Psychopath Hervey Cleckley THE MASK OF SANITY, Section 4: Some questions still without adequate answers, Part 2: What can be done?, 68. Treatment or control

68. Treatment or control

Several decades ago, while preparing the first edition of this book, I was

profoundly impressed by two difficulties that stood in the way of dealing effectively

with the psychopath. One of these was his apparent immunity, or relative immunity,

from control by law. The other was his lack of response to psychiatric treatment of any

kind.

Today both of these difficulties exist and, it seems to me, with little alteration.

Let us consider first the question of legal control, of the problems that arise when steps

are taken to protect the community and the patient from his misconduct. It is only on

very unusual occasions that a psychopath can be committed as legally incompetent, and

even when this occurs it is not likely that he can be kept long under medical supervision.

Let us consider an example:

After years of expensive, fruitless, heartbreaking, and faithful efforts to keep him

out of disaster, the family of a young (and in most respects typical) psychopath

succeeded in having him pronounced incompetent and sent to a state hospital. Unlike

most psychopaths, this patient had shown strong indications that he might murder one

or more members of his family. This and the prodigious obviousness of his disability

and his danger to the community strangely enough overbalanced the customary

psychiatric concepts in this isolated instance, and he was admitted to be socially

incompetent. There is no denying that this procedure was incorrect according to clearly

defined medical rules.

After a few weeks of study he was found not to show any of the technical signs

of irrationality (none of which had ever been suspected), diagnosed as a "psychopathic

personality," and sent home as "sane and competent."

One of the psychiatrists at the hospital who had participated in this procedure

explained his attitude as follows. He believed that this particular patient, no matter what

his proper diagnosis might be, was more seriously disabled than a great many of the

patients who would spend the rest of their lives in the institution. He also believed that

the discharged patient was more dangerous to the community and more difficult to care

for at home than, perhaps, half of those in the state hospital. The members of the staff,

he felt, were motivated in their action by several impulses, directed by several

judgments.

First of all, it was not in accordance with official psychiatric concepts to call such

a patient psychotic. It was also against the rules of the hospital to keep a nonpsychotic

patient against his will. There was, in addition, in

434 THE MASK OF SANITY

some members of the staff a tendency to resist efforts to slip in or palm off on the

hospital these psychopaths who are considered technically not eligible for care. There

was opinion expressed about how crowded the place was already and about the dangers

of being overrun with psychopaths if an exception was made and this one kept. Some

felt it would not serve the cause of justice if this man were admitted by the staff of the

state hospital to have mental disability, because this appraisal might be utilized in the

future dozens or hundreds of times to help him evade legal penalties for the antisocial

acts these doctors, like everyone else, realized he would continue.

There are not a few among those in charge of our state hospitals who feel that,

with conditions as they stand, it would be more fitting for persons of this sort, when

segregation or supervision of some type is urgently necessary, to be placed not in our

present psychiatric institutions but in reformatories or prisons. There are others who

feel that psychiatric care and many of the services and facilities now available in our

mental hospitals could and should be made available to severely maladjusted

psychopaths.

As our evidence has shown, I hope, the psychopath notoriously avoids the petty

and temporary restraints that might be legally imposed. Those imprisoned for serious

crimes return at length no less prone to continue these crimes. Even when under life

sentence, the psychopath tends more readily than others to obtain parole and become

again a social menace. Not only can he (perhaps involuntarily) mimic sanity in

superlative fashion but also moral rebirth, salvation, and absolute reform, or perhaps

transformation into a supercitizen. Among many examples one patient stands out:

This brilliant and charming young man, when in his early twenties, murdered

another without provocation. Despite a typical record of psychopathic behavior, he so

impressed the authorities that parole was granted after a few years. That which, if

properly understood, would have warned the parole board against the extreme danger of

releasing this man was interpreted as a mitigating factor, as grounds for giving him

another chance. It was argued that emotional handicaps and variations from the normal

personality patterns had played a part in his unfortunate deed. This, they reasoned,

made him less culpable and more deserving of leniency. Like nearly all of his kind, he

now showed no superficial signs of nervous or mental disorder (as this is generally

understood) but indications of great promise. He inspired trust and confidence and

gave a convincingly (theoretical) demonstration of reform, self-control, trustworthiness,

sound ethics, and high ideals. Shortly after his release he again committed murder, this

time of a woman and again with no discernible motivation of any consequence.

