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October 31, 2004

A Death in the Box

By MARY BETH PFEIFFER
 
By the time Jessica Lee Roger was discovered on the floor of her prison cell on Aug. 17, 2002, it was too late. In the 24 minutes since guards had last checked her, she had tied a bed sheet around her neck and, after many attempts over three years in prison, finally strangled herself. When word of Roger's suicide spread through the cellblocks of the Bedford Hills Correctional Facility that sultry weekend, two correction officers cried. Fellow inmates were angry. The superintendent, who was away for a few days, was devastated. A mentally ill young woman had died, and she had died in the most stressful and isolating place in the New York state prison system. Jessica Roger, 21, killed herself in the ''box,'' and many thought she didn't belong there. 

For more than a third of Roger's 1,200 days at the prison in Westchester County, she was, as she said in a letter to her mother, ''locked up and locked in'' as punishment for her fits of rage and resistance. For 250 days, she was confined to her cell, unable to participate in programs or communal meals. She spent another 160 days in the ''special housing unit,'' what inmates call the box. The box is the most severe punishment in prison: the final threat, the ultimate time out. It is a small barren chamber set apart from the general population with a concrete floor, a steel door and no clock to mark the time. The essential quality of the box is isolation -- a gloved hand passes food through a sllot in the door; a caseworker's muffled voice filters through the holes in a small Plexiglas window. Inmates are allowed few personal possessions. Lights are never fully extinguished. It is four walls for 23 hours a day -- a psychologically punishing experience by design. For people like Jessica Roger, it can also be an incubator of psychosis. 

Forty years ago, America's seriously mentally ill were housed in psychiatric hospitals that kept them too long and often without good cause. As those hospitals closed, a promise to provide care in communities went unfulfilled. At the same time, America's prison capacity grew; it has quadrupled since 1980. People with untreated mental illness are often poor and homeless. Many commit petty crimes, creating arrest records that often lead to harsh sentences. Today some 250,000 Americans with mental illness live in prisons, the nation's primary supplier of mental-health services. 

Mentally ill inmates do not do well in the tense and rulebound world of prison. They create scenes, lash out unpredictably and cannot or will not obey orders. Special housing units are intended for the most violent inmates, but they also tend to collect those who are troublesome and mentally ill. More than 800 of the 4,300 inmates in New York's special housing units suffer from mental illnesses like schizophrenia, major depression or personality or trauma disorders. They may talk to voices only they can hear. They may see conspiracies in simple routines. They may have little emotional control or be obsessed by inexplicable fears. For these people, prolonged confinement to a cubicle-size room is a grueling psychological test that many fail. About 6 percent of inmates in New York have been housed in the box since 1998. Yet 34 percent of suicides, 26 in all, have occurred there. 

This isn't news to prison officials, who have been sued over special housing units in at least 10 states. In California, a federal judge said that placing the seriously mentally ill in such confinement was ''the mental equivalent of putting an asthmatic in a place with little air to breathe.'' Over the years, advocates in New York have challenged conditions in the box at four state prisons. Those lawsuits resulted in incremental but largely isolated changes -- increasing the mental-health staff at one prison, providing inmate counseling at another. But the underlying problem remains: when people with mental illness end up in prison, the need to treat them collides with the need to keep prison order, and everything about the system favors the latter. 

Consider Attica, the infamous New York prison, where in 1998, after 18 years of fighting in court, officials settled a lawsuit on behalf of mentally ill inmates in its special housing unit. The prison promised to monitor inmates closely, provide better mental-health care and do a better job of training staff members. Nineteen months later, a court expert found that little had changed: the symptoms of ill and psychotic inmates were routinely written off as ''malingering.'' Men who broke down were hospitalized and inexplicably returned to the box afterward, only to break down again. Since the settlement, there have been seven suicides at Attica, among New York's highest. Frustration with this slow pace of change led advocates for mentally ill inmates to file a suit against the entire state prison system in 2002. The suit, for which witnesses are now being deposed, asserts that mentally ill inmates are punished for exhibiting symptoms of illness that the system has failed to treat. Relegated to the box, they become sicker from the ''near total lack of human contact.'' 

