The Mask of Sanity

by Hervey Cleckley

  It is my earnest conviction that, traditionally confused with a fairly heterogeneous group under a loose and variously understood term, a type of patient exists who could, without exaggeration, still be called the forgotten man of psychiatry. If this patient can be presented as he has appeared so clearly during years of observation, if some idea can be given of his ubiquity, and, above all, if interest can be promoted in further study of his peculiar status among other human beings, I shall be abundantly satisfied. It is difficult to contemplate the enigma which he provokes without attempting to find some explanation, speculative though the attempt may be. My efforts to explain or interpret are, however, tentative and secondary to the real purpose of this volume, which is to call attention to what may be observed about our subject.

  3. Not as Single Spies but in Battalions

  In attempt to determine the incidence of this disorder in the population as a whole is opposed by serious difficulties. The vagueness of officially accepted criteria for diagnosis and the extreme variation of degree in such maladjustment constitute primary obstacles. Statistics from most psychiatric hospitals are necessarily misleading, since the psychopath is not technically eligible for admission and only those who behave in such an extremely abnormal manner as to appear orthodoxly psychotic (that is to say, as suffering from another and very different disorder) appear in the records. If the traditional legal and medical rules were regularly followed, statistics from state hospitals and from the federal psychiatric institutions would show no psychopaths at all. Let it also be noted that these institutions contain a vast majority of the patients hospitalized in the United States for mental disorder. Most statistical studies, therefore, cannot be regarded as even remotely suggesting the prevalence of this disability in the population.

  These facts notwithstanding, it is still impressive to note what the records of a typical psychiatric institution reveal during a period of twenty-nine months shortly before the first edition of this book was published in 1941.* During this period 857 new patients were admitted to one federal hospital, where a staff of ten psychiatrists, including myself, classified them after careful examination and study. Of this group, 102 received the primary diagnosis of psychopathic personality, being considered free of any other mental disorder that could account for the difficulties that led to their admission. This group, comprising nearly one-eighth of all those admitted, indicates that the disorder is far from rare. The records also show 134 other patients classified under alcoholism or drug addiction, many of whom I believe, for reasons brought out in the appendix, were fundamentally like those diagnosed as psychopaths, the addiction and other complications being secondary. If even one-half of these are considered as psychopaths, we arrive at a figure of 169, or almost one-fifth of the total.

  These statistics from one psychiatric institution cannot, of course, be taken as proof that the disorder is so prevalent everywhere. One must not overlook the fact, however, that each of these patients was accepted despite rules specifically classifying him as ineligible and often as a result of conduct so abnormal or so difficult to cope with that he was considered a grave emergency. Another factor worth mentioning is the psychopath’s almost uniform unwillingness to apply, like other ill people, for hospitalization or for any other medical service. The survey at least suggests that these patients are common and that they constitute a serious problem in the average community and a major issue in psychiatry.

  I have been forced to the conviction that this particular behavior pattern is found among one’s fellow men far more frequently than might be surmised from reading the literature. If the nature of the disorder in question defines itself throughout the course of this work with sufficient sharpness and clarity to be recognizable as a pathologic entity, little doubt will remain that it presents a sociologic and psychiatric problem second to none.

  The man who develops influenza or who breaks his arm nearly always thinks at once of calling his doctor. The unconscious victim of a head injury is promptly taken by his family, by his friends, or, lacking these, by casual bystanders to a hospital where medical attention is given. Persons who develop anxiety, phobia, or psychosomatic manifestations are likely to seek aid from a physician. Even those who demur and delay since they fear they will be called weak or silly because of symptoms commonly classed as psychoneurotic can be, and usually are, persuaded by their families after varying periods of reluctance to ask for help.

  Children, of course, often seek to avoid both the pediatrician and the dentist, despite the advice of parents. But the parent seldom fails, when need of treatment is a serious matter, in getting the child, with or without his willingness, into the hands of the doctor. Many patients ill with the major personality disorders we classify as psychoses do not voluntarily seek treatment. Some do not recognize any such need and may bitterly oppose, sometimes by violent combat, all efforts to send them to psychiatric hospitals. Such patients, however, are well recognized. Medical facilities and legal instrumentalities exist for handling the problem, and institutions are provided to accept such patients and hold them, if necessary against their own volition, so long as it is advisable for the patient’s welfare or for the protection of others.

  When we consider on the other hand these antisocial or psychopathic personalities, we find not one in one hundred who spontaneously goes to his physician to seek help. If relatives, alarmed by his disastrous conduct, recognize that treatment, or at least supervision, is an urgent need, they meet enormous obstacles. The public institutions to which they would turn for the care of a schizophrenic or a manic patient present closed doors. If they are sufficiently wealthy, they often consider a private psychiatric hospital. It should also be noted here that such private hospitals are necessarily expensive and that perhaps not more than 2 or 3 percent of our population can afford such care for prolonged periods. No matter how wealthy his family may be, the psychopath, unlike all other serious psychiatric cases, can refuse to go to any hospital or to accept any other treatment or restraint. His refusal is regularly upheld by our courts of law, and grounds for this are consistent with the official appraisal of his condition by psychiatry.

