The Mask of Sanity. Hervey M. Cleckley

An effort was made to see if this rational and intelligent man, even though he failed seven times, seventy times, and seven times seventy times, might at last achieve a positive reaction to indefatigable forgiveness and succeed in finding some way to exist without supervision as incessant as that required by a traditional madman. Little or no hope was held that he might leave the hospital and live as a normal man; but something would have been gained if, still sheltered in a psychiatric hospital, he could enjoy the freedom of the grounds and an occasional pass into town.

      Be it noted that during seven years of psychiatric study and observation he had never shown any sign technically regarded as indicating a psychosis. That is to say, he was always entirely rational in conversation, alert, above average in intelligence by psychometric tests, free from delusions and hallucinations, and had not shown the slightest evidence of “deterioration.” Nor had he ever shown retardation, a true depression of the cyclothymic type, increased psychomotor activity, flight of ideas, or any other condition which it is permissible to class as psychosis. He had been free also from any symptom characteristic of a psychoneurosis.

      During his long and frequent periods within closed wards he was superficially agreeable to his physicians most of the time but extremely fretful about his confinement. He spoke eloquently of having learned his lesson and always pressed his request for parole or discharge with good logic. Once after making an especially convincing plea for freedom and with the possibility of parole within the next few days, he succeeded during the night in obtaining whiskey by lowering on a cord an empty Coca-Cola bottle which he had obtained and which some confederate filled for him. He at once proceeded to get rather high in the dead of night to the great astonishment of the attendants, who had regarded him as a “sane” man but who were now at a loss to understand his senseless guffaws, sudden maudlin outcries, and impulsive lurches about the ward. Not realizing that he could possibly have obtained liquor, they feared for a moment that he must have developed an ordinary psychosis. On being approached he cursed, sobbed feebly, and was brought back to bed, passing intestinal gas with frequent loud and unpleasant effects, grinning almost triumphantly at the nurse who had hurried to him at each detonation.

      The next morning he admitted the drinking after being confronted with the Coca-Cola bottle to which the string was still attached. He was at first superficially penitent but soon could be seen to show pleasure at his cleverness, which he seemed to feel afforded just cause for a bit of gloating. He seemed to have no deep sense of regret and could not understand why the episode delayed his parole. He became, indeed, definitely vexed and talked incessantly for a day or two about his failure to get a square deal.

      This patient, entirely sane by orthodox psychiatric standards, having spent the better part of seven years closely confined among other men who, to him as to any layman, were unmistakable lunatics and nowise agreeable company, was given another series of chances to win his freedom.

      The opinion has often been expressed that the psychopath, who in some ways seems to behave like a badly spoiled child, might be helped if he could be put in a controlled situation and allowed to feel the unpleasant consequences of his mistakes or misdeeds regularly, as he commits them.

      With this patient such a policy was pursued and the effort was protracted to remarkable lengths. Such a plan of treatment or re-education perhaps may accomplish a good deal with some patients of this type. With Arnold it yielded no discernible fruits.

      His parole was restored time after time. He expressed a clear understanding that he was obligated not to leave the hospital grounds. Each time, in accordance with his past behavior, he would promptly disappear. After a few hours, several days, or perhaps a week, the police would call to say they had him in custody. Back on his ward he seemed properly regretful and immediately expressed confidence in himself, explaining that the last misadventure had served as the lesson he needed. He was soon allowed to go out on the grounds again. Two or three small acts of defrauding, the temporary misappropriation of an automobile (which he would usually abandon after his whim for a ride had been fulfilled), or some other succession of deeds incompatible with parole status always brought him back under strict supervision. After a short time he was given still another trial.

      He spoke fulsomely of the handsome treatment he was receiving, protested an earnest affection for his physician, and swore staunchly that he would justify this faith shown in him. Always he seemed entirely sure that his difficulties were a thing of the past. Unlike the patient whose behavior is distorted by compulsion in the ordinary sense, he showed no evidence of a struggle, no awareness of anything that gave him doubt about his future success in achieving what he planned.

      This alert, intelligent man remained always free from confusion, from any indication of powerful impulses or yearnings, from all conscious influences that might account for his spectacular failure to gain freedom. He expressed eloquently very natural desires to live an unrestricted life outside his familiar wards where he was locked in with very psychotic men. He mentioned no force or conflict, in many long interviews, that might make it difficult for him to conduct himself in a way that would bring him release from hospitalization. He denied experiencing the slightest pleasure from alcoholic beverages. And, indeed, he always seemed miserable, melancholy, and quite unlike his usual buoyant self when he had partaken of drink.

      He did sometimes, as a matter of fact, continue ten days or two weeks without mishap. At his own request he was detailed to help the attendants on the infirmary ward, which he did ably, faithfully, and apparently with interest. A merry, rather witty person, he freely admitted that he had made a fool of himself and a mess of his life, but always maintained that he would never again break his word, which he had given not to drink, not to stay out beyond the limits of a pass, and not to violate any other hospital regulations. He was usually friendly and courteous to his physician and to other personnel and went out of his way to be attentive to physically ill patients, apparently taking mild pleasure in any kindness he could do them.

      He continued to request a pass to go downtown, but seldom insistently, often smiling or laughing with apparent relish as he admitted that his past performances did not justify the further confidence he begged. It was an academic point, apparently, this admitting of fault or guilt. It seemed more an expression of being polite and proper than anything indicative of comprehension about cause and effect. But he made these gestures attractively. His characteristic approach was tentative and with what looked like a dash of humor at his own expense.

      One Sunday morning he was given a pass after he had made a special point that he wanted to attend church. Arnold did not return. Some of the hospital attendants on their way home that night found him several miles out in the country staggering about in the rain on a lonely road, his trousers hanging down about his heels, seriously impeding his progress and tripping him from time to time into the ditch where he rolled and thrashed, hallooing wildly or cursing in aimless violence. Soaking wet, covered with mud and vomitus, he was brought back to the hospital.

      The next morning he faced his physician with a hangdog expression through which a merry glance soon darted. Smiling, he lightly damned himself for the worst sort of fellow imaginable and swore good-humouredly that he had learned his lesson. Within a week parole was restored and shortly thereafter he celebrated his freedom by somehow obtaining whiskey without leaving the grounds and hobbling into the recreation building, where a dance was in progress, a picture of agitated dejection. He stumbled about in purposeless lunges, eyes rolling, mouth open and drooling saliva, then collapsed sensationally on the floor before attendants could seize him.

      These episodes are entirely typical of his last few months in the hospital. During this time a limited degree of freedom was restored to him within a few days after each episode and each time he failed as promptly and as spectacularly as in the incidents described above. Altogether he was arrested some dozen or more times during this short period, nearly always within a few hours after leaving the hospital grounds.

      He had frequent superficially serious talks with his physician in which he expressed despair over his situation, remorse for his all but incredible record as a failure, and a quick, cheerful confidence in his future. What might be called a thin and bright surface of sincerity which is hard to indicate without paradox seemed to distinguish him from his fellows who are also described in this work. This quality, not in the simplest sense false, seemed not only consistent but almost complete.