Socratic Questions in Broadmoor
“Psychopaths” are at the extreme. The tool most used to diagnose “antisocial personality disorder” is the Hare Psychopathy Checklist, a scale devised by the Canadian psychologist Robert D. Hare. There is a cutoff score above which the test taker is given the diagnosis of antisocial personality disorder. Being a “psychopath” is widely considered to be an extreme version of this. Something often said about those called psychopaths, and by extension about the others within the broader category, is that they lack a conscience.
This claim is intriguing. Are there really people who completely lack a conscience? If so, how does this come about? Are they born with something missing? Or does something happen to them that destroys their conscience? Most fundamentally, what does it mean to say that they lack a conscience?
I have spent a lot of my life teaching ethics, which is still taught by the method invented by Socrates. This starts by asking people what they think is right or wrong, pressing them to state their views with maximum clarity and explicitness. Then they are challenged to defend their beliefs in the face of counterexamples and opposing argument. The student is pushed into a journey of self-exploration, rather than being given “the answers” by the teacher. Some students, those who think being taught is being given information or conclusions to take away, are baffled by this and doubt that they are being taught properly. Be that as it may, the teacher learns a lot about the students and about the very different structures and styles of moral belief and thinking that people have. There are very different views about what conscience is.
To say that people with antisocial personality disorder lack a conscience could mean one or more of several things. It could mean that they lack any empathy for other people: that they cannot imagine how other people feel. Or it could mean that they lack sympathy: that they can imagine the feelings of, for instance, those they hurt, but do not care about them. It might mean that they do not feel guilt. It could be that they lack certain moral concepts, such as “cruel,” “unfair,” “dishonest,” “right,” or “selfish.” Or it might mean that they lack a sense of moral identity: a conception of the sort of person they are, or of the sort of person they hope to be, together with a set of values guiding those hopes. The conscience or lack of conscience of people with this diagnosis seemed a promising field to investigate.
Dr. Gwen Adshead, a psychiatrist at Broadmoor Hospital, has many patients with the diagnosis of antisocial personality disorder. She and I found that we shared an interest in their morality or lack of it, and we jointly devised a project to investigate these questions in some of those patients in Broadmoor.
My part of the project used a series of interviews with men who had a diagnosis of antisocial personality disorder. The aim was to probe their morality and values by asking questions about ethics. Partly in homage to the inventor of the approach, but perhaps with a touch of pretentiousness, I called this series “the Socratic interviews.” The following account reports on these “Socratic” interviews. To introduce them, I will say a bit about antisocial personality disorder and then outline briefly the content of the interviews and the guiding questions behind them.
There are many questions, to be raised later, about the general category “personality disorders.” The particular diagnosis of antisocial personality disorder—including psychopathy at the severe end—is heir to a tangled history of moral, legal, and psychiatric concepts. They include those marked out by the nineteenth-century term “moral insanity” and the early twentieth-century terms “constitutional psychopathic inferiority” and “sociopath.”1 The modern conception of a psychopath has been greatly influenced by Hervey Cleckley, who in the mid-twentieth century was a professor of psychiatry at the University of Georgia Medical School. He reported on the psychopaths among his patients in The Mask of Sanity.2
Cleckley’s hunch (though he knew he lacked evidence to support it) was that psychopaths were born that way: “Increasingly I have come to believe that some subtle and profound defect in the human organism, probably inborn but not hereditary, plays the chief role in the psychopath’s puzzling and spectacular failure to experience life normally and to carry on a career acceptable to society.”3 His book has two sides, one influencing popular stereotypes and legends about psychopaths and the other influencing psychiatric thinking.
