The Mask of Sanity. Hervey M. Cleckley

      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 failure 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 where a psychotic patient lay in a continuous bath. He did not try to injure the man seriously, 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 medico-legal 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, one might say, why not let these people out of the mental hospitals and leave them 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 very serious crimes. 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, 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, annoyed other guests by trying to borrow money, sponge on them for a meal, sell them something useless or non-existent, etc. 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 pretences, ran up debts without regard to the possibilities of payment, 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, short-changing, and various types of fraud, sharp practice, and connivance, that exist on the fringe of more or less 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 divers 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, floated little loans, etc., joined others swindled or defrauded in small matters and took their problems up 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