My colleague and ally in the fight against psychiatric medicalization, Allen Frances, has written elsewhere about the consequences of pathologizing narcissistic behavior, particularly as it relates to the presidency of Donald Trump. He has a new book on the psychology of the Trump revolution, Twilight of American Sanity, published last year. Frances was chairman of the American Psychiatric Association’s DSM-IV Task Force and is professor emeritus of psychiatry at the Duke University School of Medicine.

I wish here to second Dr. Frances’s contentions regarding the misguided application of psychiatric diagnosis to Donald Trump and to comment briefly on the philosophical-existential consequences of medicalizing narcissistic behavior, particularly its effect on the principle of individual responsibility.

What happens when a person’s behavior is explained in terms of psychiatric disorder? When a label of mental illness is applied to an individual, perhaps the most significant consequence is that his behavior is thereafter viewed through the lens of mental disorder. Everything a person does suddenly becomes explainable in terms of mental illness, especially disagreeable behavior. It is, in essence, a way of saying, “That person is not really responsible for what he does. He is mentally ill. He can’t help the way he behaves because his behavior is the product of his illness.”

Now, of course, there is no point-to-point relationship between mental illness and responsibility. Even psychotics can be and are responsible for their behavior. I have written elsewhere on this subject (see Ruffalo, 2017).

But a commonly held view is that people diagnosed as mentally ill quite literally have no control over their behavior. They act the way they do because of some yet-to-be discovered brain disease akin to Parkinson’s or Alzheimer’s. This is perhaps most apparent in the “loss of control” theory espoused by proponents of the disease model of addiction. But it is also present in psychiatric conceptualizations across the range of mental disorders. When a diagnosis of mental illness is made, free will is negated. Behavior lacks volition. Man becomes machine.

When Donald Trump’s behavior is explained as mental illness, we deprive him of responsibility for his conduct. No longer is his behavior intentionally misguided, detrimental, or ill-advised; it becomes merely a representation of his mental illness. His behavior goes from being bad to being mad. The consequences of this shift are far-reaching; if he isn’t responsible for his conduct, then he shouldn’t be held responsible for his conduct. This is why, for example, we don’t send to prison people adjudicated not guilty for reasons of insanity. Clearly, this is a consequential shift in formulation.

To put it a slightly different way: If one disagrees with Donald Trump’s policy, labeling him as mentally ill doesn’t do anything to discredit his policy actions. In fact, pathologizing Trump’s behavior doesn’t do any more to discredit his actions than labeling John Nash as schizophrenic does to discredit his economic theories. (Nash was recipient of the Nobel Prize in Economics and is the basis for the film A Beautiful Mind).

Psychiatrists and psychotherapists—as well as the armchair mental health professionals in the media—would be wise to put down the DSM and focus on what is real—Trump’s decisions as president. Only then can we hold him accountable for his actions.


Ruffalo, M. L. (2017, December 8). Reexamining schizophrenia as a brain disease [Blog post]. Retrieved from