Challenges and Ethical Implications in Rural Community Mental Health: The Role of Mental Health Providers

Abstract

This manuscript reviews the unique challenges, barriers, and ethical implications of providing mental health services in rural and underserved areas. Community mental health centers in rural areas are often underserved due to shortages of mental health providers and limited resources. Individuals living in rural areas are at increased risk of developing mental health condition with limited access to mental health clinicians and healthcare facilities. These access to care issues are often exacerbated by geographical barriers as well as social, cultural, and economic challenges. A rural mental health professional may encounter several barriers to providing adequate care to individuals living in rural areas. For example, limited services and resources, geographic barriers, conflict between professional guidelines and community values, managing dual relationships, and challenges pertaining to confidentiality and privacy are several barriers to providing adequate care in rural areas. We will briefly summarize the primary ethical domains that are especially influenced by rural culture and the complex responsibilities of mental health providers in rural areas including barriers to care, crisis intervention, confidentiality, multiple relationships/dual roles, limits of competency, and rural mental healthcare practice implications.

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FRESH FOCUS
Community Mental Health Journal
https://doi.org/10.1007/s10597-023-01151-9
evidence-based or promising practice models, and improve
health outcomes and community impact. The APA Com-
mittee on Rural Health seeks to increase awareness of the
unique ethical challenges and considerations that are inher-
ent to the practice of psychologists and mental health pro-
viders working in rural, remote, and frontier regions (herein
referred to inclusively as “rural”).
Despite the high number of individuals living in rural
areas, rural areas face shortages of mental health profession-
als and services (Bureau of Health Workforce, 2021), with
this access to care crisis being well documented (Jameson
& Blank, 2007; Moore, et al., 2010). Heightening this crisis,
individuals residing in rural areas have been found to be
more likely than urban residing individuals to experience
a mental health condition (Rural Health Information Hub,
2019a). Recent studies reveal that rural populations also
have higher suicide rates than urban areas, with the suicide
rate among rural farmers being 3.5 times higher than the
general population (Eisenreich & Pollari, 2021; Steelsmith,
et al., 2019).
The coronavirus pandemic (COVID-19) is also a sig-
nicant stressor in many people’s lives. In a recent study,
half (53%) of rural adults have stated that COVID-19 has
According to the U.S. Department of Agriculture, approxi-
mately 46 million people, or 14% of the United States popu-
lation, live in rural areas within the United States (Dobis,
et al., 2021). Several national associations have shed light
into the unique healthcare needs of rural communities in the
United States, such as the Rural Health Network Develop-
ment Program and the American Psychological Associa-
tion (APA) Committee on Rural Health. The Rural Health
Network Development Program is funded by the United
States Health Resources & Services Administration, with
overarching goals that address rural community needs
such as improve access to care, utilize and/or adapt an
Amanda Palomin
Amanda.palomin01@utrgv.edu
1 Department of Psychological Science, University of Texas
Rio Grande Valley, 1201 W. University Dr, Edinburg,
TX 78539, USA
2 Manakai O Malama, Hawaii, USA
3 Cabin Creek Health System, Charleston, WV, USA
4 School of Medicine, Department of Psychiatry, The
University of Texas Rio Grande Valley, Edinburg, USA
Abstract
This manuscript reviews the unique challenges, barriers, and ethical implications of providing mental health services in
rural and underserved areas. Community mental health centers in rural areas are often underserved due to shortages of
mental health providers and limited resources. Individuals living in rural areas are at increased risk of developing mental
health condition with limited access to mental health clinicians and healthcare facilities. These access to care issues are
often exacerbated by geographical barriers as well as social, cultural, and economic challenges. A rural mental health
professional may encounter several barriers to providing adequate care to individuals living in rural areas. For example,
limited services and resources, geographic barriers, conict between professional guidelines and community values, man-
aging dual relationships, and challenges pertaining to condentiality and privacy are several barriers to providing adequate
care in rural areas. We will briey summarize the primary ethical domains that are especially inuenced by rural culture
and the complex responsibilities of mental health providers in rural areas including barriers to care, crisis intervention,
condentiality, multiple relationships/dual roles, limits of competency, and rural mental healthcare practice implications.
