As mental health professionals, these men and women respect the long-standing “Goldwater rule” which inhibits them from diagnosing public figures whom they have not personally examined. At the same time, as explained by Dr. Bandy X Lee, who teaches law and psychiatry at Yale School of Medicine, the rule does not have a countervailing rule that directs what to do when the risk of harm from remaining silent outweighs the damage that could result from speaking about a public figure — “which in this case, could even be the greatest possible harm.” It is an old and difficult moral issue that requires a great exertion of conscience. Their decision: “We respect the rule, we deem it subordinate to the single most important principle that guides our professional conduct: that we hold our responsibility to human life and well-being as paramount.”

Hence, this profound, illuminating and discomforting book undertaken as “a duty to warn.”

Robert Jay Lifton: I don’t think so. I think the Goldwater Rule is a little ambiguous. We adhere to that portion of the Goldwater Rule that says we don’t see ourselves as making a definitive diagnosis in a formal way and we don’t believe that should be done, except by hands-on interviewing and studying of a person. But we take issue with the idea that therefore we can say nothing about Trump or any other public figure. We have a perfect right to offer our opinion, and that’s where “duty to warn” comes in.

Moyers: Duty to warn?

Lifton: We have a duty to warn on an individual basis if we are treating someone who may be dangerous to herself or to others — a duty to warn people who are in danger from that person. We feel it’s our duty to warn the country about the danger of this president. If we think we have learned something about Donald Trump and his psychology that is dangerous to the country, yes, we have an obligation to say so. That’s why Judith Herman and I wrote our letter to The New York Times. We argue that Trump’s difficult relationship to reality and his inability to respond in an evenhanded way to a crisis renders him unfit to be president, and we asked our elected representative to take steps to remove him from the presidency.

Moyers: Yet some people argue that our political system sets no intellectual or cognitive standards for being president, and therefore, the ordinary norms of your practice as a psychiatrist should stop at the door to the Oval Office.

Lifton: Well, there are people who believe that there should be a standard psychiatric examination for every presidential candidate and for every president. But these are difficult issues because they can’t ever be entirely psychiatric. They’re inevitably political as well. I personally believe that ultimately ridding the country of a dangerous president or one who’s unfit is ultimately a political matter, but that psychological professionals can contribute in valuable ways to that decision.

Moyers: Do you recall that there was a comprehensive study of all 37 presidents up to 1974? Half of them reportedly had a diagnosable mental illness, including depression, anxiety and bipolar disorder. It’s not normal people who always make it to the White House.

Lifton: Yes, that’s amazing, and I’m sure it’s more or less true. So people with what we call mental illness can indeed serve well, and people who have no discernible mental illness — and that may be true of Trump — may not be able to serve, may be quite unfit. So it isn’t always the question of a psychiatric diagnosis. It’s really a question of what psychological and other traits render one unfit or dangerous.

Moyers: You write in the foreword of the book: “Because Trump is president and operates within the broad contours and interactions of the presidency, there is a tendency to view what he does as simply part of our democratic process, that is, as politically and even ethically normal.”

Lifton: Yes. And that’s what I call malignant normality. What we put forward as self-evident and normal may be deeply dangerous and destructive. I came to that idea in my work on the psychology of Nazi doctors — and I’m not equating anybody with Nazi doctors, but it’s the principle that prevails — and also with American psychologists who became architects of CIA torture during the Iraq War era. These are forms of malignant normality. For example, Donald Trump lies repeatedly. We may come to see a president as liar as normal. He also makes bombastic statements about nuclear weapons, for instance, which can then be seen as somehow normal. In other words, his behavior as president, with all those who defend his behavior in the administration, becomes a norm. We have to contest it, because it is malignant normality. For the contributors to this book, this means striving to be witnessing professionals, confronting the malignancy and making it known.

Moyers: Witnessing professionals? Where did this notion come from?

