Sociopathy A
as a
Human Process
Viewpoint
George
E.
Vaillant,
MD
Case histories of narcotic addicts who also were imprisoned for were selected to illustrate some underlying dynamics of Cleckley's so-called psychopath and some principles useful in their management. Often in outpatient settings, such individuals seem to be without anxiety, unable to experience depression, and without motivation for recovery; but in inpatient settings, such deficits appear illusory. Once such chronically sociopathic individuals are prevented from "running," their resemblance to individuals with severe but thoroughly "human" and comprehensible personality disorders becomes evident. In treatment, external controls are important. It is vital both to appreciate the contagion of the psychopath's invisible anxiety and to provide such individuals with alternative defenses with which to mitigate their depression. Finally, sociopaths must be realistically, but not punitively, confronted with the consequences of their behavior.
felony
character disorders are a confusing area One reason for confusion is that in an the management of these disorders produces therapeutic frustration. This frustration blurs our perception of important clinical realities, and the de¬ fensive maneuvers of the sociopath become wrongly inter¬ preted as signs of that incurable entity, the psychopath. These signs include an apparent absence of anxiety, an ap¬ parent lack of motivation for change, and an apparent ina¬ bility to feel depression.1 This pejorative term, psychopath, is accurate only insofar as it describes the back of a pa¬ tient fleeing therapy. If a psychiatrist sees the same pa¬ tient in a prison hospital, he may doubt that such a dis¬ order exists. For then he sees sociopaths face-to-face, and they are human. He is able to do what Edward Glover sug¬ gested 50 years ago; he can "apply to the special problems of anti-social behavior the principles established by Freud to mental function as a whole."2 What I am suggesting is that when the psychiatrist is protected from therapeutic frustration, when control is es¬ tablished and flight is not possible, the stigmata of psy¬ chopathy disappear. This report will be an effort to examine why in the eyes of most psychiatrists the outpatient socio¬ path may appear incorrigible, inhuman, unfeeling, guilt¬ less, and unable to learn from experience; and yet in a
sociopathic The psychiatry. outpatient setting of
prison hospital, the sociopath is fully human. I shall try to demonstrate that Cleckley's psychopath, immortalized in the Mask of Sanity,3 is a mythical beast. To illustrate that our textbook conceptions of the psychopath are illusions, I have chosen three narcotic ad¬
dicts. All had extensive criminal records; all were sent against their will to the US Public Health Service Hospi¬ tal at Lexington, Ky. All demonstrated an absence of anx¬ iety, an absence of motivation to change, and an absence of overt depression. But, once immobilized, they became indistinguishable from Otto Kernberg's "borderline" patientsJ and Elizabeth Zetzel's "primitive hysterics"5 that are familiar to most psychiatric teaching units. Such pa¬ tients do not appear psychologically healthy, but they ap¬ pear neither alien nor untreatable. Over a period of time, seemingly organic and immutable deficits emerge as dy¬ namic and understandable defense mechanisms. Absence of
Anxiety
An apparent absence of anxiety is a clinical hallmark that sets the real sociopath apart from most psychiatric outpatients. One reason that sociopaths conceal anxiety is that their parents often experienced great difficulty toler¬ ating tension in others. They often used inappropriate means to relieve or to obscure anxiety in their children. The sociopath may confide to the psychiatrist that he had a "normal" family but that he was a "bad seed." He main¬ tains that his parents (unlike the wicked fairy-tale step¬ parents who allegedly bring up neurotics) gave him "ev¬ erything" he wanted. He often blames society for his behavior, but not his parents. His parents willingly cor¬ roborate the story. In the Mask of Sanity, Cleckley pro¬ vides us with innumerable examples of wicked children and noble parents.1 The psychopath seems the very anti¬ thesis of the fairy-tale hero. An unsolicited letter from a woman whom I had never seen provided a vivid illustration of what may lie beneath parental innocence: Dear Sir: My son is a dope addict and because he no longer knows the truth himself, I don't know how long it has lasted. I do know that I cannot continue the way I've been doing; I have no re¬ I have about 30 pawn tickets on which I cannot sources left. even pay the interest. Every time I renew things, he'd hock them again. He had been arrested a total of five times, dismissed from all cases. The lawyers and the bail cost me about $1,500. [In short, she paid $1,500 to shield him from the normal consequences of his ...
Accepted for publication Aug 14, 1974. From the Department of Psychiatry, Harvard Medical School and Cambridge Hospital, Cambridge, Mass. Reprint requests to the Department of Psychiatry, Cambridge Hospital, 1493 Cambridge St, Cambridge, MA 02139 (Dr. Vaillant).
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behavior.] When he was working he made $60 a week. He was sup¬ Now he has posed to pay me $12 a week but I seldom got it. started selling off my books, and, as I've already weeded these .
.
.
down to bare essentials in the interest of space, this makes me very nervous [not angry but nervous]. One example of how dis¬ sipated this is he says he sold his camera for $5. His camera was
complete with case was a $10.50 Christmas gift difficult it was for her to decide to whom the cam¬ era really belonged!] He is inarticulate and quarrels quickly and finds fault. He writes like a child and misspells words. He's losing his hair in front and has lost a tooth on the upper right. He is thin. I've lost a Brownie and from me. [How
my social career also. I have not had my hair fixed for a yeardoing it myself. I have not bought any new clothes, and the getups no one even wants to walk to I wear to school are a disgrace the door with me. I know I am an 'indulgent' mother, but what can I do? I don't want to let him go. I see these jungle addicts in the house, and I know that I am the buffer which is keeping him from looking like them. One example of how bad off I am is that every month I have one or two bounced checks, and the bank charges me $4 because of my what I am trying to say is that I have $288, that is poor record all I have left until September 15 when we go back to school. [The parents of sociopaths seem more in need of parental care than their children] Nevertheless, in one way or another, my son gets the money from me.... Last week he promised if I would give him $15 on Tuesday and Wednesday, he would go to the hospital on Thursday. I got up at 5:30 a.m. on Thursday and Friday, but he didn't want to go; and as we had such a terrible heat spell, I can't blame him. At night, I lock my door and barred the door and jammed the lamp against it besides. Occasionally, he frightens me. [Although reluctant to let her son experience anxiety, she subtly amplifies her own secret fears.] Other times he seems so young and helpless. He is 22 and he is beautiful. Please tell me what to do. ...
..
.
The sociopath is supposed to be unable to postpone grat¬ ification; but in a family matrix intolerant of anxiety, postponement of gratification is difficult to learn. The let¬ ter demonstrates that it is never clear who is dependent on whom and who needs the help. The son's delinquency frightens his mother, but rather than oppose it, she con¬ ceals it. When she calls for help, she writes to a physician whom she has never seen and who is 700 miles away. As the sociopath matures, he is not without anxiety; but it remains invisible to many observers—including judges and psychiatrists. Why? Neither the explanation that he cannot feel it nor the more sophisticated explanation that his anxiety is defended against by the ego mechanism of acting out is entirely satisfactory. There are two other reasons that his anxiety is invisible. First, there are times that the sociopath makes his anxi¬ ety very clear to us; but at such times, our empathie re¬ sponse may blind us to it. By this I mean that the socio¬ path elicits from physicians and social workers the same response that he elicited from his parents. We behave as if to ask him to bear his anxiety would be too cruel, too dis¬ ruptive, too sadistic, too authoritarian. Instead, we, too, respond by distorting the very reality that would help him to learn that anxiety is acceptable—both to himself and to others. Too seldom therapists are able to say to sociopaths, "I am sorry that you are feeling bad, but I think that you can manage the feeling." Second, we are often blind to the sociopath's anxiety be-
cannot bear it or because the sociopath has man¬ aged to transfer his anxiety to us. The resulting staff ap¬ prehension then serves to make the patient unreachable, unfeeling, incurable, and unaware that the staff anxiety that surrounds him was originally his own. (The situation is analogous to that of the well-defended Kraepelinian psychiatrist; he calls the acute schizophrenic's affect "flat" cause we
when, in fact, the affect is
one
of stark
terror.)
