There is no doubt that One Flew Over the Cuckoo’s Nest is one of the seminal films in mental health fiction. Its legacy is still strong forty years later – barely a week passes without one of my patients mentioning the film, usually comparing it to the ward or my proposed treatment plan.

One Flew Over the Cuckoo's Nest

But it is exactly that legacy that haunts the fight against mental health stigma. This film has so permeated the public consciousness that when folk think of mental health, they think about One Flew Over the Cuckoo’s Nest.

So, how accurate is it? Are mental health units full of Nurse Ratcheds? What conditions do the ward’s patients suffer from? And is electroconvulsive therapy really that barbaric?

But first:

It is 2015, not 1975.

Why is this point important? Because medicine’s approach to mental illness has changed dramatically over the past forty years. A lot of the problems I identified with One Flew Over the Cuckoo’s Next stem from it being a product of its time. It is partially reflective of psychiatry in the sixties and seventies. Like all contemporary pieces, it is unfair to judge it with a modern eye.

Yet what I hope to do is correct misconceptions that have carried over into today’s thinking around mental health.

Institutionalisation
One Flew Over the Cuckoo’s Nest takes place in what the sociologist Goffman termed a “total institution”, where a group of people are confined in a controlled setting for a prolonged period of time.

Its features include all activities of daily living taking place in the same location, with a large batch of people all conforming to the same schedule and rules. There is also a marked divide between staff and community members – in this case, patients.

This heightened control becomes obvious in the film when McMurphy (Jack Nicholson’s character) tries to change the ward’s schedule for the baseball World Series. While there is a show of democracy in the voting, the act is rigged by the staff. The belief that order and schedule is vital to mental health is being applied here by force and against autonomy.

The other most obvious point is the institutionalisation of the characters. McMurphy is stunned to find out that most of his fellow patients are voluntary and not compelled to stay on the ward. Then why do they stay?

Because any total institution equips people to survive in that environment and not to grow beyond it. This effect is also widely seen in prisons and the military. These patients have grown so used to the ward that they don’t know how to leave it.

However, psychiatry emptied its institutions in the 1980s, moving towards a “care in the community” model and later to the recovery model. Which basically means wanting people to live their own lives on their terms, with support given to achieve those personalised goals. It is basically the polar opposite of institutionalisation, though we do still cause this in some mental health units – e.g. in forensic mental health services, and in patients who stay for a long time.

Mental illness
One of the questions the doctors ask of McMurphy is whether or not he has a mental illness. It is a question we could also ask of the other patients on the fictional ward of One Flew Over the Cuckoo’s Nest.

Again, we must look at historical psychiatry. The vogue in the mid-20th century was that institutions were the preferred method of delivering mental health services. Therefore, if you had any sign of a mental health problem, into hospital you would go. It was partly based on the scientific thinking of the time, and probably more realistically on the fears within the community of what mentally ill people do if left unsupervised.

Fast-forward forty years to a modern mental health unit. One – given the current state of NHS mental health funding, you’ll be lucky if we can find you a bed at all. Two – only the most severe episodes of mental illness require hospital admission.

I still have older patients asking me if they can come into hospital “for a rest”. Respite admissions were very common in the institution era. Now, I can hardly think of a place less restful than a mental health unit.

Of the main patient characters in One Flew Over the Cuckoo’s Nest, I can’t identify one who requires hospital admission. The so-called “chronics” may require highly-supported living arrangements, but not hospital.

Because all these people are relatively well, they may have problems that could be addressed by long-term therapy, robust medication, supported accommodation, or just a more understanding community.

Not one of them has a definable, recognisable mental illness. Especially not McMurphy.

Nurse Ratched
I had heard terrible things about the iconic Nurse Ratched before watching this film. And yet I found nothing terrible about her.

One-Flew-Over-The-Cuckoos-Nest-Nurse-Ratched

Here is a woman doing her job in an institution that completely defines that role. She is as much a prisoner of this system as they are. In fact, at times, I realised that I would enforce the boundaries in exactly the same way she did.

Does she make some questionable decisions? Absolutely. I found the dynamic between her and Billy particularly troubling. I also thought the nursing staff did absolutely nothing to de-escalate a situation unless they felt their authority was being threatened, not when they felt their patients were suffering emotional or physical harm.

But do I think she had a vendetta against McMurphy, or wished to bully the patients? No, I don’t. I think she genuinely thought she was doing the right thing.

And those people make for the most terrifying villains.

Treatments
Never do I hear as much about One Flew Over the Cuckoo’s Nest as when discussing electroconvulsive therapy, or ECT. It is undoubtedly controversial – for one, it is the only form of treatment that requires consent or a second opinion under the Mental Health Act.

And in the 1960s, it went down pretty much as you see in the film. In 2015, however, it is a very different beast. ECT always takes place under general anaesthetic. A muscle relaxant mutes the effects of the seizure on the body. And it’s only given in the most severe episodes of depression and psychosis, usually when people are dying from dehydration and malnutrition.

It is definitely not used as a punishment for bad behaviour. It’s also not used for tranquillisation.

The medication ethics are also pretty shit in One Flew Over the Cuckoo’s Nest. When McMurphy asks what tablet he’s being given, the nurse patronises him and then Nurse Ratched threatens him. Even when compelled to receive treatment, people should be informed about what it is you want them to take. We are trying to move beyond the paternalistic model of medicine where you just do exactly what your doctor says – because why the hell should you?

See also group therapy. Is group therapy for everyone? Nope. Should you be compelled to do it? Probably not. The evidence suggests that any compelled therapy will be pretty much useless. It requires consent and active participation. It requires a trained facilitator who won’t use the threat of your mother against you (and should instead be looking into those mother issues, because that seems a significant factor in this case).

Verdict?
I’ll be honest: I really enjoyed this film.

It shows people with mental health problems as individuals, with in-depth characters, dreams and desires. It didn’t do psychiatry a lot of favours, but then 1960s psychiatry didn’t do itself a lot of favours.

I find it difficult that so many people still turn to One Flew Over the Cuckoo’s Nest as their benchmark for what mental health and psychiatry are actually like.

How do we combat that? We include more characters with mental illness in our dramas, our comedies, our documentaries. We tell the truth about mental health now.

What did you think of One Flew Over the Cuckoo’s Nest? Leave a comment!

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