The expert who helped write the mental disorders manual explains why Trump doesn’t have one

There are a few options for people who want to see President Donald Trump removed from office. There are plenty of calls for impeachment over his various scandals. There’s the ongoing investigation into Trump’s ties with Russia, led by Robert Mueller. And then there’s the effort to remove the president by diagnosing him with a personality disorder and invoking the 25th Amendment, which allows Congress to remove presidents deemed unfit to lead.

Law experts say this is unlikely to happen. Dr. Allen Frances says it shouldn’t happen. Frances is a well-known psychiatrist who literally wrote the book on personality disorders, and he’s been vocal in stating that Trump does not have one. Trump should be removed, according to Frances in his new book Twilight of American Sanity, but not because he’s mentally unfit. He should be removed because he’s a bad president.

The Verge spoke to Frances about diagnosing mental illness, why Trump doesn’t have any of the ones attributed to him, and where we go from here. This interview has been lightly edited and condensed for clarity.

Tell me a little bit about your background. You’re a psychiatrist, and I know you were involved in writing the Diagnostic and Statistical Manual of Mental Disorders, and specifically writing the criteria for narcissistic personality disorder, which is something people often “diagnose” Trump with.

Yes, since 1977, I’ve been very heavily involved in the development of the DSM.

We make the decision to introduce narcissistic personality disorder in DSM-III and I wrote the version that’s still used now. The decision to include it was purely for clinical purposes and we never dreamed it would result in the diagnosis of NPD being used in political warfare now. I think that if we’d had that thought along the way, we would have thought twice about including it.

Really, Trump is not the cause of the world’s problems, he’s more a symptom of them. Trump is not the underlying societal disease, he’s more signaling how dangerous our future is.

You write in the book that Trump does exhibit some of the criteria of narcissistic personality disorder, like his grandiose delusions, but that he doesn’t have it because these traits don’t cause him distress. Why is that distinction so important?

Trump causes enormous distress to others, but his behavior doesn’t bother himself. In fact, he gets rewarded for them, he’s not necessarily out of sync with larger society. He’s always terrific at feathering his own nest and he’s been rewarded for his world-class narcissism rather than being punished for it. Having the symptoms themselves does not constitute a mental disorder. In order to qualify as a mental disorder, the individual would have to have distress related to them.

So many of these behaviors in the DSM occur in perfectly normal people, so we don’t think everyone should be labeled mentally ill just because they have symptoms included in one disorder or another. Lots of traits are distributed in the whole population, and some people have a lot of it, but it doesn’t mean they’re mentally ill unless it’s causing them a great deal of distress.

And you think that even if he did “officially” have it, it wouldn’t make a difference.

This argument that NPD should disqualify Trump from presidency doesn’t make sense. First, he doesn’t have it. And even if he did, so what?

Narcissism is very common in political leaders, celebrities, doctors, lawyers, and professors, but it’s not a disqualifying criteria for governing. Even if people have mental disorders, that doesn’t mean they can’t be great leaders. We don’t want that idea. Abraham Lincoln and Winston Churchill both had very severe mental disorders and were among the best leaders.

The decision to keep someone as a leader should be based not on psychiatric name-calling but rather on the person’s behaviors and adherence to the Constitution and confidence as a leader. He should be impeached of his behavior and because he’s a terrible president, not because he supposedly has a mental illness.

NPD is not a reason that someone wouldn’t be president. The arguments of the people making the case for narcissistic personality disorder are confusing bad behavior with mental disorder and they shouldn’t be distracting from Trump’s very bad behavior with futile, psychiatric name-calling.

Right, so you think he should be removed because of what he’s done, regardless of whether he has any “mental illness” or not.

Yes. There are also two other diagnoses people like to give him. One is delusional disorder. Sure, Trump has been a conspiracy theorist ever since his first contacts with Roy Cohn, who was the mastermind behind the Communist witch hunts. But he’s been successful with conspiracy theories! He got into the presidential arena with Obama birther stuff. “Crooked Hillary,” the most powerful tool used in the election campaign, and “fake news,” is how he does things now. He uses conspiracy theories, yeah. But you’re not delusional if a substantial part of the US population believes you! Delusions are personal and for an audience of one. When people believe you and support this, that still makes him a bad person for understanding the world, but that doesn’t make him crazy.

The third diagnosis is dementia, because he’s repeating the same words more now than he did 15 years ago. But I would attribute that more to habits and knowing certain words or catchphrases that captivate the audience, and so you repeat them. Trump is certainly not demented when it comes to being self-serving or deceiving others.

Do you think the DSM is being misapplied here? Or is it often misapplied at large?

The one clearest lesson from 40 years of experience is that if anything in the Diagnostic Manual can be misused, it will be misused, especially if there’s an external award for the misuse, and so I very much object to using psychiatric labels, particularly in the political context.

I wrote a book, Saving Normal, about a similar issue. We’re over-diagnosing people who are basically well and providing them with medications that do more harm than good, while neglecting those with severe mental illness, who desperately need help and can’t get it.

There’s been some discussion about the Goldwater rule — which states that psychologists shouldn’t diagnose public figures they haven’t treated — and whether we need to retire it when it comes to Trump. I take it that you don’t support the movement to retire it?

The mental health community understands the risk of Trump and feels compelled to provide a duty to warn about his dangers, but they’re misguided in the tools they’re using. As far as controversy over the Goldwater rule, it’s a tempest in a teapot to me. Worrying about Trump’s psychological state and responding to each of his tweets distracts us from the larger mission of containing him, and that containment will only happen politically.

The political tools are the appropriate ones. Whenever we confuse bad behavior with mad behavior, we’re associating the public’s mind the notion that all bad actions come from mental illness and, therefore, most people who are mentally ill must be bad people. I’ve met thousands of mentally ill people over the years, and with a few exceptions, most of them are very well-meaning, decent people, it’s an insult to them to be lumped with Trump.

A lot of your book is about the greater issues you see in American society. What have you seen that’s changed in the past 40 years?

American politics has become polarized in the last 40 years. I think the people of the US have also been polarized by the extensive and successful propaganda campaigns of right-wing talk radio, internet sites, Fox News.

The two people who most influenced advertising were a nephew of Sigmund Freud, Edward Bernays, and the father of behavioral psychology, John Watson. Advertising basically is applied psychology — the ability to influence people without their being aware of it. Those techniques have been very successful in brainwashing a large proportion of our population and polarizing the political process.

So, what do you think should happen going forward?

The Democratic Party has its heart in the right place, but has a remarkable deficit in strategic savvy. During heat of the Trumpcare debate, they didn’t have an alternative policy. I don’t necessarily trust the Democratic Party at this point to be an effective opposition to the destructive climate, facts, and medical policies of the Trump administration. I think there has to be much more active public participation in pushing the politicians in the right direction.

I was politically missing in action for every tumultuous issue in the last 50 years. I think all of us have to rise to this occasion and protect our democracy and protect the environment that we’ll be handing to our children and grandchildren.

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