The Violence of Diagnosis

I worked on a partial care unit for children and adolescents for 3 years at a prominent hospital, while obtaining my master’s on the weekend in the city. I loved it… eventually. Initially, I had such a deep visceral reaction my first month on the unit. My first few months might even be identified as traumatic. The crisis was intense; the level of violence in the stories of the youth I held space for was unbelievable. Sometimes the youth were not even aware or able to recall their trauma histories. At times, I felt grateful for the brain’s mechanism to protect and dissociate.

At 23 years old, I loved working on a team making decisions together, arguing various points of view. We had relationships with the crisis staff, transportation staff (super important things always happened in that van), psychiatrists, clinical social workers, psychologists, colleagues who were mental health specialists like me—who I just simply admired. I remember my supervisor saying I was a sponge. I drank it all up. This included the traumatic material as well.

After my nervous system simmered or I began to become numb to the level of intensity, the drama, and trauma; I started to feel jaded and a bit frustrated with the whole system, not just our unit. Even the word “unit” made me think of both the police station, and a hospital (granted we were in a hospital), but I wondered (in my novice mind) “How do kids feel about coming to the hospital for support with their emotions?” Their classmates back at school knew they left class early, got into a hospital van, and knew they “acted out in class.” There had to be a better way. We were helping them; why did it feel like they were being punished for what had happened and was happening to them?

As conscious as we could be… as connected to the surrounding community and inviting to the “hood” as we could be for a hospital unit, still Black and Brown youth were primarily diagnosed with behavioral disorders—diagnoses that followed them… for a long time.

Still, lighter-skinned kids would be believed a tad more, heard a tad more, and definitely complimented on the instances of “good” behavior more. Still, staff who would have days of “I just can’t do this today,” or “I can’t work with this child anymore; it’s too much…” were seen (unsaid of course) as “not as strong” and would not be promoted as often. Still darker-skinned kids were generally receiving diagnoses of conduct disorder and oppositional defiant.

I remember co-leading the latency- aged group, welcoming them at the door with music and smiles as they came in from school. Of course, they were generally deeply upset to be here, yet they felt safe enough to express their emotions with us. One youth, who I secretly adored because he was so honest, bold, and rightfully angry shoved the door hard, and it slammed against the wall causing a big bang. Many of the youth jumped. Some began crying. Some ducked behind the table. Two grabbed my hands, another my co-lead’s waist. One youth ran to the corner and hid; another attempted to lock themselves in the bathroom. Meanwhile another attempted to run away out of the room. Two other youth began cursing at the youth who slammed the door shouting, “Are you dumb!? Why would you do that? You are gonna hurt somebody! You could’ve hurt Ms. Jenn’s hand! You have a serious problem!”

We helped deescalate the situation, and process the situation. We had the space to ensure the youth did not have “his points lowered.” But I thought to myself—this is it… this is trauma personified. Some of us fight; some of us flee. Some of us freeze. Some of us have no choice but to hold space despite our reactions. Some of us hold onto what feels most safe in the room or the world. Some of us are just in our feelings, not thinking about how our actions might impact countless others. I kept saying to myself that the level of rage and deep grief that the youth are displaying in spaces where they feel least in control and least seen, must be deeper than what they’ve experienced. Don’t get me wrong, what many people experience is DEEP ENOUGH and we are allowed REACTIONS UPON REACTIONS. However, the deep-rooted sadness, the weariness, the despair, the heaviness—sometimes I would look into an 8-year-old child’s eyes and see elders. I could feel the messaging and voice of their ancestors, “Well, I guess it’s always gonna be that way.” Or “Well, that’s how it’s always been done, Ms. Jenn.” So weary. Then we would begin to hear from the family members or caregivers, and would receive similar messaging. I always found myself focused on what was NOT being said, not just the “storyline.” I would hear a feeling of legit struggle for freedom, whether or not the person realized it themselves. Freedom from the systems, from the scrutiny, from the intergenerational pain, from medication (self-administered or prescribed), and from the constant labor. Emotional and physical labor. The labor it takes as a POC to just survive in a wealthy, able-bodied, hetero, white world.

I felt as though mental health practices were “the best of what we had” but not enough. As a POC, working predominantly with other POC, I believe it is safe to say that we are tired of getting “just enough.” It is truly depressing in a clinical and metaphorical sense.

At the Root of Our Depression Is Colonization

What we are feeling is an accumulation of hundreds of years of acquisition from our bloodlines. This is not a curse. This is where it’s at, here and now, with us because many of us have the privilege of having the space, time, and energy to acknowledge, feel, label, name, and process our emotions. If you’re reading this, then yes, you are privileged. We have the generational bandwidth and responsibility, and perhaps—even with social media and grassroots organizing communities on the rise (they’ve always been there)—we have the support to work this through. We may have the words, the consciousness, and the space to unpack what our ancestors could not.

