Seventh Circuit Decision Urges Consideration of Negative Psychological Effects of Solitary Confinement
In Sanders v. Moss, 153 F.4th 557 (7th Cir. 2025), the U.S. Court of Appeals for the Seventh Circuit considered whether prison health care providers exhibited deliberate indifference to Cordell Sanders’ mental health needs in violation of the Eighth Amendment. The court ruled that Mr. Sanders could not prevail on his claims. Despite the decision, this case importantly highlights the complexities in prolonged solitary confinement as a means to address mental health conditions.
Facts of the Case
In 2004, Mr. Sanders was sentenced to 20 years in prison for homicide and entered the Illinois Department of Corrections (IDOC). His time there was characterized by sexual misconduct, assaultive behaviors, and damaging property, which subsequently led to him being placed in segregation from 2009 to 2017. In 2013, he was followed by several mental health providers employed through Wexford Health Sources, who diagnosed him with antisocial personality disorder, schizoaffective disorder, depressive disorder, and intermittent explosive disorder. While in segregation, he had several suicide attempts over the years and was noted to have further sexually inappropriate and impulsive behaviors that led to further restrictions of his yard time.
As a result of his long period of segregation, he filed a Monell liability claim under 42 U.S.C. § 1983 action, alleging that both the prison’s health care providers and Wexford exhibited deliberate indifference to his mental health needs in violation of his Eighth Amendment rights.
Mr. Sanders named several mental health providers who treated and saw him over the course of several years, starting in 2013. He also saw psychiatric providers for medication management regularly. He claimed the providers were deliberately indifferent to his mental health needs and that they provided a course of treatment they knew was ineffective, including recommending additional segregation time rather than recommending less. Mr. Sanders also claimed Wexford Health Sources failed to issue guidance on what a mental health provider should do when participating in disciplinary hearings and claimed that he was told he would only be seen by mental health providers if he was suicidal.
Upon review of the chart records from Mr. Sanders’ mental health providers, it was noted that he was intermittently placed between suicide watch, crisis care, and segregation. Generally, these conditions would be in response to suicidal gestures or attempts and behavioral outbursts. Providers further noted that, despite Mr. Sanders’ behaviors, when they would meet with him, he would generally present with an appropriate demeanor and would usually deny any suicidal or homicidal thoughts and that he was generally compliant with his prescribed mental health medications.
Because of Mr. Sanders’ mental health condition and behaviors, he was deemed “seriously mentally ill” per Wexford’s Adjustment Committee. The role of the committee is to seek input from providers for its Mental Health Disciplinary Form regarding inmates such as Mr. Sanders, where the provider’s recommendation regarding segregation is generally followed.
The district court decision was appealed three times to the Seventh Circuit. In the first appeal, the district court’s decision to revoke Mr. Sanders’ in forma pauperis status and dismiss his complaint on the grounds that his allegations did not demonstrate imminent danger of serious physical harm was reversed. In the second appeal, the Seventh Circuit reversed the district court’s decision to dismiss Mr. Sanders’ case as a sanction for misrepresenting to the court that he received mental health treatment only when he was deemed a harm to himself. The following describes the decision following the third appeal.
Ruling and Reasoning
The U.S. Court of Appeals for the Seventh Circuit’s ruling was separated based on Mr. Sanders’ Monell claims against the mental health providers and against Wexford. The opinion was authored by Judge Lee, with Judge Rovner authoring a concurring opinion.
The Seventh Circuit Court found that the district court did not err in granting summary judgment to the defendant’s providers. The court said that, to prove that the mental health providers violated Mr. Sanders’ Eighth Amendment rights, they needed to be shown to be deliberately indifferent to his mental health needs, with conduct that “must be such a substantial departure from accepted professional judgment, practice, or standards as to demonstrate that the person responsible did not base the decision on such a judgment” (Sanders, p 568). Although Mr. Sanders retained a psychiatrist for expert testimony, he was only able to opine on the impact of Mr. Sanders’ incarceration course on him and could provide no opinion on whether his treatment was a significant departure from standard practice or on whether the treatment he received was ineffective.
The court recognized that, although providers may have known about the harms of segregation, there was no evidence on which a jury could conclude that any other mental health provider would have made any different recommendations in a similar situation. And although lack of exercise and outdoor time could be considered a violation of the Eighth Amendment, there was no basis of these treatment decisions deviating substantially that would classify it as deliberate indifference. The Seventh Circuit also found that the district court did not err in offering summary judgment in favor of Wexford Health Sources.
Regarding Mr. Sanders’ claim that he would only get mental health treatment if he were in crisis, it was noted that Mr. Sanders failed to provide any evidence showing a pervasive pattern of not getting treatment unless he was in crisis, noting that he was seen persistently by mental health providers. Furthermore, Mr. Sanders’ claim that Wexford failed to give direction to its mental health providers on how to complete a Mental Health Discipline Form did not appear valid. There was no evidence that a further detailed policy at the time would have had any impact on his care or evidence that Wexford failed to adequately train its mental health professionals in this policy.
Concurring Opinion
Although Judge Rovner concurred with the majority opinion, she also highlighted Mr. Sanders’ suffering while being in segregation for several years, including being in his cell for a minimum of 22 hours per day, being shackled outside of his cell (even during medical appointments), and having minimal interactions with other peers. This experience was not unique to him as an inmate, and Judge Rovner cited literature regarding the negative psychological effects of solitary confinement of more than ten days. She further commented on the level of care mental health care providers owe to a prisoner in solitary confinement: “it is my hope that our evolving understanding of the psychological effects of solitary confinement on the one hand, and lack of penological benefit, on the other, will inform our understanding of deliberate indifference, liberty interests, and Eighth Amendment standards in cases where defendants were, in fact, responsible for imposing the condition.” (Sanders, p 573-574).
Discussion
The Sanders case sheds light on a conundrum within the correctional system in handling challenging mental health cases with limited resources. It forces the question of what the correctional psychiatrists’ role should be in addressing these matters, not only from a provider perspective for individual patients but also a consultative one in developing a more progressive prison policy and structure regarding segregation, especially among those with serious mental illness.
This appears to be a widespread problematic practice in the correctional setting, as Judges Lee and Rovner stated that, although there is recognition that prolonged solitary confinement and lack of outdoor time could potentially be constituted as a violation of Eighth Amendment rights, there is no evidence to suggest that this is a substantial departure from standard practices. Outside of correctional environments, there is no standard of care where someone would be placed in such a setting for prolonged periods of time. In a community mental health setting, even if someone were a significant risk of self-harm or harm to others and placed in a seclusion setting, the goal of care would be to stabilize that patient and provide trauma-informed care to minimize the potential harm and overall amount of time there. Although there are significant differences in these settings, we must ask ourselves what justifies the differences in treatment for our patients depending on where they are and whether we are neglecting our nonmaleficence duty as physicians when we endorse or recommend prolonged solitary confinement as a standard of care.
Judge Rovner’s invocation of “evolving standards of decency” echoes Supreme Court opinions in Atkins v. Virgina, 536 U.S. 304 (2002), and Roper v. Simmons, 543 U.S. 551 (2005), highlighting the role that psychiatry and scientific research may play in helping mold contemporary views of criminal responsibility and punishment and guide society away from potentially outdated and deleterious practices. The widespread practice of placing people in solitary confinement in correctional settings is certainly one deserving reconsideration and reform.
- © American Academy of Psychiatry and the Law
