Sociopatia or Personalidad Psicopatica. Begun

25
THE SOCIOPATHIC OR PSYCHOPATHIC

PERSONALITY
by
JEROME BEGUN, M.D.
H.
according to the diagnostic and statistical manual of mental

O FFICIALLY,
0 disorders,
individuals to be
placed
otherwise known as the &dquo;Grey Manual&dquo;, the comment is made that
in this category are ill principally in terms of society and of
conformity with the prevailing cultural milieu and not only, or necessarily, in terms
of personal discomfort and relations with other individuals.
Sociopathic reactions are very often symptomatic of underlying personality dis-
order, neuroses or psychoses, or occur as the result of organic brain injury or disease.
The &dquo;Grey Manual&dquo; further comments that before a definitive diagnosis in this group
is employed, strict attention should be paid to the possibility of the presence of a
more primary personality disturbance; such underlying disturbance will be diagnosed
when recognized.
The psychiatric nomenclature does not officially recognize the psychopathic
personality as a disrete entity. Attempts to define more clearly the nature of the
various behaviour patterns which make up this poorly understood group have not
been wholly successful, and the term continues to appear in the psychiatric literature.
It was J. C. Prichard who first offered a systematic description of the so-called
&dquo;moral disorders&dquo;; in 1855, he described a series of cases which he termed &dquo;moral
insanity and &dquo;moral imbecility&dquo; which were the prototypes of the psychopathic state
as it is generally understood today.
In 1888, Koch introduced the term &dquo;psychopathic inferiority&dquo;, and Kraepelin
later included in this group a variety of syndromes described in terms of the most
obvious presenting symptom; for example, excitability, impulsivesness, lying, crimin-
ality. The term &dquo;constitutional psychopathic inferior&dquo; was used by Adolph Meyer in
1905; it should be noted, however, that Meyer did not use the term &dquo;constitutional&dquo;
in the sense of congenital, but rather to indicate the traits inquestion were acquired
early and were thoroughly ingrained in the personality.
Actually, however, many of the problems of the psychopathic personality were
already recognized as early as in the fourth century B.C. when Plato analysed the
nature of the &dquo;tyrant&dquo;. The admirers of the tyrant proclaim that he leads the best of
lives : his power enables him to give untrammelled expression to his acquisitive,
agressive, and sexual desires (Republic II, 361), and who could ask for more? Plato
sets out to expose his symptoms, internal dynamics, his desperate predicament, and to
prove him the unhappiest of men, leading the worst of lives (IX, 571-575). He pin-
points the absence of internal controls: lawless desires which normally reveal them-
selves only in dreams are given free rein; the inevitable exhaustion of external re-
sources leaves the tyrant at the mercy of continual and frenzied desires; he is
constantly filled with confusion and remorse; he is always in need within and
thoroughly improverished; he is envious, treacherous, unjust, friendless and apparently
incapable of friendship; he is thoroughly unhappy for his pleasures are chiefly attemps
even delineates the &dquo;stormtrooper&dquo; or gangster potential of
to escape
tension. Plato
the tyrant in the situation in which democracy breaks down. All this is set within the
context of a dynamic explanatory theory-a tripartite psychic model of reason, willful
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26
emotion, and appetite (symbolized as the man, the lion, and the dragon, with the last
a demanding, capricious, veritable Freudian Id). Health is defined in repressive terms
as the man, helped by the lion, keeping the dragon in its place. Plato’s account differs
from contemporary analyses in seeing the aethiological process as one of killing off
controls rather than failing to grow or mature them. On the issue of conscience in the
psychopath, he is with those who find it repressed rather than non-existent. And, of
course, he has not stripped off neurotic components. But he has gone far in recog-
nizing a distinct type, in delineating its central symptom of amorality, and probing for
its underlying mechanisms and quality of feeling.
Cleckley, in his 1941 and 1950 editions, considers the psychopatliic personality
to be a form of psychosis because of the lack of integration of the affective com-
ponents into the personality. Cleckley lists the following characteristics :
1) Superficial charm and good &dquo;intelligence&dquo;.
2) Absence of delusions and other signs of irrational &dquo;thinking&dquo;.
3) Absence of &dquo;nervousness&dquo; or psychoneurotic manifestations.
4) Unreliability.
5) Untruthfulness and insincerity.
6) Lack of remorse or shame.
7) Inadequatly motivated antisocial behaviour.
8) Poor judgement and failure to learn by experience. ,
9) Pathological egocentricity for love.

10) General poverty in major affective relations.
11) Specific loss of insight.
12) Unresponsiveness in general interpersonal relations.
13) Fantastic and uninviting behaviour with drink and sometimes without.
14) Suicide attempts, rarely successful.
15) Sex life impersonal, trivial and poorly integrated.
16) Failure to follow any life plan.
The maladjustment is a chronic one, and the psychopath tends to project the blame
for his actions on others. He tends to act out his conflicts so that the environment
suffers, rather than the patient. He is a rebellious individualist and non-conformist.
Anothed very rough way of classifying is by the onion and garlic types of
psychosis, as one famed psychiatric writer put it, where the onion type of psychosis is
one that continues to bother the ingester after it has long ceased to bother society, as
opposed to the garlic type, that continues to bother society long after it has ceased
bothering the ingester.
One can also classify these people under the official four categories of:
1) Antisocial Reaction.
2) Dissocial Reaction.
3) Sexual Deviation.
4) Addiction-either alcoholism or drug addiction.
The aetiology is unknown; some claim an exclusively organic aetiology, others main-
tain that it is due to psychogenic factors. Many writers have emphasised difficulties in
identification leading to a formless or confused ego ideal. An unstable, inconsistent,
material figure, or rejection or an emotional deprivation early in life are believed to
produce such difficulties in identification. According to M.S. Guttmacher, in
Current Problems in Psychiatric Diagnosis, 1953, psychopathic behaviour is &dquo;generally
the result of affect starvation during the first years of life&dquo;. The most
malignant
psychopaths are probably the products of affect starvation plus sadistic treatment in
early childhood.
27
A famous example of the psychopath, who has brought joy to many in the garb
of re-interpretation in classical music, is: Peer Gynt.
This is a legend taken from the Norwegian folklore collections of P. C.
Asbjornsen, and re-written by the dramatist, Henrik Ibsen. It is folklore, mixed with
experience, and even touches of family history. This work is Ibsen’s most fantastic
piece, the one with the most formlessness about it. In it are germs of ideas worked
out more fully in later plays. In the story, Peer the Poet and Dreamer, who is also a
lovable rascal, dreams of being what he is not. Peer is carried from abandoned youth
to senile old age, in scenes of wild riot. The hero fights his way among pixies, wrestles
in the coils of the boy’s symbol of his own indeterminateness and confusion. Peer may
be said to embody mankind’s (or the psychopath’s) disinclination to face the realities
of life with firmness and integrity. He cares nothing for consequences, even though
the Green-Clad Woman confronts him with an Ugly Brat, symbol of his lust. Out of
sight, out of memory, that is the tragedy of Peer’s romance with Solveig. He is a
gifted, charming, irresponsible and selfish scalawag. When the Button-Moulder finally
calls him to account-as Death, in the rnorality play, calls to Everyman, Peer suddenly
realizes that he has been a bungler of life, with his motto, &dquo;To thyself be enough&dquo;.
Only the unselfish devotion of his beloved Solveig brings him at length to the above
realization of his own character, and saves him from being thrown into the melting
pot to be cast in a new mould. In his case, he is, in the end, cleansed in faith and hope
and love of Solveig.
Another case from classical music, having a somewhat different ending, is
Richard Strauss’s Till Eulenspiegel, who although taken from actual life, and
eventually turned into a representative of those tumultuous times (1300-1350 A.D.),
actually displays all the criteria of psychopathy.
I will not go further into the comparison or analysis of pieces such as Mozart’s
Do Giovanni, Bizet’s Carmen, Offenbach’s The Tales ofHoffman, nor the famed
people of the ancient past, such as Alexander the Great, Caligula, Genghis Khan,
Timur, and others, who again meet our criteria, in retrospect. Most of our famed
frontiersmen fall into this category as well.
Another famous example from present-day, contemporary, newspapers and
phenomenology is Caryl Chessman.
On this point I will not linger, since I am sure that both our memories and the
newspaper morgues are sufficient for further recall of all further data.
Dr. Benjamin Karpman, of St. Elizabeth’s Hospital in Washington, D.C., the
noted editor and publisher of the Archives ofCriminal Psychodynamics, suggests
that those cases of psychogenic aetiology be termed :
1 ) Secondary or symptomatic psychopathy in which the abnormal behaviour is
motivated by neurotic or psychotic unconscious dynamics or idiopathic psycho-
pathy, which he has termed anethopathy.
2) Primary psychopathy, which is practically untreatable and difficult to test.
Karpman suggests this term to replace idiopathic or constitutional psychopathy.
The life-long pattern of acting-out with little or no anxiety indicates a lack of
internalisation of the cultural values and consequent failure to develop a normal
repression pattern. The inability to conform to prevailing standards on an emotional
basis of some suspected psychopaths who have nevertheless been able to intellectually
control and contribute in social situations and society suggests that intellectual control
and ego strength are unimpaired. Emotional control, as indicated by impulsive (not
compulsive activity, inability to relate, improverishment of affect, and emotional
immaturity, is definitely impaired.
28
Karpman’s psychodynamic portrait of the psychopath reveals that the psycho-

