Office of the Inspector General

U.S. Department of Justice

Review of the Federal Bureau of
Prisons’ Use of Restrictive Housing for
Inmates with Mental Illness

Evaluation and Inspections Division 17-05

July 2017

EXECUTIVE SUMMARY
Introduction
The Federal Bureau of Prisons (BOP) is responsible for confining offenders in
environments that are safe, humane, cost-efficient, and appropriately secure. To
do so, the BOP utilizes various forms of Restrictive Housing Unit (RHU) to confine
certain inmates, including those with mental illness. However, according to recent
research and reports, as well as the BOP’s own policy, confinement in RHUs, even
for relatively short periods of time, can adversely affect inmates’ mental health and
can be particularly harmful for inmates with mental illness.
As of June 2016, of the 148,227 sentenced inmates in the BOP’s
122 institutions, 9,749 inmates (7 percent) were housed in its three largest forms
of RHU: Special Housing Units (SHU) in 111 institutions; 2 Special Management
Units (SMU) at the U.S. Penitentiaries (USP) in Lewisburg and Allenwood,
Pennsylvania; and the USP Administrative Maximum Security Facility (ADX) in
Florence, Colorado.1
The Office of the Inspector General conducted this review to examine the
BOP’s use of RHUs for inmates with mental illness, including trends in the use of
restrictive housing and the screening, treatment, and monitoring of inmates with
mental illness who are housed in RHUs. We found significant issues with the
adequacy of the BOP’s policies and its implementation efforts in this critical area.
Results in Brief
BOP Policies Do Not Adequately Address the Confinement of Inmates with Mental
Illness in RHUs, and the BOP Does Not Sufficiently Track or Monitor Such Inmates
BOP guidance and policies do not clearly define “restrictive housing” or
“extended placement.” Although the BOP states that it does not practice solitary
confinement, or even recognize the term, we found inmates, including those with
mental illness, who were housed in single-cell confinement for long periods of time,
isolated from other inmates and with limited human contact. For example, at the
ADX, we observed an RHU that held two inmates, each in their own cell, isolated
from other inmates. The inmates did not engage in recreation with each other or
with other inmates and were confined to their cells for over 22 hours a day. Also,
in five SHUs, we observed single-celled inmates, many with serious mental illness.
One inmate, who we were told was denied ADX placement for mental health
reasons, had been single-celled for about 4 years.
Although the BOP generally imposes a minimum amount of time that inmates
must spend in RHUs, it does not limit the maximum amount of time and does not

The USP Allenwood SMU closed in October 2016, during the course of our review. USP
Lewisburg is the only remaining BOP institution that maintains the SMU program.
1

i

monitor inmates’ cumulative time in RHUs.2 The BOP also does not track its housing
of inmates in single-cell RHU confinement, nor does it account for their confinement
in all RHUs throughout BOP institutions. As a result, inmates, including those with
mental illness, may spend years and even decades in RHUs. For example, we
learned of an inmate with serious mental illness who spent about 19 years at the
ADX before being transferred to a secure residential mental health treatment
program. In addition, our sample of inmates with mental illness showed that they
had been placed in the ADX for an average of about 69 months. Similarly, we found
that between fiscal years (FY) 2008 and 2015, inmates with mental illness averaged
about 896 consecutive days, or about 29 months, in the SMU. We further found that
inmates with mental illness spend disproportionately longer periods of time in RHUs
than their peers. Equally concerning, our review showed that 13 percent of the
inmates with mental illness in our sample were released by the BOP directly into the
community after spending nearly 29 months in the SMU prior to their release.
By contrast, officials in six of the eight state departments of corrections told
us that they limit the length of time inmates with mental illness can be placed in
restrictive housing. In 2015, three states (Massachusetts, Mississippi, and New
York) had at least a 30-day limit, while three other states (Colorado, Maine, and
Pennsylvania) no longer placed inmates with serious mental illness in RHUs at all.
Mental Health Staff Do Not Always Document Inmates’ Mental Disorders, Leaving
the BOP Unable to Accurately Determine the Number of Inmates with Mental Illness
and Ensure that It Is Providing Appropriate Care to Them
BOP data showed that, as of 2015, only 3 percent of the BOP’s sentenced
inmate population was being treated regularly for mental illness. Yet, the BOP’s
FY 2016 Performance Budget Congressional Submission cited an internal BOP
study, which suggested that approximately 19 percent of federal inmates had a
history of mental illness. Moreover, a 2006 Bureau of Justice Statistics report
concluded that 45 percent of federal inmates had symptoms or a recent history of
mental illness.
We found that the BOP cannot accurately determine the number of inmates
who have mental illness because institution staff do not always document mental
disorders. The BOP’s FY 2014 data estimates that approximately 12 percent of
inmates have a history of mental illness; however, in 2015, the BOP’s Chief
Psychiatrist estimated, based on discussions with institutions’ Psychology Services
staffs, that approximately 40 percent of inmates have mental illness, excluding
inmates with only personality disorder diagnoses. Similarly, one institution’s
Deputy Chief Psychologist estimated that 50 percent of that institution’s inmates
may have Antisocial Personality Disorder; nevertheless, we found that this disorder
was documented for only about 3.3 percent of the BOP’s total inmate population.
Because mental health staffs do not always document inmates’ mental disorders,
the BOP is unable to ensure that it is providing appropriate care to them.

