Psychotherapy Used To Enforce Social Norms English Literature Essay

By the end of the 1950's psychotherapy had reached the pinnacle of its notability in the American consciousness. Psychiatrists were knights of reason and order saving damsels from the bourgeoning dragons of the mind. By 1960, however the dragons had become the psychiatrists and the institutions of psychiatric care themselves. Budapest trained psychoanalyst Thomas Szasz, in The Myth of Mental Illness (1960), criticised his own field and called the idea of psychotherapy "scientifically worthless and socially harmful." [1] In The Divided Self: A Study of Sanity and Madness (1960), R.D. Laing argued that the schizophrenic patient was often pretending to be mad, making a fool of himself and the doctor as a way of keeping dangerous people at bay. Michael Foucault's Madness and Civilisation (1961) presented an account of the origin of the asylum and proposed that the contemporary hypothesis of insanity was a cultural invention of control; the mad who had once been a tolerated part of society and life's idiosyncrasies became seen as threats, confined to asylums, and silenced. Sociologist Erving Goffman's Asylums (1961), described mental institutes, as built on a power dynamic in which patients were subjugated as a way not of curing mental illness but of establishing the power and authority of the psychiatric and mental health professionals. [2] Foulcault argued that the concepts of sanity and insanity were social paradigms that did not reflect quantifiable patterns of human behaviour, and that, rather, were indicative only of the power of the 'sane' over the 'insane'.

These studies paved away for the birth of the anti-psychiatry movement and looked at psychotherapy and mental illness as mechanisms of social purification masquerading as science with little diagnostic or therapeutic value. Therapy meant learning to adopt the moral codes of a particular society, not treatment of an illness. Despite the prestige and influence of these books in intellectual circles, none of them had the widespread impact of two novels that were some of the post-war period's most well-known representations of mental institutions and the growing anti-psychiatry sentiments of Cold War America. These novels are Sylvia Plath's The Bell Jar (1963) and Ken Kesey's, One Flew Over the Cuckoo's Nest (1962). Both novels endorse the anti-authoritarian expression of the 1960s 'counterculture' movement, whilst simultaneously providing a social critique as well as a chastisement of psychiatric institutions. Against this framework, these novels serve not only as an factual interpretation of a decidedly personal experience of psychiatric afflictions in regards to both authors, but also as a scathing social criticism of psychotherapy as a whole.

While the anti-psychiatry movement had already started to develop in the same period of Plath's own hospitalisation in the 1950's, the movement is frequently associated with Kesey's One Flew Over the Cuckoo's Nest which resulted in the criticism of psychotherapy mainstream society in the 1960's. These dramatic readjustments in the way psychotherapy was viewed provides a crucial milieu for apprehending the analysis of psychoanalysis put forth both The Bell Jar and One Flew Over the Cuckoo's Nest. In The Bell Jar, Sylvia Plath tells the account of Esther Greenwood who oscillates between mental institutes, chronicling her mental breakdown, institutionalisation and shock treatment with almost irrefutable detail. Plath sought to write the novel she described as a "pot-boiler" in 1962. She recorded in her journal in March of 1959, "There is an increasing market for mental hospital stuff. I am a fool if I don't re-live it, recreate it." [3] This was an epoch that corresponded specifically with the time in which condemnations on psychotherapy by Laing, Goffman and Szasz secured centre stage in the public eye. Looking to the growing trend in novels concerning mental illness of the 1950s for inspiration, Plath strived to embody, in her own terms how "isolated a person feels when" they are "suffering a breakdown". The Bell Jar is distinctly bound to the prevalent 1950s mental health novels and memoirs she termed "potboilers" [4] , and to the more erudite anti-psychiatry protest narratives that had begun to circulate extensively by the time Plath started to outline the novel in 1962.

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Another example of this growing trend in mental health chronicles of the 1960s is Ken Kesey's One Flew Over the Cuckoo's Nest. Kesey began writing his novel in 1960 whilst still a literature student working the graveyard shift at a mental institution and partaking in government-sponsored drug experiments. As he worked on the psychiatric ward in the Menlo Park Veterans Hospital, he grew sympathetic toward the patients and like Plath began to scrutinise the boundaries regarding the sane and insane. Kesey began to ruminate whether lunacy really implied the common practise of conforming to a perfunctory and mindless system or the struggle to break out from such a system altogether. In One Flew Over the Cuckoo's Nest, one of the psychiatric patients named Scanlon, articulates what could be a commentary either on Goffman's theory or modern description of tragedy: "Hell of a life. Damned if you do and damned if you don't. Puts a man in one confounded bind, I'd say." [5] Either obey and be released or maintain your dignity and be kept in the ward. Kesey visualised the-then pervasive system of "Therapeutic Community" (KK, 44) as a means of coercing the internal soul to suit someone else's notion of the model external environment. In this practise, patients are made to reveal their secrets to one another in an attempt to make the ward "as much like… democratic, free neighbourhood as possible - a little world Inside that is a made-to-scale prototype of the big world Outside that you will one day be taking your place in again." (KK, 44) In One Flew Over the Cuckoo's Nest, Kesey and Plath transform the mental ward into a representation of the tricks of control afoot in post-war American society.