Keywords Rural population · Ethics · Mental health practice · Barriers
Received: 23 February 2023 / Accepted: 27 May 2023
© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2023
Challenges and Ethical Implications in Rural Community Mental
Health: The Role of Mental Health Providers
AmandaPalomin1· JulieTakishima-Lacasa2· EmilySelby-Nelson3· AlfonsoMercado1,4
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Community Mental Health Journal
impacted their mental health, while two-thirds state that
they are experiencing more mental health challenges now
as compared to a year ago (American Federal Bureau Fed-
eration, 2020). Recent ndings highlight that mental health
treatment disparities exist during COVID, such as rural resi-
dents receiving less outpatient treatment than residents from
large metropolitan areas (Lin, Pham, & Hser, 2023).
Additionally, mental health treatment disparities were
also found to exist amongst race/ethnic minorities. The
consequences of limited access to health care for rural indi-
viduals are exacerbated by geographical barriers as well as
social, cultural, and economic challenges (Nelson, 2009).To
better understand rural communities, it is important to know
there are several common characteristics that identify a rural
area: (a) small populations and long distances to rural medi-
cal centers, (b) potential overlapping of personal and pro-
fessional relationships between community residents and
health care providers, (c) limited availability of health care
access, (d) limited transportation, (e) strong sense of self-
reliance and independent thinking from residents, (f) shared
values and culture of the residents, (g) limited rural ethi-
cal resources and (h) stigma towards mental health services
(Bushy, 2009). These characteristics also act as barriers that
hinder access to mental health treatment.
Within these barriers include lack of transportation, lim-
ited nances, lack of insurance, and limited awareness of
services (Brenes, et al., 2015; Jensen, et al., 2020). Commu-
nity mental health centers (CMHC) facilitate community-
based outpatient mental health services to both children and
adults. Frequently, CMHC’s predominantly provide indi-
viduals living in rural areas access to mental health services
(Sherman, Barnum, Buhman-Wiggs & Nyberg, 2009). Han
and Ku (2019) posit that reducing the urban-rural gap in
behavioral health services may be accomplished by enhanc-
ing behavioral health sta in rural health centers. These
community mental health centers have frequently been
faced with challenges and ethical obstacles when providing
mental health care due to limited resources that are further
explained below (Williams, 2021).
Treatment shortage presents ethical obstacles that are
distinctively challenging to mental health providers work-
ing in rural and underserved areas. Ethical aspects of care
are especially relevant when the issues being addressed are
stigmatizing, which frequently is the case for mental health
conditions. Mental health providers in rural areas are often
faced with dicult situations where the appropriate resolu-
tion is in conict with a traditional adherence to a standard
ethics code. For example, clinicians may need to practice
outside their area of expertise due to a shortage of quali-
ed mental health care workers (Hastings & Cohn, 2013).
In rural and underserved communities, it is possible that
aspects of a clinician’s personal life may overlap with the
patients. A clinician and client may frequently run into each
other at the grocery store, or their children may attend the
same school or be in the same class. Naïve and overly sensi-
tive approaches to ethical adherence can be incompatible
in rural practice and risk inadequate care. We will briey
summarize the primary ethical domains that are especially
inuenced by rural culture and values including conden-
tiality, dual/multiple relationships, limits of competency,
mandated reporting/crisis intervention, and many diverse
and complex professional responsibilities of rural mental
health providers.
Rural Values and Culture
To properly provide mental health services to individuals
living in rural areas, mental health providers must under-
stand rural culture, values, and beliefs (Jensen, et al., 2020).
Each rural community has its own unique history, culture,
and needs. While rural areas share commonalities, it is
equally important to understand the intricacies that com-
prise rural culture, beliefs, and values across dierent rural
communities. In doing so, clinicians specically aim to
understand dierences and life experiences that may dier
from individuals living elsewhere to provide the best care
possible.
