Psychopath Hervey Cleckley THE MASK OF SANITY, Section 1: An Outline of the Problem, 2. Traditions that obscure our subject

Raising general questions about personality disorder, we have briefly considered

(1) persons suffering from illnesses that progress to major mental disability and (2) the

numerous citizens of our nation, many of them able and well educated, who hold beliefs

generally regarded as unsupported by evidence and considered by many as irrational or

even fantastic. Aside from these groups and aside from all types of patients recognized

as psychotic, there remains for our consideration a large body of people who are

incapable of leading normal lives and whose behavior causes great distress in every

community.

This group, plainly marked off from the psychotic by current psychiatric

standards, does not find a categorical haven among the psychoneurotic, who are

distinguished by many medical characteristics from the people to be discussed in this

volume. They are also distinguished practically by their ability to adjust without major

difficulties in the social group.

Who, then, are these relatively unclassified people? And what is the nature of

their disorder? The pages which follow will be devoted to an attempt to answer these

questions. The answers are not easy to formulate. The very name by which such

patients are informally referred to in mental hospitals or elsewhere among psychiatrists

is in itself confusing. Every physician is familiar with the term psychopath, by which

these people are most commonly designated.50 Despite the plain etymologic inference of

a sick mind or of mental sickness, this term is ordinarily used to indicate those who are

considered free from psychosis and even from psychoneurosis. The definitions of

psychopath found in medical dictionaries are not consistent nor do they regularly accord

with the

AN OUTLINE OF THE PROBLEM 11

ordinary psychiatric use of this word.*

In a 1952 revision of the psychiatric nomenclature14 the term psychopathic personality

was officially replaced by sociopathic Personality. Subsequently the informal term, sociopath,

was often used along with the older and more familiar psychopath to designate a large

group of seriously disabled people, listed with other dissimilar groups under the heading

personality disorder.62 Still another change in the official terminology was made in 1968

when the designation sociopathic personality was replaced by personality disorder, antisocial

type.15 In referring to these people now formally classified by the term antisocial personality,

I shall continue to use also the more familiar and apparently more durable term,

psychopath. The diagnostic category, personality disorder, officially includes a wide variety of

maladjusted people who cannot by the criteria of psychiatry be classed with the

psychotic, the psychoneurotic, or the mentally defective. Until fairly recent years, it was

by no means uncommon for the report of a detailed psychiatric examination made on a

patient in a state or federal institution to end with this diagnostic conclusion:

1. No nervous or mental disease

2. Psychopathic personality

Traditionally the psychopath (antisocial personality) has been placed in general

diagnostic categories containing many other disorders, deviations, abnormalities or

deficiencies, most of which have little or no resemblance to his actual condition. From

the category personality disorder, as last defined in 1968, a number of these dissimilar

and apparently unrelated psychiatric conditions have been removed. It is not likely

however that all the confusion promoted by the older classifications will subside

promptly.

In the early decades of our century a large group of abnormalities, mental

deficiency, various brain and body malformations and developmental defects, sexual

perversions, delinquent behavior patterns, chronically mild schizoid disorders, were all

classed as constitutional psychopathic inferiority.123

* Stedman's Medical Dictionary (1972): "Psychopath: The subject of a psychoneurosis. One who is of

apparently sound mind in the ordinary affairs of life but who is dominated by some abnormal sexual,

criminal or passional instinct."

Dorland's Illustrated Medical Dictionary (1974): "Psychopath: a person who has an antisocial

personality. sexual p., an individual whose sexual behavior is manifestly antisocial and criminal."

Blakiston's New Gould Medical Dictionary (1949) gives: "A morally irrespsonsible person: one

who continually comes in conflict with accepted behavior and the law."

Curran and Mallinson- (1944) say: "The only conclusion that seems warrantable is that some time

or other and by some reputable authority the term psychopathic per. sonality has been used to

designate every conceivable type of abnormal character."

