Lecturer | Author | Educator

MEDICAL HUMANITIES CURRICULA

Dr. Stripling writes and lectures full-time and does curriculum consulting. Use the following paper, delivered at a 2006 CCTE conference, to teach literature and medicine.

Teaching Literature and Medicine:

Ken Kesey’s One Flew Over the Cuckoo’s Nest

There’s a special kind of writing that relates medical history and scientific issues in a captivating way. It’s called literature and medicine, an interdisciplinary field of study established thirty years ago. Of course medical issues have appeared in literature since the time of Homer. And two well-known novels, Mary Shelley’s Frankenstein (1818) and Aldous Huxley’s Brave New World (1932), are frequently taught works. The authors’ engaging stories placed characters in situations beyond the realm of what was known. They also show how literature explores issues that science has not yet anticipated.

More recent examples in this genre, which used to be called medicine in literature, are Charlotte Gilman Perkin’s late-nineteenth-century autobiographical story, “The Yellow Wallpaper,” which is her riveting account of descending into madness; and David Feldshuh’s late-twentieth-century play Miss Evers’ Boys, which describes the unconscionable forty-year Tuskegee Syphilis Study conducted by the U.S. Public Health Service. With weighty medical issues and scientific topics in the daily headlines, teachers feel the classroom is the right place to explore important social matters. They include discussions on the global spread of infectious diseases such as a probable bird flu pandemic, the ethical issues surrounding stem-cell research and cloning, and the continuing controversies over diagnosing and medicalizing mental illnesses (we are a Prozac nation).

In fact, Harvard University recognized its duty to educate students to be responsible and informed citizens by instituting its new interdisciplinary core curriculum. It believes that English students can learn science and science students can understand English literature. Harvard’s program is good pedagogy because the brain loves diversity. Whether English students or science students, studying scientific issues situated in literature helps them understand the human character and condition. Their teachers recognize that this dual literature-and-medicine facility helps their students deal with twenty-first century cutting-edge issues. Harvard’s “skills across the curriculum” approach to teaching is sweeping American colleges.

One very accessible work taught in the literature and medicine genre is Kesey’s popular One Flew Over the Cuckoo’s Nest (1962). It’s helpful for students studying the novel to first get a fundamental understanding of America’s long and arduous history in learning to identify and to treat mental disorders. Before we had psychoanalysis and institutions, the mentally ill (who were not distinguished from the retarded and nonconformists) roamed the streets, were confined by relatives, or were thrown into prisons with criminals. When demonic causation (“The devil made me do it”) could no longer explain aberrant behavior, moral movements to control the environment were tried. In the late nineteenth century so called “rest cures” became popular with the rich to cure their nervous disorders, and in the early twentieth century, during the Eugenics Movement, individuals were forcibly sterilized for feeblemindedness and many types of unacceptable behaviors such as alcoholism, promiscuity, criminal acts, epilepsy, and even running away from home. It was all done, of course, “for the greater good.”

Then in the 1930s a neuropsychiatrist from Washington, D.C., Dr. Walter Freeman, pioneered his drastic ice-pick psychosurgery, also known as lobotomy. Anxious and fearful patients underwent his surgery to change their antisocial behavior. The surgery involved partially destroying one of the brain’s frontal lobes, causing great disfiguration. Often it relieved them of their psychological suffering so they could go back to the environment in which the disorder developed, Freeman said, “without the long, painful process of developing insight in the patients” (Robinson et al 15). Of course Freud had something to say about this. What the treatment did was change the patient’s undesirable personalities to others described as slothful, irritable, and angry. Nonetheless, in A History of Psychiatry Edward Shorter points out, “The idea of operating on the brain to cure madness does not seem intrinsically unreasonable. Physicians have always intuited that a physical intervention in the brain, perhaps cutting some tract causing compulsive behavior or removing a center producing some malignant protein, might put an end to a pattern of psychosis” (225).

Finally, in 1946 the National Institute of Mental Health was created, recognizing the need to diagnose and to help the mentally ill. This brought about mental institutions in which patients were studied and treated. Cuckoo’s Nest is set into a mental institution where a power struggle exists between the staff and patients afflicted by many types of mental illnesses. The period is the rebellious, psychedelic sixties, a prosperous time following World War II. Drugs were rampant, and the counterculture challenged authority. It is a classic description of mental illnesses and encapsulates Kesey’s own experimentation with alternative forms of perception. After taking graduate writing classes at Stanford University, Kesey took a night shift job as a Veteran’s Administration psychiatric ward orderly. He observed the patients. Many of them weren’t crazy, he believed, but rather they were just nonconformists in a sterile environment. While drug induced, Kesey hallucinated about an Indian sweeping the floors. He became “Chief Broom,” his schizophrenic narrator who had developed a bicultural schism, fitting neither into the white nor the American Indian world. The novel was an immediate success. But it is a myth that Kesey wrote all of it in a drug-induced state.

