By Ofer Zur, Ph.D. and Steve Gonzalez, Psy.D.1
Adapted from: Lazarus, A. A. and Zur, O. (Eds.) (2002). Dual Relationships and Psychotherapy, New York: Springer. Chapter 21, pp. 315-328.
Printed with permission.
At approximately 9:00 AM Eastern Standard Time on September 11, 2001, my long-term “therapeutic relationship” with most of my patients unexpectedly changed. When the World Trade Center in New York City and the Pentagon military installation in Washington, DC were attacked, my relationship with my patients immediately became a clear dual relationship. War had been declared against and by the United States and at that moment, it became perfectly evident that my primary role was no longer as psychologist but as a Naval Officer with a secondary function as staff psychologist. When our unit was mobilized a short time later, my patients and I became shipmates: the office was replaced with a ship and the couch with bunks. We were no longer doctor and patient, but comrades in arms with the common goal of national defense.
1Steve Gonzalez, Psy.D. Lt. MSC, U.S. Navy
Table Of Contents
General Background of Military Psychology
Unavoidability of Dual Relationships in Military
Who is the client?
Power and “Unusual authority”
Conflict Between the Military and Professional Ethics Codes
General Background of Military Psychology
The practice of psychology or psychiatry in the military is a unique situation, and is markedly different from private practice and most other non-military settings. Active duty military clinical psychologists or psychiatrists fulfill dual roles as therapists-clinicians and commissioned military officers. In addition to these multiple roles, psychologists also have dual agency as they carry responsibility for and loyalty to their clients, as well as the military or the Department of Defense (DOD) (Hines, Adler, Chang, & Rundell, 1998). Johnson (1995) describes military psychologists as “serving two masters.”
The opening example of this chapter illustrates such multiple roles. Functioning within the framework of multiple relationships is part and parcel of what military psychologists do on an everyday basis. More often that not, these circumstantial multiple roles are unavoidable. Comparisons have been made between military psychologists and rural, small town, correctional or hospital psychologists. However, the unique status of military psychologists stems from the often isolated nature of military bases and even more so from their binding commissioned status, where they are required to place military interests and national security above the interests of their clients.
Concerns about dual relationships in the military are part of the larger concern of the armed forces about fraternization. Fraternization, one form of multiple relationship, is defined by the Air Force Instruction 36-2909 as “a personal relationship between an officer and an enlisted member which violates the customary bounds of acceptable behavior” (Professional and Unprofessional Relationships, 1996, p. 2, cited in Staal and King, 2000). Staal and King then describe how the power imbalance between officers and enlisted members is evident by the stressed importance of rank. They go on to explain the reasons the military gives this much attention to fraternization, which are: the risk of depreciation of the superior’s authority; conflict of interest; or fostering concern about favoritism among the surrounding members.
- When therapist and client are members of a small close-knit military community.
The most apparent aspect of dual relationships in the military consists of the same dynamics as any rural, isolated or small community. Military psychologists are likely to interact regularly with their clients in numerous settings, such as at the only general store on the base, in a recreational league, in a band, at parties, at children’s school activities, community gatherings or committees. Many military bases are located in remote, isolated or highly secured areas. Others are overseas where they are isolated not only with fences but also with language and cultural barriers. Invariably, the focus on security leads such communities towards self-containment, self-sufficiency and often, for security reasons, intentional isolation. Needless to say, in many of these settings psychologists have only one general store at which they can shop, one school to which they can send their children and one baseball league or band in which they can play. In some situations dual relationships with one’s dentist, physician, or supervisee can be avoided by a referral to another military or to an off-base clinician. However, in many other situations of deployments, assignments to remote locations, or the availability of only one psychiatrist or psychologist, there is no option of referral and dual relationships necessarily come into play.
This one aspect of dual relationships in the military bears close resemblance to the prevalent and unavoidable dual relationships in other small, close-knit communities, such as rural (Barnett & Yutrzenka, 1994; Hargrove, 1986; Jennings, 1992; Schank & Skovholt, 1997), religious (Geyer, 1994; Montgomery & DeBell, 1997), feminist (Greenspan, 1995; Lerman & Porter, 1990; Stockman, 1990), gay (Brown, 1991; Smith, 1990), and ethnic minorities (Sears, 1990).
