The Mask of Sanity

by Hervey Cleckley

  Let it be understood that I am not advancing an opinion that those who are persuaded by prophets that the world will end next Thursday or that those who appeal to faith healers to protect a child from the effects of meningitis should be pronounced as clinically psychotic and forcibly committed to hospitals. Despite the similarity between the way such beliefs are adopted and the way a schizoid or paranoid patient arrives at his delusions, and despite the similar lack of evidence for considering either true, people such as those now under discussion are usually capable of leading useful lives in harmony with the community and sometimes of benefit to society. Few things, in my opinion, are more basic than the necessity for men to allow each other freedom to believe or not to believe, however sacred, or however false, different creeds may be held by different groups.

  Convictions that the world is flat, that one must not begin a job on Friday, or that Mr. Arthur Bell of Mankind United193 is omnipotent are apparently held by some in reverent identity with the deepest religious attitudes of which they are capable. In this basic sense, each man’s religion, as contrasted with the dogma or illusion in which he may frame it, his basic attitude and emotional response to whatever meaning and purpose he has been able to find in his living, deserves respect and consideration. The Methodist, the Mormon, and the Catholic, as well as the man who cannot accept any literal creed as a final statement of these issues, can honor and value, in a fundamentally religious sense, the valid reverence and the ultimate subjective aims of a good Mohammedan. This is possible without the ability to share his pleasant convictions about the likelihood of houris in paradise.

  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 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:

  No nervous or mental disease

  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 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 mentioned. 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 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, how
ever 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 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 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.

  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 psychop
ath 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.