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Ken Kesey and the Rush to Deinstitutionalization

Whatever the literary strengths of One Flew Over the Cuckoo’s Nest, the book has done much to harm both the mentally ill and their communities.

· 11 min read
Ken Kesey and the Rush to Deinstitutionalization
Nurse Mildred Ratched (Louise Fletcher), in a publicity photo from the 1975 film version of One Flew Over the Cuckoo’s Nest.

Ken Kesey (1935–2001) was a great admirer of manliness, a quality that would inform his countercultural indictment of America’s attitude toward mental illness, and of postwar America more generally. The darkly comic 1962 novel for which he is known, One Flew Over the Cuckoo’s Nest, likened US society to an asylum in which men (in particular) are stripped of freedom and psychologically castrated. Inspired by interactions with patients at a San Francisco-area Veterans’ Hospital—which sometimes coincided with his own participation in clinical studies on the use of mescaline, LSD, and other hallucinogenic drugs—Kesey came to believe that these institutions only made people sicker, notwithstanding the grand scientific pretensions under which they operated.

First edition of One Flew Over the Cuckoo’s Nest

Cuckoo’s political message was aimed at both emptying America’s asylums and extinguishing the climate of social oppression that, as the author saw it, lay behind them. On both fronts, Kesey’s programmatic recommendation was to provide everyone, including those who seem troubled or dysfunctional, with more autonomy. It’s a viewpoint that’s gained enormous influence in the 60 years since One Flew Over the Cuckoo’s Nest was published. Unfortunately, whatever the literary strengths of Kesey’s signature novel, the movement it helped inspire has done much to harm both the mentally ill and the communities in which they live.

The protagonist of One Flew Over the Cuckoo’s Nest is Randle Patrick McMurphy, a manual laborer, gambler, “big redheaded brawling Irishman,” and dishonorably discharged Korean War veteran who’d once led a breakout from a POW camp. After being convicted of various crimes (including statutory rape), McMurphy opted for a stay in a mental hospital as a tactic to avoid serving out his jail sentence. Famously depicted onscreen by Jack Nicholson in the Oscar-dominating 1975 film adaptation, McMurphy radiates robust health and charisma, even if his endless schemes sometimes play out at the expense of other hospital patients who’ve fallen under his influence.

Those fellow patients are generally depicted as weak and sickly, but not mentally ill in the sense that we now understand that term. They are universally cowed by Nurse (Mildred) Ratched, Cuckoo’s main villain (played by Louise Fletcher on the big screen). She calls the shots on the ward, and represents “the juggernaut of modern matriarchy,” in the words of Dale Harding, the ward’s closeted, deeply introverted intellectual. To McMurphy, she’s simply a “ball-cutter.” And the plot of Cuckoo pivots on the struggle for ward control between McMurphy and Ratched. Her more extreme means of asserting control include the use of a lobotomy during the book’s horrifying climax, a procedure Harding describes as “frontal-lobe castration.”

Actor Jack Nicholson and director Miloš Forman, during the filming of One Flew Over the Cuckoo’s Nest

Men who wind up in mental hospitals are not typically regarded as hero material. Indeed, the patients currently confined to what remains of America’s asylum system include thousands of men who committed crimes far more brutal than those ascribed to the fictional McMurphy. But Kesey’s depiction channels a more sentimental view, shared by many modern-day scholarly critics of institutionalization. This is a view that tends to highlight such historical cases as that of Elizabeth Packard (1816–1897), whose husband wrongfully confined her to an Illinois insane asylum on the basis of her freethinking religious ideas. (After being freed, Packard would found a group called the Anti-Insane Asylum Society.)

A scene from an illustrated book about Elizabeth Packard’s late-19th-century legal saga.

On one hand, it seems like a deeply progressive message. But modern feminist readers of Cuckoo will be outraged by McMurphy’s behavior toward the hospital’s female staff, not to mention his (now unprintable) language in regard to the ward’s black orderlies. Though Kesey presented McMurphy as a hero, both men, the real and fictional alike, would be cancelled in a heartbeat in 21st century America.

The book’s narrator is “Chief” Bromden, a half-Indian WWII veteran who stands six foot seven. Staff and patients alike erroneously presume him to be deaf and dumb, which makes him an ideal observer. The longest-tenured patient on the ward, the Chief is also one of the few patients who is truly mentally ill. He intersperses his narration with running commentary on “the Combine,” a sinister, mechanized force that he imagines governs the country. The government men who acquired the Chief’s family’s land to build a dam when he was a boy were agents of the Combine. So is Nurse Ratched. In a literal sense, the Combine is a figment of Chief’s imagination. In a metaphorical sense, Kesey clearly suggests, it’s not.

