Historical Context

Ken Kesey (1935-2001), born in Colorado and reared in Oregon, appreciated nature and loved wrestling. He received a degree in speech and communication from the University of Oregon. Then, with a Woodrow Wilson Scholarship, he enrolled in the Stanford University Creative Writing program. While a graduate student, he participated in life-altering psychology department research involving psilocybin, mescaline, amphetamine, and LSD. For several weeks Kesey, a 24-year-old paid research volunteer, ingested these mind-expanding drugs. Later, as a Veterans Administration psychiatric ward orderly on the night shift, he observed that many of the patients, rather than being crazy, were just nonconformists in a sterile environment. While drug-induced, Kesey hallucinated about an Indian sweeping the floors, who became Chief Broom, his schizophrenic narrator in One Flew Over the Cuckoo's Nest. His novel was an immediate success, allowing Kesey and his wife Faye to buy a farm that became a site for an influential bohemian community experimenting with drugs, believing altered mental states could improve society. Because Kesey's parties were notorious for illegal drug use, he was soon arrested and jailed for several months. Nonetheless, with his new fame, Kesey drew the attention of Neal Cassady (hero of Jack Kerouac's On the Road) and others, and soon the hippie-aesthetic, antiwar group the Merry Pranksters was formed, exploding into the psychedelic era.

In 1964 the notorious Pranksters drove cross-country in a Day-Glo bus, ostensibly to see the New York World's Fair, but it became instead a creative adventure. Cassady drove the bus, and its riders dropped acid and smoked marijuana along the journey, which was filmed for posterity. The bus became a metaphor for "living your art," and the saying "You're either on the bus or you're off the bus" was Beat Generation lingo for creative tripping. The exploits of the Pranksters are the subject of Tom Wolfe's The Electric Kool-Aid Acid Test (1968), a book voraciously consumed by antiestablishment hippies in search of the universe within. Kesey went on to write other novels, but none achieved the success of Cuckoo's Nest, which subsequently influenced popular culture with its stage and film productions. Late in life, Kesey, the pied piper of the psychedelic era, took drugs only for his diabetes and hepatitis C, finding the pure adrenaline of experiencing nature enough. He died on November 10, 2001, in Pleasant Hill, Oregon, following surgery for liver cancer.

Cuckoo's Nest continues to be a prototypical depiction of mental illness by describing various mental disabilities as well as the legal and ethical issues arising from them. The novel's publication brought to the American consciousness what a slow and arduous process it has been to define and to devise treatment for mental disorders. From Colonial times, before the proper diagnosis of the mentally ill and retarded, madmen roamed free. Alternatively, shamed families cruelly locked abnormal relatives in an attic or chained them to a wall. Society's first priority was to feel safe, then to punish the evil they believed inherent in the mentally ill. The very first mental institutions were small, primitive nontherapeutic holding facilities, such as the one founded in Williamsburg, Virginia, in 1773. Until larger mental asylums were created, particularly troublesome individuals, including the poor, were incarcerated with criminals or sent to the poorhouse.

Over time many unusual theories have been espoused regarding the diagnosis and treatment of mental illness. In the late 1700s, Philadelphia's Dr. Benjamin Rush, a signer of the Declaration of Independence and the Father of American Psychiatry, challenged demonic causation and believed moral treatment that controlled the environment would cure insanity in acute patients. Thinking brain arterial disease resulting from gluttony caused mental illness, he advocated a restricted diet, extensive bleeding, emetics to encourage vomiting, and hot or cold showers to slow metabolism. He also invented the gyrator, a spinning chair or plank upon which the patient was tied, designed to increase the brain's blood supply. Rush's Medical Inquiries and Observations upon the Diseases of the Mind made him a revolutionary authority on madness, and he became a popular lecturer. Much later, in the mid-1800s, Christian social reformer Dorothea Dix (1802-87) raised money to establish the first state mental institution in Massachusetts after she saw the mentally ill housed with criminals in unsanitary conditions.