Similar to individuals of minority populations, it is sug-
gested that people living in rural areas fall along a continuum
of acculturation to mainstream (urban) culture and original
(rural) culture (Slama, 2004). This continuum identies the
degree to which rural values, traditions, and customs dier
from those of urban life. It is important to understand that
the people who reside in rural areas aid in creating the dis-
tinct culture that make each community culturally unique
(Bischo, et al., 2014). These nuances of rural life are
important to understand because the culture that is created
also inuences attitudes and beliefs towards mental health
services. A culture that creates stigma around mental health
services makes it dicult for clinicians to appropriately
serve these communities (Slama, 2004). When a mental
health provider shows a lack of respect or knowledge of the
cultural aspects in rural areas, negative consequences such
as mistrust in the clinician and hinderance of the therapeutic
relationship may arise (Bushy, 2009).
Self-Reliance and Family
Rural values include self-reliance, conservatism, a distrust
of outsiders, religion, work orientation, emphasis on family,
individualism, and fatalism (Jensen, et al., 2020; Wagen-
feld, 2003). Three of the most common values are self-reli-
ance and family, which may stem from individual’s living at
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Community Mental Health Journal
increased distance from any type of services (Slama, 2004).
The values of self-reliance and family has aided in the sur-
vival of individuals living in isolated environments (Bushy,
2009). These values can be seen as both an aid and deterrent
to seeking mental health care. In one circumstance, self-
reliance can assist an individual battling illness by receiving
social support from family and close friends. However, self-
reliance may also discourage an individual from seeking
help for reasons such as having a ‘tough it out mentality,”
worries pertaining to the stigma associated with seeking
help, and concerns pertaining to condentiality (Tummala
& Roberts, 2009). Additionally, if the family unit does not
encourage positive change towards mental health and prog-
ress, accessing and committing to mental health treatment
may not be likely.
Social Support and Resilience
Rural social support systems have distinct characteristics.
There are three dierent levels of social support for indi-
viduals living in rural areas: family, friends, and neighbors;
groups and organizations; and services provided by health
departments (Tummala & Roberts, 2009). The rst two
types of support (family/friends and community groups/
organizations) are typically the most frequently used types
of support for individuals living in rural areas (Tummala &
Roberts, 2009). These types of support systems are condu-
cive of helping an individual that may be struggling through
hardship or geographical barriers. Obtaining help from
other avenues other than formal services (i.e., mental health
care) may be the rst line of defense for an individual who
lives in a rural area. In addition to social support systems,
individuals living greater distances from urban centers (e.g.,
rural areas) predicted higher levels of resilience (Knutson,
et al., 2023).
Barriers to Accessing Mental Health Services
in Rural Areas
Barriers to community mental health care exist and are
much more prevalent in rural and underserved areas. In a
review paper published by Turner and colleagues (2016),
the authors examined factors impacting mental health treat-
ment among ethnic minority groups. The conceptual model
postulated in the paper highlights specic barriers of acces-
sibility (e.g., transportation, aordability), availability
(language and multicultural competence), appropriateness
(spiritual and cultural values, worldview), and acceptabil-
ity (stigma and social support). Additionally, barriers asso-
ciated with dysfunctional patterns in families and lack of
resources have also been found when seeking mental health
services (Hughes, et al, 2022). These same barriers can be
commonly applied to individuals living in rural and under-
served communities.
Accessibility, Availability and Acceptability
Barriers to mental health services in rural communities pri-
marily include accessibility, availability, and acceptability
(Rural Health Information Hub, 2018). Accessibility barri-
ers in rural areas are embodied in transportation diculties,
such as lack of transportation and large travel distances to
mental health facilities (Brems, et al., 2006). Individuals
living in rural areas are also aected by rural economics
which increase the accessibility barrier. These individuals
have low salaries, limited benets, and limited insurance,
which increase the likelihood of uninsured individuals seek-
ing services (Bushy, 2009). Availability barriers in rural
areas include limited availability of skilled mental health
providers, as well as providers with limited language and
cultural competence skills (Summers-Gabr, 2020). Lastly,
acceptability barriers arise from attitudes and beliefs that
may hinder an individual from seeking and pursuing mental
health care. Individuals living in rural areas are also aected
by rural economics. These individuals earn low salaries,
limited benets and limited insurance are provided, which
increase the likelihood of uninsured individuals seeking ser-
vices (Bushy, 2009).
