The longer Donald Trump is in office, the more he shocks and alarms us with his strange and extremely unpresidential behavior.

From the incoherent, fallacious interview he gave the New York Times on December 28 to Tuesday's tweet about his "nuclear button" to his Saturday morning assertion that he is a "very stable genius," the remarks keep getting more menacing, bizarre, and portentous of disaster.

As Vox's Ezra Klein recently wrote, "The president of the United States is not well."

But how unwell is he, really? Could the behavior be caused by some illness eating away at his mental capacity, or is it just bad behavior?

This is a question of crucial importance, not just because the vice president and the Cabinet (or Congress) would need certainty about his mental incompetence to invoke the 25th Amendment and declare him unable to do his job — an option that, while still highly unlikely to be used, is now regularly being discussed.

Of course, the question of his mental health would ultimately come down to a medical opinion. And no doctor, as far as we know, has evaluated the president's mind for fitness to serve as president.

Yet there is a growing call from a group of psychiatrists — the best medical experts at interpreting aberrant human behavior — for exactly this: an emergency evaluation of the president's mental capacity, by force if necessary.

Leading this call is Bandy Lee, an assistant professor in forensic psychiatry (the interface of law and mental health) at the Yale School of Medicine who has devoted her 20-year career to studying, predicting, and preventing violence.

She recently briefed a dozen members of Congress — Democrats and one Republican — on the president's mental state. And this week, she, along with Judith Herman at Harvard and Robert Jay Lifton at Columbia, released a statement arguing that Trump is "further unraveling." The Dangerous Case of Donald Trump, a collection of essays from 27 mental health professionals that Lee edited, was published in October.

These efforts have not been welcomed by all of Lee's colleagues in psychiatry — some say her warnings are unethical and break the Goldwater Rule, the American Psychiatric Association's stipulation that its members never publicly discuss the mental health of a public figure. One esteemed fellow psychiatrist accused her in the prestigious New England Journal of Medicine of having "misguided and dangerous" morality.

I caught up with Lee recently by phone to talk about why she believes Trump is so dangerous, what an evaluation would entail, the president's upcoming physical exam on January 12, and why she thinks it's her ethical duty to educate the public and lawmakers about the option of containing the president against his will to do a psychiatric evaluation.

Lee notes that her position and opinions are her own and do not represent the views of Yale. Our conversation has been edited for length and clarity.

Eliza Barclay

You put the book together seven months ago. What has happened since then that you think has made Trump even more dangerous?

Bandy Lee

The special counsel's indictments started a crisis — a mental health crisis in a president who is not able to cope well with ordinary stresses such as basic criticism or unflattering news.

His trip to Asia brought a lot of ceremonial deference and customs of flattery that kept him doing better for a while. But that indicated a greater danger to us — that someone [was] that susceptible to fawning pointed to instability that would make him more volatile when he returned. And that's exactly what happened.

When he returned and faced the progress of the special counsel's investigation, he became more paranoid, returning to conspiracy theories that he had let go of for a while. He seemed to further lose his grip on reality by denying his own voice on the Access Hollywood tapes.

Also, the sheer frequency of his tweets seemed to reflect the frantic state of mind he was entering, and his retweeting some violent anti-Muslim videos showed a concerning attraction to violence. And then there were the belligerent nuclear threats this week.

I'd also like to emphasize that we are not diagnosing him — we keep with the Goldwater Rule. We are mainly concerned that an emergency evaluation be done.

Eliza Barclay

And you are really worried that his mental disturbances will lead to a military confrontation with North Korea — and a nuclear holocaust.

Bandy Lee

Yes — but that is not the only danger we're facing. There's everything in between: provoking our allies and alienating them, instigating civil conflict, and laying a foundation for a violent culture that could give way to epidemics of violence — not to mention poke a beehive in the Middle East by declaring Jerusalem as Israel's capital. All of these actions are consistent with the pathological pattern he has already shown of resorting to violence the more he feels threatened. And it is no accident that gun deaths are up at least 12 percent since 2016, and there is an increase in schoolyard bullying and an unprecedented spike in hate crimes that continue to this day.

Eliza Barclay

But is it a medical consensus? There are some prominent psychiatrists and psychologists — for instance, Jeffrey Lieberman, the chair of psychiatry at Columbia University Medical Center and former president of the American Psychiatric Association — who have criticized your book.

In a letter in the New England Journal of Medicine last week, he called your morality "misguided and dangerous." He seems to think you are saying there are already medical reasons to oust the president.

