5320: u7 d1: dual relationships

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5320: U7 D1: Dual Relationships

The dilemma of dual relationships, particularly in rural communities, can present
significant ethical challenges. Review the articles by Gonyea, Wright, and
Earl-Kulkosky (2014) and by Witt and McNichols (2014) in the studies for this
unit.

In your initial post, discuss some of the methods used to manage potential dual
relationships from the perspective of a provider and from the perspective of a
supervisor. Describe at least one similarity and one difference in the ways a
provider and a supervisor address dual relationship situations.

NOTE: 250-300 Words and at least 1 scholarly journal

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Assessing the Needs of Rural Counselor Supervisors in Texas

Witt, Karl J; McNichols, Christine. Journal of Professional Counseling, Practice, Theory, & Research; Austin Vol. 41, Iss. 2, (Summer/Fall 2014): 15-29.

https://capella.alma.exlibrisgroup.com/openurl/01CAPELLA_INST/01CAPELLA_INST:Services?
genre=article&atitle=Assessing+the+Needs+of+Rural+Counselor+Supervisors+in+Texas&author=Witt%2C+Karl+J%3BMcNichols%2C+Christine&volume=41&issue=2&spage=15&
07-01&rft.btitle=&rft.jtitle=Journal+of+Professional+Counseling%2C+Practice%2C+Theory%2C+%26+Research&issn=1556-6382&isbn=&sid=ProQ%3Apsychology_

Abstract

This study explored the needs of rural counselor supervisors (LPC-Ss) in Texas. Fifty participants responded to an online survey consisting of Likert-type items and free-response
questions. Rural supervisors commented on their connectedness to their communities and profession, resources, multiple roles, boundaries and dual relationships, self-care, and
personal factors. Supervisors felt disconnected from their profession and unsupported in supervisory roles but reported low burn-out rates. They reported perceived areas for
additional training and suggestions for counselor education programs. Other findings paralleled earlier research regarding rural mental health professionals.

Headnote
This study explored the needs of rural counselor supervisors (LPC-Ss) in Texas. Fifty participants responded to an online survey consisting of Likert-type items and free-response
questions. Rural supervisors commented on their connectedness to their communities and profession, resources, multiple roles, boundaries and dual relationships, self-care, and
personal factors. Supervisors felt disconnected from their profession and unsupported in supervisory roles but reported low burn-out rates. They reported perceived areas for
additional training and suggestions for counselor education programs. Other findings paralleled earlier research regarding rural mental health professionals.

Key words: rural, supervision, counseling, mental health, LPC-S, counselor education, counselor training

A journey from one end of Texas to the other carries a traveler over some of the most diverse regions in the United States (US). While Texas hosts several booming
metropolises, many Texans reside in rural agricultural communities (US Census Bureau, 2013), and many of those communities suffer from a shortage of qualified mental health
professionals (Texas Department of State Health Services [DSHS], 2014). Most of the state’s 18,641 Licensed Professional Counselors (LPCs) reside in urban areas (Texas State
Board of Examiners of Professional Counselors [TSBEPC], 2014); seventeen percent of Texas counties lack LPCs altogether (DSHS, 2014). Since the TSBEPC requires
supervision by an LPC-Supervisor (LPC-S) in a counselor’s early career, the presence of LPC-Ss is important to increasing services. Breen and Drew (2012) and Oetinger,
Flanagan, and Weaver (2014) both observed that exposure to rural settings can help attract new practitioners, yet only nine percent of LPC-Ss work in rural areas (TSBEPC,
2014). Researchers have explored the needs of counselors working in rural settings, but few have investigated the needs of rural supervisors. This study sought to answer the
question, “What are the needs and experiences of rural supervisors practicing in Texas?” Findings from this study will help stakeholders appreciate rural circumstances and
explore ways to assist and support rural supervisors in Texas and elsewhere.

Existing literature contains multiple, conflicting definitions of the term “rural,” often based on one of more than 15 US government definitions (Coburn et al., 2007). The most
common three are from the Census Bureau, the Office of Management and Budget (OMB), and the US Department of Agriculture’s Economic Research Service (ERS). ERS
specifically designed a method, the rural-urban commuting area (RUCA) codes, to address other systems’ shortcomings (ERS, 2014). RUCA codes combine population density,
the Census Bureau’s geographic tracts, OMB’s commuting patterns, the 2010 national census, and the 2006-2010 American Community Survey to differentiate between urban
and rural. In the RUCA method, “rural” is defined as any geographic area where the aforementioned factors result in a RUCA code of four through ten (Coburn et ah, 2007).

Rural communities differ from urban ones in attitudes, beliefs, and values (Breen & Drew, 2012; Saba, 1991). Relationships often are more tightly knit, intersect in multiple
ways, and are heavily influenced by family name and history (Cohn & Hastings, 2013; Curtin & Hargrove, 2010). There may be a lack of specialized services and concomitant
multiple roles; a person who works as a judge may also be a local emergency first responder (Breen & Drew, 2013; Saba, 1991). Rural regions are often characterized by aging
populations facing poverty and a lack of employment, medical insurance, and resources (Curtin & Hargrove, 2010). Qualified mental health providers may be lacking, and
mental health concerns are often first addressed by law enforcement or primary health care workers (Robinson et ah, 2012). People who need services may not know how to
access them, and affiliated stigmas may dissuade exploration. At times, the high visibility of daily activities in small communities further deters help-seeking and reduces
therapeutic gains, especially when communities view helpseeking negatively (Curtin & Hargrove, 2010; Riding-Malon & Werth, 2014). Individuals living in rural settings often
become their own advocates, first turning to families and faith communities before pursuing formal mental health assistance. For these reasons, rural mental health providers
must work with and within these systems to be successful. Urban counselor training programs may take things like support groups, community centers, public transportation,
and day-treatment centers for granted, unaware that rural settings may lack these resources (Helbok, ). These differences affect the way mental health practitioners and
supervisors carry out their work.

Though little supervisor-specific rural counseling research exists, supervisors are also practitioners. Furthermore, LPC-Ss help supervisees conceptualize counseling, plan
treatments, and work with rural clients under the LPC-S’s license. It is therefore important to examine the rural counseling literature to better understand the supervisory
context. The complexities of multiple relationships often arise in rural counseling literature (Breen & Drew, 2012; Cohn & Hastings, 2013; Helbok, 2003; Malone, 2010; Oetinger,
Flanagan, & Weaver, 2014; Paulson, 2013). While rural citizens take abundant dualities for granted, counselors and supervisors may experience professional and personal
difficulties (Paulson, 2013), leading some to question training approaches and the rural relevance of the American Counseling Association’s ethical code (Gillespie & Redivo,
2012). Furthermore, mental health resource deficiencies and practitioner shortages often force rural counselors and supervisors to work as generalists who address and
supervise a wide range of concerns and roles, including those for which they have little or no training (Breen & Drew, 2012; Paulson, 2013). Travel to expand clinical and
supervisory competence through conferences and workshops may also be cost-prohibitive (Cohn & Hastings, 2013; Breen & Drew, 2012; Hastings & Cohn, 2013; Helbok, 2003;
Malone, 2010; Oetingei; Flanagan, & Weaver, 2014; Paulson, 2013; Saba, 1991). Similarly, Cohn and Hastings (2013) note limited experience and exposure may impact
practitioners’ multicultural competence and may create unique challenges in supervision (Paulson, 2013).

