In an age when the current White House occupant has inspired unprecedented levels of armchair psychiatry, Allen Frances remains one of the foremost authorities in the field. As the chair of the Diagnostic and Statistical Manual of Mental Disorders (DSM) IV Task Force, he helped draft the criteria defining narcissistic personality disorder and other mental illnesses. He previously served as the chairman of the psychiatry department at Duke University School of Medicine and founded the Journal of Personality Disorders and the Journal of Psychiatric Practice. In other words, Frances knows his personality disorders.

I spoke with Frances, whose most recent book is Twilight of American Sanity: A Psychiatrist Analyzes the Age of Trump, about the problem that is Trump and how to end the distractions that keep us from solving it.

Kali Holloway: You famously wrote the DSM entry for narcissistic personality disorder, which has been consistently associated with Trump since he launched his presidential campaign. You’ve spoken about your disagreement with that assessment. Can you talk a little bit about why you think that description is off?

Allen Frances: Yes. First of all, Trump is, without a doubt, a world-class narcissist. Not just among the great narcissists of our day, but among the great narcissists of all time. You have to go back to Nero in Rome maybe to find someone as self-involved and destructive as he is.

The idea that narcissistic personality disorder could serve as a political weapon to remove him from office under the 25th Amendment is absurd on many grounds. First off, it’s a very tenuous psychiatric diagnosis. When we introduced it in 1980 for the first time in the DSM-III, we did it strictly for clinical purposes, never imagining that it would ever be used as a political weapon. It was almost removed by DSM-5 in 2013; it just barely made it into the final draft of the system. It won’t be included in the World Health Organization Classification of Psychiatric Disorders that will be published next year.

Secondly, some of our best and worst presidents have been narcissistic. It’s never been seen as a sign by itself of incompetence for the office. It’s the behaviors that may be associated with it that need to be addressed, not the diagnosis. The diagnosis doesn’t really add much to the discussion. In fact, instead of clarifying it muddies the waters.

Thirdly, the criteria of a narcissistic personality disorder require a whole series of narcissistic behaviors and attitudes. All of which Trump displays with magnificent extravagance, but it also requires that there be, as a result, clinically significant distress or impairment. Trump is a great causer of distress in others. He’s creating horrible impairment in our democracy, but there’s no evidence to indicate that he would meet the grounds of clinically significant distress or impairment to himself.

He’s been rewarded for being this narcissistic idiot his whole life, not punished for it. He has not hidden himself. He is the most transparent personality in the world. Every thought is out there in a tweet. He has been this person throughout his whole life. He won the election—admittedly with the help of rigging and gerrymandering—but with this personality on full display.

We desperately have to contain this dangerous, impulsive, irritable, ignorant, despicable president. But we’re not going to contain him by idle, sideline, armchair, impotent psychiatric diagnosis. The only way to contain him is through political action. The ruminations about his psychology, his mental status, his psychiatric diagnosis are a terrible distraction from the political steps that need to be taken by Congress immediately and by the voters in the midterm election.

KH: Just continuing on this thread, you’ve previously said that Trump is ‘more bad than mad,’ which essentially means we’re dealing with someone who isn’t mentally ill; he just isn’t a good person. I wonder if, for a lot of people, seeing a president behave in ways that are so outlandish and nonsensical, we subconsciously feel like a personality disorder has to be at work because it’s so hard to make sense of it otherwise.

AF: Yeah. Confusing mad and bad is a very dangerous precedent. It’s not at all restricted just to Trump. The National Rifle Association happens to believe that whenever there’s a mass murder, the person must have been crazy. It’s not the guns that did it; it’s the crazy person. They actually work hard to get the mentally ill more armed. They are against laws that restrict arms for the mentally ill, but then the minute there’s a serial murder, any kind of homicide, it’s the crazy person who did it, not the gun. We are criminalizing mental illness. We have 350,000 people with mental illness in jail because they couldn’t get treatment. We’re medicalizing bad behavior.

When the Harvey Weinsteins and Tiger Woods and all the others get caught with their pants down, the first claim is sex addiction: “I’ll go off for a rehab program and I’ll be cured in a month.” We’re medicalizing immorality. We’re medicalizing people who rape and say they have mental disorders. Bad behavior is part of the variety of human nature. Only a small portion of bad behaviors are done by people who are mentally ill. Most bad people are not mentally ill; most mentally ill people aren’t bad. When we confuse the two, it’s a stigmatizing insult to the mentally ill. It’s terrible for them to be lumped with Trump because most of them are well-meaning and well-behaved, and Trump is neither.