Consider the following example of concealed anxiety in
a
sociopath:
Case 1.—I was informed by several upset senior staff members that an unmanageable and notorious "psychopath" had returned to the US Public Health Service Hospital at Lexington, Ky, for the tenth time. He was reported to be on the admission ward out of control and holding the security staff at bay with a broom handle. It was with conscious fear that I learned that this unseen man was to be transferred to the psychiatric unit where I worked. I
anxious. Once transfer was effected, I realized my fears were without substance. Confined to the isolation room and stripped to his shorts, he countered my anxiety with tranquility and charm. With injured innocence, he asked, "How can I regain my self-respect if I'm not given some clothes and let out of seclusion?" His behavior was beyond reproach; his privileges were soon returned, and so he left the unit. A year later he returned. After having been refused medica¬ tion, he had cut his wrists. It was at this point that I reviewed his chart, started to talk to him, and for the first time saw him in hu¬ man dimensions. From suburban New York, he was the only child of middle-class, and apparently long-suffering parents. Only dur¬ ing his fifth admission to Lexington was it learned that his mother was secretly addicted to meperidine hydrochloride (Demerol) and that his father was an alcoholic. But his social history is not what is most pertinent. Rather more remarkable was the covert staff anxiety that was disclosed by his hospital record during this, his tenth admission. The Lexington medical staff was highly sophis¬ ticated to inappropriate demands for medication; but in one year, this known psychopath received the following results from labora¬ tory procedures: six urinalyses—all normal; two urine cultures—no growth; ten different blood chemistry evaluations—all normal; an electrocardiogram; three roentgenograms of the chest and one of the skull; two gallbladder examinations; two gastrointestinal series; a barium enema; and a spinal tap—all of which were nor¬ mal. At no time had he been organically ill. Although he had never had a fever or evidence of an infection, he received penicillin. Although the patient was in a hospital that virtually never gave narcotics, even to patients with painful ill¬ ness, he had received phénobarbital, codeine, pentobarbital (Nembutal), methadone hydrochloride, and chloral hydrate-all after his withdrawal period was completed. He also received 34 other medi¬ cines including meprobamate, imipramine hydrochloride, chlorwas
promazine, methamphetamine hydrochloride, chlordiazepoxide hydrochloride, and hydroxyzine hydrochloride.
There is little question that the staff response to this pa¬ tient was unique. Nevertheless, he serves as an example of the difficulty that even sophisticated staff had in recogniz¬ ing his anxiety, tolerating it or believing that he should tolerate it. The irrational therapeutic response he evoked had not become conscious in anyone's mind and, during the year, had been diffused among a large number of
people. Significantly, this tenth admission onment; it
stay in one
was his first impris¬ the first time he ever had been made to place. Shortly after his second visit to the psy-
was
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chiatric unit, he built up a relationship in psychotherapy with one of the staff. Through this relationship, he learned to tell the physician on night duty, "I don't want any medicine-I just want to talk." (Admittedly, nonsociopathic patients can often learn to do this within a few days of hospitalization.) Once this lesson was learned, once his anxiety was conscious, he required—and received—no addi¬ tional drugs. He caused the staff less anxiety; but he was able to show them more of his own. Previously, the patient had been unable to postpone gratification, but this was partly because nobody really tolerated his distress when he did so. This man not only defended against anxiety with drugseeking behavior, but he also manifested clear conversion symptoms. Psychiatrists, however, conceive of sociopathy and hysteria as two different syndromes and fail to recog¬ nize conversion in the sociopath. The hysteric is a woman; she is not out of control, and is immensely human. We see her conversion symptoms as a defensive process, and we perceive her distress behind these defenses. We believe her to be treatable. In contrast, the sociopath is usually a man and his physicians perceive him to be out of control. His defenses are invisible and his conversion symptoms are seen as conscious, hostile manipulation rather than un¬ conscious efforts to conceal anxiety. Unfortunately, unrec¬ ognized defenses can seem to psychiatrists like deliberate offense; the psychiatrists defend themselves. Human beings are labeled "psychopaths." Lack of Motivation
Sociopaths have a second hallmark that makes them appear inhuman: supposedly, they lack motivation for change. Sociopaths are supposed not to learn from experi¬ ence. Often psychiatrists who have successfully banished the pejorative terms psychopath and sociopath from their vocabularies, replace the terms with "passive-dependent" or "inadequate personality." In such cases, the psychia¬ trist perceives the distress but shrinks from the seemingly overwhelming oral, passive, and receptive qualities of these individuals. His own helplessness may be projected onto the patient. At this juncture, it is well to recall two things. First, adolescents sometimes seem unable to learn from experience, yet this is a temporary artifact of one stage of development. Second, if individuals respond to an unconscious fantasy or impulse, this is different from being unable to learn. Sociopaths are more adolescent than ineducable. Case 2.—A 30-year-old black addict prisoner received the admis¬ sion diagnosis of passive-dependent character disorder; his behav¬ ior over the preceding four years was consistent with the diag¬ nosis. He had grown up in New Orleans. His father, a pullman porter, had always made an adequate living, but he was an ex¬ tremely ineffectual man. At 8 years, the patient was a better car¬ penter than his father. In order that his father might resemble the fathers of his friends, he used to daydream that his father would spank him. His mother, the family disciplinarian, was also the patient's chief competitor in arguments and power struggles. But he could remember his mother forbidding him to do only one thing-to play the trumpet. When he reached adolescence, his uncle gave him a trumpet; he took it up with a vengeance. He ex-
perimented briefly with meperidine, but never became addicted. He took five years of college training in music and band teach¬ ing. He also became a successful jazz musician. However, when he reached the point where he was performing well-applauded trum¬ pet solos, he abruptly gave up the instrument. There was no rea¬ son except, "I was not as good as other people thought I was." For the same reason, he turned down a well-paying job with the Chi¬ cago Department of Education. Two years after giving up the trumpet, he had an affair with a "flashy woman." After she had canceled a date, the patient, un¬ aware of any resentment, developed an overwhelming, inexplicable urge to take meperidine. He rapidly became addicted and four years later came to Lexington as a prisoner. He had no insight into his problems and wanted psychotherapy to relieve his func¬ tional gastric bloating and, magically, to cure his addiction. Many months later he began to speak about his love of the trumpet and said that he gave it up because, "I was afraid of be¬ coming addicted to it. I was afraid that I would only be able to play the trumpet and be interested in nothing else." His fantasies about drugs became more explicit. He felt that marihuana was harmful. Although marihuana improved his trumpet playing, it made him think that he was too powerful. It might lead him to be¬ come "wild" and to drive his car too fast. In contrast, he felt that heroin was helpful to society and should be legalized. Heroin just made him drowsy and obtunded his sexual drive. When he got angry now, he got severe "ulcer" pains; these pains could be re¬ lieved with heroin. Only at the end of treatment was he able to talk tentatively about the anger he felt toward whites—especially policemen. [Ten years before he had belonged to CORE, but after he gave up the trumpet, he had also lost his interest in civil rights.] Any acknowledgment of negative transference toward me or resentment of his mother was assiduously avoided.
Throughout, it was difficult to mobilize this man's moti¬ vation for treatment. Had he not been in prison, he would never have kept his appointments. Yet after a year of psy¬ chotherapy, it was clear that beneath his "passive-depen¬ dent" camouflage there lurked a fairly competent individ¬ ual who went to extraordinary pains lest some of his competence become visible to others. It is not that socio¬ paths do not feel; they feel, but fear lest they feel too much. For them recovery becomes synonymous with un¬ consciously forbidden sexual and aggressive competence. It is dangerous at 8 years to be a better carpenter than your father. Case 3.—Another Lexington patient had wished two years be¬ fore her imprisonment to put her illegitimate baby up for adop¬ tion. Instead, her mother insisted on keeping it. The patient re¬ membered watching in silent rage while her mother triumphantly passed her daughter's baby off to the mother's friends as her own. A year later, the patient married a drug addict. During this period she wrested her child away from her mother and brought the child to live with her. The mother was furious and the patient felt ex¬ tremely guilty at depriving her mother of the child. At this point she became addicted. When she was imprisoned, her mother re¬ gained control of the child. Initially, the patient's anxiety over resumption of this struggle once she left prison was invisible. Instead, the patient tried to avoid help and preferred to deny herself parole than to return to this conflict. The details of her dilemma and the fact that at age 10 years her father had repeatedly sexually molested her came out only after months in therapy that she, too, would have fled had she not been in prison. In the setting of a prison hospital, however, this woman's lack of interest in "getting well" became dynam¬ ically understandable.
