Inside Asylum Walls

“Nobody will ever convince me that the splendor of individual courage cannot triumph over all the fates. Neither family death, nor personal illness, nor “hard times,” nor heavy responsibility solely borne, nor hazards met without warning can defeat one man standing alone who refuses to relinquish his courage. I knew such a man. He was my father.”

– Dorothy Powers, In Tribute to My Dad.

About a year ago, I visited a small bookshop in Spokane, Washingon. As an independent book store for nearly four decades, 2nd Look Books was full of second-hand treasures and local history. A bright red book caught my eye. Boldly titled: “Dorothy: POWERS TO THE PEOPLE”, it contained a collection of columns written by journalist Dorothy Rochon Powers for the pages of The Spokesman-Review.

The inside cover had a hand-written note from the author dated September 16, 1989. It was addressed to a dedicated reader, perhaps the author’s friend. “I wish you many happy memories in these pages. Thank you for reading my column! – DRP”

As per my usual habit, I flipped open the book to a random page. To my surprise, the book fell open to an article titled, “Inside Asylum Walls: The Patient’s View.” It must be fated for this book to land in the hands of a psychiatrist, I thought, and so of course I purchased the book.

Published in December 1957, the article by Powers reported on conditions at Eastern Washington State Hospital. As part of her research, Powers repeatedly visited the institution and conducted interviews with members of the staff. Then with the assistance of officials, she got herself “committed” and spent time there disguised as a patient.

What she found was disturbing. The institution was overcrowded and understaffed. “To a state mental hospital with 2,064 patients — and facilities for 1,861; to a staff of 13 doctors, where the American Psychiatric Association standards show 28 are needed; to an institution with 20 nurses instead of 166,” Powers wrote (pg 99). This was shocking. In comparison, the institution where I am currently training as a resident physician can provide services for up to 99 patients, with four attending psychiatrists on-site every workday and a half-dozen resident psychiatrists serving as helping hands. The physicians are supported by a robust staff of nurses, techs, and social workers.

In 1957, there were too few hands on deck at the Eastern Washington State Hospital. Members of the staff did their best, but the amount of work was overwhelming. Not only were they outnumbered, but they also cared for some of the most severely mentally ill people in the state. There would have been people who were diagnosed with debilitating illnesses such as chronic schizophrenia or catatonia. Some would be so paralyzed by their minds that they depended entirely on caretakers for basic functions, such as eating, bathing, and toileting. Powers described their despair. “‘It’s all we can do to keep them clean,’ sighs an attendant, ‘much less spend any time working with them'” (pg 101).

Remember, this was before the advent of psychopharmacology, before antipsychotic medication such as chlorpromazine and haloperidol and clozapine revolutionized psychiatric medicine. This was before the 1960s, when the social movement for deinstitutionalization of the chronically mentally ill gained momentum and lead to the replacement of long-stay psychiatric hospitals with an outpatient care-focused model and the goal of reintegrating patients into the their community. Powers’ article, among many others across the nation, helped instigate change. Today, Eastern Washington State Hospital has a patient capacity of just over 280 beds, according to Wikipedia. The changes over the years are reflective of our society’s evolving attitudes and growing understanding towards mental health.

The picture that Powers’ paints may seem foreign and strange, as the landscape of behavioral healthcare has transformed so drastically. But some things remain familiar. As I read, I was vividly reminded of people I have met in my current work in psychiatric wards. The 1950s were not so long ago – some of these patients may still require care today. Powers provided powerful quotes: “‘You keep wondering why you’re different, what the people at home are saying. Right now, I worry whether the neighbors will still let their children come see me, when I get home… if I get home'” (pg 100).

People in the past as they do today still yearn for home, fear rejection, and desire healing. They have hopes and fears and dreams that, though clouded with their illness, remain deeply, unconditionally, and essentially human.

