Running head: PSYCHOTHERAPY EVIDENCE-BASED PRACTICE MOVIE PAPER:
Psychotherapy Evidence-Based Practice Movie Paper: One Flew Over
Kathryn Grice
Regis College
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PSYCHOTHERAPY EVIDENCE-BASED PRACTICE MOVIE PAPER:
Psychotherapy Evidence-Based Practice Movie Paper: One Flew Over
Introduction
The purpose of this paper is to apply knowledge acquired over the spring term of NU646
to a movie portraying a character or characters experiencing a psychological disorder/mental
illness. Additionally, comparisons will be made between the movie portrayal and current
evidence-based practices. The movie I chose for this paper is One Flew Over the Cuckoo’s Nest
a film produced by Zaentz & Douglas in 1975 based on the 1962 novel by Ken Kesey (Pink &
Jacobson, 2007)
Movie synopsis
This film was set in 1963 and was filmed in Oregon State Hospital (Pink & Jacobson,
2007). The main character of Randle McMurphy (played by Jack Nicholson) is prisoner who has
been sent to the state hospital to be assessed. From the outset, it is clear that McMurphy is
malingering. I have watched this film multiple times and it is still unclear to me if the primary
antagonist, Nurse Ratchet, truly believes McMurphy is ill or if her desire to keep him on her unit
is vindictive in nature. McMurphy quickly challenges hospital policy and routines and Nurse
Ratchet’s authority. Some of McMurphy escapades include organizing gambling in the bathing
room, a breakout fishing trip on a “barrowed” boat, and a night of drinking and partying. You see
the other men on the unit open up, they appear happier and perhaps healthier. This endears the
viewer to McMurphy; it feels like he is helping them. The film concludes on a rather morbid
note. After a violent interaction with Nurse Ratchet, it appears that a psychosurgery is performed
on McMurphy leaving him in a near vegetative state. His friend Chief “mercifully” kills him and
escapes from the facility.
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Psychological Disorder and Treatment
No clear diagnosis of McMurphy ever occurs in the film. He most certainly has a
personality disorder. Like much of the prison population McMurphy’s character appears to have
antisocial personality disorder. Although the movie portrays his actions has having a positive
effect on many of the patients, McMurphy’s actions were based on personal gain not any form of
altruism. His character fails to conform to social norms, he is dishonest, manipulative, and
inconsiderate of others. Despite this, he is also charming when he stands to gain from this
behavior. First termed psychopathy, antisocial personality disorder was the first personality order
to be recognized (Ogloff, 2006)
Group therapy is conducted by Nurse Ratchet each day. These sessions do not seem to be
therapeutic. Nurse Ratchet is a poor moderator and she does not create a threptic atmosphere.
Her main techniques seem to rely on embarrassment, guilt, and punitive action. Confidentially is
not respected.
After breaking a window and fighting with ward staff McMurphy undergoes several
rounds electroconvulsive therapy (ECT). The film portrays this as punishment rather than a
treatment. McMurphy was led into a room filled with people, he strapped to a table without
being told what was happening. The film then shows McMurphy receiving the electrical shock
and experiencing what appears to be a violent and painful seizure.
At the end of the film McMurphy undergoes psychosurgery. This again, seems to be
more punishment for poor behavior than a treatment. His character appears on screen unable to
talk or even ambulate on his own. His eyes have a blank stare and he is unresponsive when to his
friend attempts to connect with him.
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PSYCHOTHERAPY EVIDENCE-BASED PRACTICE MOVIE PAPER:
Evidence Based Practice
The DSM-5 criteria for diagnosing antisocial personality disorder states that there must
be a pervasive pattern of behavior of disregarding and violating the rights of others occurring
since the age of 15; this is evidenced by three or more of the following: 1) failure to confirm to
social norms AEB multiple arrests, 2) a pattern of deceitful behavior, 3) impulsivity, 4)
irritability and aggression, 5) reckless disregard for the safety of self or others, 6) consistently
irresponsible behavior and 7) lack of remorse (American Psychiatric Association [APA], 2013).
Additionally, there should be evidence of a conduct disorder before the age of 15, the behaviors
must not occur exclusively during exacerbations of schizophrenia or bipolar disorder and the
individual must at least 18 (APA, 2013). The film does not offer any mental health history for
McMurphy, but assuming he had a pattern of behavior beginning before the age of 15 consistent
with a conduct disorder, he meets criteria for antisocial personality disorder.