In August 2016, the BOP issued a revised SMU policy that now limits the duration of time an
inmate can spend in the SMU. We discuss the revised SMU policy throughout the report.
2

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Since the BOP Adopted Its New Mental Health Policy, BOP Data Shows a 30 Percent
Reduction in Inmates Who Receive Regular Mental Health Treatment
The BOP adopted a new mental health policy in 2014, increasing the standards
of care for inmates with mental illness. However, since the policy was issued, the total
number of inmates who receive regular mental health treatment decreased by
approximately 30 percent, including 56 percent for inmates in SMUs, and about
20 percent overall for inmates in RHUs during the scope of our review. Based on our
review, it appears that mental health staff may have reduced the number of inmates,
including those in RHUs, who must receive regular mental health treatment because
they did not have the necessary staffing resources to meet the policy’s increased
treatment standards. Indeed, we found that, as of October 2015, the BOP had filled
only 57 percent of its authorized full-time Psychiatrist positions nationwide and that it
had significant staffing issues with regard to Psychologist positions as well.
This treatment trend was particularly pronounced among SMU inmates at
USP Lewisburg, which confined over 1,100 SMU inmates as of June 2016. Based on
our sample of SMU inmates, we found that, prior to the new policy, the number of
inmates (16) whose mental health care level was increased equaled the number of
inmates (16) whose care level was decreased. In contrast, after the new policy was
adopted, all 27 inmates whose care level changed had a decrease and therefore
ostensibly required less treatment. By May 2015, only about 2.5 percent of SMU
inmates at USP Lewisburg were categorized as requiring regular treatment,
compared to about 11 percent of ADX inmates and 7 percent of SHU inmates
nationwide, which we believe raises treatment concerns for inmates in USP
Lewisburg’s SMU.
While the BOP Has Taken Recent Steps to Mitigate Mental Health Concerns for
Inmates in RHUs, Additional Actions Can Be Taken
The BOP has taken a number of steps to mitigate the mental health concerns
for inmates in RHUs. These efforts include diverting inmates with serious mental
illness from placement in traditional RHUs (i.e., SHUs, the SMUs, and the ADX) and
into alternative programs such as secure residential mental health treatment
programs. While these are positive BOP initiatives, limited inmate capacities, slow
inmate progression through the programs, high staffing needs, and a lack of formal
performance metrics with which to measure the effectiveness of these programs
limit their utility and the BOP’s ability to expand their use to other institutions.
Recommendations
We make 15 recommendations to the BOP to improve its screening,
treatment, and monitoring of inmates with mental illness housed in RHUs.

