highlight how R&N practice may instigate ethical issues for psychologists and how the Code provides guidance in applying the ethical principles to decision-making in R&N communities. We will provide case examples that are a compilation of our own experiences and that of other R&N psychologists with whom we have worked and suggest practical applications for ethical decision-making using the Code. By way of background, we are both practicing R&N psychologists in Canada. The first author has a independent practice in her lifelong community of North Eastern Alberta. Her time is divided between clinical practice in a rural town and an Aboriginal health clinic and teaching for Athabasca University and at Blue Quills First Nations College. She describes her practice as generalist in nature with predominantly community consultation, assessment, treatment, and counselling aspects. The second author is an Associate Professor and the Director of the Rural and Northern Psychology Programme in the Department of Clinical Health Psychology at the University of Manitoba. Within this role, she is based in a large rural health region where she is involved in a variety of activities including administration; supervision of pre- and postdoctoral residents and new faculty; research; program development and evaluation; education (to health care providers and general public); and the provision of clinical services (assessment, consultation, treatment) to children, youth, adults, and older adults.
The Practice Setting
In Canada, 90% of the land mass is considered R&N and, by some definitions, approximately 20% of Canadians live in small and rural dispersed communities (Barbopoulos & Clark, 2003; Canadian Institute for Health Information [CHIH], 2006; Nigro & Uhlemann, 2004; Romanow & Marchildon, 2003). R&N Canadians vary with respect to cultural, ethnic, and religious composition (Mcllwraith & Dyck, 2002), yet tend to share a strong sense of community belonging (CIHI, 2006). The communities in which they reside also vary with respect to factors such as income, housing, employment, and presenting health concerns.
The health of R&N Canadians involves complex environmental, cultural, social, and psychological factors. There are typical remote service issues such as lack of childcare and public transportation, but more significantly, health care tends to be less accessible (McIlwraith & Dyck, 2002; Mitura & Bollman, 2003; Pong, 2007). The population dispersion makes it expensive and difficult to provide health care services, and there are also significant shortages of health and mental health providers including psychologists (Brannen & Johnson-Emberly, 2006; Romanow & Marchildon, 2003). In fact, the ratio of psychologists to population is four times higher in urban areas in Canada (Bazana, 1999; Romanow & Marchildon, 2003), and there are significant issues with recruitment and retention in R&N areas (Mcllwraith & Dyck, 2002; Mcllwraith, Dyck, Holms, Carlson, & Prober, 2005). As a result, psychology services are much more readily available in urban centers and many R&N Canadians cannot access psychological treatment. Alternatively, they access less appropriate, but more available, services tiirough medical, legal, or other public services (McIlwraith & Dyck, 2002). Even when psychology services are available locally, residents may be reluctant to access them due to negative community attitudes toward mental health treatment and the marginalization of psychology within the Canadian health care system (CPA, 2007; Hunsley & Crabb, 2004; Mcllwraith & Dyck, 2002; Romanow, 2006).
Psychologists who practice in rural Canada tend to be less experienced than their urban counterparts, and most Canadian psychology students receive no formal training or exposure to R&N practice considerations (Barbopoulos & Clark, 2003; Mcllwraith et al., 2005). This is despite a recent Royal Commission in Canada that indicated a distinct need for the further development of R&N psychological services (Romanow & Marchildon, 2003), and despite market demands. As a result, we are more likely to find junior psychologists with little or no formal training or exposure to R&N practice trying to navigate the realities of R&N practice, including the ethical issues associated with this context.
R&N psychologists often face challenges related to distance, fewer colleagues and allied health professionals, and limited training, research, and professional infrastructure. The social networks and values of R&N communities position the practicing psychologist within a cultural system that may be vastly different from urban settings. Working within this context may increase the psychologist's sense of responsibility, increasing dieir anxieties about ethical decision-making (Bauman, 1998), and fostering the need for R&N psychologists to have a mature and reflective understanding of ethics, professional practice, and die required ethical and decision-making acumen inherent in the Code (CPA, 2000).
The Canadian Code of Ethics for Psychologists: A Guiding Framework
CPA recognizes its responsibility to help assure ethical behaviour and attitudes on the part of psychologists and requires all members to adhere to the current edition of the Code (CPA, 2000; Truscott & Crook, 2004). The majority of provincial and territorial regulatory bodies in Canada have also adopted the Code. The Code, collectively developed by many psychologists in Canada, has an internationally unique structure of core principles, standards, and an ethical decision-making system (Schank & Skovholt, 2006; Truscott & Crook, 2004). It is primarily a descriptive code which is based on four broad principles: I) Respect for the Dignity of Persons, II) Responsible Caring, III) Integrity in Relationships, and IV) Responsibility to Society. Each of these four principles is followed by value statements that are clarified with a set of specific ethical standards that illustrate the application of the principle and values. Although all four principles are to be weighted equally in ethical decision-making, situations arise where these principles may conflict, and this is not possible. As such, the principles have been arranged in descending order according to the recommended weight each should be given when conflicts do occur. The Code also offers psychologists a 10-step process for making ethical decisions.
