"If He's Crazy What Does That Make You?" The Negative Perception of the Mentally Ill During the Twentieth Century and the Power of the Film One Flew Over the Cuckoo's Nest
by Jordan Carroll
Siena College Honors Thesis
2010
Reader
Date "If He's Crazy What Does That Make You?"; The Negative Perception of the Mentally Ill
During the Twentieth Century and the Power of the Film One Flew Over the Cuckoo's Nest.
Jordan Carroll
Honors Thesis
Dr. Karen Mahar
Dr. Karen Boswell
Dr. Paul Santilli
March 21, 2010 2
In 1975, Fantasy Films released the film adaptation of the popular 1962 Ken Kesey novel, One Flew Over the Cuckoo's Nest. Its tagline asked American citizens a very important question, "If he's crazy, what does that make you?"
That same year, Janet Gotkin sat in front of a Senate subcommittee and gave a testimony of her ten-year stay at several mental institutions, where she was treated for a psychotic break in which she displayed suicidal tendencies during her freshman year of college. The Senate subcommittee was investigating the use of drugs known as neuroleptics in juvenile institutions, jails and homes for the mentally retarded. 1 In his opening statement, subcommittee chairman
Senator Birch Bayh noted that the investigation was based on the idea that drug abuse was not limited to unauthorized use on umuly inmates or patients, but also included the "administration of mind-controlling drugs to unwilling, competent persons and the unnecessary use of these powerful medications on those institutionalized."2 In simpler terms, the employees at these institutions were charged with drugging patients, often daily, in order to control symptoms and behavior they did not want to treat tlu·ough other, therapeutic, but more difficult medical means.
Janet Gotkin was just one of many mental patients who shared their experience with these powerfuldrugs. In her prepared statement, she conceded that her only claim to expertise on the subject was her "experience as a psychiatric guinea pig. "3 She described how medication
"turned me into a fucking invalid, all in the name of mental health":
I became alienated from myself, my thoughts, my life, a stranger in the normal world, a prisoner of drugs and psychiatric mystification, unable to survive anywhere but a psychiatric hospital ... It was so hard to think, the effortwas so great; more often than not I would fallinto a stupor of not caring or I would go to sleep. In eight years I did not read an entire book, a newspaper, or see a whole
1 Robert Whitaker, Mad in America; Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill" (New York; Perseus Books Group, 2002), 177. 2 th st U.S Senate Subcommittee to Investigate Juvenile Delinquency. 94 Congress; I session. 3 th st U.S Senate Subcommittee to Investigate Juvenile Delinquency. 94 Congress; 1 session. 3
movie. I could not focus my blurred eyes to read and I always fell asleep at a film. People's voices came through filtered,strange. They could not penetrate my Thorazine fog; and I could not escape my drug prison ...These drugs are used,not to heal or help, but to torture and control. It is that simple.4
Senator Bayh spoke of the need to eliminate the "chemical straight jacketing of thousands."
Testimony at these hearings indicated that drugs were being administered to the mentally ill not for therapeutic reasons, but instead, in Bayh's words,to "make the custodial job easier." 5 That same year a grand jury investigation of Greystone Park Psychiatric Hospital in Morris County,
New Jersey,found unsupervised patients living in unspeakable filth,doctors with limited English ignoring their rounds, and unscreened employees with criminal records ignoring their duties as
well. It was labeled a "prison without an exit."6 Gotkin's testimony brought to light perhaps the
worst abuse of the mental care system against its patients,and as a result the frequent
administration of mind-altering drugs by psychiatric medical professionals,such as neuroleptics,
was coming to national attention.7
Prior to the 1960s and 1970s,the treatment of the mentally ill,particularly in institutions,
frequently made news. In fact,there are articles from the New York Times that report
overcrowding in East Coast mental institutions as early as 1902. In one particular institution,
over 250 patients were found sleeping in corridors because there were not enough dormitories to
8 accommodate them. Why the sudden spotlight on the plight of the institutionalized mental
patient in 1975? This paper will find that although there was a reformmovement within the
4 Robert Whitaker,Mad in America, 176. 5 U.S Senate Subcommittee to Investigate Juvenile Delinquency. 94th Congress; l st session. 6 Joan Cook,"Grand Jury Finds Abuses of Patients at Greystone," New York Times, May 30, 1975,67. 7 See,for example, coverage of the 1975 Supreme Court ruling in O'Connor v. Donaldson, which won the right of those involuntarily committed to mental hospitals to treatment and not just custodial care, "U.S. Backs Treatment as a Right to Mental Patients," New York Time, January 16, 1975, 10. 8 "Many Insane in Bay State," New York Times, December 15, 1902. 4
fieldof psychiatry, the civil rights movement also had a positive effecton the lives of mental
patients. And although the majority of reform efforts inspired by the civil rights movement had
already peaked, concern over the treatment of the mentally ill was just gaining ground in 1975.
However, the I 970's were a pivotal decade for the rights of the mentally ill and One Flew Over
the Cuckoo's Nest was an example of this concern, but it was hardly the only manifestation of
this movement. The state of institutionalized mental health care created steady headlines in that
decade, mostly due to lawsuits filed on behalf of the mentally ill. Although there was a reform
movement within the psychiatric field that predated the 1962 publication of Ken Kesey's novel
One Flew Over the Cuckoo's Nest, and which criticized the worst abuses within institutionalized
mental health care, this paper concludes that it was unlikely that the internalreform movement,
by itself, would have been successful without public exposure of these practices in the form of
newspaper headlines and Cuckoo's Nest. With the film and the civil rights movement occurring
together and reflectingthe spirit of the times, and also the strides made as a result of the internal
reform movement of the mid I 950's, the mentally ill gained rights they did not previously have.
In 1971, New York Times reporter John Sibley covered a symposium in which
psychiatrists argued that the fundamental right of a mental patient ought to be the "right not to be
9 a mental patient." The panelists in attendance at the symposium agreed that all too often
patients are "railroaded" into state-funded hospitals against their will and usually at the request
of their families. Families that had to care for mentally ill family members often felt overwhelmed and burdened and were unsure how to care fortheir loved ones. Many family caretakers viewed these institutions as the only acceptable placement forthe apparently mentally ill. Dr. Gurston D. Goldin stated that his fellowpsychiatrists would regularly diagnose a patient
9 John Sibley, "Mental Patients Held Vulnerable; Their Rights Are Demanded at Conference Here," New York Times (March 28, 1971), 29. 5 with a psychiatric abnormality when in reality the problem was "unmet social needs," that today might be called an emotional disability, treatment for which was better suited to a social worker.
Furthermore, panelists pointed out the ineptitude of some professionals to correctly diagnose patients and feltthat overcrowding in mental institutions was a result. Dr. Alan D. Miller, the
State Commissioner forMental Hygiene, had slightly improved the situation by mandating that patients be admitted to mental hospitals "only if they showed definite symptoms of mental illness." 10
Perhaps the most devastating effect of the placement of individuals into these institutions was the custodial care they received. The men and women treated at these facilities were rarely seen by doctors, and as the duration of their stay increased, the practices of the institutions wore down their ability to resist unwanted treatment, causing a blatant abuse of their civil rights. At the time Sibley's article was written, New York law allowed emergency commitments to a mental hospital against an individual's will forup to 30 days. The basis for this stay could be an unsworn allegation of a family member.
In some instances, for example at Greystone Park Psychiatric Hospital in New Jersey, the care the mentally ill received could not even be definedas custodial; a 40 page report uncovered the deplorable conditions of the entire facility, as well as conditions that were considered to be even worse in the "closed" wards where the more disturbed and regressed patients were treated. 11
Patients were leftunsupervised with no treatment for theirillnesses , bathroom floors were covered with dirt, urine and human excrement, and in some wards only one cup was given for all patients to drink water from. The conditions were classified as "antitherapeutic" and sent the message that the patients being housed there were no better than animals - less than human.
