What we value in some as steadfastness may arise from potentialities that, through different shaping, might emerge in others as incorrigibility, inelasticity, or perhaps as those elements which may make a psychiatric disorder irreversible. Granting the likelihood of great variation in the basic potentialities of the organism, let us not forget that in so complex a matter as personality maturation and social adjustment not only defects but talents also may contribute to conflict, to confusion, to distortion of the life pattern, and, perhaps, to serious clinical disorder.
If what is good or wise or sound comes, or appears to come, mixed, so to speak, with what is untrue or deleterious and is identified in a single concept, and designated by the same term, peculiar difficulties may be noted. Such difficulties, it seems reasonable to think, might be especially disturbing to the superior child. Conscientious acceptance of what is most necessary for normal growth and development may, under these circumstances, sometimes necessitate commitments to what must later be rejected if the organism is to survive. The deeper the capacity for loyalty, the more profound may be the stress, confusion, and eventual disillusionment.
The psychopath’s inner deviation from the normal impresses me as one subtly masked and abstruse. So, too, it has often seemed that interpersonal and environmental factors, if they contribute to the development of his disorder, are likely to be ones so disguised superficially as to appear of an opposite nature. Something pertinent to this concept may be conveyed in these words by Thompson:277
Everything spiritual and valuable has a gross and undesirable malady very similar to it and possessing the same name. Only the very wise can distinguish between them.
I do not believe that the cause of the psychopath’s disorder has yet been discovered and demonstrated. Until we have more and better evidence than is at present available, let us admit the incompleteness of our knowledge and modestly pursue our inquiry.
Part II: What Can Be Done?
This disease is beyond my practice.
—THE DOCTOR IN MACBETH
66. Illness and Misconduct
A good deal has already been said about the difficulties and disappointments arising in our efforts to treat these patients generally known as psychopaths. A few more points will be added presently to the opinions already expressed, but if we are to make any progress therapeutically it seems first necessary to clarify some broader issues.
Aside from the intrinsic obdurateness of the disorder which we find in the patient himself, there exist surrounding difficulties and absurdities that have made it quite impossible even to approach the central problem in any way except one that axiomatically predetermines defeat. Challenged by what is perhaps the most difficult therapeutic task in psychiatry, the physician is denied ordinary access to the area in which the task must be accomplished. It is only in exceptional instances that the therapist can get his hands on the patient, and even then he has little more opportunity to take useful measures than would a surgeon called upon to remove the gallbladder of a jackrabbit in full flight. Our medical, legal, and social concepts are so formulated and our institutions so devised that it is usually impossible to bring the psychopath into the range of treatment. Nor is it usually possible for him to be brought under the control of any agency that can protect him or others from the damaging effects of his disorder.48,49,50 This point is emphasized by Thompson in a helpful study:278
The administrative officers of penal institutions attempt to have such individuals transferred to mental hospitals because they believe them to be mentally ill. Knowing how little they can do for them and what difficult problems they are, the superintendents of mental hospitals attempt to get rid of them as soon as possible and transfer them back to the prison as “not psychotic.” Passed from prison to hospital and back again, wanted in neither, the psychopathic delinquent is essentially the orphan of both penology and psychiatry.
Many observers have apparently been impressed by the remarkable facility people of this sort show in avoiding the control of prolonged confinement in prisons or hospitals and in evading other usual and expected penalties for persistent illegal conduct. Hare in 1970 makes this comment:116
The hedonistic and self-centered acts of many psychopaths often go relatively unpunished. Studies by Robins (1966) and Gibbens, Briscoe, and Dell (1968) have shown that a surprisingly large number of psychopathic persons somehow manage to avoid incarceration in spite of the fact that their behavior may be grossly antisocial. In many cases they are protected by family and friends who may themselves be their victims. In other cases they may be charming and intelligent enough to talk their way out of prosecution. In any event, their behavior may be relatively unchecked and unpunished; and therefore very rewarding, persistent, and firmly established. [pp. 111–112]
The exceptional patients who commit very serious felonies and are convicted sometimes, it is true, come and may remain under the legal restraints of prison. Like the patient with traditionally recognized psychosis, the psychopath cannot be counted on to seek treatment and even less to submit voluntarily to protective measures.
Two crucial points confront us in any attempt to deal practically with the disorder which has engaged our attention: (1) the question of distinguishing between illness (true disability) and willful or culpable misbehavior and (2) the question of legal responsibility or competency. These two matters are deeply interwoven and bring us eventually to the same basic problem. It will be helpful, however, to approach that problem through these two channels. Let us take them in order.