The remainder of the book is a fascinating documentary of life in the eastern side of Washington State. Powers captured the highs and lows of the human experience. She flew in a giant Air Force refueling jet at 40,000 feet in the air at 600 miles an hour. She mingled with inmates in Washington State Penitentiary. She climbed a 15-story bare steel scaffolding. She reported on the thunderous eruption of Mount St. Helens. Throughout it all, she described people with understanding and compassion.

When I travel, I love these pieces of local history. Upon my next visit to Spokane, I plan to return the book where I found it so that someone else can also discover its treasures. May the next lucky person also find inspiration in Powers’ stories!

More Information

Powers, DR. Dorothy: Powers To The People. Cowles Publishing Company. 1988. Print.


In April, I went to Japan for three weeks for vacation. I chose a handful of cities to visit and spent few days in each. One of these was Hiroshima, where I visited the Peace Memorial dedicated to the people who were killed in the atomic bombing on August 6, 1945.

Before I went to the memorial, I don’t think that I understood the devastation of nuclear weapons. I knew that the bombs released enormous amounts of heat and radiation, and that the aftereffects of radiation exposure such as cancer were horrible. Knowing wasn’t the same as seeing photographs of the sick and dying, or the ragged, blood-stained uniforms the schoolchildren had worn, or hearing the stories narrated by survivors, most of whom had been children and are now old men and women.

The exhibit is constantly changing, especially as society changes and living memory fades. At the time, the main museum was undergoing renovation, but there were others nearby, including a special exhibit titled “The Twinkling Stars Know Everything,” after a collection of stories by the mothers and fathers of first-year students of Hiroshima Itchu Junior High School. The school was located only a kilometer away from the hypocenter of the bomb, and nearly the entire class died. They were only thirteen years old.

I learned about another collection of stories at the memorial and decided to read it: Hiroshima, by John Hersey. Originally published in The New Yorker, this book follows the lives of six people who were present in the bombing.

Genbaku “A-bomb” Dome © Jennifer Hsu

Of the six, the individual who most caught my interest was Dr. Terufumi Sasaki, a 25-year-old surgeon who had just completed his training at the Eastern Medical University in China. I felt great empathy with this young physician, as I am similar in age and stage of training. Dr. Sasaki was working in the Red Cross Hospital in Hiroshima. When the bomb fell, he found himself to be one of the few uninjured physicians on staff, and soon he and the other physicians were overwhelmed by the thousands of injured who came to the hospital for help.

Quote from the book:

“By three o’clock the next morning, after nineteen straight hours of his gruesome work, Dr. Sasaki was incapable of dressing another wound. He and some other survivors of the hospital staff got straw mats and went outdoors — thousands of patients and hundreds of dead were in the yard and on the driveway — and hurried around behind the hospital and lay down in hiding to snatch some sleep. But within an hour wounded people had found them; a complaining circle formed around them: “Doctors! Help us! How can you sleep?” Dr. Sasaki got up again and went back to work. Early in the day, he thought for the first time of his mother, at their country home in Mukaihara, thirty miles from town. He usually went home every night. He was afraid she would think he was dead.” – Hersey, J. Page 25

I can hardly imagine how exhausted and terrified he must have been.

Hiroshima is one of the most striking and terrifying proofs of the horrors of war. But my visit there also showed me the greatness of the human spirit and the possibility of forgiveness and healing. At the memorial, I stopped to listen to a student choir – one of many which take place throughout the year, dedicated to the children killed in the bombing – when a Japanese man turned to me and attempted to give me a pamphlet. When I indicated that I could not read Japanese, he used broken English to tell me about why the students were singing. Then he asked where I came from. When I said that I came from America, he smiled broadly and said that he loved Americans, and that he hoped to travel across the world to visit our country one day, too.

More Information

Hersey, J. Hiroshima. Vintage Books, NY. Reprint edition, 1989.

Ikegami, N. The Twinkling Stars Know Everything. First English Edition edition, 1984.

I Am Not Sick, I Don’t Need Help

Have you ever been in denial?