Bandy Lee

This is a disagreement over ethical rules, not medical assessment. It would be hard to find a single psychiatrist, no matter of what political affiliation, who could confidently say Trump is not dangerous. I am sure there are some who feel unsure, or feel that they don't have enough information or the expertise, and that is fine, since not everyone has devoted her 20-year career to studying, predicting, and preventing violence like I have. But there has not been a single serious mental health expert who disagrees on the medical side.

Regarding ethics, prominent professionals have begun to speak out since we have gained influence, but their ethics have not been convincing to me. Dr. Lieberman has broken the Goldwater Rule in his article for Vice, even as he claims to be speaking for the rule. The situation with Trump does not seem to be as dire for him as for us. And I am astonished to find from his numerous articles [about our book] that he still has not read it.

On the other hand, in the book we have as authors Phil Zimbardo, Judith Herman, and Robert Jay Lifton, who are notable not only for their contributions to mental health but for their amazing ethical record. These are living legends who have also stood on the right side of history, even when it was difficult, and they stand as beacons for me. No one matches their moral and professional authority, in my mind.

Eliza Barclay

One thing that seems to make a lot of people uncomfortable about psychiatrists like yourself commenting on Trump's mental disturbances is that you have not evaluated him. So how is your assessment ethical? Why should the public take it seriously?

Bandy Lee

We are assessing dangerousness, not making a diagnosis. The two are quite separate: Assessing dangerousness is making a judgment about the situation, not the person. The same person may not be dangerous in a different situation, for example. And it is his threat to public health, not his personal affairs, that is our concern.

A diagnosis, on the other hand, is a personal affair that does not change with situation, and you require all relevant information — including, I believe, a personal interview. Most people who are dangerous do not have a diagnosable mental illness, and most people with mental illness are more likely to be victims than perpetrators.

Also, once you declare danger, you are calling first for containment and removal of weapons from the person and, second, for a full evaluation — which may then yield diagnoses. Until that happens, physicians and mental health professionals are expected to err on the side of safety and can be held legally liable if they fail to act. So we're merely calling for an urgent evaluation so that we may have definitive answers.In doing that, we are fulfilling a routine, public expectation of duty that comes with our profession — the only part that is unusual is that this is happening in the presidency. Perhaps this is reason to build in a fitness for duty, or capacity, exam for presidential candidates, just like for military officers, so that this does not happen again.

Eliza Barclay

Okay, so you're calling for an evaluation; you're serious about that. How could he possibly be evaluated, since it seems like he wouldn't voluntarily do it?

Bandy Lee

We encounter this often in mental health. Those who most require an evaluation are the least likely to submit to one. That is the reason why in all 50 states we have not only the legal authority, but often the legal obligation, to contain someone even against their will when it's an emergency.

So in an emergency, neither consent nor confidentiality requirements hold. Safety comes first. What we do in the case of danger is we contain the person, we remove them from access to weapons, and we do an urgent evaluation.

This is what we have been calling for with the president based on basic medical standards of care.

Surprisingly, many lawyer groups have actually volunteered, on their own, to file for a court paper to ensure that the security staff will cooperate with us. But we have declined, since this will really look like a coup, and while we are trying to prevent violence, we don't wish to incite it through, say, an insurrection.

Eliza Barclay

And you've been on Capitol Hill talking to lawmakers about this, too.

Bandy Lee

Yes — at first I was keeping this confidential and was horrified when it first leaked out to the press sometime over the summer, but [the lawmakers] seem surprisingly okay about it, and so I will tell you.

First, I do not reach out to legislators, and I don't advocate for particular political outcomes. Those are the basics of being an expert consultant. I am making a medical warning, and it's not a partisan issue. They can make it one, but we ourselves cannot be politically motivated or invested in a certain outcome. This is always the case, from the most basic courtroom consult to being called to testify before the different branches of government. We are expected to be professional in this way.

Medical ethics encourage us to be of public service by consulting with the government. So when Congress members reach out to us, we are open to consulting with them, no matter what party. A half-dozen of them got in touch after the Duty to Warn conference at Yale in April. Then an influential former Congress member started making arrangements for me to testify before all of Congress. That kept getting postponed while the Mueller investigation advanced.

That was when a former assistant US attorney stepped in and used her contacts to arrange for meetings with a dozen key Congress members [including Rep. Jamie Raskin (D-MD)] on December 5 and 6. James Gilligan of NYU, one of the foremost experts on violence in the country, and I went and spoke to them about medical matters only, to share our medical knowledge and concern.

Eliza Barclay

And how did those conversations go?

