—From a nursery rhyme
At the recent annual meeting of the American Psychiatric Association, I had the opportunity to be on a panel to discuss a screening of One Flew Over the Cuckoo’s Nest. By many criteria, it was one of the three best movies of all time. The panel was pulled together by Lawrence Richards, MD; the other panelists were Roger Peele, MD, and Michael Schwarz, MD. The movie was shown at 9 AM—an ungodly time to watch a movie; nevertheless, it was very well attended. My role was to discuss community psychiatry, and in this regard the film proved to be provocative . . . I stayed over an hour afterwards to discuss the reactions with the audience.
What I hadn’t anticipated, having not seen the movie for almost 40 years, was how eerily well it paralleled my career and the evolution and devolution of community psychiatry. Not only that, but the movie was screened on my birthday.
Our abbreviated history
The book One Flew Over the Cuckoo’s Nest, written by Ken Kesey, who had worked in a VA hospital, was published in 1962. In that year, I was a 16-year-old, fascinated with Freud’s The Interpretation of Dreams and deciding to become a psychiatrist.
In 1963 - 1964, a play based on the book had a successful run on Broadway. Both the book and the play portrayed a repressive, overcrowded psychiatric hospital. Whether President Kennedy was familiar with either the book or play is unclear, but he pushed through the landmark Community Mental Health Act in 1963, paving the way for the deinstitutionalization of the state hospitals like the one portrayed by Kesey. In 1966, my soon-to-be wife and I spent some psychology class time at a state hospital in Michigan—one even worse than that depicted in the book and movie.
The film wasn’t made until 1975, the same year I started my psychiatric career at a community mental health center at an army base in rural Alabama. In many respects, this was the heyday of community mental health—there were hundreds of federally funded centers across the US, well on their way to providing comprehensive services in the communities instead of in the state hospitals. By 1981, President Reagan, began the dismantling of these centers by substituting block grants, whereby states could use these funds for other public services, such as highways.
Around 1988, two different societal trends affecting psychiatry gained traction in the US: the recovery movement and managed care, emphasizing consumer empowerment and management control of treatment, respectively. It was then that I became a director of an academic, not-for-profit managed care system. The experience of trying to reconcile and resolve those movements ethically led to the book The Ethical Way: Challenges and Solutions for Managed Behavioral Healthcare (Jossey-Bass, 1997).
By the 21st century, more and more patients were ending up in jails or prisons. Earlier, those same patients might have been hospitalized. From 2008 to 2012, I worked part-time in a medium-security prison in Wisconsin. To my surprise, because of federal funds from lawsuits (ie, federal suits that required Wisconsin prisons to provide treatment for inmates equivalent to that offered in the community)—I had more resources and time to help patients than I did in the public outpatient clinic in Milwaukee.
More than 50 years since One Flew Over the Cuckoo’s Nest was published and almost 40 years since the movie was released, the issues seem as relevant today as they were back then.
The Recovery Movement
For his portrayal of R. P. McMurphy in the film, Jack Nicholson won his first academy award. He instigated the inmates to obtain more rights and empowerment. For the screening, I wore a T-shirt of McMurphy with the saying, “what would McMurphy do?”—both to get into the mood of the movie and because I have been called an instigator too.
In combating the authority of the staff (whether that authority was well-meaning or malicious), the results turned out to be mixed: a patient suicide, violence to the staff, and a mercy killing after McMurphy’s lobotomy. There was also the awakening of some other patients, especially the Native American “Chief.”
Today we face a similar ethical challenge. To what extent should patients and consumers manage their treatment versus following the expertise of clinicians? At its extreme, we have anti-psychiatrists who desire the end of psychiatry. At its best, we have therapeutic alliances.