The primary purpose of the Code, as with many others, is to provide a framework to assist psychologists in making consistent and objective choices when faced with ethical dilemmas (Hadjistavropoulos, Mally, Sharpe, Green, & Fuchs-Lacelle, 2002). The Code is unique, however, in its explicit acknowledgment of potentially conflicting principles and the inclusion of weighting guidance and an explicit process for decision-making when ethical principles conflict (Schank & Skovholt, 2006). These unique features of the Code can be particularly helpful for psychologists working in environments where conflicts may be more commonplace, such as R&N settings.
The current article explores ethical complications within the context of R&N Canadian practice and in consideration of the Code (CPA, 2000). Unfortunately space does not permit an exhaustive discussion regarding the specific application of all relevant ediical standards or a detailed illustration of the application of weighting guidelines and the 10-step decision-making process outlined in the Code. Nonetheless, we wish to acknowledge the contribution of these particular aspects of the Code in guiding our resolution of the ethical dilemmas presented in this paper.
Applying the Canadian Code of Ethics for Psychologists Within the R&N Context
An overlapping relationship (often called dual or multiple relationships) occurs when a psychologist has a relationship or connection with a client in addition to the therapist- client relationship. This may occur before, during, or after the professional relationship, and may arise either by choice or by chance (Truscott & Crook, 2004). Overlapping relationships increase the probability of boundary crossings and boundary violations and it is important to distinguish between these two concepts.
Boundary crossings are benign overlapping relationships. They are more common in environments where the psychologist lives in close proximity to clients and may move in the same social circles. Boundary crossings are often unavoidable in R&N practice and can be considered a normal and healthy part of R&N living (Scopelliti et al., 2004; Zur, 2006). Boundary crossings include appropriate self-disclosure, home and community visits to clients, or other minor deviations from a strict professional role. In boundary crossings, the psychologist is not standoffish but continues to perceive all nonoffice or nonprofessional relationships as potentially risky (Zur, 2006). Boundary violations, on the other hand, impair judgment and objectivity and have clear potential to be exploitative and harmful to the client, the professional relationship, and the profession of psychology. Treating members of one's own family, close friends, or others with whom one has a significant relationship are boundary violations, as are behaviours with clients such as excessive self-disclosure or involvement in sexual relationships. Boundary violations are never acceptable (Scopelliti et al., 2004).
Discriminating between a boundary crossing and a boundary violation occurs on a case-by-case basis and is dependent on context, such as the cultural background and theoretical orientation of the client and psychologist (Endacott et al, 2006). Understanding the difference between boundary crossings and boundary violations is complex, even when they appear harmless. Each requires due diligence and ongoing risk-benefit analysis (Barbopoulos & Clark, 2003; Charlebois, 2006; Zur, 2006).
Psychologists in urban practice may find it easier to maintain clear professional boundaries because they live in a less-embedded environment. Compared to R&N psychologists, urban psychologists may enjoy greater anonymity, experience fewer chance encounters, and experience less community pressure related to limited resources. In R&N communities, overlapping relationships become an expected aspect of care due to the increased likelihood of family or friendship ties, chance encounters, coinvolvement in community activities, the multiple roles people play in the community, and community norms that support overlapping relationships (Helbok, Marinelli, & Walls, 2006; Schank & Skovholt, 2006; Zur, 2006).
Compelling psychologists to avoid overlapping relationships does not consider the necessary or therapeutic nature of some of these relationships (Austin, Bergum, Nuttgens, & Peternelj -Taylor, 2005; Helbok, 2003). Some authors suggest that effectively managed overlapping relationships may increase the effectiveness of R&N psychological services (Scopelliti et al., 2004). Behnke (2008) has suggested that "finding oneself in a multiple relationship is not necessarily a sign that one has engaged in unethical behaviour. It may rather be a sign that one is fully engaged in the life of a community" (p. 62). This can enhance understanding of community needs and community members, and can heighten the unique bonds between psychologists and clients (Scopelliti et al., 2004). It also speaks to the artificiality of boundaries in therapeutic practice. A boundary is merely a metaphor for conceptualising ethical issues. In reality, these relationships are one component of a complex series of interactions within the professional relationship (Austin et al., 2005).
Dr. Frontier has been working in a small rural community for the past 2 years, where she works closely with the local mental health program as the team's consultant. Dr. Frontier is also very active in the community and, as a result, often interacts with team members and their families in various social contexts. One day, Dr. Frontier is approached by one of the mental health clinicians asking if she would be available to provide therapy services to the clinician and her family. The clinician explains that she does not feel comfortable accessing therapy services through the mental health program, as she has known the clinicians on this team for years, both as colleagues and friends. Although the clinician also considers Dr. Frontier a "friend", she has known her for a shorter period of time and socializes with her only wimin the context of work functions. The psychologist is the only other therapy resource in the community.
