Learning Objectives
- 1.
Describe the characteristics of rural settings that make for ethical dilemmas regarding dual relationships.
- 2.
Understand relationships and confidentiality.
- 3.
Define dual relationships as according to the CRCC Code of Ethics.
- 4.
Define confidentiality and privacy as according the CRCC Code of Ethics.
- 5.
Discuss the ethical dilemmas around dual relationships rehabilitation counselors face in rural and small town settings.
- 6.
Understand issues of rural and small town settings.
- 7.
Discuss the ethical dilemmas around confidentiality and privacy rehabilitation counselors face in rural settings.
- 8.
Discuss ethical models rehabilitation counselors can use to evaluate and work through ethical dilemma.
Introduction
Rehabilitation counselors in rural and small town settings are likely to face complex ethical dilemmas regarding dual relationships and confidentiality and privacy (Malone & Dyck, 2011). These dilemmas are due to the multilayered environmental, cultural, social, and psychological factors that come with living and working in rural areas (Malone & Dyck, 2011). Rural communities are often geographically isolated and have lower population densities, resulting in limited employment opportunities, healthcare and human services and providers, public transportation, and childcare options (Dyck & Hardy, 2013; Malone & Dyck, 2011). Rural areas are also disproportionately affected by loss of industry, environmental changes, and natural disasters (Chipp, Johnson, Brems, Warner, & Roberts, 2008). Rural and small town communities often struggle with difficulties in accessibility of available services, long wait times, lack of information, potential for lost work time, and accessing available providers who may not be the most appropriate (Dyck & Hardy, 2013). Aside from availability, rural cultural norms, stigma, and lack of anonymity may prevent people from accessing services (Dyck & Hardy, 2013). Cultural norms often include value for self-reliance and hardiness, which can perpetuate stigma associated with disability and prevent people from seeking help. For example, in a study on the help-seeking behaviors of farmers in Canada , cultural norms of pride and independence were found to be the most significant factors for why people did not seek mental health services (Dyck & Hardy, 2013). Furthermore, some rural settings, such as Native American or first-generation immigrant communities, finding culturally appropriate services, have been found to be the major issues that hinder people from seeking services (Dyck & Hardy, 2013).
This chapter will be a discussion of the importance of understanding dual relationships in rural and small town communities and confidentiality and privacy. We will use the Code of Professional Ethics for Rehabilitation Counselors (2010) as a framework to examine dual relationships and common challenges rehabilitation counselors face in rural settings. While rehabilitation counselors are often trained to not participate in dual relationships, this may not be possible in rural communities. Rural areas are small, often with tight-knit communities. Therefore, it can be unavoidable for rehabilitation counselors and clients to have intersecting connections and overlapping roles. Rehabilitation professionals may struggle with how to preserve boundaries both personally and professionally and maintain confidentiality and privacy of clients. These overlapping roles can also affect treatment boundaries. To be successful in a rural area, rehabilitation professionals may be expected to be highly active within the community they serve, participating in various community and religious activities, and serve on various community boards and many of the same activities in which clients may also participate.
We will first examine dual relationships and discuss what they are, what are the characteristics of rural and small town communities that foster the likelihood of dual relationships, what do the Code of Professional Ethics for Rehabilitation Counselors (2010) and the literature have to say about dual relationships, and what are the benefits of dual relationships. We will then discuss ethical dilemmas regarding confidentiality and privacy , examining the role of continuing education and supervision in supporting ethical practice, and the pros and cons of technology to manage ethical dilemmas. Strategies to manage dual relationships and protect confidentiality and privacy will be provided. We will wrap up the chapter by examining two ethical models rehabilitation counselors can implement in practice: Herlihy and Corey’s decision-making model and Tarvydas integrative model for ethical behavior.
Characteristics of Rural Setting that Create Dual Relationships
rural communities are unique not just because of their small population density or distance from an urban setting, but also because of the combination of their social, economic and geographical characteristics as well as their residents’ cultural, religious and personal values. (p. 137)
Three important characteristics of rural communities that can lead to dual relationships include the limited availability of services, cultural and personal values, and hesitancy to seek outside services. Let’s look at each of these a little closer.
Limited Availability of Services
Rural communities face significant shortages of services and providers, as well as geographic and transportation barriers that can hinder a person’s ability to seek services (Cates, Gunderson, & Keim, 2012; Nelson et al., 2007). Added to this mix is the fact that rural community members face higher likelihood of not only health issues and risk for disability in general but are more likely to live with severe conditions and have more profound needs than their urban counterparts. Rehabilitation counselors working in these communities are therefore likely to work with not only fewer resources but be faced with the high probability of managing dual relationships as they are going to have to rely heavily on community leaders and family and friends to help support the client.
Cultural and Personal Values
Increased sense of self-reliance and self-care
Strong work ethic that can hinder a person’s willingness to take time off from work and focus on one’s health
Increased reliance on informal supports (i.e., family, neighbors, church, and other community groups)
Strong sense of community ties and interdependence on one another to provide informal support (Cates et al., 2012; Chipp et al., 2008; Nelson et al., 2007)
Hesitancy to Seek Outside Services
People can be hesitant to seek services outside of one’s community due to distance, transportation issues, and environmental and climatic barriers such as mountain ranges or weather conditions. Hesitancy to seek outside resources can also be due to the inability or even unwillingness of family and friends who are likely to provide main forms of support to travel long distances (Cates et al., 2012). Additionally, due in part to self-reliance and community interdependence, people can be reluctant to seek services in another farther away and unfamiliar location. This reluctance and unfamiliarity of outside communities and providers can create distrust of people outside of one’s community or even providers new to the area. A long-time rehabilitation counselor in the community can be faced with the conflict of how to persuade a person to seek the needed treatment. Other and potentially very serious issues can arise if a rehabilitation counselor is not able to persuade a client to work with another provider, especially if the provider is outside of the area. Clients may be left with inferior care, the potential for worsening of health, and inappropriate services that may not only hamper health but also affect one’s participation in employment, education, and activities of daily living. Furthermore, the counselor can be faced with legal or licensure issues when faced with such an issue and is asked to potentially practice outside their scope of competence. New rehabilitation counselors, especially those new to a community, may also be seen as outsiders (Halverson & Brownlee, 2010). Community members may be very hesitant and distrustful of a new counselor. Counselors may find themselves being faced with dual relationships, as the likely way they may be able to have consumers seek them out and gain trust is through community involvement and getting to know people on a more intimate level.
