How many people in authority, in schools, prisons, nursing homes, hospitals and mental health organizations believe they know what’s best for the people they care for when in fact they do them great harm?
This question was recently addressed by American Icons Studio 360 on National Public Radio in a review of the American classic film One Flew Over the Cuckoo’s Nest starring Jack Nicholson.
The film begins with Randall Patrick McMurphy (Nicholson) in transit from a work farm where he’d been imprisoned for assaulting someone in a bar room brawl. His previous history of violent behavior along with his weird, erratic conduct on the work farm have caused the authorities to refer him to a hospital for psychiatric assessment. In his first meeting with Dr. Spivey, the hospital’s chief psychiatrist, we get a strong impression that McMurphy is playing a game of cat and mouse and Spivey is clearly aware of it. Does McMurphy have a serious psychiatric disorder or is he hoping for a leisurely gig in the hospital’s psychiatric ward?
McMurphy’s brief stay in the psychiatric ward supervised by Nurse Ratched is a disaster, both for McMurphy and another young man, Billy Bibbit. Ratched is not only responsible for managing the ward which requires her to supervise the nursing staff, the orderlies and the dispensing of medication to patients, she also leads a daily therapy group of the men in the ward who are able to participate, including McMurphy. Although she’s a qualified registered nurse, Ratched has virtually no formal training or experience in family therapy, group therapy or in leading a therapy group. The role she performs as group leader lies outside the boundaries of her competence, education, training, and supervised experience.
Nurse Ratched is totally well intentioned. That’s what so scary. She doesn’t see her behavior as it really is. Who sees that they’re really evil?” -Louise Fletcher who plays Nurse Ratched.
In working with McMurphy and the other ward patients Ratched commits six ethical violations that slowly build upon each other in a crescendo of empathic breaches and sadistic interventions that have tragic results.
First, she refuses to discuss letting the men watch the World Series, telling them brusquely that “The business of this meeting is therapy!”
Second, when McMurphy is on the verge of getting a majority vote from the men in favor of changing the ward schedule to watch the Series, Ratched arbitrarily nullifies the vote by counting other members of the ward who are in a vegetative state and unable to vote let alone participate in group therapy.
Third, she blames McMurphy for the loss of the men’s recreation room privileges and cigarette rationing because he encouraged them to gamble. This causes them to rebel, she loses control of the group and the orderlies are required to restrain the men and restore order.
Fourth, in a review of McMurphy’s case with the Dr. Spivey and the members of his psychiatric staff – after McMurphy smashes the widow of the nurse’s station to retrieve the men’s cigarettes – Ratched tells the others in a bone chilling tone of voice, “If we send him back to the work farm, we’ll just be passing on our problems. I’d like to keep him on the ward. I think we can help him.”
Fifth, shortly after this meeting she orders Electro Convulsive Therapy for McMurphy which knocks him for a loop. A warning that’s surely not lost on other members of the group who may also be tempted to rebel against her iron clad rule.
The last and most sadistic of Ratched’s interventions is reserved for Billy Bibbit in group, after she found him naked in bed with one of McMurphy’s girlfriends the morning following an all night party organized by McMurphy. When the others applaud Billy for overcoming his sexual performance anxiety with his willing companion, Ratched tells him, “Aren’t you ashamed. What worries me is how your mother is going to take this.” Billy pleads with her not to tell his mother and she responds, “Your mother and I are old friends.” After more pleading, she asks him, “Don’t you think you should have thought of that before you took that woman into that room?” Billy collapses. As the ward attendants carry him away, Ratched looks at McMurphy with unbridled hatred. Later they find Billy with his throat slashed.
When McMurphy learns of Billy Bibbit’s suicide, he lunges at Ratched and attempts to strangle her. The ward attendants drag him away. After this final act of defiance, Ratches has McMurphy lobotomized. And Chief Bromden who’s formed a close personal friendship with McMurphy smothers him with a pillow out of compassion, and perhaps to protect the others from seeing McMurphy in such a hopeless state. Bromden then yanks a water fountain from the floor in the ward bathroom, hurls it through a window and escapes to freedom.
Here’s how I’d re-write the story with the aim of attaining justice for the ward patients.
