The Cuckoo’s Nest; decriminalising mental illness

The BMJ doesn’t often publish obituaries of provincial American doctors. But it gave Dean Brooks a full page send-off. Why?

From 1955 till 1981 Dean Brooks was superintendent of Oregon State Hospital. That’s where they filmed One Flew Over the Cuckoo’s Nest. It’s a 1975 classic film. It tells the story of Randle P McMurphy, a petty criminal who decides it might be more comfortable to serve out his sentence for statutory rape in a hospital rather than doing hard labour in prison. He, and we, find out how wrong he was, and he ends up, well, I won’t spoil the story but in his defeat he has enabled someone else to live. The film won five Oscars and made Jack Nicholson a superstar.

Back to Dean Brooks. The book from which the film was (quite faithfully) taken was published in 1962 and set in Oregon State Hospital. Ten years later Hollywood producers called to say they would like to make the film there. Brooks was interested. He felt strongly about the dignity of psychiatric patients and saw it as a chance to advocate for the mentally ill. And he thought it would be fun. He discussed the proposal with patients. They were keen. His fellow doctors were ambivalent. The hospital authorities were adamant: they forbade him to speak to the film people. So he didn’t. But his wife did. As Brooks said, “It’s easier to ask for forgiveness than permission”.

Brooks insisted that the patients be treated with respect, and that members of the film team, including the director and scriptwriter, spend time with the patients. The crew lived in the hospital before filming started, and during the 14 weeks of filming the actors lived there too. They stayed in role during breaks from filming. When Jack Nicholson arrived, he couldn’t tell them from the patients.

Around 90 patients took part in the filming. The director asked Brooks to read for the part for hospital superintendent. Brooks threw down the stilted script, and he and Jack Nicholson ad-libbed their scenes together. They are brilliant. Also unscripted was a scene where McMurphy’s future care is discussed by the doctors, mostly played by psychiatrists at the hospital, and the chief nurse, the chilling Nurse Ratched. Louise Fletcher’s performance won her an Oscar.

In the 1960s patients admitted with acute mental problems were housed together with long-stay patients with developmental problems. The film could have been a freak show. But it isn’t, although most doctors will recognise patients from their days in psychiatric units. They will recognise the group therapy sessions. They will recognise the doctors’ and nurse’s discussion of McMurphy’s mental state.

For the anti-psychiatry movement, the film was a gift. The group sessions, led with deceptive reasonableness by Nurse Ratched, may initially appear therapeutic. But as they develop, and particularly when McMurphy challenges her authority, they are instruments of coercion and control. If that doesn’t cow the patient, the next punishment for insubordination to her regime is ETC without anaesthesia. The ultimate threat for those who fail to conform to rigid ward rules is lobotomy, and the patients know it.

Oregon State Hospital in Salem, Oregon circa 1920

Oregon State Hospital in Salem, Oregon circa 1920 (Photo credit: Wikipedia)

Brooks was aware that ‘Cuckoo’s Nest’ could be used as a weapon against psychiatry. He insisted that the film be set in 1962, when the book was published, with a disclaimer pointing out that by 1975 psychiatry had moved on from the regimes depicted in the film. Brooks saw that the story is an allegory about power and how it is abused in any institution.

The film’s message is as relevant as ever. How many hospital superintendents in 2013 would welcome a film crew making a feature film like Cuckoo’s Nest into their hospital? I can’t see any chief executives allowing it. And any doctor making the case for filming would quickly be subject to gagging, the modern contractual version of ECT. True, psychiatric care has changed. Nevertheless, chemical coshes are still used to control patients for the convenience of society.

Are there any institutions which don’t seek to smother dissent? The talk in the prison service may be about rehabilitation but the reality is about control. And how many care homes manage to put the dignity of frail elderly residents above institutional needs? As in everyday life, it is very hard to counter passive aggression, and the easiest strategy is to submit.

In an interview recorded a few months before he died, Dean Brooks describes what putting patients first meant for him. When he went to Oregon in 1955, most psychiatric patients were obliged to wear identical baggy outfits. Brooks’ patients wore their own clothes. The lights in their dormitories were turned off at night so they could sleep better. Every opportunity was taken to break down barriers between the hospital and the community. He set up a task force of ten patients, ten staff and ten members of the community. He organised a 16-day wilderness hike for 51 chronic patients and 51 members of staff, an exercise in shared survival which proved transforming for relationships between patients and staff and healing for a substantial number of the participants.

Up to his death he campaigned for the decriminalisation of mental illness. And, something that particularly struck me, he always sorted his mail into piles. Then he opened letters from patients first. He left mail from managers to the last.

Homage to a remarkable man, remarkably memorialised in an Oscar-winning Hollywood film.

In an interview for Mad in America in January 2013, Dean Brooks talked about his philosophy and his work.

His obituary appeared in the BMJ on 16th July 2013

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