path is not only childlike in his primitive selfishness but is a kind of untamed and
undomesticated animal in human form. He is usually &dquo;on the go&dquo; for one thing or
another, which he acquires by taking advantage of someone, whether legitimately or
illegitimately. Karpman distinguishes two subtypes, the agressive-predatory and the
passive-parasitic, but the latter also resorts to aggressive predatoriness when proper
host are unavailable-albeit without the same push and daring of the aggressive
psychopath.
In regard to the passive-parasitic, Karpman says : &dquo;Instead of being actively
aggressive, this type of an individual has much less energy output and feeds himself
by ’sponging’ on his environment for all his needs in a passive and entirely parasitic
way. His victims are willing, yet unwilling hosts. Such aggression as there may be is
very minimal and not more than is absolutely necessary to satisfy immediate needs.&dquo;
(Psychoanalytic Review, Chapter 34, 102, 1947.)
The patient views the world as a huge breast which gives only bad milk, and
himself as the starved child. The people who succumb with pity to his appeals are
&dquo;suckers&dquo;; the ones that don’t are &dquo;bastards&dquo; and the world is made up entirely of
suckers, bastards and himself.
Typical of such patients is the lack of any positive or generous human emotions,
or sympathetic or tender affect, of gratitude or appreciation. These patients show no
guilt, remorse or regret. The total picture is one of self-gratification. There are
almost no unconscious mechanisms, because there is no repression of instinctual
demands and no deferment of pleasure. Further, the patients are completely lacking
in insight into the nature of their disturbances. Karpman further states that the
psychopathy is a very specific mental disease. He emphasises that this is the group
from which the so-called habitual criminals come. In such cases, usually no deep-
seated psychic motivations can be elicited, and patients appear to be &dquo;psychopath
fast&dquo; no matter what is done for them in terms of psychotherapy, and their patterns
of reaction continue unchanged. The conspicuous trait in their mental makeup is
complete egocentricity, which is reflected also in their narcissistic sexual behaviour.
The psychopath has no respect for the social amenities, no sense of obligation or
responsibility, no shame or sense of honour. Although neurotics, psychotics, and
mental defectives may occasionally share the same character traits, Karpman insists
that only psychodynamic analysis can distinguish between different behaviours
which, revealing the same surface features, are yet basically different.
Karpman takes seriously the hypothesis that the intellectual myopia or poor
judgment of the psychopath is caused by dissociation of the emotional from the
intellectual life and the latter has little or no influence upon the former. It is this
dissociation that prevents psychopaths from realizing that concrete acts are to their
disadvantage even though they know abstractly that this is the case.
Not only their affective life, but also their thinking is shallow. Despite the
deliberateness and cunning of their planning, they become bored with their aims
and entangled in their own machinations. They put endless time into planning their
misdeeds when they would derive much greater profit by spending their energies in
a more constructive manner. Indeed, Karpman interprets their disregard for
consequences and lack of vision as indicative of irrationality not only in their

behaviour but also in their thinking.
The dissociation of intellect and feeling in the psychopath explains both his
failure to understand the inner significance of other people’s reactions and lack of
insight into the meaning of his own actions. Objectively considered, his exploits
29
leem directly calculated to bring failure and disgrace upon himself, so perverse and
3istasteful are the situations in which he seeks to be amusing orplay a perfectly
nnocent joke on somebody or merely put someone in his place. Just as he is
ncapable of understanding the degree of hurt that he inflicts upon others, so he lacks
nsight into the meaning of those actions that are injurious to himself. Like a child,
he is capable of great mischief without any commensurate hatred or ill-will. Although
:he psychopath rarely commits suicide, he is motivated by what appears to be an
_mpulse towards relative non-life and woos disintegration for its own sake.
Psychopathy is not just an arrest at a primitive level or characterized merely by
an absence of mental conflicts or psychodynamics, but has specific reactions and
mental mechanisms. The psychopath lacks affection and has no personal relations,
little sense of responsibility or self-control, is unable to tolerate delay, frustration,
egularity and routine, and is antisociallyof orientated. In his relations, he tries to
anoeuvre, hurt, &dquo;use&dquo;, take advantage the other person, partly because he is
fraid of the other one having a hold over him. He is excessively self-centred, and
is narcissism manifests itself also in underlying ideas of grandeur, in particular
oncerning his cleverness and his ability to get away with his misdeeds. It is a slight
o his narcissm to put up with everyday inconveniences or to hold an ordinary job,
ince he expects special treatment and excessive rewards. He may even act socially for
limited period provided it is for antisocial purposes, say, hold a routine job satis-
actorily in order to defraud. He has psychopathic ideals and an irrationally glorified
elf-concept. He sees himself as a master criminal without the frailties of ordinary
umans, such as affection, guilt, remorse, gratitude, anxiety. He cannot tolerate the
wareness, the anxiety others commonly feel, since this would make him human and
ulnerable; the violent psychopath will risk his life to prove he is not &dquo;chicken&dquo;. He is
ot altogether devoid of a conscience but he does his best to blunt its manifestations,
nd he reacts to anxiety or guilt differently a neurotic or normal person so that these
motions, instead of deterring him, rather incite him to behave more antisocially.
Neurotics as well as ordinary people are amenable to the pressures of society and
he influence of others through a variety of levers. It is these levers which the psycho-
to blunt. By breaking up a continuity in time, space and
ath has managed
emotional relationships, or by denying the consequence of his actions, he can im-
munize himself. By making himself invulnerable to anxiety and guilt, he wards off
these incentives towards socialization. His narcissism enables him to deny emotions
almost completely; and he fights off socialization in order to indulge his primitive
impulses. At the same time, he is unhappy, frustrated and lonely. The psychopath
professes that he wants to be what he is-&dquo;and a villain I’ll be&dquo;-yet there is an
underlying hopelessness and despair. Many offenders would change, if they could
hope to succeed socially. But the grapes are sour.
It is a great strain to be an outcast and to lack the most ordinary satisfactions.
Criminals lack sublimations, a social attitude and interest; they are not part of any
community. They have poor capacity for enjoyment, get pleasure neither from
memories nor from anticipation, are inhibited in their imagination (as long as it is
not criminal), hence develop an overwhelming need for pleasure and thrills for
drugs, drink, promiscuity, excitement, sensation and sadistic satisfactions. Sexual
promiscuity appeals to their egos but also helps to fill a gap and to avoid involve-
ment in personal relations.
The psychopath’s excessive and grandiose narcissism goes hand in hand with a
disturbed relationship with reality and disturbances of thinking. These are not as
marked as in the psychotic, and the psychopath does not suffer from delusions; his

