Last April, Dr. Bandy Lee, a Yale School of Medicine forensic psychiatrist, organized a conference called Duty to Warn about what she and some colleagues considered the necessity of alerting Americans to the threat posed by the mental health of Donald Trump. Out of this conference came a book put together by Lee: The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President. Lee’s outspokenness has been controversial, with some in her field arguing that she is undercutting the profession of psychiatry by diagnosing the president from a distance. (Her response to that and much else is below.)

Lee has been back in the news more recently, and not just because of all the talk about Trump’s mental health surrounding the release of Bob Woodward’s Fear and the publication of the infamous, anonymous New York Times op-ed. Lee herself recently claimed that two White House officials reached out to her last year, around the publication of her book, with their own fears about Trump.

I spoke by phone with Lee, who is also a project leader for the World Health Organization and an expert on violence prevention. During the course of our conversation, which has been edited and condensed for clarity, we discussed how she dealt with the White House staffers who reached out to her, why she says she isn’t “diagnosing” the president, and whether Donald Trump is really getting worse.

Isaac Chotiner: What details are you allowed to share about people in the Trump administration who you say reached out to you?

Bandy Lee: It’s not a matter of being allowed. I didn’t get much information because I didn’t wish to compromise my role as educating the public. So they called me, two separate phone calls, stating essentially the same thing: that they were scared of President Trump’s behavior and felt he was mentally unraveling. Once I was assured that they did not feel themselves in imminent danger, I told them I could not take any more information, but rather, needed to refer them to the emergency room.

So just to clarify: The danger that these people felt was because they were in direct contact with the president, not because they thought he was going to do something in terms of policy?

No, it was in their daily interactions.

And how big of a gap was there between the two phone calls?

Quite a big gap. About five hours.

OK, so it’s not a coincidence, these people are clearly talking to each other.

I think so. I didn’t ask.

When they said who they were, had you heard of them?

No, not at all.

And is your sense that they reached out to you because of your book?

They said so, yes. They said because of this book, they knew me to be respectable and dependable, or something like that. That I would be a reliable person to get advice from.

Did they specifically comment on anything that people following the president on Twitter or following the news every day would find surprising, or was it more just that type of behavior but in private?

It was their private interactions.

Right, but was the content of those interactions similar to what we see in public?

I didn’t ask about the actual—I didn’t ask what they were scared of.

So what were the ethical issues about you not wanting to talk more to them?

After several months of trying to figure out how to respond to [Trump’s election], when I spoke with colleagues it was pretty unanimous. There was a universal agreement that Mr. Trump was dangerous because of mental instability, and yet no one had spoken up. I held an ethics conference on whether or not mental health professionals should discuss this, and they came to the conclusion that overwhelmingly we should, for ethical reasons. But not many showed up to the conference, and actually not many were speaking up, because they feared for their own personal and family’s safety.

They were also afraid that they would be vindictively litigated against. So at this point, even after the book is out, not many mental health professionals were coming forth to speak about this issue. I felt that educating and alerting the public about the dangers was far more important than an individual treatment role.

When I referred them to the emergency room, I was hoping that the emergency room psychiatrist would respond and either help these staff members, or intervene if necessary. But nothing happened after that, that I know of. And I tried reaching the on-call psychiatrist at the emergency room I referred them to, and wasn’t able to get any information.

What was the response from people in your profession to your book, and what is the state of the debate on some of the issues you were trying to raise?

The book actually incurred an enormous response. It was an instant New York Times best-seller. For a multi-authored specialized knowledge book, this was rather surprising.

For those within our field, within mental health, we had garnered a lot of respect after the book came out. Those who have specialized knowledge will know that we kept the standard quite high, to, you might say, peer-reviewed standards, while still making the language accessible. And we removed all financial conflicts of interest. In other words, none of us are taking any profit from the book. And all of the income is being donated for the service of public mental health.

What was the main thing you were trying to get across in the book?

The initial impression for those who don’t read the book is that we’re diagnosing and we’re violating ethics. But people who have read the book would come back to us and state that they were really astonished by the ethical rigor and just how accurate and rigorous our assessment was.

The message is basically that we wanted the public to know of the dangers we saw. Dangerousness is different from diagnosis, so we tried to explain that. But the main crux is that the situation is worse than it appears, that it will grow worse over time, and that eventually it will become uncontainable.

How do you identify dangers without diagnosis?

Diagnosing is not what mental health professionals do most of the time, it’s just a very small part of what we do. For diagnosis, you need all the relevant information. And usually also a personal interview, although the science is pointing in the direction of not needing a personal interview all the time. Whereas the rest of the time, we are evaluating, assessing, sometimes predicting, protecting the public or the patient from dangerousness. So there is a lot that we do that does not involve diagnosing.

So this book warns about danger. Danger is more about the situation, not so much about the person. In other words, the same person in a different situation may not be dangerous. It also does not need all the information: You just need enough information to raise alarms, and you can act on the dangerousness that you see.

What is the specific danger that you see?

