In the

United States Court of Appeals For the Seventh Circuit ____________________ No. 23-1335 CORDELL SANDERS, Plaintiff-Appellant, v.

ANDREA MOSS, et al., Defendants-Appellees. ____________________

Appeal from the United States District Court for the Central District of Illinois. No. 1:16-cv-1366 — Jonathan E. Hawley, Judge. ____________________

ARGUED FEBRUARY 10, 2025 — DECIDED AUGUST 28, 2025 ____________________

Before EASTERBROOK, ROVNER, and LEE, Circuit Judges. LEE, Circuit Judge. Despite suffering from serious mental health issues, Cordell Sanders, an inmate formerly at Pontiac Correctional Center, was forced to spend eight years in segre- gation housing after committing multiple disciplinary of- fenses. Pursuant to 42 U.S.C. § 1983, he sued the prison’s health care provider, Wexford Health Sources, as well as his mental health care providers, Andrea Moss, Kelly Haag, Todd Nelson, Linda Duckworth, and Stephen Lanterman, for 2 No. 23-1335

exhibiting deliberate indifference to his mental health needs in violation of the Eighth Amendment. 1 The district court granted summary judgment for the defendants. On appeal, Sanders contends that the individual defend- ants failed to provide adequate mental health services and to advocate for him during his disciplinary proceedings to lessen his sanctions. As for Wexford, Sanders argues that the company employed a widespread practice of denying mental health treatment to inmates until they were in crisis. He also claims that Wexford had an obligation to enact a policy its mental health providers could follow when participating in disciplinary proceedings, but failed to do so. This case is a tragic one. We have no doubt that Sanders struggled with severe mental health needs while at Pontiac and that his prolonged time in segregation did little to address them. But the question before us is whether the record con- tains evidence from which a rational jury could find that the defendants’ conduct violated Sanders’s Eighth Amendment rights. This is a difficult standard to meet, and, despite the vo- luminous record, we discern no evidentiary basis from which a jury could find in Sanders’s favor and affirm. I Because Sanders challenges the district court’s order granting summary judgment to the defendants, we recount

1 In addition, Sanders sued the Illinois Department of Corrections and

certain of its correctional officials in this action, and the district court granted them summary judgment which Sanders also appealed. Sanders eventually settled with the Department and its officials and dismissed his appeal. No. 23-1335 3

the facts in a light most favorable to him. See Burton v. Downey, 805 F.3d 776, 783 (7th Cir. 2015). In 2004, Sanders was sentenced to twenty years in prison for homicide. He was sixteen at the time. Since entering the Illinois Department of Corrections (IDOC), Sanders has com- mitted a myriad of offenses, including assaulting and threat- ening staff, repeatedly engaging in sexual misconduct, and damaging property. These incidents generated “tickets” for which he received disciplinary action. Such sanctions took the form of segregation, reduction of outdoor yard access, and other restrictions. Relevant here, as a result of his violations, Sanders was placed in segregation at Pontiac for over eight years from 2009 until 2017. 2 A. Sanders’s Providers IDOC contracts with Wexford Health Sources to provide mental health services for inmates at Pontiac. Moss, Haag, Nelson, Duckworth, and Lanterman are current and former Wexford health professionals who treated Sanders at Pontiac. Moss, Haag, and Lanterman are licensed clinical social work- ers, while Nelson and Duckworth are employed as mental health professionals. (For ease of reference, we will call them

2 Defendants formally refer to his placement as “segregation hous-

ing,” while Sanders applies the label “solitary confinement.” We use the term “segregation” as reflected in the record. While the parties also dis- pute how to characterize the conditions Sanders faced during his place- ment, they agree that the privileges and freedoms of inmates in segrega- tion housing were severely limited compared to those in the general prison population. For example, inmates assigned to segregation housing at Pontiac are held in their cells for at least 22 hours a day. And for most of Sanders’s time at Pontiac, segregation inmates were allowed out of their cells only for showers, yard, visits, and use of the law library. 4 No. 23-1335

“the Providers.”) They, along with other mental health pro- fessionals at Pontiac, diagnosed Sanders with various mental issues, including antisocial personality disorder, intermittent explosive disorder, schizoaffective disorder, and depressive disorder. The Providers evaluated Sanders when he attended peri- odic individual and group therapy sessions. According to Sanders, some of these sessions lasted no longer than five to ten minutes. The Providers also performed brief assessments outside of his cell while he was in segregation. And they met with him when he engaged in suicidal behavior. And, alt- hough the Providers did not treat Sanders on a consistent, on- going basis while he was at Pontiac, the undisputed record indicates that other mental health providers offered similar mental health services to Sanders during this time frame. In addition to these providers, Wexford also employed psychologists and psychiatrists to treat inmates at Pontiac. These professionals assessed Sanders on a regular basis, cre- ated individualized treatment plans for him, and managed his medications, which included antidepressant, psycho- tropic, and mood-stabilizing drugs. 1. Andrea Moss Moss first evaluated Sanders during an individual therapy session in April 2013. During this session, Sanders com- plained to Moss about having to “do 100% of [his] time” and not having the opportunity for good-time credit. Moss did not treat Sanders again that year, but, throughout 2014, 2015, and early 2016, Moss observed Sanders more than a dozen times while he was in segregation and evaluated him during indi- vidual therapy sessions. No. 23-1335 5

