President Donald Trump is a clear and present danger to the United States and the world.

He has reckless disregard for democracy and its foundational principles. Trump is also an authoritarian plutocrat who appears to be using the presidency as a means to enrich himself and closest allies as well as family members. Trump’s proposed 2018 federal budget is a shockingly cruel document that threatens to destroy America’s already threadbare social safety net in order to give the rich and powerful (even more) hefty tax cuts. His policies have undermined the international order and America’s place as the dominant global power. It would appear that he and his administration have been manipulated and perhaps (in the case of Michael Flynn) even infiltrated by Vladimir Putin’s spies and other agents. The world has become less safe as a result of Trump’s failures of leadership and cavalier disregard for existing alliances and treaties.

Donald Trump’s failures as president have been compounded by his unstable personality and behavior. It has been reported by staffers inside the Trump White House that he is prone to extreme mood swings, is cantankerous and unpredictable, flies into blind rages when he does not get his way, is highly suggestible and readily manipulated, becomes bored easily and fails to complete tasks, is confused by basic policy matters and is unhappy and lonely. And despite bragging about his “strength” and “vitality” during the 2016 presidential campaign, Trump appears to tire easily and easily succumbs to “exhaustion.” Trump is apparently all id and possesses little if any impulse control. He is a chronic liar who ignores basic facts and empirical reality in favor of his own fantasies.

Between the scandals and the emotionally erratic behavior, Donald Trump would appear to be a 21st-century version of Richard Nixon, to date the only American president forced to resign under threat of forcible removal. In all, this leads to a serious and worrisome question: Is Donald Trump mentally ill? Moreover, what does Trump’s election reveal about the moods and values of his voters? How are questions of societal emotions and collective mental health connected to the rise of fascism and authoritarianism in America? Do psychiatrists, psychologists and other mental health professionals have a moral obligation to warn the public about the problems they see with Donald Trump’s behavior?

In an effort to answer these questions, I recently spoke with Dr. Bandy Lee, a psychiatrist at Yale University who specializes in public health and violence prevention. She recently convened a conference that explored issues related to Donald Trump’s emotional health and how mental health professionals should respond to this crisis. The proceedings from this conference will be featured in a forthcoming book expected later this year.

Our conversation has been edited for length and clarity. A longer version can be heard on my podcast, available on Salon’s Featured Audio page.

How did a person like Donald Trump become president?

My being a psychiatrist, I will inevitably see things from that lens. I also tend to think about the social context that gives rise to the current conditions. For me the big shift in our society has been the increasing inequality, and with that a certain segment of the population will end up suffering from an undue amount of poverty — a relative poverty actually, deprivation, a lack of education, a lack of health care and mental health care. All those things will contribute to worsening of collective mental health.

As a clinician, when you watch Trump’s behavior day after day — his lying and obfuscation, his apparent confusion and anger management issues — what are you thinking?

I’ve been thinking from the very beginning that he exhibits many signs of mental impairment. I recently organized a conference on this at Yale. Afterwards, there has been almost an army of people who have shared with me how they have been wanting to speak about this issue. I did not expect to get such a massive response.

What are your peers’ specific concerns and what are they afraid of?

This situation has come to such a critical level. In fact, a state of emergency exists and we could no longer hold back. We have an obligation to speak about Donald Trump’s mental health issues because many lives and our survival as a species may be at stake.

What are two or three things you could cite about Donald Trump’s behavior that causes you the greatest concern, worry or alarm?

There are certainly the symptoms that he displays. He has a great need for adulation. He is angry if reality does not meet his needs. People have been expecting him to settle into his role and become normal or more “presidential,” but that does not ordinarily happen among those with such personality traits. In fact, what we’re seeing is a creation of his own reality, a reality that will meet Trump’s own emotional needs and the need to impose that reality on others. It is his imperviousness to facts and reality that could place us all at great risk.

On one hand, he can just be cantankerous, moody, angry and a spoiled child. I’ve described him as a man-child or a clown king. But how do we separate that from saying, “OK, there is something going on clinically”?

One does not make the other mutually exclusive. In fact, one can both be immature and a jerk, dangerous and ill-intentioned. In other words, bad as well as mad. It’s really the combination that makes it so toxic and unpredictable that we felt that there was a need to speak out.

How should the “Goldwater rule,” the ethical requirement not to diagnose a person you have not examined, be balanced with mental health professionals’ responsibilities as American citizens and members of the global community?

In an ordinary situation where matters were not so intense, we could balance out our political activism and separate that from our professional goals and actions. But when there is such a grave mental disability that is affecting the public sphere, the political sphere, such as in the current position of power, then those lines get blurred. Given that all human health exists in an ecological system, there is no rule that politics will never enter the sphere of health or the mental health profession. Right now we’re seeing that it does.