Rehabilitation counselors must recognize the need for developing an in-depth cultural awareness of the community they serve, which will include issues around dual relationships including confidentiality and privacy, the likelihood of developing dual relationships, and the benefits and risks of dual relationships. Chipp et al. (2008) in their study of ethical dilemmas faced by rural providers found that the smaller the community a provider works in, the more likely that provider recognizes the need to seek the support of community leaders and elders as well as involves the family to provide support to clients. Providers also reported the need to rely on community leaders to learn about the culture of the area as well as effective strategies to work in the culture and ways to adapt one’s practices and access or develop effective and culturally appropriate resources.
Dual Relationships
Rehabilitation professionals working in rural communities are likely to encounter frequent potential instances of nonprofessional, or dual, relationships with clients. Therefore, according to Schank, Haldeman, Helbok, and Gallardo (2010), “the issue becomes how to handle dilemmas and overlap, rather than how to avoid them” (p. 503).
Dual relationships are defined as overlapping informal relationships between the rehabilitation counselor and client, outside of the therapeutic relationship (Malone & Dyck, 2011). Dual relationships can “before, during, or after the professional relationship, and arise either by choice or by chance” (Malone & Dyck, 2011, p. 207). Dual relationships may be low or high risk.
Low-risk dual relationships are overlapping relationships or boundary crossings, which may be common, may be non-harmful, and may even be beneficial (Malone & Dyck, 2011). These low-risk situations are most likely to occur where the counselor both lives and is active in the community in which a person works (Malone & Dyck, 2011). For example, these interactions can occur in grocery or department stores, church, and social events, and other common situations where incidental contact can occur between counselor and clients. According to Malone & Dyck (2011), low-risk boundary crossings can also include “home and community visits to clients, or other minor deviations from a strict professional role” (p. 207). Malone and Dyck go on to state that to ensure nonmaleficence, professionals must “perceive all non-office or nonprofessional relationships as potentially risky” and “use appropriate self-disclosure” and discuss risks and benefits with clients (p. 207).
High-risk dual relationships are called boundary violations (Malone & Dyck, 2011). These high-risk relationships have the potential to be much more problematic as they include complex situations such as working with colleagues, family members, current and former intimate partners, business and community relationships, leisure activity affiliations such as sports leagues, or situations in which children of both parties are friends. These high-risk relationships have a significant potential to be damaging not only to the client but also to the counselor and to the rehabilitation counseling profession itself.
Dual Relationships: Intimate and Nonprofessional Relationships
- 1.
Prohibition of sexual or romantic relationships with current clients
- 2.
Sexual or romantic relationships with former clients
- 3.
Prohibition of sexual or romantic relationships with certain former clients
- 4.
Nonprofessional interactions or relationships other than sexual or romantic interactions or relationships
- 5.
Prohibition of counseling relationships with former romantic partners
While the issue of intimate relationships with clients is a serious issue, rural rehabilitation counselors are likely to face more problems with non-intimate dual relationships. Let us examine some of these issues rehabilitation counselors may face in more detail and how certain characteristics of rural settings can lead to dual relationships. Let’s begin with intimate relationships.
Intimate Relationships
The Code prohibits counselors from engaging in sexual or romantic relationships with current clients (Standard A.5.a) and states that counselors should avoid such relationships with former clients or their former romantic partners or family members for at least 5 years (Standard A.5.b). Even after 5 years is up, the Code states that counselors must “give careful consideration to the potential for sexual or romantic relationships to cause harm to former clients. In cases of potential exploitation and/or harm, rehabilitation counselors avoid entering such interactions or relationships” (Standard A.5.b). The Code is very clear that counselors are not to engage in an intimate relationship with a former client who has “a history of physical, emotional, or sexual abuse or if clients have ever been diagnosed with any form of psychosis or personality disorder, marked cognitive impairment, or if clients are likely to remain in need of therapy due to the intensity or chronicity of a problem” (Standard A.5.c).
While it should be common sense for rehabilitation counselors to not engage in intimate relationships with clients, this is a significant issue in practice and the number one cause for the filing of formal complaints (Understanding Counselor Liability Risk, 2014). According to the most recent Healthcare Providers Service Organization (HPSO) Report (Understanding Counselor, 2014), “the most frequent professional liability allegations asserted against counselors involve inappropriate sexual/romantic relationships with clients or the partners or family members of clients” (p. 9).
While intimate relationships with clients, former clients, or family members can pose a serious problem, it can become even more complicated in rural and small town settings. In rural settings, the avoidance of intimate relationships with clients or their family members may prove to be very complex where there are limited choices in the selection of intimate partners or intimate partners who may not be related to or well acquainted with clients. For example, a counselor may begin an intimate relationship and find out that the new partner is related to a client. However, the Code does not address how rural counselors should navigate such complexities. Nor is there much research and literature on the complexity and navigation of counselor-client intimate relationships .
