The Mask of Sanity. Hervey M. Cleckley
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A few years ago he was given a place at a gasoline filling station and seemed, surprisingly, to show considerable interest in his work for several days. It was then discovered that he had been drawing off all the gasoline he could and taking it to a near-by town where he sold it and bought morphine from dope peddlers, most of which he, in turn, sold at a tremendous profit to local addicts.
He has been consistently arrogant and aggressive toward his neighbors and acquaintances over trifles. After taking a few drinks he has often threatened others, claimed things that were not his own, and made such a nuisance of himself that local police would be called to deal with him.
He is boastful and histrionic, more eloquently and aggressively so with a few highballs, and much given to temper tantrums. He frequently threatens to kill himself over some petty vexation and once offered a pistol to his wife, urging her grandiloquently to shoot him. He has never made an attempt, however, to harm himself, though his opportunities have been unlimited.
He has been reported as having convulsive seizures. These developed when he was refused special attentions by physicians and seemed, according to descriptions of them, plainly and consciously designed toward obtaining various ends. This manifestation has also been noted when he was confined to jail and wanted to be sent to a mental hospital in order to escape charges that had been brought against him. These so-called seizures have been observed several times in this hospital by competent psychiatrists. They did not in any way suggest epilepsy nor were they convincing as possible reactions of true hysteria. The patient is unquestionably conscious and shows that he is behaving intentionally in this way to gain a recognized end. Unlike a conversion phenomenon, the purpose is not concealed from his conscious awareness.57, 77
Though occasionally confused after heavy drinking (perhaps with the addition of drugs), he has at all other times been entirely rational, alert, shrewd, and free from delusions and hallucinations.
Early in Frank’s career he was on several occasions given a diagnosis of hysteria, sometimes of both psychopathic personality and hysteria. Once he was given a diagnosis of psychopathic personality with psychotic episodes. There was not, however, any evidence of behavior or symptoms different from what he has shown on other occasions. There is reason to suspect that the real and pressing need to keep this patient hospitalized may have played an important part in his being so classified. The genuinely irrational and incompetent behavior, no doubt, supports the use of such a term as psychosis, despite the lack of any additional symptoms.
The irrational behavior which has characterized him is not based on a delusional system or on any loss of the good reasoning ability he shows on examination. Some of his most turbulent misconduct has, of course, been while he was intoxicated. At such times he naturally lacked his customary shrewdness and alertness, but one cannot conscientiously call this a psychotic episode beyond and above his well-known inadequacy but rather the manifestation of inebriety. I do not mean to say that this man is normal but only that he has none of the recognized types of mental disorder, episodic or constant. If his drunken and wayward episodes are to be termed psychotic, then his state at other times must be termed psychotic, since it is in his shrewd, technically sane condition that he decides to add the picturesque touches of intoxication which he well knows will bring him to the attention of the police.
At this hospital, at the state hospitals, and at the other institutions to which Frank was sent in recent years, he has been considered a sane man without psychotic episodes. The symptomatic diagnoses of drug addiction and chronic alcoholism have been added. During all these years he has shown no evidence of deterioration or regression, and today at thirty-eight he is the same clever, alert person he was described as being twenty years ago. Unlike nearly all real morphine addicts he does not show ordinary withdrawal symptoms or other signs of physical illness and acute distress when, after being admitted to the hospital, he is deprived of opportunities to obtain the drug.
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