Dr. Allen Frances is a Professor Emeritus of Psychiatry at Duke University and the creator of the diagnostic criteria for narcissistic personality disorder. That condition has been in the news frequently, as many have suggested that President Trump may be so afflicted. In his new book, Twilight of American Sanity, Dr. Frances suggests that it is not Trump who is crazy. It is us. A full transcript follows this interview:
Dr. F. Perry Wilson: In 1973, the American Psychiatric Association came forward with what would be called the "Goldwater Rule," which stated that it would be unethical for psychiatrists to attempt to diagnose public figures from afar. Nevertheless, the Trump presidency has prompted a resurgence of psychiatric diagnosis from both professionals and laypeople. Dr. Allen Frances is the former Chair of Psychiatry at the Duke University School of Medicine. He's also the author of Twilight of American Sanity: A Psychiatrist Analyzes the Age of Trump. Dr. Frances, thank you for joining me on Doc 2 Doc.
Dr. Allen Frances: My pleasure.
Dr. F. Perry Wilson: You authored the DSM criteria for narcissistic personality disorder. This is something that many people have attributed to President Trump. You are not one of them. Do you stand by the assertion that he does not have this disorder?
Dr. Allen Frances: Well, Trump is absolutely a world-class narcissist. He has every criteria met except for two. In addition to having the features of being grandiose, unempathic, self-involved, selfish, all the things that go into being Trump, you have to have distress or impairment, significant distress or impairment.
Trump is a man who causes immense distress in others, but doesn't seem to experience it very much himself. Although he's created tremendous impairment for our country and for his business colleagues, he, himself, has been very well rewarded in politics and also in business for being a narcissist. I think that it's reckless for people to attribute the damage he's causing to mental illness. He's much more bad than mad.
Dr. F. Perry Wilson: Mental illness is characterized… almost every type of mental illness is characterized by this fact. It affects your life in a negative way. I think you're making the argument that if you're the president, you have done pretty well for yourself — which most of us would agree with — but it reminds me sort of of Nixon's famous quote when he said, "If the president does it, it's not illegal." Can the president have a mental illness or by the virtue of his success, does that take mental illness off the table?
Dr. Allen Frances: We've had two amazing leaders the last century and this who had real severe mental illness. Abraham Lincoln and Winston Churchill both suffered from classic clinical depression that no one would doubt. You can be a terrific leader and have a very severe mental illness, at least intermittently, in part of your life. But I think the issue with Trump is that he's just an incompetent, blustering, deceitful conman. No one has ever been less suited for the presidency of the United States, and we shouldn't confuse his bad behavior with mental illness.
To lump Trump with the mentally ill is a tremendous insult to them. It stigmatizes them. Most people who are mentally ill are well meaning and well behaved, and really fine people. Trump is none of those. So that when we confuse mental illness with bad behavior, we, first of all, insult the mentally ill, and secondly, we underestimate just how evil Trump is and how dangerous.
Dr. F. Perry Wilson: What is it about him that prompts people to even speculate as opposed to just saying, "Oh, well, this guy might not be an effective leader?"
Dr. Allen Frances: Well, first of all, there was a lot of concern about Richard Nixon along the lines of him being quite paranoid. Appropriate concern. I think the thing about Trump is that he's completely irresponsible, quite ignorant, impulsive, insulting, corrupt, self-serving, that he'll say and do anything at the whim of the moment. But I think we confuse the behaviors of a trickster and a conman with real mental illness. I think it makes us ineffective in dealing with him. The taming of Trump will be a political taming. It won't be a psychiatric name calling. Trump will not be removed from office under the 25th amendment because he's unfit psychiatrically. That would require Pence and the majority of the cabinet voting him unable to continue in office. That will never happen. He may well be impeached, but he won't be removed from office on psychiatric grounds.
Meanwhile, we're missing the point. Congress has to tame Trump. Congress has to make sure that no one man, especially someone so unstable and so selfish as Trump, can press the nuclear button or start war with Korea. Congress has to take over the right to declare war, which presidents have abused frequently in the last 50 years. I think it's a political problem. The public is responsible. The public has to demonstrate against the reductions in medical coverage, against Trump's terribly unfair tax proposals.
The government of the United States will be turning over in 2018. The public has a responsibility to make sure that more responsible people are in charge. So the taming of Trump, the defensive democracy, the return to sane national policies, that's a political problem. Impotent, psychiatric name calling misuses psychiatric diagnosis insults patients and Trump isn't bothered by it. If he were bothered by it, he'd be tweeting about the psychiatrists. He couldn't care less.
Dr. F. Perry Wilson: Let me play devil's advocate here. Clearly, you're not a fan of the president. You want congress to take action against him. Wouldn't a consensus from psychiatrists saying, "Something isn't right here," at the very least provide them more political cover for doing what you believe needs to be done than just saying, "Oh, well, this is a guy who makes some bad decisions?" Wouldn't that help them if a prominent psychiatrist came and said, "I have concerns about this guy's rationality?"
Dr. Allen Frances: Well, I think that there's nothing about Trump that isn't completely transparent. He may well be the most transparent person who ever lived. His behavior, his outrageous taking advantage of other people, his conspiracy theories, all of these go back 45 years. It's not as if he's a different person now than when he was in his 20s. He's certainly no different now than when he was running for office.