Her efforts brought national focus upon human rights abuses. Since that time, numerous civil rights laws help differentiate criminals from the mentally ill who are often involuntarily committed upon proofthey would be a danger to themselves or others. With an increased awareness of civil liberties also came an individual's right to refuse treatment. State-specific rules apply to involuntarily committing and treating teenagers. The remedy for being confined against a person's will is to have a lawyer file a habeas corpus petition with the court asking the institution to show cause why that person should be held. Thus, insanity (lacking mental capacity) is foremost a legal term, rather than a medical one.

In the late nineteenth century the upper class with socially acceptable nervous diseases oftentimes voluntarily availed themselves ofshort and long-term residencies, such as in Philadelphia neurologist S. Weir Mitchell's rest cure, involving isolation, electrical massage, and a milk diet. Charlotte Perkins Gilman in "The Yellow Wallpaper" chronicles her incipient insanity and the "wise man" who withdrew her from all active stimulation by putting her to bed to rest. At the end of her treatment, she was ordered to return to domestic life and only "have but two hours' intellectual life a day" and "never to touch pen, brush, or pencil again." After three months, these conditions pressed her "near the borderline of utter mental ruin," she wrote later ("Why I Wrote 'The Yellow Wallpaper'"). Ironically, after Dr. Mitchell read her account of descending slowly into madness and the ineffective cure, he altered his future treatment for neurasthenia (meaning "tired nerves") and melancholia (depression). Another popular spa treatment to calm agitation was hydrotherapy, which was more than a nice warm bath. For instance, one practice was to wrap an agitated patient in cold (50 degree), wet sheets. A very disturbed patient could be placed in a continuous bath 18 hours a day for two to three weeks, or however long it took to change the aberrant behavior. The dangers of hydrotherapy were hypothermia, convulsions, and even drowning.

Another part of U.S. history, the 1920s eugenics movement, unfortunately influenced the 1940s Nazi practice of sterilizing the feebleminded. In Germany it led to euthanizing the congenitally inferior in order to purify the population. The movement began after the American Civil War when medical professionals, who saw few results from the Moral Movement, embraced the idea of Social Darwinism (countries fail from inherent weakness). Patients were being increasingly subdued by drugs such as chloroform, bromides, and ether, and 30 states, with the support of prominent Americans, legalized forced sterilization. In Virginia, Carrie Buck was an institutionalized 18-year-old unwed mother whose mother and child were also feebleminded. She was forcibly sterilized under Virginia's 1924 eugenics law. Her case was appealed to the Supreme Court, claiming that the plaintiff, under the Fourteenth Amendment, was denied due process and equal protection of the laws. However, Supreme Court Justice Oliver Wendell Holmes in Buck v. Bell (1927) upheld the state eugenics law, declaring "three generations of imbeciles are enough." With this precedent, over the next 40 years 60,000 people nationwide were sterilized for other types of unacceptable behaviors or conditions, such as alcoholism, promiscuity, criminal acts, epilepsy, and running away from home. In an attempt to make restitution, several governors have formally apologized to their states' eugenics victims.

Besides sterilization procedures performed for the greater good, in the 1930s Washington, D.C., neuropsychiatrist Dr. Walter Freeman pioneered his drastic ice-pick psychosurgery. Also known as lobotomy, it initially involved partially destroying one of the brain's frontal lobes, thus causing great disfiguration. Freeman explains in "Glimpses of Postlobotomy Personalities" how, when all else fails, the desired change in the patient's anxious and fearful personality is effected: "Without the long, painful process of developing insight in the patients, psycho-surgery somehow relieves them of their sufferings and makes it possible for them to go back to their homes and to survive in the very environment in which their disorders developed" (Robinson and Freeman, 15). In his case studies, however, the postoperative realities sound grim. Patients often were described as slothful, irritable, and angry. Nonetheless, in A History of Psychiatry Edward Shorter points out, "The idea of operating on the brain to cure madness does not seem intrinsically unreasonable. Physicians have always intuited that a physical intervention in the brain, perhaps cutting some tract causing compulsive behavior or removing a center producing some malignant protein, might put an end to a pattern of psychosis" (Shorter, 225). The relationship between the brain and the mind is being continually studied, of course, with new methods of brain imaging such as MRI (magnetic resonance imaging), CT (computerized tomography), and PET (positron-emission tomography) proving immensely helpful in diagnosing and mapping progressive diseases. Although the adverse publicity arising from Cuckoo's Nest caused lobotomy to be largely replaced with antipsychotic drugs, today successful psychosurgeries like cingulotomy relieve severe compulsive neuroses and depression.