I mean, the other problem with this is it treats Trump as if he’s a one-off and he’s crazy. It takes away from the fact that we’re crazy for having elected him.

KH: I actually wanted to go there because I know you started writing Twilight of American Sanity before Trump made his bid for the presidency. You’ve said you had already noticed signs of what you identify as the ‘societal disease’ that would lead to Trump’s rise. 

AF: Trump is not a one-off. We act as if we could just remove Trump from office, we would return to societal sanity. Trump is a symptom of our disease, not the disease itself. He’s a reflecting mirror on our soul and the image is not pretty. The racism, misogyny, LGBT prejudice [and] xenophobia that partly brought him to office—these issues need to be addressed. These things are not just an aspect of Trump.

KH: He’s a symptom of a serious disease.

AF: As Clinton says, there’s a deplorable element to Trump’s support. It’s fueled by an underlying racism, misogyny, LGBT prejudice, anti-Semitism, and so forth. We have to address that, not just make believe it’s Trump’s creation.

There’s another large part of Trump support that comes from economic inequality. Especially in rural America amongst impoverished whites, there’s been a tremendous reduction in life expectancy, a terrific opioid epidemic, an inability to find decent paying jobs, an increasing inequality, the absence of health care, and the people left behind in America are rightfully upset with the status quo. Their message is completely valid. They just picked the worst possible messenger. He’s done everything in his power in his first year of office to betray them with every one of his policies, especially the tax cut and the medical coverage deduction.

Then we have self-proclaimed evangelicals, who are led by hypocritical religious leaders who are anything but Christian. Christ preached love, Trump preaches hate. Christ rewarded morality, Trump is one of the most immoral people in the country today. Christ never preached against abortion or homosexuality, even though both were common in the Roman Empire he lived in. His biggest targets of disapproval were the rich and the religious hypocrites—the two groups Trump most represents. The leaders of the evangelical movement have sold their souls to the devil in leading their flock to support someone whose policies are the very opposite of Christian charity and love.

Then there’s a fourth group. The fourth group is the political and economic cynics who are using Trump as the vehicle for their policies. His distracting tweets and bizarre behavior have allowed a tax cut that represents a kind of reverse Robin Hood, a stealing from the needy to feed the greedy, and efforts to take away medical coverage from those people most in need.

So we have four groups supporting him. The deplorables, the disadvantaged, the deceived religious, and the cynicals. We have to look at the problems each presents to American democracy and the challenges each presents to American democracy, rather than focus attention just on Trump’s psychological quirks.

If he were gone and we had Pence and Ryan in office, that would probably be less short-term dangerous for America because they’re less likely to impulsively press the button. But in the long term, they’re more dangerous, because they’re more plausible representatives of the horrible Koch and Mercer policies that Trump is the face of.

KH: I want to go back to talking about the deplorables and the disadvantaged who are part of Trump’s base, because I have a really hard time distinguishing between Trump and his followers. If Trump isn’t mentally ill, but is just a bad person, I have to wonder what that says about his followers. There’s this idea that we all have to have empathy for Trump supporters who have been left behind. But it’s always been true that the people who by and large didn’t vote for Trump—people of color and other marginalized people—have suffered far more and far longer with far more extreme consequences than any of the groups that feel they are being put upon right now, and therefore voted for Trump.

The conversation that suggests Trump’s base voted for him because of the degradation of life quality they’ve experienced over the last 50 years seems like an obvious centering of their white pain over groups that have suffered much longer.

AF: The way I see it is, I think it’s important not to discount Trump followers because it’s easy to do that. I tend to do it. But we should try to understand the situation; otherwise, we’re not going to be able to reach them. I think some are irredeemably deplorable. The old right types are irredeemably deplorable, as are the cynics, the people who use him for economic and political gain. I can understand their behavior, but I detest it.

Take West Virginia, the pivotal state. It had the largest support for Trump. The biggest margin, 70 to 30. Most of the people who voted for Trump were simply deceived by the 40-year, well-funded campaign waged by exploitive, greedy billionaires that has brainwashed them into believing their anger should be directed toward immigrants or people of color or other sexual orientations, rather than toward the terrible maldistribution of wealth that’s occurred in this country over the last 50 years. I don’t feel angry at them; I feel angry at the alt-right. I don’t feel angry at many of the people in West Virginia who voted for Trump, because their lives are terrible and he made false promises that they believed.

I feel no anger toward the many religious people who continue to support Trump because I think they’re following their leaders. I think their leaders are despicable. I mean, you take someone to provide political support and do prayer breakfasts with someone as uncharitable, as immoral, as deceitful as Trump. To get him their “legitimization” based on a political, cynical, political capitalization. I think they’re detestable—the leaders are. I don’t think the people who follow them and follow the propaganda are detestable.