The Code (CPA, 2000) states that overlapping relationships are generally to be avoided, but acknowledges exceptions that must be carefully considered and ethically resolved as they could harm the client or result in the delivery of inferior services (Truscott & Crook, 2004; Yonge & Grundy, 2006). Overlapping relationships are covered in Principle UI of the Code, Integrity in Relationships. Relevant ethical standards of this principle direct psychologists to avoid overlapping relationships that may cause a conflict of interest (Ethical Standard ??.33) and to develop and use safeguards when in unavoidable overlapping relationships (Ethical Standards ??.34 and ??.35). For example, supervision, consultation, or thirdparty consent may enable psychologists to ethically maintain unavoidable overlapping relationships (CPA, 2000; Yonge & Grundy, 2006). Ethical Standard ??.35 also stresses the need to resolve the situation in a manner that is consistent with Principles I and II, namely Respect for the Dignity of Persons and Responsible Caring, respectively. Therefore, in making a decision, the psychologist must also consider issues such as fair distribution of services and not unfairly exclude those who are vulnerable or disadvantaged. Weighing out the potential risks and benefits of offering services versus not, and obtaining informed consent, which includes clarifying the nature of overlapping relationships, are also considerations in this process. Not surprisingly, R&N psychologists may find themselves in a situation where the aforementioned principles conflict. In accordance with the Code, the relative weighting of principles can then be adjusted to assist with decision-making.
Consistent with the Code's 10-step process, psychologists seeking to make good ethical decisions about overlapping relationships are well advised to identify individuals/groups potentially affected by the decision (e.g., client, family, community), identify ethically relevant issues and weighting guidelines (e.g., Principles I, ?, and III), consider factors that might influence the development of or choice between potential courses of action (e.g., community pressure, friendship with referral source), consider various options (including consideration of best and worst possible outcomes), and consult with parties affected by the ethical decision (e.g., client, family, referral source), as well as colleagues before arriving at a decision. Realistically, psychologists in R&N practice need to explore how, not if, they can manage overlapping relationships (Scopelliti et al., 2004), yet at the same time not automatically assume there are no other options. When unavoidable, the potential risks associated with overlapping relationships (e.g., bias, lack of objectivity, and risk of exploitation) can be effectively minimised by including affected parties in the decision-making process, clarifying boundaries and expectations (e.g., how to respond to chance encounters), accessing professional consultation, monitoring and adapting the course of action as deemed necessary, and appropriately documenting the aforementioned steps (Schank, Helbok, Haldeman, & Gallardo, 2010). When approached in an ethical manner, unavoidable overlapping relationships needn't be damaging and can, in fact, enhance services by increasing the psychologist's knowledge base and facilitating the development of positive community relationships.
Dr. Frontier felt uncomfortable accepting the clinician and her family as clients. Not only did Dr. Frontier believe that her preexisting relationship with the clinician may impact her objectivity, she was also concerned about the impact this may have on the other family members' perception of her objectivity and their openness and ability to truly participate in the therapeutic process. At the same time, it did appear that there were fewer risks associated with working with Dr. Frontier than with one of the other clinicians in the community, who had much closer relationships with the potential client. In considering the various issues, Dr. Frontier consulted a colleague in another community and spoke to the potential client about her concerns. Not wanting to disadvantage the potential client, Dr. Frontier explored other possible treatment options. With some discussion, it was agreed the best solution in this particular case would be to have Dr. Frontier's colleague provide family therapy services via telehealth, to which the potential client readily agreed.
Issues of high visibility, small community size, and community norms and expectations all have the potential to contribute to the community pressure felt by the local R&N psychologist. To provide competent and successful services, R&N psychologists must be familiar with and sensitive to the specific values and culture of the area in which they practice and how these factors influence community expectations (Helbok, 2003).
Community expectations are a significant consideration for R&N psychologists (Endacott et al., 2006; Schank & Skovholt, 2006), particularly as ethical action always takes place within a community and impacts more than just the psychologist and client (Austin, 2007). For example, there is often an assumption that R&N psychologists will take the role of expert and leader in community development (Schank & Skovholt, 2006). This may pressure a R&N psychologist to work in a community psychology role or to work beyond the limits of their competence (competency issues are discussed in more detail under Generalist Practice). There may also be expectations that psychologists provide practical and tangible services, which may compel the psychologist to focus more on services that result in concrete problem-solving rather than services aimed at self-actualization and community empowerment (Schank & Skovholt, 2006).
The increased visibility of R&N psychologists also causes pressure based on reputation, appearance, or behavioural expectations (Schank & Skovholt, 2006). R&N psychologists are often expected to relate to community members at a social as well as a professional level. This may influence the ability of the psychologist to secure trust from key members of the R&N social network, many of whom will have considerable knowledge about the psychologist's personal life (Helbok, 2003; Schank & Skovholt, 1997). Although lack of anonymity may foster trust, lack of privacy increases pressure for the psychologist (Helbok, 2003).