Recently I have been pinching myself in disbelief. Am I really graduated from medical school? Are people actually going to start calling me “doctor?” Wow! It is terrifying, yet exciting. As a fresh graduate, I know that I still have a long road ahead of me before becoming a board-certified physician, but right now I have been feeling so incredibly blessed.

This period of time between graduation and the beginning of residency has been incredibly relaxing. I spent most of it vacationing. In April, I traveled throughout Japan for three blissful weeks. Then, I went on a scenic car trip from Texas and all the way up through New Mexico, Nevada, and Idaho to Washington State. Beautiful, isn’t it?

Driving by the Sierra Nevada © Jennifer Hsu

During these trips, I also read several books. One of these is “I Am Not Sick, I Don’t Need Help” by Xavier Amador, Ph.D., a clinical psychologist. I found it to be a quick, pleasurable read, because of the author’s concise and clear writing style. He also does a spectacular job of evoking empathy and understanding through clinical vignettes and personal stories.

If you know somebody with serious mental illness who is in “denial” and refuses to seek treatment or take medication, then this book is for you.

Dr. Amador divides this book into five parts. The first part provides information about mental illness, particularly schizophrenia. The second part describes the LEAP (listen, empathize, agree, partner) methodology that Dr. Amador developed, which has shown positive results in his work with patients and their families. The third part focuses on the feelings of betrayal and guilt that a patient and their family may feel when the patient is taken against their will to the hospital, and how to re-build trust. The fourth part discusses the value of assessing a person’s awareness of their illness and its purpose in formulating a cooperative treatment plan.

The fifth section is the most memorable of all. In it, Dr. Amador tells us about his brother Henry, who was diagnosed with schizophrenia. I could feel the love and care between the brothers, nearly palpable from the page, and I admired that he shared his brother’s story with us. It is a poignant reminder that every patient, no matter how “crazy” or psychotic, is loved by somebody. I admit that I shed some tears reading Henry’s story.

I highly recommend this book for anyone with a family member with mental illness. It is also a wonderful read for any health professionals.

Key Takeaways
  • “Denial” is the wrong term for poor insight in a person with mental illness. In patients with schizophrenia, the executive (frontal) part of the brain is often dysfunctional, resulting in a symptom called anosognosia, which is the condition in which a person with a disability seems unaware of its existence.
  • Reflective listening is listening with only one goal: to understand. It is not commenting, disagreeing, judging, or reacting in any way.
  • It is not necessary for the patient to believe that they have a mental illness. But, it is necessary for the patient and their support network (family, health provider) to work together for success. Prioritize finding common ground and collaboration, not arguing over who is “right.”

“I can’t guarantee that LEAP will definitely eliminate medication and service refusal in the person you’re trying to help, but I can promise that if you faithfully follow the guidelines I give, they will help lower tension, increase trust, and greatly increase the likelihood that the person you are trying to help will follow your advice.” – Amador, X. Page 3.

“I have never talked anyone out of a delusion and, to my knowledge, I have never talked anyone into one either. The point is, when you’re facing someone who rigidly holds irrational beliefs, you gain nothing by disagreeing.” – Amador, X. Page 84.

“I loved Henry, and when someone you love is in pain, it is hard not to empathize. Learning to listen lead to empathy. And my empathy ultimately resulted in my brother showing a real interest in my thoughts about the illness he felt he did not have and the medications he was sure he did not need.” – Amador, X. Page 113.

More Information

Amador, X. I Am Not Sick I Don’t Need Help! How to Help Someone with Mental Illness Accept Treatment. Vida Press. Kindle Edition. 2012.

“LEAP®”; “L.E.A.P.®“;“Listen-Empathize-Agree-Partner®”; “Listen, Empathize, Agree, Partner®” and all similarly punctuated versions are registered trademarks of the LEAP Institute, are protected under the laws of the United States Patent and Trademark Office (USPTO), and may not be used without express license of the LEAP Institute.

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