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In the Shadow of Nurse Ratched

Film portrayals perpetuate courtesy stigma. Republished from Crosscurrents March 2010 issue with permission.

By: Ned Morgan

Mainstream film has never been very kind to mental health nursing. More often, it has either undersold the role of nursing – pushing it to the fringes as window dressing to the work of doctors – or promoted a stigmatized and distorted view of nurses as uncanny instruments of punishment and control.

Ann Greene, a British Columbia–based mental health nurse, witnesses the power of film to influence and reinforce popular portrayals of her profession when she takes nursing students onto psychiatric units. “Many student nurses still relate the whole role of the nurse to One Flew Over the Cuckoo’s Nest,” she says. “Everybody seems to know about it.”

Trina Gouthro, a public health nurse in Truro, Nova Scotia, says these damning portrayals hurt both the profession and the people it serves. “Such film depictions are highly problematic because they contribute to a mistrust and fear of mental health nurses by the public, which may deter some people from seeking the care they need,” she says.

It’s a sort of stigma by association, attaching itself to those who work with that highly stigmatized population – people with mental illness. This “courtesy stigma,” as it is called, has been examined in the experience of psychiatrists and has been implicated in the devaluation of and low recruitment into the profession. Mental health nursing may arguably be even harder hit by the stigma.

Keri De Carlo, a mental health nurse and nurse educator at St. George Hospital and Community Health Service in Sydney, Australia, has examined these popular portrayals. In an ethnographic analysis that explored how mental health nursing was depicted in 19 American films from 1942 to 2005, De Carlo concluded that mental health nursing was considered abnormal, secret and dangerous work. The study, published in a 2007 issue of the International Journal of Mental Health Nursing, found that films depicted the role of mental health nurses overall as one of “custodial companionship” and “doctors’ handmaidens.”

“Film is an influential social agent that replicates and reinforces stereotypes,” says De Carlo. “Negative stereotypes and perceptions of mental health nursing are replicated and reinforced through the media, serving to sustain mental health nursing in a stigmatizedposition.”

Gouthro traces this stigmatized position to the perception that mental health nursing is “low-class work requiring no skill or expertise.” In a recent article in Issues in Mental Health Nursing, Gouthro argues that the decision to enter mental health nursing may be perceived as a personal flaw in the nurse, be it psychological or intellectual. As the most widespread transmitter of ideas and images, film certainly reinforces these notions. “Stigmatizing portrayals of mental health nursing in film can contribute to the distorted view of mental health nurses as controlling and untherapeutic,” says Gouthro.

It’s a distorted view that stigmatizes mental health nurses even within the nursing field. Greene, a former board member of the Canadian Federation of Mental Health Nurses (CFMHN), has experienced the stigma since beginning her career in the 1970s. “On my first day on the job as a graduate nurse, a registered nurse who was getting close to retirement asked me, ‘Why would you start your career in psych nursing? This is where you end your career.’”

With more than 60 years of stereotyped portrayals in mainstream film and television (see sidebar), is there an end in sight to the real-world stigma of the profession? “Mental health nursing is still seen as the country cousin, and it’s not valued in the same way as medical or surgical nursing,” says Greene. She is concerned about the erosion of mental health nursing within undergraduate nursing programs across the country. “The CFMHN did a cross-country environmental scan of nursing schools and found that many offer no course in mental health nursing and that clinical hours are minimal.”

However, Greene sees some positive developments, particularly where nursing schools are introducing relational practice into their curricula. “That really is the core of mental health nursing – entering into therapeutic relationships with patients.”

De Carlo sees the problem as latent in the larger medical profession: “I talk a lot to general nurses, and our world is still seen as strange, a bit deviant, weird, exotic,” he says. “The geographical space that psychiatric nursing occupies has changed from large, isolated institutions to being attached to a general hospital. But our world is still seen as secret, full of crazy people who are expected to be eccentric, different.”

Shrink Wrap

The depiction of psychiatry in films reveals a fixation with the darker aspects of the history of psychiatry – for instance, the Victorian-style asylum – that continues to cast its long shadow. The image of the asylum as a cursed, forsaken place has been showing up in films from Bedlam (1946) to 12 Monkeys (1995) to Shutter Island (2010).