If The Bell Jar and One Flew are in many respects indicative of the mental health narratives that gained recognition in the immediate post-war era, they are similarly indicative of post-war's absorption with the dynamic forces of conformity and rebellion. Both the novel's social critiques have powerful semblances with the condemnations of the 1950's 'consensus culture' as seen in the works of the decade's sociologists and beat poets. Conventional institutions and the orthodoxy they enforce are symbolised by the psychiatric ward and the boundaries it enforces between the sane and insane. For Plath, insanity materialises as emancipation from social obligations, predominantly the constraints that society inflicts upon women. For patients like Esther Greenwood, wealth is also the criterion for admission and the novel demonstrates the sheer divergence between public and private care. From this perspective, the novel's criticism of psychotherapy directs itself against the conformity of middle-class American society whilst simultaneously endorsing a reallocation of wealth and resources whose direct recipients were the prosperous, middle-class citizens in society.

The Bell Jar's criticism of psychotherapy and the medical establishment initiates with a blistering treatment of Esther's boyfriend Buddy Willard a medical student. Esther recalls that "Buddy had won a prize for persuading the most relatives of dead people to have their dead ones cut up whether they needed it or not, in the interests of science." [6] For Esther, such coaxing embodies a variety of autocratic medical procedure, in which physicians endeavour to safeguard public benefits rather than the wellbeing of the individual patient.

Marriage to Buddy transpires also as a personal incarceration and is regarded by Esther as a form of obligatory mental incarceration. Her relationship with Buddy earns the respect and approval from not only Esther's mother but also her counterparts in college. This provides enough of a reason for her to break out of the bonds of conformity:

"I also remembered Buddy Willard saying in a sinister, knowing way that after I had children I would feel differently, I wouldn't want to write poems any more. So I began to think maybe it was true that when you were married and had children it was like being brainwashed, and afterwards you went about numb as a slave in some private, totalitarian state" (81)

Here Esther is observing a gap between what society demands she experiences and what she eventually experiences, and this gap intensifies her growing neurosis. The terms "slave" and "totalitarian" invoke the Szaszian view on the hindrances of psychotherapy, which contended that "totalitarian" or psychiatric medicine was "involuntary incarceration." [7] Plath's invocation of this 'totalitarian' psychotherapy resonates with the notion of the "Combine" in One Flew Over the Cuckoo's Nest.

Confinement, control, and loneliness had been the words defining the dark moods of the cold war, still at its chilliest whilst Kesey and Plath were working on their novels. As Plath had commented in her Journals, "The great fault of America… is its air of pressure: expectancy of conformity… I have my own dream, which is mine and not the American dream" (Plath J, August 1st 1958, 411-412). The cold war era extolled science and even fed on the fear of loss or control engendered by its growth. Ken Kesey volunteered for government-sponsored drug experiments at the Menlo Park hospital in 1959, where he was paid to take LSD, Ditran, mescaline, IT-290. The CIA had hoped to develop these substances as a means for mass mind control. Before long, these drugs found their way onto the mainstream American popular culture and became the talk of artists, writers, musicians and actors in that phantom entity, the counterculture As Kesey himself said in 1987:

"We were asked by the government, 'Hey, go into that little box over there. There's something in that little box that we don't have the hair to go into.' So they hired a bunch of college students to go in there… then they said, 'Don't let them back in that box!'" [8] 