The literature on dual relationships in general has warned practitioners about the dangers of dual relationships and the problem of a ‘slippery slope,’ where non-sexual dual relationships end up, through a snowball type escalation, as exploitive and/or sexual relationships (Bersoff, 1999; Borys, 1992; Kitchener, 1988; Koocher & Keith-Spiegel, 1998; Pope, 1991; Pope & Vasquez, 1998, and Woody, 1998). There is no evidence to suggest that psychologists who interact with their patients as shipmates, colleagues or acquaintances, as is done routinely in the military, in any way hinder the therapy process. Zur’s (2001a, b) account of dual relationships and familiarity as beneficial to therapy in small non-military communities also applies to military settings.
- When psychologists are also consultants to the military.
Unlike almost all other clinical settings, in the military, superior officers or an individuals’ commanders have the authority to assign individuals under their command or supervision to seek mental health services or undergo an evaluation in accordance with various military regulations (Mental Health Evaluations of Members of the Armed Forces, 1997; Requirements for Mental Health Evaluations of Members of the Armed Forces, 1997; Staal & King, 2000). The result of such assignments is dual or multiple relationships between psychologists and their clients.
An important aspect of these dual relationships is the primacy of the military role over the clinical. This primacy is known throughout the military community as the “need to know” clause, which refers to the right of a Commanding Officer to view or be privy to specific patient information that would in all other non-military circumstances be considered confidential. Specifically, if the information revealed in a session is deemed by the psychologist to be a threat to national security or a potential safety hazard or concern, the patient’s Commanding Officer must be notified and he/she could potentially initiate administrative or legal action against the patient. Recent patient impassivity, depression, chemical dependency, and self-mutilative behavior are common examples of a much broader list of possibilities that put this clause into effect. As noted above, supervisors not only have the authority to demand a psychological evaluation but also the right to know significant clinical information if it has any potential bearing on national security.
A related dual relationship that military psychologists face is their dual role as clinician and forensic evaluator. In general, the clinical role comes first and the psychologist is later ordered by the military to perform an evaluation of competency or suitability for service determination. Similar complexities are often experienced by therapists in private practice with regard to child custody and other forensic situations. However, therapists in these non-military settings have the choice of whether or not to step into the forensic role; or, if they do not, the option is still available to protest being deposed to a judge. Such choices do not apply to military psychologists.
Johnson (1995) reflects on clinical-forensic dual relationships: “It is quite common for military psychologists to engage in clinical functions only to later serve in a DOD ‘gatekeeper’ role, recommending discharge from service or, worse, divulging sensitive material in a forensic format. In this case, as in many others, the client was inadequately prepared for this role switch” (p. 11).
- When the client is also the therapist’s superior.
A dual relationship circumstance that evokes difficult, if not impossible, ethical dilemmas for military psychologists is the issue of treating or assessing a service member of a higher rank. All active duty psychologists are commissioned officers and the majority of patients seen are from the enlisted community. Nevertheless, there are individuals who present to the clinic of a higher rank than the provider. This situation frequently causes confusion and discomfort, if not anxiety and trepidation, in the treating psychologists. These situations are even more difficult if the involved depositions or the evaluation will be used to determine the (superior) patient’s fitness or suitability to perform certain military duties. In these situations, the challenge for psychologists is to remain as objective as they would if the patient was their subordinate and not lose their clinical or military bearings.
When psychologists are ordered to evaluate senior members within their own chain of command, they can protest and argue with their direct supervisors against the assignment. However, ultimately they have no choice but to obey the order. Staal and King (2000) present such a case and discuss what may happen if the evaluation of such a case included the presence of a mental health condition. This evaluation could result in negative consequences, such as the revocation of responsibilities or privileges; restriction of entry to certain areas or access to security information; demotion of the individual from his position of command. Such a recommendation is likely to effect the attitude and behavior of the restricted superior toward the therapist in post or during non-clinical contacts.
