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Professional Client Service User Relationship

Professionalism is defined as “the competence or skill expected of a professional”1 and “the practising of an activity by professionals rather than amateurs”.1 Marilyn Peterson speaks of boundaries as “the limits that allow a safe connection based on the client's needs.”2 In One Flew Over the Cuckoo's Nest and Patch Adams, I would be exploring the effects of boundaries when they are exploited by the professional which can cause severe repercussions to both parties.

The Professional

“The professional provides a service based on a special relationship with those whom he or she serves. This relationship involves a special attitude of beneficence tempered with integrity.”3

There are two types of professionals in One Flew Over the Cuckoo's Nest and in Patch Adams. These characters take the role of either official or unofficial professionals. In the former film, the important official professional is Nurse Ratched, whereas in the second movie these are the psychiatrist and the Dean. These characters are presented in the films as the ‘villains' as they exploit their power for their own personal satisfaction rather than to help their patients. The unofficial ‘professional' in One Flew Over The Cuckoo's Nest is Randle Patrick McMurphy whilst in Patch Adams, these are Hunter Patch Adams and some of his colleagues. Although McMurphy is only a patient in the asylum, through his boundless energy, he instils some life to some of his fellow inmates and indirectly helps one of them break free from the invisible chains of the asylum - their prison. Adams on the other hand, is not a dangerous person. He discovers that helping other people gives him personal fulfilment and joy in life - “By helping them, I forget my own problems”.4

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In One Flew Over the Cuckoo's Nest, Nurse Ratched is portrayed as a powerful creature who stifles her patients from experiencing life by domineering over them. Her method of professionalism is to follow by-the-book to a fault way. She allows no one to take this authority from her as she has the right to do so as she is a so-called ‘professional'. However, she does more harm than good. Her methods of controlling her patients include a mind-numbing routine which is followed religiously every single day; the group therapy sessions, which are purposely done to debase the patients; and her agenda to turn them against each other. Although from a distance she may appear that she respects their opinion, when McMurphy asks her if they can watch the baseball match, she refutes the idea and tries to manipulate her use of language in order to suit her. Even through the way she speaks, which command status and self-determinism, her patients are given no voice with which to express themselves. Her only concern is to preserve an aura of professionalism; of dignity and respect. Everyone in the mental hospital either hates her of fears her - this includes the patients, staff and doctor. It is only through terror that they comply with her. She has the power to keep McMurphy committed to the asylum for an indefinite period of time, even though she is aware that he is not mentally ill.

The fearless McMurphy on the other hand is clever and rebellious. He immediately positions himself as a leader at the asylum and thus creates conflict with Nurse Ratched. He takes a role of a professional in various ways. He tries teaching the Chief Bromden basketball; he distracts his fellow patients from fighting by throwing water at them; he takes them out on a boat trip; and demands that patients be given rights. Nevertheless one should add that this is for the most part, done for selfish purposes. A single word carries value and power which can easily be abused, as could be seen when he lied to the boat owners that he and his fellow inmates were professionals. This can be paralleled to the lax way Nurse Ratched performs her duties towards her patients. Through McMurphy's influence, the Chief escapes from the asylum as he decides that it would be better to face the world, than to remain in an environment where power was abused and where one's life was at stake.

The head of the psychiatric ward, Dr Prack in Patch Adams plays a significant, though short role. When Hunter Patch Adams was a patient at the asylum, he noticed that Dr Prack was not really listening and understanding him, but asking a fixed set of questions. The use of non verbal communication such as eye contact, was sparse which impedes with the needs of the patient. This leads Adams to question the value of the psychiatrics methods as he becomes conscious of its harm on the patients, who were staying longer as their problems remained unresolved. A fellow patient inspires him to take a new perspective into seeing things and to not be afraid, lazy or conform. At the University, Adams is taught by Dean Walcott, a man who strives for power and who has rigid fixed ideas of how a professional should and should not act.

“Professional ethics can also be dynamic, and generative of contexts in which the challenges posed by science, economics, changing social values and so on are debated”.5 Adams's approach to the term ‘professional' was unconventional at that time. He devalues the efficacy of books and the methods which have been used throughout the centuries. This causes friction with the Dean. Adams's methods exert a positive influence over the patients as they need less medicine, etc through his wild imagination, easy-going attitude, and humour to connect with the patient and meet their needs. However Adams's cheating could cause a great conflict with his profession as a Doctor. This is because this profession entails a crucial responsibility to know what one is doing as it deals with life and death situations. His room-mate said that he would rather be a ‘prick' and learn all there is to know so he would be able to save a person's life rather than make him laugh.

