The Diagnosis Paradox

We can review the thinking of primitive man and be amused at the evil and malevolent forces
blamed for his misfortunes, or we can review the history of recent centuries and chuckle at the
errors in the assignment of blame that resulted from lack of scientific knowledge, while we
smugly assure ourselves that new scientific breakthroughs and logical reasoning now enables us
to assign accurate causes for most of man’s problems. (Bowen, Murray. Family Therapy in
Clinical Practice, Kindle edition, 419-420.)

In my 20+ years as a practicing family therapist I’ve grown accustomed to clients telling me
about their “narcissistic father,” “bipolar mother” or “Asperger’s brother.” This togetherness
move invites my understanding and agreement with the difficulty of dealing with such a person.
The labels are meant to be factual and descriptive. As therapy becomes more acceptable and
accessible, people increasingly are aware of psychiatric terms, at least on a superficial level.
While an official diagnosis sometimes has been made, family members often assign these labels
based on Google searches or popular self-help books.

Clients regularly report that a previous therapist told them that their relative has this or that
diagnosis based solely on the description they provide, without meeting the person.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) was created in 1952 by the
American Psychiatric Association so that mental health professionals in the United States could
communicate using a common diagnostic language. (Roger K. Blashfield, Jared W. Keeley,
Elizabeth H. Flanagan, and Shannon R. Miles. “The Cycle of Classification: DSM-I Through
DSM-5.” Annual Review of Clinical Psychology,

This standardization helped to destigmatize patients. Today, people who might otherwise resist
asking for help, may do so to treat a known condition like depression or anxiety. Families can be
more understanding of otherwise inexplicable and frustrating behaviors once their child has been
diagnosed with ADHD or Asperger’s syndrome. (The diagnosis can also usher in a host of other
problems. For those interested, research the Bowen theory concept, family projection process.)

The concern addressed here is the shift from the use to the misuse of psychiatric terms – the
diagnosis paradox. On the one hand, I’m being told a person has a mental disorder, while on the
other hand, I’m hearing that the person is kind of a jerk. (Problems with the DSM have been
reported elsewhere.)

Using the logic of DSM categorization, a mental disorder is a syndrome of associated features
like an autoimmune illness, or a genetic abnormality presenting with various signs and
symptoms. It’s considered virtuous to approach the sick with compassion and understanding.
When someone labels someone else “a narcissist,” they mean to insult and blame, often invoking
the diagnosis as an excuse to avoid them. It is also a way to relieve oneself preemptively of any

responsibility for relationship problems. After all, how can you be expected to deal with
someone who’s bipolar? In general, it’s a conversation-ender.

After deciding that someone has one of the psychiatric conditions accounting for difficult
personalities, it’s common practice to say the person is the disorder – (a narcissist, a borderline,
“She’s OCD,” etc.) Other conditions with different connotations are framed more gently, for
example, “He has autism.”

The diagnosis paradox is most egregious when psychiatrists and other professionals use their
knowledge of the DSM to discredit public figures. Are they describing an illness or a character
defect? Both? Should the listener feel compassion? Fear? Contempt? Does a mental health
diagnosis make a person unfit for their job? If so, which diagnoses? For how long? It’s unclear
and, unfortunately, extremely subjective. (See Family Systems Journal, 14.2, Book Review: The
Dangerous Case of Donald Trump by Lorna Hecht-Zablow, MFT.)

I have begun telling clients that I don’t speak DSM because I can't understand their thinking
without the benefit of descriptions and examples in plain language. Removing the labels
facilitates greater objectivity and consideration of the larger family system.


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