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This article was published in partnership with Public Health Watch, a nonprofit investigative news organization.

In her nine years working in a mental health unit of the Washington State Penitentiary, S. Acosta has seen some horrific things. 

She has worked with prisoners who have cut off their own body parts, stuffed items like pens or carrots up their urethra, swallowed razor blades or balloons filled with meth, and painted what she calls, “pretty pictures on the walls with their feces.” 

But Acosta has also witnessed prisoners brought back from the clutches of mental illness.  

At times, the stress of the job leaves her mentally and emotionally drained. When she is feeling overwhelmed, she cries in her office during lunch.

“When I get off work I have to sit in complete silence on my couch for an hour just to fully unwind from the day,” Acosta said.

Nowhere is the country’s mental health crisis more severe than in U.S. jails and prisons, which have become de facto housing for those who suffer from mental illness.

On any given day, the Washington State Department of Corrections segregates more than 400 prisoners of its average population of about 12,816 for “treatment” of mental illness. The diagnoses span the gamut, from psychosis and depression to anxiety and schizophrenia.

I have been inside a residential treatment unit at WSP since 2018 because of a suicide attempt. My time here has given me firsthand experience with Washington state’s administration of mental health care to incarcerated people. These observations, as well as conversations with various prison staff — some of whom asked to remain anonymous because they are not generally permitted to be interviewed by prisoners — paint a picture of a system in dire need of repair.

What it takes to get medication

Inside the Baker and Adam units — which comprise WSP’s mental health wing — medication is the primary form of treatment, though many prisoners also have access to infrequent therapy. Typically, prisoners collect their medicines from the “pill line,” located in the hallway of each unit. But since the middle of June, we have been on modified lockdown due to three suicides in one week. Now, a nurse delivers medications to our cells off a rolling cart.

Once a prisoner receives their medication, he is expected to take it on the spot. The nurses or prison guards conduct a mouth check to make sure that the person has swallowed his pills. This is because prisoners commonly try to save the pill by cheeking the medication — hiding it in the space between their gums and cheek — so they can trade it later for other goods, like coffee or different drugs, or use it themselves to get high by crushing and snorting it. Some believe they are better off without the medication and throw the pills away. 

If a prisoner with a mental illness is considered to be a danger to himself or others, he is taken to what Washington DOC policy calls a “close observation area” and sometimes placed on an involuntary medication plan, depending on their diagnosis. 

The process of medicating a patient involuntarily is not subtle: I have witnessed a group of guards dressed in riot gear — heavily padded vests, hard plastic knee and arm pads, helmets with face shields, and gas masks — approach a prisoner’s cell and spray it with oleoresin capsicum, or pepper spray. Sometimes the person is also zapped with a Taser-like device before being restrained while a nurse injects the medication.

This can impact the nearby prisoners. The spray — an irritant that triggers the mucus membranes and causes the eyes to water and the lungs to burn — spreads into surrounding cells.

Passing the time

The treatment units provide some recreational time and programs, but they are limited and can be canceled due to staff shortages. Typically, when the prison is short-staffed, recreation time and programs in the treatment unit have been the first to go.  

Prisoners can walk the track, use the exercise bikes, lift weights, or play basketball,Ping-Pong, cornhole, volleyball or cards. There are programs for prisoners to write, play music, raise and release monarch butterflies, and care for kittens from the Blue Mountain Humane Society until they can be adopted. 

Michael Gebre described his participation in the writing group — one of the longest-running groups in the treatment units — as an important opportunity to express himself.

“It provided me with a creative avenue to … understand who I was and what I was becoming,” he said, adding that it was “one of the greatest experiences for me in finding my own voice.”

But the benefits of programming can be hard to come by, said Ben Burkey, who is 18 years into a 64-year sentence.

“I feel I have more mental health issues here because of the lack of programs,” he said. “[For] the few programs they have had, I have been told I don’t fit the criteria because I’m a de facto lifer.” 