Cleckley had many of the prejudices of his time and place. His book attacks modern “permissiveness,” and “intellectuals and esthetes” for their liking of “what is generally regarded as perverse, dispirited or distastefully unintelligible.” What they liked included the writings of Gide (who “openly insists that pederasty is the superior and preferable way of life for adolescent boys”) and Joyce (“a collection of erudite gibberish indistinguishable to most people from the familiar word salad produced by hebephrenic patients on the back wards of any state hospital”).4 In his description of one male patient who had had oral sex with four black men, Cleckley’s disapproval focuses, not on whether the men’s consent was genuine, but mainly on the choice of partners. The man “hit upon the notion of picking up four Negro men who worked in the fields not far from his residence. In a locality where the Ku Klux Klan (and its well-known attitudes) at the time enjoyed a good deal of popularity, this intelligent and in some respects distinguished young man showed no compunction about taking from the field these unwashed laborers whom he concealed in the back of a pickup truck, with him into a well-known place of amorous rendezvous … Although he expressed regret and said his prank was quite a mistake, he seemed totally devoid of any deep embarrassment.”5
Cleckley helped create the popular stereotype of the psychopath as not really human, a satanic monster hiding behind the mask of sanity—“the exquisitely deceptive mask of the psychopath,” who uses extraordinary facility and charm to pose as a normal person.
We are dealing here not with a complete man at all but with something that suggests a subtly constructed reflex machine which can mimic the human personality perfectly. This smoothly operating psychic apparatus reproduces consistently not only specimens of good human reasoning but also appropriate simulations of normal human emotion in response to nearly all the varied stimuli of life. So perfect is the reproduction of a whole and normal man that no-one who examines him in a clinical setting can point out in scientific or objective terms why, or how, he is not real.… The psychopath, however perfectly he mimics man theoretically, that is to say, when he speaks for himself in words, fails altogether when he is put into the practice of actual living.6
Cleckley’s influence on psychiatrists lay not in his image of the monster behind the mask but in his powerful descriptions of the behavior of some of his psychopathic patients.
One memorable case was “Milt,” who was 19 when he arrived at the hospital. He had done a lot of antisocial things. When criticized for them, he made charming apologies, but he never seemed really to appreciate the seriousness of what he had done, and he continued to carry on in the same way. Here is one example: Once he was driving his mother back from the hospital after she had major surgery. The car broke down in the middle of a very long bridge. With darkness falling, Milt set out to walk to a garage half a mile away to get a fuse. He said he would get a ride and be back in less than fifteen minutes. After an hour his distraught mother managed to get a ride home. She called hospitals to see if Milt had had an accident.
On the way to the garage, Milt had stopped at a cigar store for ten to fifteen minutes to check football results. Then he called on a girl living nearby and chatted casually for an hour. All this time he remembered his mother was waiting. When he finally collected the car and came home, he was cross with his mother for not having waited. He showed “a bland immunity to any recognition that he had behaved irresponsibly or inconsiderately.”7
Cleckley used this and other case descriptions to draw up a list of the distinguishing characteristics of psychopaths. These included superficial charm, unreliability, insincerity, lack of remorse, egocentricity, emotional poverty, and a failure to follow any life plan. This “Cleckley psychopath” is the origin of current diagnosis, including the Hare Psychopathy Checklist.8
In the Psychopathy Checklist, Robert Hare distinguishes two factors that are highly correlated with each other but have different patterns of intercorrelations with other variables. Factor One represents personality traits typical of the syndrome: “selfish, callous and remorseless use of others.” Factor Two reflects socially deviant behavior: “chronically unstable, antisocial and socially deviant lifestyle.” If the diagnosis of being a psychopath is supposed to explain antisocial behavior, Factor One does the work, as Factor Two hardly gets beyond listing the behavior to be explained. And Factor One is more relevant to questions about conscience. It includes glibness and superficial charm, a grandiose sense of self-worth, pathological lying, being conning and manipulative, lack of remorse or guilt, shallow emotions, being callous and lacking empathy, and failure to accept responsibility for one’s own actions.