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Perhaps the following vignette sums up the point of this section. Because the above patient deprecated her low self-image still further whenever her own strengths be¬ came evident, I asked her if she remembered how the ugly duckling story had ended. Without hesitating, the patient recounted the story as follows: The ugly duckling had been all black; the other ducks went off and left the ugly duck¬ ling all alone—end of story. The
Inability
to
Experience Depression sociopath is his apparent in¬
The third hallmark of the
ability to experience depression and his inability to ac¬ knowledge that others matter to him. But it may be as preposterous to ignore depression in the sociopath who vehemently denies its existence, as it would be to ignore sexuality in the hysteric who feigns lack of interest in the subject. Case 4.—A 25-year-old prostitute was sentenced to Lexington for five years for drug peddling. She was the daughter of a strict, middle-class, Christian Scientist family. Since age 16 years, the patient had been incorrigibly delinquent, and at first she seemed the very model of the classical psychopath. Only after a year of imprisonment at Lexington and after
many weeks of psychotherapy was depression more than an intel¬ lectual concept to this woman. Only gradually were another set of facts obtained. When the patient was an infant, her mother, unable to accept the responsibility of parenthood, had delegated her daughter's care to others. Like Arthur Miller's fatherless Willy Loman, the patient grew up feeling "kind of temporary" about herself. One day she finally protested to me, "You inject sadness into me." Until that time she had hidden behind a private rose-colored version of Christian Science or behind angry, child¬ like dissatisfactions that lifted too rapidly to resemble clinical
depression.
After several months of therapy, and following a rather friendly hour the time before, she began to speak about her fears of intimacy; then, feeling anxious, she drew into herself and said, "I guess I am destined to be lonely." Two months later, on an oc¬ casion when she was denying that she felt any warmth or inti¬ macy toward me, she spoke of herself as an IBM machine. She de¬ clared that I was seeing her only because "You were assigned to
me." I wondered about her reluctance to consider the alternative formulation that she was human and that I might have chosen to work with her. She answered, "You are confusing and upsetting me. If you go on, I will stop therapy." During the next hour she was silent for the entire hour except to ask who solved the riddle of the sphinx; then, she described the sphinx as "a woman who ate everyone who was wrong." When I asked, "Do you mean that you're afraid of devouring people that you care about?" the pa¬ tient retorted, "An astute observation, but what can you do about it?" During the next hour she spoke of getting close to her family; "I don't believe other people have feelings or emotions. When I see that they do, I push them away." On one occasion she became upset at a compliment and said, "The danger of intimacy with people is that people will depend on you; and, then, you may hurt them and let them down. It is not nice to punish those who love ...
you." She handled separation in the following dissociative manner. She canceled the hour before I went away on vacation. She then wrote me an exceedingly cheerful postcard that ended with, "I have put my neurosis on the shelf till you get back." When I re¬ turned, like a good sociopath, she spent two appointments de¬ manding tranquilizing drugs and then skipped the next appoint-
ment.
Near the expiration of her sentence, she said, "Of course, I'm fond of you. You listen like a parent and you're a good teacher." She skipped the next session. When she returned, she said, "Can you give me any reason why I should continue with therapy?" When I suggested that at this point one purpose of continuing was in order to say goodbye, she declared, "I never said goodbye to anybody!" She spent the next two sessions in angry manipulation and vituperation, and canceled all future appointments. She let a year go by; then, safely distant from me by several hundred miles, began to write. For five years she continued to write me sensible, warm, and often appropriately depressed letters. She did not re¬ turn to
drug
use.
Glover has said of
sociopaths:
In addition to his incapacity to form deep personal attachments and his penchant to cause suffering to those who are attached to him, the psychopath is essentially a non-conformist, who in his re¬ action to society combines hostility with a sense of grievance21"1281·
sociopath's "incapacity" represents defensive pro¬ inability. Close relationships arouse anxiety in them. Terrified of their own dependency, of their very real "grievances," and of their fantasies of mutual destruction, they either flee relationships or destroy them. As the above case history illustrates, the depression of sociopaths resembles that of bereaved children. Bowlby has suggested that mourning in childhood is characterized by a persistent and unconscious yearning to recover the lost object.6 The persistent crime and polydrug abuse of the sociopath represents a similar quest. Bowlby tells us that in lieu of depression, bereaved children, like socio¬ paths, exhibit intense and persistent anger that is ex¬ pressed as reproach toward various objects including the self. However, Bowlby notes that such anger, if misunder¬ stood, seems often "pointless enough to the outsider." Fi¬ nally, sociopaths, like children, often employ "secret" anodynes to make loss unreal and overt grief unnecessary. But the
cess, not
Their need for secrecy is based on the fact that "to confess to another belief that the loved object is still alive is plainly to court the danger of disillusion." These defensive maneuvers then, serve to hide the child's and the socio¬ path's depression from our psychiatric view. The painstak¬ ing controlled studies of the Gluecks' have established be¬ yond reasonable doubt that the sociopath usually was a neglected (ie, bereaved) child7 and that for this reason, se¬ rious delinquency (unlike most psychiatric conditions) can be prospectively predicted by age 6 years.8 In conclusion, I would like to recapitulate certain themes that were present in the above case histories. All had lacked a benevolent, sustained relationship with the same-sexed parent. All were afraid of intimacy and of as¬ suming responsibility for it. None could believe that oth¬ ers could tolerate their anxiety, and all devoutly feared re¬ sponsibility for achieving success by open competition. They could neither identify with authority nor accept its criticism. Finally, their persistent, seemingly mindless delinquencies made symbolic sense if interpreted dynamically-as one might interpret misbehavior in a dream or in a child's play therapy. In short, psychopaths are neither born that way nor incapable of change. I believe that their "incomprehensible" behavior is a product of a well-de¬ fended ego and of a strict, albeit primitive, conscience.
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THE EGO MECHANISMS OF SOCIOPATHY
If the ego of the psychopath is not inadequate and if his superego is not absent, what are the underlying dynamics of the psychopath that make him or her seem so inhuman? Certainly, they employ very different styles of defense from neurotic outpatients. The classical defenses that un¬ derlie the neuroses are as distressing to the owner and as insignificant to the observer as a run in a stocking or a stone in one's shoe (ie, repression, isolation, reaction for¬ mation, displacement, and dissociation).9 The defense mechanisms that underlie sociopathy seem as harmless to the owner and as unbearably gross to the observer as a strong cigar in a crowded elevator (ie, denial through fan¬ tasy, projection, turning against the self, hypochondriasis, and acting out). Because nobody likes them, these latter defenses are less well understood. Therapists have diffi¬
culty feeling sympathetic toward delinquent, prejudiced, passive-aggressive, and hypochondriacal individuals. Ex¬ cept in children, we are apt to call such defenses sins, not
coping behavior. Nevertheless, before the defensive armor of the socio¬ path is viewed as too different from our own, consider those hopeless character disorders-adolescents. They, too, make extensive use of the sociopath's defenses. They use mood-altering drugs without moderation and see others, not themselves, as out of step. Their physical complaints are often imaginary; so are many of their most passionate
loves. No other age group is so passive-aggressive or so masochistic. Yet adolescence is a self-limiting disease! Thus, it becomes possible to view the ego mechanisms that underlie drug addiction, paranoia, hypochondriasis, ec¬ centricity, and masochism as immature defenses." True, we are unable to cajole, psychoanalyze, or beat somebody out of adolescence. They need to grow out of it slowlywith a little help from their peers. If we can wait 15 to 20 years, it becomes possible to demonstrate that intractable delinquents and addicts also remit.1011 Although we build walls (concrete or social) to protect ourselves from sociopaths, our efforts to save ourselves are in vain. The more we punish them, the less they learn. This aspect of sociopaths is maddening and defies logic. However, Bowlby might remind us that it does not do much good to beat a bereaved child.6 There is also a second explanatory facet to the seeming illogic of sociopathy. Can you imagine a hypochondriac, an exhibitionist, or a paranoiac existing alone on a desert is¬ land? Of course not. These seemingly immutable character traits exist only in the presence of other people. In brief, immature defenses are not always the incurable bad habits that they appear on the surface. Sometimes, they are a means of making a painful truce with people whom we can neither live with or without. If neurotic defenses are more often the modes with which we cope with instincts, immature defenses are most often the ways we cope with people.12 In adult life, projec¬ tion, hypochondriasis, fantasy, and masochism perpetuate a subtle process that we usually acknowledge only be¬ tween mother and infant and perhaps between lovers— namely, a merging of personal boundaries. A cherished or a loathed person may suddenly cause pain within a hypo-
