Joe spent a tour as an infantryman in Iraq. He saw a lot of death among the enemy, civilians and fellow American soldiers. He’s fallen on hard times now: he’s homeless, diagnosed with PTSD, and addicted to alcohol and heroin. Despite all he’s witnessed and done, there’s one memory he just can’t handle. When it comes to mind, he pushes it away and, usually, takes a drink or few.
The thought is about his buddy Lyle Jr. One day Joe, his platoon sergeant, and half a dozen other soldiers were on patrol. Joe heard a noise behind him. He turned around and as he did so, his buddy Lyle Jr. stepped forward into the spot that Joe would have been in if he had kept walking. At that instant, a sniper’s bullet struck and killed Lyle Jr. From all that that happened in his year in Iraq, this is the one experience that Joe just can’t handle. “It should have been me… I wish it was me. Lyle Jr. was my buddy, like a brother to me, an older brother I never had… He was a much better person than I am. He was happy, he was kind, he never said a negative thing about anybody… It should have been me.”
Or let’s consider the case of Lisa. She was repeatedly sexually abused by her father from the age of four until he died of a heart attack when she was 14. “He was a monster,” she says. But what hurts Lisa the most is that her mother knew and didn’t do anything. “I’ll never forgive her. I was a kid and she knew… she knew.” By calling her father a monster, Lisa has coped by recategorizing her father, removing him from membership in the human race. He was a monster and monsters hurt people. That’s what one would expect. She hates him and remains damaged by him. She would spit on his grave if she could. But it was her mother’s betrayal that has left her with the most emotional pain and bitterness.
Our diagnostic manuals have introduced many benefits to psychiatry: they have increased the reliability of patients’ diagnoses, increased the validity of the diagnostic criteria, improved research by permitting the study of more homogeneous populations, and removed theoretical constructs from the diagnostic criteria that were not supported by research.
But diagnoses are labels, labels that explain a lot about a person and the interventions that are likely to help them, no doubt. But they don’t – cannot – explain so much more. Each person carries a universe of meaning within them. Diagnoses don’t undercover those universes. They don’t explain where the hurt lies. And if you don’t know where your patient’s hurt lies, how can you help them heal that hurt?
So, in the context of a trusting therapeutic relationship, remember to follow the hurt.
Until next time,
“Ask not what disease the person has, but rather what person the disease has.”
– William Osler