It begins in a consultation meeting shortly after McMurphy tries to strangle Nurse Ratched. Dr. Spivey, his psychiatric colleagues, Nurse Ratched with bandages around her throat and a new character, me, cast as a creative counselor and life coach. We’re all sitting around the conference table trying to figure out what to do with McMurphy. I suggest that they make no radical medical interventions and that I be permitted to lead a therapy group of the men in the ward with McMurphy as my co-leader, without Ratched. She vehemently opposes me in an angry outburst that stuns Spivey and the others. She gives me the same unbridled look of hatred that she gave to McMurphy. Then her face suddenly turns blank as if she’s depersonalizing. She stands up slowly and barely manages to walk out of the room. As she leaves, I wonder how much help this poor alienated woman might get from a supportive peer group of her colleagues, these men in the room and the other nurses who work with her on the ward. But at the moment it’s all I can do to think about how I’m going to persuade Spivey to authorize the therapy group sessions.
Later, alone with him in his office, I make my pitch. I propose a 12-week program of narrative therapy for the group, two hours a day, weekends off during which I’ll encourage the men to engage in recreational activities of their own choosing. I remind Spivey of the time McMurphy stole a boat and taught his ward brothers how to catch big fish with little fish. The symbolic significance of this modeling behavior is not lost on Spivey. I also encourage him to imagine what other therapeutic tricks McMurphy might have up his sleeve in the future. We both agree that McMurphy certainly has a proven track record in organizing social activities for the men. I tell Spivey the therapy will have the following goals:
- I’ll encourage the men to think of the present stories of their lives as flawed stories in which they’re stuck and that are not working for them.
- I’ll encourage them to recall exceptions to these dominant stories by thinking of special times or unique moments in the past when things seemed to work better.
- I’ll encourage them to separate themselves from their internal struggles and think of their problems in terms of what might be changed on the outside that might make them feel better.
- And slowly I’ll encourage the men to create new and better stories or landscapes of consciousness and action that might give them hope.
Spivey, appearing skeptical, presses me for specific therapeutic interventions I would make in the course of the group sessions. I tell him I’ll ask the group about their thoughts and feelings when:
- McMurphy tried to pull the water fountain from the floor in the bathroom and failed but proudly said, “At least I tried!”
- He stole the boat and took them on their fishing trip. This, I tell Spivey, will stimulate the men to recall unique outcomes or moments in their own lives in which they were able to cope and live more successfully.
- When McMurphy organized the basketball game and kept nagging an inert Chief Bromden to throw the ball as the other members of the team watched them.
- When he organized an all night party for them.
- He encouraged Billy to dance with and make love to his girlfriend. Again, I would expect this to stimulate memories of moments in their own lives when they did as well or almost as well as Billy.
- When McMurphy stayed with them for their all night party when he could easily have escaped with his girlfriend before they were discovered by Ratched and the others.
I further tell Spivey that I’ll give these moving, deeply empathetic men the time they need to express their grief over the loss of Billy Bibbit. And I’ll also encourage McMurphy and Chief Bromden to talk about their relationship and their feelings toward each other in view of the fact that McMurphy was the only person in the ward who succeeded in getting the apparently deaf and dumb Bromden to speak.
Spivey, softening a bit, asks me how I intend to evaluate the effectiveness of the therapy. I tell him that he and the other psychiatrists on his staff will be a reflecting team that observes each session and evaluates the group’s progress over time. The team will meet once a week to review the progress of each individual in the group based on appearance, behavior, thought processes, mood, affect, intellectual functioning and sensorium. Each individual’s level of functioning will also be evaluated at reduced levels of medication determined by the psychiatrists and this will result in solid pre-/base-line, post analyses of variance. Spivey, being a rational man of science with a keen taste for evidence based practice, is of course delighted by these proposed measurements. But he squirms a little when I tell him the reflecting team will also join the ward patients and share their thoughts and feelings about what happened after each session. Sensing that I’m losing him, I roll the dice and audaciously propose a control group from another psychiatric facility also lead by me and McMurphy, with a reflecting team that doesn’t have direct contact with the patients. I tell Spivey that he and his colleagues will be on the cutting edge in evaluating the direct therapeutic impact of a reflecting team on the test group. When I ask him to give me the odds of disproving the therapeutic value of his reflecting team, his eyes light up like a pinball machine and he almost jumps off his chair with glee!
That’s is how I close the deal with Spivey, eminent psychiatrist and man of science who, it shouldn’t surprise you, also claims a highly coveted place in Appendix J among the DSM-V’s distinguished contributors (just kidding). I never once try to sell him on the real value of the reflecting team: To show the ward patients how deeply their psychiatrists, nurses and counselors, including McMurphy, truly care about them.
