The next morning with fresh sunlight streaming into the hotel, the youngest member of the group, having finished breakfast, met Dr. _____ in the lobby. He was emerging from a telephone booth. Tall, self-assured, clear-eyed, neat as a dandy, and fashionably dressed, he looked the fine figure of a man.
He spoke affably. With a disarming, boyish smile he made some reference to the previous evening. His polite expressions and poised tone made clear the implication that it had been a pleasant occasion and had cemented friendships.
The inconspicuous trace of condescension first noted on meeting him was now more obvious, but this somehow tended to make his cordiality seem more precious. He was as sober as a man can be and showed no signs of hangover. Indeed, as his other companion of the night had said, he must have been drinking very moderately.
The former admirer of Dr. _____, who was an old friend of the lady whom he had offered to “psychoanalyze” in a parked car before, stopped at her house later in the day to say goodbye before leaving the city.
“Come in. I must speak to you,” she said. There was some indignation in her tone but more mischief and merriment.
“What about your friend, the famous psychoanalyst?” she said, relishing, in all friendliness, the other’s discomfiture. She was a person of some sophistication and poise. Being also pretty, vital, and desirable to men, she knew well how to take care of herself in ordinary company. She had been married for several years and gave a strong impression of being happy and in love with her husband.
“Well,” she continued, “I must tell you. You are interested in queer people.”
“Early this morning the cook came and woke me up. ‘It’s the telephone,’ she said. ‘Damn the telephone, Lou!’ I told her. ‘Don’t you know I was up till all hours last night?’ ‘Yes’m,’ she answered, ‘but the gentleman says you’ll speak with him, and it’s important business.’
“I picked up the phone, “ ‘Good morning, Mary’ said an unfamiliar, self-assured, masculine voice. I was wondering who it could be—knowing me well enough to use my first name and still so pompous. Then, just as I recognized the voice:
“ ‘Mary, this is Doctor _____.’ From his tone you’d have judged he thought I ought to sing for joy!
“ ‘Yes indeed,’ I said. He then baldly suggested that I make a date with him for this afternoon. He’d come out for me at 4 P.M. or, better still, he suggested, I could meet him at a drugstore downtown.
“Really, there was something so superior about him, a sort of indescribably cool insolence, or I don’t know what … about his manner, I mean … and after last night! … not just the proposition itself … that I fairly turned white with rage.
“I wanted so much to blast him with scorn that I was at a loss for words. When you get that mad it’s easy to lose your head. The calm and effective expression of indignation by which ladies in Victorian novels squelched ‘insults’ is hard to put into the idiom of today. Trying not to make myself unnecessarily ridiculous, but trusting the reply would register as final, I said:
“ ‘Is that so? Sorry, but I’m afraid I’ll have to forego that pleasure.’
“He then insisted, not like a lover or even like one who’s making any decent pretense of being a lover, but coolly, almost arrogantly, like a fake gentleman who’s after a servant girl. I must have succeeded in making myself a little clearer by this time, for he resigned himself about this afternoon. But I wasn’t done with him.
“He then began to say that he would be back in this city soon, probably every now and then. He’d like to see me on some of these occasions. He’d call me when he came. No, perhaps it would be better if he dropped me a note and let me know when he’d be here. Then I could call him! I was getting so vexed that I scarcely caught the implication that he didn’t want to telephone and find George here.
“For a moment I couldn’t answer. Then I suddenly remembered the way he announced himself: ‘Mary, this is Doctor _____!’ The overwhelming effrontery of the whole farce came over me. It was too much! ‘Mary, this is Doctor _____!’ That priceless ass calling me by my first name and referring to himself as ‘Doctor _____!’ And under such circumstances! Why, he probably pictured us having our little bout of ‘love’ in the same strain. ‘You’re so lovely, Mary, do let me take off your pants!’ ‘Oh, Doctor — (blushing), you’re so genteel and handsome!’
“Can you beat it! I ask you as an old friend! The bumptious swine didn’t even have enough delicacy in what he probably thought of as lovemaking to grant me the intimacy to call him Jack, or Harry, or Percival, or Happy Hooligan, or whatever else he’s named. He’s such an indescribable prig that he probably doesn’t even allow himself to think of himself in terms of a first name.
“I just had time to get out the words which must have come with something of a lilt:
“ ‘Yes, you just wait until I call you!’
“I’m ashamed to confess they were almost lost in a burst of laughter. It wasn’t ladylike at all the way I laughed. It was belly-shaking laughter. Homeric laughter. Rabelaisian laughter, maybe. I couldn’t stop.
“Lou, the cook, came back in and asked what was the matter. ‘I can’t explain,’ I told her and went on laughing.
“What sort of people are you psychiatrists anyway?” she now asked in her spirited, arch way, again enjoying her old friend’s discomfiture which was now almost lost in wonder and amusement. “I bet that bat-house troubadour went away thinking I had become hysterical with delight at the opportunity he offered.”
“That might not be absurd after all,” the friend murmured, remembering the self-possession and happy assurance with which Dr. _____ had emerged from the telephone booth that morning.
