Book Review: One Flew Over the Cuckoo's Nest

The Chief's flashback

The novel is set in a ward of an Oregon mental hospital in late 1959, at the time of the Kennedy/Nixon presidential election race. However, such outside events play little part in the closed universe of the ward, recounted in flashbacks by Chief Bromden, the catatonic narrator. Bromden is a giant half-Columbian Indian, who once lost his native village to a government hydroelectric dam. He has lived in the ward for 15 years receiving over 200 shock treatments and retreating into feigned deaf and dumbness. He sweeps the ward, all the time observing (or hallucinating) the operation of a giant influencing machine, ‘the combine’. The combine controls the world, ‘adjusting the Outside as well as the Inside’. It spreads dense fog over the ward, clouding the Chief's brain, slowing time and shrinking and swelling everything with electric beams. Its agent in the ward is Nurse Ratched, the Big Nurse. She sits in her office before ‘a web of wires like a watchful robot, tending her network with mechanical insect skill… dreaming of a whole world of precision, efficiency and tidiness where the schedule is unbreakable.’ (p.27) All the machines, real and imaginary, are directed by her: the fog machines, clocks, radios, television, floor magnets, microphones in Chief's broom handle, the gears and tubes in everybody else (checked monthly by X-rays). The Big Nurse also controls the Black boys, her attendants, hand-picked because ‘they hate enough’. Dr Spivey, the chief medical doctor, a timid intellectual theoriser, is dominated by Nurse Ratched. He is largely absent, coming only to group meetings.

The all male population of the ward is a jumbled group of obsessives, hysterics, botched lobotomies, epileptics, manics, catatonics and schizophrenics, separated into Acutes and Chronics (wheelers, vegetables and walkers). Many are voluntary and all are passive, institutionalized and fearful, ‘rabbits’ according to one character, and ‘victims of the matriarchy’. Big Nurse manages the ward and its unchanging routines of sedation and group meetings, ECT and psychosurgery with military precision. Sefelt, an epileptic with sore gums from Dilantin, sums it up, ‘What a life, give us some pills to stop a fit, give the rest shock to start one’ (p.146). The recently developed neuroleptics such as Chlorpromazine are apparently not yet in use.

Into the cuckoo's nest with a laugh ‘loud and free’ comes redheaded Randall Patrick McMurphy, in biker cap and cowboy boots. In a prison farm for assault and rape, he has manoeuvred his transfer to the State Hospital to avoid work. When Dr Spivey reads out his provisional diagnosis ‘psychopath’ at his first group meeting, McMurphy is already challenging: ‘I fight and I fuh – pardon me ladies – means I am, he put it, overzealous in my sexual relations. Doctor is that real serious?… Do I look like a sane man?’ (p.41) For most, the answer is an energetic yes. McMurphy's sanity takes the ward by storm. He jokes and plays pranks, organizes gambling syndicates and basketball games, and campaigns for the World Series to be shown on TV, while taking bets on whether he can defeat Nurse Ratched (‘the ball cutter’) and her rules. The Chief immediately warms to McMurphy as his lost father, an aristocratic American Indian dispossessed and driven to alcoholic death by the government. When the Chief, fighting against his fears of the combine, votes with McMurphy to watch the World Series, Nurse Ratched's command is loosened. Bromden's fog and hallucinations reduce and he begins to find his voice.

McMurphy's war with the Big Nurse continues through twists and turns. One day, McMurphy leads 12 disciples to the Outside, on a fishing trip, organized by his ‘Aunt’ Candy, a prostitute (naturally goldenhearted!). The men take control of the boat and break out into jubilant laughter, while McMurphy goes below deck with Candy.

But the showdown with Nurse Ratched is inevitable. After a fight to stop the Black attendants abusing a patient, McMurphy and Chief are sent to the Shock Shop. For the first time, Chief, following McMurphy's example, fights off the after-effects of ECT. McMurphy organizes a party on the ward, with whiskey and whores (and alcoholic cough syrup!). When Chief sees everyone ‘drunk and running and with laughter and carrying on in the centre of the combine's most powerful stronghold’ (p.243) he realizes the combine is not invincible. But when Ratched returns in the morning she humiliates Billy, a patient who McMurphy has set up with Candy for his first sexual experience (to cure his stutter). When Billy cuts his throat McMurphy assaults Big Nurse, and ripping her uniform off, exposes her as a woman, not a machine. He is straitjacketed and led away for a lobotomy, to return a vegetable. In a final sacramental scene Chief Bromden takes McMurphy out of his mindless body by smothering him to death. Then, lifting a control panel in the showers, Chief smashes his way to freedom and the natural world of his childhood. The power of the Big Nurse is broken. The voluntary patients all sign out. The cuckoo's nest is liberated.

