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Mental Hospitals in “One Flew Over the Cuckoo’s Nest”

Architecture and ethics in Hollywood hospitals.

I started this blog by writing about very popular recent films, like Twilight and The Girl with the Dragon Tattoo. However, my last post focused on the classic film A Clockwork Orange, and I was surprised by well it was received. So this time, let’s tackle one of the giants: One Flew Over the Cuckoo’s Nest.

Just how realistic is this movie when it comes to the general rules, layout, and procedures in a mental hospital? First, let me just get this statement out: As wonderful as the film of Cuckoo is, the book is even better. I said this before, for Dragon Tattoo and for A Clockwork Orange. Notice that I did not say this for Twilight, as I personally believe those books make you dumber for reading them.

But this blog is about the movie. When I was in grad school, I worked as a psychiatric technician at the county mental hospital. If you’re not familiar with that job, it’s sort of a combination of three major duties. First, I was assigned between two and five patients each day, and I would interact with them, play games, talk about their needs, eat with them, etc. At the end of my shift, I’d write a report of everything in each patient's record.

Part 2 was to complete intake interviews with new patients and orient them to the hospital by giving a tour and explaining the rules. Finally, I was sort of an ad-hoc security guard, in case any of the patients decided to escape (which only happened once while I was there) or attack (which happened pretty frequently).

The basics

Cuckoo’s Nest is basically about a man named McMurphy who decided that life in a mental hospital would be easier than life in prison, so he decides to “fake” being “crazy” to be moved. The rest of the movie is about his interactions with the other patients and with the villain of the story, Nurse Ratched.

When I worked at the hospital, we did occasionally get prisoners who had been moved, so that part is correct. Most prisons don’t really have the facilities necessary to help people with mental issues. However, a big difference between the movie and reality is that while I worked there, the hospital only got two or three people from the prison, and they had attempted suicide.

McMurphy goes through an interview upon arrival, which is also pretty realistic. My job during this aspect of my duties was to fill out a two-page form that was partially patient responses to questions (like, “What day is it?” “What do you hope to get out of your hospital stay?” and “Are you planning to escape?”), and partially my observations of the person during the interview (such as whether he or she was cooperative or showed verbal symptoms of schizophrenia). I also had to do a strip search for each person (not my favorite part), checking for any cuts, bruises, or contraband the person might be trying to sneak in.

The Architecture of the Hospital

Cuckoo’s Nest was filmed in an actual mental hospital, which of course makes this aspect of it very realistic. The hospital used was Oregon State Hospital. One purpose of the book and movie was to highlight the terrible conditions of mental hospitals of the time, especially in terms of these huge “mansion” type buildings. Why are all these old hospitals so frikken’ big? The answer is the Kirkbride Plan.

In the mid-1900s, there weren’t a lot of good pharmaceutical treatments for mental illness, so the number of patients in need of a place to live was massive. While early mental hospitals couldn’t handle the numbers and treated people extremely badly, a trend called “Moral Management” called for these people to be treated with the care and respect that everyone deserves. So the Kirkbride Plan for mental hospitals was created. The Plan called for spacious, clean buildings that provided fresh air, sunlight, gardens or courtyards, and comfortable rooms for the patients.

Oregon State Hospital was built using the Kirkbride plan, so in this way, the movie shows a pretty representative physical structure. What’s interesting about the Kirkbride Plan and Moral Management was not just the physical expectations, however; patients were also supposed to be treated with a high level of ethical respect. This is where Cuckoo’s Nest—and Oregon State Hospital—both get interesting.

Ethics in Mental Hospitals

When I was trained to work in the county mental hospital back in the late 1990s, ethics were a big deal. Respect confidentiality, respect patient needs, respect patient safety first and foremost. Oregon State Hospital (the real one) is actually pretty infamous for treating the patients fairly terribly. Perhaps most well-known is that in 2004, a search of the hospital grounds unearthed a total of 3,500 cremated bodies of former patients who had been stuck inside copper barrels over the past 100 years of the hospital’s existence. Only about half of the hospital is currently being used, because a lot of the original buildings had to be closed down due to things like leaky roofs, asbestos, and lead paint.

In the movie, lack of concern about patient safety is an interesting theme. The guards are portrayed as easily corruptible simpletons who can be bribed with a bottle of booze. (While I worked at the hospital, I guess some people might have thought I was a simpleton, but the patients certainly didn’t have access to loads of cash or entire bottles of booze). Interestingly, the African American guards are also depicted in a somewhat racist fashion, but unfortunately at the time, many undesirable jobs were “assigned” to citizens with fewer options (kind of like undocumented workers today who work in dangerous meatpacking plants). Everyone who works at the hospital in the movie has decided that ECT (electric shock therapy) should be used to punish unruly patients, instead of as actual treatment for schizophrenia (which used to be common) or depression (which is still fairly common).

Of course, the highlight of Cuckoo’s Nest is the fascinating interaction between McMurphy and Nurse Ratched. She has complete control over his life, something with which he struggles mightily. He is surprised to discover that it is up to her and the psychiatrists whether he is “released,” and that he doesn’t just have to wait until his prison sentence is up.

This aspect of the movie is true. If a patient volunteers to reside in the hospital, he or she can check out at any time. But if a patient is assigned to the hospital by a judge or referred there by somewhere like a prison, the staff can decide whether to release that person based on his or her possible danger to self or others.

But what about the terrible way Ratched treats McMurphy? I’ve met a lot of psychiatrists and I observed dozens of people while I worked at the hospital. Sure, it’s possible that somewhere, there’s an evil person corrupting his or her patients. But I think this must be highly unlikely. In my experience, people who work in the field of mental health do so not because they want to get rich, hold power over others, or conduct weird experiments. They get into the field of mental health because they want to help people.

This conclusion isn’t particularly dramatic, and it won’t make for good cinema. Cuckoo’s Nest is realistic in some ways, and it was a hugely important movie for the time, because it helped bring attention to some hospitals with unethical practices or unsafe living conditions. Both the book and the movie are insightful views into societal problems such as stereotypes about people who have mental disorders. But the film is largely out of date in terms of depicting hospital staff as manipulative or evil. From what I saw when I worked in a similar institution, mental hospitals are calm, healing environments—as they should be.

Copyright Wind Goodfriend, Ph.D.