30
ego is better organized but more antisocial. He has obvious lacunae in his thinking, ir
particular as to cause and effect, but they are characteristically selective. He does nom
anticipate being caught, even when this is obviously bound to happen; yet he spend=
much time thinking of the future and scheming. It is not true that he does not learr-
from exeprience; he does perfect his methods of safe-cracking, but he fails to socialize
He is not altogether unaffected by punishment, but he does his best to wipe out such
unpleaseant memories. His denial mechanisms are remarkable, and it is these that are
mainly responsible for his thinking difficulties.
Pathological lying, both for no reason and to cover up misdeeds, is frequent. Ii
is another way of falsifying reality and denying feelings. It also enhances his sense oi
cleverness. He prefers to steal rather than ask for something, partly for fear of being
rebuffed or obligated, and he will imagine he is &dquo;conning&dquo; somebody, even when he
is not, for the same reasons.
The psychopath spends an inordinate amount of time and energy in creating
complications, trouble and excuses. Somehow there are always complications and
crises when he is around, even when apparently he has not produced them. He has
an excess of energy, perhaps due to a failure of inhibiting mechanisms, partly
because he does not spend his strength on work; many psychopaths socialize when
they get older and get tired of fighting society. The psychopath is a study in con
trasts and has excessive ambivalence-that is one reason he cannot tolerate con
tinuity.
When we consider the psychopath, we immediately encouiiter several facts
several practical and important facts, that align him with the psychotic and sharply
distinguish him from the psyclioneurotic. One cannot rely on him to handle himself
in the social group without serious danger to himself and others. He shows even
poorer judgment than many of the orthodoxly psychotic about accepting hospitaliza-
tion, treatment of any sort, or submitting to restrictions, however urgently these may
be needed. In striking contrast to the psychoneurotic group, he seems unable to
realize that the failures and misfortunes his activity brings upon himself, his family
and others are attributable to him or that anything
can be done to prevent their
repetition.
In a practical sense, then, and despite his lack of academic symptoms charac-
teristic of those disorders traditionally classed as psychosis, he seems to belong with
that group. Certainly his problems cannot be dealt with medically or by any otherI
satisfactory means unless similar legal instrumentalities for controlling his situation
are set
up.
In a number of cases, patients reveal through subsequent years of contact many
indications of a basically unhappy home situation. In many of these, the parents’
marriage was apparently a rlationship in which both husband and wife by their
virtues succeeded in avoiding the customary signs of their unfulfilment in each
other, of their unadmitted but deep frustration. It does not appear that they failed
to love each other in many senses of the word, but there is a good deal to indicate a
serious lack of response to each other as mates, a lack not confined to sensual matters.
Whatever hollowness each sensed in the guarded privacy of his own awareness,
or a bit beneath the awareness, was bravely suffered and outer indications of
chagrin
or complaint were avoided in the best traditions of honourable conduct. The
missing
of fulfilment was, it seems, attributed to the universal fate of man and with little or
no conscious cynicism both marital partners found considerable
compensation in
constructive social activity. The spontaneity and personal contact lacking in relation-
ships between the man and wife were not lacking in the less crucial relationships
31
each had with friends and acquaintances. In fact they both were more than
ordinarily sociable, informal, and even fun-loving. They did not, however, have
either delight or real understanding together. What could not be fulfilled in the most
important channels sought outlet in secondary relationships and activities, enriching
these beyond what is ordinary. Without insincerity, this surface of happiness con-
veyed strong impressions that the couple was proportionately happy in central areas.
Such an impression they themselves apparently shared.
Both husband and wife, adequate, mature and wise in so many respects, were
able to avoid neurotic symptoms, sexual infidelity, cynicisms, etc., despite their
deprivations. Even by intelligent and commendable efforts they were, it seems, un-
able to convey to their child many feelings for which his need was extreme. It would
not be correct to say that they did not offer affection or that they were consistently
too strict or too lenient in matters of discipline or teaching. From the patient, thirty
or more years later, it is not possible to obtain information that seems a reliable
guide to what his own real affective reactions might have been.
In the integral processes of supplying the complex emotional needs of their
child, it is not hard to believe that their handicaps were comparable to that of one,
however wise and learned, who must undertake to make love chiefly with his in-
tellect. There is no proof of it, but it gives one some reason to wonder if the child
gradually realized or somehow reacted to, the fact that centrally in his parents, and
therefore, in his universe, something essential was missing or somehow unreal. If so,
it is likely that he never succeeded in comprehending the nature of what he surmised
only by its absence.
Available clues are tenuous. The apparent facts are not always unequivocal.
There are, however, some indications that by over-generous praise and commenda-
tion rather than severity their child was encouraged to accomplish a good deal
more than he could without undue effort. A form of forced growth, as it were.
It is not surprising that parental pampering or spoiling has been thought of as
a possible cause for the psychopath’s later behaviour. It is true that in many respects
these patients suggest a badly spoiled, self-centred child who insists on having his
way immediately and without regard to cost to others or their rights. It is true that
these extremely pampered children tend not to weigh properly the unpleasant con-
sequences reasonably to be expected from carrying out injudicious acts. The over-
indulgent, over-protective parent, by intervening, spares them the painful effects in
such situations and this tends to spare them also some learning they will need. It is
quite surprising that reliable evidence of such over-protection and giving way to
every whim has not been found more often in the background of the psychopath.
Healy long ago pointed out that antisocial behaviour often seemed to occur as
a response to
unhappy life situations, and Alexander has formulated such disorder in
psychoanalytical terms as a purposive acting-out of unconscious pathological situa-
tions.
Careful study of these patients, including psychoanalysis of some, has indicated
a parental background characterized by inconsistency and lack of unanimity or
parental discipline resulting in conflicting, unstable identifications in the son. A
weak, indulgent, pampering, frivolous mother, in combination with a stern, authori-
tarian, domineering father whose severity was fitful and inconsistent appeared
frequently in the background of Knight’s cases. Knight feels that important causal
relationships between this early situation and the subsequent disorder are likely and
that such an influence may play an important part in the defective development of
conscience and ordinary social and personal evaluations.

32
Adelaide Johnson, with Eicheler, at Rochester, Minneapolis, along with Szurek

agrees that the relationship with the mother is the important one. She unconsciously
encourages the amoral or antisocial behaviour of the child. The parent’s attempt to
satisfy her own unconscious needs through the activity of the child leads to various
distortions of the child’s self-regard. Frustrated in too great a measure in his de-
pendent needs, he is later as an adult, continually, seeking their gratification by
fantasies, verbalized or acted out with others, and never content with what he finds.
Heaver regards the type of early environmental conditioning provided by the mother
as one of the most important psychodynamic elements affecting the social maladjust-
ment of the psychopath. The father is indifferent, critical and distant while the
mother gratifies all his desires. The psychopath is unable to identify with the father
and comes to resent the masculine world. He finds himself more comfortable in a
woman’s world and feels inferior and insecure in a masculine environment. All his
behaviour then becomes a protest against his own sex and any implication of intra-
sex rivalry. Thus he succeeds in punishing his parents and especially his father.
Knight states that innumerable personality shadings and accents are possible
from a son’s reaction to such parental management. The one regular result seems to
be the fostering of excessive passive demands and expectations in the son, such
passive, childish, feminine wishes being in marked conflict with the masculine
strivings inculcated by the father and by the cultural ideology absorbed from
schooling and from contacts with other males.
Knight finds further indications of oral fixation in the cases that are ordinarily
called psychopaths and he also brings out the point that with them, treatment seldom
lasts long, since, becoming dismayed at the long road they must travel, they quit, on
one pretext or another, or talk their relatives into believing they are badly handled
or that they are now &dquo;cured&dquo;.
Karpman states that while it is true that the psychopath does not have the
psychotic’s distorted appreciation of reality, his appreciation of reality is entirely
pathologic, even though it is different from that of the psychotic.
Lindner, in his Rebel Without a Cause, showed that traumatic experience
elicited from the patient as having occurred at as early an age as six or eight months
is interpreted as being reached by pre-verbal memory processes. Distorted attitudes
towards the parents and a peculiarly adverse primal scene experience seem in this
interesting presentation to be primary influences in a lifelong pattern of severe
behaviour disorder. An impressive and closely knit scheme of interwoven cause and
effect emerges in the detail report, and, indeed, seems to account for the clinical I
picture in terms of pathological motivation and purpose. Ather patients studied are
reported to have shown similar traumatic experiences at an early age and similar
reactions to these experiences. Satisfactory therapeutic results were reported in these I
cases.
Many sociopathic patients soon appear to be behaving similarly, and in their