Besides psychosurgery, electroshock therapy (EST), also called elec-

troconvulsive therapy (ECT), which is also prominently featured in Cuckoo's Nest, has proved a valuable psychiatric treatment for mental illness. In 1938, after an earlier scientist observed that schizophrenics seemed symptom-free following seizures, Italian scientists Cereletti and Bini devised electroshock therapy as an efficient way to manage uncontrollable patients. Today, a severely depressed patient receiving ECT, administered in a series of treatments, has an intravenous relaxant administered and a mouth guard inserted before an anesthetic renders him unconscious. The airway is protected, and electrodes are connected with conducting jelly on the temples. Electric current comparable to a 60-watt bulb shoots through the brain causing a 20-second grand-mal seizure. The patient wakes about 30 minutes later, confused and disoriented, with a headache and short-term memory loss. In essence, ECT helps disturbed patients regain the control necessary to enter into a therapeutic relationship. Short-term impaired memory follows; complications from possible fractures and dislocations caused by muscle contractions are a thing of the past. For generations Kesey's Cuckoo's Nest inflamed the public consciousness by depicting ECT as a means to punish misbehaving patients, easily associating it with electrocution. Over the years attempts to pass state laws banning ECT have failed. As horrific as it sounds, some neuro-psychiatrists still find ECT to be an effective treatment for severely depressed and suicidal patients, especially after psychotherapy and slow-acting, cyclical drug regimens fail. Depression, more than a character weakness and feeling just down, is a brain disease often detectable on a PET scan that indicates receptor chemistry abnormality. It affects millions of Americans who often feel ashamed they cannot pull themselves up by their bootstraps. Hence, they often fail to seek help. New electromagnetic brain treatments, easily applied and without side effects, are proving effective, and recent NIH DNA studies indicate a 50 percent to 80 percent genetic component. In 2003 scientists, after working decades, documented a clear link between a gene controlling serotonin levels in the brain and depression, leading to possible new drugs. Tying genes with behavior, scientists say depression has roots in both genetics and personal history (i.e., nurture and nature).

The beginning of World War II brought more awareness to mental and emotional problems with more than a million inductees rejected for military duty as unsound. This was shocking evidence of public fragility. Returning servicemen, on the other hand, benefited both from medical advances, such as penicillin and blood banking, as well as from psychiatric screening. Subsequently, the number of psychol ogists proliferated and terms such as post-traumatic stress disorder (PTSD) were coined. PTSD, formerly referred to as battle fatigue or shell shock, is not new, but the term continues to be applied to returning soldiers with ongoing problems such as loss of concentration, sleep disturbances, nightmares, flashbacks, intrusive thoughts, and emotional stress. This spotlight on identifying prospective mental disorders brought about the National Institute for Mental Health in 1949, advocating more study on the origins of mental illness, its diagnosis, and its treatment. For the first time—in the place of hospitalization—the new drug chlorpromazine was used to relieve anxiety and control delusions. Thorazine, the prescription straitjacket, was used to treat and ameliorate depressive or compulsive disorders. With the widespread use of these drugs and others, the psychopharmaceut-ical revolution in mental health care began. Ironically, as the 1950s rolled in, the counterculture movement looked to their drugs, such as LSD and peyote, to escape from the conventional rationality.