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A lack of personal privacy is another frequent finding in the literature. Some authors (e.g., Cohn & Hastings, 2013; Rollins, 2010) labeled this high visibility as “being on stage”
or “the fishbowl effect.” Personal public outings may require more intention and reflection than in an urban setting. Having a drink in a restaurant, joining certain interest
groups, or socializing with various people could have negative consequences for counselors, their families, and clients (Paulson, 2013). For some, feelings of isolation develop
from constantly being watched by clients and supervisees (Breen & Drew, 2012; Hastings & Cohn, 2013; Helbok, 2003; Oetinger, Flanagan, & Weaver, 2014; Paulson, 2013).
Reduced social support can lead to distress and burnout (Hastings & Cohn, 2013). Counselors might also feel restricted as advocates since advocacy on contentious topics might
harm a counselor’s practice and personal life, lead to mistrust of the counselor and strain community relationships (Bradley, Wreth, Hastings, & Pierce, 2012). Limited financial
resources, substandard pay, demanding caseloads, and rural poverty are other oft-cited challenges for both counselor and supervisors (Oetinger, Flanagan, & Weaver, 2014;
Hastings & Cohn, 2013; Paulson, 2013). Such factors may provide barriers to those practicing in rural settings or considering rural practice.

Researchers have suggested ways to aid rural professionals. Some stressed collaboration and continuing education through telehealth and online training modules for
supervisors (Nelson, Hewell, Roberts, Kersey, & Avey, 2012; Riding-Malon & Werth, 2014). Paulson (2013) recommended peer supervision for supervisors as an avenue to gain
support. Participants in the Breen and Drew (2012) study recommended that counselor education programs stress the importance of seeking supervision throughout one’s
career. Finally, Paulson (2013) recommended a formal rural counseling course that would specifically address issues related to working in a rural setting.

Despite some of the challenges inherent in rural work, many counselors and supervisors highlight the positive aspects of working in this setting. Oetinger, Flanagan, and Weaver
(2014) surveyed 51 rural practitioners; 47% reported being very satisfied. They extolled the inherent diversity of their work, opportunities to help the underserved, work and
recreation in natural surroundings, and the slower pace of life. Additional benefits added by Cohn and Hastings (2013) included career flexibility, work with generations of the
same family, rural connectedness, school loan assistance, and a lower cost of living. Paulson (2013) found that rural supervisors greatly valued providers’ relationships,
collaboration opportunities, and rural interconnectedness. Curtin and Hargrove (2010) summed up the benefits of rural practice this way: “Many of the potential problems
associated with work in smaller, rural communities may be translated as opportunities for creative practice” (p. 549).

Much of the research conducted over the past ten years focuses on the experiences of rural counselors. As counselors, rural supervisors share many of the same experiences.
This study seeks to extend the supervisor-specific literature by asking, “What are the needs and experiences of rural supervisors practicing in Texas?”

Method

Participants

The study had 50 participants: 29 females (58%), 20 males (40%), and 1 selfdescribed other (2%). Participants described themselves as White («=44, 88%), Hispanic or
Latino/a («=2, 4%), American Indian or Alaska Native («=2, 4%), Black or African American («=1, 2%), and Native Hawaiian or Other Pacific Islander («=1, 2%). Ages ranged
as follows: 26 to 35 («=4, 8%), 36 to 45 («=9, 18%), 46 to 55 («=13,26%), 56 to 65 («=16, 32%), and 66 or older («=8, 16%). Moss, Gibson, & Dollarhide (2014) found that
seasoned practitioners perceive counseling and practice differently than their newer colleagues. It follows that there may be differences between a seasoned counselor who is a
new supervisor and a supervisor with more years of supervisory experience but less experience overall. Participants held their practitioners’ licenses from three to 36-plus years
and time in rural settings ranged from less than one to over 36 years. Experience as an LPC-S ranged from less than one to over 36 years. The number of years each participant
has been fully licensed as an LPC, the amount of time working in rural settings, and the length of time as an LPC-S are reported in Table 1.

The authors also sought a representative geographic sample. The Texas Counseling Association (TCA) divides membership into five regions comprised of southeastern Texas
(Region I), southern Texas (Region II), western Texas (Region III), northeastern Texas (Region IV), and central Texas (Region V; see Table 2).

Procedure

The public roster of Texas LPC-Ss («=3,911) was obtained from the TSBEPC website in June 2014. Eliminating unlisted («=133) and out-of-state («=95) addresses left 3,685
LPC-Ss. Using the May 2014 RUCAzip code correlations co-developed by ERS and ORHP, each address was classified as rural or urban. Addresses with codes one through three
were considered urban; codes four through ten denoted rural areas. Zip codes with multiple RUCA codes and seven addresses created after the 2010 census were categorized
by matching census tracts from the Federal Financial Examination Council Geocoding System and Google Maps with uncorrelated RUCA data. The resulting rural LPC-Ss («=344)
were all mailed postcards inviting participation in an anonymous electronic survey with a second invitation four weeks later. Fifty-three individuals agreed to participate; fifty
actually completed the study.

Instruments

The authors created a survey derived from existing rural mental health literature, interactions with rural supervisors, and observations of supervisory processes. Qualtrics web-
based survey software was used to collect demographic data and responses to 26 standalone Likert-type items (see Table 3) and five free-response questions. The five free-
response questions were: (a) What areas of training do counselor education programs need to include or improve, (b) Counselors often wear multiple hats in their professional
settings. What roles do you play in your setting, (c) How do you engage in self-care as a rural supervisor (d) What are the benefits of working as a supervisor in a rural setting,
and (e) What other issues do you feel rural supervisors face?

Data Analysis

Different analytic approaches were used for the two types of data collected. For standalone Likert-type items, median, mode, and frequency are the only meaningful descriptive
statistics (Boone & Boone, 2012). The endorsement frequency for specific responses, the mode, and the median for each item are reported in Table 3. The researchers also
independently conducted a conventional content analysis for each of the free-response questions, as described by Hsieh and Shannon (2005). For each question, responses
were read repeatedly to discern initial common thoughts and ideas. A color coding system was created to categorize similar data. Each color code was given a descriptive label
highlighting the pattern for that text. Researchers then discussed and reconciled patterns and labels. Resulting patterns were reported.

Results

Quantitative Results

Participants responded to Likert-type items about their connectedness to and collaboration with others, professional development, professional roles, dual relationships,
technology, resources, and particular aspects of rural culture. Rural supervisors frequently or very frequently worked as generalists and fulfilled multiple roles in their settings.
Despite distances, they did not use technology for distance supervision. They considered the financial resources for mental health to be inadequate and frequently or very
frequently engaged in professional development activities. LPC-Ss also felt connected to others in their communities but disengaged from other counseling professionals. The
Likert-type items and responses are reported in Table 3.

Qualitative Results

Free-response questions solicited suggestions for counselor education programs, roles played, self-care regimens, and benefits and issues of rural supervision. For the first
question, participants recommended that counselor education programs improve training in business management; diagnostic skills and substance abuse counseling, especially
dual diagnosis and treatment; boundaries and dual relationships; and couple and family work. Business acumen and “middle management techniques” were consistently
stressed. Participants noted that supervisees needed better training about boundaries and dual relationships. One respondent wrote, “many of my practicum students come to
me from a larger city and have no idea whatsoever how difficult it is in a small town to maintain boundaries”, and another added, “[Supervisees need to know] how to navigate

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dual relationships in a small rural community including how to deal with invitations to social events, church, and community activities.” Finally, a participant observed, “family
counseling is needed to a greater extent in rural settings and most counseling graduates have had only one course in family therapy and/or diversity.”

