Journal of Rural Community Psychology                                                                                            Volume E16 (1)

 

 

Multiple Relationships, Chance Encounters, and Confidentiality:

A challenge for the small town psychologist

 

Thomas D. Linz

Marshall University

 

 

ABSTRACT

Rural Psychologists face many challenges that occur to a lesser degree for their urban counterparts. Although the APA Ethical Principles of Psychologists and Code of Conduct provide guidelines for psychologists these do not address the relationship between chance encounters, multiple relationships and threats to confidentiality that all too common for the small town rural practitioner. This paper is an attempt to delineate this relationship between these three and the impact of the psychologist’s behavior on the client and community’s perception of the profession of psychology.

 

INTRODUCTION

 

The Ethical Guidelines put forth by the American Psychological Association (2010) are meant to protect the public and the practitioner from undue harm.  These guidelines prompt psychologists to be ever vigilant of ethical dilemmas and once aware of such encourage resolution. Some innocent situations, such as the chance encounter, can become ethical problems. It must be understood that the psychologist’s behavior in such potentially awkward situations may have ramifications on how s/he and the profession is viewed by others in the community. Such difficulties may be increased in small rural communities where ‘everybody knows your name’ as well as your business. It seems plausible that the behavior of psychologists, in the service of ethical practice, may contribute to the social stigma associated with mental health issues and services. Is living in one community and practicing in another a realistic solution to such situations or does the failure of the practitioner to participate in the life of the community add to the stigma of mental health and the ‘strangeness’ of the therapeutic relationship?

Working in small towns or rural communities can present psychologists with challenging choices between maintaining their ethical boundaries and being a part of the community.  Take, for example, the notions of confidentiality and multiple relationships. In this article we will consider how the interpretation of ethical guidelines may cause difficulties in small rural communities due to the high incidence of chance encounters, the necessity of dual relationships, and the potential for violations of confidentiality. Chance encounters/multiple relationships are seen as situations with considerable potential for issues of confidentiality, yet failure to act as part of the community can hinder the development of rapport.  This may be especially true in rural communities where attachment to “place” is essential to the foundations of identity and trust.  The question of how to address such situations will be discussed as well as implications for training and directions for research.

The APA Ethical principles of psychologists and code of conduct 4.02 state that:

 “(a) Psychologists discuss with persons (including, to the extent feasible, persons who are legally incapable of giving informed consent and their legal representatives) and organizations with whom they establish a scientific or professional relationship (1) the relevant limits of confidentiality and (2) the foreseeable uses of the information generated through their psychological activities.” (See also Standard 3.10, Informed Consent.)(APA, 2010)

This definition does not appear to address the risk of a breach of confidentiality inherent in the chance encounter or multiple relationships.  The most significant concern in any multiple relationships involves the power differential and the potential for harm, this including chance encounters that can involve an implied dual/multiple relationship. As members of a community all people are in multiple relationships with others regardless of station in life. The smaller and more isolated the community, the more likely such multiple relationships exist.  For example, a client may be the teacher of the psychologist’s child, a pastor, a fellow church member.  The psychologist and others are in multiple relationships with the various aspects of the community, one’s professional life, private life, as a parent, and spouse.

Chance encounters in smaller, rural communities add a wrinkle to multiple relationships that is not as common in larger urban areas.  The number and type of these relationships and happenstance encounters appear to multiply as the community size diminishes, specifically because the number of options to meet needs is reduced as there is a greater likelihood that community members serving multiple roles also increases.

In their national survey of psychologists, Helbok, Marinelli, and Walls (2006) explored the differences between small towns/rural and urban/suburban psychologists across several variables; confidentiality, multiple- relationships, burnout, competence, and visibility.  Statistically significant differences were noted, some of these differences included a higher frequency of chance encounters/multiple relationships, and more confidentiality challenges for psychologists in small towns/rural areas versus urban/suburban areas. 

  According to the APA Ethical principles of psychologists and code of conduct 3.05 (APA, 2010):

“A multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person”.  In regard to patients there is always a chance of ethical dilemma even when passing in the street or a store.  Specifically, if a patient is acknowledged by the psychologist outside of the professional relationship/consultation room without first being acknowledged by the patient, and there being no other cause for the psychologist to know the individual other than through the professional relationship, then this act may place that individual in a precarious position and confidentiality can be violated. That is, of having to explain to any others with them, who they may prefer not to disclose the relationship, how they know the psychologist. In doing so, it removes the choice from the patient regarding the decision of who to disclose about their treatment and who they would rather not, thus violating the principle of autonomy. On the other hand, failure to acknowledge the person can create a situation where rapport is jeopardized and, indeed, relationships within the community can become downright strange.

Take for example, the situation in which the psychologist is seeing the child of a principal at one of the local high schools.  The psychologist may also find her/himself drawn to participating in various community groups related to youth issues that may also involve the principal.  Such a set of interactions may be complicated by discussions of the role of parenting in various youth issues.  In such a situation, the psychologist has a dilemma that must be discussed with all involved.  Obviously, withdrawing from participation in the group removes the psychologist’s expertise from the community which can be unfortunate.  On the other hand, chance encounters during group meetings and other situations may add to the discomfort of both the client and the psychologist, thus necessitating some type of resolution.