Hare himself sees psychopathy in terms of Factor One, and sees the diagnosis of antisocial personality disorder (based on both factors) as being of limited use. He claims that the personality traits of Factor One have predictive value, whereas a diagnosis of antisocial personality disorder catches a mixed bag and predicts little.9
There are questions about how people end up with a diagnosis of antisocial personality disorder. The people I interviewed in Broadmoor were there because they had committed a major crime and because they were assessed as having a psychiatric problem. The latter distinguished them from “ordinary” criminals needing punishment. There are also questions about whether a medical diagnosis is appropriate. How different are they from ruthless people in ordinary life who manage to get their way either without committing crimes or else without getting caught? How do they compare with some of the politicians, businesspeople, media magnates, heads of academic institutions, captains of industry, and others who may also sometimes be lying, callous, manipulative charmers with a grandiose sense of self-worth and little remorse? And how do they compare with people who have committed similar crimes but who are sent to prison rather than to see psychiatrists?
One obvious question is how far someone with the antisocial record of Factor Two, combined with the glib, conning, callous personality of Factor One, should qualify as having a disorder rather than just as being morally bad. Could the person with antisocial personality disorder turn out to be the “rational amoralist” who haunts philosophical books on ethics?
At least as far back as Plato, philosophers have tried to meet the challenge of explaining why anyone should bother about the claims of morality. One form of the challenge is the demand for arguments that will defeat the amoralist. But this theoretical construct, the “amoralist,” turns out to be a slippery character.
The simple version of the amoralist is someone utterly self-interested and prepared to trample ruthlessly on anyone else. But because society is set up to deter people from acting like this, a rational amoralist will have to operate in heavy disguise. To avoid legal punishment or social ostracism, a self-interested person must try to “pass” as someone who respects the interests of others. Whatever the underlying attitude, at least the behavior is less of a threat. A second change results if the amoralist has ordinary human desires for relationships. The deepest relationships are incompatible with being approached in a spirit of self-interested calculation. Emotional involvement with others may make some cracks in the barrier against altruism.
As a result of these changes, there is a paring down to the conceptual core of amoralism. The pure “conceptual” amoralist might not be selfish. He might often care about other people and act toward them with benevolence and even generosity. But he does this because he wants to, not because of thoughts that he ought to do so or about moral obligations. To “moral” uses of words like “ought,” “right,” “wrong,” “duty,” and “obligation,” he will react as Oscar Wilde did when asked if he was patriotic: “Patriotism is not one of my words.” One aim of these interviews was to see how far people diagnosed with antisocial personality disorder are like either the original or the modified amoralist.
The people being interviewed had all done some terrible things. (All their names and initials have been changed.) The interview plan started from a framework I used for previous work on the psychology of twentieth-century atrocities. Thinking about Auschwitz, the Gulag, Hiroshima, or the Rwandan genocide, there is an obvious question: How can people do such things? I approached this by asking about the restraints in everyday life that prevent people from torturing or killing each other. I proposed a set of restraints and then asked what had happened to them in Nazi Germany, Rwanda, and other places. In these interviews I used a similar strategy. When the people I was interviewing committed their terrible crimes, were the normal restraints overwhelmed by other things? If so, how were they overwhelmed, and by what? Or did they lack the normal restraints? Either way, what went on inside them? How did they think about what they did?
What are the factors that, most of the time, restrain people from cruelty, violence, and killing? One obvious factor is self-interest. The death of a competitor might be profitable. Assaulting an enemy might give psychological satisfaction. But society is usually organized in ways intended to make the cost too high. For rational self-interested people, such temptations usually are outweighed by the risks of social disgrace and long-term imprisonment.
Of course, self-interested calculation is not the whole story for most people. Plato’s brilliantly simple “ring of Gyges” thought experiment is designed to bring this out. If you had a ring that made you invisible, so that you could commit crimes without suffering punishment and disgrace, would you have any reason not to steal, not to rape, or not to attack people who antagonize you? The ring of Gyges is a challenge to spell out the moral resources we have: the restraining motives that are not just self-interested.
These moral restraints are rooted in our psychology. Central are what can be called “the human responses.” We are capable of feeling sympathy for other people. Although the response can be deadened or overridden, we can be delighted by others’ joy or distressed by their suffering. And we have a tendency to show other people respect. Again the response can be deadened or overridden, but most of us avoid behavior that humiliates others. We are appalled to see someone being spat on. These human responses of sympathy and respect are linked to empathy: to our imagining what it is like for someone else to experience suffering or indignity.
