w hen eve ryone knows everyone - BCACC · While casual encounters in rural communities are...

w h e n e v e r y o n e

k n o w s e v e r y o n eEthical chal lenges for counsel lors

working in rural communities

14 INSIGHTS maGazINe

by Carolyn Camilleri with rebeCCa sCott, rCC, and laura rhodes, rCC

INSIGHTS maGazINe 15

coUnseLLIng In a RURaL commUnIty offers both rewards and challenges. Of considerable note are challenges

associated with rules of conduct, or ethics, by which counsellors live and practice. Here, we look at some of these challenges as a means of opening discussion, offering some support and suggestions, and, it is hoped, leading to a better understanding of the issues.

THe fAcTs Of rUrAl life

When Rebecca Scott was in Vancouver, she never thought about or expected to run into clients in the community. Almost 2.5 million people live in Greater Vancouver. When she moved to Dawson Creek, however, a town of just over 12,000, she needed to address the issue of day-to-day interactions with clients outside of the office.

“To continue in my chosen profession and live in a rural community, I needed to understand the rules governing confidentiality and how they are necessarily adjusted for counsellors living and working in rural settings,” says Scott.

Before looking at the rules, let’s first consider some of the key challenges faced by rural counsellors. In Ethics for the Practice of Psychology in Canada, Truscott and Crook discuss the contrast between working in large cities and working in rural areas.

“Psychologists in large urban centres have a much easier time avoiding multiple relationships because of the large population of potential clients from which to draw, their workplace life is much more likely to be separate from their

home life, and they can more readily refer clients to other professionals.”1

By contrast, the rural experience means a smaller pool of clients, limited referral sources, more challenging circumstances to deal with as a result of different cultural norms, and “unless one is willing to live as a hermit, multiple relationships are a fact of life.”2

The rules for confidentiality in the fifth edition of CCPA’s Standards of Practice clearly state that, “Practitioners in small communities protect private knowledge and ensure confidentiality in the face of intricate social networks and lines of communication that lead to the availability of informally gained knowledge.”3 The same document acknowledges the difficulties rural counsellors have in upholding those very rules: “In rural communities, and in certain other workplace circumstances, such as in closed communities or remote, northern, and isolated areas, it may be impossible or unreasonable for counsellors to avoid social or other non-counselling contact with clients, students, supervisees, or research participants.”4

This highlights another significant difference, one that Truscott and Crook point to: “Urban psychologists also have the benefit of the relative anonymity of the large city so that dual relationships — whether harmful or not — are less likely to occur.”5

And the smaller the community, the more impossible it is to be anonymous. Laura Rhodes, a mental health clinician with Northern St’at’imc Outreach Health Services, works out of Lillooet, which has a population of 1,800.

“Everyone knows me, so it is difficult to volunteer, hang out, or be in the community,” says Rhodes.

“in a rural setting, the potential for harm by turning away a client with whom we have another relationship must be weighed heavily against the potential for harm resulting from the dual relationship.”


The advice offered in the CCPA Standards of Practice leaves room for interpretation. “Counsellors should manage such circumstances with care to avoid confusion on behalf of such individuals and to avoid conflicts of interest.”6

“Such circumstances” refers to counselling people with whom past relationships exist, and entering into business and financial relationships with clients is strongly discouraged. However, it also could be applied to attending community functions, going to a recreation centre, and even shopping at the same stores or supporting the local Little League baseball team — activities that encourage acceptance and trust within a close-knit community.

But the ambiguity in ethical codes is inevitable, says J.A. Schank, given the range of dilemmas that counsellors may confront. “As a result, therapeutic decisions about ethical and values issues are often made intuitively and automatically. The counsellor draws upon an internalized ethical stance, grounded in both personal values and knowledge of formal codes.”7

It is under these circumstances that Scott, Rhodes, and other rural counsellors must understand and refine the rules of confidentiality in order to practice at all.

mAnAging relATiOnsHips

Because of the likelihood of casual encounters in non-professional settings, Scott, after consulting with other counsellors from smaller communities, established rules for how these situations

would be handled. “As a prerequisite to any

type of counselling session, it is essential to discuss with clients, beyond the standard limits to confidentiality, those circumstances when paths can and do cross and how they will be managed,” she says.

CCPA Standards of Practice supports this.

“As a routine, counsellors should discuss with their clients the manner in which they intend to respond to them should they meet outside their counselling

workplace and their intention to avoid behaviour in such circumstances that could have the potential to embarrass clients or inadvertently call attention to their status as a client and/or to their counselling issues.”8

In practical terms, that means Scott tells clients what will happen when they run into each other at the grocery store.

“I explain to clients that I will not identify myself or the client, nor will I acknowledge the client as a client. Essentially, I would act no differently towards them than I would towards someone I didn’t know,” says Scott. “If the client chooses to acknowledge me, I will reply, but I will not engage in any discussion of therapy or our client-counsellor roles in an environment outside of the office where sessions are held.”

Scott does this for the client’s privacy and her own.

“The preliminary discussion also prepares the client so they know what to expect and don’t feel snubbed or insulted by my behaviour towards them,” says Scott.