When asked about roles and self-care, LPC-Ss reported working as managers, community crisis intervention contacts, legal consultants to colleagues, teachers or trainers,
committee members and project coordinators, and janitors and babysitters beyond their counseling and supervisory commitments. Participants engaged in self-care through
healthy eating and exercise, being in nature, traveling, spending time with others, practicing spirituality, engaging in personal and professional development, and using time
management techniques. Some respondents reported that time constraints inhibited their self-care. Others “recognize[d] the need to recharge my batteries” and “knowing what
gets me reconnected with things that matter.” Perceived benefits of rural settings consisted of no competition with other providers, the atmosphere (e.g., being close to natural
beauty, no traffic, slower pace), connection to community, the rewards of conducting supervision, and being able to meet the community’s needs. Many respondents commented
on how fulfilling supervision in a rural area can be. One respondent wrote,

The interns are passionate and eager to serve in their communities. Since there are not many interns, the needs for supervisors is lessened which allow me to invest in the
interns more than if I had a full case of interns. I’m able to help train them for the needs of our area and refer to interns and licensees with confidence in their skills, abilities,
and desire to help others. The interns become lifelong friends and colleagues since we need to help each other in rural communities. We form our own support systems for
counselors.

The open question about what issues rural supervisors face resulted in five patterns: a lack of resources for referrals such as supervisors, doctors, and other helping agencies; a
lack of funding and reimbursement; a lack of access to continuing education; difficulty managing dual relationships and boundaries; and a lack of professional support. When
talking about the lack of resources in a rural community, one participant described the issue this way: “how to cope with the strain of feeling that you have to take everyone
because there are no options for referrals.” Another respondent stated, “I often feel obligated to take on an intern because there are so few options available to them.” Issues
related to boundaries were also repeated with one participant stating,

I often face challenges maintaining boundaries. My children also attend school and befriend my clients (as there is only one school system) which creates a unique issue. If I
were to need clinical help for myself, it would be difficult to find someone I do not already have a relationship with professionally.

Finally, a lack of access to continuing education was a common pattern. Many discussed issues relating to having to travel a great distance to receive continuing education. One
respondent stated it this way:

It’s difficult to access continuing education that is not offered online. We often must travel six hours for live trainings. This requires significant time away from our practice as
well as costly travel. We are not able to meet other supervisors and counselors in our rural areas when trainings are halfway across the state of Texas.

Discussion

This study sought to explore and describe the needs of rural supervisors. Results confirmed and enhanced existing literature about rural practice. Paralleling Paulson’s (2013)
research with counseling supervisors, rural LPC-Ss generally felt connected to their communities but disconnected from other mental health practitioners. This might be due to
the distance and time required to connect with professional counterparts, as it is with counselors (Breen & Drew, 2012; Hastings & Cohn, 2013). This lack of connection stems
from competition for a limited paying client base (Cohn & Hastings, 2013); findings from this study suggest similar fears from supervisors. Respondents in the current study
described low levels of participation in professional counseling organizations and collaboration with university training programs, which might also contribute to disconnected-
ness and isolation. As with their non-supervisory colleagues, rising conference and membership costs and a lack of pertinence to rural settings could also be prohibitive factors
(Breen & Drew, 2012). Supervisors might be unaware of nearby training programs or universities’ roles as resources. Though respondents engaged in professional development
activities, qualitative data conveyed fewer faceto-face opportunities for rural supervisors.

Confirming Paulson’s (2013) results, participants felt unsupported as counselor supervisors. As they strived to balance multiple roles, many unrelated to their expertise, role
confusion and invalidation sometimes resulted. Though facilities were adequate, respondents decried the lack of local qualified professionals and financial resources for mental
health. Unique to this study, despite these obstacles, supervisors reported low burnout rates. This may be due to respondents’ age and experience combined with active, quality
self-care.

Another finding concerned dual relationships and boundaries within rural communities. Participants noted that while they often fulfilled various community roles, only some had
to deal with dual relationships or boundary management with clients similar to Paulson’s (2013) findings. This study also inquired about dual relationships and boundary
management with supervisees. Incidents were fewer with supervisees than with clients, and frequent conversations about these issues may have decreased the likelihood of
problematic occurrences. These results might also indicate that seasoned rural counselors adeptly handle this rural norm.

Supervisors also discussed counselor preparation and distance supervision. They felt universities did not adequately prepare students for rural work. They also very rarely used
distance technology and preferred faceto-face interactions. Many also highly valued helping supervisees grow and developing lasting collegial relationships with them.

Implications

Several implications can be drawn from this study. One prevalent need is for rural counselor supervisors to feel supported and connected to colleagues. Professional
memberships and continuing education may help. Counseling organizations might continue to closely monitor membership costs and services’ relevance. While online continuing
education is valuable, contact is crucial to reducing isolation. Regional organizations and universities might host local conferences or workshops, especially on issues such as
boundary management, finding resources, and self-care. Increased rural training placements for student counselors may provide fresh perspectives, aid with caseloads, and
prepare future rural counselors.

Counselor educators should consider a focus on uniquely rural issues. Navigating, rather than avoiding, realistic dual relationships; rurally-oriented multicultural training; and
working within systems as an outsider might be beneficial. Practical lessons on locating resources, making referrals, using non-mental health professionals, and managing
businesses may also be constructive. Programs might also infuse self-care and rural exposure into the curriculum.

Advocacy efforts might be made on behalf of rural practitioners. Minimal resources make it hard to meet community needs. Based on participant responses, advocating for
proper payment and reimbursement for LPCs and LPC-Interns from insurers and Medicaid could have positive wide-ranging effects.

Limitations

The study had some inherent limitations. While each TCA region was represented, there were more participants from Region IV (northeast Texas) than the other four regions
combined. Findings may be heavily colored by the experiences of rural counselor supervisors working within that region. There may also be differences between those who
responded to the survey and those that did not. The design relied on potential participants to manually enter a survey link web address from a mailed postcard. The extra steps
and reliance on practitioners’ technological prowess may have decreased the number of participants or differentiated respondents from the larger population. Although results of
this study may be generalized to other rural contexts, conditions in Texas may differ significantly from other rural areas. Therefore, caution is warranted when applying these
findings.

Future Directions

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This study examined the needs of LPC-Ss working in rural Texas. The findings support prior literature and open the way for new areas of research. Investigating relationships
between the age and experience of rural counselor supervisors and their ability to deal with complicated issues pertaining to dual relationships and boundaries might be one
avenue. Another research area might explore how rural counselor supervisors develop methods of self-care despite dealing with high levels of professional isolation. Looking
more closely at how and why rural counselor supervisors feel isolated, especially when competition for resources and paying clients exists, may also give practitioners valuable
information about how to best help those working in rural settings. Finally, this study only explored rural supervisors in Texas. Subsequent studies from other rural areas or with
national samples can further enhance the literature.

Conclusion

There is no doubt that the need for mental health services in rural areas is rising (Robinson et ah, 2012; DSHS, 2014). Those who currently work in rural settings have a diverse
set of needs; however the solutions may be tangible and feasible as professional organizations, counselor education programs, and LPC-Ss, both in Texas and beyond, work
together to meet the needs of rural supervisors and strengthen rural mental health services.

