When Jack Nicholson’s McMurphy caused havoc in a mental institution on screen in 1975, he did it in a time period when popular imagination only began to ponder the presence of the psych ward. Our culture has since made positive strides in deinstitutionalization, but the portrayal of mentally ill patients in films and television hasn’t quite followed this trend. Exactly forty years after its release, One Flew Over the Cuckoo’s Nest is still one of the most progressive and emotionally complex films about a psych ward ever produced.

In the film, McMurphy checks into a psychiatric hospital and questions whether he and his fellow inmates are receiving proper treatment. He begins to counteract the sedation and electro-shock therapy used on patients by organizing illegal field trips and encouraging the men around him to misbehave. When he realizes that many of the patients are not being held in the hospital by a legal sentence, and are instead volunteering to live in poor conditions, he explodes.

McMurphy: Jesus, I mean, you guys do nothing but complain about how you can’t stand it in this place here and you don’t have the guts just to walk out? What do you think you are, for Chrissake, crazy or somethin’? Well you’re not! You’re not! You’re no crazier than the average asshole out walkin’ around on the streets and that’s it.

In 1975, psychiatric hospitals were undergoing a series of reforms. Only 14 years prior to the film’s release, Dr. Erving Goffman had released his findings that psychiatric facilities did more to “institutionalize” patients, rather than treat or rehabilitate them, making them lifelong dependents of the system. Thus, the narrative in Cuckoo’s Nest was a radical one, but it has only been met with derivative projects which largely miss the point of the original film’s social criticism.

One notable exception to this trend is 1999’s Girl, Interrupted, in which a young woman recovers from emotional trauma among patients with complex needs. The film imitated the tone of Cuckoo’s Nest, portraying the psychiatric hospital itself as both an escape from reality and a frightening place to end up. However, while the patients in Cuckoo’s Nest are assumedly better off living mainstream lives away from harmful experimental treatments, Girl, Interrupted eventually communicates that some women actually do belong on the inside. Lisa (Angelina Jolie) becomes increasingly sadistic and incapable of human connection, even taunting a fellow patient into suicide. At the end of the film, the audience realizes that while the protagonist, Susanna (Winona Ryder) is capable of getting past her mental illness thanks in part to her temporary hospitalization, Lisa belongs in an institution in order to protect the public. The film takes a step beyond the analysis of hospitalization in One Flew Over the Cuckoo’s Nest, but ultimately does not show the same forgiveness for Lisa that the Cuckoo’s Nest does for even its more volatile characters.

Typically, psychiatric hospitals are not portrayed as they exist in real life: as a means to an end for those suffering from mental illness. They instead adhere to a media trope which originated in the primary antagonist in One Flew Over the Cuckoo’s Nest, the infamous Nurse Ratched. Psych wards, according to contemporary fictional media, are hyperbolic, terrifying places where only ghoulish orderlies and monstrous nurses work. 2001’s A Beautiful Mind traps its hero, Nash, by forcing him into a psych ward temporarily.

Films like Shutter Island and Sucker Punch damn their heroes to a life spent behind bars if they’re not intelligent enough to escape. Sarah Connors has to be rescued from a psych ward in Terminator 2: Judgement Day. Even Orange is the New Black, the Netflix series lauded for its progressive messages on diversity, portrays the prison’s psychiatric ward as a place for the show’s mentally ill character, Suzanne (aka “Crazy Eyes”), to avoid at all costs. There is no discussion among the characters as to whether psychiatric care will help Suzanne; it’s simply a given that the psych ward will only harm her further.

Oregon State Hospital, where "One Flew Over the Cuckoo's Nest" was filmed

Mel Brooks and Alfred Hitchcock satirized films like these in High Anxiety, set in the Psychoneurotic Institute for the Very, Very Nervous. They lampooned the way mental illness and hospitalization are often used in thrillers, as stylized threats for characters navigating inner turmoil. Some independent films, including It’s Kind of a Funny Story and Secretary utilize psychiatric hospitals as working parts of their characters’ recovery from mental illness. In It’s Kind of a Funny Story, Craig checks himself into a psychiatric ward, telling the audience that his stay did not cure his depression, though it certainly helped him.

Craig: Okay, I know you’re thinking, “What is this? Kid spends a few days in the hospital and all his problems are cured?” But I’m not. I know I’m not. I can tell this is just the beginning. I still need to face my homework, my school, my friends. My dad. But the difference between today and last Saturday is that for the first time in a while, I can look forward to the things I want to do in my life.

On Season 3 of Cheers, which aired in 1984, Diane (Shelley Long) checks herself into a psychiatric hospital. She begins dating her psychiatrist, Frasier (Kelsey Grammer), and continues the relationship after leaving the hospital. Ironically, Shelley Long was checked into a psychiatric hospital following a suicide attempt in 2004, and her co-star Kelsey Grammer has spoken publicly of his lifelong battle with clinical depression. Both actors, familiar with mental illness, happened to contribute to one of the more forgiving depictions of psychiatric hospitalization on screen in the last four decades.

A balanced portrayal of psychiatric hospitals, condemning only harmful aspects of treatment without turning the entire enterprise into a cartoon, is not a popular one, but it is arguably the only way to continue One Flew Over the Cuckoo’s Nest’s now-forty-year legacy. Looking back on the impact the original film had on modern audiences and the stigma surrounding mental illness, we can only wonder why subsequent films haven’t quite measured up.

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