By Paula Bradley, InPsych production editor

Issues affecting people living in rural and remote Australia have been highlighted by the widespread drought affecting more than 70% of the continent. InPsych production editor, PAULA BRADLEY, spoke to new Director of Branch and Regional Operations, Ted Campbell, from Port Macquarie, NSW, and psychologists from Far North Queensland, Western Australia, Victoria and King Island to paint a picture of 'what life is like' in  the country at the end of 2002.

Ted Campbell lives in a town that only has 120 days of water left. "If we don't get substantial rain by March, Port Macquarie and towns all along the East Coast of New South Wales and into Queensland are going to run out of water. The situation is becoming very serious indeed," he says.

The impact on psychologists working in these areas is serious too. As the potential and existing clients of private practitioners become more needy, their ability to pay for help decreases and many can no longer continue with sessions. Psychologists working for local mental health services experience overload (more than usual) and struggle to meet the needs of their clients.

"When you have a mental health service under stress - with demand greater than resources can meet - and you have a natural disaster on top of that, then the system goes into crisis. If that natural disaster is located in one particular area, we can cope with it because resources can be relocated from other places. But when drought is affecting 90% of NSW, you can't relocate those resources," Mr Campbell says.

Another problem in NSW is that west of the Great Dividing Range, provision of psychiatric services is extremely limited. "There are less than a handful of psychiatrists servicing that entire area," Mr Campbell says. "In Wagga Wagga (a regional city in southern NSW), the psychiatric inpatient unit can't operate because they don't have a psychiatrist. In an effort to keep the system going in the region, psychiatrists are being flown in two days a week, which is horrendously expensive."

"It is like this in many other places - people with mental health issues can't get to psychiatrists - the only mental health professionals they can get to are psychologists. Yet they can't access those psychologists, because they can't afford it."

Mr Campbell believes it is critical that partnerships between psychologists and GPs are developed to help provide that access. "This is why the Federal Government's Better Outcomes in Mental Health Care (BOMHC) is so significant for people in the bush,"  he says.  "Although it is just a toe in the water at this stage, it opens the way for psychologists to be paid with Commonwealth funds."

Some psychologists have been disappointed with the BOMHC program, with local GPs referring clients to agencies that pay low rates for allied health services that don't necessarily include psychologists.

Mr Campbell urges APS Branches and Regional Groups to work closely with their local Division of GPs to sell what psychologists can offer and what their expertise is worth. "My Branch has worked very hard with our local Division of GPs, who now value psychology and wouldn't dream of doing anything without psychologists," he says.

Earning a living in the bush
Whether in drought-affected areas or not, Mr Campbell says it is often the case that private practitioners in the bush find it difficult to earn any living from private clients and rely on referrals from government agencies.

This has been the experience of Anna De La Rue, a psychologist based on King Island  (in Bass Strait), who found that setting up a  private practice on the island very difficult. She found "a great need" for her services but often ended up working for nothing or received payment in lieu such as books, food and even a German Shepherd puppy.

So she searched all available avenues for third-party funding and began making inroads at the hospital, where staff previously had no idea about what she could offer as a psychologist. All her hard work and lobbying resulted in her receiving funding from the mental health service, rural health and drug and alcohol programs and other government initiatives such as Rural and Remote Students at Risk of Homelessness.

Compared with running her own practice, the downside is the "unbelievable amount of paperwork" in reporting back to the various agencies and unpaid time taken to do so.
Ms De La Rue is also an ambulance officer, registered nurse, yoga teacher and a marriage celebrant, which is indicative of what usually happens in small communities: "if you can do it, you will do it," Ms De La Rue says. "From my personal point-of-view, I might attend to someone involved in a car accident or attempted suicide, then if I am on duty as a nurse, I will care for them in hospital and later possibly counsel them in relation to the incident. It is an unusual situation I suppose, but one that is challenging and very rewarding."

