The Radical Politics of Being Misunderstood

Diagnosis has a terrible history.

That is not a sentence therapists say often enough.

We like to imagine the history of mental health as a steady march toward truth: each generation becoming more enlightened, each edition of the diagnostic manual correcting the mistakes of the last, science gradually clearing away prejudice until only objective reality remains.

But diagnosis has never existed outside culture.

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It has always been shaped by the people with the power to decide what is normal, whose suffering is legitimate, whose difference is dangerous and whose humanity is negotiable.

Women were diagnosed with hysteria when their bodies, emotions, sexuality or refusal to comply exceeded what men found acceptable. The supposed disorder was located inside women rather than inside the conditions constraining them.

In 1851, physician Samuel Cartwright invented drapetomania, a supposed disease that caused enslaved Black people to flee captivity. The desire for freedom was treated as pathology because acknowledging its sanity would have required acknowledging the depravity of slavery. The diagnosis revealed nothing about the enslaved person. It revealed the moral sickness of the society doing the diagnosing.

Homosexuality remained classified as a mental disorder by American psychiatry until 1973. Gay people did not suddenly become healthier that year. The institution finally began to acknowledge that it had mistaken cultural prejudice for clinical truth.

Every era has produced diagnoses that tell us more about the fears of the culture than about the people being diagnosed.

Diagnosis has been used to understand suffering. It has also been used to make oppression appear scientific.

As a therapist, I believe we have an ethical obligation to hold both truths.

Our profession has been capable of extraordinary insight and extraordinary harm. Humility is not optional in a field with that history.

And yet, I spend a significant part of my professional life helping people pursue diagnoses.

How can both things be true? Because the opposite of bad diagnosis is not no diagnosis.

It is better diagnosis. More collaborative diagnosis. More contextual diagnosis. Diagnosis rooted in curiosity rather than control. Diagnosis that begins not with, How do we explain this person?

But with, Have we understood them correctly?

Nobody arrives unlabeled

People often tell me they do not want a label.

I understand why.

A diagnosis can feel like a box imposed by someone with more authority. It can follow you through medical records, shape the care you receive and influence how professionals interpret you before you have said a word.

But the question is not whether we will live with labels. The question is whether the labels we live under are true.

Because nobody arrives in my office unlabeled. Long before someone receives a formal diagnosis, they have usually accumulated dozens of unofficial ones:

Lazy.
Dramatic.
Manipulative.
Immature.
Controlling.
Too sensitive.
Too intense.
Attention seeking.
Defiant.
Selfish.
Difficult.
Broken.
These are labels too.

The difference is that they masquerade as observations rather than interpretations. They are treated as truths about character instead of hypotheses about behavior.

They are diagnoses of morality.

And unlike the words written in medical charts, these labels become embedded in identity.

One of the most painful things I witness clinically is not a person discovering that they are autistic, have ADHD, OCD, PTSD or an eating disorder.

It is watching them realize how many inaccurate conclusions they had already drawn about themselves.

I guess I am just lazy.
I guess I ruin relationships.
I guess I am bad at being an adult.

Everyone else can do this, so I must not be trying hard enough.

Human beings need explanations. When something is consistently harder for us than it appears to be for everyone else, we search for a reason.

When nobody offers us an accurate one, shame fills the vacuum.

Children rarely conclude that the adults around them have fundamentally misunderstood them. They conclude that they are the problem. That belief can preserve attachment to caregivers, teachers and communities—but it does so by sacrificing the child’s trust in themself.

Years later, I meet adults who are capable, accomplished and deeply caring, yet remain quietly certain that they are defective.

Not because a professional diagnosed them.

Because they have been diagnosing themselves morally for decades.

Description is not explanation

This is one of the fundamental problems with the way diagnosis is sometimes used: a diagnosis can describe what is happening without telling us why.

Oppositional Defiant Disorder is a particularly important example.

ODD describes a persistent pattern of angry or irritable mood, argumentative or defiant behavior and vindictiveness. Its diagnostic criteria identify observable patterns.

But a behavioral description is not an etiology.

ODD does not, by itself, tell us why a child is resisting.

It does not explain whether the behavior emerges from trauma, sensory overwhelm, chronic invalidation, neurodevelopmental differences, anxiety, unmet communication needs, a threatening environment or a nervous system that experiences the loss of autonomy as danger.

It tells us what adults see.

It does not necessarily tell us what the child experiences.