For dangerousness, I’m a violence expert. Future violence is best predicted by past violence. And here we have someone who has shown verbal aggression, which usually means physical aggression may not be far; who has boasted about sexual assaults, and that says more about violence than sexuality. He has incited violence in public gatherings. He has shown an attraction to violence and powerful weapons. He has taunted a hostile nation with nuclear power repeatedly, and since then he has instituted policies that traumatize innocent children.

Back in January, the American Psychiatric Association said that it was calling for an end to what it called “armchair psychiatry” and affirmed what is called the “Goldwater rule”—which is from 1973—which they defined as “refrain[ing] from publicly issuing professional medical opinions about individuals that they have not personally evaluated in a professional setting or context.” What is your response?

The American Psychiatric Association has been taking action in alarming ways since this administration. So going back to 2017, two months post-inauguration of the president, they reinterpreted the Goldwater rule in a way that it was never written to be and never was in the past. They said that the Goldwater rule does not just involve diagnosis, it involves any comment of any kind on a public figure, no matter how dangerous the situation is. And that actually is a very alarming. They called it a reaffirmation of the Goldwater rule, but it’s essentially a new rule.

The Goldwater rule originally was agreed upon almost universally. It was very non-controversial. In fact it was so archaic, most people didn’t even know about it. It mainly stated that we should not diagnose to the media without having personally examined and gotten authorization to do so on a public figure.

“What we’re seeing is simple repetition now, and worsening, greater frequency of his poor coping mechanisms.” — Bandy Lee

They changed the interpretation into what essentially people have been calling a gag rule. Members of the profession were so alarmed that dozens have resigned, they’ve been calling for a vote. This should be very alarming. The American Psychological Association had also changed its ethical guidelines under political pressure during the George W. Bush administration, and that led to psychologists administering torture.

Armchair psychiatry does not apply because we’re not talking about saying anything we couldn’t from afar. We are talking precisely about the public health implications.

Why would they do this, do you think?

Well, according to one of the high-ranking officials, it was due to the fear of losing government funding. Regardless of the reasons, it is an alarming act.

One thing that you constantly hear in media coverage of the president is that he’s getting worse. But at the same time, if you go back and watch some of those early Iowa speeches, it’s all there. The bragging about sexual assault, as you said, happened years ago. You can go back and find pretty much everything you’re talking about, the violence, going back several years. Again, I know you’re not going to diagnose, but do you have reason to think that things are getting particularly worse?

Oh yes. Absolutely. So you say things are all there. Yes. We knew enough to predict that in the office of the presidency, under the pressures of this office, that he would get worse. And he’s actually rapidly getting worse. The Washington Post measured that in the first six months of this year, he quadrupled the number of lies that he told last year. In other words, in six months he had told [almost] double the number of lies that he did in the entire first year of his presidency.

Well, right. But you could say, well, he tells more lies because his political and legal situations are worse, so he’s forced to tell more lies to keep his political standing up, or something.

I think this is one of the reasons why mental health expertise can be helpful: Because we know that it’s not just an isolated sign. And we can look at the patterns and figure out whether it’s strategy or whether it’s symptoms. We by now have a lot of high-quality data, in terms of his reactions to situations in real-time, over considerable periods of time. So through the patterns, and also through the collection of symptoms, if you will, we can easily figure out that a large part of this is not strategy, and we would have been able to tell you so a year and a half before most people realized.

What sorts of things are you talking about, besides lying?

The increasing frequency in lying, the increasingly belligerent tweets, his inability to vary his responses to situations. For example, he cannot let a criticism go. He has to fabricate reality to situations that are distressing to him. And the thing about pathology, as opposed to normal reaction, is pathology actually becomes more rigid and more predictable. A healthy individual might be able to vary their response, especially if it’s strategy. They can choose to act differently if something is not working. Whereas pathology tends to become more and more rigid as it worsens. And what we’re seeing is simple repetition now, and worsening, greater frequency of his poor coping mechanisms.

OK, but to take a different example, it’s obvious that the president is a racist who has racist beliefs and engages in racism frequently. I think sometimes when he engages in racism, it’s just to get his supporters riled up, rather than from any deep-seated particular belief. So I guess it’s hard to disaggregate under specific circumstances and say he’s lying here because he’s mentally unstable versus he’s lying here because he’s in an embarrassing situation.

Right. That’s why you look at patterns. You’re absolutely right. When we just isolate a single instance, then it’s almost impossible to tell. But with Mr. Trump, we have decades of information and patterns to look at. And we have better information on him than most of our patients, even, by now. Information that is relevant to dangerousness. And actually, diagnosis has nothing to do with dangerousness. Even if we were to have a diagnosis today, it tells us nothing about his ability to function in office, or his dangerousness. These are different evaluations.

And in fact, if we were to do a mental health evaluation on him, I would recommend a capacity evaluation, and a dangerousness risk assessment above a diagnosis. A diagnosis is more about the personal mental health of the president and that’s not really a priority when he has such an important public function, and we’re mainly concerned about public health and safety.