In institutions where psychiatric treatment is given, the psychopath, I

SOME QUESTIONS STILL WITHOUT ADEQUATE ANSWERS 435

believe, is much more likely than others who have committed serious crimes to

convince his psychotherapist that treatment has been effective, that it has brought true

insight and profound changes that now make him no longer a danger to society. This

may lead to his being presented as one who richly deserves parole or pardon. The daily

papers report many cases of armed robbery, rape, and murder resulting from such

confidently optimistic estimates of therapeutic success. It is my impression that many

of the attitudes underlying permissiveness have also contributed to this. And I think a

gross overestimation of the influence of psychiatric treatment on criminals, whether or

not they are psychopaths, has played a major role in these tragic events.57,165

Although some protection to society is afforded by dealing out sentences of

varying length to psychopathic offenders on the assumption that they are normal and to

be punished in accordance with the degree of blame their crimes are judged to deserve,

such protection is not reliable. The assumption that they will thereby learn their lesson

and become safe inhabitants of the community is an assumption at sharp variance with

simple facts. Poorly adapted as our present methods are to prevent the repetition of

crime, we find them rapidly approaching travesty and farce when we look for what

security they offer against initial crimes of tragic magnitude. An example will make the

point clear:

In big letters on the front page of newspapers all over the United States the

"Bestial Sex Slaying" of an 11-year-old girl by a boy 17 years of age is proclaimed.

Details of torture and dismemberment follow. The horrible impact of impulses

perverted from the aims of Eros and fused with those of hate and brutality arouses

disgust and vengefulness in millions upon millions. Additional articles point out that

the murderer, now remarkably callous and undisturbed by his act, had, over a period of

many years, shown gross maladjustment and indifference to social values, to ordinary

aims, and to the rights of others. He had on several occasions been placed in a reform

school and kept for various periods determined in accordance with the legally estimated

seriousness of his antisocial acts and with the amount of punishment these were

officially regarded as deserving.

Had this boy expressed a few delusions or reported even once that he heard an

imaginary voice (like many people who are quite harmless), he could have been

hospitalized as long as hospitalization was regarded by experts as advisable. Lacking

these and the other accepted technicalities which are presumed to determine

competency and sanity, he could not be held in any institution beyond the arbitrary term

to which he had been sentenced. His conduct had so strongly indicated that he could

not without danger to others be left unrestricted in the community that his parents

protested to

436 THE MASK OF SANITY

the authorities against his release from custody. They urged that he be kept in the

institution and gave adequate reasons for their plea. The authorities had no means of

heeding this warning - no legal grounds for an alternative to the technically correct

procedure of dismissing the patient. The regrettable results reflected in newspaper

headlines soon followed.

If such patients could be evaluated in terms of their behavior and committed, like

other psychiatric patients, not to limited terms of confinement but for indeterminate

periods, the community would obviously obtain far better protection. The patient could

then be held until his condition, as appraised by experts, indicated that he could be

released with safety to himself and others. Let us grant that even the best of experts is

not likely to prove infallible in such an appraisal. Even the wisest and most experienced

psychiatrist may be misled by the appearance of profound change in the true

psychopath who will later show himself to be as dangerous as before.

Some practical help might be afforded in controlling the psychopath by the

general application of laws designed to increase progressively the penalty and term of

confinement for those who repeatedly demonstrate by antisocial acts that they have not

learned through experience and that they are still dangerous to the community. Some of

these principles are reported to be embodied in the Greenstein Act (Pennsylvania),104

which was so designed that the psychopath, as well as other disordered but generally

neglected persons who commit legal offenses, can be dealt with by safer as well as more

rational and humane methods. Perhaps there is a need for similar changes throughout

the nation.