That distinction matters enormously.

I think about the number of children with a PDA profile who receive an ODD diagnosis in childhood, and grow into adults who never revisit that framework.

I think of a client I’ll call R, who arrived describing herself as someone who “sabotages her own life.” She could not stick to a schedule, resented every deadline she had agreed to, and had been called controlling, defiant and difficult since she was a kid—first by parents, teachers, later by partners and employers. She had internalized all of it as a character flaw. What changed wasn’t her behavior. What changed was the question underneath it. Instead of asking how to make her more compliant with structure, we asked what happened in her body the moment a request stopped feeling like her own choice. Once she understood her resistance as a nervous system defending its autonomy rather than a moral failing, the same behavior her past providers had called manipulative became legible as self-protection. She was the same person. She had simply stopped being asked to survive a framework that had never fit her.

The adults who labeled someone like R as a child, and the colleagues and partners who label her now, see refusal, argument, avoidance, escalation and attempts to control the environment. Those behaviors may satisfy the descriptive criteria for ODD in childhood, or simply read as “difficult” in adulthood.

But description can become the end of curiosity.

When a child’s resistance is interpreted primarily as willful defiance, adults frequently respond with increased control, firmer consequences, reward systems, compliance programs and escalating behavioral demands.

When that same resistance is understood as a threat response arising from a persistent drive for autonomy, the questions change.

What is this demand communicating to the child’s nervous system?
What happens when autonomy feels endangered?
What environmental conditions increase or reduce the threat?
How can we preserve dignity and shared agency while still meeting genuine needs?

The child may not have changed at all. Our understanding has.

And when understanding changes, relationships and interventions can change with it.

That is why I resist the idea that a diagnosis automatically constitutes an explanation.

Sometimes it is only a description of how another person’s distress inconveniences the people around them.

Who is the diagnosis for?

Perhaps this is the question we should ask of every diagnosis: who is it serving?

If a diagnosis deepens a person’s self-concept, helps them understand the patterns of their life, guides meaningful treatment, provides access to accommodations, connects them with community or replaces shame with compassion, it may serve the person being diagnosed. But if it does none of those things—if it merely categorizes, predicts, stigmatizes or makes professionals feel more certain—then it was never really for the person carrying it. It was for the system trying to organize them: language mistaken for compliance, illumination mistaken for explaining someone away.

Diagnosis should not exist merely to make professionals, schools, parents or institutions more comfortable with their uncertainty.

A diagnosis that happens with someone can become a language.

A diagnosis that happens to someone can become a sentence.

When diagnosis becomes doctrine

In my clinical work, I often sit with people who are deconstructing high-demand, high-control religions or communities that function like cults (and often are).

Deconstruction is rarely just a matter of deciding that you no longer believe a particular doctrine.

It is the slow, disorienting process of recognizing that the entire framework you were given for understanding yourself may have been designed to preserve the system rather than reveal the truth.

You were told your doubt was rebellion. Your anger was sin. Your boundaries were selfishness. Your fear was conviction. Your unhappiness meant you were not faithful enough.

Your questions were dangerous because the system already had an answer for everything—including an explanation for why you could not trust your own perception.

When clients begin deconstructing, they are not simply asking, “Do I still believe this?”

They are asking:

Which parts of me are actually mine?
Which feelings was I taught to fear?
Which needs did I learn to call sinful?

Who benefited from my believing that the problem was always me?

Diagnostic deconstruction can look remarkably similar, particularly when diagnosis happened to someone rather than with them.

A diagnosis may have been delivered as a verdict by someone with greater institutional authority. It may have been placed in a chart with little collaboration, curiosity or context. It may then shape every future clinician’s interpretation of the person.

Once the diagnosis becomes the official story, everything can be used to confirm it.

If you disagree, you lack insight.
If you become angry, you are dysregulated.
If you object to mistreatment, you are oppositional.
If you explain yourself persuasively, you are manipulative.
If you comply, the framework was right.
If you resist, the framework was right.
That is not understanding.

It is a closed system.

Closed systems are almost impossible to challenge because every challenge is reinterpreted as proof of the system’s authority.

This is why diagnostic harm can be so profound. The person has not merely been given an inaccurate word. They have been given a framework that teaches other people not to believe them—and may eventually teach them not to believe themselves.

Deconstructing that framework can require much of the same work involved in leaving a high-control community:

Recognizing coercion that was presented as care.

