"The Mask of Sanity"

I'd like to share a chapter from another book that has been highly influential in my life, and that would be the seminal work "The Mask of Sanity," written by Dr. Hervey Cleckley.

I'll share chapter 40, titled "The Clinical Alcoholic" for further clarification.

"The term clinical alcoholic is chosen for convenience to signify the large group of
pathologic drinkers who are still making some genuine effort to adjust in normal life but
are using drink to escape reality which they cannot quite face and, by a vicious cycle,
making themselves steadily more inadequate to face this reality. Such drinkers may, in
several respects, be contrasted with the psychopath (antisocial personality) just as the
non-alcoholic neurotic contrasts with the psychotic patient.
 
Like the psychopath, their drinking is not primarily for pleasure or has at least
ceased to afford much pleasure. They often give a strong impression of drinking to
avoid sober self-appraisal or some other aspect of reality. With alcohol they can remain
a little more comfortably and longer in the false world of fantasy or in analgesia. They are often introverted people, often tenderminded and shy. Alcohol enables them to be less self-conscious and to make their way with greater ease into the social group. They become more and more disabled for real life, and reverses due directly or indirectly to their alcoholism accumulate, making it ever
more urgent for them to escape into the numbness of drink.

To a certain point this picture is not unlike that of the psychopath. Perhaps the
psychopath sometimes arrives at his life scheme by way of phases almost identical with
those of some neurotic drinkers, and perhaps the neurotic drinker may regress to levels
at which he can be plainly recognized as a psychopath. Some of the patients described
here as partial psychopaths might be placed by some observers in the class of neurotic
drinkers.

For the purpose of drawing a useful distinction, however, the following points
are offered:
Often the neurotic drinker wants to get well. This may not be obvious, but with
proper psychiatric treatment it may be possible to obtain sincere cooperation. Although
the neurotic drinker lacks insight and often cannot get well by his unaided efforts, he
retains a capability of gaining insight, and good improvement is often possible under
treatment. The psychopath's actual conduct when drinking, and sometimes when sober,
is bizarre, often shameful and shocking, and actively damaging to himself. In the neurotic drinker such tendencies, if present, are much less pronounced. The neurotic drinker on his spree is unintentionally destroying his chances for success and happiness, but this does not appear to be his fundamental aim; his fundamental aim apparently is to avoid facing his failures. Although this aim may be present in the established psychopath, it is not easily or regularly discernible. The latter appears to be driving primarily at evading, or ignoring, or destroying life itself, that is to
say, life in the sense of social attainments and subjective integration.

Drinkers who can be classed as neurotic show better capacity for insight and may
come voluntarily to seek treatment or may be persuaded by relatives to do so. The
psychopath will not come voluntarily, except when he seeks hospitalization to avoid
legal action, and he cannot be persuaded to carry out sincerely any therapeutic program.
To summarize, then, it may be said that the neurotic drinker is capable of insight
and wants to get well. 

The psychopathologic picture is more readily comprehensible in
terms of cause and effect and, under favorable conditions, is perhaps reversible. The
psychopath, on the other hand, despite his superficial appearance of being a normal
man, shows in his whole behavior pattern deviation and disorder that seem
fundamental. His real drives, when one tries to surmise them from his reactions, strike the observer as foreign to ordinary human impulse. The process, if reversible at all, is not ordinarily found to
be so. Apparently there is no latent insight that can be aroused or sincere desire to
become well or, rather, to become like other men. I do not mean to state dogmatically
that the psychopath's illness is irreversible but merely that in my own experience it has,
in typical cases, proved to be so. It may be said that the process of schizophrenia as
compared with hysteria is relatively less reversible, that it ordinarily brings about a
greater and deeper disintegration of the personality. Despite this fact, schizophrenics
often recover. Perhaps the psychopath, too, can recover. Perhaps some generally
satisfactory means of treating him can eventually be devised.

