The Real Cuckoo's Nest

Diagnosed as suffering from a bipolar disorder, an Oregon man was discharged from a hospital with a bottle of pills — and little else. "Few, if any, instructions and not much follow-up," according to Alex Horwitz '80, the forensic psychiatrist who was, much later, assigned to the case after it took a disastrous turn.

Not realizing what might happen, the young man stopped taking his medication once he felt better and, in the weeks that followed, smoked marijuana with friends and tried amphetamines. It turned out to be a lethal recipe: He became paranoid and delusional, then took aim from a second-floor window one day and shot and killed a neighbor he feared would do him harm.

A murderer? Yes, except the state found him guilty by reason of insanity and remanded him to Oregon State Hospital (OSH) in Salem, where Horwitz is a clinical director, managing an inpatient forensic psychiatry ward of about 40 patients. OSH is also where Ken Kesey's One Flew Over the Cuckoo's Nest took place, a facility where much progressive work in the field of psychiatry has since been done, Horwitz observes.

Although many at the institution today respond quickly to modern treatment and drug therapy, some who were deemed criminally insane still remain hospitalized years later – "sadly part of a rapidly growing forensic population," the psychiatrist says.

"Because society tends to prefer keeping the mentally ill out of their neighborhoods, the psychiatric institution has increasingly become a place where a lot of money is spent on tall fences with razor wire, camera-controlled security gates and the trappings of the correctional system."

And because the system makes it easier to plead insanity — but difficult for many to get out of the hospital — the Oregon murderer recently spent his 30th birthday in jail and could well spend many more there. While it has hospitalized and healed him, the system does not know what to do with him next.

How did Horwitz get involved with so challenging, and so frustrating, a system? For starters, he comes from a family of doctors (his grandfather was a surgeon and father a psychiatrist). But, he says, he continues to be drawn to the patients themselves — to their needs and his ability to help them. During the course of Horwitz's work, he is sometimes called on to testify before Oregon's Psychiatric Security Review Board (an appointed body with legal authority akin to a parole board), and he occasionally testifies in court.

"Considering all the barriers," says Horwitz, a man whose work seeks to overcome them, "we do have much success."

— E.B.