Lifton: I first came to it in terms of psychiatrists assigned to Vietnam, way back then. If a soldier became anxious and enraged about the immorality of the Vietnam War, he might be sent to a psychiatrist who would be expected to help him be strong enough to return to committing atrocities. So there was something wrong in what professionals were doing, and some of us had to try to expose this as the wrong and manipulative use of our profession. We had to see ourselves as witnessing professionals. And then of course, with the Nazi doctors I studied for another book — doctors assigned, say, to Auschwitz — they were expected to do selections of Jews for the gas chamber. That was what was expected of them and what for the most part they did — sometimes with some apprehension, but they did it. So that’s another malignant normality. Professionals were reduced to being automatic servants of the existing regime as opposed to people with special knowledge balanced by a moral baseline as well as the scientific information to make judgments.

Moyers: And that should apply to journalists, lawyers, doctors —

Lifton: Absolutely. One bears witness by taking in the situation — in this case, its malignant nature — and then telling one’s story about it, in this case with the help of professional knowledge, so that we add perspective on what’s wrong, rather than being servants of the powers responsible for the malignant normality. We must be people with a conscience in a very fundamental way.

Moyers: And this is what troubled you and many of your colleagues about the psychologists who helped implement the US policy of torture after 9/11.

Lifton: Absolutely. And I call that a scandal within a scandal, because yes, it was indeed professionals who became architects of torture, and their professional society, the American Psychological Association, which encouraged and protected them until finally protest from within that society by other members forced a change. So that was a dreadful moment in the history of psychology and in the history of professionals in this country.

Moyers: Some of the descriptions used to describe Trump — narcissistic personality disorder, antisocial personality disorder, paranoid personality disorder, delusional disorder, malignant narcissist — even some have suggested early forms of dementia — are difficult for lay people to grasp. Some experts say that it’s not one thing that’s wrong with him — there are a lot of things wrong with him and together they add up to what one of your colleagues calls “a scary witches brew, a toxic stew.”

Lifton: I think that’s very accurate. I agree that there’s an all-enveloping destructiveness in his character and in his psychological tendencies. But I’ve focused on what professionally I call solipsistic reality. Solipsistic reality means that the only reality he’s capable of embracing has to do with his own self and the perception by and protection of his own self. And for a president to be so bound in this isolated solipsistic reality could not be more dangerous for the country and for the world. In that sense, he does what psychotics do. Psychotics engage in, or frequently engage in a view of reality based only on the self. He’s not psychotic, but I think ultimately this solipsistic reality will be the source of his removal from the presidency.

Moyers: What’s your take on how he makes increasingly bizarre statements that are contradicted by irrefutable evidence to the contrary, and yet he just keeps on making them? I know some people in your field call this a delusional disorder, a profound loss of contact with external reality.

Lifton: He doesn’t have clear contact with reality, though I’m not sure it qualifies as a bona fide delusion. He needs things to be a certain way even though they aren’t, and that’s one reason he lies. There can also be a conscious manipulative element to it. When he put forward, and politically thrived on, the falsehood of President Obama’s birth in Kenya, outside the United States, he was manipulating that lie as well as undoubtedly believing it in part, at least in a segment of his personality. In my investigations, I’ve found that people can believe and not believe something at the same time, and in his case, he could be very manipulative and be quite gifted at his manipulations. So I think it’s a combination of those.

Moyers: How can someone believe and not believe at the same time?

Lifton: Well, in one part of himself, Trump can know there’s no evidence that Obama was born in any place but Hawaii in the United States. But in another part of himself, he has the need to reject Obama as a president of the United States by asserting that he was born outside of the country. He needs to delegitimate Obama. That’s been a strong need of Trump’s. This is a personal, isolated solipsistic need which can coexist with a recognition that there’s no evidence at all to back it up. I learned about this from some of the false confessions I came upon in my work.

Moyers: Where?

Lifton: For instance, when I was studying Chinese communist thought reform, one priest was falsely accused of being a spy, and was under physical duress — really tortured with chains and in other intolerable ways. As he was tortured and the interrogator kept insisting that he was a spy, he began to imagine himself in the role of a spy, with spy radios in all the houses of his order. In his conversations with other missionaries he began to think he was revealing military data to the enemy in some way. These thoughts became real to him because he had to entered into them and convinced the interrogator that he believed them in order to remove the chains and the torture. He told me it seemed like someone creating a novel and the novelist building a story with characters which become real and believable. Something like that could happen to Trump, in which the false beliefs become part of a panorama, all of which is fantasy and very often bound up with conspiracy theory, so that he immerses himself in it and believing in it even as at the same time recognizing in another part of his mind that none of this exists. The human mind can do that.

