OFFICE OF THE

CORRECTIONS
OMBUDS
Systemic Report: Mental Health Access & Services
Elisabeth Kingsbury, JD, OCO Policy Director
June 2021
The Office of the Corrections Ombuds (OCO) is established in Chapter 43.06C RCW.
Duties of the office include investigations into complaints regarding the health, safety,
welfare, and rights of incarcerated individuals in the Washington Department of
Corrections (DOC). This report is provided pursuant to RCW 43.06C.040, which
requires a public report at the conclusion of an investigation. This report has been
edited to protect confidential information. OCO investigations and underlying records
are confidential pursuant to RCW 43.06C.040 and 43.06C.060. Any persons wishing to
report a complaint to OCO can do so via its online complaint form at oco.wa.gov or via
its free, unmonitored hotline (360-664-4749).

Brief Summary of Concern
In 2019, community stakeholders and OCO identified access to mental health treatment
as a strategic priority for the office to analyze systemically in 2020. Stakeholders and
staff chose to review mental health because of the known challenges associated with
accessing mental health services in correctional environments, as well as the potential
for tremendous benefit for individuals throughout the system if access concerns were
remedied.

Summary of Key Recommendations
•

DOC should ensure that staff conducting mental health screenings have
caseloads that allow for thorough review of each case and that screenings and
assessments occur in suitably confidential areas.

•

DOC should ensure that quality, timely mental health treatment services are
available to anyone in DOC custody who demonstrates a clinical need for
treatment.

•

DOC should ensure that an individual’s mental health status is considered
throughout the disciplinary process, including when reviewing infractions,
determining guilt, and imposing sanctions.

•

DOC should develop comprehensive policies that address
o Residential Treatment Units (RTUs)
o Individual Behavior Management Plans (IBMPs)
o Individuals in violator status

•

DOC should reduce the frequency of placement and length of stay in any
segregated housing for individuals with mental health conditions.

•

DOC should provide additional mental health and de-escalation trainings to staff
to increase positive and effective engagement with individuals who have mental
health conditions.

Special Considerations
OCO recognizes the significant and unique ways in which mental health disorders
impact Black, Indigenous, Latinx, and all people of color who are incarcerated. We urge
readers to bear in mind our nation’s historical framework of racism and social injustice
when considering the challenges faced by individuals with mental health conditions in
prison, as discussed in this review. The experiences of incarcerated people with mental
health disorders who identify as LGBTQIA+, women, and people with co-existing
intellectual disabilities or other disabilities should also receive special consideration.
OCO began consistently collecting demographic data for every complaint in 2020, and
thus we do not have sufficient information to identify trends specifically related to race or
other underserved populations in the complaints we received until that time.
Anecdotally, however, OCO staff have noted concerning differences in the treatment of
people of color with mental health disorders. OCO will continue to collect relevant data
in order to better assess these concerns in the future. For now, we call upon DOC to
make every effort to address the concerns identified in this report in ways that provide
special attention to the impact on underserved populations.

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Finally, the Covid-19 pandemic brought with it certain unprecedented challenges that
must be acknowledged here. Undeniably, incarcerated individuals and prison staff
throughout the nation and in our state have been profoundly impacted by the pandemic.
OCO suspects that time may reveal lasting mental health effects for many individuals
who endured months of quarantine and isolation. Presently, however, OCO has not
observed any significant change in the types of complaints received from individuals
who reported being on DOC’s mental health caseload; the concerns observed in 2019
related to treatment access persisted through 2020, but did not appear to intensify
following the onset of the pandemic. We encourage DOC to remain vigilant about
providing mental health support to all those individuals who endured and continue to
endure quarantine and isolation due to Covid-19 restrictions.

Scope of Review
This report analyzed mental health complaints received by this office between
November 2018 and November 2020. These complaints were identified by OCO staff
as primarily involving a mental health concern at the time of intake. 1
Using data collected by OCO between November 2018 and November 2020, we
identified approximately 335 complaints 2 that alleged difficulties accessing mental
health treatment or other problems directly impacting or related to mental health.
Having a mental health condition while incarcerated can result in exceptional difficulties
beyond those already associated with incarceration. These include obtaining adequate
treatment, disparate treatment, misperceptions and stigma, and increased vulnerability.
This report primarily addresses access to treatment but additionally includes closely
related concerns regarding the disciplinary system, segregated housing, and the roles
and duties of mental health and custody staff.
This report should not be considered an exhaustive list of all problems related to mental
health that occur within DOC. OCO suspects many concerns go unreported for a variety
of reasons, including obstacles such as incarcerated individuals’ fear of reprisal or
limited ability to self-advocate.
As stated above, the focus of this report is mental health treatment, as well as certain
ancillary matters that often exacerbate individuals’ mental health conditions. This report

Data specifically includes complaints tagged in OCO’s database with a mental health case
factor as well as most complaints that reference “mental health” or “MH” in the case details.
2
Some complainants filed more than one complaint related to ongoing or new concerns. The
data set we examined had 257 unique complainants.
1

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does not examine certain topics related to mental health which the office has
investigated, or is investigating, separately. These include:
•
•
•
•
•
•

Mental wellness concerns related to the impacts of Covid-19 quarantine and
isolation (multiple reports published in 2020)
Suicide and suicide prevention (multiple reports published in 2020; one report
published in 2021)
Single-person cell assignments due to post-traumatic stress disorder or other
mental health condition (report published in 2021)
Use of force and use of restraints on individuals experiencing mental health
crises (forthcoming report on use of restraints)
Gender dysphoria diagnoses and access to hormone replacement therapy
(forthcoming report on systemic transgender concerns)
Access to mental health services while participating in Therapeutic Community
(forthcoming report on TC)

Additionally, this report does not examine disorders frequently associated with mental
health disorders, including:
•
•

Intellectual disabilities, learning disabilities, or traumatic brain injuries
Neurodevelopmental disorders, including attention deficit hyperactivity disorder
and autism spectrum disorder

Finally, this report identifies OCO’s primary concerns and recommendations regarding
topics raised repeatedly in complaints filed with our office. These are meant to serve as
overviews and should not be interpreted as being comprehensive examinations on any
given topic.

