The questions about President Donald Trump’s mental stability have become so intense that Trump himself felt compelled to tweet out a defense of his cognitive abilities, insisting that he is a “very stable genius.”

The president’s own assessment aside, there is no system in place to scientifically evaluate any president’s most basic cognitive functions and mental health. In light of that, how worried should the public be about Trump? Very worried, says Dr. Bandy Lee, the Yale University forensic psychiatrist who edited the recent book,   “The Dangerous Case of Donald Trump.”

In a new podcast interview with International Business Times, Lee discussed why she and other health professionals believe the president’s instability has become a full-scale “emergency” and has put the country on the verge of a catastrophe. She also reviewed her recent meeting with congressional lawmakers about the situation — and discussed how many of them expressed deep concern about the situation. 

What follows is a lightly edited excerpt of the podcast interview. Subscribers can click here for the full discussion.

IBT: What is the Goldwater Rule?

Lee: The Goldwater rule, which stipulates actually only psychiatrists, not to diagnose a public figure without having done a personal examination and gotten authorization. That rule came about because of Mr. Barry Goldwater... When Senator Goldwater was running for presidency, a magazine [surveyed] 12,000 psychiatrists and got back less than 10 percent of responses saying that Mr. Goldwater was unfit to be president. 

The magazine sensationalized it, not mentioning the over 90 percent who didn't comment or said they couldn't comment. [It was] publicized as them saying Mr. Goldwater was mentally ill and psychiatrists were saying he was unfit. After that, in 1973 when the American Psychiatric Association was putting together the ethical guidelines, it included the rule not to diagnose a public figure. 

I actually agree with that. I'm a strong proponent of the Goldwater rule as it is in the code. I don't believe it is even possible to diagnose someone from afar, because you need all of the medical records, and you don't know what you'll find in a personal interview. There's a lot that goes into a diagnosis. 

It's not Mr. Trump's personal health that is of our concern. Our concern are the effects he is having on public health by virtue of his being in his office. In other words, whenever I'm speaking of Mr. Trump, I'm really speaking about Mr. Trump in the office of the presidency. His mental signs of instability, signs of dangerousness, are of interest to us only because it poses a public health threat. 

You argue that we can clinically conclude that President Trump is a dangerous risk. What leads you to that conclusion?

So I wouldn't say so strongly that it's a conclusion. We're looking for a conclusion. But there are signs of a risk of danger. And therefore, it becomes an emergency. In the rest of our practice, mental health professionals are charged with doing risk assessments of basically every one they see in their office or even in the public, because there are signs that may be obvious to the mental health professional, who deals with this on a daily basis. But the public may not notice. 

And so in our everyday practice, we're not only legally authorized, but legally mandated to report, to warn and to take steps to protect potential victims when there are signs of danger. And this is only risk of danger. It doesn't have to be a definite conclusion about danger, which would only come after a full examination. So what you're doing at that point is trying to get everyone safe. You're containing the person, removing them from access to weapons and performing an urgent evaluation. These are the things that one does when someone poses a danger. 

What are the most concerning behaviors you’ve seen from President Trump?

I'm a violence expert and therefore I've studied predicted and prevented violence for over two decades. The best predictor for future violence is past violence. He has shown verbal aggressiveness. He has boasted about sexual assaults. He has incited violence at his rallies. He has endorsed violence at key moments of public speeches, which could unleash out a whole culture of violence. And he has shown an attraction to violence and powerful weapons, as well as taunted continually a hostile nation with nuclear power. All these signs are signs of dangerousness.

We have seen president’s in the past make belligerent statements — for instance, George W. Bush taunted terrorists, telling them to “bring it on.” How different is President Trump from past presidents?

Mr. Trump is quite unusual in that he has raised enough concerns that there is an unprecedented movement in the mental health community. In fact, now there are thousands of [us] in the national coalition that we've formed...

We held a conference about the ethics of doing this. And after that, the meeting was highly publicized. It was in April of last year. And after that hundreds and hundreds, and now thousands, multiple thousands of mental health professionals have come forth, formed a national coalition. We have recently even issued a statement after the tweet regarding the size of nuclear buttons, that we really do feel that this is a state of emergency in terms of the unraveling. 

It is unprecedented in American history that this many mental health professionals would express their concerns. You might say that other presidents were dangerous in the past, but it's not so much in the mental health territory, in that it's not the instability of the president that is causing the dangers.

What kind of instability are we talking about?

There are two different sources perhaps. One might be considered psychological, and one is cognitive. So both are dangerous because of his position in the presidency. 

The psychological part would be his impulsivity, recklessness, paranoia, his loss of touch with reality at times, his inability to think about consequences, lack of empathy, rage reactions, belligerence toward others, and his constant need to demonstrate power. Those would be some psychological signs that point to violence and danger. 

The other consideration would be the cognitive signs that many have commented on. And there has been a progress in a direction where he is less able to complete sentences. He is less able to keep with a thought. He uses less complex words, repeats words in stories, and he has loose associations.