Pharmaceutical attempts at psychotherapy in Cuckoo's Nest have little to do with a cure, but are presented as instruments of addiction designed to keep people in line and out of their wills: "Miss Ratched shall line us all up against the wall, where we'll face the terrible maw of a muzzle-loading shotgun which she has loaded with Miltowns! Thorazines! Libriums! Stelazines! And with a wave of her sword, blooie! Tranquilize all of us completely out of existence." (KK, 262) Nurse Ratched personifies this oppressive, mechanised, dehumanised and emasculation of modern society and indeed psychotherapy, bent on the persecution and conformity of its own. She is a minion of the intangible "Combine" (KK, 6) , a term coined by Chief Bromden who himself has become a "six-foot eight sweeping machine, scared of its own shadow" (KK, 62) as a result of the Nurse's tyrannical presence. Bromden appears as a reluctant and somewhat faulty component of this mechanism and its ambitions. Bromden's vision of the Combine and its machinery has been moulded by the displacing wounds of his past: the loss of his family's tribal fishing grounds by government construction of a hydroelectric dam. In an instant of oneiric anxiety, he describes the hum of the Combine as being "a lot like the sound you hear when you're standing late at night on top of a big hydroelectric dam. Low, relentless, brute power." (KK, 76) The dam represents machinery that destroys one way of life in service to another and the incapacity for an individual to be unobstructed. The asylum and psychotherapy, in Kesey's world performs a similar task.

Psychotherapists are peripheral in One Flew Over the Cuckoo's Nest. The ward depicts the nightmare of middle management, and Bromden transforms Nurse Ratched into a slave of the Combine who make's sure it runs efficiently and on time. Her name suggests her role as a gear paw that permits a gear to go in only one direction. The angrier she becomes, the more machinelike and therefore, funny she becomes: "…she really let's herself go and her painted smile twists, stretches to an open snarl, and she blows up bigger and bigger, big as a tractor, so big I can smell the machinery inside the way you smell a motor pulling too big a load" (KK, 5). Bromden finds in Big Nurse's satchel no signs of being human - "no compact or lipstick or woman's stuff" only "a thousand parts she aims to use in her duties today - wheels and gears, cogs polished to a hard glitter, tiny pills that gleam like porcelain, needles, forceps, watchmakers' pliers, rolls of copper wire" (KK, 4). He sees her as a caricature frozen in her chosen mask to enable her to enforce social norms. Her manipulative skill and ability to destroy by insinuation render her an infuriating and insidious corporate tool. She executes her cold professionalism with an unshakable sanctimonious piety. A former army nurse, part of the military hierarchy, she performs her job without emotion, and her almost puritanical sexlessness makes her inscrutable and inhuman, indeed 'wretched'. Her lack of sensuality represents a puritanical society's fear of what it cannot control. Bromden makes it clear, however, that the ultimate villain, if there is one at all is the Combine and elucidates that "…it's not just the Big Nurse by herself, but it's the whole Combine, the nation-wide Combine that's the really big force, and the nurse is just a high ranking official for them" (KK, 164).

Into this world of machinelike rigidity and morbidity falls trickster Randall P. McMurphy, who like Chief Bromden fakes his madness and in doing so avoids the great American game of paying dues through work. The reports of his former military service in the Korean War give him an aura of being one capable of heroic acts of courage, and it is ironic that he led an escape from a Communist prison camp only to land himself in its American equivalent. The fundamental oppositions in One Flew Over the Cuckoo's Nest as well as The Bell Jar are not between madness and sanity but between being trapped and free. The problem Kesey's and Plath's novels frame are what it means to be free in a world governed by a relentless but elusive machine.

In The Bell Jar, psychiatric institutions define as 'insane' those individuals who do not fit the mould in society and in Esther's case those women who do not fit the established images of womanhood. She is torn between orthodox and unorthodox alternatives, and it is her irresolution according to Plath, that forms her "neurosis". "I am never going to get married", she tells Buddy Willard, who replies predictably, "You're crazy" (SP, 89). Esther tells him she is torn between an urban or country life, between matrimony and her profession, between abstinence and promiscuity. Her aversion to marriage is thus regarded as a form of mild insanity, neurosis and Buddy is unsuitable insofar that he represents the oppressing practices of medical and mental health institutions. The novel envisages this irresolution in the representation of a fig tree and Esther visualises her "life branching out before me like the green fig tree" that branches out offering several different options for Esther. She can only choose one fig, but as she wants them all, she sits paralysed with uncertainty causing the figs to eventually "wrinkle and go black" falling to the ground at her feet (SP, 73).

