The Mask of Sanity

by Hervey Cleckley

  The chief aim of this book is to help, in however small a way, to bring patients with this type of disorder into clearer focus so that psychiatric efforts to deal with their problems can eventually be implemented. It has of course been necessary and in every way desirable to eliminate all details that might lead to the personal identification of any patient whose disorder has been studied and recorded. All patients referred to have been carefully shielded from recognition. It is nevertheless true that the psychopath engages in behavior so unlike that of others and so typical of his disorder that no act can be reported of a patient from Oregon seen ten years ago without strongly suggesting similar acts by hundreds of psychopaths carried out in dozens of communities last Saturday night. I can only express regret to the scores of people whose sons, brothers, husbands, or daughters I have never seen or heard of but who have, no doubt, reproduced many or perhaps all of the symptoms discussed in this volume. This disorder is so common that no one need feel that any specific act of a psychopath is likely to be distinguishable from acts carried out by hundreds of others.

  In discussing the possible influence of environment on the development of this disability, I hope I will not promote unjustified regret or remorse in any parent. Hundreds of times fathers and mothers have discussed their fear that some error or inadequacy on their part caused a child to become a psychopath. Most parents of such patients personally studied impress me as having been conscientious and often very kind and discerning people. As will be brought out later, I do not believe obvious mistreatment or any simple egregious parental errors can justifiably be held as the regular cause of a child’s developing this complex disorder. All parents, no doubt, make great as well as small mistakes in their role as parents. It has seemed at times that the very points about which some mothers and fathers feel most uneasiness are the opposite of those so regretted by others and assumed to be the crucial mistakes that have contributed to the maladjustment of a child. Less than in most other kinds of psychiatric disorder has it seemed to me that one could find and point out as causal influences gross failures on the part of the parents which people of ordinary wisdom and good will might have readily avoided.

  During recent years it has become popular to blame parents in glib and sweeping terms for all, or nearly all, of the misconduct or inadequacy of their children. It has also become popular to insist that society and not the one who commits the crime should be held responsible for murder, rape, or armed robbery.57 Sometimes these claims are made without any appeal to evidence at all but merely by repetition of the familiar cliche. Some psychiatrists have even attempted to account for antisocial behavior by assuming that the parents unconsciously want their sons or daughters to commit criminal or immoral acts and that the progeny carry out these wishes while remaining unconscious of their motives.148,149,150 These conclusions, like many others that have been drawn in the attempt to give fundamental and dynamic explanations of things still unknown, rest chiefly on theoretical assumptions—assumptions made on the basis of analogy or arbitrarily interpreted symbolism about what is in the unconscious but what is never brought forth into consciousness or otherwise submitted or demonstrated. This, I maintain, does not constitute genuine evidence as it is known to science, law, or common sense. I hope that the great numbers of conscientious and honorable parents who to my knowledge have struggled courageously over the years, despite grief and frustration, to rehabilitate their sons and daughters (and to make restitution in their behalf to society) will not be led by such fanciful explanations to blame themselves unjustly.

  Cruvant and Yochelson62 have expressed the opinion that strong and inappropriate negative attitudes toward psychopaths are commonly aroused in psychiatrists who attempt to deal with them as patients. It is scarcely surprising if such reactions tend to occur, when one considers all the disappointments and the frustrations involved in treatment and the repeatedly demonstrated irresponsibility and callousness of these patients.

  When there is an opportunity to follow the career of a typical psychopath, his pattern of behavior appears specific—something not to be confused with the life of an ordinary purposeful criminal or of a cold opportunist who, in pursuit of selfish ends, merely disregards ethical considerations and the rights of others.

  This pattern, I believe, differs no less distinctly than the specific and idiomatic thought and verbal expressions of schizophrenia differ from those of the mentally defective and from other psychiatric conditions. Never in faults of logical reasoning, or in verbal confusion or technical delusion, but rather in the sharper reality of behavior, the psychopath seems often to produce something as strange and as obviously pathologic as the following statement taken from the letter of a patient with schizophrenia:

  Financial service senses worries of 35 whirlpools below sound 1846, 45, 44, A.D. Augusta City treasury, Richmond County treasury, United States Treasury of Mississippi River flood area. Gentlemen will you come to … and idenafy none minastrative body that receives the life generated by fourth patented generative below sound. Further arrange financial credit for same. Would like two bedrooms at up town Hotel and convenient to roof garden. Until you gentlemen decide further what my occupation is you may as well announce me as comforting 35 whirlpools below sound. May you gentlemen have gray eyes and thick bones as the flat sense minastrated are very valuable in idenafying me.

  Even such a relatively simple bit of word salad stands out at once as indicative of profound and specific disorder within the writer. As in the words of the schizophrenic, so in the behavior of the psychopath there seems to work a positive knack for producing situations which can be accounted for only in terms of a psychiatric condition which is unique.

