Elevating the System:

Exploring Alternatives to Restrictive Housing

Restrictive Housing Systems Study,
Program Validation and
Best Practice Recommendations
Submitted March 2021
Independent Report Commissioned by the Massachusetts Department of Corrections (MADOC)

CONTENTS
3
4
7
9
11
14
20
21
24
32
38
39
41
46
47
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Cover Letter
Executive Summary
Assessment and Methodology
Restrictive Housing: Operational Discussion
U.S. Department of Justice Investigation into
Mental Health Watch
Review of Existing Systems
Current Restrictive Housing
Focused Population Study
Experiences of the System
Key Observations
Recommendations and Options
Option 1: Enhancements to System
Option 2: Structured Intervention
Appendix A: Structured Intervention Units (SIU)
Appendix B: Acronyms

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Cover Letter
Dr. Elizabeth M.Falcon
PsyD, CCHP-MH, MBA
CEO and Founder,
Falcon, Inc.

February 1, 2021
Carol A. Mici Commissioner
Massachusetts Department of Correction
State of Massachusetts
50 Maple Street
Milford, MA 01757

Re: MADOC Restrictive Housing Systems Study
Dear Commissioner Mici,
I write on behalf of the Falcon team of experts engaged to study
the Commonwealth of Massachusetts Department of Correction
(MADOC) Restrictive Housing Systems. With your leadership over
the past two years, MADOC is emerging as a national leader in state
corrections: your inmate population has consistently declined every
year for more than ten years; you have improved and expanded
treatment services for the Seriously Mentallly Ill (SMI); you have
provided thoughtful suicide prevention training for your correctional
staff, and, with this aspirational study, you have positioned MADOC
to implement systemic changes to restrictive housing - improving
the overall health, safety and security of inmates and also your staff,
for many years to come.
Falcon’s Report, Elevating the System: Exploring Alternatives to Restrictive Housing, is enclosed,
and includes our Key Observations and Recommendations and Options for your consideration.
Senior Expert and Falcon Vice President, Dr. Robin Timme, Psy.D., ABPP, CCH-MH has taken the
lead for Falcon, and assembled and drawn upon a team of national experts to conduct htis study
and develop key observations and recommendations: Falcon Senior Corrections Experts, Rick
Raemisch, Scott Semple, Mark Richman, PhD, and David Stephens, Psy.D. and all have participated
in this systems study.
Falcon’s six-member inter-disciplinary team has worked collaboratively with your senior staff
members to 1) conduct a focused review of data and population trends, 2) review and assess
MADOC’s existing systems and restrictive housing practices, 3) facilitate a series of workshops for
internal and external stakeholders, 4) tour five of your 16 institutions, 5) interview individuals and
small groups of current and former inmates and staff, 6) identify and analyze key observations,
and, 7) develop the enclosed set of recommendations and options.
Thank you for the opportunity to assist you and the Department of Correction. Falcon would
like to continue to work with you, and we would be very pleased to participate in discussions
as you develop next steps. Please feel free to contact me or Dr. Timme if you would like more
information about the enclosed report
Sincerely,

Elizabeth Falcon
Psy.D., CCHP-MH, MBA
Encl.

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Executive Summary
The Massachusetts Department of Correction
(MADOC) has long been a leader in correctional
policy and practice across the United States.
Consistent with their stated mission “to promote
public safety by incarcerating offenders while
providing opportunities for participation in
effective programming to reduce recidivism,”
MADOC commissioned a study aimed at
assessing its use of restrictive housing and
associated programs. MADOC leadership
sought to validate those aspects of its
disciplinary system that were working well, and
to suggest specific evolutions in policy and
practice that can bring MADOC’s use of
restrictive housing in line with best correctional
and clinical practices today and in the future.
Falcon Correctional and Community Services,
Inc. (“Falcon”) was tasked with studying three
domains of inquiry:
1. Perform a comprehensive review of
MADOC’s existing Restrictive Housing
practices, including policies, procedures,
processes, and operations.
2. Conduct a thorough analysis of the
Restrictive Housing System for the purposes
of program development and validation.
3. If it is found that areas of improvement are
possible, provide a range of actionable
short- and long-term solutions.
This independent assessment was undertaken
by an interdisciplinary team of Falcon
consultants, including those with expertise in
the administration of prison systems and
facilities, correctional medical and behavioral
health, management of criminogenic risk, and
large-scale system assessment, leadership and
organizational change. The six-member team
worked to validate current and historical efforts
made by MADOC leadership to enhance
treatment of those in the disciplinary process,
identifying opportunities for further evolution,

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and identified additional recommendations
based on information discovered in the process
of answering these specific questions.
The purpose of this independent assessment
report is to function as a collaborative road map,
arriving at recommendations for system
improvement and pivoting toward guidance for
implementation. This report aims to maximize
the use of alternatives to restrictive housing
practices, while enhancing system-wide safety
and security. Ultimately, the team did arrive at
key observations and recommendations for
system elevation. It should be noted that all
observations, conclusions, and
recommendations offered in this report are
done so to a reasonable degree of professional
certainty, based on the information available at
the time of writing.

CONSULTING TEAM
Robin Timme, Psy.D., ABPP, CCHP-MH
Project Manager
Senior Expert
Rick Raemisch
Chief Expert
Elizabeth Falcon, Psy.D., MBA, CCHP-MH
Chief Expert
Scott Semple
Senior Expert
David J. Stephens, Psy.D.
Senior Expert
Marc Richman, Ph.D.
Senior Expert

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CORE WORKING GROUP
Carol Mici

Commissioner

Chris Fallon

Deputy Commissioner - Prisons
Division

Nancy White

General Counsel - Legal Division

Sheryl F. Grant

Senior Litigation Counsel - Legal
Division

Key Observations
1. Senior leaders recognize the evolving nature of
correctional practices, lean into the issue of
Restrictive Housing reforms, and are flexible
and adaptable.
2. There exists a deep mistrust of MADOC from
public advocacy groups and the legislative
Criminal Justice Reform Caucus (CJRC).
3. MADOC is forced to be reactive to outside
pressures in enacting system improvements,
policy changes, and reforms.

Steve Kenneway

4. MADOC experiences outside groups as
unsympathetic to the challenges faced by those
providing care and custody in prisons.

Andrew Peck

5. Leadership views this study as an opportunity to
confirm what is done well, but also for proactive
system change and implementation of best
practice correctional and rehabilitative models.

Acting Assistant Deputy
Commissioner - Prison Division Northern Sector
Undersecretary for Criminal Justice

Stephanie Sullivan

Assistant Deputy Commissioner Clinical Services

Allison Hallett

Acting Assistant Deputy
Commissioner - Reentry

Doug DeMoura
Superintendent

6. Conceptually, it is helpful to separate ‘Pre-DDU’
[i.e., Restrictive Housing Units (RHU)] from the
Department Disciplinary Unit (DDU) itself, which is
a physical place rather than a condition of
confinement.
7. Conditions of confinement in the DDU result in
prolonged stays in Restrictive Housing.

Jennifer Gaffney

8. Procedural due process afforded to those
referred to the DDU can create unpredictable
lengths of stay in Restrictive Housing.

Mitzi Peterson

9. Programming for criminogenic needs in the DDU
should be assessed and enhanced, to improve
the quality of time-out-of-cell for meaningful
interaction, not only the quantity.

Deputy Commissioner - Clinical
Services & Reentry
Acting Assistant Deputy
Commissioner - Health Services

Michael Rodriguez
Superintendent

Michael Grant

Deputy Commissioner - Career &
Professional Development

Matt Moniz

Operations Analyst Manager

Dean Gray

Superintendent

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Recommendations and Options
1.

Develop a team, plan, and schedule for implementation of system enhancements
decided upon based on review of recommendations and options in this report.

2. Develop a transparent communication strategy.
3. Dissolve the DDU.
4. Consider eliminating all use of Restrictive Housing as currently defined.
5. Study Mental Health Watch and assess the allegations made in the Department of Justice
(DOJ) Report, using the opportunity to enhance safety and quality of healthcare delivery.
6. Use the disciplinary process to assess clinical and criminogenic needs that contributed to
requirement for increased restrictions.
7. The Secure Adjustment Unit (SAU) has excellent potential – consider expansion,
segmentation by risk level, and clinical or criminogenic tracks within the program.
8. Evaluate the effectiveness of treatment and programming in the revised specialized
housing, including the experiences of those who live and work in those programs, and
expand bed capacity when implementing enhancements.
9. Create a Substance Use Disorder treatment program for those with positive Urine Drug
Screens (UDS) or who are otherwise entering the disciplinary system secondary to use of
drugs or alcohol.
10. Expand availability of tablets and tablet-based treatment and programming system-wide.
11. Enhance training initiatives, including matching staff to specialty programs.

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Assessment and Methodology
Falcon consultants utilized a multi-method
approach to information-gathering and data
analysis, utilizing a combination of quantitative
and qualitative sources. In addition to an initial
data and document request, Falcon consultants
submitted two additional data requests
supplementing those documents that were
provided and those that were publicly available.
Documents included legal, policy, and
operational guidance, along with various site
procedures and clinical practices. Data sets
were generally obtained through public access
databases available through legislative and
statutory oversight bodies like the Restrictive
Housing Oversight Committee (RHOC).

These sources of information were reviewed
and incorporated into this written report.

Falcon consultants facilitated two series of
workshops spanning the months of May through
October of 2020, interviewing various internal
and external stakeholder groups, and inviting
participation from a broad array of stakeholder
groups. Workshops included those with lived
experience as formerly incarcerated persons,
some of whom had been placed in Restrictive
Housing during their periods of incarceration.
Additionally, local advocacy groups participated
in several workshops, along with a wide array of
administrative, operational, and healthcare
representatives from MADOC and its contracted
providers of medical, mental health, substance
use disorder treatment, and criminogenic risk
programming.

In addition to the Core Working Group of
MADOC leadership, on June 1st and June 2nd,
the team held virtual two- to three-hour
workshops with the following subject matter
groups internal to MADOC: 1) Legal, Policy and
Classification; 2) Treatment and Programming;

In addition to workshops and small focus
groups, two of Falcon’s consultants conducted
site tours, which included individual and group
interviews with staff and inmates within five
MADOC facilities. Falcon consultants presented
preliminary impressions to the Core Working
Group of MADOC in July of 2020, and provided
an overview and update to the RHOC in
September of 2020 at the request of its Chair,
Undersecretary of Criminal Justice, Andrew
Peck. Lastly, the Consulting Team held a final
workshop with the Core Working Group on
December 4, 2020 to provide a feedback
session regarding key observations,
recommendations, and to suggest strategies for
implementation.

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MADOC leadership was notably engaged and
cooperative throughout the study, and it was
clear to the team that MADOC leadership its
authentically invested in evolving their system
of care and custody. It should be noted that this
study was conducted during a global pandemic
that has put on full display the unique
vulnerabilities of prisons, systems of public
health and public safety, and the people who
live and work within them.

Workshops and Focus Groups

3) Release, Systems Issues, and Follow-Up.

Subject Matter Groups
1.

