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PsychopathTHE MASK OF SANITYSection 2: The MaterialPart 1: The disorder in full clinical manifestations 14. Chester
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14. Chester In his first admission to the closed ward of a psychiatric hospital, Chester W., 24 years of age, was friendly and alert. His freedom from anything that would suggest an ordinary psychosis was immediately noticeable. He explained to the examiner that he did not suffer from any nervous or mental disorder and emphasized the statement that no question of such a condition had ever come up in his case. He said that he came to the hospital for further examination of a serious injury to his ankle which he sustained while in the army and for which he hoped to get a pension. When told frankly that, according to accompanying reports, he had been admitted because of persistent antisocial and irresponsible behavior, spectacular alcoholic episodes, and extreme maladjustment, he affected considerable surprise and insisted that some mistake had been made. In fact, his surprise seemed real. 128 THE MASK OF SANITY It was pointed out to him that unquestionable evidence from his parents, relatives, and friends, as well as from a social service report, established the fact that he had been stealing, defrauding others, and making a boisterous nuisance of himself when drunk since he was 16 years of age. It was brought to his attention that he had been expelled from a military school for gross and inveterate misconduct, had been confined in jail a dozen times recently for similar reasons, and had been supported and protected by his father, who spent a good part of his time getting this son out of the troubles which he made for himself and others almost daily. The patient appeared as if very much astonished at such reports, denied everything, and, in a convincing fashion, dismissed the question of all personal difficulties and maladjustment as little short of preposterous. After careful observation in the hospital for a month, no evidence of delusions, hallucinations, or any other sign of what is regarded as a psychosis could be discovered. Chester was presented before a medical staff of ten psychiatrists who unanimously considered him sane and competent and made the diagnosis of psychopathic personality. He was kept in the hospital on pretexts and out of common sense because of his long history of extreme maladjustment. He was at all times alert and usually cooperative, reacted with a very natural dislike to being on a closed ward, and continually asked for a discharge, insisting that he was entirely sane and improperly hospitalized. On being granted parole of the grounds, he promptly left without permission and went home. At the insistence of his father he was granted a furlough status. Within a few days he had insolently suggested sexual intercourse to a respectable matron, committed several inconsequential thefts, and sold for $1.25 a good rug taken from his parents' home. After having a few drinks, he is reported to have cursed and further expressed his contempt by spitting on the foot of a great uncle who encountered him on the street and politely engaged him in conversation. Later that afternoon he talked eloquently to a half-dozen or so bystanders in the park about patriotism, honor, God, and the true meaning of morality. Meanwhile, he had cashed several small checks on a nonexistent bank account and, posing as the emissary of a respected cousin (whose husband was cashier in a local bank), obtained $15.00 which he convinced an old friend of the family was needed to settle a small obligation that had arisen after banking hours. When drinking, he usually became rowdy. He made no effort whatsoever to find employment and roamed about the town or countryside, often sleeping in the woods and fields. His father and brothers had no choice but to seek him out in the byways and hedges and bring him in, often laboring THE MATERIAL 129 strenuously at this task far into the night. He was often found dirty, disheveled, and alone. Toward his family he was sullen and carping, his reactions those of petty irritation. He complained constantly that his father meddled with him and at times ascribed all his troubles to this interference. Finding it impossible to supervise such a person, even with the frequent assistance of local police, who obligingly locked him up in jail for a day or two during his worst episodes, the father soon sent him back to the hospital. On arrival he was manifestly vexed and seemed at a loss to understand his situation. "I can't see why they don't let me alone. I don't bother anybody. Why can't I go about my business like any other man?" These and similar remarks he repeated many times in tones showing well the dissatisfaction that any normal man would feel on being, without cause or reason, deprived of his liberty. Before returning to the hospital, Chester had complained bitterly to his father, stating that he would kill himself rather than come. The father recognized this threat of suicide as insincere but typical of the somewhat dramatic airs often assumed by the patient. Except for past experience with such threats, it would have been natural to think desperation would be consistent with his intensely strong distaste for restraint of any sort. He was kept now on a closed ward, from which he repeatedly schemed to escape, once stealing keys from an attendant and several times fomenting plots among other patients. After two weeks he succeeded in his efforts and soon appeared at home (fifty miles from the hospital) in a magnificent state of boisterous intoxication. He continued at home in complete idleness except for some enterprising petty thefts, long speeches about the need of increased virtue in women (delivered in local poolrooms), several brawls arising from his being caught cheating at dice games, some bold-faced begging, and numerous maneuvers to obtain money