Statutory Authority
Per RCW 43.06C.040, OCO has the authority to initiate “… an investigation upon his or
her own initiative, or upon receipt of a complaint from an inmate, a family member, a
representative of an inmate, a department employee, or others, regarding any of the
following that may adversely affect the health, safety, welfare, and rights of inmates:
(i) Abuse or neglect;
(ii) Department decisions or administrative actions;
(iii) Inactions or omissions;
(iv) Policies, rules, or procedures; or
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(v) Alleged violations of law by the department that may adversely affect the
health, safety, welfare, and rights of inmates.”

Investigative Actions
OCO took the following actions in furtherance of this review:
•
•
•
•
•
•
•
•
•
•
•
•

analyzed complaints of unmet needs of incarcerated individuals with mental
health conditions received by OCO;
surveyed incarcerated individuals;
reviewed grievances related to mental health access and the responses provided
by DOC;
reviewed mental health records of incarcerated individuals;
solicited input from outside stakeholders and community members;
discussed concerns with DOC mental health staff members;
discussed concerns and preliminary recommendations with DOC administration
over the course of several months;
reviewed nationwide best practices as identified by state and national
organizations and scholars;
analyzed states’ policies regarding mental health access for incarcerated
individuals, including sister states of Oregon and Idaho;
reviewed Washington DOC Health Plan;
reviewed selected mental health training materials for new DOC employees; and
reviewed DOC policies, including:
o Mental Health Services (DOC 630.500)
o Close Observation Areas (DOC 320.265)
o Involuntary Antipsychotic Administration (DOC 630.540)
o Disciplinary Sanctions (DOC 460.050)
o Restrictive Housing (DOC 320.255)
o Health Services Management of Alleged Sexual Misconduct Cases
(DOC 610.025)

Findings
I. Screening & Assessment
Mental health providers screening at intake have high caseloads and must
conduct some screenings and assessments in areas where confidentiality is
compromised.
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•
•
•

Mental health providers are responsible for processing an extremely high number
of mental health screenings daily.
Lack of suitably confidential areas for mental health screenings of individuals in
reception/intake in some facilities.
OCO has received complaints of lack of timely responses to kites requesting
initial mental health assessments.

II. Psychotherapy
OCO has received numerous complaints from individuals who reported difficulty
accessing mental health therapy.
It should be noted that the majority of complaints received on this topic related to
access, not quality, of services offered. Specific concerns about psychotherapy relayed
to OCO include:
•
•
•
•
•
•
•
•

Long wait time for accessing therapy.
Lack of timely responses to kites requesting routine appointments.
Lack of timely responses to kites when requesting help from mental health
providers when in distress.
Lack of variety of treatment options offered in smaller facilities; lack of access to
treatment in lower-custody facilities.
Lack of group therapy classes. 3
Lack of access to services because the individual does not have a diagnosed
mental health condition, despite their desire to improve their mental wellbeing. 4
Lack of access to therapy following a traumatic event such as a staff assault.
Lack of mental health therapy available through DOC while in work release.
Despite the fact that individuals remain in DOC custody while in work release,

DOC reports that mental health providers may propose evidence-based group therapy ideas to
a committee for approval – Dungeons & Dragons is an example of one that has become popular
and engaged people who otherwise might not have been open to therapy. Group therapy
classes are led by a psychologist or other qualified mental health provider. Because providers’
caseloads are significant, groups are limited.
3

DOC reports that space is also a limiting factor. Particularly with older facilities, mental health
providers often must use spaces outside of health services. The most significant limitation is
that an officer must be assigned to wherever a group is held during the time at which it is held.
DOC reports that it relies on volunteer-led groups to support individuals who do not have a
clinical need for therapy but who find it beneficial to process challenges with another person
who will listen. [DOC has confirmed that it does not have enough mental health providers to
offer therapy to everyone who wants but does not have a medical need for therapy.]
4

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DOC does not provide mental health treatment to individuals in work release.
The burden of arranging one’s own services in the community may be particularly
significant for some individuals with mental health conditions, cognitive
disabilities, and/or traumatic brain injury.

III. Medication
OCO has received numerous complaints from individuals who have alleged
concerns related to psychiatric medication.
•
•
•

•
•

DOC prescriber decreased in dosage or discontinued psychiatric medications
that the individual considered effective in the past. 5
DOC prescriber prescribed psychiatric medication(s) that the individual reports
was/were previously ineffective.
DOC prescriber discontinued psychiatric medications without counseling,
planning, or proper titrating, resulting in individuals suffering significant
withdrawal symptoms. 6
Delays in obtaining appointments with mental health prescribers.
Lack of clear self-care criteria that an incarcerated individual might demonstrate
when DOC is seeking an order for involuntary antipsychotic medication.

DOC reports that certain medications – particularly Wellbutrin and Seroquel – may be misused
and are therefore prescribed only as last resort options.
5

DOC also reports that individuals frequently are prescribed sedating medications while in jail
prior to being received by WA DOC. DOC reports that, although people may desire to continue
these prescriptions, DOC will not support continued use unless a corresponding diagnosis is
present.
DOC also reports that its formulary may differ from the formulary previously accessed by an
individual, which could impact the medications available to that person.
DOC reports that psychiatrist providers were instructed to ensure that an appointment with the
patient occurs prior to discontinuation of any psychiatric medication. The volume of complaints
received by OCO about this issue has decreased significantly since DOC addressed this
concern in mid-2020.

6

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IV. Disciplinary Process
The disciplinary process does not provide sufficient opportunity for the full
consideration of a person's mental health condition when reviewing infractions,
determining guilt, and imposing sanctions. 7
Specific complaints relayed to OCO include:
•
•

Individuals receiving infractions for behaviors stemming from a diagnosed mental
health condition.
Sanctions given to individuals with active mental health conditions are excessive,
meaningless, and/or ineffective in achieving behavior modification.

In reviewing complaints on this topic, OCO has observed:
•

•

Instances in which individuals with active symptoms of mental health disorders
were not offered a department advisor to assist with a disciplinary hearing.
Disciplinary policy does not provide specific guidelines about when a staff advisor
should be appointed and when one must be appointed.
Few instances in which it appeared that the hearing officer considered the mental
health condition of the person at the time of the infraction for purposes of
determining guilt or sanctions.

V. Self-Harm & Close Observation Areas (COAs)
Self-harm, suicide attempts, and death by suicide continue to be of great concern
to OCO.
OCO released a series of reports on deaths by suicide and suicide prevention in 2020. 8
Recently OCO published a report on our investigation of deaths by suicide that occurred
during 2020. We reiterate the need to adopt and implement the recommendations
included in those reports.

