Cuckoo's Nest and Community Psychiatry
All Fowled Up
Posted Aug 22, 2014
At the most recent American Psychiatric Association convention a screening of One Flew Over the Cuckoo’s Nest was held and a panel discussion followed, as reported by H. Steven Moffic MD in the May 21, 2014 issue of Psychiatric Times. The movie was well attended and the discussion lively. In the article Moffic relates his history in the community psychiatry movement and its supposed relation to the movie. He concludes, “Now more than 50 years since "One Flew Over the Cuckoo’s Nest" was published and almost 40 years since the movie was released, the issues seem as relevant today as they were back then.”
Nothing, I find, could be further from the truth. Moffic declines to point out the glaring flaws in Cuckoo’s Nest and the dismal failure of community psychiatry movement. Many of the issues raised by both have been long settled and are mainly of historical interest now. But they apparently still need a re-look.
First the movie. The element of coercion in psychiatry i.e. forced treatment seems to weigh on the conscience of some psychiatrists. It’s time to put this issue to rest. Psychiatrists don’t force treatment on patients, the state Superior Courts do that. In any setting, mandated treatment is performed under the auspices of state law. If being a paid agent in this process is morally offensive, find another avenue of practice.
Of particular note, and almost always forgotten, is that in Cuckoo’s Nest all the patients were voluntary. They wanted to be there. Only Randall Patrick McMurphy received court mandated treatment and, as an obvious sociopath, he should have been discharged forthwith.
The community psychiatry movement, about which Dr. Moffic romantically reminisces, was based on two scientifically flawed premises, and doomed to failure from the beginning. The movement from state hospital to “Community Mental Health Centers,” arose from the Community Mental Health Center Act, with the backing of JFK, and stated – with no evidence for either conclusion – that, one, somehow chronic mental illness was caused by being in the hospital (called “institutionalism”) and, two, that somehow chronic mental illness could be prevented with early “point of contact” i.e. community intervention.
As the plethora of American homeless mentally ill persons attests (these are the persons summarily discharged from the old state hospitals) mental illness is not caused by the hospital. Interestingly, the state hospitals were
built in the 19th Century on the assumption that the hospitals themselves would cure mental illness. And second, mental illness proved to be primarily of biological origin and no amount of intervention, early or late, prevents it.
But why Cuckoo’s Nest so many years later? Why do 21st Century psychiatrists romanticize a fatally flawed past and still feel apologetically paralyzed by the issues it raises? Why can’t we as members of a fully accredited, scientifically based medical specialty, articulate exactly what we do and why we do it, without a mumbled, finger weaving, preamble or apology?