Whenever Moss met with Sanders, he denied having sui- cidal or homicidal ideations. Sanders had remarked to Moss that “the only time” he left the cell was when he met with her. In Moss’s view, however, Sanders generally presented appro- priately and only occasionally displayed inappropriate mood, behavior, concentration, and affect. 3 Moss recommended that Sanders receive an outpatient level of care, except for one instance on October 27, 2015, when Sanders tried to commit suicide. 4 After the attempt, Lanterman met with Sanders to evaluate him. Sanders would meet with Moss again eight days later. At that meeting, he denied being suicidal. Rather, Sanders was upset that his shoes had been taken away and told Moss, “This is the only way I get anything done [because] no one is responding to my grievances.” Out of an abundance of cau- tion, Moss evaluated his suicide risk, placed him on suicide watch, and recommended that he receive crisis care.

3 According to Sanders’s medical file, mental status examinations gen-

erally measured the propriety of his appearance, behavior, mood, affect, concentration, memory, speech, and thoughts. 4 Prior to his treatment by the Providers, Sanders attempted to commit

suicide at least once when he overdosed on his pain medication in 2010. Sanders also claimed he attempted suicide in 2012, when he suffered an episode of psychosis and cut himself around his stomach area. Defendants dispute this 2012 attempt, pointing out that Sanders cites no corroborating medical records and concedes he never told anyone about this incident. However, we accept self-serving testimony on summary judgment so long as it based on personal knowledge. See Whitlock v. Brown, 596 F.3d 406, 411 (7th Cir. 2010). 6 No. 23-1335

2. Stephen Lanterman Lanterman initially encountered Sanders while he was conducting rounds in the segregation housing area in April 2015. He noted that the meeting was unremarkable. When they met three months later, Sanders relayed that he heard unintelligible voices and felt suicidal. Sanders also complained that a correctional officer spat on him and falsely accused him of some unspecified misconduct. Lanterman was concerned about Sanders’s appearance, behavior, and mental status, but Sanders denied experiencing suicidal or homicidal ideations. Nevertheless, based on his observations, Lanter- man placed Sanders on suicide watch, so that he could be monitored every ten minutes. The next day, Sanders reported to Lanterman that he felt better and had time to cool off. He again denied feeling sui- cidal and said that he was taking his medication. For his part, Lanterman noted that Sanders’s mood and mental state were stable. And, while Lanterman took Sanders off suicide watch, he recommended that Sanders be placed in crisis care. Lanterman next treated Sanders on October 27, 2015, the day Sanders attempted suicide. During the examination, Sanders told Lanterman that he had overdosed on pills. At the conclusion of the appointment, Lanterman diagnosed Sand- ers with major depression with psychotic affects, recom- mended that he receive crisis care, and placed him on suicide watch. Lanterman examined Sanders again the next day. Sanders explained that he was depressed and angry the day before be- cause the facility had taken away his yard access. But he once again denied having suicidal or homicidal thoughts. No. 23-1335 7

Lanterman noted that Sanders was calm, coherent, and had a congruent affect (that is, his emotional expressions aligned with his mood). Lanterman maintained his recommendation that Sanders receive crisis care and placed him on suicide watch. Two days later, on October 30, 2015, Sanders met again with Lanterman and said that Prozac seemed to be helping his mood. He also reiterated that he was not having suicidal thoughts. And so, Lanterman took Sanders off suicide watch but continued crisis care. August 2016 was the next time Lanterman encountered Sanders while performing rounds in the segregation unit. He continued to see Sanders during routine segregation rounds through November 2016 with no reported concerns. 3. Todd Nelson Nelson first assessed Sanders in January 2015. Sanders had called for a crisis team member because, he claimed, he had no access to the yard for a year or a TV for the prior three years. During their session, Sanders told Nelson that he was not contemplating suicide and was not a danger to others. Nelson marked down three risk factors (feelings of hopeless or helplessness, signs of depression, and increased anxiety) and five protective factors (opposition to suicide, future ori- entation/sense of hope, support system, sense of responsibil- ity, and compliance with medication). Based on this evalua- tion, Nelson did not order crisis care and recommended that Sanders be returned to segregation housing. Nelson ex- plained to Sanders that he should direct his concerns about yard and TV privileges to security personnel. 8 No. 23-1335

