The Mask of Sanity

by Hervey Cleckley

  In his work, which is primarily concerned with psychopathology in general, Kahn, in accordance with established practice, lists types which have been almost universally quoted as characteristic subdivisions into which the psychopath can be classified:156

  The nervous

  The anxious

  The sensitive

  The compulsive

  The excitable

  The hyperthymic

  The depressive

  The moody

  The affectively cold

  The weak-willed

  The impulsive

  The sexually perverse

  The hysterical

  The fantastic

  The cranks

  The eccentric

  The authors whom we have quoted and briefly discussed are not responsible for the confusion that surrounds the psychopath. Such an approach to the subject was the traditional approach that for decades prevailed in psychiatry. Even the most wise and painstaking efforts cannot clarify a subject unless the subject is available. Many of the works mentioned I hold in high respect. In them other subjects are handled in such a way that those who seek reliable information can find it without undue difficulty.

  It is hoped that these points may help us keep in mind that in our attempts to understand the psychopath we must struggle not only with the intrinsic problem of trying to distinguish and evaluate a complex psychiatric disorder but also with an almost impregnable approach. To touch our subject itself we must somehow make our way through a surrounding zone dense with false or dubious assumptions, mined with terms that at the same time make sense and nonsense. The approach to our subject is, furthermore, still skillfully camouflaged by traditional influences that may, before we know it, have us talking about two or four or seven other things, no matter how earnestly we strive to speak of one at a time.

  Since the last edition of this book was published in 1964 discussion of the psychopath has continued and further attempts have been made to evaluate his status. A remarkable, and curiously misleading, presentation of the subject was offered only a few years ago by a lay writer, Alan Harrington, first in the popular magazine Playboy and later in Psychopaths, a book amplifying his theme.118

  A serious and regrettable confusion, I believe, is likely to come from opinions quoted by this author that seem very plainly to advocate that the psychopath be admired, chosen as a leader, or at least as a model for other men. Referring to one of these opinions, the author says, “The menacing psychopath is embraced. Incredibly … it seems at first shock … we are urged to turn into an ‘antithetical’ version of the outlaw and find our way to his radical vision of the universe.”118

  Some of the people quoted or cited by the author of the Playboy article (and the subsequent book) seem to be spokesmen for, or prominent figures in, the recent movement of rebellion often referred to as the counterculture. In this movement we find zealots who embrace hallucinatory confusion under the influence of potentially brain-damaging psychedelic drugs and aggressively proclaim it as religious experience. Here, too, we find the antihero, often a figure flaunting treason and dishonor along with his unkempt beard, barefootedness, and defiantly frayed blue jeans. In this so-called counterculture the antihero was not only welcomed but by some virtually enshrined. It has been fashionable also in this movement to degrade the high passion and glory of sexual love to a significance not far from that of a belch. Perhaps, in this general and heedless effort to reverse the basic values, almost anything traditionally regarded as undesirable, or despicable, might be automatically stamped with the sign of approval.

  After many quotations from people who may be reflecting elements of this movement, the author, himself, encourages us to “ask … if the psychopath’s time has come, if there may be a world-wide need for him.” He goes on to say, “Could the coming of the psychopath be a natural and inevitable result of our drastically deteriorating environment (which helps fling him up) as well as one answer to it and, who knows, a potential remedy for such deterioration?”118

  Other opinions expressed by the author include these: “Although originally founded upon an anti-social condition, it [psychopathy] offers exciting new alternatives to the way we have lived until now … the distinction blurs hopelessly between present day psychopathic patterns as observed in prisons, institutions and clinics, and equivalent behavior, which may often be put to use in good causes outside of these places … would it be best,” he asks, “to teach our children the psychopathic style in order that they may survive?” He speaks of “Brilliant individuals among us that are basing their own lives on the psychopathic model” and, referring to them, he cites the opinion that, “What was formerly diagnosed mental illness has turned into the new spirit of the age.” He seems quite serious in repeatedly asking if we should imitate the psychopath, if we should “yield to insanity accepted as normal? Cultivate one’s own latent psychopathy, perhaps trying to adapt it to good ends?” He also says, “Conceivably the times ate railing for an idealized version of the psychopath as savior.”118

  Other quotations are given from writers who claim that psychopaths should be considered as having found the great answers to life. In response to such opinions, the author asks, “Have we come to the hour of the psychopath, the advent of psychopathic man … when what was once presumed to be a state of illness is abruptly declared to be a state of health, … can it be true that, with the dramatic appearance of the psychopathic ideal, a new man has come upon us, that in order to survive the turbulent years ahead, far from seeking to treat the psychopath in clinics, we should rather emulate him, learn how to become him?”