It has already been pointed out that in earlier times many types of dangerous or bizarre conduct which today are regarded as illness were attributed to witchcraft, demon possession, or other supernatural agencies.210,275,300,301 Along with and subsequent to this interpretation we find the practice of attributing misfortune, and ordinary physical and psychiatric diseases to sin or some other form of voluntary wrongdoing. Those conditions earliest recognized as having a medical aspect are the ones in which injury, symptoms (somatic or psychic), and other outward features are most obvious. The overtness rather than the real degree of seriousness seems to have been the chief clue in these determinations. The medical practitioner was called upon to help with the mangled leg or the carbuncle while exorcism and other mystic rites were still the only measures provided for the patient suffering from such obscure pathology as leukemia or Addison’s disease. Even when ideas still prevailed that wrongdoing was the primary cause of disease, treatment by the physician was accepted as an appropriate step to take in dealing with some of these afflictions.51,300 The compound fracture that followed a fall was treated by the surgeon during times when the fall was regarded as the result of a sorcerer’s spell. So, too, salvarsan was administered to the patient with syphilis even by those who regarded him as ill primarily because of his voluntary wrongdoing.
After overt and vividly macroscopic expressions of psychosis (running naked through the streets and wildly shouting out messages received from the dead, arguing that one’s body lacks an anus or one’s blood is pure pus) had for some time been accepted as illness, decades passed before the patient with masked or cryptic schizophrenia and the well-oriented, careful, and brilliantly reasoning paranoiac could count on so regular or so early medical attention as they receive today. We have not yet learned to distinguish such patients very readily and they sometimes remain without treatment or any protective social measures until their disorder is far advanced. Murder or some other tragic consequence may be necessary to bring them to examination and eventually to what treatment is available for their condition.
Forms of expressions of illness are not necessarily less serious, less dangerous, or less genuine because the superficial appearance of the patient reveals less obvious signs of a disorder. One of the factors contributing to our present difficulty in distinguishing the aspect of illness in the psychopath is, I believe, not dependent on the degree of whatever disorder he shows but on its type or nature.
Few (sane) th
eologians, philosophers, or jurists would contend today that present concepts of disease and methods of dealing with it, whether manifested in a predominantly somatic aspect or otherwise, have damaged religion or made nonsense of moral values. When something can be done to help the situation in its medical aspect, this is done without waiting to reach agreement on nonmedical absolutes, however important these ultimate questions may be for each of us.
The patient with pneumonia might not have become ill if he had not suffered exposure while he was out in severe weather robbing the bank. Another patient’s hemorrhoids may or may not be related to his lazy habits of sitting around all day or to his becoming constipated and then unwisely taking powerful laxatives advertised in the papers. Here we may find a patient whose anxiety seems to be, in part at least, caused by a (cowardly) fear of accepting the responsibilities (and opportunities) of a new job and also by an old pathologic (wrong) tendency to rely on his mother for support and protection.
A man in severe agitated depression may say all his viscera have rotted until the stench is lethal and that his neighbor’s crops wither under his glance. His throat may show deep lacerations from his last desperate attempt at suicide. No one questions the plain fact that he is ill and gravely ill. Some psychopathologists believe that he is ill primarily (or largely) because of his unconscious hate for those he loves and his impulses to destroy them.2,3,79 Even those who hold this belief agree that therapy is appropriate. It is also agreed that he must be supervised and protected, if necessary against his own will and judgment.
Just who or what (in a final philosophic showdown) is to blame for these situations is difficult indeed for anyone to say. That they are pathologic conditions deserving every available measure for their correction is not as difficult to determine.
An important point to express and, if possible, to establish is this: medical attention or any other practical step to help or ameliorate misfortune or pain must not wait for a threshing out on philosophic, metaphysical, and religious planes of the ultimate whys and wherefores, the final determining of blame or responsibility. It is possible and practicable to meet these emergencies at another point.
Reasons have been expressed already for the opinion that the psychopath differs fundamentally from the ordinary criminal or rascal.* Whether or not this argument is valid, let us seek a remedy for what obviously demands attention. Not only a patient’s welfare but that of the community must be given consideration in any step we decide to take.
Many types of behavior formerly regarded as voluntary wrongdoing or the just results of sin are now classed as disease. This does not prove that eventually all wrongdoing will be plainly revealed as disease and all conduct necessarily evaluated at a level at which good and bad are nonexistent. There are, however, indications that medical, legal, and social remedial steps are often useful in dealing with situations that we have not yet assayed and may never unanimously assay in final terms of ethics.
Let us remember, however, that there are good reasons to believe that this tendency to reclassify wrongdoing as illness has in recent decades gone too far—perhaps in some instances to the point of absurdity. Some commentators use the term sickness, or illness, glibly in referring to the cause of any bank robbery, embezzlement, forgery, murder, income tax fraud, or violation of traffic laws. The assumptions that underlie this practice are not usually supported by any actual evidence from psychiatric investigation but depend entirely upon the arbitrary choice of a term to exonerate those who have perpetrated antisocial acts.
It has become exceedingly popular to say routinely that crime is not the fault of the criminal but of society. Many commentators also insist that there is no such thing as a bad child but only bad parents. All this tends logically to promote the feeling that a person can do no wrong and need take no responsibility for his own misconduct, however deplorable or harmful to himself or to others. Suppose I want to rob a bank. Well, why not? If I do, I am not to blame. The blame instead will be put on society, or on my parents, or perhaps on a teacher in the first grade who traumatized me by discipline and must now be responsible for my rebellious self-expression. If we need other scapegoats to exonerate all criminals of any possible guilt, we might blame the grandparents, who from this viewpoint must in turn have been responsible for the evil in the criminal’s parents. Arguments approximately as glib and unrealistic as these are to be found today in scientific literature.57 In trying to understand or estimate the psychopath, let us avoid these gratuitous and so often far-fetched assumptions. Is it possible that we have sometimes gone to extremes during recent years in this direction to a degree comparable to the follies of witchcraft in another?