DOC reports having developed a plan to implement a modified disciplinary pilot program in two
Residential Treatment Units (the Special Offender Unit (SOU) at Monroe Correctional Complex
and the Treatment and Evaluation Center (TEC) at Washington Corrections Center for Women).
Modifications would focus on the appropriateness of sanctions, rather than guilt. DOC reports
that this pilot program began at SOU and TEC in March 2021.

7

DOC has yet to respond to OCO's Overview Report on 2019 Suicides and/or implement
certain recommendations.
8

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•

•
•

•

OCO has observed at least two instances in which an individual’s PULHESDXTR 9 R code, which indicates a history of self-harm or suicide attempt, was not
updated following incidents of serious self-harm.
OCO has been informed of incidents in which DOC staff did not create safety
plans for individuals prior to their release from COA.
OCO has been informed of a lack of a suitably confidential areas for interviewing
individuals in COA in at least one facility. This concern was cited in at least one
case as a reason why an individual’s safety plan had not been created.
OCO has received complaints in which people have remained in COAs for
extended periods of time, pending transfer. 10

VI. Residential Treatment Units (RTUs)
Individuals seeking admission to a residential treatment unit (RTU) express
concerns about the process and programming is limited in many RTU settings.
•

•

OCO has received complaints from incarcerated individuals who had requested
RTU-level care but had been denied admission. The reasoning behind the
decisions related to admission, and to discharge, as well, is not always clear or
transparent. 11
OCO has received complaints regarding the lack of programs, education, and
activities available in all RTUs. Specifically, the need for a recreation aide in
WCCW’s Treatment and Evaluation Center (TEC) program has been
communicated to our office on multiple occasions.

In 2019, DOC launched an internal workgroup to address concerns related to
Residential Treatment Units. Multiple disciplines were represented within the
workgroup members; custody and classification staff, psychology and psychiatry staff,
facility administration, and headquarters staff participated. OCO and Disability Rights
Washington DOC assigns health services codes to every individual incarcerated in its system.
These codes, known as PULHES or PULHES-DXTR codes, are meant to note the presence
and severity of various health-related factors, such as medication delivery requirements,
mobility limitations, developmental disability, and use of mental health services. The PULHES
R code should reflect a person’s history of self-harm: R-0 is the default (no data), R-1 indicates
there is no history of self-harm or suicide attempt in the past ten years, R-2 indicates that there
is a history of self-harm or suicide attempt in the past ten years.

9

10

DOC reports that transfer delays have occurred due to Covid-19 restrictions.

DOC reports that RTU admission/transfer process must remain extremely flexible to allow
maximum benefit to incarcerated individuals and staff.

11

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Washington (DRW) also were invited and sent representatives. OCO was encouraged
by the frank discussion that took place over the course of the two-day kickoff meeting in
November 2019. Subcommittees continued to meet, and a second workgroup meeting
occurred in February 2020. However, all subsequent meetings were canceled and
tasks associated with the workgroup were put on hold due to the Covid-19 pandemic.

VII. Individual Behavior Management Plans (IBMPs)
Clear guidelines do not exist for the creation of IBMPs and IBMPs vary
significantly in detail and individualization. 12
Individual Behavior Management Plans are one of a handful of tools that DOC may
employ in an effort to support behavior modification for incarcerated individuals. IBMPs
are typically created when mental health staff are aware that an individual is engaging in
on-going, challenging behaviors that are associated with some underlying mental health
condition. This tool has the potential to be extremely powerful: if successfully carried
out, IBMPs can facilitate behavior change that is beneficial to the incarcerated
individual, other incarcerated individuals, and DOC staff. Among these benefits are a
less restrictive setting for the individual and a safer environment for other incarcerated
individuals and staff.
However, no policy exists that directs DOC on when, how, or for whom an IBMP should
be created. OCO has observed that plans vary significantly from facility to facility. OCO
has also observed that some plans focus on punitive responses to behaviors, including
the use of restraints, rather than incentivizing positive behaviors. OCO believes that this
is an underused, sometimes misused, tool that, when implemented correctly, has the
potential to contribute significantly toward better conditions system-wide.

VIII. Intensive Management Unit (IMU) Placement
People with past and present mental health conditions frequently are assigned to
segregated housing for extended periods of time. This practice goes against years
of research that has shown that time spent in solitary confinement exacerbates mental
health symptoms. Specific complaints relayed to OCO describe the impact of
segregation exacerbating symptoms of mental health disorders, sometimes resulting in
destructive or self-harming behaviors, often resulting in infractions and sanctions,
causing time in solitary confinement to be repeatedly extended or increasingly harsh.
DOC reports that a revised version of the IBMP protocol has been drafted that addresses
many of these concerns.

12

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OCO has also observed that people who have been deemed unsuitable for Residential
Treatment Units – often due to persistent disruptive behavior or failing to engage in
treatment – have limited appropriate housing options. As a result, these individuals,
often diagnosed with personality disorders (in contrast to mood disorders), are routinely
placed in IMUs. OCO is concerned that individuals’ symptoms may be exacerbated
once placed in segregation. For those people who do not experience psychiatric
decompensation, the social and physical environment of IMU is not therapeutic, making
it difficult to effectively receive and benefit from treatment. 13

IX. Americans with Disabilities Act (ADA) Accommodations:
Individuals with psychiatric disabilities sometimes experience difficulty securing
necessary modifications to programs, services, and activities via DOC’s
accommodation request process. OCO has observed DOC’s difficulty bridging its
ADA and mental health siloes in order to provide ADA-mandated accommodations to
someone who has a mental health disability. OCO has observed instances in which
FRMT records do not reflect multi-disciplinary collaboration with regard to
accommodations. DOC’s response to OCO’s Persons with Disabilities report indicated
a willingness to establish multi-disciplinary teams to handle these situations, but the
progress of this work is unknown.
Specific complaints relayed to OCO include:
•
•
•

An insufficient number of jobs for incarcerated people exist in some closed
treatment areas.
Some off-unit supervisors express disinterest in hiring and supporting
someone with a mental health condition as an employee.
In some cases, DOC required an individual to actively engage in some form
of mental health treatment before agreeing to grant an accommodation
related to the psychiatric disability.

X. Support & Training for Staff
DOC staff members may benefit from additional training to positively and
effectively engage with individuals who have mental health conditions. Many of
DOC reports that their collaborations with Amend and the Vera Institute of Justice have
addressed these concerns, in part. DOC’s internal Restrictive Housing Workgroup continues to
craft and implement related changes.