Persons who show evidence of schizophrenic illness or of almost any other

psychiatric disorder (excepting that of the psychopath) can, through existing facilities,

usually be reached and sensibly dealt with before any legal offense against others is

committed. In addition to the valuable contribution offered through the Greestein Act

and similar legal measures, I believe there is also need for some means of committing

psychopaths on the primary basis of their demonstrated disability and need. Perhaps all

or nearly all of these patients will in the demonstration of their disorder eventually

commit antisocial acts by which they might, through facilities such as those afforded by

the Greenstein Act, be reached. It is nevertheless true that very serious disability or

gross maladjustment may, as in other psychiatric patients, be obvious despite the

relatively trivial nature of the offenses which usually bring the psychopath into court.

Relatives, long confused about the nature of this problem, often sacrifice

themselves grievously to keep the patient out of court, to prevent his going to jail, to

spare his reputation (and perhaps their own, also), and to give him every advantage in

the vain hope he will soon change his ways. Effective

SOME QUESTIONS STILL WITHOUT ADEQUATE ANSWERS 437

and rational handling of many patients might be expedited if relatives could initiate legal

action for commitment through the same courts and agencies set up to deal with other

psychiatric patients, and in the same way, without having to wait for still another crime

and another conviction of the patient for legal offense as an obligatory condition, a

prerequisite, to such steps. If the same procedure followed in dealing with other serious

psychiatric conditions could be utilized without what many relatives would regard as

"branding him a criminal," many advantages in addition to those afforded by the

Greenstein Act might result.

Would this jeopardize the liberties of the citizen? Would it enable unscrupulous

relatives, psychiatrists and jurists to deprive people of the right to make their own

decisions concerning treatment and hospitalization without sufficient cause? Would just

about anyone whose conduct did not suit his neighbors (or his spouse, or his old maid

aunt) find himself in danger of being declared psychiatrically ill and put away

indefinitely?

These are, indeed, important considerations. As pointed out so well by Hall110

and Cumming,64 among others, a basic safeguard of freedom provided by law exists in

the right to trial by a lay jury. The law, with good reason it seems, is firmly resistant to

encroachments upon the jury's responsibility. It looks with distrust upon movements

which may tend to place into the hands of an expert or specialist final decisions which

might deprive a citizen of his liberty or arbitrarily determine the length of his

incarceration whether it be in prison or in a psychiatric institution. This is very probably

one of the reasons why it has been so difficult to devise legal measures to bring

psychopaths under better control. Urgent as the need is for better control of these

patients, we must recognize the grave danger which the law must take pains to avoid

and try to work patiently with our legal colleagues toward some better solution of a very

subtle and complex problem.

Even the laws that are now in force anywhere in our nation, if applied regularly

and promptly, might enable us to gain far better control over the the psychopath and to

curtail more effectively his trespasses against society and his persistence in a selfdamaging

career. If his parents, other relatives, and friends would no longer keep on

coming to his aid and paying him out of his deliberately self-made troubles but instead

would let him face the ordinary consequences and suffer the ordinary penalties,

something important would be accomplished. Though one could not count on the true

or typical psychopath learning adequately by his experience and achieving a cure, even

he would, at least, be better controlled and not left free to continue without substantial

interruptions his persistently destructive career.

If the nature of his abnormality were better understood it would not then

438 THE MASK OF SANITY

be used as grounds for mitigating sentences, or for granting early parole, but might warn

even the most permissive authorities against the dangers involved.

