Flying Back Over the Cuckoo's Nest

I first saw "One Flew Over the Cuckoo's Nest" in 1975 while I was in college and readily identified with the hell-raising, force-of-nature R. P. McMurphy portrayed by Jack Nicholson. McMurphy represented rebellious individuality and freedom in opposition to the establishment's spirit-crushing conformity machine.

Five years later I was a behavior specialist in a secure facility serving young men with mental retardation who had committed felonies. Barely 22 years old and working in an environment with sometimes alarming levels of violence and aggression, I began to regard Nurse Ratchett with more sympathy.

After more than a quarter century in the field, with much time learning, reflecting, and making more mistakes than I can count, I view things from a certain vantage point. I now see all the characters in the story - staff and patients alike - as casualties of a corrosive process of institutionalization. McMurphy may have had brain tissue extirpated, but Ratchett has lost whole parts of her soul.

"One Flew Over the Cuckoo's Nest" is full of operatic moments and epic confrontations. It's theater, not reality, but it holds a mirror up to a reality with which many of us are uncomfortably familiar. Nurse Ratchett is a caricature, but I've known many of her real-life referents, professionals with power over people's lives, who had neither the wisdom nor humility to use that power responsibly. I've also seen decent people with good intentions lose their way with tragic results. In my experience, poor working conditions, weak leadership, unprocessed trauma, inadequate supervision, and ineffective training can be insidious and nearly as destructive as laziness, arrogance, fear, and selfishness. In this way Ratchetts are made as often as they are born.

The soul-erosion on all sides can be subtle and quiet, progressing unnoticed like a malignancy. Neurologist and teacher Oliver Sacks chronicles this process in A Leg to Stand On, a memoir of his own hospitalization and rehabilitation from a life-altering accident. While hiking in Norway, Sacks fell off a cliff, fleeing from a murderous bull (I kid you not; read the book). The quadriceps in his left leg tore completely loose from the patella and his femoral nerve was damaged, leaving him without sensation or motor control. Completely alone on the mountain, Sacks realized he would die unless he dragged his body back down the trail to reach help, which he did.

As in all his books, Sacks takes the reader on a journey through neurological phenomena and the human experience. This time, he shares his personal story of struggling to recover from a devastating injury while enduring spirit-withering treatment at the hands of his medical caregivers. Perhaps most interesting, after being moved from a room in which he'd been confined for several weeks, the author discovered that his visual field, at least the stereoscopic component, had shrunken to conform to the dimensions of that room. Everything within the boundaries of his confinement was clearly three dimensional, but the world beyond it was curiously flat and less distinct. His vision had accommodated to the diminished size of his world. In due course his vision normalized, but the experience provided a profound insight into what it means to be a patient and what is involved in recovery.

With each step, each advance, one's horizons expanded, one stepped out of a contracted world - a world one hadn't realized was so contracted. I found this in every sphere, physiological and existential...

We speak, glibly, of "institutionalization," without the smallest personal sense of what is involved - how insidious, and universal, is the contraction in all realms... and how swiftly it can happen to anyone, to oneself.

The implication for those of us supporting people with psychiatric, developmental, and physical disabilities is clear. The people we support live in very small worlds, worlds often kept small by the manner in which we deliver services. Helping people expand the size of their worlds -socially, vocationally, physically, emotionally, recreationally, and existentially - must be a top priority. Institutionalization isn't about the kind of buildings or real estate one occupies, it's about the loss of power, movement, freedom, and vision.

But how do we keep ourselves from becoming institutionalized?

Oliver Sacks points out that the process is often unseen and unheard, and can overtake any of us unaware. Awareness and the will to resist institutionalizing influences in ourselves and in others is a good start. Reflecting on our own practices and questioning our assumptions can keep us from becoming lazy or lapsing into superstition. Celebrating successes - individual and group - can keep us positively focused. Practicing honesty and individual integrity, honoring the good work of others, courageously confronting our colleagues when needed, receiving praise with grace and correction with gratitude, and perhaps most importantly of all, approaching the lives of others with humility, are all ways we can keep our humanity as we help others to live full lives.

-October 2005