A year passed before Nelson saw Sanders again for an in- dividual therapy session in January 2016. According to Nel- son, Sanders seemed fine and presented no issues of note. Nelson continued to see Sanders when he made segregation rounds and during individual therapy sessions through April 2016. During this period, the only problem Sanders raised re- lated to the expiration of his medication, which Nelson reme- died by arranging for it to be re-ordered. On July 24, 2016, Sanders overdosed on medication and was placed on suicide watch. Nelson was assigned to treat Sanders the following day. Sanders told Nelson that he had dislocated his thumb “during a staff assault” and became su- icidal when the medical staff failed to see him. And so, he overdosed on Motrin. However, Sanders informed Nelson that he felt better and did not have any suicidal or homicidal ideations. Nelson observed that while Sanders was fully ori- ented, appropriately groomed, and had a clear and coherent thought process, he was guarded and suspicious and exhib- ited a flat affect. At the same time, Nelson found Sanders to be cooperative, appropriate, stable, and noted that there were no signs of psychosis. Nelson nonetheless recommended that Sanders remain on suicide watch. Nelson then evaluated Sanders daily for four consecutive days. On one of the days, Sanders bit his own arm. Sanders told Nelson that the biting was his attempt to get medical at- tention for his injured thumb. The next day, Sanders pro- fessed his realization that biting his arm to get medical atten- tion displayed poor judgment. He told Nelson that he knew the appropriate procedure to obtain medical attention. After repeatedly observing that Sanders was stable, coop- erative, and presenting appropriately, as well as the absence No. 23-1335 9

of any psychotic affects, Nelson removed him from suicide watch on August 2, 2016. Nelson continued to see Sanders during segregation rounds through February 2017 with no re- ported concerns. 4. Kelly Haag Haag met Sanders for the first time when conducting seg- regation rounds in August 2015. Sanders informed her then that he was “o.k.” and Haag did not notice anything amiss. Her observations of Sanders during segregation rounds in November 2015, June 2016, and July 2016, were similarly un- remarkable. Haag next saw Sanders in December 2016 during his group therapy session. Based on their interactions, Haag found that Sanders displayed improved impulse control and insight with no observable signs of psychosis, agitation, or distress. According to Haag, she explained to Sanders how to go about requesting mental health services or crisis care in times of need. He acknowledged understanding this process. Haag met with Sanders in at least seven additional group therapy sessions from December 2016 through March 2017. Haag also continued to see Sanders during segregation rounds in March and April 2017, all without any reported concerns. On one occasion, Haag noted that Sanders’s inabil- ity to refrain from behaviors that resulted in disciplinary in- fractions indicated poor impulse control. But, at Haag’s as- sessments, Sanders repeatedly denied having suicidal or homicidal ideations and generally presented appropriately. 5. Linda Duckworth Duckworth met with Sanders only a handful of times be- tween February 2015 and August 2016. During their first 10 No. 23-1335

encounter, Sanders told Duckworth that he was upset about receiving a disciplinary ticket for masturbating in front of a female officer, so he broke a sprinkler. Sanders refused to talk further about it in front of the other officers who were present. At the conclusion of the examination, Duckworth found Sand- ers’s behavior, mood, and affect inappropriate but recom- mended an outpatient level of care. Later that same afternoon, Sanders threatened to cut him- self with a paper cup, and Duckworth came by his cell to speak with him. According to Sanders, he had been falsely ac- cused of the ticket for masturbating, and his property had been taken away for three days. Duckworth provided Sanders with deep breathing and meditation exercises to help him cope with stress. She observed him to be alert, attentive, fully oriented, mildly distressed, and at minimal risk of suicide and, thus, recommended that he continue outpatient care. Duckworth later treated Sanders in two individual ther- apy sessions in May and July 2015 and saw him during one segregation round in May 2016. At no time did she see any- thing of concern. Duckworth assessed Sanders with various disorders, including mood disorder, antisocial personality disorder, schizoaffective disorder, intermittent explosive dis- order, adjustment order, and narcissistic traits. Duckworth’s final encounter with Sanders was in August 2016 to evaluate his suicide risk. She assessed certain risk fac- tors, including Sanders’s concerns about serving too much segregation time and having lost his underwear in May 2015; his difficulty adjusting to the loss of freedom, status, and priv- ilege; his murder conviction; and his prior suicide attempts. Duckworth also found countervailing factors, including Sanders’s opposition to suicide, his support system, his No. 23-1335 11

coping and problem-solving skills, and his compliance with psychotropic medication. Based on her examination, she rec- ommended that Sanders return to segregation housing rather than crisis care. B. Sanders’s Disciplinary Proceedings When an inmate is accused of a major violation of prison rules, the case is heard by the “Adjustment Committee.” The committee holds a hearing and determines whether the indi- vidual committed the alleged offense. It then recommends what it believes to be the appropriate discipline to the warden, including possible segregation. For inmates, like Sanders, whom IDOC has designated as being “seriously mentally ill,” the Adjustment Committee fol- lows a 2014 IDOC administrative directive and solicits input from the relevant Wexford mental health providers in a Men- tal Health Disciplinary Review form. To complete the form, the mental health provider reviews the inmate’s mental health records and the disciplinary report and opines on whether: (1) the individual’s mental illness may have contrib- uted to the behavior at issue; (2) segregation is likely to signif- icantly impact the inmate’s mental health; and (3) the of- fender’s mental health should be considered when determin- ing the appropriate discipline. The mental health provider can also recommend a specific term of segregation or no seg- regation time at all. The provider plays no role in deciding whether the inmate committed the alleged misconduct. Under the IDOC directive, the Adjustment Committee must consider the opinions of the mental health provider in the Mental Health Disciplinary Review form. If the mental health provider recommends a specific term of segregation or 12 No. 23-1335

