The Mask of Sanity

by Hervey Cleckley

  Without restraint and without any effective treatment, the psychopath continues, progressively accumulating in his social wake, woe, confusion, despair, farce, and disaster, beyond any measure of these things I can convey. Exonerations in courts on the grounds of “insanity” are followed by discharges from hospitals because “no nervous or mental disease” is found. Sometimes when incompetency cannot be medically or legally established, common sense attempts a compromise and, perhaps unofficially, shows recognition of an aberration through leniency of judgment or an assumption of mitigating circumstances with the practical result of reducing terms of confinement in proportion to the degree of dangerous abnormality evident. This all too frequently amounts to diminishing whatever protection is offered the public directly in proportion to the degree of menace indicated by the disorder.

  When given long-term psychotherapy in either prison or hospital the psychopath has more ability than any other type of patient to simulate the changes of attitude that may convince even the most conscientious therapist that he has effected a cure and that his patient is now ready for release and no longer a source of danger to others. Often the psychopath is clever and convincing enough to make the therapist feel also that the cure was specifically effected through cherished items of the therapist’s creed of psychiatric theory.

  We must remind ourselves once more of the gross and tragic misunderstanding that determined legal and medical attitudes toward patients suffering from ordinary types of psychosis in past centuries before we can realize the monstrous inefficacy of our present methods of dealing with psychopaths. Pinel, who is so justly venerated by the world today, did not discover any cure or any satisfactory treatment for the psychotic patients whom he liberated from the chains and dungeons into which they were thrown by a society that apparently could not realize they were ill but assumed them merely evil and vicious. Indeed, a hundred or more years passed before any regular therapy even remotely effective became available for patients in most psychiatric institutions. Even if another hundred years should pass before we discover a truly effective method of treatment for psychopaths, or for other offenders who commit brutal crimes, we must make a beginning by reappraising them as Pinel did by reappraising psychotic patients and revising methods for their care. Such a step in understanding these other kinds of disordered people must be made before we can hope to progress far toward the solution of their problem. Let us without delay recognize them for what they are and begin more realistically to plan medical and social facilities through which they can be intelligently treated or, at the very least, through which they will not be mistreated or left without control to endanger the community.

  In properly set-up hospital or detention units and through adequate outpatient control, efforts might be made to utilize the excellent abilities of these patients and to provide whatever degree of supervision is found necessary to keep them occupied and out of trouble. This supervision would, as with other socially disabled patients, vary widely with various persons.

  Such institutions and other community facilities and the regular practice of committing suitable patients to their supervision would soon bring new viewpoints to countless parents who, in shame and grief, blush over what they take to be the deeds of wickedness and depravity of their children and who wreck their own lives and fortunes seeking to protect, to rehabilitate, and to reform them. Women might learn in time not to sacrifice so readily their fortunes, their life plans, their grief, and their energy in indefatigable and fruitless struggles to support and nurse and pamper maturity into husbands and lovers whose profound deficit makes such maturity (by such means) impossible.

  In speaking of hospital units and other facilities for parole and supervision, I do not propose that vast and expensive institutions be built in addition to those designed for patients with the traditional problems of psychiatry. I suggest rather that psychopaths be recognized clearly as a separate group and dealt with by rules and methods specifically adapted to cope with their problems and their behavior. Units for their care and control might be maintained in our existing institutions. It seems possible that such a step might lead to substantial economies instead of an additional burden of expense to the public. Vast sums of money are now being issued daily by the state to bring psychopaths repeatedly through due processes of the law, and all to no avail. At great cost relatives send them hopefully for treatment in expensive hospitals, which they leave on personal whim or prankish impulse. Enormous sums are wasted in futile efforts to reestablish them in business and to compensate victims for their continual malfeasances and follies. It is doubtful that the cost of even a most elaborate setup of detention units and outpatient facilities, which I do not propose, would equal the financial loss they now inflict, in addition to their socially damaging effects upon the community.

  Even if no really adequate therapeutic measure should become available in the foreseeable future, it seems reasonable to hope that with facilities specifically designed for the direction and control of the psychopathic group these people might be maintained at a better level of adjustment despite the continued need of support and restriction. Even if we cannot count on curing their disorder, the goal of bringing about improvement in control and adjustment is not to be despised.

  Impressed by points of similarity between the psychopath and the spoiled child, some psychiatrists have maintained that promising therapeutic possibilities might lie in establishing a really effective control whereby the patient would regularly, promptly, and persistently experience the logical results of (1) socially acceptable conduct and (2) irresponsible and destructive conduct. Mangun196 long ago reported encouraging results from such a program and Woolley299 also expressed hopefulness about this approach to the problem.

  Subsequently Thorne279 emphasized similar measures. Hare in 1970 gives this interesting summary of Thorne’s approach:116

  On the assumption that the psychopath’s behavior reflects a maladaptive life style that is maintained by reinforcement from family, friends, and associates, Thorne has outlined what he considers to be the requirements of successful therapy with psychopaths. These are summarized as follows.