Legal, Policy and
Classification
2. Treatment and
Programming
3. Release, Systems
Issues and Follow-Up

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Following completion of this first series of
workshops to orient to the system, the team
held an additional series of focus groups, each
lasting approximately 90 minutes, with
participation from internal and external
stakeholders, including supervisory and line
staff from MADOC, Wellpath, LLC (contracted
provider of healthcare services), Spectrum
Behavioral Health (contracted provider of
Substance Use Disorder treatment and
programming for criminogenic thinking),
Prisoners’ Legal Services (PLS), and former
clinical and program staff. Topics for focus
groups included the following: Programming,
Staffing and Training, Security Operations,
Advocacy, Mental Health System Overview,
Data and Documents, Healthcare Operations,
Legislative, People with Lived Experience,
Former Clinical and Program Employees.
On July 16th, the Consulting Team held a fourhour workshop with the Core Working Group to
summarize the work to date, and to confirm a
thorough understanding of the MADOC prison
system and its substantive and procedural
disciplinary processes and placements.
On September 24th, three members of the
Consulting Team presented the study, methods,
and preliminary observations to the RHOC,
requesting and receiving feedback, concerns,

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Focus Groups Topics
•
•
•
•
•
•
•
•
•

•
•

Programming
Staffing and Training
Security Operations
Advocacy (Prisoners’ Legal Services)
Mental Health System Overview
Data and Documents
Healthcare Operations (Wellpath)
Legislative
People with Lived Experience

Former Clinical and Program
Employees

questions, and additional guidance as the team
began formulating this report. Following that
meeting, additional focus groups were held with
a group of legislators on October 1st, and a
group of formerly incarcerated persons on
October 6th. Both of the latter groups were
arranged with the assistance of PLS, an
engaging and passionate group of legal and
mental health professionals who were very
helpful to the Consulting Team in the data
collection process.

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Restrictive Housing: Operational Discussion
Restrictive Housing1 is defined in the Code of
Massachusetts Regulations (CMR)2 as any
placement in a correctional facility that requires
confinement to a cell for more than 22 hours
per day on average, with the exceptions of
conditions imposed on the order of a healthcare
provider. This CMR definition is based on that
promulgated in the Criminal Justice Reform Act
(CJRA) of 2018, which codified for the definition
under Massachusetts law as, “[A] housing
placement when a prisoner is confined to a cell
for more than 22 hours per day; provided,
however, that observation for the mental health
evaluation shall not be considered restrictive
housing.3
While these definitions approximate those
contemplated by accreditation and professional
bodies, namely the American Correctional
Association (ACA)4 and the National
Commission on Correctional Health Care

(NCCHC),5 placement in the DDU is an
important departure, and one that allows for up
to ten years of confinement in conditions that
would otherwise be labeled as Restrictive
Housing by most definitions (i.e., average of 22
or more hours per day confined to cell, longer
than 15 days, without the order of a healthcare
provider). Similarly, conditions imposed on the
order of a healthcare provider as the least
restrictive means of ensuring safety from
imminent harm to self or others, while a critical
exercise in medical autonomy, do present the
risk of inappropriate use, prolonged isolation,
and other conditions that - but for the order of
the healthcare provider - would be considered
Restrictive Housing. Both exceptions warrant
attention in this report.

We use the term Restrictive Housing, but consider it to be analogous with terms such as segregation, solitary
confinement, isolation, and any other condition that requires confinement to one’s cell for an average of 22 hours per
day, without the written order of a healthcare provider.
1

2

103 CMR 425.05.

SECTION 87. Said section 1 said chapter 127, as so appearing, is hereby further amended by inserting after the definition
of “Residential treatment unit” the following definition: “Restrictive Housing,” a housing placement where a prisoner is
confined to a cell for more than 22 hours per day; provided, however, that observation for mental health evaluation shall
not be considered restrictive housing. Available: malegislature.gov/Laws/SessionLaws/Acts/2018/Chapter69.

3

According to ACA’s Restrictive Housing Expected Practices (January, 2018), Restrictive Housing is “a placement that requires an inmate to be confined to a cell at least 22 hours per day for the safe and secure operation of the facility.”

4

5
According to NCCHC, solitary confinement is defined qualitatively as the housing of a person with minimal or rare
meaningful contact with other individuals. The definition references “sensory deprivation” and “few or no educational,
vocational, or rehabilitative programs.” They conclude, “Regardless of the term used, an individual who is deprived of
meaningful contact with others is considered to be in solitary confinement.” See Position Statement on Solitary
Confinement (Isolation) available: https://www.ncchc.org/solitary-confinement.

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In their updated report titled Time-in-Cell 2019:
A Snapshot of Restrictive Housing6 (September
2020), the collaboration between Correctional
Leaders of America (CLA) and the Liman Center
at Yale Law School defined Restrictive Housing
as, “holding individuals in a cell for an average
of twenty-two hours or more a day for fifteen
days or more (pp. 1).” The focus on 15 days
appears to derive international bodies that have
focused on prolonged solitary confinement that
eventually equates to torture, but we believe
the moment an individual is placed into those
conditions, the potential for prolonged solitary
confinement exists on day one, and thus we
afford little weight to the 15-day criterion.
Falcon consultants recognize that the qualitative
components of isolation from others, (i.e.,
sensory deprivation, lack of meaningful contact,
minimal access to care, decreased
interpersonal engagement, etc.) are critical to
appreciating the impact of Restrictive Housing
on individuals. However, quantitative definitions
are necessary to standardize these conditions
of confinement across varied iterations of
restrictive settings across jurisdictions. In this
way, definitions of Restrictive Housing take on a
letter and a spirit; the former represented in
specific definitions like the one promulgated
internationally in the United Nation’s Nelson
Mandela Rules, nationally by the ACA and the
Liman Report, and locally represented in the
CJRA and 103 CMR 425.05. The latter spirit is
represented more qualitatively in the NCCHC
Position Statement or the writings of the World
Health Organization (WHO).7 Both are critical to
examine in this report.

hours per day, and without the order of a
licensed healthcare provider. Additionally, the
team considered the quality of time-out-of-cell
as a critical qualitative component to the
definition, recognizing those components that
may be less measurable, yet just as important
as the quantitative elements.
Recognizing it as a condition of confinement
rather than a physical location, the team
observed people housed in units called RHUs,
but who were not – in fact – living in Restrictive
Housing conditions of confinement by this
definition⁸ ; similarly, if a person were confined
in a general population (GP) cell under the same
conditions (i.e., 22 or more hours per day
in-cell), he or she would still be considered to
be in Restrictive Housing under this operational
definition.

For the purposes of this study, the Consulting
Team defined Restrictive Housing as any
condition requiring a person to potentially
remain in a cell for an average of 22 or more

The updated Liman Center Report is available: law.yale.edu/liman/solitary2020.
Enggist, S., Moller, L, Galea, G. & Udesen, C. (Eds.). (2014). Prisons and health. World Health Organization. Available:
https://www.euro.who.int/__data/assets/pdf_file/0005/249188/Prisons-and-Health.pdf.
⁸ Example: people identified as requiring additional clinical services were removed from their cells more frequently
6
7

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U.S. DOJ Investigation into Mental Health Watch
On November 17, 2020 the United States DOJ
issued a report titled Investigation of the
Massachusetts Department of Correction (“DOJ
Report”),9 along with a press release. According
to the DOJ Report, MADOC was notified on
October 22, 2018 that the DOJ had opened an
investigation pursuant to the Civil Rights of
Institutionalized Persons Act (CRIPA).10 DOJ
focused their investigation on two specific
areas, including whether MADOC, “violates the
constitutional rights of prisoners who have
serious mental illness, or who are otherwise at
risk of serious harm from restrictive housing, by
placing them in restrictive housing for
prolonged periods of time,” and whether
MADOC, “violates the constitutional rights of
geriatric and palliative care prisoners by failing
to provide them with adequate medical care.”
According to the DOJ Report, on November 21,
2019, MADOC was notified of two additional
areas of investigation, specifically whether they,
“provide prisoners in mental health crisis with
constitutionally adequate mental health care,”
along with investigating whether MADOC,
“provides prisoners in mental health crisis with
adequate supervision to provide reasonable
protection from self-harm.” The DOJ Report
stated,
“We are closing our restrictive housing - for
housing other than mental health watch - and
the geriatric and palliative care portions of our
investigation without issuing a Notice of
constitutional violation.” The DOJ Report
concluded the following conditions in their
notice to MADOC:
•

[MADOC] fails to provide constitutionally
adequate supervision to prisoners in mental
health crisis.

•

[MADOC] fails to provide adequate mental
healthcare to prisoners in mental health
crisis.

•

[MADOC]’s use of prolonged mental health
watch under restrictive housing conditions,
including its failure to provide adequate

9
10

mental health care, violates constitutional
rights of prisoners in mental health crisis.
While a comprehensive review of the Suicide
Prevention and Mental Health Watch Systems
were beyond the scope of this study, there are
overlaps with Restrictive Housing as codified
and defined in Massachusetts. Most importantly,
mental health crises and self-directed violence
are unfortunately common occurrences in
Restrictive Housing settings across the country.
Effectively minimizing or eliminating the use of
Restrictive Housing will thus reduce the
occurrence of these psychiatric emergencies
and placement on Mental Health Watch.
The DOJ’s report suggests that the condition
imposed on Mental Health Watch equate to
Restrictive Housing conditions of confinement
due the overly restrictive nature of Mental
Health Watch, the lack of adequate mental
health treatment that occurs while on Mental
Health Watch, and the potential for prolonged
isolation, regardless of the order of a healthcare
provider. In other words, while the
Commonwealth of Massachusetts and MADOC
specifically exclude Mental Health Watch from
the legal and regulatory definitions of Restrictive
Housing, the conditions of confinement in
practice equate to Restrictive Housing by
another name; or as the DOJ Report asserts,
“The legislature’s decision to exclude mental
health units from the definition of ‘restrictive
housing’ does not make it so (pp. 15-15).”
While it was beyond the scope of this study to
comprehensively evaluate Mental Health Watch,
the Consulting Team did not witness any of the
egregious scenarios referencedin the DOJ
Report during site visits. However, it is the
strong recommendation of Falcon consultants
that those allegations are investigated
thoroughly and that MADOC use this as an
opportunity to proactively examine healthcare
effectiveness, safety, and quality for those
accessing the medical observation and Mental
Health Watch.

Full report available: https://www.justice.gov/opa/press-release/file/1338071/download.
42 U.S.C. §1997b.

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Review of Existing System
To conduct a study of this scope and substance,
a thorough understanding of the existing
system is crucial. Falcon consultants reviewed
hundreds of documents provided by MADOC,
conducted workshops and focus groups, and
visited five facilities in August of 2020. Falcon
consultants aimed to capture the Restrictive
Housing System in the following areas:
conditions of confinement, due process
experienced by those who are alleged to have
committed infractions, placement of individuals
into disciplinary detention,referral to and
placement in the DDU, the process of
identification, referral, diversion, and placement
into Secure Treatment Units (STU), the SAU, and
the clinical determinations for individuals to be
excluded from Restrictive Housing on the
professional judgment of Qualified Health and
Mental Health Professionals.
On August 18th and 19th, two members of the
Consulting Team toured five MADOC facilities,
including:
1.