Limited access to care has also been found to be a promi-
nent issue for cultural and linguistic minority groups seek-
ing community mental health services (Siantz, et al., 2022).
Specically, system fragmentation, limited availability of
linguistically appropriate care, and stigma signicantly
impact access to mental health care for these individuals
(Siantz, et al., 2022). It should be noted that COVID-19
impacted the ability for individuals to engage in physical,
social, and health needs in rural communities (Matias, et
al., 2020). In turn, barriers to mental health through acces-
sibility and availability were further exacerbated during
COVID-19. Mental health providers located in rural areas
have also reported inadequate funding and resources, insuf-
cient compensation for services, and lack of support that
reduces chances of collaboration (Hastings & Cohn, 2013).
Stigma
While there is stigma associated with mental health prob-
lems themselves, it is suggested that there is also stigma
associated with accessing mental health services in rural
communities (Komiti, et al., 2006). Fear of being stigma-
tized may deter a person from not only seeking help but also
admitting and acknowledging the need for help itself. As the
“goldsh phenomena” implies, individuals living in rural
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Community Mental Health Journal
opportunities that t and highlight the needs and skills of
rural practitioners (Jameson & Bank, 2007). Potential train-
ing opportunities may include course work, research experi-
ence, seminars and practicum sites in rural and underserved
areas. Training should include an understanding of cultural
factors that inuence the delivery of treatment for those in
rural areas (Johansson, et al., 2019). Recently, a rural psy-
chiatry training program on the Texas-Mexico border illus-
trated how providing training opportunities in rural and
underserved communities can produce skilled clinicians to
address community needs in underserved areas (Dingle, et
al., 2022).
The National Institute of Mental Health (NIMH) also
provides grant and funding opportunities to conduct
research and training to evaluate and address mental health
needs of rural areas. For example, the Oce of Rural Men-
tal Health Research (ORMHR) aims to examine the follow-
ing: conduct research on mental disorders that are unique to
residents of rural areas, conduct research on improving the
delivery of services in rural areas, and disseminate informa-
tion to appropriate public and nonpublic entities to increase
and improve mental health services in rural areas (NIMH,
n.d.). Additionally, the NIMH has recently presented fund-
ing opportunities such as a call to evaluate the eectives
of implementing sustainable evidence-based mental health
practices in low-resource settings, such as rural areas.
Despite various options for state and federal funding, oppor-
tunities are still limited and a call to action to increase this
benet is critical to address the mental health crisis in rural
and underserved areas.
Additionally, beyond just training future clinicians and
implementing research projects in rural areas, recruiting
and retaining mental health providers such as psychologists
to work in rural areas is also crucial. Increasing practica
and internship opportunities in rural areas can increase the
exposure of future clinicians to the possibility of working in
these underserved areas (Jameson & Bank, 2007). Another
strategy to recruit and retain clinicians in rural areas include
state and federal Loan Repayment Programs (LRP). These
funding sources have played a signicant role in some rural
areas that oer LRP.
Behavioral telehealth has been suggested as a reasonable
solution to the accessibility barrier encountered by individu-
als living in rural areas (Lombardi, et al., 2022; Swinton,
et al., 2009). During COVID-19, behavioral telehealth ser-
vices were implemented more frequently globally, including
rural areas, to continue providing services despite experi-
encing social isolation (Hirko, et al., 2020). If behavioral
telehealth is not accessible, or if face-to-face sessions are
preferred, clinicians may also oer home-visits to increase
access to care (Boydell, et al., 2006). Additionally, oer-
ing appointment times during evening and weekends may
areas are aware that there is a limited amount of privacy
and anonymity due to the desire of individuals wanting to
know about other people’s lives in their community (Slama,
2004). This fear is magnied when avoiding being seen
entering a facility is dicult if not impossible (Barbopoulos
& Clark, 2003). It should be noted that stigma varies from
community to community, and smaller rural areas have been
suggested to have higher levels of stigma associated with
seeking mental health treatment (Brems, et al., 2006).