Visibility also impacts the confidentiality of clients, as community members are likely to be aware of who is using psychological services, and psychologists may unintentionally have more information about a client than that client consented to release. Support staff may be familiar with clients and other agencies may openly share information about clients with the psychologist (Helbok, 2003; Helbok et al., 2006). Charlebois (2006) found that distinctions needed to be made between confidentiality, anonymity, and privacy for rural clients. She suggests that only confidentiality can justifiably be offered to the client in a rural area. In R&N communities, personal information is more readily available (and is often offered to psychologists) through common, informal, sharing networks or gossip (Helbok, 2003). These networks are often part of the protective community fabric and the expectations to share confidential information without consent is unlikely to be seen as a harmful act by some members of the community (Schank & Skovholt, 2006). In fact, in some communities, family bonds may be valued over individuality and, as a result, confidentiality may be viewed as self-centered and destructive to the community (Schank & Skovholt, 2006). This, in turn, can result in the R&N psychologist feeling pressured to share confidential information without client consent.
Community pressure is dependent on the context or culture of the R&N community in which the psychologist practices and may become more pronounced as the community size decreases or when community isolation increases (Endacott et al., 2006; Helbok, 2003; Scopelliti et al., 2004). In qualitative interviews, Malone (2010) found that rural Canadian psychologists expressed anxiety in relation to perceived community pressure. This is consistent with Bauman's (1998) suggestion that increased unspoken responsibility fosters anxiety. In a recent mail-out survey comparing the practices of over 400 rural and urban psychologists, Helbok et al. (2006) found rural psychologists reported more community pressure but also reported fewer ethical dilemmas related to this increased pressure.
Dr. North is a psychologist working in a remote community. He was attending a large team meeting where members were discussing the various mental health services in the area and ways to improve accessibility to these types of services. Within the context of this discussion, various team members began discussing typical reasons why clients access services and the ways in which they learn about these services. During this conversation one of the team members made reference to her neighbor whom she had recently seen going to the psychologist's office and turned to Dr. North to ask "What's her problem?" and "How did she end up coming to see you?" When Dr. North hesitated to provide a response to her question, the team member reminded him that, because they are all working on the same team, it is entirely appropriate to disclose this type of information and they would be able to access this information directly from the client's file.
The value of integrity is implicit in most codes of ethics (Truscott & Crook, 2004; Yonge & Grundy, 2006). Integrity in relationships is a particularly salient issue in the cultural context of embedded environments where overlapping relationships are more common. Principle III, Integrity in Relationships (CPA, 2000), directs psychologists to monitor the need for and cultural appropriateness of disclosure, to act in the best interest of community members, and to foster public trust in the discipline of psychology. Sinclair and Pettifor (2001) warn that "failures to meet expectations of integrity. . have provided the basis for a large number of complaints against psychologists. Such failures can undermine scientific progress and public trust in psychology" (p. 72). The implied or explicit promise of the psychologist to keep client information private is central to the professional psychological relationship and the perception of integrity (Truscott & Crook, 2004). In the Code, confidentiality and privacy are central ethical standards within Principle ?, Respect for the Dignity of Persons (CPA, 2000). Principle IV in the Code, Responsibility to Society, speaks to the importance of having knowledge about and respecting the culture, social structure, and customs of a community. Although community considerations are essentia], the Code clarifies that the psychologist's greatest responsibility is to their clients (Sinclair & Pettifor, 2001).
There are several ways R&N psychologists can resolve ethical dilemmas related to community pressure. These include triaging services, maintaining clearly articulated boundaries, initiating discussions regarding confidentiality and privacy, maintaining good self-awareness regarding ones limits of competence, openly discussing limits of competence with clients and health care providers, accessing appropriate consultation, and protecting private time. R&N psychologists must also be prepared to respond in a culturally respectful and ethically informed manner to community pressure to share confidential information with family members in the absence of client consent. A reasonable solution may be to discuss ethical guidelines and obligations with the family and explore possible ways to respond to the family's needs in a way that does not compromise the responsibility to the client. It has been the first author's experience that, in many instances, family members are not seeking specific pieces of information but rather more general guidance regarding ways to support their loved one in their time of need.
Dr. North was surprised by the team member's pointed question about her neighbor and felt pressured by the other team members to disclose the requested information. The team appeared confused by Dr. North's reluctance to disclose this information and his obvious efforts to redirect the conversation. Although Dr. North did not disclose the requested information, he felt dissatisfied with his handling of the situation and was concerned that the team may view him as not being a "team player." After carefully considering the situation and consulting with a colleague, Dr. North decided to approach the team leader about revisiting this issue during their next team meeting. Dr. North shared his position privately with the team leader in a manner that was respectful to the team process and norms but also to the culture of the community and the general feedback he had received from clients about general privacy concerns. Dr. North shared this perspective during the next team meeting and also proposed a solution that respected both the team's need for information as well as the community's expectations for privacy/confidentiality. Dr. North offered to provide the team with general information summarising his clients' presenting issues, diagnoses, and referral sources as opposed to providing specific information regarding each client. The team saw this as a reasonable solution.