Roger had attempted suicide in the box at least four times before she succeeded. Once, she tied a sheet around her neck during a 100-day sentence, which was meted out after she refused orders and overturned furniture. She left a note with the outline of her hand spattered with blood: ''This is how I feel.'' She was sent to a prison psychiatric hospital for a month, where she was counseled, medicated and treated. Then, although she received a diagnosis of bipolar disorder, borderline personality disorder and other mental illnesses, Jessica was returned to complete her punishment in the small airless cell that had broken her. Within days, she again attempted suicide. 
 

Jessica Roger was a large young woman with hazel eyes and a ponytail of dark blond hair. She was needy, bright and emotionally so much a child that in the visiting room she would cling to her mother, head on her shoulder, arms wrapped around her. Born and raised in Poughkeepsie, N.Y., Roger had been in and out of mental hospitals 17 times since she was 11; she had gotten only as far as the fifth grade. 

When she was 16 years and 4 days old, just past the threshold at which children become adults under New York criminal law, Roger was arrested for the relatively minor offense of biting her sister's arm in a fight. But while in custody, the explosive teenager kicked a jail guard who was trying to refasten the handcuffs that had slipped from her wrists. She was convicted of second-degree assault of a correction officer. 

Dutchess County Court Judge George Marlow tried hard to avoid sentencing Roger to prison. He approved a plea deal to send her to an intensive program for emotionally troubled juveniles, one of few suited to her. But while she waited in the hospital for a bed to become available, she set fire to a mattress. The deal collapsed. ''When someone has a documented history of mental illness, as this defendant does,'' the judge said at her 1999 sentencing, ''there ought to be a place where there could be both isolation and treatment. That is the only humane response.'' Lacking that place, Marlow made what he called one of the most painful decisions in a 32-year career: sentencing Jessica Roger to 3 1/2 to 7 years in prison. It was her first foray into the criminal-justice system. 

New York is one of more than 30 states that operate 23-hour confinement units and prisons, sometimes called ''supermax'' facilities. Many of these were built in the 1990's in a frenzy of construction; there are now more than 20,000 inmates nationwide in these units. The resurgence of isolated confinement is often dated to the 1984 lock-down at the federal penitentiary at Marion, Ill., after rising violence led to the murder of two guards. But it was also fed by America's incarceration binge: prisons crowded with gang members, the drug-addicted and the mentally ill presented a daunting management challenge. And in an era when the rehabilitative ideal had long been waning, punitive forces took another step forward. ''The supermax,'' said Gov. Tommy Thompson of Wisconsin in 1996, ''will be a criminal's worst nightmare.'' In New York and elsewhere, there was little public debate about the effect that the units would have on the people confined there. 

Between 1998 and 2000, New York built special housing units for 3,000 inmates, almost doubling capacity in the belief that completely shutting off troublemakers would make prisons safer. Under the state's disciplinary system, rule-breaking inmates face escalating sanctions. Smoking or failing to carry an ID card, for example, could mean a loss of phone, recreation or commissary privileges. Harassing staff members or refusing an order could mean cell confinement, called ''keeplock.'' A sentence to the box was meant for the worst offenses, which is how Glenn S. Goord, commissioner of the New York State Department of Correctional Services, has defended the units. (Goord declined to be interviewed for this article, citing the pending litigation.) In a November 2000 report on prison safety, he described some of the offenses by those in the box: Anthony Burton punched and stabbed an officer with a pen; Carlos Rodriguez stabbed another inmate to death; Claudio Cuadrado cut an officer with a razor. ''The inmates confined in disciplinary housing,'' he said in a press release last fall, ''are 'the worst of the worst.''' 

