To drift with every passion till my soul
Is a stringed lute on which all winds can play,
Is it for this that I have given away
Mine ancient wisdom and austere control?
Surely there was a time I might have trod
The sunlit heights, and from life’s dissonance
Struck one clear chord to reach the ear of God:
Is that time dead?
Oscar Wilde
“Helas”
Such drifting with passions may indeed prevent the development of greatness and cheat the drifter of achievement and of deep happiness. There are many ways in which a man can waste his energy, cheapen his emotional powers, and bring about his maladjustment. There are many ways, perhaps by which a man can fall into mental disorders and many types of disorder into which he can fall.127 Flowers of evil, whether splendid, redolent and darkly glittering, or mediocre, may choke out the blossoms ordinarily considered desirable. But the psychopaths whose stories are offered here do not seem driven wildly and at random by such winds of passion as those referred to in Oscar Wilde’s familiar verse, nor is it likely that their souls are played upon like stringed lutes. One may listen indefinitely for the tragico-romantical notes of such a vibration, but he will listen in vain. The winds of passion are blowing almost imperceptibly, if at all, and no strings are in the lute. No vivid fleurs du mal will be culled from this garden, for the garden is barren.
40. The Clinical Alcoholic
The term clinical alcoholic is chosen for convenience to signify the large group of pathologic drinkers who are still making some genuine effort to adjust in normal life but are using drink to escape reality which they cannot quite face and, by a vicious cycle, making themselves steadily more inadequate to face this reality. Such drinkers may, in several respects, be contrasted with the psychopath (antisocial personality) just as the non-alcoholic neurotic contrasts with the psychotic patient.
Like the psychopath, their drinking is not primarily for pleasure or has at least ceased to afford much pleasure. They often give a strong impression of drinking to avoid sober self-appraisal or some other aspect of reality. With alcohol they can remain a little more comfortably and longer in the false world of fantasy or in analgesia. They are often introverted people, often tender-minded and shy. Alcohol enables them to be less self-conscious and to make their way with greater ease into the social group. They become more and more disabled for real life, and reverses due directly or indirectly to their alcoholism accumulate, making it ever more urgent for them to escape into the numbness of drink.273
To a certain point this picture is not unlike that of the psychopath. Perhaps the psychopath sometimes arrives at his life scheme by way of phases almost identical with those of some neurotic drinkers, and perhaps the neurotic drinker may regress to levels at which he can be plainly recognized as a psychopath. Some of the patients described here as partial psychopaths might be placed by some observers in the class of neurotic drinkers.
For the purpose of drawing a useful distinction, however, the following points are offered:
Often the neurotic drinker wants to get well. This may not be obvious, but with proper psychiatric treatment it may be possible to obtain sincere cooperation. Although the neurotic drinker lacks insight and often cannot get well by his unaided efforts, he retains a capability of gaining insight, and good improvement is often possible under treatment. The psychopath’s actual conduct when drinking, and sometimes when sober, is bizarre, often shameful and shocking, and actively damaging to himself. In the neurotic drinker such tendencies, if present, are much less pronounced.
The neurotic drinker on his spree is unintentionally destroying his chances for success and happiness, but this does not appear to be his fundamental aim; his fundamental aim apparently is to avoid facing his failures. Although this aim may be present in the established psychopath, it is not easily or regularly discernible. The latter appears to be driving primarily at evading, or ignoring, or destroying life itself, that is to say, life in the sense of social attainments and subjective integration.
Drinkers who can be classed as neurotic show better capacity for insight and may come voluntarily to seek treatment or may be persuaded by relatives to do so. The psychopath will not come voluntarily, except when he seeks hospitalization to avoid legal action, and he cannot be persuaded to carry out sincerely any therapeutic program.
To summarize, then, it may be said that the neurotic drinker is capable of insight and wants to get well. The psychopathologic picture is more readily comprehensible in terms of cause and effect and, under favorable conditions, is perhaps reversible. The psychopath, on the other hand, despite his superficial appearance of being a normal man, shows in his whole behavior pattern deviation and disorder that seem fundamental. His real drives, when one tries to surmise them from his reactions, strike the observer as foreign to ordinary human impulse. The process, if reversible at all, is not ordinarily found to be so. Apparently there is no latent insight that can be aroused or sincere desire to become well or, rather, to become like other men. I do not mean to state dogmatically that the psychopath’s illness is irreversible but merely that in my own experience it has, in typical cases, proved to be so. It may be said that the process of schizophrenia as compared with hysteria is relatively less reversible, that it ordinarily brings about a greater and deeper disintegration of the personality. Despite this fact, schizophrenics often recover. Perhaps the psychopath, too, can recover. Perhaps some generally satisfactory means of treating him can eventually be devised.
Taking the group of chronic alcoholics as a whole, we are likely to find here people in whom the excessive drinking is a common symptom of underlying disorders that vary widely in type and in degree somewhat as we might say that fever may arise from a bad cold, measles, pneumonia, tuberculosis, meningitis, and other differing illnesses too numerous to list.