body. In prejudice the obnoxious trait of a parent, inadvertently absorbed in childhood, may be pro¬ jected onto some hapless minority group. The promiscuous daydreams of a minister become mysteriously acted out by his delinquent daughter. In The Glass Menagerie the fragile animals of Laura's fantasy came suddenly to lifechondriac's
inside her mind. Put another way, if our inner worlds include relatively constant people toward whom we have relatively unambivalent feelings, in real life, our external relationships remain relatively assured, loving, autonomous, and welldemarcated. However, the interpersonal relationships of sociopaths remain perpetually murky and entangled. In an effort to preserve an illusion of interpersonal con¬ stancy, immature defenses permit ambivalent mental rep¬ resentations of other people—especially of parents—to be conveniently "split" (into good and bad) or moved about, and reapportioned. Just as neurotic mechanisms (eg, dis¬ placement, isolation, and dissociation) transpose feelings, immature mechanisms magically maneuver feelings and their objects. If we fail to understand the defensive process, we take the sociopath's defenses personally and condemn them. Perhaps one reason that we often label immature de¬ fenses perverse is that, once touched, we rarely can di¬ vorce ourselves completely. One reason immature defenses are so taboo is because they are contagious. In the pres¬ ence of a drug addict, liberals become prejudiced; the masochist elicits our own latent sadism, and the malin¬ gerer our passive-aggression. When baited by their adoles¬ cent children, even the most reasonable and staid parents become hopelessly involved and utterly unreasonable. And yet the process by which this all happens is obscure and, if noticed, quite mysterious to an outsider. This phenomenon does much to account for the inhumanity of man to man that is seen throughout much of our criminal justice sys¬ tem. But there is no culprit. Only anticipation and under¬ standing will allow therapists to disentangle themselves from the defenses of the sociopath. TREATMENT
One conclusion of this report is that the dynamics of the so-called psychopath differ little from those of Kernberg's so-called borderline." Nevertheless, conventional psychiat¬ ric management is not the answer to effective treatment. 1. Before treatment can begin with a sociopath, the therapist must find some way of dealing with the patient's self-destructive behavior. Be it via parole, commitment to a prison hospital, or the ideological grip of Synanon, real control over behavior is a sine qua non of treatment. Sociopaths are too immature for the therapist to suggest that a given behavior is self-detrimental and then to stand by helpless when they do it. Not only do sociopaths interpret such helplessness as lack of concern, but also un¬ checked, self-detrimental behavior scares the therapist. Although voluntary outpatient therapy may foster auton¬ omy, this advantage is for naught if the therapist becomes so frightened that he is defensively blind to the human qualities of his patient. Therefore, it is no accident that we find the borderline imprisoned by suicide precautions in psychiatric teaching hospitals and the psychopath re-
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locked up in maximum security institutions. 2. Control is important not only to prevent self-destruc¬ tion but also to overcome the sociopath's fears of intimacy. His wish to run from the pain of honest human encounter and from tenderness must be frustrated. He must be im¬ mobilized long enough for him to be perceived as human. The challenge to psychiatry, however, is to separate con¬ trol from punishment and to separate help and confronta¬ tion from social isolation and retribution. Possible models
peatedly
include sustained employment enforced through parole, house residence enforced by probation, "addic¬ tion" to methadone clinics, or the kind of therapeutic com¬ munity behind bars that Kiger has devised for sociopaths at the Utah State Hospital.13 All seem vastly preferable to
halfway
jails or psychiatric hospitalization, per se. In every case the hope of freedom is preferable to the threat of impris¬ onment. Sociopaths should work for liberty, not pay for past mistakes.
3. Too vigorous intervention or protection from harm be as bad as too little. Sociopaths are made worse by good defense lawyers. Their anxiety should not be con¬ trolled. But it is not always easy to remember that acute anxiety, like untreated insomnia, is a self-limiting, nonfatal illness. The only way that the therapist can show the sociopath that anxiety is bearable is by bearing it with him and by not trying to alleviate it. The therapist must recognize that his wish to control the sociopath's anxiety (whether by psychotropic drugs or by solitary confine¬ ment), is countertransference. In fact, the therapist's own anxiety can be openly acknowledged to the sociopathic pa¬ tient. Brought up to believe that anxiety is too dreadful to be borne and too awful to confess, the sociopath is reas¬ sured that someone can be anxious and yet in control. 4. Sociopaths, like children, deny their depression and repress parental neglect. The therapist must learn to put little trust in their childhood histories as initially given. 5. From the start, the therapist must accurately assess each of the sociopath's defenses. To relabel the "socio¬ path" as "borderline"—as is currently fashionable—will ob¬ scure differential diagnosis and lead to perceiving de¬ fenses as immutable or as attacks on the therapist. No defense, however, can be abruptly altered or abandoned can
without an acceptable substitute. Successful treatment demands that the therapist try to help the patient develop a substitute for each defense. For example, addicts give up addiction bit by bit; their abstinence is achieved via a pro¬ cess analogous to mourning. Countless criminals have re¬ placed acting out with reaction formation and projection with altruism. 6. Interpretation of defenses like
projection, denial major acting out is rarely
through fantasy, masochism, effective. Besides substitution, confrontration is the or
best
way to breach immature defenses. 7. Finally, one-to-one therapeutic relationships are rarely adequate to change the sociopath. A therapisteven five times a week—is not enough to satisfy an or¬ phan. At the start of the recovery process, only the church, self-help residential treatment, and addicting drugs pro¬ vide relief for a sociopath's pain; they all work 24 hours a day. Conventional psychotherapy is most effective in help-
ing people who have received too much or the wrong sort of parental attention. Only group membership or caring for others, or both, can eventually provide adults with parenting that they never received. The paths out of sociopathy are like the paths out of drug addiction" and adolescence. These are usually quite independent of formal therapy and are derived from peer identifications. Membership in altruistic but revolutionary movements like Black Panthers, in self-help groups like Alcoholics Anonymous and Synanon, or even marriage to a person as needy as themselves are all more useful than intensive psychotherapy. A compulsory but real job, out¬ side of prison, offers more than vocational counseling or prison trade schools.14 The therapeutic community at the maximum security ward of the Utah State Hospital, where the inmates hold the keys both to the outside and to
the seclusion rooms," offers more than programs that try psychopaths into patients. Why? Sociopaths know only too well that they have harmed others; they can meaningfully identify only with people who feel as guilty as themselves. They can abandon their defenses against grief only in the presence of people equally bereaved. Only acceptance by peers can circum¬ vent the sociopath's profound fear that he may be pitied. Only acceptance by "recovered" peers can restore his de¬ fective self-esteem. Finally, the psychopath needs to ab¬ sorb more of other people than one person, no matter how loving, can ever provide. Sociopaths need to find groups to which they can belong with pride. to transform
This investigation was supported in part by the Grant Foundation, New York, and National Institute of Mental Health grants MH-10361 and MH38798. This report was published with permission from the Massachusetts Jour¬ nal of Mental Health, Boston.
Name and Trademarks of Drugs
Nonproprietary
Chlorpromazine—Chhr-PZ, Cromedazine,
Thorazine.
References 1. Cleckley HM: Psychopathic states, in Arieti S (ed): American Handbook of Psychiatry. New York, Basic Books, 1959, pp 567-588. 2. Glover E: The Roots of Crime. New York, International Universities Press, 1960. 3. Cleckley HM: Mask of Sanity. St. Louis, CV Mosby Co, 1941. 4. Kernberg O: The treatment of patients with borderline personality organization. Int J Psychoanal 49:600-619, 1968. 5. Zetzel E: The so-called good hysteric, in The Capacity for Emotional Growth. London, Hogarth, 1970, pp 229-245. 6. Bowlby J: Pathological mourning and childhood mourning. J Am Psychoanal Assoc 11:500-541, 1963. 7. Glueck S, Glueck E: Unraveling Juvenile Delinquency. Cambridge, Mass, Harvard University Press, 1950. 8. Glueck S, Glueck E: Toward a Typology of Juvenile Offenders. New York, Grune & Stratton Inc, 1970. 9. Vaillant GE: Theoretical hierarchy of adaptive ego mechanisms. Arch Gen Psychiatry 24:107-118, 1971. 10. Vaillant GE: A 20-year follow-up of New York narcotic addicts. Arch Gen Psychiatry 29:237-241, 1973. 11. Glueck S, Glueck E: Criminal Careers in Retrospect, New York, Commonwealth Fund, 1943. 12. Freud A: The Ego and the Mechanisms of Defense. London, Hogarth Press, 1937. 13. Kiger RS: Treatment of the psychopath in the therapeutic community. Hosp Community Psychiatry 18:191-196, 1967. 14. Vaillant GE: A 12-year follow-up of New York narcotic addicts: IV. Some characteristics and determinants of abstinence. Am J Psychiatry 123:573-584, 1966.