Nonprofessional Interactions
Rehabilitation counselors working in rural communities will find it very difficult to avoid at some level dual relationships with current and former clients or their families. The only realistic way to avoid such situations is to avoid all human contact. Counselors are likely to attend the same religious organizations, shop at the same stores, or even be provided a business service by a client or a client’s family member. For example, a transition rehabilitation counselor may work with the teenager of the only service garage owner in the area. If the counselor’s car is in need of repairs, it cannot be expected that the counselor is to go out of the way to find another garage. Or, a rehabilitation counselor who covers a whole county may provide services to the only plumber or electrician in the counselor’s community, services that the counselor at some point likely to require and may not have other options for several miles. The rural rehabilitation counselor is also likely to cover a whole county or large region, with few other resources and providers to work with and provide to referrals. The rehabilitation counselor may be expected to provide a wide variety of services to the community including vocational counselor, mental health provider, resource provider to locate and access other health and human services, as well as consultant to other health providers. Additionally, as previously discussed, in some communities for a counselor to be welcomed into a community and trusted, it may be expected that the individual participate in certain activities and organizations where the likelihood of running into clients or gaining referrals will occur.
A counselor who works for the local small college provides multiple student affair services including general and career counseling and disability services.
A Native American counselor may have frequent out-of-therapy contact with clients and their families and may collaborate with local helpers and healers.
A sport and faith-based counselor may attend events where clients are usually present.
A counselor who is fluent in American Sign Language and also a chemical dependency provider may socialize with clients and family members of clients within their small communities.
A counselor who is gay and is active in local LGBTQ community organizations may be sought for therapy precisely because he is visible within their own small community.
A counselor who wants to support local businesses within her community must then deal with the strong possibility of business transactions with current or former clients and the families of those clients .
Related to Schank and colleagues’ example is that when seeking out therapy, people are likely to self-match with a counselor, to seek out a counselor that “shares their attitudes, race, education, social class, and/or religion” (Gonyea, Wright, & Earl-Kulkosky, 2014, p. 125). People “feel more comfortable discussing their lives and presenting issues when they believe their therapist holds the same values or shared cultural experience” (Gonyea et al., 2014, p. 125). Gonyea and colleagues suggest that self-matching may be more likely in rural settings where people are more inclined to not trust outsiders and therefore may be more likely to seek out counselors who belong to the same circles as them. Self-matching can become even more complex when the therapist belongs to a minority population. “In addition to the limited number of available therapists in a small community, there are far fewer minority therapists in general. Therefore, when minority clients attempt to self-match, there is a strong likelihood that a dual relationship dilemma will be encountered” (Gonyea et al., 2014, p. 126).
Additionally, dual relationships are likely to naturally develop through time. Brownlee (1996) states that the longer a professional lives and works in a rural community, the more likely the individual will develop overlapping professional and personal relationships with others, and it will become impossible to avoid such interactions. Therefore, rehabilitation counselors are likely to encounter and have to manage dual relationships, and it may become impossible to avoid dual relationships as time goes on.
Finally, rehabilitation counselors who are from the same community in which they live and work are going to have to learn how to manage dual relationships. The counselor is likely to be acquainted with many clients or their family or friends, or clients will know of the counselor’s family or be acquainted with the counselor’s friends or neighbors. People may feel more comfortable seeking out a counselor from one’s own community. A counselor who is local may have an easier time developing trust and building a therapeutic alliance with clients instead of someone who is not local .
Can Dual Relationships Be Beneficial?
While the CRCC does not condone dual relationships, it is recognized in the Code that sometimes nonprofessional interactions may be beneficial. The Code states that rehabilitation counselors avoid nonprofessional interactions with clients “except when such interactions are potentially beneficial to clients or former clients” (A.5.d). Potential interactions include “attending a formal ceremony (e.g., a wedding/commitment ceremony or graduation); purchasing a service provided by clients or former clients; hospital visits to ill family members; or mutual membership in professional associations, organizations, or communities” (A.5.d).
Research in rural ethics has suggested that some dual relationships may actually be beneficial (Dyck & Hardy, 2013; Malone & Dyck, 2011; Nelson, Pomerantz, Howard, & Bushy, 2007). According to Malone and Dyck (2011), at least low-risk boundary crossings “are often unavoidable in rural practice and can be considered a normal and healthy part of rural living” (p. 503). Behnke (2008) agrees, stating that “finding oneself in a multiple relationship is not necessarily a sign that one has engaged in unethical behavior. It may rather be a sign that one is fully engaged in the life of a community” (p. 62). In rural settings, counselors are likely to be expected to have to be active in the community or face being viewed as an outsider (Chipp et al., 2008). According to Chipp et al. (2008), being labeled as an outsider can have a serious negative effect on an already-resource-strapped community as community members may be less likely to seek that counselor’s services, continuing to leave a gap in available services. Therefore, counselors are likely to lack anonymity or the ability to maintain nonoverlapping boundaries.
A careful balancing act occurs requiring the rehabilitation counselor to very carefully monitor the relationship or even the potential relationship. For example, Halverson and Brownlee (2010) in their study on ethical dilemmas social workers in remote areas of Canada face found that social workers did avoid dual relationships when possible. However, as they were often the only therapist serving a community, workers recognized that dual relationships were inevitable. In fact, surveyed workers reported that it was vital to develop strong ties to the community through active involvement in various organizations. Community involvement helped workers to network, to build valuable relationships with community leaders and elders, and to become a part of the “circle of trust” in the community (p. 255). Participants did report that it could be stressful to deal with dual relationships and had to be diligent that they discussed the likelihood of boundary crossings with all clients, included the definition of dual relationships and the likelihood in their informed consent forms, and developed and discussed techniques to manage dual relationships with colleagues and clients. Participants also made sure to fully assess a potential dual relationship before taking on a client as well as throughout the therapeutic process, asking the question “what is in the best interest of the client?”
