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Two weeks ago, Sherri Foster tried to hang herself. Again. At 34, the former toy-store clerk has attempted suicide so many times that even her mother, Shirley Weber, an account manager at Gerber Advertising, has given up counting. This time, guards found Foster on Jan. 18, hanging in her cell at Oregon Women's Correctional Center. Officially, the mother of two is in prison for attempted assault. But Weber says her daughter's real crime is being mentally ill. Foster suffers from borderline personality disorder. It's one of the most widely studied diseases in psychiatry, but one that modern medicine has yet to conquer. Mental health experts say long-term therapy is the only answer, but many avoid dealing with the disorder, both because treatment is often unsuccessful and because the patients are so volatile. Borderlines, as they are called, have uncontrollable urges to hurt themselves (one in 10 eventually takes her own life), yet the state is loath to put them in psychiatric hospitals.
"It's a dilemma," says Bill Toomey, who oversees the commitment of mentally ill Multnomah County residents to hospitals. "It's very hard for this population. Should they be barred from treatment? No. They have just as much right and perhaps more need than a lot of people. What I'm saying is, it's not available right now." As a result, the estimated 62,000 Oregonians and 5.2 million Americans who suffer from the devastating illness are left with few places to turn, each one a living testament to the limitations of mental health treatment. In cases like Foster's, the corrections system is forced to pick up the slack. Currently, about 13 percent of the state prison population has been diagnosed with a mental illness; that number has grown slowly but steadily as the state has downsized psychiatric hospitals. Although borderlines don't make up the majority of mentally ill prisoners, they present some of the most confounding problems, as Foster's case shows. For the better part of seven months, while Foster was awaiting trial, she sat alone a jail cell for 23 hours a day with no reading or writing materials, no bedding and nothing to wear but an unrippable "suicide smock." "A [guard] would walk by every 15 minutes to see if she was still alive," says Greg Scholl, her public defender. "That's about it." For a woman with an illness characterized by a tremendous fear of abandonment, the ordeal was unimaginable. As Foster's brother, Scott Weber, sees it, his sister is not only a prisoner of the state, but of her own disease, as well. "My sister was marginalized by this borderline personality disorder diagnosis to the point where the only place for her to go was prison," he says. "It really does seem to me she's being punished for being desperately suicidal." That's not even the most distressing part of the story. Sad as it sounds, given the nature of Foster's illness and the way the state structures its mental health services, prison may be the place where Foster has the best chance of reaching her 35th birthday. Sherri Foster's history reads like a cookbook for psychiatric calamity. It starts even before Foster's birth, when her father had a serious breakdown and checked himself into Dammasch State Hospital. He recovered enough to go back to work, but still suffers from psychiatric problems. He is said to have molested Foster at some point in her life, although it's unclear to what degree. While Foster has told counselors she was victimized repeatedly between ages 5 and 15, her brother believes there were only a handful of incidents. As soon as Shirley Weber found out about the abuse, she yanked her children from the home and filed for divorce. In high school, her brother says, Foster was victimized again; a teacher raped her. Scott Weber, who is raising Foster's grammar-school-aged daughter (Shirley Weber has custody of Foster's adolescent son), says his younger sister was bright but never confident in her intellectual abilities. Instead, she found other outlets for her energy, focusing on extracurricular activities such as ice skating, basketball and school clubs. Although gregarious, Foster had a difficult time making friends. By the time she was a young teen, her mother knew something was wrong. "She would be so intense about what other people would think of her," Shirley Weber says. "Her own self-confidence was in question." Before graduating from Wilson High School in 1981, she fell into a tumultuous relationship with Ken Foster, who had his own serious troubles. Their 10-year marriage careened from passionate to destructive and back again. According to psychiatric records, it was a sort of marital duel in which suicide threats were used as sabers to cut each other down. "It appeared that an affinity between my sister and Ken was their woundedness," Scott Weber says. They divorced in 1992. Two years later, Ken finally followed through on his