illegally, including forgery. Despite peaceful intervals of a week or more, he continued to demonstrate an irresponsibility so utter that one is taxed to describe it. After several additional experiences in jail he was brought back to the hospital by his father, who confessed himself at his wit's end. During psychiatric examinations the patient again denied that he had caused any trouble or done anything which would justify his being brought to the hospital. He admitted having taken a few drinks and tried to conclude some wise business deals but still insisted that he never drank much or ever behaved irresponsibly or in such a way as to cause trouble. He glibly dismissed all the massive accumulation of detail concerning his lack of responsibility, his failure to show normal interests in life, his indifference to the serious trouble he gave relatives and friends, and the purposeless folly that had consumed all his efforts for years. The adroitness 130 THE MASK OF SANITY with which he denied everything and the brisk, facile manner in which he excused himself and glossed over his record made it clear that his mind was free of any seriousness whatsoever in regard to his past and of any real intention to behave more sensibly in the future. One thing only in this man impressed his examiners as having some emotional weight. This was his vivid chagrin at being confined and his persistent, restless longing to be free. Many attempts were made to make him realize that he could stay out of the hospital only by avoiding inappropriate conduct and acts plainly damaging or embarrassing to others and by conducting himself so as not to be an unbearable burden on his family and on the community. He admitted that he did not really enjoy or have any particular reason for doing as he did, and reports substantiate this, representing him as a sullen, glum fellow in bars and poolrooms, a man without convivial gaiety or other signs of stimulation, apparently more unhappy in his efforts to celebrate than in his usual state. I am convinced that this man obtains no delight at all from whiskey, that whatever may be his purpose in drinking, it does not result in the attainment of pleasure. Every effort was futile to make him see what was so obvious, that he had brought his troubles on himself, and that only by staying sober could he retain his freedom. He absolutely refused to face any fact and slipped nimbly from reality to the world of his evasions. A few weeks later, because of a death in his family, he was allowed to go home in custody of his father. He immediately got out of the house and slipped off to a nearby town, where he drank himself into a state of maudlin intoxication, made a nuisance of himself in several public houses, engaged in minor street brawls, and wandered cursing and muttering aimlessly through the streets until found by his relatives. At the funeral the next day, having skillfully obtained more whiskey, Chester appeared at first poised and sober. Signs of drunkenness, however, soon appeared, and the patient proceeded to make a shocking and memorable impression. Vomiting and defecating while in the aisle of the church contributed to this effect. As an elder brother was attempting to expedite his departure with minimum conspicuousness, these momentary and incomplete reactions took place. The father sent him back to the hospital as soon as arrangements could be made. Although the patient could not have been unaware that his father had informed the hospital of his conduct and explained the circumstances under which he returned, he said with the greatest assurance on arriving that he had voluntarily come back before expiration of his furlough, merely for the day and in order to have the furlough extended. He insisted that his conduct at home had been above reproach and demanded parole privileges THE MATERIAL 131 until arrangements were made for him to leave the hospital. At this time he was entirely free from all effects of alcohol. This man is the son of a rather prosperous farmer and merchant. His home is in a Southern town of four thousand inhabitants. His father, though not highly educated, is a successful, sensible man and genuinely respected in the community. Of his three siblings, a sister is married and in good circumstances, one brother is a physician, and the other is a lawyer. All are successful and seem well adapted to their environment. The patient was raised in the same environment with his sister and brothers, but from early youth, unlike the other children, he showed some signs of his present inadaptability. He learned rather easily in school and successfully completed his studies each year until he reached the sixth grade. His truancy then became so pronounced that he could not be kept in school any longer. On being sent to a strict military school, he proved intractable and was expelled after a few weeks. Though remarkably lazy and unpersevering, he showed at this time what appeared to be a slight interest and an astonishing talent in tinkering with radios. His parents, who throughout his whole life have shown exceptional patience and gone to no little expense and trouble with him, sent him to New York to study radio work. He was very eager to go and urged this plan on the family. His older brother, the physician, was a house officer in a New York hospital at the time and agreed to keep in touch with him and try to exercise any necessary supervision. From the very beginning it became apparent that the venture was useless. Chester could not be induced to attend classes. He showed no interest whatsoever in his work or in anything else, lying about his room much of the time and going out alone on adventures without much purpose or content on missions to borrow a dollar through solemn-faced fraud or, by cheating or some sort of chicanery, to pick up a little extra change or to beat the game by getting a free ride on the bus or the subway and, perhaps, to climax the day by slipping