R&N practice conditions (such as lack of referral resources) often necessitate a generalist approach (Helbok, 2003). This common practice consideration is reflected in the R&N psychology residency in Manitoba where "consistent with generalist rural practice, interns and residents provide consultation, assessment, and treatment (individual, family, and group) services to a broad patient base that ranges with respect to age, ethnicity, culture, and presenting concerns" (Dyck, Cornock, Gibson, & Carlson, 2008, p. 244). Specialization is impractical as R&N service needs require practitioners to be multiskilled in working with diverse populations (Barbopoulos & Clark, 2003; Mcllwraith et al., 2005; Perkins, Larson, & Burns, 2007). Generalist practice can contribute to greater job satisfaction but also fosters ethical issues related to competence, scope of practice, and appropriate training. It may also challenge the confidence of the psychologist (Helbok, 2003; Mcllwraith et al., 2005). Unfortunately, professional training specific to generalist practice in R&N settings is rare. This is despite the need for R&N psychologists to work with health care systems and interdisciplinary teams and provide consultation, outreach, community assessment, program development, and evaluations (Helbok, 2003; Mcllwraith et al., 2005).
R&N psychologists face the dilemma of providing needed services that may not exist without their efforts. Yet, the quality of such services may be compromised if they work outside their area of training. R&N psychologists must decide whether to offer services themselves, refuse to do so (considering the ramifications for the client, family, community), provide limited service, or provide service outside their area of competence (Schank & Skovholt, 2006). The scarcity of R&N mental health resources and specialists may pressure psychologists to work as generalists, often beyond the limits of their education (Barbopoulos & Clark, 2003). The primary challenge is to provide optimal care, often with a minimum of resources, without violating the competency principle of ethics codes (Helbok, 2003; Schank & Skovholt, 2006). In the Manitoba program mentioned earlier, the supervisors role-model ways to deal with limits of competence. Common supervisory discussions involve dealing with pressure to provide services, self-awareness about limits of competence, and identifying when additional supervision or consultation is required (Dyck et al., 2008).
Dr. Rural is a psychologist working in a small rural community. She is approached by a daycare worker from the community to discuss a 5-year-old child in that individual's care. The worker indicates she is very concerned about this child's unusual behaviours and disinterest in other children. The worker states she has read a number of articles about autism and believes this child should be assessed for this condition. She has reportedly spoken to the parents about this and they are eager to have their daughter assessed. Unfortunately, the closest child psychologist, Dr. Child, is over 700 km away and the family has no financial means of travelling to that community for the assessment. The daycare worker has asked Dr. Rural if she would consider doing the assessment. Although Dr. Rural has some child experience and has assessed older children for autism, she has only ever seen one child under the age of seven and this was several years ago (and not for an autism assessment). There are no other resources in the community and the daycare worker and family are pleading with Dr. Rural to see the girl, as a confirmed diagnosis would enable them to access additional specialized programs in the community.
Competence is an important component of professional practice and the reason that many clients choose to seek the services of a psychologist. However, most ethical codes do not clearly define competence (Helbok, 2003). Generally, competence (including cultural competence) is considered to be a multidimensional concept comprised of knowledge, skills, judgment, and diligence in the provision of professional services (Truscott & Crook, 2004). Even when trained as generalists, it is not possible to be competent in the provision of all psychological services to all client groups. Psychologists in R&N practice need to assess their competencies within the context of community and client needs, professional expectations for specialization and competency, and ethical standards (Schank & Skovholt, 2006).
The Code (CPA, 2000) clarifies the values of competence and self-knowledge and states that, "psychologists would offer or carry out (without supervision) only those activities for which they have established their competence to carry them out to the benefit of others" (p. 16). R&N psychologists must be intimately aware of their own comfort levels, their strengths and weaknesses, and how far outside their area of expertise they may be practicing (Helbok, 2003; Yonge & Grundy, 2006). The ethical dilemmas inherent in generalist practice are intensified when there are fewer accessible alternative services. This can cause angst for the R&N psychologist. However, such dilemmas can be ethically resolved through self-awareness, which is enhanced by seeking consultation and supervision, and by articulating limits and documenting these steps appropriately.
Recognising her limits of competence and the importance of ensuring access to appropriate service, Dr. Rural sought consultation from the nearest child psychologist, Dr. Child. Upon hearing the details, Dr. Child agreed to assess the child herself (which would require the family to travel a considerable distance) or to act as a consultant on the case. Dr. Child felt they could competently complete the assessment jointly but that this would involve, among other things, Dr. Child directly observing aspects of the assessment via videoconferencing. Dr. Rural arranged a meeting with the daycare worker and the parent to discuss the assessment options and the risks and benefits associated with each. Dr. Rural was careful to document these steps in her file. By doing so, the client and the referral source were included in the decision-making process.
Interdisciplinary collaborations are a core professional activity for many R&N psychologists. Effective collaborations are useful for addressing complex, multifaceted problems and goals and for achieving common ground (Austin, Park, & Goble, 2008; Van Vliet, 2009). Within the R&N context, effective collaborations with health care professionals, teachers, and social workers may facilitate referrals (Schank & Skovholt, 2006), provide a more integrated community response, and improve the services available to R&N community members (Barbopoulos & Clark, 2003). R&N psychologists may also find it particularly helpful, if not essential, to include Aboriginal elders, spiritual advisors, and paraprofessionals in this group of collaborators. Including these key community members can facilitate quality of care and contribute to the psychologist's understanding of and sensitivity to cultural and community factors. For the R&N psychologist, collaboration can also help prevent burnout, work overload, and a sense of isolation (Helbok, 2003).