threats. On Oct. 15, 1994, he killed himself by drinking charcoal lighter fluid. "That seemed to push her over the brink," Shirley Weber says. "At that time, she started declining. The decline was rather steady and continuous. She's continuing to worsen." After Ken's death, Foster was having uncontrollable violent and suicidal thoughts more and more frequently. "It would be a month or two between episodes," Weber says, "then it was weeks and finally it would be a matter of days." The episodes led to numerous, but brief, hospitalizations. She was admitted several times after cutting her wrists or overdosing on prescription drugs. By then, she had tried group homes, day treatment centers and many different medications, but could find no relief. A victim of sexual abuse and a survivor of suicide, Foster could take only so much more. Then, in 1996, a counselor branded her with three words that would define the nature of her treatment from then on: borderline personality disorder. Only later did Weber realize how much this label would change her daughter's life. The disorder--the symptoms, its stigmatization among mental health workers and the state's inability to provide proper treatment for it--is exactly what put Sherri Foster behind bars. "Suddenly, the people weren't there for her, the facilities weren't there for her, she couldn't get into Oregon State Hospital," Weber says. "The doors were shut fast." Foster's family pinpoints the incidents of March 8 as an example of how the diagnosis itself left her with nowhere to turn. On that day, Foster was fighting a raging mental battle: One side screamed for suicide and the other cried for help. Foster's plan was to check into a hospital emergency room, where she could be sedated and treated. Otherwise, she was sure she would take her own life. What Foster didn't realize was that a new therapist, Aart Lovenstein, had sent several area hospitals a "client alert." Lovenstein, a counselor with Mental Health Services West, urged the hospitals to admit Foster "only if medically necessary"--for example, if she was bleeding severely--but not if she was threatening suicide. "Please note hospitalization does not prevent suicide but increases power struggle," he wrote, making a a common argument against hospitalizing borderlines. That winter day, four different hospitals turned Foster away before she tried an old trick, something that had worked at least once before: At 3 am, she showed up at Providence St. Vincent Medical Center brandishing a kitchen knife. No one was hurt, but three employees were shaken by the incident. "I meant no harm," she later told a psychologist. "All I really wanted was for the guards to stop me and lock me up in their hospital." Instead of getting treatment, Foster wound up in Washington County jail. She spent the better part of last year in her cell awaiting trial; for much of that time, she was in grueling isolation on a suicide watch. "They weren't a mental hospital, they couldn't handle her," Weber says. "Now we've compounded her problems. I don't know how you'd go through that and not come out affected in some way." The lynch pin of modern psychiatry can be summed up in one word: drugs. No longer limited to talking cures, electroshock therapy or lobotomies, as they were a few decades ago, modern psychiatrists have new weapons in their black bags. They can soothe the schizophrenic with Zyprexa, even out the rough edges of the bipolar with Tegretol and enliven the depressed with Prozac. But mind-altering medications work best when the illnesses are caused by problems with the brain's chemicals. Unfortunately, although some experts believe there is a biological component to borderline personality disorder, it is not well understood. As a result, in the midst of astonishing psychiatric miracles, modern science has yet to develop the magic borderline personality disorder pill. Medications are still used, with varying degrees of success, to treat the symptoms. Instead of a biological problem, borderline personality disorder is more of a mixed-up way of dealing with the world that a person learns in her childhood and develops over many years. Three-quarters of those diagnosed with the disorder are women, and many are also victims of sexual abuse, leading some to speculate that the experiences are linked. Borderlines generally don't have the symptoms we think of as typical of mental illness--the hallucinations, the "multiple personalities," the tendency to hear voices. Instead, the main features of the illness are a longstanding pattern of impulsive behavior, an intense fear of abandonment and sudden and dramatic shifts in self-image. "These individuals may suddenly change from the role of a needy supplicant for help to a righteous avenger of past mistreatment," according to the DSM-IV, the bible of psychiatric diagnoses. Therapists label borderlines as manipulative, needy and incredibly sensitive to any perceived