no segregation, the directive requires the committee to adopt the provider’s recommendation. If the committee disagrees and believes that a more restrictive disciplinary action is nec- essary, it must appeal that decision to the warden, who makes the final determination. At one time or another, each of the Providers either com- pleted a Mental Health Disciplinary Review form or partici- pated on the Adjustment Committee for Sanders. For example, in May 2015, Sanders faced the Adjustment Committee for sexual misconduct, and Moss recommended no more than six months of segregation time, yard restriction, and “C grade” placement. 5 In September 2015, Sanders came before the committee for writing “a sexually graphic and wholly inappropriate” letter to a court reporter. Nelson recommended a recreation re- striction. The Adjustment Committee, which included Lanter- man, followed Nelson’s recommendation and assessed one month of yard restriction. Days later, after Sanders committed another sexual misconduct offense, Nelson recommended a segregation term of two months, and the committee followed Nelson’s recommendations. Sanders was brought before the Adjustment Committee again on October 27, 2015, after disobeying multiple orders to remove items covering his cell window. Haag recommended zero to three months of segregation as well as other less severe restrictions. The committee, which included Moss, adopted

5 C Grade indicated a further restriction in institutional privileges. No. 23-1335 13

Haag’s recommendations and did not recommend segrega- tion. Duckworth sat on the Adjustment Committee to hear two sets of violations by Sanders on July 24, 2016, and July 27, 2016. He had been ticketed with assaulting staff after throw- ing liquid on officers, threatening to stab them, disobeying multiple orders, damaging property, and impairing surveil- lance. The committee adopted the mental health provider’s recommendation of one year of segregation along with lesser restrictions. 6 C. Wexford According to Sanders, Wexford employed a practice of ig- noring the mental health needs of inmates until they reached a crisis state. At his deposition, he testified that on November 3, 2015, he knocked on his cell door while Moss was walking down the gallery to tell her that he needed to talk, but Moss did not respond. He was later informed by a prison guard that Moss told the guard that she did not want to speak with Sand- ers unless he was suicidal. Sanders also testified that Moss had indicated to him on another occasion that she would only see him if he was suicidal, but he could not remember when that occurred. Sanders admitted, however, that he was seen by another mental health professional on November 3, just not Moss. Sanders also faults Wexford for failing to issue guidance explaining exactly what a mental health provider must do when participating in disciplinary proceedings. He points to

6 It is not clear from the record which mental health provider com-

pleted the Mental Health Disciplinary Review forms for these violations. 14 No. 23-1335

Nelson’s testimony that he did not review Sanders’s mental health records prior to completing the Mental Health Disci- plinary Review form but relied on input from colleagues who regularly treated Sanders. In a similar vein, Lanterman testi- fied that he did not necessarily meet with an accused inmate every time he completed the form and that, when he sat on the Adjustment Committee, he relied on the opinions of the reviewing provider. Additionally, Sanders points to Duck- worth’s testimony that she does not consider an inmate’s seg- regation history when she fills out the Mental Health Discipli- nary form.7 II Sanders initiated this action pro se in September 2016. Shortly after he brought the case, IDOC reduced Sanders’s segregation term, and he was transferred to the general pop- ulation in September 2017. In an amended complaint, Sanders alleged that Wexford and the Providers violated his right to be free of cruel and unusual punishment under the Eighth Amendment. As to the former, Sanders contends that Wex- ford had a practice or custom of ignoring inmates’ mental health needs until they were in crisis. As to the latter, he claims that the Providers were deliberately indifferent to his mental health needs and failed to advocate for his removal from segregation housing. This is the third appeal Sanders has filed in this case. The first time, we reversed the district court’s decision to revoke

7 Sanders also cites testimony from Haag, but she did not, as Sanders

claims, admit that she disregarded his segregation term during discipli- nary proceedings. Rather, she stated that she did not calculate the term when completing an assessment after segregation rounds. No. 23-1335 15

his in forma pauperis status (IFP) and dismiss his complaint on the grounds that his allegations did not demonstrate immi- nent danger of serious physical harm. Sanders v. Melvin, 873 F.3d 957, 959–60 (7th Cir. 2017). Sanders had to make this showing because he already had three strikes under 28 U.S.C. § 1915(g). Id. at 959. On remand, Sanders retained counsel, paid the filing fee, and filed the operative complaint. In the second appeal, we reversed the district court’s order dismissing Sanders’s case as a sanction for misrepresenting to the court that he received mental health treatment only when he had harmed himself or had credibly threatened to do so. Sanders v. Melvin, 25 F.4th 475, 484–85 (7th Cir. 2022). In both instances, “Sanders ha[d] not yet been directed to substantiate his allegations.” Sanders, 873 F.3d at 962. Since then, the parties were provided an opportunity to conduct discovery, and the defendants moved for summary judgment, which the district court granted on all counts. The latest order is the subject of this appeal. III We review the district court’s order granting summary judgment de novo after construing all factual disputes in Sand- ers’s favor. See Burton, 805 F.3d at 783. We begin with Sand- ers’s claims against the Providers before turning to his claims against Wexford. A. The Providers Sanders contends that the Providers were deliberately in- different to his mental health needs in two ways. First, they provided a course of treatment they knew to be ineffective. Second, during disciplinary proceedings, they recommended 16 No. 23-1335