13

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the complaints received by OCO that relate to mental health allege some component of
inappropriate or less than ideal staff conduct, such as:
•
•

Individuals have reported instances in which custody staff in RTUs allegedly
failed to act when an individual expressed self-harm or suicidal ideation.
Individuals have reported instances in which some IMU staff members allegedly
did not adequately or appropriately respond to people experiencing an increase
in mental health symptoms and/or people in mental health crisis.

XI. Special Populations14
Individuals who have been returned to prison from community custody or
transferred to prison from jail often have unique needs that demand specialized
focus from DOC staff.
Individuals in this status (typically referred to as “violators”) frequently arrive having
recently used substances and then are forced into rapid detox. Individuals who have
been arrested and need mental health assessment and stabilization are often sent to
prison for these services, where they are added to the already significant caseloads of
DOC mental health providers. Additionally, when people in violator status have never
been to prison before, department staff have no medical or mental health history that
can inform treatment decisions. Even when a violator is returning to prison, that
person’s health records are not readily available immediately upon return.

XII. Administrative Concerns
DOC can take additional steps to ensure access to ongoing, quality mental health
care.
OCO is unaware of any quality assurance and improvement processes that DOC has in
place which include a specialized focus on mental health care. 15
OCO was informed that a Memorandum of Understanding between DOC and
Washington’s Department of Social and Health Services (DSHS) regarding temporary
transfers to a state psychiatric hospital has remained pending for many years. DOC
Various stakeholders have relayed concerns to OCO regarding the minimal release planning
conducted for individuals with mental health conditions. While OCO recognizes the tremendous
importance of release planning for this population, we have not opened cases on the topic
because we do not have jurisdiction over individuals outside of DOC’s physical custody.

14

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mental health providers have indicated to OCO that there are many individuals
incarcerated in DOC who, these providers believe, are too ill to be housed in prison or
require treatment that cannot be provided by DOC. Facilitating transfer to a state
psychiatric hospital would at least provide the opportunity and appropriate setting for
periodic patient stabilization when necessary.

Recommendations
I. Screening & Assessment
Recommendation 1: DOC should review and revise the current mental health
screening and assessment processes to:
a. Achieve a more reasonable daily caseload that allows staff to perform a
thorough review of the documents accompanying new intakes.
b. Ensure that suitably confidential space exists where mental health staff
are able to screen and assess individuals.
c. Ensure that assessments are provided on a timely basis.

II. Psychotherapy
Recommendation 2: DOC should ensure that quality, timely mental health
treatment services are available to anyone in DOC custody who demonstrates a
clinical need for treatment. Efforts to address this may include increasing the
number of qualified mental health providers available to provide short- and longterm mental health treatment services. 16
Recommendation 3: DOC should ensure maximum availability of group
therapy. This could include prioritizing custody coverage of all necessary spaces
proposed for use by mental health providers. Ideally, this could shift custody time
to supporting individuals as they return to or sustain stability, rather than using
custody time to respond to incidents stemming from mental health crises.
Recommendation 4: DOC should meet the demand for additional mental
wellness programs available to assist incarcerated people with addressing past
trauma. This could include developing additional programs led by qualified
DOC reports that it had prepared a request package before the pandemic that was submitted
for legislative approval in the 2020-21 session. If approved in full, the proposal would have
funded additional mental health staff positions, reducing mental health providers’ caseloads
from approximately 90 patients to approximately 70 patients.

16

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individuals (staff and/or volunteers) and/or implementing evidence-based peer
support programs.
Recommendation 5: DOC should create better behavioral health linkages for
individuals in work release. This could include re-creating a work release
program with a special focus on supporting individuals with mental health needs.
Recommendation 6: DOC should support race equity measures by ensuring
that the demographics of mental health staff and contract providers reflect the
racial and ethnic diversity of the incarcerated population.

III. Medication
Recommendation 7: DOC should ensure that prescribers are no longer
discontinuing medications without first meeting with the patient to plan for this.
Resolving this may include tracking data to ensure that this practice is no longer
occurring.
Recommendation 8: When grave disability is being considered for the basis of
a referral for involuntary antipsychotic medications, DOC should provide the
patient with objective indicators of self-care for the patient to demonstrate for
some sustained period of time.

IV. Disciplinary Process
Recommendation 9: DOC should ensure that an individual’s mental health
status is considered throughout the disciplinary process. Changes to ensure
consideration of mental health status may include implementation of a unique
policy or protocol to allow different handling of disciplinary cases for individuals
who are assessed as S-3 or higher17, infracted while in an RTU or COA, or when
the circumstances indicate a need for input from mental health staff in order to
fairly determine guilt and sanctions.

The PULHES S code is meant to reflect a person’s mental health service utilization. Any
number greater than 1 (no identified mental health need) indicates that the person is on DOC’s
mental health caseload. S codes 2, 3, 4, and 5 (most significant) reflect increasing mental
health services use and needs.

17

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V. Self-Harm & Close Observation Areas 18
Recommendation 10: DOC should ensure all appropriate staff are aware of the
need to update PULHES-DXTR R codes.
Recommendation 11: DOC should ensure staff are adhering to the
requirements of DOC 320.265 Close Observation Areas related to the creation of
mental health safety plans prior to discharge from COA.
Recommendation 12: DOC should ensure that suitably confidential space
exists where mental health staff are able to meet with and assess individuals.
Recommendation 13: DOC should ensure that approved transfers out of COA
are prioritized.

VI. RTUs
Recommendation 14: DOC should develop a comprehensive RTU policy that
addresses:
a. objective criteria for admission;
b. modified disciplinary system;
c. modified classification system;
d. pathway out of RTU, including objective criteria for discharge;
e. mandatory specialized mental health training for RTU custody staff; and
f. programming availability in RTU (to include programming support).

VII. IBMPs
Recommendation 15: DOC should develop a comprehensive IBMP policy,
which may include:
a. objective criteria for who should or must have an IBMP;
b. guidelines for incentives that may be used;
c. guidelines for safety responses that may be used, including whether/when
use of restraints may be part of an IBMP;
d. mandatory training for all mental health providers that addresses how to
write an IBMP;
e. mandatory training for any DOC custody staff who routinely work with
individuals who have IBMPs; and
DOC reports that the Chiefs of Psychology initiated in April 2021 an audit of all COA
admissions. The audit will conclude in June 2021.

