Milos Forman, the director of One Flew Over the Cuckoo's Nest, died on April 13, aged 86. This iconic film, released in 1975, is, even today, familiar to our medical students. Many have seen it and approach their psychiatric placements at medical school, in the 21st century, as if practices from the middle of the last century were still prevalent.
It was based on a book of the same name by Ken Kesey, published in 1962. There are some differences between the film and the book, and the most germane relates to the charges that resulted in the protagonist, Randle Patrick McMurphy, being sent to the psychiatric institution.
McMurphy was an Irish-American Korean war veteran who had been awarded the Distinguished Service Cross, but later dishonourably discharged for insubordination. In the book he was a criminal found guilty of statutory rape. But in the screen version, he was sent to the psychiatric institution for committing petty offences and for an "incident on the farm" where he worked.
This rewriting of this element of the story was presumably to garner sympathy for him with the audience. He faked insanity so that he would be sent to a psychiatric hospital rather than prison, in the hope of having a comfortable, restful time there.
Once in hospital, his insubordination was evident from the beginning, when he came in contact with the powerful Nurse Ratched. She became the personification of those who were in charge of locked psychiatric wards in these institutions - cold, controlling, heartless and cruel.
More powerful than the doctors, nurse Ratched had the clout to exact the ultimate punishment on McMurphy when he attempted to dismantle her control, by giving him shock therapy and later, having him lobotomised.
This procedure involves cutting the nerves between different parts of the brain so as to alter behavioural disturbances such as aggression and extreme agitation. It was initially carried out on patients in the late 1880s but fell into decline until 1935 when it was reinstated as a treatment for psychiatric illness.
Lobotomy was still in use in the 1960s when the book was written, but by 1975, the year the film was released, it had disappeared from psychiatric practice following the discovery of antipsychotic and antidepressant medications.
One of the more caring people in the film was the psychiatrist, Dr John Spivey, who in real life was Dr Dean Brooks, Director of Oregon State Hospital, where the film was set. The other is Chief Bromden, a gentle giant, who narrates the story. He is an electively mute Native American and McMurphy's only confidant.
As a study of the rigid and oppressive nature of institutional processes in psychiatry the film is a masterpiece. Yet even at the time that it was released the practice of psychiatry and the state of its institutions was changing over to care in the community. The practices depicted were obsolete.
The same cannot be said for the book, which was published at the height of the antipsychiatry movement in the 1960s. This was promulgated by radicals such as Thomas Szasz, Foucault, Cooper, Scheffe, Laing, Lacan, Lidz and Goffman, among others.
Put simply, their view was that mental illness either did not exist or if it did, it was due to oppression and other environmental causes, among them what were termed "schizo-phrenogenic parents". Such illness required therapy, not pills or ECT.
While the book, and subsequently the film, may have hastened the end of institutional care, already in train, it has left the public with a view of psychiatry that is still seen through that particular, defunct, cinematic lens.
Even in general parlance patients who are discharged following treatment in psychiatric units (now almost all exclusively in general hospitals) are described as being "released" even though they have sought treatment of their own volition, just as with people with heart disease or arthritis.
The use of medication to treat severe depression, for example, is still met with hostility from many, while the use of legal detention to treat a person who is psychotic and placing themselves or others at risk of grave ham is frowned upon as evidence of hegemony and social control.
Terms such as "lunatic", "basket case" and "funny farm" are still used as slang for mental illness.
One Flew Over the Cuckoo's Nest has had an enduring impact and some of that may be due to the personal story of Forman himself. His mother died in a Nazi Concentration camp during WWII, while he left his native Czechoslovakia during the 1968 Communist invasion. Oppression, witnessed and experienced, has thus been a metier of his life and perhaps it is that familiarity which gave this work its enduring power.
May he rest in peace.