Taking the group of chronic alcoholics as a whole, we are likely to find here
people in whom the excessive drinking is a common symptom of underlying disorders
that vary widely in type and in degree somewhat as we might say that fever may arise
from a bad cold, measles, pneumonia, tuberculosis, meningitis, and other differing
illnesses too numerous to list. Alcoholics Anonymous, whose excellent work it is appropriate to mention here, has, in my experience with this group as a whole, appeared to be one of the most
valuable therapeutic agencies available. Many gravely maladjusted patients in whom
alcoholism was at the same time a disabling symptom and a secondary but major causal
agent in disastrous life patterns have, through this agency and its program, made
changes and progress that with no exaggeration can be called remarkable. Some
patients whose behavior and emotional attitudes definitely suggested the psychopath's
disorder have to my knowledge not only avoided for years the disabling effects of their
former drunkenness but also other unrewarding and antisocial activities. Whether or
not these were psychopaths in the full and deepest sense is not a question that can be
answered confidently. It is my belief that this type of disorder, like all other psychiatric disorders, may
be seen in almost limitless variations of degree and severity. 

We see the utterly disorganized schizophrenic who has for twenty years been on the worst ward of a state hospital, and we also see schizoid reactions and limitations that persist for decades in
people who continue to be self-supporting and to a considerable degree socially
competent. I recall one patient who has expressed to me delusions typical of full-blown
schizophrenia over some years and who is still an able worker with many pleasant social
relations and recreational activities. Many more come to mind whose delusions are less
extreme but who for decades have manifested autistic withdrawal, oddities, emotional
distortions, and impairments consistent only with a schizoid reaction. We also see manifestations identical with those of full-blown schizophrenia in every respect except their transiency. A 30-year-old man who, after taking a small dose of testosterone, experienced not only hallucinatory sexual and spiritual sensations within himself but also in others will serve as an excellent example. Vivid delusions were very prominent for approximately a week. These included an absolute conviction that all virtuous women at the mere sight of him caught the impact of magic, glowed with a fire
both erotic and holy, and were visibly transformed. It was also his belief that this
caused harlots who might sense his powers a block off to run up alleyways in shame.
 
For several days, through false perceptions, he specifically "felt" men and women some
miles away responding viscerally, intellectually, and spiritually, and in diverse ways, to
what had miraculously become incarnate in his person. After being psychotic for a
week and without specific treatment, he regained insight, lost his schizophrenic
symptoms, and has for a number of years remained entirely free of them. In the other disorder, that of the psychopath, I believe there also occur similar variations in chronicity, in severity, in completeness, in depth, and in every other respect. Although malignancy and irreversibility seem typical of the psychopathology as we meet it clinically in its advanced or long fixed forms, outwardly similar behavioral and characterologic patterns sometimes prove reversible. 

Few, if any, features of the full psychopath are more impressive than his inability to respond with consistent acts or in other ways that would indicate deep or genuine desire to change his situation. In
therapeutic programs it is characteristic of him not to make valid or persistent efforts to
cooperate. In their relations with Alcoholics Anonymous, psychopaths sometimes show
at first what seems extraordinary zeal, sincerity, and promise, only to reveal after varying
intervals that the whole matter was only a sort of prank or lightly taken adventure in
versatile careers of self-ruin.

Fundamental points in the Alcoholics Anonymous system of group therapy and
self-reorganization are the following:
1. The need for a most profound intention (an authentic and major desire) to
overcome one's disability.
2. The necessity for extensive and basic changes in attitude and orientation at the
core of the personality.

At both of these points we find in the full psychopath an almost uniquely
unfavorable situation. Although I know of nothing available today that can be counted
on to succeed regularly, the evidence has suggested that Alcoholics Anonymous may in
some cases affect favorably latent resources very difficult to reach by most methods in
patients showing reactions that may have something in common with those of the
typical psychopath." 

In almost 5 years of experience in Washington, I can say without a doubt that the town is indeed, well, "crazy."