These are all signs of cognitive impairment. Of course, it could be of any source. It could be psychiatric, neurological, medical, medication induced. So all of these we would not know until there is a full examination. But again, as I said, the diagnosis in itself would be very useful and informative but would not tell us if the president is fit or has the capacity to serve in his position. And not having the cognitive capacity would also be very dangerous because of the power of his position and the arsenal he has at his command.

President Trump’s speaking style, tone, aggressiveness and brashness were evident on the campaign trail — and arguably many people voted for him because they wanted a president with those qualities. What if the qualities you are sounding an alarm about are precisely the ones that people voted for?

That would be fine if that were a personality style, and if it were within normal limits. So what we could offer perhaps, as mental health professionals, is that we could distinguish between what are normal traits, and what are signs of pathology. Signs of pathology could be masked to the ordinary untrained observer. For instance, severe pathology could come across as being incredibly goal driven or strategizing because the person is very intense in their drive, but it may not be out of healthy reasons. Those are the things that we could point out through patterns and severity. 

We see people with these impairments day in and day out on a daily basis. Whereas the ordinary population would be mostly exposed to healthy individuals and so they will interpret what they're seeing in terms of health, or more likely to. And that is where we feel that we could educate the public and alert them about warning signs, worries and signs.

What do you think should be done to address the concerns you and other health professionals are raising?

What actually should be done would not be my domain. That would be up to the lawmakers or whoever would be part of the political process. But my role is to educate the public. It is a glaring omission that we require fitness for duty exams for every military officer or civilian service person, but currently there is no such requirement for the commander in chief. And it is very unfortunate that we've gotten to this place that it has taken a sitting president to be questioned in this way.

But since we have gotten this far, it is incumbent upon us, I believe, that we should air those concerns and the need for a capacity evaluation. In this president, urgently, we are saying that we are in a state of an emergency where we are seeing signs of deterioration over time and at one point, it's going to become an imminent emergency or likely to become one. And in such cases, we're required to err on the side of safety as mental health professionals. We could be held legally liable if we do not. 

And so it's by these principles, and the humanitarian goals of medicine that are universally declared, that we should protect public health and well being, it's safety and survival, that we are voicing our concerns and trying to call out to the public about the need for an evaluation.

What processes could be put in place to make sure a mental health evaluation of a president wasn’t tainted or influenced by partisanship or politics?

If a health professional is professional, it has nothing to do with politics or ideology. It has to do with health versus illness, life versus death. And as expert consultants to courts, forensic psychiatrists like myself are routinely asked to do evaluations where the court system or the legal profession will weigh in. In order to  make either a decision in criminal court, in civil cases, or in other legal situations, we make our recommendations. But the decision is left up to the courts and the lawyers. 

In this situation [with Trump], we could make our recommendations based on evidence, objective science, science that would be very easy to arrive at a consensus on because it's based on a objective standard procedure, but then the decisions would be political.

Is it fair or even possible to diagnose a public official’s mental state from afar? Are media clips of speeches or are tweets really enough to make an evaluation of what’s going on? 

It has to be contextualized and it has to be put in relation to all the other signs we are seeing in all other observations. Can we evaluate? Yes. Certainly we can do evaluations. But can we diagnose? I don't think so. I diagnosis is a very complex process. So in other words, any evaluation from afar is a tentative one and I do believe it's unethical to voice any of those assessments unless there is an emergency. So it's unethical for health professionals, especially psychiatric professionals, to speculate on diagnosis from afar. 

But actually, the Goldwater rule itself says that we should educate the public about the various conditions, psychiatric issues in general terms, when we're asked about public figures. 

And so it's okay and in fact encouraged to educate the public in an ordinary situation. But when there is a danger, when the public itself is at risk, we do feel an obligation to speak about whatever danger signs we are seeing, in order to warn the public, especially since there is really no mechanism to go about more privately containing the individual in office, containing them, removing them from access to weapons, and doing an urgent evaluation with or without consent. That is what we usually do, but we haven't been able to because of the office of the presidency. 

You met with members of congress recently about some of these issues. What did you tell them? And what questions did they have for you?

First of all, I don't have a political affiliation and my actions are not political. I am open to serving as an expert consultant to either party. And there was a former Congress member, an influential one, who was going to arrange my testifying before all of Congress. That did not happen, kept being postponed. So it was really the Mueller indictments that caused a great deal of concern for us. 

[That’s] when a former assistant U.S. attorney jumped in, and she arranged these private meetings with various Congress members. And so we went in privately, thinking it would be a very sensitive topic to bring up. But what was astonishing was the level of enthusiasm and eagerness to speak with us. Some did not even allow us to complete our presentations. They said, “You don't need to convince us. We are very concerned. We have been wanting to talk about this.”

One member actually said he had never waited for a meeting this much in eleven years. So basically, they were saying that all Democrats would be willing to express their concerns and have concerns. On the Republican side, it appears that some members have concerns, but whether or not they will express them or act upon them is another matter. And so they charged us with going ahead and continuing to do what we are doing, that is to educate the public, to speak about our concerns, so that the public could be brought on board, because they themselves cannot do anything without the public support.

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