  Such opinions as these, and many others quoted or expressed directly by the author, give rise to a number of thoughts. First, let me say that the question of whether or not it is desirable to be a psychopath seems not so much a real question as a pretext for sophistry. For a sophistry that is not only obvious but monumentally frivolous. It strongly suggests to me the sort of argument that might arise about whether or not a physician should use treatment in behalf of the patient or in behalf of the microorganisms which are in the process of killing him.

  It is true that the psychopath is extremely difficult to understand or to explain. Confusion has often arisen about just what is indicated by the term. Any reasonable sane person who feels or says that we should emulate the psychopath must, one might presume, have a poor understanding of what the term indicates and must, surely, be talking about something else. Textbooks over the years, as we know, have often listed widely differing disorders under this term. A sincere choice of the real psychopath as model or leader by anyone familiar with the Subject would be beyond absurdity.

  Even in these times of fiercely dictated permissiveness, this choice would have to be called by the currently censored, but quite accurate terms, perverse and degenerate. A true taste for the psychopath as leader or model, or as object of admiration, also suggests to me the peculiarly pathological and unappealing aestheticism of Huysmans’ fictional character, des Esseintes, who, after withdrawing from nearly all natural activities, takes another step:142

  And a pale smile hovered over his lips when finally his servant brought him a nourishing enema compounded with peptone and informed his master that he was to repeat the little operation three times every twenty-four hours.

  The thing was successfully carried out and des Esseintes could not help secretly congratulating himself on the event which was a coping stone, the crowning triumph, in a sort, of the life he had contrived for himself. His predilection for the artificial had now, and that without any initiative on his part, attained its supreme fulfillment. A man could hardly go farther; nourishment thus absorbed was surely the last aberration from the natural that could be committed.

  What a delicious thing he said to himself it would be if one could, once restored to health, go on with the same simple regime … Last but not least, what a direct insult cast in the face of old Mother Nature, whose never varying exigencies would be forever nullifie
d. [p. 325]

  The basic judgment and the moral orientation underlying a deliberate choice of the actual psychopath as model or leader could hardly deserve more consideration or respect than the judgment and orientation leading to a militant demand that Richard Speck be installed as National Supervisor of Nursing Education in the United States and that the Congressional Medal of Honor be awarded to the Boston Strangler.

  28. Clarifying the Approach

  In spite the difficulties that have been discussed, efforts to study the psychopath have proceeded. No drastic change in the official psychiatric attitude has occurred, and no step has been taken to make it possible to deal satisfactorily with the disorder by medical methods. But information has been accumulating that may someday bring this about.

  The studies of Partridge have been valuable in focusing attention on the type of patient who needs attention as a separate entity rather than in a confused group. In his writing can be found a discernible and well-presented clinical picture. Partridge’s three general types include only psychopaths, and the relatively modest distinctions among them impress us as valid rather than imaginary. Here, too, we find a clear rejection of the time-honored assumption that psychopaths are marked by gross physical defects and “stigmata of degeneration” and that this disorder has been satisfactorily related to inborn defects. This valuable contribution, though largely ignored by many authorities, merits recognition today.233,234,235,236

  Long ago, when the psychopath was, even more than at present, confusingly submerged in a nonspecific category (known only by terms applied also to a wide variety of gross physical defect states), Healy and those who worked with him began to emphasize the purposive or reactive nature of antisocial behavior.9,124,125 Careful attention was given to the emotional deprivations and distortions of aim that lay behind maladapted acts, and evidence of influences essentially psychogenic were noted and evaluated.

  In work with juvenile delinquents, Healy pointed out that under similar conditions of insecurity or emotional deprivation one child might show anxiety and passive withdrawal and another, aggressive mischief, apparently in response to the personal stress. These observations have been helpful over the years in efforts to interpret and to deal with behavior disorder.

  Although relatively neglected for a long period by those concerned with interpretive or causal as contrasted with simply descriptive formulations, the psychopath received attention from Alexander, who makes an interesting contrast between ordinary neurosis, in which repressed impulses find a symbolic or substitutive expression in subjectively unpleasant symptoms, and character neurosis, in which the unconscious drives are believed to appear in maladapted objective behavior. In both disorders unconscious conflict is postulated. In orthodox neurosis this conflict may give rise to conscious anxiety without visible source, or impulses (repressed and ungratified) may be manifested indirectly by displacement (as in obsessions and compulsions), or otherwise (as in conversion paralysis and anesthesia). In character neurosis, according to Alexander, unconscious impulses obtain a degree of fulfillment in another manner, by a pattern of pathologic behavior in which apparently purposeless and sometimes self-defeating and social acts are carried out persistently. This pattern is followed despite penalties and in the absence of adequate conscious incentive.9,11,12 This formulation has attracted much popular interest.