Limited Crisis Resources
As recent studies have attested, individuals living in rural
areas are more likely than urban dwelling individuals to
experience a mental health condition (Rural Information
Hub, 2019a; Weaver, et al., 2013). According to the Cen-
ter for Behavioral Health Statistics and Quality (CBHSQ)
(2017), about 6.5 million people living in rural areas expe-
rience having a mental health condition. In 2016, about
2,300 individuals living in rural areas reported experiencing
a major depressive episode, while only half of these indi-
viduals reported receiving treatment (Center for Behavioral
Health Statistics and Quality, 2017). Suicide rates by age,
sex, race, and ethnicity are magnied in rural areas (Center
for Disease Control and Prevention, 2017). Reports from
the National Center for Health Statistics revealed that from
2000 to 2018, the suicide rate in rural areas in the United
States increased by 48% (Pettrone & Curtin, 2020). Thus,
this data highlights the crisis of mental health that rural and
underserved communities are facing.
Moreover, rural provider shortages can also create added
challenges for individuals faced with mental health crises
or situations that are mandated to be reported by law. Men-
tal health organizations and providers in rural locations are
often underfunded and understaed which can impede crisis
response capabilities (Moore, et al., 2010). For example, in
the state of Alaska there are only ve psychiatric hospitals
(Substance Abuse and Mental Health Services Adminis-
tration, 2018), with only one public and ve private hos-
pitals. Individuals who are in crisis are often detained by
village public safety or law enforcement ocers and may be
restrained through physical means (handcus) or medica-
tion to ensure they can be safely transported for psychiatric
care (Compton, et al., 2010).
Possible Solutions to Barriers
One of the most important issues in rural mental health
practice to be addressed is the shortage of mental health
providers in rural areas, which highlights the barrier of
availability. For this purpose, graduate programs should
incorporate training tailored to providing resources and
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Community Mental Health Journal
health center or see them entering or exiting the treatment
facility. Patients may be related to sta, providers, or other
recipients of services, leading to low condentiality and a
need for higher level of sensitivity and protection.
Possible Solutions to Confidentiality Issues
Individuals may feel reluctant to seek mental health ser-
vices for the fear that what they discuss may be discussed
publicly. Because of this, mental health providers working
in rural areas should take extra precaution and refrain from
discussing information that may be linked to a particu-
lar client publicly (Werth, et al., 2010). Further reluctance
towards seeking mental health services may also pertain to
the lack of privacy from the public when accessing mental
health services in person. Rural residents are more likely to
utilize primary care services to address their mental health
needs due to stigma and a shortage of mental health services
in their area (Gale, et al., 2010). Rural integrated primary
care community health centers oer an increased level of
condentiality and privacy protection for patients access-
ing behavioral health services, as they seek care in the same
clinic as general primary care patients. These patients run a
lower risk of being identied as a behavioral health patient
than patients seeking treatment at a mental health clinic. As
the healthcare eld has continued to advance by integrating
behavioral health services, rural communities have greatly
beneted by gaining access to previously unavailable men-
tal health services. When psychologists work as primary
care team members, patients have access to timely quality
mental health treatment through same-day consultation and
established brief therapy services.
Federally Qualied Health Centers (FQHCs) are out-
patient clinics that were designed to provide health-care
services for underserved areas through the Health Center
Program. Approximately 1 in 5 individuals living in rural
areas are served by the Health Center Program (Rural
Health Information Hub, 2021). It is common that these
health centers integrate behavioral health within the same
facility as general health care. These health centers often
provide various services including primary care, behavioral
health, chronic disease management, dental care, pharmacy
services, and preventative care in rural areas. Telemental
health services have been implemented through FQHCs to
address the barriers of access in rural areas. The pandemic
has further expanded behavioral health access via innova-
tions in telemental health services. Some of the most vul-
nerable and high-risk rural individuals gain access to much
needed behavioral healthcare via integrated services in their
community health center, where they feel most comfortable
and supported. Similar to FQHC’s, school-based mental
health programs have also been found to aid in addressing
provide residents of rural areas more exibility and avail-
ability to seek mental health services. In cases where home
visits by clinicians or telehealth services are not feasible,
utilization of a hub and spoke model to telehealth, which
entailed clients to travel to nearby access points to receive
telehealth from centrally located providers, have been found
to signicantly increase access to care (Tarlow, et al., 2020;
Williams, 2021). Overall, some examples of addressing the
barrier of access to care may be addressed through behav-
ioral telehealth, home-visits, exible scheduling, and utiliz-
ing the hub and spoke model.