Over a period of many years I have remained discouraged about the effect of

treatment on the psychopath. Having regularly failed in my own efforts to help such

patients alter their fundamental pattern of inadequacy and antisocial activity, I hoped for

a while that treatment by others would be more successful. I have had the opportunity

to see patients of this sort who were treated by psychoanalysis, by psychoanalytically

oriented psychotherapy, by group and by milieu therapy, and by many other variations

of dynamic method. I have seen some patients who were treated for years. I have also

known cases in which not only the patient but various members of his family were given

prolonged psychotherapy. None of these measures impressed me as achieving

successful results. The psychopaths continued to behave as they had behaved in the

past.

Among such patients I recall a young millionaire whose family was able to place

him in an institution where every possible resource of psychiatry was available, including

psychoanalysis by one of the best-qualified and best known men in our country.

Everyone was eager that the patient stay as long as advisable and that every means of

therapy be utilized, however expensive, time-consuming, or protracted. Despite these

apparent advantages nothing of importance was accomplished. At first the patient

expressed great determination to obtain help and to get well. Evidence of such a desire

steadily diminished, and eventually it became apparent that he had no real interest in the

goals he had set for himself and of which he spoke for a while so eloquently. After a

long and tremendously expensive period of hospitalization he left, apparently without

regret, discontinued all pretense of seeking treatment, and returned to his familiar ways

of behavior.

I am impressed also with the recollection of another patient, a woman in her

thirties, for whom almost limitless wealth and strong family cooperation provided every

therapeutic advantage. I referred her, long ago, to a colleague outstanding as a leader

not only in psychiatry but also in psychoanalysis. Everything conceivable that might be

needed in the most ambitious plans for treatment was available. After a careful study of

the patient, this able and honest physician advised against any prolonged therapeutic

endeavor, since he felt that the chances for substantial benefit were not sufficient to

justify the attempt.

The family of still another patient had been told that a distant and renowned

psychiatric institution might find some way to alter a persistent pattern of antisocial and

self-defeating behavior in their 34-year-old son. I believed that he was a psychopath and

did not feel hopeful. Psychiatrists at

SOME QUESTIONS STILL WITHOUT ADEQUATE ANSWERS 439

the hospital, after studying him at length and in depth, concluded that his maladjustment

was probably a result of complex influences in early childhood, that it could be

accounted for in dynamic terms.

They concluded also that long-term psychoanalytic treatment offered a fairly

good chance of success, especially if it could be undertaken with the patient living

outside an institution in a large city where he could find employment but where his

financial affairs could be strictly controlled, not by his analyst, but by another medical

person. There were several other features to a complicated situation that was set up in

the hope of maintaining control of the patient and keeping him under analytic

treatment, for years if necessary. This plan called for the expenditure of funds available

to few families. Despite all these efforts no notable changes occurred, in behavior or in

outlook.

These failures are typical of many others I have observed over the years. For a

while I had hoped that long-term treatment might be more effective if the patient could

be induced voluntarily or constrained by commitment procedures to remain with the

therapist for enough time to give his methods a thorough and adequate trial. I am no

longer hopeful that any methods available today would be successful with typical

psychopaths. I have now, after more than three decades, had the opportunity to

observe a considerable number of patients who, through commitment or the threat of

losing their probation status or by other means, were kept under treatment not only for

many months but for years. The therapeutic failure in all such patients observed leads

me to feel that we do not at present have any kind of psychotherapy that can be relied

upon to change the psychopath fundamentally.

Nor do I believe that any other method of psychiatric treatment has shown

promise of solving the problem. Physical methods of therapy including electric shock

have been attempted.66 Prefrontal lobotomy, topectomy, and transorbital lobotomy

have been used in a few patients with severe disorder.18,67,126,173,213 Some encouragement

was expressed by a few observers about the effects of these measures, but apparently

they have not proved to be a real solution of the problem.

