The Mask of Sanity

by Hervey Cleckley

  Through the writings of Jonathan Swift excellent illustration is given of a peculiar distortion of those sympathetic relations which constitute the very essence of biology. It is not the charm of a lovely woman that attracts Swift’s attention but the fact that she has sweat pores, excretions. Similar pathologic preoccupations with decay have also been noted by Havelock Ellis and cogently discussed.74,75 To the psychopath the basic axioms of life must seem different from what they seem to normal people and also very different from what they seem to people with severe obsessive disorders. Obsessive patients, according to the concept of Straus, are unable to appreciate what is normally obvious about many positive aspects of experience. This underlying and often unrecognized attitude can be better illustrated than described. Let us consider briefly an item that is vividly pertinent:

  A young man who apparently was not quite happy in his marriage had been seen occasionally with other women. According to rumor he had been or was about to be unfaithful to his wife. A cousin, also married and a few years older, was, in my presence, attempting to bring the other fellow to his senses. The counselor was a man of remarkable learning and intellect. He did not approach the problem by harping on conventional morality or the personal injustice that the other’s wife might be done. Maintaining a light touch, half-teasing in his remarks but also seriously trying to be helpful, he spoke of how often young married men drift astray. He made, in a playful, unmoralizing style, some good arguments for avoiding adultery. Then, as if to diminish the temptations which he felt might be troubling the young man, he said: “Remember that when you kiss a girl you are sucking on the end of a tube twenty-five feet long and that the other end is filled with ____.”*

  Exposition or further discussion can contribute little or nothing to the remark as it stands. Whether the estimated length of the gastrointestinal tract is accurate or not has little pertinence. No one can argue with the literal truth of the counselor’s statement. But who can avoid wondering about what might have led to the arrival at such a conception of a woman’s kiss? And to such a response to such a stimulus?

  What Straus and Havelock Ellis have brought out is not discernible in the reactions of the psychopath. It is, as a matter of fact, somewhat veiled in the reactions of most obsessive patients. Observation of the psychopath makes it increasingly plain, however, that he is not reacting normally to the surroundings that are ordinarily assumed to exist. I cannot clearly define the specific milieu which such a patient encounters and to which his reactions are related. There is much to suggest that it is a less distinctly or consistently apprehended world than what Straus describes as the inner world of the obsessive patient. It is my belief that it may be a world not less abnormal and perhaps more complexly confusing. We should remember, however, that we have no direct evidence to prove that a deficiency or distortion of this sort exists in the unconscious core of the psychopath. We can only say that his behavior strongly and consistently suggests it. This discussion has been based, of course. on a hypothesis that the psychopath has a basic inadequacy of feeling and realization that prevents him from normally experiencing the major emotions and from reacting adequately to the chief goals of human life.

  There are other theories that attempt to explain the disorder without taking into consideration the question of such a defect. Alexander has assumed that the psychopath’s behavior arises from forces similar to those which in the psychoneurotic are by many believed to be the fundamental cause of his distressing symptoms.9,11 Postulating unconscious conflict and repressed impulses also in the psychopath, he was led to believe that the antisocial, unprofitable, and self-damaging acts of the psychopath are purposive and unconsciously motivated expressions of the conflict. In the classic neurosis, subjective symptoms develop and the patient complains of weakness, headache, or obsessions or develops compulsive rituals, conversion paralysis, blindness, and so on. As these manifestations are thought by some to be reactions of the organism to inner stress, reactions that serve the purpose of protection, relief of anxiety, and gratification (by substitution or displacement) of rejected or frustrated impulses, so, too, according to Alexander, the pathologic behavior of the other type of patient is an acting out of impulses similarly neurotic. Thus interpreted, the psychopath has, in a sense, genuine and adequate reasons (like the neurotic for his symptoms) for the apparently foolish and uncalled-for things he does that damage himself and others. He himself does not know the reasons or clearly recognize his aims or the real nature of the impulses, and his acts do not constitute a wise solution for his problem; but the acts, according to Alexander, are purposive. This concept of the psychopath as acting out the neurotic problem (in contrast with the more passive development of ordinary symptoms) has been accepted by many psychoanalysts.79,180,188,207 It is an interesting concept, but it rests chiefly on psychoanalytic theories and assumptions about the unconscious and not upon regularly demonstrable evidence.

