7. The Antiauthoritarian Impulse
The movie One Flew Over the Cuckoo’s Nest, directed by Milos Forman, struck a nerve in American audiences when it was released in 1975. Randle McMurphy, the free-spirited Korean War veteran who feigns a mental disorder to escape a work farm sentence, and Nurse Ratched, the unwavering disciplinarian who supervises the ward to which McMurphy is admitted, quickly became part of popular culture in the United States. The movie won Oscars for Best Picture, Best Director, Best Actor (Jack Nicholson), Best Actress (Louise Fletcher), and Best Screenplay (adapted by Lawrence Hauben and Bo Goldman). It was a critical success and an instant cult classic.
Ken Kesey published his novel One Flew Over the Cuckoo’s Nest in 1962. After volunteering for LSD studies at the Palo Alto V.A., Kesey became a night attendant on the hospital’s psychiatric ward, working midnights to 8 a.m. When he wasn’t mopping the floors or looking in on patients, Kesey sat and talked to people or used the typewriter in the nurse’s station to draft pages of his novel. He perused the psychiatric journals and read about psychotropic drugs. Some nights, he wrote under the influence of LSD, peyote or some other hallucinogen. He even arranged to try electric shock therapy.
Among historians of medicine, Kesey’s novel is remembered as an “anti-psychiatry” manifesto. In his History of Psychiatry, Edward Shorter discusses Cuckoo’s Nest in relation to Szasz’s The Myth of Mental Illness (1960), Foucault’s Madness and Civilization (1961), and Goffman’s Asylums (1961). Similarly, Gerald Grob, the author of numerous books on the history of mental health, situates the novel in relation to other antipsychiatry texts of that era, including Shock Treatment (1964), starring Lauren Bacall, and Frederick Wiseman’s Titicut Follies (1967).
This installment of Reason’s Frontier discusses Kesey’s 1962 novel against the backdrop of contemporaneous developments in postwar psychiatry. It’s worth noting at the outset that Kesey set his story in a mental hospital at a time when state hospitals were receding in importance, particularly in California. Over the previous five years, Short-Doyle programs had been facilitating a decline in the state hospital population. Releases from state hospitals exceeded admissions. While 264 Californians per 100,000 were being hospitalized for mental illness in 1957, only 209 per 100,000 were in 1962. The California Department of Mental Hygiene had just announced a long-range plan to minimize the use of state hospitals. These plans called for therapeutic intervention closer to home, “as early as possible, as continuously as possible.”
The novel’s villain, Nurse Ratched, is a creature of the old and increasingly beleaguered state hospital system, a system that for decades had been criticized by psychiatrists themselves. You might recall how Aaron Rosanoff— the administrator in charge of California’s mental hospitals from 1939 to 1943— had wanted to restrict the flow of patients to those hospitals. They had become, in his words, “physically and mentally unhygienic, esthetically revolting, and altogether intolerable.”
Kesey’s Nurse Ratched is closely identified with the traditional state hospital system. She keeps her unit “running like a smooth, accurate, precision-made machine” and disapproves of “the present permissive philosophy” in psychiatric care. Although views of the state hospital system were rapidly changing in the early 1960s, Ratched lives to administer the tried-and-true policies. Even within the fictional universe of the novel, Ratched is an anomaly. When he is injured in a fistfight, McMurphy meets “a little Jap [sic] nurse” who salves his wounds. Suggesting that Ratched and some of the other nurses were “a little sick themselves,” she reassures McMurphy: “it’s not all like [Ratched’s] ward.”
On his first day McMurphy pegs Ratched as a “ball-cutter,” someone who “tr[ies] to make you weak so they can get you to toe the line.” She actively discourages any sign of independence. Even more, Ratched convinces her patients they are “rabbits” by exploiting their deepest fears, especially their fear of becoming a “Chronic” patient. Mr. Harding, a melodramatic Acute patient, confesses to McMurphy: “We need a good strong wolf like the nurse to teach us our place.” McMurphy later realizes, to his horror, that Harding and most of the other men had been voluntarily admitted to the unit rather than involuntarily committed. “Sure!” stammers Billy Bibbit to McMurphy. “I could go outsider to-today, if I had the guts.” Whereas real-life hospital administrators were actively encouraging Californians to pursue treatment outside the inpatient wards, Ratched continually reminds her charges that “many of [them]” had to be in the hospital because they “could not adjust to the rules of society in the Outside World.”