Alcoholics Anonymous,7 whose excellent work it is appropriate to mention here, has, in my experience with this group as a whole, appeared to be one of the most valuable therapeutic agencies available. Many gravely maladjusted patients in whom alcoholism was at the same time a disabling symptom and a secondary but major causal agent in disastrous life patterns have, through this agency and its program, made changes and progress that with no exaggeration can be called remarkable. Some patients whose behavior and emotional attitudes definitely suggested the psychopath’s disorder have to my knowledge not only avoided for years the disabling effects of their former drunkenness but also other unrewarding and antisocial activities. Whether or not these were psychopaths in the full and deepest sense is not a question that can be answered confidently.
It is my belief that this type of disorder, like all other psychiatric disorders, may be seen in almost limitless variations of degree and severity. We see the utterly disorganized schizophrenic who has for twenty years been on the worst ward of a state hospital, and we also see schizoid reactions and limitations that persist for decades in people who continue to be self-supporting and to a considerable degree socially competent. I recall one patient who has expressed to me delusions typical of full-blown schizophrenia over some years and who is still an able worker with many pleasant social relations and recreational activities. Many more come to mind whose delusions are less extreme but who for decades have manifested autistic withdrawal, oddities, emotional distortions, and impairments consistent only with a schizoid reaction.
We also see manifestations identical with those of full-blown schizophrenia in every respect except their transiency. A 30-year-old man who, after taking a small dose of testosterone, experienced not only hallucinatory sexual and spiritual sensations within himself but also in others will serve as an excellent example. Vivid delusions were very prominent for approximately a week. These included an absolute conviction that all virtuous women at the mere sight of him caught the impact of magic, glowed with a fire both erotic and holy, and were visibly transformed. It was also his belief that t
his caused harlots who might sense his powers a block off to run up alleyways in shame. For several days, through false perceptions, he specifically “felt” men and women some miles away responding viscerally, intellectually, and spiritually, and in diverse ways, to what had miraculously become incarnate in his person. After being psychotic for a week and without specific treatment, he regained insight, lost his schizophrenic symptoms, and has for a number of years remained entirely free of them.
In the other disorder, that of the psychopath, I believe there also occur similar variations in chronicity, in severity, in completeness, in depth, and in every other respect. Although malignancy and irreversibility seem typical of the psychopathology as we meet it clinically in its advanced or long fixed forms, outwardly similar behavioral and characterologic patterns sometimes prove reversible. Few, if any, features of the full psychopath are more impressive than his inability to respond with consistent acts or in other ways that would indicate deep or genuine desire to change his situation. In therapeutic programs it is characteristic of him not to make valid or persistent efforts to cooperate. In their relations with Alcoholics Anonymous, psychopaths sometimes show at first what seems extraordinary zeal, sincerity, and promise, only to reveal after varying intervals that the whole matter was only a sort of prank or lightly taken adventure in versatile careers of self-ruin.
Fundamental points in the Alcoholics Anonymous system of group therapy and self-reorganization are the following:
The need for a most profound intention (an authentic and major desire) to overcome one’s disability
The necessity for extensive and basic changes in attitude and orientation at the core of the personality
At both of these points we find in the full psychopath an almost uniquely unfavorable situation. Although I know of nothing available today that can be counted on to succeed regularly, the evidence has suggested that Alcoholics Anonymous may in some cases affect favorably latent resources very difficult to reach by most methods in patients showing reactions that may have something in common with those of the typical psychopath.
41. The Malingerer
The malingerer, so far as his relation to the psychopath is concerned, may be dismissed with a few words. Many psychopaths malinger at times. They seldom malinger consistently over long periods toward a constant aim. The malingerer pure and simple sticks to his purpose and, on gaining his objective, uses it in some fairly human way. Malingering is merely an incident in the psychopath’s versatile career. Even if he should succeed in obtaining a large fortune by efforts at malingering, he will not be able to use it consistently or to keep out of subsequent difficulty. No life of ease and riches, it seems, could tempt him from his well-known ways.
Perhaps the chief occasions for malingering by psychopaths arise when they fail to escape the consequences of antisocial deeds. Faced by the prospect of confinement in prison or other unwelcome measures, they feel it would be well to simulate some other mental disorder that will get them to a hospital instead. Any psychopath of much experience in this field is entirely aware of the fact that he will soon be recognized at the psychiatric institution, correctly diagnosed, and, under prevailing conditions, dismissed without much delay. If circumstances are unusual and the hospital, in recognition of the patient’s thoroughly demonstrated disability attempts a practical solution by keeping him under supervision and care, he can nearly always take legal steps to effect his release and return to the community and to his old disquieting activities.