backgrounds it is often possible to get suggestions of what might once have produced
feelings of rejection. Many patients have reported experiences not unlike those
descirbed by Lindner. Not infrequently, sometimes under hypnosis or drug narcosis
sometimes with consciousness not greatly altered, incidents have emerged that seem
to offer valid clues to a convincing explanation. Not a few patients told of witnessing
the primal scene, sorne at ages scarcely above infancy. Many signs of emotional
reactivity often accompanied various revelations.
Much, but by no means all, of the material resented by the sociopath impresses
one as probably representing fabrication or
fantasy, confused with memory, rather
33
than actual facts. It has often been noted that the psychopath will very convincingly
report entirely false incidents and attitudes in others, particularly in parents, that
tend to put responsibility for this difficulty on others. This is a factor deserving
competent attention, for it can enter very subtly into material obtained from patients
of this sort.
When signficant, objective events can be checked through others, confirmatory
evidence can be obtained, sometimes but not always. The point most difficult to
corroborate is the actual or innermost personal reaction of the patients to the events
they report.
Itmust be admitted that all strongly emotional and deeply experiences
not
specificto each human being accurately communicable. The nearest approxi-
are
mations to success in this field occur in poetry, music, etc. It is scarcely original to
emphasise that scientific or any objectively referential language is abviously
notoriously ineffective and quite untrustworthy in this area. It must be granted,
then, that no genuinely verifiable material can be obtained from any patient or
from any other person unless it includes his significant affective states, attitudes or
ex periences. Clues from derams often suggest significant attitudes or impulses not
directly discernible, and, though many interesting surmises can be made on this
basis, little is found in the reactivity of these patients to corroborate them adequately
or to open up
progressively helpful channels of investigation.
One may test the proposition that there is a qualitative difference between the
asocial psychopath and the genius by a hypothetical case which reflects common
experience. In one culture or era, certain writings or paintings may be looked upon
as the products of depraved personalities, may be condemned, and the creator may
be characterized, among 6ther things, as a psychopath. Yet a decade later this same
individual may be acclaimed as an original creator, a man of genius. This illustrates
the unsoundness of attempting to exclude socially contributive abnormality from the
category of psychopaths. Modigliani, Eugene O’Neill, Baudelaire and many others, if
described purely in terms of egocentric interest in a circumscribed area and general
obliviousness to conventional responsibilities, would undoubtedly fit into the category
of psychopaths. They fit the same patterns as those who follow almost monotonously
stereotyped socially undesirable forms of activity.
The genius exhibits a certain fixity of interest and insists on doing his work to
the exclusion of other considerations and often without regard to either anticipated
rewards or consequences. Very few of the great contributors to literature and art
have received either adequate recognition or recompense of any sort in their own
lifetime. Men who, by the product of their originality, enrich their fellow men are
called geniuses and the stereotype of their behaviour is proclaimed in terms of
praise: they are credited with persistence in working towards their goals. When the
results of persistence are socially offensive, the perpetrators or subjects are often
described as psychopaths. Society then needs to make judgments on the basis of the
nature and quality of the act rather than the actor. This requires some further
discussion.
If we were to make a distinction between psychopaths in general and those who
create works of genius, it might be noted that the productions of the genius appear
to represent a sublimation or at least a higher and more refined type of activity than
the more primitive gratificational activities of the psychopath. The distinction might
then be related to the level of satisfaction sought by the individual rather than by the
dynamics. The lashing out at society, which is represented in the artistic works of
Hogarth, Goya, Daumier, and the seething criticism poured forth by O’Neill,
34
Joyce, Cervantes, appear to be simply a higher level of social assault than the
behaviour of the man who beats up an innocent pedestrian &dquo;for kicks&dquo;.
It has been interesting to note that exeperiences ordinarily withheld or deeply
repressed in other people sometimes are much more quickly and readily divulged by
these patients. Though shame and terrible conflict are sometimes claimed in such
matters and superficial indications of such claims may be impressive, the therapist
feels, generally, that he is unable to get at any level in which such effects are major
or even quite real.
Many speculations and interpretations seem useful and entirely congruous with
what the psychopath shows clinically. Distortions, attenuations, short-circuiting,
blockages might be surmised on the basis of inborn deficiency, active organic
pathology, or as arising through conditioning by experience similar to what Masser-
man and others have vividly demonstrated in animals with experimental neurosis.
Strictly Freudian and any other dynamic factors and mechanisms may gradually
and pathologically alter or condition functional patterns and circuitings until the
organism loses much of its normal response.
I will not attempt to enter the field of legal competency and criminal responsi-
bility, since that is a specialized field and reserved entirely for those more familiar
with forensic psychiatry than I.
However, it should be noted that this business of insanity traces back a long
way. In English law particularly, although the concept existed for a long time in
Roman law as well. One of the early definitions in law equated the mentally ill
person, the irresponsible person, with the madman, the furiosus, the man who tore
his hair, attacked people, and in general caused a public furor. Lord Coke was
largely responsible for making the general proposition and was followed by Matthew
Hale (Lord Hale), who delved into the question of partial insanity. He states in his
Pleas ofthe Crown, which was written in the latter sixteen-hundreds (although the
first edition did not appear until 1736): &dquo;It is very difficult to define the indivisible
[It is believed the judge meant ’invisible’] line that divides perfect and partial in-
sanity, but we must rely on circumstances duly to be weighed and considered lest,
on the one side, there be a kind of
inhumanity towards the defects of human nature,
or, on the other side, too great an indulgence given to great crime. The best measure
that one can think of is: such a person as labouring under melancholy distempers
hath yet an understanding as ordinarily a child of fourteen years hath, such a person
may be guilty of treason or felony ...&dquo; He went on, by the way, to comment &dquo;The
moon has a great influence on all diseases of the brain&dquo;. He talked about insanity
that was partial either as to degree or as to subject (and insanity was a topic of
diligent discussion in those days); that is, by the latter he meant what was referred
to later on as monomania. The person, it was thought, could be entirely sane on
some topics and decidedly insane on others; this
concept was held true even in
M’Naghten’s day. The wild-beast test came along a bit later, in which we have the
notion of the madman, the person wholly out of contact with his environment. Thus,
Earl Ferrers was executed in 1706 because the court found that he did not have a
total want of reason. Subsequently, in the Hadfield case in 1800 Lord Erskine (by
dint of his oratorical prowess) succeeded in setting up delusion as the great criterion
of insanity.
The chief difficulty with the legal distinction of insanity dates from the judicial
commentary on the 1V’Naghten case in England. It is worthwhile to remember that
the American judges struggled with his problem even before the M’Naghten case
came up. It was in 1834 in this
country that the &dquo;irresistible impulse&dquo; test was laid
35
in Ohio. Roscoe Pound, probably the most eminent living legal scholar in this
country, has pointed out that the irresistible impulse test was laid down in an
attempt to meet some situations which arose in frontier communities in cases of
so-called &dquo;honour killings&dquo;, that is, where a spouse was found in flagrante delicto by
his or her mate. In other words, the sympathy of the community was with the
defendant. They did not want to acquit such a person outright, as the fact of a
killing having been done was clearly established, but they wanted to find a back
door, and found such a back door by way of this &dquo;irresistible impulse&dquo; test, which is
law today in about twenty States of the Union. Not all of the States are quite clear
on this but in somewhere between eighteen and twenty States it is admissible as a
defence.
However, all this preceded the M’Naghten case and the great furore it created.
It is worth remembering, as Dr. Diamond has pointed out in his historical study of
tlie M’Naghten case, that no defence was introduced; it wasn’t necessary. The
motion was made by the Crown Prosecutor; he pointed out on the basis of the
medical evidence that M’Naghten was by general standards, according to his lights
and the lights of the judges, insane. Consequently, M’Naghten was found not guilty
by reason of insanity. The public was much upset. They envisaged the gates of the
mental hospitals and the jails both being turned wide open and furious madmen
going about the streets like raging lions seeking whom they might devour. So they
referred this matter to the judges of England and the judges wrestled with it quite a
bit. (It is believed they were honest and intelligent men.) As Judge Dee said in the
Pike case in 1869, in New Hampshire, their intentions were certainly good, but they
made the path of justice considerably more devious and incomprehensible than it
had been before.
The M’Naghten rule has plagued many courts and psychiatrists ever since. Even
at the time of its inception there was much criticism of it by psychiatrists and legal
scholars as well. Only two or three years after the 1V’Naghten decision came down,
Luther Bell, one of the founders of The American Psychiatric Association, made
some very caustic remarks in one of his annual reports as Superintendent of McLean
Hospital, referring to the &dquo;meditations of closet philosophers&dquo; and indicating that

