Long before we make our entrance into the world we can feel; the tactile sense is our first sensory experience. We shift our barely formed bodies away from uncomfortable stimuli in a self-protective, reflexive manner. We are programmed to survive. From our first weeks and months of gestation, within the safe environment of the uterus we prepare for a world filled with the unknown and the unexpected and we have to be able to endure all of the forces that will impact us throughout infancy, childhood, adolescence adulthood and old age.

But we do not learn all of the strategies to continue the healthy development of our minds, our bodies and our spirits alone. In order to thrive we require consistent, nurturing attention, we need not only to feel but to be felt, stimulated, attuned to. Our brain, body and spirits are shaped by nature and by our interaction with the people who take our care in their hands .When the care is “good enough” we thrive. When we are completely abandoned, we do not survive. When we are mistreated, neglected, deprived our development takes a myriad of deviant courses and almost always leads to emotional, social and physical pathology. Some of the pathology is self-protective though immature and dysfunctional. Aggression in a violent environment can make one the leader of a gang instead of their victim, alcohol can temporarily soothe and numb an anxious soul; amphetamines propel the mood out of depression. The downward spiral, however, inevitably leads to a desolate cycle of homelessness, locked psychiatric units medical illnesses and to jail where this narrative begins.

I think about a healthy early infancy, about reaching out and being gently held and about the attachment bond that nourishes the mind, body and spirit as I watch the inmate sitting at the table in SuperMax, where the inmates are in isolation due to their high profile status or history of repeated violence inside the jail. It is unnaturally and painfully quiet here, there are no human voices and every sound echoes. John (not his real name) plays with a pencil in his hand, tapping it on the table, grasping it tightly in his fingers, carefully stripping the paper from around its graphite core. This inmate is very muscular with tattoos on his upper arms. He is clean and his jail garb fits him like a second skin. John is expressionless and there is a rigid, defensive tone to his body that telegraphs “keep away I can be dangerous.” I will not touch him and he will not reach out to me.

He is a 3rd strike inmate, sentenced to 25 years to life, housed in SuperMax jail while he awaits his last appeal. He has been brought down from State Prison and is also on “suicide watch” having overdosed twice on pills that he confiscated from another inmate. John has not been diagnosed or treated in the jail system for mental illness, I am here because he wanted to talk to a “psych” about his case, and he believes that this interview will convince the judge to lighten his sentence. He is not here for therapy. John’s rap sheet reads like a dictionary for the correctional system; it lists every conceivable felony from the adulthood on and I am sure that his juvenile record is just as bad. Although I can predict what his early childhood experiences were he surprises me when I ask about his mother.

‘She was a saint” he says, still not displaying any emotion. He goes on to explain that his mother, a young, single immigrant, worked 12 hour shifts in a factory in order to stay off welfare and that he was cared for by an older cousin who had 4 children of her own. I know that memories of that long ago difficult time will be hard for him to talk about and I am surprised again when he states that he was the whipping boy for his male and female cousins and, until he gained in size and strength, he endured daily abuse at their hands. They referred to him as a bastard, took his food and tormented him at night. He smiles as he says this, a smile that doesn’t reach his eyes. But his hands betray him; he is white knuckled as he grips the pencil making holes in the flimsy table we sit at. I realize that his hands have felt the cold steel of guns, they have been wrapped around the pulsing neck of an inmate he tried to strangle in prison, they have been soaked in warn, sticky blood. When I ask him why he wanted to talk to me he says that he is “depressed” and wants to be court ordered to a mental health treatment facility where he can get help instead of going back to prison. He thinks that my documentation will facilitate this.

John has no conventional way to express his depressed feelings and in this environment he would be at risk if he did; he radiates anger and bitterness, he blames the “system” for his transgressions, he smiles when he talks about abuse and the only evidence I have for his depression is his suicide attempts and his story. I believe that he is depressed and protecting himself from ridicule and abuse by hiding his feelings. I listen and take notes; he left school in the 7th grade, was conscripted into a gang in South Central Los Angeles, he has never married or had a lasting relationship, he has used drugs and prefers alcohol. He never knew his father but heard that he died in prison. Mother is also deceased; she had diabetes that was never treated. He shows me an old picture of his mother; yellowed and creased and kept close to his heart in his shirt pocket. Finally, I see a glimpse of sorrow on his face but he quickly hides the sadness behind a sly smile and asks me if I think that he needs medication for his depression. In a parting statement, John’s feelings finally surface. He tells me that he was in prison throughout his mother’s illness and when she died. He doesn’t know where she is buried and wasn’t at her bedside to hold her hand. His face becomes contorted and he seems to hold his breath for a moment before shaking the feeling off and standing up to go. The loss of an idealized relationship with his mother and the guilt that he feels are palpable but this leaves him exposed and vulnerable and he quickly resumes his rigid and impenetrable persona.