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as a
Human Process
Viewpoint
George
E.
Vaillant,
MD
Case histories of narcotic addicts who also were imprisoned for were selected to illustrate some underlying dynamics of Cleckley's so-called psychopath and some principles useful in their management. Often in outpatient settings, such individuals seem to be without anxiety, unable to experience depression, and without motivation for recovery; but in inpatient settings, such deficits appear illusory. Once such chronically sociopathic individuals are prevented from "running," their resemblance to individuals with severe but thoroughly "human" and comprehensible personality disorders becomes evident. In treatment, external controls are important. It is vital both to appreciate the contagion of the psychopath's invisible anxiety and to provide such individuals with alternative defenses with which to mitigate their depression. Finally, sociopaths must be realistically, but not punitively, confronted with the consequences of their behavior.
felony
character disorders are a confusing area One reason for confusion is that in an the management of these disorders produces therapeutic frustration. This frustration blurs our perception of important clinical realities, and the de¬ fensive maneuvers of the sociopath become wrongly inter¬ preted as signs of that incurable entity, the psychopath. These signs include an apparent absence of anxiety, an ap¬ parent lack of motivation for change, and an apparent ina¬ bility to feel depression.1 This pejorative term, psychopath, is accurate only insofar as it describes the back of a pa¬ tient fleeing therapy. If a psychiatrist sees the same pa¬ tient in a prison hospital, he may doubt that such a dis¬ order exists. For then he sees sociopaths face-to-face, and they are human. He is able to do what Edward Glover sug¬ gested 50 years ago; he can "apply to the special problems of anti-social behavior the principles established by Freud to mental function as a whole."2 What I am suggesting is that when the psychiatrist is protected from therapeutic frustration, when control is es¬ tablished and flight is not possible, the stigmata of psy¬ chopathy disappear. This report will be an effort to examine why in the eyes of most psychiatrists the outpatient socio¬ path may appear incorrigible, inhuman, unfeeling, guilt¬ less, and unable to learn from experience; and yet in a
sociopathic The psychiatry. outpatient setting of
prison hospital, the sociopath is fully human. I shall try to demonstrate that Cleckley's psychopath, immortalized in the Mask of Sanity,3 is a mythical beast. To illustrate that our textbook conceptions of the psychopath are illusions, I have chosen three narcotic ad¬
dicts. All had extensive criminal records; all were sent against their will to the US Public Health Service Hospi¬ tal at Lexington, Ky. All demonstrated an absence of anx¬ iety, an absence of motivation to change, and an absence of overt depression. But, once immobilized, they became indistinguishable from Otto Kernberg's "borderline" patientsJ and Elizabeth Zetzel's "primitive hysterics"5 that are familiar to most psychiatric teaching units. Such pa¬ tients do not appear psychologically healthy, but they ap¬ pear neither alien nor untreatable. Over a period of time, seemingly organic and immutable deficits emerge as dy¬ namic and understandable defense mechanisms. Absence of
Anxiety
An apparent absence of anxiety is a clinical hallmark that sets the real sociopath apart from most psychiatric outpatients. One reason that sociopaths conceal anxiety is that their parents often experienced great difficulty toler¬ ating tension in others. They often used inappropriate means to relieve or to obscure anxiety in their children. The sociopath may confide to the psychiatrist that he had a "normal" family but that he was a "bad seed." He main¬ tains that his parents (unlike the wicked fairy-tale step¬ parents who allegedly bring up neurotics) gave him "ev¬ erything" he wanted. He often blames society for his behavior, but not his parents. His parents willingly cor¬ roborate the story. In the Mask of Sanity, Cleckley pro¬ vides us with innumerable examples of wicked children and noble parents.1 The psychopath seems the very anti¬ thesis of the fairy-tale hero. An unsolicited letter from a woman whom I had never seen provided a vivid illustration of what may lie beneath parental innocence: Dear Sir: My son is a dope addict and because he no longer knows the truth himself, I don't know how long it has lasted. I do know that I cannot continue the way I've been doing; I have no re¬ I have about 30 pawn tickets on which I cannot sources left. even pay the interest. Every time I renew things, he'd hock them again. He had been arrested a total of five times, dismissed from all cases. The lawyers and the bail cost me about $1,500. [In short, she paid $1,500 to shield him from the normal consequences of his ...
Accepted for publication Aug 14, 1974. From the Department of Psychiatry, Harvard Medical School and Cambridge Hospital, Cambridge, Mass. Reprint requests to the Department of Psychiatry, Cambridge Hospital, 1493 Cambridge St, Cambridge, MA 02139 (Dr. Vaillant).
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behavior.] When he was working he made $60 a week. He was sup¬ Now he has posed to pay me $12 a week but I seldom got it. started selling off my books, and, as I've already weeded these .
.
.
down to bare essentials in the interest of space, this makes me very nervous [not angry but nervous]. One example of how dis¬ sipated this is he says he sold his camera for $5. His camera was
complete with case was a $10.50 Christmas gift difficult it was for her to decide to whom the cam¬ era really belonged!] He is inarticulate and quarrels quickly and finds fault. He writes like a child and misspells words. He's losing his hair in front and has lost a tooth on the upper right. He is thin. I've lost a Brownie and from me. [How
my social career also. I have not had my hair fixed for a yeardoing it myself. I have not bought any new clothes, and the getups no one even wants to walk to I wear to school are a disgrace the door with me. I know I am an 'indulgent' mother, but what can I do? I don't want to let him go. I see these jungle addicts in the house, and I know that I am the buffer which is keeping him from looking like them. One example of how bad off I am is that every month I have one or two bounced checks, and the bank charges me $4 because of my what I am trying to say is that I have $288, that is poor record all I have left until September 15 when we go back to school. [The parents of sociopaths seem more in need of parental care than their children] Nevertheless, in one way or another, my son gets the money from me.... Last week he promised if I would give him $15 on Tuesday and Wednesday, he would go to the hospital on Thursday. I got up at 5:30 a.m. on Thursday and Friday, but he didn't want to go; and as we had such a terrible heat spell, I can't blame him. At night, I lock my door and barred the door and jammed the lamp against it besides. Occasionally, he frightens me. [Although reluctant to let her son experience anxiety, she subtly amplifies her own secret fears.] Other times he seems so young and helpless. He is 22 and he is beautiful. Please tell me what to do. ...
..
.
The sociopath is supposed to be unable to postpone grat¬ ification; but in a family matrix intolerant of anxiety, postponement of gratification is difficult to learn. The let¬ ter demonstrates that it is never clear who is dependent on whom and who needs the help. The son's delinquency frightens his mother, but rather than oppose it, she con¬ ceals it. When she calls for help, she writes to a physician whom she has never seen and who is 700 miles away. As the sociopath matures, he is not without anxiety; but it remains invisible to many observers—including judges and psychiatrists. Why? Neither the explanation that he cannot feel it nor the more sophisticated explanation that his anxiety is defended against by the ego mechanism of acting out is entirely satisfactory. There are two other reasons that his anxiety is invisible. First, there are times that the sociopath makes his anxi¬ ety very clear to us; but at such times, our empathie re¬ sponse may blind us to it. By this I mean that the socio¬ path elicits from physicians and social workers the same response that he elicited from his parents. We behave as if to ask him to bear his anxiety would be too cruel, too dis¬ ruptive, too sadistic, too authoritarian. Instead, we, too, respond by distorting the very reality that would help him to learn that anxiety is acceptable—both to himself and to others. Too seldom therapists are able to say to sociopaths, "I am sorry that you are feeling bad, but I think that you can manage the feeling." Second, we are often blind to the sociopath's anxiety be-
cannot bear it or because the sociopath has man¬ aged to transfer his anxiety to us. The resulting staff ap¬ prehension then serves to make the patient unreachable, unfeeling, incurable, and unaware that the staff anxiety that surrounds him was originally his own. (The situation is analogous to that of the well-defended Kraepelinian psychiatrist; he calls the acute schizophrenic's affect "flat" cause we
when, in fact, the affect is
one
of stark
terror.)