I wish I could be optimistic about the accomplishments of psychiatry in treating

and curing the psychopath. Some spokesmen for mental hygiene movements and for

greater extensions of psychiatric influence tend to credit us, I fear, with far more power

and effectiveness than we have really attained. Hundreds of millions of dollars are being

spent to promote mental hygiene and psychiatric care. Many seem to believe that if we

only had enough psychiatrists, or enough dynamically oriented psychiatrists, all

problems of mental health, crime, and delinquency could be solved.44 This claim

440 THE MASK OF SANITY

is seldom made directly in such absolute terms, but the implication plainly underlies

many eloquent appeals for more and more funds from the state and federal

governments.44,165,185 Some of the more zealous spokesmen even seem to feel that

psychiatry has recently made such profound discoveries and devised such effective

methods of eliminating not only illness and crime but also prejudice, superstition, and

human error that we can and should settle racial and international problems and even

revise the basic standards of morality.44,185

Despite these enthusiastic and at times embarrassing claims in our behalf, our

actual achievements should encourage profound modesty. So far no statistical evidence

has been obtained to support a belief that our most ambitious, protracted, dynamic, and

reputedly scientific methods of psychotherapy have proved more effective even in the

psychoneuroses than the warmhearted but unpretentious methods used over the years

by kind and wise physicians in the general practice of medicine.42,57,77,251,276 There is, we

must conclude, no evidence to demonstrate or to indicate that psychiatry has yet found

a therapy that cures or profoundly changes the psychopath.107

I find that I am still in thorough agreement with these opinions expressed in 1969

by Lothar Goldschmidt:97

Psychiatrists have participated in legal proceedings (actively on behalf of clients

and passively on behalf of the court) on the assumption that treatment is superior to

the penal system. What treatment consists of has rarely, if ever, been described. Is it

psychoanalysis on the traditional couch five times a week? Drug therapy?

Electroconvulsive therapy? Whatever the case, psychiatry has been subjected to much

abuse and has become an object of legal manipulation.

A more cautious approach is long overdue. Psychiatry cannot pretend omnipotence.

Members of the profession are fully aware that at the present state of our knowledge,

treatment (in any form) is not a feasible means of either cure, rehabilitation, or even

improvement of a large number (if not the vast majority) of sociopaths, many other

character disorders, and many patients with a chronic psychosis with or without criminal

tendencies. Often, custodial care remains the only alternative to prevent a patient from

acting in a way dangerous to himself or to society.

Since psychiatrists are not keepers of public morality, they cannot be designated a role

of either jailers or judges. Their function is frequently limited to that of consultant.

There are many who believe that the relations between law and psychiatry have become

increasingly unscientific and unmedical, at times with disastrous impact on our society.

The time-honored system of reward and punishment, in spite of its known limitations,

cannot be arbitrarily replaced with vague though beautiful sounding statements about

"treatment" as long as there is no sound medical or scientific evidence

SOME QUESTIONS STILL WITHOUT ADEQUATE ANSWERS 441

showing better results with the newer concept. Utopia has not yet been reached.

There seems to be an urgent need for the American Psychiatric Association and for

state and local representatives of psychiatry to take a firmer stand to dissociate psychiatry

from this abuse of psychiatry. Misinterpretations and distortions of mental hygiene

principles should be exposed and prevented. No legislative decisions about treatment

should be encouraged unless they are based on documented and scientifically proven

results. Should the profession neglect to do so, it will be argued that psychiatry passively

condones the release of dangerous criminals into society.

If we have not yet devised adequate legal methods of controlling these destructive

people and do not at present have a therapy to offer that has been demonstrated as

effective, what, then, can we do?

Let us try to promote a general understanding of the serious nature of the

psychopath's abnormality and of its strong tendency to persist despite all efforts toward

correction or treatment. Let us cooperate with our legal colleagues in efforts to devise a

more effective means of keeping psychopaths under adequate control. The degree of

control should, insofar as possible, be regulated by the need, that is, by the degree of

disability that the patient continues to demonstrate. Let us recognize Psychopaths as

differing greatly from the psychotic and psychoneurotic patients for whom our present

hospitals and clinics have been designed and our current methods of treatment or

control established.