John has a protective shield around him and has learned not to share his pain, his rage, and his fears. He is a survivor of sorts, emotionally abandoned and stunted, relying on physical strength and street smarts. When the interview is over, the pencil is stuck in a hole, stripped of its cover and John shuffles back to his cell with a deputy.

In my report I eschew the inadequate form that psychologist are given and write my own evaluation. My assessment concludes that John is extremely depressed and unable to verbalize his feelings, he is at high risk for self harm given his prior attempts and he urgently needs mental health treatment. This will, I know, complicate the prosecution’s goal of quickly sentencing him to life in prison without treatment but I take the chance, the opportunity to meet needs that have never been addressed.

There is abundant research that links early childhood abandonment, emotional and physical abuse and neglect to long term pathology across multiple domains (social, emotional, medical). In the U.S 1 in 6 state male inmates reported being physically or sexually abused before age 18 and 56% of male inmates reported experiencing physical trauma in childhood. Traumatic and abusive experiences continue in jail and prison with no relief from the consequent symptoms of depression, anxiety, PTSD and fear.

There is little attention paid to the reality that incarceration is in itself an abandonment experience and a traumatic separation from one’s habitual environment. The correctional system has its own destructive culture that categorizes all inmates as “guilty” and all mentally ill inmates as “malingerers and dings” and this imposes another layer of abuse upon the inmates who have been victimized, re-victimized

The jail mirrors and escalates the life experiences of the traumatized child who has been harmed in multiple ways. In Los Angeles, the correctional system has historically punished, neglected and allowed harm to come to mentally ill incarcerated individuals. There have been and still are on going Federal Investigations and law suits and a very recent statement by the Department of Justice that the mental health system in the Los Angeles Jails system is so bad that it is “unconstitutional.”

One in six jail inmates receive any kind of mental health treatment even though more than half of jail inmates have mental health conditions. (Journal of the American Academy of Psychiatry Law) Treatment for the mentally ill inmate is another cause for concern. The use of medication has increased by 200% from 2009-2012 and “chemical restraints” are recommended for inmates who are “out of control” due to delusions and hallucinations. Deaths have occurred when inmates have underlying medical conditions and are over-medicated for restraint purposes. There is mental health treatment, now, in the correctional system and aside from medication, this is the group therapy modality and it is often court mandated.

Several issues arise from the predominant use of the group modality; research has demonstrated that it does not allow for or encourage the sharing of powerful and private feelings of depression, shame and fear especially in an inmate group. Studies have also indicated that group therapy uses the shame model to induce feelings of shame so that behavioral changes will take place. Re-shaming after multiple childhood experiences with shame is not a positive motivating intervention.

Treatment for PTSD the most common result of enduring childhood trauma continues to be tested and studied across multiple populations; veterans, children, etc. The symptoms of PTSD; dissociation, somatization, affect dysregulation are complex issues for clinicians to treat and a very recent study on the effects of exposure-based cognitive behavioral therapy noted no improvement in depression, general anxiety or physical symptoms (Journal of Anxiety Disorders). Treatment for PTSD will prove to be a costly endeavor for the correctional system to bear.

A recent article in Journal of Psychiatry and Law exposes the following realities “lack of qualified health care professionals to work in prisons, lack of visionary correctional leadership, increasing health care costs” all contribute to the on-going dilemma of mental health in the correctional system.

In addition, public sentiment about the mentally ill and mentally ill inmates is a chronic challenge for any improvement. Although communities across the country, when polled, show some positive changes in their views on mental illness in general, the public consensus remains negative and these populations are deemed less deserving of any form of assistance.

Mentally ill inmates who have a history of abandonment and abuse are voiceless victims in a system that embraces punishment, induces shame, promotes isolation and discourages any expression of depressed or anxious feelings. In order for these individuals to speak freely, they must be able to trust and that is the underlying message.