Is Donald Trump Mentally Ill?

You might have thought that Donald Trump, the current president of the United States, is mentally ill and obviously so. You might even have thought you had the medical name of his affliction handy: “malignant narcissism,” the name of the disorder that combines psychopathy with narcissism. But Allen Frances, the psychiatrist who wrote the definition of “narcissism” in the DSM, the Bible of American psychiatry, wants you to know you’d be wrong. As he writes in his book, Twilight of American Sanity: A Psychiatrist Analyzes the Age of Trump, Frances thinks it’s clear that while Trump may be a horrendous person, he doesn’t have any mental illness. This is why Frances says he declined a TV producer’s invitation to provide a psychiatric diagnosis of Trump’s mental condition, during the 2016 presidential campaign. Frances declined because he “saw no evidence that Trump had a mental disorder.” Plus, he was barred from conjecturing in that manner by the “useful ethics policy” of the American Psychiatric Association’s Goldwater rule. Psychiatrists, he says, have “no right to use professional credentials to medicalize their political beef” with a politician.  

I’ll return to the Goldwater rule at the end. Why, though, does Frances think Trump has no mental illness? Here’s his answer:

Trump’s amateur diagnosticians have all made the same fundamental error. They correctly note that the disorder’s defining features [of narcissism] fit him like a glove…But they fail to recognize that being a world-class narcissist doesn’t make Trump mentally ill. Crucial to the diagnosis of Narcissistic Personality Disorder is the requirement that the behaviors cause clinically significant distress or impairment. Otherwise, many, if not most, politicians (and almost all celebrities) might qualify. Trump is a man who causes great distress in others but shows no signs himself of experiencing great distress. His behaviors, however outrageous and objectionable, consistently reap him fame, fortune, women, and now political power—he has been generously rewarded for his Trumpism, not impaired by it.

That answer should astonish you. Nearly every line of it must be dissected to grasp the extent of Frances’ audacity.

Allen Frances

It’s true that a mental condition should negatively impact the prospective patient before it can be called a disorder. Doctors still take something like the Hippocratic Oath to heart; they want to first do no harm to the patient. Thus, if a person shows no signs of distress, the doctor has no overriding reason to intervene, since doing so might cause more harm than good. Only if the patient is clearly suffering can the doctor feel assured that even if the treatment should fail or cause some additional discomfort, as it frequently does, the risk is worth it to have the chance of relieving the initial suffering. Moreover, impairment is considered a precondition of having a mental disorder, because psychiatry is scientistic and so the psychiatrist would prefer not to descend to the free-for-all level of dabbling in normative reflections on what should count as mental health, that being a mere philosophical question. Thus, the psychiatrist borrows her professional values from society at large and so she defines “disorder” in terms of dysfunction. A disorder causes impairment which prevents the individual from functioning normally in society. That’s what society cares about—the extent to which members fit in and don’t interfere with its norms—and so that’s how the psychiatrist skirts the philosophical questions about the ideals of human excellence.

Note that both of these factors have to do with the profession of psychiatry, not with the potential patient’s inherent mental condition. The psychiatrist sees herself as heroic and her profession as scientific, and that’s why she thinks of mental disorders partly in consequentialist terms. Frances concedes that Trump’s mental condition appears to be narcissistic. That is, Trump has all the disorder’s inherent defining features; moreover, it’s obvious that he has them, because his is a severe, putrefied case. But those features have the wrong effects, says Frances. This means merely that there’s no cause for medical alarm in Trump’s case. Trump is flourishing, so medically intervening in his life would violate the doctor’s oath to do no harm, and Trump functions well in society, so society wouldn’t take the brunt of the normative assessment, given that the psychiatrist sees herself as dealing only with hardnosed, quantitative matters.

Granting all of this, then, it’s still misleading to say, with Frances, that Trump hasn’t any mental disorder, when what Frances really means is that Trump’s palpable narcissism has anomalous results which don’t happen to call for medical remedy. To say that Trump isn’t mentally disordered, for the above reasons, is to speak about psychiatry not Trump. As soon as we turn to what’s intrinsic to Trump, to a study of how his mind operates, regardless of how society happens to receive him, we’re led to conclude that Trump walks and quacks like a duck. If having all the internal components of malignant narcissism doesn’t make for a mental disorder, because psychiatry refuses to get involved if there’s no distress or impairment, and mental disorders go only where psychiatrists have no fear to tread, that amounts to a mere semantic difference. Just say that Trump has a grotesque mental condition, equivalent to the set of all the intrinsic features of malignant narcissism, but not that he has a mental disorder (because psychiatrists don’t want to get involved in Trump’s particular case).