Consider the following example of concealed anxiety in
a
sociopath:
Case 1.—I was informed by several upset senior staff members that an unmanageable and notorious "psychopath" had returned to the US Public Health Service Hospital at Lexington, Ky, for the tenth time. He was reported to be on the admission ward out of control and holding the security staff at bay with a broom handle. It was with conscious fear that I learned that this unseen man was to be transferred to the psychiatric unit where I worked. I
anxious. Once transfer was effected, I realized my fears were without substance. Confined to the isolation room and stripped to his shorts, he countered my anxiety with tranquility and charm. With injured innocence, he asked, "How can I regain my self-respect if I'm not given some clothes and let out of seclusion?" His behavior was beyond reproach; his privileges were soon returned, and so he left the unit. A year later he returned. After having been refused medica¬ tion, he had cut his wrists. It was at this point that I reviewed his chart, started to talk to him, and for the first time saw him in hu¬ man dimensions. From suburban New York, he was the only child of middle-class, and apparently long-suffering parents. Only dur¬ ing his fifth admission to Lexington was it learned that his mother was secretly addicted to meperidine hydrochloride (Demerol) and that his father was an alcoholic. But his social history is not what is most pertinent. Rather more remarkable was the covert staff anxiety that was disclosed by his hospital record during this, his tenth admission. The Lexington medical staff was highly sophis¬ ticated to inappropriate demands for medication; but in one year, this known psychopath received the following results from labora¬ tory procedures: six urinalyses—all normal; two urine cultures—no growth; ten different blood chemistry evaluations—all normal; an electrocardiogram; three roentgenograms of the chest and one of the skull; two gallbladder examinations; two gastrointestinal series; a barium enema; and a spinal tap—all of which were nor¬ mal. At no time had he been organically ill. Although he had never had a fever or evidence of an infection, he received penicillin. Although the patient was in a hospital that virtually never gave narcotics, even to patients with painful ill¬ ness, he had received phénobarbital, codeine, pentobarbital (Nembutal), methadone hydrochloride, and chloral hydrate-all after his withdrawal period was completed. He also received 34 other medi¬ cines including meprobamate, imipramine hydrochloride, chlorwas
promazine, methamphetamine hydrochloride, chlordiazepoxide hydrochloride, and hydroxyzine hydrochloride.
There is little question that the staff response to this pa¬ tient was unique. Nevertheless, he serves as an example of the difficulty that even sophisticated staff had in recogniz¬ ing his anxiety, tolerating it or believing that he should tolerate it. The irrational therapeutic response he evoked had not become conscious in anyone's mind and, during the year, had been diffused among a large number of
people. Significantly, this tenth admission onment; it
stay in one
was his first impris¬ the first time he ever had been made to place. Shortly after his second visit to the psy-
was
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chiatric unit, he built up a relationship in psychotherapy with one of the staff. Through this relationship, he learned to tell the physician on night duty, "I don't want any medicine-I just want to talk." (Admittedly, nonsociopathic patients can often learn to do this within a few days of hospitalization.) Once this lesson was learned, once his anxiety was conscious, he required—and received—no addi¬ tional drugs. He caused the staff less anxiety; but he was able to show them more of his own. Previously, the patient had been unable to postpone gratification, but this was partly because nobody really tolerated his distress when he did so. This man not only defended against anxiety with drugseeking behavior, but he also manifested clear conversion symptoms. Psychiatrists, however, conceive of sociopathy and hysteria as two different syndromes and fail to recog¬ nize conversion in the sociopath. The hysteric is a woman; she is not out of control, and is immensely human. We see her conversion symptoms as a defensive process, and we perceive her distress behind these defenses. We believe her to be treatable. In contrast, the sociopath is usually a man and his physicians perceive him to be out of control. His defenses are invisible and his conversion symptoms are seen as conscious, hostile manipulation rather than un¬ conscious efforts to conceal anxiety. Unfortunately, unrec¬ ognized defenses can seem to psychiatrists like deliberate offense; the psychiatrists defend themselves. Human beings are labeled "psychopaths." Lack of Motivation
Sociopaths have a second hallmark that makes them appear inhuman: supposedly, they lack motivation for change. Sociopaths are supposed not to learn from experi¬ ence. Often psychiatrists who have successfully banished the pejorative terms psychopath and sociopath from their vocabularies, replace the terms with "passive-dependent" or "inadequate personality." In such cases, the psychia¬ trist perceives the distress but shrinks from the seemingly overwhelming oral, passive, and receptive qualities of these individuals. His own helplessness may be projected onto the patient. At this juncture, it is well to recall two things. First, adolescents sometimes seem unable to learn from experience, yet this is a temporary artifact of one stage of development. Second, if individuals respond to an unconscious fantasy or impulse, this is different from being unable to learn. Sociopaths are more adolescent than ineducable. Case 2.—A 30-year-old black addict prisoner received the admis¬ sion diagnosis of passive-dependent character disorder; his behav¬ ior over the preceding four years was consistent with the diag¬ nosis. He had grown up in New Orleans. His father, a pullman porter, had always made an adequate living, but he was an ex¬ tremely ineffectual man. At 8 years, the patient was a better car¬ penter than his father. In order that his father might resemble the fathers of his friends, he used to daydream that his father would spank him. His mother, the family disciplinarian, was also the patient's chief competitor in arguments and power struggles. But he could remember his mother forbidding him to do only one thing-to play the trumpet. When he reached adolescence, his uncle gave him a trumpet; he took it up with a vengeance. He ex-
perimented briefly with meperidine, but never became addicted. He took five years of college training in music and band teach¬ ing. He also became a successful jazz musician. However, when he reached the point where he was performing well-applauded trum¬ pet solos, he abruptly gave up the instrument. There was no rea¬ son except, "I was not as good as other people thought I was." For the same reason, he turned down a well-paying job with the Chi¬ cago Department of Education. Two years after giving up the trumpet, he had an affair with a "flashy woman." After she had canceled a date, the patient, un¬ aware of any resentment, developed an overwhelming, inexplicable urge to take meperidine. He rapidly became addicted and four years later came to Lexington as a prisoner. He had no insight into his problems and wanted psychotherapy to relieve his func¬ tional gastric bloating and, magically, to cure his addiction. Many months later he began to speak about his love of the trumpet and said that he gave it up because, "I was afraid of be¬ coming addicted to it. I was afraid that I would only be able to play the trumpet and be interested in nothing else." His fantasies about drugs became more explicit. He felt that marihuana was harmful. Although marihuana improved his trumpet playing, it made him think that he was too powerful. It might lead him to be¬ come "wild" and to drive his car too fast. In contrast, he felt that heroin was helpful to society and should be legalized. Heroin just made him drowsy and obtunded his sexual drive. When he got angry now, he got severe "ulcer" pains; these pains could be re¬ lieved with heroin. Only at the end of treatment was he able to talk tentatively about the anger he felt toward whites—especially policemen. [Ten years before he had belonged to CORE, but after he gave up the trumpet, he had also lost his interest in civil rights.] Any acknowledgment of negative transference toward me or resentment of his mother was assiduously avoided.
Throughout, it was difficult to mobilize this man's moti¬ vation for treatment. Had he not been in prison, he would never have kept his appointments. Yet after a year of psy¬ chotherapy, it was clear that beneath his "passive-depen¬ dent" camouflage there lurked a fairly competent individ¬ ual who went to extraordinary pains lest some of his competence become visible to others. It is not that socio¬ paths do not feel; they feel, but fear lest they feel too much. For them recovery becomes synonymous with un¬ consciously forbidden sexual and aggressive competence. It is dangerous at 8 years to be a better carpenter than your father. Case 3.—Another Lexington patient had wished two years be¬ fore her imprisonment to put her illegitimate baby up for adop¬ tion. Instead, her mother insisted on keeping it. The patient re¬ membered watching in silent rage while her mother triumphantly passed her daughter's baby off to the mother's friends as her own. A year later, the patient married a drug addict. During this period she wrested her child away from her mother and brought the child to live with her. The mother was furious and the patient felt ex¬ tremely guilty at depriving her mother of the child. At this point she became addicted. When she was imprisoned, her mother re¬ gained control of the child. Initially, the patient's anxiety over resumption of this struggle once she left prison was invisible. Instead, the patient tried to avoid help and preferred to deny herself parole than to return to this conflict. The details of her dilemma and the fact that at age 10 years her father had repeatedly sexually molested her came out only after months in therapy that she, too, would have fled had she not been in prison. In the setting of a prison hospital, however, this woman's lack of interest in "getting well" became dynam¬ ically understandable.
