Shortly after Christmas in 2016, Albert Okal began acting strangely in the Wayne County Jail. He was “jumping around, seeing things,” his lawyer says. The 41-year-old was facing a charge of driving while intoxicated in southeastern Missouri.

This story is published in partnership with St. Louis Post-Dispatch

Okal does not recall why he became so agitated, but his lawyer said Okal does remember how the jail staff responded: They cuffed his wrists and ankles to a “restraint chair,” where they force-fed him, covered his head with a blanket, addressed him with the n-word and refused to let him use the bathroom, leaving him to urinate and defecate on himself. He remembers being restrained for five days, his lawyer said.

Last fall, Okal sued Wayne County, the county sheriff Dean Finch, and a number of jail staffers, claiming this experience left him with physical pain and emotional trauma, as the St. Louis Post-Dispatch previously reported. Wayne County jailers have denied placing Okal in the device.

Okal’s lawsuit is the latest keyhole into the use of restraint chairs within the nation’s jails. There are more than 3,000 jails around the country, and they are usually run by counties with little state or federal oversight, often far from civil rights lawyers, journalists and other informal watchdogs. Some states have tasked agencies or non-profits with inspecting jails. Under Missouri law, grand juries are charged with inspecting jails in their counties.

Many people arrive at these facilities while extremely intoxicated or suffering from a mental health crisis, and experts on jail operations say these devices—which allow jailers to cuff or strap someone down by their arms and legs, and sometimes shoulders and torsos—can be helpful in stopping them from harming themselves or others.

But the experts caution that after the imminent threat passes, using the chair can be dangerous, leading to deaths by overdose and blood clots resulting from extended periods in the same position. Some states, including Florida and Utah, have banned the use of such restraints in certain state facilities, but some county jails still use them, as do some immigration detention facilities. A Marshall Project review of lawsuits and press reports found the chair linked to 20 jail deaths in the past six years, and in 2014, USA Today connected the device to more than 36 deaths going back to the late 1990s.

Additionally, at least nine other people have sued jails around the country since 2013, citing restraint chairs as part of a wider claim of abuse; in some cases, they describe being beaten, tasered or pepper-sprayed while strapped in. Last year, the U.S. Department of Justice investigated the Boyd County Detention Center, a 206-bed jail in Catlettsburg, Kentucky, finding that jailers there punished prisoners—some of whom had attempted suicide—by placing them in a chair with “their genitals exposed to passers-by.”

Since Okal filed his lawsuit, 10 others have told The Marshall Project that officers at the Wayne County Jail often use the restraint device. There is even an unofficial record, according to several detainees: In 2014, a man named Stacie Black says he was held in the chair for 28 days following a suicide attempt.

“At the jail, when you talk about the chair, my name always comes up,” he said by phone from the Farmington Correctional Center in Missouri, where he is now serving a 30-year sentence for drug possession. Unlike Okal, Black said he was allowed to get up for occasional showers, bathroom breaks and 15-minute visits with his mother. But it was still grueling.

“You ever try to sleep sitting up for a month at a time?” he said. “I [now] have to sleep with my head down and rear end up, because my back is hurting, and it’s the only way I’ll be comfortable.”

Wayne County Sheriff Dean Finch, who faces re-election in November, declined to comment. After three calls to the jail, The Marshall Project sent a list of questions to the county’s lawyer Albert M. Spradling, III, who said the sheriff and his staff could not answer due to “ongoing or threatened litigation.”

Five people who say they were detained with Black, and one former officer who worked in the jail at the time, described seeing him strapped down during that four-week period. “I would hear him cry,” said Jennifer Key, who was incarcerated with Black and worked as a “trustee” in the facility, preparing food and doing laundry. (She has since been released and works at an addiction treatment center.) “One day I heard him scream. Other days he’d be lethargic. His body was just giving out.”

The American Bar Association and American Correctional Association have published standards limiting the use of these devices, which have earned nicknames like the “Devil’s Chair,” the “Be Sweet Chair,” and the “Strap-o-lounger.” The Wayne County Jail’s own manual says that anyone strapped into the device “shall” be watched continually for two hours and then given a medical assessment, after which they should be checked every 15 minutes. Both Black and Okal say they were never given medical attention, and Black says he was left alone for hours at a time.

Though most people survive short stints in the restraint chair, some have died from blood clots resulting from inactivity. In 1997, Michael Valent, a 29-year-old Utah prisoner with schizophrenia, died when a blood clot entered his lungs after he spent 16 hours in the device. His death prompted Utah lawmakers to ban its use. “It’s just like if you’re on an international flight: They don’t want you to sit for eight hours,” said Steve Yerger, a private consultant who has trained jail staff around the country on how to use restraint chairs safely. “There better be a damn good reason for keeping someone in a chair for more than five hours.”