This patriarchy is similarly demonstrated in the character of Dr. Gordon, the first psychotherapist Esther visits following her breakdown. She expects that he will aid in her recovery, but she immediately distrusts him because he is attractive and can "see right away he was conceited" (SP, 124). This fuels her increasing mistrust of psychotherapy and the medical establishment. This scepticism first manifests itself when she visits Buddy at medical school and witnesses a woman giving birth. Esther recoils at the idea that a drug can erase a woman's memory of pain which would encourage her to "go straight home and start another baby" (SP, 62). Dr. Gordon and indeed her mother similarly urge her to overlook her sorrow rather than attempting to understand or alleviate it. Dr. Gordon does not appear to regard Esther when she communicates her symptoms and eventually reveals that he has indeed paid her very little attention. Following her first shock treatment, he asks her for the second time where it is she attends college and reiterates an inane comment about the attractive girls stationed there during the war. He does not attempt to empathise with her torment; rather, he merely attempts to make her 'normal' again by means of electro-shock therapy that augments rather than diminishes her pain. Indeed after having received the brutal treatment Esther reflects, "I wonder what terrible thing it was that I had done" (SP, 138), revealing that she felt castigated for not adhering to society's patriarchal whims. Buddy's and Dr. Gordon's male-orientated inclinations are apparent in the "totalitarian" customs of the medical sphere, so that despotic medical and psychiatric establishments operate as a mechanism for sexist conventions.

This gender-orientation in the medical sphere is also present in Cuckoo's Nest, but rather it is manifested as matriarchal as opposed patriarchal. The qualities of piety and communal concern that had been taught to women to keep them quelled become in Nurse Ratched's hands an instrument of power and emasculation. With the exception of the prostitutes in the novel, women are uniformly menacing and terrifying figures. Chief Bromden and McMurphy, the brash, gaudy and sexually uninhibited protagonist of the novel both have the tendency to depict the misery of the mental patients as a question of castration or emasculation at the hands of "ball-cutter" Nurse Ratched (KK, 54). Fear of women is a fundamental theme in the narrative, and is used as a tool by the "Big Nurse" to enforce social norms within the confines of the asylum as one of the patients Harding reveals, "We are victims of a matriarchy here" (KK, 56). More explicit references to castration occur within the novel, fortifying Kesey's idea of emasculation by the glacial Nurse. When Rawler, a patient residing in the "Disturbed" ward, commits suicide by severing his own testicles, Chief Bromden ruminates "What makes people so impatient is what I can't figure; all the guy had to do was wait" (KK, 112), implying that the institution and indeed psychotherapy as a whole would have castrated him eventually. The asylum, administered by females, handles only male patients, reveals how women and the medical world can use emasculation as a means to supress individuality. Towards the conclusion of the narrative, after McMurphy receives three electro-shock treatments already that do not appear to have had any effect on him, the Big Nurse suggests taking more drastic measures: "an operation". By this she is inferring a lobotomy, but McMurphy pre-empts by joking about castration. Both operations nevertheless, strip a man of his humanity, independence, and faculty for sensuality. Kesey portrays the two operations as symbolically the same.

Yet in The Bell Jar insanity while serves as the mechanism for women's liberation and an exodus from gender constraints and sexual discrimination, it simultaneously emerges as a site upon which new bourgeois privileges take shape. Esther's suicide attempt carries her to a public hospital in the city, where she comes upon raucous inmates and a team of medical professionals who behave callously and indiscriminately towards their patients, without regard for individual identity. The food is unpalatable and she kicks the attendant who serves the patients two varieties of beans with no meat. The meagreness of the institutions' diet is also exhibited in its pitiful degree of medical attention, as witnessed in the repetitive treatment plan, which comprises of cyclical and superfluous examination of each patient's temperature. In protest to the inadequacy of the treatment she is given, Esther shatters the nurse's thermometer in an act of defiance. She displays obvious disdain for the public hospital and its standard of care, referring to her mediocre and interchangeable doctors as things like "Doctor Soandso" or "Doctor Syphilis" (SP, 172-173). As a result of this bad behaviour she is immediately relocated presumably given more shock treatments as punishment. This is the ham-fisted choice of an uncongenial institution that focuses solely on its own bureaucratic requirements above the demands of its patients.

Within the highly distinguished universe of the elegant private hospital she moves to after her expulsion from the public city hospital, patients move up and down a graduated hierarchy ranked according to the individual patient's mental recuperation. "Either I got better, or I fell down, down like a burning, burnt out star, from Belsize, to Caplan, to Wymark" (SP, 200). Esther considers her own ambiguous position within that system and this fear of descending propels Esther along a sequence of intensifying accomplishments and undertakings which assess her restoration to normality. Every movement onward in the advancement of recovered mental wellbeing is rewarded with corresponding privileges such as "walk privileges" or "shopping privileges" (SP, 208). The novel carefully distinguishes between other patients who fall short of these rewards and those like Esther who attain them. The patient's social exchanges are carefully monitored, indicating the concept that such compliance is crucial to their successful recovery. This hierarchy is similarly demonstrated to a more extreme level in Cuckoo's Nest by the separation of the patients into "Acutes", "Chronics" or "Vegetables". The narrative reveals that some Chronics were once patients who arrived at the hospital as Acutes but were mentally crippled by excessive shock treatment or lobotomies, common practices of torture in the asylum to keep the patients in order. A hospital, usually a place where the unwell go to be healed, now becomes a damaging environment. Ellis, Ruckly and Taber for instance are electroshocked in "The Shock Shop" (KK, 62) to such a degree that they become docile or even vegetables. The hospital is no longer concerned with therapy or healing, but rather it seeks to dehumanise and manipulate patients until they are weak and willing to conform to social norms.