  Alexander maintained, and many of his followers still maintain, that antisocial conduct often represents an unconscious but purposive effort to obtain punishment in order to expiate and gain relief from (unconscious) feelings of guilt. As a hypothesis this is indeed ingenious and appealing. It has attracted many adherents. I have not been able, however, to discover such a sense of guilt or remorse (conscious or unconscious) in any of the psychopaths I have studied. Nor have I seen any convincing evidence of such unconscious guilt revealed in the work of Alexander or of other observers who accept his formulation. Such guilt is often assumed but, so far as I know, never demonstrated. I must therefore remain skeptical of this popular interpretation, however pleasant it might be to solve the problem of the psychopath by an interpretation so simple and so graceful.

  The more experience I have had with psychopaths, the stranger it has seemed to me that a theory should insist that they have such deep and influential unconscious feelings of guilt when they are at the same time so plainly callous and free from remorse about grievous wrongs and crimes that they clearly recognize as their own. It strikes me as a quaint fantasy to assume without real evidence that they unconsciously go to such pains to obtain punishment and win redemption for unknown sins when they plainly and glibly ignore responsibility for every known misdemeanor and felony and pride themselves in evading penalties and in flouting the basic principles of justice.

  The term neurotic character adopted by Alexander to designate the psychopath, although it may be of value in suggesting belief in a psychogenic etiology, is not conducive to progress in dealing with our problem. This point has been well emphasized by Karl Menninger in a discussion of the practical need of a new official name for the psychopath.208 As pointed out by Menninger, the word character in such a use offers possibilities of confusion, if one patient has a neurotic character and another a neurotic personality, then just what is a character? And just what is a personality? And just how do they differ? There is, we may emphasize again, a considerable possibility of arousing the ghosts of a faculty psychology in the use of these terms.

  Menninger makes another point in speaking of neurotic character that I believe is of essential importance. “The condition” he writes, “is closer to a psychosis than to a neurosis and the term neurotic is, therefore, misleading.”208

  A helpful study of the psychopath by Henderson presented in the Salmon Lectures (1938) and subsequently published128 called attention to the seriousness of the problem. From this presentation the reader is able to get clear ideas about actual patients as they appear clinically and the need for better methods of handling them.

  Over a period of several decades Karpman also called attention to the psychopath, pointing out how little serious effort has been made by psychiatrists to understand or to deal with the essential problem. He maintained that psychogenic factors are responsible for the behavior disorder in many instances and believed that most patients classified as psychopathic personality should be called neurotic. A small residue of patients for whom he proposed the term anethopath, are, in Karpman’s opinion, essentially unlike the others in that they are disabled by intrinsic defect rather than by dynamic psychopathologic reactions.160,161,162,163,164

  In these studies the very great egocentricity, the inability to form any important or binding attachment to another, the failure ever to realize and grasp the very meaning of responsibility, all features that I believe to be most essential, are emphasized by Karpman and made clear as seldom done in other literature on the psychopath. It is doubtful if anyone else has done more to elucidate this psychopathologic picture and similar antisocial behavior disorders.

  In the system of classification that prevailed when the first two editions of this book were prepared, the diagnosis of psychopathic personality was listed among those conditions considered as being “without mental disorder.” In the New York State Department of Mental Hygiene Outlines for Psychiatric Care the general term was subdivided as follows:225

  Psychopathic personality

  With pathologic sexuality. Indicate symptomatic manifestations, e.g.: homosexuality, erotomania, sexual perversion, sexual immaturity.

  With pathologic emotionality. Indicate symptomatic manifestations, e.g.: schizoid personality, cyclothymic personality, paranoid personality, emotional instability.

  With asocial or amoral trends. Indicate symptomatic manifestations, e.g.: antisociality, pathologic mendacity, moral deficiency, vagabondage, misanthropy.

  Mixed types.

  The first division, pathologic sexuality, will be discussed in Chapters 37 and 59.

  Suffice it to say here that only th
e last term, sexual immaturity, has been characteristic of our group.

  In the second division, pathologic emotionality, the schizoid, cyclothymic, and paranoid personalities are regarded as relatively mild and relatively static deviations of the same types familiar in schizophrenia, manic depressive psychosis, and paranoid psychosis. Their disorder or disability is very different clinically from that discussed in this volume. The typical psychopath shows little or no indication of suffering from a deviation in the direction of such a disorder as schizophrenia, manic-depressive psychosis, or paranoia but shows a disorder quite different. Characteristic schizoid or cyclothymic traits are not discernible features of the psychopath. Although psychopaths tend to blame their troubles on others, they do not, like patients with real paranoid deviation, organize and persistently follow out highly purposive plans or hold tenaciously to strong affective attitudes. Emotional instability is, in a shallow sense, applicable to the psychopath, but this quality scarcely seems an outstanding or fundamental deviation. Many, as a matter of fact, show less evidence of anxiety, uneasiness, and other reactions implied by emotional instability than the average person.