Do we treat people with mental illness for their benefit or for ours?

To believe in something that nobody else does makes one either crazy or a visionary.

I have noticed that mental health professionals are quick to point out that “things have changed a lot” whenever One Flew Over the Cuckoo’s Nest is mentioned. The novel by Ken Kesey is seared into the American psyche. Reading the book prompted me to consider conforming to our cultural norms, as well as how modern psychiatry contrasts with the portrayal of a 1950’s Oregon insane asylum.

 The story is told through the eyes of a Native American patient, the Chief, but it revolves around the protagonist, McMurphy, challenging the authority of Miss Ratched, a.k.a. the Big Nurse. Her interventions blur the line between treatment and restraint. The distinguishing feature is that the purpose of restraint is to control behavior, while treatment is for a disease.

What is a mental illness? There is a codebook of diagnoses. But for me, a mental illness is way of thinking, feeling, or behaving that is either distressful to the person, others, or both.

Conformity begets comfort. Different beliefs and ways of living challenge the status quo. When McMurphy joined the ward, he dared to ask why: why can’t they do their chores earlier so they could watch the World Series? Why did Miss Ratched have to play the music so loudly over the speakers? By questioning Miss Ratched’s authority, he gave the other patients permission to deviate as well.

Coercive authority rules with fear, harshly punishing the first to be defiant. Most people are willing to tolerate injustice until they either cannot pretend it doesn’t exist or they are very unlikely to be singled out for resisting it. We often need a brave soul, willing to become a martyr, to catalyze movements against oppression. In spite of the warning signs, Martin Luther King, Jr. remained steadfast in pursuit of justice. Recently, Edward Snowden sacrificed his comfortable American life so that we may know the truth about our government’s surveillance programs. How often is the crazy thing to do the right thing to do?

In the daily group counseling sessions led by Miss Ratched, fear and shame are her principal therapeutic tools. Her goals are more to assert power and reaffirm their sickness rather than prepare patients to reintegrate into society. McMurphy is appalled in the first session by how the patients tear into her chosen target of the day, similar to how chickens peck at an injured compatriot. Fortunately, the inpatient group counseling sessions that I recently witnessed were grounded in respect; everyone was encouraged to share his or her perspective with the goal of cultivating skills to better handle stressful situations. Rather than pointing out what is wrong with someone, good psychologists lead their clients to self-discover how their pattern of thinking and behavior can be improved.

McMurphy has been arrested for repeatedly gambling. He uses his shrewd street skills in the asylum to pilfer other patients; however, they admit that he is not “cheating.” In one famous scene, he checks that the Chief can lift a heavy control panel before getting all of the doubtful patients to bet against him. Though deplorable a half-century ago, betting has become a more socially acceptable mode of income. For example, professional gamblers are now profiled on popular poker television programs. Sports betting is legal in some states and, arguably, normal behavior when male college basketball teams annually vie for supremacy. What portion of our economy is related to betting on the stock market? As a portion of our gross domestic product, the finance industry has tripled since 1947, rising from 2.5% to 7.5% in 2010. My point is that the negative moral (and in his case, legal) judgment passed on McMurphy is inconsistent with celebration of other forms of gambling in our culture.

Gambling isn’t bad in itself. I believe all adults should have the freedom to use their money however they choose. However, gambling is a problem when a husband loses his family’s retirement savings. It is a major problem when people do not pay their losses, which is precisely what happened when President Bush bailed out big banks. There is a glaring double standard to punish $200 stolen from a gas station with prison time and administer nothing for holding our economy hostage. For the richest, the rules seem to be, “heads I win, tails you lose.” The only sane thing to feel is outrage.

After realizing that he will only be released by abiding by the rules, McMurphy begins to conform. During this time when he is not himself, his jolliness disappears. The other patients are disappointed, but they understand that it is “the smart thing to do.” This is applicable to my career.

The default path for me would be to proceed into a residency program after medical school, and possibly a fellowship thereafter; this would undoubtedly make me a competitive candidate to be hired by a hospital as a board-certified physician in a given specialty (I have not decided what kind that would be). I would be fully sanctioned to practice medicine. Among other reasons, I am most concerned that it would be impossible to maintain my desired lifestyle with the workload of a resident. My contact with friends in residency gives the impression that entering it is equivalent to crossing an event horizon. My goal is use science to improve the health of others. Toward that end, I am weighing whether I should try to fit the mold or sculpt something from scratch. To most in medicine, not doing a residency would be “crazy.”

Electro-convulsive therapy (ECT) is used in the book as a form of punishment. I would like to highlight how the procedure has changed and the evidence of its efficacy. First, with the use of anesthetics and muscle relaxants, patients no longer convulse, i.e., activate all their muscles in a tonic-clonic seizure from the waves of electrical activity throughout the brain. As a result, they no longer wake up feeling like they just ran a marathon. ECT has short-term efficacy as treatment for depression; now, it is largely reserved for severely suicidal patients and those who have not responded to treatment modalities. The major adverse effect of ECT is memory loss, which predominantly affects short-term memory and cognitive function shortly following the procedure, but some patients have reported persistent memory deficits. ECT is an important example of treatment that (a) has been around for a long time, (b) has proven efficacy, and (c) still lacks an understanding of its mechanism(s) of action. So, it is okay to help people without understanding exactly how. To maximize my healing powers, I plan to hone the placebo effect. Given our culture’s belief in research, my scientific training should help.

For the two patients that commit suicide in the book, death was their only escape. People wish to die after losing hope; unfortunately, this is common. Suicide is more frequent than homicide in the U.S. This means that Americans are statistically more likely to die at their own hands than those of another. But we do not hear about suicides, because the victims are socially isolated. This is a silent epidemic.

Mental health facilities are investigated when individuals commit suicide. Do we need an audit of our culture? I lay some of the blame on greed. In America success is often measured in dollars. What does it typically mean when someone says, “He’s doing very well?” Your worth as a human has been monetized. Frustratingly, careers nowadays are plagued by trade offs between pay, purpose, workload, and required training.

I do not insist that all mental illness is a consequence of our perverted culture, or that mental illnesses are merely a myth created for control. However, I am concerned that our culture’s maligned values contribute to unnecessary suffering. And I am concerned that some behavior is labeled as mental illness purely for power and profit; many mental illness diagnoses confer an indefinite prescription to medication.

If mental distress is the consequence of a mismatch between one’s inner and outer world, then there are two general solutions. The medical model claims that the problem lies within the person, that he or she has a brain chemical imbalance that can be remedied with a pill. Conversely, a social change framework seeks to correct the features of a pathological environment. Those who cannot or will not participate in society often end up either homeless or in prison. Our legal system has a full-blown mental health crisis.

Mental health treatment has moved away from punishment and control toward a model of rehabilitation. This is a good. Furthermore, the wide array of pharmacologic options now available has helped countless lives. We should continue to pursue better treatments for individuals suffering from mental illness.

One Flew Over the Cuckoo’s Nest remains relevant today. Kesey’s novel demands that we continue to ask difficult questions about the nature of mental illness and its treatment.

Why is that children born today have a higher risk of developing a mental disorder than their parents or grandparents? Have our genes changed or is it our way of living?

When we treat mental anguish, are we being numbed into complacency?

When we medicate away non-normative thinking and behavior, are we prone to stagnate as a culture? To believe in something that nobody else does makes one either crazy or a visionary.

Do we treat people with mental illness for their benefit or for ours?