But there’s no need to concede even this to Frances. To say that a doctor won’t operate unless the patient shows distress or impairment is absurd, because this discounts the need for preventative medicine. One of my uncles died from prostate cancer. Apparently, like many men, he had that cancer for years before it was discovered, because that particular cancer can cause no hardship until it’s too late and it nevertheless kills the person. Had the cancer been discovered early, the doctor would of course have taken action to prevent that eventual outcome. Likewise, a psychiatrist might foresee that even if an individual’s apparent mental disorder seems currently benign, it poses a significant risk of great future distress and impairment. Indeed, this would especially be so in the case of psychopathy or malignant narcissism, since individuals with either of those conditions are experts at disguising their feelings and at adapting to social norms by manipulating others into accepting them. Psychopaths are those who are actually monstrous even though they seem outwardly normal. That’s the terror of this mental condition, which should make it an exception to the doctor’s rule about first doing no harm.

In any case, of course this mental condition has the potential to cause the individual acute distress and impairment. To wit, if not treated, the individual may commit a crime and end up in prison. Trump has arguably committed numerous financial crimes over several decades, such as fraud, but his wealth insulated him because he could afford an army of accountants and lawyers to game the system, so he’s escaped prison. Now that’s he’s gotten into politics, though, he risks impeachment or at least international humiliation, because of his shameless misconduct. He can be tried in the court of public opinion for being a monster that wrecked America. Who is Allen Francis to say that some such disastrous potential outcome wouldn’t cause Trump clinically significant distress and impairment? Trump would still be rich, but he’d be shunned in many parts of the world, not to mention potentially imprisoned if convicted by Congress. Moreover, he risks dragging down his family because of his reckless financial ties to Russia, conflicts of interest, and possible treachery. Might not Ivanka’s and Jared’s embarrassment cause Trump significant distress? What would Trump do if he’s found guilty by Mueller’s investigation? Why presume Trump’s chaotic presidency will end as smoothly as his business dealings? Frances says Trump’s conduct has “consistently” benefitted, not harmed him, but that’s specious because wealth isn’t as impermeable a shield in politics as it is in business. Trump’s bowing out of the presidency could spark a civil war, and the risk of his suicide or assassination is raised by the damage caused by his narcissistic mental condition. So even given the specifics of Frances’ professional definition of “mental disorder,” there are grounds for psychiatric intervention in Trump’s case as a form of preventative medicine. And again, in the exception of malignant narcissism or psychopathy, leaning on this point about the need for signs of distress or impairment is wrongheaded.

Turning to another section of his shocking case for Trump’s mental healthiness, there’s an odious implication of Frances’ acknowledgment that Trump has been rewarded for his misconduct, not impaired by it. Of course, Frances means to condemn all Americans except for Trump, for living in a sick culture. Hence the title of his book and the quote by Nietzsche at the start of his prologue, called “Trump isn’t crazy. We are”: “Insanity in individuals is somewhat rare,” writes Nietzsche. “But in groups, parties, nations, and epochs, it is the rule.” What Frances is perhaps unwittingly implying is that mental disorders are for poor people, not the wealthy or for those who are tremendously successful, because the latter won’t suffer as much as the poor and thus there will be less need for a psychiatrist to swoop into action to save the plutocrat—from his mansion, harem of mistresses, collection of sports cars, overflowing bank account, and so on.

It’s almost as if Frances meant to validate the Foucauldian criticism that the alleged pure science of psychiatry has actually reinforced unjust societal stereotypes (e.g. of women and homosexuals) and class divisions. At least, Frances couldn’t help doing so, because he’s blundered into philosophical territory in which, even as an arrogant psychiatrist, he doesn’t belong. What Frances is saying, in effect, is that psychiatrists should treat only those who suffer greatly, and since rich men like Trump can’t be expected to suffer, because their wealth insulates and endlessly distracts them, no rich man should be diagnosed as having a mental disorder. This in turn means that the principles of psychiatry have been established rather like the American penal system, as a weapon of the power elites to burden the masses who can’t afford to wage legal warfare, and thus to prevent them from challenging the ill-gotten privileges of the upper class. Just as the government outlaws poor people’s drugs, to humiliate the poor and to train them to think of themselves as inferior, while rich people’s drugs are ruled legal for the benefit of the pharmaceutical industry, which psychiatry serves, the rich are honoured as being mentally healthy by definition, even when they’re as hideously deranged as Donald Trump. This is to say that American psychiatry presupposes and prioritizes the imperatives of capitalism. At least, that’s what Frances is implying.

