Treatment and Legislation: The Machine VS. McMurphy


Treatment and Legislation: The Machine VS. McMurphy

            Without much legislation during the early days of reform in the care of psychiatric patients, many patients were left to suffer inhumane forms of care, most of which were punitive rather than true form of rehabilitation. Reading One Flew Over The Cuckoo’s Nest, we are able to see the way this system of care ‘treated’ some patients, most notably R. P. McMurphy. Life within the institution for McMurphy became a game he could never win—it was a game between a system built to reform at any cost versus one rebellious patient.

History of changing mental health treatments

As difficult as it is to believe with mental health problems still carrying a great stigma, during the middle 20th century, finding adequate mental healthcare was even more daunting, leaving many at the mercy of a system wrought with growing pains and legal legislation. In fact, what was even considered treatment for psychological and emotional disorders was blurred.

According to the Oxford English Dictionary, “treatment” might be defined as “management in the application of remedies; medical or surgical application or service”. Looking for medical definition of “treatment, we find many definitions broken down by the types of treatment such as “casual,” “active,” and more specific such as “electroshock treatment,” or “narcotic treatment” (MediLexicon). We can see, then, that even now that definition is ambiguous, but was even more so during the 1960s and 70s.

In  his 1974 paper entitled “The Right to Effective Mental Treatment “ Ralph Kirkland Schwitzgebel outlines for us that our court system did not become involved in deciding which “treatments” were deemed appropriate in a patient’s treatment plan (Schwitzgebel). Therefore, the former definition of “treatment” remains ambiguous.  According to the Yale Law Journal in an article entitled “Civil Restraint, Mental Illness and The Right to Treatment,” it might include any treatment found within the medical definition, left solely to the discretion of treatment providers, as the judicial system believed themselves inadequately educated in such matters as to decide what was best for a patient (Yale ). We, then, can conclude that many medical professionals were left with a great deal of freedom in deciding what “treatment” was.

During the 19th century, caring for the mentally ill was built around a theory called “Moral Treatment” (Luchins). Moral treatment included keeping patients from their families, involvement in Christian based study, and recreational and occupational therapy (Luchins). This theory was born from the post-Civil War belief that good Christians carried good character, and were therefore the most mentally fit (Luchins). However, there was a shift in the discourse, leading to adaptations of more modern scientific approaches.

The 20th century brought us new treatments such as electroshock and insulin therapies, psychotropic drugs, and the adaptation of psychoanalysis in the treatment of the mentally ill (Luchins). Not all facilities and medical professionals could agree that these therapies alone were effective, and so there came to be a hybrid system that still embraced the moral treatments of prior decades mixed with the more scientific therapies of the early 20th century (Luchins). Some hospitals participated in that hybrid system, while others adapted to one more than the other (Luchins). State owned facilities tended to fall into the hybrid category such as in Salem State Hospital in Oregon (Luchins). What eventually became clear was that one form of contemporary treatment, the lobotomy, was ineffective, and that, even for all the laud it had received in the early days of research, the research had been tainted with “misrepresentation” and “sensationalized reporting”( Diefenbach, et al. ). Thus, the by the mid-twentieth century, the lobotomy was on its way out of the normal practice of most treating psychiatric physicians (Diefenbach, et al.). According to legislation, though, it could still be used if considered applicable “treatment” for the mentally ill. “Treatment” became a hot topic buzzword in the mid-twentieth century as well when speaking of those who might be considered criminally ill.

For those who might plead guilty, yet insane, in a court of law, they would be incarcerated in a state hospital for some length of time until the state deemed them safe to live in free society. Problematic for the states, though, was the fact some mentally ill patients were only receiving punitive treatment while committed, which was no more effective than mainstream incarceration ( Yale ). So, the courts legislated that in the 1966 case Rouse v. Cameron that any person who was found to be guilty, yet insane, while in custody of a treatment facility must then receive adequate treatment to rehabilitate them towards an end of being able to function in society ( Schwitzgebel ). There was never a guarantee of freedom outside the institution as some people were considered to be “chronically mentally ill” and risks to the safety of society, but that was nonetheless the goal to work towards ( Schwitzgebel ). Without just “treatment,” patients of mental facilities could bring suit against the facility in which they were housed citing “unconstitutional treatment,” and could be, if not released, transferred ( Yale ). This became, no doubt, a sticking point with institutions around the nation that did not want to taint their reputations, and ultimately their bottom lines. Patients had the constitutional right to adequate rehabilitative treatment, beginning in 1966. No matter what their criminal charges, mental health providers had to give them “treatment” or face civil lawsuits.

Life in the “Cuckoo’s Nest”

            All this history of change in the mental health system convenes in the Ken Kesey novel One Flew Over the Cuckoo’s Nest. The novel, originally published in 1962, was published during the heart of the changes seen by those involved in the psychiatric care system. Kesey’s characters represent all aspects of those who found themselves involved with mental health care.