12 THE MASK OF SANITY

After the ordinary mental defectives and most of the cases with demonstrable brain

damage or developmental anomalies were distinguished, a considerable residue of

diverse conditions remained under the old classification.

As time passed and psychiatric study continued, an increasing number of

observers felt that the term constitutional was scarcely justified for some of the several

disorders listed in the categories just menioned. Eventually the term was officially

discarded in our country and psychopathic personality was adopted, not only for the type of

patient to be discussed in this volume but for a good many others easily distinguished

from him in life but only with difficulty in the nomenclature.

Some time after the period during which it was generally assumed, by the

physician as well as by the clergyman, that abnormal behavior resulted from devil

possession or the influence of witches, it became customary to ascribe all or nearly all

mental disorder to bad heredity. Even in the early part of the present century this

practice was popular.210 Before relatively recent developments in psychopathology and

before any real attempt had been made to understand the meaning and purpose of

symptomatology, the invocation of inborn deficiency or "hereditary taint" was, it would

seem, grasped largely for the want of any other hypothesis.

Another factor contributing to the popularity of belief in hereditary causation lies,

perhaps, in the fact that families of patients in state hospitals were investigated and all

deviations recorded. Most of these histories revealed aberrant behavior, if not in a

parent or grandparent, at least in some great uncle or distant cousin. It is surprising that

some investigators gave such little consideration to the fact that few men stopped on

the street could account for all relatives and antecedents without also disclosing one or

more kinsmen whose behavior would attract psychiatric attention.* This is not to say

that there is no reasonable likelihood of inborn deficiencies playing a part, perhaps a

major part, in the development of the psychopath. It is to say that one is not justified in

assuming such factors until real evidence of them is produced. If such evidence is

produced, these factors must be weighed along with all others for which there may be

evidence and not glibly assumed to be a full and final explanation.

In recent years a contrary tendency has become prominent in psychiatry, a

tendency to make, on the basis of symbolism and theoretical postulates sweeping and

unverifiable assumptions and to insist that these prove the

* The ease with which defective heredity may be found in any case in which one looks for it is well

known. A study published in 1937 revealed that 57 percent of a group of normal people showed a

positive family history of "neuropathic taint._

AN OUTLINE OF THE PROBLEM 13

cause of obscure personality disorders to lie in specific infantile, or even intrauterine,

experiences.82, 166, 238 This practice has become exceedingly popular and has, in my

opinion, led to many fanciful and absurd pseudoscientific explanations of the

psychopath and of other psychiatric problems. Let us bear in mind that the currently

prevalent psychodynamic theories are of such a nature that they can be glibly used to

convince oneself of the truth of virtually any assumption, however implausible, that one

might make about what is in the unconscious but what is never brought to

consciousness or otherwise demonstrated. Let us not mistake these easy and

unsupported assumptions for actual evidence.

After many years of work in psychiatry as a member of the staff in a closed

hospital devoted to the treatment of mental disorders, and after many other years in

charge of the psychiatric service in a general hospital, I believe that these curious people

referred to as sociopaths or psychopaths, in the vernacular of the ward and the staff

room, offer a field of study in personality disorder more baffling and more fascinating

than any other. The present work has been attempted because of an ever-growing

conviction that this type of disorder is far less clearly understood than either the well

defined psychoses or the neuroses and that this lack of understanding is, furthermore,

not sufficiently recognized and admitted. Although I do not pretend to achieve a final

explanation of so grave and perplexing a problem, it is hoped that a frank and detailed

discussion may, at least, draw attention to the magnitude of the problem.48

The chief aim of this study is to bring before psychiatrists a few of these cases,

typical of hundreds more, who have proved so interesting to the writer, so difficult to

interpret by the customary standards of psychiatry, and all but impossible to deal with or

to treat satisfactorily in the face of prevalent medicolegal viewpoints. Many of these

cases have been classified consistently as psychopaths by not one but a number of

expert observers, usually by several staffs of psychiatrists, and nearly always with

unanimity. Others are so similar and so typical that few, if any, experts could find

grounds to question their status. It is my belief, however, that this diagnosis, as it is

authoritatively defined and as it is generally understood, fails to do justice to the kind of

patients considered here.