Ethical dilemmas
Ms De La Rue's situation also illustrates the ethical dilemmas facing psychologists in the bush: it is impossible to be anonymous and dual relationships are often unavoidable. In recognition of this, the APS Ethics Committee has recently prepared a draft 'Guidelines for Psychological Practice in Rural and Remote Settings' for consideration by Branch Chairs and ultimately the Society's Board early next year.

Mr Campbell says the current ethical standard on dual relationships, which says that if you know someone in a social setting, that you should not see them in a professional capacity, is not viable in the bush. "We would violate that all the time," he says.

"Similarly, the ethics currently say that if we are counselling one member of a family, that we should not counsel another. This is based on a city concept that there are alternatives to you and your practice, which obviously is not the case in many rural areas."

The only clinical psychologist based at Geraldton in Western Australia, Sue Lucking, who works part-time for the local mental health service and part-time in private practice has come up against this problem. "It is very hard to adhere strictly to the current guidelines set by the APS,"  she says.

"If someone at the hospital needs my services, with whom I may have had occasional contact as a mental health worker, then what do you do? Are you going to deny them access to the only clinical psychologist in town when they need that expertise? Ultimately you have to consider what is going to impact on the client - asking them to travel 450 kilometres (to Perth) to see another clinical psychologist is probably not going to be in their best interests."

Psychologist David Lonergan, who is based at Cairns in Far North Queensland, says he is supportive of the draft guidelines. In his experience, managing situations when he bumps into clients in social settings is much more realistic than trying to avoid them altogether.

Mr Lonergan travels to towns on the Atherton Tablelands and up to Cape York, and often there's only one place to have dinner and a drink after work. "You are probably going to bump into a client in that situation. The best thing to do is acknowledge them without necessarily entering into a conversation,"  he says.

Where dual relationships are concerned, Mr Lonergan says a change to the ethics would benefit many rural practitioners who can potentially offer lifespan support to local families, as many country GPs already do. "If psychologists stay in one place long enough, then they can really get to know families, build up that trust and become the 'family help'," he says.

Isolation
Professional isolation is another big issue for psychologists in the bush. Convenor of the APS Interest Group on Rural and Remote Psychology, Ailsa Drent, says professional development (PD) courses are difficult to access, with the "double whammy" of loss of earning time and travel/accommodation costs. Ms Drent says limited access to PD feeds into another problem - maintaining one's professional identity in the midst of a culture where the community barely understands what psychologists really do.

Ms De La Rue agrees that it is difficult not having anyone to talk the same language. "As a professional, sometimes you need support and someone to share experiences with. I liaise with the GPs on the island, but there is a very high turnover - some are 'psychologically minded' and some are not."

"Professional development is not always easy to get: it is just too expensive to fly off the island for workshops or conferences. But on the flip side, there are incredible opportunities for personal growth here - the isolation really makes it a rural and remote environment - it's unique,"  she says.

A helpful option in accessing PD, according to Ms Lucking, is the recording of PD workshops, which she says the Clinical College is doing more often. She would otherwise have to travel 450 kilometres to Perth. Ms Lucking also uses her personal network of city psychologists to send her information gained from conferences/workshops or contacts a presenter and asks for a copy of his or her paper.

Mr Campbell also experiences the difficulties associated with attending Professional Development meetings/workshops. He is a member of the NSW Clinical College, which meets mostly in Sydney on weekday evenings starting at 5 or 6pm. To attend the meetings, he has to take two days off, which results in a substantial amount of lost earnings.

He is confident, however, that a Working Party whose terms of reference were recently approved by the APS Board, will provide some options for many other psychologists in the same situation. The Working Party will survey what video-conferencing facilities are available and their cost effectiveness.

One idea is to hire space on the internet to link with individuals for PD activity and another is to tap into existing video-conferencing facilities such as the Health Channel. Mr Campbell urges any members with ideas to contact him via email < ted.campbell@maynegroup.com>. The Working Party hopes to report back to the Board by mid next year.