- When the client becomes a comrade.
Other dual relationships unique to the military are those derived from the fact that the primary role of the psychologist is not that of a clinician but of an enlisted person. The opening vignette of this chapter illustrates how quickly the role of a military psychologist can shift from clinician to comrade. Staal and King (2000) describe a case in which the psychologist was assigned to the same tent as the client during military exercises. One must take into account that the majority of military organizations combine all ranks of enlisted personnel during training and other exercises for the sake of building comraderie and unity among members. This in turn increases the probability that future professional or social contact will occur. As members become better acquainted with one another and branch out to meet other servicemen, the web of connection in the military unit as a whole thickens. The result is even more dual relationships.
Who is the client?
In most non-military settings, the question of who the client is remains relatively straightforward. This is not the case in the military. One of the main issues among the many difficult dilemmas encountered by military psychologists on a daily basis is the identification of the client. Who do military psychologists serve? And where do their loyalties lie? Simply put, is the client the service member sitting in the office, or the DOD (or the military or the government)? Or both?
The ultimate client is the military or DOD and not the actual person who is sitting in the office. This fact has profound significance for the therapeutic encounter. This is a unique dual relationship situation in which the military psychologist is faced with dual allegiances and dual loyalties. This is especially true if a service member is directed by his/her commanding officer to appear for a psychiatric evaluation as per specific military instructions (Mental Health Evaluations of Members of the Armed Forces, 1997). In these circumstances, neither the patient nor the psychologist has a choice of whether or not to enter into the clinical relationship (Johnson, 1995; Staal & King, 2000). While psychologists attempt to assess thoroughly and accurately, they are aware that in these situations the client is the referral source, which is the Army, Navy, military, government, or DOD, but is not the individual service member who is sitting in the office. Remaining objective is an absolute requirement for military psychologists and must be sought at all costs. Responding to the referral source’s specific questions is the undisputed assigned obligation of psychologists even if it may result in an adverse effect, such as dismissal, for the service member.
The question of who the client is becomes even more acute when, as described above, the original clinical or client focus of therapy switches to an evaluation of military seemliness. The difficulty in these cases lies in the sequential dual relationships where the primary obligation shifts from the service member being treated to the military. Acknowledging and coming to terms with the issue of who the client is, continues to be essential in order for military psychologists to perform their duties. Informing clients about the implications of this fact prior to the onset of treatment or evaluation is the ethical, clinical, and moral obligation of the therapist.
Power and “Unusual authority”
Unlike most clinical settings, psychologists in the military often have an enormous amount of power over their service member clients. Orme and Doerman (2001) describe the notion of “unusual authority” that military psychologists have over their patients by virtue of the psychiatric diagnosis or recommendations that are being made. If during the assessment of a service member for fitness and suitability for a position, severe mental health pathology conditions are evidenced and the member is found unfit or unsuitable during assessment of a service member for fitness or suitability for a military position, a specific recommendation for administrative separation from the service will be made to the member’s commanding officer. Such a recommendation by a psychologist may in essence terminate the service member’s military career.
The question then becomes, how does the psychologist balance the needs of the individual service member in conjunction with satisfying the obligation to and directive of the “ultimate client,” the military? In these “need to know” situations where the fitness of the service member is questioned, the service member’s livelihood, identity or ability to provide for a family can be in direct conflict with the military’s need to retain fit, competent and reliable soldiers. While obtaining an Informed Consent from clients at the onset of the clinical encounter is the ethical and moral act, the dilemma psychologists face is still extremely difficult. Psychologists must obey the order to conduct and report an objective evaluation and also try to attend to the individual wishes and needs of the service member. These kinds of power relationships are often part of forensic and other evaluations pertaining to fitness for duty or Workers’ compensation. However, military evaluations are more complex because often neither the individual patient nor the psychologist has much choice in the matter.