Moyers: It’s as if he believes the truth is defined by his words.

Lifton: Yes, that’s right. Trump has a mind that in many ways is always under duress, because he’s always seeking to be accepted, loved. He sees himself as constantly victimized by others and by the society, from which he sees himself as fighting back. So there’s always an intensity to his destructive behavior that could contribute to his false beliefs.

Moyers: Do you remember when he tweeted that President Obama had him wiretapped, despite the fact that the intelligence community couldn’t find any evidence to support his claim? And when he spoke to a CIA gathering, with the television cameras running, he said he was “a thousand percent behind the CIA,” despite the fact that everyone watching had to know he had repeatedly denounced the “incompetence and dishonesty” of that same intelligence community.

Lifton: Yes, that’s an extraordinary situation. And one has to invoke here this notion of a self-determined truth, this inner need for the situation to take shape in the form that the falsehood claims. In a sense this takes precedence over any other criteria for what is true.

Moyers: What other hazardous patterns do you see in his behavior? For example, what do you make of the admiration that he has expressed for brutal dictators — Bashar al-Assad of Syria, the late Saddam Hussein of Iraq, even Kim Jong Un of North Korea — yes, him — and President Rodrigo Duterte of the Philippines, who turned vigilantes loose to kill thousands of drug users, and of course his admiration for Vladimir Putin. In the book Michael Tansey says, “There’s considerable evidence to suggest that absolute tyranny is Donald Trump’s wet dream.”

Lifton: Yes. Well, while Trump doesn’t have any systematic ideology, he does have a narrative, and in that narrative, America was once a great country, it’s been weakened by poor leadership, and only he can make it great again by taking over. And that’s an image of himself as a strongman, a dictator. It isn’t the clear ideology of being a fascist or some other clear-cut ideological figure. Rather, it’s a narrative of himself as being unique and all-powerful. He believes it, though I’m sure he’s got doubts about it. But his narrative in a sense calls forth other strongmen, other dictators who run their country in an absolute way and don’t have to bother with legislative division or legal issues.

Moyers: I suspect some elected officials sometimes dream of doing what an unopposed autocrat or strongman is able to do, and that’s demand adulation on the one hand, and on the other hand, eradicate all of your perceived enemies just by turning your thumb down to the crowd. No need to worry about “fake media” — you’ve had them done away with. No protesters. No confounding lawsuits against you. Nothing stands in your way.

Lifton: That’s exactly right. Trump gives the impression that he would like to govern by decree. And of course, who governs by decree but dictators or strongmen? He has that impulse in him and he wants to be a savior, so he says, in his famous phrase, “Only I can fix it!” That’s a strange and weird statement for anybody to make, but it’s central to Trump’s sense of self and self-presentation. And I think that has a lot to do with his identification with dictators. No matter how many they kill and no matter what else they do, they have this capacity to rule by decree without any interference by legislators or courts.

In the case of Putin, I think Trump does have involvements in Russia that are in some way determinative. I think they’ll be important in his removal from office. I think he’s aware of collusion on his part and his campaign’s, some of which has been brought out, a lot more of which will be brought out in the future. He appears to have had some kind of involvement with the Russians in which they’ve rescued him financially and maybe continue to do so, so that he’s beholden to them in ways for which there’s already lots of evidence. So I think his fierce impulse to cover up any kind of Russian connections, which is prone to obstruction of justice, will do him in.

Moyers: I want to ask you about another side of him that is taken up in the book. It involves the much-discussed video that appeared during the campaign last year which had been made a decade or so ago when Trump was newly married. He sees this actress outside his bus and he says, “I better use some Tic Tacs just in case I start kissing her,” and then we hear sounds of Tic Tacs before Trump continues. “You know,” he says, “I’m automatically attracted to beautiful — I just start kissing them. It’s like a magnet, just kiss, I don’t even wait.” And then you can hear him boasting off camera, “When you’re a star, they let you do it. You can do anything, grab them by the…. You can do anything.”

