The Mask of Sanity

by Hervey Cleckley

  Though occasionally confused after heavy drinking (perhaps with the addition of drugs), he has at all other times been entirely rational, alert, shrewd, and free from delusions and hallucinations.

  Early in Frank’s career his disturbance was diagnosed on several occasions as hysteria, sometimes as both psychopathic personality and hysteria. Once he was given a diagnosis of psychopathic personality with psychotic episodes. There was not, however, any evidence of behavior or symptoms different from what he has shown on other occasions. There is reason to suspect that the real and pressing need to keep this patient hospitalized may have played an important part in his being so classified. The genuinely irrational and incompetent behavior, no doubt, supports the use of such a term as psychosis, despite the lack of any additional symptoms.

  The irrational behavior which has characterized him is not based on a delusional system or on any loss of the good reasoning ability he shows on examination. Some of his most turbulent misconduct has, of course, been exhibited while he was intoxicated. At such times he naturally lacked his customary shrewdness and alertness. However, this cannot conscientiously be called a psychotic episode beyond and above his well-known inadequacy but rather the manifestation of inebriety. I do not mean to say that this man is normal but only that he has none of the recognized types of mental disorder, episodic or constant. If his drunken and wayward episodes are to be termed psychotic, then it would seem that his state at other times might also be termed psychotic, since it is in his shrewd, technically sane condition that he decides to add the picturesque touches of intoxication which he well knows will bring him to the attention of the police.

  At this hospital, at the state hospitals, and at the other institutions to which Frank was sent in recent years, he has been considered a sane man without psychotic episodes. The symptomatic diagnoses of drug addiction and chronic alcoholism have been added. During all these years he has shown no evidence of deterioration or regression, and today at 38 years of age he is the same clever, alert person he was described as being twenty years ago. Unlike nearly all real morphine addicts, he does not show ordinary withdrawal symptoms or other signs of physical illness and acute distress when, after being admitted to the hospital, he is deprived of opportunities to obtain the drug.

  If the reports that he takes morphine have any factual basis, such use must be sporadic. There is little or no evidence that effects of the drug have regularly played any major role in his behavior. It appears that his chief connection with drugs has been through his part in peddling them illicitly.

  His career in the hospital has been marked by frequent paroles which are always terminated by his failing to return, returning drunk, or being taken up by the police for petty theft, swindling, and futile and unprovoked disorder. Though ingratiating and outwardly cooperative when he is trying to obtain parole or discharge, he constantly schemes to escape or, surreptitiously, to call upon high authorities to have him released. Once, while helping attendants on the disturbed ward, he succeeded in turning hot water into a tub in which a psychotic patient lay in a continuous bath. He did not try to injure the man seriously, but merely to hurt him a little as a joke. This is a fair example of the inane, humorless mischief that underlies the pretentious front assumed by this former pastor.

  Despite his medicolegal status, which, of course, is technically regarded as constituting sanity, those interested in finding some practical way to protect him and his family and to cope with the ever accumulating problems succeeded on one occasion in having him committed by the court. Those close to the situation evidently found in his behavior reasons for action more compelling than the abstract criteria which stood in the way of such a step. After being held in the hospital for several months, despite his reiterated demands for discharge against medical advice, he called in an attorney.

  Frank had in the past always found no difficulty in leaving when it suited his purpose or his whim. In view of his well-demonstrated inability to live in freedom, he was now, by means of the legal commitment, kept against his wishes in order to spare his family, the community, and himself the hardships he had brought about before and was sure to bring about again. The attorney for the government, in attempting to resist habeas corpus proceedings, found himself in a familiar dilemma, as the following quotations from his letter will show:

  It is evident that the medical staff at the hospital are using the term insane to convey the meaning of the medical definition of the word rather than the legal definition. In other words, the thought back of the use of the word appears to me to be that it is the opinion of neuropsychiatrists that this man is not suffering from a mental disease as physicians understand the term, that he does not have a psychosis. It does appear, however, that it is their opinion that the state of his mind due to drug addiction and also manifested by his past antisocial behavior is such as to warrant the conclusions that he is incompetent and that he should receive treatment in a hospital for the cure of nervous and mental diseases. To say, however, that he is incompetent but not insane presents a rather inconsistent picture with which to go into court. We may be confronted with such a question as why he needs to be in a hospital for the care of nervous and mental diseases if he has no nervous or mental disease.

  I am inclined to think that the terms insanity and incompetency so far as their legal significance is concerned are used interchangeably and that the important point to be considered, whether you call a man insane or merely admit that he is incompetent, is whether the person is incapable of administering his personal estate in the normal manner of a prudent man and whether there is definite evidence of a more or less prolonged departure from normal behavior as compared with the standards of the community, such as dissipation of funds, unwise purchases, and utter lack of appreciation of values.