  Some interpretations of schizophrenia79 assume that it is largely through the relatively undamaged remnants of the personality that the positive features of the psychosis emerge. If the process is complete, if the personality has, so to speak, entirely dissolved in the underlying id, the machinery to express most of the usual symptoms will be lacking. In response to stress and conflict, what remains of the personality produces, by familiar mechanisms, most of what is generally regarded as characteristic of the disorder. The more fundamental feature, and the one that particularly distinguishes schizophrenia from the psychoneuroses, is the disintegration of the personality.87 In the psychopath we maintain there is also a generalized abnormality or defect of the personality that can be compared with schizophrenia and contrasted with ordinary psychoneurosis (in which the personality is “intact” and the organism maintains “sane” social relations). It cannot be said that the disorder is that of schizophrenia, but in the whole of the patient’s life we find such inadequacy of response, such failure of adaptation, that it seems plausible to postulate alterations more fundamental and more extensive than in classic psychoneurosis.

  Beyond the symptomatic acts of the psychopath, we must bear in mind his reaction to his situation, his general experiencing of life. Typical of psychoneurosis are anxiety, recognition that one is in trouble, and efforts to alter the bad situation. These are natural (“normal”) whole personality reactions to localized symptoms. In contrast, the severe psychopath, like those so long called psychotic, does not show normal responses to the situation. It is offered as an opinion that a less obvious but nonetheless real pathology is general, and that in this respect he is more closely allied with the psychotic than with the psychoneurotic patient. The pathology might be regarded riot as gross fragmentation of the personality but as a more subtle alteration. Let us say that instead of macroscopic disintegration our (hypothetical) change might be conceived of as one that seriously curtails function without obliterating form.

  In addition to outwardly visible demolition or shattering in material structures, other changes may occur. These may be intracellular and leave the appearance unchanged but greatly alter the substance. Colloidal variations in concrete may rob it of its essential properties although the appearance of the material remains unaltered. Steel under certain conditions is said to crystallize and lose much of its strength. The steel so affected looks the same as any other, and no outer evidence of the molecular rearrangement which has so greatly altered the substance can be detected. For the purpose of analogy, one can consider not only intracellular or molecular but also intramolecular changes. Let us think of the personality in the psychopath as differing from the normal in some such way. The form is perfect and the outlines are undistorted. But being subtly and profoundly altered, it can successfully perform only superficial activities or pseudofunctions. It cannot maintain important or meaningful interpersonal relations. It cannot fulfill its purpose of adjusting adequately to social reality. Its performance can only mimic these genuine functions.

  Karl Menninger, in Man Against Himself,207 pic
turesquely developed the argument that antisocial behavior sometimes represents an indirect search for punishment, a veiled but essentially self-destructive activity. The hypothesis of an active “death instinct” advanced by Freud is, in this dramatic study, applied to many types of disorder.8,87 In localized symptoms, as well as in broad maladjustments, self-damaging impulses are interpreted as fulfilling their negative purpose.

  In the patients presented here the general pattern of life seems to be more complex. Although thefts are sometimes committed, checks forged, and frauds perpetrated under circumstances that invite or even assure detection, similar deeds are also frequently carried out with shrewdness and foresight that are difficult to account for by such an interpretation. It is also characteristic for the real psychopath to resent punishment and protest indignantly against all efforts to curtail his activities by jail sentences or hospitalization. He is much less willing than the ordinary person to accept such penalties. In the more circumscribed symptoms of acting out, in many of the disorders referred to by Fenichel79 as impulse neuroses, the unconscious but purposive quest for punishment might more plausibly be conceived of as a major or regular influence.247 The validity of such an assumption, however, whether or not it is plausible, must be determined by what actual evidence can be produced to establish it, and not by mere surmises and inferences about what may or may not be in the unconscious.