References
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AuthorAffiliation
Karl J. Witt and Christine McNichols

The University of Texas at Tyler

AuthorAffiliation
Author Note:

Karl J. Witt, Assistant Professor of Counseling, Department of Psychology and Counseling, The University of Texas at Tyler; Christine McNichols, Assistant Professor of
Counseling, Department of Psychology and Counseling, The University of Texas at Tyler. This project was funded by a research grant from the Texas Association of Counselor

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Details

Subject Supervisors;
Rural areas;
Counseling;
Mental health;
Medical personnel;
Health services;
Studies;
Census of Population;
Multiculturalism & pluralism

Location United States–US
Company / organization Name:

NAICS:
Bureau of the Census
926110

Title Assessing the Needs of Rural Counselor Supervisors in Texas
Author Witt, Karl J; McNichols, Christine
Publication title Journal of Professional Counseling, Practice, Theory, & Research; Austin
Volume 41
Issue 2
Pages 15-29
Number of pages 15
Publication year 2014
Publication date Summer/Fall 2014
Section RURAL SUPERVISORS
Publisher Taylor & Francis Ltd.
Place of publication Austin
Country of publication United Kingdom, Austin
Publication subject Education
ISSN 15566382
e-ISSN 21689156
Source type Scholarly Journal
Language of publication English
Document type Journal Article
Document feature References; Tables
ProQuest document ID 1658219097
Document URL http://library.capella.edu/login?qurl=https%3A%2F%2Fwww.proquest.com%2Fscholarly-journals%2Fassessing-needs-rural-counselor-

supervisors-texas%2Fdocview%2F1658219097%2Fse-2%3Faccountid%3D27965
Copyright Copyright Texas Counseling Association Summer/Fall 2014
Last updated 2022-02-02
Database ProQuest Central

Education and Supervision (TACES). The authors thank the TACES research grant committee for their support.

Correspondence concerning this article should be addressed to Karl J. Witt. Email: [email protected]
Copyright Texas Counseling Association Summer/Fall 2014

Database copyright © 2023 ProQuest LLC. All rights reserved. Terms and Conditions

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NAVIGATING DUAL RELATIONSHIPS IN RURAL COMMUNITIES

Gonyea, Jennifer L J; Wright, David W; Earl-Kulkosky, Terri. Journal of Marital and Family Therapy; Hoboken Vol. 40, Iss. 1, (Jan 2014): 125-36.
DOI:10.1111/j.1752-0606.2012.00335.x

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Abstract

The literature examining dual relationships in rural communities is limited, and existing ethical guidelines lack guidelines about how to navigate these
complex relationships. This study uses grounded theory to explore rural therapists’ perceptions of dual relationship issues, the perceived impact of minority
and/or religious affiliation on the likelihood of dual relationships, and the ways rural therapists handle inevitable dual relationship situations. All of the
therapists who participated in the study practiced in small communities and encountered dual relationship situations with regularity. The overarching theme
that emerged from the data was that of using professional judgment in engaging in the relationship, despite the fact that impairment of professional
judgment is the main objection to dual relationships. This overall theme contained three areas where participants felt they most needed to use their
judgment: the level of benefit or detriment to the client, the context, and the nature of the dual relationship. Surprisingly, supervision and/or consultation
were not mentioned by the participants as strategies for handling dual relationships. The results of this study are compared with established ethical decision-
making models, and implications for the ethical guidelines and appropriate ethical training are suggested. [PUBLICATION ABSTRACT]

Headnote
The literature examining dual relationships in rural communities is limited, and existing ethical guidelines lack guidelines about how to navigate these
complex relationships. This study uses grounded theory to explore rural therapists’ perceptions of dual relationship issues, the perceived impact of minority
and/or religious affiliation on the likelihood of dual relationships, and the ways rural therapists handle inevitable dual relationship situations. All of the
therapists who participated in the study practiced in small communities and encountered dual relationship situations with regularity. The overarching theme
that emerged from the data was that of using professional judgment in engaging in the relationship, despite the fact that impairment of professional
judgment is the main objection to dual relationships. This overall theme contained three areas where participants felt they most needed to use their
judgment: the level of benefit or detriment to the client, the context, and the nature of the dual relationship. Surprisingly, supervision and/or consultation
were not mentioned by the participants as strategies for handling dual relationships. The results of this study are compared with established ethical decision-
making models, and implications for the ethical guidelines and appropriate ethical training are suggested.

The authors’ collective experiences of practicing in small communities led us to question how therapists in these communities handle the inevitability of dual
relationships. As we discussed anecdotes from our respective practices, it became apparent that tension exists between a client’s desire to have a familiar
therapist and the ethical standards of our field. We turned to the American Association for Marriage and Family Therapy (AAMFT) Code of Ethics for answers
about how to navigate these delicate situations. Couple and family therapists are admonished to “make every effort to avoid [dual relationships] at all costs”
(AAMFT, 2001; p. 1); however, no mention is made of how to accomplish this in settings with limited alternatives.

The issue of dual relationships in areas with limited alternatives is complicated by clients’ attempts to self-match. Self-matching occurs when clients select a
therapist who shares their attitudes, race, education, social class, and/or religion (Jones, Botsco & Gorman, 2003; Whalley & Hyland, 2009; Willging,
Salvador & Kano, 2006; Wintersteen, Mesinger & Diamond, 2005). Clients feel more comfortable discussing their lives and presenting issues when they
believe their therapist holds the same values or shared cultural experience. A large percentage of Americans living in small communities may be able to
achieve this owing to homogeneity in small communities, but not without creating ethical challenges for the therapist.

The ethical challenges for rural therapists are compounded when they also belong to a minority group. In addition to the limited number of available
therapists in a small community, there are far fewer minority therapists in general (AAMFT, 2004). Therefore, when minority clients attempt to self-match,
there is a strong likelihood that a dual relationship dilemma will be encountered.

This study aims to explore areas not previously considered in the ethics literature, paying particular attention to how therapists practicing in rural areas
navigate these complex relationships. The next section provides the foundation for this study by reviewing the unique set of circumstances and community
variables that increase the likelihood of dual relationships in rural areas and the ways existing ethical decision-making models fail to consider the challenges
of rural practice.

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CHALLENGES OF RURAL PRACTICE

Rural communities are partially defined by their isolation that forces residents to rely more heavily upon one another. Smaller communities have increased
potential for dual relationships, in general, and those between clients and therapists in particular (Erickson, 2001). Although the lack of boundaries may
seem natural and is often used as fodder for sitcoms set in small communities, in real-life, it sets the stage for dual relationship dilemmas.

For many residents, this closeness is positive and helps build identity and sense of belonging to that community in terms of Us versus Them. Therefore,
residents of rural areas are often hesitant to seek services from an outsider (Murry, Heflinger, Suiter & Brody, 2011) because they are not to be trusted,
which can lead to multiple levels of personal and professional relationships. Further, persons from rural areas may resent an outsider offering assistance
(Erickson, 2001; Jesse, Dolbier & Blanchard, 2008).

Similarly, those who belong to a religious community or a minority group may prefer professional services from someone within their group or at least from
someone who may share familiar values. Research has found that people want a therapist and they believe to be like themselves (Jones et al., 2003;
Wintersteen et al, 2005) and when clients’ ethnicity matches that of their therapist, they attend more sessions and have a greater likelihood of treatment
completion (Erdur, Rude & Baron, 2003).

Competing Ethical Principles

The absence of attention to how therapists in rural settings navigate potential dual relationships is compounded by the ambiguous and vague discussion of
dual relationships in the AAMFT Code of Ethics, which states:

Marriage and family therapists are aware of their influential positions with respect to clients, and they avoid exploiting the trust and dependency of such
persons. Therapists, therefore, make every effort to avoid conditions and multiple relationships with clients that could impair professional judgment or
increase the risk of exploitation (American Association for Marriage & Family Therapy, 2001; p. 1).

If one’s interpretation of the code is that when multiple relationship situations arise, MFTs should ensure that these relationships do not impair professional
judgment or increase the risk of client exploitation, then the dilemma is not “how to avoid dual relationships,” but “how does one tell when multiple
relationships will impair professional judgment” and “what is the obligation of the therapist in warning or explaining the dilemma to the client?”

