Nurse Ratched and Randle McMurphy

Hope Flew Over The Cuckoo’s Nest

May is Mental Health Awareness Month, and there’s probably no film in existence which speaks so loudly and provocatively about mental illness, the (mis)treatment of patients, and the failures with the system as Milos Forman’s One Flew Over the Cuckoo’s Nest. Its legacy is still strong 45 years later, but it is that same legacy that plagues the fight against the stigma of mental illness. This film has become so ingrained in the public consciousness that often, when folks think of mental illness, One Flew Over the Cuckoo’s Nest immediately comes to mind—though probably less so among the younger generation, as mental health is so much better understood these days.

An adaptation of the 1962 Ken Kesey novel of the same name, Cuckoo’s Nest combines the personal and professional experiences of Kesey, a famous counterculture figure, and reflects the era in which it was written. Kesey developed the novel as a graduate student at Stanford University’s Creative Writing Program, and the story was partly inspired by Kesey’s part-time job as an orderly. He was also participating in experiments involving LSD and other psychedelic substances for Stanford’s Psychology Department. While talking to patients under the influence of LSD, Kesey began to perceive that removing people from society who didn’t conform to the norm had turned functional people insane instead of allowing them to function in society. Kesey’s use of LSD also caused him to have hallucinations while working as an orderly. He often believed he saw a giant Native American mopping the floors of the hospital, which led him to later add the character of Chief Bromden as the narrator of the story.

the men of the ward sit discussing their difficulties on the psych ward, with McMurphy seated center

Directed by Forman In 1975, Cuckoo’s Nest took the world by storm with Jack Nicholson’s charismatic lead performance and Forman’s inventive directing. The film tells the story of Randle McMurphy (Nicholson), a criminal who lies his way into a mental institution in order to evade his sentence of hard labour for the statutory rape of a 15-year-old girl, thinking that this will be an easy ride. He soon meets his nemesis in Nurse Ratched (Louise Fletcher), who controls the ward with a strict, authoritarian, and demeaning style. McMurphy, being incredibly stubborn, attempts to gain the trust of his inmates and spark a rebellion against Ratched. The story addresses themes of conformity, gender roles, homophobia, misogyny, racism, and mental illness, making for a complex and thought-provoking film. There are some changes between the film and the book, notably that Chief is not the narrator of the film; he is an important character, however, played by Will Sampson.

Cuckoo’s Nest was filmed in Oregon State Hospital, a working mental hospital, which significantly adds to its realism. One purpose of the book and film was to shine a spotlight on the terrible conditions of mental institutions of the time, especially in terms of these vast “mansion” type buildings. In the ’60s, there were nowhere near as many medicinal treatments for mental illness available as there are now, so the number of patients who required a place to be treated was enormous. As early psychiatric hospitals couldn’t handle the numbers and notoriously treated patients badly, a trend called “Moral Treatment” called for the mentally unwell to be treated with the care and respect that everyone deserves. Thus, the Kirkbride Plan for mental institutions was created. The Plan called for clean and spacious buildings that provided fresh air, sunlight, outside space, and comfortable facilities for patients.

Oregon State Hospital was built to conform to the Kirkbride plan, so the film shows a realistic portrayal of hospitals at that time. What’s different about the Kirkbride Plan and Moral Treatment was not just the improvement of living conditions; patients were supposed to be treated with the utmost ethical care. This is where Cuckoo’s Nest—and Oregon State Hospital—both get intriguing. Oregon State Hospital is pretty infamous for treating their patients terribly. Perhaps most well-known is that during a search of the hospital grounds in 2004, a total of 3,500-5,000 cremated remains of former patients were unearthed, who had been placed inside copper barrels over the previous 100 years of the hospital’s existence—unreturned to their families, or in some cases not identifiable at all, their causes of death unknown.

McMurphy sits on the shoulders of another patient as they play basketball

Psychiatry’s approach to mental illness has changed dramatically over the past 45 years. A lot of what is depicted in the book and film no longer applies to the treatment of mental health; indeed, the story led to major changes in psychiatric practices. So let’s look at how things have changed.

From the moment McMurphy enters the mental hospital, authoritative measures are placed on him. He believes that this is going to be a walk in the park in comparison with his stint at the prison farm, but as soon as he sees the patients, and how acutely ill some of them are, he suddenly realises the situation he’s got himself into. He’s not scared of the men—this is one of McMurphy’s best qualities, as he treats everyone equally and sees the people behind their labels—but living his best life is not going to happen here.

He scours the ward for people to hang out with. McMurphy is a very social animal; he likes being around people, being the centre of attention, and getting up to mischief. Is he mentally ill? Absolutely not, and he freely admits that to Dr. Spivey (Dean Brooks, the actual Director of the Oregon State Hospital). He finds a group of men playing poker and pretty much takes over the game, like a tomcat spraying his scent. If this had been a prison, the men wouldn’t have welcomed this behaviour, but here in the hospital, the men are not used to oppressive behaviour from anyone other than Nurse Ratched.