Between 2020 and 2022 during the COVID-19 pandemic, programs and recreational opportunities could be limited or suspended at any given time according to changing infection numbers and health care measures. Prisoner movement was often limited to the dayrooms. During quarantines, we were locked in our cells all day except for 10 to 20 minutes to shower, clean or use the phone as time and staffing allowed.

Corrections officer Pence, who requested I not use her first name because these are generally not shared with the prison population, managed one of the units during a 48-day quarantine. Pence helped calm her section by syncing prisoners’ tablets at the kiosk, which allowed them to message friends and family, rent movies, listen to music and play games. She also used the dayroom phones to order much-needed commissary items like food, coffee and hygiene products for some residents who ran out of time to do so themselves. 

“When there are no counselors available, I try to listen to someone’s problems and maybe give some ‘mom advice.’ Sometimes that is enough to get them through the night,” Pence said. “When someone is going through a rough patch, they just want to feel validated and heard.” 

Pence added that she makes sure to send relevant information to the prisoners’ primary therapists.

Staffing troubles

The DOC says it provides specialized training for officers who work in residential treatment units, but participation is not mandatory. Due to critical staff shortages, relief staff have been pulled from the ranks of those who do not regularly work in the units. In some cases, this has led to assaults on staff and disruptions.

There are eight mental health counselors and therapists and one licensed psychologist assigned to the units. They generally work 8:30 a.m. to 4:30 p.m. weekdays. There is only one counselor on call outside of those hours. Each counselor has between 15 and 20 prisoners in their caseload, and typically spends one hour a month with each patient, according to a DOC spokesperson.

There are no clear instructions for prisoners to reach their counselor in times of need.  Sending a kite — the prison form of written communication — or making a request with an officer may get them seen in a week or two. But sometimes the request is never conveyed to the counselor, and often the counselor doesn’t have time.

I know of prisoners who have cut themselves, threatened suicide or declared a “mental health emergency” to gain the attention of a counselor sooner. Even in dicey situations, the wait time can be anywhere from an hour to two days. 

In 2019, the advocacy group Disability Rights of Washington won a lawsuit against the state about its restrictive environment and limited treatment. 

As part of the settlement, the department received $5 million to hire additional program staff and retrofit the cell doors in one of the three treatment units. The latter allowed prisoners to enter and exit their cells using keys, providing much more opportunity for them to be outside of the cells during the day and evening.

These allowances were curtailed during the pandemic but finally reinstated in January 2023. The treatment units also have extended recreational time in the yard, allowing residents of all three units to commingle. New recreation staff have been hired to oversee programs. 

But staff shortages remain a problem, and programs are still canceled as a result. The department is aggressively campaigning for recruits, and has recently made some hires. 

Officer Pence said she thinks the improvements have been good for morale. Increased programming provides prisoners with something to “take care of and nurture,” she said, adding that one unit sergeant erected spaces for cornhole games so that staff and the incarcerated population could build rapport.  

Reasons for hope

Washington state has its fair share of problems, but there are staff here who sincerely care about creating better outcomes for the population. There are several new hires who have good attitudes and appear to be adjusting well. There is also a new sergeant who is keeping things calm and figuring out ways to get us out of our cells during the modified lockdown. 

Acosta said that she enjoys her job because she gets to see the humanity inside the prison. 

“The best part of my job isn’t the crazy things that make good stories,” she said. “It’s making an offender laugh for the first time after a long and difficult depressive episode. It’s hearing a terrible rendition of a rap song and the rapper being able to do it with pride despite how awful it is. It’s hearing an offender saying thank you for helping him.”

Pence said that the treatment units are the one place where she feels she can still make a difference. That’s why she has worked here for six of her nine years with the corrections department. 

“If I can talk someone out of thinking about harming themselves, then it is a good day,” she said.

Disclaimer: The views in this article are those of the author. Prison Journalism Project has verified the writer’s identity and basic facts such as the names of institutions mentioned.

Jeffrey McKee is a writer incarcerated in Washington.