Lifton: In addition to being a strongman and a dictator, there’s a pervasive sense of entitlement. Whatever he wants, whatever he needs in his own mind, he can have. It’s a kind of American celebrity gone wild, but it’s also a vicious anti-female perspective and a caricature of male macho. That’s all present in Trump as well as the solipsism that I mentioned earlier, and that’s why when people speak of him as all-pervasive on many different levels of destructiveness, they’re absolutely right.

Moyers: And it seems to extend deeply into his relationship with his own family. There’s a chapter in The Dangerous Case of Donald Trump with the heading, “Trump’s Daddy Issues.” There’s several of his quotes about his daughter, Ivanka. He said, “You know who’s one of the great beauties of the world, according to everybody, and I helped create her? Ivanka. My daughter, Ivanka. She’s 6 feet tall. She’s got the best body.”

When Howard Stern, the radio host, started to say, “By the way, your daughter —” Trump interrupted him with “She’s beautiful.” Stern continued, “Can I say this? A piece of ass.” To which Trump replied, “Yeah.” What’s going on here?

Lifton: In addition to everything else and the extreme narcissism that it represents, it’s a kind of unbridled sense of saying anything on one’s mind as well as an impulse to break down all norms because he is the untouchable celebrity. So just as he is the one man who can fix things for the country, he can have every woman or anything else that he wants, or abuse them in any way he seeks to.

Moyers: You mentioned extreme narcissism. I’m sure you knew Erich Fromm —

Lifton: Yes, I did.

Moyers: — one of the founders of humanistic psychology. He was a Holocaust survivor who had a lifelong obsession with the psychology of evil. And he said that he thought “malignant narcissism” was the most severe pathology — “the root of the most vicious destructiveness and inhumanity.” Do you think malignant narcissism goes a long way to explain Trump?

Lifton: I do think it goes a long way. In early psychoanalytic thought, narcissism was — and still, of course, is — self-love. The early psychoanalysts used to talk of libido directed at the self. That now feels a little quaint, that kind of language. But it does include the most fierce and self-displaying form of one’s individual self. And in this way, it can be dangerous. When you look at Trump, you can really see someone who’s destructive to any form of life enhancement in virtually every area. And if that’s what Fromm means by malignant narcissism, then it definitely applies.

Moyers: You said earlier that Trump and his administration have brought about a kind of malignant normalcy — that a dangerous president can become normalized. When the Democrats make a deal with him, as they did recently, are they edging him a little closer to being accepted despite this record of bizarre behavior?

Lifton: We are normalizing him when the Democrats make a deal with him. But there’s a profound ethical issue here and it’s not easily answered. If something is good for the country — perhaps the deal that the Democrats are making with Donald Trump is seen or could be understood by most as good for the country, dealing with the debt crisis — is that worth doing even though it normalizes him? If the Democrats do go ahead with this deal, they should take steps to make clear that they’re opposing other aspects of his presidency and of him.

Moyers: There’s a chapter in the book entitled, “He’s Got the World in His Hands and His Finger on the Trigger.” Do you ever imagine him sitting alone in his office, deciding on a potentially catastrophic course of action for the nation? Say, with five minutes to decide whether or not to unleash thermonuclear weapons?

Lifton: I do. And like many, I’m deeply frightened by that possibility. It’s said very often that, OK, there are people around him who can contain him and restrain him. I’m not so sure they always can or would. In any case, it’s not unlikely that he could seek to create some kind of crisis, if he found himself in a very bad light in relation to public opinion and close to removal from office. So yes, I share that fear and I think it’s a real danger. I think we have to constantly keep it in mind, be ready to anticipate it and take whatever action we can against it. The American president has particular power. This makes Trump the most dangerous man in the world. He’s equally dangerous because of his finger on the nuclear trigger and because of his mind ensconced in solipsistic reality. The two are a dreadful combination.