But attorneys, psychiatrists and legislators who have visited New York's special housing units describe the occupants in different terms. While some are violent criminals befitting the system's most extreme form of punishment, many others are mentally disturbed people consigned to the box for lesser offenses -- creating disturbances, using drugs or failing to follow orders. In fact, in 1986 assault counted for half of sentences to the box; in 2000 just 15 percent of special-housing-unit sentences were for assault. 

Prison is an inherently dangerous place, and it is easy to understand why correction officers view the box as an irresistible tool for controlling violence. Donald E. Premo Jr. has served as a correction officer and supervisor in New York prisons for 19 years. When inmates refuse orders or start fights, whether they are mentally ill is irrelevant, he said: they are a security threat, and his job is to contain them. ''It's not so much the harm to them,'' Premo said of mentally ill inmates who are sent to the box. ''But what is the harm to the facility if they are not controlled?'' The statistics in New York do show a significant drop in staff and inmate assault, but staff attacks had been dropping before the units were built. A study of facilities in three other states found little evidence of improved safety. Still, Premo and other officers say they have no doubt that the special housing units have made prisons safer. 

Among Roger's personal papers were dozens of yellow disciplinary citations, mementos from her time at Bedford Hills: she repeatedly refused to tuck in her shirt; she tossed toilet water; she smoked cigarettes in her cell and shouted obscenities at staff members; she bit an inmate. She was 280 pounds of attitude and illness who, in one profanity-laced outburst, told an officer: ''That's what I'm in here for, hitting one of you. . . . '' Roger's second sentence of 60 days in the box was for an ''unhygienic act'' -- spitting on an officer. She made it thhrough 56 days before attempting suicide. 
 

"There's not a room she's not in,'' says Joan Roger, 46. Jessica's mother is sitting at the green Formica-top table of her three-room apartment in a downcast neighborhood of Poughkeepsie, a Hudson River city about 80 miles north of Manhattan. The white walls of the apartment are crowded with photographs. There's Jessica at 11 months clutching a teddy bear, and at 4, beaming and bright-eyed in matching short sets with her older sister, Cora. There's Jessica at 13 with her mother and grandmother. And in her mother's bedroom, a picture of Jessica in her casket, wearing a lavender Tasmanian Devil T-shirt and jeans, framed by a heart-shaped wreath of faded silk flowers. There's a visible bruise on her forehead that adds to her mother's questions. 

Wisps of hair fall from a tight knot and across Joan Roger's ruddy face. Her sweatshirt is stained and worn. She accepts blame, maybe too much, for what happened to her Jet, as she called her daughter. Driven by ''mood swings,'' Joan was verbally abusive to her daughters, she said -- ''fine one minute, the next minute I was off and running.'' Her ex-husband, Kevin Roger, 46, recalls Joan yelling awful things at the girls and once grabbing a knife from her hand that, she acknowledges, ''had his name on it.'' Joan left the girls with Kevin around the time Jessica turned 11. Jessica was shattered. 

Kevin Roger's alcohol abuse is a refrain in Jessica's letters and records. But unlike Joan, Kevin, who is suing the state prison system, does not apologize. ''I drank,'' he says. ''I still drink. It's legal.'' 

''To me,'' Jessica Roger told a psychiatrist when she was 17, ''my life has been nothing but hell.'' She spent much of her adolescence in institutions for troubled and sick children. She broke more than a dozen windows during her fits and tantrums. She first attempted suicide by overdosing on pills when she was 13. She was a regular at the local psychiatric emergency room. She might have gone on this way except that there came a point at which her behavior -- a fight with her sister -- ceased to be regarded as the acting out of a troubled adolescent and instead became a crime. This time police insisted that charges be filed, and Roger's fate was sealed. 
 