Souza Baranowski Correctional Center
(SBCC)

2. MCI – Shirley
3. MCI – Concord
4. MCI – Cedar Junction
5. Old Colony Correctional Center (OCCC)
The purpose of these visits was to view the
RHUs, as well as to observe the Residential
Treatment Units (RTU), the DDU, the STUs, the
SAU, and the two Bridgewater State Hospital
inpatient “annex” units at OCCC. During these
site visits, the Consulting Team conducted
dozens of interviews with incarcerated persons
in group and individual formats, as well as
interviews of line staff from MADOC, Wellpath,
and Spectrum.

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Serious Mental Illness (SMI)
Recognizing that rates of behavioral health
crises and disorders are overrepresented in
prisons across the United States, systems and
facilities have categorized a sub-group of
clinical presentations as representing SMI.
Individuals with SMI are not only
disproportionately represented in jails and
prisons, but once incarcerated, they are more
likely to be housed in Restrictive Housing where
they are particularly vulnerable to
decompensation, exacerbated psychiatric
disturbance, self-injury, and suicide. For this
reason, tracking of the SMI population in the
disciplinary process is critical to effectively
providing the clinical safeguards to which those
with SMI are entitled and deserving.
The designation of SMI generally refers to a
sub-group of psychiatric disorders and/or level
of functional impairment that requires greater
clinical services to address higher levels of
acuity. These conditions generally reflect
breaks with reality (i.e., psychotic distortions,
hallucinations, delusions), severe depression or
suicidality, extreme affective states (i.e., manic
or hypo-manic episodes), and other symptoms
that create substantial impairment in one’s
ability to maintain their safety, the safety of
others, or to maintain their own health and basic
activities of daily living. Across the country, and
indeed between community and correctional
jurisdictions, the definitions of SMI vary
tremendously, and how the term is defined has
important ramifications; in most cases, being
classified as having an SMI entitles an individual
to financial or social program benefits, clinical
services, housing locations, and state-funded
community-based programs like Assertive
Community Treatment (ACT) and other ‘deepend’ mental health services.

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The CJRA of 2018 specifically defined SMI in
MADOC as follows:
A current or recent diagnosis by a QMHP of one
or more of the following disorders described in
the most recent edition of the Diagnostic and
Statistical Manual of Mental Disorders:
a.

Schizophrenia and other psychotic 		
disorders

b.

Major depressive disorders

c.

All types of bipolar disorders

d.

A neurodevelopmental disorder, 		
dementia or other cognitive disorder

e.

Any disorder commonly characterized
by breaks with reality or perceptions of
reality

f.

All types of anxiety disorders

g.

Trauma and stress related disorders

h.

Severe personality disorders; or a 		
finding by a QMHP that the inmate is at
serious risk of substantially deteriorating
mentally or emotionally while confined
in Restrictive Housing, or already has so
deteriorated while confined in 		
Restrictive Housing, such that diversion
or removal is deemed to be clinically 		
appropriate by a QMHP.

CJRA and policy, affords substantial
entitlements and protections, but also dilutes
the clinical impact of that designation. No longer
does the designation carry the clinical
connotation, for example, that the person
requires a higher level of care, presents with
greater acuity, necessitating more significant
clinical services.
Reflecting on the community standard, the
Substance Abuse and Mental Health Services
Administration (SAMHSA) states that SMI is,
“defined by someone over 18 having (within the
past year) a diagnosable mental, behavior, or
emotional disorder that causes serious
functional impairment that substantially
interferes with or limits one or more major life
activities.”11 The Centers for Medicaid Studies
(CMS) notes that “… states define SMI in different
ways depending on the entity, context, and
purpose for which it is being used (e.g., legal,
clinical, epidemiological, or operations).” 12 In
sum, the definitional parameters of a construct
like SMI have intended and unintended
consequences, and the implications ripple
through systems of care. In the community,
casting a wider definitional net entitles those
who may not require deep-end services and
supports to valuable and often scarce clinical,
financial, and other social supports, while
reducing personal independence and
autonomy. Meanwhile, to restrict the definition
disqualifies people who otherwise would have
received potentially critical supports prior to the
imposition of a more restrictive definition.

As a result of this greatly
expanded definition of SMI
The CJRA was implemented on
within MADOC facilities, the
January 1, 2019, and overnight the
number of inmates diagnosed
caseload of inmates designated
with SMI grew exponentially.
SMI nearly quadrupled, from 660 to
The CJRA was implemented
2,493.
on January 1, 2019, and
overnight the caseload of
inmates designated SMI
nearly quadrupled, from 660 to 2,493. Having a
designation of SMI in MADOC, according to the

11
12

www.samhsa.gov/find-help/disorders.
As an example, see Arizona Revised Statutes 36-551.

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Some states take a more subjective approach
the definitional issue, allowing for clinical
judgment and impairments in functional
capacities to drive the designation of SMI.13
These states do not list required diagnoses,
such as psychotic disorders, depressive
disorders, or affective disorders, while other
states are more specific in requiring a threshold
diagnosis and evidence of impaired role
functioning.14 Still others take an even more
restrictive approach to designation of SMI,
listing very specific diagnoses that are
necessary and sufficient for a designation of
SMI; for example, in Idaho, SMI, “means any of
the following psychiatric illnesses as defined by
the American Psychiatric Association in the
Diagnostic and Statistical Manual of Mental
Disorders (DSM-5) incorporated in Section 004
of these rules: (7-1-15):
a.

Schizophrenia spectrum and other 		
psychotic disorders

b.

Bipolar disorders (mixed, manic and 		
depressive)

c.

Major depressive disorders (single 		
episode or recurrent)

d.

Obsessive-compulsive disorders”15

The Commonwealth of Massachusetts has set a
narrower definition for SMI in the community
than in the Department of Correction,
specifically identifying non-qualifying disorders
that would qualify under the MADOC definition.16
Additionally, the Commonwealth of
Massachusetts identifies qualifying mental
disorders that further limit the scope of the
definition of SMI, which must be diagnosed to
qualify for those services in the community.

The impact of this expanded definition under
the CJRA has been felt throughout the
correctional system, and staff and inmates are
very aware of it. Correctional Officers reported
feeling frustrated that SMI had lost its meaning
in their purview, and that so many people
seemed to be designated SMI now that the
protections and services required for the
population seemed to apply inappropriately to a
great many inmates.
Similarly, clinical staff at each facility are now
forced to create their own work-arounds to
manage their caseloads and triage the patients
who are of the highest acuity levels. For
example, under the new definition of SMI, an
inmate diagnosed with Attention-Deficit
Hyperactivity Disorder (ADHD) qualifies as
having a SMI.17 Meanwhile, an inmate
diagnosed with Schizophrenia, hearing
command hallucinations and falsely believing
people are trying to harm him, is designated as
having a SMI. The two are very likely to have
different treatment needs, require differing
levels of care, but are categorized together
under the CJRA definition. As a result, mental
health departments were noted to maintain their
own lists of what might be called acute and
sub-acute populations, further segmentation of
the SMI population to restore the clinical
relevance to the term.
Lastly, it was observed through interviews with
staff and patients that the definition of SMI
under the CJRA resulted in increased
dependence on the State, a loss of autonomy,
and a sense of entitlement to enhanced mental
health services and social supports in the
community following release. As articulated
previously, the definition of SMI in MADOC is
very different than that in the Massachusetts
Department of Mental Health (DMH), and for
many of these people returning to the
community, they simply will not qualify for those
deep-end services once they are released.

As an example, see Arizona Revised Statutes 36-551.
As an example, see Maryland Priority Populations: https://maryland.optum.com/content/dam/ops-maryland/documents/
provider/providermanual/Maryland_ASO_MNC_BH2564_7.1.20.pdf.
15
Idaho Administrative Code IDAPA 16.07.33 Section 100, Page 5.
16
104 CMR 29.00.
17
ADHD is categorized as a Neurodevelopmental Disorder in the DSM-5.
13
14

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Defining MADOC’s Current Restrictive
Housing System and Due Process
The Restrictive Housing System exists within the
larger context of prison discipline, housing,
classification, and administrative responses to
alleged rule violations. These concrete aspects
of operations reflect the philosophical mission
of a prison system, influencing and reflecting
organizational culture, interdisciplinary training,
and the built environment, in addition to ideals
of deterrence, incapacitation, rehabilitation, and
retribution that are often unwritten. It should be
noted that there is no Restrictive Housing
placement in MCI – Framingham, nor is there a
female DDU in MADOC, having eliminated the
practice among the female population entirely.
What follows applies to the male population
residing in MADOC facilities.
When an individual residing in GP is alleged to
have committed an infraction warranting
removal from GP for investigation and potential
discipline, he is immediately taken to a Health
Services Unit (HSU) for evaluation by a Qualified
Health Professional (QHP) and QMHP who
make the clinical determination as to whether
placement in Restrictive Housing is
contraindicated. Although the HSU is the most
common location for these evaluations by QHPs
and QMHPs, in certain locations the evaluations
take place in examination rooms just outside
the sallyport for entry into the RHU. This was
observed by the Consulting Team at MCI –
Shirley. The individual is placed into one of
these spaces and the evaluations occur here
prior to admission to the RHU, consistent with
MADOC policy.18 Clinical contraindications to
placement in Restrictive Housing may include
injury sustained in the immediate incident,
unstable medical conditions requiring further
assessment or intervention in the HSU, as well

as identification of elevated risk for self-directed
violence, psychiatric decompensation, and the
opportunity to immediately triage someone
experiencing an acute psychiatric emergency
on to Mental Health Watch for further
evaluation, stabilization, and treatment planning.
Completion of these evaluations prior to
placement in a RHU affords a clinical safety net
by which QHPs and QMHPs can exercise
medical autonomy,19 delaying or avoiding
placement in RHU for those with unacceptably
high levels of clinical risk, to refer appropriate
individuals for placement in one of the STUs,
and to advocate for diversion to RTUs when
indicated. In practice, this is often an
opportunity for members of the interdisciplinary
team to ensure patient safety while deliberately
consulting on potential risk, review the events
leading to the alleged infraction, and to share
information regarding the appropriateness of
various interventions and housing placements.

103 CMR 423.08 Restrictive Housing Placement and Limitations on Placement in Restrictive Housing.
Medical Autonomy refers to the clinical independence of qualified health care professionals to practice medical and
behavioral health services without interference from custody staff. With clinical independence comes the responsibility
to practice according to one’s legal and ethical mandates, consistent with the laws of the local jurisdiction (usually
professional regulation bodies), as well as the Hippocratic mandate to ‘do no harm.’ NCCHC describes Medical
Autonomy in essential Standard P-A-03 Medical Autonomy, and rightfully places oversight and accountability on the
Responsible Health Authority (RHA) for monitoring and Continuous Quality Improvement (CQI) rather than on the
custodial component of operations.

18

19

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Page 15

If the person is determined to require additional
clinical services prior to placement into the
RHU, he is transferred to the HSU until
medically cleared by a QHP and QMHP. In this
way, the Restrictive Housing System meets the
standard for Suicide Prevention and
Intervention as promulgated by NCCHC, as the
QMHP conducts suicide risk screening and
assessment, diverting the individual onto Mental
Health Watch as indicated. NCCHC Standards
state that these processes are clinical in nature,
and fall under the purview of health care
professionals, noting, “Although many suicides
are unpredictable, a suicide prevention program
can help reduce risks. Inmates may become
suicidal at any point during their stay, but
high-risk periods include… [c.] After admittance
to segregation or single-cell housing.”
Compliance indicators,20 21 for this standard
include the following criteria, among others:
1.