To further address mental health services barriers, estab-
lishing mental health programs in rural area schools, men-
tal health awareness campaigns, community based mental
health programs, and public education campaigns that pro-
mote where one can access mental health services have
been suggested (Johansson, et al., 2019). For example, the
School-Based Health Center (SBHC) model works with
schools and communities in rural areas to improve chil-
dren’s mental health (Rural Health Information Hub, 2020).
This program can screen children for mental, behavioral,
and developmental disorders such as anxiety, depression,
and attention decit/hyperactivity disorder.
Addressing Condentiality in Rural Health
Limited Patient Privacy
Rural and underserved communities tend to be small and
intimate settings, where neighbors, family members, and
community ties tend to be close and interrelated, causing
condentiality and privacy to be limited. Individuals living
in the same rural community are easily exposed to personal
aspects of each other’s lives, leading to low anonymity in
daily lifestyle and practices. Providers living in rural com-
munities may regularly encounter situations where patient
condentiality is threatened in daily life and social or com-
munity activities.
The lack of privacy in small rural communities can inten-
sify the stigma related to receiving mental health treatment
in community-based treatment centers (Hastings & Cohn,
2013). Unfortunately, there are vulnerabilities to conden-
tiality in clinic procedures, documentation, practices, and
clinic member communication during consultations and
collaboration. Rural community members that seek treat-
ment experience a higher likelihood of being identied as
a patient, increasing the risk of complicating factors related
to mental health stigma (Rural Health Information Hub,
2019b). This transparency of treatment utilization is mani-
fested when rural community members readily recognize
each other’s cars parked outside of a community mental
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Community Mental Health Journal
stay objective and ensure these relationships do not become
harmful. In addition, to optimize outcomes, it is necessary
to ensure that therapeutic or professional relationships are
objective and do not become harmful.
Having several roles within the community can also cre-
ate ethical issues that are typically more dicult to resolve
than in urban locations due to limited rural resources, pro-
fessional networks, and personal support (Bolin, Mechler,
Holcomb, & Williams, 2008). Psychologists who live in the
rural area in which they provide services have a higher level
of visibility and experience lower levels of privacy (Hast-
ings & Cohn, 2013). The constant conict between profes-
sional and community standards facing psychologists and
their families can create professional and personal isolation,
which can increase burnout rates and decrease job satisfac-
tion (Hastings & Cohn, 2013; Kee, et al., 2002). In turn,
increased burnout and poor job satisfaction may prompt
psychologists to leave their rural practice, which can exac-
erbate the already critical shortage of mental health provid-
ers and services in rural areas.
Possible Solutions to Dual/Multiple Relationships
For mental health professionals who live and practice in
small rural areas, avoiding interactions with clients out-
side of therapy is almost impossible. Despite the benign
nature of these casual interactions psychologists must keep
in mind key considerations before deciding to establish a
multiple relationship. Considering the high risk of commit-
ting boundary transgressions, it is important to be proac-
tive and have early and repeated open discussions about the
topic within the professional community, as well as formal
training on ways to foresee and handle these kinds of situa-
tions as they arise in clinical practice. Insight into the factors
leading to boundary transgressions may help mental health
professionals avoid them.
Considering dual relationships may not be completely
avoidable, especially in rural areas, Campbell & Gordon
(2003) provide several examples and considerations to take
when evaluating the outcomes that may result from engag-
ing in dual relationships. Some suggestions include setting
clear expectations and boundaries with clients, frequently
consulting with other professionals, always maintaining the
client’s condentiality, and terminating multiple relation-
ships as soon as possible. Even though dual relationships
may not be avoidable in rural settings, it is still the clini-
cian’s responsibility to ensure that they are abiding by state
laws and ethical codes to prevent negative outcomes that
may arise due to the relationships (Jameson & Blank, 2007).