  The therapist must have complete control over the financial resources of the psychopath, usually by being made trustee of his accounts.

  Relatives and other interested parties must agree not to bail the psychopath out of his difficulties; he must be required to face the consequences of his own behavior.

  The therapist must be very persistent in gradually getting the psychopath to exert some limits and controls over his own behavior.

  The therapist should not protect the psychopath from the legal and social consequences of his actions.

  The therapist should make it clear to the psychopath that he understands him thoroughly, knows what to expect, and will be convinced of his good intentions only through actions and not words.

  The psychopath must be shown repeatedly that his behavior is self-defeating.

  The therapist should search for a leverage point to stimulate more socially acceptable behavior. As a last resort, the therapist may have to use money, which he controls, as an incentive.

  In addition to these points, Thorne suggested that a great deal of patience, time, and money are required; in several cases, an investment of $15,000 per year for as long as 10 years was needed to effect a satisfactory outcome. It is not surprising therefore that no controlled research using Thorne’s methods has been carried out; the investment in time and money is far too great and, many would say, not worth the effort. [p. 112]

  Is it not our responsibility as psychiatrists to agree, despite all our notable differences about etiology, terminology, and technicalities of method that such patients as those discussed here need medical reappraisal?

  My proposals and opinions may be in many respects incomplete, superficial, or erroneous. It is too much to ask that the viewpoint of any one observer in so complex and confusing a matter be generally accepted as final. The whole field of psych
iatry, by its very nature, abounds in questions still unanswered and about which diverse opinions naturally exist and arguments inevitably arise. If we cannot agree that the psychopath has anything like a “psychosis” or even a “mental disorder,” can we not all agree that some means is urgently needed of dealing more realistically with whatever it is that may be the matter with him? If some practical means of controlling the psychopath can be devised, perhaps eventually, we may find his disorder to be not altogether beyond our practice.

  Appendix

  Statistics obtained from the records of one federal psychiatric hospital prior to the publication of the first edition of this book gave these facts concerning the prevalence of psychopaths among the general group of mental patients. It was a hospital of 1,067 beds devoted exclusively to the diagnosis and treatment of mental disorders.* During the period under consideration, from February 9, 1935, to June 12, 1937, there were 857 new admissions. These patients, after several weeks of observation, careful physical, neurologic, and psychiatric examination, and study of social service reports, were given diagnoses by a staff of ten psychiatrists. A review of the records over this period showed the following distribution of diagnoses among the 857 patients admitted:

  Dementia praecox: 212

  Dementia paralytica: 139

  Psychopathic personality: 102

  Chronic alcoholism: 60

  Chronic alcoholism with deterioration: 41

  Psychosis with mental deficiency: 31

  Manic depressive psychosis: 28

  Psychosis, type undetermined: 27

  Epilepsy: 26

  Psychosis with cerebral arteriosclerosis: 24

  Psychoneurosis: 20

  Other organic brain disease: 19

  Mental deficiency: 15

  Acute alcoholic hallucinosis: 14

  Toxic psychosis: 11

  Traumatic psychosis: 10

  Psychopathic personality with psychotic episodes: 8

  Psychosis with pellagra: 8

  Drug addiction: 8

  No nervous or mental disease: 7

  Syphilis of the central nervous system: 7

  Other psychoses with alcohol: 6

  Psychosis with somatic disease: 6

  Encephalitis lethargica: 4

  Senile psychosis: 3

  Acute alcoholism: 3

  Involutional melancholia: 2

  Traumatic neurosis: 2

  Korsakoff’s psychosis: 2

  Meningitis, tuberculous: 2

  Meningitis, pneurnococcic: 1

  Hyperthyroidism: 1

  Progressive muscular atrophy: 1

  Multiple sclerosis: 1

  Huntington’s chorea: 1

  Psychosis with endocrine dyscrasia: 1

  Tabes dorsalis: 1

  Paranoia: 1

  Cerebral gumma: 1

  Paranoid condition: 1

  These statistics are not, of course, to be taken as typical for all psychiatric hospitals. They represent the admissions in a hospital maintained by the federal government through the Veterans Administration for the care of ex–service men. The majority of the patients were veterans of World War I, although Spanish-American War veterans, a very few Civil War veterans, former soldiers discharged from peacetime service, and young men from the Civilian Conservation Corps are represented in the figures given.

  The group being considered consisted chiefly of men with an average age level in the early forties. The hospital is located on the southeastern seaboard. Most of the patients were drawn from the adjacent states, but every section of the country was represented.

  Several factors must be weighed before any attempt is made to draw conclusions from the bare figures given above. The general policy in federal hospitals maintained for the treatment of veterans at that time differed considerably from the policy of state hospitals. Although patients classed as chronic alcoholics and psychopaths were not considered eligible for treatment and, according to regulations, should not have been admitted, the authorities tried at all times to give the veteran the benefit of any doubt and were undoubtedly more lenient in general than those at the state hospitals. Consequently, many patients who turned out to be psychopaths pure and simple and who probably would not have been accepted at state hospitals were taken into federal hospitals.