  Section Two: The Material

  Part I: The Disorder in Full Clinical Manifestation

  5. Max

  This patient first came to my attention years ago while I was serving my turn as officer of the day in a Veterans Administration psychiatric institution. His wife telephoned to the hospital for assistance, stating that Max had slipped away from her and had begun to make trouble again. With considerable urgency and apparent distress she explained that she was bringing him to be admitted as a patient and begged that a car with attendants be sent at once to her aid.

  He was found in the custody of the police, against whom he had made some resistance but much more vocal uproar. The resistance actually was only a show of resistance consisting for the most part of dramatically aggressive gestures made while he was too securely held to fight and extravagant boasts of his physical prowess and savage temper. His general demeanor in this episode suggested the familiar picture of small boys, held fast by peacemakers, who wax ever more eloquently militant as the possibilities of actual conflict diminish.

  He came quietly with the attendants and on arriving at the admission ward was alert, self-assured, and boastful. Extolling his own mettle as a prizefighter, as a salesman, and as general good fellow, he was nevertheless friendly and even flattering toward the examining physician and the hospital.

  He was far from what could be called drunk. In fact, it would be stretching a point to say he was “under the influence.” He had been drinking, it is true, but he knew well what he was doing, and only by an impracticable flight of fancy could one attribute his behavior primarily to liquor.

  At the admitting ward of the hospital, accompanying papers promptly revealed that the patient’s desire for treatment arose in consequence of some checks which he had forged in Spartanburg, S.C. He had been arrested and convicted, but an agreement was reached whereby, instead of being sent to jail, he might come to the hospital for psychiatric treatment.

  His wife, his attorney, and representatives of a veterans’ organization pointed out that he had frequently been in hospitals for the treatment of mental disorder and maintained that he was not responsible for his misconduct.

  He seemed pleased to be at the hospital and was expansive and cordial but a little haughty despite his well-maintained air of camaraderie. Alth
ough a small man, only 5 feet, 6 inches tall, he made a rather striking impression. His glance was fresh and arresting. His movements were quick, and he had an air of liveliness vaguely suggestive of a chipmunk. Though preposterously boastful, he did not show any indications of a psychosis.

  The hospital records showed that he had been a patient eight years previously for a period of two months. During this time of study he showed no evidence of a psychosis or a psychoneurosis and was discharged with a diagnosis of psychopathic personality. He was found to have tertiary syphilis, but neurologic examination and spinal fluid studies showed no evidence of neurosyphilis.

  Though at first cooperative and agreeable on this previous admission, he soon became restless and expressed dissatisfaction with the hospital. He was granted parole, but on his first pass into town he got into an altercation in which words were more prominent than blows and was held by the police for disturbing the peace.

  After losing parole, he became constantly unruly in petty ways, often insulted the nurses and attendants, and several times egged on mildly psychotic patients to fight each other or to resist the personnel on the ward. On being questioned about this conduct by physicians, he glibly denied all and showed little concern at being accused. Since he was not considered as suffering from a real nervous or mental disorder and since it was difficult to keep him on any ward except the closely supervised one among actively disturbed patients, he had been discharged.

  Records show that he sought hospitalization on other occasions after having been fined a half-dozen or more times for brawling on the streets and for petty frauds. There is every reason to believe, from the evidence of careful reports by the Red Cross and by social service workers, that when his troubles with the civil authorities became too discomforting he sought the shelter of a psychiatric hospital.

  Several months previously he had spent six weeks at a Veterans Administration hospital in Maryland after getting into similar trouble with the police in Wilmington, Delaware. He complained at the time of having spells during which he lost his temper and attacked people, often, according to his story, with disastrous results, since, again according to his story, he had at one time been featherweight boxing champion of England.

  According to the psychiatric history at the Maryland hospital, he had, in describing these spells, mentioned some points that would suggest epilepsy. As soon as he came to the hospital and was relieved of responsibility for the trouble he had made, the so-called spells ceased. His description of them varied. Sometimes, when particularly expansive, he boasted of superconvulsions lasting as long as ten hours, during which he made windowpanes rattle and shook slats from the bed. After being in the hospital for several weeks and apparently beginning to grow bored, his talk of spells died down and he seemed to lose interest in the subject. He was discharged after the staff had agreed that the alleged seizures were entirely spurious and the patient himself had all but admitted it. The diagnosis of psychopathic personality was made.

  Between his first visit to the present hospital and his recent return, he had been in five other psychiatric institutions, each time following conflicts with the law or pressing difficulties with private persons. In all the records accumulated during these examinations and investigations, no authentic symptom of an orthodox mental disorder is noted. True enough, there are statements by wives and other interested parties about spells and opinions by the laity, such as the following which was quoted by his attorney on one occasion to shield him from the consequences of theft:

  I had occasion to be in Dayton, Ohio, recently and talked to the people running the … Loan Company at … Street, having stopped there for about an hour between trains en route for Chicago. I was informed by these gentlemen that he had wheels in his head.