Again, not all multiple relationships are unethical, and
considering these relationship nuances may lead clinicians
to rigidly restrict access to care that is needed. In fact, the
the access to care barrier for children. Recently, Chan-
drasekhar and colleagues (2023) found that school-based
mental health interventions have improved overall resil-
iency in racially and ethnically diverse youth.
While access to integrated-health care options, such as
through FQHCs, aid in creating a sense of comfort pertain-
ing to a client’s privacy and maintaining condentiality,
some mental health practices in rural areas may not be avail-
able in an integrated care setting. When this is the case, it is
not only the responsibility of mental health care providers
to ensure a client’s condentiality and privacy, but also the
responsibility of clinic sta. Werth et al. (2010) emphasize
the importance of clinicians training their oce sta regard-
ing condentiality and monitoring compliance to ethical
standards pertaining to privacy and condentiality.
Dual/Multiple Relationships
Increased Demand on Rural Mental Health Providers
Mental health professionals who live and practice in small
rural areas are frequently faced with ethical predicaments
pertaining to the maintenance of proper professional bound-
aries. The various roles mental health providers are expected
to play when working in rural areas include the following:
clinical services, consultation, outreach, sta consultation
and intervention, case management and resource navigation,
crisis/disaster response and recovery, and the community’s
psychologist. Working in underserved rural communities
places an increased demand on rural psychologists to pro-
vide treatment to people they know when these individuals
are unable to access other care. Even though not all multiple
relationships are unethical, in some instances multiple rela-
tionships may still pose a danger to clients, a risk to the cli-
nician, or a barrier to quality objective care for the patient.
While it may appear relatively easy to dene what multiple
relationships are at a conceptual level, it is important to be
aware that identifying and navigating potential multiple
relationship dilemmas as they develop can be much more
challenging.
Psychologists working in these locations may nd mul-
tiple relationship situations particularly challenging with
regards to social relationships, business or professional rela-
tionships, overlapping relationships between patients and
psychologists’ family members and friends’ family (Werth,
et al., 2010). Rural community standards and expectations
can contribute to ethical dilemmas that conict with existing
professional codes and guidelines (Bushy, 2009; Pomerantz,
2009). Although the American Psychological Association
(2017) Ethics Code does not prohibit multiple relationships
(Standard 3.5), psychologists must maintain the ability to
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Community Mental Health Journal
Sect. 2 Competence and Sect. 7 Education and Training.
These recommendations are highlighted and can be applied
through utilization of video conferencing. For example cli-
nician’s working in rural areas may seek consultation via
video conferencing to discuss recommendations and pos-
sible supervision for providing services that are outside the
margins of one’s competence (Werth, et al., 2010). Rural
psychologists should constantly assess and seek continued
training on best practices including completing continu-
ing education and maintaining updated scientic literature
knowledge about best practices with telehealth.
Discussion
It is evident that unique challenges, barriers, and ethical
implications are present when providing mental health ser-
vices in rural and underserved areas. Such barriers include
lack of transportation, discomfort with seeking professional
services, limited awareness, and stigma. Despite an esti-
mated 46 million people living in rural areas, there is an
overall shortage of mental health professionals in rural areas
that has plagued the United States (Bureau of Health Work-
force, 2021; U.S. Census Bureau, 2021). The consequences
of this shortage include higher suicide rates in rural areas
than in urban areas. These treatment shortages result in ethi-
cal obstacles that challenge mental health providers work-
ing in rural and underserved communities.
Mental health professionals working in rural and under-
served areas must be aware of and understand rural values
and culture to provide services eectively and competently
to individuals living in these communities. The culture of
rural areas, despite sharing some similarities, are often dis-
tinct. It is important that many mental health professionals
are uent in the intricacies that make each area unique to
avoid mistrust of clinicians and to facilitate stronger thera-
peutic alliance (Bushy, 2009).