iii

TABLE OF CONTENTS
INTRODUCTION ............................................................................................ 1
Background ........................................................................................ 1
Types of Restrictive Housing Units .......................................................... 2
Mental Illness among BOP Inmates ........................................................ 4
BOP Mental Health Care Levels .............................................................. 5
BOP Policies Impacting Inmates in RHUs, including those with Mental Illness ..... 7
Prior Reports on the BOP’s Use of Restrictive Housing and Inmates with
Mental Illness .................................................................................... 11
Scope and Methodology of the OIG Review............................................ 14
RESULTS OF THE REVIEW ............................................................................ 15
BOP Policies Do Not Adequately Address the Confinement of Inmates
with Mental Illness in RHUs, and the BOP Does Not Sufficiently Track or
Monitor Such Inmates ........................................................................ 15
Mental Health Staff Do Not Always Document Inmates’ Mental Disorders,
Leaving the BOP Unable to Accurately Determine the Number of Inmates with
Mental Illness and Ensure that It Is Providing Appropriate Care to Them ......... 34
Since the BOP Adopted Its New Mental Health Policy, BOP Data Shows a
30 Percent Reduction in the Number of Inmates Who Receive Regular
Mental Health Treatment .................................................................... 37
While the BOP Has Taken Recent Steps to Mitigate Mental Health Concerns for
Inmates in RHUs, Additional Actions Can Be Taken...................................... 51
CONCLUSION AND RECOMMENDATIONS ........................................................ 63
Conclusion ........................................................................................ 63
Recommendations ............................................................................. 65
APPENDIX 1: METHODOLOGY OF THE OIG REVIEW........................................ 67
Standards ......................................................................................... 67
Data Analysis .................................................................................... 67
Site Visits ......................................................................................... 70

iv

Interviews ........................................................................................ 70
Inmate Case File Review..................................................................... 71
APPENDIX 2: BOP POLICIES GOVERNING RESTRICTIVE HOUSING AND MENTAL
HEALTH SCREENING, TREATMENT, AND MONITORING ................ 73
Restrictive Housing Units .................................................................... 73
Mental Health Screening, Treatment, and Monitoring .............................. 78
APPENDIX 3: BOP RESIDENTIAL MENTAL HEALTH TREATMENT PROGRAMS ....... 84
APPENDIX 4: THE BOP’S RESPONSE TO THE DRAFT REPORT ........................... 86
APPENDIX 5: OIG ANALYSIS OF THE BOP’S RESPONSE .................................. 91

v

INTRODUCTION
Background
The Federal Bureau of Prisons (BOP) is responsible for confining offenders in
environments that are safe, humane, cost-efficient, and appropriately secure. To
ensure safe and orderly environments for inmates and staff, the BOP utilizes
various forms of Restrictive Housing Unit (RHU) for the confinement of some
inmates, including inmates with mental illness. The U.S. Department of Justice
(Department, DOJ) defines restrictive housing as “any type of detention that
includes removal from the general inmate population, whether voluntary or
involuntary; placement in a locked room or cell, whether alone or with another
inmate; and inability to leave the room or cell for the vast majority of the day,
typically 22 hours or more.”3 In recent years, studies have suggested that the
frequency, duration, and conditions of confinement of restrictive housing, even for
short periods of time, can cause psychological harm and significant adverse effects
on these inmates’ mental health. For example, research suggests that “isolation
can be psychologically harmful to any prisoner — psychological effects can include
anxiety, depression, anger, cognitive disturbances, perceptual disorders, obsessive
thoughts, paranoia, and psychosis” — some of which may be long lasting.4
According to some experts, inmates who have spent long periods in isolation are
more likely to recidivate and have a more difficult time creating the lasting social
bonds that are necessary for reintegration into society.5 The BOP’s own policy also
recognizes that “an inmate’s mental health may deteriorate during restrictive
housing placement.”6
As of June 2016, of the 148,227 sentenced inmates in the BOP’s
122 institutions, 9,749 inmates (7 percent) were housed in its 3 largest forms of
RHU: Special Housing Units (SHU) in 111 institutions; 2 Special Management Units
(SMU) at the U.S. Penitentiaries (USP) in Lewisburg and Allenwood, Pennsylvania;
and the USP Administrative Maximum Security Facility (ADX) in Florence, Colorado.

DOJ, Report and Recommendations concerning the Use of Restrictive Housing (January
2016), 3. While the BOP has taken several corrective actions in response to the recommendations in
this report, we found that several issues remain unresolved and require the BOP’s immediate
attention.
3

4 Jeffrey L. Metzner, MD, and Jamie Fellner, Esq., “Solitary Confinement and Mental Illness in
U.S. Prisons: A Challenge for Medical Ethics,” Journal of the American Academy of Psychiatry and the
Law, 38 (March 2010): 104–08.