additional time in segregation (and other restrictions) rather than recommending less. “The Eighth Amendment’s ban on ‘cruel and unusual punishments’ obligates prison officials to provide medical care to prisoners in their custody.” Dean v. Wexford Health Sources, Inc., 18 F.4th 214, 234 (7th Cir. 2021) (quoting Estelle v. Gamble, 429 U.S. 97, 102 (1976)). A prison official’s “deliberate indifference to serious medical needs of prisoners” violates the Eighth Amendment. Estelle, 429 U.S. at 104. To prove a deliberate indifference claim, a plaintiff must first show that he suffers from an “objectively serious medical condition.” Petties v. Carter, 836 F.3d 722, 728 (7th Cir. 2016) (en banc). Additionally, a plaintiff must establish that the prison official acted with a “sufficiently culpable state of mind.” Farmer v. Brennan, 511 U.S. 825, 834 (1994) (quoting Wilson v. Seiter, 501 U.S. 294, 297 (1991)). A prison official has a sufficiently culpable state of mind when the official “knew of a substantial risk of harm to the inmate and acted or failed to act in disregard of that risk.” Id. (citation omitted). A court considers “the totality of an in- mate’s medical care” to assess “whether that care evidences deliberate indifference to serious medical needs.” Petties, 836 F.3d at 728–29 (citing Cavalieri v. Shephard, 321 F.3d 616, 625– 26 (7th Cir. 2003)). The standard to prove deliberate difference is a difficult one: a medical professional’s treatment decision “must be such a substantial departure from accepted profes- sional judgment, practice, or standards as to demonstrate that the person responsible did not base the decision on such a judgment.” Id. (internal quotation marks omitted). No. 23-1335 17

One way to establish such a departure “is where a prison official persists in a course of treatment known to be ineffec- tive.” Id. at 729–30 (citing Walker v. Peters, 233 F.3d 494, 499 (7th Cir. 2000)); see, e.g., Greeno v. Daley, 414 F.3d 645, 654–55 (7th Cir. 2005). That said, “[a] medical professional is entitled to deference in treatment decisions unless no minimally com- petent professional would have so responded under those cir- cumstances.” Stewart v. Wexford Health Sources, Inc., 14 F.4th 757, 763 (7th Cir. 2021) (internal quotation marks omitted). And “expert medical evidence is often required to prove” a substantial departure from accepted professional judgment, practice, or standards. Eagan v. Dempsey, 987 F.3d 667, 683 (7th Cir. 2021) (internal quotation marks omitted). 1. Sanders’s Treatment The parties do not dispute that Sanders’s mental health needs presented an objectively serious medical condition. Ra- ther, the parties focus on whether the Providers acted with deliberate indifference when they continued to provide, as Sanders sees it, knowingly ineffective treatment. We find that the record lacks sufficient evidence from which a reasonable jury could make this determination. The Providers’ notes documented both complaints from Sanders about his mental state and segregation as well as statements confirming that he was fine and had no mental health concerns. Sanders urges us to disregard the latter, cit- ing the unreliability of self-reporting. But, even if we construe the record in Sanders’s favor (as we must), in an area as mul- tifaceted as mental health and its treatment, we cannot dis- cern how a jury would be able determine the effectiveness of the course of treatment provided to Sanders without expert evidence. See Petties, 836 F.3d at 729 (observing “the need for 18 No. 23-1335

specialized expertise to understand the various implications of a particular course of treatment” in cases where the risk of harm is not obvious). In this way, this case is markedly differ- ent from an obvious case of deliberate indifference such as when a prison official gives an aspirin to a patient facing a serious risk of appendicitis. See Sherrod v. Lingle, 223 F.3d 605, 611–12 (7th Cir. 2000). Here, Sanders retained psychiatrist Dr. Stuart Grassian as a mental health expert, but Dr. Grassian’s opinions were lim- ited to the psychiatric impact of Sanders’s incarceration at Pontiac. He offered no opinions about the effectiveness of the specific treatment Sanders received from the Providers. For instance, when asked to evaluate whether Sanders’s group therapy was beneficial, Dr. Grassian responded: “I do not know enough about the group therapy. I didn’t attend it. I’m telling you what his experience was.” To be sure, Dr. Grassian does criticize the Providers for failing to spend sufficient time with Sanders to “really get[] to know him.” But he does not suggest that the time they did spend with Sanders demonstrated a “complete abandonment of medical judgment.” See, e.g., Murphy v. Wexford Health Sources, Inc., 962 F.3d 911, 916–17 (7th Cir. 2020) (affirming summary judgment on the ground that expert’s opinions “d[id] not go so far” to make this showing) (citing Norfleet v. Webster, 439 F.3d 392, 396 (7th Cir. 2006)). And while Dr. Grassian expressed some disagreement with the treatment Sanders received (which we must credit at summary judg- ment), he offers no opinion as to whether the treatment the Providers gave to Sanders represented a substantial depar- ture from accepted professional standards or suggested that such decisions were not actually based on their professional No. 23-1335 19