Confidentiality and Privacy
Arguably, the most critical ethical issue rehabilitation counselors face working in rural areas involves confidentiality and privacy both for the counselor to protect client information and for the counselor himself or herself (Chipp et al., 2008; Shank et al., (2010). According to Arthur and Swanson (1993), confidentiality is “the ethical duty to fulfill a contract or promise to clients that the information revealed during therapy will be protected from unauthorized disclosure” (p. 91). According the Code (B.1.c), rehabilitation counselors are to respect the confidentiality of the people they serve: “Rehabilitation counselors do not share confidential information without consent from clients or without sound legal or ethical justification.”
Privacy, however, is an “evolving legal concept that recognizes individuals’ rights to choose the time, circumstances and extent to which they wish to share or withhold personal information” (Herlihy & Sheeley, 1987, p. 479). The Code (B.1.b) states “Rehabilitation counselors respect privacy rights of clients. Rehabilitation counselors solicit private information from clients only when it is beneficial to the counseling process.”
While rehabilitation counselors must ensure the confidentiality of the clients served, they must also be mindful of cultural values . For example, the Code (B.1.a) states that rehabilitation counselors must maintain cultural competence in safeguarding the confidentiality of clients: “Rehabilitation counselors maintain beliefs, attitudes, knowledge, and skills regarding cultural meanings of confidentiality and privacy.”
Client confidentiality and privacy can be difficult to maintain due to a variety of factors unique to small rural communities. These factors include dual relationships between rehabilitation counselors, other providers, clients, families, and other community members, the high level of interconnectedness of rural communities, low population density, and high visibility of community members and counselors (Malone & Dyck, 2011; Shank et al., 2010). In turn, these factors create for an interesting mix of issues around confidentiality and privacy that rehabilitation counselors are likely to face including reliance on informal supports, community gossip, confidentiality and collaborations, counselor’s personal confidentiality, and indirect confidentiality issues. Let’s look more in-depth at these issues.
Reliance on Informal Supports
As rural people often rely on informal supports of family, friends, and local groups, along with the seemingly continuous budget cuts of community services, there is an even higher expectation that family, friends, and community groups are to provide the majority of support to loved ones with disabilities (Halverson & Brownlee, 2010). This shift in expectations and support puts more pressure on rehabilitation counselors and other providers to try to protect client confidentiality. Informal supports such as family and friends are going to naturally expect to be included in service and decision-making process.
Community Gossip
Due to the low density of rural settings and high visibility of community members , counselors will likely hear much information about a client or a client’s family outside of therapy. For example, a counselor’s friends and family, such as spouse or significant other, children, or parents, may be acquainted with a client of the counselor, and the client’s name and information may be brought up in regular conversation at meal time or get-togethers. This puts the rehabilitation counselor in a predicament, the counselor having to decide what to do with the information and whether or not this knowledge should be shared with a client (Shank et al., 2010).
Confidentiality and Collaborations
There are also concerns with confidentiality and collaborations with others. Rehabilitation counselors who work with other providers are going to share client information. However, Malone and Dyck (2011) report that collaborating providers in rural areas are more likely to informally share information and “discuss cases openly without consent or expect this of all providers” (p. 211). Furthermore, rehabilitation counselors who do not engage in similar behavior of informally sharing confidential information or challenge informal oversharing “behavior of other professionals may alienate themselves and lose referral sources” (Malone & Dyck, 2011, p. 211).
Counselor Personal Confidentiality
As rural communities are small and tight-knit, the community is going to hear information about a local rehabilitation counselor just as that counselor is likely to hear information about clients. This includes personal information about the counselor, the counselor’s family, counselor or family activities, and family reputation whether it be good or bad. Counselor confidentiality can be difficult enough for rehabilitation counselors new to the community and prove near impossible for counselors from the area. Current and potential clients are likely to have family and friends who personally know the counselor or the counselor’s family.
Indirect Confidentiality Issues
Rehabilitation counselors are likely to face other issues with confidentiality that are indirectly related. Rural communities are fish bowls, with it being easy to look into the community and see what is going on. High visibility makes it easy for people to recognize people or their vehicles seen coming and going from the counselor’s office, a name on client paperwork to other providers and agencies, or a private practice counselor depositing client checks at the bank (Malone & Dyck, 2011; Nelson et al., 2007). Also, people who use rehabilitation or other community resources are likely to know receptionists and other nonclinical staff (Coduti & Mannninen Luse, 2015; Nelson et al., 2007).
Due to such issues, rural rehabilitation counselors must take extra steps to protect client confidentiality and privacy. Counselors who do not take every precaution to protect confidentiality and even inadvertently break confidentiality can create serious harm for the individual as well as the community. Breaks in confidentiality and privacy result in the prevention of people from seeking services not only from a particular counselor or agency but other providers as well, increase stigma around seeking services, and can be a potential ethical violation of one’s credential and/or licensure (Chipp et al., 2008; Schank et al., 2010). Rehabilitation counselors must be vigilant in ongoing discussions with clients regarding how much information is warranted to provide to well-intentioned others who do want to help or are actively involved in supporting the individual.
Role of Continuing Education and Supervision in Supporting Ethical Practice
An issue related to the ethical issues of both dual relationships and confidentiality includes the lack of focus of education and availability of supervision in rural areas. Counselor education programs, continued education, conferences, and even counselor literature do a poor job addressing rural issues and ethical dilemmas (Chipp et al., 2008; Halverson & Brownlee, 2010; Malone & Dyck, 2011; McAreavey, 2014; Shank et al., 2010). Education, training, and literature that do address dual relationships unfortunately usually recommend that counselors do not engage in such relationships , with little focus on how to effectively manage these relationships.