In contrast to Ratched, Dr. Spivey, the ward psychiatrist, means well but is debilitated by timidity. Like his male patients, Spivey is cowed by the Nurse. Under Ratched’s “dry-ice” stare, all of the “doctors, all ages and types . . . retreat with unnatural chills.” Like Billy Bibbit and the others, Dr. Spivey is a “frightened, desperate, ineffectual little rabbit.” Indeed, Kesey tells us every psychiatrist has failed to stand up to Ratched; Spivey is more a victim of her regime than an accomplice.
In fact, Dr. Spivey attempts to structure the ward as a therapeutic community, “a democratic ward, run completely by the patients and their votes, working toward making worth-while citizens.” Spivey’s ideas are, in fact, entirely mainstream— consistent with postwar trends in inpatient psychiatry . Ratched, however, rejects the “present permissive philosophy” in state hospitals. When McMurphy maneuvers Spivey into proposing a carnival day, complete with games and crepe streamers, Ratched squelches the idea. McMurphy’s antics seem to amuse the mild-mannered doctor; Ratched maintains her composure but entirely disapproves.
It is striking that the novel’s psychiatrist, Dr. Spivey, is one of the least threatening characters in the book— a strange fact about a book considered an anti-psychiatry classic. It’s my view that Cuckoo’s Nest is better understood as an “antiauthoritarian fable” (to quote the novelist and screenwriter Larry McMurtry). Although Kesey criticizes certain aspects of state-hospital psychiatry, he is more concerned with the dynamics of power— and gender— on the hospital ward. The struggle between Nurse Ratched and Randle McMurphy is not about the real-life conflicts between patients and health care providers: it is a symbolic battle between individual freedom and repressive authority.
Over the course of the novel, Nurse Ratched’s most sinister motives are slowly revealed. When McMurphy leads a fistfight against three sadistic aides, Ratched orders up successive rounds of electric shock therapy as a form of punishment. Electric shock therapy had been used in U.S. hospitals since the 1940s to treat major depression, manic-depressive illness, and other severe illnesses. There was, in fact, little opposition to the procedure as late as 1960, apart from L. Ron Hubbard’s Church of Scientology (which would also oppose psychosurgery and psychotropic drugs). By dramatizing electric shock therapy as a punishment for rebelliousness, Kesey’s fictional account incited widespread opposition to the treatment despite its effectiveness. Kesey has Harding, one of the patients, explain to the readers: “Shock treatment has some advantages. . . It simply induces a seizure. . . . [A] number of supposed Irrecoverables were brought back into contact with shock.” One would expect something different from an anti-psychiatry manifesto.
In real life, Harding explains, procedures such as electric shock therapy and lobotomy were used “only in the extreme cases nothing else seems to reach.” (Having worked as an attendant at the Palo Alto V.A., Kesey knew the difference between gravely disabled patients and unruly nonconformists.) But Ratched uses these procedures as “punitive measures.” In the end, Ratched subdues McMurphy with a needless and clearly punitive lobotomy. In 1949, the number of lobotomies performed in the United States during a single year peaked at over 5,000 procedures. The introduction of Thorazine and other drugs in the 1950s hastened lobotomy’s demise. By 1962, when Cuckoo’s Nest was published, lobotomy was far down the path to extinction. Although it is Nurse Ratched who suggests the operation to tame McMurphy’s “aggressive tendencies,” the horrific conclusion to the novel incited popular anger toward the psychiatric profession.
By the 1960s, Californians at both ends of the political spectrum were disputing some of psychiatry’s most fundamental claims. Despite Kesey’s nuanced and often darkly comedic characterizations of Nurse Ratched and Dr. Spivey, many readers of the novel came to see real psychiatrists and nurses as agents of an implacable “system” designed to deprive individuals of their freedom. The liberationist Left believed that the mental health enterprise was oppressive and countersubversive. At the same time, the anticommunist Right knew a Communist conspiracy when it saw one. Some right-wing critics believed the mental health professions were undermining the nation’s moral fabric by instilling subversive values and undermining religion. Others detected “a subtle and diabolical plan of the [Communist] enemy to transform a free and intelligent people into a cringing horde of zombies,” “a regimented nation, brain-washed and brain-fed through a powerful army of psychiatrists.”
When he addressed the American Psychiatric Association in 1963, Al Auerback— who had played an instrumental role in passing California’s Community Mental Health Services Act of 1957— urged his colleagues to see “the nature and extent of this problem.” “The issues at stake,” he said, “no longer permit [we] psychiatrists to remain [politically] uninvolved.”
A note on sources: Complete citations can be found in Justin Suran, "Toward an Illusionless City: The Province of Psychiatry in Twentieth-century San Francisco" (Ph.D. diss., Univ. of California, Berkeley, 2003).