In The Bell Jar, the criticism of established institutions such as psychotherapy is concurrently connected up in the forthcoming demise of one of the leading twentieth century bodies, the welfare state. If insanity is the outcome of Esther's defiance to socially-prescribed standards, recovered sanity will grow to be a disenchanted return to her previous, socially-adequate self. Towards the end of the novel, Esther's doctors declare her "whole and well", "patched, retreaded and approved for the road" (SP, 233), ascribing her to probation with full benefits. Esther's treatment depends on surrendering herself to social guidelines and customs rather than evading them. As opposed to terminating her stay in the hospital however, Esther chooses to stay in the hospital before her return to college. Joan, her friend, is also permitted to leave the asylum, but elects to stay in a town in close proximity, sharing accommodation with one of the hospital's nurses. Both circumstances reveal that the psychiatric institution appears to have ingrained itself in the fabric of their personal consciousness.

The most striking example of this punitive influence is in Ken Kesey's novel, when McMurphy realises that he is the only involuntary patient amongst the Acutes. He realises that most of the patients have made the conscious decision to remain institutionalised due to sheer dread of their re-adjustment to the outside world after being so recurrently and incessantly disparaged. The voluntary patients choose to stay under Nurse Ratched's control out of fear of existing in a society that frowns upon individuality and abnormality. Billy Bibbit exclaims, "If we had the g-guts! I could go outside today, if I had the guts" (KK, 167). Psychotherapy has convinced them that they are too deficient to exist naturally in society outside of the confines of the ward. This differentiates McMurphy from the other patients as he considers himself sane due to his ability to make his own rational choices while other patients are programmed to consider themselves insane through their refusal to take risks in the outside world. When McMurphy attacks Nurse Ratched after she provokes Billy leading to his eventual suicide, he is lobotomised against his will. Her intention was to condemn McMurphy to a fate worse than death, but he is venerated by Bromden who euthanises him, assuring that McMurphy will forever be a symbol of resistance instead of a lingering cautionary tale for future patients on Ratched's ward. Soon after his death, the patients recover their sanity and self-assurance and summon the strength to finally leave the tyrannical clutches of Big Nurse and her Combine.

Valerie, Esther's friend in The Bell Jar who has been lobotomised, but adores the institute and wishes to remain there. Parading the scars that protrude like "horns" on her forehead, Valerie boasts:

'"I've had a lobotomy."

I looked at Valerie in awe, appreciating for the first time her perpetual marble calm. 'How do you feel?'

'Fine. I'm not angry any more. Before, I was always angry. I was in Wymark, before, and now I'm in Caplan. I can go to town, now, or shopping or to a movie, along with a nurse.'

'What will you do when you get out?'

'Oh, I'm not leaving,' Valerie laughed. 'I Like it here." (SP, 185)

For Valerie like the Acutes in Kesey's novel, obedience has been internalised as a self-inscribed behavioural imperative and they continue to adopt the tenets of the institution despite being released from it.

Both The Bell Jar and One Flew Over the Cuckoo's Nest operate not only to reveal the injustices that took place within the psychiatric world but they also reveal the consequences of the refusal of the individual to submit to the order of the state. Psychotherapy in these novels is presented as mechanism to enforce social conventions through coercive practices in a highly oppressive and paranoid cold war political climate. The fundamental oppositions at work within the novels are not the within the notion of sanity or insanity but between being restricted and being free. Plath and Kesey battle furiously against monotony, conformity and against those who attempt to schematise and subordinate the liberation and unpredictability of the human spirit and free-will. Both novels endorse the anti-totalitarian perspective of the anti-psychiatry movement, whilst simultaneously providing a social critique as well as a chastisement of psychiatric institutions. In such a dehumanised world, renegades, castaways and those who are unwilling to bend to society's expectations, may be the only ones left to claim humanity.

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