  Nearly always he does refuse and successfully oppose the efforts of his relatives to have him cared for. It is seldom that a psychopath accepts hospitalization or even outpatient treatment unless some strong means of coercion happens to be available. The threat of cutting off his financial support, of bringing legal action against him for forgery or theft, or of allowing him to remain in jail may move him to visit a physician’s office or possibly to enter a hospital. Subsequent events often demonstrate that he is acting not seriously and with the understanding he professes but for the purpose of evasion, whether he himself realizes this or not. He usually breaks off treatment as soon as the evasion has been accomplished.

  Since medical institutions traditionally refuse to accept the psychopath as a patient and since he does not voluntarily, except in rare instances, seek medical aid, it might be surmised that prison populations would furnish statistics useful in estimating the prevalence of his disorder. It is true that a considerable proportion of prison inmates show indications of such a disorder.31,184,240 It is also true that only a small proportion of typical psychopaths are likely to be found in penal institutions, since the typical patient, as will be brought out in subsequent pages, is not likely to commit major crimes that result in long prison terms. He is also distinguished by his ability to escape ordinary legal punishments and restraints. Though he regularly makes trouble for society, as well as for himself, and frequently is handled by the police, his characteristic behavior does not usually include committing felonies which would bring about permanent or adequate restriction of his activities. He is often arrested, perhaps one hundred times or more. But he nearly always regains his freedom and returns to his old patterns of maladjustment.

  Although the incidence of this disorder is at present impossible to establish statistically or even to estimate accurately, I am willing to express
the opinion that it is exceedingly high. On the basis of experience in psychiatric out-patient clinics and with psychiatric problems of private patients and in the community (as contrasted with committed patients), it does not seem an exaggeration to estimate the number of people seriously disabled by the disorder now listed under the term antisocial personality as greater than the number disabled by any recognized psychosis except schizophrenia. So far as I know, there are no specific provisions made in any public institution for dealing with even one psychopath.

  4. Method of Presentation

  Before attempting to define or describe the psychopath (antisocial personality), to contrast him with other types of psychiatric patients, or to make any attempt to explain him, I would like to present some specimens of the group for consideration.

  This procedure will be in accord with the principles of science in method at least, since, as Karl Pearson pointed out in The Grammar of Science, this method always consists of three steps:119

  The observation and recording of facts

  The grouping of these facts with proper correlation and with proper distinction from other facts

  The effort to devise some summarizing or, if possible, explanatory statement which will enable one to grasp conveniently their significance

  Long ago, keeping these steps clearly in mind, Bernard Hart gave an account in The Psychology of Insanity119 of personality disorder that has, perhaps, never been surpassed for clarity and usefulness. Psychopathology has not been a static field, and many new concepts have arisen which make Hart’s presentation in some respects archaic and unrepresentative of viewpoints prevalent today in psychiatry. This point notwithstanding, the method followed by Hart remains an example of how the problems of a personality disorder can be approached with maximal practicality with minimal risks of mistaking hypothesis for proof or of falling into the schismatic polemics that, scarcely less than among medieval theologians, have confused issues and impeded common understanding in psychiatry. Without claims to comparable success in the effort to follow Hart’s method, I acknowledge the debt owed one who set so excellent an example in the early years of this century.

  The most satisfactory way in which such clinical material could be presented is, in my opinion, as a series of full-length biographic studies, preferably of several hundred pages each, written by one who has full access to the life of each subject. Only when the concrete details of environment are laid in, as, for instance, in an honest and discerning novel, can the significance of behavior be well appreciated. Certainly no brief case summary and probably no orthodox psychiatric history can succeed in portraying the character and the behavior of these people as they appear day after day and year after year in actual life.

  It is not enough to set down that a certain patient stole his brother’s watch or that another got drunk in a poolroom while his incipient bride waited at the altar. To get the feel of the person whose behavior shows disorder, it is necessary to feel something of his surroundings. The psychopath’s symptoms have for a long time been regarded as primarily sociopathic.233,235,236 It is true that all, or nearly all, psychiatric disorder is in an important sense sociopathic, in that it affects adversely interpersonal relations. In most other disorders the manifestations of illness can, however, be more readily demonstrated in the isolated patient in the setting of a clinical examination. In contrast, it is all but impossible to demonstrate any of the fundamental symptoms in the psychopath under similar circumstances. The substance of the problem, real as it is in life, disappears, or at least escapes our specialized means of perception, when the patient is removed from the milieu in which he is to function.