Another issue related to dual relationships and confidentiality is the lack of supervision that rural counselors often face (Malone & Dyck, 2011). For example, a rehabilitation counselor who works for a vocational rehabilitation agency or another organization providing vocational services to an area may likely have a supervisor; however, that supervisor may cover a large region with limited access to supervisees. As rehabilitation counselors may lack appropriate supervision, interdisciplinary collaborations with other area professionals and community leaders or elders will be highly important to ensure appropriate ethical behavior and competence (Malone & Dyck, 2011).
Implications of Technology to Manage Dual Relationships and Safeguard Confidentiality
The use of technology to provide therapeutic services such as telephone and videoconferencing and email has been found to be an effective means of delivering services (Dyck & Hardy, 2013; Halverson & Brownlee, 2010). The therapeutic alliance has also been found to be as equivalent in teleservices as in face-to-face services (Dyck & Hardy, 2013). Technological services can provide a highly effective way to address the needs of isolated and resource-poor communities, increasing service options for the people as well as referral and consultation options for local providers. Technological services can be conducted in the home or a local centralized location, reducing the need for traveling long distances as well as decrease travel barriers due to geography or climate . Telehealth and online services, particularly if conducted in the home, also address physical barriers to a building, making services potentially even more accessible, especially for those with severe disabilities. Home-based technological services can increase client comfort, decrease anxiety of being in an unfamiliar space, and facilitate trust, therapeutic alliance, and client disclosure (Halverson & Brownlee, 2010). Such services can also address social issues related to stigma, providing clients the privacy, confidentiality, and anonymity they desire. For rehabilitation counselors, the use of technology also addresses ethical dilemmas regarding dual relationships and confidentiality as well the lack of anonymity for the counselor himself or herself (Dyck & Hardy, 2013). A rehabilitation counselor could provide services to remote communities outside of one’s own community, decreasing concerns of multiple relationships and trying to manage such relationships. A rehabilitation counselor who provides teleservices to a remote community can also more effectively safeguard confidentiality and privacy for clients. Finally, the use of teleservices can expand options for both the rehabilitation counselor and the client. Other providers who use technology can offer their services to a rural rehabilitation counselor and community or serve as a consultant to the rehabilitation counselor.
Limitations to the use of technology must be noted, however. The remoteness of a community and economy is the most significant barrier (Dyck & Hardy, 2013). Rural areas are more likely to experience poverty than more urban areas and lack funding and other resources to bring in telecommunication providers such as telephone and the Internet to create the necessary infrastructure. These factors affect the availability of technological services, Internet, and Internet speed which in turn affects quality of services such as videoconferencing. The expense of home computers, software, Internet service, and the time and energy potentially needed to learn how to use technology are additional factors which can create limitations to the use of service provision.
Rehabilitation counselors and other providers who utilize technological services such as videoconferencing and email must also consider the potential for hackers breaching technology and accessing counselor notes, email, calendars, and billing software that likely has highly confidential client information. Despite the best efforts of rehabilitation counselors to protect client information even with the use of secure Internet connections, encrypted email and case files, firewalls, malware, and antiviral software, there is no guarantee that a counselor’s, or a client’s, information will not be hacked .
Recommendations to Manage Dual Relationships, Confidentiality, and Privacy
This section of the chapter will provide guidelines to rehabilitation counselors on how to more effectively manage dual relationships and how to help protect confidentiality and privacy.
In cases where nonprofessional interactions may be potentially beneficial to clients or former clients, rehabilitation counselors must document in case records, prior to interactions (when feasible), the rationale for such interactions, the potential benefits, and anticipated consequences for the clients or former clients and other involved parties. Such interactions are initiated with appropriate consent from clients and are time-limited.
Rehabilitation counselors are responsible for reading, understanding and following the Code, and seeking clarification of any standard that is not understood. Lack of knowledge of knowledge or misunderstanding of an ethical responsibility is not a defense against a charge of unethical conduct.
- 1.
Decision-Making Models and Skills. Apply appropriate decision-making models.
- 2.
Addressing Unethical Behavior. Address unethical behavior in oneself and other rehabilitation counselors, and adhere to the Code.
- 3.
Conflicts Between Ethics and Laws. Obey both laws and statutes of the state counselors being practiced unless there is a conflict with the Code.
- 4.
Knowledge or Related Codes of Ethics. Rehabilitation counselors have knowledge of other professional codes.
- 5.
Consultation. Rehabilitation counselors are to consult with other knowledgeable professionals when faced with dilemmas.
- 6.
Organization Conflicts. If an organization is in conflict with the Code, rehabilitation counselors are to make this known to supervisors and other officials of the organization and work to address the conflict .
Increase awareness and understanding of issues on rural healthcare ethics as perceived by rural residents and healthcare professionals, including the contextual influence on ethical issues and how the issues are different from non-rural settings.
Increase awareness and understanding of rural healthcare ethics decision-making, including how living and working in regionally diverse rural communities affect the response to ethical issues.
Collaborate with rural healthcare professionals to draft guidelines for dealing with common, recurring ethical conflicts.
Explore, assess, and propose models for “doing ethics” in small rural health facilities.
Develop and implement ethics training curriculums and other educational resources for and with rural clinicians, administrators, and policy makers.
Provide an ethics perspective to administrators and policy makers charged with allocating healthcare resources, supported by empirical data on potential urban-rural healthcare disparities.
Foster a dialogue with the general healthcare ethics community regarding the unique nature of rural ethical issues .
Work with community leaders to become competent in the local culture and develop culturally acceptable strategies that ensure confidentiality.
Keep a private log of client information that is not part of official records.
Expand regular office hours to include early, late, and weekend appointments so people do not have to explain or feel they must provide excuses to employers, coworkers, and others regarding their whereabouts.