Separating accountability from obedience.

Distinguishing self-reflection from compulsive self-doubt.

Recovering anger as information rather than evidence of pathology.

Learning that disagreement is not dysfunction.

Remembering that authority and accuracy are not the same thing.

And asking, perhaps for the first time: What do I know about myself when I am no longer required to interpret every experience through the framework I was handed?

Deconstruction is not the reflexive rejection of everything an authority ever said.

It is the recovery of discernment.

It is the right to examine what you were told, understand the context in which it was offered, keep what is truthful and useful, and refuse what requires the abandonment of your humanity.

This is the same discernment a diagnosis deserves. Not blind acceptance because someone credentialed handed it to you. Not blind rejection because diagnosis has a violent history. But an honest asking: does this framework explain me, or does it explain me away?

Sometimes radical self-love means receiving a diagnosis that finally explains your life.

Sometimes it means carefully dismantling a diagnosis that has been used to explain you away.

Diagnosis and the sorting of human worth

Autism’s diagnostic history makes the relationship between classification, power and human value impossible to ignore.

Hans Asperger worked in Nazi-era Vienna within a medical system shaped by eugenics. Historical scholarship has found that he accommodated and paticipated in Nazi ideology and, on several occasions, actively cooperated with the regime’s child “euthanasia” program, referring children to a clinic he knew participated in killing those the regime deemed a burden. The full extent of his knowledge and involvement remains debated among historians, but his documented referrals and relationship to the Nazi medical apparatus have permanently complicated the history attached to his name (as they should).

This is one reason many autistic people refuse the outdated label Asperger’s.

That refusal is not simply a preference for updated diagnostic terminology. It is an ethical position.

We refuse a framework that divides autistic people into those who appear useful enough to be accepted and those whose needs make their lives seem less valuable.
We refuse to participate in ableist eugenics.

We refuse the idea that proximity to neurotypical productivity should determine who receives dignity. We refuse to sort autistic people into the ones society should accommodate and the ones it is permitted to discard.

Diagnosis should help us understand people.
It should never be used to rank them.

It should never decide who is valuable, who is productive enough, who deserves resources or whose life is worth sustaining.

There are no “good” autistic people whose ability to work, speak, mask or comply earns them humanity—and no “bad” autistic people whose disability forfeits it.

Support needs are not measurements of human worth.

Intelligence is not a moral achievement.

Productivity is not the price of being allowed to live.

The history of Hans Asperger’s work sits inside a regime that turned medical classification into a mechanism for deciding who belonged in society and who should be eliminated.

Rejecting that legacy means more than changing vocabulary. It means refusing the underlying hierarchy.

It means insisting that diagnosis must never again become a polite clinical language for sorting lives into those worth protecting and those deemed burdensome.

Misdiagnosis did not end with history

It would be comforting to tell ourselves that hysteria, drapetomania and the pathologizing of homosexuality belong to a less enlightened past.

But people are still misdiagnosed repeatedly.

Autistic people—particularly women, queer and trans people, people of color, highly masking people and those whose presentations do not match a narrow stereotype—may accumulate diagnoses for anxiety, depression, personality disorders, trauma and eating disorders before autism is ever considered.

Borderline Personality Disorder is one of the most common of these misdiagnoses in autistic women. The overlap is easy to see on the surface: emotional intensity, rejection sensitivity, meltdowns that look like “dysregulation,” relational patterns that get read as instability rather than as the exhaustion of a lifetime spent masking. A clinician untrained in how autism presents in women may see the emotional intensity and stop looking, because BPD is the diagnosis they already have a script for. What that clinician often misses is the underlying cause: not a personality disorder, but a nervous system in chronic overwhelm, doing exactly what an overwhelmed autistic nervous system does. The treatment implications are not minor. BPD treatment frequently centers on distress tolerance and interpersonal effectiveness within existing demands. An autistic woman misdiagnosed this way is taught to tolerate a life that was never built for her nervous system in the first place, instead of being supported in building one that is.

ADHD is treated as laziness or lack of discipline. OCD is trivialized as perfectionism or neatness. Trauma responses are mistaken for fixed personality traits. Dissociation is dismissed as attention seeking. Eating disorders are reduced to vanity or a desire for thinness. Chronic illness is attributed to anxiety when tests fail to provide easy answers. Autistic overwhelm is interpreted as emotional instability. PDA distress is framed as manipulation.

The names have changed.