"Mommy these people are stressing me out again. They took my sheets, my blankets and my mattress out of my cell because I keep hiding under the bed and covering myself so they can't see me. . . . Mommy I really feel like hurting myself but I am afraid to tell these people because I don't want them to put me in a cold . . . cell with nothing but a thin mat and a gown. . . . Mommy the feeling of hurting myself is getting stronger. Why won't these feelings just stay out of my head forever? I can't deal with them anymore. My thoughts about hurting myself are racing now they are going faster than before.'' 

When Roger wrote to her mother in June 2001, she was serving 60 days in keeplock -- locked in her cell for all but an hour of exercise a day -- for setting fire to a book, yelling duuring the inmate count and other offenses. These forays into solitude were intended, a hearing officer told her, as ''an understood deterrence to future similar behavior.'' But like many ill inmates, Roger seemed inured to punishment. In a county jail, she was so uncontrollable that a stun device was used on her more than once. Another time, jail officers stripped her of her jumpsuit and bra, after she refused to do it herself, and put her in a suicide-proof gown. ''Do whatever you want to me,'' she impassively told a jail officer in 1998. 

Inmates like Roger are at the heart of a societal debate -- played out mostly in courts, academic publications and the reports of reform organizations -- over whether seriously mentally ill peeople belong in isolated confinement. But it's a question that is debated in prisons too, with lines sometimes drawn in unexpected ways. The Department of Correctional Services runs New York's prisons, but clinical care of the mentally ill is left to the Office of Mental Health. Bedford Hills Superintendent Elaine Lord, who retired in March, was known as an advocate for mentally ill inmates for whom harsh punishment in the box could be destructive and lead to a spiral of misbehavior. Lord, who declined to be interviewed for this article, sometimes clashed with mental-health clinicians, who advocated punishment to curb what they saw as inmate ''malingering'' or ''manipulating'' -- feigning or using illness, usually to get out of disciplinary sanctions. 

It is a classic tug of war in an overburdened system in which the corrections side is supposed to take the ''bad'' inmates and the mental-health side is supposed to take the ''mad'' -- and where both sides have limited resources, arguments ensue as to who belongs where. In a deposition taken for the lawsuit against the state, the superintendent summed up a school of thought with which she agreed. ''We need to stop arguing about whether people are mad or bad,'' testified Lord, who cried at the inquiry into Roger's death, ''and design some effective interventions.'' 

Roger's borderline personality disorder marked her as willful, manipulative and, incorrectly, all but untreatable. In her time at Bedford Hills, she was sentenced to 16 terms in disciplinary confinement, mostly in keeplock, on 46 separate charges. She had two sentences to the box totaling about five months. She was luckier than others in New York. Inmates who are mentally ill spend on average about three years in special housing units, according to a Correctional Association of New York survey. They get caught in a vortex of worsening illness and behavior that leads to ever more punishment. 

The debate over the effects of isolation on even a normal human psyche is longstanding. In 1821, the New York Legislature directed its prison at Auburn to conduct an experiment: put 80 of its worst offenders into what a group promoting the idea described as ''complete solitary confinement, free from all employment, all amusement, all pleasant objects of external contemplation.'' The inmates soon became suicidal and psychotic. One leapt from a gallery when his door opened; another beat his head against the walls of his cell. The experiment was abandoned within two years. ''A degree of mental anguish and distress may be necessary to humble and reform the offender,'' the warden, Gershom Powers, wrote, ''but, carry it too far, and he will become either a savage in his temper and feelings, or he will sink in despair.'' 

Modern research on prisoners of war; immobilized spinal-injury patients; solo, long-flight pilots; Antarctic dwellers and prison inmates has shown the human mind vulnerable to unraveling during periods of isolation and sensory deprivation. In 1979, Stuart Grassian, a Harvard Medical School psychiatrist, was asked to assess 14 inmates who were housed in the small, windowless cells of a solitary confinement unit at a maximum-security prison in Walpole, Mass. One inmate could not recall the days before he slashed his wrists. Another described feelings of panic and fear of suffocation. Many heard voices, were hypersensitive to sounds or obsessed over thoughts of torture and revenge on guards. Since then, Grassian has evaluated scores of inmates in New York and other states, and has no doubts about what he calls the ''toxic'' effect of isolation. 