It quickly becomes clear that the real problem is how to address inevitable dual relationships, rather than how to avoid them. Some suggestions include
openly discussing the inevitability and potential of out of session contacts between therapist and client (Faulkner & Faulkner, 1997) or having a preconceived
plan to negotiate social contacts with clients and seek immediate consultation if boundaries feel threatened (Jennings, 1992).

Rural clinicians are likely to be professionally isolated, making it difficult to obtain supervision or consultation. These clinicians may be secluded from the
mainstream of their profession and may have limited colleagues from whom they can seek support, collaboration, or supervision. Rural therapists’ sense of
isolation is also compounded by fewer opportunities for professional development, continuing education, and limited access to support services.

These collegial issues also create a challenge to maintaining client confidentiality (Weigel & Baker, 2002). A client’s confidentiality can be compromised
through the “grapevine” in small communities when the client is seen leaving the therapist’s office, parked in front of it, or even while sitting in the waiting
room. The few therapists in a rural area often have regular contact with one another, and informal conversations between providers can increase threats to
client confidentiality. Rural therapists rely on one another for professional development and resources. Withdrawing from such informal exchanges could
alienate close colleagues and leave a rural therapist with even fewer resources. Rural therapists are left with the choice between increased threats to clients’
rights to privacy or alienation of a close colleague.

Models of Ethical Decision-Making

Many ethical decision-making models suggest the following for the resolution of ethical dilemmas: (a) consulting the ethical guidelines of therapy
professions; (b) seeking supervision or consultation with peers; (c) creating a pros and cons list to determine the possible consequences and/or alternative
courses of action; or (d) some combination thereof (Corey, Corey & Callahan, 1998; Erickson, 2001; Forester-Miller & Davis, 1996; Smith & Smith, 2001;
Steinman, Richardson & McEnroe, 1998; Tarvydas, 1998; Welfel, 1998). As noted previously, these guidelines may not provide enlightenment because they
are ambiguous and require interpretation, the very foundation of the original dilemma!

Few existing models specifically refer to issues of power and maneuverability, that is, the roles and positions therapists take with clients. The professional
guidelines assume therapists hold the position of power when interacting with clients. Yet, depending on the nature of the out-of-session contact, the client
may occupy a powerful position in the relationship. In a unique acknowledgment of potential limitations to both sides of a dual relationship, Haas and Malouf
(1995) suggest therapists ask themselves and their supervisors specific questions prior to engaging in a potential dual relationship. For example, how might
engaging in the dual relationship inhibit clients’ ability to make autonomous decisions; how might the therapist acknowledge his or her privileged position in
the relationship; will the dual relationship affect the therapist’s ability to intervene effectively and congruently. The suggested questions imply that the
therapist is able to conceive a number of alternatives and have insight into multiple perspectives on the situation, yet the inability to do so when interacting
with friends and relatives is precisely why dual relationships are discouraged.

Most ethical decision-making models assume that therapists have equal access to professional resources across community types (rural compared to urban).
In fact, models ignore the existence of barriers to obtaining supervision and consultation in rural areas even though the limited availability of these in small
communities has been well documented (Weigel & Baker, 2002). None of the models reviewed suggest alternatives to supervision or ways of navigating a
dual relationship if, indeed, it is unavoidable. The potential consequences to seeking consultation with peers or feedback from supervisors in rural
communities are also not addressed in the ethical decision-making models reviewed for this study.

Clearly, one model or set of ethical standards does not encompass all possible dual relationship dilemmas or all the factors contributing to it. Therefore, a
more comprehensive exploration of the processes through which clinicians make ethical decisions is called for. To meet that goal, this study specifically
examines (a) the ways rural therapists perceive dual relationships and the resulting impact on clinical practice; (b) the strategies clinicians believe they
employ to negotiate dual relationships; and (c) the perceived influence of minority or religious affiliation on dual relationship situations.

METHOD

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Design of the Study

This study used a naturalistic paradigm to explore the experiences of therapists in rural settings. Among Fincoln and Guba’s (1985) naturalistic paradigm
axioms, several were relevant here: (a) realities are multiple, constructed, and holistic; (b) the knower and the known are inseparable; therefore, the
participant and researcher influence one another; (c) generalization is only possible through the formulation of working hypotheses that are context and time
specific; and (d) unlike traditional inquiry that is value-free, the naturalist paradigm states that inquiry is value-bound by the choice of the problem, theory,
and context.

This study sought to explore how rural therapists interpreted the AAMFT ethical guidelines as they made decisions about whether to have dual relationships
with the clients they served. Their experiences then constituted multiple realities and, while tied professionally to the ethical guidelines, their interpretation
of the guidelines allowed the therapist to construct their understanding and approaches to ethical dilemmas of dual relationships. This qualitative approach
allowed for an emphasis on the participant’s view (Creswell, 1998) of their experience of dual relationships in rural areas and how they navigate such
situations. Specifically, the present study questions how the experience of dual relationships decision-making is handled when the therapist’s professional
supports are limited.

Description of Participants and Selection Process

Participants were Clinical and Associate members of an AAMFT Division in the Southeast practicing in rural areas. Rural areas were selected using the
categories of urbanicity established by Bachtel (2004) at the county level: Urban, Suburban, Rural Growth, and Rural Decline. Approximately, 50 members
were in the pool of potential participants.

Once the purposive sample was drawn from the current listing of active members of the Division, participants were contacted via telephone based on
information provided in the Division directory. After providing verbal consent, telephone interviews were conducted. Multiple researchers were involved in
gathering the data through phone interviews, and this served as one of the forms of investigator triangulation (Denzin, 1978). Attempts to contact the 50
members were made, and six therapists participated in the phone interviews. Some participants expressed a desire to have more time to reflect on the
questions. The researchers experience confirmed that additional data collection methods could provide more respondents and richer data. Therefore,
researchers decided on an additional data collection method, which would be to collect data at the annual Division Spring Conference.

Conference attendees self-selected to participate in the study after hearing it described and announced. An additional screening by the authors was used to
ensure that participants met the criteria established at the outset of the study. Attendees were provided consent forms and study questions on the first day
of the conference and asked to return both by noon on the last day. This ensured that participants were able to reflect on their experiences and practices to
give as detailed explanations as possible. Participants provided information about the population size in their practicing area and completed survey forms
where they provided demographic information such as age, race, type of practice, and length of practice. In addition, participants provided their perception
of the degree to which their minority or religious affiliation influenced requests for therapeutic services from acquaintances in other settings, and how they
make decisions in response to these requests.

Between telephone interviews and the annual Division conference, fifteen therapists provided data for this study. Of these, five self-identified as African
American, one self-identified as racially mixed (Caucasian and Phillipina), and the remaining nine participants self-identified as Caucasian. Participant ages
ranged from 29 to 60; however, most participants reported having been in practice for over 20 years. All practiced in areas designated as rural according to
Bachtel (2004). Participants practiced in either private (N = 6) or public settings (N = 6), while three practiced in both types of settings. Seven participants
practiced in catchment areas whose populations were 20,000-50,000, six practiced in catchment areas whose populations were 50,000-100,000, and two of
the participant’s catchment areas were over 100,000 people. Some worked in communities that served more than one county, or in counties that served
multiple cities.

A detailed description of participant demographics is provided to illustrate several considerations regarding the results. First, the participants in this study
represent very experienced clinicians, the majority having practiced more than 20 years. The perception of one’s ability to navigate complex dual
relationships may be related to a sense of clinical competency evident in an experienced sample. Second, how long clinicians had lived in their rural
community is unknown, a factor that may influence the likelihood of dual relationships. And lastly, most of the participants worked at least part time in public
settings where they may or may not have control over the decision to see the a client known in another setting.

