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A Psychologist Living and Working in a Remote Community

The reality of being a psychologist, or other mental health professional, in a rural or remote (or otherwise isolated) community, is that relationships are more complicated than in urban areas. APA discusses multiple or dual relationships (APA 2002), and Zur (2006) discusses boundary crossings or violations. Ofer Zur has courageously discussed the reality of issues involved in practice in rural life. However, still, many psychologists argue that any relationship outside the therapeutic relationship must be rife with problems. I argue that open discussions and consultations among rural and remote practitioners are critical, because urban practitioners, and those who practiced in a rural area for 3 or 5 years, simply are not the experts in this. Pursuant to this argument, I will tell some of my life story, and then challenge others who practice in remote, rural, or frontier communities to dialogue about how we best handle the realities.

First, a story of professional development and family life. I grew up in a city and always wanted to live in the country. I travelled west after college and landed in Okanogan County in 1972, bought land in the mountains with a group of people, and built geodesic domes without electricity or running water. After my first child, that “idyllic” country lifestyle lost appeal for me, and I moved to the neighboring town and went back to school for my first masters degree, marking the beginning of my professional career. My future husband was a mental health counselor at the rural community mental health agency where I did my master’s level practicum in 1981 and 82. I moved away for a year and worked in a different community mental health clinic, and then moved back home to Okanogan County. My husband became the clinical supervisor for a Tribal mental health program, and I began private practice as a sole proprietor at the master’s level. My practice was busy, successful, and with each client or patient came ever increased social isolation. On my 48^th birthday I started a doctoral program in clinical psychology at Fielding University, which is a non-traditional APA approved program that is structured to allow students to work and attend school, and theoretically, live and practice in rural remote areas. However, I had to move to the city for a practicum and again for a full year for my internship.

Families of psychologists in rural and remote areas have unusual challenges. We see previous and current clients and their families everywhere. It is a way of life. My children grew up knowing that “clients” were everywhere, and although my children could never know who the clients were, often the clients knew who the children were. My younger son said “I felt like there was a lot of stuff about your work I wasn’t supposed to know, and anything you did tell me it was really important I not remember too carefully… I knew there were kids around me who were your clients or their parents were your clients… I always assumed I was bumping into people all the time who would know my parents.” My older son went to day camp one summer and two little fellow campers saw me pick him up, and later told him in detail all about how I helped the judge keep them away from their parents.

As discussed above, outside therapy relationships are impossible to avoid in rural and remote practice. For example, I did a court ordered evaluation of a parent who was unhappy with the result and confronted me aggressively as I was holding the hand of my young son and trying to get into my car, and I obtained a restraining order. I hired someone to do work at my house, who after a year said he had been my client 20 years ago as a teenager. For several years, a previous client was my primary care provider’s nurse. Simply put, between my husband and me, we have seen so many people professionally, that we dare not risk friendships because of that possible previous relationship.

This lived experience of professional vs personal life compares in some ways to the small town family doctor or minister, but they do not have ethical standards that are so prohibitive as to make it virtually impossible to have friendships and practice in the same community. Teachers are another group of professionals who are often known in the community, but they have implicit if not explicit permission to know their students in public situations. In contrast, until recently, our ethical codes were extremely prohibitive regarding any relationships “outside the office.” Thankfully, a few clinicians like Ofer Zur, who coined the “outside the office” relationship construct, have opened the topic for discussion.

Challenges to rural and remote psychologists. There is a basic mathematical tendency wherein the potential complexity of social networks will grow at an exponential rate in relation to the number of individuals within them. This means the total relationships within a community of 50,000 is far more complex than in one of 5,000 than can be described by a simple factor of ten. If expressed as the square of the total population, the possible social interaction within a community with 100 times the size of my home town in Omak (from 5,000 to 500,000) would see its social network's complexity increase by a factor of 10,000. The inverse of this is true as well. There is an exponential reduction in complexity as we move down in population size, which squeezes the number of social interactions possible. This helps explain why a psychologist who lives in a community of 5,000 will have increasing difficulty having relationships with anyone if they cannot be around current and ex clients outside the office.

We cannot live and work in a rural remote area, actively avoid outside relationships, and have any reasonable quality of life. Our lives are not separate from our practice as psychologists; the relationships simply are different than what urbanites experience. As a result, there are inadequate guidelines and standards for us ruralites and we would benefit from open dialogue about our lived experience. Those who worked at a rural or remote clinic for a few years have not experienced the depth of this relationship dilemma; and, similarly, my experience does not generalize to that of the psychologist who works in the community in which he or she was born and raised, as frequently happens in the Native American communities in Washington other states.

My increasing personal discomfort associated with these dilemmas has triggered my involvement with our state association. I was recently appointed as the WSPA Rural Health committee chair and invite rural psychologists and students to discuss the issues unique to rural psychology and rural health.

American Psychological Association (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 47, 1597-1611.

Zur, O. (2006). Therapeutic Boundaries and Dual Relationships in Rural Practice: Ethical, Clinical and Standard of Care Considerations. Journal of Rural Community Psychology. Volume E9 Number 1.