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Military psychologists and psychiatrists frequently face ethical quandaries involving boundary crossings, or extratherapy contact, and multiple relationships. A multiple relationship is defined as necessarily engaging psychotherapy patients in nonclinical roles, such as coworker, superior officer, neighbor, or friend. In contrast to their civilian counterparts, military mental health professionals must often engage patients in many different contexts and roles. In this article, we consider the distinctive features of mental health practice in the military and offer military providers several practice guidelines for avoiding harm to patients in military settings. This article is also designed to enhance sensitivity to multiple-role risks among nonpsychiatric providers.

Introduction

Clinical psychologist LCDR Steve Jones began a regimen of brief cognitive-behavior psychotherapy with a 19-year-old hospital corpsman who presented to the mental health clinic with complaints of depression and difficulty in relationships. A careful assessment confirmed the diagnoses of dysthymia (mild but chronic depression) and a dependent personality disorder (which had not interfered with performance to date). After 2 months of weekly therapy, the client showed moderate improvement in mood, although he had become increasingly dependent on the support of LCDR Jones. With little notice, both the psychologist and the patient were then deployed for a 3-month period aboard one of the Navy's hospital ships. As a department head, LCDR Jones was in his patient's direct chain of command. He attempted to have the corpsman transferred to a different area of the ship, but his superior officer downplayed the issue of the preexisting therapy relationship. Although they continued with less-frequent sessions to address the patient's mild depression and difficulty with adjustment to the ship, both individuals felt uncomfortable about their new military roles with respect to one another and the more public nature of their occasional sessions. When the patient began to have serious performance problems, LCDR Jones was required to sign formal performance counseling forms. The patient terminated therapy at that point, and his performance further declined. Eventually, the executive officer ordered a fitness-for-duty evaluation. As the only mental health professional onboard, LCDR Jones, despite strong protests concerning his preexisting clinical relationship with the corpsman, was required to perform the evaluation and ultimately to find his patient unfit for duty on the basis of his personality disorder. The patient was administratively separated from the Navy. He later filed an ethics complaint against ICOR Jones for abandoning his clinical role and moving from provider to supervisor without warning.

Active duty military psychologists and psychiatrists are often faced with ethical quandaries regarding the blending of clinical and military roles with respect to mental health patients. As commissioned military officers bound to place the military mission foremost, these providers often report difficulty avoiding blurred boundaries and maintaining clear professional roles with patients. In addition, an increasing number of military psychologists and psychiatrists are being deployed as members of sea-going medical teams (e.g., on aircraft carriers and amphibious assault ships) and ground combat forces (in Army and Marine assault units). Mental health providers, as embedded members of deployed units, must view every member of the unit as a potential patient, and traditional ethical models of avoiding multiple roles are often rendered irrelevant or unhelpful by the frequent necessity of blurring role boundaries with current patients.1 In this brief article, we highlight the significance of ethical proscriptions against multiple relationships with psychotherapy patients and describe why such multiple roles can be especially problematic in military environments. We present several brief case examples of difficult multiple-role situations in military environments, and we offer some clear recommendations for military mental health care providers. We also hope to increase sensitivity to multiple-role dilemmas among nonpsychiatric colleagues and medical unit leaders.

What Are Multiple Relationships?

Multiple relationships occur when a provider participates simultaneously or sequentially in two or more relationships with a patient, and potential harm to the patient is exacerbated when there are substantial differences or conflicts between the two roles.2 Multiple relationships are also common when a mental health provider is treating a patient and is simultaneously in a relationship (professional or personal) with a person closely associated with the patient or when a provider promises to enter into a different kind of relationship (e.g., business or romantic) with a patient at some future time.3 Kitchener2 pointed out that multiple relationships are prone to become harmful when one or more of four conditions are met, i.e., (a) multiple roles cause the patient's expectations about one of these roles to go unmet, leading to surprise or anger; (b) the behaviors or obligations associated with one role are incompatible with the behaviors expected of another role; (c) conflicts of interest arise between the provider's professional obligations and his or her own personal, social, or political interests; or (d) substantial relational power asymmetry makes the patient vulnerable to exploitation. One can easily see how any of these conditions may cause a mental health patient to feel shocked, angered, or manipulated.

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