Nurse Ratched with a stern look on her face

These men have been confined in this same place together for a long time. They are made to conform to a schedule that repeats day after day. All of their living activities, with the exception of sleeping, happen in the same room with white walls and the same song playing over and over. If you weren’t crazy before you went in there, it wouldn’t take you long to become so. This is the central theme of the story, in a sense; that being institutionalised, in whatever form that takes, will inevitably affect your mental health for the worse. Yes, structure can indeed help people get through their day, but a complete lack of freedom to choose leads to oppression and a lack of self-confidence, something that Nurse Ratched is particularly skilled at enforcing.

Nurse Ratched is considered one of the greatest onscreen villains ever, yet what she actually does to the men, at least on the surface, is very little. We don’t know her background in the film, why she is so cold and heartless, but we at least hope that even back then people didn’t become a mental health nurse with anything but good intentions. She believed she was doing the right thing for her patients and was never told to do anything differently by her superiors—in fact, Dr. Spivey said she was one of the greatest nurses they had. Why? Because she kept the ward controlled. Her methods of enforcing this control were at times cruel, but things were very different for women back in 1962 when her character was written. She would not have had the freedoms most women have today, and she had to adapt her role to protect herself.

Nurse Ratched was powerful and emasculated the men in her care, but it was the only way she felt she could keep order. If a man portrayed the warden role, would we see that behaviour as castrating? Would we even notice it? Or would we just brush it off like you would any Sergeant Major giving a drill, or would we find that this open-style therapy was actually good for them? Ratched’s domination of the patients is arguably required for her to run the institution without incident. Anything less would lead to chaos, which inevitably does happen when McMurphy arrives on the scene.

the ward pretends to watch the World Series on the TV

McMurphy, while being the protagonist we’re rooting for, is not a good man. He’s in prison for statutory rape, he regularly gets into brawls, he’s a misogynist, and he does whatever he wants without any real consideration for how it will impact the people he appears to care so much about. He (and arguably Ken Kesey) see Nurse Ratched’s authority and power over the men as unfeminine, and her character is portrayed negatively because of this, whereas sex workers Candy (Mews Small) and Rosie (Louisa Moritz) are portrayed as fun, playful, pretty, dizzy, and subservient. They are the girls of the patients’ dreams. They are always available and make no demands for anything other than money and a good time. They are portrayed positively, as more maternal and dependent caregivers than the nurses. To write this in 1962, just as the feminist movement was emerging, appears to show Kesey’s distaste for women redefining their traditional gender roles.

McMurphy and Nurse Ratched are more similar than they think, though at the opposite ends of the spectrum when it comes to authority. Both want it, and both have it to a degree. Nurse Ratched has got her control down to a science by subtly belittling the patients, making them talk about their personal issues among the others in “therapy.” These matters are often sexually related, which in the case of Harding (William Redfield), who is terribly jealous of his wife, results in him being mocked for being gay. Then there’s the case of the sweet Billy Bibbit (Brad Dourif), who has a stutter and has been made to believe his attraction to women and romantic nature is somehow disgusting; he too is teased by the group. Billy is terrified of Nurse Ratched, and we find out at the end it’s because she is friends with his mother, who he desperately does not want to disappoint. Presumably, she and Ratched are similar characters, and Ratched knows precisely how to manipulate him and each of the men under her care in the same way: by preying on their weaknesses.

Nurse Ratched stands with her hands on her hips while 3 black male orderlies smirk behind her back

McMurphy, on the other hand, gains his control by undermining Ratched’s authority. He plants seeds in the minds of the patients, leading them to believe in something better. He gives them hope. Even when he doesn’t succeed in lifting the huge marble sink unit that he wanted to throw through a window to make his escape, he says, “At least I tried.” It creates a spark in the men, and unlike the previous day when they were too scared to stand up to Ratched, they all raise their hands in a vote to play the World Series on the TV. It seems cruel that despite a majority vote, as the Chief raises his hand, she still doesn’t permit the showing, but she is fully aware that if she gives an inch, McMurphy will take a mile. It will just be the start; if she loses control, then it’s gone forever. Nobody can see her as weak or giving in. Additionally, she is probably frightened of what might happen if the men become so excited about watching the ballgame.

Would this happen now? Hopefully not. While Ratched’s belief (or at least excuse) that order and schedule are vital to mental health, it’s applied here by force and against autonomy. Depriving people of harmless pleasure is not good for the mind.

McMurphy is later stunned to find out that most of his fellow patients are voluntary and not compelled to stay on the ward. He can’t understand why they would want to be there. It is because most institutions equip people to survive only in that environment and not to grow beyond it or prepare for life outside. This effect is also widely seen in prisons and the military. The patients in the ward have become so used to being there that they don’t know how to leave. Paradoxically, the more McMurphy tries to escape, the harder it is for him to leave. In giving up his place in prison, he unknowingly gave up his sentence, which only had 68 days left to run. Now that he was in the care of the doctors, his stay was determined by them. Indeed, Nurse Ratched chooses to keep him there. She is enjoying the game of cat and mouse, despite the roles changing every few minutes. She enjoys the challenge and prolonging his torture. McMurphy makes it easy for them to keep him by appearing to be a dangerous individual, which by the end, he has to become.