the M’Naghten decision was pretty much out of touch with the facts even then. And,
of course, we have all been objurgating it ever since, despite which attacks it seems
to persist.
The Scots, a very practical, hardheaded people, got around part of the problem
in the 1860’s when they enunciated the doctrine of diminished responsibility, which
possibly had previously been called &dquo;partial responsibility&dquo; by Lord Hale. They
recognized that there are some persons whose judgment and grasp of reality are, at
best, somewhat impaired by mental illness or defect, but not to a degree to warrant
finding such persons insane. Scotland was unique in utilizing that doctrine until
1958, when England adopted it by statute, incidentally, rather than by judicial
decision.
It is well to remember, in passing, that with the single exception of this English
rule, which is parliamentary, the big test has been laid down by the judges, and the
most that the legislatures have accomplished since is to embalm these mistakes of the
judiciary by putting into statutory form what the judges where thinking at the time.
New Pork, for instance, has the right-and-wrong test written right into law and
recently has created a commission to study it and make some recommendations as to
modifications.
This approach, it is believed, is doomed to failure, for once a statute is written,
36
any proposed change in it must be instituted through the legislators, a group pretty
much swayed by current legal anachronistic misconceptions and what appears to be
a native antipsychiatric bias.
In the District of Columbia (which in some ways is not the most progressive,
but in other ways appears to be ahead of most of the leagl profession) a furore
arose over the Durham decision. By way of meeting this judicial crisis, the Bar
Association of the District of Columbia set up a committee to ascertain what the Bar
Association ought to recommend to Congress in the line of a definition of insanity
admissible as a defence. Now it would be difficult indeed to imagine just what sort
of definition of &dquo;legal insanity&dquo; would be drawn up by Congress or by the State
legislature for that matter. Although the intention of the Bar Association was to
spike the Durham rule, fortunately they rejected the majority report of their com-
mittee and adopted the minority report. This report stated, in effect, that the
Durham rule was adequate as it stood and ought to remain unaltered.
It is worthwhile to remember also that in Continental law in general no attempt
is made by law to lay down a definition in statutory form. It can be said that
Continental rule is merely that if a person is mentally ill and is suffering from a
mental disease, that person cannot be held responsible for his crime. It is left to the
wisdom of the courts and their advisers oft determine the fine points of applicability
of this rule to individual cases. In Italy, the court recognizes the doctrine of
diminished responsibility by reason of mental illness as well. However, this doctrine
is not officially recognized in this country, having been rejected by the Supreme
Court in a divided opinion a number of years ago. The court admitted that a person
could be so drunk that he might not be considered fully responsible for his actions,
but denied that this standard could be similarly applied to cases involving mental
illness.
Subsequently, the American Law Institute has attempted to redefine the issue
of criminal responsibility with respect to mental illness, and their definition has
already been adopted in a few States. What does this much- toured American Law
Institute formulation state?In essence, it states that a person may not be held respon-
sible for criminal conduct, if, at the time of such conduct and as a result of mental
disease to that effect, he lacks substantial capacity either to appreciate the criminality
of his conduct or to conform his conduct to the requirements of law. It is a rehash
of M’Naghten and irresistible impulse rules. There is a slight distinction, perhaps.
Under the M’Naghten rule there had to be a complete lack of understanding on the
part of the defendant as to the nature and quality of his offence, whereas this new
definition at least acknowledges the possibility of a coexistence of some awareness on
the part of the accused as to the nature and quality of his act, with a total inability
to exercise restraint or judgment with respect to such act. However, it should be
pointed out that if the lawyers were attempting a clarification of the issue by creating
a fixed criterion for the determination of the state of mind necessary to
legal absolu-
tion from criminal responsibility, they have failed eminently in this by introducing as
the crux of their definition as indefinite a word as &dquo;substantial&dquo;.
No doubt more will be said on the question of the Durham rule, but for the
moment no elaboration will be made. A similar rule was laid down in a decision of
the New Hampshire Court in State v. Pike, 1869. This decision was reached largely
as a result of the legal studies of Judge Dee, as
pointed out in an exhaustive study of
the rule by a member of the New Hampshire Bar, Mr. John Reid. In effect the court
maintained that the question of any possible mental disease of the defendant is
purely a matter of fact for the jury to determine rather than a test for the court to
37
lay down.heJudge Dee led to his opinion by

was a study of legal precedent-a matter
of logic, whereas the Durham
says, rule, as enunciated by Judge Bazelon of the
Court of Appeals for the District of Columbia, was arrived at prctty much on
medical grounds. It is both interesting and encouraging that their two paths came
together. Although the two rules are not precisely the same in wording, in essence
they are alike: the act must be a product of mental disease or defect.
The American Law Institute went one step further and tried to rule out the
sociopathic personality (whatever that term may designate) by excluding from its
definition of those mental ills which mitigate criminal responsibility any mental
disease or defect marked exclusively by violations of law. Most of us will agree,
however, that sociopathic personalities have symptoms other than violating the law.
Thus, since overt criminal activity is certainly not unique to this group and does not
constitute their only symptom, this proviso cannot be relied on as an effective means
of excluding them from a more liberal rule regarding the criminal responsibility of
the mentally ill.
That brings us down to the present time. Two States now have the product test,
all recognize the &dquo;right-and-wrong&dquo; test, and approximately twenty States utilize the
so-called &dquo;irresistible impulse&dquo; rule. This, then is the situation.
One can be very pessimistic about the prospects of extending the Durham rule
to other jurisdictions. The area where it now holds sway, the District of Columbia,
is not only tiny, but is a great distance from California as well, where a com-
mission is now in action on the problem of overhauling the legal structure dealing
with criminal responsibility and the mentally ill not only with a view to laws for the
legislature to pass, but also in regard to the procedures of administrative care and
custodial protection of these individuals.
There are possibilities for outflanking the whole problem of the definition of
criminal responsibility of the mentally ill. One device for outflanking was proposed
by Prof. Weihofen and Dr. Overholser in the classic article, &dquo;Mental Disorder
Affecting the Degree of a Crime&dquo;, in the Yale Law Journal of 1947. In this article,
which followed the Fisher decision of the Supreme Court in which the idea of
diminished or partial responsibility was rejected, Prof. Weihofen and Dr. Overholser
demonstrated very clearly that this concept was still sound. Subsequent to the paper
&dquo;On Malice Aforethought&dquo;, by Dr. Bernard L. Diamond, on the situation in Cali-
fornia, the Supreme Court of New Mexico acknowledged this concept, making a
total of eleven States which now have the concept of diminished responsibility, as
well as, surprisingly enough, all the military courts-the Army, the Navy, and the
Marines. The United States Court of Military Appeals several years back adopted
this principle.
Partial responsibility must not be confused with partial insanity. The term
partial insanity referred to the old idea, which is now totally archaic and obsolescent,
of monomania of a person who is insane in some spheres of mental activity and not
insane in others. The legal definitions of criminal responsibility, whether they be
M’Naghten, irresistible impulse, or Durham, are all-or-none concepts. An individual
is either sane or he is insane. Either he gets full punishment for his crime or he gets
no punishment and is sent to a mental institution.
This all-or-none concept of the law becomes, of course, absurd when applied to
the continuous spectrums of psychological activity shown by all mcntal patients and
by all defendants. The task becomes one of fitting the psychological spectrum of all
possible gradations of mental activity into the rigid all-or-none concepts of the law.
Tlris can be observed by a legal trick which is accomplished in this manner. In