Data Analysis

An interview guide (see Appendix A) was developed with open-ended questions that invited the participants to convey their experiences with dual
relationships in rural communities. This interview guide provided a common set of questions for all participants, and left room to explore new areas that
might emerge. Data were analyzed using a sorting procedure that calls for searching for what Wolcott (1994) terms patterned regularities in the data. We
looked for common themes and patterns of behavior that would give an understanding of the experiences of the participants. Participant responses were
then compared with the suggested procedures for ethical decisionmaking reported earlier.

Our analysis process was guided by grounded theory (Charmaz, 2002; Glaser & Strauss, 1967); a qualitative methodology used with the goal of finding new
theory or emerging themes in phenomena studied. This method seemed most appropriate to the limited understanding of how dual relationship dilemmas
are handled by clinicians when such dilemmas are frequent or inevitable. Consistent with a grounded theory approach, data collected from the first interview
were compared with data from the second interview, and this process of comparison was repeated with each data collection (Strauss & Corbin, 1998).

Each phone interview was transcribed by the research interviewer, and non-phone written interviews were reviewed. The interviewers (J.G. and T.K.)
recorded notes immediately following the data collection. These process notes included clarification questions asked, information on the date and type of
contact, insights, questions, and connections to other responses.

The research investigators then carefully examined the data and completed the task of comparison, developing new categories relative to the answers. Open
coding methods (Charmaz, 2002) were used to organize the data, and initial categories were developed. Themes emerged from the categories and
subcategories as data analysis continued. These themes are discussed in detail in the results section that follows.

Trustworthiness and Credibility

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To ensure trustworthiness (Merriam, 1998) and credibility, qualitative terms that are similar to reliability and external validity, we used detailed descriptions
of the research methods and credibility audits to review the research methods, interviews, and findings. A licensed marital and family therapy (MFT), who
has practiced for more than 20 years, served as an internal auditor of the data to open code the data from the interviews and written responses. In addition,
an external auditor (2nd author) reviewed all drafts of the results to verify that the categories and themes were consistent with the interviews.

Transferability, the degree to which a study can be applied to other contexts by different researchers, was established by providing detailed information about
the participants and contextual factors that may be relevant to future research efforts. For example, the Appendix A reports the guiding questions used and
the demographic information, such as practice setting, catchment population, and years in practice are reported in the following section.

RESULTS

Although interviews varied somewhat, participant responses reflected the inevitability of dual relationships in rural areas, consistent with the existing
literature. As expected, a common experience among participants was receiving referrals for persons that they knew in other settings on a frequent or
occasional basis. Also as expected, participants received referrals based on religious and minority affiliation, although most of these were based on religious
as opposed to minority affiliation.

Similar themes emerged across clinicians in terms of how they handled potential dual relationship situations. The therapists who participated in this study
universally referred the potential client elsewhere when the referral was well known. Among those that made referrals to avoid the dual relationship, they
took care to explain the dual relationship dilemma to clients in order to preserve the existing relationship and ease the transition to a trusted colleague. For
example:

The most common type of referral comes from my church. I usually refer them on and explain the problem inherent in dual relationships. Generally, people
are clueless about this [dual relationships] issue and appear disappointed but do okay once they get started with a colleague.

Even among those who reported engaging in the relationship initially, all stressed the importance of evaluation and assessment at the beginning of therapy.
For example, several participants engaged in two to four sessions during which they assessed the clients’ needs, their own ability to meet those needs, and
the likelihood that the therapeutic relationship might violate the ethical guidelines by potentially “exploiting the trust and dependency of such persons” or
“impair professional judgment or increase the risk of exploitation” (American Association for Marriage & Family Therapy, 2001; p. 1). One participant
reported engaging in the relationship:

depending on my conversation with the referral, for a 3 or 4 session evaluation with the clear understanding that I may make a referral, continue to see the
client myself, or have a professional consultant in the fourth session to help us decide the appropriate next phase.

Strategies for Handling Dual Relationships

During the open coding procedure, responses developed into the overarching theme of professional judgment which contained three areas where participants
felt they most needed to use this judgment: (a) level of benefit or detriment to the client; (b) the context; and (c) the nature of the dual relationship.

Professional judgment. Whether explicit or implied, participants’ approach suggested they had used professional guidelines as the source of their decision-
making. One participant discussed the “limits of therapy,” while another came to an agreement that “boundaries will be kept” with the clients with whom he
or she entered into a dual relationship. Elaborating on how boundaries were kept, one participant stated:

NOT discussing client info with staff. When necessary for support, speak vaguely to the school counselor. Make it clear to students and any others I see in
community that I do not/will not identify them seek them out in public social settings. I also make it clear that I do not/will not identify other clients-or talk
about them any professional relationship to anyone. Clarity around boundaries is extremely important in maintaining them.

Several participants appeared to use a strict interpretation of the AAMFT ethical guidelines concerning therapy with persons known from other contexts,
unequivocally stating that they would refer the client elsewhere based on their understanding of “making every effort to avoid … multiple relationships”
(American Association for Marriage & Family Therapy, 2001; p. 1). These participants did not disclose any conditions under which they would agree to
conduct therapy with persons known from other contexts.

Professional judgment is a broad category and precisely the aspect of navigating complex relationships that this study was undertaken to explore. When
prompted about how they used their professional judgment, participants elaborated on how they make the decision to refer the client or engage in the dual
relationship. Participants were aware of the people or groups with whom they are most experienced or those the therapist felt most competent in helping and
with whom they were most likely to engage in therapy: one partipant reported, “I know I work best with couples, single adults of adolescents, not children
and not addictive adults.” Several noted the client’s need for treatment, the severity of the presenting issue, intake information, or expertise in couples
versus family work as issues to consider when deciding to take the case. For example, when participants felt that the client needed immediate intervention
and making a referral might delay treatment, they were more willing to engage in a dual relationship. In this case, ensuring that the client received timely
therapy was temporarily prioritized over the admonishment to avoid a dual relationship.

The remaining three emergent themes reflect specific aspects of the dual relationships decisionmaking articulated by participants. Although participants used
their professional judgment in each of these areas, they were specific enough to warrant separate elements.

Level of benefit or detriment to client. Promoting clients’ well-being was a factor in most decisions therapists’ decision-making in their clinical practice.
Specifically, they used their judgment about the degree of benefit to the client when deciding whether or not to engage in a dual relationship: one stated
“professional judgment and instinct regarding my ability to be helpful to the client.” In the words of one participant, he or she was aware of the potential
“negative impact of a dual relationship” on the clients well-being and the existing relationship. Despite this sentiment, many participants specifically
mentioned that the dual relationship was a lesser concern than promoting client safety. For example, one therapist would “suggest another referral unless an
emergency or crisis is presented.”

Another aspect of benefit to the client used as a deciding factor in engaging in the dual relationship was whether or not the client would not have sought
therapy. A participant provided an example of such a circumstance:

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I have made one exception and accepted a client who told me she checked me out carefully at church and would otherwise not go to another therapist. She
disclosed a ritual abuse history and indicated a need to feel safe first since some of her abusers were trusted people in positions of authority.

For this therapist, engaging in the relationship meant the particular client was able to receive services. Other participants’ responses suggest that they use
their judgment about what the client needs and what they can offer at that time as means of determining whether or not to pursue the dual relationship.

Context. Participants indicated concerns about the context within which they knew the potential client. One participant differentiated between contexts such
as “church affiliate versus friend,” while another made the distinction between “whether I know them personally or professionally” as influential factors in
their decision to pursue a therapeutic relationship or refer a client to another therapist. Participants were more willing to conduct therapy with a professional
associate than with a personal associate. A few were very specific in their understanding of a need to keep personal and professional relationships separate,
responding “I would not see someone with whom I have a personal relationship” or “I don’t see family members of friends or acquaintances.” Others made
decisions based on a more graduated sense of the personal acquaintance. One participant considered taking the case of someone with whom he or she had a
professional relationship to be unlikely to impair professional judgment or exploit clients and therefore upholding the ethical standards of the field. Another
participant noted receiving referrals from a sister program and would engage in the dual relationship in the interest of “continuum of care.”

