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Impact of Rank in Psychotherapy

Impact of Rank in Psychotherapy
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By Navy Capt. (Ret) Richard D. Bergthold, Director, Navy Clinical Psychology Internship Program, Walter Reed National Military Medical Center
May 30, 2017

Psychotherapy is always a relationship with a power differential (discuss amongst yourselves).

I think this statement is almost always true. The relationship between doctor and patient places the doctor in the position of “expert” while the patient is seeking assistance – often out of great need, or even desperation. This uneven relationship is further complicated in the Military Health System when military rank is introduced as another variable potentially impacting the relationship. And it can cut both ways.        

When I was a new intern (Navy lieutenant), my first assigned patient was best described as a “crusty” submarine commander who only kind of wanted to be in therapy. As I recall he had some “interpersonal difficulties” that came to the attention of the squadron and he was strongly encouraged to seek assistance. I remember being petrified in the presence of any officer above my rank – this was deliberately instilled in me during what was then called “Officer INDOCRINATION School” – and the fact that he was my patient did not mitigate my fear.

I thought I was faced with a choice: I could be reflexively deferent and short-circuit the therapy process, or I could accentuate my role as “expert” and potentially offend the senior officer. Fortunately, I had a great supervisor who helped me see the situation as other than binary. I was able to explore ways of being respectful while at the same time asserting – and even confronting – patients when that was necessary. Supervision and consultation can be a great help in sorting out these various power differentials in therapy.

A Navy psychologist and mentor taught me a couple of strategies for working with senior officers:

1) Start every session greeting your patients with their rank and last name, thereby acknowledging their senior position and experience. After that, say what you need to say! (I find most senior officers respect your investment in academic and clinical training).

2) Line officers (or even other senior medical officers) are often uncomfortable with the idea of receiving therapy, but some seem to tolerate the process when the therapist uses a relaxed conversational style, and communicates with stories and metaphors. Anything that makes the experience more like consultation often puts the senior officer at ease.

More often than not our patients are junior officers or enlisted personnel. This can be a double whammy of power differential. When my patient is a junior officer or an enlisted service member, I try to do a couple of things:

1) I always refer to patients by their rank and last name (they’ve worked hard to earn that title).

2) I bring up the rank issue to model that we can talk about it at any time in the therapy process (in much the same way I might address any issue of diversity).

A rank difference between therapist and patient can be an unacknowledged “ghost in the room” that interferes with therapy. But keep these tips in mind and in most cases the ghost can be easily banished.


The views expressed in Clinician's Corner blogs are solely those of the author and do not necessarily reflect the opinion of the Psychological Health Center of Excellence or Department of Defense.


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