Nurse Ratched’s agenda is control, though she cloaks her totalitarian impulse in rhetoric about therapy and democracy. (McMurphy says that Nurse Ratched’s control methods remind him of those of the “Red Chinese” whose clutches he escaped back in Korea.) Before McMurphy is subjected to electric shock treatment, Ratched informs him that not only is this to be done for his own good, but that it had been recommended by his wardmates. And throughout the book, the patients participate in their own oppression by informing on each other and probing each other’s weaknesses during group therapy sessions.

Though Cuckoo helped popularize the idea that mental illness is a mythical projection of society upon non-conformists, it built on the work of others. This included social activist Albert Deutsch, whose 1948 book, The Shame of the States, chronicled the genuinely disgraceful state of America’s overcrowded, unsanitary, underfunded system of asylums (as they were then known). His goal was to arouse public pressure in favor of improving those facilities, not eliminating them.

Cover of first edition of The Shame of the States, by Albert Deutsch

Published 14 years later, Cuckoo, by contrast, does not portray its hospital setting as decrepit. One of Kesey’s best comic creations is “Public Relation,” an unctuous fool who makes the occasional appearance on the ward. He leads tour groups from “the Outside” to show off various recent improvements, such the elimination of straitjackets, a TV, “sanitary drinking fountains,” and “chrome bathroom fixtures.” At one point, he says, “A man that would want to run away from a place as nice as this … why, there’d be something wrong with him.” By way of satire, Kesey was clearly suggesting that improvements in the superficial physical trappings of asylums wasn’t his main concern: These institutions damage their occupants even when well-maintained.

A similar argument was made by prominent sociologist Erving Goffman in his famous book Asylums: Essays on the Condition of the Social Situation of Mental Patients and Other Inmates, published just a year before Cuckoo. While working undercover at a hospital in Washington, DC, Goffman concluded that the regimented sociology of asylums was that of “total institutionalization,” as in prisons. In such an environment, obedience to authority was expected, betrayal of one’s peers was common, and the deprivation of liberty was seen as necessary for safety—a dehumanizing worldview that is alien to true therapy, and which encourages the mental pathologies these institutions are supposed to cure.

Kesey satirized the objectiveness of mental-illness diagnoses through the notion of “adjustment.” “You men are in this hospital … because of your proven inability to adjust to society,” Nurse Ratched says. Yet Kesey depicts McMurphy as being, in some ways, better-adjusted than people from “the Outside.” Toward the end of the book, the wardmates take a madcap fishing excursion. The gas-station attendants try to sell them things they don’t need, and the fishing-boat captain balks at doing business with them on the grounds of a vaguely described liability issue. In both cases, McMurphy handles the situation more capably than their psychiatrist chaperone.

Nineteenth-century American progressives saw asylum programs as distinctly modern institutions, the pride of a civilized nation that rejected the pre-modern practice of confining “distracted” citizens to jails and almshouses. Many progressives of Kesey’s day subsequently rejected that idea by arguing that asylums were, in fact, medieval. Kesey opposed both these schools of thought by situating the problem with asylums precisely in their fundamentally modern nature. For Kesey, the very idea of modernity, with its fixation on sterility and regimentation, is fundamentally hostile to men such as Chief and McMurphy, sons of a vanishing, wilder West. (The book takes place in Oregon.) World War II, then a recent experience, had been an especially powerful force in mobilizing the American technocratic state during an age when many Americans still lived on farms. And it’s notable that Nurse Ratched was formerly an army nurse.

Cuckoo casts an even more skeptical gaze on psychiatric medicine than on mental illness. Head psychiatrist Doctor Spivey is a sympathetic but slight man. And Nurse Ratched, while the doctor’s inferior in formal terms, dominates him and co-opts his authority for her own purposes. The only truly therapeutic development in the whole novel is McMurphy’s arrival on the ward, which the sensitive Chief reports as eliciting the “man smell of dust and dirt from the open fields, and sweat, and work,” and so dispersing the previous ambience of “piss and sour old-man manure, of Pablum and eyewash, of musty shorts and socks musty even when they’re fresh back from the laundry.”

McMurphy makes the patients healthier by demonstrating a rebellious vitality they hadn’t realized was possible. On the way home from the fishing excursion, a triumph that McMurphy had led and dreamed up in the first place, the Chief reflects, “I noticed vaguely that I was getting so’s I could see some good in the life around me. McMurphy was teaching me. I was feeling better than I’d remembered feeling since I was a kid, when everything was good and the land was still singing kids’ poetry to me.”