We still know very little about the etiology of antisocial personality disorder. Imaging
studies have shown evidence of dysfunction in both the frontal and temporal lobes, and perhaps
some other brain structures. Some studies show evidence of changes to brain anatomy
specifically in the frontal lobe. Other scholars still believe that environmental and social
influences are responsible for the factors leading to development of antisocial personality
disorder (Harvard Health Publishing, 2019; Ogloff, 2006). It is commonly believed that it is a
combination of environmental influences, genetics factors and brain anatomy that contribute to
this personality disorder (Harvard Health Publishing, 2019). Discouragingly, there is very little
established evidence-based practice for treatment of antisocial personality disorder. This may be,
in part, due to the fact these patients are not often represented in mental healthcare in general, as
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very few of these individuals seek treatment for their disorder (Black, 2020; Bosch, Rijickmans,
Decoene, & Chapman, 2018).
National Institutes for Health and Care Excellence (NICE) guidelines for treating
antisocial personality disorder recommend first addressing any comorbid disorders. The
providers should also consider lengthening the duration of treatment of said comorbid disorders
when occurring with antisocial personality disorder. In the case of McMurphy, he seems to likely
meet criteria for substance (alcohol) abuse disorder. Substance used should be addressed first
based on NICE guidelines. Treatment guidelines stress that the provider understands the
likelihood and impact of treatment being met with 1) poor compliance, 2) high attrition,
3)misused of prescribed medication and 4) drug interactions (National Institutes for Health and
Care Excellence [NICE], 2013). The primary psychotherapy intervention supported by NICE is
group-based cognitive and behavioral therapy. Black (2020) reminds us that those with antisocial
personality disorder are not likely to have the motivation to make changes and unless they
willingly enter therapy they are not likely to make any progress. It is unlikely that the character
of McMurphy would positively engage in group-based cognitive and behavioral therapy
(appropriate for both his diagnoses) related to either is substance used disorder or antisocial
personality disorder.
Pharmacological treatment of antisocial personality disorder is based on symptom
management and should not be routinely used as treatment (NICE, 2013). There are no
medications specifically approved for the treatment of antisocial personality disorder (Black,
2020). Comorbid depression and anxiety should be treated per standard guidelines for each
diagnosis. I don’t think the character McMurphy was experiencing either depression or anxiety.
Lithium carbonate has been shown to decrease hostility and aggression amongst prison
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populations and reduce bullying, fighting and emotional outbursts in aggressive children (Black,
2020). Additionally, phenytoin has shown to decrease impulsive aggression. Neither ECT nor
psychosurgery are indicated as treatment of antisocial personality disorder.
Critical Analysis
One Flew Over the Cuckoo’s Nest, the 1962 novel by Ken Kesey, was written to expose
the realities of inpatient psychiatric care. Although I have not read the book, reviews I have read
assert the film did book justice. Also, in reviewing history and reading film analysis of others,
the film was historically accurate to its 1963 setting; except for ECT and psychosurgery being
utilized as punishment (Boschini & Keltner, 2009; Pink & Jacobson, 2007; Goodfriend, 2012).
But, how does this reflect current practices?
Group therapy is still a common modality used in in-patient/hospital settings. I would like
to say the way the therapy is delivered is far superior to that delivered by Nurse Ratchet,
however my experience is, this is not always the case. Groups at my hospital are conducted by
nurses, therapists, peer specialist and mental health workers (MHWs). In general, the groups are
more therapeutic, goal oriented and supportive of the patients. There also some people I work
with, mostly MHWs, who tend to treat patients like naughty children who need disciplined.
Perhaps, if we as a society, better valued mental health and had better trained and paid workers
this would not occur. We do a better job of ensuring our patient medications are well controlled
and accounted for. Patients are not required to take their medications unless on court ordered
meds. I also know that my facility provides more patient oversight (15-minute checks) and
increased programing.