Long gone are the days that if you had any sign of a mental health problem, you’d be committed to a hospital. Back then the scientific thinking was that this was the way treatment should be given, and probably because mental health had way more of a stigma attached to it. Communities were afraid to have mentally ill people living among them unsupervised. However, mental institutions in the UK were emptied in the 1980s, moving towards a “care in the community” model, which meant encouraging people to live as independently as possible with support given to achieve personal goals. It is pretty much the polar opposite of institutionalisation.

Sounds much better, right? Well, fast-forward 45 years to a modern mental health unit, and you’ll be lucky to get a bed at all. Only the most severe cases are admitted to hospital now. Most people do not need to be committed unless they are a danger to themselves or others. Would any of the characters in Cuckoo’s Nest be hospitalised today? I would bet that no, they wouldn’t. Even the most chronic patients would most likely require only highly supported living, not to be locked up.

McNulty bites on a tongue protector while receiving ECT

Of course, Cuckoo’s Nest is famous for its disturbing scenes of Electroconvulsive Therapy (ECT). In the film, it is given as a punishment for unruly behaviour to Cheswick, McMurphy, and (presumably) The Chief. It is still used today in some cases, but in a very different manner.  ECT always takes place under general anaesthetic. A muscle relaxant is given to dampen the effects of the seizure on the body. It’s only offered in the most severe cases of depression and psychosis, usually when people are dying from dehydration and malnutrition. It is definitely not used to treat bad behaviour or to tranquillise patients.

Chief’s story is an intriguing one. Everyone at the hospital, staff and patients, believe that he is deaf and dumb. But he reveals to McMurphy — a man who intrigues him, a man with a free spirit, who doesn’t treat him like the majority of white Americans at the time did — that he can speak perfectly and has high intelligence, he just chooses not to communicate. When Chief talks about his father, he uses the word “shrunk” to describe what his father did to himself by drinking until he was a shrivelled, yellow-skinned husk of a man. He drank to numb the violence the world was afflicting on him. Chief’s father is a victim of society forced to make himself small rather than live his truth in all its “largeness.” Chief says that the world “worked on” his father in the same way that the hospital is “working on” McMurphy. He perceives the struggles against oppression in his own life and community as similar to the way the hospital is suppressing McMurphy’s freedom.

McMurphy and Chief laugh together

By the end of the film, McMurphy has had many chances to escape, yet perhaps subconsciously, he chooses not to. He jumps the wire fences, steals the hospital bus, patients included, and takes them all fishing on a boat. Then Randle invites Candy and Rosie to a party on the ward at Christmas. He could easily jump the fence and escape at any time, but he doesn’t. Even at the end of the party, he doesn’t go. Has he too become institutionalised? The party is the final straw for Nurse Ratched, and after shaming Billy Bibbet for spending the night with Candy, Billy takes his own life in a truly upsetting moment. In a rage, McMurphy attacks Nurse Ratched, almost strangling her to death. Yes, he blamed her for Billy’s death, as there was no reason for him to be in the hospital in the first place, and she had systematically destroyed his self-confidence, which stopped him from ever wanting to leave. Billy, in the minutes before his suicide, stood up for himself finally and even spoke without a stutter very briefly before she ripped his newfound confidence away by using his mother’s shame as a weapon once again.

But McMurphy is fully aware that he too is responsible for Billy’s death. He pushes it too far, and Billy and the rest of the ward pay the price. Somewhere in the middle of Nurse Ratched’s and McMurphy’s ideals could be the perfect way to treat mental health, and indeed that is, on the whole, what happens today. However, the shortage of access to mental health care in the UK and the U.S. is a massive problem that needs to be addressed.

McMurphy is, in the end, his own greatest enemy. After the attempted murder of Nurse Ratched, he is given a frontal-lobe lobotomy. The rest of his friends are unaware; it is only Chief that sees his return to the ward in the middle of the night. McMurphy is a zombie now, his spirit gone, numbed to everything, just like the Chief’s father was. He does what he feels is the most compassionate thing to do and suffocates him with a pillow. He then lifts the marble sink with his enormous strength and throws it through the window, making his escape. McMurphy’s spirit lives on in Chief, and his rebellious nature will give hope to many. Taber (Christopher Lloyd) is the only person to witness the Chief’s escape and cheers, making him the next person inspired by this freedom. Notably, it is only those who have been committed to the hospital who have a real desire to leave—those with the least amount of self-loathing.

Martini and Billy dance with Rosie and Candy

One Flew Over The Cuckoo’s Nest is one of the greatest, funniest, most poignant, and tragic novels ever written and films ever made. It shows that people with mental health problems are individuals, with in-depth characters, dreams, and desires just like anyone else. It didn’t do psychiatry a lot of favours, but then 1960s psychiatry didn’t do itself a lot of favours. It changed the way patients were treated for the better and made a massive contribution to the change in societal opinion of those with mental health conditions. The film’s star-studded cast of peculiar actors all gave the performances of their lives for this movie and made cultural history in the process.

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