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Mental Healthcare Then and Now Dermot Connolly Stenberg College

MENTAL HEALTHCARE THEN AND NOW Abstract Using the background of the 1975 movie one flew over the cuckoos nest, this paper is a comparison of mental health care treatments in the 1960s compared to present day methods of treatments. The topics of institutionalization and deinstitutionalization are two of the underlying themes expressed in this paper. Institutionalized care is represented by the repressive and authoritarian forms of treatment presented in the movie whereas deinstitutionalization is

represented through the desires for self determination and individuality presented by the patients. The evolution of two of the treatment modalities; electroconvulsive therapy and group therapy which are presented in the movie, are explored in greater detail against todays treatment models. Keywords: institutionalization, deinstitutionalization, electroconvulsive therapy and group therapy.

MENTAL HEALTHCARE THEN AND NOW Mental Healthcare Then and Now A novel written in 1962 and adapted into a screenplay in 1975 (IMDB, 2013), one flew over the cuckoos nest was written at a time when mental illness was being treated using the institutionalization care model and just before the advent of deinstitutionalization in the United States. (Unite for sight, 2013). The story is set in a psychiatric ward operated and run by a stern and controlling Nurse Ratched who reinforces the rules and regulations of the ward. Nurse Ratched represents the authority, conformity and repression associated with institutionalization (Sparknotes, 2013), where hospital procedures such as restraints, lobotomies and electroconvulsive therapies are overseen with authority designed to control rather than rehabilitate. In a battle of good vs. evil, deinstitutionalization is represented through the self

determination, freedom and individuality of psychiatric patient Randall McMurphy. (Sparknotes, 2013). The movie portrays several treatment modalities in this biased representation of mental health care in 1960s America. Using the movie as a backdrop, the purpose of this discussion is to review the evolution of mental health care treatment since the 1960s. This will be achieved using the examples of the group and electroconvulsive therapies portrayed in the movie. While this discussion will focus on the evolution of mental health care practices, it is also a representative look at the institutionalized and deinstitutionalized models of nursing care. In order to better understand the evolution of mental illness and the social misconceptions surrounding it, an analysis into the evolution of its treatment options is important. At a time when mentally ill patients were treated in dangerous and unhealthy situations, the need for institutional in-patient care was being called for by many activists. (Unite for sight, 2013). What resulted was the voluntary and involuntary treatment of mental illness in hospitals where patients lived while undergoing treatment. The introduction of institutionalization was welcomed by


many as an effective way to treat the mentally ill and relieve the burden from families struggling to deal with the illness. (Unite for sight, 2013). Calls for reform of the institutionalized model gathered momentum when evidence of human rights violations and poor living condition began to surface. Such violations are depicted in the movie One flew over the cuckoos nest where the use of restraints and the abuse of treatment modalities are used to control patients rather than rehabilitate them. (Forman, 1975). Calls for deinstitutionalization gathered momentum following the 1973 study carried out by David Rosenhan, a psychiatric who was greatly opposed to the use of the DSM to classify abnormal behavior. (Rosenhan, 1973). His study involved the use of pseudopatients who feigned hallucinations in order to get admitted into different psychiatric hospitals. All were diagnosed with a mental condition before being admitted and treated. (Rosenhan, 1973). He followed up his study by agreeing to a request made by one hospital to continue to send pseudopatients. Over the coming weeks, the hospital claimed to detect several pseudopatients when in fact Rosenhan has sent none. (Rosenhan, 1973). Rosenhans report is significant in that it highlighted in inability of psychiatrics to detect mental illness although others have since argued that the evolution of mental illness has ensured greater accuracy in detection since this experiment was conducted. (Rosenhan, 1973). In the movie we see McMurphy undergo electroconvulsive therapy in response to his attempt to rally the patients against the institutionalized regime. (Forman, 1975). The treatment is presented as a barbaric act used to control McMurphy where he is physically restrained and administered electric shocks to his brain without anesthetic. (Forman, 1975). While the scene appears inhumane, it turns out that it is quiet representative of the process at the time. During the 40s and 50s, electroconvulsive therapy was commonly used in the treatment of mood disorders

MENTAL HEALTHCARE THEN AND NOW such as depression where patient were administered high doses for long periods of time.

(Hollander, 2002). As a result, up to 40% of patients treated suffered complications resulting in a mortality rate of 1 in 1000. (Hollander, 2002). Advances in electroconvulsive therapy however have resulted in a greater understanding into its potential benefits. In a process far removed from its use in the 1950s, the treatment is now administered under anesthetic and is widely regarded as the most effective means of treating depression. (Szalavitz, 2012). In fact in a recent study carried out in Scotland, functional magnetic resonance imaging (FMRI) was used on a selection of test subjects who had just undergone electroconvulsive therapy. Analysis of the patients brain scans showed a decrease in conductivity in the left side of the dorsolateral prefrontal cortex of the brain. An area commonly associated with negative thoughts, anxiety and criticism. (Szalavitz, 2012). While attempting to describe the benefits of todays group therapies, Yalom identifies that one of its strengths is its ability to work as a cohesive unit towards a common goal. (Yalom & Leszcz, 2005). The group environment provides each member with the opportunity to explore new methods of therapy under the direction of a group therapist and support from its members. (Yalom & Leszcz, 2005). In fact the role of the therapist is considered central to development of group cohesion facilitating the trajectory of the group towards their common goals. (Yalom & Leszcz, 2005). Comparing the model presented by Yalom with the group therapies facilitated by Nurse Rached and several differences can be seen. Instead of the devolvement of group cohesion, the clients in the movie are imposed with Nurse Racheds vision of reality. Clients are made to feel ashamed of their past through reminders of their shortcomings which resulted in one client taking his own life. (Sparknotes, 2013). When the therapeutic value of her authority is questioned, she does not display any positive regard or empathy, instead her clients are subjected


to submissive treatments aimed at controlling their behavior instead of empowering them to take control of their own treatment. (Sparknotes, 2013). The community based treatment models in use today are representative of the evolution of mental health care treatments. This evolution can be traced back to the initial welcome introduction of institutionalized care and its subsequent calls for deinstitutionalization. Justification for deinstitutionalization is represented in the repressive and controlling forms of treatment portrayed in the movie one flew over the cuckoos nest. By comparing the past and present use of group and electroconvulsive therapies, this paper has shown that the evolution of mental health care treatment has being a positive one in which the needs of the client has taken precedent over the needs of institutionalized regimes.

MENTAL HEALTHCARE THEN AND NOW References: Forman, M. (1975). One flew over the cuckoos nest. Retrieved from: Hollander, A., B. (2002). Electroconvulsive therapy. Retrieved from: IMDB (2013). One flew over the cuckoos nest. Retrieved from: Rosenhan D., L. (1973). On being sane in insane places. Holah Psychology. Retrieved from: Sparknotes (2013). One flew over the cuckoos nest. Retrieved from: Szalavitz, M. (2012). How electroconvulsive therapy works for depression. Time. Retrieved from: Unite for sight (2013). Module 2: A brief history of mental illness in the U.S. mental health care system. Retrieved from: Yalom, I. D., & Leszcz, M. (2005). The Theory and Practice of Group Psychotherapy (5th ed.). USA: Basic Books.