Rhodes manages casual encounters in the same way, being respectful and letting people approach her for conversation or greetings in public. She also notes that behaviour in public is important.

“it turns out to be more than counselling. you are a role model and you try to set a good example for others.”

In Ethics for the Practice of Psychology in Canada, Truscott and Crook discuss the contrast between working in a large urban centre and working in rural areas.


“Expectations and accountability for our conduct is high. It is inevitable that community members see and witness how you interact and treat people. In turn, this reflects how many people will seek out our services,” says Rhodes. “It turns out to be more than counselling. You are a role model and you try to set a good example for others.”

In other words, you are always “on.”“Privately, I have some friends I

can relax and spend time with,” says Rhodes.

Carefully chosen friends, that is. The Standards of Practice states, “Lack of anonymity requires rural counsellors to think carefully as they develop new social networks. Boundary management is a challenge in small communities as multiple relationships are inevitable.”9

While casual encounters in rural communities are impossible to avoid, overlapping relationships may be expected and necessary. For example, in addition to her private practice, Scott also works for a government agency in child and youth mental health and offers EAP/EFAP services to almost all the community organizations, including the school district.

“Naturally, when I am dealing with a child in the community, I run into many clients. There is a huge overlap, and if I am to fulfil my role effectively for any of my clients, this overlap is unavoidable,” says Scott.

She hits upon an important point: fulfilling her role effectively means providing needed services whether or not there is an overlap. As Crook and Truscott say, “In a rural setting, the potential for harm by turning away a client with whom we have another relationship must be weighed heavily against the potential for harm resulting from the dual relationship.”10

Again, clear discussion with clients is a critical step, as dictated in the Standards of Practice: “When counsellors work with individuals who have a relationship with each other, such as parents and children, or adult partners, [counsellors] take initiative to identify who the clients are, and the expected roles for the relationship with each, and clarify the expected use of any information that may be generated.”11

Failure to clearly discuss overlapping and dual relationships in session can lead to a fracture in the client relationship.12

And while counsellors may do everything in their own power to ensure confidentiality, it doesn’t prevent people from talking to each other. As R. Riding-Malon and J.L. Werth Jr. point out, “Most rural psychologists regularly report … dealing with the continuous challenge of protecting the confidentiality of clients in a community where knowing everyone’s business may appear to be a way of life.13

After all, confidentiality may be

compromised when a client is seen

walking in or out of an office.

mAnAging perspecTive

Remaining objective is not easy, says

Scott, but it is vital, especially in an

environment where it is so difficult to

maintain boundaries and identity.

“To protect my clients, remain

objective, and function as a member of

the community has meant adopting a

“it is critical for any counsellor to be self-aware, and when a session or client becomes more familiar than therapeutic, it is time for an open, honest discussion with the client and, as a last resort, a referral to another counsellor.”

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rule for my practice that when a client is in my office, they are my client; when they leave my office, they are no longer my client until they return.”

Discussing this rule with clients is another essential part of the first session, with questions and concerns addressed as they come up in subsequent sessions. And it’s a rule that’s important for two reasons, as J.A. Schank indicates: “A primary objective for rural and other small-community practitioners is to keep the needs of clients foremost and to be vigilant in situations that could impair the practitioner’s objectivity.”14

Both Rhodes and Scott have clients who readily point them out as their counsellor to friends and others in the community.

“And that is their prerogative,” says Scott. “However, it is critical for any counsellor to be self-aware, and when a session or client becomes more familiar than therapeutic, it is time for an open, honest discussion with the client and, as a last resort, a referral to another counsellor.”

That is, providing another counsellor is available, which is not always the case and again puts the counsellor in the position of having to choose between harm caused by not providing a needed service and harm caused by a dual relationship. As Truscott and Crook say, “… referral sources are limited and distant so that clients can be severely disadvantaged.”15

The lack of counsellors also means there are fewer opportunities to access clinical supervision.

“While the landscape is continually changing, there are still very few qualified counsellors in rural settings,” says Scott. “Individuals who are providing counselling services are often doing so without the benefit of clinical

supervision, experience, support, or education.”

“A large part of keeping ourselves, as counsellors, on-task and self-aware, is to have clinical supervision in some capacity,” says Scott. “It even helps to be able to run scenarios past another person, particularly someone who has grown up in a rural community, which makes them very familiar with this conundrum.”

mOre cOnUndrUms

Scott and Rhodes both comment on the shortage of and need for counsellors in rural and remote communities.

“An overwhelming number of people in the North are in need of counselling services, especially now, when unemployment in the oil and gas and mining industries is at an all-time high,” says Scott.

A side effect of this is that without employment benefits, people may not have access to EAP/EFAP services nor can they afford to pay counselling fees.

“A consideration for counsellors to be aware of is adjusting their fees to

accommodate this need, or perhaps working on a sliding scale,” says Scott. “Sessions can be cut in half to reduce costs for clients, as well.”

“However, it is important to be aware of our own motivation and how that fits with our clients’ needs,” she adds.