38
crimes of murder, assault, and violence, there are varying degrees of crime having
varying definitions which have to do with the existence of, shall we say, legal fictions,
symbolizing certain psychological attributes such as deliberation, meditation, malice
aforethought, purpose, design, and the like.
This existing legal structure is ready-made for the application of a continuous
spectrum of psychological behaviour if one is willing to indulge himself in the tricky
reasoning that is utilized by the courts. When we say that a person is partially
responsible and when we speak of diminished responsibility we are not referring to
some schizophrenic-like split in his behaviour. We remain perfectly aware that a
person is mentally ill in every sense of the word and that his mental illness pervades
every aspect of his personality. What we are saying is that even though such an
individual does not meet the legal criteria for total exculpation under the
M’Naghten rule, his mental illness should still be taken into account in determining
the type of crime of which he can be convicted and the type of punishment or
treatment which he shall receive. Thus, we maintain that individuals who are not so
ill in the eyes of the law, as evaluated strictly within the confines of the all-or-none
concept, nonetheless remain mentally ill by psychiatric standards and must be so
considered by courts of law in the determination of their criminal responsibility. This
is possible now in California and ten other States, as well as in all of the military
courts.
We should not be disturbed by the fact that the Supreme Court of the United
States in 1946 in the Fisher case rejected this idea. It was not properly presented to
them and they did not make a clear-cut ruling on it. Furthermore, because of the
peculiar relationship of the Supreme Court to State courts, the jurisdiction of the
Supreme Court of the United States does not extend over the States in these
criminal matters. As a result, the only area of the country affected by this adverse
decision is Washington, D.C., and the federal courts. The vast majority of criminal
cases involving mental illness do not fall within federal law. We believe there exists
absolute fool-proof reasoning as well as a wealth of legal traditions and legal philo-
sophy which could be used to demonstrate the legal validity of this concept of mental
illness as a partial defence. It is inevitable that it will spread throughout the country
and that even the federal courts and the District of Columbia will adopt it when it is
put to a fair test. This concept became law by legislative enactment in England in
1957. This, then, is one way of outflanking the problem of the criminal responsibility
of the mentally ill.
Another way would be through the abolishment of the plea &dquo;Not Guilty by
Reason of Insanity&dquo;, except as an optional rather than mandatory procedure. With
the abolition of the plea of not guilty by reason of insanity, all defendants, no matter
how mentally disordered, would be tried if capable of understanding the nature of
their trial; otherwise the trial would be deferred until such time as they could
comprehend and participate in the trial. The entire court would then determine
only the question of guilt or innocence of the defendant on strictly behavioural
standards, disregarding the issue of legal insanity, and sentencing of this individual
through the Departments of Correction would result in a totally indeterminate
sentence. The Departments of Correction would then be charged with the responsi-
bility of doing whatever is necessary for the treatment and rehabilitation of this
person. Such treatment could be accomplished without further procedure, legal
whether it involves psychotherapy, shock treatments, psychopharmocological treat-
ment, confinement in a maximum security prison, or commitment to one of the
several very excellent prison camps. At such time that a board composed of

39
I
~enologists, psychiatrists, psychologists, social workers, sociologists, custodial officers,
;and others felt that this individual had recovered, he could then be returned to
society.
The great advantage of such a procedure would be this : when psychiatrists
insist on a definition of criminal responsibility, whether it be a liberal or a con-
servative one, it is implied that a special minority of criminal offenders merit unique
treatment and that all the rest of them are somehow deliberately iniquitous and
don’t deserve any such special dispensation of justice.
It is hoped that if Departments of Correction could he changed to primarily
treatment agencies rather than a punitive agency, then perhaps the philosophy of
treatment-psychiatric, psychological, sociological, and penological-would be ex-
tended not only to the psychotic cases, but more important still, broadened to
include all persons convicted of crimes. They would all receive whatever treatment
they needed, whether or not they committed the crime under the Durham,
M’Naghten, or irresistible impulse rules of criminal responsibility. The whole
emphasis of the legal system then would be put on treatment, rehabilitation, and
protection of society, without regard for the arbitrary legal and psychiatric fictions
defining criminal responsibility.
We now come to the field of treatment for the psychopath. At the present time,
when one considers the M’Naghten rule, these people are considered sane and
competent. Therefore, the general treatment in the past has been, according to the
aforementioned ruling, to discharge these people within the meaning of the said
law. Cleckley, on the other hand, since arguing that these patients are psychotic, in
the true sense of the word, believes they should be hospitalized and not for a definite
sentence as in a penal institution, but for an indeterminate length of time which is to
be determined by those people specializing in psychotherapeutics, who are to have
complete care of such case until the time they deem the patient is cured. Cleckley
quite dramatically points to the fact that previous treatment of psychopaths has been
insufficient, that their imprisonment has worked no change in their personality or
their aggressions upon society in general and that a predetermined length of sentence
merely permits them their eventual liberty and the eventual return of these &dquo;psycho-
tics&dquo; to society at large.
These principles are adequately embodied in the Greenstein Act of Penn-
sylvania, which is so designed that the psychopath, as well as other disordered but
generally neglected persons who commit legal offences, can be dealt with by safer as
well as more rational and humane methods. The need for similar changes through-
out the nation is urgent. To date, this has been followed to some extent by the
States of California, Massachusetts, and Michigan, to mention but a few.
If such patients could be evaluated in terms of their behaviour and committed,
like other psychiatric patients, not to limited terms of confinement but for in-
determinate periods, the community would obviously obtain far better protection.
The patient could then be held until his condition, as appraised by experts, indicated
that he could be released with safety to himself and others.
Safeguards, however, must be created for the average individual-Cleckley
mentions the possibility that &dquo;railroading&dquo; by unscrupulous relatives, psychiatrists,
jurists, might tend to deprive other patients or persons of their life and property
through immoral, injudicious, and completely selfish and/or illegal motives. One
other point must be made here, namely that the present spate of articles in various
popular magazines pointing to a possible smaller number of institutions, of smaller
overall size, implies increased budgets, with actually more institutions and increased

40
staff. Considering the general inadequacy of such institutions, with shortages om

physicians, nurses aides, attendants, etc., this would mean overcrowding beyond
bearable limits. When one considers, however, the depredations of psychopath+
upon society and the cost of both to their relatives and to society in general, the=
cost of an increased institutional force, plus increased institutions in themselves,
would be markedly lower than the cost of permitting them to continue their depreda-
tions. It is suggested therefore, that education of the public in regard to these fields
must continue, and especially must the point be brought home to the public, that
these persons are indeeed &dquo;sick&dquo; in the true psychiatric sense of the word,and that
they need attention and care which can be given them adequately only in an
institution devoted to such cases and having proper facilities.
Treatment of the psychopath has to date been notably ineffectual. Electric
shock, lobotomy, and drugs have been tried without any success. Psychological
treatment, whether psychoanalysis or psychotherapy,
has not proven effective. In
Europe, particularly in Denmark at Herstedvester, some success is reported when
the psychopath is confined and treated by a concentration of all the energies of
those who form the circle within which the patient lives-the staff, his fellow
detanees, his family. All must collaborat in an atmosphere of freedom. Present
day attitudes towards treatment are clearly highlighted by Bromberg and Schmide-
berg. Schmideberg feels that punishment is not often a deterrent. The whole life
pattern shows self-desructive tendencies, but suicide among psychopaths is rare.
The borderline between psychopathy and schizophrenia is sometimes vague and can
be crossed in either direction. Although anxiety and guilt are said to be charac-
teristically absent, she (Schmideberg) is sure that they exist but are denied, indeed
antisocial acts often arise as an expression of anxiety. The sadic element is clear
enough in the various agrressive acts, and masochistic traits in some cases make
punishment worse than useless since this is just what the patient unconsciously
seeks. Trauma in early life is not important as a cause and maternal deprivation is
but one factor. Treatment out of prison is often preferable since only in society can
the psychopath face his relationship problems in the work and sexual sphere. The
difficulty is that the severe psychopath did not want to change: his sole interest in
doctors is in using them to get out of trouble. Interpretations of behaviour given
during psychotherapy are simply used by the patient.
Analytical treatment must be employed with caution since the defences against
real insight are enormous. Success can be hoped for in reluctant patients only
when they are obliged under threat of punishment to receive treatment; thus pro-
bation and suspended sentence are, in her view, invaluable. The art of the
therapist consists of turning the enforced relationship into a genuine one, and it is
mainly this genuine relationship that socializes the patient. Suspended sentence and
probation are admirable devices which provide just the right blending of authority
with threat from the court and support from the therapist. The process of producing
motivation is half the problem, and once the patient wishes to change, the process
becomes one of re-education. One criterion of success is stability at work, for if a
man is not in work he will steal. Adjustment is always hard because the psychopath
expects disproportionate praise for anything he does. Bromberg calls attention to

the facts that impede treatability of the psychopath. He points out that the psy-
chiatrist’s attitude towards the psychopath reflects a persistent anachronistic feeling
towards psychopathic persons, a survival of society’s former unconscious reaction
towards the insane, for the most part now happily resolved. This hostile and punitive
attitude results in control, incarceration, and restriction of the psychopath by the