Archetypes, fantasies and comic strip Freud

Combining mythic parables and archetypes with finely detailed realism and savage black humour, the novel was immensely popular, especially among the 1960s generation.

At one level it is a simple story of Good versus Evil. McMurphy is the lone Western hero, teamed with Chief, the noble Red Man. They are the Lone Ranger and Tonto, fighting Nurse Ratched, the civilizer, administrator of machine culture, and deadly matriarchal destroyer of manhood. This is the battle for the Old West of self-reliance, anarchic humour and the masculine physical life, against the humourless, conforming forces of modern civilization, hydroelectric dams and women.

McMurphy is a saviour and redeemer, Christ figure and holy fool, whose madness is not insanity but a gift. He is the lost father, ‘the fisher of men’, returning to be sacrificed and martyred on an (electric) crucifix, so disciples can be reborn.

So strongly present are these symbolic heroes and villains that the novel can be read solely as a comic strip melodrama. Indeed, the Chief describes the ward as ‘like a cartoon world where the figures are flat and outlined … a goofy story that might be real funny if it weren't for the cartoon figures being real guys’. Big Nurse is unredeemably Evil, a robotic, castrating matriarch. McMurphy is a Holy Fool, Bromden a Noble Primitive. These one dimensional stereotypes lead to a sentimentalized oversimplification of the moral problems posed by the novel. Cuckoo veers towards a comic book Freudian (or Wilhelm Reichian) solution, where repressed sexuality lies behind every psychosis and only a thoroughly free and abandoned sexuality will remake men, and the world. (Forget the women!). This is not liberation, only escape to regressive male sexist fantasies. McMurphy sexually assaulting Ratched is no more an answer than Ratched lobotomising McMurphy is. In the years since Cuckoo was written an awareness of feminism has made McMurphy's sexually violent fantasies and hostility to women much less magnetic than once may have been the case.

The symbolic conflict between the characters, is heightened even further in the theatre. It becomes a comic morality play, rousing and absurd. One curmudgeonly critic commented:

the play was literally a howling success… Nurse Ratched, who even brow beats her medical advisor, is less a character than a stand-in for external power (like the police). Prohibited drinking, smoking of pot, crude fornication are joyfully viewed as signs of happy release from oppression… a trite canon of hand-me-down psychoanalysis, facile rebelliousness and ‘revolution without pain’. No wonder young people flocked to the play! [3]

But to be lured only by the easy symbolism is to overlook the comic brilliance and realistic authenticity of the novel. The book is in turn grimly and hilariously funny. It is full of incidental wisecracks, absurdities and black humour (as when Santa Claus visits the ward one Xmas to be nabbed by the aides, and leaves six years later ‘clean shaven and skinny as a pole’.) McMurphy resists with his laughter: ‘when you lose your laugh you lose your footing’. As the men start laughing on the fishing trip, the grip of the combine is released. It is easy to imagine readers everywhere laughing too.

The novel is very convincing in its descriptions of the regulations and rituals of a mental hospital at the end of the 1950s. Kesey carefully builds up pictures of the ward, with its corridors, showers and seclusion, its day-room and nursing station, and its schedules of sedation and confinement, eating and sleeping. The descriptions of the group meetings and the way they are ‘theoretically democratic’, but in reality coercive, are savagely accurate. (Even Maxwell Jones is cited.)

The notorious descriptions of ECT and lobotomy are accurate in technical detail, if embellished metaphorically. After lobotomy, the patient Ruckley is brought back to the ward

… two weeks later, bald and in front of his face an oily purple bruise and two little button-sized plugs stitched one above each eye… [Later] the technicians got more skill and experience… no more button holes in the forehead, no cutting at all – they go in through the eye socket. (The infamous transorbital lobotomy of Walter Freeman. [4], p.18])

The realism is compelling and scary, but not an exaggeration. John Cawte in his tempered and humane account of Australian wards of the period evokes the same claustrophobia, desperation and violence [5]. The difference is that in Cuckoo the ward is seen through the schizophrenic mind of Chief Bromden. How believable can this be, with his first rank symptoms and hallucinatory fog? Bromden answers at the end of his first monologue ‘… but, please. It's still hard for me to have a clear mind thinking on it. But it's the truth even if it didn't happen.’ (p.13)

It is the truth, and also a big joke.