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“A professional should have legitimised authority.”3 This contradicts Adams's use of practising medicine alongside with his undergraduate colleagues who ran a clinic without a licence. One of his mottos is to “improve quality of life, not just delay death”.4 He does this effectively by trying to brighten his patients' life. Adams redefines the term ‘Doctor'. To him it means a trusted and learned friend and that is what he seeks to achieve with his patients. His home clinic, which he runs for free, is a place where the patients become doctors to other patients. This reciprocation creates a harmonious and interdependent setting. Despite losing Carin, he comes to a greater understanding and realization of how much being a doctor means to him, “I wanted to become a doctor so I could serve others. And because of that, I've lost everything. But I've also gained everything.”4

According to David Morrell, professional values consist of “confidence, confidentiality, competence, contract, community responsibility and commitment.”3 This can be clearly seen in Adams but not quite so in Nurse Ratched.


“Professional boundaries are important because they define the limits and responsibilities of the people with whom you interact in the workplace”.6

This image illustrates, “a zone of helpfulness is in the centre of the professional behaviour continuum.”7 This ensures that the majority of client interactions should be effective and safe to the patients. The two extremes: over-involvement and under-involvement should be avoided. Over-involvement includes boundary crossings, and violations. Under-involvement includes distancing, disinterest and neglect which can cause negative outcomes to the client and the nurse. There is a gradual transition with no definite lines separating the zone of helpfulness from the ends of the continuum.

In One Flew Over the Cuckoo's Nest, Nurse Ratched's character is portrayed as under-involved. She can be likened to a robot and seems to express some psychopathic traits - insensitivity, emotionless and detachedness to her patients' needs. Because of her lack of empathy and understanding, the patients “may feel betrayed, abandoned, and/or poorly served”.8 This is damaging to her patients as she does not focus on them to become functional in society and thus, their stay is either prolonged or their condition worsened. She talks to her patients as if they were children and encourages them to be dependent on her rather than autonomous, which is a violation to the ethical codes. She is there for them only on an external level - to do her work but not on an emotional level, and thus her patients' requirements are not met. One can conclude that her satisfaction in being in power - which interferes with the way she interacts with her patients - causes McMurphy's lobotomy and death, Bill's death and her narrow escape from being strangled.

Although McMurphy is a patient, his crossing over boundaries causes consequences to other characters as well as to himself. McMurphy is not really psychologically ill, rather a dangerous person. McMurphy's lack of respect and regard to authority induces him to cross over boundaries with Nurse Ratched. He challenges her when he calls on votes on ward policy, disrespects her, and nearly chokes her to death. Because of the strong boundaries in this setting, which clashes with his rebellious character, he indirectly causes his own death.

“It is a general misconception that having good boundaries will distance you from others.”6 The doctors and the Dean in Patch Adams value prestige and are insensitive to the patients needs. They refer to their patients by their number, unlike Adams, who calls them by their name. The Dean wants to be seen as a person of esteem - with standards and codes, and is concerned with professional distance. He is constantly telling his students to avoid transference. “Our job is to rigorously and ruthlessly train the humanity out of you... make doctors out of you.”4 His perspective of how he sees his profession is heavily contrasted with Adams's, whose aim is to reduce all boundaries to an equal level as the patients and nurses. Adams perspective of the hierarchal system is far more shocking in his eyes than death, “Death is not the enemy gentlemen. If we're going to fight a disease, let's fight one of the most terrible diseases of all, indifference”.4

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Adams's lack of boundaries are sometimes costly. He defies rules, and may come across as arrogant and impolite. He also uses disrespectful and offensive language with the Dean. The irony of the story is that his desire to reach out in person to the patients, by not being detached and objective, costs his friend Carin to be murdered. After being inspired by him, she loosens the boundaries by visiting a severely mentally disturbed person who “asks/expects service provider to socialize with him/her outside of professional setting”8 and “provide assistance to client outside of his/her role”.8 The movie ends with Adams's graduation, who is wearing a gown with no ‘back' to signify his persistence not to conform.

The two major distinctions about these two characters in One Flew Over the Cuckoo's Nest and Patch Adams, is that in the former movie, Nurse Ratched, an anagram for wretched, meaning miserable, causes negative influence over her patients. In the latter film, Adams, who was told off for being too happy, creates a positive mood on the patients. This single difference makes all the difference.


What I find striking about Adams's character in Patch Adams, is his unyielding self-determination, creativity and knack to reach out for people and lighten up their life. Being too detached carries a grave responsibility over the patients who will only fare worse in such an environment so much so that it can cost them their life as is shown in One Flew Over the Cuckoo's Nest. It is always better to avoid all kinds of extremities and personally, I think that one should seek to incorporate a balance at work and in one's day to day life to keep dissonance at bay.

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