judgment. See Norfleet, 439 F.3d at 396 (“[A] difference of opin- ion among physicians on how an inmate should be treated cannot support a finding of deliberate indifference.”). 2. Discipline Sanders also contends that the Providers acted with delib- erate indifference to his mental health needs during the disci- plinary process. Sanders insists that he is not challenging the discipline he received. Instead, he argues, a reasonable jury could find that the Providers knew of the obvious harms from segregation and, despite this, failed to exercise their clinical judgment when recommending segregation and similarly re- strictive sanctions. But, even if we were to assume that the Providers were aware of the risk as Sanders describes and take Sanders’s factual assertions to be true, the record is de- void of any evidence from which a reasonable jury could con- clude that no minimally competent mental health profes- sional would have made the recommendations they did. Furthermore, Moss, Nelson, and Haag each recommended that Sanders be docked yard time. And, because access to ex- ercise is an essential human need, we have recognized that failure to provide exercise time can violate the Eighth Amend- ment. See Delaney v. DeTella, 256 F.3d 679, 683 (7th Cir. 2001); Anderson v. Romero, 72 F.3d 518, 528 (7th Cir. 1995). Still, for the reasons explained, the record before us lacks a basis upon which a jury could conclude that Nelson’s recommendation under these circumstances substantially departed from pro- fessional norms. Sanders also criticizes the Providers for “fail[ing] to un- dertake a meaningful review of [his] medical history before recommending solitary confinement.” He cites the testimony 20 No. 23-1335

from Nelson, Lanterman, and Duckworth discussed earlier. But of these three Providers, only Nelson completed a form for Sanders. And Nelson stated that, although he did not re- view Sanders’s mental health records prior to completing the form, he relied on information from colleagues who treated Sanders on a regular basis. Nothing in the record indicates that this was such a stark departure from professional stand- ards as to constitute deliberate indifference. Lastly, even if no minimally competent mental healthcare provider would have made the recommendations the Provid- ers did here, Sanders has not demonstrated a genuine dispute of fact as to whether the recommendations caused him harm. By the time the Providers began participating in Sanders’s disciplinary proceedings—the earliest being Moss in May 2015—he was already serving a term of segregation set to ex- pire in January 2022 and was released from segregation in September 2017. Thus, no reasonable jury could conclude that the recommendations of the Providers caused him to serve more time in segregation than he otherwise would have. For these reasons, the district court did not err when grant- ing summary judgment in favor of the Providers. B. Wexford Sanders asserts two grounds for his Monell claim against Wexford. First, he contends that Wexford has a widespread practice or custom of ignoring the mental health problems of inmates until they are in crisis. Second, he faults Wexford for failing to give direction to its mental health professionals on how to complete a Mental Health Disciplinary Review form. We have recognized three types of entity action that can support Monell liability under § 1983: “(1) an express policy No. 23-1335 21

that causes a constitutional deprivation when enforced; (2) a widespread practice that is so permanent and well-settled that it constitutes a custom or practice; or (3) an allegation that the constitutional injury was caused by a person with final poli- cymaking authority.” Id. at 986 (internal quotation marks omitted). Moreover, inaction can give rise to liability under Monell if it reflects “a conscious decision not to take action” where necessary to “remedy a potentially dangerous prac- tice.” Glisson v. Ind. Dep’t of Corr., 849 F.3d 372, 381 (7th Cir. 2017) (en banc) (internal quotation marks omitted); see also J.K.J. v. Polk Cnty., 960 F.3d 367, 377–78 (7th Cir. 2020) (en banc). 1. Refusing Treatment Sanders contends that Wexford has a practice or custom of refusing mental health treatment until an inmate harms him- self or threatens to do so. 8 But, assuming such a practice ex- isted, Sanders has not created a genuine issue of fact as to whether such a practice was widespread. Sanders points to only one occasion when Moss told him that she did not want to see him unless he was suicidal. 9 And, while a plaintiff may

8 It does not appear that Sanders raised this precise Monell theory

when responding to defendants’ summary judgment motion below. Ra- ther than asserting a widespread refusal of treatment until a crisis occurs, Sanders submitted that Wexford lacked a policy that ensured consistent and effective mental health treatment. Defendants do not complain, so we will take Sanders’s theory as he has articulated it here. 9 The other incident was relayed by a guard to Sanders and constitutes

at least one level of inadmissible hearsay. See Washington Cnty. Water Co., Inc. v. City of Sparta, 77 F.4th 519, 529 (7th Cir. 2023) (“[I]nadmissible 22 No. 23-1335

be able to “demonstrate the existence of an official policy or custom by presenting evidence limited to his own experi- ence,” Grieveson v. Anderson, 538 F.3d 763, 774 (7th Cir. 2008), one incident cannot “plausibly be described as ‘so persistent and widespread as to practically have the force of law.’” Bridges v. Dart, 950 F.3d 476, 480 (7th Cir. 2020) (quoting Con- nick v. Thompson, 563 U.S. 51, 61 (2011)). Sanders also points to purported gaps in treatment by the Providers as evidence of a widespread practice of refusing mental health care until a crisis arises, but the record clearly shows that many other mental healthcare providers, includ- ing multiple psychiatrists and psychologists, were regularly treating him during the times that he was not seeing the Pro- viders. In fact, on this record, there can be no genuine dispute that Sanders was receiving continuous treatment for his men- tal health conditions, including before and after each suicide attempt. 2. Lack of Policy Lastly, Sanders argues that Wexford had an obligation to promulgate a policy describing what a mental health profes- sional should do when participating in a disciplinary pro- ceeding, but failed to issue one. It is not clear from the briefing what Sanders thinks such a policy should contain. For exam- ple, does he believe that Wexford should require mental health professionals to review an inmate’s mental health rec- ords in all cases, consider an inmate’s overall segregation

