One Flew Over the Cuckoo’s Nest to Silver Linings Playbook

The evolution of mental health law and its impact on individuals and families.

Posted Aug 06, 2018

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The way we as a nation have come to regard, advocate, and care for those with serious mental health issues has radically changed over the last 50 years. Reforms have brought about increasingly effective and compassionate philosophies and treatments, with greater emphasis on patient rights.

While there’s no doubt these changes have been overwhelmingly positive, preserving the lives and dignity of thousands of individuals, unintended consequences have come to weigh heavily on families with mentally ill loved ones, especially those who desperately need but are resistant to ongoing treatment.

Such consequences make the evolution of mental health law well worth exploring.

As late as the 1960’s, state-run mental health facilities housed most individuals with mental illness. These institutions—underfunded, poorly staffed, and ill-regulated—didn’t “treat” patients as much as warehouse them. Individuals were chained to radiators, given largely untested anti-psychotic drugs with terrible side effects, and subjected to poorly administered electroconvulsive therapy.

The true nature of such institutions was ultimately captured in One Flew Over the Cuckoo’s Nest, a novel set in a psychiatric hospital ripe with the very abuses taking place in real life. Published in 1962, it was later adapted into a stage play and an Academy Award-winning film starring Jack Nicholson. Its success helped spur a public backlash against the current mental health system and, over time, states began creating laws protecting the rights of those with mental illness. For example, today’s oldest legal advocacy program for psychiatric patients, New York’s Mental Hygiene Legal Service, was created in 1964, shortly after the movie’s release.

Other milestones came later. In 1986, the highest court in New York State decided the seminal case of Rivers v. Katz, upholding the fundamental right of competent adults to refuse medical treatment, thus holding that hospitals must obtain a court order to administer treatment over a patient’s objection. The very next year, a class-action lawsuit forced the closing of Willowbrook State Hospital, a state-run psychiatric facility known for the abuse and neglect of patients.

As these developments unfolded, pharmaceutical companies developed new iterations of antipsychotic drugs with a lower risk of debilitating side effects, such that by the 1990s medications made it increasingly possible for formerly committed psychiatric patients to live more independently.

Today, the lives of individuals with mental illness evoke less of One Flew Over the Cuckoo’s Nest and more of "Silver Linings Playbook," the 2012 film starring Bradley Cooper as a man with bipolar disorder who returns home after being released from a psychiatric hospital. While the movie, a romantic comedy, concludes on a decidedly upbeat note, it shows some of the struggles endured by families touched by mental illness. Various scenes portray Bradley Cooper’s character refusing to take his medication and inadvertently knocking down his mother. It also eludes to a past incident in which he nearly beats a man to death.

While such moments ring true—a fact credited to the director’s own experience raising a son with bipolar disorder—they’re still part of a work of fiction, complete with a happy ending. Consider what would happen to Bradley Cooper’s character, and his family, if his mental health deteriorates to the point that he continually refuses medication, counseling, and in-patient treatment while becoming increasingly symptomatic.

This is the scenario faced by many families today. It is not unusual for parents to feel like hostages in their own homes as they house and seek to help mentally ill adult children grappling with serious symptoms from psychosis to mania and depression. With the absence of public psychiatric facilities, their children often have no other place to go.

Compounding their burden is the high bar the law now sets for involuntary commitment to mental health facilities—the result of the very reforms spurred by the abuses of the past. Because these commitments are only permitted for short time periods, patients who are admitted to such facilities are usually quickly released back into the care of their families who feel they have no choice but to take them in. The alternative is to abandon their loved one to a life on the streets. This fear is real as many mentally ill men and women become chronically homeless.

As a mental health attorney who works closely with such families—advising on legal requirements and exceptions to these laws, as well as petitioning courts for involuntary commitments and arranging follow-up services—I can tell you that there’s an argument to be made that the pendulum has now swung too far in the direction of patient rights. While no-one wants to go back to the day of individuals being chained to radiators, high legal standards and rigid confidentiality laws make it extremely challenging for families to obtain treatment for loved ones and provide critical long-term stability.

It would serve to benefit such families if the law recognized that individuals with mental illness often lack requisite insight and/or acceptance of their conditions, such that they persistently resist necessary treatment. Further, it’s frequently beyond a family’s ability to appropriately intervene; most lack the experience, expertise, and emotional stamina to keep fighting against a rigid and limited mental health system in which assistance is costly and treatment is subject to little if any quality control.

The most effective reforms are always ongoing, reflecting new realities and public needs. I am hopeful that over time, laws concerning mental health will further evolve to better assist families as well as protect patient rights.