Cleckley's Psychopaths

The drift toward behavioral accounts of the cluster of psychological and behavioral traits that were interchangeably referred to as psychopathy, sociopathy and anti-social personality is interesting and well worth exploring (Justman, 2021). Justman's correct that before the work of the Feighner group and the adoption of Antisocial Personality Disorder (APD) in the Diagnostic and Statistical Manual of Mental Disorders (DSM)-III, the choice of concept did not seem to be vital and in the Mask of Sanity, Cleckley mentions all three terms and does not seem to think much hangs on which term we choose (Cleckley, 1988, p. 11).

It seems correct that many held the absence of guilt to be the psychological marker of psychopathy and that it was discarded primarily for reasons for reliability. As Justman reports, the Feighner group viewed an absence of guilt as "prohibitively impractical." The Feighner group and the subsequent DSM groups tried to taxonomize mental illnesses in a reliable and predictable way. However, that is not necessarily the same thing as describing psychopathy in a way that captures the underlying dysfunction that typifies the disorder. We should also hope that clinical concepts and constructs enable those working in mental health to grasp the nature of psychological dysfunction in a way that opens up the possibility of empathy and a therapeutic orientation to psychopaths.

Although the DSM III went for a narrowly behavioral account of APD, Justman does not mention that the DSM IV reintroduced personality traits to the diagnosis. According to DSM IV, APD is characterized by antisocial behavior that includes 3 or more of 7 features that include "(2) deceitfulness" "(3) impulsivity", "(4) irritability and aggressiveness" (6) consistent irresponsibility" and "(7) lack of remorse" (American Psychological Association, 1994). So, although he is right to chart the course of the journey to the behavioral construct adopted by DSM III, it is not the case that personality traits and the absence of guilt criterion had sailed over the horizon.

While Justman mentions a number of instances where an absence of guilt appears to be the defining psychological trait of psychopathy, it is clear that neither Cleckley nor Hare share that view.

When discussing Hare's Psychopathy Checklist Revised (PCL-R), Justman says…

Ironically, though, the checklist now generally used to assess psychopathy … contains 20 items, of which "lack or remorse or guilt" is but one; and all items are score on a severity scale from 0–2, suggesting that subjects may exhibit a lack of guilt in whole, in part, or not at all.

Presumably, this is "ironic" because it turns out that a lack of remorse or guilt is not the defining feature of psychopathy and Justman thinks it is. Although many clearly did hold this view, it is also clear that Cleckley, who Hare was following, did not. However, revisiting Cleckley's psychopaths does not matter simply so as to set the record straight about how central the absence of guilt is for our contemporary understanding of psychopathy, there are number of reasons why we should revisit The Mask of Sanity.

Why We Should Still Care About Cleckley's Psychopaths

There are rival contemporary accounts of psychopathy, so we should not consider Hare's PCL-R the only or final word on the matter (Cooke & Michie, 2001). However, in saying that, it is still the most commonly used account of psychopathy and there are good reasons for considering it a robust scientific construct (Malatesti & McMillan, 2014).

Hare grounded PCL-R in Cleckley's detailed descriptions of the patients he saw and tried to help during his career as a psychiatrist. So, one reason we should care about Cleckley's psychopaths is because the psychological traits he identified fed directly into the items of the PCL-R.

Perhaps the most important reason why we should continue to care about Cleckley's psychopaths is because he did. Not in the simplistic sense of adopting a caring attitude toward them, what is striking about The Mask of Sanity is the richness, insight and individuality of the descriptions. What Sacks and Luria do when describing neurological...