This case is offered for what it may be worth. No diagnosis of psychopathic personality has been made. Occasional news of him over the next few years indicated that he was still outwardly well adjusted. I believe it likely that he continues to prosper and I have not the faintest notion that he will ever reach the wards of a psychiatric hospital except in the capacity of a physician and executive. He does not really succeed in impressing people of discernment, though he continues to think he succeeds in this. He impresses many people who are themselves essentially undiscriminating. He cannot tell these from others with sounder judgment and regards himself as a great success socially as well as financially.
Such a personality shows suggestions of an inner deviation qualitatively similar to what is found in the fully developed sociopath. The shrewdness is typical. Unlike others, such as Max, whose cleverness brings only momentary success in objective dealing with the world, this man’s similar cleverness is applied with enough persistence for him to advance continuously. He advances financially and, within limits, even professionally. He is a smart fellow and, in a very superficial sense, has a glib facility in medical activities. In relations with the public he shows an excellent knack, an artful sense of showmanship.
For the more fundamental questions that immediately confront a person interested in psychiatry he apparently has no awareness, and therefore no concern. The problems of life that make up the chief and underlying interest for real psychiatrists do not exist for him. He is said to give many of his patients about what they feel they need. With relatively uncomplex and emotionally shallow persons his amazing self-confidence is perhaps more quickly effective than the deeper understanding, with its inevitable lack of certainties, that another sort of man would bring to his work.
His patients are reported to show improvement that compares favorably with that shown by most of the patients treated by physicians whose aims are more serious. We must not forget that pseudoscientific cultists frequently succeed in relieving psychoneurotic patients of their symptoms by absurd measures. These practitioners, if they work in accordance with the fundamental principles of their craft, have no awareness of the real problems underlying such symptoms and little or no ability to help patients understand and deal with these problems. Such a man as this appears to be similarly limited
. If one imagines his attempting pertinent psychiatric study of a seriously motivated person, of a person whose world is quite foreign to him, the picture becomes farcical.
This man then, the traits already mentioned notwithstanding, is one who, unlike the obvious psychopath, succeeds over many years in his outer adjustment. Granting that the behavior just described is fairly typical and is persisted in, the conclusion follows that inwardly he is very poorly adjusted indeed, The quality of happiness he knows and the degree of reality in which he experiences so much that is major in human relations are such that, despite his superficial success, he must fail to participate very richly in life itself.
Let it be pointed out that the drunkenness, immature sex attitudes, execrable taste, and deceit are not in themselves the basis for suspecting that this man is affected in some measure with the same disorder that affects the patients presented previously. Many readers would perhaps dismiss all this with the thought that our man might be more properly called a bad fellow and his status left at that. The significant points are these:
His impulse to drink does not seem to be motivated by the hope of shared gaiety. His attitude in sexual aims is so self-centered as to give the impression that even when carrying out intercourse with women he is essentially solitary, isolated in evaluations so immature that what satisfaction he achieves must be in concepts of a phallic damaging and despoiling of the female with simultaneous reassurances to puerile concepts of his own virility. Such confusing and fragmentary achievement, common enough in a groping boy of thirteen, is a poor and pathologic substitute for fulfillment compatible with deep personality integration and is inadequate for one even remotely as near adult as what is implied by this man’s outer surface.
His lack of taste and judgment in human relationships seems inconsistent with his opportunity to learn and with his ability to learn in other modes of knowing where such values and meanings do not enter. His apparent hypocrisy is probably not a conscious element of behavior. At least he is unaware of how it would seem to others, even if he assumed all the facts were known to them. It has, perhaps, never occurred to him that there might be people in the world who had other fundamental aims than his own dominant aim to drop the disguise in which he has acted his part perhaps not too comfortably during the week, and plunge into what I would call activity more representative of perverse or disintegrative drives, of aims at sharp variance with everything his outer self seems to represent.
I am well aware that many basic impulses appear in forms not socially acceptable, that they might be called immoral, vulgar, or criminal or be described by other unpleasant words. The person here discussed, when seen without his mask, seems not to be directed in any consistent and purposive scheme by these socially unacceptable tendencies but largely to blunder about at their behest. In his outer front he functions in accordance with all the proprieties, large and small, but here the reality is thin and personal participation halfhearted. He is somewhat like a small boy who succeeds in maintaining decorum and even in getting a good mark for conduct while in the schoolroom under teacher’s watchful eye. Though he looks attentive, he is only shrewdly compromising, biding his time to get at what is to him more important. When the bell rings and he escapes from what he finds to be an artificial situation, an area of formalities and polite pretenses, he becomes natural and plays in accordance with what he takes to be the actual rules and real aims of existence.
The small schoolboy learns eventually to reconcile what the classroom represented and what he sought in his hours of play. He finds in his work responsibilities and ways of celebrating much that is compatible, a core at least, that he can integrate into constructive, self-fulfilling, and, on the whole, harmonious expression of basic impulses.