Individuals working in these communities should also be
aware of the unique ethical situations with which they may
be presented. For example, because rural communities tend
to have smaller, more intimate settings, it may be dicult to
ensure condentiality and privacy. Limited patient privacy
increases the ethical decision-making demands placed on
mental health providers in rural areas, such as navigating
multiple relationships in the community. Lastly, even when
mental health services are provided in rural areas, there are
often limited treatment options and few, if any, providers to
choose from. Because of these demands, providers in these
areas are plagued with ethical situations that require navigat-
ing and understanding their own boundaries of competence.
treatment outcome of allowing overlapping relationships
might be more productive than avoiding them. Thus, eec-
tively managing boundaries and overlap is more relevant
than how to avoid multiple relationships altogether. Nev-
ertheless, practitioners must be aware that their objectivity
can become compromised during their decision-making
process. Careful self-evaluation, including examining one’s
motives and professional consultation with someone with
established expertise is advisable when a clinician engages
in multiple relationships.
Boundaries of Competence
Specialty Referral
When mental health services are available in a rural area,
there are often very few treatment options and providers to
choose from. It has been suggested that clinicians working
in rural areas operate as generalists rather than specialists in
order to serve and provide care for a diverse population of
individuals (Werth, et al., 2010). There are rarely any local
specialty referrals available which places signicant pres-
sure on generalist practices and the provider’s boundary
of competence. Often rural clinicians must evaluate their
own level of competence relating to each client’s presenting
problems and symptoms to determine whether they can ethi-
cally provide adequate care. Stuber et al. (2014) suggest that
improvement in recovery-oriented competencies in commu-
nity mental health systems may be benecial to improve cli-
ent care. Rural mental health providers are routinely faced
with referrals of cases that they may not be entirely compe-
tent to treat in the absence of appropriate referral opportuni-
ties. In these circumstances rural mental health providers
are challenged with meeting the patient’s need in an ethical
manner while transparently communicating their limitations
and plan for enhancing their competency to meet a standard
of care.
Possible Solutions to Boundaries of Competence
It is a clinician’s responsibility to always refer to the princi-
ple of nonmalecence or minimizing harm when determin-
ing a course of action for a client who may be at a clinician’s
margin of competence. A few practical solutions to address
limited competence in a specialized area of clinical psy-
chology include addressing areas of clinical and personal
growth. For example, completing Continuing Education
Units (CEUs), seeking consultation from fellow psycholo-
gists or mental health practitioners, and investigating the
seminal and cutting-edge scientic literature (Werth, et al.,
2010). These practices align with the APA Code of Conduct
1 3

Community Mental Health Journal
and inuence of culture and values are important consider-
ations when providing services to these populations. Ethical
implications pertaining to condentiality, limits of compe-
tence, and dual relationships require unique considerations
to ensure appropriate care. Mental health practitioners
working in rural areas have a responsibility and commit-
ment to individuals living in these areas to actively and con-
tinuously seek opportunities to maintain and expand their
knowledge to eectively work with these populations.
Author contributions All authors contributed to and certify respon-
sibility for the manuscript. Conceptualization and idea generation:
Alfonso Mercado, Julia Takishima-Lacasa, and Emily Selby-Nelson;
Writing – literature search and original draft preparation: Amanda Pal-
omin; Writing – review and editing: Alfonso Mercado, Julia Takishi-
ma-Lacasa, Emily Selby-Nelson, and Amanda Palomin; Supervision:
Alfonso Mercado. All authors read and approved the nal manuscript.
Declarations
Conflict of interest The authors have no known conict of interest to
disclose.
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Rural areas face discrepancies when it comes to access to
services that require special attention to address. The enlist-
ment of the APA to assist in recognizing and disseminating
the unique ethical challenges and considerations that are
inherent in the practice of mental health providers working
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underserved areas.
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It is evident unique challenges, barriers, and ethical impli-
cations are present when providing mental health services
for individuals living in rural and underserved areas. The
barriers of accessibility, availability, and acceptability may
be exacerbated by values such as independence and self-
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The COVID-19 pandemic has also exacerbated the barriers
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