The responsible health authority and facility
administrator approve the facility’s suicide
prevention program.

2. A suicide prevention program includes the
following:
•

Facility staff identify suicidal inmates
and immediately initiate precautions.

•

Suicidal inmates are evaluated
promptly by the designated health
professional, who directs the
intervention and ensures follow-up as
needed.

•

Acutely suicidal inmates22 are
monitored by facility staff via constant
observation.

•

Non-acutely suicidal inmates23 are
monitored by facility staff at
unpredictable intervals with no more
than 15 minutes between checks.

The best practice guidelines were followed by
MADOC as demonstrated in our facility tours,
process studies, and interviews. These
evaluations provide QHPs and QHMPs an
opportunity to prevent placement of an
individual into Restrictive Housing when certain
clinical contraindications are present, including
when an inmate is potentially suicidal and to
identify and evaluate any inmate diagnosed
with a SMI. During site visits, officers, inmates,
patients, and clinicians corroborated the
practices reflected in policy, and the Consulting
Team conducted mental status examinations of
patients being placed on Mental Health Watch,
some receiving treatment while on Mental
Health Watch, and many who had accessed the
Mental Health Watch System.
Once clinical emergencies or contraindications
are ruled out by QHPs or QMHPs, the individual
is admitted to the RHU on pre-hearing detention
status, pending investigation, and potentially
referred for placement in the DDU due to the
severity of alleged infractions. Because a DDU
referral can result in placement into the DDU for
up to ten years, additional due process
protections are afforded to the individual,
although those procedural components can
result in prolonged stays in the RHU awaiting
adjudication of the DDU referral. What was clear
in policy, procedure, and practice was that
reviews of these individuals happen both
formally and informally, and if an individual is to
remain in the RHU or DDU for lengthy periods
of time he is considered for early release,
tracked, and reported to the RHOC on a
quarterly basis.

20
National Commission on Correctional Health Care (NCCHC). (2018). Standard P-B-05 Essential. Standards for
health services in prisons. NCCHC.
21
National Commission on Correctional Health Care (NCCHC). (2015). Standard MH-G-04 Essential. Standards for
mental health services in correctional facilities. NCCHC.
22
Acutely suicidal (active) inmates are those who are actively engaging in self-injurious behavior and/or threaten
suicide with a specific plan (NCCHC P-B-05 [pp. 39]).
23
Non-acutely suicidal (potential or inactive) inmates are those who express current suicidal ideation (e.g., expressing
a wish to die without a specific threat or plan) and/or have a recent history of self-destructive behavior (NCCHC P-B-05
[pp. 39]).

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units are becoming less common, while the
‘pre-DDU’ components are closer to the
emerging standard of penological practice.
Considering the operational definition utilized in
this study, the Consulting Team considered
those housed in any RHU or in the DDU to be
housed in conditions of confinement that reflect
a Restrictive Housing status.

Operationally, administratively, and legally, the
DDU is identified as separate and distinct from
the RHUs. The Consulting Team quickly
recognized that it was helpful to separate the
system into ‘pre-DDU’ and ‘DDU’ components,
understanding that the DDU is a relatively
unique, small, but critical component to the
disciplinary system. In the experience of the
Consulting Team, these long-term segregation

Current Restrictive Housing Process:

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Page 17

Focused Population Study
To complete this assessment, the Consulting
Team requested and was provided with access
to individual and aggregated data regarding the
population placed in Restrictive Housing,
including specific demographic indicators,
length of stay, and additional relevant
information as requested. Monthly, quarterly,
and bi-annual reports to the RHOC were
instrumental in compiling this focused
population study. Those reports, issued by the
Executive Office of Public Safety and Security
(EOPSS) were observed to be outstanding in
the experience of the Consulting Team,
unmatched in our experience, providing useful
data pertinent to common concerns regarding
restrictive housing practices, such as reasons
for placement in Restrictive Housing, length of
stay, placement reviews and early releases,
mental health status, self-injurious behavior and
suicide, and additional aggregate and
individual-level data presented in a manner that
allows for others to conduct ad hoc analyses.
While the team did hear complaints from
advocacy groups regarding delays in the
production of these reports, their quality and
utility appear to be unquestionable.24

Based on a review of data from the 2019
calendar year reporting period, the following
calculations and observations were particularly
relevant and contributory to key observations
and subsequent recommendations:
•

The Total Average Daily Population has
steadily trended downward in recent years25
The corresponding chart represents that
decline.

•

MADOC had an operational capacity of 561
beds for males in Restrictive Housing until
July 2019, when they closed units, resulting
in a reduction to 501 beds, followed by a
reduction in beds to 481 in October of 2019,
and reduction to current number of 450
beds.26

•

In all, MADOC has reduced its number of
beds in Restrictive Housing by 111 or 20%
since July of 2019, continuing to remain
below 65% of capacity even as the number
of beds decreased substantially.

According to the organization of the data
provided by EOPSS, the RHOC also considers
those housed in RHUs separately from those
housed in the DDU and considers those in the
Restrictive Housing Unit serving Disciplinary
Detention (RHU-DD) separately from those held
in RHU for other reasons (i.e., awaiting hearings,
unwilling to leave, verified safety needs, etc.).

24
For additional information, statistics, membership, and further guidance, see: https://www.mass.gov/restrictive-housingoversight-committee.
25
MADOC. January 1, Snapshot 2011-2020.
26
MADOC. Number of inmates held in Restrictive Housing Units within each state correctional facility. Monthly
Restrictive Housing Report to the Restrictive Housing Oversight Committee.

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•

•

On January 7, 2019, 328 male inmates were housed
in RHUs: 3.73% of the inmate population at that time,
and 58.5% of capacity.
On April 1, 2019, 298 male inmates were housed in
RHUs (53.1% of capacity).

•

On July 1, 2019, 298 male inmates were housed in
RHUs (59.4% of capacity after reduction by 60
beds).

•

On October 1, 2019, 312 male inmates were housed
in RHUs (64.9% of capacity after reduction by 30
beds).

Date

Males
Housed

Capacity
Percent

1/7/2019

328

58.5

4/1/2019

298

53.1

7/1/2019

298

59.4

10/1/2019

312

64.9

1/6/2020

308

64.3

4/6/2019

290

64

•

On January 6, 2020, 308 male inmates were
housed in RHUs: 3.71% of the inmate population at
that time, and 64.3% of capacity).

•

On April 6, 2020, 290 male inmates were housed in RHUs (64% of capacity).

•

The Average Length Of Stay (ALOS) in RHUs in 2019 was 18 days, while the Median ALOS was
10 days.

•

The ALOS in RHUs for an individual on the mental health caseload was 19 days, while the
Median ALOS was 9 days.

•

In 2019, just under 50% of those housed in a RHU (non-disciplinary) met the definition of having
SMI.

•

In 2019, approximately 57% of those housed in the DDU were on the mental health caseload.

•

In 2019, 142 male inmates were placed in Restrictive Housing for using or possessing illicit
substances, having a UDS that was positive for illicit substances, or for consuming or producing
alcohol.27

•

Of those held in Restrictive Housing in 2019, approximately 57% had been placed in Restrictive
Housing previously.

•

Of those held in the DDU in 2019, approximately 1 in 4 had been held in the DDU previously.
Percent of Repeats

60%
50%
40%
30%
20%
10%
0%

2019

27
Class 2 Offenses, including 2-11, 2-14, and 2-19. Introduction and dealing in illicit substances, a Class 1 Offense
(1-15), was not included in this analysis.

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Experiences of the System
During the study period, the Consulting Team
Process Observations
had the opportunity to interact with an
estimated 200 stakeholders, including those
To further assess the practices in place within
currently incarcerated, those formerly
the Restrictive Housing System, the Consulting
incarcerated with lived experience, those
Team observed each relevant step in the
employed by MADOC and its contracted
disciplinary process. Consultants witnessed
providers, those formerly employed by MADOC intervention by staff responding to conflicts, the
and contracted providers, and those
use of clinical staff or specific MADOC staff to
representing advocacy and legislative efforts on establish rapport, the immediate resolution of
behalf of incarcerated populations and the
that conflict through restraint, and the
people of the Commonwealth. These
placement of the individual into restrictive
interactions occurred in scheduled workshops,
conditions of confinement that protected
small focus
himself and others
groups,
from imminent
individual
danger.
Stakeholders:
meetings,
Additionally, staff
public
described these
• Currently Incarcerated
hearings, and
procedures as
• Formerly Incarcerated
during site
routine,
• MADOC Employees and Contractors
visits on
incorporating
• Former MADOC Employees and Contractors
August 18th
multidisciplinary
and 19th. The
responses to
• Advocacy representatives
team
reduce uses of
• Legislative representatives
conducted
force and arrive at
• People of the Commonwealth of Massachusetts
interviews in
alternatives to
GP, RTUs,
more restrictive
HSU, RHUs,
interventions. The
Bridgewater State Hospital “annex” units
Consulting Team also observed the role of
[Intensive Stabilization and Observation Unit
nursing and mental health clinicians who
(ISOU) and Recovery Unit (RU)], the STUs
conducted evaluations in the HSU following an
[Secure Treatment Program (STP) and Behavior
incident, and prior to placement into an RHU.
Management Unit (BMU)], and the DDU. Those
While touring the RHUs, the consultants
site visits were attended by two of Falcon’s
observed clinical staff conducting wellness
Senior Consultants, one former state Secretary
checks and individual out-of-cell therapy
of Corrections and one psychologist, who
sessions in the RHUs and in the DDU. The team
obtained temporary licensure to practice in the
observed groups occurring in the STP and an
Commonwealth of Massachusetts. The
RTU, and toured various classrooms dedicated
psychologist provided MADOC and Wellpath
to the SAU. Additionally, the Consulting Team
with names of all those interviewed, and
observed first-hand the interdisciplinary
clinicians then provided immediate follow-up
communication occurring around those housed
with the inmate in accordance with agency
in the RHUs and the DDU, noting that all
protocol. What follows is summary material from members of the interdisciplinary treatment
these conversations and themes observed by
teams had clear familiarity with patients.
the on-site Consulting Team.

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From our observations, the processes observed
during the site visits reflected the policies
promulgated by MADOC and its contracted
providers of healthcare services, which in turn
are representative of the standard of practice as
described by relevant professional
organizations.