Grassian's findings are part of a body of research that is consistent and ample but also, in the words of a recent article in The Prison Journal, ''weak methodologically.'' For one, his research was conducted in the context of a lawsuit -- often the only way to get access to the cloistered world of prisons. And it is based on observing and interviewing inmates rather than tracking them over time or comparing them with control groups. A research team in Canada tried to settle the debate in the late 1990's by comparing the mental health of 23 inmates segregated for 60 days with those who were kept with the general population. It found no harm to the isolated inmates, who were less mentally healthy than the control group. However, the study's subjects -- many of them volunteers -- had access to personal possessions, televisions and computers. In an article in the Canadian Journal of Criminology, the researchers cautioned that their findings are ''somewhat irrelevant'' to conditions in the United States, ''where prisoners can sometimes be segregated for years for disciplinary infractions with virtually no distractions, human contacts, services or programs.'' 

Researchers and advocates generally do not object to short periods of confinement for ill and unruly inmates; they recognize that truly violent prisoners must be contained. But since the 1980's, the number of New York inmates serving special-housing-unit sentences of longer than six months has increased at six times the rate of the population. Inmates can, and do, spend years in the box. In 2002, New York had among the nation's highest proportion of inmates -- nearly 8 percent -- in isolated confinement, which includes the box and keeplock. ''The scale of punishment in New York State is particularly onerous,'' said Hans Toch, a prison researcher who is a professor of criminal justice at the State University at Albany. ''They think nothing of putting someone into a segregation setting for a year and a half for what is a serious but not horrendous offense.'' 

Carlos Diaz, 46, had been in a special housing unit in New York for five years when he hanged himself with a shoelace in 2000. He had accumulated so many infractions that he had 10 years left in the box. Such deaths are investigated by an oversight board called the New York State Commission of Correction, which found that Diaz had been virtually abandoned. Although he was at one point ''extremely delusional,'' no one was monitoring his condition or providing mental-health care. ''It is a well-established fact,'' the commission noted pointedly, ''that inmates serving long-term sentences in S.H.U.'s are likely to decompensate due to extended periods of isolation and sensory deprivation.'' 

In 2001, the commission investigated two deaths six months apart that painfully illustrate lapses in mental-health care that lead ill inmates to act out and be disciplined. In each case, severely mentally ill inmates at separate prisons died from ''decreased intake of food and water'' -- they starved, in other words -- one after announcing a hunger strike and the other while on a suicide watch. The Commission of Correction was searing in its criticism: ''In both cases, the inmates had been identified as having significant mental-health and/or medical problems and were not afforded the care and treatment that these services are required to provide.'' Significantly, the commission's findings are nonbinding; they are often rejected or ignored. 

Cases like these are symptoms of a system under strain. The number of mentally ill inmates grew by 78 percent since 1991, while mental-health staffing has grown by 57 percent. Complicating matters, jobs often go unfilled. Pedro Molina appealed for help in 2001 at a prison with chronic recruiting problems. His note in Spanish was found weeks later on a stack of 40 requests; no one had translated or triaged the request, and Molina, 27, hanged himself in the box. 

When another inmate, Ralph Tortorici, 31, killed himself in 1999, Goord himself expressed frustration, appealing to the Office of Mental Health for more psychiatric hospital beds. ''I am seriously concerned about the potential for unfortunate occurrences similar to the premature demise of Mr. Tortorici,'' Goord wrote. Tortorici suffered from schizophrenia and believed the government had implanted computer chips in his body; he was so ill that he had been hospitalized four times for periods of up to a year. The prison system's lone 189-bed hospital has not been expanded since opening in 1980. Since then, New York has built 38 prisons. 
 