There is Nurse Ratched, the one most responsible for patients’ care besides the doctors. We have voluntarily, even if coerced, admitted patients such as Billy Bibbet. Chronic patients grace the pages alongside their counterparts, the Acutes. Then we have what would have been considered a “criminally ill” patient, R.P McMurphy. McMurphy, who faked mental illness because he thought it might be easier than serving out his time on a prison work detail, challenges seemingly every system and routine within his new found home (Kesey). All this challenging of authority is a game to him (Kesey). What he never dreamed could happen is that it was a game he could never win. Unlike his games of poker, the clinical deck was stacked against him by a system set out to ensure his “treatment”. This system was, in part, controlled by one Nurse Ratched. We see early on in the story just how the system functions as we are informed by Chief Bromden.

Giving us our first peek at Nurse Ratched, Chief tells a story of a woman whose basket does not contain “woman stuff,” but instead “parts she aims to use” such as “wheels and gears,” “forceps,” and “pliers” (4). Chief Bromden paints a picture of woman who is in charge of a machine, a “combine” that is used to control the minds of the patients (3-8). His story is punctuated, however, by the line “…it’s the truth even if it didn’t happen” (8). So, while this is obviously a fictional account of the goings on behind the walls built by an author, one might be led to believe that somewhere in the United States, something like this was happening. As well, Bromden’s characterization of Nurse Ratched set the mood for us readers to understand her as a part of a system that controlled the aspects of treatment for its patients.

One patient, McMurphy makes it clear upon arrival he will not be part of Ratched’s system. He immediately refuses to shower (11). He goes on to comment to the Acutes that he “…came to this establishmet….to bring you birds fun an’ entertainment” (11). Fun and entertainment might be considered a positive thing, but for the members of the ward, all of whom are part of a regimented system of treatment set forth by the powers that be, their idea of fun does not necessarily align with the ideas of McMurphy. The Acutes, who even find delight in being part of the system by tattling on one another, are initially wary of the “leadership” offered to them by McMurphy (14-24). Another nurse even questions “what on earth would make a man want to do something like disrupt the ward…” to which Nurse Ratched plainly answers “You seem to forget, Miss Flinn,  that this is an institution for the insane” (25). Despite McMurphy’s admitting that he was in this place only because he had grown bored with the work farm, Nurse Ratched still recognized him as “insane” (11, 25). McMurphy does admit that “a couple hassles” at the prison caused the court to rule him a “psychopath,” but it is still fairly obvious McMurphy is playing the system (13). Nonetheless, Nurse Ratched will see to it that McMurphy receives treatment as the court has so ordered.

Nurse Ratched recognizes McMurphy as a “manipulator,” but nonetheless does not address that issue with him or his counselor (24). Instead, she treats him as any other patient, only with a more guarded knowledge that he would love nothing more than to “take over” (24). Perhaps, this is representative of a system bound by the law to “treat” those the court found to be criminally ill. What it no doubt represents is Ratched’s disdain for the change in mental health policy, from the “moral treatment” of the past to the new policies of psychoanalysis and drugs.

As she speaks to Miss Flinn, Ratched outlines the case history of Mr. Taber while simultaneously filling a syringe that will be his medication for the day (25). Nurse Ratched says to Miss Flinn that the “present permissive philosophy in mental hospitals” has allowed manipulative patients to “take over” (25). With changing policies, she can strike back using the very “treatments” meant to help patients, and with the laws as they were, she can hide her own manipulation and retaliation under the umbrella of helping and treating patients.

Chief Bromden describes the ward as a machine, a “combine” (25). He believes Nurse Ratched to be part of this machine—the center of it, in fact (25-26). She sits, as Bromden describes, “in the center of this web of wires like a watchful robot” who knows “which wire runs where and just what current to send up to get the results she wants” (25-26). With this image, we are led to believe that Nurse Ratched is not following orders or protocol, but rather developing her own methods with which to run the ward. She knows how to get results. More importantly, she is allowed to decide what “treatment” is and which treatments will be used. This becomes most obvious during the end of the story when McMurphy is given a lobotomy as “treatment”.

After several of McMurphy’s attempts at bringing his form of “entertainment” to the ward, paired with failed attempts to administer electroshock therapy to McMurphy, it is finally ordered that he receive a lobotomy. The lobotomy was not the result of an informed medical decision from a medical professional, but rather a reactionary violent attack on a patient who had infuriated and humiliated the one who sat at the center of a spider’s web control panel. Nurse Ratched had caused the death of Billy Bibbit by humiliating him, causing him to commit suicide (273-274). In reaction to his friend’s senseless death, McMurphy attacks Nurse Ratched, exposing her breasts (275). The nurse, of course, found no wrong in humiliating a grown man for engaging in sexual activity, “treating him” so to speak, but was indignant that she, herself, was humiliated. Although she was injured physically in the confrontation, we are given a sense that her psyche was damaged as much, if not more, than her physical being, for when she returned to the ward and the men approached her “she jumped back two steps” (276). She had already accomplished what she set out to do with McMurphy, however.