41
psychiatrist. In all of this, the psychiatrist, like society in general, rejects the psycho-
path because of the unconscious need to defend himself against his own aggressive
_mpulses. The rebellious, maladjusted individual, in unconsciously perceiving
~ociety’s hostility, reacts by withdrawing into a psychological community (the gang)
whose &dquo;semantic dementia&dquo; is a common symptomatic defence. The defensive
weapon serves a double-edged purpose, satisfying
both the aggressive feelings of the
psychopath towards society and his moral masochism. The nucleus of the conflict
within the psychopath revolves around a moral masochism that keeps him in a
position where he will be constantly hurt and derided, while at the same time
preserving his own psychological autonomy. This masochistic position was originally
a refuge from rejection or denial of emotional needs in a very early oral period. In
the therapeutic situation with the psychiatrist, the psychopath meets the therapist
with distrust; he reacts to psychotherapeutic attempts wih defiance, acting as society
unconsciously wishes him to-as an irretrievably rebellious person. The treatability
of the psychopath turns upon a simultaneous mitigation of the reflection within the
therapist of society’s attitudes and a dissolving of the potential patient’s character
defences.
In therapy of this type the emotional environment achieved has the function
of unfreezing the psychopath’s defensive character front by presenting a facsimile of
reality and desensitizing the psychopath to the frightening social atmosphere that
surrounds him.
The main difficulty in treating psychopaths is that they have no desire to
change, and hence are not genuinely motivated for treatment. This is inherent in
their fundamentally antisocial orientation, and it must therefore be expected that
they come for treatment only under direct or indirect pressure or when on the verge
of disaster. The fundamental difference between the therapy of neurotics and
psychopaths is that for the latter we have to develop techniques to treat unwilling
patients; this means, that we have to motivate them initially as well as to remotivate
them constantly for treatment and change. Psychoherapy of psychopaths resembles
in some aspects that of children, who, as Anna Freud has pointed out, because
of their immaturity, cannot be expected to have genuine insight or a wish to change.
There is, however, this essential difference, that with offenders we have to work very
fast to gain a hold over them, as otherwise they will not come back for treatment, or
they will commit new offences for which they will be arrested. Another aspect that
the treatment of offenders and children has in common is the degree to which we
have to work with the environment and not only with the patient himself. In the
case of the offenders the probation officer and the court usually represent the &dquo;en-
vironment&dquo;. We need them to give us realistic information, since the patient often
minimizes or hides the truth. We also need their co-operation to persuade the patient
to attend and to take the treatment seriously. Their handling of the patient and ours
should supplement each other and be co-ordinated and we may ask for greater
leniency or strictness as the situation indicates.
The Association for the Psychiatric Treatment of Offenders, APTO, has estab-
lished an unusual setup in which it co-operates with the courts without being em-
ployed by them, and takes the patient for treatment as a condition of probation or
deferred sentence. It is the task of treatment to turn the enforced relationship into a
genuine one or it will be of no therapeutic value, but unless a patient is forced to
attend treatment, he might not come and if he were not from time to time stirred up
by court appearances, memories or anticipation of jail, it would be hard to evoke any
emotions in him.

42
One of the characteristics of the psychopath is, as so many persons trying to-
help him have learned to their disillusionment, that as a rule he fails to respond both-
to kindness and to harshness. That is why he is so often regarded as untreatable_
How ever, quite often the right combination of both these attitudes seems the answer.
Although many psychopaths claim that they are unaffected by arrest or prison,
this is really not the case, and if they are reached at a moment when they are deeply
upset, they often respond to kindness. However, unfortunately for therapy, psycho-
paths manage as a rule to re-establish their mental balance very quickly, and once
they have done so, they are immune to influence; if they get out of a painful
situation, they succeed in a peculiar way of resigning themselves to it, denying all
emotions, &dquo;hardening&dquo;, and in both cases they become unreachable. This immunity
to normal continuous emotions is one of the greatest stumbling blocks to therapy.
One reason the patient manages so successfully to ward off emotions is because
of his narcissism. Whenever his narcissistic bubble and his ideas of grandeur are
pricked, he is open to influences, at least for a short time. Thus, getting arrested
may be of therapeutic value, provided it is correctly utilized.
The psychopath is essentially a failure in socialisation. Tlre airir of therapy is to
make him educable and then to educate him, to make him sociable and then to
socialize him, to give him values and social identifications. This presupposes the
establishment of a personal relationship. This cannot be achieved merely by a
detached attitude, but the therapist must show interest and emotions. However, he
should not allow the patient to take advantage of him too much. The patient is
likely to manipulate the therapist, but, in the long run, the therapist should succeed
in out-manipulating the patient. One way the psychopath gains his antisocial aims
is with his unbounded energy and the complications he is capable of creating with
which he outwears others. Actually, treatment within the community, co-operation
with the court and other team approaches are more successful than a one-to-one
psychiatric relationship with therapist. If the patient’s energy has somewhat worn
off, if his tricks repeated themselves too often, he can be made to feel that he is neither
so clever nor so successful as he likes to believe. At such moments he is amenable to
influence which then has to he used constructively.
It is one of the advantages that we can create teamwork, the therapist being
aided, supplemented or counterbalanced by the clinical director, psychologist,
reading instructor, probation officer, etc., utilizing the courts, sometimes the lawyer,
employer, family or whoever can be mobilized. We are trying to create an institu-
tion outside an institution, utilizing the situations and crises the patient creates,
outmanoeuvring and tiring him out. After all, there is a limit to the number of
situations he can create, and to convey to him that he is repeating himself and his
behaviour is rather boring, is often more effective than indignation.
To influence the patient, we must reach him emotionally. He has desensitized
himself to feelings of affection, gratitude, remorse or anxiety. He has succeeded in
disconnecting cause and effect, in breaking up continuity in time or space, in denying
to himself the inevitable consequences of his’behaviour, in building a narcissistic
armour against reality. The task of therapy is to resensitize him and to undo and
correct the above-described mechanisms. To reach him, we must evoke emotions,
and burst the bubble of his narcissistic ideas of grandeur. This is rarely attainable by
mere reasoning. It is usually crises, arrest, appearance before the court, being sent to
jail serious trouble with his family, losing his job that shake belief in his own
cleverness and superiority that evoke emotions or at least make him amenable to
experiencing emotions and sensitive to influence for a while. While the usual

43
nsight therapy with neurotics-mainly orthodox psychoanalysis-regards life crises

s a disturbance of therapy and only tliose patients as suitable for treatment who
are under no immediate pressure and can afford to concentrate on therapy, the
ife of the psychopath consists of continuous crises, and treatment must utilize these
rises for therapeutic purposes. The psychopath is not unaffected by punishment;
he succeeeds in getting over his upsets too easily and quickly, desensitizing him-
self with the help of denial mechanisms. If therapy can catch him at the right
moment and in the right way, and mobilize his emotions, he can be sensitized to
’nfluence.
For therapy to become effective, we must utilize the emotions stirred up by such
crises as arrest or appearance before the court, may provide the ensuing situation
some hold over the patient. If the patient is reassured for the practical situation will
straightened out too quickly, he rarely sees the therapist again. Yet, unless he has the
hope of getting such help, he will not be bothered either. Thus, treatment is based on
a very delicate balance, and moreover it is essential to maintain this balanced situ-
ation, not to allow it to become too definite in either direction, and this is where the
co-operation with the probation officer is invaluable.
It is not enough to evoke uncontrolled emotions in the patient; we must make
them bearable to him. We are dealing with very explosive material. The reason the
patient denies painful feelings is because he cannot tolerate them, and if we evoke
them incautiously, almost anything may happen. There is only so much horror, fear,
guilt regret or despair anybody can tolerate, and the psychopath, who has particular
cause to feel them, is especially sensitive to them. Remorse and regret can be borne
better once the patient is behaving in a social manner and has some hope for the
future; the same is true of anxiety, if we give him an &dquo;out&dquo;. Though psychopaths
glorify the outcast and deny all feelings, underlying is a desperate hopelessness and
loneliness. Offenders get tired of fighting society and being outcast, and often they
would socialize if the yhad hope that they might succeed.
The apparent insensitivity of the psychopath has usually been preceded by a
period of extreme oversensitivity. He has been excessively hurt, and in order not to
be hurt again tries to make himself immune and to hurt and to manipulate others;
yet this is bound to lead to more hurts. Also, if he allowed himself to feel normally,
he would be bound to experience overwhelming guilt, remorse, regret, loneliness and
despair.
It is not true, as is commonly believed, that the psychopath has feelings of no
guilt, but they do not serve the normal socializing purpose. Many such patients react
even to a fleeting sensation of guilt with extreme resentment. which leads only to
increased antisocial reactions. If they can learn to cope with guilt by social be-
haviour, which in turn brings its rewards and also alleviates the patient’s conscience,
a great step has been achieved. Neurotic reactions, if
they develop in the psychopath,
should not be combatted, but rather encouraged, since they counter his primitive
impulsiveness and antisocial attitude. The main socializing factor is attachment to,
and identification with, a socially oriented person-often the therapist or probation
officer. The emotional satisfaction derived from a personal relationship helps him to
cope with otherwise unbearable feelings.
One way of teaching the patient to accept his emotions is for the therapist to
react normally to the patient’s situations which he relates with bland indifference.
The therapist can establish a human relationship with a criminal who has a long
prison record. For example, when he gives the therapist a gruesome description of
his prison experiences in a most objective manner, by the therapist saying that he