  64. Aspects of Regression

  The persistent pattern of maladaptation at personality levels and the ostensible purposelessness of many self-damaging acts definitely suggests not only a lack of strong purpose but also a negative purpose or at least a negative drift. This sort of patient, despite all his opportunities, his intelligence, and his plain lessons of experience, seems to go out of his way to woo misfortune.47 The suggestion has already been made that his typical activities seem less comprehensible in terms, of life-striving or of a pursuit of joy than as an unrecognized blundering toward the negations of nonexistence.8,207

  Some of this, it has been suggested, may be interpreted as the tantrum, like reactions of an inadequate personality balked, as behavior similar to that of the spoiled child who bumps his own head against the wall or holds his breath when he is crossed.

  It might be thought of as not unlike a man’s cutting off his nose to spite not only his face, but also the scheme of life in general, which has turned out to be a game that he cannot play. Such reactions are, of course, found in nearly all types of personality disorder or inadequacy. It will perhaps be readily granted that they are all regressive. Behavior against the constructive patterns through which the personality finds expression and seeks fulfillment of its destiny is regressive activity although it may not consist in a return, step by step, or in a partial return to the status of childhood and eventually of infancy. Such reactions appear to be, in a sense, against the grain of life or against the general biologic purpose.

  Regressive reactions or processes may all be regarded as disintegrative, as reverse steps in the general process of biologic growth through which a living entity becomes more complex, more highly adapted and specialized, better coordinated, and more capable of dealing successfully or happily with objective or subjective experience. This scale of increasing complexity exists at points even below the level of living matter. A group of electrons functioning together make up the atom which can indeed be split down again to its components. The atoms joining form molecules which, in turn, coming together in definite orderly arrangement, may become structurally coordinating parts of elaborate crystalline materials; or, in even more specialized and complex fashion, they may form a cell of organic matter. Cells of organic matter may unite and integrate to form the living organism we know as a jellyfish. Always the process is reversible; the organic matter can decompose back into inorganic matter.

  Without laboriously following out all the steps of this scale, we might mention the increasing scope of activity, the increasing specialization, and the increasing precariousness of existence at various levels up through vertebrates and mammals to man. All along this scale it is evident that failure to function successfully at a certain level necessitates regression or decomposition to a lower or less complicated one. If the cell membrane of one epithelial unit in a mammalian body becomes imporous and fails to obtain nutriment brought by blood and lymph, it loses its existence as an epithelial cell. If the unwary rabbit fails to perceive the danger of the snare, he soon becomes in rapid succession a dead rabbit, merely a collection of dead organs and supportive structures, protein, fat, and finally, inorganic matter. The fundamental quest for life has been interrupted, and, having been interrupted, the process goes into reverse.

  So, too, the criminal discovered and imprisoned ceases to be a free man who comes and goes as he pleases. A curtailment in the scope of his functioning is suffered—a regression in one sense to simpler, more routine, and less varied and vivid activities. The man who fails in another and more complex way to go on with life, to fulfill his personality growth and function, becomes what we call a schizophrenic. The objective curtailment of his activities by the rules of the psychiatric hospital are almost negligible in comparison with the vast simplification, the loss of self-expression, and the personal disintegration which characterize his regression from the subjective point of view. The old practice of referring to the extremely regressed schizophrenic as leading a vegetative existence implies the significance that is being stressed.

  Regression, then, in a broad sense may be taken to mean movement from richer and more full life to levels of scantier or less highly developed life. In other words, it is relative death. It is the cessation of existence or maintenance of function at a given level.