As these situations are ever present, especially in small towns/rural areas, a paraphrasing of the principle 1.04 “Informal Resolution of Ethical Violations” (APA, 2010) may be appropriate:

“When psychologists (know of probable future) ethical (situations with a patient), they attempt to (address such concerns) by bringing it to the attention of that individual (in order that there can be clarification of boundaries and behavior should such situations occur).  Chance encounters are such situations in need of addressing.”

It is vital to address the chance encounter with patients early in the therapeutic relationship, as some psychologists do routinely.  The reason for the psychologist’s behavior of not acknowledging them to any greater degree than they would any other stranger should be made clear.  It is crucial that the patient be informed of this being related to the value placed on protecting the individual patient’s privacy.  Given that some people may like to be acknowledged, being treated as a stranger by the psychologist, if unexplained, will be left to the imaginations of the patient leading to idiosyncratic interpretations, such as viewing the psychologist as arrogant, or being angry with the individual.

The issues related to these chance encounters, how to interpret the clinician’s behavior, and boundaries need to occur during the psycho-educational discussion of confidentiality and the process of treatment that should occur at the initial session.  During the initial visit with a new patient it is important to define and delineate boundaries and confidentiality in order for the psychologist and patient to have the same working definition. Specifically it should be made clear that discussions of a therapeutic nature should only occur in the consultation room. With child and adolescents this discussion occurs with the parent or guardian being present. Confidentiality can be described as a “pledge” that the therapist makes that what is discussed or done in the sessions will not be discussed with others without permission. The rationale for this pledge is that it is not the psychologist’s place to decide who knows about their business. It should be pointed out that while there are no secrets in regard to what is done in therapy it is a very private place and as such a there is no limit placed on the patient unless self-imposed. Therefore, in contrast they can talk to anyone they choose about anything that is said or done in the session as it is their business. Such a stance by the psychologist supports the principle of respecting the patient’s rights and dignity. Of course the exceptions are articulated (e.g., safety, and special situations) also.  Part of this conversation must also address social and chance encounters. The chance encounter should be understood as having the risk or potential for breach of confidentiality.  Therefore to avoid such a risk and being viewed as arrogant or otherwise it should be made clear that the patient will be interacted with any other stranger, including being ignored, unless the patient acknowledges or approaches the psychologist first. While we as psychologists may respect our patients do we give them the autonomy to choose whether or not to acknowledge therapist outside of the therapy setting? In some regard, other multiple relationships can have a protective effect as the psychologist and the patient may know each other from church, civic organizations, etc.

It may be the case that, as psychologists become more experienced in their roles as therapists in small communities, they become more comfortable with their multiple roles.  As such, their behavior may actually serve to reduce the stigma associated with mental health services since the community may begin to see them as a ‘regular Joe/Joesphine,’ rather than as some mysterious mind reader.  As it becomes clearer that the psychologist is skilled at maintaining appropriate boundaries and confidentiality, she/he may be even more sought out by the community to contribute to various mental health issues.  Indeed, the psychologist can become a catalyst for mental health change in the community by working with other professionals and paraprofessionals in both formal and informal ways to meet the behavioral health needs of the communities.

So, if such skill comes with experience, how can such experience be distilled into lessons that can be offered to psychologists in training?  Indeed, it appears that graduate students and newly minted psychologists may find themselves most uncomfortable in such situations and may, as a result, shy away from work in small communities where such dilemmas are common place.  If this is the case, then those with the most ‘professional energy’ may find themselves uncomfortable enough in such settings to favor the anonymity of larger, more widely served areas.  This is important to address several issues:

1.       Additional research and policy change is needed to create a clear set of ethical guidelines that take into account the cultural and contextual needs of various individuals and communities.  Psychology has long been a science of the individual and it is time that we note the contextual complexities that affect our relationships with our clients and that this recognition takes a formal policy-oriented format.

2.       Graduate students and new psychologists must receive training in how to ascertain the impact of dual relationships in small communities and how to manage such common daily occurrences in a way that does not damage the client but also may enhance the role of the psychologist in the community.

In summary, it is not possible to strictly codify human behavior.  As such, APA has recognized the need for flexibility and has left much to the discretion of the psychologist in determining how to manage individual behavior in community settings.  It is important that the field turn their empirical attention to understanding the typical manner that such issues are handled so that more effective education can be offered to your students in the field.

REFERENCES

American Psychological Association (2010) Ret. from http://www.apa.org/ethics/code/index.aspx

Helbok, C.M., Marinelli, R.P. and Walls, R.T. (2006) National Survey of Ethical Practices Across Rural and Urban Communities. Professional Psychology: Research and Practice. Vol. 37, No. 1, 36–44.