rejection. Often they seem to have almost no control over their own behavior and exist in a devastating stew of self-loathing, rage and fear. "At its extreme, they cannot pull themselves together," explains Dr. Lyn Blackshaw, a psychologist who works for the state. "It's a terror, it's a horror. It's just like death being there a couple inches away." The most frightening aspect of the disease is the patients' uncontrollable urge to hurt themselves. It's not unusual for a person suffering from borderline personality disorder to attempt suicide a dozen or more times. "Sometimes they make manipulative suicidal attempts to overcome the feelings of emptiness and aloneness," says Gregory Hamilton, a Portland psychiatrist who has written two books related to the subject. "Other times they make attempts to end their suffering, to kill themselves. Other times, they make attempts in order to get revenge on the world because it's such a hard place." In spite of the disorder, most sufferers are able to function relatively normally in society as long as nothing interrupts their regular routine. Sherri Foster, for example, managed to keep her job as a clerk at Toys 'R' Us near Washington Square for 13 years, although she cut back her hours when her symptoms flared up. Nonetheless, successful treatment has proven elusive. "Truly, we're stumped as far as how best to treat a person with serious borderline personality disorder," says Bob Nikkel, deputy assistant administrator of the state Office of Mental Health Services. In 1992, the state sought an answer by opening a special unit for the most intractable cases at Dammasch State Hospital and giving them intensive long-term treatment. "The people who worked on that ward deserved medals," says Eugene Minard, a retired staff psychiatrist at Dammasch. "So many of the patients were eating broken glass, putting bags over their heads, cutting on themselves." It only took three years and about 50 patients before mental health workers admitted defeat and closed Ward L, as it was called. At that point, a state task force had concluded that long-term hospitalization didn't help the patients--and may have even hurt them by increasing their dependence on others. Not everyone supports the decision to close the ward. Some suspect that the conclusion, made as the state was trying desperately to close Dammasch, was fueled more by budgetary concerns than by sound psychiatric practice. "It isn't the way you would want to treat all borderline patients, but it provided a safety valve for the legal system, for the mental health system and for the patients," Hamilton says. "In-patient treatment can be beneficial for borderline patients. It's documented in the literature. Perhaps the state chose not to read that literature." The closure left seriously ill people like Foster almost nowhere to turn. In the past three years, the state hospital has served just seven people whose primary diagnosis is borderline personality disorder. The rest find treatment as they can in a hodgepodge of community services, only a handful of which are specifically geared toward this particular illness. Now, state mental health workers say the best hope is long-term outpatient therapy, which involves developing tools for managing extreme emotions. The problem, however, is that people with borderline personality disorder often can't control their behavior, so they don't make much progress. And many therapists don't like to take on borderline personality disorder clients because they're so volatile and frustrating. Some jokingly call the disorder the "pain in the ass diagnosis." In the social-service world, the term has taken on a pejorative, non-clinical meaning: A particularly obnoxious or manipulative client may be referred to as "borderline." In Foster's case, her family says, the label was used against her. Her disruptive behavior didn't help matters, either. Several mental health providers told her she couldn't join their programs. "Sherri's kind of burned people out," her mother says. Foster's arrest didn't stop her suicidal thoughts. She tried to end her life several times while sitting in a Washington County jail cell waiting for her case to be adjudicated. Once she attempted to drown herself in the sink. By August, jail personnel were so worried about Foster's safety that they tried to get her committed, if only temporarily, to a local hospital psychiatric ward where she could be stabilized. "I knew commitment wasn't going to solve her criminal case," says Scholl, Foster's public defender, "but they would put her in the hospital for a little while, which might be better than jail." As Scholl soon found out, though, short-term hospitalization by commitment--the state's main technique for dealing with most mentally ill people in crisis--is not a simple achievement for someone with borderline personality disorder. According to Nikkel, some judges, particularly in the Portland area, are reluctant to commit borderlines. The thinking goes something like this: Hospitalization doesn't stop borderline patients from trying to kill themselves once they're discharged; therefore the suicidal patient should not be hospitalized--even if there's no other treatment available. On Aug. 7, Circuit Court Judge Gregory E. Milnes decided against commitment. Instead of the hospital, Foster was sent back to jail, where the suicide watch
