A Re-Write of “One Flew Over the Cuckoo’s Nest” that addresses serious ethical issues with an ending in which the ward patients are encouraged to heal and grow.

This post identifies a number of serious ethical issues in the treatment of patients in the psychiatric ward in the film One Flew Over the Cuckoo’s Nest and proposes a re-write of the story climax in which the ward patients, including McMurphy, are encouraged to engage in narrative group therapy.
The film (Forman, 1975) begins with Randall Patrick McMurphy in transit from a work farm where he had been imprisoned for assaulting someone in a bar room brawl. His previous history of violent behavior along with his bizarre, 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 Dr. Spivey is clearly aware of it. Does McMurphy have a serious psychiatric disorder or is he hoping for a leisurely gig in the hospital psychiatric ward?
Ethical Dilemmas Dramatized in the Story
McMurphy’s brief stay in the psychiatric ward supervised by Nurse Ratched is a disaster, both for McMurphy who is ultimately lobotomized, and another young man, Billy Bibbit, who commits suicide.  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 daily therapy group sessions for the men in the ward who are able to  participate, including McMurphy. Although she is a qualified registered nurse, Ratched appears to have virtually no formal training or experience in family therapy, group therapy or in leading a therapy group. Thus the role she performs as group leader clearly lies outside the boundaries of her competence, education, training, and supervised experience (American Psychological Association, 2002, 2.01). And this leads to six additional ethical violations that slowly build upon each other in a crescendo of empathic breaches and sadistic interventions from Ratched that by any ethical let alone humanitarian measure can surely be viewed as an iatrogenic nightmare. In reviewing these ethical violations (I’m tempted to call them travesties), key phrases to keep in mind from the American Psychological Association’s  Principle A: Beneficence and Non-malfeasance, include: “Take care to do no harm…seek to safeguard the welfare and rights of [patients]…when conflicts occur…attempt to resolve these conflicts in a responsible fashion that avoids or minimizes harm…[and be] alert to and guard against personal…social, organizational or political factors that might lead to misuse of…influence” (Koocher & Keith-Spiegel, 2008, p. 551)

In the first of these breaches, Ratched 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 the other members of the ward, all of whom are in a vegetative state and unable to vote let alone participate in group therapy.

Third, Ratched 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 with a bone chilling expression, “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 McMurphy is sent for electro convulsive therapy, 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 toxic of Ratched’s interventions is reserved for Billy Bibbit in group, after she finds 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 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. In this tragic moment, we can add violation of confidentiality to Ratched’s long list of ethical violations (American Psychological Association, 2002, 4.05).

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, McMurphy is lobotomized and Chief Bromden, who has developed 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. He then pulls a water fountain from the floor in the bathroom, hurls it through a window and escapes to freedom.

 The Rewrite of the Story Climax

 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, Andre Moore, a creative life coach and recovering psychoanalyst sit around the conference table discussing 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 my recommendation in an angry outburst that stuns Spivey and the others and 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, gracefully and walks out of the room. As she leaves, I wonder how much help this poor alienated woman might get from a supportive peer group composed of these men and the other nurses in 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 Spivey in his office, I make my pitch to him. 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:

  1. 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.
  2. 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.
  3. 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.
  4. 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:

  1. McMurphy tried to pull the water fountain from the floor in the bathroom and failed but proudly said, “At least I tried!”
  2. 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.
  3. 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.
  4. When he organized an all night party for them.
  5. 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.
  6. 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 deeply empathetic men (a few of whom remind me of the Elephant Man) 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, post, post analyses of variance. Spivey, being a rational man of science with a keen desire 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, witha 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 null hypothesis on the therapeutic value of his reflecting team, his eyes light up like a pinball machine and he almost jumps off his chair with glee! This is how I close the deal with Spivey, eminent psychiatrist and man of science who, it shouldn’t surprise you, also claims a place in Appendix J among the DSM-IV-TR’s distinguished contributors (just kidding). I never once try to sell Spivey on the real value of the reflecting team: To show the ward patients how deeply their psychiatrists, nurses and psychotherapists (including McMurphy) care about them, caring steeped in the value of benevolence (White, 1985; Goldenberg et al, 2008; Schwartz, 1994, 1992).

I leave Spivey’s office breathing a sigh of relief and think to myself that pitching Nicholas Cummings at Kaiser Permanente would have been a piece of cake compared to him. Why? Because Cummings would probably have been smart enough to realize that we don’t need a control group to evaluate the efficacy of the therapy.

References

American Psychological Association. (2002). The ethical principles of psychologists and code of conduct. Washington, DC: Author.

Forman, M. (1975). One Flew Over the Cuckoo’s Nest. Drama. Los Angeles: Fantasy Films.

Goldenberg, H., Goldenberg, I. (2008). Family therapy: An overview. Belmont, CA: Brooks/Cole.

Koocher, G.P., & Keith-Spiegel, P. (2008). Ethics in Psychology and the mental health professions (3rd Ed). New York: Oxford University Press.

Schwartz, S. H. (1994). Are there universal aspects in the structure and content of human values? Journal of Social issues, 50, 19-45.

Schwartz, S. H. (1992). Universals in the content and structure of values: Theoretical advances and empirical tests in 20 countries.In M. Zanna (Ed.), Advances in experimental social psychology, 25, 1-65.

White, M. (2007). Maps of narrative practice. New York: W. W. Norton.

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