Moyers: One of your colleagues writes in the book, “Sociopathic traits may be amplified as the leader discovers that he can violate the norms of civil society and even commit crimes with impunity. And the leader who rules through fear, lies and betrayal may become increasingly isolated and paranoid as the loyalty of even his closest confidants must forever be suspect.” Does that sound like Trump?

Lifton: It’s already happening. We see that it’s harder and harder to work for him. It’s hard enough even for his spokesperson to affirm his falsehoods. These efforts are not too convincing and they become less convincing from the radius outward, in which people removed from his immediate circle find it still more difficult to believe him and the American public finds it more difficult. He still can appeal to his base because in his base there is a narrative of grievance that centers on embracing Trump without caring too much about whether what he says is true or false. He somehow fits into their narrative. But that can’t go on forever, and he’s losing some of his formerly loyal supporters as well. So he is becoming more isolated. That has its own dangers, but it’s inevitable that it would happen with a man like this as his falsehoods are contested.

Moyers: You bring up his base. Those true believers aren’t the only ones who voted for him. As we are talking, I keep thinking: Here we have a man who kept asking what’s the point of having thermonuclear weapons if we cannot use them; who advocates using torture or worse against our prisoners of war; who urged that five innocent young people here in New York, black young people, be given the death penalty for a sexual assault, even after it was proven someone else had committed the crime; who boasted about his ability to get away with sexually assaulting women because of his celebrity and power; who urged his followers at political rallies to punch protesters in the face and beat them so badly that they have to be taken out on stretchers; who suggested that maybe some of his followers might want to assassinate his political rival, Hillary Clinton, if she were elected president, or at the very least, throw her in prison; who believes he would not lose voters if he stood in the middle of Fifth Avenue and shot someone. And over 63 million people voted to elect that man president!

Lifton: Yes, that’s a deeply troubling truth. And I doubt the people who voted for him were thinking about any of these things. What they were really responding to was a call for change, a sense that he was connecting with them in ways that others never had, that he would express and represent their interests, and that he would indeed make this country one dominated again by white people, in some cases white supremacists. But as you say, these people who embraced that narrative unquestioningly are a lesser minority than the ones who voted for him. And of course, he still didn’t win the popular vote. But it’s true — something has gone wrong with our democratic system in electing a man with all these characteristics that make up Donald Trump. Now we have to struggle to sustain the functional institutions of our democracy against his assault on them. I don’t think he’ll succeed in breaking them down, but he’s doing a lot of harm and it’ll take a lot of effort on the part of a lot of people to sustain them and to keep the democracy going, even in its faltering way.

Moyers: He still has the support of 80 percent of Republican voters — 4 out of 5. And it seems the Republican Party will tolerate him as long as they’re afraid of the intensity of his followers.

Lifton: Yes, and that’s another very disturbing thought. Things there could change quickly too. What I sense is that the whole situation is chaotic and volatile, so that any time now there could be further pronouncements, further information about Russia and about obstruction of justice, or another attempt of Trump to start firing people, including Mueller, and that this would create a constitutional crisis which would create more pressure on Republicans and everybody else. So even though that is an awful truth about the Republicans’ hypocrisy in continuing to support him, that could change, I think, almost overnight if the new information were sufficiently damning to Trump and his administration.

Moyers: Let’s talk about the “Trump Effect” on the country. One aspect of it was the increase in bullying in schools caused by the rhetoric used by Trump during the campaign. But it goes beyond that.

Lifton: I think Trump has had a very strong and disturbing effect on the country already. He has given more legitimacy to white supremacy and even to neo-fascist groups, and he’s created a pervasive atmosphere that’s more vague but still significant. I don’t believe that he can in his own way destroy the country, just as he can’t eliminate climate awareness, but he can go a long way in bringing — well, in stimulating what has always been a potential.