It is hoped that such a presentation may be of interest to physicians in general

practice and, perhaps, to medical students, as well as to those whose work is confined

more specifically to personality disorders. It is, indeed, the physician in general practice

who will most often be called on by society to interpret the behavior of such patients as

these and to advise about their treatment and their disposition.

These people, whom I shall usually call psychopaths for want of a better

14 THE MASK OF SANITY

word, are, as a matter of fact, the problem of juries, courts, relatives, the police, and the

general public no less than of the psychiatrist. Referring to such patients, Henderson

says:128

It is often much against his better judgment that the judge sentences a man whose

conduct on the face of it indicates the action of an unsound mind to serve a term of

imprisonment. But he is almost forced to do so because, according to our present statutes

governing commitment, the doctor may not feel that he is justified in certifying the

individual as suitable for care and treatment in a mental hospital.

It is important that the average physician at least be aware that there is such a

problem. According to the traditional standards of psychiatry, such patients are not

eligible for admission to state hospitals for the psychotic or to the numerous hospitals

of the same type maintained by the federal government for veterans of the armed

services. They are classed as sane and competent and, theoretically at least, are held

responsible for their conduct. Being so classed, none of the measures used to protect

other psychiatric patients (and their families and the community) can be applied to bring

them under any sort of treatment or restriction, even when they show themselves

dangerously disordered. By many psychiatrists they have in a technical sense, been

considered to be without nervous or mental disease. There are many arguments that

can be brought forward in support of these beliefs, particularly if one adheres strictly to

the traditional and currently accepted definitions of psychiatry and minimizes or evades

what is demonstrated by the patient's behavior.

It is difficult, however, for society to hold these people to account for their

damaging conduct or to apply any control that will prevent its continuing. Those who

commit serious crimes have a history that any clever lawyer can exploit in such a way as

to make his client appear to the average jury the victim of such madness as would make

Bedlam itself tame by comparison. Under such circumstances they often escape the

legal consequences of their acts, are sent to mental hospitals where they prove to be

"sane," and are released. On the other hand, when their relatives and their neighbors

seek relief or protection from them and take action to have them committed to

psychiatric hospitals. They, not wanting to be restricted, are able to convince the courts

that they are as competent as any man.

It is pertinent here to remind ourselves of the considerable change that has

occurred during recent centuries in the legal attitude toward antisocial conduct and

punishment. Formerly, all who broke the laws were considered fit subjects for trial, and

penalties were inflicted without regard to questions of responsibility or competency. As

Karl Menninger,210 among others,275,300 has emphatically pointed out, not only were the

irrational considered fully

AN OUTLINE OF THE PROBLEM 15

culpable, but also young children and idiots. It has also been said that at an earlier date,

animals and even articles of furniture, a tree (or a stone), were brought to trial, fantastic

as it seems to us now, and sentenced to legal penalties.

Today the murderer who hears what he believes is God's voice telling him to kill

is not, as a rule, considered legally responsible for his crime. He is likely to be

committed to a psychiatric hospital for the protection of society and for his own best

interest, but not as a punishment. This legal attitude has become so axiomatic, so

familiar to the man on the streets, that it is well for us to remember it is relatively new.

Since publication of the earlier editions of this book much more drastic changes

have been called for and, to some degree, have occurred in popular and even in legal

attitudes toward serious antisocial activity. Some of the demands made in behalf of

what is often called permissiveness are based on false assumptions, often on truly

absurd assumptions. Among these, apparently, is the relatively popular conviction that

those who perpetrate heinous and brutal crimes should not really be blamed or, at the

most, not be blamed greatly, or seriously punished. Another assumption is that

psychiatry has discovered an effective means of curing even the most vicious criminals,

and that they should not be sentenced to prisons but regularly sent to psychiatric

hospitals. This concept is indeed flattering to psychiatry in view of our record with its

woeful lack of evidence that we possess any means of this sort whatsoever.