McMurphy returns to the ward on a gurney with a chart attached that read “LOBOTOMY” (277). Was this a necessary case for an outmoded, ineffective, overly-sensationalized treatment? One could argue that prior treatments given to McMurphy were ineffective, leaving Nurse Ratched with no choice following her assault. We must, though, look to the fact Ratched knew McMurphy was manipulating the system from the time he stepped foot onto the ward. How can we explain such an extreme procedure on a man who was no more than lazy, trying to escape a few blisters and a sore back on a work farm?

Looking back to her prior treatment of patients, we might see that she allowed them to be abused and molested by people who were no more than orderlies—men who were to simply usher these patients from place to place in the facility are allowed to utilize Vaseline to “take temperatures” of patients, even though the connotation is that they were raping these men (9).

She humiliated Billy Bibbit by reminding him his she knew his mother, a woman he undoubtedly feared, and whom Ratched was sure to tell about Billy’s sexual escapades (272). Not only was Billy embarrassed “he cut his throat” (274). This was not just a conversation between patient and caregiver, this was a conversation intended to humiliate, as it was carried out in front of his peers. The only conduct that should have been discussed was the breaking of a rule, but rather Nurse Ratched decided to invoke “moral treatment” reminding Billy that he was a horrible human for doing things which not only she, but his mother would not approve (272). Her goal was to break his spirit, and break it she did, never mind the cost.

Nurse Ratched also found a way to break the spirit of Cheswick. By not allowing Cheswick the autonomy to choose when and how many cigarettes to smoke, she kept him feeling as though he was a helpless child (144-151). Cheswick, who was relying on McMurphy to help him fight the battle for this small amount of freedom, was broken when he learned McMurphy was not voluntarily commited, and even though he understood why McMurphy could not make more of a fuss over the cigarettes, he also knew he no longer had a partner, and so he drowned himself (150-151). His spirit, just as Bibbit’s was broken. In fact, there is only one patient who she could not break.

Chief Bromden, rather than become weaker during the story, seemingly gained strength. He had already planned to leave the ward before McMurphy returned following his lobotomy, but he said “I didn’t want to leave just yet” (277). He was waiting to see what else would happen on the ward, and that something else was McMurphy’s return as a vegetable (277). Seeing his friend, an otherwise healthy human being, come into the ward as someone who would be a chronic, seemingly gave Bromden the last dose of strength he needed to break free, and after he killed McMurphy, he did, in fact, leave the ward (277-278). So while she busied herself breaking men with her self-imposed “treatments,” Bromden refused to fall into her trap. He, too, had been a manipulator of the system—something Ratched had seemingly missed, and he was able to completely break her system rather than the reverse.

Seeing that Nurse Ratched had treated these men in any way she saw fit, misusing her power to keep her ward running the way she wanted it, we can then understand that McMurphy was a threat to her authority. He was out to break her spirit, to take a gamble on making Ratched so out of sorts that she lost control (66). He was not mentally ill, though. By her own admission he was manipulating her, the prison, and the rest of the residents on the ward—“He is what we call a ‘manipulator’, Miss Flinn, a man who will use everyone and everything to his own ends” (24). This woman with this knowledge and all her power does not try to deescalate the situation, but rather allows McMurphy to carry on, and then administers “treatment” for his behavior.

What we see in One Flew Over the Cuckoo’s Nest is a representation of a changing, but still broken system of mental health care where the war was still ongoing between patients and caregivers for fair and adequate treatment without abuse. McMurphy was never going to win his game with Nurse Ratched, because the machine (the judicial system) had ensured his treatment. McMurphy was simply a man caught in an unjust system, a machine, with only the goals of ensuring its own well-being above and beyond that of the human beings who needed its care.

Works Cited

Diefenbach, Gretchen. Et al. “Portrayal of Lobotomy in the Popular Press; 1935-1960.

Journal of the History of the Neurosciences. 8:1.60-69. 1999. PDF.

Kesey. Ken. “One Flew Over The Cuckoo’s Nest.” Penguin Classics. New York. 2003. Print.

Luchins, Abraham. “Moral Treatment in Asylums and General Hospitals in 19th Century

America.” The Journal of Psychology. 123: 6. 585-607. 1974.PDF.

MediLexicon. “Treatment”. 2014. Web.

Schwitzgebel, Ralph Kirkland. “The Right to Effective Mental Treatment.” California Law

Review, Inc. 62:3.936-956. 1974.PDF.

The Yale Law Journal. “Civil Restraint, Mental Illness, and the Right to Treatment.” The Yale

Law Journal Company. 77:1. 87-116. 1967. PDF