The practice of psychology in rural areas offers unique challenges for psychologists as they try to provide optimal care, often with a minimum of resources. Psychologists are frequently required to be creative and flexible in order to provide effective services to a wide range of clients. However, these unique challenges often confront psychologists with ethical dilemmas and problems for which their urban-based training has not prepared them. The author examines how certain characteristics of rural communities may lead to specific ethical dilemmas. By being a part of a small community, psychologists will inevitably face multiple relationship dilemmas. Confidentiality is harder to maintain in a small town, particularly with its informal information-sharing network. To provide services to meet community needs, with a limited number of referral options, psychologists typically need to be generalists. This may lead to concerns about scope of practice, training, and experience with diverse populations. Psychologists also face other competency issues, such as a lack of supervision and consultation resources. Other concerns addressed include the psychologist's personal life, and the blurring of professional and personal roles. Suggestions are made for coping with each of these ethical issues, although more quantitative research and discussion are needed on the practice of psychology in rural areas.

This study examines ethical dilemmas and problems that are encountered by psychologists across rural and urban communities. A survey instrument was created on the basis of previous surveys of ethical practices. A national sample of 1,000 psychologists stratified into urban and nonurban practitioners was surveyed; 447 usable surveys were returned. Data analysis revealed significant differences between small town/rural and urban/suburban groups for several ethical categories. Notably, small town/rural psychologists are more likely to encounter several types of multiple relationships than their urban counterparts. Small town/rural practitioners are also more likely to be highly visible, or well-known, in their communities. Qualitatively, respondents described their struggles with dual relationships, and several offered suggestions to cope with boundary issues. These findings suggest the need to study the practice of psychology in rural communities in more depth, to study the impact of rural characteristics on clients and practitioners, and to create a conceptual model of best practices for rural practitioners.

Ethical dilemmas and boundary challenges are parts of daily life for psychologists who live and practice within small communities. Although rural psychologists are most readily identified as "small-community psychologists," there are a number of other settings that can be considered small communities-colleges, communities of color/ethnicity/culture, lesbian/gay/bisexual/transgender (LGBT), military, faith-based, feminist, criminal justice and corrections, suburban, disability, deaf/hearing impaired, chemical dependency, school districts, sport psychology, graduate training programs, and therapists who see other therapists as clients. Psychologists in these small communities strive to balance a traditional individualist perspective with a need to participate in and contribute to the overall wellness of the community in which they live and work. The 3 invited commentaries provide additional depth through their perspectives on rural, LGBT, and Latina/o community practice. Their insights model thoughtful and contemporary practice that challenges, enriches, and educates the larger field of ethical psychological practice.

The purpose of this study was to examine potential differences in the practice of psychology across urban and rural communities. The review of the rural literature suggests that psychologists in rural areas are likely to encounter numerous ethical dilemmas and problems that are related specifically to the characteristics of such communities. To date, however, much of this literature has been based on theory and the individual experiences of practitioners. This study sought to quantify any differences in the practice of psychology across communities for such ethical issues as multiple relationships, competency, burnout, confidentiality, and visibility in the community. A survey instrument was created based on previous surveys of ethical practices. A national sample of 1000 psychologists, stratified into urban and non-urban practitioners, was obtained from the American Psychological Association. After several mailings 447 usable surveys were returned. Data analysis revealed significant differences between urban/suburban and small town/rural groups, particularly for the dependent variables of multiple relationships and visibility. Significant differences were found across gender such that male psychologists are more likely than female psychologists to engage in a range of multiple relationship behaviors, and female psychologists are significantly more likely to make use of support from supervisors, colleagues, family and friends. Psychologists in private practice are significantly more likely than those in institutional settings to engage in multiple relationships, to find their work satisfying and rewarding, and to have control over their work environment; whereas practitioners in institutional settings are more likely to have support from colleagues and supervisors, and to work when too distressed to be effective. Psychologists with more experience are significantly more likely to engage in multiple relationship behaviors than those with less experience. Psychologists with a psychodynamic orientation are more likely to make use of supervision and to discuss case work with colleagues than other orientations. The most common concern listed, across community type and gender, is a lack of alternative referral sources. Results from this survey are compared to previous surveys of ethical practices. Qualitative results are categorized and discussed. Suggestions are made for future research based on these findings.

Findings from the current study indicate that sertraline is efficacious in the treatment of bulimia nervosa. A double-blind controlled trial of sertraline is recommended for future research.