I don’t think the 35 to 40 percent of the people who support Trump are one homogenous mass. Trump said he could shoot someone in daylight on Fifth Avenue and probably 20 percent of the public and a lot of congressmen would find excuses for his doing it. I think that his 35 to 40 percent support now [won’t] necessarily persist into the future as his grotesque behavior alienates more sensible people who are brainwashed by the propaganda that helped get him elected.

KH: When we talk about Trump voters, we can’t leave out that Trump didn’t just win the economically disenfranchised or the economically vulnerable among his base; he won every socioeconomic class of whites. How do you account for the mentality of the voters who are not in any dire economic straits? What is there to justify their votes for Trump?

AF: Actually, I canvassed last weekend in Darrell Issa’s district in California. It was a striking experience how many people of middling means were saying, “Well, he’s been great for my 401k.” Yes, Trump’s average supporter is not the distressed person in West Virginia. Among people with considerable means, Trump is a bonanza in terms of the tax cuts that are fueling this crazy stock-market. People who own the corporate stock—the shareholders and the corporate executives—are crazy happy to have someone like Trump. His antics cover up, in a way, the rip-off of the tax cut. It’s a pure scam.

Everyone’s talking about Trump’s psychological motivations and not doing the kinds of things [we need]. Why wasn’t there a demonstration in Washington against the tax cuts or the threats to medical coverage? I mean, there’s going to be a Woman’s March this month, but who cares? There should be much more attention to fighting his policies and much less attention on the person and the priorities of Trump.

KH: Earlier, I think the phrase you used is that Trump is a ’causer of distress.’ From the moment he launched his campaign, I’ve been interested in the ways Trump causes trauma and what the long-term repercussions of that will be, especially for vulnerable populations. We have a president who tells children their parents are from sh*thole countries, who is consistently triggering women, who essentially has declared millions of people unwanted in this country. Do you have any thoughts on how we might see this imprint in the years to come?

AF: I think the way to deal with trauma is to turn passive into active. I’ve never been politically active in my whole life. I’ve been missing in action at just about every important political moment up until this one. I think people have to stop screaming at their TV sets, stop thinking about complaining about Trump, and get out to vote.

I think the vast majority of Americans are decent people. The trouble is that a vocal minority is better at propagandizing. Another thing about Trump’s support is it’s completely dependent on Rupert Murdoch. It’s amazing how much power Rupert Murdoch has now.

KH: It’s astounding and frightening.

AF: All [Murdoch] has to do is turn Fox News against Trump and Trump is toast.

Rupert Murdoch, in fact, controls the political fate of America. So we have one person of dubious good will who determines who’s going to be president of the United States. I think that it shouldn’t be like that. We the people have to take back our country. Democracy is a very fragile thing in the history of the world. Even the Athenian democracy lasted for just about 70 years. Democracy is not a given. Our democracy now is under threat.

We only have four defenses of democracy. Congress, which has been a disgusting failure. The courts, which have done their best, but god knows what will happen with Trump’s appointments to the Supreme Court and lower courts. The media, which have been good but have been largely discredited in the minds of many because of Trump’s propaganda campaign. Then we the people. We’ve been very inactive. I’m very disappointed that there wasn’t more obvious pushback in this last year against Trump.

No one ever considered a midterm election could be this important, because usually, things only tilt the balance back to the middle. But this midterm election is different. We may be entering two slippery slopes. One, for the protection of our democracy against Trump’s attacks against it. Two, for the defense of the world’s climate, and what could be a catastrophic and irreversible set of amplifying changes.

I think that it’s a matter now of duty to public citizenship and responsibility to our children and grandchildren. People have to stop whining about his diagnosis and get on the streets, canvas and find a political voice. Our Congress should be passing a bill that makes clear to Trump that only they can declare war. It’s an article in the Constitution. It’s been ignored by presidents since World War II. To our detriment, we’ve been in a lot of stupid wars because of that. It’s time that Congress make clear to this unstable president that it—not he—is responsible for declaring war. Trump makes clear the tremendous hole in our government procedures. We need to have a protocol for starting nuclear war that doesn’t leave the button near his irritable trigger finger. He could press that button instead of tweeting in the morning and no general would know.

We need to have a protocol that makes clear that this is a consensus decision and not made solely by what may be the most unstable person in the country. These are political steps that need to be taken, and people need to stop this unsure preoccupation with psychological motivations and diagnosis, and realize that we’re under political threat.

It’s our job as citizens to push back in any way we can.

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