18

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f. routine audits of IBMPs by qualified headquarters staff.

VIII. IMU Placement
Recommendation 16: DOC should reduce the frequency of placement and the
length of stay in any segregated housing, including A and B units of SOU, for
individuals with serious mental health conditions.
Recommendation 17: DOC should explore best practices for successfully
housing and treating individuals with behavioral challenges, regardless of
diagnosis, in a setting that is not IMU or other segregated housing.

IX. ADA Accommodations
Recommendation 18: DOC should continue to use multi-disciplinary teams to
routinely address the need for accommodations that arise from individuals’
mental health disabilities.

X. Support & Training for Staff
Recommendation 19: In order to equip DOC correctional officers and other
staff with the knowledge and skills needed to support individuals with mental
health conditions, DOC should:
a. Strive to facilitate culture change among staff in order to best support
incarcerated individuals, the efforts of mental health staff, as well as goals
associated with institutional safety.
b. Set and communicate clear conduct and support expectations for all staff
members who interact with individuals who have mental health conditions.
c. Provide in-depth mental health awareness trainings to all DOC staff. It is
critical that staff are able to recognize behaviors associated to mental
health conditions before they become problematic for the individual, staff,
and facility.
d. Provide in-depth training on de-escalation techniques to all DOC staff.
e. Provide specialized training on mental health conditions and basic
behavior theory to all staff who work in RTUs and all staff assigned to
COAs. These staff members must be better able to understand how an
individual’s behavior may be impacted by a mental health condition.
f. Provide specialized training on mental health conditions to hearing officers
and Resolution Program coordinators.
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g. Consider implementing additional training strategies and requirements as
used by other jurisdictions, including Oregon DOC. 19

XI. Special Populations
Recommendation 20: DOC should create policy or protocol language that
specifically addresses the unique needs of individuals in violator status.

XII. Administrative Concerns
Recommendation 21: DOC should ensure implementation of internal quality
assurance measures for mental health care. This may include:
a. Conducting an overall mental health system assessment.
b. Implementing routine peer-review of mental health records to ensure
quality and consistency across the system.
Recommendation 22: DOC should work with DSHS to set a clear pathway to
allow DOC to temporarily transfer individuals in need of in-patient psychiatric
care to Eastern or Western State Hospitals.

19

See OAR 291-048-0220.

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STATE OF WASHINGTON

DEPARTMENT OF CORRECTIONS
P.O. Box 41100 • Olympia, Washington 98504-1100

July 29, 2021

Joanna Cams
Office of Co!1'ections Ombuds
2700 Evergreen Parkway NW
Olympia, WA 98505
Dear Ms. Cams:
The Washington Department of Co!1'ections appreciates the opportunity to respond to the
June 26, 2021 Office of Co!1'ections Ombuds (OCO) report 011 the ' Mental Health Access
& Servic.es.'

Recommendation
Rec.01nmendation 1: DOC should
review and revise the ctment mental
health screening and assessment
processes to:
a. Achieve a more reasonable
daily caseload that allows
staff to perfom1 a thorough
review of the documents
accompanying new intakes.
b. Ensure that suitably
confidential space exists
where mental health staff are
able to screen and assess
individuals.
C. Ensure that assessments are
provided on a timely basis.

Response
The department is preparing decisions packages
for the 2022 supplemental budget to request two
additional psychology positions and capital
funds to create a more effective in take/reception
process.

Recommendation 2: DOC should
ensure that quality, timely mental
health treatment services are
available to anyone in DOC custody
who demonstrates a clinical need for
treatment. Efforts to address this may
include increasing the number of
qualified mental health providers
available to provide short- and long-

The department provides in the DOC health
plan mental health assessment, medication and
treatment se1v ices:
h!ffis://www.doc.wa.gov/docs/publications/600HAO0l.pdf
Staff p1io1itize treatment, to include individual
and group therapy, psychiatii c medica tion, and
case management services, based on clinical

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tenn mental health treatment
se1vices.

Recommendation 3: DOC should
ensure maximum availability of
group therapy. This could include
prioritizing custody coverage of all
necessa1y spaces proposed for use by
mental health providers. Ideally, this
could shift custody time to supporting
individuals as they return to or
sustain stability, rather than using
custody time to respond to incidents
stemming from menta l health crises.

assessment and evaluation. Individuals request
se1vices via kite and department staff are
trained to identify early indicators of mental
health concerns and refer identified individuals
for a mental health assessment. Individualized
treatment is provided based on clinical
assessment. The department routinely reviews
its distribution of staffing resources to make
sure positions are located where the greatest
patient needs exist.
The department is preparing a decision package
to increase the number of mental health
providers at key locations with the intent to
provide mental health se1vices for more
individuals.
Many facilities continue to experience
COVID-19 as a banierto increasing the use
of group therapy.
The physical space available to
accommodate groups with appropriate
co!1'ectional supe1vision is a significant
banier to providing more group therapy.
Leadership for psychology and health
se1vices at each facility have been asked to
evaluate the physical space available at
each co1Tectional facility and identify
potential space available to hold treatment
groups. The health services managers will
then work with p1ison administrators to
develop implementation plans for
utilization of those spaces.
If additional resources are needed to create
access to space this work will help to
infonn decision packages in ctl!1'ent and
future years.
The assessment of space is estimated to be
completed in September 30, 2021.

Recommendation 4: DOC should
meet the demand for additional
mental wellness programs available

The department is contracted with Amend at the
University of California-San Francisco. The
p1ima1y focus of this work is to identify and

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to assist incarcerated people with
addressing past trauma. This could
include developing additional
programs led by qualified individuals
(staff and/or volunteers) and/or
implementing evidence-based peer
support programs.

incorporate a co1Tectional culture with a public
health-oriented mission. The work is focused on
creating a healthier prison population, staff and
communities. One of the goals of the
partnership is the improvement of the health
and wellbeing of the incarcerated and avoidance
of re-traumatization.
A comprehensive list of the therapy and support
programs available through the department can
be found at
https://w,vw.doc.wa.gov/co1Tections/programs/d
escriptions.htm - therapy-support.
In collaboration with the department's
con-ectional program administrator and family
& volunteer services manager, there are a series
of steps planned to re-introduce these programs
as the state 's con-ectional facilities begin
reopening following COVID-19. Below are two
importan t examples of popular and effective
"peer-based" programs utilized in support of
thos e in the department's custody and care:
Yoga Behind Bars (YBB) is a ve1y popular
evidence-based activity led by trained
incarcerated individuals. There are plans to
expand the YBB program across more facilities.
There is a trauma-based component of the YBB
program, which will be included in the training
of new leaders and roll-out of the program
across most con-ectional facilities.
Alcoholic Anonymous/Narcotics Anonymous
(AA/NA) groups are volunteer-led groups
offered at most, if not all, facilities. Availability
is dependent on volunteers though this has
historically not been a challenge.
The department identified funding available
through the Incarcerated Individual Bettennent
Fund (IIBF) that will be used to research,
develop and introduce a pilot program to focus
on wellness within the next 12 months.