When Cuckoo’s Nest and the 1975 movie starring Jack Nicholson as its misfit antihero “Mack” McMurphy and Louise Fletcher as the authoritarian Nurse Ratched, first came out, shocked readers and viewers were repulsed by the graphic depictions of mental patients in an institution and the many kinds of barbaric treatments administered to them. The idea of lobotomy and electroshock therapy (EST) took many people out of their comfort zones. But the scientific inspiration for EST is a marvel of science. In 1938 two Italian scientists observed schizophrenics to be symptom-free following seizures, and EST as an efficient way to manage uncontrollable patients was born.

Today, a severely depressed patient receiving EST, administered in a series of treatments, has an IV-relaxant administered and a mouth guard inserted before an anesthetic renders him unconscious. The airway is protected, and electrodes are connected to conducting jelly on the temples. Electric current comparable to a 60-watt bulb shoots through the brain causing a 20-second grand-mal seizure. The patient wakes about 30-minutes later, confused and disoriented, with a headache and short-term memory loss. In essence, EST helps disturbed patients regain the control necessary to enter into a therapeutic relationship. Short-term impaired memory follows; complications from possible fractures and dislocations caused by muscle contractions are a thing of the past.

For generations Cuckoo’s Nest inflamed the public consciousness by depicting EST as a means to punish misbehaving patients, easily associating it with electrocution. The movie’s graphic portrayal of treatments administered to unforgettable characters changed the course of medical history: electroshock treatment was replaced by talk therapy and drugs like Prozac. But it also went underground. Over the years attempts to pass state laws banning EST have failed. As horrific as it sounds, some neuropsychiatrists still find EST to be an effective treatment for severely depressed and suicidal patients, especially after psychotherapy and slow-acting, cyclical drug regimens fail.

But the subjects in Cuckoo’s Nest are not all graphic, grotesque violence, like watching a CSI autopsy television show. English students of all ages will enjoy reading how humor heals and will come to understand that sexuality is also a part of institutional behavior. There are many types of mentally ill people depicted in Cuckoo’s Nest: schizophrenics, psychopaths, obsessive-compulsives, depressives, and passive-aggressives. Sometimes the line between sanity and insanity is blurred, as is the case with this black satire’s protagonist, Mack McMurphy. But what Mack, who has actually conned his way into the mental institution to escape prison work detail, proves is not that laughter has the power to heal but, rather, that it can lift a spirit desperately in need of healing. Mack takes the inmates on a therapeutic fishing trip that reads like fun road literature, and their laughter at fishing mishaps rings out over the lake. It is contagious and therapeutic. More importantly, it gave them a hopeful spirit as it activated endorphins and enhanced respiration, becoming an antidote to apprehension and panic.

Sexuality is also a part of life—even in an institution. Mack arranges for Billy Bibbit, thirty-one but mentally an adolescent controlled by his mother, to lose his virginity to a smuggled-in prostitute during a drunken evening on the ward. Mack’s attempt to restore a manly independence in the men may release some from psychosomatic illness; however, for Billy, things are not that simple. Nurse Ratched, in her zeal to keep things under control, shames him into extreme guilt. Fearful of his mother, he commits suicide. Cuckoo Nest is filled with rich literary references to Melville’s Moby Dick (good versus evil overtones) and suggests Billy Budd’s stuttering, innocent protagonist. Christ-like images can also be tracked throughout the novel.

Of the many questions posed in Cuckoo’s Nest, first and foremost is, who among us is completely sane? And how important are experiencing laughter and maintaining self-respect for the institutionalized? Ethical queries include, would electroshock therapy and lobotomy administered as therapy or punishment be ethical now; and is extreme nonconformity (sometimes manifest as an immigrant’s cultural schism) a mental illness? One of the most intriguing parts of the novel is tracing Mack’s influence on the Chief’s passage out of the fog of schizophrenia.

Cuckoo’s Nest is as relevant today as it was in the sixties when it horrified readers. It is arguably the most influential novel of its time and continues to influence twenty-first century medical issues and ethics. As the students read the classic novel, they become immersed in its rich characterization and setting and explore its ideas, helping them to think critically about important issues. Its themes, such as showing how mental illness derives from culture as well as from disease, are important to all of us because we are all patients. Its significance stems from showing how literature has the power to change our society because modern concerns can be anticipated and addressed to varying degrees in literary works. And its lesson is, we have much to learn from the past, which literature encapsulates, and we can never know what the future holds.

The merging of literature and medicine, which William James described in a letter to his brother Henry as two distinct languages and cultures, now gives teachers a fearless way to show their students how they can understand pertinent medical and bioethical issues. Use more literature and medicine stories in your interdisciplinary classroom. There are many to choose from.

