If everyone involved with the management and care of society's most visible antisocial members (either protecting others from them or attempting to rehabilitate them) would translate the sadness and despair engendered by such work into attempts to understand and prevent the next generation of similar casualties, society would be better served. For this reason, perhaps a fixed proportion of the budget of every institution involved with "breakdown products" should be permanently assigned to primary prevention.

I would like to briefly outline my personal experience with such people so that there might be a better understanding of some of the influences which have led me to a preoccupation with primary prevention. In 1965 I began work as a psychiatrist in the prison hospital at Penetanguishene, Ontario - a maximum security facility for the so-called "criminally insane". My job was to introduce therapeutic community programs into the traditional custodial culture of the hospital. Four 38-bed "ranges" soon evolved into the Social Therapy Unit and by the late 60's and early 70's this intensive treatment program had become one of the stopping points for those interested in the treatment of psychopaths and the management of dangerous patients. ^1,2,3,4 Maxwell Jones, George Sturrup, and many others came to observe and comment. In 1977 the Parliamentary Committee set up to investigate causes of prison violence came to see the Social Therapy Unit and one of the recommendations in their final report to Parliament was that similar programs be established in all medium and maximum security prisons in Canada. The members of the Committee could see that the patient population in the Social Therapy Unit was not greatly different from that found in prisons.⁵

Since 1972 my responsibility as a part-time consultant at the hospital has been to examine accused persons sent to the hospital for a period of one or two months on a court order for an opinion about their mental state at the time of their offense -- their dangerousness, and their treatability. A great many of these patients have been those who fit best into the psychopathic category and most have been charged with murder and/or rape or attempts thereat.

Thus, having been involved rather closely with a great many psychopaths over quite a few years, and having been able to follow many of them professionally or personally after their initial period of examination or treatment, I have found myself in the rather uncomfortable position of being viewed as knowledgeable about psychopaths.^{6, 7} Uncomfortable because, as with others who have had first-hand experience with large numbers of psychopaths over a long period of time, there is a sense of bewilderment about what the condition really is. There seem to be forever the cases that don't quite fit diagnostically, as well as the eternal question, "What is wrong with these patients?" Notwithstanding that, for me, Cleckley has always made the most sense of the subject, capturing as he does with his eloquent prose and his sixteen point check-list the essence of psychopathy as I have experienced it.⁸

1. Superficial charm and good intelligence
2. Absence of delusions and other signs of irrational thinking
3. Absence of "nervousness" or psychoneurotic manifestations
4. Unreliability
5. Untruthfulness and insecurity
6. Lack of remorse and shame
7. Inadequately motivated antisocial behavior
8. Poor judgment and failure to learn by experience
9. Pathologic egocentricity and incapacity for love
10. General poverty in major affective reactions
11. Specific loss of insight
12. Unresponsiveness in general interpersonal relations
13. Fantastic and uninviting behavior with drink and sometimes without
14. Suicide rarely carried out
15. Sex life impersonal, trivial, and poorly integrated
16. Failure to follow any life plan

One major problem which has frequently occurred for me as a court psychiatrist (in a country where psychopaths have been found not guilty by reason of insanity on quite a few occasions) is the difficulty in establishing the severity of psychopathy. This issue is of some importance for it has always been argued that it is only the severe psychopath that can be found legally "insane". But just how do you establish the degree of severity? Is it related to the age of onset of first symptoms, or the total number of symptoms exhibited, or the degree of impairment in the person's general functioning in life, or the severity of one or more of the symptoms, such as the extent of the inability to empathize? What does seem clear is that when a particular psychopath is found not guilty by reason of insanity by a court, the reasons have more to do with the courtroom than the clinical state. The relative skill, interest, and experience of the Crown and Defense counsel, the nature of the offense (particularly gruesome or apparently illogical) and its effect on the jury, the age and previous record of the accused, the views of the judge, and the attractiveness of the alternative verdicts - all of these seem to be in practice what determine the issue rather than the presumed severity of psychopathy present in the accused.