Along with die benefits, collaboration may also foster concerns such as enhanced risk of blurred roles and the potential for compromised client confidentiality (Helbok, 2003; Helbok et al., 2006; Schank & Skovholt, 2006). Casual information sharing, more common in R&N areas, may mean colleagues and coworkers discuss cases openly without consent or expect this of psychologists. In these settings, even general discussions can be misinterpreted as being about specific clients (Schank & Skovholt, 2006). Psychologists in R&N practice who decline to share confidential information or who challenge the behaviour of other professionals may alienate themselves and lose referral sources (Helbok, 2003; Schank & Skovholt, 2006).
In consideration of the aforementioned, it appears particularly important that R&N psychologists be skilled in interdisciplinary collaboration. Indeed, training in this area has been recommended for Canadian clinical psychologists (Crossley, Morgan, Lanting, Bello-Haas, & Kirk, 2008, p. 231) and Mcllwraith et al., (2005) have incorporated interdisciplinary collaboration considerations into their R&N psychology training program.
Dr. Remote, a clinical psychologist in a remote community, works in a salaried position as a consultant to the local mental health team and also has a small independent practice. She was attending the monthly mental health intake meeting as the team consultant when one of the new referrals being discussed happened to involve a client she had previously seen in her independent practice. One of the team members had noticed this individual going into the psychologist's office some time ago and concluded this individual must have been a client of Dr. Remote. In an effort to identify the best course of action for the individual, the team began asking Dr. Remote about the nature of her work with this client.
Confidentiality is another important component of ethical psychological practice. It is a foundation of codes of etiiics in psychology and is only limited in extreme circumstances, such as dangerousness. Although it can be a foreign concept in highly interconnected small communities (Wihak & Merali, 2007), confidentiality plays a vital role in the provision of psychological services. Breaking confidentiality may increase the stigma around seeking psychological services (Helbok, 2003).
Principles I (Respect for the Dignity of Persons) and III (Integrity in Relationships) of the Code and their application to the issue of confidentiality were previously discussed in the Community Pressure section and will not be repeated here. Readers may recall that the Code acknowledges the importance of community considerations but emphasizes the psychologist's greatest responsibility is to their client (Sinclair & Pettifor, 2001). Also relevant to the issue of confidentiality within the context of interdisciplinary collaboration is the importance of collegial respect, which is also outlined in the Code (CPA, 2000).
Although Canadian psychologists must "encourage others, in a manner consistent with the Code, to respect the dignity of persons" (CPA, 2000, p. 14), Sinclair and Pettifor (2001) remind psychologists to demonstrate humility and respect and avoid being dictatorial. The ability of psychologists to influence agencies or community processes is complex and requires nuanced ethical decision-making. It has been our experience that this is most likely to be accomplished within the context of positive working relationships and where the psychologist has approached ethical issues in a manner that shows respect for the existing system but where the psychologist also articulates the ethical challenges they face, the guidelines offered by the Code, and the decision-making process they used to arrive at a solution.
Principle II, Responsible Caring, also speaks to how breaches of confidentiality risk damaging the client and the professional relationship (Truscott & Crook, 2004). Psychologists are required to be acutely aware of the need for discretion as information (recorded, collected, and shared) can be misinterpreted or misused by otiiers to the detriment of clients (CPA, 2000). Considerations for R&N practice may mean enhanced levels of informed consent to protect client privacy within interdisciplinary collaborations. Finally, Principle IV, Responsibility to Society, speaks to respect for die society in which psychologists work. Psychologists are required to work effectively with others. They may require training to develop the requisite skills for appropriate and effective collaborative work. This includes respecting other professionals and cultures. Psychologists must respect naturally occurring support systems and avoid unnecessary disruptions to these groups. This means developing the necessary skills to consider ethical standards in conjunction with prevailing community mores in a manner that facilitates ethical, collaborative relationships (CPA, 2000).
Interdisciplinary collaboration may require psychologists to advocate for the role of psychology, facilitate clearly articulated team member roles and responsibilities, navigate differing levels of professionalism, and develop particular protocols to maintain confidentiality within such collaborations. In accordance with the Code these collaborations can be successfully and ediically maintained by respectfully setting clear boundaries and building effective relationships. Interdisciplinary collaborations can assist R&N psychologists to provide more effective integrated services, increase their cultural awareness and sensitivity, and reduce the isolation of R&N practice.
