Stephen Seager knows he could lose his job, but he doesn’t care. He didn’t ask his employer’s permission to write Behind the Gates of Gomorrah, an account of the rampant and unchecked violence that Seager says he’s both witnessed and experienced as a psychiatrist at California’s Napa State Hospital. The forensic facility, the second-largest in the country, houses “the school shooters, the James Holmeses, and Jeffrey Dahmers of the world,” as Seager puts it. Nor did he warn the hospital that the book is being published this week.

“I want their honest response,” he told me over the phone from his home in northwest California. “We’re getting the shit kicked out of us and no one cares. Not just the staff, the patients. And they can’t leave at the end of the day—they have to live there. If this stops one of them from getting beaten, it was all worth it.”

In his book, Seager describes his first year at one of Napa State Hospital’s high-risk units: a fenced-in “secure treatment area,” reminiscent on the outside of a “sprawling prisoner-of-war-camp in a World War II movie,” and on the inside of the fictional Baltimore State hospital depicted in The Silence of the Lambs. Of the approximately 12,000 patients living at Napa State—the majority of them rapists, killers, and mass murderers who have been deemed by a judge not guilty by reason of insanity or unfit to stand trial—it’s the real “bad actors” who are housed in the secure treatment area. Despite being assured at orientation that new hires wouldn’t be assigned “inside the fence,” Seager is thrown directly into one of these high-risk units, and quickly learns that the use of the word “secure” to describe this treatment area is little more than hyperbole.

From the moment Seager enters the unit, he is surrounded by violence. He ends his first day in the emergency room with 10 stitches in the back of his head, after getting caught in the crossfire when a raging patient clobbers another patient over the head with a chair.

The entire next year is filled with incidents like these. The rare calm days bring a mix of relief and anxiety over when the next explosion will occur. Seager writes about being threatened by a patient with a shank carved out of an eyeglass stem. Nurses and doctors are injured on a regular basis while trying to break up patient fights. A Halloween dance at the hospital is considered a success because “no one got punched or stabbed.” The man who got hit with a chair on Seager’s first day eventually dies, while the man who hit him never faced consequences.

“When I originally sold the book I actually had to tone the violence down,” Seager told me, explaining that the only real name used in the book is his and that the details of the stories he uses are slightly altered to protect his patients’ privacy. “It’s worse than I made it out in the book. I have half of my nurses out on disability at any one time. Almost all of the doctors have been assaulted at one time or another, usually when you have your guard down.”

Three and a half years after Seager first started at Napa State, he’s still working in the same unit. Though he says he is scared every day—making sure to steer clear of big crowds like the cafeteria line, and avoiding eye contact in the hallway—he is committed to helping the patients he’s been tasked with treating. Which, he says, is exactly why he wrote this book.

“Actually, some of these people do get better. The problem is that if they get beat up while they’re getting better, that really sets them back,” Seager said. “If we could just make the place safer we could make them better and send them on their way.”

Napa State Hospital was originally built in 1875 and, like the five other facilities in California’s state hospital system, served as a traditional psychiatric hospital until it started taking court referrals in 1990s. Today, about 90 percent of the patient population is funneled into these hospitals through the criminal justice system. But despite being filled with perpetrators of violent, often heinous crimes, facilities like Napa State are still hospitals, not prisons. Their patients are committed, but not locked up. There are police officers at hospital entrances, and others stationed nearby on call to respond quickly to staffers’ wearable alarms when a fight breaks out. But uniformed guards do not patrol the halls of even the highest-risk units. So the most violent patients are left to terrorize the others freely, with only doctors and nurses to stop them.

Though employees had long petitioned for more security at Napa State, the issue of patient violence really came to a head, at least publicly, in 2010 when a Napa State psychiatric technician named Donna Gross was strangled to death by a patient on hospital grounds. Gross’s death sparked outrage from her colleagues and prompted a number of studies and investigations into the conditions at Napa State and other state forensic psychiatric hospitals.

A 2011 report by SEIU1000, the California arm of Service Employees International Union, (PDF) found that “mental health workers became crime victims on the job at a rate 5.5 times higher than the general population of workers,” and that patient-on-staff violence has increased significantly as the ratio of patients from the penal system has grown. An investigation into Gross’ death by the California Fatality Assessment and Control Evaluation program (PDF) concluded that state forensic psychiatric facilities needed to develop a violence injury prevention program that would include assigning hospital police or security personnel to monitor patients for aggressive behavior, requiring that individual employees be accompanied by security or co-workers when walking through unsecured areas, and ensuring that personal alarms worn by employees are functional throughout the whole facility.

In an emailed statement to The Daily Beast, a spokesperson for the California Department of State Hospitals noted the changes that were implemented in the wake of Gross’ murder, including the creation of the Safety Now Coalition, an employee group that meets with the hospital’s executive director once a month to discuss safety concerns, and the implementation of a Personal Duress Alarm System, a wireless device worn by all staff members that yields quick response from hospital police.

But, according to the Los Angeles Times, Napa State still reported about 3,000 assaults on patients and staff in 2012, the year following the funding increase and changes prompted by Gross’ murder.