The psychiatric climate in the 1960s when Cuckoo's Nest was published included two main schools of thought: the behaviorists and the humanists. A leading American behaviorist, B. F. Skinner (1904-90), believed we could solve major mental problems by improving our understanding of human conditioning. When he objectively observed aberrant behavior, he felt it should be ignored or punished. Good behavior, he thought, could be positively conditioned with encouragement and reward. Behaviorists tended to pigeonhole patients into categories in which they would be forever tracked. The other major view of the time came from the humanists who hesitated to label the patient but who also socially constructed mental illness. For example, Scottish psychiatrist R. D. Laing (1927-89), "the philosopher of madness," believed that a schizophrenic only acted abnormally as a mechanism to cope with a stressful situation. This view is increasingly seen as outdated as work is underway to confirm a genetic mutation as the disease's cause. Two million American schizophrenics have lost touch with reality, hallucinate, and suffer from this disabling disease. Laing vehemently opposed the dehumanizing use of ECT and lobotomy. American psychiatrist Thomas S. Szasz (born 1920) took humanism a step further by writing about "the myth of mental illness" and the ethical and moral issues physicians contend with. He advocates patient autonomy, including the right to refuse involuntary "imprisonment" and treatment. For better or worse, in recent times mental patients have greater civil rights, and more scrutiny is given to psychiatric institution admission methods, leaving the standard five-day admission to include a quick psychiatric evaluation, drug readjustment, and then release. The result is that a large population of mental patients is not benefiting from lengthy psychotherapeutic interactions with caring psychiatrists and, therefore, is left to fend for itself, often on the street.

Mental institutions in the1970s, due in part to Cuckoo's Nests adverse publicity that fostered hostility against authority, were seen as warehouses that inflicted physical and sexual abuse on patients. With the current trend toward deinstitutionalization, more patients are treated on an outpatient basis with psychotropic drugs. There are new ways to diagnose and many other types oftreatment for mental illness, of course, besides psychosurgery, ECT, drugs, and confinement. In the early part of the twentieth century American psychotherapy, which tended to classify disorders by symptoms rather than causations, proliferated. It stemmed in part from the work ofAustrian Sigmund Freud (1856-1939), the Father of Psychoanalysis. Psychotherapy slowly became popular and arguably successful. Some of the concepts that Freud's talk therapy popularized, as translated, included the Oedipus complex; the id, ego, and superego; anxiety and defense mechanisms; repression, displacement, and rejection; and the libido and death instinct. His therapeutic approaches include dream analysis, free association, and transference. Indeed, Freud even made the terms hysteria and penis envy household words, but today criticism ofhis unorthodox research methods and emphasis on sexuality makes his practices less relevant. Currently, one in four American adults seeks professional psychological advice some time during his or her life for services ranging from treating severe depression to counseling on life strategies. The stigma is gone. New disorders, some consider fads, are continually being defined, including the seemingly pervasive attention deficit hyperactivity disorder (ADHD). In 1995, 2.5 million American children were on Ritalin. In the 1980s multiple personality disorder (MPD) became epidemic. In essence, critics claim personality traits formerly seen as eccentric or troublesome are being pathologized, causing the field of psychiatry to grow. Again, for better or for worse, in recent times drug therapy—even with its side effects—continues to replace lengthy patient-oriented talk sessions as the gold standard of care.

Because the history of mental illness reaches back as far as the written word, this abbreviated version provides merely a snapshot illumination of specific issues in Cuckoo's Nest. Age-old attempts to treat madness seem from our perspective today, cruel and unusual. Besides, with pathology poorly defined, odd behavior alone would be cause for confinement. Today, while new methods advance understanding and care, a significant part of the future of mental illness diagnosis may lie in constant revelations arising from brain imaging and the deciphered genome, with the promise of targeted treatments. Nonetheless, even with vast knowledge of the human body, Edward Shorter adds, "Science wanders astray easily in the world of quotidian anxiety and sadness, in the obsessive traits of behavior and the misfiring personality types that are the lot of humankind. Here the genetic trail grows dim and the neurotransmitters evaporate. Biology counts for little, culture and socialization for lots" (A History of Psychiatry, 288). The nature versus nurture debate is very much alive.

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