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Recommendation 5: DOC should
create better behavioral health
linkages for individuals in work
release. This could include recreating a work release program with
a special focus on supporting
individuals with mental health needs.

The department has developed a continuity of
care document for use with the Health Care
Authority (HCA) and managed care providers
and is slated for implementation by November
30, 2021 . This will be the fotmdation for a
similar plan for those people transitioning from
a state con-ectional facility to work release.
The work release programs have individualized
plans, which may include exclusive focus on
treatment. The department will continue efforts
across organizational divisions (Prisons,
Reentiy, Health Se1vices, Community
Co1Tections) to develop and implement a plan
for greater collaboration to ensure treatment
needs are met in the community.

Recommendation 6: DOC should
support race equity measures by
ensuring that the demographics of
mental health staff and contract
providers reflect the racial and ethnic
diversity of the incarcerated
population.

The Mental Health Leadership Team will
continue to consult with Equity and Inclusion
Administrator Dr. Ad1ian Thompson and the
health se1v ices staffrecrnitment team about
ways in which to improve the racial and ethnic
diversity of mental health staff. These efforts
will include more intentional recrnitment
strategies such as career postings with
professional groups for people of color. Plans
will be developed in collaboration with Dr.
Thompson to improve retention of staff. This
may include mentoring opportunities as well as
training in cultural competence.

Recommendation 7: DOC should
ensure that prescribers are no longer
discontinuing medications without
first meeting with the patient to plan
for this. Resolving this may include
tracking data to ensure that this
practice is no longer occuning.

A memo was sent to all psychiatric
prescribers by the director of mental health
and the chief of psychiatry in July 2020, with
a follow-up in June 2021. The memo strictly
prohibited the discontinuation of medications
without having assessed the patient and
discussed it with them.
The chiefs of psychology, the chief of
psychiat1y and health services managers are
expected to use vigilan t supe1v ision to
identify if this occurs, even if a patient does
not report a concem. This will be monitored
through filed izrievances and accom1tability

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checks with health care providers, if such
prac:tices are detennined to have resrnfaced, a
more vigorous approach will be considered.
Recommendation 8: When grave
disability is being considered for the
basis of a refeffal for involuntaiy
a ntipsychotic medications, DOC
s hould provide the patient with
objective indicators of self-care for
the patient to demonstrate for some
s ustained period of time.

The self-management of psychiatric symptoms
fo1m (Attachment A) was developed for use
when considering involunta1y antipsychotic
medications. An official agency fonn is
developed and will be published by July 30,
2021 . The fonn identifies the expected
behaviors indicative of adequate self-care. The
fo1m gives the patient up to 30 days (the
timeframe can be varied based on patient need,
health and safety) to improve prior to a refeffal
for involuntaiy medications. Training of staff
will occm by July 30, 2021.

Recommendation 9: DOC should
ensure that an individual's mental
health status is considered throughout
the disciplimuy process. Changes to
ensure consideration of mental health
s tatus may include implementation of
a tmique policy or protocol to allow
different handling of disciplinaiy
cases for individuals who are
assessed as S-3 or higher, infracted
while in an RTU or COA, or when
the circumstances indicate a need for
in put from mental health staff in
o rder to fairly detennine guilt and
s anction

In March 2021, the department began to pilot a

new disciplina1y process at Washington
Co!l'ections Center for Women (WCCW) and
Monroe Con-ectional Complex-Special
Offender Unit for those people with a serious
mental illness. The pilot includes a review of
serious infractions by a person's prima1y
therapist. The review is used to detennine
whether fi.mctional limitations contributed to the
infracted behavior and whether the person has
the mental status to participate in the infraction
hearing.
If either of thes e situations is found, the
infraction will be dismissed. When the
infraction is dismissed, the treatment team is
responsible for the development of an
inte1v ention plan to assist in the reduction or
elimination of the concerning behavior.
If the infraction does result in a hearing and the
infraction is upheld, the treatment team will
recommend a modified sanction designed to
assis t the person in the reduction or elimination
of the behavior. These individuals are not
subject to the traditional sanctions used in the
disciplina1y process. The pilot is modeled after
a program in the Oree:.o n Department of

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Coffections and is scheduled to conclude at the
end of September 2021 . After the conclusion of
the pilot, the procedure (Attachment B) will be
reviewed and adjusted as needed and is
expected to roll out more broadly in the first
quarter of 2022.
Recommendation 10: DOC should
ensure all appropriate staff are aware
of the need to update PULHESDXTR R codes.

Refresher training was provided on May 20,
2021 to all psychologist 4 staff to review the
criteria for establishing R codes and the
expectations for making necessaiy updates to
those codes. These staff have been directed to
reinforce with their staff the importance of
reliable reporting of these codes. The chiefs of
psychology will monitor the completion of the
training and ensure all staff have been reminded
of the importance of reliable coding by July 31,
2021.

Recommendation 11 : DOC should
ensure staff are adhering to the
requirements of DOC 320.265 Close
Obse1v ation Areas related to the
creation of menta l health safety plans
prior to discharge from COA.

Active monitoring of all close observation area
(COA) admissions and discharges by the chiefs
of psychology began in March 2021. The
monitoring ensures that per protocol and policy,
discharge suicide risk assessment (SRA)
evaluations are conducted along with safety
plans before a person is released from the COA.
The monitoring includes quarterly audits for
COA documentation by each chief of
psychology.

Recommendation 12: DOC should
ensure that suitably confidential
space exists where mental health staff
are able to meet with and assess
individuals

The chiefs of psychology assessed the physical
plant of each COA location to identify the
confidential space adjacent to the COA w here
inte1views and evaluations may occm. The
assessments of inte1v iew spaces were
completed as of June 30, 2021 . Health se1v ices
managers and prison administrators will be
notified of any areas tha t do not have
confidential inte1v iew spaces and will be asked
to collaborate on how this can be addressed.