Our habit of misunderstanding people has not.

And misdiagnosis does not merely delay the right treatment.

It can reorganize a person’s entire understanding of themself.

A person given the wrong framework may spend years trying to change the wrong thing. They may be taught to suppress signals that were trying to protect them, distrust perceptions that were accurate and accept responsibility for harms they did not create.

They may become exceptionally skilled at performing wellness while becoming progressively less well.

Diagnosis as correction

This is why diagnosis can be an act of radical self-love—not because diagnosis is inherently benevolent, but because an accurate, collaborative diagnosis can correct a story that has been injuring someone for years.

Diagnosis does not necessarily tell us who we are.

Sometimes it tells us who we were never.

Never lazy.
Never dramatic.
Never choosing overwhelm.
Never deliberately difficult.
Never failing because we lacked character.
Never broken in the ways we had been taught to believe.

I have watched people’s faces change when they understand that the behaviors they spent decades condemning had context.

The transformation is not always, Now I have a diagnosis.

Often it is: So I wasn’t making it up. So there was a reason. So I was working much harder than anyone knew. So perhaps I do not have to hate myself for this anymore.

The diagnosis itself is not the healing. The change in attribution can be.

Someone who believes executive-functioning difficulties reflect laziness tries harder, fails harder and becomes more ashamed; someone who understands executive functioning as a neurological process can build external supports instead. Someone who believes sensory overwhelm is weakness learns to endure escalating pain; someone who understands it as a nervous-system response can seek regulation and accommodation instead. Someone who believes they are inherently disorganized buys another planner; someone who understands that they have ADHD can begin designing a life that works with their brain rather than endlessly punishing it for being the brain it is.

Accommodation is not surrender.

Self-understanding does not eliminate accountability. It makes meaningful accountability possible.

You cannot care effectively for a nervous system you insist you do not have.

The politics of telling a truer story

People sometimes ask whether diagnosis is limiting.

In my experience, shame is infinitely more restrictive.

Shame tells you not to ask for help, not to wear the headphones, not to leave the gathering, not to stim, not to rest, not to disappoint anyone, not to let them see how difficult this is—not, in the end, to be yourself.

I have watched people spend decades trying to become someone whose nervous system they simply do not possess.

No diagnosis imprisoned them as effectively as shame did.

Radical self-love is not accepting every diagnosis we are given.

History should prevent us from doing that uncritically.

It is not pretending disability does not exist, romanticizing struggle or imagining that every limitation will disappear once we understand it.

Radical self-love is insisting on being understood as accurately as possible.

It is refusing explanations that require us to betray our own lived experience.

It is asking who benefits from the story we have been told about ourselves.

Sometimes radical self-love means pursuing a diagnosis.

Sometimes it means rejecting one.

Sometimes it means replacing ten inaccurate labels with one that gives us language, context and community.

Sometimes it means recognizing that the framework was created to make our behavior manageable for other people, not to make our lives understandable to us.

Diagnosis, at its best, is not a verdict.

It is a collaborative act of meaning-making. It says: here is a possible map. Does it resemble your terrain? Does it help explain where you have been? Does it make it easier to care for yourself? Does it create more dignity, agency and choice?

If the answer is no, we should not demand that a person reshape their life to fit the map.

We should question the map.

Every era has produced explanations that justified misunderstanding people. Sometimes we called them medicine. Sometimes we called them religion. Sometimes we called them parenting, discipline, professionalism or common sense.

The language changed. The pattern remained.

When people with greater power misunderstand people with less, the cost is borne by the misunderstood.

That is why being accurately understood is not merely a personal comfort.

It is political.

Radical self-love is not simply learning to like yourself.

It is deciding that the story you were given about yourself is no longer credible.

It is replacing inherited shame with curiosity.

It is reclaiming your perception from systems that taught you to distrust it.

It is refusing to measure your worth by your compliance, productivity, palatability or proximity to someone else’s idea of normal.

It is asking not only what is wrong with me, but who taught me to believe that. Who benefited when I believed it? What became possible for the people around me when I blamed myself?

And finally: what if they were wrong?

That is the radical politics of being misunderstood.

And that is why, despite the violent and deeply imperfect history of diagnosis, I still believe that diagnosis—when it is collaborative, contextual, humble and rooted in dignity—can be one of the most radical acts of self-love we ever undertake.

Not because a professional has finally told us who we are. But because, at last, we have been given language with which to tell a truer story.