You mentioned Erich Fromm. I met him through [the sociologist] David Riesman. David Riesman was a close friend, a great authority on American society. He emphasized how there’s always an underbelly in American society of extreme conservatism and reactionary response, and when there’s any kind of progressive movement, there’s likely to be a backlash of reaction to it. Trump is very much in that backlash to any kind of progressive achievement or even decent situation in society. He is stimulating feelings that are potential and latent in our society, but very real, and rendering them more active and more dangerous. And in that way, he’s having a very harmful effect that I think mounts every single day.

Moyers: Some people who have known Trump for years say he’s gotten dramatically worse since he was inaugurated. In the prologue to The Dangerous Case of Donald Trump, Dr. Judith Lewis Herman writes this: “Fostered by the flattery of underlings and the chance of crowds, a political leader’s grandiosity may morph into grotesque delusions of grandeur.” Does that —

Lifton: That’s absolutely true. It’s absolutely true. And for anyone with these traits — of feeling himself victimized, of seeking to be the strongman who resolves everything, yet sees truth only through his own self and negates all other truth outside of it — is bound to become much more malignant when he has power. That’s what Judith Herman is saying, and she’s absolutely right. Power then breeds an intensification of all this because the power can never be absolute power — to some extent it’s stymied — but the isolation while in power becomes even more dangerous. Think of it as a vicious circle. The power intensifies these tendencies and the tendencies become more dangerous because of the power.

Moyers: But suppose that if Donald Trump is crazy, as some have said, he’s crazy like a fox, which is to say all this bizarre behavior is really clever strategy to mislead, distract and deceive others into responding in precisely the manner that he wants them to.

Lifton: I don’t think that’s quite true. I think that it’s partly true. As I said before, Trump both disbelieves and believes in falsehoods, so that when he did thrive on his longstanding and perhaps most egregious falsehood — the claim that Obama was not born in the United States — he’s crazy like a fox in manipulating it because it gave him his political entrée onto the national stage — and also, incidentally, was not rejected by many leading Republicans. So he was crazy like a fox in that case. But it’s more extreme even than that. In order to make your falsehoods powerful, you have to believe in them in some extent. And that’s why we simplify things if we say that Trump either believes nothing in his falsehoods and is just manipulating us like a fox or he completely believes them. Neither is true. The combination of both and his talent as a manipulator and falsifier are very much at issue.

Moyers: You may not remember it, but you and I talked l6 years ago this very week — a few days after the terrorist attacks of Sept. ll — and PBS had asked me to go on the air to talk to a variety of people about their response to those atrocities.

Lifton: I haven’t forgotten it, Bill.

Moyers: And in our discussion, we talked about your book, Destroying the World to Save It, about that extremist Japanese religious cult aum shinrikyo that released sarin nerve gas in Tokyo subways, you compared their ideology to Osama bin Laden: “He wanted to destroy a major part of the world to purify the world. There was in this idea, or his ideology, a sense of renewal.” We saw it in that Japanese cult. So the issue I am getting at is that such an aspiration can take hold of any true believer — the desire to purify the world no matter the cost.

Lifton: It is a very dangerous aspiration, and it’s not absent from the Trump presidency, although I don’t think it’s his central theme. I think it’s a central theme in Steve Bannon, for instance, who is an apocalyptic character and really wants to bring down most of advanced society as we know it, most of civilization as we know it, in order to recreate it in his image. I think Trump has some attraction to that, just as he had attraction to Bannon as a person and as a thinker, and that influence is by no means over. He’s still in touch with Bannon. So there is this apocalyptic influence in the Trumpean presidency: The world is destroyed in order to be purified and renewed in the ideal way that is projected by a Steve Bannon. And there is a sense of that when Trump says we’ll make America great again, because he says it’s been destroyed, he will remake it. So there is an apocalyptic suggestion, but I don’t think it’s at the very heart of his presidency.

Moyers: So our challenge is?

Lifton: I always feel we have to work both outside and inside of our existing institutions, so we have to really be careful about who we vote for and examine carefully our institutions and what they’re meant to do and how they’re being violated. I also think we need movements from below that oppose what this administration and administrations like it are doing to ordinary people. And for those of us who contributed to this book — well, as I said earlier, we have to be “witnessing professionals” and fulfill our duty to warn.