ECT came into use in the 1930’s after several recorded cases of dramatic patient
improvement. Increasing is usage in the 1940s and 1950s, ECT was often given in higher doses,
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and for longer periods of time then given today and was administered without anesthesia (Kerner
& Prudic, 2014). Once used far more liberally, ECT is now limited to cases of severe mental
illnesses when there is a critical need for treatment or in cases of treatment resistance (failure or
intolerance to pharmacotherapy) (Kadiyala & Kadiyala, 2017). ECT today occurs under far more
controlled conditions than those in the film. Patients receive anesthesia and are closely monitored
by and anesthesiologists.
Disturbingly humans have been practicing varied versions of psychosurgery since Before
Common Era (Faria, 2013). The modern practice of psychosurgery took off in 1935. Walter
Freeman introduced the “ice pick” lobotomy in 1936 and would go on to perform between 2,500
and 4,000 lobotomies until 1967 when he was banned from performing the procedure (Faria,
2013). By the time Ken Kesey published his book, lobotomies were largely being replaced with
stereotactic and functional neurosurgery. By 1967 haloperidol was introduced ushering in a new
wave of psychotropics and an extinction of the rather barbaric practices seen in One Flew Over
the Cuckoo’s Nest.
Conclusions
The film One Flew Over the Cuckoo’s Nest delivers a surprising accurate depiction of an
in-patient hospitalization of an individual with antisocial personality disorder in 1963.
Fortunately, much has changed in the field of psychiatry/psychotherapy/ psychopharmacology in
almost 60 years. Unfortunately, we still do not have a solid understanding of how to prevent and
treat antisocial personality disorder.
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References
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental
Disorders (5th ed.). Arlington, VA: Author.
Black, D. (2020). Treatment of antisocial personality disorder. Retrieved 4/17/2020, from
https://psychcentral.com/lib/treatment-for-antisocial-personality-disorder/
Bosch, L., Rijickmans, M., Decoene, S., & Chapman, A. (2018). Treatment of antisocial
personality disorder: Development of a practice focused framework. International
Journal of Law and Psychiatry, 58, 72-78. http://dx.doi.org/10.1016/j.ijlp.2018.03.002
Boschini, D., & Keltner, N. (2009). Different generations review One Flew Over the Cuckoo's
Nest. Perspectives in Psychiatric Care, 45(1), 75-79. http://dx.doi.org/10.1111/j.17446163.2009.00205.x
Faria, M. (2013). Violence, mental illness, and the brain - A brief history of psychosurgery: Part
1 - From trephination to lobotomy. Surgical Neurology International, 4(49).
http://dx.doi.org/10.4103/2152-7806.110146
Goodfriend, W. (2012). Mental Hospitals in "One Flew Over the Cuckoo's Nest. Retrieved from
https://www.psychologytoday.com/us/blog/psychologist-the-movies/201205/mentalhospitals-in-one-flew-over-the-cuckoo-s-nest
Harvard Heatlh Publishing. (2019). Antisocial personality disorder. Retrieved from
https://www.health.harvard.edu/a_to_z/antisocial-personality-disorder-a-to-z
Kadiyala, P., & Kadiyala, L. (2017). Anesthesia for electroconvulsive therapy: An overview with
an update on its role in potentiating electroconvulsive therapy. Indian Journal of
Anesthesia, 61(5), 373-380. http://dx.doi.org/10.4103/ija.IJA_132_17
9
PSYCHOTHERAPY EVIDENCE-BASED PRACTICE MOVIE PAPER:
Kerner, N., & Prudic, J. (2014). Current electroconvulsive therapy practice and research in the
geriatric population. Neuropsychiatry (London), 4(1), 33-54.
http://dx.doi.org/10.2217/npy.14.3
National Institutes for Health and Care Excellence. (2013). Antisocial personality disorder:
prevention and management. Retrieved from https://www.nice.org.uk/guidance/cg77
Ogloff, J. (2006). Psychopathy/antisocial personality disorder conundrum. The Royal Australian
and New Zealand College of Psychiatrists, 40(6-7), 519-528.
http://dx.doi.org/10.1080/j.1440-1614.2006.01834.x
Pink, J., & Jacobson, L. (2007). One flew over the cuckoo's nest. BMJ, 334. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1831997/
Tartakovsky, M. (2019). The surprising history of the lobotomy. Retrieved 04/17/2020, from
https://psychcentral.com/blog/the-surprising-history-of-the-lobotomy/
Zaentz, S., & Douglas, M. (1975). One Flew Over the Cuckoo's Nest [Motion picture]. United
States: Fantasy Films.