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.


  • As a psychotherapist and combat vet who attained Sgt. E-5, I had little difficulty working with higher ranking ex-NCOs and ex-officers. This was due to my year of heavy combat in 1968 in the 1st Cavalry division. I was given more respect for that than for my psychology training. The exception to this was Marine vets who were officers and fighter pilots. I was Army and not an officer and only had 2 yrs. active duty and 4 yrs reserve. Can't please them all. But this rank thing and and the "transference" in the therapeutic relationship are extremely important issues that if not addressed are usually the elephant in the room that impedes progress in therapy. Should be significant training in the military and the VA for both these issues.

  • I think the relative influence of rank varies by service, military occupational speciality and experience of the provider. For example and arguably, rank seems to carry more weight and influence within the USMC and USA compared to the USN and USAF. Likewise, certain military occupational specialities (e.g. line/infantry) adhere to a more stricter version of the "chain of command" compared to others (e.g. staff/medical community). In either case, I have never found this (rank differential) to be too impairing provided I mindfully adjust my TTP to adapt to the patient I am speaking with. There are any number of potential impediments to rapport development and the strategy for navigating them is essentially the same (e.g. unconditional positive regard, meeting the patient where they are at, and adult/agent to adult/respondent communication).

  • Very good question. For those not previously involved in Military Culture, I would simply suggest to follow Sean's advice above, and to watch, listen, and learn. May I offer that Rank comes from two maturing streams of knowledge and experience: Leadership, and Specialized Job Skills. One consists of innate abilities, experience, and Professional Military Training (think Recruit Training, Professional Schools and Academies, and Senior/Junior Mentoring). The other is similar, but more technical in it's orientation. Job skills are taught based on principals of Scientific Management, assessment of individual abilities, and academic learning about the job you will be performing on the equipment you will be using, and how all of that fits into the operational needs of combat.

    If rank is impairing to the process of therapy, it is largely found in the counter-transference. A Medical Officer/Therapist will find a different dynamic than will a Counselor/Therapist in a Fleet/Family Service Center, and a Counseling Psychologist/Therapist who is a VA Provider or Civilian Counselor/Private Practice Therapist. All of the settings are significantly different. There are trainings available through a number of resources for any one who serves the Behavioral/Mental Health needs of Former service, Veterans, and Active Duty/Reserves.

    If interested in serving any of the identified populations, look at the resources and trainings, the Home Base program through The Red Sox and Mass Gen Hosp, among a wealth of others.

    My personal recommendations are to simply be genuine, accepting, and open to the person in front of you. That Unconditional Positive Regard, that openness to explore the clients felt needs and wants will lead you in the direction you need to go.

    As an old retired GySgt (Marine Gunny), and now a Licensed MFT working in a County Behavioral Health System, I don't see many veterans, but I do see a few Former Service Members. Through it all I have learned that skill of respecting the person first, listening more than talking, and just being present in the moment. Your Professional Skills will guide you from there.

  • I enjoyed this article and can relate on a professional level as a peer support specialist for a VA clinic. Veterans often trust me with information they have not shared with their clinician even after prolonged therapy sessions. There is no perception of differentiation of power. There is also no barrier of "technical jargon" I speak their language.
    As a Veteran I have had difficult encounters with high ranking officers at times and this was a barrier for me in my civilian life when advocating for myself.

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