Popular among some groups who consider themselves progressive is the belief

that society instead of the criminal should be held responsible for the unprovoked

murders, brutal rapes, and other outrages that blight our civilization. Another factor

that sometimes seems to play a part in the doctrine of permissiveness is the popular

psychiatric theory that crimes are often carried out in order to obtain punishment for

unconscious feelings of guilt weighing on the tender conscience of the criminal.

Referring to a sane man convicted of murdering in cold blood and without provocation,

eight young women some years ago, one psychiatrist was quoted as expressing the

conviction that this murderer should be regarded as being just as free from guilt as any

of his victims.

We might also bear in mind that once only obvious irrationality was regarded as

personality disorder, as disability. Medically we recognize the fact that many less

obvious disorders are more serious and incapacitating than those with gross superficial

manifestations that can be readily demonstrated. In our attempts to appraise the

psychopath and his disorder, it will be helpful to bear these facts in mind and not to

forget that our present medicolegal criteria are based on knowledge that is far from

complete.

16 THE MASK OF SANITY

These people called psychopaths present a problem which must be better

understood by lawyers, social workers, schoolteachers, and by the general public if any

satisfactory way of dealing with them is to be worked out. Before this understanding

can come, the general body of physicians to whom the laity turn for advice must

themselves have a clear picture of the situation. Much of the difficulty that mental

institutions have in their relations with the psychopath springs from a lack of awareness

in the public that he exists. The law in its practical application provides no means

whereby the community can adequately protect itself from such people. And no

satisfactory facilities can be found for their treatment. It is with these thoughts

especially in mind that I seek to present the material of this book in such a manner that

the average physician who treats few frankly psychotic patients may see that our subject

lies in his own field scarcely less than in the field of psychiatry. After all, psychiatry,

though still a specialty, can no longer be regarded as circumscribed within the general

scope of medicine.35

In nearly all the standard textbooks of psychiatry the psychopath is mentioned.

Several recent textbooks have indeed made definite efforts to stress for the student the

challenging and paradoxical features of our subject. Often, however, tucked away at the

end of a large volume, an obscure chapter is found containing a few pages or paragraphs

devoted to these strange people who take so much attention of the medical staffs in

psychiatric hospitals and whose behavior, it is here maintained, probably causes more

unhappiness and more perplexity to the public than all other mentally disordered

patients combined. From some textbooks the medical student is likely to arrive at a

conclusion that the psychopath is an unimportant figure, probably seldom encountered

even in a psychiatric practice. Nor will he be led to believe that this type of disorder is

particularly interesting. Not only is the chapter on psychopathic personalities often

short and sometimes vague or halfhearted, but even this until fairly recently was nearly

always involved with personality types or disorders which bear little or no resemblance

to that with which we are now concerned. Although it is true that these other

conditions were for many decades officially placed in the same category with the one

discussed here, which I believe is a clinical entity, it is hard to see how any student

unfamiliar with the latter could profit by encountering it vaguely placed in a company of

assorted deficiencies and aberrations that are by no means basically similar.

It is my earnest conviction that, traditionally confused with a fairly heterogeneous

group under a loose and variously understood term, a type of patient exists who could,

without exaggeration, still be called the forgotten man of psychiatry. If this patient can

be presented as he has appeared so clearly during years of observation, if some idea can

be given of

AN OUTLINE OF THE PROBLEM 17

his ubiquity, and, above all, if interest can be promoted in further study of his peculiar

status among other human beings, I shall be abundantly satisfied. It is difficult to

contemplate the enigma which he provokes without attempting to find some

explanation, speculative though the attempt may be. My efforts to explain or interpret

are, however, tentative and secondary to the real purpose of this volume, which is to call

attention to what may be observed about our subject.

Psychopath

THE MASK OF SANITY

Section 1: An Outline of the Problemf