Professional Experiences
Core Working Group
The Consulting Team kicked off this study with a
series of workshops and focus groups with a
Core Working Group, as well as additional
leadership from MADOC and contracted
providers of healthcare and programs. At the
statewide level, the Commissioner participated
in several of the workshops along with Deputy
Commissioners overseeing prisons, healthcare,
programs, re-entry, and human resources, along
with strong representation from the legal
department. These leaders were joined by
several additional regional and facility-level
administrators who assisted with organizing
smaller focus groups to include those providing
care and custody inside housing units,
specialized treatment programs, and specifically
within RHUs and the DDU.
In general, MADOC leadership was well-versed
in national standards of correctional practice,
specifically accredited by the ACA and citing
the NCCHC Standards for Prisons in their
policies. MADOC leadership includes multiple
ACA auditors and those who work on
accreditation issues and it was clear that
MADOC policies were developed based on the
requirements put forth in the standards of both

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professional bodies. Consistent with best
practices, policies aligned with those standards,
and processes observed in facilities reflected
consistency with the policies of the agency.
MADOC leaders were equally as familiar with
the history of their agency, including the
statutory and legal influence on operations in
recent decades, often citing case law, quoting
statutes, and otherwise adept at explaining not
only what the policy is, but why it is that way.
The Core Working Group described a deep
sense of obligation and pride in the delivery of
services, feeling responsible not only to the
incarcerated population, but also to the staff
working within facilities and the constituents
beyond the walls. This sense of obligation was
matched by intense frustration expressed to the
consultants regarding the level of adversary
and animosity perceived from outside advocacy
groups and legislators. This group of leaders
was among the most educated and articulate
we have seen, with notable strengths observed
in those who work in data collection, synthesis,
and presentation; legal affairs; and the design
and delivery of mental health services.

Site-Level Interviews
The Consulting Team met with site-level
MADOC employees and contracted providers
of healthcare and programs during initial
workshops, follow-up focus groups, and during
site visits. In general, a close partnership was
observed between custody and healthcare staff
yet maintaining clear boundaries between
those responsible for treatment and those
responsible for security.

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Custody personnel who were responsible for
overseeing and working within specialized
housing units like the STUs, the RTUs, and the
DDU used the same language and rehabilitative
messaging that was observed in statewide
leadership meetings, with notable awareness
and rehabilitative ideals reflected at the
Superintendent and Captain levels of the
facilities. Furthermore, correctional officers
working on housing units were aware of the
CJRA and its language, clearly trained in the
requirements of the new law. In that vein,
several officers expressed frustration at the
revised definition of SMI, describing it as less
helpful for them in determining urgency of
referrals, need for advocacy or diversion, and
the sense that those who are “SMI by statute”
are somehow attempting to manipulate the
system to avoid unpleasant consequences for
their actions.
In general, correctional officers were aware of
the procedures and policies related to
Restrictive Housing, including the rights
afforded to those with SMI specific to time-outof-cell. Officers agreed with inmates interviewed
that the quality of programming while out-of-cell
could be improved, specifically in the DDU, and
even the Captain of that area was aware that
MADOC and its contracted provider were
working to enhance the quality of those
services.

Housing practices, as well as those involving
the triaging of patients to the HSU, on to Mental
Health Watch, or for referral through CourtOrder to the Bridgewater State Hospital annex
units.
Mental health clinicians described having
access to their patients and not feeling that
issues of dual loyalty28 negatively impacted
their delivery of care. Clinicians were observed
conducting individual therapy sessions in the
DDU, and the process for moving patients and
arranging private visits appeared to be
adequate. They stated that there are times
when their requests to see a patient face-toface in Restrictive Housing or in the DDU are
denied, but those denied requests are
temporary due to exigent circumstances of risk.
The clinicians stated that they are still able to
see the patient cell-side, and once deemed no
longer an imminent risk, the patient is presented
to the clinician in a private setting. Clinicians
were aware of some of the more complicated
ethical dilemmas encountered in correctional
healthcare, such as not ‘clearing’ a patient to
enter Restrictive Housing, but rather evaluating
for urgent or imminent risk that would warrant a
higher level of care in the HSU or on Mental
Health Watch.

With respect to mental health staff, consultants
interviewed regional and site-level directors,
along with mental health clinicians within
various facilities. The working relationship
between the contracted providers and the
MADOC healthcare leadership team was
obvious, and several of those interviewed had
worked for both employers throughout their
careers. Site directors were clearly invested in
patient care and were able to readily discuss
the clinical presentations of their more acute
patients after those patients were interviewed
by the consulting psychologist. Directors,
clinical supervisors, and clinicians were all able
to articulate the policies germane to Restrictive

Dual loyalty is an ethical dilemma encountered by healthcare providers working within settings of confinement that
create a conflict between professional duties to the patient, and the interests of another party, such as that
accompanying delivering care in a setting consecrated to security (i.e., the State). See: Pont, J., Stover, H. & Wolff,
H. (2012). Dual loyalty in prison health care. American Journal of Public Health, 102(3), 475-480. DOI: 10.2105/
AJPH.2011.300374.

28

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Of note, clinical staff at each facility described a
complicated response to the revised definition
of SMI under the CJRA; at once appreciating the
reduction of reliance on Restrictive Housing for
more inmates and patients, while also feeling
frustrated by the dilution of the clinical
importance of the SMI designation. Each mental
health department had developed its own
improvisational tracking method to clinically
triage the more acute patients to ensure that
those with the highest clinical needs received
the greatest level of service.

Currently Incarcerated Persons
The Consulting Team interviewed approximately
100 inmates across five MADOC facilities,
conducting formal and informal interviews.
Interviews occurred in group and individual
settings, and in private spaces when requested.
Because this study was conducted during a
global pandemic that highlighted the
epidemiological dangers of correctional
facilities, the experiences of inmates and staff
were impacted by recent emergency policies
that limited movement, programming, and
interaction with others. Just as the free world
had been in quarantine and community lock
down, MADOC prisons had initiated several
emergency measures to limit the introduction
and transmission of COVID-19. At the time of
the site visits, MADOC facilities had no known
positive cases in any of the facilities toured, and
inmates were beginning to realize a slow but
steady return to some sense of normalcy in
facility operations. While some inmates took the
opportunity to convey a sense of distrust
associated with the measures taken by MADOC
to limit movement and programming, most
commended the department for the steps taken
and the communication received from
leadership, and all stated that they had not
been denied medical or mental health
treatment because of the lock down and
quarantine measures. It was apparent that the
agency was effectively communicating with the
population to ensure that they were aware of
the existing and evolving safety precautions.

Restricted Housing Unit (RHU)
The RHUs visited were each obviously below
capacity, one at SBCC with just three inmates,
relatively clean and quiet in the experience of

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2020

the Consulting Team. Inmates housed in these
units described a variety of reasons for their
segregation from GP, each verified with MADOC
leadership. Reasons encountered included:
pre-hearing detention, disciplinary detention of
less than 15 days, awaiting the outcome of a
DDU referral and investigation process, awaiting
transfer to the DDU. Several of those
interviewed had been in the RHU for more than
30 days, one inmate more than 60 days, each
of them navigating the due process afforded in
the DDU referral and investigation procedures.
It should also be noted that those few inmates
awaiting transfer to the DDU had not been
moved because of restrictions on inter-facility
transfers due to the global pandemic (according
to MADOC personnel). Those housed in RHUs
commonly complained of procedural ambiguity
around their reasons for remaining in RHU,
describing frustration and exhaustion with what
felt like indefinite placements to them. Two
described not knowing why they were in RHU,
producing incident reports and paperwork that
seemed to suggest both were the subject of
ongoing investigations, which was confirmed
with MADOC leadership.
Clinically, those housed in the RHU reported
that they were able to access medical and
mental health services as requested or as
expected, consistent with their treatment plans,
although some complained they were not
getting their preferred treatment or medications.
During mental status examinations of those
housed in RHUs, there were no active
symptoms of acute mental illness reported or
observed. None of those housed in the RHUs
reported psychotic symptoms, such as
hallucinations or delusional beliefs, and there
were no signs of the same observed. None of
those interviewed reported active or passive
suicidal ideation, intent, or plan, and although
some described feeling mild anxiety or
depressed mood, these reports were either
linked directly with their placement in RHU, the
nature of the ongoing pandemic and resultant
restrictions on movement and visitation, and
clinical staff were aware of those experiences.
Despite no evidence of acute symptoms of
mental illness observed in those living in RHUs,
several were designated as having SMI. These
individuals reported diagnoses of Post-traumatic
Stress Disorder (PTSD) and “anxiety,” and each
was known to clinical staff.

Page 23

Secure Treatment Program (STP)
The STP is a 19-bed treatment unit at SBCC that
offers diversion from the DDU for inmates who
are designated with SMI based on traditional
conceptualizations of the clinical term (i.e., more
acute diagnoses like psychotic disorders or
bipolar disorders). There is discretion for
inmates not in the DDU referral process to be
admitted, as well. Due to their propensity for
rule violations and violence, this group of
inmates receives enhanced residential mental
health treatment while ensuring the safety of
self and others.
Patients residing in the STP were generally
diagnosed with major mental illnesses, including
psychotic disorders, major mood disorders, and
personality disorders that included the potential
for breaks with reality and possible imminent
danger to self and others as a result. The visit
included observation of two simultaneous group
therapy sessions, which were then turned over
to the consultants for private group and
individual meetings. The inmates here
appeared to be appropriately identified and
housed, and treatment was obviously occurring.
There were no complaints regarding time-outof-cell, and some conveyed that they were
grateful to be in the STP rather than the DDU,
appreciative of the conditions of confinement in
the STP and the access to more intensive
treatment. Several of the inmates on this unit,
however, were relatively incoherent in speech,
demonstrating active symptoms of psychosis,
but not imminently dangerous, reaffirming
appropriate placement in this level of care. One
inmate described feeling bored by the material
offered in programming, stating that he had
been in the STP for years and felt that the
manualized components were repetitive and a

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more relational or interpersonal approach to
therapy would be beneficial. The diagnostic
heterogeneity in the STP, including for example
Schizophrenia and Borderline Personality
Disorder, makes selection of treatment materials
challenging given the varying treatment packages
appropriate for the differing presentations.

Behavior Management Unit (BMU)
The BMU is a 10-bed unit at MCI – Cedar
Junction that offers diversion from the DDU for
inmates who are designated as SMI due to
significant character pathology and/or comorbid diagnoses (i.e., Personality Disorders).
Opened in July of 2010, the BMU provides an
incentive-based model of treatment that
includes prosocial activities that are specifically
designed to address individualized behaviors
that contributed to the disciplinary sanction.
Similar to the STP, interdisciplinary treatment
teams can refer individuals to the BMU who are
not necessarily designated as SMI, or who are
not currently in the DDU referral process.
Patients residing in the BMU were generally
diagnosed with a combination of major mental
illnesses and severe personality disorders,
primarily elevated levels of Cluster B Personality
Disorder like Antisocial, Narcissistic, and
Borderline Personality Disorders. While these
inmates were noted to have presentations of
such severity that breaks with reality were
possible and danger could be imminent,
interviews revealed an instrumentality or
conditionality to threats of self-harm or harm to
others that was not apparent in the STP
population. In our experience, the population
housed in the BMU is the most treatmentrefractory and challenging clinical population,
generally due to a pervasive history

Page 24

of physical and psychological trauma and a
lifelong history of intractable interpersonal
conflicts. This population challenges the
traditional models of mad versus bad, as they
do not fit neatly into categorical models of
diagnoses but certainly have a SMI that
warrants intensive clinical attention. Risk for
self- and other-directed violence in this
population is very high generally. The
Consulting Team witnessed a patient being
removed and isolated in a therapeutic module
to prevent imminent harm to self or others. In
the time the Consulting Team completed its tour,
the patient had been approved for CourtOrdered admission to the ISOU at Bridgewater
State Hospital. The BMU had exceptionally high
levels of staffing, including two officers on each
floor, two sergeants, a lieutenant, three mental
health clinicians, and a clinical supervisor, for a
total of ten patients. Patients in the BMU
generally did not want to participate in the
treatment programming available, and some felt
they would have preferred to remain in the
DDU, despite obvious risks that this population
poses if placed in Restrictive Housing.

