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Representation Of Mental Disorder In The Movie Of “One Flew Over The Cuckoo’S Nest”

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In its report on the global mental health situation published in 2004, World Health Organization recognized the underestimation of the importance of mental disorders worldwide, and according to figures published in the same report, the burden of disease among mental disorders accounts for almost 12% of global morbidity and, by 2020, they will be responsible for almost 15% of years of life lost, in 2004 there were 120 million patients suffering from depression, 37 million dementia (Yusuf, 2017). Mental illness is a magnifying glass that reflects the defects of a society. Cinema, for its part, is a distorting mirror of these illnesses. Movies have been shown to influence the image of patients about mental illness, psychotherapy and psychiatrists or other mental health workers. Cinema is an integral part of our life and comes to enrich it with a lot of information. It is a way to create social representations that affect and influence us (McCann & Huntley-Moore, 2016).

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The appearance of mental illness in cinema staged very quickly as early as in 1920 in “The Cabinet of Doctor Caligari. In 1975, One flew over the cuckoo’s nest, a movie directed by Milos Forman, that later became one of the most popular movies of all time, had a major impact on public perceptions of psychiatry and mental illness. The movie emphasized mental illnesses more specifically Antisocial personality disorder from different perspectives (McCann & Huntley-Moore, 2016). The aim of the present paper is to highlight, discuss and examine the antisocial personality disorder shown in the movie of Miloš Forman “One flew over the cuckoo’s nest”. This essay defines the mental illness, discusses different signs, symptoms and psychosocial/spiritual/cultural impact of the illness on the individual, their family and the workplace or community, explores the different nursing diagnoses applicable for the disorder, gives different nursing interventions and their rationales. Different treatments are discussed and recommendations are given to an effective dealing with patients presenting Antisocial personality disorder.

Body & storyline

The movie storyline is about a psychiatric patient named Randall Patrick McMurphy, a convicted criminal who is admitted to a psychiatric ward after faking insanity in order to finish his sentence in a mental hospital. He was touched by the distress and loneliness of the patients. Under the care of the nurse Ratched, he quickly opposes by his strong personality to the old repressive methods of the nurse Ratched by encouraging the other inmates to stand against the ward’s policy and routine. As a continue of McMurphy’s violent actions, he attempted to strangle the nurse Ratched because he thinks she was responsible for the death of Billy Bibbit, another patient in the ward. As a result, nurse Ratched sent him to a special ward to undergo a lobotomy, a special treatment that was used for patients deemed disturbed. The treatment leaves him in a vegetate state before another patient strangled him and rescued him from his life as a “vegetable” as described in the movie (Muncan & Mainescu, 2017).

Identification of the illness

This movie inspired a generation to rethink the current medical procedures and treatment of the mentally ill patient (Blažková, 2018). Especially patients suffering from Antisocial personality disorder, a disorder manifested by Randall McMurphy, one of the main characters of the movie. The disease is a serious, chronic and very complex mental disorder. It can dramatically affect the way a person feels, thinks and reacts to their surroundings. We talk about antisocial personality disorders when certain character traits are very marked, frozen, or they become unsuited to certain situations. This is reflected in the person’s personality in almost all spheres of his life, inevitably and sustainably causing suffering for the person and those around him and disrupts their social and professional functioning (Derefinko and Widiger, 2016).

Signs & symptoms

The main character of the movie (Randall McMurphy) is presenting symptoms of Antisocial personality disorder classified in the cluster B personality disorder and defined as “a pervasive pattern of disregard for and violation of the rights of others”. Patients suffering from this disorder tend to perform actions most of the people would find unacceptable, irresponsible, impulsive, and deceitful. It can also have superficial charm, grandiose sense of self-worth, need for stimulation, pathological liar and lack of remorse (Timmermann et al. , 2017).

In the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), three criteria were present in Mr. McMurphy which leaded him to be considered as an Antisocial personality disorder: Firstly, The pervasive pattern of violation of the rights of others, as indicated by three or more of the following: 1) The failure to conform to social norms with respect to lawful behaviors by repeatedly performing acts that are grounds for arrest, 2) deceitfulness, such as repeated lying, and conning for personal pleasure, 3) impulsivity, irritability and aggressiveness, 4) reckless disregard for safety of others, 5) consistent irresponsibility and lack of remorse. Secondly, the individual is at least 18 years old. Thirdly, there is evidence of conduct disorder with onset before age of 15. Finally, the occurrence of antisocial behavior is not exclusively during the course of schizophrenia or a manic episode (Lynam et al. , 2015).