Therapist participants were more likely to engage in the dual relationship if he or she has expertise with a particular population or presenting issue that was
otherwise unavailable in the area, in part out of the belief that the particular treatment the therapist offers is unique and that it would be an undue hardship
to the client to pursue this unique help elsewhere. For example:

Trauma using Eye Movement Desensitization and Reprocessing (EMDR) is my specialty -if it is a very slight acquaintance (i.e., plumber, workman, etc) I
would have to think about it as I am, to the best of my knowledge, the only one using EMDR.

Nature of relationship. The nature of the relationship was considered a separate theme from that of context and was based on a distinction between type of
relationship (context) and the level of intimacy or closeness in the relationship with a client (nature of the relationship). Examples from responses include the
influence of “the degree of interaction outside therapy,” “if I do not have an intimate relationship with them I will see them,” and “if I know we will socialize I
will refer” as more intimate levels of contact with potential clients that would preclude a therapeutic relationship. Participants distinguished between a high
level of intimacy (personal relationships) and low levels of intimacy (professional relationships) and considered high levels of intimacy to be a barrier to a
successful therapeutic relationship. Participants defined knowing someone “well” in one or more of the following ways: (a) persons with whom they
socialized; (b) persons with whom their children played; (c) friends; (d) family members/acquaintances of friends; (e) students where a spouse works; and
(f) sharing a specific activity.

Participants might engage in a professional relationship with someone known from the gym or an exercise class owing to the low levels of intimacy involved,
but they were aware of their influential positions and potential likelihood of their impaired professional judgment when the current relationship was one
where there was a high frequency of contact and a high degree of intimacy, such as a through a Bible study group or book club.

DISCUSSION

The strategies participants used to determine whether or not to refer a potential client reflect several aspects of the ethical decision-making models
reviewed, although they did not use any model in its entirety. The four strategy themes derived from participant responses are present in some of the ethical
decision-making models previously outlined. Conversely, seemingly, important aspects of the models are absent from participant responses and discussed
below.

Professional Judgment

Despite the underlying assumptions about the inherent risks to judgment in a dual relationship, the primary tool for navigating the complexity of a dual
relationship among our participants was the use of their professional judgment. Consistent with the question posed in the conceptualization of this study,
therapists practicing in small communities appear to be aware of this integral conflict and ask themselves, “How do I tell when multiple relationships will
impair my professional judgment?” These results indicate that therapists are intentional in handling potential dual relationships to minimize the impact on
their ability to effectively manage the therapy process.

Although not explicitly stated in any of the models reviewed for this study, virtually all of them imply using professional judgment. Several advise generating
a list of potential courses of action along with the possible consequences of these actions (Corey et al, 1998; Forester-Miller & Davis, 1996; Smith & Smith,
2001; Steinman et ah, 1998; Tarvydas, 1998; Welfel, 1998). The results of this study add to the ethical decision-making literature and supplement the
AAMFT Code of Ethics by indicating specific aspects of the therapeutic relationship therapists in practice should consider when exploring courses of action and
their consequences, for example, judgments about client motivation, the therapists’ ability to be helpful to the client, the potential for triangulation, and the
three specific themes discussed below.

Level of Benefit or Detriment

It is clear that dual relationships are discouraged, yet therapists may engage in them anyway if they believe it will yield more benefit than harm for the
client. A therapists’ main goal is for clients to grow, improve, and heal. Toward this end, therapists were intentional in assessing the potential harm to the
client and the probable benefits.

This theme reflects the models that suggest therapists weigh the potential risks and benefits to seeing the client. Only Gottlieb (1993) proposes discussing
with the client the potential consequences or what their relationship posttherapy might entail should they engage in the dual relationship. The majority of
attention is focused on how contact outside of sessions prior to and during therapy might impede the therapeutic process. Posttherapy contact is particularly
important for those practicing in a small community where the likelihood of such contacts in the community is very high.

Haas and Malouf (1995) suggest therapists ask themselves to reflect on their ability to be helpful. It is a therapist’s obligation to best meet the needs of their
client, but also their prerogative to refuse cases when they are not able to meet those needs. For example, if a therapist realizes that she would be limited in
what issues she can address and how she can address them, she might not be able to provide quality therapy and would consider discussing that with the
clients. An important point for consideration is that the results of this study indicate that therapists practicing in small communities may not feel they have
the same latitude to refuse a case when the assessment of the situation suggests that the client would be more harmed by their refusal.

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Kitchener’s (1988) model also addresses power, but through the understanding of the different roles, one might have in dual relationships. For example, one
partner in a couple’s session is the principal of the school the therapist’s child attends. In session, the therapist may be perceived as having power. During
interactions with the school, the principal is clearly in a position of power, not only with the therapist, but also her or his child. Therapists who practice in
small communities are well aware of these types of power dynamics and considered them in assessing the level of benefit or detriment to the client as well
as the context and nature of the relationship discussed below. Context and Nature of the Relationship

The models reviewed herein do not attend to contexts in which decisions are made about ethical dilemmas. The lack of distinction between contexts may
lead to the assumption that all out of session contacts between client and therapist are equally problematic to the process and outcome of therapy. The
therapists in this study felt that there are differences between types of relationships (context) and the levels of intimacy (nature of the relationship) inherent
in the different types.

Most therapists have encountered a client outside of therapy, either at the grocery store, the dry cleaners, or a physician’s office. Usually these meetings are
unexpected and spontaneous. In the case of a dual relationship, the assumption is that meetings outside of therapy are expected and at times may even be
regular, as in the case of a fellow parishioner. A consistent theme in the responses of the participants reflected an attempt to understand the context and the
nature of the relationship between therapist and client outside of the therapy room, or in other words, attempt to determine the regularity with which they
might see one another and the quality of their out of session relationship, consistent with the models proposed by Smith and Smith (2001) and Gottlieb
(1993).

This is an important point because the limited number of couple and family therapists who represent cultural or religious minorities is likely to present an
increased potential for dual relationships as clients attempt to self-match. This is underscored by a survey of AAMFT membership (2004), which reported that
the overwhelming majority of their members reported being White/ NonHispanic (93%: n = 2236) with approximately only 2% of respondents falling in each
of the following groups: African American, Hispanic/Latino, Asian, American Indian, and Other/Prefer not to answer.

The energy and attention necessary for handling a dual relationship is usually greater than that of another client. The therapist participants acknowledged
this additional investment by considering whether or not they actually have enough time to handle such a case and its unique circumstances. This very
specific, and practical consideration is not present in the reviewed models. In fact, a number of everyday impediments to rural practice are not mentioned in
the models, but should be added to the list of practical obstacles to rural practice.

Supervision and/or Consultation

The literature on ethical dilemmas in rural areas notes the increased likelihood of encountering dual relationships and limited access to supervision. Two
points strongly reflected in the results of this study; one through its prominence and the other through its absence. The rural therapists in this study
generated the same concerns and issues that are represented in the literature regarding the increased potential for dual relationships. Study participants
received referrals or were sought out by persons known to them in other settings and that these referrals came from a number of community sources: fellow
church members, family members of friends, parents of children’s classmates, persons with whom spouse has a professional relationship, and persons with
whom the therapist has a professional relationship (e.g., dentist, plumber, other therapist).