Kesey, LSD and social psychiatry

Kesey wrote the Chief's opening monologue under the influence of peyote and claims not to have edited it any further. While a creative writing student at Stanford in 1958 he had enrolled in US government experiments on LSD at Menlo Park Veterans' Administration Hospital, Palo Alto. After the experiments ended, he worked as a night attendant, writing on duty, often under the influence of LSD. He even arranged to experience an ECT, getting a friend to rig up an apparatus. Kesey's story is told by Tom Wolfe in his The electric kool-aid acid test [6]. According to Wolfe, Kesey

would write like mad under the drugs. After he came out of it he could see that a lot of it was junk. But certain passages – like Chief Bromden in his schizophrenic fog – it was true vision, a little of what you would see if you opened the doors of perception, friends.

Cuckoo became part of an era that saw several celebrated critiques of psychiatry arise. It was a kind of golden age for social psychiatry, and antipsychiatry. In 1960, Thomas Szasz came out with The myth of mental illness where he argued that the notion of mental illness was ‘scientifically worthless and socially harmful’ [7]. Michael Foucault's Madness and civilization (1961) argued that madness was a social construct of the Age of Reason [8]. Erving Goffman's Asylums (1961) exposed mental hospitals as ‘total institutions’ where infantilized patients were ‘exiled from living’ [9]. RD Laing in The divided self (1962) [10], foreshadowed his ideas that ‘madness need not be all breakdown. It may also be breakthrough, potential liberation and renewal…’ [11], and close at hand, in fact in the same hospital as Kesey, Gregory Bateson, Don Jackson, Jay Haley and others had been minutely analysing the communicational contexts of schizophrenia and proposing the Double Bind Hypothesis [12]. The Double Bind has been famously misinterpreted as a theory that ‘the schizophrenogenic mother’ caused psychosis by her contradictory communications. (Nurse Ratched would be the exemplary schizophrenogenic mother!) But Bateson was trying to catch something more intricate, by locating pathology in the social field, not the individual. His theory attempted to make madness intelligible by understanding its social context and communication patterns. It proposed that in closed interactional systems, confusions can arise between levels of communication, generating contradictory injunctions or paradoxes. Systems can get stuck in self-perpetuating tangles, and psychosis is one possible outcome. In the cuckoo's nest, Big Nurse and the patients are mutually bound in interactions that disqualify and dismay. All are caught in paradoxical webs, at least until McMurphy arrives, as Batesonian ‘news of difference’. Double Bind Theory abstractly knitted together the new ideas of social psychiatry. It was very influential, and hotly disputed. Whether Kesey knew about the theory or had ever met Bateson or Jackson is not recorded [13], but there are some clues. Bateson is rumoured to have introduced Allen Ginsberg to LSD at Menlo Park [14] and Kesey did correspond with Thomas Szasz [15].

Cuckoo gave fictional expression to the new social and community psychiatry. It found immediate responses. Jack Kerouac pronounced the arrival of a great new American novel, and Time magazine hailed ‘a roar of protest against middlebrow society's rules and the invisible rulers who enforce them’ [16]. The wave of reaction to post-war conformity was cresting. Cuckoo linked the Beatniks to the Hippies as the psychedelic era took off. Kesey, with his Merry Pranksters, travelled across the country in a Day-Glo painted bus, to spread the message of the new age. He visited Timothy Leary, returned to San Francisco for the famous Acid Test parties, then fled to Mexico, a fugitive from the very government that had introduced him to LSD [6].