Recommendation 13 : DOC should
ensure that approved transfers out of
COA are prioritized.

Transportation agrees that transfers will occur
with four or less people, when needed, to move
a person out of the COA. Headquarters-based
classification staff will be monitoring the

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timeliness of the classification process for these
individuals. Mental health leadership will
continue to work closely with classification and
transportation staff to priodtize individuals to
minimize length of stay in COAs.
Recommendation 14: DOC should
develop a comprehensive RTU policy
that addresses:
a. objective criteria for
admission;
b. modified disciplina1y system;
C. modified classification
system;
d. pathway out of RTU,
including objective criteria
for discharge;
e. mandato1y specialized mental
health training for RTU
custody staff; and
f. programming availability in
RTU (to include
programming support).

The residential treatment unit (RTU) workgroup
is expected to begin meeting by the end of
August 2021 . The workgroup includes health
services, prisons and classification staff along
with representation from OCO and Disability
Rights Washington (DRW).
The charter of the workgroup includes the
development of policy to support the RTU. The
policy will address the process and general
criteria for admission and discharge from RTU
level of care, and training for staff working in
RTUs.
The modification of the disciplinaiy process to
accommodate those individuals with serious
mental illness is ctmently being piloted as
discussed above and includes modified
sanctions and behavioral approaches designed
to support those with mental health conditions.
A modification of the classification system for
those people placed in residential treatment
units will be discussed for changes to the
classification policy. Efforts to identify and
implement additional programming
opportm1ities continue in coordination with the
Reent1y Division and local community-based
organizations.

Recommendation 15 : DOC should
develop a comprehensive IBMP
policy, which may include:
a. objective criteria for who
should or must have an
IBMP;
guidelines
for incentives that
b.
maybe used;
c. guidelines for safetv

The Managing Challenging Mental Health
Patient Protocol, which directs the development
and implementation of individual behavior
management plans (IBMP), was updated to
improve the multi-disciplinaiy approach to the
IBMP process as well as insure greater
utilization of incentivizing prosocial behaviors
over ending negative behaviors. (Attachment
C). The department will develop euidelines for

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responses that may be used,
including whether/when use
of restraints may be part of an
IBMP;
d. mandato1y training for all
mental health providers that
addresses how to write an
IBMP;
e. mandato1y training for any
DOC custody staff who
routinely work with
individuals who have IBMPs;
and
f. routine audits of IBMPs by
qualified headqua11ers staff.
Recommendation 16: DOC should
reduce the frequency of placement
and the length of stay in any
segregated housing, including A and
B units of SOU, for individuals with
serious mental health conditions.

incentives to be used to improve standardization
across facilities. It is key however, that
flexibility remains so that the incentives
included in the IBMP is as individualized as
possible. The updated protocol calls for IBMPs
continued beyond six months to be reviewed by
a chief of psychology to ensure the quality and
efficacy of the plans developed and
implemented. The psychologist 4s, who are
most frequently invo!Yed in developing IBMPs,
were trained on the updated protocol on June 3,
2021 . Training for other staff involved with the
implementation ofIBMPs, to include
coffectional officers, will be developed by Oct.
1, 2021 and implemented by Janua1y 2022.
Througl1 work with the Vera Institute of Justice
and Amend, the depanment has progressively
addressed both the frequency and length of stay
in restrictive housing. The department's use of
restrictive housing has consistently declined
since 2012, particularly for those with serious
mental health concerns. Since 2012, the
administrative segregation population has been
reduced by a third (Over 570 in 2012, 420 June
of 2021 ). There has been a:'\:'\ percent <lecrea.c:e
in the median length of stay in maximum
custody and a 45 percent reduction in selfhann/suicide attempts in restrictive housing.
The department also reviewed the number of
extensions for investigations past 30 days and
has developed strategies for a more rigorous
consideration process to be used when
considering approval for those extensions . The
department has increased its scrutiny of those
who have extensions granted to farther reduce
the length of stay in restricted settings were
11JJJJW]Jrialt::.
By policy, the department has stopped the use
of assigning disciplina1y segregation as a
sanction and instead focus on sanctions
designed to disincentivize behaviors of concern.
Work is being done to pilot projects like

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transfer pods and transition pods to limit
restrictive housing and place incarcerated
individuals in the least restrictive environment
given their circumstances.
Recommendation 17: DOC should
explore best practices for
successfully housing and trea ting
individuals with behavioral
challenges, regardless of diagnosis, in
a setting that is not !MU or other
segregated housing.

As the department expands its continuum of
care by developing strategies for intensive
outpatient treatment (i.e. more frequent
therapeutic inte1ven tions), it is expected that
some of these individuals' treatment needs
will be met in a general population and reduce
the frequency of placement in restrictive
housing.
I.nfonnation and documentation gathered from
programs in the New York and Massachusetts
con-ectional systems are being reviewed and
considered to detem1ine if similar programs
may be a good fit for the department and
those in our facilities . These programs include
small units (40-100 beds), an emphasis on
incentivizing behavior and the use of
dialectical behavior and cognitive behavioral
treatment approaches. The department this
includes an assessment of ctmently available
physical plant and operational resources to
detennine feasibility for implementing a
similarly designed program.

Recommendation 18: DOC should
continue to use multi-discipl!ina1y
teams to routinely address the need
for accommodations that aris e from
individuals' mental health
disabilities.

The department will continue to use multidisciplina1y teams to routinely address the need
for accommodations that arise from an
individual's mental health disabilities.

Recommendation 19: In order to

In collaboration with the training and

equip DOC co!1'ectiona.l officers and

development unit (TDU):

other staff with
the knowledge and skills needed to
support individuals with me11tal
health conditions,
DOC should:
a. Strive to facilitate culture
change among staff in order

a. Culture change is a constant goal of the
agency and is communicated via the
mission, vision and values training
cun-ently assigned to new employee
orientation (NEO) for all new staff and
annual in-se1vice (AIS) and the
leadership values course for supe1visors.

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b.