IO Ibid. 11 Joan Cook, "Grand Jury Finds Abuses of Patients at Greystone," 67. 6
Donald G. Collester, the prosecutor in Morris, New Jersey, that conducted the investigation, stated that the purpose of making the grand jury's findings public was to heighten public awareness of the conditions in the hospital. Despite all of the evidence, including over 40 separate allegations of patient abuse, no indictments were administered because the allegations were assault charges that would amount to a $500 fineor six months in jail.12
Janet Gotkin' s testimony brought to light perhaps the worst abuse of the mental care system against its patients, and as a result the frequent administration of mind-altering drugs by psychiatric medical professionals, such as neuroleptics, was coming to national attention. 13 An internal reform movement within the fieldof psychiatry had already occurred in the mid 1950's when new drugs that made it possible forpatients to leave mental institutions and receive community care. But, the Senate hearings and One Flew Over the Cuckoo's Nest were public events that made similar observations about the treatment of the mentally ill within institutions.
Most Americans, it seems safe to say, were not following the Senate hearings on institutionalized care. Many, and perhaps even most, adult Americans, however, either saw or knew about One
Flew Over the Cuckoo's Nest, which hit the screen in November I 975, and won Oscars for Best
Picture, Best Director, Best Screenplay, Best Actor, and Best Actress in 1976. 14 Although other films released during the 1970's, such as Klute (1971) and An Unmarried Woman (1978), expressed negative views of psychiatry, it was the powerful images of One Flew Over the
Cuckoo's Nest that suggested the institutional treatment of the mentally ill was abusive. More
12 Ibid. 13 See, for example, coverage of the 1975 Supreme Court ruling in O'Connor v. Donaldson, which won the right of those involuntarily committed to mental hospitals to treatment and not just custodial care, "U.S. Backs Treatment as a Right to Mental Patients," New York Times, January 16, 1975, IO. 14 Bryan P. Stone, Faith and Film,· Theological Themes at the Cinema (St. Louis: Chalice Press, 2000), 95. 7 than the Senate hearings, the setting and characters of this award-laden film were what most
Americans were likely to think of when they considered the quandary of the mentally ill.
One Flew Over the Cuckoo's Nest is still considered to be one of the greatest accomplishments in American film. It presides at number twenty on the American Film
Institute's "100 Best of 100 Years," and is only the second film to sweep all five of the notable
Oscar awards.15 First staged as a Broadway play in 1963, with Kirk Douglas in the lead, the
1975 filmstars Jack Nicholson as Randle P. McMurphy, a convicted rapist who believes he can
get out of prison by pretending to have a mental disability. 16 Although Nicholson seems to be a
mischievous character by nature, with his dark grin and sinister facial features,ultimately in this
rendition of Kesey's novel, Nicholson develops into a Christ-like character who attempts to
overcome an oppressive system that dominates all the patients in the mental institution. As
McMurphy, Nicholson escapes from prison, knowing he will be caught and sent to a mental
hospital, which he believes will offer a more easily manipulated environment and thus an earlier
release. But he soon discovers just how difficult it will be to convince the staffthat he is
mentally well and ready to be released. In fact, it seems likely that he will be held for a period
much longer than his prison sentence, perhaps forever. This reflected a reality. In 1971, the
Supreme Court agreed to consider the legality of the "indefinite incarceration of compulsive
lawbreakers" at a mental institution in Maryland. This review was inspired not by the
psychiatric reform movement, but by civil libertarians, who argued that the definition of mental
illness was "vague," and that the right against self-incrimination was violated by forced
psychotherapy. According to the New York Times, the context was the "controversy over the
Soviet Union's sending of dissenting intellectuals to mental hospitals." The defendant had been
15 Academy Awards Winners and History. http://www.filmsite.org/oscars70.html 16 Bill Davidson, "The Conquering Anti-Hero," New York Times (12 October 1975), 267. 8
held for a period longer than his original sentence, thus the question was whether this constituted
"cruel and unusual punishment" in violation of the Constitution.17 The court ruled in favor of the
mental patient in the summer of 1972, stating that Maryland had no right to confine him any
further.18
In One Flew Over the Cuckoo's Next, McMurphy, discovers he had made a grievous
error: not only is he indefinitely incarcerated, he, like all the other patients, is given medication
and procedures that will undoubtedly cloud his thinking and prevent him from ever appearing
mentally competent. He may be trapped forever in a mental asylum run by a number of nurses,
most notably Nurse Ratched, who is consistently critical of McMurphy's disruptive behavior,
which appears to her to be proof that he is a continuing danger to society.
Nurse Ratched is played by Louise Fletcher. In a Rolling Stone interview published
before the premiere of the movie, Fletcher stated that she portrayed the role differently that it
was played during its run on Broadway, where her character was an "intractable tyrant" who
does whatever she can to maintain control over every aspect of the patients' lives in the hospital.
In the film, Fletcher's Nurse Ratched "smiles and greets patients and really believes her methods
are good ones." 19 While McMurphy himself is not actually mentally ill, the other patients in the
hospital that interact with McMurphy suffer from a wide range of mental illnesses, spaiming fromautism to schizophrenia. Although he later finds out that nearly all of his fellow patients are being held voluntarily, while he is not, McMurphy recognizes that the voluntary patients are emotionally and medically manipulated by Nurse Ratched, who convinces them that they must remain in the hospital. Thus they are all held against their will, and McMurphy tries to convince
17 "Court to Review Crime 'Patients,"' New York Times, December 21, 1971, 24. 18 McNeil V Director, Patuxent Institution, 407 U.S. 245 (1972). 19 Tim Cahill, "Jack Nicholson; Knocking Round the Nest," Rolling Stone, December 4, 1975. 9 his fellow patients to fightthe emotional and medical domination that is brought upon them by
Ratched. Among McMurphy's friends are the Chief, a massive Native American that pretends to be deaf and mute forthe bulk of the film, Martini, a grown man with the mental capacity of an elementary school student, Billy Bibbit, an extremely shy and impressionable stutterer with a complex about his mother, Cheswick, a restless neurotic that is frequently brought to tears, and
finally Harding, a man who claims to be the most sane and rational out of all the patients. There are also a number of characters in the filmthat are known as the "chronics;" these men have no
communication skills (they do not even participate in the group therapy that the others are forced
to engage in), and simply meander around the asylum. Some of these characters were actually
patients in the mental institution in Oregon where the movie was filmed.20 Jack Nicholson's
McMurphy is significant because he is the only patient in the filmwith any real agency, making
Ratched label him as a troublemaker looking to disobey the rules of the hospital and also
persuade the other patients to do so as well.
The conflict between the strong personalities of McMurphy and Ratched are almost
immediately evident to the viewer. The clash starts with simple disagreements and mind games,
most of which Nurse Ratched wins. However the disagreements soon become more serious. By
the end of the film, the interaction between the two essential characters transcends into a battle
between good and evil, and freedom versus domination.
In one memorable scene, McMurphy suggests during the patients' daily group therapy
meeting that the work schedule be revised so that the men will be able to watch the first game of
the World Series that is airing the next day. Ratched, in an effort to humiliate the protagonist in
front of his peers, holds a vote in which she influencesthe other patients to not vote along with
20 Bryan P. Stone, Faith and Film; Theological Themes at the Cinema, 96. 10
McMurphy. The vote is tied and McMurphy's only hope lies in the hands of one of the
"chronics." When none of the "chronics" raise their hands to vote, Ratched dismisses the meeting, feeling very satisfied that she overruled McMurphy. The next day during group therapy
McMurphy convinces Ratched to hold another vote. The count is still nine to nine, and the possibility of viewing the World Series once again lies in the hands of one of the chronics. After a series of attempts, McMurphy finally convinces the Chief to raise his hand, although it is still unclear to the viewer if he knows what he is actually voting for. When McMurphy contentedly points out to Ratched that the Chief has raised his hand and voted forthe schedule change, she
states that it was too late, since the vote was cast after group therapy had concluded for the day.
While it might seem like Ratched had won, McMurphy rallies the other patients and makes up a
play-by-play of an imaginary baseball game:
Koufax... Koufax kicks. He delivers. It's up in the middle! It's a base hit! Richardson is rounding first. He's going for second. The ball's into deep right center. David cuts the ball off! Here comes the throw. He throws it to second! He slides! He's in there! He's safe! It's a double! Richardson's on second base! Koufax looks down, he's looking at the great Mickey Mantle now! Here comes the pitch! Mantle swings! It's a fucking home run! 21
McMurphy's commentary is followedby a vociferousroar from all of the other men in the ward
and then by a sharp camera angle to Ratched, who is watching with contempt from the sanctuary
of her nurse's station.