out of a restaurant without paying for his meal. His brother, after earnest and persistent efforts to persuade him to take advantage of his opportunities, had to give up and send him home. Many other efforts have been made to help this young man find some place in normal life. Various positions have been found for him, but he always refuses to maintain the slightest interest in any work. The ordinary pleasures of mankind seem to have as little charm for him as work. Though he has had sexual relations with prostitutes and other available girls, he never formed a real attachment for any. Even casual physical encounters with women claim his interest far less than sporadic bouts of solitary drunken torpor in remote cotton fields or aimless hours spent 132 THE MASK OF SANITY idling about uninspiring hamburger stands and poolrooms. When at 22 years of age he ran off to enlist in the army, his father did not try to interfere, hoping the discipline of that life would stabilize him. Since the incidents just mentioned, he has on several other occasions obtained parole and violated it promptly by carrying out various antisocial acts which seemed to have no definite purpose, no conceivable explanation in terms of human impulse. He has also succeeded again in escaping from closed wards. On getting out, he always repeats his former conduct. Sometimes he has remained cooperative for a month or more, abiding by the rules of his ward, helping attendants with their work, assisting and directing frankly psychotic patients. During such periods he would talk frequently with his physician, discussing his plans for the future, maintaining that he fully realized drinking or stealing or not taking life seriously enough was his trouble and declaring that he would never act so unwisely again. He appeared to be a sane, quick-witted young man with good judgment and reasonably earnest intentions. So convincing was the impression he made that time after time the various physicians who had charge of his case would decide that parole was advisable despite his history. Within a few hours or sometimes a few days, he would appear at his home in a wretched state, land in jail because of unacceptable behavior, take an automobile and get caught, or, lacking opportunity for something more active to do, get himself too drunk to leave town and fall into the hands of the local police. On one occasion, several days after being returned by his family from such an escapade, Chester came to me smiling and at ease. He spoke briefly of his plans for the future and insisted on having parole at once. In support of this request he sought to make the point that he had proved himself trustworthy and reliable under all circumstances. Looking me squarely in the face, he asserted with modest firmness, "You know that I'm a man of my word." He repeated this statement several times and spoke most intelligently and convincingly in his own behalf. When asked how he pretended to be a man of his word after breaking it so many times, so flagrantly, and so recently, he showed no sign of being confounded. His memory was of course clear, and he accurately recognized all the circumstances under which he had given his word not to leave the hospital, not to steal or to forge or to drink whiskey, as well as his invariably and prompt violations of every promise. He seemed to seek in the phrase a man of his word, which he uttered in tones of quite pride and assurance, some magical charm which would irrationally persuade me to trust him. Indeed, he himself appeared to be well convinced by his statement. On seeing this man for the first time, one would have read into him a fair degree of sinTHE MATERIAL 133 cerity and conviction. To me he seemed rather to be activated by a mimicry of these things, an insubstantial shadow of emotion which the patient, knowing nothing else, confused in his own mind with what he assumed other people felt when they used such a tone. Having never in his whole life, so far as I could find in examining him, looked a fact of this sort in the face, he was untroubled by even the hardest, sharpest contrast between fact and falsehood and stood free to indulge, with a kind of automatic imitation-sincerity, in any fantasy he chose. During his repeated hospitalizations, his case was reviewed many times. No evidence of a psychosis in the commonly accepted sense of the word was found in his past record or in his current behavior or thought. At each presentation before the medical staff, every member has agreed that he is "sane and competent" and that he should be classified under the term psychopathic personality. He is bright rather than dull, and his reasoning powers on all general matters and on test questions are average or better than average. Here, then, is a man whose measurable intelligence is not at fault, whose extrinsic situation is normal, and who is entirely free from the delusions and other mental disorders of the recognized psychoses. His environment is favorable and his opportunities, past and present, insofar as they can be estimated, appear better than the average. He is not visibly indifferent or emotionally isolated in the ordinary sense of those words, but, in sharp contrast to the schizophrenic or the deteriorated patient with organic brain disease, he reacts with a very natural antipathy to his situation when confined. Several of the psychiatrists who observed him have expressed the belief that he detests being in the hospital more than any man they ever saw there. Why, then, does he always take these active steps to get himself back in confinement just as soon as he gets away? It has been clearly demonstrated to him that he will have to spend most of his life in confinement as long as he persists in his present ways. The opinion held by some physicians is that such people as this patient are merely spoiled, that they would behave more sensibly if not pampered, and that if promptly confined to jail or left in whatever other