67. Legal Competency and Criminal Responsibility
It has been mentioned that the psychopath does not often cooperate willingly in treatment over any considerable period of time and that he also seems to be remarkably free from the ordinary legal and penal restraints that prevent others from repeatedly carrying out antisocial activity. Questions of legal competency and criminal responsibility play a fundamental part in the efforts of society to cope with psychopaths. Let us consider these concepts more closely.
The term competency in connection with our present problem is pertinent to questions of legal commitment, which is a procedure by which the psychiatric patient can, when necessary, be placed under treatment and appropriate restrictions even if this has to be done against his will and, if necessary, by force. Responsibility seems in many respects to be another aspect of the same thing. The incompetent person has been legally pronounced unable to look after his own affairs or make his own decisions about crucial matters. If a person is held to be legally responsible by a court, he is then considered to be culpable for any crime or other misdeed he may have committed and hence subject to legal penalties. Many assumptions, some of them about matters on which few entirely agree, lurk in various degrees of disguise in the almost limitless implications of these terms.
Probably most laymen, and perhaps some physicians, think of both incompetency and a lack of legal responsibility as identical with psychosis or insanity. As so helpfully pointed out by Davidson,68 this is incorrect, or at least incomplete and sometimes misleading. According to the law, Uncle John’s will may be entirely valid, although he insisted for years that he talked with his dead grandmother and was diagnosed as having schizophrenia. Every psychiatrist knows people who hallucinate and are delusional but who should not be deprived of their liberty and sent against their will to institutions. A good example is offered in a 50-year-old woman who for fifteen years has carefully listened to a voice from her stomach which she “knows” is real and which often directs her. Advice given by the voice has on the whole been quite sensible and practical—never irrational! She has for a decade come at intervals to the outpatient clinic. So far as can be ascertained, her life has been undisturbing to others, and she has, with fair competency, carried out her own affairs.
It is true, nevertheless, that nearly everywhere in the United States it is usually necessary for medical evidence to establish the presence of a “psychosis” and for the court to pronounce a patient “insane” before he can be committed or in any way handled therapeutically or prophylactically against his wishes. Mental deficiency, it is true, may also serve as a basis for such action, although it is sometimes the practice to say that the degree of deficiency is so great as to render the patient psychotic. There are those who will argue that nevertheless he does not have a “psychosis.”
The technicalities of procedure vary from state to state. Items redolent of necromancy, and in which the glow of witch fires is still reflected, are not uncommon in these doings. Until after publication of the first edition of this book, in my native state the patient was “charged, with being a lunatic.” Most physicians and jurists would perhaps agree that for practical purposes incompetency, in the sense of making legal commitment advisable, indicates a disability (disorder or deficit) of such degree that the patient cannot be counted on to make a (
normally) correct appraisal of his condition and (therefore) to choose what treatment or protection he needs.
In considering the questions that arise concerning legal competency and responsibility, let us remember that the determination of competency, on which commitment depends, is usually carried out by a few selected experts—a lunacy commission. On the other hand, as Cumming so well emphasized, questions of responsibility on which terms of imprisonment or even the death penalty may depend are determined by a jury of twelve laymen.64 Usually when a person is legally adjudged incompetent, it is on the basis of his being psychotic. Sometimes, however, a person who is psychotic may be held legally responsible because he is considered as knowing the nature and quality of his criminal deed and that it is wrong.
A case referred to by Guttmacher is illustrative. Let us quote from his interesting discussion:105
Spencer married a woman who had been raped about six years before. The man was found guilty of rape and was given a sentence of five years. They usually give longer sentences in Maryland, but he got five years. Spencer’s wife, a very frail person, died without medical attention while this man was serving his penitentiary sentence. The cause of death was not determined, but Spencer was sure that her death was the result of the rape, which had occurred six years before, about three years before he had married her. The idea possessed him that his wife was not going to be able to rest in her grave unless she was really avenged, and he decided that it was his mission in life to right this great wrong. A few months after this man had been released from the penitentiary, Spencer went up to him and asked him to take a walk. They started walking down the road together, and Spencer was overheard by some people who passed to say, “You have been responsible for my wife’s death. I hear voices at times telling me that I must kill you. Her spirit will never rest unless I carry out this request. I know that I am likely to hang for it and it’s the wrong thing for me to do, but there is nothing else left for me to do.” Whereupon he killed him. He pleaded insanity and the court, upheld by the court of appeals, ruled that he was not insane. The court of appeals said it was clear that the witness heard Spencer say that he was doing what he knew to be wrong and that he would be punished. That was all that the court needed to know in order to satisfy itself that he was a responsible agent.
The Mask of Sanity Page 59