While some counsellors may object to a sliding fee scale because it undervalues services, rural counsellors may have little choice. As Truscott and Crook say, “The pool of potential clients is much smaller, so turning away referrals can represent a very real financial hardship.”16

Another challenge that counsellors in remote communities may face is location and geography.

“As an outreach mental health clinician, I fill in the gaps that Interior Health and local Indigenous communities are unable to meet,” says Rhodes. “And believe me, it is outreach.”

Rhodes explains that in remote areas, geographical challenges influence the quality and quantity of their services, and some of the communities are very remote.

“When I was in university, my first goal was to buy a 4 x 4 to work in the North,” says Rhodes. “Well, that was a good decision since some of the roads are very narrow and long.”

About every 10 days, Rhodes drives to Seton Portage on a 70-kilometre route of rocks, cliffs, debris flows, and mud. At the higher elevations, there is snow almost all year round, with a small break in July to early August.

“It is a busy day of four to five clients, with a one-hour-and-40-minute drive there and then back,” says Rhodes. “There is a ‘shuttle’ that CN Rail and the Tsal’alh community provide to town once a day. Some clients like to come into town to shop,

“A large part of keeping ourselves,

as counsellors, on-task and self-aware, is to have

clinical supervision in some capacity.”

The BCaCC maintains a list of clinical supervisors at its head office in victoria and now provides a members-only online discussion forum for rCCs wishing to discuss with fellow members any matter related to counselling.

and then see me before they return home. The shuttle ride is about an hour.”

To maintain contact with clients, Rhodes uses the phone and Skype, which, despite widely known concerns about privacy, offers at least the hope of providing more consistent and much-needed service in remote communities.

Services like etherapyessentials.com and therapyonline.ca and platforms like Medeo and Livecare (see pages 30-31) represent new options for counsellors that may be especially beneficial for those who are serving remote communities, according to Riding-Malon and Werth:

“The use of technology in all aspects of psychology will continue to grow, especially in rural and other underserved areas where the accessibility and availability of mental health professionals is limited and seeking mental health care is stigmatized. Established practitioners would benefit from learning about the opportunities and challenges for telepsychology and seeking ways to incorporate this new technology in their practices. Further, practitioners living near training programs may want to initiate a relationship with their local training program and request educational outreach programs on technology and its professional applications.”17

And while there are many challenges, counselling in rural and remote communities is very much in demand and can be very rewarding.

“It is about culture and rhythm. Hamlets and communities have unique events, priorities, and concerns not found in large cities,” says Rhodes. “We concern ourselves with finding good evidence-based resources

our clients can afford and access when needed. We do not have treatment centres, detox centres, or transition houses for our clients. With community non-profit agencies, we have created services that are short term until we can bridge the time and travel to access mainstream programs in Kamloops or the Fraser Valley.”

If you are a counsellor working in a rural community, both Scott and Rhodes encourage you to reach out to someone and talk about the challenges you are facing. You may be surprised and relieved to discover some great solutions.

Continue the conversation about rural and remote counselling at the BCACC members-only discussion forum at bc-counsellors.org. ■

Rebecca Scott, MA, RCC, CCC, is the owner of Balance Counselling Ltd in Dawson Creek. For more than 12 years, Rebecca has helped individuals and families struggling with various issues to open their eyes to change and then helped to facilitate that change. Rebecca believes in identifying uniqueness and innate strengths in individuals and encourages clients to take an active role in the counselling process and ultimately their success. Rebecca feels a strong connection with the community enhances its quality and the lives of those in it. rebeccajscott.ca

Laura Rhodes, MACP, RCC, CAP, works as an RCC with Northern St’at’imc Outreach Health Services. She has provided services in Lillooet for the last 12 years in various capacities. Her main focus is working with St’at’imc people experiencing trauma, depression, and anxiety. Laura enjoys providing educational workshops and capacity-building in all six communities. She is also a volunteer for the Lillooet Friendship Centre Society, which provides many social services she supports. Empowering people to make healthy choices that are right for them is her motivation.


EndnOTEs

1. Truscott, D., & Crook, K. (2013). Ethics for the Practice of Psychology in Canada, Revised and Expanded Edition. Edmonton: University of Alberta, 153-154.


3. Canadian Counselling and Psychotherapy Association. Standards of Practice, 5th Edition, April 2015, 10-11.




7. Schank, J.A. (1998). Ethical Issues in Rural Counselling Practice. Canadian Journal of Counselling, 32(4), 270-284.




11. Canadian Counselling and Psychotherapy Association. Standards of Practice, 5th Edition, April 2015, 26.


13. Riding-Malon, R., & Werth Jr., J.L. (2014). Psychological practice in rural settings: At the cutting edge. Professional Psychology: Research and Practice, 45(2), 86.

14. Schank, J.A. (1998). Ethical Issues in Rural Counselling Practice. Canadian Journal of Counselling, 32(4), 270-284.



17. Riding-Malon, R., & Werth Jr., J.L. (2014). Psychological practice in pural settings: At the cutting edge. Professional Psychology: Research and Practice, 45(2), 89.

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