Will Sampson as Chief Bromden in a climactic scene from One Flew Over the Cuckoo’s Nest

But then, when they all get back, Nurse Ratched reasserts her authority, ordering all the fishing-trip participants “to take special showers because they were suspected of vermin.” When McMurphy sticks up for an objecting patient, a fight ensues between the orderlies and McMurphy and the Chief, which leads to the latter two being sent to the “Disturbed” ward. They’re subjected to shock treatment, then returned to Nurse Ratched’s ward just in time for a late-night party that McMurphy had planned previously. The revelers smoke marijuana, drink heavily, and trash the ward. When Nurse Ratched arrives the next morning, she finds one patient, Billy, still entangled with a prostitute whom McMurphy had invited. Billy then commits suicide when Nurse Ratched threatens to tell his mother about the incident, causing McMurphy to assault Nurse Ratched in retaliation, which in turn leads to the story’s grim denouement. The Chief, unable to bear the sight of his hero’s emasculation, performs an act of deadly mercy, and breaks out, to a freer life. And it is in this kind of dramatic all-or-nothing escape from institutionalization, not in a gradual process of reform, where Kesey places the seeds of hope.

Today’s conventional wisdom on the wave of deinstitutionalization that began in the 1960s and 1970s has it that this was a good idea, badly implemented: There simply weren’t enough “community”-based supports in place to absorb and treat the large numbers of formerly institutionalized individuals. But the nature of Chief’s escape suggests that Kesey imagined that the merits of deinstitutionalization didn’t depend on new amenities being created. You just had to smash the system and let people out. Freedom was seen as the precursor to mental health, full stop.

In the world of Cuckoo, in fact, no one’s really fully mentally ill per se. And to the extent they are mentally ill, it’s a good thing. Chief Bromden, in particular, understands much that the sane characters do not. This kind of romantic treatment of mental illness signals an area in which the ascendant 1960s-era variant of liberalism began to manifest a clear breach with the more classical variety: While classical liberal thinkers such as Locke and Mill promoted individual freedom, they always allowed that, for some, the mentally ill in particular, freedom could have destructive consequences.

Between 1955, when the first antipsychotic drugs became available, and 2015, the number of inpatients in public psychiatric hospitals in the United States dropped by over 90 percent, in part thanks to Cuckoo’s influence. As a result, we re-learned lessons about just how many bad things can beset mentally ill people, and sometimes those around them, on “the Outside”—including suicide, assaults on strangers in public transit, mass shootings, intra-family homicides, homelessness, and fatal encounters with police. In many cases, moreover, the idea of deinstitutionalization proved a myth, as hundreds of thousands of mentally ill people simply ended up in prisons. In these cases, releasing the mentally ill from institutions not only didn’t make them healthier; it also made them less free.

Ken Kesey’s original road-trip bus, which he called Further.

Drugs are an important theme in Cuckoo—mainly the (then novel) antipsychotic variety, which Kesey describes as creating a stupefied Huxleyan dystopia. Indeed, psychopharmacology is depicted as just another tool for Nurse Ratched to use in exercising control—an ironic theme given Kesey’s own use of drugs. After Cuckoo, in fact, Kesey became a celebrity activist in support of drugs (his deeds famously recounted in Tom Wolfe’s Electric Kool-Aid Acid Test). And his “Merry Pranksters” more or less officially launched America’s psychedelic era with their 1964 road trip from California to New York and back. Drug use spread throughout urban communities nationwide, often at the exact moment when those communities were supposed to be welcoming and stabilizing mentally ill individuals leaving institutional settings. The consequences were predictable.

One irony here is that Kesey’s outlook had a decidedly conservative element: He sought to restore something of the rugged individualism that once made this nation great. He hated softness and the conformism he saw as pervasive in postwar America. His message was powerful in its simplicity—to promote health and strength, we must relieve oppression. This theme overlapped with the civil rights agenda, even if racial justice was not Kesey’s top focus.

Kesey’s satirical depiction of society as a despotic psych ward was ingenious. But it also relied on something of a straw man. He frames the situation as so dire and apocalyptic that literally any other option is better, since things clearly can’t get any worse. But in many ways, Kesey’s understanding of early postwar America was completely detached from the reality of everyday life for most of the country. When Cuckoo was published, jazz, one of the few art forms both uniquely excellent and uniquely American, was in its prime. During what my colleague Fred Siegel termed the “unprecedented flowering of popular art” in postwar society, close to ten percent of the population tuned into the New York Metropolitan Opera’s Saturday afternoon radio broadcast. General Motors set a standard for corporate dynamism, and for a capitalist-led system of sharing benefits among shareholders, workers, and consumers alike. Feminism, civil rights, and even the early stirrings of gay rights were all in evidence. The Apollo moon landing was less than a decade away. This was the society that Ken Kesey said reminded him of a listless psych ward.

Even Kesey’s basic understanding of what freedom means now seems shallow and incomplete. We inhabit an era in which all manner of sexual interests, self-identification, and mental-health difficulties (both real and invented) are accepted and normalized. We’ve never been more nominally free to express ourselves as individuals. Yet everywhere, people complain of being monitored and oppressed.

Kesey wasn’t wrong that the battle for freedom and autonomy is important. But the idea that it can be won simply by knocking down walls, and letting the well and unwell sort everything out for themselves, proved an enduring and destructive delusion.

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