Due to low density of rural communities and high visibility of residents, including counselors, other strategies to safeguard confidentiality include the use of community spaces such as a school, church, private room of a library, or a community hall, the use of local businesses after hours, or working with clients in the home (Coduti & Mannninen Luse, 2015).
“Will doing this be helpful to my client?”
“Will this action likely harm anyone?”
“To whom do I owe an obligation or allegiance in this situation?”
“Will this action likely promote dependence on me by my client?”
“Are my actions consistent with how other providers treat their clients?”
“Have I allowed my judgment to become impaired as a result of inadequate attention to my own care of needs?”
“Is a post-therapy relationship avoidable, and if it is, why am I considering entering it?”
“One year from now, will I be satisfied with my decision?”
- Obtain Informed Consent
Be very clear with clients about confidentiality and limits, how records are kept, services, incidental contact, overlapping relationships and how they should be handled, and consultation with other providers.
- Document Thoroughly
Must document thoroughly overlapping relationships and reason for entering into the relationship. Must document consultation with other professionals around overlapping relationships and other ethical issues and discussion with clients.
- Set Clear Boundaries and Expectations
Discuss with clients professional and client expectations in the therapeutic relationship and clarify obligations and limitations, especially where it may be difficult to control out-of-office contact. Need to consider best and worst possible outcomes of relationships and need to address ways to prevent harm. Must self-monitor continuously.
- Pay Attention to Issues of Confidentiality
It can be tough to remember where information was gathered from (in or outside of sessions with a client). Word travels quickly in small communities, and rumors can be prevalent .
Instructional Features
Discussion Box 6.1
Joe is the only vocational rehabilitation counselor covering an entire county. He provides vocational services to Juan, whose parents, Mrs. and Mrs. Hernandez, are very active in the community and are major monetary supporters of local youth programs. Juan’s mother is also the town’s mayor. There has been much community gossip that the Hernandez’s are having financial and marital difficulties which could significantly impact the community. One youth program that they are the major contributor of is a program in which Joe is a board member. The previous week when the board met, there was discussion of these rumors and what it could mean to the program if the Hernandez’s could no longer support it. One of the board members is a teacher in the local high school and knows that Joe and Juan work together. She pulls Joe aside after the meeting and asks him if he knows what is going on or if he can find out. Joe has noticed during his last few sessions with Juan that the youth appears sad, withdrawn, and having difficulty completing employment search activities Joe assigns him. During their next meeting, Joe asks Juan if everything is alright.
- 1.
Discuss the differences between confidentiality and privacy related to this scenario.
- 2.
When would Joe violate Juan’s privacy?
- 3.
When would Joe violate Juan’s confidentiality?
- 4.
Discuss Joe’s obligation to the youth program and the board, if any, regarding information he learns during his meeting with Juan.
- 5.
What are the appropriate steps Joe should take to ensure Juan’s confidentiality and privacy?
Research Box 6.1
See Malone and Dyck (2011).
Objective: Using the Canadian Code of Ethics for Psychologists (CPA), the researchers examined ethical dilemmas rural and remote providers faced and their ethical decision-making process.
Methods: This was a qualitative examination of ethical dilemmas the two authors have faced as rural and remote psychologists. The authors discuss several real case scenarios they have experienced using the CPA which provides real-world, practical solutions that other providers can implement.
Results: Providers can face many ethical situations working in rural and remote areas including dual relationships and confidentiality, pressure from colleagues to divulge client confidential information, and competence and self-awareness of one’s limitations.
The authors discuss the importance of locating colleagues and supervisors whom the provider can trust to work through ethical dilemmas with. Due to limited service providers in rural and remote communities, providers often have to develop a generalist approach to be able to see clients with a wide variety of needs. The authors do discuss both the pros and cons of developing a generalist practice. Providers who practice as generalists are better able to serve a diverse population. However, there are concerns regarding competence, scope of practice, and training. To help counter ethical concerns, providers must develop relationships and collaborate with colleagues throughout the local and regional healthcare systems. Well-developed collaborations with other providers are highly useful to meet the often complex medical, personal, and environmental needs of community members.
Conclusion:
It is important for rural providers to develop relationships with colleagues or supervisors they can rely on to assist in processing and solving ethical dilemmas. Rural providers must also locate appropriate resources such as training, literature, and research that focus specifically on rural ethical dilemmas. The authors conclude with highlighting the rewards of working in rural and remote communities and possible benefits of engaging in dual relationships and having close ties with the community.
- 1.
Compare the CPA to the CRCC Code of Ethics, focusing on dual relationships, confidentiality, competence, interdisciplinary teamwork, training, and supervision.
- 2.
What does each Code discuss regarding these topics?
- 3.
Does one Code provide more thorough guidelines for rural counselors to use? Explain.
- 4.
How can you implement suggestions from this article into your own work as a counselor?
- 5.
How could you implement suggestions from the CPA into your own work in an ethical manner?
Decision-Making Models
Due to the number of different helping professions and the various populations that are served, there are a variety of different ethic al decision-making models that may be helpful. “These models cover a variety of foci, including multiculturalism, collaboration, counselor education, and counselor settings, such as schools and community agencies” (Heller Levitt, Farry, & Mazzarella, 2015, p. 84). While having a variety of models to choose from, and no two are like, can be very helpful, this can also become overwhelming to counselors when looking for a model that best serves one’s needs.
Herlihy and Corey’s Decision-Making Model
Identify the problem: Recognize a problem that exists, and determine the type of problem it is: ethical, legal, professional, clinical, or a combination. Then, gather as much information as possible. Make sure to document thoroughly throughout the process.
Identify and examine relevant codes and principles: Consult the appropriate professional ethical code(s) and principles. Make sure to completely understand the code’s standards and principles as well as possible implications. Make sure to evaluate if one or more standards and principles have priority over others.