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Perhaps the following vignette sums up the point of this section. Because the above patient deprecated her low self-image still further whenever her own strengths be¬ came evident, I asked her if she remembered how the ugly duckling story had ended. Without hesitating, the patient recounted the story as follows: The ugly duckling had been all black; the other ducks went off and left the ugly duck¬ ling all alone—end of story. The
Inability
to
Experience Depression sociopath is his apparent in¬
The third hallmark of the
ability to experience depression and his inability to ac¬ knowledge that others matter to him. But it may be as preposterous to ignore depression in the sociopath who vehemently denies its existence, as it would be to ignore sexuality in the hysteric who feigns lack of interest in the subject. Case 4.—A 25-year-old prostitute was sentenced to Lexington for five years for drug peddling. She was the daughter of a strict, middle-class, Christian Scientist family. Since age 16 years, the patient had been incorrigibly delinquent, and at first she seemed the very model of the classical psychopath. Only after a year of imprisonment at Lexington and after
many weeks of psychotherapy was depression more than an intel¬ lectual concept to this woman. Only gradually were another set of facts obtained. When the patient was an infant, her mother, unable to accept the responsibility of parenthood, had delegated her daughter's care to others. Like Arthur Miller's fatherless Willy Loman, the patient grew up feeling "kind of temporary" about herself. One day she finally protested to me, "You inject sadness into me." Until that time she had hidden behind a private rose-colored version of Christian Science or behind angry, child¬ like dissatisfactions that lifted too rapidly to resemble clinical
depression.
After several months of therapy, and following a rather friendly hour the time before, she began to speak about her fears of intimacy; then, feeling anxious, she drew into herself and said, "I guess I am destined to be lonely." Two months later, on an oc¬ casion when she was denying that she felt any warmth or inti¬ macy toward me, she spoke of herself as an IBM machine. She de¬ clared that I was seeing her only because "You were assigned to
me." I wondered about her reluctance to consider the alternative formulation that she was human and that I might have chosen to work with her. She answered, "You are confusing and upsetting me. If you go on, I will stop therapy." During the next hour she was silent for the entire hour except to ask who solved the riddle of the sphinx; then, she described the sphinx as "a woman who ate everyone who was wrong." When I asked, "Do you mean that you're afraid of devouring people that you care about?" the pa¬ tient retorted, "An astute observation, but what can you do about it?" During the next hour she spoke of getting close to her family; "I don't believe other people have feelings or emotions. When I see that they do, I push them away." On one occasion she became upset at a compliment and said, "The danger of intimacy with people is that people will depend on you; and, then, you may hurt them and let them down. It is not nice to punish those who love ...
you." She handled separation in the following dissociative manner. She canceled the hour before I went away on vacation. She then wrote me an exceedingly cheerful postcard that ended with, "I have put my neurosis on the shelf till you get back." When I re¬ turned, like a good sociopath, she spent two appointments de¬ manding tranquilizing drugs and then skipped the next appoint-
ment.
Near the expiration of her sentence, she said, "Of course, I'm fond of you. You listen like a parent and you're a good teacher." She skipped the next session. When she returned, she said, "Can you give me any reason why I should continue with therapy?" When I suggested that at this point one purpose of continuing was in order to say goodbye, she declared, "I never said goodbye to anybody!" She spent the next two sessions in angry manipulation and vituperation, and canceled all future appointments. She let a year go by; then, safely distant from me by several hundred miles, began to write. For five years she continued to write me sensible, warm, and often appropriately depressed letters. She did not re¬ turn to
drug
use.
Glover has said of
sociopaths:
In addition to his incapacity to form deep personal attachments and his penchant to cause suffering to those who are attached to him, the psychopath is essentially a non-conformist, who in his re¬ action to society combines hostility with a sense of grievance21"1281·
sociopath's "incapacity" represents defensive pro¬ inability. Close relationships arouse anxiety in them. Terrified of their own dependency, of their very real "grievances," and of their fantasies of mutual destruction, they either flee relationships or destroy them. As the above case history illustrates, the depression of sociopaths resembles that of bereaved children. Bowlby has suggested that mourning in childhood is characterized by a persistent and unconscious yearning to recover the lost object.6 The persistent crime and polydrug abuse of the sociopath represents a similar quest. Bowlby tells us that in lieu of depression, bereaved children, like socio¬ paths, exhibit intense and persistent anger that is ex¬ pressed as reproach toward various objects including the self. However, Bowlby notes that such anger, if misunder¬ stood, seems often "pointless enough to the outsider." Fi¬ nally, sociopaths, like children, often employ "secret" anodynes to make loss unreal and overt grief unnecessary. But the
cess, not
Their need for secrecy is based on the fact that "to confess to another belief that the loved object is still alive is plainly to court the danger of disillusion." These defensive maneuvers then, serve to hide the child's and the socio¬ path's depression from our psychiatric view. The painstak¬ ing controlled studies of the Gluecks' have established be¬ yond reasonable doubt that the sociopath usually was a neglected (ie, bereaved) child7 and that for this reason, se¬ rious delinquency (unlike most psychiatric conditions) can be prospectively predicted by age 6 years.8 In conclusion, I would like to recapitulate certain themes that were present in the above case histories. All had lacked a benevolent, sustained relationship with the same-sexed parent. All were afraid of intimacy and of as¬ suming responsibility for it. None could believe that oth¬ ers could tolerate their anxiety, and all devoutly feared re¬ sponsibility for achieving success by open competition. They could neither identify with authority nor accept its criticism. Finally, their persistent, seemingly mindless delinquencies made symbolic sense if interpreted dynamically-as one might interpret misbehavior in a dream or in a child's play therapy. In short, psychopaths are neither born that way nor incapable of change. I believe that their "incomprehensible" behavior is a product of a well-de¬ fended ego and of a strict, albeit primitive, conscience.
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THE EGO MECHANISMS OF SOCIOPATHY
If the ego of the psychopath is not inadequate and if his superego is not absent, what are the underlying dynamics of the psychopath that make him or her seem so inhuman? Certainly, they employ very different styles of defense from neurotic outpatients. The classical defenses that un¬ derlie the neuroses are as distressing to the owner and as insignificant to the observer as a run in a stocking or a stone in one's shoe (ie, repression, isolation, reaction for¬ mation, displacement, and dissociation).9 The defense mechanisms that underlie sociopathy seem as harmless to the owner and as unbearably gross to the observer as a strong cigar in a crowded elevator (ie, denial through fan¬ tasy, projection, turning against the self, hypochondriasis, and acting out). Because nobody likes them, these latter defenses are less well understood. Therapists have diffi¬
culty feeling sympathetic toward delinquent, prejudiced, passive-aggressive, and hypochondriacal individuals. Ex¬ cept in children, we are apt to call such defenses sins, not
coping behavior. Nevertheless, before the defensive armor of the socio¬ path is viewed as too different from our own, consider those hopeless character disorders-adolescents. They, too, make extensive use of the sociopath's defenses. They use mood-altering drugs without moderation and see others, not themselves, as out of step. Their physical complaints are often imaginary; so are many of their most passionate
loves. No other age group is so passive-aggressive or so masochistic. Yet adolescence is a self-limiting disease! Thus, it becomes possible to view the ego mechanisms that underlie drug addiction, paranoia, hypochondriasis, ec¬ centricity, and masochism as immature defenses." True, we are unable to cajole, psychoanalyze, or beat somebody out of adolescence. They need to grow out of it slowlywith a little help from their peers. If we can wait 15 to 20 years, it becomes possible to demonstrate that intractable delinquents and addicts also remit.1011 Although we build walls (concrete or social) to protect ourselves from sociopaths, our efforts to save ourselves are in vain. The more we punish them, the less they learn. This aspect of sociopaths is maddening and defies logic. However, Bowlby might remind us that it does not do much good to beat a bereaved child.6 There is also a second explanatory facet to the seeming illogic of sociopathy. Can you imagine a hypochondriac, an exhibitionist, or a paranoiac existing alone on a desert is¬ land? Of course not. These seemingly immutable character traits exist only in the presence of other people. In brief, immature defenses are not always the incurable bad habits that they appear on the surface. Sometimes, they are a means of making a painful truce with people whom we can neither live with or without. If neurotic defenses are more often the modes with which we cope with instincts, immature defenses are most often the ways we cope with people.12 In adult life, projec¬ tion, hypochondriasis, fantasy, and masochism perpetuate a subtle process that we usually acknowledge only be¬ tween mother and infant and perhaps between lovers— namely, a merging of personal boundaries. A cherished or a loathed person may suddenly cause pain within a hypo-