The devices can also play a role in deaths from a variety of other causes. “People who are seen as a safety threat may actually be having a medical crisis,” said Homer Venters, former chief medical officer for New York City’s Correctional Health Services. “Putting someone in a restraint may cause you to not see the help they need.” He pointed out that low blood sugar, alcohol withdrawal and psychotic episodes all may lead people to exhibit behavior that makes them appear dangerous when they are not.

Stacie Black has been arrested numerous times over the years, usually for drug possession; he admits that he was addicted to methamphetamine. Soon after one arrest, in November 2014, he attempted to hang himself with a sheet and survived. He says the jail staff put him in the chair out of a concern that he would try again, but that as time went on he was simply told the sheriff would not let him out. He claims at one point he said something to make an officer angry and he was pushed over, causing his legs to stick up in the air.

“He was mouthy to the employees he didn’t respect,” recalled a former Wayne County jailer who asked not to be named, fearing reprisal. Although Black “wasn’t the ideal inmate,” he added, “he was in the chair for an uncomfortable duration.”

Black said he made the best of his situation: He was seated near the desk where new arrivals were booked, so he chatted with everyone he could. “I ain’t never met a stranger,” he said. “It’s a small community, and I’m from there, so I know all the cops, all the jailers.” On Sundays, a local man would come to the Wayne County jail and tell jokes and sing country songs on a karaoke system. Sometimes he wore an Elvis costume. Black said he would serenade him directly.

At night, the foot traffic made it impossible to sleep, especially combined with his upright position. On one occasion, Black said, a friendly officer uncuffed his hands and let him sleep on the ground, with his feet still strapped in. At mealtimes, he’d get one hand uncuffed, so he could eat from a tray on his lap.

“Every time I’d go to see him,” recalled his mother Robin Trainer, “someone would pass by me and say, ‘They’ve got him in that damn chair again!” During their 15-minute visits, her son would tell her he sometimes had to beg in order to use the bathroom. As the weeks passed, Black found even the most simple tasks frustrating. “You sit there and you can’t scratch your nose,” he said. “I’d try to turn and use my shoulder to scratch it.”

His friend Breanna Dyer, with whom he was arrested, could hear him from the other end of the jail: “I’d hear him screaming, ‘Get me out of this damn chair!’”

Sometimes Key, the trustee, would sneak him Kool-Aid and coffee. She was held from June 2014 until March 2015, after violating her probation for an earlier theft charge, and she remembers Black asking her whether it was day or night, since he could not see a window. She would also pass messages to Amy Black, his wife, who was also held in the jail.

Black’s wife described being placed in the chair herself on at least a dozen occasions, while in and out of jail for probation violations and failures to pay child support. (She said she couldn’t afford to make payments because she was locked up for so long.) A lot of detainees are addicted to drugs, she said, “and they would let people have seizures and puke all over themselves.”

In other jails, people have died in the device from aspirating on their own vomit.

Many of those who corroborated Black’s account in interviews with The Marshall Project also said the chair was used frequently on people who didn’t pose an imminent physical threat. “They couldn’t handle peoples’ mouthing. If you cussed one time they’d put you in the chair,” said Monica Harris, who served time for failing to appear in court after an arrest for driving without a license.

Black said he does not know why the sheriff’s staff finally let him out of the chair after 28 days. He did not attempt suicide again and was released in early 2015 when his charges were dismissed. Later that year, he was arrested again for drug possession and was convicted and sent to prison, where he remains.

After the five days Albert Okal says he spent in the chair, others held at the jail said the staff used a wheelchair to get him to a cellblock, where they told a group of detainees to clean him up. “He was soaked in his own urine and feces,” Jeremy Sykes, who was facing assault charges at the time, wrote in a message from state prison.

Detainees helped Okal shower and gave him a bunk and clothes, Sykes said. For several days the group fed him and gave him water until he could walk on his own, with no help from staff. “They did the best they could to take great care of Albert,” he said.

Okal’s lawyer, Steve Walsh, declined to make him available for an interview due to the pending litigation. Walsh said that lawsuits like Okal’s—and the threat of future lawsuits—often force jails to change their practices. “It could be a condition of settlement to do something about this chair,” he said. “Maybe dismantle it and put it in the junk pile.”

Christie Thompson contributed reporting.