Fans of TV sitcoms may fondly recall Cheers as the friendly neighborhood bar in Boston “where everybody knows your name.” The regular denizens of Cheers descended the stairs to be enveloped by an unwavering sense of camaraderie.

Of equal appeal to these characters, however, was the fact that the bar served as a refuge from the outside world. In truth, outside of a close network of other regulars, relatively few patrons of Cheers “knew their names.” The bar offered a certain sense of anonymity — a place where most other people wouldn’t possess any knowledge of their personal histories, their past mistakes, their baggage, their quirks. Even psychiatrist Frasier Crane frequented Cheers to escape his problems and, in some instances, his clients.

Contrast that with the environment encountered by counselors who work in rural areas, where the phrase “everybody knows your name” is oftentimes a truism, not just a homey slogan. This life-in-a fishbowl aspect of rural counseling offers unique challenges that encompass ethical decision making, boundary issues and counselor self-care.

For instance, says Lauren Paulson, a licensed professional counselor and American Counseling Association member who has conducted research on the topic, counselors in rural areas face greater pressure than their suburban or urban counterparts to serve as role models for clients, even when the counselor is not working. While Frasier Crane could step into Cheers without giving it a second thought, Paulson says drug and alcohol counselors who work in rural areas might question the advisability of having a glass of wine at a local restaurant. “A lot of the (rural) counselors I have talked to said they felt they needed to go out of town before they could truly let down,” says Paulson, a visiting assistant professor at Allegheny College and an adjunct professor at Edinboro University, both in Pennsylvania.

“You’re kind of on display when you’re a counselor in a rural area,” says Dorothy Breen, an ACA member who moved from a metropolitan area just outside of New York City 23 years ago to take a job at the University of Maine. In addition to being an associate professor at the university, Breen maintains a home and a private counseling practice in the western part of the state, which is much more rural in nature than the comparatively cosmopolitan university town of Orono (population 9,114 at the 2000 census). “The rural setting really influences my work and my life in a lot of ways,” says Breen, who is conducting research on rural counseling during her sabbatical from the university. “I constantly have to be aware of the ethics and boundary issues at play — at the gym, at the bank, in church, at school, in the grocery store. It’s easy to find myself … right next to one of my clients (in the course of doing everyday activities).”

Culture shock

Though the concept of multicultural competency has steadily taken on more import for counselors, both Breen and Paulson say there is a general lack of information about rural culture and rural counseling in the professional literature and in graduate counseling programs.

“Knowing your culture. That’s something that gets stressed to all counselors, but not all counselors understand that there is a distinct rural culture,” Paulson says. “At the same time, it’s diverse. Each rural culture is unique. Most counselors have been trained from urban models, and these counselors can experience culture shock as they try to make their way in the rural community without knowing how to ‘speak the language.'”

“It’s not just a matter of providing counseling in rural areas,” Breen advises. “It’s a matter of providing rural counseling. Rural counselors often need different treatment suggestions and face different considerations (than their colleagues in urban and suburban environments).” For example, she says, in an urban area, a counselor might encourage a depressed client to get out of the house and visit an art museum. “But that’s not always available in a rural area. Instead, it might mean going to a school basketball game — the very central part of social life in some rural communities — or doing something active, such as getting out in the woods.”

It is essential that counselors practicing in rural areas understand and respect their clients’ cultural values and beliefs, many of which revolve around family, Breen says. For instance, Breen provides counseling services in a rural school because the area where she lives doesn’t have school counselors. In encouraging students to pursue their education past high school, she has learned the importance of involving families in these discussions. In many cases, these students will be the first in their families to attend college. Sometimes, Breen says, the parents are worried about who will take care of them if their sons or daughters leave the rural community and decide not to return. Other times, students voice concerns that they will not be accepted back fully into the culture even if they want to return after college.

