The Mask of Sanity

by Hervey Cleckley

  Faithfully following Freud’s method of establishing proof by analogy, a prominent psychiatrist in his well-known book Beyond Laughter103 has given us a remarkable interpretation of the drum majorette. Most of us are likely to think that the average man’s pleasant reaction to these well-built, sparsely clad young ladies who prance happily and often somewhat sexily before the band at football stadiums can be pretty well accounted for by tastes and impulses quite obvious in nearly anyone’s consciousness. Such tastes and impulses, according to the interpretation in Beyond Laughter, must be considered as superficial or perhaps even as the result of reaction formation. The lissome girl, we are solemnly told, stands out before the grouped band just as an erect penis stands out before the larger mass of the body. This analogy is taken as evidence that interest and excitement about the provocative lass do not lie primarily in the fact that any ordinary man would find her attractive. In our unconscious she is said to be equated with the erect male organ, and it is maintained that men really feel toward her, as she stands projected before the group, as they unconsciously feel toward the penis of another male. Our positive reactions toward her, we are told, arise from our unrecognized and unaccepted homosexuality. No corroborative evidence is offered, nor any doubt expressed, about this interpretation. It is soberly offered as a fact, presumably discovered by science.103

  The Dutch psychiatrist Peerbolte238 uses a similar method of analogy to establish what he considers satisfactory evidence of emotional trauma during embryonic or fetal life. A patient dreams that she is in a chapel and that the figure of Christ with a wooden leg walks toward her. The interpreter concludes that this indicates that she was frightened and shaken up by her father’s penis when those who were to become her parents had intercourse while she was a fetus in her mother’s uterus.

  Distrust for such glib use of the popular methods of interpretation has been strongly expressed by a few prominent and well-qualified psychoanalysts. Masserman, in a delightful article, gives us an important lesson in his brilliant satire, “The Psychosomatic Profile of an Ingrown Toenail.” Let us quote from this article:202

  Consider, I said, the toenail. Anthropologists have pointed out that man’s mind developed when his arms were freed of the task of locomotion so that he could walk about the earth in an upright position, manipulating its resources and thinking about the heavens. Moreover, osteologists tell us that all of this in turn depended upon the hallux and its toenail. But libidinally speaking, the nail represents even more than this. Actually, it is the most protuberant part of the body, hard and rounded; in locomotion it describes a most suggestive to-and-fro movement—obviously, then, it is a basic penile symbol displaced for a change, downward. But let us also remember the anatomic origin of this important little phallus, namely the nail-bed—also a most significant term. This in turn consists of an invagination of vascular tissue into a zone called, with intuitive propriety, the stratum germinativurn or matrix—a region consummately feminine in its conformation, physiology, and import. Here, then, we have a psychosomatically significant microcosm; a womb-equivalent ever generating a masculine imago which normally goes forth to meet, explore, and conquer the external world.

  But now consider what happens when this normal functioning is disrupted by frustration and conflict; when, specifically, the erect nail is stubbed and traumatized, or is too long opposed by unyielding reality in the form of a repressive shoe. Clinically and perhaps personally we know the effects all too well: the nail, particularly at the peripheral portions of its individuality (or more technically, its “ego boundaries”) turns about and digs its way back into the flesh of its origin. To those properly indoctrinated with psychosomatic understanding, however, a much deeper significance can be discerned in this process. It will be obvious, indeed, that the counter-cathected ungual masculinity, blocked from its exteriorizing libidinal outlets, introverts upon itself and eventually even seeks final regression through the mechanism of re-encapsulation and vascularization—i.e., a return to uterine existence. This formula, derived as it is by analogic thinking enlightened by metapsychologic insight, could of course stand on its merits alone about as well as others derived from similar research endeavors; fortunately, however, it can be further validated by objective clinical observation. Thus, it can be demonstrated that analysands of both sexes with ingrown toenails actually do have masculine aspirations and intra-uterine fantasies, and the mere fact that analysands without ingrown toenails have the same unconscious dynamisms serves merely to emphasize once again how the study of the abnormal can reveal profound truths about all mankind.

  The material just quoted is from a lecture that Masserman gave to point out, by a playful reduction to absurdity, some of the overenthusiastic and unreliable uses of dynamic methods in psychology and psychiatry. Let us quote also his comments on the audience’s reaction to his lecture:202

  Here I ended my Lecture on Psychosomatics, rewarded by what I was sure was an understanding gleam in the eye of some of my listeners and trusting that, though I lacked the ribaldry of a Rabelais or the subtlety of a Voltaire, I might still have aroused a healthy whimsy of doubt about some of the verbal gymnastics that pass for serious thinking and investigation in the field. Imagine my consternation, therefore, when on meeting some of the members of the audience days and weeks later I was actually congratulated on the clinical and analytic perspicacity with which I had derived the specific dynamic formula for the etiology and possible therapy of that hitherto unexplored psychosomatic disorder—onychocryptosis, or ingrown toenail!

  In dwelling on the pitfalls and possibilities of error that we face in attempts to explain the psychopath’s disorder on a psychogenic basis, I do not mean to discount sober efforts to accomplish this by realistic methods. Let us, however, be cautious and tentative and try always to distinguish surmise from evidence.

