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When Randle P McMurphy is thrust into an American psychiatric hospital in the early 1960s, the torpid air begins to crackle. As the anarchic McMurphy, Aaron Pierre gives a storming performance but although Clint Dyer’s stirring take on Ken Kesey’s 1962 novel boldly reframes the story, the text can’t support his ideas.

McMurphy immediately locks horns with authoritarian Nurse Ratched (Olivia Williams). He pivots and provokes, urging fellow patients to resist, play and party. Pierre roams the space with a pumped-up strut or an incongruous dainty scamper. He gives good fraternal hugs, but there’s a frantic vulnerability beneath the booming laugh.

Dyer’s devastating 2022 production of Othello with Giles Terera tore the plaster off a remorselessly racist world. By casting Cuckoo’s Nest’s inmates with predominantly Black actors, Dyer gives Kesey’s tale a new political edge, as pawns in a system designed to disempower. Each time Ratched addresses the men as “boys”, it’s an implicit sneer.

But race isn’t mentioned in the text – except for Chief Bromden (Arthur Boan), sole survivor of an Indigenous tribe and a selective mute, who channels the anguish of industrialised psychiatry. What is explicit in both the original novel and this 1963 adaptation by Dale Wasserman is a relentless misogyny – so this reading feels at once radical and retrograde.

“I fight and fuck,” proclaims McMurphy. His freewheeling individualism shades into reclaiming the alpha male. The patient backstories we hear involve a stifling mother or dissatisfied wife, and this regime is all coercion and control – lobotomy is “castration of the brain” – and in Nurse Ratched, it’s personified as female.

Williams, who took over the role late in rehearsals, gives Ratched a ramrod spine and starched smile. She is nominally subordinate to a shambles of a doctor (Matthew Steer) who snickers at the medical notes and scurries away from trouble – but there is little check to the increasingly vicious abuse of her authority.

Kesey knew this environment from the inside. As a student, he enrolled as a guinea pig in a government research study on the effects of LSD and other hallucinogens. Soon after his novel was published, he crossed the US with his band of Merry Pranksters in a psychedelic bus – raising a countercultural finger to mid-century mores. His novel was championed by the anti-psychiatry movement, and institutionalised cruelties emerge strongly in Chris Davey’s livid lighting, flaring scarlet and blue. Medication is pacifying, group therapy becomes licensed snitching or bullying, electroconvulsive therapy an excruciating ritual.

Watching in the round, we become a ring of often appalled observers. The floor, with its white and pond-green tiles, is a tight circle, but in Ben Stones’s design, the Old Vic’s high ceiling gives the confining space an aspirational pull, a yearning to elevate up and away.

The patients navigate flurries of distress and delirium: the strong ensemble, led by Terera’s refined Dale Harding, a paisley robe over his uniform, creates an unobtrusive patina of tics and deflections. Dyer bookends his production by invoking Congo Square in New Orleans, a historic site of celebration and resistance for Black and Indigenous people. His crackling version sees the play’s cruelties through their eyes – but it’s very much the male gaze.

• At the Old Vic theatre, London, until 23 May