In my last column, “Military Culture and the Effective Treatment of Military Personnel: Group Versus the Individual” I discussed how an important aspect of military culture is group identity and how the focus is generally not on the individual.
I also discussed how this reality is important for the clinician to appreciate and how it impacts clinical care. In this second column I discuss the hierarchical structure of the military and its relevance to clinical practice.
The Hierarchical System and Its Impact on Clinical Care
The military is built on a rigid and unambiguous hierarchical system. By definition, it would be considered a class system (i.e., the arrangement of people within specific social and economic groups). It is likely one of the most open and transparent cultural class systems in the world, and it ascribes its success and survival to maintaining this structure.
The most glaring example of the military class system is rank. In general, the military is divided into two groups: officers and enlisted. Officers are college-educated men and women who are placed in the highest leadership positions within the military. Within the officer corps, there are various ranks, each related to experience, type of job, and success in past positions.
Officers are compensated at a higher level than enlisted members and are discouraged from interacting with enlisted members in social settings (e.g., going to dinner on the weekends). Within the officer corps a similar class system exists. For example, in the Army it would be unusual for a senior officer (colonel) to fraternize with a junior officer (first lieutenant).
This hierarchical mindset extends to the family members of the officers as well. It would be unusual for the wives of a colonel and a first lieutenant to be close friends. Although some enlisted members have college degrees, most that enter the service as enlisted men or women do not.
Enlisted members hold various leadership positions but are always under the direction of an officer. The enlisted group also has a separate class system within its ranks. It is made up of junior enlisted members (e.g., private first class, specialist) and senior enlisted members, or noncommissioned officers (NCO; e.g., staff sergeant, master sergeant).
Similar to the officer corps, the fraternization between junior- and senior-ranking enlisted members is discouraged. The taboo of interaction between family members is still present; however, it is less pronounced than it is among members of the officer corps. In both groups, there is a tremendous power and influence differential among ranks. Deference must always be paid to those of higher rank. Disrespect is not tolerated and can even be grounds for punishment under the Uniform Code of Military Justice, which consists of the legal rules that govern the military.
The basis for maintaining such a rigid hierarchical class structure is not to create the “haves” and “have nots” but to support a system in which responsibilities are easily delegated and accountability is transparent. If this type of structure is not in place, then little would be accomplished, and it would be difficult to find people to “volunteer” for difficult and dangerous tasks, which are common in the military.
Implications for the Clinician
It is important for the clinician to understand that the service member’s status may have some connection to his or her presenting problem. A junior enlisted member or officer is more likely to present with problems associated with lack of autonomy, independence, and overall adjustment to the military culture.
For the senior enlisted member or officer seeking psychiatric services, it is likely that the presenting problem is of a more serious nature (depression, anxiety, marital or occupational problems, substance abuse/dependence). The reason is what I refer to as “double stigma”: Not only is the senior service member faced with the general stigma associated with seeking psychiatric help in the military, but he or she is also faced with the stigma of showing weakness as a senior person.
As a result, he or she will likely be reluctant to seek help until functioning is dramatically reduced. The clinician needs to be sensitive to these issues and consistently reinforce the service member’s decision to seek help.
Other issues to be aware of are that the nonmilitary clinician may be viewed by the junior enlisted member as an “officer equivalent” and be treated accordingly (e.g., calling the clinician “sir” or “ma’am,” standing at attention when the clinician walks in); senior service members may feel disrespected if not referred to by their rank; and junior service members may be under pressure from superiors to seek help. The latter has considerable implications for treatment outcome, particularly as related to compliance and attitude toward the therapist.
Furthermore, there are a number of ethical issues to be considered, not the least of which is the issue of voluntary consent to treatment.
**This article was adapted from Dr. Moore’s latest book “Treating PTSD in Military Personnel: A Clinical Handbook-Second Edition” published by Guilford Press.