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Challenges Facing Therapists in a Small Town
By Janel J. Brush
Health practitioners in rural settings are confronted with ethical dilemmas on
a daily basis with regards to confidentiality, dual relationships, and boundary
issues. The following article will address several situations involving these
issues and practical solutions in handling these potential ethical dilemmas without
compromising the practitioners commitment to their Professional Code of
small towns, people often joke that what you do beats you home, makes headlines
in the local paper, or is the main topic of conversation at the beauty and coffee
shops. For obvious reasons, confidentiality can be somewhat problematic for the
practitioner. As a school therapist, the clients I work with many times end up
being one of the following: the child/children of a neighbor, my insurance agent,
grocer, police officer, all the way down the line to my personal friends. It would
be great if there was another school counselor to refer these cases to, but unfortunately,
Im it! How can these ethical gray areas be dealt with?
to Set Boundaries on Gossip
First, let us visit about confidentiality.
The best practice, in order to eliminate confidentiality problems, is only to
share information about clients with those people whom the client has signed a
release of information for. The client needs to be told this unwritten rule up
front. Then, if someone in the community has privy information, it is either because
the client has shared that information or someone who I have signed a release
for has shared. By having releases signed, it covers me legally and puts the responsibility
back on the clients and their providers to maintain confidentiality. Another issue
faced almost on a daily basis is constantly being in situations where people are
discussing children/parents that I am working with. The information being discussed
may not even have any merit or, on the other hand, may be true. It is very difficult
not to want to set the record straight, but the best thing to do is to exit the
area (teachers lounge, break room, local eating establishment) if at all
possible. If you cant leave, you need to refrain from comment. If asked
a question directly, it is best to tell people you cant discuss the case
without a release of information signed by the client allowing you to do so. Sometimes,
people are not happy with this response, and on occasion, I have mentioned that
Im sure they wouldnt want me to share their personal information if
the tables were turned. This usually pacifies the majority, but as always, you
cant please everyone.
Way to Handle Dual Relationship
Having a professional relationship with
people you do business with in the community is another ongoing issue. A few of
these people may include the following: your physician, clergy, department of
human services, public health, your childs teacher, and numerous others.
If at all possible, one should try to limit these connections, especially if the
person is your client in your professional capacity, as it puts the practitioner
in a one-up position which skews boundaries, and may even cause the client to
feel obligated to give you special treatment that they wouldnt give under
other circumstances. For example, you are working with one of the local law enforcement
officers children, and he/she stops you for speeding. Upon seeing you, they
say they will give you a warning. My response would be, If you didnt
know me, would you give me a warning? If their response is no, they would
give me a ticketI would have to insist that they write me up. Crazyyes,
but ethically sound. The best rule of thumb, again, is to try and avoid those
dual relationships if at all possible. (If they cant be avoided, discuss
openly with the client, up front, what problems could occur, and try to be active
problem-solvers rather than reactive after the fact. Engage the client by empowering
him/her to come up with a plan to assist in dealing with the potential issues
that you both have brainstormed.
Boundaries in Public Places
What about those times when clients feel compelled
to share their life story or latest life event with the practitioner in the grocery
store, gas station, laundry mat, church, and numerous other public places.
Lets talk about how each of these situations might
be handled should they arise. For example, Julie (a client) approaches me in the
produce aisle at the grocery store. Julie starts to tell me about the huge fight
she and her daughter got into the previous night. Several people we both know
are within hearing distance. I take Julie aside and model by whispering, Julie,
it would be better if we could discuss this in a more private place. Would it
work for you to come by my office tomorrow at 3:15pm? Julie says, Yes,
and I respond, Great, Ill talk to you then. I then proceed to
another section of the store and return to the produce on my way out of the store.
Ive just done two things. First, I gave Julie a definite time so she knew
she would have a chance to talk, and secondly, Ive assisted her by modeling
how she should be talking about private matters (i.e., voice tone and place).
Redirection to Set a Boundary
My next example finds me pumping gas at
the local gas station. Tom, one of my special needs students, is riding his bike
by and sees me. He approaches me with a big grin and says, Mrs. Brush, you
know that problem I have with wiping? I went all day today and didnt get
any on my underwear. I reply in a soft voice, Thats great Tom.
This is one of those things we talked about that is private. So next time, I know
youll remember to tell me when we meet at school. What if I
forget?, says Tom. Whisper to your teacher to write it down for you
along with anything else youd like to tell me. Tom says, OK,
Mrs. Brush, and rides off on his bike. In this situation, the words were
already out of Toms mouth before I could redirect him, so I tried to salvage
the conversation by making it into a learning experience.