Although Dr. Remote had worked as a consultant for the team for some time, she had never clarified her role within the context of the team and how this differed from her role as a independent practice psychologist in the community. She saw this situation as an opportunity to clarify her roles and her response to requests for client information. At the same time, Dr. Remote felt it was important to acknowledge the potential value that treatment history can have in current treatment planning and his understanding of the clinician's request for this information. Dr. Remote discussed these issues with the team and it was agreed that the intake worker would ask the potential client directly about their treatment history. In order to eliminate future barriers for appropriate information sharing, Dr. Remote also discussed the consent process that would be needed in order for her to disclose information about any of her private clients.
Professional Development and Support
Although psychologists require ongoing professional development and support, particularly in ethics, R&N-specific professional development is not common. Literature suggests psychology tends to be urban-centric with insufficient professional training opportunities specific to rural practice (Barbopoulos & Clark, 2003). Given this, it is not surprisingly that rural psychologists rate their professional training and their ethical training as insufficient (Schank & Skovholt, 2006). Regular peer consultation and clinical supervision are essential for good practice and maintaining competence (Schank & Skovholt, 2006; Truscott & Crook, 2004), particularly for those who work in relative isolation (Helbok, 2003; Mcllwraith & Dyck, 2002; Schank & Skovholt, 2006). In qualitative interviews, Charlebois (2006) found Canadian rural counsellors wished they had more access to peer consultation. In a qualitative study, Malone (2010) found that, although participants found professional development and support more difficult, they also had creative solutions for getting those needs met, such as developing geographically separated networks of peers. That said, options for supervision and consultation are often limited by geographical, environmental, and economic difficulties (Schank & Skovholt, 2006).
Continuing education, additional training, and retraining are important ways to stay professionally current. Unfortunately, qualitative studies of rural Canadian practitioners confirm that they have fewer opportunities for continuing education or find participating in professional development more difficult (Charlebois, 2006; Malone, 2010). Finally, psychologists in rural practice often deal with personal and professional isolation (Barbopoulos & Clark, 2003; Schank & Skovholt, 2006). Professional isolation results in fewer opportunities to consult on difficult cases, engage in collaborative work with other psychologists, or conduct research. This can result in a decreased sense of accomplishment and fewer opportunities for intellectual stimulation, collégial support, and sharing of ideas (Barbopoulos & Clark, 2003; Helbok et al., 2006; Schank & Skovholt, 2006). This is compounded by the fact that many psychologists in R&N practice work individually in independent practice, causing further isolation. In the absence of collegial feedback, R&N psychologists may rationalize nontraditional practices, be less aware of unethical behaviour, and compromise standards due to isolation (Helbok, 2003). An extreme manifestation of isolation can be compassion fatigue or burnout. This may present as emotional exhaustion, loss of purpose and energy, depersonalization or cynical attitudes, and loss of a sense of personal accomplishment (Helbok et al., 2006). Rural practice can pose risks for burnout when there are high workloads, difficulties setting limits, significant travel, and lack of resources and support (Schank & Skovholt, 2006).
As the only psychologist in a large rural heath region, it was not uncommon for Dr. North to be asked to sit on committees, attend meetings related to various community health issues, and provide educational presentations to various organisations. Although he was very busy with his other clinical responsibilities he recognised the importance of participating in activities of this nature and often found it difficult to refuse, particularly when the requests came from referral sources, his own health care providers, and/or individuals with whom he also had social contact. Dr. North was also becoming concerned about his limited participation in continuing education activities, as these appeared particularly challenging to fit into his busy schedule. Despite his passion for rural work, Dr. North felt he could no longer manage these demands and was becoming increasingly concerned about burnout.
Diligent psychologists continually attend to their skills and professional judgment so that their competence is not compromised (Helbok, 2003; Truscott & Crook, 2004). Indeed, many jurisdictions require continuing professional development. The Code (CPA, 2000) holds psychologists responsible for developing and maintaining professional skills and for routinely assessing and discussing ethical issues with peers or senior colleagues. The principle of Responsible Caring highlights the importance of psychologists staying up-to-date on knowledge and research in the field and being aware of practice risks. This includes reading, peer consultation, and professional development activities. Ethical Standard 11.12 specifically addresses potential burnout and the importance of engaging in self-care as a way to prevent impaired judgment. The importance of remaining current is part of the principle of Integrity in Relationships which requires maintenance of competence in their area of specialization and a commitment to maintaining the standards of the discipline (CPA, 2000).
R&N psychologists experience difficulties in acquiring appropriate training, consultation and supervision, and professional development. This may increase isolation and burnout risks which, in turn, can diminish competency. However, professional development issues can be ethically resolved with creative solutions that include fostering long-distance collégial networks, consulting with other professionals familiar with R&N practice, and using technology to mediate distance for consultation and for professional development.
Recognising some early signs of burnout, Dr. North decided to schedule some vacation time and to use this time to reflect on his current situation and some possible solutions. Dr. North contacted some other rural psychologists he knew and consulted them about his predicament. With the input of his colleagues, Dr. North decided to approach his employer about his concerns and some possible solutions he had identified. These included prioritizing community needs, setting appropriate limits, and ensuring regular participation in continuing education opportunities. Perhaps most useful, was Dr. North's establishment of monthly teleconference meetings with other rural psychologists. These meetings provided Dr. North and the other group members with regular opportunities to consult on both clinical and practice issues particularly relevant for rural practice.