One Flew Over the Cuckoo's Nest is ultimately about the inner workings of the
oppressive system that Ratched upholds in the mental institution. While the film depicts doctors
and other medical workers walking through the halls, Ratched always seems to be in the
background making important decisions that affect the patients; she is the sole symbol of power
21 One Flew Over the Cuckoo's Nest, DVD, directed by Milos Forman (1975; Fantasy Films, 2000). 11
and supremacy in the film. Despite the hierarchy that most hospitals share, it seems as though
the nurses and doctors are simply following the protocol she implements, as she is the one with
the highest degree of authority who has the most hours of contact with the patients, and leads the
therapy groups.
In the film McMurphy is depicted as the Christ-like figure and there are specific areas of
the hospital that have religious symbolism. McMurphy takes the other patients under his wing in
an attempt to free them fromwhat he feelsare unfair and desperate conditions. As he becomes
closer with his fellow patients he tries multiple times to liberate them at his own cost. Similar to
other Christ-like figuresin literature and film, McMurphy holds a superior status than that of the
rest of the group. He also strives to change the routines of the mental institution and ultimately
suffers for his attempts at the hands of an oppressive leader, Nurse Ratched. Although
McMurphy is unable to save himself in the end, he does leave a powerful impression on the
Chief, which results in his escape from the mental institution. With regard to other religious
symbolism, one of the most important areas in the filmis the nurses' station which is located in
the same room as the common area where the patients spend the bulk of their time, either playing
cards or in group therapy. This office is the axis of power and control in a mental institution full
of chaotic patients, with McMurphy as their ringleader. It is from the nurse's station that all
rules and regulations are announced via a public address system; it is where medicine is handed
22 out, and where negotiable possessions such as cigarettes are held. This area is the most sacred
of all; in one scene a patient even sticks out his tongue to receive his medication, much like one 2 would do to receive Holy Communion during Mass. 3 This is perhaps a reflection of the
heretofore unquestioned authority of Nurse Ratched. Nurse Ratched is number five on the
22 Bryan P. Stone, Faith and Film,· Theological Themes at the Cinema, 99. 23 Ibid. 12
American Film Institute's "Top 25 Villain's" list, proving that she is a frighteningcharacter for any viewer, not just individuals that suffer frommental illnesses. She was a vindictive and evil character who knew the vulnerabilities of her patients and used them to her advantage when she could.
Although we have no exit survey of viewers to demonstrate the connection they made between the film and the state of mental health hospitals, One Flew Over the Cuckoo's Nest was released during a decade when the conflicted state of mental health care in institutionalized settings was already creating headlines.
While it is true that the condition of asylums and other headlines pertaining to the mentally ill fillednewspapers across the nation, the stigma that went along with actually having a mental disability was also well known. Mental illness was associated with a certain degree of disgrace, and more often than not led to secrecy and denial among those af11ictedand their family members. Even the Kennedys, a presidential family that is considered by some to be
American royalty, hid the diagnosis of JFK's sibling, Rosemary, in what was considered by formerdirector of the National Institute of Mental Health, Dr. Bertram Brown, to be the,
"biggest mental health cover-up in history."24 Twenty years after Rosemary Kennedy received a lobotomy that would render her unable to communicate, her striking and extremely successful brother entered the White House with what seemed like the perfect American family; a beautiful young wife, two gorgeous children and a train of photogenic, thriving siblings, some of whom would attempt to follow in his footsteps. In the midst of all this fame, it is not surprising that there was no mention of Rosemary, JFK's younger sister by only sixteen months. From an early age it became evident that she had certain mental deficiencies that perhaps could be dealt with
24 Annette Witheridge, "The Lost Kennedy," Daily Mail, August 15, 2009, 30. 13
more easily today; however during this era anyone considered to be "slow" was labeled mentally
retarded. In a familythat prided itself on perfection, Rosemary was an embarrassment.25
Even more than her condition, Rosemary's fate would not only be hidden from he public,
but also fromsome of her closest relatives, most notably her mother. As Rosemary aged into her
twenties and became a beautiful young woman, Lawrence Learner, a biographer for the Kennedy
family, explained that there was a fear of "pregnancy, disease and disgrace." It was at this point
that Joseph Kennedy Sr. took matters into his own hands and arranged for his daughter to meet
with two physicians who claimed they could help. In 1941, Walter Freeman, a respected
physician and neuroscientist of the era, stated, "It has been said that if we don't think correctly, it
is because we haven't 'brains enough.' Maybe it will be shown that a mentally ill patient can think more clearly and constructively with less brain in actual operation."26 Based on this statement, it is not surprising that Dr. Freeman would perform thousands of lobotomies by the end of his career.
Dr. Freeman and his assistant Dr. Watts explained a procedure that promised to stabilize
Rosemary's mood swings, and claimed that the only noticeable side effect would be a shaved head. The surgical lobotomy was a groundbreaking procedure in which the neural connection between the prefrontal cortex and the thalamus were severed. Dr. Freeman and Dr. Watts performed thousands of lobotomies during the l 940's and 1950's and boasted that the treatment would dramatically alter the mood and behavior of mentally ill patients.
Joseph Kennedy scheduled the procedure to be done and did not inform his wifeor
Rosemary's eight brothers and sisters about her operation until it was over. Years after the
25 Ibid. 26 Walter Freeman, "Brain-Damaging Theraputics," Disease of the Nervous System 2. (1940) 83. 14 surgery was performed, Dr. Watts recalled, "We went though the top of the head. I think she was awake. She had a mild tranquilizer. I made a surgical incision in the brain through the skull. It was near the front. It was on both sides. We just made a small incision, no more than an inch. "27 While Dr. Watts was doing the cutting, Dr. Freeman took notes on the procedure, asking Rosemary to recite the Lord's Prayer and count backwards, all the while making estimates on how far to cut into her frontal lobe based on how quickly and accurately she responded. The lobotomy ended when Rosemary became incoherent.
Rosemary was cured of her mood swings. However, from that day on she was completely taciturn and disjointed, unable to maintain her own bodily functions, wash, dress or even communicate clearly. Shortly after the procedure Rosemary was sent to live in Jefferson,
Wisconsin at St. Coletta's Institute for Backward Children, with only her mother Rose, and her younger sister Eunice to visit her. By today's medical standards, the lobotomies performed by
Freeman and Watts are considered medical malpractice; however, during the 1940's and 1950's the procedure was applauded by magazines like Time and multiple newspapers, including the
New York Times. Freeman and Watts were able to hide the fact that they were not getting their desired results. They claimed that the surgical lobotomy was a medical cure that would result in
the mentally disabled becoming functionalmen and women without psychiatric symptoms. The
reality was that Freeman and Watts hid the tragic results of their procedure and misled lay people
with their exaggerated positive results. While this procedure was meant to alleviate the suffering
of a profoundly ill person, the fact that the results were skewed to obtain a more positive view of
their new procedure cannot be overlooked.
27 Ibid. 15
Similar to Rosemary, individuals with physical and mental disabilities prior to 1970 were discriminated against; unable to join teams, clubs, or organizations, and often overlooked by the public education system. Despite continued efforts by professionals in the medical field, activists, and reporters who covered important events and in some cases even the relatives of the mentally disabled, one way or another it seemed that the demand for a better treatment system for the mentally ill continually fell on deaf ears. However, among the multiple lurid headlines that negatively affected the American public's thoughts about the existence of the mentally ill were moments of hope, when psychiatric pioneers and other individuals, including judges and politicians, campaigned for better treatment, facilities, and laws protecting the mentally ill and developmentally disabled.
During the 1960's, laws protecting the mentally ill were largely unsuccessful because they were not always carried out. Judge Justine Wise Polier recalled that in the New York state family court system, child psychiatrists made her hearings more complicated and costly with multiple diagnostic evaluations and tests, however it was rare that a treatment plan was enacted after testing.28 The changes that developed over the next fewyears did not spark from the failure of mental institutions or fromjudges like Justine Wise Polier, who were critical of the system.