44
could not understand how the patient could be so detached about it and showing
feelings himself. Only by the therapist expressing emotion can the patient allow
himself to feel anything. Sometimes one can elicit feelings by taking the patient b~
surprise, e.g., when he claims that he does not really mind prison, ask him in some
other context about some specific details of prison life, and then he may blurt out
&dquo;I would not wish it on my worst enemy&dquo;.
The lack of emotion in the psychopath is overdetermined; it is also a solution
to his extreme ambivalence. Thus, it is therapeutically important to make him
accept and cope with extremes of emotion and antitheses of attitudes. It is often
effective to approach him simultaneously on two levels, thus taking cognizance of
the contrasting attitudes. Sentences, the second half of which contradicts the first.
are a good way of talking to him. &dquo;Yes, you had a pathetic childhood, but that does
not justify ...&dquo; &dquo;Your wife did treat you badly, but you provided her ...&dquo; &dquo;You do
hate your father, but there are moments ...&dquo;
Talking like this is not just being fair and moderate, but is a way of evoking
contradictory emotions at the same time, and this makes it harder for the patient to
deny them. Changing the emphasis on a certain matter, taking it sometimes very
seriously, and then again minimizing it, drawing attention to it, and again over-
looking it, is another way in which the patient’s emotions are evoked, moved, calmed
down. This teaches him to vary and modify his emotions, to control and accept them.
It is essential that the patient should learn to get satisfaction from social
situations, ordinary activities, from fore-pleasure, anticipation, memories, and not
merely from immediate satisfactions; from ideals and sublimations, and not only
material pleasures.
If he is treated too well by his therapist, this has a bad effect on him, not only
because it encourages him in his ideas of grandeur and antisocial behaviour, but
because he becomes too glib and soon develops a contempt for the doctor. Often a
good approach with a psychopath is to use a peculiar mixture of jeering at him
while showing him some understanding and a moderate amount of sympathy. Many
patients think the therapist intelligent merely because he is rude to them. Because
of their ideas of superiority, anybody who can show himself to be superior to them
and can prove them to be wrong here and there, is, of course, a very superior person.
If, however, we condemn the patient altogether, we cannot treat him.
By correcting his thinking difficulties and making him face reality, we evoke
emotions, both the painful ones he tries to avoid and the satisfaction he might get
from normal life. Alternately, more normal feeling leads to more normal thinking
and observations and better functioning. One cannot separate emotions from
reality-sense and thinking. The same interrelation can be demonstrated concerning
his concept of the self, ego ideal, values, ideals and object relations. The aim is to
develop the ego and orient it socially, rather than make the unconscious conscious,
and to develop values, ideals, sublimations, self-control, to educate, re-educate and
socialize.
We should also take time here to discuss the final outcome of many psycho-
paths. To date, the following trends have been noted:
1. Many burn out during their late 40’s to early 50’s. Apparently, psycho-
analytically speaking, there is no longer any need to vent their spleen upon
society, as representatives of their own parents, who are now, generally,
deceased.
2. A number, percentage not calculated, become openly psychotic, and adjust
on a frankly schizophrenic level. They enter institutions as completely

45
I
I
3. Conversely, some
there.
delusional, and frequently end their days
able to drop their overt delusions and
&dquo;schizophrenics&dquo; are
hallucinations, and are able to make an essentially &dquo;sane&dquo; readjustment,
within the meaning of the M’Naghten Ruling, albeit only as adjudged
psychopaths and/or sociopaths.
4. Lastly, and most dramatic of all, is the fact that a very small number of
-
these psychopaths can go through a &dquo;religious&dquo; experience, which seems to

alter their personality drastically, and from which, emerging with the attar-
of-roses, a conversion in the opposite takes place. Whereas before they were
sinners, now, with all humility, they have become the saints, the examples,
the preachers and the missionaries.
Another mode of treatment, based as the above, on the narcissism and low
evel of anxiety of these individuals as long as their acting out takes place, is the use
f the hospital and its restraining influence and structure. One attempts, by re-
training this group, and preventing their acting out, to mobilize their anxiety. At
he same time, however, one uses the very structure of the institution with its very
ontrols, as a model for the fostering in the patient of a super-ego. Theoretically,
vith the many prohibitions capable of being imposed, and the consequent mobiliza-
ion of anxiety, yet with the prevention of acting out, the psychopath turns or should
urn into an artificial neurotic. Once in this ersatz state, the now neurotic ex-
sychopath can be treated as one would treat the usual neurotic. Hopefully, with
he same expected rate of cure.
However, one must continue to prevent acting out in sublimated forms. For
xample, the psychopath may pick out the particular major symptom and ignore or
this
orget, temporarily,
the rest of his previous symptomatology. It will he noted that
is merely a substitution for general acting out.
Then again, the theoretically neurotic may actually suppress his acting out
himself. He will in effect be saying: &dquo;I beat you to the punch&dquo;. He is also trying to
the best of his ability, as he has in the past, to &dquo;con&dquo; the physician and attendants in
charge of his particular person and/or ward. He is trying in the best way he knows,
to show that he is &dquo;WELL&dquo; now, and supposedly has developed &dquo;INSIGHT&dquo;.
However, by not actually believing his verbal statements and continuing with the
charted course of suppression of acting out, and restraint, the internal pressure will
continue to build up, beyond the capacity of the psychopath to handle this pressure.
The end result will be an explosion of this pent-up pressure, and anxiety, plus release
of this anxiety through physical action and acting out.
Some psychopaths can, in such an artificial environment, with the support
of the institution, actually do quite well. Since the institution can supply all the
needed supplies of narcissism the psychopath needs so badly. As well as filling in
all the chinks in his fence of internal inadequacy. However, it should be noted here,
that it is only through the external support supplied by the aforementioned institu-
tion that the psychopath can continue in this stable fashion. Should, however, this
support be withdrawn, as through discharge, etc., there is every reason to believe
that the continued pattern of acting out will once more reassert itself, since the
artificial support is no longer at hand. The average psychopath still needs to he
helped to express his feelings, and not his behaviour.
One final point should be made before we conclude our discussion. Many times,
we find psychiatrists talking at cross-purposes with each other. They are indeed ’
discussing the same basic problem, but from different points. From:
1. The Genetic

46
2. The Dynamic
3. The Behavioural and Descriptive
viewpoints. It is therefore respectfully suggested, that before any other debate, etc.,
takes place, that a clarification of views take place prior to any serious policy making:
I
decisions, in order that a mutually understood decision can be reached.

Sociopatia or Personalidad Psicopatica. Begun

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25

THE SOCIOPATHIC OR PSYCHOPATHIC

according to the diagnostic and statistical manual of mental

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9) Pathological egocentricity for love.

Karpman’s psychodynamic portrait of the psychopath reveals that the psycho-

consequences and lack of vision as indicative of irrationality not only in their

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Adelaide Johnson, with Eicheler, at Rochester, Minneapolis, along with Szurek

Many sociopathic patients soon appear to be behaving similarly, and in their

Hospital, referring to the &dquo;meditations of closet philosophers&dquo; and indicating that

lay down.heJudge Dee led to his opinion by

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staff. Considering the general inadequacy of such institutions, with shortages om

expects disproportionate praise for anything he does. Bromberg calls attention to

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nsight therapy with neurotics-mainly orthodox psychoanalysis-regards life crises

Downloaded from isp.sagepub.com at SIMON FRASER LIBRARY on June 10, 2015

Downloaded from isp.sagepub.com at SIMON FRASER LIBRARY on June 10, 2015

these psychopaths can go through a &dquo;religious&dquo; experience, which seems to

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Downloaded from isp.sagepub.com at SIMON FRASER LIBRARY on June 10, 2015

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