Works Cited:

Cousins, Norman. Anatomy of an Illness: As Perceived by the Patient. New York: Bantam, 1981.

Gilman, Charlotte Perkins. “Why I Wrote the Yellow Wallpaper.” World Wide School Library. Originally in 1913 Forerunner. http://www.worldwideschool.org

James, William. The Letters of William James. Ed. Henry James [his son]. Boston: Little, 1926.

Kesey, Ken. One Flew Over the Cuckoo’s Nest. (40^th Anniversary Edition). New York: Viking, 2002.

One Flew Over the Cuckoo’s Nest (1975 movie). D. Milos Forman. Jack Nicholson, Louise Fletcher, Danny DeVito, Christopher Lloyd. Misfit inspires reform. Based on Kesey novel.

Robinson, Mary Frances, Ph.D. and Walter Freeman, M.D., Ph.D. “Glimpses of Postlobotomy Personalties.” Psychosurgery and the Self: New York: Grune, 1954: 15-32.

Shorter, Edward. A History of Psychiatry. New York: Wiley, 1997.

Stripling, Mahala Yates. “Illness and Culture.” Bioethics and Medical Issues in Literature. Westport, Ct.: Greenwood Press, 2005: 101-120. http://medicalhumanities.net/chapter.html

“What’s Wrong with Harvard?” (Chronicle of Higher Education May 7, 2004) http://chronicle.com/weekly/v50/i35/35a01401.htm [subscriber-access only]

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LITERATURE AND MEDICINE—World Literature II (Curriculum designed for Tarrant County College, 2000)

The relationships between medicine and literature are many and varied, dating back to the Ancient Greeks. In this course you will read works that access the different viewpoints of the medical practitioner, patient, and family. With today’s climate of advanced technology and managed-care time limitations, it is more important than ever to focus on both the duty and ability to relate to a patient. All across the country increasing numbers of humanities courses address these concerns. TCC’s new course highlights medical issues in short stories, poetry, case studies, plays, movies, biography, autobiography, journals, and letters. From these literary models, students will learn communication skills, professional ethics, and how to develop a caring attitude in delivering patient care; that is, they will learn a healing art.

TOPICS:

The History of Medicine		Alternative Medicine
The Mind and Healing		Social and Cultural Issues
AIDS and Tuberculosis Epidemics		Mental and Chronic Illness
Moral and Ethical Concerns		Death, Spirituality, and Dying

INSTRUCTOR:

Mahala Yates Stripling, Ph.D.

National lecturer (Yale Medical School; UTMB-Galveston; Stanford); and author (The Journal of Medical Humanities, Medical Humanities Review, Bioethical and Medical Issues [Greenwood Press, 2004], and biographer for Richard Selzer ).

TIME:		LOCATION:		REGISTER:
Spring 2002 Jan-May		TCC-South Campus 9:00-12:30 Friday		Nov-Jan 2333.

READINGS-MOVIES-PLAYS INCLUDE:

The Bible (“Ecclesiasticus”), Chaucer’s “The Doctor’s Tale,” John Donne’s “Death Be Not Proud,” Defoe’s The Journal of the Plague Year, Hawthorne’s “Dr. Rappacini’s Daughter” (ss & movie), Mary Shelley’s Frankenstein (movie), Dickinson’s “I Heard a Fly Buzz When I Died,” Flannery O’Connor’s “Good Country Doctor,” Raymond Carver’s “What the Doctor Said,” Alice Walker’s “Medicine,” Charlotte Perkins Gilman’s “The Yellow Wallpaper,” S. Weir Mitchell, Sir Arthur Conan Doyle’s “The Curse of Eve,” James Dickey’s “Diabetes,” Robert Frost’s “Out, Out__”, Maya Angelou’s “The Last Decision,” John Keats’ and William James’ Letters, Richard Selzer’s Follow Your Heart (play), Robin Williams’ Patch Adams (movie), Anton Chekhov’s “Misery” and “A Doctor’s Visit,” Sir Thomas Browne’s “A Letter to a Friend,” William Carlos Williams’ “The Use of Force,” Franz Kafka’s “A Country Doctor,” W. Somerset Maugham’s The Summing Up (excerpt), Dylan Thomas’ “Do Not Go Gentle intoThat Good Night,” and Philip Larkin’s “Faith Healing.”

TEXTS: On Doctoring, ed. R. Reynolds; Richard Selzer’s The Doctor Stories.

PLAYBACK THEATRE: class creates a whole tableau of "how I feel"

*Students will have the opportunity to explore their own special interests.