Consult with others: It is important to discuss problems with colleagues and supervisors. Consulting with others can be very helpful as they may have more expertise in an area, had similar experiences, and can offer another perspective. Make sure to document throughout the consultation process.
Check your emotions: Throughout this whole decision-making process, it is important for the counselor to be self-aware of one’s emotions. The counselor will need to “check to see whether you are being influenced by feelings such as fear, self-doubt, frustration, disappointment, or an overwhelming sense of responsibility” (Herlihy & Corey, 2015, p. 21). It can also be very beneficial to talk about and process emotions with colleagues and supervisors.
Involve the client: Counselors must make sure they are following the general principles, particularly autonomy in the decision-making process, and the ethical standards such as informed consent. Clients should be involved in the problem-solving process; it is their case after all by including the client in the process they are being empowered to make the best decision for himself or herself.
Cultural considerations: Make sure to be fully aware of what role one’s personal cultural and worldviews may have in the problem and decision-making process. Counselors must also consider the client’s culture and worldview and ensure the problem is a good fit for the individual.
Problem-solve: The counselor can start to generate possible solutions. It is wise to develop many possible solutions .
Consider all consequences: As all possible solutions are generated, it can be highly beneficial to either rank them or develop a pro/con list to help both the counselor and client understand what all potential consequences may entail. Eliminate solutions that do not have an effective or favorable outcome or may cause further problems. Again, it is important to include the client in this process throughout.
Evaluate selected courses of action: Now that possible solutions have been whittled down to a few options, it is important to compare them to the counselor’s general principles and standards. Standler (as cited in Herlihy & Corey, 2015) recommends testing options. This test includes the test of justice (assess personal sense of fairness in this option), the test of publicity (would the counselor want this solution and his/her behavior broadcasted on the news?), and the test of universality (would the counselor recommend this same solution to another helper?). If the counselor is satisfied to each answer, then he or she can move on the final step. If not, then test another possible solution.
Implementation: Now, the counselor and client can carry out the decided course of action. Once the solution is implemented, it is important to follow up to assess its effectiveness and consequences.
Tarvydas Integrative Model for Ethical Behavior
- Themes or Attitudes in the Integrative Model
Maintain an attitude of reflection.
Address balance between issues and parties to the ethical dilemma.
Pay close attention to the context(s) of the situation.
Utilize a process of collaboration with all rightful parties to the situation.
- Stage I. Interpreting the Situation Through Awareness and Fact-Finding
Component 1. Enhance sensitivity and awareness.
Component 2. Reflect, to determine whether dilemma or issue is involved.
Component 3. Determine the major stakeholders and their ethical claims in the situation.
Component 4. Engage in the fact-finding process.
- Stage II. Formulating an Ethical Decision
Component 1. Review the problem or dilemma.
Component 2. Determine what ethical codes, laws, ethical principles, and institutional policies and procedures exist that apply to the dilemma.
Component 3. Generate possible and probable courses of action.
Component 4. Consider potential positive and negative consequences for each course of action.
Component 5. Select the best ethical course of action.
- Stage III. Selecting an Action by Weighing Competing, Nonmoral Values
Component 1. Engage in reflective recognition and analysis of personal competing values.
Component 2. Consider the contextual influences on values selection at the collegial, team, institutional, and societal levels.
- Stage IV. Planning and Executing the Selected Course of Action
Component 1. Figure out a reasonable sequence of concrete actions to be taken.
Component 2. Anticipate and work out personal and contextual barriers to effective execution of the plan of action and effective countermeasures for them .
Component 3. Carry out and evaluate the course of action as planned.
Future Implications that Potentially Will Influence Service Delivery and Approaches
Due to geographical, demographical, and cultural factors of rural and small town settings, rehabilitation counselors who serve these communities are likely to make adaptations to services that are different compared to their urban counterparts, particularly when it comes to managing dual relationships and safeguarding confidentiality. Therefore, there are implications for policy makers and funding agencies, educators, and researchers to ensure rehabilitation counselors are able to provide high-quality, ethical services in rural settings.
Policy makers and funding agenc ies must recognize that rural communities face many barriers to access appropriate care. Rural communities face geographical, climatic, and infrastructural barriers; limited community services; and limited employment opportunities and jobs that provide adequate health insurance. These factors limit options for community members and place much stress on available services and providers. Rehabilitation counselors working in resource-poor communities are more likely to work with people they have social connections with. While dual relationships can be beneficial as research has indicated, rural counselors have indicated that managing such relationships can be stressful, often not ideal, and if not managed correctly can have negative consequences for clients, counselors, and the community. The likelihood of having to engage in dual relationships creates issues in assuring client and even counselor confidentiality and privacy. And again, as with dual relationships, breaks in confidentiality have very serious consequences for all involved including the community. Rural communities and counselors would benefit from legislation and policies strategically geared toward their unique needs. Furthermore, rural communities and agencies require funding to bolster service options and alleviate stress from the few available service providers and decrease risks for dual relationships and confidentiality and potential consequences. Additionally, counselors require funding to seek out appropriate training and supervision to be able to effectively manage dual relationships and confidentiality. Counselors and agencies would also benefit from funding to develop training services for other rural providers. Funding geared toward technology and technological infrastructure would also help to increase service options to rural communities and increase collaboration, training, and referral resources for counselors. However, technology is not the only answer either. Policy makers , funding agencies, and local community providers must come together to adequately understand the many issues dealt with in rural settings and develop specific interventions that will be most effective.