The American public bought this and now they must have buyer's remorse. Attributing this to mental illness makes it sound like Trump is a one off and that it's all his problem. I think that's a mistake. I think that Trump is a mirror on our soul and this is a shock treatment kind of moment where we should be wondering about ourselves. What's wrong with us that we could possibly put the future of mankind, the future of our children and our grandchildren in someone this reckless? So, I think this is an important opportunity for society to take stock of ourselves, not to just make the false claim that it's one man's mental illness.
Dr. F. Perry Wilson: The central thesis of your book essentially is Donald Trump isn't crazy. We are. You suggest that the United States and Americans are under some types of delusions. Can you go into that a little bit? How are we crazy?
Dr. Allen Frances: Sure. Well, I started writing this book two years before I could or anyone else could imagine that Donald Trump would ever be running for president, much less elected. I thought that even before Donald Trump there were terrible signs that we were leaving to our children and our grandchildren, and their children, a much worse world than the one that we inherited, that we're in a kind of delusional denial about the problems, existential threats facing us in terms of global warming, terrific overpopulation. The population of the world has tripled in my lifetime, and every trouble spot in the world, every civil war, every mass migration, every loss of life, great loss of life, from natural disaster, or pandemic, is due to the fact that there's been this tremendous increase in uncontrolled population in the last 50 years.
We're using up resources that are irreplaceable in a way that's wasteful and unfair to our kids. So the problems that society faces are being ignored well before Trump, but he's taken every existential threat and made it exponential through actions in this very short period of eight months that are tremendously detrimental to our world and to the future our kids will be experiencing.
Dr. F. Perry Wilson: You're a psychiatrist, so I'm going to challenge your psychiatry skills here a little bit. As a psychiatrist, you need to be able to identify with your patients regardless of whether you necessarily agree with them. So talk to me about Trump supporters, not the man himself, but he clearly has a strong base of support, in some cases, truly rabid support for him. Are these people, in your opinion, suffering from a delusion or can you empathize with their situation?
Dr. Allen Frances: I think that's an excellent question. I have a capacity to empathize with patients to hone through experiences with thousands of them, but unfortunately that doesn't extend to Trump nor does it extend to the Nazis, or the KKK, or the religious bigots that marched in Charlottesville. But I have tremendous empathy for most of the supporters for Trump, that they've been left behind. There's been a tremendous, unfair distribution of income and resources in this country in the last 50 years. Up until about 1970, it was great being a working man in the United States.
Ever since the development of high technology of computers, jobs have been replaced at a dizzying rate, and that's been extenuated through the globalization of labor so that right now it's a struggle to get a job. The jobs are low paying, they're not enough to really keep a family in a decent living circumstance. The rural areas of America are being hollowed out. Small towns can't hire doctors, can't hire teachers, schools are closing down, kids are moving away. It's a disastrous situation for many people in America, and the message that they're sending to us is a clear and, I think, a very valuable one that we have got to reduce the inequality in this country.
The top 20 people in the United States in wealth have as much wealth as half the population. That's just dead wrong. It's been 50 years of maldistribution of great inequality. The trouble is that their message is valid, but the messenger couldn't be more false. There's no more a false profit of the common man than Donald Trump and all of his policies to date have been the direction of stealing from the poor to give to the rich, depriving maybe 30 million people of medical care — if he has his way — in order to give huge tax breaks to billionaires and to corporations that are already storing $2 trillion or more.
I think the main point here is that we have to have full respect for Trump supporters and we have to help them see where their self-interest lies in a sincere way, not just with symbolic demonstrations. We have to make this country united again around its values. Trump is making America very small again. We have to make it great again.
Dr. F. Perry Wilson: You've said before that Trump is a snake oil salesman. He's offering a solution to these very real problems, but the solutions are, themselves, false or transparent or ineffective. If that's the case, then what is the real medicine, in your opinion, that this country needs to escape from our own insanity?
Dr. Allen Frances: Well, I think what's happened for the last 40 years is a remarkably successful propaganda effort that has pitted race against race, has pitted social conservatives against social liberals in an effort to avoid the fact, to make unclear, to obscure, that there's been this tremendous increase in equality and to the detriment of the common people. I think we have to unify again as a country. I think we have to come together, and I think that can be done.
If you take surveys of the American public, you'd find that on almost every issue there's a commonsense majority answer that makes perfect sense for the future. The politicians have polarized around positions that most people would not hold. We can find commonsense solutions to taxation, to abortion, to gun control. All of these issues are amenable if we reduce the propaganda that's turning one group in America against another.
Trump is just the greatest expert, the greatest conman, at creating divisiveness. So, I think our people have to come together. The good thing about Trump is that he is such a terrible president that he's creating the biggest backlash you could possibly imagine. Actually, I'm fearful of Trump being impeached. I think that Pence and Ryan in office would be much better because more plausible perpetrators of policies that would be very detrimental to the average American. There's no administration that would be less useful to Trump supporters than a Pence-Ryan administration. I think the democratic party has gone far astray. It's lost its base and it's time for it to recover that base.
Dr. F. Perry Wilson: Well, Dr. Frances, the new book is called Twilight of American Sanity. It is available wherever fine books are sold. Thank you once again for joining me today.
Dr. Allen Frances: It's been my pleasure and let's hope things work out much better than they appear to be working out right now. I'm hopeful about the future even though the current situation looks so difficult.