hearsay evidence does not create a factual dispute at summary judg- ment.”) (citation omitted). No. 23-1335 23

time, meet with the inmate in person before making a recom- mendation, or always recommend a reduced segregation time (or, perhaps, all the above)? What is clear is that IDOC already had a procedure in place to ensure the involvement of mental health profession- als in the disciplinary process for seriously mentally ill in- mates. And his own proceedings before the Adjustment Com- mittee demonstrates the significant impact that their recom- mendations could have on the outcome. Furthermore, given the existing policy, there is no evi- dence in the record from which a reasonable jury could find that the failure to promulgate a more detailed policy created a risk so obvious as to constitute deliberate indifference. And Sanders has presented no evidence to show that the absence of such a policy caused the Providers to treat him in a way that violated the Eighth Amendment. Dr. Grassian does vaguely suggest that Wexford failed to adequately train its mental health providers regarding the risks posed by solitary confinement to inmates suffering from mental illness, but he says nothing about whether the detailed policy Sanders proposes was necessary or, if so, whether the need would have been obvious to Wexford. Thus, the district court did not err in granting summary judgment to Wexford on Sanders’s Monell claims. IV For these reasons, the district court’s grant of summary judgment is AFFIRMED. 24 No. 23-1335

ROVNER, Circuit Judge, concurring. Although I agree that there can be no liability for these defendants under our delib- erate indifference standard, I write separately to emphasize what I have said more extensively in my dissent in Johnson v. Prentice, 29 F.4th 895, 906 (7th Cir. 2022), and what my brother, Judge Hamilton, has written recently in his concurrence in Jackson v. Anastasio, No. 23-1703, 2025 WL 2437947, at *10 (7th Cir. Aug. 25, 2025) (Hamilton, J., joined by Rovner, J., concur- ring), about our evolving understanding of solitary confine- ment and its deleterious effects. It is undisputed that Cordell Sanders was living with seri- ous mental illness. Because of repeated rules infractions, Sanders spent eight continuous years in solitary confinement. This isolation was all-encompassing. Sanders was held in his cell for 22 to 24 hours a day. Occasionally, he was let out to shower, for visits, to use the solitary confinement law library, or to attend “yard” in slightly larger cells that look like very narrow, chain-link-fenced dog runs, which Wexford’s own expert described as “isolated cubicles.” He did not have ac- cess to out-of-cell religious, educational, or vocational pro- gramming. When he did leave his cell, Sanders was shackled, even during medical appointments. His cell had no outside windows and little air flow, subjecting him to extreme tem- peratures and stifling conditions. He had little to no ability to interact with other prisoners. For at least five of the eight years of his solitary confinement, he was on “yard re- striction,” meaning that he was only allowed to leave his cell for exercise in the isolated cubicle once a month, for a single hour, and often he did not get even that miniscule relief. Despite (or perhaps because of) spending eight years in continuous solitary confinement, he was unable to conform No. 23-1335 25

his behavior to prison expectations or to act in a manner that benefited his own interest. During his time in solitary confine- ment, Sanders expressed suicidal thoughts, harmed himself, and attempted to take his life multiple times. He overdosed on pain medication in 2010. He sliced his stomach in 2012. He overdosed on 69 pills on October 27, 2015, and overdosed again on pills on July 24, 2016—his fourth suicide attempt in six years. Two days later, in continued distress, he began to bite his wrist. Sanders’ experience with solitary confinement is not unique. The amicus briefs of former correctional officials, as well as that of mental health professionals with extensive ex- perience studying the psychological and physiological effects of solitary confinement detail the abundant research describ- ing the destructive and devastating mental health effects of even the most minimal time spent in solitary confinement. See R. 53 and 54. The effects are universal. According to one re- searcher’s survey, “[t]here is not a single published study of solitary or supermax-like confinement in which nonvoluntary confinement last[ing] for longer than 10 days … failed to re- sult in negative psychological effects.” 1 Of course prison staff must have measures to enforce rules violations and to keep inmates and staff safe. But the amicus brief from former correctional officials claims that the in- creased use of solitary confinement is “not associated with re- ductions in facility or systemwide misconduct and violence.”2

1 Craig Haney, Mental Health Issues in Long-Term Solitary and “Super-

max” Confinement, 49 Crime & Delinquency 124, 132 (2003)). 2 Benjamin Steiner & Calli M. Cain, U.S. Dept. of Justice Programs,

Bureau of Justice Statistics, The Relationship Between Inmate Misconduct, (continued) 26 No. 23-1335