  Statements such as the foregoing, opinions that he is “undoubtedly goofy,” that he does not behave like a man in his proper senses, abound in the ponderous stack of letters, medical histories, social service reports, records of court trials, and other material that has accumulated in this man’s wake. One who reads his strange and prolix story and, even more, one who knows the hero personally is only too ready to fall into the vernacular and agree. Nevertheless, it was equally true on reviewing his record at the time of his new admission that no symptom impressing a psychiatrist had been manifested and that many groups of psychiatrists had, after careful study, continued to find him free of psychosis or psychoneurosis, in other words, sane and responsible for his conduct and even without the mitigating circumstance of a milder mental illness.

  Once during this period he had been sent to prison in a southern state for forgeries a little more ambitious than his routine practice. At the instigation of his second and legal wife, who consistently flew to his aid (despite her chagrin at the patient’s having meanwhile consummated two bigamous marriages), well-meaning officers of a veterans’ organization became interested and took up the cudgels.

  Wearying sharply of prison, the patient had for some time been talking on all occasions about a blow on the head which he had sustained while in service. This alleged incident, though absent from his military records, had cropped up frequently but not regularly during his hospitalizations. Sometimes the blow, which he had sustained accidentally from the butt of a gun that a companion was breaching, had merely left him dizzy for a moment. Again it had knocked him unconscious for a short period and necessitated several days’ rest in his tent.

  Max now became more specific about his wartime injury and explained that he had suffered a severe concussion, lying out stark and unconscious for some eight or nine hours. Attorneys pointed out his many periods of treatment in psychiatric hospitals. The governor soon agreed to parole him into the custody of a federal hospital in Mississippi.

  During his present sojourn in the hospital he was for several weeks happily adjusted on the admission ward, busy doing small favors for the physician, congenial with all the personnel, and helpful and kindly toward psychotic patients. He was alert, quick-witted, nimble with his hands, and entirely free from delusions, hallucinations, or any of the broader personality changes associated with the ordinary psychoses. He was by no means “nervous,” even in the lay sense, and showed no emotional instability or signs of ungovernable impulse. Rather than an excess of anxiety, he showed the reverse, apparently finding little or nothing in his present situation or in all his past difficulties to cause worry or uneasiness.

  As the time passed, however, he began to grow restive. He became somewhat condescending toward the physician, frequently referring to himself as a man of superior education and culture and boasting that he had studied for years at Heidelberg.

  Shortly before the time set for him to come before the staff, he demanded his discharge. This was denied. He now became involved in frequent altercations with attendants and sometimes fought desultorily with other patients. These fights always started over trifles, and Max’s egotism and fractiousness raised the issue. He never attacked others suddenly or incomprehensibly as might a psychotic person motivated by delusions or prompted by hallucinations. The causes of his quarrels were readily understandable and were usually found to be similar to those which move such types as the familiar schoolboy bully. Usually his adversaries were patients also disposed to quarrel. No signs of towering rage appeared or even of impulses too strong to be controlled by a very meager desire to refrain.

  He always took care not to challenge an antagonist who might upper hand. During this period he talked much of his past glories as a pugilist, describing himself as former featherweight champion of all the army camps in the United States. The desire to show off appeared to be a strong motive behind many of his fights. As will be brought out later, he was indeed a skillful boxer. These stories were not delusion but the exaggeration and falsifying, sometimes unconscious or half-conscious, that are often seen in sane people and sometimes even in those who are able, intelligent, and highly successful.*

  Max was often caught sowing the seeds of discontent among other patient
s whom he encouraged to break rules, to oppose attendants, and to demand discharges. He made small thefts from time to time. This trend culminated in his kicking out an iron grill during the night and leaving the hospital. He took with him two psychotic patients, and numerous others testified that he had tried to persuade them to leave also.

  The next afternoon he was returned to the hospital by the police after being arrested in the midst of a brawl that he had caused by cheating at a game of chance in a low dive. He had taken a few beers but was shrewd, alert, and well in command of his body and his faculties.

  He now insisted on his discharge from the hospital against advice and was brought before the medical staff. The diagnosis of psychopathic personality was again made. In his demands to be released, he arrogantly maintained that he had been pardoned outright by the governor of the state which had imprisoned him, pointed out vehemently that he was sound in mind and body, and expressed strong indignation at being confined unjustly in what he referred to as a “nut house.” It was then pointed out to him that he was not pardoned but merely paroled, and he was told that if discharged at present he would be returned to the penitentiary.

  Here his wrath began to subside at once and marvelously. Hastily, but with some subtlety, his tone changed, and he began to find points in common with the advice he had been receiving from the staff. He left the room in a cordial frame of mind, tossing friendly and fairly clever quips back at the physicians, nearly all of whom he had known during some of his many admissions to various hospitals.