Notably, absent in participants’ responses was mention of bringing these dual relationship issues to supervision to reflect on the potential consequences;
however, it is unclear whether the availability of supervision is limited in the areas where participants practice or whether the participants do not consider
supervision as one of the tools useful in navigating dual relationships. As noted earlier, one participant did report using a consultant “in the fourth session to
help us decide the appropriate next phase.” This participant used consultation as part of the therapeutic decisionmaking process rather than as a means of
determining, a priori, potential problems associated with the dual relationship or as feedback in maintaining healthy boundaries in an ongoing dual
relationship. Although intended to clarify the dual relationship, it is equally likely that the use of a consultant, a role different from a supervisor, may create
an additional dual relationship that rural therapists must navigate.

A lack of supervision and consultation opportunities may possibly contribute to ethical concerns resulting from limited access to clinical resources.
Suggestions for therapists to remedy this concern and obtain supervision have included group, telephone, and Internet supervision, yet each presents
problems (Kanz, 2001; Weigel & Baker, 2002). For group supervision, practitioners from rural areas may have to drive several hundred miles to receive
supervision or risk discussing a client with whom someone else in the group has a relationship. Telephone supervision provides one option for supervisees
who may be geographically isolated, but there are still some ethical considerations. Sending recorded sessions in the mail increases threats to confidentiality;
cell phones are an insecure method of discussing client information that could potentially be intercepted, and the amount of time and expense to send
recordings via postal service may be prohibitive. The availability of Internet supervision is alluring, yet presents concerns about (a) divulging confidential
information over an insecure mode of communication; (b) the difficulty in obtaining informed consent from clients for this type of supervision; (c) the
importance of nonverbal cues of the therapist, supervisor, and client; and (d) liability and licensure issues when Internet supervision takes place across state
lines (Kanz, 2001).

CONCLUSION

An objective of this study was to gather data to illustrate the complexities of dual relationships in rural areas. The overwhelming majority of the rural
therapists who participated in this study did face the dilemmas of dual relationships. Indeed, most had fairly well-established strategies for handling these
relationships both before and during treatment.

The hope is that this research will foster a better understanding of the complexities of dual relationships in rural areas as well as support further research in
this area. The results of this study may serve to clarify ethical guidelines around dual relationships in both the literature and practice. The qualitative
exploration utilized in this study allowed the researchers to begin to understand the way therapists think about their process for ethical decision-making.
Follow-up interviews with therapists who are in the process of evaluating a dual relationship situation in their rural communities would greatly enhance our
understanding of the practice of ethical decision-making. Also, interviews focusing on the themes derived from this study would address the multiple
obstacles to confidentiality and maintaining therapeutic boundaries in small communities.

The implications of this study are significant: it seems clear that the nature of these relationships is more than duality. Participants noted that whether a
relationship is personal or professional, the types of boundaries regulating it, and the context of out-of-session contacts as important factors in making
ethical decisions. The consideration of these factors in decision-making reflects the reality that dual relationships are inevitable in small communities and

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places more emphasis on evaluating the process of therapy than on the duality. In the words of one participant, “I live in a community of 5,000-if I am going
to work, I must navigate these crossovers.”

This has implications for MFT training programs’ curriculum regarding AAMFT ethical guidelines and the ethical guidelines in general. The current guidelines
do not address the process for decision-making with regard to dual relationships. Programs can help therapists in training develop a more introspective and
less legalistic decision-making process, which would address the complexity of mitigating factors and provide an opportunity for them to explore their own
biases in a supportive environment.

Clients want to be in relationships with people like themselves and often look for therapists that they believe have similar values or experience.
Unfortunately, in rural communities where the pool of available therapists is often limited, practicing therapists have little guidance in how to make an ethical
decision because of the ambiguity of the ethical guidelines and the neglect of the challenges to rural practice in existing ethical decision-making models.
These therapists may also have difficulty navigating complex dual relationships because there are few opportunities for supervision in their communities.
Instead, they learn to rely on their professional judgment about the level of benefit or detriment to the client and therapeutic relationship and the context
and the nature of the relationship as they make their decisions about engaging in it.

References
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AuthorAffiliation
Jennifer L. J. Gonyea and David W. Wright

The University of Georgia

Terri Earl-Kulkosky

Fort Valley State University

AuthorAffiliation
Jennifer L. J. Gonyea, PhD, is a Lecturer and Undergraduate Coordinator, Department of Child and Family Development, The University of Georgia and in
practice at Samaritan Counseling Center of Northeast Georgia, Athens Georgia; David W. Wright, PhD. is an Associate Professor, Department of Child &
Family Development, The University of Georgia, Athens, Georgia; Terri Earl-Kulkosky, PhD. is an Assistant Professor, Department of Behavioral Sciences, Fort
Valley State University, Fort Valley, Georgia.

This research was made possible through consultation with Edwin Risler, PhD (Athens, GA) and the Georgia Association for Marriage and Family Therapy
Board and members.

Address correspondence to Jennifer L. J. Gonyea, Department of Child and Family Development, The University of Georgia, Dawson 123, Athens, Georgia
30602; E-mail: [email protected].

Appendix
AAPPENDIX

GUIDING INTERVIEW QUESTIONS FOR CLINICIANS

The following questions were used as a guideline during phone interviews and distributed to participants at the annual Division Spring Conference for review.
The researchers gave a brief description of the purpose of the study and a consent script, either at the beginning of the interview or in writing for those
recruited at the Division Conference.

1. I am interested in knowing more about your experiences as a family therapist practicing in a small community. Do you receive referrals for clients that you
already know from another setting?

a. (If yes) Flelp us understand how you think about these referrals? (factors you consider, type of relationships, specific examples).

2. What are the settings that you might know some of these referrals from?

3. Describe how you respond to these requests for therapy from people you already know? (Appropriate follow-up questions as needed to understand the
factors.)

4. What influences your decision to see the client? (Appropriate follow-up questions as needed to understand the factors.)

5. What influences your decision to refer the client? (Appropriate follow-up questions as needed to understand the factors.)

6. Tell us about a time you received a referral from your religious or minority community?

a. Which affiliation?

b. How do you think knowing the person/family impacts your ability to conduct therapy with the person or family?

7. What is your perception of how often you get referrals based on this affiliation?
Copyright Blackwell Publishing Ltd. Jan 2014

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Details

Subject Decision making;
Rural areas;
Therapists;
Professional ethics;
Regions

Title NAVIGATING DUAL RELATIONSHIPS IN RURAL COMMUNITIES
Author Gonyea, Jennifer L J; Wright, David W; Earl-Kulkosky, Terri
Publication title Journal of Marital and Family Therapy; Hoboken
Volume 40
Issue 1
Pages 125-36
Number of pages 12
Publication year 2014
Publication date Jan 2014
Publisher Blackwell Publishing Ltd.
Place of publication Hoboken
Country of publication United Kingdom, Hoboken
Publication subject Social Services And Welfare, Matrimony, Psychology, Sociology
ISSN 0194472X
e-ISSN 17520606
CODEN JMFTDW
Source type Scholarly Journal
Language of publication English
Document type Feature, Journal Article
Document feature References
DOI https://doi.org/10.1111/j.1752-0606.2012.00335.x
Accession number 25059416
ProQuest document ID 1501475688
Document URL http://library.capella.edu/login?qurl=https%3A%2F%2Fwww.proquest.com%2Fscholarly-journals%2Fnavigating-dual-

relationships-rural-communities%2Fdocview%2F1501475688%2Fse-2%3Faccountid%3D27965
Copyright Copyright Blackwell Publishing Ltd. Jan 2014
Last updated 2023-02-23
Database ProQuest Central

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