C.

d.

e.

f.

g.

to best support
incarcerated individuals, the
efforts of mental health staff,
as well as goals associated
with institutional safety.
Set and co111111unicate clear
conduct and support
expectations for all staff
members who interact with
individuals who have mental
health conditions.
Provide in-depth mental
health awareness trainings to
all DOC staff. It is critical that
staff are able to recognize
behaviors associated to
mental health conditions
before they become
problematic for the
individual, staff, and facility.
Provide in-depth training on
de-escalation techniques to all
DOC staff.
Provide specialized training
on mental health conditions
and basic behavior theo1y to
all staff who work in RTUs
and all staff assigned to
COAs. These staff members
must be better able to
tmderstand how an
individual's behavior may be
impacted by a mental health
condition.
Provide specialized training
on mental health conditions to
hearing officers and
Resolution Program
coordinators.
Consider implementing
additional training strategies
and requirements as used by
other jmisdictions, including
Oregon DOC.

b. Staff working in specific areas where
individuals are known to have a mental
health concem, such as an RTU, specific
training objectives are addressed
through the RTU workgroup. Because a
person's functioning is impacted by a
mental illness, they may not clearly
express their needs and for this reason, it
is recommended that a "universal
precautions" approach be used and
respond by engaging the person and
assisting them with identifying their
concerns or making refe1nls. Staff are
expected to address all people with
respect and individually.
C. Training specific to individuals
experiencing mental health symptoms is
provided to all staff who attend both
con11mmity co1Tections officer academy
(CCOA) and co1Tectional worker core
(CWC). The training is instructed by
mental health professionals and is two
hours in length.
In-depth
de-escalation techniques are
d.
taught to all staff drning both academies
(CCOA and CWC). In addition, it is part
of the CCOA AIS. For new employee
orientation (NEO), the training is an
eight-hour course. The employees
attending ewe receive 12 hours of
training. Employees receive six hours of
initial training in CCOA.
e. & f. More specific training can be
developed and provided to people in
specialized job classes. Such training
would require resomces to develop
appropriate cu1Ticula, instrnct courses
and establish the training as a priority
for the agency. A proposal for what
would be required for these
reco1mnendations will be prepared for
presentation to the department's
executive leadership by September 30,
2021.
g , The department will connect with its

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counterparts in Oregon and other
jurisdictions to leam more about tlleir
programming and detennine if there are
components that can assist with
enhancing training.
Recommendation 20: DOC should
create policy or protocol language
that specifically addresses the unique
needs of individuals in violator
status.

The department recognizes the unique
healthcare needs of those in violator status. To
further adapt the screening, assessment and
treatment process for the unique population, a
workgroup will be fonned to address the need
to develop policy and protocol to address the
population. The initial charter of the workgroup
has been drafted and participan ts identified
(Attachment D). The workgroup is targeted to
begin meeting by August 15, 2021.
The department is also reviewing options for
both contracting and resource requests that may
be part of decision packages this year and in the
future to support targeted resources within state
con-ectional facilities for those held on a
community violation and increase the use of
community jail beds.

Recommendation 21 : DOC should
ensure implementation of internal
quality assurance measures for
mental health care. This may include:
a. Conducting an overall mental
health system assessment.
b. Implementing routine peerreview of mental health
records to ensure quality and
consistency across the system.

The mental health leadership at the department
developed an audit tool that provides an indepth assessment of the quality of mental health
services provided to individuals in the
department's custody (Attachment E). The tool
is used as a component of clinical supe1v ision
(peer-to-peer) as well as in the biannual
operational inspections conducted at each
facility.
All mental health staff meet with their
supe1visors on a regular basis, the frequency of
which is not less than monthly. Chart
documentation is reviewed and evaluated
according to the standards in the audit tool. The
outcomes of the chart audits provide guidance
for the clinical staff to improve their work, as
documented on superviso1y conference fo1ms.
This model of clinical supe1v ision is consistent
with industry standards.

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In addition to these audits, the biannual
operational inspections provide a facility-wide
assessment of the quality of menta l health
services and identify any systemic concerns at
each location. Action plans developed from the
outcomes of the operational inspections address
any concerns in the quality of care provided.

Reconunendation 22: DOC should
work with DSHS to set a clear
pathway to allow DOC to temporarily
transfer individuals in need of inpatient psychiatric care to Eastern or
Westem State Hospitals.

The department recognizes access to inpatient
psychiatric care for the most severely mentally
ill population can be an important tool. A
statuto1y mechanism exists that authorize, a
transfer between the Department of Co!1'ections
to an inpatient institution that cares for the
mentally ill. Court decisions also require certain
procedural safeguards prior to such transfers.
Additionally, any transfers would need to be
accomplished in a manner that also allow, the
Department of Social and Health Services
(DSHS) to accomplish its broader mission. The
department has explored the possibility of a
MOU with DSHS, but it has yet to find a
workable MOU that meets these goals. The
department can continue to fmther explore such
an MOU. The department would like to
emphasize its continued committed to providing
care to those individuals w ho remain in
department custody and any process that would
be developed to transfer someone to an
inpatient facility would only be considered to
provide care once all care options within the
department are exhausted.

The infonnation provided in the mental health access & se1vices systemic report by the
Office of Co!1'ections Ombuds was useful to ensm·e the Department of Co!1'ections is
designed and managed to provide safety for the persons in its custody.
We also appreciate your team's understanding of the unique processes across the
co!1'ectional system and the addition otpolicies and procedures, as well as additional
resource requests, being put in place to address them. We are working proactively to
continuously improve quality assurance standards tlu·oughout the department.

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Moving fo1ward, the Washington Department of Con-ections will continue to collaborate
w ith the Office of the Con-ections Ombuds to strengthen procedures and practices that
positive impact individuals' health, safety and welfare.
Sincerely,

~ ~ """" Policy
Washington Department of Con-ections
SM:kr
cc :

Che1y l Stran ge, Secreta1y
Sean Mmphy, Deputy Secreta1y
Julie Martin, Chief of Staff
Jeremy Barclay, Director of Engagem ent and Outreach

Attachment A:
• Self-Management of Psychiatiic Symptoms
Attachment B:
• SMI Hearin gs MEMO & SMI Heatings m emo process (attached as 17-089)
Attachment C :
• Managing Challenging Mental Health Patients Protocol (IBMP)
• 13-069 IBMP
• 13-595 MH Functional Assessment
Attachment D:
• Project Charter
Attachment E:
• Monthly supervision score card
• Operational Inspection Audit Preparation - MH Sections

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**The full DOC response with attachments can be found on the OCO website.
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