Instead, change was put in motion by activists of the civil rights movement that eventually turned their attention toward the mentally ill.
Audiences viewing the film in 197 5 would have brought with them the backdrop of the countercultural movement, which would seem like an obvious context for a filmin which a clear-sighted individual is dropped into an escape-proof system created by "the establishment" to keep troublemakers quiet. Vincent Canby, a film reviewer for the New York Times, found the
28 Alan A. Stone, Mental Health and the Law; The Facts and the Future, http://americanmentalhealthfoundation.org/a. php?id=69. 16 acting in the film by both Jack Nicholson and Louise Fletcher to be more convincing than the parallels drawn fromthe movement of the 1960's to the film. He wrote, "The connection does not work well. All it does is conveniently distract us from questioning the accuracy of the film's picture of life in a mental institution where shock treatments are dispensed like aspirins."29 The content of the film would cause filmgoers to question the integrity of the mental health system, and of the professionals who worked closely with patients. In fact, it fits more closely to the civil rights movement than to the internal reform movement within the field of psychiatry that already begun. Once these civil libertarians achieved legal victories over racism, others sought to attain constitutional rights, including equal protection and due process, forthe mentally disabled. It is in this way that the reform of mental hospitals in the 1970's grew out of the much larger civil rights movement that was also predated by an internal reform movement within the psychiatric profession. The internal reformmovement that started in the mid 1950's helped to close down mental institutions, both federal and non-federal that gave custodial care to their patients.
At the start of the l 970's, supporters of the reform in mental hospitals were making tremendous strides. In 1972, after a 19-month long case in Alabama, Federal district judge Frank
M. Johnson ruled for the first time that persons deprived of their liberty and committed to institutions because they were mentally ill or mentally retarded had a constitutional right to adequate treatment.30 Judge Johnson stated that he planned to establish and implement standards that were designed to enforce three conditions: "a human psychological and physical environment, qualified staff in numbers sufficient to administer adequate treatment and
29 Vincent Canby, "One Flew Over the Cuckoo's Nest," New York Times, November 20, 1975. 30 Boyce Rensberger, "Impending Ruling by U.S Judge Promises Hope for the Neglected in Mental Institutions," New York Times, March 26, 1972. 17
31 individualized treatment plans." Furthermore, Judge Johnson felt that long-term hospitalization led to deterioration rather than improvement in the patient's quality of life,so his final ruling also included a provision that no patient could be confined against his or her will fora period longer than six months.32 Although the suit only involved two state hospitals and one state school in Alabama, several national mental health and legal organizations were prompted to filesimilar suits in other states: one against a school for the mentally retarded in Massachusetts and another
33 against Willowbrook State School in New York.
In 1975,just three years after the case in Alabama, the Supreme Court came to a unanimous decision that mental patients who were not dangerous to others could not be confined in institutions against their will ifthey did not receive therapy or if they could survive outside of an institution with the help ofrelatives or friends.34 The verdict was controversial to say the least. The president of the American Psychiatric Association,Dr. Judd Marmor, released a statement saying that his group was disappointed that the court had not ruled on mentally ill patients' right to treatment:
It was a decision of freedom,not on the right to treatment. We are concernedthat if those patients [who are released under the Supreme Court ruling] still need treatment, there should be some mechanism to see that they get it ... to let them wander out into society like derelicts is not right. Treatment should be provided within the context of freedom, such as in half-way houses or outpatient facilities. If they need treatment, we feel that they should have the right to it.35
While Dr. Marmor was upset and confused by the ruling, the director ofthe National
Institute of Mental Health, Dr. Bertram S. Brown, applauded the Supreme Court's decision. He
31 Ibid. 32 Ibid. 33 Ibid. 34 Lawrence K. Altman, "Experts Raise Questions Over Ruling on Mentally Ill," New York Times, June 28, 1975, 15. 35 Ibid. 18 recognized that the judgment would enact major changes in the mental health care system in the
United States, however he felt these changes were necessary. He asserted that the ruling would,
"give strong impetus to the movement away from treatment in large institutions, which too often may become merely custodial confinement."36 Instead, he feltthat whenever possible, patients should be treated within their own community. Although headlines in the various newspapers during these cases did promote the idea of positive change for the mentally ill, many of them also had negative undertones about the patients that were being released.
In 1979, Robert Michels stated "thirty years ago, 75% of all psychiatric treatment was conducted in hospitals. Today 75% takes place in an outpatient setting. That's progress."37
However, at this time the percent of hospital beds occupied by psychiatric patients in the United
States was 40%, and the number of patients that were cared for in nursing homes, prisons or other locations was rising. These statistics caused John Talbott, an employee at Payne Whitney
Psychiatric Clinic to say "we have merely shifted the mentally ill population, not decreased it."38
The community health movement that freed thousands of mentally ill patients was popular among many doctors and psychiatrists, but it was largely unpopular with citizens because there were simply not enough community health facilities to accommodate patients that were released.
Patients that did not have community health care or did not seek to get it enter the streets, often annoying and scaring community members. Thousands of deinstitutionalized patients in
Manhattan's Upper West Side finally got the attention of the community and Manhattan
36 Ibid. 37 "Psychiatry on the Couch." Time, April 2, 1979. 38 Ibid. 19 councilman and liberal reformer Antonio Oliveiri. He stated "the indiscriminate dumping of
39 mental patients is creating new psychiatric ghettos in the cites. The policy is absurd."
Previous to the cases that gave more freedom to the mentally ill, citizens and medical professionals saw a need forreform in mental health care. At the same time that One Flew Over the Cuckoo's Nest was being written, Melvin J. Maas wrote a letter to the editor of the New York
Times in which he reiterated the words of Albert Deutsch, "The time for talking has ended. The
40 time for doing has arrived." Deutsch made this statement at an annual meeting of the
President's Committee on Employment of the Physically Handicapped in Washington. With these words Deutsch insisted that there should be a program to fight discrimination in employment for any man or woman with a history of mental illness.
Promoting the idea that the mentally disabled, which includes the mentally ill and developmentally disabled, should be able to apply, interview and accept a job is all well and good; however, even today, of all disabled men and women between the ages of 16-64, only
60.1 % of disabled men and 55.8% of disabled women are employed.41 Furthermore, when questioned by the United States Department of Labor, more than half of the non-working adults stated that they encountered difficulties finding employment. Fifty-two percent of disabled
Americans who were questioned answered that they felt that there were no appropriate jobs
42 available forthem. It is possible that the reason for such low employment rates and opportunities forthe disabled is partially a result of the American public's confusion about what it actually means to have a mental disability or illness.
39 Ibid. 40 Melvin J. Maas, "To Aid Mentally Handicapped," New York Times, June 23, 1961, 28. 41 United States Department of Labor, Statistics About People with Disabilities and Employment, 42http://www.dol.gov/odep/archives/ek01/stats.htm. Ibid. 20
What the public and mental health professionals know about mental disabilities and illnesses has changed drastically over time. Perhaps the most difficult mental illness to diagnose and treat is schizophrenia. In the earlier decades of the 20th century, many of the individuals that were confined to mental institutions were diagnosed as schizophrenics, and given only occasional dosages of medication, or even worse, were treated no better than experimental guinea pigs. In a New York Times report in 1986, Dr. Shervert H. Frazier, the director of the
National Institute of Mental Health, stated that schizophrenia is "possibly the most complex puzzle in biomedicine," since its cause is unknown and the symptoms and progression are completely unpredictable frompatient to patient. What has been confirmed however, in a 1984 report fromthe National Institute of Mental Health, is that, "while schizophrenia is by no means the most common mental illness, it is probably the most costly and devastating in terms of human suffering." 43
Schizophrenia has been classified as a disease that produces symptoms so irregular and bizarre that doctors and ordinary citizens alike are perplexed and often scared of those suffering from the illness. The idea that the disease indicates a split personality is incorrect; etymologically, the term means a schism or a shattering of the mind, however the schism is often evident, according to Dr. David J. Robinson, as a mismatch between a person's thoughts and emotions, or emotions and behavior. The illness is characterized in the medical field as a syndrome that is actually a group of illnesses that share common signs and symptoms. 44 Patients regularly have hallucinations, delusions, speech and behavioral abnormalities and negative symptoms. Hallucinations are perceptions that are experienced when no actual stimulus is
43 Ibid. 44 Dr. David J. Robinson, Reel Psychiatry,· Movie Portrayals of Psychiatric Conditions (Michigan: Rapid Psychler Press, 2003), 22. 21
present, and while the most common types are auditory or visual, hallucinations can occur in all
senses. A misperception of an existing, or a false interpretation of data is known as an illusion.45
Delusions are false beliefs that are fixedin the mind of the patient despite the obvious proof from
outside sources that the delusion is false. It is important to note that delusions experienced by
schizophrenics are not caused by any other identifiable illness or retardation, nor are they caused by substance abuse of any type of cultural factor; they are simply caused by the disease. Speech irregularity that schizophrenics experience may include not being able to connect thoughts, or simply making up words, while behavioral abnormalities include anything from bizarre to vacant, aimless activity. 46
In some instances schizophrenics think they are having a conversation with someone that is not there, or that may not actually exist at all, while at other times they are totally absent, showing no feeling or emotion and speaking in a monotone voice with a void facial expression, unaware of the world around them. What is the most difficult perhaps is the fact that it is not uncommon for schizophrenics to experience these wild symptoms at one point in time, and very shortly afterto show no signs of mental illness at all. The essential factor that determined the type of care schizophrenics would receive remained in the hands of the medical professionals that oversaw them, and the nature of the symptoms patients presented. While it is true that some of the drug treatments used at this time seemed to border on cruel and unusual punishment, most specifically in Janet Gotkin's case, other new medications developed during the 20th century had therapeutic effects that allowed schizophrenics to come closer to reality.