Each morning at Bedford Hills, Jessica Roger would visit Andy DeMers, a correction officer she had made friends with. She would put her head, puppy-dog-like, on the high counter he manned. It was a ritual they shared: He would ''tune'' her nose, making a noise as he tweaked it. One day, she called to him as she was led to a van bound for the prison psychiatric hospital. ''Who's going to tune my nose?'' she asked. DeMers recalled that ''there was a sweetness inside her,'' a quality he said few officers saw. Officers aren't trained to connect with inmates but rather to control them, many experts told me, leading to many confrontations and failures of opportunity. ''She was reachable,'' said DeMers, who has since retired. 

Betty Guzzardi, a petite woman in her 50's, lived on Roger's cellblock in the months before her suicide. She was one of a handful of mother hens who would try to lift Roger's spirits. ''We used to tell her, 'You're a young girl; you'll be getting out,''' said Guzzardi, who has a daughter Roger's age. The women would play cards and Yahtzee with her, and Roger would laugh and enjoy the company. Guzzardi once watched Roger pull an electrical outlet cover off a wall and gouge her wrists with the broken pieces; she had often seen her cry. When told that Roger had been put into the box two days before her suicide -- in an incident that apparently began with Jessica smoking and ended with her throwing a chair -- Guzzardi was incredulous. ''Are you crazy?'' she told an officer. ''She's too depressed. 

''The whole facility was like 'How could they do this knowing how she was?' It was very upsetting to us that a young girl like that took her life, and more than that, the facility helped her take her life.'' 

State prisons bear the brunt of what is often called the ''criminalization'' of mental illness. In New York, the tally of mentally ill inmates has swelled to 7,500, or 11 percent of the population. Unprepared for the task, the system has tried to respond, if inadequately. Units have been built for mentally ill prisoners who cannot live with the general population. Therapy programs have even been started at a few special housing units. In the face of the systemwide lawsuit, the state is proposing to expand these services, along with measures to reduce time in the box for good behavior and for offenses that stem from mental illness. But advocates say that more in-patient hospital beds and dedicated units are needed for mentally ill inmates, along with training to help correction officers recognize the manifestations of illness. Just as important, better oversight is needed of a system with little accountability. 

Thanks to a previous lawsuit against Bedford and the 1987 settlement that was reached, the prison has among the highest levels of mental-health staff in the state and the mental-health care that Roger received was most likely far superior to that in the rest of the system. Women in the special housing unit are monitored regularly and given monthly therapy. But while the lawsuit improved care, it did not achieve what Jessica Roger needed most. It did not keep her out of the box. Facilities in at least four states preclude the seriously ill from 23-hour confinement; a proposal to do that in New York has languished in the State Legislature. Had it been law, Roger might still be alive. 

In her final tortured hours, Jessica Roger was moved from the box to a suicide observation cell and back again. She exhibited ''self-injurious behaviors'' on the way back to special housing, the Commission of Correction's report states, questioning why she wasn't returned to observation. But mental-health staff members had considered a prior gesture to be ''manipulative,'' the report asserts; Roger, they thought, was trying to get out of the box. ''The ultimate tragedy,'' writes Terry Kupers, a prison expert and psychiatrist, in an article in The Correctional Mental Health Report, ''is when overconcern about malingering leads mental-health staff to miss what would otherwise be clear signs of an impending suicide.'' 

On Aug. 20, 2002, Roger's counselor closed out her file, recalling recent encounters with Jessica. ''This writer would ask inmate if she had decided if she wanted to get a new ticket yet (misbehavior report) and inmate would laugh and say she wasn't going to get locked.'' Before long, however, the inevitable happened. 

''Inmate acted out after hours and was sent to S.H.U.,'' the counselor wrote. ''Writer was informed of her death yesterday morning on 8/19/02. She will be missed.'' 
 

Mary Beth Pfeiffer, who is on leave as the projects editor at The Poughkeepsie Journal, is a 2004 Soros Justice Media Fellow.