But the area of confusion that interests me most, and that has, I think, enormous significance for all of us, is the problem of psychopathy showing up in places other than a mental hospital or prison. Henderson, described the "creative psychopath", workers at the Mayo Clinic speak of "restricted psychopathy", and Cleckley refers to the "partial psychopath" when he talks about "incomplete manifestations or suggestions of the disorder" -- in psychiatrists, physicians, businessmen, etc.⁹ My own patients have often accused me of being psychopathic (as well as most other diagnostic categories!) but I have always replied that they did not understand the difference between administrative skill and psychopathy. Both they and I suspect that the differences are subtle!

When Cleckley talks about psychopaths as those who "fail to know all those more serious and deeply moving affective states which make up the tragedy and triumph of ordinary life, of life at the level of important human experience", we think we know precisely what he means. Or again, when he says of a psychopath that his "objective experience is so bleached of deep emotion that he is invincibly ignorant of what life means to others" it rings a resonant note. The problem is that although Cleckley's sixteen point check-list does seem to convey the essence of psychopathy, each of the sixteen points taken by itself is imprecise, value laden, or just plain "mushy". How then can we translate seemingly valid descriptions like "bleached of deep emotion" into something that is more reliably measurable? Perhaps we need to go in the direction that Mordechai Rotenberg calls for when he says that "a true psychopath" is in fact an empirically non-existent entity which was never clearly defined in either medical or legal terms. He argues that we should be studying certain forms of insensitivity and looking for specific physiological measures that are stable and replicable predictors of specific insensitivities.¹⁰

My own view is that there are three interpersonal qualities which constitute the essence of psychopathy. Empathy, as defined by Stotland, "an observer reacting emotionally because he perceives that another is experiencing an emotion", trust, or basic trust as elaborated by Erikson, and the capacity to give and receive affection.^11,12,13 When I look over Cleckley's check-list of symptoms, as well as other diagnostic systems, it seems to me that almost all attributes assigned to psychopaths are understandable if one assumes deficient capacities for trust, for empathy, and for affection. My view is that were we better able to understand and measure these three qualities in adults, the problems of measuring the severity of psychopathy and understanding psychopathy in the "normal" population would come clearer.

It is of some interest that these three qualities, if they do in fact constitute the central core of psychopathy, seem central to the capacity of human beings to form mutually satisfying, long-term co-operative relationships. Perhaps it is not surprising then that these three qualities also seem to be at the core of the ethical teachings of the world's major religions. Parenthetically, they are very much the realities that persons in psychotherapy talk about. It is curious indeed that the qualities most lacking in those persons who cause so much difficulty for society should have such widespread meaning for human existence.

A review of the literature with regard to both the environmental origins of psychopathy and the origins of the capacities for trust, empathy, and affection seem invariably to point to the same place -- the very earliest months and years of human experience. We are all familiar with the kinds of early experience often seen in the psychopath's background. As Selma Fraiberg has said, "These are the diseases that are produced in the early years by the absence of human ties or the destruction of human ties. In the absence of human ties those mental qualities that we call human will fail to develop or will be grafted upon a personality that cannot nourish them, so that at best they will be imitations of virtues, personality facades."¹⁴

But once again, Cleckley has put his finger on the problem. "A very large percentage of the psychopaths I have studied showed backgrounds that appear conducive to happy development and excellent adjustment." My own view is that we have been struggling with a problem similar to that of learning about the effects of exposure to small amounts of radiation which produce pathological effects fifteen years later. Because we have been trying to study such phenomena before we could accurately describe and measure either small dosages of radiation or the kinds of damage they cause much later in life, we inevitably have come up with contradictory findings.

I have great hope that a clearer understanding of these matters will evolve as we increasingly learn how to observe and document the emotional subtleties of infant-parent-infant interactions -- as we, so to speak, make such observations under higher and higher magnification. The burgeoning new field of infant mental health, the growing number of clinicians focusing on this area, and the variety of research being done all suggest that we may soon be able to sort out, as Cleckley says, the "important relationship between the abstruse, paradoxically compounded, and ambivalent nature of the influences and the complex and deeply masked nature of the disorder such factors may shape." Instead of the crude fact "he was moved through thirteen foster homes in the first three years of life" we can now talk about specific details of attachment, about the emotional availability of caregivers for example and at many different stages of development in the first eighteen months. Moreover, we can now study these phenomena with such techniques as the microanalysis of video tape recordings.

