Chapter Text
As I explained in the first essay, in the clinic I work at, we distinguish between people with weak and strong ego structures which is a conceptual distinction I will be using here as well, mainly because it really helps to illustrate the differences between our two favourite heroes. While Sherlock shows the classic signs of having a weak ego structure – lack of control over his own emotions, inability to predict them in others, weak impulse control, difficulty establishing and ending relationships – John has a more mature self. This means that he has the basic ability to recognise, distinguish and name his own and other people's emotions and that he is able to regulate these emotions, predict them in others and establish and dissolve connections without it turning into existential drama.
This is a great example: Sherlock experiences intense emotion (fear) and freaks the hell out, John experiences intense emotion (anger) and goes for a walk
The reason this is important can best be explained by a metaphor:
The idea is that structure and conflict are to each other as the stage and plot of a play. When you see an actor moving on stage, you at first expect their actions to be directed by the plot of a play. In time, however, you might realise that what the actors are doing is equally likely to be caused by the fact that the stage has holes, that it dips unexpectedly and that the cleaners left a broom lying around. That means that it becomes especially hard to identify the plot of the play when the stage it takes place on is unstable and unpredictable.
If we translate this to people, it means that in the case of Sherlock and his rather weak ego structure, what happens with him emotionally is not only due to the pervasive themes, dreams and fears which drive his life but can equally be caused by his inability to regulate his own emotions, check his own impulses etc. Much of what Sherlock does is aimed at trying to survive emotionally, and that leaves very little room for the acting out of specific intra-psychic conflicts. This isn't to say that John doesn't have some structural problems of his own – his complete inability to articulate his feelings, for example, is far from healthy and probably the reason for his limp – but on the whole, his structure is more predictable and stable and so we can make out his existential themes, his conflicts, more easily.
(Note that this is not a value judgment on either Sherlock or John as a person. Personally, I often enjoy working with “structurally weak” patients because they tend to be a lot more honest and authentic in their interactions than the “structurally strong” neurotics who are so set on presenting a specific face to the world that they are often hard to reach.)
Now, what ARE the themes and conflicts that drive John? Off the top of my head I would say they are “needing to be needed,” ”needing to serve” and “enjoying danger”. I will get into each of these in turn, as I consider psychiatric diagnoses that have been bandied about in regard to John and tell you how I would diagnose him if he walked into my practice.
My diagnosis of John will concentrate on four aspects: 1) Why I don't believe John Watson suffers from PTSD, 2) why I think he suffers from depression at the beginning of the series, 3) the meaning of his limp and 4) the themes and conflics that underly his personality and express themselves in these symptom.
In this I will draw on the two very different manuals of diagnosis that I am learning to use right now: The international Classification of Diseases (ICD 10), published by the WHO and which, much like the DSM, is based on mostly atheoretical clusters of symptoms and checklists, and the Operationalized Psychodynamic Diagnosis (OPD-2). The OPD is a psychodynamic diagnosis manual, meaning that it is based on the ideas of psychoanalysis and its current great-grandchildren. It looks at the (above described) level of ego-structure and at intra-psychic conflicts, or themes, which dominate a person's life and lead to specific problems. In addition, I will also talk a bit about my clinical experience and how you start to recognise certain prototypes of patients and which one John would be.
Why I don't think John Watson suffers from PTSD
Don't fire her, ok, John? She is probably working off of somebody else's diagnosis in the first place and she never said you have PTSD, she just said you have trouble adjusting to civilian life. Which is true!
Before I get into this, I think it is important to clarify some terms and assumptions here. Depending on where on the internet you spend your time, you might come to believe that trauma and PTSD are the same thing. The assumption seems to be that PTSD is what happens after people are traumatised and that traumatised people invariably exhibit PTSD. Not so. Rather, PTSD is one specific way in which SOME people react to being exposed to trauma. It is not standard, universal or even expected. Some people see gruesome sights and don't even process it as trauma. Seem people are traumatised by gruesome sights and react with shock, intense emotion and some nightmares and other intrusions, all of which disappear after a couple of weeks. Some people might become depressed, develop an eating disorder, a somatoform disorder or compulsions after suffering trauma.