Discussion and Conclusion
Codes of ethics for psychology have increasing emphasis on social responsibility. This responsibility extends beyond individual clients to the families, groups, communities, organisations, and societies that might also be impacted by psychological services. This makes sense as the science of psychology itself is dependent on how individual and societal considerations interact (O'Neill, 2005). For R&N psychologists, professional ethics codes, such as the Canadian Code of Ethics for Psychologists (CPA, 2000), offer guidance in a context diat is rife with ambiguity (Schank & Skovholt, 1997). The Code is currently under revision and it is likely that the increased focus on social responsibility will be inherent in that development. This requires a review of the impact of the Code for special populations and practice considerations, including R&N professional practice.
In our review of the demographic and practice considerations of R&N psychological practice, we considered five ediical dilemmas in relation to the Code (CPA, 2000). Overlapping relationships highlighted objectivity considerations and the importance of carefully considering and ethically resolving unavoidable overlapping relationships. Community pressure underscored integrity concerns and the importance of Canadian psychologists respecting prevailing community norms/culture, and recognising how societal expectations may impact their practice. Generalist practice accentuated competency concerns and the importance of self-awareness. Interdisciplinary collaboration highlighted confidentiality considerations and the importance of developing the necessary skills to develop ethical collaborative relationships within the context of prevailing community norms. Finally, professional development and support highlighted the importance of psychologists continually attending to their skills and professional judgment so that dieir competence is not compromised.
The ethical issues and dilemmas presented by this paper consistently highlighted the importance of R&N psychologists' access to collégial networks that include other R&N psychologists as well as more specialized urban psychologists. These networks are beneficial to both R&N and urban psychologists alike. R&N psychologists benefit by gaining access to resources that can assist them successfully navigate the various practice and ethical issues that arise. Urban psychologists benefit by gaining an understanding of R&N practice and by access to areas of expertise that may be particularly well-developed in their R&N colleagues (e.g., consultation, community empowerment, interdisciplinary collaboration). Although not yet consistently available in all R&N communities, technological advances such as Internet access and videoconferencing (telehealth) have proven beneficial at reducing professional isolation, improving access to continuing education opportunities, and offering additional treatment alternatives/referral options for R&N psychologists. Open discussions with clients and health care providers regarding such issues as overlapping relationships, chance encounters, limits of competence, confidentiality/privacy issues, and expectations and boundaries were also highlighted, as was the importance of appropriate documentation. These strategies are consistent with literature regarding minimising risk in small community practice (Schank et al., 2010).
R&N practice, although poorly defined in the literature, represents a distinct community of practice which may include specific ethical practice considerations. The lack of research and theory specific to R&N practice hampers die psychologist's ability to provide empirically validated services, equitable treatment and services, or solutions to complex rural issues (Barbopoulos & Clark, 2003). As practicing R&N psychologists we have encountered a high level of practical wisdom among our peers. This knowledge, if made explicit, would be an important resource to psychologists in R&N practice, those in training, and urban psychologists who may work with clients from these and other small communities. A better understanding of professional ethics in R&N practice could better protect R&N clients, educate the public about psychology in R&N practice, and provide R&N psychologists with ways to implement ethical values in everyday practice. These are important aspects to consider as die Code continues to evolve.
Lastly, although the purpose of the present paper was to highlight ediical issues related to R&N practice, it is important that readers do not lose sight of the numerous rewards of working within this context. Indeed, the characteristics of R&N practice that contribute to ethical complexity also contribute to the rewards. For example, the small community context increases the likelihood of overlapping relationships but also enables the psychologist to develop a much richer and more complete understanding of their clients than is typically permitted within the weekly 50-min therapy hour (Schank & Skovholt, 2006). The limited availability of resources figures prominently into ethical dilemmas related to competency but also contributes to a stimulating work environment characterised by clinical variety, role diversity, and rewarding opportunities for collaboration. Ultimately, it is important that ethical complexities associated with R&N practice continue to be recognised and explored but that diese not overshadow the numerous joys and rewards associated with this area of practice.
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Received February 14, 2011
Revision received May 16, 2011
Accepted May 17, 2011
Judi L. Malone
Karen G. Dyck
University of Manitoba
Judi L. Malone, Centre for Psychology, Faculty of Humanities and Social Sciences, Athabasca University; Karen G. Dyck, Rural and Northern Psychology Programme, Department of Clinical Health Psychology, University of Manitoba.
Correspondence concerning this article should be addressed to Judi L. Malone, P.O. Box 556, St. Paul, Alberta TOA 3A0, Canada. E-mail: firstname.lastname@example.org…
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Publication information: Article title: Professional Ethics in Rural and Northern Canadian Psychology. Contributors: Malone, Judi L. - Author, Dyck, Karen G. - Author. Journal title: Canadian Psychology. Volume: 52. Issue: 3 Publication date: August 2011. Page number: 206+. © Canadian Psychological Association Aug 1996. Provided by ProQuest LLC. All Rights Reserved.
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