continued. "I was dumbfounded," Scholl says. "I've had lots of clients that got committed on much less egregious facts than these." Scholl was worried. Because his client was charged with attempted murder--a charge Scholl says was outrageous--she was facing a mandatory minimum sentence of 71?2 years in prison. He decided to look into the insanity defense, a much-talked-about but rarely used legal strategy. If the defense were successful, Foster would be placed under the jurisdiction of the Psychiatric Security Review Board and committed at least temporarily to Oregon State Hospital for treatment. After that, the board would keep close tabs on Foster and help her find and stay in appropriate outpatient programs. Again, however, Scholl was stymied by Foster's diagnosis. Personality disorders, he discovered, are specifically excluded from the state's insanity defense statutes. "Oregon State Hospital is where she belongs," Scholl says, "but there's no way to get her there." With the insanity defense ruled out, Scholl knew Foster was in trouble. He couldn't risk trial because of the long mandatory sentence. And Deputy District Attorney Christopher Quinn had been unwilling to offer a plea bargain. In November, Quinn finally relented. If Scholl could get Foster into a highly supervised group home, the DA said, he might agree to reduce the charges. Because she'd been so difficult in the past, Foster had only one choice: She could live in the county's new, state-of-the-art community corrections center, where she would receive intensive supervision and some treatment. In exchange, the DA would reduce the charge to Attempted Assault 1, which does not carry a mandatory minimum prison sentence. After two days in the center, Foster was back in jail. She had attempted suicide twice, violating the terms of her probation. On
Nov. 24, Circuit Court Judge Gayle Nachtigal said she had no choice but to send Foster to prison on a 17-month sentence. Now, even the prosecutor who put her behind bars can't help but think that something is wrong. "In my view, there just weren't any options left," says Quinn. "I wish there were." Sherri Foster is far from the only person with borderline personality disorder who has a disturbing story. Several similar cases have made headlines recently. In April, a woman named Emily Comeaux shot and killed herself in the lobby of Providence Portland Medical Center after being refused the treatment she demanded. (A state report says the hospital did nothing wrong.) In September 1996, a Kaiser nurse suffering from the disorder said she killed a patient by injecting air into her IV line. Investigators could find no evidence of a crime--the statements may have been calculated to manipulate and gain attention--but the nurse lost her license and her job and caused the deceased's family untold grief. A few decades ago, women like Sherri Foster could have checked themselves into Dammasch State Hospital, like Foster's father did. It's debatable whether that would have helped her illness, but at least she wouldn't be in the situation she's in now--in prison, where treatment is limited. It's tempting to look for someone to blame: the counselor who told hospitals not to admit Foster, the DA who prosecuted her, the mental health system that failed to treat her. But it's not that simple. Though it might make us feel good to point fingers, there are no clearcut solutions in dealing with borderline personality disorder. Recently, the state has begun to think about the problem. Attorney General Hardy Myers has appointed a task force to look at civil commitment laws. Some members hope to make it easier to hospitalize mentally ill people, including those with borderline personality disorder. In addition, the task force that decided to close Dammasch's Ward L will reconvene to examine the current treatment options for borderlines. Finally, researchers are working to develop better medications to treat these difficult patients. Until then, the picture is depressing. Given the choices available to people with borderline personality disorder and the severity of Foster's case, it's tough to see how to prevent her from taking her own life outside of a prison setting. "If they release her, there's no way she can cope," says Shirley Weber. "The whole thing is going to repeat itself. Either she's not going to be with us--she'll succeed in killing herself--of she'll be right back in the penal system." That may be the only place where she can survive. |