body. In prejudice the obnoxious trait of a parent, inadvertently absorbed in childhood, may be pro¬ jected onto some hapless minority group. The promiscuous daydreams of a minister become mysteriously acted out by his delinquent daughter. In The Glass Menagerie the fragile animals of Laura's fantasy came suddenly to lifechondriac's
inside her mind. Put another way, if our inner worlds include relatively constant people toward whom we have relatively unambivalent feelings, in real life, our external relationships remain relatively assured, loving, autonomous, and welldemarcated. However, the interpersonal relationships of sociopaths remain perpetually murky and entangled. In an effort to preserve an illusion of interpersonal con¬ stancy, immature defenses permit ambivalent mental rep¬ resentations of other people—especially of parents—to be conveniently "split" (into good and bad) or moved about, and reapportioned. Just as neurotic mechanisms (eg, dis¬ placement, isolation, and dissociation) transpose feelings, immature mechanisms magically maneuver feelings and their objects. If we fail to understand the defensive process, we take the sociopath's defenses personally and condemn them. Perhaps one reason that we often label immature de¬ fenses perverse is that, once touched, we rarely can di¬ vorce ourselves completely. One reason immature defenses are so taboo is because they are contagious. In the pres¬ ence of a drug addict, liberals become prejudiced; the masochist elicits our own latent sadism, and the malin¬ gerer our passive-aggression. When baited by their adoles¬ cent children, even the most reasonable and staid parents become hopelessly involved and utterly unreasonable. And yet the process by which this all happens is obscure and, if noticed, quite mysterious to an outsider. This phenomenon does much to account for the inhumanity of man to man that is seen throughout much of our criminal justice sys¬ tem. But there is no culprit. Only anticipation and under¬ standing will allow therapists to disentangle themselves from the defenses of the sociopath. TREATMENT
One conclusion of this report is that the dynamics of the so-called psychopath differ little from those of Kernberg's so-called borderline." Nevertheless, conventional psychiat¬ ric management is not the answer to effective treatment. 1. Before treatment can begin with a sociopath, the therapist must find some way of dealing with the patient's self-destructive behavior. Be it via parole, commitment to a prison hospital, or the ideological grip of Synanon, real control over behavior is a sine qua non of treatment. Sociopaths are too immature for the therapist to suggest that a given behavior is self-detrimental and then to stand by helpless when they do it. Not only do sociopaths interpret such helplessness as lack of concern, but also un¬ checked, self-detrimental behavior scares the therapist. Although voluntary outpatient therapy may foster auton¬ omy, this advantage is for naught if the therapist becomes so frightened that he is defensively blind to the human qualities of his patient. Therefore, it is no accident that we find the borderline imprisoned by suicide precautions in psychiatric teaching hospitals and the psychopath re-
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locked up in maximum security institutions. 2. Control is important not only to prevent self-destruc¬ tion but also to overcome the sociopath's fears of intimacy. His wish to run from the pain of honest human encounter and from tenderness must be frustrated. He must be im¬ mobilized long enough for him to be perceived as human. The challenge to psychiatry, however, is to separate con¬ trol from punishment and to separate help and confronta¬ tion from social isolation and retribution. Possible models
peatedly
include sustained employment enforced through parole, house residence enforced by probation, "addic¬ tion" to methadone clinics, or the kind of therapeutic com¬ munity behind bars that Kiger has devised for sociopaths at the Utah State Hospital.13 All seem vastly preferable to
halfway
jails or psychiatric hospitalization, per se. In every case the hope of freedom is preferable to the threat of impris¬ onment. Sociopaths should work for liberty, not pay for past mistakes.
3. Too vigorous intervention or protection from harm be as bad as too little. Sociopaths are made worse by good defense lawyers. Their anxiety should not be con¬ trolled. But it is not always easy to remember that acute anxiety, like untreated insomnia, is a self-limiting, nonfatal illness. The only way that the therapist can show the sociopath that anxiety is bearable is by bearing it with him and by not trying to alleviate it. The therapist must recognize that his wish to control the sociopath's anxiety (whether by psychotropic drugs or by solitary confine¬ ment), is countertransference. In fact, the therapist's own anxiety can be openly acknowledged to the sociopathic pa¬ tient. Brought up to believe that anxiety is too dreadful to be borne and too awful to confess, the sociopath is reas¬ sured that someone can be anxious and yet in control. 4. Sociopaths, like children, deny their depression and repress parental neglect. The therapist must learn to put little trust in their childhood histories as initially given. 5. From the start, the therapist must accurately assess each of the sociopath's defenses. To relabel the "socio¬ path" as "borderline"—as is currently fashionable—will ob¬ scure differential diagnosis and lead to perceiving de¬ fenses as immutable or as attacks on the therapist. No defense, however, can be abruptly altered or abandoned can
without an acceptable substitute. Successful treatment demands that the therapist try to help the patient develop a substitute for each defense. For example, addicts give up addiction bit by bit; their abstinence is achieved via a pro¬ cess analogous to mourning. Countless criminals have re¬ placed acting out with reaction formation and projection with altruism. 6. Interpretation of defenses like
projection, denial major acting out is rarely
through fantasy, masochism, effective. Besides substitution, confrontration is the or
best
way to breach immature defenses. 7. Finally, one-to-one therapeutic relationships are rarely adequate to change the sociopath. A therapisteven five times a week—is not enough to satisfy an or¬ phan. At the start of the recovery process, only the church, self-help residential treatment, and addicting drugs pro¬ vide relief for a sociopath's pain; they all work 24 hours a day. Conventional psychotherapy is most effective in help-
ing people who have received too much or the wrong sort of parental attention. Only group membership or caring for others, or both, can eventually provide adults with parenting that they never received. The paths out of sociopathy are like the paths out of drug addiction" and adolescence. These are usually quite independent of formal therapy and are derived from peer identifications. Membership in altruistic but revolutionary movements like Black Panthers, in self-help groups like Alcoholics Anonymous and Synanon, or even marriage to a person as needy as themselves are all more useful than intensive psychotherapy. A compulsory but real job, out¬ side of prison, offers more than vocational counseling or prison trade schools.14 The therapeutic community at the maximum security ward of the Utah State Hospital, where the inmates hold the keys both to the outside and to
the seclusion rooms," offers more than programs that try psychopaths into patients. Why? Sociopaths know only too well that they have harmed others; they can meaningfully identify only with people who feel as guilty as themselves. They can abandon their defenses against grief only in the presence of people equally bereaved. Only acceptance by peers can circum¬ vent the sociopath's profound fear that he may be pitied. Only acceptance by "recovered" peers can restore his de¬ fective self-esteem. Finally, the psychopath needs to ab¬ sorb more of other people than one person, no matter how loving, can ever provide. Sociopaths need to find groups to which they can belong with pride. to transform
This investigation was supported in part by the Grant Foundation, New York, and National Institute of Mental Health grants MH-10361 and MH38798. This report was published with permission from the Massachusetts Jour¬ nal of Mental Health, Boston.
Name and Trademarks of Drugs
Nonproprietary
Chlorpromazine—Chhr-PZ, Cromedazine,
Thorazine.
References 1. Cleckley HM: Psychopathic states, in Arieti S (ed): American Handbook of Psychiatry. New York, Basic Books, 1959, pp 567-588. 2. Glover E: The Roots of Crime. New York, International Universities Press, 1960. 3. Cleckley HM: Mask of Sanity. St. Louis, CV Mosby Co, 1941. 4. Kernberg O: The treatment of patients with borderline personality organization. Int J Psychoanal 49:600-619, 1968. 5. Zetzel E: The so-called good hysteric, in The Capacity for Emotional Growth. London, Hogarth, 1970, pp 229-245. 6. Bowlby J: Pathological mourning and childhood mourning. J Am Psychoanal Assoc 11:500-541, 1963. 7. Glueck S, Glueck E: Unraveling Juvenile Delinquency. Cambridge, Mass, Harvard University Press, 1950. 8. Glueck S, Glueck E: Toward a Typology of Juvenile Offenders. New York, Grune & Stratton Inc, 1970. 9. Vaillant GE: Theoretical hierarchy of adaptive ego mechanisms. Arch Gen Psychiatry 24:107-118, 1971. 10. Vaillant GE: A 20-year follow-up of New York narcotic addicts. Arch Gen Psychiatry 29:237-241, 1973. 11. Glueck S, Glueck E: Criminal Careers in Retrospect, New York, Commonwealth Fund, 1943. 12. Freud A: The Ego and the Mechanisms of Defense. London, Hogarth Press, 1937. 13. Kiger RS: Treatment of the psychopath in the therapeutic community. Hosp Community Psychiatry 18:191-196, 1967. 14. Vaillant GE: A 12-year follow-up of New York narcotic addicts: IV. Some characteristics and determinants of abstinence. Am J Psychiatry 123:573-584, 1966.
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