Education programs, continuing education training and research, place little emphasis on the unique needs of rural settings, with most of educational programming and research maintaining an “urban-centric” viewpoint (Coduti & Mannninen Luse, 2015; Malone & Dyck, 2011). Research has repeatedly indicated that rural counselors face challenges surrounding dual relationships and confidentiality that are both “quantitatively and qualitatively different than those faced by urban providers” (Chipp et al., 2008, p. 545). Unfortunately, rural providers often rely on anecdotal strategies to manage dual relationships and assure confidentiality (Schank et al., 2010). Researchers must examine counselor ethical decision-making processes and resulting implemented strategies to evaluate benefits and risks of dual relationships and management. Rehabilitation counselors, like any other human service and healthcare providers, are most often trained to avoid dual relationships. Additionally, while rehabilitation education, training, and research is well informed regarding the importance of confidentiality and consequences of breaking it, there is little investigation of how to safeguard confidentiality in rural settings with low population density and high visibility. Rural counselors would be well served by the provision of well-examined strategies to manage dual relationships as well as strategies to recognize when and when not to enter into a dual relationship and effective strategies to protect confidentiality. Through empirical well-informed education and training geared specifically toward rural ethical issues, rehabilitation counselors could provide high-quality, ethical, and culturally sensitive services to their communities.
Summary
It is hoped that this chapter will help students to recognize that rural and small town settings are unique and that working in these communities will provide not only many challenges but also many opportunities. Rural and small town communities are diverse, vibrant communities that deserve respect to be provided a range of empirically sound and ethical services that meet their needs. This chapter sought to address the issues rural and small town settings face along with cultural values that create for unique ethical dilemmas for rehabilitation counselors particularly regarding relationship dynamics.
The Code, while designed to provide broad guidelines to assist in multiple settings, may be too ambiguous and not culturally sensitive for rural and small town communities. Furthermore, there is a significant gap in education, training, supervision, and research to provide rural-focused strategies to assist counselors to be able to effectively problem-solve and manage ethical dilemmas. Rural counselors are likely to have to deal with dual relationships and must be able to effectively manage these precarious relationships. Training counselors to avoid such relationships is simply not realistic, nor may it be ethical. Without the provision of empirically validated training and supervision, rural counselors have been left on their own to develop and implement anecdotal strategies to manage dual relationships and confidentiality. Furthermore, rural and small town communities are often tight-knit; rely on informal supports such as family, friends, and informal groups; and are resource-poor. Therefore, it would be unethical to ignore the potential necessity of counselors to have to engage in dual relationships.
Working in a rural community and engaging in some types of dual relationships with clients can be a positive and beneficial experience. Counselors who take the time to become engaged in a rural or small town setting will recognize that these are rich and highly diverse communities, with self-reliant, highly resourceful, very caring, and connected community members. In-depth community involvement allows counselors to be highly visible and become a trusted community member in which people feel comfortable seeking services from, recognize and bring awareness to community needs, and dispel stigma attached to disability and service seeking. Counselors can more fully engage the community as a whole and individuals in conversations about how to tackle community concerns and develop strategic services that are culturally appropriate to fit the community’s needs. Dual relationships can also be beneficial to allow the counselor to work more closely with individual clients to develop holistic, really in-depth, highly effective services that include a variety of informal supports from family members to friends, to community groups, and to the involvement of local businesses. Counselors working in resource-strapped communities, who can ethically manage boundary crossings, will have informal resources and supports, such as community leaders and elders, whom they can turn to for their own guidance as well as to assist in service provision.
Case Study
Miguel is a 15-year-old young man who is a freshman in high school. He has Duchenne muscular dystrophy. Miguel attends his IEP meeting and recognizes you, the only vocational rehabilitation counselor in the county, as a friend of his parents. You ask Miguel to meet you for a few minutes after the meeting to discuss a little more in-depth what VR services include and some of Miguel’s personal and career goals. Miguel appears embarrassed talking to you. When you ask him what questions he has, he asks if you are going to tell his parents everything you discuss. Explain dual relationships, confidentiality, and privacy in terms a 15-year-old young man would understand. Discuss the steps you can take to ensure Miguel’s confidentiality and privacy.
Resources
National Rural Health Association: http://www.ruralhealthweb.org/Research and Training Center on Disability in Rural Communities: http://rtc.ruralinstitute.umt.edu/employment-vocational-rehabilitation/
Rural Health Information Hub: https://www.ruralhealthinfo.org
Rural Health Research Gateway: https://www.ruralhealthresearch.org/centers
Rural Policy Research Institute: http://www.rupri.org/
US Department of Health & Human Services: Federal Office of Rural Health Policy: http://www.hrsa.gov/ruralhealth/
Chipp, C., Johnson, M., Brems, C., Warner, T., & Roberts, L. (2008). Adaptations to health care barriers as reported by rural and urban providers. Journal of Health Care for the Poor and Underserved, 19, 532–549.
Dyck, K., & Hardy, C. (2013). Enhancing access to psychologically informed mental health services in rural and northern communities. Canadian Psychology, 54(1), 30–37. doi:10.1037/a0031280.
Halverson, G., & Brownlee, K. (2010). Managing ethical considerations around dual relationships in small rural and remote Canadian communities. International Social Work, 53(2), 247–260. doi:10.1177/0020872809355386.
Malone, J. L., & Dyck, K. G. (2011). Professional ethics in rural and northern Canadian psychology. Canadian Psychology/Psychologie Canadienne, 52(3), 206–214. doi:10.1037/a0024505.
McAreavey, R. (2014). On being let loose in the field: The execution of professional ethics. Sociologia Rualis, 54(1), 71–93.
Nelson, W., Pomerantz, A., & Howard, K. (2007). A proposed rural healthcare ethics agenda. Journal of Medical Ethics, 33, 136–139. doi:10.1136/jme.2006.015966; 10.1037/a0024505
Schank, J., Helbok, C., Haldeman, D., & Gallardo, M. (2010). Challenges and benefits of ethical small-community practice. Professional Psychology: Research and Practice, 41(6), 502–510. doi:1.1037/a0021689.