In fact, “data reveal[] a clear relationship between the use of restrictive housing in facilities and [] indicators of facility dis- order.”3 Studies have also demonstrated that reducing soli- tary confinement decreases prison violence dramatically. 4 In light of the uncontroverted harm to prisoners, forty-five states have introduced bills to regulate, limit, or ban solitary con- finement. 5 As of 2023, twenty states had introduced bills to limit solitary confinement to fifteen days or less, three of which have passed, and only Iowa, Idaho, Utah, North Da- kota and Wyoming had not yet introduced a single bill on the topic. 6

Institutional Violence, and Administrative Segregation: A Systematic Review of the Evidence in Restrictive Housing in the U.S.: Issues, Challenges, and Future Directions, at 179 (Nov. 2016), http://www.nationaljailacademy.org/_doc- uments/resources/administrative-segregation/doj-restrictive-hous- ing.pdf. [https://perma.cc/5PS9-TG3E] 3 Allen J. Beck, U.S. Dept. of Justice, Office of Justice Programs, Bureau

of Justice Statistics Use of Restrictive Housing in U.S. Prisons and Jails, 2011–12, at 10 (Oct. 2015), https://bjs.ojp.gov/con- tent/pub/pdf/urhuspj1112.pdf. [https://perma.cc/4SVJ-6GYQ] 4 See, e.g., Marc A. Levin, Texas Public Policy Foundation, Testimony of

Marc A. Levin, Esq., Director of the Center for Effective Justice at the Texas Pub- lic Policy Foundation Before the U.S Senate Judiciary Subcommittee on The Con- stitution, Civil Rights and Human Rights, at 3 (Feb. 2014) (noting decreases in violence associated with reducing solitary confinement across multiple states), https://www.judiciary.senate.gov/imo/media/doc/02-25-14Levin- Testimony.pdf. [https://perma.cc/L3UU-QFY5] 5 Jean Casella, New Report and Public Database Track Legislation to Limit

or End Solitary Confinement, Solitary Watch (January 2023), https://solitary- watch.org/2023/01/25/new-report-and-public-database-track-legislation- to-limit-or-end-solitary-confinement. [https://perma.cc/65XX-RSDP] 6 Id. No. 23-1335 27

And so, in the end, Sanders suffered terribly for, at most, a minimal positive effect on prison security, and possibly even a negative effect. Although we once looked at outdoor exercise time in prison as recreational, our “evolving stand- ards of decency” allow us to understand that “conditions which may have been acceptable long ago may be considered unnecessarily cruel in light of our growing understanding of human needs and the changing norms of our soci- ety.” Delaney v. DeTella, 256 F.3d 679, 683 (7th Cir. 2001) (in- ternal quotation marks omitted). For several decades, we have recognized that exercise is one of the basic human neces- sities and an essential component of health. Anderson v. Romero, 72 F.3d 518, 527–28 (7th Cir. 1995). It “is no longer considered an optional form of recreation but is instead a nec- essary requirement for physical and mental well-be- ing.” Delaney, 256 F.3d at 683. Consequently, “long stretches of [solitary] confinement can have serious adverse effects on prisoners’ psychological well-being” and can be described as cruel under the Eighth Amendment if “unrelieved by oppor- tunities for out-of-cell exercise.” Pearson v. Ramos, 237 F.3d 881, 884 (7th Cir. 2001); see also Davenport v. DeRobertis, 844 F.2d 1310, 1313 (7th Cir. 1988) (“[I]solating a human being from other human beings year after year or even month after month can cause substantial psychological damage.”). Of course, that basic human need must be balanced against secu- rity and penological interests of the prison, but “‘[t]o deny a prisoner all opportunity for exercise outside his cell would, the cases suggest, violate the Eighth Amendment unless the prisoner posed an acute security risk if allowed outside of his cell for even a short time.’” Delaney, 256 F.3d at 687 (quot- ing Anderson, 72 F.3d at 527). 28 No. 23-1335

This case addresses the level of care mental health care providers owe to a prisoner in solitary confinement. In Jack- son, Judge Hamilton addressed the question of when discipli- nary solitary confinement implicates a prisoner’s liberty inter- est. Both cases at their core, however, ask courts to consider when solitary confinement breaches norms of humane and ethical treatment of prisoners. As Judge Hamilton points out, the United States sponsored rules in the United Nations enti- tled “Standard Minimum Rules for the Treatment of Prison- ers” which prohibit as a form of torture solitary confinement of more than fifteen consecutive days. Jackson, 2025 WL 2437947, at *10 (Hamilton, J., concurring). Sanders endured solitary confinement for more than eight years. And as Judge Hamilton further notes, “recent case law … reflects a judicial intuition that prolonged punitive solitary confinement should be a thing of the past, ” as it is not consistent with “’evolving standards of decency that mark the progress of a maturing society.’” Id. at *16 (quoting Walton v. Nehls, 135 F.4th 1070, 1072 (7th Cir. 2025)). Although we find no liability for these defendants given their limited role in the assignment of Sanders’ solitary con- finement, 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 in- form our understanding of deliberate indifference, liberty in- terests, and Eighth Amendment standards in cases where de- fendants were, in fact, responsible for imposing the condition. With our growing understanding of human needs, mental ill- ness, and the devastating effects of solitary confinement, our standards of decency and humaneness must evolve to reflect the changing norms of a civilized society.