Secure Adjustment Unit (SAU)
Inmates in the SAU were generally those who
had repeat low- to mid-level infractions and
were clearly not appropriate for or benefiting
from Restrictive Housing to modify behaviors.
The three-tiered unit lends itself to having 20
out of cell together, enhancing the availability of
socialization and interaction. Interviews
revealed a sense of frustration with placement
in the program, with some reporting that they
were only there because they feared returning
to their original facilities due to conflicts with
other inmates. Mental status examinations did
not reveal any active psychosis or major mood
instability, although the program did appear to
be capable of serving individuals with SMI and
more acute diagnostic categories.

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2020

Department Disciplinary Unit (DDU)
Inmates in the DDU were the most vocal about
their conditions of confinement and perception
that they were being warehoused and unfairly
punished. The DDU is designed as a facility
whose aim was punitive long-term supermaximum confinement. Interviews revealed
deep anger and resentment toward correctional
staff and the facilities in which they were
housed. “If you treat me like an animal, I’m
going to act like an animal,” said one inmate.
The Consulting Team conducted dozens of
interviews in the DDU, focusing specifically on
the SMI Contraindicated population, those with
diagnosed SMI awaiting bed space in the STUs.
Of those with whom the Consulting Team
spoke, none were diagnosed with major mental
illnesses like psychotic disorders or bipolar
disorders, and most described diagnoses of
Posttraumatic Stress Disorder or “anxiety.”
Several were not prescribed medications.
Mental status examinations did not reveal active
symptoms of psychosis or major mood
instability, neither reported nor observed, and
no inmates were identified as being in any
acute distress. Inmates in the DDU complained
that their time out of cell could be more
productive and meaningful, describing
programming as shackling them to a Restart
chair “and staring at a wall.” They described
high rates of turnover in the programming staff,
and several chose not to leave their cells to
attend groups as a result.

Page 25

Formerly Incarcerated Persons
On October 6, 2020, the Consulting Team met
with three formerly-incarcerated persons,
arranged by PLS. Their perspectives were
incredibly valuable in developing an
appreciation of the culture inside facilities, and
how Restrictive Housing plays a role in
perpetuating a harsh and punitive climate.
What follows is a summary of the themes heard
during the focus group with respect for the
privacy of those who shared their stories.
•

Those interviewed described serving
substantial multi-year sentences in MADOC
prisons, including repeated or lengthy stays
in Restrictive Housing in general, and the
DDU specifically. It was reported that
Restrictive Housing had been used as an
administrative tool to protect vulnerable
inmates from others, despite the person’s
objection.

•

Interviewees noted that things appear to
have improved slightly in recent years,
specifically with the introduction of tablets
and tablet-based programming.

•

People articulated a frustration that
Restrictive Housing and the DDU did not
address the root causes of the conflicts that
led them to the disciplinary system, but
rather served as an attempt to incapacitate
and punish further.

•

Interviewees described serving sanction
time without notice of their alleged
infraction, but due to ongoing conflicts in
GP, being unable to return to less restrictive
housing.

•

One interviewee described serving five
years in the DDU prior to the more recent
reforms, noting that it was “lock-in-a-box”
then, with no programming, indicating
improvement in recent years.

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Key Observations
1. Senior leaders recognize the evolving
nature of correctional practices, lean into the
issue of Restrictive Housing reforms, and are
flexible and adaptable.
Across the country, we are witnessing a social
movement for criminal justice reform with
sweeping implications throughout the justice
system. While the outcry for reform today
focuses on issues of mass incarceration,
institutional racism, and the intersection of
public safety and public health, restrictive
housing reforms have been at the forefront of
systemic evolution for many years. In fact, the
modern movement toward more humane
practices was spearheaded by the Settlement
Agreement reached in Massachusetts in 2012.29

In fact, the modern movement
toward more humane practices
was spearheaded by the
Settlement Agreement reached in
Massachusetts in 2012.
The intervening years have seen that case cited
in many subsequent legal and legislative efforts
to reform the practice of restrictive housing, and
those efforts have had a profound impact on
penological practices across the country. In
many ways, it is not surprising that the same
system that reached that Settlement Agreement
is now circling back to revisit the issue nearly a
decade later. While the 2012 Settlement
Agreement applied specifically to inmates with
SMIs, the intervening years have seen steady
declines in the reliance on restrictive housing to
manage the larger population, reducing the
number of beds in restrictive housing areas, and
successfully eliminating the practice altogether
in the female facility.

29

MADOC invited this independent assessment
knowing that changes would be imminent and
requested that the Consulting Team identify
strengths and opportunities for improvement, a
relatively rare example of proactive leadership
in our experience. For decades, correctional
policy has been shaped by legal action, or the
threat of the same, and in recent years we are
seeing a new generation of leadership that no
longer believes that lawsuits are necessary for
enhancements and implementation of improved
practices. This was clear with this project, and
MADOC leadership was eager to learn and
share with us their ideas, seeing this as an
opportunity to improve their system. This study
builds upon reforms already underway including
creation of the Central Office Restrictive
Housing Oversight Committee developed in
recent years to review all inmates in Restrictive
Housing on a monthly basis.
Additionally, this study was conducted during a
global pandemic, with all meetings, workshops,
focus groups, and presentations, with the
exception of the on-site visits were conducted
virtually, as the pandemic remained a global
threat.
These unique and unprecedented challenges
notwithstanding, the Consulting Team found in
MADOC a Core Working Group of unmatched
leadership in our experience. The core group
included Commissioner Carol Mici, several of
her Deputy Commissioners and their Assistant
Deputy Commissioners, superintendents from
all over the Commonwealth, and strong and
impressive involvement from those responsible
for overseeing medical, behavioral health, and
criminogenic programming. Access to
necessary data and documents was granted
without question or delay, often receiving
hundreds of pages of documents just days after
requesting them. Similarly, access to various

Disability Law Center v. Massachusetts Department of Correction, et al. 960 F.Supp.2d 271 (D.Mass 2012).

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Page 27

stakeholder groups was provided in a
transparent and collaborative manner, inviting
the Consulting Team to work directly with PLS to
interface with formerly incarcerated persons,
former employees, and even arranging a
meeting with the CJRC. While on site visits,
consultants were provided with unfettered
access to inmates and staff without question,
and consultants were able to engage in
individual and group meetings.
Worthy of specific attention in this regard was
the use of technology and data we witnessed
during the study. The community-facing image
of MADOC represented on its website,
including an extensive series of user-friendly
dashboards, and easy access to research
statistics and reports is exemplary. In addition to
the helpful content, user guides and instructions
assist the user with accessing and interpreting
desired data and statistics. Linking to the RHOC
and associated reports, statutes, and
documents made assessing the system
unusually efficient during a very challenging
time. Lastly, the Consulting Team’s contacts with
Operations Analyst Manager, the MADOC Data
Analytics Unit, and the Research and Planning
Division were invaluable and unmatched in our
collective experience. Not only did they provide
extensive data and documents immediately
upon request, but they also participated in
instructional sessions to orient to the available
data and completed customized studies to
facilitate further investigation.
In our collective experience, this level of
collaboration and transparency during a study
of this type and potential consequence,
represents a refreshing and unique strength for
this department.

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2020

2. There exists a deep mistrust of MADOC
from public advocacy groups and the
legislative CJRC.
Not uncommon in prison systems across the
country, advocacy groups and passionate
legislators see prison systems as institutions in
need of reform, at a time when reforms are
enjoying bipartisan support. The Consulting
Team empathizes with MADOC leadership as
systems are complicated by a wide array of
complexities including budgetary restraints,
policy, procedure, organized labor, culture, and
of course the mandate for public safety. While
this is a common conflict for institutions, in our
experience we have seen no more passionate
or professional group of advocates. They are
influential, well-organized, well-informed by
former employees and formerly-incarcerated
persons, and even have some statutory
mandates to represent the interests of those
currently incarcerated.
The Consulting Team heard a perception of
general opaqueness from the department, with
many calling for increased transparency. More
specifically, PLS, the CJRC, and formerlyincarcerated persons advocating for change
described a lack of “compliance” with the CJRA
of 2018. While the compliance concerns were
somewhat vague, there were specific concerns
reported regarding delays in the provision of
the quarterly and bi-annual data and reports to
the RHOC. While the Consulting Team did note
that the reports were several months behind,
we also recognize the potential ramifications of
publicly releasing data of that kind and
consequence, the importance of its accuracy
and reliability, and the need to establish strong
and consistent procedures for collecting,
synthesizing, analyzing, and reporting. Delays
notwithstanding, the quality and utility of those
reports is unquestionable and unprecedented
in our experience.

Page 28

3. MADOC is forced to be reactive to outside
pressures in enacting system improvements,
policy changes, and reform.
Leadership at MADOC indicated to the
Consulting Team that they would like to
proactively implement programs and systemic
changes but experiences the advocacy and
resultant legislation, lawsuits, settlements, etc.
as unwavering and all-consuming. This results in
inefficient efforts that have unforeseen and
undesirable impacts on the preferred strategic
goals of the larger system. For example, when
new programs are required within the
department due to external forces (i.e.,
Settlement Agreements), they are not efficiently
incorporated into the larger system, resulting in
operational and fiscal redundancies and
inefficiencies. Layered capital and operating
costs result in unintended silos of operations
and services that ideally could be integrated
within existing staffing and operational
structures.
4. MADOC experiences outside groups as
misinformed and unsympathetic to the
challenges faced by those providing care and
custody in prisons.
Working in prisons and directing prison systems
is very challenging work, consistently identified
as some of the most stressful occupational
environments in the nation. Unique stressors
have been shown to produce rates of PTSD in
correctional officer samples many times higher
than the general public, and rates of somatic
and behavioral health conditions and crises
– including suicide – are substantially higher in
populations of people who work in correctional
settings. And yet, those who choose this
profession are committed to public safety, and
many have a deep sense of the rehabilitative
ideal. When outside entities mandate changes
within the department, MADOC is responsible
for implementing those changes, and navigating
through the unintended consequences.

30

For example, when the CJRA was implemented
on January 1, 2019, it redefined the term SMI to
ostensibly encompass all mental illnesses. By
expanding the definition of SMI, the CJRA
effectively eliminated the use of Restrictive
Housing for more than 2,400 inmates who then
fell under that definition. Clinically, however, the
term has long carried important meaning with
respect to the acuity and functional impairment
that accompanies traditional diagnoses of
psychotic disorders, bipolar disorder,
depressive disorders, and other conditions that
reflect substantial need for ongoing clinical
care. The SMI population generally requires
prioritized clinical services, enhanced in both
quantity and quality, to maintain an adequate
baseline of functioning. In sum, the term SMI
now incorporates both acute and non-acute
populations, muddying the waters of the term.
Additionally, because of the contraindications
for SMI in Restrictive Housing, certain conditions
must be met for placement therin30. Additionally,
the waiting lists for STUs anecdotally went from
approximately 8 or 9 to nearly 100.
5. Leadership views this study as an
opportunity to confirm what is done well, but
also for proactive system change and
implementation of best practice correctional
and rehabilitative models.
MADOC leadership proactively invited this
assessment of the Restrictive Housing System,
recognizing that the study would include
validation of some components, but could
potentially include significant recommendations
for enhancement to the system. Throughout the
study period, MADOC leadership, line staff, and
contracted partners all openly recognized that
there are opportunities for improvements, and
we found a dedicated workforce eager to
implement programmatic enhancements.