In such a man as the one we are considering, little harmony of this sort appears. Unlike those presented as clinical psychopaths, he has learned to carry out the formalities rather consistently and appears as actually living in a constructive and socially adapted pattern. Actually this is a surface activity, a sort of ritual in which not much of himself enters, For his more natural and inwardly accepted impulses he has found little reconcilable with what he gives lip service to. So he must turn to patterns of behavior so immature and (subjectively) chaotic that they mock and deny all that his surface affirms.
The outer layers of socially acceptable functioning extend little deeper into affect than any other exercise empty of all but formality. He has apparently learned to carry out a lip service in matters that he finds unreal and tedious and to take pride in how well this is performed. As an alternative to the barren channels of formality, the inner man finds for the more valid fulfillment of real impulse only pathways or outlets that sharply deviate from the surface channels, that cannot in any way be integrated with them, and that in themselves remain relatively archaic, poorly organized, undirected toward any mature goal, and socially regressive or self destructive.
It is confusing to interpret such a personality in terms of bad and good. From a psychiatric viewpoint, at least, such aspects of a maladjusted human being cannot be assessed authoritatively.
Years after the incidents recorded in this report, some news of the good doctor was received which I believe would stand as “Paradox in Paradise.” It was brought to the young psychiatrist who had accompanied Dr. _____ during the spree just cited by an earnest, middle-aged lady with a strong penchant for talking about psychology and psychiatry and psychoanalysis, about anything containing the prefix psyche for that matter. Striking at once for her hearer’s closest interests, she began to talk about a wonderful lecture she had recently heard in a distant town at some woman’s club or literary society which was fostering the cause of mental hygiene.
The lecturer was marvelous, she insisted. He stirred up such enthusiasm that half the ladies present had begun to study psychology. And his subject! He talked about the queerest people! They were not exactly insane, but they really did the most fantastic things! They were even harder to understand than lunatics themselves! But the lecturer understood them, though he confessed in all modesty that some points about them were a puzzle even to one of his own experience. He was a most impressive person—so poised and authoritative, yet always quiet-spoken. He was such an intellectual person. A man of wide and profound culture. And such a gentleman!
“I declare, I believe half of the women in our club wished they could exchange roles with his wife! With all that grasp of psychology, just imagine what a husband he must be!”
She would like to learn more about these people … psychopathic personalities or psychopaths the doctor had called them. And the doctor’s name … She uttered it in hushed tones of admiration.
Section Three: Cataloging the Material
Part I: Orientation
27. Conceptual Confusions Which Cloud the Subject
While preparing the first edition of this volume, many years ago, I was impressed and sometimes astonished by the dearth of pertinent material about the psychopath in most psychiatric textbooks. It seemed not only surprising but almost incredible to find how little space was devoted to this disorder. With psychopaths making up so large a proportion of the patients who must be dealt with, and their problems being so serious, it was indeed difficult to understand why they were almost ignored.
If the medical student, the resident physician, or the beginner in psychiatry could find little help from the textbooks, it would seem that he might obtain from monographs or special treatises the information he needed. Despite the existence of several large and scholarly volumes on the psychopathic personality, I was unable to discover anywhere a book that came to grips with the subject in such a way as to give real or practical assistance. There was, furthermore, relatively little published at the time in psychiatric journals that had much bearing on the urgent and major problems with which so many strove in helplessness and in confusion.
Through the literature of many decades pertinent articles were scattered. Some of these gave serious attention to t
he subject. Not always readily accessible to the average physician who dealt directly with these numerous patients, this largely buried but valuable material did not regularly influence methods or generally clarify the fundamental issues.
Surrounded by what almost seemed a conspiracy of silence, a desert of evasiveness or indifference, not only the relatives of the patients but also courts, physicians, and medical institutions had, it seemed little to guide them in a task of the first order.
At present there are indications of more practical interest in the problem. Popular textbooks, it must be admitted, still have relatively little to say, but in their current treatment of the psychopath there is a happy departure from the once almost universal procedure of mixing the few pages or paragraphs on this subject with all manner of unrelated deficiencies as, for example, congenital organic brain diseases.
The confusion and equivocation in which our subject has been all but lost can be better understood from a historical survey. Since the first edition of this book was prepared, Maughs205 has published a thorough and valuable study of this sort. It is not practical here to do justice to the evolution of concepts which Maughs traces through more than a century and a half. A few points, however, have so much bearing on our central problem that they demand notice.
Early in the nineteenth century Pinel recorded his surprise in finding that many patients do not show the disordered reasoning assumed to be necessary for psychotic behavior. He is quoted by Maughs thus:205
I thought that madness was inseparable from delirium or delusion, and I was surprised to find many maniacs who at no period gave evidence of any lesion of the understanding.
Prichard’s descriptions of a “moral insanity” and Benjamin Rush’s beliefs about derangement of the “will” suggest that such patients as we now call psychopaths, or antisocial personalities, were observed and that the absence of delusion and irrationality of thought was noted. Maughs gives a most helpful account of the efforts to interpret such disorder in terms of disease that spares the intellect but attacks other “faculties” such as “moral affections,” “will,” “sense of Deity,” and “emotions.”205
The Mask of Sanity Page 32