The DO Book Club, Aug. 2024: ‘One Flew Over the Cuckoo’s Nest’

Many may be familiar with the movie, but “One Flew Over the Cuckoo’s Nest” actually echoes a children’s song, which served as the origin for the 1962 novel. The book and song, which connect to the line “One flew east, one flew west, one flew over the cuckoo’s nest,” cleverly cover a variety of themes—the difficulty of confinement, the freedom enjoyed by birds far from the nest and the need for comfort. Author Ken Kesey’s counterculture novel is a difficult read, but its coverage of mental health disorders is, despite advances in treatment, still relevant today.

It is a story of the conflict of wills, and it advocates against the inhumane treatment of patients. It is also a call for reform, contrasting confinement against individualism. It is also a microcosm, representing and reflecting individuals in society as well as freedom and restraint, nature vs. nurture and how technological advances impact medicine.

Bearing witness to struggle

“One Flew Over the Cuckoo’s Nest” is a complex, descriptive story of Randle P. McMurphy, a self-centered but charming con artist who fakes psychosis to get admitted to a psychiatric institution. The novel is narrated by Chief Bromden, the son of a Native American chief, who pretends to be mute to protect himself from society, an action that denies him his human dignity. Conditions within the hospital ward become a metaphor for society, an institution against which the novel protests.

Many events contribute to Chief’s loss of self. When he was 10, his attempts to speak to government officials go ignored, as he witnesses his alcoholic father get deeper and deeper into his struggles. He loses himself by not sustaining a connection with nature, as the government confiscated his tribal homelands in the Columbia Gorge for public works. During his own military service in Europe, Chief becomes frightened by the machine that sent white clouds of fog over the airfields, obscuring his vision and making him feel alone. Thus, Chief’s schizophrenia seems a reasonable response to the inhumanity he has suffered.

Chief is McMurphy’s principal disciple; at the end of the novel, readers see a stunning transfer of power between the two. Through Chief’s actions at the book’s conclusion, the author presents the lesson that one must affirm life and directly face and confront risks and challenges in spite of social obstacles.

Rebelling against authority

The novel has characters larger than life, with exaggerated interplay between good vs. evil and ideals vs. society’s structure. The books’ protagonist (McMurphy) is a tough convict, self-transferred from jail to an asylum because of wild, defiant behavior. McMurphy thinks asylum work will be easier than prison work, which carries the extra attraction of being able to con a few inmates out of money. McMurphy challenges the moral authority of Nurse Ratched, the ward superintendent, who uses manipulation and an insincere, fake smile to turn inmates against one another, preying on their fears and weaknesses. 

McMurphy counters her technique and provides a model of rebellion. He uses laughter, comic exaggeration and absurdist acts, teaching resilience to other inmates. He defies authority openly while winning the admiration of inmates, who slowly begin their own acts of defiance and independence. In various ways, McMurphy defies Nurse Ratched’s authority and manages to get away with it for a while.

McMurphy discovers that unlike most of the other inmates, his admission was involuntary—and the only person who can determine who is fit to leave and live in society is Nurse Ratched. McMurphy switches gears and gives other inmates a taste of freedom and self-empowerment. He gets in trouble when he and Chief resist an orderly trying to force drugs on an unwilling inmate.

After electric shock therapy, McMurphy’s resilience is broken. He begins to look more and more like the other inmates. As a token of their appreciation, other inmates arrange an escape, and McMurphy celebrates the occasion by having a party. However, McMurphy is unable to escape, and he pays a heavy price for the debacle.

The novel’s characters are in line with Kesey’s sensibilities and the spirit of 1960s counterculture. McMurphy struggles against strict institutional rules informed and enforced by the nurse superintendent. Just as in society, the unit has laws and punishment. The inmates follow these rules or suffer consequences. McMurphy challenges these procedures routinely. Kesey portrays individual struggle against a conformist society as a noble and meaningful task. McMurphy fights within the small world of the hospital; however, the struggle can be extended to the world outside of the asylum.

The loss of identity

This theme of institutional conformity resonated in our group’s discussion of the novel in a narrative medicine workshop. The theme extends beyond asylums and into hospital wards as well. The workshop’s participants, which included faculty, residents and medical students, all noted the loss of individuality and dignity, along with the loss of self-identity, when someone is admitted to the hospital. Workshop participants noted that patients are objectified and described by their disease or room, instead of their individual names.

While higher case volumes and time constraints contributed to loss of identity, the hospitalization process itself and the focus on pathogenesis, diagnosis and charting diminished the patient identity. One participant noted that during their own hospitalization, they personally experienced a raw, out-of-control feeling as they lived by someone else’s assessment, treatment plan and rules.

“One Flew Over the Cuckoo’s Nest” is a result of Kesey’s interest in the relationship between sanity, insanity, consciousness and mind-alternating drugs. The author was employed as a psychiatric ward attendant, and later volunteered to take LSD as a research subject. Kesey’s novel is more than an indictment of mental institutions—it attacks conformity and established authority in a style replete with parables and ironic commentary.

The novel is an important read as it confronts power, authority and absolute governance. It also weighs individualism vs. strict conformity to society. In the end, this novel is a tragic, inspirational account of one man’s self-sacrifice and struggle against hypocrisy and oppression. The novel’s complex characters and unique settings reveal the conflict between authoritarianism and individualism, a universal conundrum.

Today, mental illness remains ignored and misrepresented. Attitudes regarding mental health are slowly changing, but a stigma still exists. Thanks to advocacy and humanitarian reform, there are incremental changes happening within health care. Patient-centered approaches to diagnosis and treatment plans are a hallmark of narrative medicine, and they are a welcome contrast from a physician-driven biomedical, scientific model, as illustrated in this thought-provoking novel.

Related reading:

The DO Book Club, June 2024: ‘Autobiography of Andrew T. Still’

The DO Book Club, May 2024: ‘Perimenopause for Dummies’