  I have noted incidents in the early life of some psychopaths that might serve as factors likely to promote rebellion against society, distort the normal aims of life, interfere with the development of basic values, and go far, perhaps, toward accounting for much of the behavior so familiar to all who know them well. Some of these early experiences might indeed go far toward explaining their emotional status that has been so effectively and succinctly summarized by William and Joan McCord in their excellent book. They say:191

  The psychopath feels little, if any, guilt. He can commit the most appalling acts, yet view them without remorse. The psychopath has a warped capacity for love. His emotional relationships, when they exist, are meager, fleeting, and designed to satisfy his own desires. These last two traits, guiltlessness and lovelessness, conspicuously mark the psychopath as different from other men.

  But similar experiences also can be demonstrated in the background of many well-adjusted, happy, and successful adults. In a few of the cases reported here an impressive account was given of incidents and reported reactions (with indications of emotion) that could theoretically be said to explain emotional withdrawal (despite maintenance of excellent rational contact) from the areas or levels of living in which severe hurt, deep joy, genuine pride, shame, dignity, and love are encountered and experienced. Protest reactions, loss of insight, an acting out of unconscious impulses, a behavioral caricature, or a diatribe against life and its (for the psychopath) subjective emptiness could be interpreted as major causal factors in the disorder we encounter clinically. Such interpretations may be correct, but usually there are more elements of assumption or speculation than of evidence in what is offered in support of the argument.

  A very large percentage of the psychopaths I have studied show backgrounds that appear conducive to happy development and excellent adjustment. Whatever part psychogenic factors may play, I am inclined to believe that there may be an important relationship between the abstruse, paradoxically compounded, and ambivalent nature of the influences and the complex and deeply masked nature of the disorder such factors may shape. If such a relationship exists, it may to some degree explain the
special difficulties we have encountered in obtaining from the psychopath convincing subjective information about what has happened and about how he was affected by it.

  In the patients presented here, social service reports and all ordinary information usually indicated normal and helpful family attitudes and general environments. The families themselves often impressed the examiner as good, healthy, wise, and eminently well-adjusted people whose children were particularly fortunate because of what they could offer as parents. When opportunities arose, as they sometimes did, to learn more of matters inward, subtle, and deeply personal, the observer was occasionally led to suspect that even in these apparently superior parents there were attitudes, frustrations, emotional confusions, and deficiencies that might have played a masked but crucially adverse role in the infinite complexities and paradoxes of parent-child relationships.

  This is not to say that the parents were wrongly judged as conscientious or as superior people or that in many important respects they were not well adjusted. Despite conscientiousness and a good deal of wisdom and success, characteristics might exist which could, perhaps, subtly distort the milieu of an infant or a child.246

  People may be fair, kind, and genial, may hold entirely normal or even admirable attitudes about all important matters and yet unknowingly lack a simple warmth, a capacity for true intimacy that seems to be essential for biologic soundness (substantiality) in some basic relationships. There are men and women of whom it might correctly be said that it is impossible for them ever to become really personal. This aspect (or ingredient) of human experience is difficult to describe or to signify accurately. We do not encounter it squarely in thinking but feel it in perceptive modes or at reactive levels not readily translatable into speech.96 Let us remember, however, that such qualities may be found in parents of those who are not psychopaths.

  Some who show only superior qualities in all their activities as citizens, in their work, and in all definable responsibilities seem to feel little need for the sort of specific attachment and affective closeness which perhaps constitute the core of deep and genuine love. They also seem to have little perception of such a need in others. There are people who show in changeless formality, poise, and cool “sensible attitudes” outer indications of what is being discussed, but it is not they who concern us at present. In others, genial informality and manifestations of more than ordinary warmth may prevail in relatively superficial friendships and routine social contacts, in professional and business associations, at dinner parties, and at club meetings. Where intimacy is normally limited they may be spontaneous and show cordiality as real as anything appropriate for such occasions. Their inner formality and remoteness is not encountered until the observer approaches areas of privacy, deep levels of personal affect that ordinarily are only reached in relations between mates, between parent and child, or in the few other very intimate and cherished friendships or sharings of personal understanding and feeling that man never achieves in wholesale measure. Parents of this sort may give an impression of affording each other and the child all that is ideal, and affording it in abundance. One such parent will, however, leave the other (if normal) so deprived in essential needs that the child may be turned to for the exclusive and possessive intimacy normal between mates but full of pathologic potentialities in the other relationship.

  The observations reported by Kanner in his study of infantile autism illustrate some of the points that are being discussed here.157 In the brilliant and outstandingly successful parents of these seriously disabled infants a complex and profound emotional deficiency was regularly encountered. During all my years of experience with hundreds of psychopaths, however, no type of parent or of parental influence, overt or subtle, has been regularly demonstrable.