  On the other hand, this very factor, the policy of giving the veteran every possible benefit of doubt, tended to make the proportion of psychopaths appear lower among this group of 857 patients than if the same group had been diagnosed elsewhere. Since those who are put in this classification do not draw compensation, being considered by law responsible for their own maladjustment, the Veterans Administration insisted that the diagnosis be made only on the most convincing evidence and when the possibility of other psychiatric conditions for which compensation is paid was thoroughly ruled out. As everyone who deals with such questions knows, it is often extremely difficult to rule out “neurasthenia,” “hysteria,” “psychasthenia,” and posttraumatic neuroses when these conditions are claimed by patients eager for pension money. Taking into consideration the fact that the psychopath is almost invariably just the sort of person who will bend his efforts to get everything possible from the government, or from any other source, and that he is entirely unscrupulous and often very clever in doing so, the difficulty will be still further appreciated.

  In my frank opinion some of the patients listed here in the psychoneurotic and posttraumatic groups were really psychopaths and nothing more. Men who had sustained skull injuries or had records of concussion, whether the injury dated from army service or not, were nearly always given the advantage of the possibility that their maladjustment resulted from cerebral trauma. Everyone knows that although personality changes sometimes follow such injuries, they by no means always follow. This was known, of course, to the psychiatrists in the federal hospitals. Yet it cannot be denied that with so strong a policy prevailing to eschew even the remote possibility of injustice to a veteran, many probably received the posttraumatic diagnosis who might otherwise have been called psychopaths.

  Similar factors seemed to play a part when questions of psychoneurosis arose. When a patient had once been called psychoneurotic, any change which would deprive him of his compensation brought protest and calls for further examinations, not to speak of the strong political pressure which was sometimes exerted. Without meaning to accuse any psychiatrist in the Veterans Administration service of responding to such pressure, I believe that such conditions might tend to make cases about which there is an honest doubt gravitate from the psychopathic personality group to one of the others.

  No doubt it is better to let one hundred guilty men go unpunished than to hang one who is innocent, and so this policy in regard to diagnosis may have been justifiable. Nevertheless, it must be considered as a factor in the statistics under discussion.

  There was another important influence that worked against making a diagnosis of psychopathic personality in the group of patients considered here. Often the need for hospitalization was plain and urgent. Sometimes the patient had for years continuously demonstrated his inability to conduct himself or his affairs without constant supervision. Occasionally such patients were a serious and immediate danger to the lives of others. Under such circumstances the necessity to admit the patient to the hospital and to keep him there was compelling. The diagnosis of psychopathic personality, with its implication of a person legally sane, does not qualify a patient for admission and leaves him free to depart from the hospital at will if he is admitted. The practical and often imperative necessity to keep such patients under supervision served, in my opinion, as an influence to make conscientious physicians on the staff try to place the patient’s disorder on some other basis and, whenever the possibility of any other causal factor could be invoked, to consider some other diagnosis. Usually when such other factors, for instance, slight trauma to the head, diabetes, or possible alcoholic deterioration, could be established, they were recent in appearance, and the fo
lly and misconduct were of many years prior duration. Yet this new possibility is seized on as a practical expedient. I do not mention this tendency to condemn it, for, after all, it was vitally important to hospitalize these patients and to keep them under supervision. As a factor in the present statistics, however, it cannot be ignored.

  Perhaps many other patients in the 857 listed might have been added to the 102 in the psychopathic personality group. The forty-one patients described as having chronic alcoholism with deterioration and the fourteen patients with acute alcoholic hallucinosis seemed nearly all, in varying degree, to be of the same type as the group of 102 patients. This is to say that aside from their temporary hallucinosis or their more recent deterioration, the fundamental personality disorder was the same. Most of those listed under the heading “chronic alcoholism with deterioration” were, as a matter of fact, also given the secondary diagnosis of “psychopathic personality.” I believe that few, if any, people who use alcohol to such an extent that they have to be confined for treatment in psychiatric institutions are normal.

  Here, again, the benign policy of the Veterans Administration seemed to play a part. It was not customary to make the diagnosis of psychopathic personality unless the condition was pronounced and inescapable, the intention being to spare veterans whenever possible the stigma that was felt by some to go with this term.

  Most of the patients diagnosed as having chronic alcoholism with deterioration showed very little deterioration indeed. There seemed little doubt that their maladjustment, which extended back many years, resulted primarily from a personal inadequacy, whatever complicating factors may have been added by the deterioration. My belief is that some physicians tended to see evidence of deterioration in the poor judgment and bizarre conduct which are notoriously typical of the psychopath pure and simple. Not even those who spend their lives dealing with mental mechanisms in others are entirely free from similar factors in themselves, and it is a well-known human tendency to explain things such as the fantastic behavior of these patients on a tangible basis, such as damaged brain structure, instead of on the ill-defined basis of psychopathic personality, a term implying something far less clearly understood than schizophrenia or any of the other psychoses.