Another difference in rural counseling is the strength of the connection between the counselor and the community, says Breen, who adds that this is simultaneously one of the most positive and most challenging aspects of being a rural counselor. “You really do get to know people, and they depend on you,” she says. “You’re not just the counselor there; you get involved in the community. If you weren’t involved, you wouldn’t be able to be the counselor because they wouldn’t trust you. You’re seen as the person in the community to go to for all kinds of things, and that’s a different kind of lifestyle. You need to be able to balance being available to people with maintaining boundaries and having personal time.”

“Knowing that’s the way it is — being on stage all the time — is important before making the decision to practice in a rural area,” she continues. “It comes as a shock to many urban counselors.”

Ethical uncertainties and other challenges

Working as a counselor in a rural area, “You have to be a generalist,” Breen says. “You have to be prepared for everything.” But that reality can also leave rural counselors questioning whether they might be working outside their scope of practice. “The difficult part when considering counselor ethics is that some people in rural areas won’t get the help they need because a specialist isn’t available,” Breen says. “So the question becomes, do you, as a counselor, try to help them instead to the best of your ability?”

Paulson says rural counselors oftentimes must use creative problem solving to make up for a lack of resources, including in the areas of support and supervision. She encourages these counselors to be deliberate in “setting up sidewalks.”

“That means using one of the strengths of their tight-knit rural communities and forming collaborative networks,” she says. “It’s crucial in a rural area to form relationships with the local general practitioner, other mental health professionals, school counselors and other disciplines.” She also recommends that rural counselors make use of peer networking and supervision and take advantage of opportunities to connect with other colleagues at conferences, through professional associations and through online directories. She would like to see the profession develop a central network to allow rural counselors to connect so they could provide support and guidance to one another.

In Breen’s case, there are no doctors or similar professionals in her town. Instead, she collaborates most closely with a local pastor in discussing certain clients. Breen emphasizes that she always obtains signed permission from clients before working with the pastor, but because they generally view Breen and the pastor as primary caretakers of the rural community, clients normally welcome the collaboration. “We’re all there is here, and we try to help people get their needs met the best we can,” Breen says.

Paulson says that’s one lesson some counselors in urban and suburban areas could most benefit from learning from their colleagues in rural areas — making the most of all the resources immediately available to them and building connections with other professionals.

Counseling students and counseling professionals considering the possibility of practicing in a rural area should give serious forethought to how they will navigate the fishbowl aspect of living and working in a small community, especially as it relates to boundaries, privacy, confidentiality and other facets of professional ethics, Breen says. “I’ve handled that by being pleasant but saying very little about myself out in the community. I keep a pretty low profile. Part of it is just having the confidence not to have to talk about myself and being comfortable letting clients see me as I am — for example, in my workout clothes with my hair pulled back — when I’m not in the office.”

If counselors are constantly on display in rural communities, so too are their clients — and their potential clients. “As a counselor, you have a lot of information about members of the community, so you have to think about how to handle that,” Breen says. “In fact, you have a lot of information about your clients before they even start talking to you. As a counselor, you have to be careful, because that information might not be correct, or it might not be the client’s perspective. … I do not talk about myself very much (out in the community). I also do not talk about other people. I think it’s so important to not get into general gossip (as a rural counselor). I truly avoid that because I don’t want to give the impression that I would spread around any information I might have.”

Although counselors are taught to protect client confidentiality, the rural communities in which counselors work might not carry that same expectation, Breen says, and that can be a challenge. “In a rural area, people are very open in some ways. They will very innocently talk about things openly because they assume that everyone else knows already.”

Breen gives an illustration of a typical dilemma that a rural counselor might encounter. While eating at a local restaurant with her family, the counselor is approached by a mother who mentions some problems her child is having. Even though the mother has shared details of the situation in front of the counselor’s family, “My husband and daughter have to accept that I can’t say anything else about it to them,” Breen says. “It’s important for counselors to talk with their family ahead of time so they understand what your job is like and what your professional ethics are. But can you expect your children to keep things confidential when a client or a client’s family or a member of the community has shared details openly in front of them? This is a challenge. While in rural areas, some people may tend to not care about confidentiality, it is important as a professional to do my best to maintain confidentiality.”