Perhaps instead of feeling like something is “wrong with us” or the people we work with, we can acknowledge that we are here to unpack 400 plus years of psychological enslavement. We are here to unpack the pattern. Perhaps we are here to build into our lives spaces of nonwork and rest; to be reunited with communities that are family; to relearn our Mother Tongues, if forgotten or never taught; to be more creative and silly, to utilize our joys with our craft; and to be nurtured back to health. We are here to reform healthy attachments and spit up the emotional poisons of colonization from our relationships and how we see ourselves. Maybe some of us are here to reconstruct old belief systems and outdated ways of “curing what ails us.”

Various diagnoses throughout the years have been used to affect public law and policy by dictating immigration and citizenship laws. For example, the first federal immigration act of 1882 “which prohibited entry to the United States of any ‘lunatics, idiot, or any person unable to take care of himself or herself without becoming a public charge.’” The wording is absolutely atrocious and quite telling. In 1907, legislation added “imbeciles, feeble-minded, any mental abnormality ever… which justifies the statement that the alien is mentally defective.” “Alien,” meaning people of different races and ethnicities, which was conflated with mental illness in the eyes of immigration authorities in the early 20th century. That bias still persists today, both consciously and unconsciously.

“An interpreter at Ellis Island noted, ‘over fifty percent of the deportations for alleged mental disease were unjustified’ based on ignorance on the part of the immigrants or the doctors and the inability of the doctors to understand the particular immigrant’s norm or standard.” The 1924 Immigration Act started a national quota system to restrict immigration of people from ethnicities, ethnic origins, and races that were “undesirable” based on diagnosis. By the 19th century, people born out of the States occupied “an unusually high percentage of patients in mental hospitals and asylums.” In fact, 80% of the population in the New York City Lunatic Asylum between 1847 and 1870 were immigrants. Eugenics movements and scientific racism attempted to prove the inherent supremacy of Anglo-Saxon and was what informed both psychiatric practice and immigration policy.

Current-day mental health systems seek to prove what is socio-culturally superior, through the descriptions of humans in the DSM. The people described as “normal and healthy” are very Western people. Medicalization and rugged individualism support late-stage capitalism through pathologization of big emotions and attempting to medicate big emotions that are a result of the suffering from systemic inequalities and lateral violence. We cannot diagnose without context. We cannot separate human emotions and experiences from the social context they were created, and exist within. This is the path and the invitation to the part where we are innately unlearning and relearning.

Tools of Colonization

This is where real reform can happen. We can evolve outdated colonial diagnosis into a new emerging field of collective-empowerment, which encompasses our history, practices, and emphasis on therapists’ own emotional health, as well as the full spiritual breadth and humanity of all therapy participants. Diagnosis, although it can be a tool, like all tools that aren’t adequately supported and based on guides for context can become weapons. They become as dangerous as the trauma we are attempting to get better from.

I know many people I have served would say that they were never given an opportunity to discuss the diagnoses given to them by a practitioner. That is why I enjoyed doing therapeutic work at a university; we were not mandated to create and use ICD-9 codes and pathologize what arises from trauma. Some people I have worked with would say that I may have brought up a set of symptoms or expressions as we spoke about a particularly abusive parent or lover as a way to understand that something “deeper, more profound, is there.” I am not always proud of how I have managed sessions, crises, or individuals whom my colonial education dictated were “deniers or resistant.” Yes, absolutely there are deeply wounded people in the world who should not have access to others while the former are in an unconscious or unnecessarily violent, traumatized, or completely inhumane state.

There are individuals I have supported who had said, “I am so grateful I understand depression better—how it shows up in my body, as a Dominican man, (for example) with my trauma history—and if I didn’t take (insert anti-depressant medication) for a year, I might not be alive and in love today.”

So, I want to honor and acknowledge that individuals have benefited from understanding a set of symptoms that have impacted them, and they are not alone. Yet, just because diagnosis is “what we have,” it doesn’t mean it’s what we now need.

Human suffering is not black and white. Neither is the mental health system. While we are understanding and learning from what has been done, what we continue to do, and who we continue to leave out of mental health conversations . . . in the meantime, people need support—sometimes BIG support, around their pain points. Sometimes the safest way is to manage the pain, while we allow a person to return to their bodies. After people, return to their bodies and feel that they are in their “right mind,” they can make decisions about what they need and how they want to heal—and most importantly the ROOT of that dis-ease. If we do not examine and honor the root of the suffering, such as colonization and dehumanization, we will continue to experience the same suffering over and over and over without a map.

Excerpted from Decolonizing Therapy: Oppression, Historical Trauma, and Politicizing Your Practice, © 2023 by Jennifer Mullan. Used with permission of the publisher, W. W. Norton & Company.

Jennifer Mullan

Jennifer Mullan, PsyD, is a clinical psychologist, international speaker, organizational consultant, course creator, community builder, and decolonized mental health movement starter. She received ESSENCE magazine’s 2020 Essential Hero Award in the category of Mental Health, and her @decolonizingtherapy Instagram page has profoundly shifted the world’s understanding of therapy and mental health.