Despite the increase in literature available to Americans through newspapers and magazine articles, the disillusionment with psychiatry started long before members of the
45 Ibid. 46 Ibid. 22
American public began reading about the conditions in asylums and speaking out against the treatment of the mentally ill. In fact, although the main impetus for change in the mental care system came from activists in the civil rights movement, the second most notable catalyst came from the anti-psychiatry movement. In 1959 when One Flew Over the Cuckoo's Nest was first written (it was published three years later) and Randle P. McMurphy was brought to lifeby Ken
Kesey, many authors and doctors suppo1ied an anti-psychiatry sentiment. Dr. R. D. Laing was a
Scottish psychiatrist who was born in 1927 and died in 1989. He was a renegade who broke all the traditional views about psychotherapy that psychiatrists ought to have. Instead, he sought new treatments formental illnesses, most notably schizophrenia, and was largely concerned with the thoughts and feelingsof his patients. In fact, he feltthat experiencing the side effects of schizophrenia could be a positive experience forpatients, he even went so faras to describe the disease as a sort of psychedelic epiphany that was farsuperior to normal experience.47 Dr. Laing was considered unorthodox by the majority of his medical colleagues; he actually believed that his patient's insanity might be "a sane reaction to an insane world."48
Although Laing authored many articles and books about madness, it was his firstbook,
The Divided Se([, published in 1960, that classified him as a rebel within the medical field. After the book's publication he became the leader of the British anti-psychiatry movement that quickly made its way to the United States. Perhaps his most unconventional position was his declaration that the thought process of schizophrenics was comprehensive and even superior to that of mentally "healthy" men and women. Near the end of his career in the 1980's, he rejected his earlier hypotheses and admitted that many of his methods for treating schizophrenics were
47 "Psychiatry on the Couch," Time, April 2, 1979. 48 John T. McQuinston, "R.D. Laing; Rebel and Pioneer on Schizophrenia is Dead at 61," New York Times, August 24, 1989, D21. 23 unsuccessful. What is refreshingabout Laing however is that he did not attempt to defend the incorrect ideas he promoted during the earlier part of his career; he simply stated that society had to do something with the people that were "too disruptive."49 Furthermore,like so many doctors and psychiatrists that came after him, Laing felt that treatment plans such as administering large dosages of drugs, lobotomies, insulin induced comas, electroshock therapy and the use of straitjackets should not have been permitted by the medical system. He maintained these beliefs throughout the whole of his career,despite the fact that some negative practices, like the lobotomy, insulin shock therapy and electroshock therapy to treat schizoplu·enia had been abandoned by the medical fieldwhile he was still practicing.
Another supporter of the anti-psychiatry movement and an individual that had a great influence on psychiatry and law during the 1960's was Dr. Thomas Szasz, author of the book
The Myth of Mental Illness. He felt that psychiatry was a dangerous and oppressive field of medicine, and he was concerned with the unparalleled and incredible violations of the civil rights of the insane.50 Similar to Laing, Szasz believed that mental patients should have been given the freedom to withdraw completely from the world of facts and allowed to escape into the world of their fantasies,which they created. He had a deep compassion forthe mentally disturbed and as a result he was constantly criticizing and attacking physicians and psychiatrists. Szasz reasoned,
The tragedy of modern 'scientific' medicine is that what physicians have gained in competence they have lost in compassion. Formerly physicians could cure little and hence had to comfortmuch ...today physicians can cure more and hence want to comfort less ...the moral: so long as physicians and patients persist in confusing the two main justifications of medical treatment,namely the existence of disease and the expectation of a cure, the delivery of even the most technically competent medical care will remain personally unsatisfactory forboth patient and physician.51
49 Ibid. 50 Alan A. Stone, Mental Health and the Law,· The Facts and the Future. 51 Bruno Bettelheim, "If Insanity Exists It Is Saner Than Sanity; The Facts of Life," New York Times, May 30, 1976, 158. 24
With the aid of men like R.D Laing and Thomas Szasz, the 1960's ended with both state legislatures and federal judges questioning the authority of psychiatrists and the mental hospitals in which they worked. At this time there were a slew of cases that all dealt with the violation of liberty and sovereignty of various men and women that were pegged as mentally ill. What made these cases even more successful was the use of the class action suit; lawyers that interviewed a small number of mental patients would claim to speak for the constitutional rights of all the patients in a particular facilitythat received the same custodial care. Many of these suits called for constitutional rights formental patients and also demanded an increase in state fundsand resources that went to mental hospitals. By the end of the 1970's these class action suits had been extremely successful in quite a few states, like New York, Massachusetts and Alabama.
Moreover, other states were compelled to alter their mental care system under the threat of a suit coming against them. 52
When dealing with the topic of neuroleptic drugs, which are anti psychotic tranquilizers used in the medical field; whether the drugs were more helpful than harmful depended on the way in which they were administered to mental patients. While it is certainly an overgeneralization to write all mental institutions off as corrupt establishments run by crooked doctors and nurses, like Nurse Ratched, the custodial care provided by some facilitiesmust be
addressed. For centuries the mentally ill have been treated with different types of medications and procedures that were meant to have therapeutic effects. In the 1920' s narcosis therapy was
popular, followed by insulin shock therapy and convulsive therapy in the early 1930's which
ultimately paved the way forelectroshock therapy. Even in the 1940's when Dr. Walter
Freeman pioneered the first surgical lobotomy in the United States, and continuing into the
52 Alan A. Stone, Mental Health and the Law; The Facts and the Future. 25 pivotal decade of the 1970's, the psychiatric world continued to see a whirlwind of new drugs, procedures and treatments, some considered to be controversial, others, ingenious.
In order to understand the treatment that characterized custodial care it is necessary to investigate the medical treatments and procedures that were performed on patients. As previously stated, it is how these drugs were administered that the conclusion can be made as to whether the drugs were helpful or hannful. With that being said, there are ce1iainly procedures that were clearly unsuccessfuland abusive in nature; however, it is also true that ce1iain types of drug therapy and other procedures could have potentially improved the quality of life for mental patients if and only if they were not administered abusively. The surgical lobotomy was viewed as innovative during the 1940's and 1950's, however later research uncovered the devastating effects this procedure had on patients' lives.
After Dr. Freeman performed his first lobotomies with Dr. Watts, a young neurosurgeon whom he recruited, Freeman wasted no time in publishing the positive results of the procedure.