It is urgent and obvious that we devise some more effective means of restraining

these people in their persistently destructive careers. Henderson says: "It is amazing and

almost paralyzing to realize the extent to which some of these cases may go before any

action can be taken legally or medically to exert adequate control."128

If a proper general understanding could be reached that such people have a

serious psychiatric abnormality and are not likely under prevailing conditions to become

better and if this fact could be disseminated, their families might be able to reconcile

themselves better to a major problem and seek more realistic ways of dealing with it.

By systems of parole, probation, and supervision designed specifically for patients

of this type and devised to meet the tort of problems they present, it is probable that

reasonably effective guidance could be maintained after hospitalization and, when

necessary, restraint be applied pertinently and effectively. We must remember that

under present conditions nearly all psychopaths are entirely on their own in the

community and that the few with whom society gets any opportunity at all to heal fall

under one or the

442 THE MASK OF SANITY

other of two methods. Neither of these methods was evolved with any cognizance of

the psychopath, but each for quite a different sort of problem.

On one hand, the existing psychiatric hospitals, parole arrangements, and mental

hygiene clinics, are set up to meet situations that arise in dealing with (legally) psychotic

and psychoneurotic patients. With patient's in these two groups, our methods,

imperfect as they may be, are relevant to the situation.

On the other hand, we have the penal system with its preordained terms of

restraint graded arbitrarily in what, perhaps during the last century, was agreed upon as a

proper dosage of punishment for this or that misdeed. Such punishments were

presumably considered as having corrective (and perhaps prophylactic) effect on

antisocial tendencies. Whatever efficacy this method may show for dealing with citizens

in general, it has demonstrated year after year its lack of success in controlling the grave

problems that continually multiply about the psychopath.104 Largely inaccessible to

ordinary social agencies, this type of patient capers, reels, or plunges along his disastrous

course.

Without medicolegal apparatus to reach him, without social instrumentalities

designed to cope with his problems or those he makes for others, and with no general

recognition even of his presence, we find ourselves emulating the ostrich and its

proverbial tactics of evasion.48 When the situation becomes too alarming or too

monumentally fantastic for us to continue these tactics and when it cannot any longer

be blandly ignored, we find ourselves fumbling between the only two methods available,

neither of which, we find immediately, is applicable to the real issues we confront.49

Psychiatrists finding its impossible under existing circumstances to continue any longrange

plans are hardly to be blamed if they tend to regard these people as birds of

passage through their institutions, that is, as patients in name only who seek temporary

refuge there from other legal restraints, create much confusion and disorder, then leave

when it suits their whim or convenience, to continue in their former maladjustment.

Turning now to penal facilities, now to psychiatric institutions, relatives, friends,

doctors, lawyers, or the community at large, all find themselves at a loss, somewhat as if

they were trying to measure areas in kilowatts or color in inches. Since the fire

extinguisher did not particularly help the child's fever, which has become alarming, we

gravely decide to apply a plaster cast. There are no really appropriate remedies available.

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

SOME QUESTIONS STILL WITHOUT ADEQUATE ANSWERS 443

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

444 THE MASK OF SANITY

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 is used 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

SOME QUESTIONS STILL WITHOUT ADEQUATE ANSWERS 445

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.

1. The therapist must have complete control over the financial resources of the

psychopath, usually by being made trustee of his accounts.

2. 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.

3. The therapist must be very persistent in gradually getting the psychopath to exert

some limits and controls over his own behavior.

4. The therapist should not protect the psychopath from the legal and social

consequences of his actions.

5. 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.

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

7. 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 psychiatry, by

its very nature, abounds in questions still unanswered and about which diverse opinions

naturally exist and

446 THE MASK OF SANITY

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 mayb be ther matter

with him? If some practical means of controlling the psychopath can eb devised,

perhaps eventually, we may find his disorder to be not altogether beyond our practice.

THE MASK OF SANITY

Section 4: Some questions still without adequate answers

Part 2: What is wrong with these patients?