  All that surrounds and has ever surrounded the schizophrenic or the man with severe obsessive illness is, of course, important to us if we seek to understand why these people became disabled. Lacking all information except what might be gained from either of these patients (with whom one is, let us say, confined in an oxygen chamber on the moon), the observer will, nevertheless, have little trouble in discerning that there is disorder and in discovering a good deal about the general nature of the disorder.

  Aside from questions of cause and effect, we have little opportunity even to realize the existence of the subject we must deal with unless the psychopath can be followed as he departs from the (essentially in vitro) situation of physician’s office or hospital and takes up his activities in the community on a real and (socially) in vivo status.

  It is with such convictions in mind that we shall often include detail of the environment, perhaps digress to the patient’s husband or parents, report glimpses of the patient through the eyes of a lay observer, and at times attempt, from what material is available, a tentative reconstruction of situations that can be experienced adequately only at firsthand. It is regrettable that so much detail of this sort is difficult and often impossible to obtain. Without adequate knowledge of his specific surroundings in the community, there is no way for more than the insubstantial image of his being, like the picture projected from a lantern slide, to reach awareness. The real clinical entity is approachable only in the unstatic, actual process of the patient’s life as he takes his specific course as a personal and sociologic unit.

  The disorder can be demonstrated only when the patient’s activity meshes with the problems of ordinary living. It cannot be even remotely apprehended if we do not pay particular attention to his responses in those interpersonal relations that to a normal man are the most profound.

  If no schizophrenic had ever spoken, we would probably have little realization of what we understand (incomplete as this is) of auditory hallucinations. The schizophrenic can, by his verbal communication, give us some useful clues in our efforts to approach many of his problems. Little or nothing of this sort that is reliable can, by ordinary psychiatric examination, be obtained from the psychopath. Only when we observe him not through his speech but as he seeks his aims in behavior and demonstrates his disability in interaction with the social group can we begin to feel how genuine is his disorder. Studying the psychopath almost entirely in the orthodox clinical setting in which patients ordinarily appear is like examining the schizophrenic with our ears so muffled that his reiterated and quite honest claims of hearing voices of the dead talking to him from the sun (and from his intestines) fail to reach our perception.

  If another analogy be permitted, let us say that a pair of copper wires carrying 2,000 volts of electricity, when we look at them, smell them, listen to them, or even touch them separately (while thoroughly insulated from the ground), may give no evidence of being in any respect different from other strands of copper. Let us, however, connect them to a motor (or have someone seize both of them at once) and we find out facts not to be perceived otherwise. The unmistakable evidence of electricity appears only when the circuit is made. So, too, the features that are most important in the behavior of the psychopath do not adequately emerge when this behavior is relatively isolated. The qualities of the psychopath become manifest only when he is connected into the circuits of full social life.

  The sort of presentation our problem requires is, of course, impossible. However, in an effort to give at least a vivid glimpse of the material under consideration, I have made use of a somewhat different form of report than that customarily offered.

  The impersonal and necessarily abstracted picture of these psychopaths in a purely clinical setting fails to show them as they appear in flesh and blood and in the process of living. In the restricted and arbitrary range of activities afforded by hospital life, their tendencies cannot be so truly and vividly demonstrated as in the larger world. To know them adequately, one must try to see them not merely with the physician’s calm and relatively detached eye but also with the eye of the ordinary man on the streets, whom they confound and amaze. We must concern ourselves not only with their measurable intelligence, their symptomatology (or, rather, lack of symptomatology) in ordinary psychiatric terms, but also with the impression they make as total organisms in act
ion among others and in all the nuances and complexities of deeply personal and specifically affective relationships. To see them properly in such a light, we must follow them from the wards out into the marketplace, the saloon, and the brothel, to the fireside, to church, and to their work.

  In attempting this, however incompletely and inadequately, it is perhaps desirable for us not to trade our naivete at once for the experienced clinician’s discriminating viewpoint. Let us first watch them in their full conduct as human beings, not neglecting even the impression they make on Tom, Dick, and Harry, before trying to frame them in a scheme of psychopathology.

  The terms I shall use to describe them may often imply that they are blamed for what they do or suggest an attitude of distaste or mockery for some of their behavior. Most psychiatrists regard such patients, unlike those suffering from ordinary psychoses, as legally competent and responsible for their misconduct and their difficulties. The faulty reactions in living which these patients show are indeed difficult to describe without sometimes using terms that come more readily to moralists or sociologists or laymen than to psychiatrists. The customary psychiatric terminology does not, I believe, offer a range of concepts into which we can fit these people successfully.

  With other patients whose disorder is frankly recognized, we can, by our impersonal and specifically medical language, communicate fairly well to each other what we have observed. Some aspects of the psychopath which elude such language may be reflected, however imperfectly, in the simplest accounts of direct impression by those who have been closest to him and have felt the impact of his anomalous reactions. For these reasons, then, and with apology, reference may be made to some actions as outlandish, foolish, fantastic, buffoonish.