McMurphy shows many signs and symptoms of antisocial personality disorder. When observing Randal McMurphy, it is evident that he has symptoms of special personality disorder characterized by charming and friendly personality, Randle shook every patient’s hand when he first arrived in the ward (Newbury-Helps, Feigenbaum and Fonagy, 2017). Moreover, antisocial personality disorder patients often suffer from impulsiveness as one of the most dominating signs of Randall in the movie when he climbed the barbed wire fence, stole the bus and the boat. Furthermore, grandiosity is also a main characteristic of Randall McMurphy from his believe that he could pick up marble bathing block. He is also a manipulative especially during card game, he tried to put World Series Game on TV and persuaded night guard to let girls in and get drunk. The last scenes of the movie showed the aggressiveness of McMurphy when he choked Nurse Ratched after Billy’s death (Wygant et al. , 2016).

Prevalence of illness

Personality disorders are among the most common mental disorders in the world, which represents a prevalence of 10% in adults worldwide. According to the WHO, an international survey using the DSM-V criteria showed that 5. 8% of men and 1. 2% of women were at risk of developing the disorder at any point in their lives (Wygant et al. , 2016). Antisocial personality disorders are fortunately rather rare in our society. There are few studies to determine their prevalence in Morocco. Yet, according to the first national survey on the prevalence of mental disorders in the Moroccan population carried out between 2003 and 2006: 16% of Moroccans experienced a personality disorder during their lifetime, and men are much more affected than women.

According to the same studies, it is estimated that for both sexes, about 1. 8% of the population would be affected, while others report a much higher prevalence of about 4. 3% of the population. For women, as for men, the age groups most affected are 15 to 44 years old (Elghazouani et al. , 2017). Psychosocial/spiritual/cultural impactMental illness has wide-reaching effects on patient’s education, employment, physical health, and relationships. In fact, the individual suffers not only the disturbing symptoms of his illness, but also the inability to participate in professional or recreational activities, often as a result of discrimination against him. He is concerned that he cannot take responsibility for his family and friends, and is afraid of being a burden to others (Balaratnasingam and Janca, 2017). Likewise, family members are likely to experience the impact of living with an antisocial mental disorder patient. In other words, the organization of the family and the relations between its members can be turned upside down. The presence of a mental health problem in a family member is not without causing some discomfort within the community as the patient is considered a burden in society.

As such, Stearns & McKinney (2018) revealed that feelings of shame, guilt, and rejection are frequently felt by those around the person living with mental health problems. Moreover, peer disagreements are also experienced and relationships between close friends and family members can become tense. The disorder causes discomfort for the patient especially spiritually where the patient is unable to perform his spiritual needs which often affects his personality, and often believes that he is beyond forgiveness of his sins. In another context, some community members directly express their wish to have the least possible contact with the ill patient (Stearns & McKinney, 2018). However, the family caregivers report in a study of Balaratnasingam and Janca (2017) that the burden of caring for and helping their loved one living with a mental health problem is on their own; caregivers claim that other family members are often difficult to engage, causing friction within family relationships at times.

Diagnostic & nursing interventions/rationales

The main character of the movie (Randall McMurphy) suffering from Antisocial personality disorder may be diagnosed by ineffective coping related to antisocial behavior as evidenced by poor judgment, and intense emotional dysregulation. The most significant example of this behaviors is the attempt of McMurphy to strangle and kill Nurse Ratched after Billy’s death. The impulsiveness and poor judgement of McMurphy towards nurse Ratched leaded him to his action. Coping mechanisms proved to be less during McMurphy’s intense emotional state which might got worse if Randall succeeded in his attempt (Yusuf, 2017).

Many nursing interventions should be implemented relating to this diagnostic: First, identifying behavioral limits and behaviors that are expected from the patient. The reason behind this intervention is that the client needs clear structure of limits since maintaining limits can enhance feelings of safety in the client. Second, the nurse has to be very clear about the consequences if policies or limits are not adhered to, because the client needs to understand the consequences of breaking the rules especially with increased impulsiveness and rule breaking of Randall McMurphy. In this case an additional intervention should be implemented as a collaborative management by encouraging the patient to pursue recreational activities that were positive in the past or may appeal to the client, because they can serve as a structure for the client to build social interactions as well as provide enjoyment.