Theoretically this should not occur, since it would seem logical and according to law for the psychopath, on being pronounced competent and free of mental disability, to fall again under ordinary legal restraints. In fact, this is not what usually occurs. Often the specific charges against the patient are relatively minor, and during the feint whereby he is hospitalized some adjustment is made so that he is brought back into the community entirely free from any restraining influence.152
42. Fictional Characters of Psychiatric Interest
Characters from literature, it may be argued, not being real people, are therefore of no value in the discussion of a medical problem. It can scarcely be doubted, however, that genuinely creative writers have often presented personalities more fully and more truly than we can readily get to know them in life. And sometimes minor writers succeed in portraying personalities that seem to be reliably true. The characters of the novelist and the dramatist are, furthermore, accessible to all who care to read about them, unlike the patient who has been seen and studied but cannot be presented personally to the reader. For the purpose of this discussion I feel that several points can be made by citing fictional characters, some of whom I believe have been no less faithfully drawn than patients reported in psychiatric examinations. Whether real people exist like them or not is beside the point, since I do not mean to use them as evidence to establish any conceptions of psychopathology but to illustrate personality reactions, whether real or imaginary, which I shall attempt to relate to the reactions considered in this volume.
Those who spend their lives in serious effort to put down in various forms a reflection of their human experience must sometimes encounter the psychopath or at least fragments of such behavior, hints of such an attitude. Abstruse and complex, psychopathologic features of many types have for centuries emerged in literary creations and seem to emerge sometimes through an inexplicable insight of the poet, novelist, or dramatist, who, by his special talent, may successfully convey what he has accurately sensed in the life about him. What he senses may not be discernible to many and it may be most difficult to convey by the direct textbook methods. The possibility of help from this source in efforts to gain understanding of the by no means simple riddle of the psychopath is a possibility that should not be rejected.
Certain personalities have been described and perhaps exist in actual life, who, unlike the ordinary criminal, seem to live by hate and cherish destructiveness not so much to gain power or material benefits but because they grow to love hate and destructiveness. The character Heathcliff as presented in Wuthering Heights by Emily Brontë might be chosen as a puzzling example of misanthropy, ruthlessness, and maladjustment which has little in common with ordinary viciousness. Heathcliff works to destroy others and to destroy what is generally regarded as happiness for himself as well. He unquestionably falls within the scope of psychopathology, a strange, terrible, and compelling figure. But he has little specific kinship with the personalities discussed here. He is strong, he is persistent, and his emotion, however distorted, appears greater by far than that of the average man. He never loses his imposing dignity, even though this dignity might be regarded as a dignity of evil. He remains integrated, not only superficially but profoundly. The personalities described in this book, in contrast, show no consistent pursuit of what might be called evil; their exploits are fitful, buffoonish, and unsustained by any obvious purpose. Consistent hatred of others is not a guiding line in their life scheme. And in Heathcliff we find evidence of more than ordinary love for Cathy, of love that appears to be genuine and changeless despite the fact that it is a major factor behind his destructiveness.
It is not common to find in literature characters that could be grouped with the patients studied here. Creative artists have often presented the villain, the psychotic, the psychoneurotic, the erratic genius, the weak, the strong, the wise, and the stupid; but we seldom find in imaginative writing anyone who could fit the picture that emerges as we consider the histories in this book. Often, however, we find characters who in some aspect or in some phase of their activities suggest what we have seen in the psychopath, and we find others no less abnormal whose qualities may be used in contrast.
Iago27,71 in Othello, perhaps the most interesting and ingenious creation of vindictiveness known to man, carries out his schemes of hate and treachery without adequate motivation in the ordinary sense. In King Lear the cruelty of Edmund, bastard son of Gloucester, is plainly pathologic. Herr Naphta in Thomas Mann’s The
Magic Mountain, although a professional Christian in holy orders, is addicted to destructiveness despite his great intellectual powers. All these characters are consistent, effective, and despite their interesting psychiatric aspects, remote front the psychopath.
Mr. Micawber in David Copperfield and Tolstoi’s Stepan Arkadyevitch Oblonsky in Anna Karenina are convincing examples of people who do not seem to learn by experience and who cannot, in important matters, be relied on by others. But neither shows the active pattern of self-defeat with which we are familiar. Both seem to represent ordinary human frailties that are much exaggerated. Falstaff (Henry II) indulges in outlandish excesses with sack, falls into humiliating situations repeatedly without evincing ordinary shame, and shows himself callous to the appeal of dignity and honor. Yet we sense in him a strong tide of normal, even if superficial, life, some Rabelaisian gusto, which makes his follies stand out in sharp contrast to the activities of the psychopath. He is bent on animal pleasure and coarse merriment whatever they may cost. We can understand him whether we should like to emulate him or not.
Mr. Burlap in Aldous Huxley’s Point Counter Point141 is presented as a pious lecher, a literary windbag, and a hypocritical opportunist. He impresses the average reader as a most unpleasant personality, and he is portrayed as lacking many of the emotional capacities which the psychopath also lacks. His opportunism works to his material advantage, and he is steady in his aims and in his progress. However inconsistent or hypocritical his affect, it seems more real than what we see in the psychopath. In the same novel we find in Maurice Spandrell a man who seems to love cruelty and to love it best in its most unpleasant forms. Despite his inexcusable practices we feel in him extraordinary emotional richness and a peculiar but impressive latent integrity which are in contrast to the cold-bloodedness and viciousness appearing in his outer life. It is plain that a personality disorder exists, but it is not the type of disorder with which we are here concerned.
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