Pinpointing film’s stigma toward psychiatrists is trickier, since it comes in many forms. According to Dr. Peter Byrne, consultant liaison psychiatrist at Newham University Hospital in London, UK, “Popular cinema, from Hollywood and elsewhere, has continued to portray mental health professionals in mostly a negative light.” This may be due to ignorance, for as Byrne points out, “the people who comprise this industry learned their psychiatry at the cinema … cinematic education began with the coercion and cruelty of Cuckoo, and the asylum looks every bit as bad as Shock Corridor (1963).” Bryne notes that while psychiatry has also been idealized in film – he cites Spellbound (1945) and Ordinary People (1980) – this is relatively rare. Byrne asks, “Where is the drama in a helpful psychiatrist supporting his or her patient?”

Non-network television drama may be bucking this trend by offering nuanced and relatively true-to-life psychiatrist characters. HBO’s The Sopranos (1999–2007) featured the sympathetic psychiatrist character Dr. Jennifer Melfi (Lorraine Bracco). Each episode of the current HBO series In Treatment (2008–) focuses on a different client of Dr. Paul Weston (Gabriel Byrne). Though at times extremely troubled in his own life, Dr. Weston is clearly a helpful psychiatrist who supports his clients.

Fact or Fiction?

Mental health nurses on the screen

The Snake Pit (1948)
One of the first major U.S. feature films to deal at length with mental illness, The Snake Pit can be commended on many levels, but not for its depiction of nurses. Committed to a state mental hospital for women, Virginia Cunningham (Olivia de Havilland) is transitioned through various wards. The treatment she receives from a kindly psychiatrist contrasts with the treatment she receives from nurses, who range from bustling no-nonsense matrons to power-hungry persecutors. Nurse Davis (Helen Craig) dislikes Virginia and is stopped short of maltreatment only when doctors intervene.

Valley of the Dolls (1967)
This popular but critically derided film of a bestselling pulp novel about the intersecting lives of three women and their relationships, careers and addiction to prescription pills shows nurses in a private sanatorium as emotionless and dedicated to unimaginative routine. Neely O’Hara (Patty Duke), a singer who is addicted to pills and has a mental breakdown, is put through the paces by heavyset nurses who administer little more than enforced hydrotherapy.

One Flew Over the Cuckoo’s Nest (1975)
Nurse Ratched (Louise Fletcher), head of a psychiatric ward, uses group therapy to pursue her coolly spiteful agenda of total control. Thanks to Fletcher’s Oscar-winning performance, Ratched has become an unfortunate byword for the mental health nurse. But if the film is viewed as an allegory of a totalitarian state (which the director and author of the original book intended it to be), it becomes clear that the character is not meant to be an accurate portrayal of a mental health nurse. Sadly, it continues to be viewed as such.

Terminator 2: Judgment Day (1991)
Sarah Connor (Linda Hamilton) believes that a cyborg travelled back in time to kill her. She lands in a psychiatric facility, where her psychiatrist, though ineffectual, is not unsympathetic. The male nurse-attendants, however, routinely beat patients and (it is suggested) sexually abuse them. The film is a dystopia, where the accepted values of the world we know are turned upside down; the nurse-attendants play to this element of the story by acting out the violent antithesis of a nurse’s true work.

Changeling (2008)
In this Oscar-nominated film based on a true story, Christine Collins (Angelina Jolie) is committed to the psychopathic ward of the Los Angeles County General Hospital in 1928 under false pretences. Having already been at the mercy of corrupt police, she is now thrust into a world where nurses are grim-faced agents of domination, stripping and hosing their victim down and subjecting her to humiliating examinations. When Christine is seconds away from a dose of punitive electroconvulsive therapy, the camera focuses on the face of the nurse controlling the machine, showing her Aryan-type features suffused with impersonal cruelty.

House (2004–)
The popular series about an unconventional, drug-abusing medical doctor finds him institutionalized for addiction and mental illness at the beginning of its sixth season. In the group therapy scenes (reminiscent of Cuckoo) the contrarian Dr. House is at loggerheads with the doctor in charge; unlike in Cuckoo, a doctor, not a nurse, conducts the therapy. Ann Greene, a mental health nurse who has seen the show, comments: “In House [season six, episode one], the nurses were all in the background, doing coercive interventions or acting as medication dispensaries. All the therapeutic interaction was done by the psychiatrist. In real life, that’s the nurse’s role.”

This article is also available in PDF format: NurseRatched.pdf