  Because of the fact that I anticipate some difficulty in trying to show that the man is incompetent but not insane, I would appreciate an expression of your views on the matter. It occurs to me also that a man ought to be confined who is a menace to others and likely to do harm to others, even though his mental condition may be due in part to inadequate mental development and in part to the use of drugs. He may be just as dangerous to himself or to others as a person suffering from a mental disease and who, according to the purely medical definition of insanity, would be pronounced insane.

  Of course, it might be asked why these people are not let out of the mental hospitals and left to the police. If they are considered responsible for their misdeeds, let them be punished. This, as a matter of fact, is what the average psychiatric hospital is nearly always forced to do, whatever its physicians may think of the wisdom and practicality of such a procedure. These men are studied, found free of recognized mental disorder which might make them unaware of what they are doing, and are sent back out into the world. They are arrested not once but many times. Most of them seldom commit such serious crimes that they are kept out of circulation in penal institutions for long periods. Only rarely can they be kept for more than a few days. They do not follow any purposive criminal life. They make a nuisance of themselves to the community as a whole and often tragically wreck the lives of those close to them, and all to no discernible end. The police and the courts tire of them. Through various influences they are forced back on the mental hospitals where they take legal action to regain their freedom, only to begin the process again.

  If, as stated in the quotations previously cited, it would be difficult to prove this man incompetent but not insane, it would be far more difficult, by existing definitions of psychiatry, to prove him “insane.” His perfectly rational (superficial) behavior under scrutiny, his freedom from delusions, his shrewdness, his alertness, and his convincing plan for a normal, useful life, in short, his plain sanity as this is ordinarily understood, make it all but impossible for a judge or a jury to call him insane. Psychiatrists, familiar with his long record of senseless behavior, are able to see more reason to do so than could be brought out before a court in terms of
abstract criteria by which the decision is determined. But according to the accepted standards of psychiatry, his diagnosis carries with it an official and automatic endorsement of the patient as sane and competent. No matter how strongly impressed by real and practical evidence to the contrary, all physicians, testifying in such a case must admit that the official technicalities approve this paradox.

  Having won his case in court, the patient was released against medical advice. Frank did not go home but remained in the city where he at once claimed the attention of the police. On being released after a few days in jail, he took a room at the best hotel and annoyed other guests by various tactics, such as trying to borrow money, sponge on them for a meal, or sell them something useless or nonexistent. He became at times loudly boastful or rowdy and eventually fell on the floor drunk. He refused to pay for his room and resisted the management’s attempts to remove him.

  He sought loans under bold-faced pretenses, ran up debts without regard to the possibilities of payment, and telephoned and wrote to his family, threatening suicide unless his demands for money were promptly met. There are indications that he was not inactive during this period in old devices of petty thievery, shortchanging, and various types of fraud, sharp practice, and connivance that exist, more or less, on the fringe of organized but illegal racketeering found in any city.

  Nothing, however, could be pinned on him by the law that led to his being effectively controlled. In all issues of this sort that arose, he had his record as a patient once legally committed and often confined to psychiatric institutions. This record was, in his ingenious hands, of considerable value as insurance against penal restraint.

  After several arrests, the police began to call on the hospital to relieve them of their problems with this man. They were told that nothing could be done since he had been legally removed and the hospital was enjoined by the court not to hold him. Soon afterward the police and various local people began to seek advice on how to deal with him from the attorney who had liberated this man.

  The patient himself soon joined in, coming repeatedly to the attorney’s office or his house, sometimes drunk and always unreasonable, to shout about the injustices of the world, borrow money, evade threatening penalties, and to demand diverse preposterous services. The veteran had promised to pay the attorney’s bill with bonus money, but now it appeared that this money had already been squandered. Hoping to collect his fee and, no doubt, from humanitarian impulses, the attorney sought to keep in touch with his client. Those with whom he had run up bills and floated little loans joined others swindled or defrauded in small matters and took up their problems with the patient’s legal representative. Soon the incessant complaints from annoyed people, the client’s own nagging or uproarious invasions upon him at all hours, and the constant queries of the police drove him to seek relief. The patient being again in jail, the attorney persuaded him to agree to return to the hospital voluntarily and pled with the physician in charge to take him back, confessing himself at fault ever to have released such a scourge on the community and on himself.

  Arrangements were made for readmission. The patient arrived in custody of a policeman. He was still somewhat stimulated from a recent intoxication but, though overbearing and pompous, showed no signs of real drunkenness nor of an officially recognized psychosis.

  Frank took a high-handed manner, swaggered about, and finally refused to come back into the hospital, saying that he had no mental disease and that he preferred to return to jail where he would soon be released to carry out important business plans and social activities. He enjoyed the incident, played up his role dramatically, and took a peremptory and haughty tone with everyone.

  He soon obtained his freedom, but some weeks later after running up big debts, giving several more bad checks, and participating in a series of senseless, bawdy escapades, he was finally returned to the hospital. Three months later he again obtained his discharge on a writ of habeas corpus but not through the same attorney. The story in its broad essentials was repeated.