See M.G.L. c. 127, sec.39A (a) and M.G.L. c. 127 sec 39B (a)-(c)

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Page 29

6. Conceptually, it is helpful to separate
‘Pre-DDU’ [i.e., Restrictive Housing Units
(RHU)] from the DDU itself, which is a place
rather than a condition of confinement.

RTUs and STUs appear to be adequate, wellstaffed, with appropriate policies and practices
in place, but bed space is insufficient given the
wait lists that exist.

Pre-DDU operations closely approximate the
emerging standard of forward-thinking prison
systems across the country, but relatively small
tweaks to that system are necessary to bring it
further in line with best practices in terms of
safety and efficacy of the system. Current
operations do an excellent job of incapacitating
imminent risk for harm to self or others in the
emergency response and initial de-escalation
following an incident. Emergency clinical
diversion into HSU and on to suicide
precautions when indicated is an area of
strength.31 People with acute mental health
conditions, such as active symptoms of
psychosis or major episodic mood instability,
are often deflected back to RTUs, triaged to
STUs, and provided with additional clinical
support if required to enter RHUs. These clinical
safeguards effectively minimize the risk of
patients ‘falling through the cracks,’ and we
found no evidence of acute symptomatology in
RHUs or the DDU. More importantly, mental
health leaders and clinicians are passionate,
committed, and creatively balance empathic
patient-centered ethics with the need for safe
and secure environments, a clear strength in
this system.

7. Conditions of confinement in the DDU
result in prolonged periods of Restrictive
Housing.

Although these safeguards were clearly in
place, in exceptional cases people do remain in
RHUs longer than 30 days. While we recognize
that the Commonwealth of Massachusetts
Courts have upheld the constitutionality of the
conditions of confinement for pre-hearing status
and what does or does not constitute the
deleterious conditions associated with
prolonged solitary confinement,32 we still
recognized that there were people held in
RHUs for longer than 30 days. In our opinion,
these conditions meet the definition of
Restricted Housing contemplated in the more
qualitative standards such as the position
statement on Solitary Confinement (Isolation)
from the NCCHC.33

In the DDU, people remain in these conditions
of confinement for months or even years,
potentially up to ten years although that is a
relatively rare exception. Furthermore, the
innately punitive culture of the DDU minimizes
the interests of rehabilitation or positive
behavior change to address the underlying
causes of the infraction that led to placement in
the DDU.
The LPU does afford more time-out-of-cell, but
is permeated by the punitive culture of the DDU
more broadly. We believe it meets the
defininition of Restrictive Housing. While the SMI
Contraindicated population may receive
additional time out of their cells, we also believe
these conditions meet the definition of
Restrictive Housing similarly to the LPU. Lastly,
the clinical team is very good at triaging the
acute population and no acute psychiatric
symptoms were observed in the DDU by
consultants during site visits, but those
designated as SMI under the CJRA are still
forced to remain in the DDU awaiting bed space
in the BMU or the STP.

31
The policies governing these operations are outstanding in our collective experience. Specifically, 103 DOC 650,
Mental Health Services is worthy of highlight.
32
Referencing LaChance v. Commissioner of Correction, 463 Mass 767 (2012); Torres v. Commissioner of Correction,
427 Mass. 611 (1998); among others.
33
See ncchc.org/solitary-confinement.

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Page 30

8. Procedural due process afforded to those
referred to the DDU can create unpredictable
lengths of stay in Restrictive Housing.
Because of the potential for lengthy sanction
time associated with DDU referrals, those
referred for a DDU hearing are afforded due
process rights that are uniquely burdensome
and result in extended stays in Restrictive
Housing Units awaiting disposition in a quasijudicial proceeding. Efforts have been made by
MADOC administration to address the
perceived lack of fairness, for example, by
removing DDU Hearing Officers from the
facilities where DDU hearings are held.
Additionally, we recognize that there is a system
of review in place, and that anyone held in
non-disciplinary restrictive housing for more
than 90 days is entitled to a hearing, notification
of the reason for continued placement in the
Restrictive Housing Unit, and additional
safeguards, due process, and administrative
oversight. These lengthier stays can also result
in a ‘time-served’ determination at disposition.
However, it is a paradox of the entitlement to
due process that people remain in Restrictive
Housing Units for months pending investigation
and hearings, resulting in undefined and
unknown periods of time in these conditions of
confinement. Inmates who navigate the DDU
referral process, as well as those professionals
who advocate for them during that process,
experience a lack of procedural justice in the
investigations and hearings.

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9. Programming for criminogenic needs in

the DDU should be assessed and
enhanced, to improve the quality of
time-out-of-cell for meaningful
interaction, not only the quantity.

Treatment for those in the DDU, specifically
programming for criminogenic thinking, was
described by all parties and interviewees as
requiring improvement. Just as important as the
number of hours a prisoner is out-of-cell is the
programming and activity that occurs during
that time. In discussing this on-site, staff from
the mental health department, MADOC officers,
and even the Superintendent were all in
agreement that the observation is worthy of
additional attention and consideration. They
described high rates of staff turnover in the
facilitator positions, difficulty filling the positions,
and finding candidates who prefer to be
correctional officers rather than clinicians.
We also observed that additional efforts were
underway to reach this population with
programming due to exigent circumstances
associated with the global pandemic. These
included increased access to tablets as well as
educational packets while out-of-cell time has
been limited.

Page 31

Recommendations and Options
1. Identify a team and develop a plan for
implementation.
Changing a system requires more than policy
directives if it is to have lasting positive impact,
and cultural shifts necessitate strong leadership
and a demonstrated commitment by people in
positions of respect and influence. There are
implications for training, health, wellness,
creativity in the built environment, and a shift in
general philosophy and the interests of justice.
In our opinion, MADOC clearly has the
competence to make substantial changes and
be a leader as criminal justice reforms continue
to evolve.
It is recommended that an interdisciplinary
implementation team create a strategic and
structured road map for enacting system
changes, looking not only for substantive
changes, but for efficiencies as changes are
implemented. For example, this could be a
good opportunity to reorganize clinical and
criminogenic programming contracts to achieve
increased efficiencies. This type of efficiency
does not need to be immediate but can be
done in preparation for the next cycle of
contracts.
It is further recommended that the
implementation team reflect representation
from multiple disciplines, including MADOC
administration, correctional officers, Wellpath
medical and mental health, Spectrum, and any
other internal stakeholders. Furthermore, it is
recommended that a Stakeholder Advisory
Group be formed to include advocacy
organizations, members of the public, local
legislators, and people with lived experience, to
invite them into the process and allow them to
feel heard and validated.

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© 2020

Good examples of existing implementation
teams or models exist, such as those
addressing justice-involved females, restrictive
housing oversight, LGBTQI populations, data,
and training. One of these existing teams may
be appropriate for this purpose given resources
already allocated to these missions.
2. Develop a transparent communication
strategy.
Given the level of interest from a wide array of
stakeholders in the community, a
communication strategy should be implemented
that informs those groups of intentions to
enhance the system in a clear and transparent
manner. It is recommended that regular updates
be provided through the RHOC, as well as
through less formal updates and venues
specifically eliciting feedback as implementation
proceeds. Taking a proactive approach to
communication of intended changes and
creating channels for feedback from
stakeholders will likely yield the most effective,
sustainable, and efficient implementation.
3. Dissolve the Department Disciplinary Unit
(DDU).
It is recommended that the DDU be dissolved,
including the DDU proper, the LPU and the SMI
Contraindicated. Those currently serving DDU
sanctions should be considered for specific
programming or housing in maximum security
facilities as appropriate, or otherwise assessed
for programs consistent with the criminogenic
needs that landed them in the DDU to begin
with. If criminal prosecution is warranted, it is
recommended that the matter be referred to
the appropriate District Attorney or other
prosecutorial body outside of MADOC.

Page 32

We believe the elimination of the DDU, and the
extensive due process afforded those referred
for placement in the DDU, could save the
department massive resources, reduce the
length of stay in RHUs, eliminate delays due to
investigations and hearings associated with that
process, reduce risk for suicide, and reduce the
use of Mental Health Watch to avoid conditions
in the DDU. It is recommended that baseline
data be collected on each of these indicators
and others, such as re-offending (internal
recidivism), to be studied on an ongoing basis
to assess success of implementation.
The DDU was already expected to move from
MCI – Cedar Junction to Souza Baranowski
Correctional Center, but no date was set due to
the global pandemic. We believe this is an
opportune moment in the history of MADOC to
implement this meaningful change, elevate
correctional practice, and impact the culture
within the system in a healthy manner.
Lastly, while we recommend dissolving the DDU
as currently operated, it is recommended that
the space be reimagined. With some facility and
programming upgrades, the space could be
valuable for additional services. Specifically, we
recognized a need for expanded treatment for
Substance Use Disorders, trauma-responsive
programming, violence risk reduction, and
criminogenic thinking.

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Page 33

4. Consider eliminating all use of Restrictive
Housing as currently defined.
In many ways, dissolution of the DDU is a
distinct matter from the elimination of Restrictive
Housing conditions of confinement, systemwide. Turning to the ‘pre-DDU’ system, MADOC
is well-positioned to make relatively minor
tweaks that could potentially eliminate its use
altogether. In this model, RHUs would afford
everyone more than two hours out-of-cell each
day, with a combination of structured and
unstructured time, except in exigent
circumstances. This is to say that an individual
deemed to be imminently dangerous could
absolutely be placed into conditions of
confinement that maintain safety and security
until such time as a less restrictive setting is
appropriate. That assessment and process,
however, should be clearly documented, with
behaviors clearly identified, and should not be
punitive but rather protective. Exigent
circumstances should be documented and
standardized so they are easily accessible for
review without undue burden.

This model assumes that no housing unit
operates under conditions of confinement that
require placement in a cell 22 or more hours
per day, by default. Every housing unit, even in
the Restrictive Housing Unit, would provide
more than two hours out-of-cell per day. This
model represents the future of disciplinary and
administrative segregation and grew out of the
Correctional Service Canada (CSC) Structured
Intervention Unit (SIU) model.34 For more
information and as one example, see Appendix
A.
Based on the Risk-Needs-Responsivity (RNR)
model, the SIU operates under an assumption
of treatment or programming need, which turns
the SIU into an assessment center. The person
undergoes an assessment to identify the clinical
and criminogenic factors driving the behaviors
that led to the infraction or disciplinary
intervention, and the person is then
programmed into the appropriate intervention
to meet those identified needs.

34
For more information on the Correctional Service Canada (CSC) Structured Intervention Unit (SIU) model, see:
https://www.csc-scc.gc.ca/acts-and-regulations/005006-3000-en.shtml.