For additional information, contact the TCC-South Campus Communications Dept. at 817-515-4562 or Dr. Stripling at 817-921-5529 (DrRhetoric@aol.com)

Tele-registration: 817-515-6788

TCC online: http://www.tccd.net

Medical Humanities Curriculum

I have a confession to make. Half of what we have taught you is in error, and, furthermore, we cannot tell you which half it is.

—Sir William Osler, addressing a graduating medical class

I. Introduction:

Medical Humanists explore the interdisciplinary attributes of medicine and literature, for instance, to uncover the art of healing. By crossing borders that separate forms of human expression, they realize the ways humans make and find meaning in life. All helping professionals (e.g., doctors, lawyers, educators) gain from these explorations.

II. The sample World Lit II curriculum that makes this a Medical Humanities course:

A. The doctor-patient relationship:

listening and touching communication (“Use of Force” and “Brute”);
physical pain v. “soul pain” (emotional detachment or rampant empathy)

When doctors (or educators) learn dispassionate “touch,” do they lose the sensitivity to the patient (student) as well?

B. The Hippocratic Oath (to be useful; first, do no harm); ethics (abortion; mercy killing)

C. Head v. heart (hubris v. humility): Shelley’s Frankenstein and Hawthorne’s “Rappacini’s Daughter” vs. Selzer’s “the bath lady” (Down From Troy 223-6)

Logic (facts/dogma) v. intuition (third-eye awareness/analogy)

D. “Twice-told tales” (different points of view) + the complication of two distinct languages/epistemologies (ways of knowing: humanism v. unilateral scientific), explaining an inability to communicate at times (and get courses established).

Literature-and-medicine brothers Henry and William James illustrate these ideals:

The Medical Ideal--to say a thing in one sentence as straight and as explicit as it can be made and then to drop it forever;

The Literary Ideal--to avoid naming it straight; but, rather, to build out the poor little initial perception--enveloping it in gigantic suggestive atmosphere (innuendo and associative reference)--until it grows like a germ into something vastly bigger and more substantial. (The Letters of Wm. James).

E. The Impostor Syndrome: We can’t ever know enough! Relates to all professions.

F. Medical Mistakes/“Failure of Will”: Learning perspective and to compartmentalize.

G. On death, dying, and disposal: metaphorical metaphysics; and Anatomy of the Spirit (to symbolically discern spirituality in the bifurcated world of Emersonian tradition).

H. Romance: hormones; perfume; what is the nature of love; empathy belly; “The Flea”

III. Relaxation, fun, and games: humor magnifies; the grotesque illuminates.

Dr. Andrew Weil’s “breathing exercises.”
The humorous side of medicine.
The Socratic Dialogue Game.
Creating Metaphors/Images.

*The above curriculum was developed specifically for students in or entering a medical profession.

*See Student Papers for individual assignments and examples.

Semester Assignments: four 2pp papers on specific readings (exact—teaches focus); one 4-5pp paper (more room to think things through); one 6-8pp research paper or interview; and two oral presentations. Aristotle’s rhetorical approach (logos, ethos, and pathos) in analyses is encouraged. The class discusses outside readings, with three questions prepared in advance. Students bring in weekly journal/newspaper articles on contemporary medicine (double points for humor). Mid-term and Final Exam.

Textbooks: Richard Selzer’s The Doctor Stories and anthology, On Doctoring, ed. Richard Reynolds, M.D. and John Stone, M.D..

The age-old Socratic Method of training doctors teaches students to think for themselves, to solve their own problems, and eventually to be their own teachers (doctor means teacher). During the training answers are freely given, with the Socratic process leading students toward their own answer. That is, a doctor’s mettle may be proved in not so much what he knows as by what he understands. [Socratic irony—wrong path) [Method used in class explorations]

The Socratic Method: A Lesson Plan (Live Wire Media)

Define the lesson you want the students to learn--decide beforehand what idea you want them to come away with.
Think up a hypothetical situation to use as a point of departure.
Devise a line of questions designed to pull the students toward your conclusion.
Make the students take a position by asking, “What would you do if . . .
Plan for a dialogue to move in several different directions.
Complicate the situation by throwing in a money wrench:“What if this happened, what would you do then?
At each step, up the ante:“Now what would you do?”
Expect to be surprised. Be prepared to think on your feet.
If all attempts to extract the right conclusion fails, play your trump cards: “What if the hero of a movie did that? How would you feel about the character?” (Pose an objective, hypothetical situation.) “Remember, you’re the hero of your own movie.” (Compare the position with the student’s self in asking, “Would that be the right thing to do.” (A consensus should develop. People usually have a good idea of what’s right!
Tips for facilitating the Socratic Method:
- Give something of yourself--share something personal. Don’t just take.
- Let the students know you don’t have all the answers. You have fears and insecurities, too.
- Be nonjudgmental.
- Listen.
- Be honest with the students
- Take the students seriously and show respect for their thoughts and opinions.