And some people might react with PTSD. PTSD is a fear response to trauma which has become chronic, not the inevitable human response to terrifying events. It is in fact a disorder that merits treatment.
As such, there are clearly defined symptoms that mark a case of PTSD, which the ICD 10 gives as:
1. The patient must have been exposed to a stressful event or situation (either short or long lasting) of exceptionally threatening or catastrophic nature which would likely cause pervasive distress in almost anyone.
This is one of the weirdnesses of this particular diagnosis: Unlike any other, it specifies the triggering event as a symptom. Which is rather problematic if you are trying to make a diagnostic manual which doesn't rely on a specific aetiology, but that is another rant for another time. So, yes, John meets this criterion by virtue of being shot in Afghanistan and then suddenly, unexpectedly finding himself back in London all alone, possibly after having been unconscious for much of the journey.
2. There must be persistent remembering or reliving of the stressor in intrusive flashbacks, vivid memories or recurring dreams, or in experiencing distress when exposed to circumstances resembling or associated with the stressor.
Now, this is a lot more difficult: Yes, we do see John wake up from a dream in which he is in danger and gets shot. And we do see him start to cry after. One perfectly legitimate conclusion to draw from that is that he had a nightmare and that this nightmare has happened before. In that case, criterion 2 might be met.
But....well. But 1) what we see is only one bad dream, not a persistent series of them. Yes, fanon has John suffering from nightmares almost continuously (and believe me, I love a good nightmare fic as much as the next fangirl). But the show only gives us this one dream and there are neither overt nor covert references to John sleeping badly or having bad dreams after this one, even though he would have plenty enough reason to throughout the series. Nightmares, it seems, are not something that is very important to John's quality of life.
Also, 2) I'm not even convinced that the dream we see is a nightmare. Yes, John is back in Afghanistan and he wakes up startled and panting. But then he looks around and it is only when he realises that he is back home that he starts to cry. The more I re-watch that scene, the more I get the impression that what is truly horrifying to John is to find himself all alone in this dingy bedsit. Nobody here is crying his name, nobody even knows him. He is not back in the excitement and danger of the battlefield, he is not in a field hospital and waiting to be declared fit enough to re-join his unit. He has been sent home and he is alone. And that is what he can't bear.
This is John Watson, untriggered by the fact he just shot somebody
I think the interpretation that this is either no nightmare at all or a singular experience for John is validated by the fact that we never see John experience any sort of flashbacks or being triggered. He is exposed to any number of stimuli that would trigger a traumatised soldier: dead bodies, explosions, shooting somebody, a flatmate unexpectedly shooting a gun, a severed head in the fridge, a man being blown up by a landmine. But he never once reacts with anything but mild annoyance or a brief flinch. People who are triggered, who experience flashbacks go white and seize up, they might start shaking and crying and in general tend to act like people who have just had a really bad fright. John? Is more annoyed by the fact that there is no food in the fridge than by being greeted by a severed head and actually re-opens the door to check that it truly is a head, after which he seamlessly slips into a conversation with Sherlock about his blog. He shoots a man, for goodness' sake, and then jokes around with Sherlock.
This is not a man anxious about being reminded of past trauma, if anything he reminds me of a friend who has done a lot of shifts as an A&E doctor: She can get emotional about patients, yes, but she is pretty unflappable when it comes to gruesome sights and genuinely just goes into this detached, professional mode when presented with, say, a patient who just tried to slit her own throat. (Says my friend: “I don't know why they were all so worried about me being affected by finding her, she was clearly still alive and the bleeding was not arterial, you could tell that straight away from the colour.”) This is pretty much exactly what we see from John when he looks at the pink lady’s body: A little flinch and then calm, competent analysis, not the shaky, barely held-together control of somebody who is reliving awful events. And yes, some people get triggered by less obvious, more idiosyncratic things that remind them of the traumatic situation, like, say, the shape of somebody's nose or the sound of a bag dropping onto a hardwood floor.
But we never see John react as if he is being triggered by ANYTHING at all.
3. The patient must exhibit an actual or preferred avoidance of circumstances resembling or associated with the stressor.