The two doctors reported that the operation relieved emotional distress, and that any intellectual loss was minimal or not detected at all. They also stated that patients reported enjoying events outside of the home more, their memory was intact, concentration improved and mood swings had diminished significantly. 53 So what then makes the prefrontal lobotomy fallinto the category of harmful? It would seem that there was a significant amount of information missing from the reports written by medical professionals. Multiple previously untold patient stories have surfaced that describe the various stages of change after a lobotomy. 54
For the firstfew weeks afterthe procedure patients rarely left their beds. In fact they were so motionless that nurses were told to keep turning them so that they would not develop
53 Ibid 122. 54 Ibid 121. 26 bedsores. The operation has been described as "surgically induced childhood" because middle aged patients would be given coloring books, dolls and teddy bears to occupy their feeble minds afterwards. About 25% of Freeman and Watt's patients never progressed beyond this stage of recovery, and just like Rosemary Kennedy, had to remain institutionalized forthe rest of their lives.55 The medical journals did not publish information about the majority of their patients that were able to return home and the side effects they experienced as a result of the lobotomy, the reports simply stated that the patients were released from the hospital. Family members became more like nurses and had to dress, undress and bath the patient daily, and in many cases they would continue to do this foryears. Freeman and Watts wrote that about 25% of patients could be "considered as adjusting at the level of a domestic invalid or a household pet," however; this was not to be viewed as a bad outcome. 56
The prefrontal lobotomy was clearly profound when it was first performed, in 1936; even the New York Times praised, "the new operation marked a turning point of procedure in treating mental cases" and asserted that Freeman and Watt's research would "go down in medical history as another shining example of therapeutic courage." This procedure is particularly relevant to the film One Flew Over the Cuckoo's Nest because in the final scenes it is revealed that followinga party that he throws in the mental hospital, McMurphy has been lobotomized, on orders given by Nurse Ratched. The alleged therapy McMurphy received as a result of his disruptive behavior in the mental hospital was a lobotomy, however it is important to note that he was not receiving custodial care. He and his fellowpatients regularly received therapy that was ostensibly to help them get healthy and to improve their quality of life. Throughout the film viewers would have seen the setting of the hospital, and in particular the recreational room,
55 Ibid 123. 56 Ibid 124. 27
which was very clean and equipped with things like televisions and pool tables to occupy the
patients. The problem and main source of conflictin the film was the abusiveness of Nurse
Ratched and the factthat she treated McMurphy with medications intended for the mentally ill
knowing that he did not have any mental illness. The relationship Ratched has with her patients,
not just McMurphy, illustrates the idea that even in presumably therapeutic settings, a mental
hospital could still be a site of horrible abuse when authority is given to the wrong person.
Other procedures that were routinely used in order to alleviate the painful symptoms of
mental illness such as schizophrenia included insulin comas and electroshock therapy. Each of
these treatments worked by inflicting stress on the brain in the hopes that the patient would
ultimately be rid of their psychotic episodes; and many were successful. The severity and
duration of the procedure or drugs effecton the brain depended on the dosage suggested by the
doctor. Furthermore, there is still debate about whether or not these procedures left permanent,
irreversible damage, making them fall into the category of possibly therapeutic, depending on
who controlled and oversaw the treatments.57 At first,because of the severity of the operation,
doctors were wary, however the uneasiness faded quickly as positive medical reports continued
to get published. In 1950 and 1951 alone, over 10,000 patients living in the United States
received lobotomies, that is the same amount that were lobotomized during the whole of the
1940's.58
For decades, treatment plans that were not always properly tested, such as insulin comas, electroshock therapy and surgical lobotomies, were the standard of care in asylums. These new techniques were thought to be the best way to control the complex and difficult symptoms of patients. Insulin coma therapy, also known as insulin shock therapy, was a form of psychiatric
57 Ibid 118. 58 Ibid 142. 28 treatment in which patients were routinely injected with large doses of insulin, producing daily comas for a period of weeks or even months. Introduced in the 1930's, it was extremely popular throughout the l 950's, especially forthe treatment of schizophrenics prior to the use of neuroleptic drugs. Insulin comas were curative forsome patients, and definitely made the jobs of nurses and doctors easier, but forothers being cared for in custodial hospitals the injections caused brain hemorrhaging and very oftenended in death. One physician stated that after the treatment patients were,
Childishly simple in mimicry and behavior ...at this time the patient is by no means any longer out of his mind and beclouded. These infantile reaction-types correspond to the behavior of his primitive personality - it is, so to speak, a regression to an ontogenetically earlier stage, a regression which we might consider in terms of brain pathology to have been called forth by a temporary suppression of the highest levels of mental functioning.59
This childlike behavior was necessary forpatients that sufferedfrom severe mood swings and aggressive behavior resulting from schizophrenia. When administered properly the treatment plan could be quite beneficial, however in hospitals administering custodial care, patients were dosed so frequently that nurses and physicians did not regularly check to see if the treatment was actually working; instead they would simply continue to inject the insulin dosages because it kept problem patients quiet, and ultimately made their jobs easier.60
Patients were routinely sent into deep insulin comas despite the intermittent research that surfacedsoon after treatments were administered suggesting that the treatment was causing more negative side effects than positive. The research conducted by investigators abroad and in the
United States was overshadowed by newspapers and magazines that praised the new medical miracle; even The New York Times claimed that numerous mentally ill patients were, "returned
59 Ibid 88. 60 Ibid 29 from hopeless insanity by insulin." Time magazine explained the success of the procedure in more detail, as a patient slipped deeper and deeper into the coma one could hear, "shouts and bellows" and that a patiently quickly, "gave vent to his hidden fears and obsessions, opens his mind wide to listening psychiatrists."61
It did not take long however, for some newspaper reporters to figure out that the use of insulin coma and shock therapy had not been tested up to the standards of many other medical procedures. On September 18, 1944, Time magazine article, "Medicine; Shocks Recommended" reported,
It is not yet certain whether insulin shock brings about more ultimate remissions of dementia praecox (schizophrenia) that would occur anyhow. All that is certain is that it cuts the average hospital stay. And no one yet knows just how any kind of shock therapy works: some think results come from temporarily depriving the brain of oxygen, or of sugar, its only food; some suggest that individual attention and the short psychiatric session following each shock are really what do the trick. Otherwise, because of the psychiatrist shortage, a therapeutic psychiatric interview is a rare event in a state mental hospital.62
Since the discovery of insulin in 1922, psychiatrists continued to use the drug on patients without knowing what produced the coma that they were so proud to accomplish. We now know for certain that when the hormone is injected it draws sugars from the blood. In the case of the mentally ill patients that received the revered drug, the large doses ultimately starved the brain of sugar, causing them to shut down in order of succession, meaning that areas of the brain that carried out higher bodily functions shut down first, followed by areas that controlled less important body functions. In this way, little by little, patients receiving custodial care lost control of the most important areas of their brain, and when they finallywoke up, sometimes afterdays, they behaved like children, often asking who and where they were.
61 Ibid 86. 62 "Medicine; Shocks Recommended," Time, September 18, 1944. 30
Another potentially beneficial treatment and a less permanent alternative to surgical lobotomy was electroshock therapy, previously described by a reporter for Time magazine.
McMurphy also endures this painful process, along with a few of his fellowpatients in One Flew
Over the Cuckoo's Nest. In a scene that is both memorable and painfulto watch, McMurphy is in a small room with at least four other individuals who were there to set up the equipment and hold him down once he received the shock. After applying the conductant and two metal plates on either side of his temples, the doctor reassures him, "Okay this won't hurt and it will be over in just a moment." Next, a nurse puts a guard in McMurphy's mouth, which she explains will keep him frombiting offhis tongue. The shock is delivered in less than a second, however the aftereffects last for nearly a minute, as the audience watches McMurphy's body writhe with excruciating pain. During this time, the fourindividuals in the room hold down his head and limbs in order to control the body movement that he cannot.
Eventually mental hospitals stopped using electroshock therapy because of the negative findingsthat were being reported. However, in 1987, research on electroshock therapy surfaced and the procedure started to be accepted by more and more psychiatrists as the favored treatment formania and major depression; but only forpatients that could not take or did not respond to other medicine. At that time, Susan Squire of the New York Times reported that more than
100,000 patients could have been receiving electroshock therapy in the United States alone.63
Although the treatment resurfaced as a respectable and appropriate way to treat patients suffering from depression, it was still very difficult to prescribe because of the controversy surrounding it.
