Fifty years ago Ken Kesey’s iconoclastic novel One Flew Over the Cuckoo’s Nest hit the bookstands and scorched into the modern psyche images of dehumanising electric shock therapy, sadistic nurses and soulless mental hospitals.

The 1962 novel was an immediate hit. In 1963 it became a Broadway play; in 1975 the movie version won five Academy Awards including Best Picture and Best Actor for Jack Nicholson.

For those under 40 and for over-40s trapped in the family attic during Age of Aquarius, the book and movie feature a rebellious anti-hero, Randle McMurphy (Nicholson) who fakes insanity to avoid prison. Unfortunately for McMurphy, his masquerade lasts too long and leads to a frontal lobotomy. A mute friend, a gigantic Native American who cannot stand to see him reduced to a limp rag doll, smothers him with a pillow.

The message was clear. Society smothers those who are rebellious and different with medicines, ECT and asylums. Insanity is all in your head; the real problem is oppression and stigmatisation.

Fast forward to 2012. Last Friday, Norway’s national theatre of the absurd, the trial of Anders Behring Breivik, came to a close. The judges’ verdict will be handed down in July or August.

Last summer Breivik killed 77 people, mostly young people, and all of them defenceless. During the 11 months since then he and his lawyers have turned the Norwegian legal and mental health systems upside down. Instead of a sociopath faking insanity to avoid prison, à la Randle McMurphy, Norwegian psychiatrists have said that a mass murderer is faking sanity to stay there. Last fall, Torgeir Husby and Synne Sørheim declared that Breivik was a paranoid schizophrenic and insane.

The prosecutors have swallowed this diagnosis. “We are not convinced or certain that Breivik is legally insane but we are in doubt,” prosecutor Svein Holden told the court last week. “So we request that he is transferred to compulsory psychiatric care.” Mr Holden said that it was better to send a non-psychotic person in an asylum than to put a psychotic person behind bars.

Breivik has protested. In a letter to the Norwegian media before his trial in April, Breivik whined, “I must admit this is the worst thing that could have happened to me as it is the ultimate humiliation.” Although he pompously describes himself as a “knight justiciar grand master”, Breivik is a true child of the post-modern age, replacing guilt with wounded self-esteem and virtue with rationality.

Other professionals disagreed with Husby and Sørheim’s diagnosis. Two forensic specialists reported that Breivik was sane. The psychiatrist who works with him, Randi Rosenqvist, states that Breivik had “adapted quite easily to the prison regulations.” She described his behaviour as “exemplary.”

The main evidence of Breivik’s craziness known to the public has been his nationalistic, anti-Islamic rants. As obnoxious as his ideas are, they fail to meet the criteria for delusional thinking. The diagnosis of schizophrenia has other holes. Breivik has no hallucinations. Having hallucinations is not an absolute necessity but the absence of hallucinations means that the other symptoms must be bizarre and disorganized thinking. However, Breivik’s thinking appears to be very carefully organised. He has been coherent in interviews. When carrying out his attack, he placed a sign on the street, “sewer cleaning in progress”, to allay suspicions about the smell of his car bomb. He has shown a level of foresight and organization atypical of many criminals, much less deranged psychotics.

Delusions are defined as false, fixed beliefs which are unshakeable in the face of evidence. This definition is a gigantic net that captures a lot of silly beliefs, lies and opinions. But the heart of delusional thinking is the strange, idiosyncratic meanings given to common facts.

Consequently, the mind of people living with schizophrenia is a desert island. But Breivik doesn’t live alone with his delusions on a desert island. His lawyers have presented to the court other extremists who share his repulsive political beliefs but disavowed his violence. Extremist is not necessarily madness.

Cultural and political beliefs are a minefield of misdiagnosis for mental health professionals. In his book The Protest Psychosis: How Schizophrenia Became a Black Disease, Jonathan Metzl says that during the 60s doctors diagnosed some African-Americans with a form of schizophrenia marked by political agitation. But after the Soviet Union and other totalitarian regimes were exposed for locking political dissidents in hospitals, the American Psychiatric Association, excluded beliefs shared by religious, cultural or political groups from the diagnosis of delusions.

The pretzel logic of law in Norway has helped Breivik. Husby and Sørheim’s finding of insanity has shifted the focus from his crimes to his beliefs. Since then, Breivik has been serenaded with peace songs and allowed to expound on his ideas. His victims are forgotten in this legal controversy. In a smug, egotistical rant, Breivik declaimed to the press, “To send a political activist to a mental hospital is more sadistic and evil than to kill him! It’s a fate worse than death.”

But murder is not a political activism and Breivik is not a political martyr like Vladimir Bukovsky, the Soviet dissident who exposed the abuse of psychiatric institutions for political reasons.  

Does Breivik deserve punishment or “treatment”? The Norwegians may end up substituting therapy for justice – but this will be neither therapeutic or just.

I am sceptical about psychiatric treatment since anti-psychotic drugs do not change political beliefs or bigotry. However, given that the Norwegian legal system has lost its belief in the restorative value of punishment, I suspect that hospitalization may be the only way to keep Breivik off the streets forever.

Several psychiatric commentators have reassures critics of the insanity finding by guaranteeing that Breivik’s confinement in a hospital will last longer than his criminal sentence. This is probably true, but Norwegians should feel uneasy about this. What if a complete cure for paranoid schizophrenia were found next month? Would it make sense, would it be just, to release Breivik from his hospital in time to have Christmas dinner with his family?

However, seeing a smiling Breivik released from prison after 21 years – the maximum sentence possible under Norwegian law — while parents still mourn their dead children may be too much for the most stoic Scandinavian to imagine. Under the circumstances, substituting a lifetime in the looney bin for 21 years in prison places a fig leaf of therapy over the rigours of justice.

The Norwegian drama has reached an impasse. The prosecutor has refused to play the avenging angel. Breivik refuses to play the babbling psycho. As a result, the court has become an asylum and Breivik has become Randle McMurphy, the misunderstood victim. Breivik and the court have taken the nihilism in One Flew Over The Cuckoo’s Nest to its logical end.

Theron Bowers MD is a Texas psychiatrist.

Theron Bowers is a psychiatrist living and working deep in the heart of Texas. Life started in Macon, Georgia. However, he spent most of his childhood in the foothills of Albuquerque, New Mexico. He has...