  Since his last admission, following the exploits just mentioned, he has been true to form. After varying periods on a closed ward, parole has been given; he has lost it repeatedly and gone back among “demented” and helpless groups with whom he is, to say the least, not at home. He has continued at all times free from the technical stigmata of psychosis, remaining crafty, intelligent, and superficially cooperative while trying to gain his ends.

  Frank takes advantage of every opportunity to make trouble in the hospital and is rather restless and extremely dissatisfied. He sends frequent letters to women in town to whom he regards himself as paying court. These are written in a neat hand, well spelled, and well expressed and are much better letters than would be expected from a man of his education. They are marked with self-righteousness, extreme egotism, trite sentimentality, and monumental falsehood. His tone is that of a lover who regards his own passion as very high and rare.

  “Only God knows,” he writes, “why I wasn’t left over there among the poppies with my heroic buddies,” falsely describing himself as a captain in charge of 272 men. “My wife never understood me!” he complains in the same letter. What does he expect of her? The question invites meditation.

  12. Anna

  There was nothing spectacular about her, but when she came into the office you felt that she merited the attention she at once obtained. She was, you could say without straining a point, rather good-looking, but she was not nearly so good-looking as most women would have to be to make a comparable impression. She spoke in the crisp, fluttery cadence of the British, consistently sounding her “r’s” and “ing’s” and regularly saying “been” as they do in London. For a girl born and raised in Georgia, such speaking could suggest affectation. Yet it was the very opposite of this quality that contributed a great deal to the pleasing effect she invariably produced on those who met her. Naive has so many inapplicable connotations it is hardly the word to use in reference to this urbane and gracious presence, yet it is difficult to think of our first meeting without that very word coming to mind, with its overtones of freshness, artlessness, and candor.

  She had passed her fortieth birthday some months before. Neither her face nor her figure had lost anything worth mentioning. Despite her composure, she gave a distinct impression of energy and playful spontaneity, an impression of vivid youth. In response to ordinary questions about her activities and interests she spoke of tennis, riding, and reading. More specific inquiry brought out opinions on Hamlet’s essential conflict, comparison between the music of Brahms and the music of Shostakovitch, an impressive criticism of Schopenhauer’s views on women, and several pertinent references to The Brothers Karamazov. She expressed opinions on current affairs that seemed to make excellent sense and talked with wit about the cyclic changes in feminine clothes and the implications of atomic physics for the future. What she had to say was particularly interesting and she said it in just the opposite of all those many ways of talking that people call “making conversation.”

  As discussion progressed, the picture of a rather remarkable woman became more and more distinct. Here was evidence of high intelligence and of considerable learning without discernible bookishness or consciousness of being “an intellectual.” Her manner suggested wide interest, fresh and contagious enthusiasms, and a taste for living that reached out toward all healthy experience. Having a cup of coffee with her or weeding a garden would somehow take on a special quality of fun and delightfulness. Something about her over and beyond her looks prompted the estimate that she would be very likely to elicit romantic impulses, strong sensual inclinations, from most men who encountered her. Here, it seemed, was natural taste without a shadow of posed estheticism, urbanity without blunting of response to the simplest of joys, integrity and good ethical sense with the very opposite of everything that could be called priggish or smug. She showed nothing to suggest she meant to give such an impression or that she had any thought as to how she seemed.
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  Even with a detailed record of Anna’s career clearly in mind, it was difficult indeed not to come to a conclusion that all the well-authenticated facts of that record should be ignored since they were so thoroughly contradicted by the obvious character of this appealing woman. The banal but nevertheless insistent thought that such a psychiatric history must apply to some other person was hard to dismiss. Prior to this interview a great deal of trustworthy information had been made available to me. Anna’s mother and father had given her story at length. A reliable psychiatrist in whose small private hospital she had been treated on numerous occasions furnished not only an ordinary history but many details from his firsthand experience with her over the last twenty years. Her family physician had grown up in the same community with the patient and, through his personal acquaintance with her and her associates since childhood, had access to a remarkable amount of unusual information. He, as well as another medical practitioner who was also a relative, gave further details. Other sources of fact and opinion lay in several patients treated in the past whose relations with Anna at various periods of her life were significant. In the course of treatment, material had emerged in these other cases that rounded out her history and afforded additional means to evaluate her own reactions in interpersonal relations.

  It is too much of a story to tell in a chapter or in a single book. And, no matter how told, it could not be believed except by those who have already had experience over years with such patterns of behavior. Familiarity with a temporary cross section of such a life (as, for instance, during a single period of hospitalization), plus a generalized account of what preceded, would almost surely convince any psychiatrist of the diagnosis, but this would probably fail to give him the challenging sense of wonder, the awe that arises from a contemplation of the accumulated detail in its specific essence.