Indeed, Frances’ apology for the rich is consistent with what I’ve argued elsewhere, which is that the rich are naturally corrupted by their power so that they become more or less sociopathic, and since the dawn of civilization, the power elites have thus served as models for the gods. So it’s not just that Frances offers this excuse for Trump’s catastrophic mental condition, to reassure the power elites that his profession poses them no harm; no, the underlying reason for this deference is that the animal side of our brain causes us to grovel before the mighty as though they were divine, because they’re the only godlike beings in plain sight. The idea is that the lower classes need to obey social conventions, and so medical intervention might be necessary in their case to ensure their functionality which helps to stabilize society. Meanwhile, the upper class members are typically above the law, or at least deferential psychiatrists like Frances may unconsciously assume the power elites ought to be so. Social conventions that determine our functionality are only for cogs in the machine, whereas the wealthy aren’t confined to the limits of mass society because they live in their own worlds, running amok in their sociopathic glory.

There’s another reason why a psychiatrist in particular would empathize with godlike power elites, even at the cost of making excuses for Trump’s monstrous derangement, which is that doctors are notorious for their god complexes. Reading his prologue, you get the sense that Frances is showing off. He wants you to know that he wrote the book on narcissism, that he didn’t deign to offer his opinion on Trump on television, and that even though some who publicly call Trump mentally disordered—like Judith Herman and Brandy Lee—are psychiatrists, Frances calls his opponents “amateur diagnosticians.”   

Another curious admission by Frances: “Otherwise,” he writes, “many, if not most, politicians (and almost all celebrities) might qualify” as having the disorder. Once again, psychiatry seems to be serving a dubious societal role. Frances wants to prevent us from sliding down the slippery slope of accusing most politicians and celebrities of being narcissists, after we’ve thusly condemned Trump. My question for Frances is this: At what point during his psychiatric training did he study social planning? Since when is it in a psychiatrist’s purview to make excuses for a society populated largely by mentally unhealthy citizens? Indeed, his overall case appears to be incoherent, since he means to condemn all Americans but Trump as being crazy for allowing Trump to be elected, while his defense of Trump commits the fallacy of special pleading on behalf of yet more American power elites, namely those who run the government and the entertainment industry.

Frances goes further afield of his profession when he says there would be three unintended consequences of psychiatrists going after Trump: doing so would stigmatize the mentally ill in general, who are not as bad as Trump; doing so would be ineffective at solving the political problem Trump poses; and removing Trump from office would only usher in Mike Pence who is arguably worse than Trump, politically speaking. The first point is more specious, asinine reasoning, since nobody is calling Trump merely mentally ill. They’re saying he’s a malignant narcissist. Frances thus needs to provide an example of a well-behaved malignant narcissist to confirm the relevance of his statement that “Most mentally ill people are well behaved and well meaning, both of which Trump is decidedly not” (my emphasis). As to the other two points, again the suspicion creeps in that a god complex may be motivating a psychiatrist like Frances to make political pronouncements as though his psychiatric training entitled him to any authority on such matters. Of course, he’s free to write on whatever subject he wishes, but it’s scientism that leads him to mix his psychiatric and utterly philosophical declarations as though they all equally have the authority of being scientific, without him offering a humble recognition that he’ll be turning to nonscientific issues on which he’s no expert. It’s also scientism that prompts him to speak of “societal insanity,” just as it was scientism that compelled Richard Dawkins to speak of culture as made up of “memes” and of environmental effects of genes as being part of an “extended phenotype.” These semantic tricks reflect the pretense that the sciences can take over the humanities, even though the humanities are laden with normative and moral questions which render scientific methods irrelevant.

Granted, in 2013, Frances criticized the DSM-V for over-medicalizing mental conditions. He said, contrary to scientism, that “psychiatric diagnosis still relies exclusively on fallible subjective judgments rather than objective biological tests.” Apparently, when arguing against his peers he could stand out by sounding like a humanist, since American psychiatry is swamped by those with a neuroscientific standpoint who wish to profit by prescribing drugs. But when arguing against the many mere amateurs who sully his profession’s neutrality by calling President Trump mentally ill, the latent arrogance of all doctors emerges and now he can distinguish himself by resorting to scientistic overstretches.