Recommendations and considerations

In many cases, Paulson says, rural counselors experience feelings of professional isolation because they do not have easy access to supervision, training, consultation or networking opportunities. Combine that with often heavy caseloads and the daily struggle to navigate boundary issues and maintain some sense of privacy within close-knit communities, and rural counselors can face increased risk for burnout, she says.

That’s why Paulson, who wrote her dissertation on supervisors working in rural areas, continues to conduct research on strategies to help rural counselors compensate. “I love working and living in a rural area, and I wanted to provide ways to support these counselors and enhance the services they provide to their communities,” says Paulson, who is helping to implement a pilot study in her county on providing supervision to mental health workers in rural areas.

Paulson and Breen both acknowledge that rural counselors often have to sacrifice half or even full days of work to access supervision and training. Paulson recommends that these counselors use technology to access webinars and online training whenever possible, in addition to pursuing training opportunities at the local, state and national levels. Both counselors would also like to see the profession do more to provide continuing education that focuses specifically on rural aspects of counseling. One educational resource that Paulson recommends is the electronic Journal of Rural Community Psychology (marshall.edu/jrcp/).

At the individual level, Breen encourages rural counselors to engage in what she terms “self-study.” In an article on professional counseling in rural settings for the ACA publication VISTAS: Compelling Perspectives on Counseling 2005, Breen and Deborah L. Drew offered questions counselors can use to engage in self-study and better understand their unique experiences. Among the questions:

• In what ways does the rural setting help your counseling practice?
• In what ways does it challenge your practice?
• How does it change your work?
• How does it change your concept of the role of a counselor?
• How does your rural professional role challenge your personal life?
• What can you draw upon from your training that focuses on rural counseling?
• What kind of training do you need to look for that focuses on rural counseling?
• What kind of support do you have that focuses on rural counseling?
• What kind of support do you need to look for that focuses on rural counseling?

“Self-study is part of making sure that you’re adhering to professional ethics the best you can given the environment,” Breen says. “It’s also helpful in understanding your need for renewal and relaxation. It’s very important as a rural counselor to take care of yourself. That might include yoga, working out or making sure to schedule that time to snowshoe or play golf. In rural areas, being outdoors is a way of life, so take advantage of it.”

Paulson also emphasizes the need for rural counselors to be intentional about practicing self-care. “It’s about making sure you’re balanced in your life and allocating time for yourself,” she says. Among her suggestions for counselors on the personal development front:

• Develop a personal wellness plan
• Spend time with friends and family
• Travel
• Exercise and watch your nutrition
• Develop your spiritual life

Although rural counselors can face unique challenges, Paulson says, it’s important for them to focus on the many positive aspects of where they work and live, including the slower pace of life, the peace and beauty of their surroundings and the rich, deep relationships they develop within their communities.

Breen, Drew and Mikal Crawford recently surveyed counselor educators to find out if their programs prepare students for rural counseling. They are in the process of analyzing the data and will interview some of the counselor educators as follow-up. Breen believes it would be wise for graduate programs to offer a course on rural counseling. “Even if graduate students are not planning to work there, they might have a client from a rural area, and it’s important to understand the culture,” she says. But to truly understand it, she adds, students and counselor educators also need to experience it. “It’s about encouraging them to get out in the rural communities and observe, to go to the ballgame, to go to town meetings, to do an internship in a rural area. Simply acknowledging that rural counseling is different is a start. But we need to prepare students to be generalists who are able to deal with a wide range of issues. We need to train students to take care of themselves and advocate for themselves and teach them what it might mean to live the rural lifestyle. And we need to train students in ethical decision making so they are better prepared to handle some of the issues they will face in rural areas.”

Speaking of teaching, rural counselors might have a few lessons they could pass on to their colleagues practicing in more populated areas, Breen says. “Other counselors could benefit from rural counselors’ understanding of their community — learning not just what is told to them in session but what life is really like for their clients and neighbors.”

Jonathan Rollins is editor-in-chief of Counseling Today. Contact him at jrollins@counseling.org.