The Mask of Sanity. Hervey M. Cleckley

by any recognized psychosis except schizophrenia. So far as I know, there are no provisions made in any public institution for the care of even one psychopath.{‡‡}

      CHAPTER 4. METHOD OF PRESENTATION

      Before attempting to define or describe the psychopath, to contrast him with other types of psychiatric patients, or to make any attempt to explain him, I would like to present some specimens of the group for consideration.

      This procedure will be in accord with the principles of science in method at least, since, as Karl Pearson pointed out in The Grammar of Science, this method always consists of three steps:103

      1. The observation and recording of facts;

      2. The grouping of these facts with proper correlation and with proper distinction from other facts;

      3. The effort to devise some summarizing or, if possible, explanatory statement which will enable one to grasp conveniently their significance.

      Several decades ago, keeping these steps clearly in mind, Bernard Hart gave an account in The Psychology of Insanity103 of personality disorder that has, perhaps, never been surpassed for clarity and usefulness. Psychopathology has not been a static field, and many new concepts have arisen which make Hart’s presentation in some respects archaic and unrepresentative of viewpoints prevalent today in psychiatry. This point notwithstanding, the method followed by Hart remains an example of how the problems of personality disorder can be approached with maximal practicality, with minimal risks of mistaking hypothesis for proof or of falling into the schismatic polemics that, scarcely less than among medieval theologians, have confused issues and impeded common understanding in psychiatry. Without claims to comparable success in the effort to follow Hart’s method, I acknowledge the debt owed one who set so excellent an example more than thirty years ago.

      The most satisfactory way in which such clinical material could be presented is, in my opinion, as a series of full-length biographic studies, preferably of several hundred pages each, written by one who has full access to the life of each subject. Only when the concrete details of environment are laid in, as, for instance, in an honest and perceptive novel, can the significance of behavior be well appreciated. Certainly no brief case summary, and probably no orthodox psychiatric history can succeed in portraying the character and the behavior of these people as they appear day after day and year after year in actual life.

      It is not enough to set down that a certain patient stole his brother’s watch, that another got drunk in a pool room while his incipient bride waited at the altar, etc. To get the feel of the person whose behavior shows disorder it is necessary to feel something of his surroundings. The psychopath’s symptoms have been said to be primarily sociopathic.209, 210, 211 It is true that all, or nearly all, psychiatric disorder is in an important sense sociopathic, in that it affects adversely interpersonal relations. In most other disorders the manifestations of illness can, however, be more readily demonstrated in the isolated patient in the setting of a clinical examination. In contrast, it is all but impossible to demonstrate any of the fundamental symptoms in the psychopath under similar circumstances. The substance of the problem, real as it is in life, disappears, or at least escapes our specialized means of perception, when we remove the patient from the milieu in which he is to function.

      All that surrounds and has ever surrounded the schizophrenic or the man with severe obsessive illness is, of course, important to us if we seek to understand why these people became disabled. Lacking all information except what might be gained from either of these patients (with whom one is, let us say, confined in an oxygen chamber on the moon) the observer will, nevertheless, have little trouble in discerning that there is disorder, and a good deal about the general nature of the disorder.

      Aside from questions of cause and effect, we have little opportunity even to realize the existence of the subject we must deal with unless the psychopath can be followed as he departs from the (essentially in vitro) situation of physician’s office or hospital and takes up his activities in the community on a real and (socially) in vivo status.

      It is with such convictions in mind that we shall often include detail of the environment, perhaps digress to the patient’s husband or parents, report glimpses of the patient through the eyes of a lay observer, and at times attempt, from what material is available, a tentative reconstruction of situations that can be experienced adequately only at first hand. It is regrettable that so much detail of this sort is difficult and often impossible to obtain. Without a good deal of his specific surroundings in the community there is no way for more than the insubstantial image of his being, like the picture projected from a lantern slide, to reach awareness. The real clinical entity is approachable only in the unstatic, actual process of the patient’s life as he takes his specific course as a personal and sociologic unit.

      The disorder can be demonstrated only when the patient’s activity meshes with the problems of ordinary living. It cannot be even remotely apprehended if we do not pay particular attention to his responses in those interpersonal relations that to a normal man are the most profound.

      If no schizophrenic had ever spoken, we would probably have little realization of what we understand (incomplete as this is) of auditory hallucinations. The schizophrenic can, by his verbal communication, give us some useful clues in our efforts to approach many of his problems. Little or nothing of this sort that is reliable can, by ordinary psychiatric examination, be obtained from the psychopath. Only when we observe him not through his speech but as he seeks his aims in behavior and demonstrates his disability in interaction with the social group, can we begin to feel how genuine is his disorder. To study the psychopath almost entirely in the orthodox clinical setting where patients ordinarily appear is like examining the schizophrenic with our ears so muffled that his reiterated and quite honest claims of hearing voices of the dead talking to him from the sun (and from his intestines) fail to reach our perception.

      If another analogy be permitted, let us say that a pair of copper wires carrying 2,000 volts of electricity when we look at them, smell them, listen to them, or even touch them separately (while thoroughly insulated from the ground) may give no evidence of being in any respect different from other strands of copper. Let us, however, connect them to a motor (or have someone seize both of them at once) and we find out facts not to be perceived otherwise. The unmistakable evidence of electricity appears only when the circuit is made. So, too, the features that are most important in this disorder do not adequately emerge when it is relatively isolated. The qualities of the psychopath become manifest only when he is connected into the circuits of full social life.

      The sort of presentation our problem requires is, of course, impossible. In an effort, however, to give at least a vivid glimpse of the material under consideration, I have made use of a somewhat different form of report than that customarily offered.

      The impersonal and necessarily abstracted picture of these people in a purely clinical setting fails to show them as they appear in flesh and blood and in the process of living. In the restricted and arbitrary range of activities afforded by hospital life their tendencies cannot be so truly and vividly demonstrated as in the larger world. To know them adequately, one must try to see them not merely with the physician’s calm and relatively detached eye but also with the eye of the ordinary man on the streets, whom they confound and amaze. We must concern ourselves not only with their measurable intelligence, their symptomatology (or, rather, lack of symptomatology) in ordinary psychiatric terms, but also with the impression they make as total organisms in action among others and in all the nuances and complexities of deeply personal and specifically affective relations. To see them properly in such a light we must follow them from the wards out into the market place, the saloon, and the brothel, to the fireside, to church, and to their work.

      In attempting this, however incompletely and inadequately, it is perhaps desirable for us not to trade our naiveté at once for the experienced clinician’s discriminating viewpoint. Let us first watch them in their full conduct as human beings, not neglecting even the impression they make on Tom, Dick, and Harry, before trying to frame them in a scheme of psychopathology.

      The terms I shall use to describe them may often imply that they are blamed for what they do, or suggest