Perhaps recognizing the weakness of his case against medicalizing Trump’s mental condition, Frances reformulates it later in his prologue: “Analyzing Trump’s psychology makes no sense,” he writes, “because it is too obvious to be interesting and impervious to cure.” I hope you are astounded by the recklessness of that statement. Again, the reader is treated to a taste of Frances’ evident god complex. Apparently, this is the secret of psychiatric diagnosis, imparted by what his Amazon biography assures us is a “leading authority” on the matter: at a minimum, the patient’s condition has to interest the psychiatrist; otherwise, how will the psychiatrist sustain the illusion of her superiority, by pretending she’s a god who can dissect another person’s life as mere fodder for her intellectual curiosity? If Trump’s monstrous vices don’t pique Frances’ interest, just imagine how lofty must be this psychiatrist’s expectations, how godlike must be his ego. In any case, Frances seems to be conceding his opponent’s entire point: Trump is mentally ill, after all; alas, says Frances, it’s too late for treatment so there’s no point in even talking about it. Thus, Frances is throwing down red herrings, making excusing for psychiatric inaction, since the issue is only whether Trump should be removed from office on medical grounds. Then there’s Frances’ specious appeal to futility, as if psychiatrists weren’t infamous for locking up incurable individuals because they pose a danger not just to themselves but to others, as Trump obviously does.

As to the chief subject of Frances’ book, he seems mystified as to how American society could be so “insane” as to have elected someone as baneful as Trump. “But what does it say about us,” he asks, “that we elected someone so manifestly unfit and unprepared to determine mankind’s future? Trump is a symptom of a world in distress, not its sole cause. Blaming him for all of our troubles misses the deeper, underlying societal sickness that made possible his unlikely ascent. Calling Trump crazy allows us to avoid confronting the craziness in our society.” Of course, Trump shouldn’t be scapegoated, but it’s ironic that the underlying, societal “sickness” responsible for Trump’s victory, namely, I take it, greed as opposed to altruism, is endorsed by capitalism as shaped by the wealthy early modernists whose concentrated power can be expected to have made them disproportionately amoral and antisocial. As Nietzsche pointed out, morality is for the weak, for those who find themselves enslaved and who thus need a backdoor way of avenging themselves on their masters. The masters themselves aren’t bound by social conventions because they create their own value systems, and because the weak masses have been conditioned to worship their mighty gods, they naturally admire the habits of their superiors. Thus, the cultural “sickness” that’s destroying the ecosystem and that regressed millions of Americans to the point that they decided to commit collective suicide by electing Trump is concentrated in precisely the power elites whose derangements Frances is wont to excuse because they don’t qualify technically as having mental disorders.

Capitalism is like a sports car. Most adults have the skills to drive one, but some more than others are interested in driving at hair-raising speed and at having everyone stare at them as they pass by. That sort of car is designed with the rich in mind. Not only can they alone afford to own one, but only they can be expected to lead relatively care-free lives and to be exceptionally ambitious so that they especially would be eager to drive in luxury at death-defying speeds. Likewise, while everyone participates in the market, the cutthroat nature of capitalism evolved with niches tailor-made for the sociopathic upper class. They, the plutocrats and the professionals, are the Machiavellian deal-makers who excel at double-crossing others to maximize profit. The culture of greed is largely as Marx put it: the ideological rationalization of the material effects of this economic system. Virtually everyone wants to earn millions of dollars, of course, but that goal is unrealistic for the vast majority. Greed is visceral rather than abstract and academic only for the lucky few who become rich or who are born into excess. The greedy, sociopathic power elites are the most cancerous cells in the American body politic. Therefore, I say again that Frances’ case strikes me as incoherent. If you want to oppose the gluttony of American consumerism, fine, but start by condemning the heart of the matter: the inhuman mental condition of plutocrats like Trump. It’s thus egregiously dunderheaded for Frances to speak explicitly of everyone’s insanity but Trump’s.

Finally, a word about the Goldwater rule: there’s a seldom-heard alternative reason why psychiatrists would be loath to diagnose public figures without having the luxury of analyzing them in a clinical setting. It’s not just that the doctors would be open to allegations of slander, nor is it just to keep American psychiatry politically neutral, nor is it even professional jealousy that laypeople can now provide their own diagnoses using websites such as WebMD. No, it’s also that we shouldn’t expect those who suffer disproportionately from god complexes to offer their professional opinions free of charge!