Forman's film

In 1975 the film Cuckoo, directed by Milos Forman, was released. The film reflected a different era. Influenced by feminism, the misogyny and mother blaming of the novel were muted. The nickname ‘Big Nurse’ is never mentioned in the film. Nurse Ratched becomes less of a misogynist's nightmare and more a smiling organizational type who knows protocol is on her side. She can even generate sympathy. (As a colleague remarked ‘I've dealt with enough McMurphys in my time to have considerable fellow feeling for Ratched’.) McMurphy is no longer a Western loner. The cowboy boots, biker cap and red curls are gone. Instead we have slick-haired Jack Nicholson with his charismatic menace and half-smile of hostility, playing his ultimate nonconformist role, to be repeated in many later films. Nicholson has taken over the image of McMurphy in the popular imagination. He is no Christ figure or flower child. The film also removes the narrative of Chief Bromden and the fogs, hallucinations and machines of the combine. It becomes a third person objective account of the struggle between an individual and the establishment. At the end of the film only the Chief leaves, and then ambiguously; the other men stay on.

What we are offered is not mythic Western, but documentary realism, even down to the film's location, Damasch State Hospital, Salem, Oregon. Dr Dean Brookes, the Superintendent of the hospital played the role of Dr Spivey, and many of the patients were extras or assistants to the film crew. This shows the remarkable distance mental hospitals had moved from the 1950s. By 1975 the cuckoo's nest had become a film studio [17]!

From Czechoslovakia, Forman linked the cuckoo's nest more to his experience of Eastern European communist oppression than to Kesey's archetypal struggles of the old West. The film is beautifully constructed and acted. It was a real crowd-pleaser, with its comic realism and touch of horror, but it lacks the book's terrifying absurdist laughter and complexity.

Looking at the film now one is struck by how strangely tame it seems. Even the famous ECT scene only reveals Nicholson's facial grimaces. There are no flailing convulsive limbs or attendants grimly holding him down. Family television has nightly depictions of violence more vivid than this, a measure perhaps of how far our thresholds for being shocked have changed.

But that the depiction of ECT was shocking in 1975 is not to be doubted. The film let the public into mental hospitals in ways that had never happened before, and the reaction was emotionally charged. The after-effects of the shock still linger. As Kesey commented ‘We think we're in the present but we aren't. The present is only a movie of the past’. The images from the cuckoo's nest are still powerfully present in public consciousness, no doubt reinforced in Australia by revelations of the real horrors that were occurring at Chelmsford and Townsville [18].

Kesey was so unhappy with the changes the script made to his novel that he took Forman to court. He protested about the absence of the combine and the shift in perspective away from Chief Bromden's narrative. He claimed to have never seen the film, probably about the only person who hasn't. It went on to win more Academy Awards than any film before it.

Kesey today

Ken Kesey died in late 2001. His poetic-paranoid vision left the public hypersensitive about psychiatry but it did serve to reduce stigma. It helped curb excesses of treatment, and advanced the causes of advocacy and patients' rights. Votes to ban ECT and psychosurgery were successful in California and Oregon in the 1970s, but legislation was never enacted. ECT (and psychosurgery to a much lesser extent) recovered a place in treatment, but in safer and better monitored forms, and with more specific indications. Notions of mental illness as rebellion and creative breakthrough from oppression and the schizophrenic patient as seer have receded. Neurobiological and genetic theories have risen to dominance, over psychosocial treatments. There are no therapeutic communities any more. The asylums are closed. McMurphy would no longer manipulate his way out of prison. He would be incarcerated for a long sentence, probably for juvenile sexual abuse. The other characters would be tranquillised and left to shuffle off to homelessness and isolation.

In his documentary Completely cuckoo (1998) about the making of the film, Charles Kiselyak returned to Damasch [17]. The progressive policies led by Dr Brooks in 1975 have disappeared. The hospital is hard to get in to, not out of. Security guards escorted the crew, barbed wire proliferated, and bureaucratic regulations flowered. Kiselyak reports ‘Ratched is now running the institute’: not, one suspects, as a nurse but as a managed care supervisor with a business degree.

The combine is still with us, more pervasive than ever, with electronic surveillance and invasion of privacy, malpractice suits and infinite data collection. Meanwhile, the marketing by pharmaceutical cartels is reshaping treatment and diagnosis. Dr Spivey collaborates with ‘Big Pharma’ now, not Big Nurse [19].

One wishes for another One flew over the cuckoo's nest for the new millennium. If only we could recreate redemptive figures like Chief and McMurphy, and monsters like Big Nurse, we would know again who we were fighting for. The fog would surely clear.