  Both hereditary factors and influences of the frustrating, or antisocial environment seem evident in the development of delinquency in many of the patients described long ago by Healy.123 In the background of the intelligent, charming psychopath who appears in a family of prominent, ethical, and successful citizens, it is often far more difficult to find convincing evidence to account for his disorder on either basis. If an inborn biologic defect exists and plays an important part in such a psychopath’s disorder, it is not necessary to assume that the defect is hereditary. Perhaps it may be the result of a subtle failure in maturation, an agenesis of unknown etiology. A much simpler and more grossly manifested defect of this sort is familiar in the pathology of congenital cerebral palsy. It is well known that encephalitis may be followed by changes in behavior and personality that cause some who have suffered from it to become indistinguishable from the psychopaths we have been discussing and that these changes may occur without any physical signs of neurologic damage.

  Many psychiatrists40,196,278 have continued to express the conviction that some organic injury or deficiency underlies the psychopath’s dysfunction. Although no neurologic lesion has been regularly demonstrated in the typical psychopath, it is also true, as Thompson reminds us, that no satisfactory proof of psychogenic factors as the cause of his disorder has been established. Referring to formulations of the psychopathology in terms of environmental influences, he says:278

  Here too much is missing that might give us a rational explanation which would be subject to scientific scrutiny, and which would meet the postulates of science necessary for validity.

  Numerous observers have reported records of electroencephalographic abnormality in psychopaths.98,172,259 Others have failed to confirm these findings of a specific abnormality.93,261 Over the past two decades still other investigators have expressed the conviction that there are nonspecific but definitely abnormal electroencephalographic findings in a significant percentage of psychopaths.73,133,134,278 In his interesting and valuable study, Psychopathy: Theory and Research, Hare in 1970 makes this summarizing comment:116

  In spite of their limitations, the EEG studies of psychopathy have produced rather consistent results. One finding, that the widespread slow-wave activity often found in psychopaths bears a certain resemblance to the EEG patterns usually found in children, has led to a cortical immaturity hypothesis of psychopathy. A second hypothesis, based on the presence of localized EEG abnormalities, is that psychopathy is associated with a defect or malfunction of certain brain mechanisms concerned with emotional activity and the regulation of behavior. Finally it has been suggested that psychopathy may be related to a lowered state of cortical excitability and to the attenuation of sensory input, particularly input that would have disturbing consequences. [pp. 35–36]

  A number of observers during the last decade have been impressed with the influence of chromosomal abnormality on aggressive and antisocial activity in the male. At one time it was reported that Richard Speck, who was convicted of murdering eight student nurses in Chicago in 1967, was an example of this condition. This report was subsequently proved false. Some commentators have gone so far as to argue that men with the XYY chromosomal pattern should be freed of legal responsibility for crimes of violence.168 Hare’s recent comment on this subject impresses me as pertinent and accurate:116

  Recent findings show that the presence of an extra Y chromosome in males (for example, XYY instead of the Normal XY) may be related to extremely aggressive behavior (see the very readable account by Montagu, 1968). Whereas XYY chromosome complements are very rare in the normal population, it appears that this chromosome abnormality is found in about 2 to 3 percent of males whose behavior is so violent and aggressively antisocial that incarceration or institutionalization is required. In most cases these XYY males are over six feet tall, and they are frequently of subnormal intelligence. Whether the XYY complement is related to extremely aggressive forms of psychopathy (as opposed to other forms of criminal, antisocial behavior) is as yet unknown. Even if it is, the relationship would not really provide evidence one way or the other on the role of hereditary factors in psychopathy, since the XYY complement is not inherited—it apparently reflects the failure of the sex
chromosomes to separate properly during formation of the sperm. Finally, the rarity of the disorder means that it could account for only a very small proportion of criminal behavior in general and aggressive psychopathy in particular. [p. 72]

  If a neurologic defect does exist in the psychopath, it is also quite possible that influences in the milieu may play an important part also in shaping his pattern of life. It seems to me likely that such a defect, if present, must be one that affects complex mechanisms of integration in a subtle and abstruse manner. Some of the superior capacities encountered so often in psychopaths suggest that their difficulties might arise not only from deficiencies but possibly, even if rarely, by misused assets.

  It seems reasonable to believe that there are varying susceptibilities to failure or to psychiatric disorder. Such susceptibilities may not necessarily be defects or intrinsically negative qualities. Could not superior emotional responses contribute to a boy’s developing maternal attachments that can prove crippling in the degree to which he has capacity for loyalty? May not the precociously brilliant child, because of his advancement, encounter deep personal and social problems earlier than the average? And, will he, perhaps, sustain trauma that he might have avoided with additional experience? Such experience may be available to the mediocre child who, in his slower progress, meets the confusing situation a little later. Those whose feelings are highly developed may be more susceptible to hurt than others. The goals of the superior person often demand of him complicated choices and sacrifices that the average person never has to face. Disillusion and suffering because of frustrations escaped by most of his fellows might, it seems reasonable to think, in the child of great talent and potentiality, stimulate attitudes of withdrawal and cynical rejection or other pathologic reactions. Exceptional talent or capacity seems almost regularly to call for exceptional achievement or fulfillment and to put the subject under extraordinary responsibility and into situations peculiarly complex. Courage and initiative lead man not only to take physical risks but sometimes also into subjective ventures of many sorts with many dangers.