Читать книгу The Mask of Sanity - Hervey M. Cleckley - Страница 12

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 an attitude of distaste or mockery for some of their behavior. Many psychiatrists still regard such patients, unlike those suffering from ordinary psychoses, as “totally responsible” for their misconduct and their difficulties. As this volume will subsequently show, I do not share such an attitude. The faulty reactions in living which these patients show are, however, difficult to describe without sometimes using terms that come more readily to moralists or sociologists or laymen than to psychiatrists. The customary psychiatric terminology does not, I believe, offer a range of concepts into which we can fit these people successfully.

With other patients whose disorder is frankly recognized we can, by our impersonal and specifically medical language, communicate fairly well to each other what we have observed. Some aspects of the psychopath which elude such language may be reflected, however imperfectly, in the simplest accounts of direct impression by those who have been closest to him and felt the impact of his anomalous reactions. For these reasons, then, and with apology, reference may be made to some actions as outlandish, foolish, fantastic, buffoonish, etc.

The chief aim of the present work is to help, in however small a way, to bring patients of this sort into clearer focus so that psychiatric efforts to deal with their problems can eventually be implemented. It has, of course, been necessary and in every way desirable to eliminate all details that might lead to the personal identification of any patient whose disorder has been studied and recorded. AH patients referred to have been carefully shielded from recognition. It is nevertheless true that the psychopath engages in behavior so unlike that of others and so typical of his disorder that no act can be reported of a patient from Oregon seen ten years ago without strongly suggesting similar acts by hundreds of psychopaths carried out in dozens of communities last Saturday night. I can only express regret to the scores of people whose sons, brothers, husbands, or daughters, I have never seen or heard of, but who have, no doubt, reproduced many or perhaps all of the symptoms discussed in this volume. This disorder is so common that no one need feel that any specific act of a psychopath is likely to be distinguishable from acts carried out by hundreds of others.

In discussing the possible influence of environment on the development of this disability, I hope I will not promote unjustified regret or remorse in any parent. Hundreds of times fathers and mothers have discussed their fear that some error or inadequacy on their part caused a child to become a psychopath. Most parents of such patients personally studied impress me as having been conscientious and often very kind and discerning people. As will be brought out later, I do not believe obvious mistreatment or any simple egregious parental errors can justifiably be held as the regular cause of a child’s developing this complex disorder. All parents, no doubt, make great as well as small mistakes in their role as parents. It has seemed at times that the very points about which some mothers and fathers feel most uneasiness are the opposite of those so regretted by others and assumed to be the crucial mistakes that have contributed to the maladjustment of a child. Less than in most other kinds of psychiatric disorder has it seemed to me that one could find and point out as causal influences gross failures on the part of the parents which people of ordinary wisdom and good will might have readily avoided.

Cruvant and Yochelson56 have expressed the opinion that strong and inappropriate negative attitudes toward psychopaths are commonly aroused in psychiatrists who attempt to deal with them as patients. This is an important point. Such reactions, there is reason to suspect, have tended to distort psychiatric appraisals of the disorder. I am not so rash as to claim total immunity from the subtle bias these patients seem to promote in so many physicians. It is hoped that the earnest wish to avoid this distorting influence will minimize effects of what can be more readily detected in the estimates of others than of one’s self. A strong personal conviction that in the psychopath we are dealing with genuine illness should be of some remedial value, to whatever degree of this prejudice I am, unwittingly, a victim.

When one has the opportunity to follow the career of a typical psychopath, his pattern of behavior appears specific—something not to be confused with the life of an ordinary purposeful criminal or of a cold opportunist who, in pursuit of selfish ends, merely disregards ethical considerations and the rights of others.

This pattern, I believe, differs no less distinctly than the specific and idiomatic thought and verbal expressions of schizophrenia differ from those of the mentally defective and from other psychiatric conditions. Never in faults of logical reasoning, or in verbal confusion or technical delusion, but rather in the sharper reality of behavior, the psychopath seems often to produce something as strange and as obviously pathologic as the following statement taken from the letter of a patient with schizophrenia:

“Financial service senses worries of 35 whirlpools below sound 1846, 45, 44, A.D. Augusta City treasur, Richmond County treasur, United States Treasur of Mississippi River flood area. Gentlemen will you come to… and idenafy none minastrative body that receives the life generated by fourth patented generative below sound. Further arrange financial credit for same. Would like two bedrooms at uptown Hotel and convenient to roof garden. Further what my occupation is you may as well announce me as comforting 35 whirlpools below sound. May you gentlemen have gray eyes and thick bones as the flat sense minastrated are very valuable in idenafying me.”

Even such a relatively simple bit of word-salad stands out at once as indicative of profound and specific disorder within the writer. As in the words of the schizophrenic, so in the behavior of the psychopath there seems to work a positive knack for producing situations which can be accounted for only in terms of psychiatric illness which is unique.