“Imagine at Microsoft if there were 1,000 employees and 3,000 assaults a year. What would CNN’s response be? The governor’s response. They deny it,” Seager said. “People are getting punched, kicked, teeth knocked out. There are five-star restaurants in Napa where you can hear the alarms.”

As recently as May, two Napa State employees were allegedly assaulted by patients on separate occasions within a few days of each other.

Seager emphasizes that 90 percent of the problems at Napa State are caused by 15 to 20 percent of the patients. Another Napa State doctor, who spoke to The Daily Beast on the condition of anonymity, agrees. That’s why, in addition to employing guards, both doctors argue that a large number of assaults could best be prevented by separating the most violent, unstable, and perpetually aggressive patients from the general population. Awaiting a signature from California Governor Jerry Brown is a bill for a program that would do just that.

The “enhanced treatment” pilot program outlined in Assembly Bill 1340 proposes the creation of a separate wing at Napa State and four other state psychiatric hospitals, with individual rooms that can only be locked from the outside, to house patients who have proven themselves prone to violence. Patients placed in “enhanced treatment” would be evaluated every three months until a clinician deemed them ready to rejoin the rest of the patients. Though the bill’s sponsors argue that enhanced treatment is necessary to making facilities like Napa State safer for their residents and employees, opponents including the American Civil Liberties Union question whether such a program infringes on patients’ civil rights.

“We have to be humane and we care about our patients but we are also not a prison,” the anonymous doctor said. “We have to wait until something happens, even though we know it’s going to happen. We’re sort of sitting ducks.”

Seager hopes his book might help change that. In the meantime, he is still going to work every day, attempting to build meaningful relationships with patients he knows could seriously hurt him at any moment.

“I’ve really gotten to be friends with a lot of these people. All of my friends at work are murderers or rapists,” he said with a chuckle. “You have to laugh or you’ll go insane.”

From Behind The Gates of Gomorrah:

As I stepped into the main building that housed Unit C, an earsplitting siren blared suddenly and a dozen strobes flashed. From doorways that lined a long corridor, people emerged at a run and began searching frantically. Some shouted. “Is everybody okay?” a large man yelled.

“Check the dining hall,” a young woman exclaimed, waving to her left, and a dozen persons surged in that direction. And still the siren wailed and lights flashed.

I stood paralyzed. To my right a casually dressed, fortyish woman with short brown hair glanced at me. She fingered my ID badge.

“Are you the new doctor?” she shouted above the din.

I nodded. She reached around my hip and flipped up the depressed red button on my individual alarm. The pandemonium ceased.

“False alarm,” she called out. The throng took a collective breath before retreating back behind their office doors.

“Happens to everyone,” the woman said, and locked the main door. “Always check the red button when you get your keys. And,” she added, bending down to scoop up said keys from the floor where I’d apparently flung them, “don’t lose these. That would really be trouble.”

“It won’t happen again,” I said. “Sorry.”

“I’m Kate Henry, the Unit C manager,” she said, and smiled. “Welcome to Napa State.”

I stood for a moment in the empty hallway. From just outside the main door a distinct “ha-ha-ha” echoed up and down the concourse.

It took a second to realize the sound was a peacock.

The door to Unit C was made of reinforced steel and had a small double-paned window. Inserting my key into the lock, I had just cracked the door open when a face appeared in the window.

The wild-eyed young man had hopelessly tangled hair and wore rumpled baby-blue scrubs. He gestured frantically. “This is 88.5 National Public Radio,” he said in a spot-on announcer’s voice.

“Donate to our pledge drive. Don’t listen for free, that’s stealing. Now here’s Ofeibea Quist-Arcton.” He spun three times, stopped on a dime, and flashed the familiar “jazz hands” pose before walking away.

I regained my composure and stepped fully inside the crowded hallway. A wooden chair whizzed past my left ear and smashed into the steel door like a gunshot.

Eyes red and prison muscles bulging, a tattooed white man behind me jumped to his feet from a crouch and swatted me aside.

The back of my head smacked into the wall. Lights blinked. Something wet trickled down my neck.

He snatched up the thrown chair and crashed it down onto the head of a charging older black man, who crumpled into a heap.

“Don’t ever fuck with me, old man!” the giant hissed, slinging the chair at the inert body. “You owe. You pay.” He backed away and walked down the corridor as a file of terrified patients pressed themselves against the walls.

He cut past the glass-enclosed nurses’ station, where a clutch of five women scattered with a terrified yelp as the big man slapped a hamlike hand on the window. One nurse pushed her hip alarm and the pulsing shriek rang out again.

“Never question who’s the boss here,” the man thundered above the din, and turned to glare at me. He stood barefoot, his neck covered with interlocking black tattooed swirls, the word HELL inked into his forehead.

“The voices made me do it,” he said, and theatrically clutched both sides of his head. Pivoting on his heels, he casually strolled out toward a nearby walled courtyard. “Don’t forget to make a pledge,” NPR-man said, and scuttled behind. “Safeway Corporation will match it.”

From BEHIND THE GATES OF GOMORRAH by Stephen Seager. Copyright © 2014 by Stephen Seager. Reprinted by permission of Gallery Books, a Division of Simon & Schuster, Inc.