Images like McMurphy being held down afterreceiving a shock remained engrained in the minds of Americans. Other descriptions, most notably from Sylvia Plath's autobiographical
63 Susan Squire, "Shock Therapy's Return to Respectability," New York Times, November 22, 1987, SM78. 31 novel, The Bell Jar, also described electroshock therapy as an exceptionally painfuland
damaging process.64 The legal system also weighed in on the controversial treatment; in 1987,
35 states legislatures had laws completely restricting the use electroshock therapy.65
Electroshock therapy was a common practice in asylums, and was frequently used to put patients into a state of confusion, which would ultimately calm them down. In Ellen Fields' memoir, The White Shirts, written in 1964, she described the process of electroshock therapy,
People tend to underrate the physical damages of anticipating shock. At any rate, they think of it as a purely mental fear. This is so false. The truth is that electric shock is physical torture of an extreme type, the fear is intensely physical. The heart and solar plexus lurch and give offwaves of - I don't know the word for it. It hasn't the remotest resemblance to anything I've ever felt beforeor since. Soldiers just before a battle probably experience this same abdominal sensation. It is the instinct of a living organism to fear this annihilation.66
Despite these new medical advances that had negative effects on the minds and bodies of patients, at the start of the 1950's the prospect for the mentally ill seemed to be changing, and perhaps for the better. In 1955 the not-for-profitJoint Commission on Mental Illness and Mental
Health was founded, and forthe first time in decades it seemed possible that the nation could now alter its views on the mentally ill and how they should be cared for. Just when it seemed like professionalsin the medical fieldwere starting to think of better ways to treat the mentally ill with the internal reform movementin the psychiatric field, yet another promising yet potentially dangerous new treatment was introduced that would become the standard of care for all mentally ill patients for the next decade; most notably schizoplu·enics. In May 1954, the first
"antipsychotic" medication was introduced in the United States by Smith, Kline & French; during this month chlorpromazine, sold under the name Thorazine, found its way to the shelves
64 Ibid. 65 Ibid. 66 Ellen Field, The While Shirts. (New York: Tasmania Press, 1964), 6. 32 and supply rooms of mental asylums across the United States. Edward Shorter, the author of A
History of Psychiatry, explained the impact of the introduction of the new drug:
"Chlorpromazine initiated a revolution in psychiatry, comparable to the introduction of penicillin in general medicine."67
Starting in 1954 and continuing well into the 1960's, an understanding of how to treat the mentally ill evolved with the use of neuroleptics such as Thorazine. Pioneers who created the medication boasted that the treatments would "normalize" the brains of the mentally ill by manipulating brain function, thus eliminating unwanted bad behavior and rendering patients docile. It was not until 1963, nearly a decade afterthe treatments were first used, that physicians realized the devastating effects the medication could have on the human brain.
The neuroleptic's effectiveness is based on their ability to bind the dopamine receptor in the brain, with these important receptors blocked, dopamine can not successfully deliver messages to the cells in the brain. The result is that the brain of an individual is altered to the degree that they can not control normal body movements, for example, reflexes,since nerve fibers in the brain rely heavily on dopamine to deliver these messages. However, too high a dose of neuroleptics in patients caused symptoms similar to Parkinson's disease. Research scientists and physicians have found that neuroleptics, such as the variety that were used to treat patients diagnosed with schizophrenia, could induce a "pathological deficiency" in dopamine transmission, and in one doctor's words, a "therapeutic Parkinsonism," if such a thing could ever
68 exist. The therapeutic intent of the doctors that prescribed these drugs was a normalized thought process for their patients, and it is true that many patients did experience curative results.
67 Edward Shorter, The History of Psychiat,y; From the Era of the Asylum to the Age o_f'Prozac. New York: John Wiley & Sons, Inc, 1997) 255. �8 Robert Whitaker, Mad in America, 164. 33
However, once the individuals working with patients in mental hospitals that administered custodial care, or routinely misdiagnosed patients realized that they could achieve "positive" results with these types of medications, they were used regularly to "chemically straightjacket" patients and make the "custodial job easier" as Senator Bayh's would conclude just over a decade later.
While doctors were using neuroleptics widely to treat patients, the type of neuroleptic
agent and the dosage varied widely depending on the severity of the illness. Unfortunately,
many individuals that should have not received these potent medications were being drugged on
a daily basis. The tradition of the use of neuroleptics started in Europe, and Thorazine was the
medication of choice because it could be injected. Injectable medications, as seen previously
with insulin comas, were ideal fordoctors and nurses because they could control the dosage and
the lasting effects intramuscularly, rather than attempting to induce patients to swallow pills
every few hours just to keep them calm. When considering that many of the patients in
institutions were confused as to why they were there in the first place, attempting to explain to
them why they needed to take multiple pills each day was an inconvenience to medical workers
and a very difficult job, and so it was easier to control them through injectable drugs as much as
possible. Eventually Haloperidol, also known as Haldol became a popular neuroleptic because it
also successfully blocked dopamine transmission in the brain most effectively when given in
high dosages.69 When these neuroleptics were given to patients that were diagnosed correctly
and in appropriate doses, the results were very beneficial. In fact, when Thorazine was first
introduced in the United States in 1955, the average population of patients in nonfederal
69 Ibid, 175. 34
psychiatric hospitals started to decline. 7° From 1955 to 1995 the number ofpatients decreased
fromnearly 700,000 in 1955 to less than 100,000 in 1995. 71 These anti psychotics do not cure
schizophrenia or other types ofmental illness, but they can control the symptoms so that patients
could leave mental institutions and live at home with their families.
Despite the factthat each neuroleptic had different effectson the patients that were
treated, they all affected one or more ofeach ofthe three different dopaminergic pathways in the
human brain. Antipsychotics have both intended and unintended effects. Whether or not the
drugs were helpful or harmful is related to the benefits ofthe intended effects, which must be
weighed against the cost ofthe unintended effects, one of which included the risk of tardive
dyskinesia. The antipsychotics affect the three dopaminergic pathways. The first dopaminergic
pathway is the nigrostriatal system, which is an essential area ofthe brain, as it controls the
7 movement ofthe body. 2 Patients suffering fromParkison's disease have severe deterioration of
the dopamine neurons that operate this pathway, and thus can control the movement oftheir
bodies less and less over time as their disease progresses. Since antipsychotic medications block
dopamine, they produce similar symptoms.
In June of 1980, Dava Sobel reported that psychiatrists generally agreed that the risk of
side effects associated with neuroleptics was acceptable when a patient was suffering from
suicidal thoughts. 73 But, when a patient was repeatedly drugged with neuroleptics over long
periods oftime horrendous side effects habitually occurred. Dr. Joseph De Veaugh-Geiss felt
70 Oakley Ray and Charles Ksir, Drugs, Society and Human Behavior. (New York: WCB/McGraw-Hill, 1999), 199. 71 Ibid. 7 2 Robert Whitaker, Mad in America, 162. 73 Dava Sobel, "Psychiatric Drugs Widely Misused, Critics Charge," New York Times, June 3, 1980, Cl. 35
that the worst of these side effects was tardive dyskinesia. This condition affectedone half to
one third of patients receiving high doses of neuroleptics for duration of a few years. 74
The second pathways that the neuroleptics inhibit is the mesolimbic system. The limbic
system is located in the area of the brain that controls emotions, and allows humans to respond to
all things around them. By blocking the receptors in the limbic system, neuroleptics blunt
emotions, and reactions; thus making patients docile and cooperative. Yet, it must be noted that
the emotional thoughts and feelings of schizophrenic patients was already in disarray, and so the
drugs were meant to help. When used in medical facilities with high rates of misdiagnosis or
neglect of patients, this type of tranquilization would result in peace and quiet for both doctors
and nurses as their patients became more and more cut offfrom the physical and emotional
world with every dosage they received. Ultimately, the treatments led to a silent hospital, but at
the cost of the brain functionof a shocking number of men and women, many of whom did not
necessarily have schizophrenia.
The mesocortical system is the final dopaminergic pathway and involves the frontal
lobes. Neuroleptics affected the interaction between the frontal lobes and the ventral tegmentum.