Bandy Lee

They received us enthusiastically! Their level of concern was surprisingly high. From the dozen we have met with, it seemed they were already convinced of the dangerousness of the president and the need for an evaluation.This month, I will be meeting with additional lawmakers to discuss what else we need to do. I have also been put in touch with the original drafters of the 25th Amendment at Fordham Law School, and so we'll see if they will give input.

Now, the president is undergoing a physical exam on January 12. The usual physical exam does not usually entail a thorough exam of mental fitness for duty, but we are hoping that some form of capacity exam will be included.

Eliza Barclay

What is a capacity exam?

Bandy Lee

A capacity exam is an independent evaluation of the ability of someone to carry out a certain function, such as to stand trial or to make medical decisions for oneself, or in a more everyday setting, to carry out a job. It is a standard process that involves an interview, various tests, and information from outside sources.

Every military officer goes through a physical and mental fitness for duty test, but the commander in chief doesn't. We are saying this is a glaring omission. If America's generals must pass a psychiatric evaluation before they're allowed to lead our troops into battle, shouldn't our presidents have to pass the same test before they're allowed to lead our generals?

The president's mental capacity to serve has come up because we can't be sure of his ability to think rationally and make sound, reality-based decisions.

Eliza Barclay

Do you know the physicians who will be doing the January 12 exam? Have you been in touch with them?

Bandy Lee

Dr. Ronny Jackson of the Walter Reed National Military Medical Center will be doing the exam. I guess this is the White House doctor, but I don't know what his proficiencies are.

Eliza Barclay

So you can't push him to do a capacity exam.

Bandy Lee

I'm not the president's private psychiatrist, so I don't feel that I have the right to contact them and require a capacity exam. But I could help educate the public and let it be known it would be desirable for the person in the office of the presidency to get a capacity exam.

Our role is not to intervene in his care, or to interfere in any way in the usual political process. We are just giving medical input as witnessing professionals who can see signs that point to danger as a public health threat that the public or lawmakers may not be aware of or see to its full extent.

Eliza Barclay

The American Psychiatric Association in its code of ethics bans its members from commenting on the mental health of public figures — what's known as the Goldwater Rule. In March, the APA expanded the rule from not only diagnosing public figures but also to sharing "an opinion about the affect, behavior, speech, or other presentation of an individual that draws on the skills, training, expertise, and/or knowledge inherent in the practice of psychiatry."

Why do you disagree with this decision?

Bandy Lee

In the book, we compare the APA's March decision to the American Psychological Association's modification of its rules to allow for torture during the Iraq War. The concern is that if we are not deliberate in our ethics, we will easily fall into complicity and compliance with political pressures, especially if they are likely to subject us to the very dangers we are warning about, just for issuing the warning.

It was directly in response to Nazism that the World Medical Association issued its Geneva Declaration to clarify the humanitarian goals of medicine. These goals echo the principles underlying the APA code of ethics, the ethical code of American Medical Association, and the Hippocratic oath. I believe we should base ethics not so much on the form of which comments are made where, but on whether that general rule continues to serve these humanitarian goals when the public's well-being and survival could be at stake.

Eliza Barclay

Won't your whole effort just be perceived by Republicans as inherently political and not independent? How do you get around that?

Bandy Lee

This is the troubling question. We have seen how everything can be turned political, even a strictly rule-bound criminal investigation by an independent special counsel! When we met with some of the lawmakers, it was before the tax reform bill, and it was apparent that there were Republican Congress members who were equally concerned about danger. But then we saw the overwhelming support of the president for their own political goals — even Sen. Bob Corker, who had publicly expressed concerns about World War III!

While we were on Capitol Hill, Democratic Congress members were telling us that Democrats would have no trouble acting on their concerns, but the question was, would Republicans? In other words, the concern was pervasive, but the question was whether they would find it politically feasible to express their concern.

Well, if the concern is World War III and political ends trump those concerns, then the chances of our not being politicized are very slim. What we need to do is to remove the danger as quickly as possible. We are used to this in psychiatry, and the law allows us to curtail liberties in this way because patients later return to thank us.

But this is very hard to explain to anyone outside the field who [is] not used to dealing with disorder of this kind. The bind is that the longer we wait, the harder it will be, and the destructiveness will only increase.

Vox, January 6, 2018

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January 6, 2018

Post Script. This is the psychiatrist who briefed Congress on Trump's mental state: She says this is "an emergency." Read what she says and then call your elected officials to ask how a man who threatens nuclear violence in Tweets can be allowed to stay in office!