When we have a president who asks, What is the point of having nuclear weapons if we cannot use them?, who urges our government to use torture or worse against prisoners, who urges his followers at political rallies to beat protesters up so badly that they’ll be taken out in stretchers, and suggests that his followers could always assassinate Hillary Clinton if she were to be elected president, there is something very wrong. All this attraction to violence, threats of violence, boasts of his own violence and sexual assaults, and incitements to violence — all these have an effect.

As a clinician, how do you figure out the causal arrows? Is Trump causing an increase in violence or is his presidency a reflection of deeper cultural problems in America?

Certainly it’s not a one-way path. It happens both ways in that we have elected a president who was somehow very attractive to his voters. But then he stokes and amplifies certain elements in the population that in turn create more conditions for violence and danger.

Why do you think more of your peers have not spoken about these concerns? Are they afraid of professional consequences? Personal threats of violence?

One of my colleagues said this was not the way she wished to spend her life — in other words, to spend the rest of her life paying for an expression of her opinion by fighting lawsuits, by fighting for her license. There was a fear of having her license taken away. Yes, the fear was present then and it is present still now, such that when I was editing this book, I had two co-editors who initially signed on, but the more they heard about the possibility that their license could be in danger, that they could somehow be targeted for this, they pulled out.

How did you overcome that fear and anxiety? It’s easier to be a bystander to history. It’s easier to say, “I’ll let somebody else do it.” Instead you actually chose to do something.

In my case, it became a grave enough emergency that my conscience would not let me rest in peace if I did not do something about it.

As a psychologist, as a human being, as a citizen, why do you think some people choose to be bystanders and others decide to act?

Bystanders do make a lot of difference. Human rights abuses could not happen if bystanders spoke up or did not approve.

On a practical level, how do you think a president should be psychologically evaluated before taking office? What do you think the actual remedies could be for dealing with Donald Trump now? Can we invoke the 25th Amendment, so that if enough people diagnose this man and there is enough of an outcry he will be removed?

I think by sounding the alarm about his mental instability and position of power that some kind of consensus as to a process would be developed. As for the 25th Amendment, I don’t think that’s really a psychiatrist’s domain. But that is certainly one avenue that has been proposed and it’s the only one that would be possible in terms of a case of mental impairment. I think what needs to happen next is a collaborative discussion among people of different fields. We could speak to the president’s mental impairment, the effects of that impairment and the dangerous situation we’re in. Other people could speak to the best political and procedural way to do something about that finding. Those would be lawmakers and politicians.

What do you think the United States is going to look like after Donald Trump leaves office?

He has exacerbated the pathological patterns of our culture. What would happen if the presidency continues? I think more damage will be done. In fact, the latter part of the book consists of some of the effects of his policies, including repealing the Affordable Care Act, his immigration policies, his tax laws and his military policies. All these things could have ramifications and reverberations throughout —his environmental policies, his educational policies. In fact, Dr. Robert Jay Lifton said at the conference that Trump’s style of governing could be described as “anti-governing.” I believe we’re at a crossroads.

We can either amplify and encourage Trump and his followers’ pathology, or we can stop it and look for ways that are more life enhancing, healing, corrective. When you see a person falling into illness, the deeper the illness grows, the less aware they will be of their illness. The more insistent they will be on destructive ways rather than ways that are healing and constructive. At a later point, doctors and hospitals will be the thing that they will avoid at all costs. That is why sometimes physicians have to hospitalize against the person’s will or put them on a stretcher. The reason why the law allows that, that society allows that is because they feel better and then they thank you for it.

That is why simply respecting the choices of the electorate when the electorate is not entirely well can spiral into situations like fascism. Remember fascism is not necessarily an ideology. It could be on the right or the left. It is also an emotional experience to a certain political structure, and people will cling to it regardless of how destructive it is to their lives, regardless of what path it takes them toward. The pull is emotional, not ideological or even rational. It’s a situation that needs intervention, healing and treatment. The way to do that is to improve societal conditions.

Why do Trump’s voters continue to support him even when his and the Republican Party’s policies will hurt them economically and in other ways as well?

Because it’s an emotional compulsion. It’s an emotional reaction. It’s not anything rational. Trying to reason with them will not help. It’s really the conditions that have to change. Malignant reality is taking hold. It’s a kind of pathology cohesion that normalizes corruption, violence and harm, and there will come a the point where we’re no longer disturbed by it. At that point, all kinds of human rights violations, wars and loss of life become possible. Mental health professionals have to become witnessing professionals who continually point out this dynamic and call it out for what it is, so that it does not become normalized.

The Trump administration, and I might argue to a large extent the Republican Party, has been leading up to a need to impose a distorted reality and a kind of imperviousness to facts onto others. Facts and evidence almost do not matter. What matters is the emotional commitment to either an ideology or what they believe will make America great again, restore their position, or give them the kind of pride or self-esteem that they feel they have lost.