The use of specific types of neuroleptics and their effect on the mesocoritcal system is very similar to a surgical lobotomy, since that procedure involves the severing of nerve fibers in the brain that connect the frontal lobes and the thalamus. 75 The fact that the use of neuroleptics became so popular for mental patients, most specificallyschizophrenics starting in the l 950's in many cases speaks directly to the custodial care and the negative relationship many doctors had with their mentally ill patients. The goal of anti psychotic drugs was to normalize the disturbed thought patterns of patients, and these drugs did work for patients that were diagnosed correctly
74 Ibid, 75 Robert Whitaker, Mad in America, 164. 36 and actually had schizophrenia, however in many circumstances patients were often misdiagnosed and ill-cared for. In these cases, rather than communicating with patients and attempting to create a medical routine that would suit their needs, professionalsin the medical field found it easier to hinder brain function in schizophrenics. With reduced brain function and the inability to experience emotions, patients in hospitals for the mentally ill across the United
States were passively led around to different daily activities, unable to advocate for themselves, as nurses and doctors alike "took care" of them with fewunpleasant disruptions.
There are fewif any writings by patients that were misdiagnosed with schizophrenia praising the effects of the neuroleptics on their minds and bodies, however there are many to the contrary. When men and women that did suffer fromschizophrenia and that were treated with antipsychotic drugs, the results were often positive; they were able to return to their homes, and often could even earn a living with the introduction of Thorazine in the United States in 1955.76
For many, these drugs were seen as the liberation of mental patients from hospitals, but for men and women that did that not have schizophrenia, these drugs had devastating effects. Patients reported widely that the medication made them feel "mummified," "closed in," "jittery," and
"fearful," while others thought that the medication was turning them into supernatural creatures like "zombies."77 Janet Gotkin's testimony during the Senate hearings of 1975 serves as one example of the negative effects that could result from the abuse of neuroleptics when prescribed by an institution that administered custodial care.
While negative headlines and articles filled the pages of newspapers across the United
States, One Flew Over the Cuckoo's Nest made Americans very uneasy about what was happening in mental institutions. For decades, thousands of patients lived in unspeakable
76 Oakley Ray and Charles Ksir, Drugs, Society and Human Behavior, 200. 77 Ibid, 176. 37 conditions while their mental and physical health deteriorated as they received custodial care in various hospitals, oftenfrom inept employees. At the start of the twentieth century and into the late 1960's, new medical procedures, whether inherently harmful in nature, like the prefrontal lobotomy, or possible helpful, like insulin comas, electroshock therapy and neuroleptics, were all viewed in the medical field as being acceptable ways to treat the mentally ill.
With the 1970's came reform, sparked by activists in the civil rights movement and the popular anti-psychiatry sentiment, as a result facilitieswere better run, and legislation was passed that extended constitutional rights to the mentally ill. It is true that this reformwas started internally in the psychiatric world with the development of drugs like Thorazine, however documents from the l 960's and l 970's still provide evidence that shows that the worst types of mental hospitals were clearly still in use. Civil rights driven legislation occurred when legal advocates outside the psychiatric field argued that patients were due their rights as humans and citizens of the United States. Unfortunately, this reform was less visible to Americans until in popular culture, such as the film One Flew Over the Cuckoo's Nest, emphasized the warehousing of mental patients in hospitals, and negative treatment of the mentally ill by medical professionals that were supposed to be caring. Americans could take what they saw in films like
One Flew Over the Cuckoos Nest, and translate that into reality, rather than acknowledging the reform movement that was actually taking place, headlines in newspapers like the New York
Times described the changing laws gave basic rights to the mentally ill. It was true that the kind of custodial care and use of neuroleptics and shock therapy depicted in One Flew Over Cuckoo's
Nest did still exist, but it was the last gasp of this kind of treatment of the mentally ill.
Fortunately for the mentally ill and those that cared for them, the reformthat came about during 38 the 1970's, although perhaps overlooked at the time, put an end to custodial care within mental hospitals, and the negative treatment of patients. 39
Bibliography
Altman, Lawrence K. "Experts Raise Questions Over Ruling on Mentally Ill." New York Times, June 28, 1975, 15.
"Behavior: Crackup in Mental Care." Time, December 17, 1973.
Bernstein, Phyllis. "The Retarded Win In This Game Show." New York Times, May 18, 1980.
Bettelheim, Bruno. "If Insanity Exists It Is Saner Than Sanity; The Facts of Life." New York Times, May 30, 1976
Boyd, Mary Ann, Ryan M. Niemiec and Danny Wedding. Movies and Mental Illness; Using Films to Understand Psychopathology. Massachusetts: Hogrefe & Huber Publishers, 2005.
Cahill, Tim. "Jack Nicholson; Knocking Round the Nest." Rolling Stone, December 4, 1975.
Canby, Vincent. "One Flew Over the Cuckoo's Nest." New York Times, November 20, 1975
Cook, Joan. "A Grand Jury Finds Abuses of Patients at Greystone." Netv York Times, May 30, 1975, 67.
"Court to Review Crime 'Patients."' New York Times, December 21, 1971, 24.
"Courts: Mental Illness and Legal Remedies." Time, November 20, 1964.
Davidson, Bill. "The Conquering Anti-Hero." New York Times, October 12, 1975, 267.
Field, Ellen. The White Shirts. New York: Tasmania Press, 1964.
Fleming, Michael, and Roger Manvel 1. Images of Madness,· The Portrayal of Insanity in the Feature Film. London: Associated University Presses, 1985.
Freeman, Walter. "Brain-Damaging Theraputics." Disease of the Nervous System 2, 1940.
Gaylin, William. "What's Normal?" New York Times, April 1, 1973, 290.
"Many Insane in Bay State." New York Times, December 15, 1902.
Maas, Melvin. "To Aid Mentally Handicapped." New York Times, June 23, 1961, 28.
McNeil. Director, Patuxent Institution, 1972. 407 U.S 245.
McQuiston, John T. "R.D Laing; Rebel and Pioneer on Schizophrenia is Dead at 61." New York Times, August 24, 1989, D21. 40
"Medicine; Shocks Recommended." Time, September 18, 1944.
Morrey, Phillip E. "Schizophrenia: Insights Fail to Half Rising Toll." New York Times, March 16, 1986.
One Flew Over the Cuckoo's Nest. DVD. Directed by Milos Forman. 1975; Fantasy Films, 2000.
"Psychiatry on the Couch." Time, April 2, 1979.
"Psychiatry: Revolt of the Aides." Time, September 13, 1968.
Ray, Oakley and Charles Ksir. Drugs, Society and Human Behavior. New York: WCB/McGraw-Hill, 1999.
Rensberger, Boyce. "Impending Ruling by U.S Judge Promises Hope for the Neglected in Mental Institutions." New York Times, March 26, 1972, 35.
Robinson, David J. Reel Psychiatry,· Movie Portrayals of Psychiatric Conditions. Michigan: Rapid Psychler Press, 2003.
Ross, Steven J. Movies and American Society. Massachusetts: Blackwell Publishing, 2002.
Shorter, Edward. The Histo,y of Psychiatry,· From the Era ofA sylum to the Age of Prozac. New York: John Wiley & Sons, Inc, 1997.
Sibley, John. "Mental Patients Held Vulnerable; Their Rights Are Demanded at Conference Here." New York Times, March 28, 1971, 29.
Sobel, Dava. "Psychiatric Drugs Widely Misused, Critics Charge," New York Times, June 3, 1980, Cl.
Squire, Susan. "Shock Therapy's Return to Respectability." New York Times, November 22, 1987, SM78.
Stone, Alan A. Jvfental Health and the Law,· The Facts and the Future. http://americanmentalhealthfoundation.org/a.php?id=69
Stone, Bryan P. Faith and Film,· Theological Themes at the Cinema. St. Louis: Chalice Press, 2000.
"U.S Backs Treatment as a Right to Mental Patients." New York Times, January 16, 1975, 10.
Whitaker, Robert. Mad In America,· Bad Science, Bad Medicine, and the Enduring Mistreatment _ of the Mentally Ill. New York: Perseus Books Group, 2002. 41
Witheridge, Annette. "The Lost Kennedy." Daily Mail, 30, August 15, 2009.