  The concept of an active death instinct postulated by Freud87 has been utilized by some8,207 to account for socially self-destructive reactions. I have never been able to discover in the writings of Freud or any of his followers real evidence to confirm this assumption. In contrast, the familiar tendency to disintegrate, against which life evolves, may be regarded as fundamental and comparable to gravity. The climbing man or animal must use force and purpose to ascend or to maintain himself at a given height. To fall or slide downhill he need only cease his efforts and let go. Without assuming an intrinsic death instinct, it is possible to account for active withdrawal from positions at which adaptation is unsuccessful and stress too extreme.

  Whether regression occurs primarily through something like gravity or through impulses more self-contained, the backward movement (or ebbing) is likely to prompt many sorts of secondary reactions, including behavior not adapted for ordinary human purposes but instead, for functioning in the other direction. The modes of such reactivity may vary, may fall into complex patterns, and may seek elaborate expression.

  In a movement (or gravitational drift) from levels where life is vigorous and full to those where it is less so, the tactics of withdrawal predominate. People with all the outer mechanisms of adaptation intact might, one would think, regress more complexly than can those who react more simply. The simplest reaction in reverse might be found in a person who straightway blows out his brains. As a skillful general who has realized that the objective is unobtainable withdraws by feints and utilizes all sorts of delaying actions, so a patient who has much of the outer mechanisms for living may retire, not in obvious rout but skillfully and elaborately, preserving his lines. The psychopath as we conceive of him in such an interpretation seems to justify the high estimate of his technical abilities as we see them expressed in reverse movement.

  Unlike the general with the retreating army in our analogy, he seems not still devoted to the original contest but to other issues and aims that arise in withdrawal. To force the analogy further we might say that the retiring army is now concerning itself with looting the countryside, seeking mischief and light entertainment. The troops have cast off their original loyalties and given up their former aims but have found no other serious ones to replace them. But the effective organization and all of the
technical skills are retained.

  F. L. Wells has expressed things very pertinent to the present discussion. A brief quotation will bring out useful points:294

  The principle of substitutive reactions, sublimative or regressive in character, has long been known, but Kurt Lewin’s (1933) experimental construction of the latter is especially apt, if not unquestionable mental hygiene. A child, for example, continually impelled to open a gate it is impossible for him to open, may blow up in a tantrum, grovel on the ground, till the emotion subsides sufficiently for him to become substitutively occupied, as with fragments of gravel and other detritus he finds there, by which he forgets his distress about the gate. Lewin, perhaps unaware of the status of this and allied observations (and their symbols) in psychiatric history, gives it the name “going out of the field”: the background is that enunciated by Woodworth and by James before him, not to say Adolf Meyer, Janet, Jung, and the psychoanalytic group generally. The human personality has the adaptive property of finding satisfactions at simpler levels when higher ones are taken away, fortunately so if this keeps him out of a psychosis, otherwise if it stabilizes him in contentment at this lower level (“going native”) or if the satisfactions cannot be found short of a psychosis (MacCurdy, 1925, p. 367). All such cases have the common regressive factor of giving up the higher-level adjustment (opening the gate) with regressive relief at a lower level (playing with the gravel).

  Another illustration given by Wells emphasizes features of the concept that are valuable to us:291

  Consider, for example, the group of drives that center about the concept of self-maintenance, the “living standards” of civilization. This means the pursuit of the diverse means to surround oneself with the maximum of material comfort in terms of residence, food, playthings, etc., for the purchase of which one can capitalize his abilities. That the normal individual will do this to a liberal limit is taken in the local culture as a matter of course, probably more liberally than the facts justify. For this pursuit involves a competitive struggle beset also with inner conflicts (e.g., ethical), which by no means everyone is able to set aside. Among regressions specific to this category are those undertakings of poverty common to religious orders, but this regression is quite specific, since these orders often involve their members in other “disciplines” from which the normal individual would flee as far (Parkman, 1867, Chap. 16). It is quite certain, though hard to demonstrate objectively, that many an individual in normal life regresses from these economic conflicts only in less degree. He does not take the vow of poverty like the monastic, nor does he dedicate himself to the simplified life of the “South Sea Island” stereotype, but he prefers salary to commission, city apartment to suburban “bungalow,” clerical work to (outside) sales.