Hahahahaha. Ahem. The story starts with Sherlock inviting John along to more trouble of the kind he is used to seeing and John can't get down these stairs fast enough to follow him. In this, Mycroft is right: John is not trying to avoid situations similar to the one that got him injured, he is seeking them out. One gets the distinct impression that John Watson loves being out with a mate and a gun and seeking danger. This, again, is not a man trying to avoid being reminded of his past trauma, this is someone who loves danger and violence.
Maybe this is his way of getting over trauma: seeking it out, meeting it head on. Which is something that happens more often than you'd realise but which also means that John is not suffering from the specific trauma response that is PTSD. Frankly, however, I get the strong impression that his love of danger is what made him seek out the army, so it would predate his current situation. It might just be a part of who John Watson is.
4. Either of the following must be present:
Inability to recall either partially or completely some important aspect of the period of exposure to the stressor, OR
Persistent symptoms of increased psychological sensitivity and arousal shown by any two of the following: Difficulty falling or staying asleep, Irritability or outbursts of anger, Difficulty concentrating, Hypervigilance, Exaggerated startle response.
We don't really know, of course, if John remembers all of what happened when he got shot but we never hear or see anything to the contrary. At the same time, he clearly has no exaggerated startle response, shows no signs of hypervigilance or difficulties concentrating and we have no information that would imply that he has problems with sleeping. He is a touch irritable at times, but not in the uncontrolled and chronic way implied here.
Firstly, then, John doesn't really fulfill the criteria for PTSD, especially if we take into account that one should only diagnose PTSD if the symptoms the patient experiences can't be better explained by another anxiety disorder or depression. But I will get into that in a moment.
Secondly, John does not “feel” like a PTSD patient to me. Now, admittedly, my gut feeling has not been acknowledged as a diagnostic tool by anyone but me, but I've diagnose roughly 70 patients in the last six months and after a while I started getting pretty good (though of course not infallible) idea of the different types of patients that come in. You see, there are two main ways people sort things into categories: by lists of criteria and by whether or not an object resembles a prototype. The practical side of learning to diagnose people has a hell of a lot more to do with prototype learning than with symptom list learning, I can tell you that.
I have seen a number of PTSD patients and not only do they exhibit the symptoms described above, they also have some other characteristic things in common:
1)
They often don't trust their therapists or doctors or the hospital or anyone in a position of power. I know, I know there is that moment where Ella writes down something about trust issues but that is never born out by anything that John DOES. On the contrary, John is not nearly as contentious and ambivalent as the traumatised patients I am used to. He does not drive her crazy with that special mixed message of “you have to come and save me – no, wait, you can't save me”. He shows no other signs of mistrust for structures, hierarchies and authorities. In fact, he shows respect and consideration for them (Thank you , for reminding me of this): He keeps asking Lestrade's permission before touching the corpses at the very least up to TGG, when investigating for Mycroft he dresses up to meet him at the office, he is annoyed by Sherlock mouthing off in court and deeply embarrassed when he falls asleep in the surgery. When Sherlock tells him to do things (like shoving him out the door and ordering him to go to the Yard in TBB) he does them, often without question. This would be rather atypical for someone who has lost trust in the world and its rules and hierarchies.
John, trying to dress up for Queen and country but apparently with his eyes closed.
2)
He also doesn't show the sense of easily breached and violated self that most trauma patients exhibit. He has no trouble with sudden loud noises in his home or safe space, he keeps cool when he is being kidnapped by strange people, he easily tolerates surprise visitors even when they have a key, he does not seem terribly worried that their landlady walks in and out of their flat or even when their windows are blown in. He seems, in fact, like somebody who has an intrinsic sense of safety, grounded in himself, so that he does not feel the need to try and control the (uncontrollable) outside.
In short, he does not act like somebody who has experienced being overpowered and violated by forces greater than himself.
In conclusion, while John Watson has clearly gone through harrowing things, he does not appear to be traumatised by them. This, I think is an important thing to remember: Not everybody who goes through trauma suffers from PTSD afterwards. In the case of John Watson, I think that what burdens him more than anything else is being back in England, having no purpose and being bored – much like Sherlock.