Another diagnostic that should be put into consideration is the risk for self-mutilation related to impulsive behavior evidenced by intense rage focused inward and assaultive behavior. One of the dominating social signs of patients suffering from antisocial personality disorder is irritability, usually followed by violent behavior. Several times throughout One Flew Over the Cuckoo’s Nest, McMurphy showed such characteristics. For example, twice McMurphy broke the glass in the nurses’ station window when he didn’t agree with Nurse Ratched’s decisions. Nursing interventions in the latter case should focus on the security of the patients as well as the one of the nurses and caregivers. For instance, the nurse has to be consistent in maintaining and enforcing the limits, using a nonpunitive approach because consistency can establish a sense of security. For this reason, the nurse should first anticipate certain situations that might lead to increased stress (e. g. , tension or rage). Then, identify actions that might modify the intensity of such situations. The rational for this intervention is that it offers a chance to deal with feelings and struggles that arise. Another intervention that may serve as a collaborative management is to determine usual methods of problem solving as well as helping the patient to identify maladaptive strategies and suggest appropriate replacements. These interventions help clients determine the most beneficial strategies and substitute them for maladaptive ones (Yusuf, 2017).

TreatmentsIn the movie

One flew over the cuckoo’s nest, Randall McMurphy received several treatments. He was arrested several times then was sent to hospital where he received some medications. Then he received an Electroshock after his maladaptive behavior in the ward followed by a lobotomy for his attempt to strangle nurse Ratched. But these treatments were proven to be ineffective to treat misconduct. Treatment of personality disorders is not easy for any worker, but for the nurse the goal is to pursue a whole program. It consists of trying to establish a relationship with this client who is generally resistant to any intervention and to succeed in making him feel respected, understood and accepted without judgment (Bateman et al. , 2016). The nurse must make the client realize that he or she can trust her/him, which is usually not obvious, because this type of client is constantly trying to test the patience and willingness to help by all kinds of maddening means: absences or repeated delays in appointments, lies, mockery, offensive remarks, even humiliating. Moreover, the patient lies easily and may even manifest a fictitious interest in treatment, but only to have peace and stay out of the service. When the client really feels accepted and his behavior becomes more reasonable and less manipulative, another objective has to be pursued in which the goal is to develop firm and resolute interactions in order to contain and to restrain his violent and destructive behaviors toward others and himself (Bateman et al. , 2016).

Issues or side-effects

The drug approach is not very effective at treating antisocial personality disorders, but becomes very useful for the treatment of certain conditions that are often associated with it. Antidepressants and anxiolytics may be necessary to reduce the symptoms of depression and anxiety, while mood stabilizers such as lithium salts prevent too great emotional differences that may trigger violent behavior, depressive mood or suicidal ideation. Serotonin reuptake inhibitors help control impulsivity and aggressive behavior, while anticonvulsants also work to reduce the intensity of aggressive seizures (Beck, Davis & Freeman, 2015).

Recommendations

As per recommendations, there are two psychotherapeutic approaches that are important for every nurse to know, in order to be part of the lineage of psychiatric treatment. The first approach is the motivational interview which should be implicated for an appropriate behavior of patients. In terms of communication strategies, motivational interviewing is valued especially in relation to gambling, alcohol or drug abuse behaviors. It is a non-opposing and non-restrictive approach that aims to stimulate the patient’s motivation for change and its maintenance until the action takes place. It also stimulates the will to persevere in the adoption of more adapted behaviors (Choy, Farber & Kellner, 2017). The second approach relies on the cognitive behavioral therapy (CBT), which is a treatment that helps change thoughts, desires, and judgments that lead to inappropriate behavior. Thus, active and concrete strategies of cognitive-behavioral therapy, can lead them to realize the repercussions of their behavior on their life and that of others. They can also help them discover their strengths, possibilities and thereby induce an interesting decrease in destructive and antisocial behaviors. This therapy combined with motivational interview both promote tolerance, respect for others and self-control that are useful for better living (Beck, Davis & Freeman, 2015).

Conclusion

“One flew over a cuckoo’s nest” takes the viewer to think about people with antisocial personality disorders who are often treated outside hospital services, but it remains that when they require specific care, their contact becomes a serious challenge for caregivers. Their attitude of confrontation, mockery, aggression, cynicism, seduction and manipulation is difficult to tolerate and does not facilitate the creation of the empathic bond necessary for any caring relationship. This thorny contact often proves depressing, even discouraging for the caregiver (Muncan & Mainescu, 2017).

However, we must remember that an approach of respect, non-judgment, positive consideration and understanding for the feelings of devaluation that often inhabit them and for their impression of abjection caused by dependence and marginal experiences, makes it possible to see these customers as human beings who are so much more than their deviant behaviors. This approach of openness coupled with an attitude of firmness and assertiveness, allows us to realize that these people need help and possibly to initiate with them constructive questioning, inducing certain changes. The patients who suffer from antisocial personality disorders do not seem often asking for our interventions, they are even generally refractory, but “sometimes the most desperate calls for help are silent. “

15 April 2020

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