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5. Study Mental Health Watch and assess the
allegations made in the DOJ Report, using
the opportunity to enhance safety and quality
of healthcare delivery.
The allegations regarding Mental Health Watch
presented in the DOJ Report are concerning
and warrant attention. It is recommended that
MADOC use this opportunity to study its suicide
prevention system and the use of Mental Health
Watch, recognizing an opportunity to enhance
safety and quality in the delivery of this crucial
healthcare component
6. Use the disciplinary process to assess
clinical and criminogenic needs that
contributed to requirement for increased
restrictions.
Regardless of the ultimate model selected, a
philosophical shift is strongly recommended, to
one that assumes some responsibility to identify
and respond to the criminogenic and clinical
risk factors that contributed to the infraction. In
this way, RHUs become assessment centers for
development of behavior plans that address the
etiology of problematic behavior.

Re-entry from a RHU is accompanied by
specific, measurable, attainable goals that
reflect behavioral progress, increased safety,
and which meet identified clinical and
criminogenic needs. It is recommended that
interdisciplinary input is invited into the creation
of these behavior plans, including from the
inmate.
Additionally, note the reduced clinical utility of
the SMI designation in this regard, while
accepting and appreciating the legal
ramifications of the CJRA. This is to say that for
clinical purposes, consider creating additional
segmentation within the SMI designation to
reflect an Acute, Sub-Acute, and Non-Acute35
categorization based on a combination of
diagnoses and level of stability or clinical need.
These categories allow for triaging clinical
needs, assigning resources to those patients
most in need of greater services, while still
affording all of those with SMI the rights and
protections included in the CJRA, consistent
with both the letter and the spirit of the law.

These are suggested terms we see emerging across the country to reflect clinical need, incorporating the dynamic
nature of mental wellness, where a patient may be Acute for a period of crisis before being Sub-Acute at baseline. We
also recognize that 103 DOC 650.06, Mental Health Services provides for Mental Health Codes and see the “A” Sub
Code and the most logical area of policy for including this enhancement..

35

Option 2: Structured Intervention

General
Population

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SerlvcH Unit

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General
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7. The SAU has excellent potential - consider
expansion, segmentation by risk level, and
clinical or criminogenic tracks within the
program.
The SAU as policy and program provides a
creative needs-driven solution to meet the
criminogenic risks of a group of inmates that
seems to find themselves repeatedly accessing
the disciplinary system within the prison system.
Generally, those in the SAU currently have
limited histories of violence or Class 1
infractions, but rather include lower-level rule
violations that certainly jeopardize the safety
and security of an institution, but our experience
was that treatment needs were common in the
population.
Because the SAU takes a RNR36 37 approach, we
recommend further segmenting the
criminogenic and clinical treatment and
programming to specifically address the needs
of this heterogeneous population, programming
inmates based on needs, classification, and
levels of functioning. Based on our review and
study, the following four areas could be worthy
‘tracks’ within the SAU, and could be further
stratified to include both Maximum Security and
Medium Security programs:
•

Trauma-responsive programming

•

Substance Use Disorder treatment and
education

•

Programming for criminogenic thinking

•

Programming for violence risk reduction

8. Evaluate the effectiveness of treatment
and programming in the revised specialized
housing, including the experiences of those
who live and work in those programs, and
expand bed capacity with implementing
enhancements.
If MADOC decides to make structural changes
to the disciplinary system, changes to the CQI
monitoring will be necessary. It is recommended
that data indicators be redefined to capture
those constructs worthy of study for quality,
safety, and to demonstrate success as defined.
Strong CQI programs can identify problematic
trends early and proactively, allowing the
implementation team to swiftly make necessary
changes to provide care and custody more
effectively and efficiently. For example, in the
interest of improved safety, you may want to
consider monitoring successful staff
engagements prior to the application of a
planned use of force.
We reviewed the document titled Secure
Treatment Units Outcomes: An Analysis of all
STU Admissions 2008 to Present, authored by
MHM Services, Inc.,38 which is an outstanding
example of a process and outcome study for
CQI. We understand that MADOC has refined its
data collection procedures and organization
and plans to create a similar procedure soon.
We recommend providing a similar annual
update if possible.
Additionally, the BMU and the STP currently
exist as a function of the existence of Restrictive
Housing. As with any large system of integrated
components, altering one component will
impact all others. To the point, if the DDU is
dissolved and if Restrictive Housing practices
are eliminated system-wide, the BMU and the
STP are no longer alternatives to Restrictive
Housing, but rather become treatment units in
Maximum Security settings. Those implications
should be examined in terms of time-out-of-cell,
treatment modules, programming, and CQI
indicators revised as appropriate.

36
Latessa, E., Cullen, F. & Gendreau, P. (2002). Beyond correctional quackery – professionalism and the possibility
of effective treatment. Federal Probation, 66(2), 43-49.
37
Bonta, J. & Andrews, D. (2007). Risk-Need-Responsivity Model for offender assessment and rehabilitation: 200706. Available: sedgwickcounty.org/media/31356/risk_need_2007-06.pdf.
38
MHM Services, Inc. (January 18, 2013). Secure Treatment Units outcomes: An analysis of all STU admissions 2008
to present. Submitted to the Department of Correction Health Services Division.

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9. Create a Substance Use Disorder
treatment program for those with positive
UDSs or who are otherwise entering the
disciplinary system secondary to use of drugs
or alcohol.
In recent months, MADOC has taken impressive
steps to implement Medication Assisted
Treatment (MAT) throughout the prison system,
and we understand that treatment will soon be
available to any inmate for whom it is medically
appropriate, regardless of housing location.
Consistent with the implementation of that
model, which reflects the community standard
of care, we recommend developing a
comprehensive Substance Use Disorder
treatment program specifically for those who
use drugs or alcohol while incarcerated.
According to reports to the RHOC, 142 male
inmates were placed in Restrictive Housing in
2019 for using or possessing illicit substances,
having a UDS that was positive for illicit
substances, or for consuming or producing
alcohol.39 Again, consistent with the evolving
standard of diversion for low-level drug
offenses in the community, we recommend
developing a diversionary program for
Substance Use Disorder treatment. This could
be included as a track within the SAU, a
component of another program, or could be a
standalone treatment program.

10. Expand availability of tablets and tabletbased treatment and programming systemwide.
Consistent with a growing trend across the
country, even more so because of the global
pandemic, tablet-based treatment and
programs in MADOC were very popular among
those we interviewed. Not only did inmates
speak highly of the access and metaphorical
escape provided by this technology.
Interestingly, staff described the transaction
necessary to charge tablets as creating a
prosocial relationship with inmates, who did not
have charging stations inside their cells and
thus, rely on officers to assist them with
charging the tablets.
We recommend expanding the availability of
tablets and tablet-based programming.
However, we also recommend that tablet-based
interventions be adjunctive or complementary
to in-person interactions, and that time-out-ofcell not be reduced in any way because of the
availability of tablets or other technology. There
are important exceptions to this latter point,
specifically the growing acceptance of
telehealth as meeting the standard of care.
Additionally, programming modules are
expanding and improving along with
partnerships between content developers and
platforms. While Falcon does not receive any
compensation for recommending programs, we
do review and endorse certain products and
delivery systems that reflect best practices in
this emerging arena. Two such programs
include a prison-specific version of Breaking
Free from Substance Use40 and Moral
Reconation Therapy (MRT),41 both of which have
electronic or tablet-based versions.

39
Class 2 Offenses, including 2-11, 2-14, and 2-19. Introduction and dealing in illicit substances, a Class 1 Offense
(1-15), was not included in this analysis.
40
Available: breakingfreegroup.com/solutions-prisons.
41
Available: moral-reconation-therapy.com.

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11. Match staffing and training to specialty
programs.
Because of the specialized nature of housing
units like RTUs and STUs, we recommend a
distinct selection process for correctional
officers who work these posts. In other systems,
we have seen self-selection, internal training
within the unit, and specialized post orders
become best practices. We recognize that the
new Job Pick system does not allow for that
level of consideration, but we believe this is a
critical element to success in these specialty
housing areas. Interviews with some of the
original employees who worked on the Secure
Treatment Program described having the right
personnel as “the key” to successful operations.
Officers were able to self-select, they were
trained internally by other officers who had
self-selected for the posts, and operations
reflected the unique nature of the people
housed in these units.
With respect to training, all officers working in
specialized housing areas, including the RTU,
STP, BMU and SAU should receive specialized
training prior to working their first shifts. Now
that Job Pick is functioning, post changes can
be predicted and training schedule just prior to
assuming the posts. Current training materials
are very good, and we recommend elevating
those materials by incorporating international
best practices from European models that
support staff and inmates on these specialty
units.
Lastly, it was noted that specialized training for
units like the RTUs, SAU, and STUs often relies
on highly-regarded facilitators who are limited in
numbers. When the trainer is on leave, it is
disruptive to timely delivery of important training
programs. To make these effective training
programs sustainable, it is recommended that
MADOC leadership invest in expansion of these
capabilities, perhaps through mentorship
programs within the training department.

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Appendix A: Structured Intervention Units (SIU)

Administrative and di sci pli nary segregation
have been eliminated and a new correctional model is in effect.

What does
that mean?

Inmates may be transferred to an SIU if they have acted in a way that may,
or has, jeopardized the security of an inmate or any other person, including
them selves, or the security of an institution, or if they co u Id interfere with
an investigation.

•
...

......~
c...

Source: Correctional Service (CSC)
https://www.csc-scc.gc.ca/acts-and-regulations/005006-3000-en.shtml

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Appendix B: Acronyms
ACA - American Correctional Association

MAT - Medication Assisted Treatment

ACT - Assertive Community Treatment

MRT - Moral Reconation Therapy

ADHD - Attention Deficit Hyperactivity
Disorder

NCCHC - National Commission on
Correctional Health Care

ALOS - Average Length of Stay

OCCC - Old Colony Correctional Center

BMU - Behavior Management Unit

PLS - Prisoners’ Legal Services

CJRA - Criminal Justice Reform Act

PTSD - Post-Traumatic Stress Disorder

CJRC - Criminal Justice Reform Caucus

QHP - Qualified Health Professional

CLA - Correctional Leaders of America

QMHP - Qualified Mental Health
Professional

CMR - Code of Massachusetts Regulations
CMS - Center for Medicaid Studies
CQI - Continuous Quality Improvement
CRIPA - Civil Rights of Institutionalized
Persons Act
CSC - Correctional Service Canada
DDU - Department Disciplinary Unit
DMH - Massachusetts Department of
Mental Health
DOJ - Department of Justice

RHA - Responsible Health Authority
RHOC - Restrictive Housing Oversight
Committee
RHU - Restrictive Housing Unit
RNR - Risk Needs Responsivity
RTU - Residential Treatment Unit
SAMHSA - Substance Abuse and Mental
Health Services Administration
SAU - Secure Adjustment Unit

DSM - Diagnostic and Statistical Manual of
Mental Disorders

SBCC - Souza Baranowski Correctional
Center

EOPSS - Executive Office of Public Safety
and Security

SIU - Structured Intervention Unit
SMI - Serious Mental Illness

GP - General Population

SPMI - Severe and Persistent Mental Illness

HSU - Health Services Unit

STP - Secure Treatment Program

ISOU - Intensive Stabilization and
Observation Unit

STU - Secure Treatment Unit

LPU - Limited Priveleges Unit

WHO - World Health Organization

MADOC - Massachusetts Department of
Correction

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UDS - Urine Drug Screen

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