The power of military psychologists over their individual member clients is real and tangible. This form of power must be clearly differentiated from therapists’ power as described by Austin (1998), Bersoff (1999), Borys (1992), Brown (1994), Kitchener (1988), Koocher & Keith-Spiegel (1998), Pope (1991), Pope & Vasquez (1998), and Woody (1998). Their argument is that the because of the power differential between therapists and clients in regular private practice settings, the latter are vulnerable and incapable of free choice and hence exploitation in the course of dual relationships is likely to occur, therapeutic benefits are significantly compromised and harm often results. Lazarus (1994) responds to these assertions by articulating the illusion of power that so many therapists believe they have over their clients. Dineen (1996) describes how professional boundaries are in fact self-serving as they increase therapists’ power. Zur (2001a) articulates how rigid boundaries, isolation and the avoidance of dual relationships also increase therapists’ power and the chance for exploitation.
In a similar vein, a lot has been written about the illusive slippery slope phenomenon (Borys & Pope, 1989; Gabbard, 1994; Pope, 1990; Sonne, 1994; Strasburger, Jorgenson, & Sutherland, 1992). This term, popularized by Strasburger, et al. (1992), has been described as follows: ” . . . the crossing of one boundary without obvious catastrophic results (making) it easier to cross the next boundary.” (Gabbard, 1994, p. 284). This snowball concept has come under intense critique for being irrational and syllogistic (Lazarus, 1994; Zur 2000, 2001a). One would think that if there is one place where the ‘slippery slope’ phenomenon would manifest itself the most, it would be the military due to the inherent dual roles, dual loyalty and the real and significant power discrepancy that psychologists assume in these settings. However, Hines et al. (1998) who studied dual agency and compared military, HMOs, and other civilian psychiatrists, reports that “. . . military psychiatrists reported the fewest boundary violations from dual relationships” (p. 831).
Another concern about power in military psychology is the form of a multiple relationship where psychologists enter into the therapeutic relationship as an advocate for the individual service member-patient but end up in an evaluatory or reporting role. After such a change psychologists are often viewed by the patient no longer as supportive but as an adversary or even worse, advocate for their parent military command. The struggle between maintaining a role of patient advocacy versus adversary is an issue military psychologists face and deal with on a regular basis. This is commonly seen in the military-forensic realm, where the military psychologist may be called in to testify by the patient’s attorney as both a fact and expert witness. The clinical testimony provided, although ideally intended to serve the best interest of the patient, may actually strengthen the case against the patient (i.e., a clinical explanation of Antisocial Personality Disorder). This dilemma may also arise if there are questions regarding the competency or sanity of patients.
All military psychologists are officers. That means that most psychologists are in positions of authority and supervision over lower ranking enlisted members. Because eighty to eighty-five percent of all military members are not officers, military psychologist are in a position of power over most military members even without a clinical relationship. If one adds the therapeutic connection, the “need to know” principle and the “unusual authority,” the power status of the military psychologist becomes enormously clear. Its significance cannot be underestimated.
Due to the dual roles and multiple relationships that are inherent in the practice of military psychology, confidentiality concerns take a different form in the military than in any civilian setting. The military position in regard to confidentiality has been described as a “strong anti-privilege position.” The general rule is that national security and military concerns override the confidentiality of doctor-client relationships. Consistent with this “need to know” clause, court-martial and other military authorities do not recognize any ethical obligation in regard to confidentiality (Johnson, 1995).
In additional to the overriding lack of protection of confidentiality, the military psychologist must follow the standard exceptions to privilege to which most non-military clinicians are bound, such as danger to self or others and child and elder abuse reporting. The military psychologist also has a duty to report spousal or child abuse to the service member’s command. In military settings, access to confidential clinical files and other threats to confidentiality pertain to several sources: clients’ command, military or DOD investigative or legal services, spousal abuse investigations, drug and alcohol abuse investigations and military personnel in charge of health records (Johnson, 1995).