It is my belief that psychopathy will be a less bewildering problem when we can more accurately describe and measure subtle emotional interactions in the earliest human experiences, and correlate them with measurable deficiencies in the capacities for trust, empathy and affection later in life.

I don't know what proportion of the population of a prison is psychopathic - partial or complete, mild or severe. Obviously the percentage depends on the diagnostic criteria used and the degree of severity you want to include or feel you can measure. To me the more important questions are: "What proportion of the general population is psychopathic? What are the consequences for society if there are too many psychopaths? Is there a critical point beyond which a social system cannot function - a critical mass for psychopathy?" To quote Selma Fraiberg again: "We have more reason to fear the hollow man than the poor neurotic who is tormented by his own conscience. As long as man is capable of moral conflicts - even if they lead to neurosis - there is hope for him. But what shall we do with a man who has no attachments? Who can breathe humanity into his emptiness?" For as Allport has said, the psychopath "lacks those normal human sentiments without which life in common is impossible."¹⁵

How do we reduce the prison population or prevent crime? I have come to view the solution to those apparently serious problems as more or less trivial compared to the more serious problems involved for all of us if our society increasingly, as it seems to, rears and rewards psychopaths. Most especially so in a world with weapons of mass destruction.

How do we go about the task of decreasing the number of psychopaths or the amount of psychopathy in our society? To me it is the same question as "How do we increase the number of people in our society who have well developed capacities for trust, for empathy, and for affection?"

A few of the steps that could be taken seem fairly obvious:

Since the earliest years are crucial, we should scrutinize every program and policy affecting infants and toddlers and ask ourselves "Whose needs are being met?"

There should be a clear recognition that the only meaningful measure of success in child rearing is an adult with highly developed capacities for trust, empathy, and affection. It follows that the current worship of child rearing practices that evoke the highest possible IQ, or the child with the greatest possible number of factual crumbs by the lowest age, or the child who can play the cello best at the earliest age should be suspect. Suspect because they may conflict with child rearing practices that produce an adult with well developed capacities for the qualities essential to harmonious co-operative human existence.

Insofar as it is the quality of emotional care during childhood that seems most crucial to the development of these capacities, attempts to raise the status of parenting would seem obligatory. In a society in which it is possible to market the most useless junk: Lysol Spray and vaginal deodorants are but two of countless examples, it should not be difficult to enhance "consumer taste" (through modern marketing techniques) for what is probably the most important job anyone can do -- the nurturing of a new member of society.

It seems peculiar in a society in which schooling is mandatory from age 6 to 16 that we turn out graduates who have no preparation for the one job they are almost certain to have - raising children. Surely, before conception is a possibility, boys and girls should appreciate:

They should know the ways in which our appetite for consumer goods and services can become so insatiable by the time children are conceived, that satisfaction of consumer cravings and status and careerism based on these are easily rationalized as having a higher priority than nurturing one's children.

They should know the subtle and damaging ramifications of our tradition of arbitrary male dominance, and the reasons why it will continue to be difficult to adequately nurture children until males become aware of, and change their irrational ways of relating to women.

It seems incredible to me that as a society we don't publicly advocate those values upon which all harmonious social interaction depend -- trust, empathy, and affection. Why shouldn't society -- all of us collectively -- reinforce our own latent awareness that these values are where it's at, and why shouldn't we do this at least as frequently and effectively as we allow ourselves to be reminded to drink Coca-Cola?

If we really want a society that selectively fosters and rewards selfishness, envy, and greed in pursuit of endless consumption of misnamed 'goods', then we should at the very least make all of the consequences of those values clear to everyone, including all the implicit personal and social costs. To do otherwise seems too much like favoring catabolism while opposing breakdown products.

Why won't such preventive measures be taken? There are many factors. In part, it is because we are presently attuned to a shorter time frame politically and psychologically than prevention necessitates. In part we are misled by the excitement and drama of intervention after a problem has occurred. The cops and robbers game, for example, is the stuff of much of our entertainment. In part it is because today's casualties have greater motivation to lobby for their own immediate needs than for prevention of tomorrow's victims. In part it is because an impossible level of proof is demanded whenever we discuss changes that appear to tamper with our present values. But mostly we just know that such proposed solutions to crime prevention are "naively idealistic."