Now the laundromat poses some interesting boundary issues. Not
only do you have clients approaching, you but you also have other people who feel
at liberty to share a wealth of information with you about your clients. It might
look and sound something like this: Im putting my rugs in the washing machine
when two girls approach me and say, Do you work with Danielle Thompson?
My response, Im not allowed to tell people who I work with. It is
confidential. Well, shes been leaving her children alone while
she goes out drinking. Weve told DHS (Dept. of Human Services), and they
havent done a thing about it. I say, Thats frustrating.
It sounds like you are really concerned about the children, and you have done
everything within your power. I politely excuse myself and exit the laundromat.
Ive not broken confidentiality, as I didnt acknowledge that I work
with Danielle, and I attempted to validate their concerns without engaging in
Control of the Conversation
What does one do when confronted at church
of all places? Several teachers attend the same church as I do. They sometimes
have difficulty catching me during school hours, so they find church a prime opportunity
to discuss children we are jointly working with. For example, Sara, a special
education teacher, stops me outside the sanctuary and says, We need to have
a meeting about Gonzales. They leave for three months every winter, and Hernandez
is missing too much school. I respond, When is a good time to call
you tomorrow to discuss this? Sara states, Call before 8:30am and...
I quickly cut her off with Great - talk to you then, and head into
How about when the practitioner is sitting down at home to enjoy
a rare meal with the entire family, and a client, who doesnt see a problem
reaching you at home, calls? More than likely, your number is in the book, or
they know someone who has it. And of course, the best one yet, thanks to technology,
they have caller ID. I feel the best way to handle such occurrences is to be preventative.
I tell clients up front that their lives are private, and what they have to say
is very important. I discuss with them that in such a small town, we will likely
run into each other, and I would prefer for them to call and set up an appointment,
so I can give them the attention and privacy they deserve rather than discussing
their personal lives in public. When a person does start sharing information,
I politely remind them about our initial conversation, and ask them to please
call me at the office where we wont be interrupted and excuse myself. I
also tell my clients that I will not take calls at home unless it is an emergency,
and I define emergency as potentially life threatening events. I also give them
800 numbers for emergency hotlines. I try to screen my calls at home, and if by
chance someone calls, I ask if it is an emergency and explain that my time with
my family is limited and ask that they contact me the following day during office
Last but not least, what do you do when a personal friend
asks you to provide services to them or one of their family members? It is best
practice not to provide professional services to friends at all costs. If you
provide services and it is a success, sometimes this can be pulled off, but if
things dont work out as the friend has imagined, the friendship is often
damaged beyond repair. I try to explain this to my friends before the situation
arises and give them a list of resources if needed. As a last resort, I have completed
ADHD evaluations, screened for depression and other mental health concerns with
the agreement that the information would be given to another professional to assess.
In those cases, I kept strictly to factual diagnosis symptomology as substantiated
by the DSM-IV criteria.
Finally, as a rural practitioner, it is important to
stick to what you know to be the truth/facts and not let gossip or other information
cloud your judgment. You need to avoid work and social situations that will compromise
your ethical standards when possible. You constantly need to be troubleshooting
and thinking in a preventative fashion. It is helpful to discuss these ethical
situations with the client in the initial visit, and give them the opportunity
to make an educated decision on whether or not to pursue a therapeutic relationship
with you or seek outside resources. Most of all, dont become the Lone
Ranger. Make sure you have someone to discuss these ethical dilemmas with and
get feedback. This will also help you to avoid burnout, which is another dilemma
facing social workers that can be discussed at length at a later date.
Reflection Exercise #3
The preceding section contained information about
ethical boundary challenges facing therapists in a small town. Write three case
study examples regarding how you might use the content of this section of the
Manual in your practice.
Peer-Reviewed Journal Article References:
Franeta, D. (2019). Taking ethics seriously: Toward comprehensive education in ethics and human rights for psychologists. European Psychologist, 24(2), 125–135.
Hryshko-Mullen, A. S., Behnke, S. H., Ogle, A. D., Rogers, T. E., Tubman, D. S., Rowe, K. L., & Dunkle, A. N. (2021). Embedded behavioral health in the U.S. Air Force: Addressing the ethics of an expanding area of practice. Professional Psychology: Research and Practice.
Jaques-Leonard, M. L., Winnick, J. B., Chancey, L. P., Golden, M. E., Gavazzi, J., Brehm, L., Heier, J., Wicoff, M., Rutt, C., & Hosterman, S. (2020). Small town living: Unique ethical challenges of rural pediatric integrated primary care. Clinical Practice in Pediatric Psychology.
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(6), 502–510.
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