Informed Consent is of utmost importance in any clinical setting, especially in the military. While all service members learn some of the information contained in Informed Consent as part of their original employment contract, there must be also an Informed Consent before the onset of treatment. Besides clinical information and clients’ rights, the written and the verbal consent must include a thorough explanation of the limits of confidentiality, privacy concerns, the potential for multiple relationships and the concern about who the client is (e.g. Department of Defense vs. the individual patient). More specifically the Informed Consent must outline the fact that if the psychologist is under the impression that the client’s mental health problems are likely to effect national security, fitness to duty or ability to perform, this must be reported to the client’s supervisor. Johnson (1995) and others have stated the obvious implication of lack of confidentiality rules, which is the avoidance of utilization of mental health services by military personnel who fear the damage to their military career that can result from a mental health consultation.
Conflict Between the Military and Professional Ethics Codes
Note: While the references to multiple relationships in this 2002 article are based on APA 1992 Code of Ethics the subsequent codes of 2002 and 2016 are generally similar to the most recent 2016 code in regard to implication of unavoidable dual or multiple relationships in military and similar settings.
The American Psychological Association (APA, 1992) has acknowledged the inevitability of multiple relationships in some settings, primarily the military and rural communities (Barnett & Yutrzenka, 1994; Zur, 2000). Nevertheless, military psychology presents clinicians with unique and extremely complex and difficult ethical dilemmas.
The 1992 APA code of ethics reflects progress from former codes (i.e. APA, 1981). Section 1.17 states:
In many communities and situations, it may not be feasible or reasonable for psychologists to avoid social or other non-professional contacts with persons such as patients, clients, students, supervisees, or research participants . . . A psychologist refrains from entering into or promising another personal, scientific, professional, financial, or other relationship with such persons if it appears likely that such a relationship reasonably might impair the psychologist’s objectivity or otherwise interfere with the psychologist’s effectively performing his or her functions as a psychologist, or might harm or exploit the other party. (b) Likewise, whenever feasible, a psychologist refrains from taking on professional or scientific obligations when preexisting relationships would create a risk of such harm. (c) If a psychologist finds that, due to unforeseen factors, a potentially harmful multiple relationship has arisen, the psychologist attempts to resolve it with due regard for the best interests of the affected person and maximal compliance with the Ethics Code. (APA, 1992, p. 1601)
Principle D states “They respect the rights of individuals to privacy, confidentiality, self-determination, and autonomy, mindful that legal and other obligations may lead to inconsistency and conflict with the exercise of these rights” (APA, 1992 p. 1599). Principle E states “When conflicts occur among psychologists’ obligations or concerns, they attempt to resolve these conflicts and to perform their roles in a responsible fashion that avoids or minimizes harm.” (APA, 1992 p. 1599). Lastly, Ethical Standard 1.02, Relationships, states, “If psychologists’ ethical responsibilities conflict with law, psychologists make known their commitment to the Ethics Code and take steps to resolve the conflict in a responsible manner” (APA, 1992, p. 1600)
These guidelines (APA, 1992) are an improvement over former ones, as they acknowledge that some dual relationships are unavoidable. However, these guidelines pose more difficulties than assistance or guidance. Almost all ethics codes emphasize and focus on psychologists’ responsibility, loyalty, and care for their individual clients. This does not fully apply to the military setting, where the DOD is defined as the client. The complexities of dual relationships and conflicts of loyalties that occur in the military are not addressed in APA’s code of ethics or that of any other professional psychotherapy association.
Several places in section 1.17 (APA, 1992) state that psychologists should refrain from entering into professional dual relationships if such a relationship reasonably “might harm” or “create a risk of harm.” These guidelines cannot be implemented in military psychology, as dual relationships are unavoidable or inevitable. Psychological reports can cause severe harm to the service-men clients if such reporting causes them to lose their specific position or even their employment and enlistment status.