Another key moral restraint is our sense of our own moral identity. Most of us have an idea of the sort of person we are. We sometimes have a picture of the sort of person we would like to be, together with values that shape that picture. Even if the picture is not well worked out or is partly unconscious, it may function as a moral restraint. We may at least know the kind of person we do not want to be, and this may hold us back from working in the arms trade or becoming a television evangelist.
The questions were designed mainly to see how far these moral restraints were present in the men I interviewed. Hoping to make the questions unthreatening, I avoided asking “Do you have a sense of right and wrong?” Instead I asked about what they would teach children about right and wrong.
I also asked whether, if they drove a car, they would park in a disabled space, and what their reasons were for doing or not doing so. If they said they would not park there, the follow-up question about reasons could tap into self-interest: “I would not want to get wheel-clamped” or “It might be awkward if people noticed.” There was also the hope of exploring some of the moral resources: sympathy for disabled people, respect for their rights, or even the sense of moral identity: “I would not want to be the kind of person who was so mean as to do that.” Some questions were intended to explore their sense of moral identity: “How would you describe the sort of person you think you are? Do you have an idea of the sort of person you would like to be?” Others explored their understanding of moral concepts such as fairness, or whether there were things that made them feel guilty.
I knew that the men I would interview not only had been diagnosed with antisocial personality disorder but had also been convicted of at least one serious crime, such as murder or rape, but before the interviews I avoided finding out what crimes they had committed, as I did not want to be biased by this knowledge. In the interviews I did not ask what their crimes had been. (Sometimes they volunteered this information without being asked.) But in order to explore their capacity for empathy and sympathy, I did ask questions along the lines of “When you did whatever it was, did you imagine how the people you harmed felt? Could you imagine how they felt? Did you care about how they felt?”
The interviews were “semistructured.” That is, a standard set of questions was in place, but I did not rigidly adhere to it. I felt free sometimes to ask “leading questions,” where it seemed this might trigger something interesting or clarify an obscure comment. The aim was something conversational rather than a strictly scientific interview. My hope was to encourage the sort of informality and ease that conversations can have in a more ordinary context. The flexibility of semistructured interviews gave scope to intuitive hunches about what might be interesting or revealing. When a person said something of that kind, I felt free to follow it up regardless of the original plan.
The interviews were intended to be qualitative rather than quantitative, employing open-ended questions rather than those requiring yes-or-no answers. The aim has been an intuitive understanding of how members of the group think about right and wrong, about themselves, and about their values. The intuitive understanding can perhaps be compared to that of a historian trying to get an idea of what H. H. Asquith was like from his letters, or trying to get a feel for the mind of Hitler from the records of his table talk or of the books he read. While not lending themselves to numerical analysis, these sources may still give a useful feel for the person.
A piece of qualitative research will often raise questions that require quantitative research. In this study, for instance, these interviews were not also given to a control group. Gwen Adshead and I considered doing this but decided against it. The control group could have been students, people in a psychiatric hospital with a different diagnosis, soldiers, nurses, or people in regular prisons. Different control groups would generate very different sets of similarities and contrasts. Each possible control group would have tilted the emphasis of the study in a different direction. Having a control group would have allowed measurement, but we thought the advantages of this would have been outweighed by the tilting effect. We wanted a broad picture of this group, not a picture mainly of the particular contrasts between them and, say, students.
But the picture based on the intuitive and conversational interviews needs further testing. The conclusions to be outlined here are suggestions. They need to be placed on firmer foundations by studies using comparative and quantitative methods. Our interviewees were psychiatric patients. They were convicted violent criminals. They had the diagnosis of antisocial personality disorder. To establish how far their distinctive personality contributed to what they said would of course require quantitative comparisons with those in the other categories. A first step would be to test some of the suggestions by a study with a control group of people without a psychiatric diagnosis but convicted of similar crimes. The picture here is a sketch. It aims partly to give an intuitive feel for a group of people whose own way of seeing things is not much understood and partly to suggest hypotheses that can be tested in future studies.