difficulties they bring down on their own heads, they would finally control themselves. I believe that consistent, prompt and regular punishment for unacceptable conduct is of great value in treating most people who persist in flagrant misbehavior, delinquency or crime. I believe it is usually of far more value than any form of dynamic psychotherapy. In this patient, however, it proved quite ineffectual. No ordinary punishment could be much more severe than confinement on a closed ward is to this particular man. He has had it thoroughly explained to him that he will remain here until he can adapt himself to normal life outside. He not only 134 THE MASK OF SANITY gives up everything that other people seek but also, because of confinement, he sacrifices the chance to follow the inappropriate and bootless patterns of behavior into which he falls almost at once when left to his own devices. Whatever strange goals or pseudogoals there may be to prompt and shape his reactions as a member of the community, these too, it seems, fail to motivate him sufficiently, fail to induce decisions and acts that would give him the freedom to pursue them. It has been demonstrated to Chester repeatedly, in the hardest aspects of the concrete, that his characteristic acts put him back in a situation he finds particularly disagreeable. This does not produce the slightest modification in his behavior. If we attempt to interpret his antisocial conduct as a rebellious manifestation, a symbolic protest against customs, principles, people, and institutions which he will not accept, we might presume he would take more pains to avoid the interruption of his efforts along this line. If there is unconscious need for him to make trouble in the community and to achieve heroic stature as a general nuisance, his steps to fulfill this need seem peculiarly illogical. They promptly result in the termination of his action. Arguments for such motivation in more effective criminal careers and in circumscribed patterns of delinquency seem more plausible than in such a case as this. If loitering, theft, swindling, "disgracing himself," running up debts, and social sabotage in general are his goals, the pursuit of these he must give up when he comes under close supervision on the closed ward. Is he seeking, then, not to fulfill these goals but to frustrate the impulses to fulfill them? Or is he seeking punishment as something even more desirable than the perverse goals surmised above? The claim of such motivational schemes has been advanced.8,207 Perhaps some patients who show more interest in their predicaments may reveal hidden attitudes, old won grudges, or forgotten but distorting influences that suggest such an interpretation. From this patient, however, none of the many psychiatrists who dealt with him could obtain any underlying material to confirm such speculations. As hypotheses about his disorder, such interpretations impress me as having very little plausibility. It might be assumed that if deep penetration of his personality and adequate exploration of his innermost life could be achieved, substantial evidence of cause and effect would emerge in some convincing explanation. It seems likely, however, that a valid explanation would prove to be one far more complex than anything just suggested. An important clinical feature of his disorder seemed, nevertheless, to lie in the specific and obdurate difficulty in finding out anything at all about less superficial attitudes or real inner purposes and meanings. In closing the summary of this case, let the point be emphasized again THE MATERIAL 135 that this man does not seem driven by hot temptations to his injudicious deeds. What he does when free fails to give him much pleasure. Chester is in no way like a man who sacrifices all the ordinary satisfactions of life for some enthralling sin which will later bring him to ruin. The well-known human motives which sometimes lead a respected and successful businessman to lose fortune and family in his pursuit of an illicitly loved woman or of some other transitory but enticing joy are not discernible in this case. My candle burns at both ends; It will not last the night; But ah, my foes, and, oh, my friends- It gives a lovely light. Edna St. Vincent Millay "A Few Figs from Thistles" Such a scheme of life, whatever might be said for its final wisdom, has no apparent place in this patient's maladjustment. The allegory of Faust selling his soul to the Devil in order to quench a thirst for rarer joys than this life holds is absurdly inappropriate. It is most difficult to believe that he is reacting to powerful drives which force or compel him into obviously disastrous actions. On the contrary, everything about him suggests a drifting approach, a casual and weak impulse, a halfhearted whim rather than an explosive release of passion in the forbidden deed. Instead of a pathologic intensity of drive there seems instead to be a pathologic general devaluation of life, a complex deficiency, confusion, or malfunction in what chooses aims and directs impulse. Nothing that he expresses or that can be observed about him suggests a great stress or inner conflict in which strong opposing forces clash and from which emerges deep instinctual gratification as he makes off with a stolen automobile, thoroughly cleans out an opponent by fraud in crap shooting, saddles his father with a heavy debt, or drains his bottle and brawlingly defies the police. Nor is there anything yet detected about him that suggests true relief of inner tension as he reacts to society's restraints and retaliations. If these are his fundamental mechanisms, they are so deeply concealed that they show no surface or subsurface repercussion of emotion that suggests in the least their nature or their existence. 136 THE MASK OF SANITY |
Next: Section 2: The Material , Part 1: The disorder in full clinical manifestations, 15. Walter
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