The main problem with the code (APA, 1992) is that it does not take into consideration the two rules by which military psychologists must abide. Johnson (1995) states, “Frequently, simultaneous allegiance to professional (ethical guidelines) and military (federal statutes) requirements is not possible, placing the military psychologist in ethical quandaries that lack elegant resolution and create a continuing environment of risk” (p. 281). Johnson describes the effort by military psychologists to satisfy the competing demands of APA and DOD as “damage control.” He then calls for collaboration between APA and DOD for the purpose of providing clear, manageable, and unified ethical guidelines. Jeffrey, Rankin, & Jeffrey (1992, cited in Johnson, 1995) describe a couple of cases that delineate the vulnerability of military psychologists to sanction. One case involved a military psychologist who was sanctioned by APA for failing to maintain the confidentiality of a service member. The second case was of a military psychologist who upheld the principle of confidentiality and was sanctioned by his commanding officer for failing to report a violation of the Uniform Code of Military Justice.
Staal and King (2000) confirm the lack of acknowledgment about the impracticality and, at times, impossibility of applying APA ethical principles to military settings. Although they display a clear comprehension of the complexities of military psychology, Staal and King still attempt to apply Gottlieb’s (1993) general ethical decision-making model to the military setting. Gottlieb’s model may be of some help in ethical decision-making in private practice and other civilian settings where therapists have choices and options about who they treat and whether or not they engage in dual relationships. However, termination of treatment, referrals to other practitioners, protection of confidentiality, avoidance of dual relationships, or refusal to treat are generally not available options for psychologists in a military setting. Hence the utility of Gottlieb’s model in military settings is nullified.
The incompatibility of the dual agency or dual loyalty with APA ethics codes was best expressed by Johnson (1995) who states that while the “mission of the military might most parsimoniously be stated, ‘to fight and win any battle as directed by appropriate authority,’ the mission of the psychologist’s professional code (APA, 1992) is the welfare and protection of the individuals and groups with whom psychologists work” (p. 291).
The military setting presents one of the most complex dual relationship situations for clinicians. These complexities derive from the fact that active duty military clinical psychologists or psychiatrists always act the dual roles of therapist-clinician and commissioned military officer. Consequently, military psychologists have dual agency as they carry responsibility and loyalty towards their individual clients and towards their ultimate client, the military or the DOD.
The paper identifies several types of unavoidable non-sexual dual relationships in the military and emphasizes the unique power position that psychologists have over their individual clients. Dual relationships in the military stem from the isolated nature of the location of military bases and the fact that psychologists must report any concern about their individual client’s fitness for duty or the possibility of threat to national security. The “need to know” clause and the “unusual authority” described above give military psychologists the power to determine the service person’s enlistment status.
The concern with power in the military is not focused on sexual or other types of exploitation but instead on the impact of the dual agency or dual loyalty on the therapeutic process. These dualities place military psychologists in extremely difficult ethical and moral impasses where they must give primacy to the needs and demands of the military over those of individual clients. This has far reaching implications on issues of confidentiality and privilege. While securing an Informed Consent is of high importance, ethically and otherwise, it does not resolve concerns about the protection of the therapeutic process. As previously described, the unfortunate result of the DOD’s or the military’s almost unrestrained access to confidential mental health records and the “need to know” clause is a low utilization of mental health services in the military.
The conflict between military laws and regulations and professional ethics codes, such as those of APA (1992) place an enormous burden on military psychologists due to the incompatibility of these two guidelines. Serving the two masters of individual clients and the military and being bound by two conflicting sets of regulations leaves psychologists in convoluted situations. Johnson’s (1995) appeal for the intense collaboration of APA with the DOD is of paramount importance in order to help psychologists deal with conflicting pressures and ethical quandaries.
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Endnote:The authors maintain responsibility for the views expressed in this chapter. The views expressed in this chapter are not to be attributed to the Department of Defense or the Navy.
Description/Order Book Dual Relationships and Psychotherapy
For a more recent article on Multiple Relationships in the Military: Johnson, W. B. & Johnson, S. J. (2017) Unavoidable and Mandated Multiple Relationships in Military Setting. In O. ZUR, (Ed.) Multiple Relationships in Psychotherapy and Counseling: Unavoidable, Common and Mandatory Dual Relations in Therapy. New York: Routledge.
For additional resources and updated bibliography on multiple relationships in military settings, click here