Craig Haney, Professor of Psychology at the University of California, Santa Cruz, before the
Judiciary Subcommittee on the Constitution, Civil Rights, and Human Rights, U.S. Senate, concerning
“Reassessing Solitary Confinement: The Human Rights, Fiscal, and Public Safety Consequences”
(June 19, 2012), 10–11. The Office of the Inspector General (OIG) separately reviewed the BOP’s
Release Preparation Program. See DOJ OIG, Review of the Federal Bureau of Prisons’ Release
Preparation Program, Evaluation and Inspections Report 16-07 (August 2016).
5

BOP Program Statement 5310.16, Treatment and Care of Inmates with Mental Illness
(May 1, 2014), 16.
6

1

In this review, the Office of the Inspector General (OIG) examined the BOP’s
use of restrictive housing for inmates with mental illness in these RHUs and
analyzed trends in the BOP’s placement of inmates with mental illness in restrictive
housing. We also evaluated the BOP’s policies and procedures related to its
screening, treatment, and monitoring of inmates with mental illness in RHUs. In
the following sections and Appendix 2, we discuss the three primary types of RHU
that the BOP uses, as well as the prevalence of mental illness among BOP inmates;
we explain how the BOP determines an inmate’s mental health needs, as well as
trends in the placement of inmates with mental illness in RHUs; we describe
previous reports related to the use of RHUs and inmates with mental illness; and
we summarize the BOP’s RHU and mental health policies.
Types of Restrictive Housing Units
There are three primary types of RHU within BOP institutions. As of January
2016, 111 institutions have a SHU to house inmates for both disciplinary reasons
and non-disciplinary reasons, such as for their own protection.7 In two BOP
institutions, a SMU houses inmates who present unique security and management
concerns.8 The ADX houses inmates who have demonstrated violent, disruptive,
and/or escape-prone behavior at other BOP institutions or those who cannot be
safely housed in the general population of other BOP institutions. We further
discuss the three primary types of RHU below, and we then discuss the prevalence
of mental illness among BOP inmates generally, followed by the availability of
mental health services for inmates housed in the different types of RHU. See
Appendix 2 for more information on SHUs, the SMUs, and the ADX.
Special Housing Units
Institution SHUs are securely separated from general inmate population
housing. In August 2015, the BOP’s former Director stated that, on average,
inmates spend about 65 days (about 2 months) in the SHU BOP-wide.9 In June
7 In November 2016, the BOP issued a revised SHU policy in response to the
recommendations detailed in the Department’s January 2016 report on the use of restrictive housing.
See DOJ, Use of Restrictive Housing, which we discuss below. See also BOP Program Statement
5270.11, Special Housing Units (November 23, 2016). We did not evaluate this new policy, as it was
issued after completion of our fieldwork. However, we note throughout this report examples of
changes to the SHU policy as they relate to our findings during the course of our review. See
Appendix 2 for more information on the revised SHU policy.

BOP Program Statement 5217.01, Special Management Units (November 19, 2008),
provides guidance and procedures for operation of the SMU.
8

In August 2016, the BOP issued a revised SMU policy. See BOP Program Statement 5217.02,
Special Management Units (August 9, 2016). We did not evaluate this new policy, as it was issued
after the completion of our fieldwork. However, we note throughout this report examples of changes
to the SMU policy as they relate to our findings on the SMU program during the course of our review.
See Appendix 2 for more information on the revised SMU policy.
9 Former BOP Director Charles E. Samuels, Jr., before the Homeland Security and
Governmental Affairs Committee, U.S. Senate, concerning “Oversight of the Bureau of Prisons: First
Hand Accounts of Challenges Facing the Federal Prison System” (August 4, 2015).

2

2016, the BOP housed about 5 percent (8,065 inmates) of its total population of
sentenced inmates in SHUs. Eighty-three percent of all BOP inmates in RHUs are
housed in SHUs; though some inmates are placed in a SHU for disciplinary reasons,
most are held there for non-disciplinary reasons, including for their own protection.
Special Management Units
The BOP established SMUs in 2008 as a program to house inmates who require
greater management of their interactions with others to ensure the safety, security,
or orderly operation of BOP institutions and to protect the public.10 Most SMU inmates
are transferred from USPs. Inmates assigned to the SMUs are expected to complete
a four-phase program, which means they have demonstrated a sustained ability to
coexist and interact appropriately with other inmates and staff, within 18 to 24
months, after which they may be designated to another appropriate facility.11
U.S. Penitentiary Administrative Maximum Security Facility
Activated in November 1994 in Florence, Colorado, the ADX has a rated
capacity of 490 inmates and confines inmates under close control. As of November
2013, the BOP determined that the average length of stay for inmates at the ADX
was 1,376 days (about 45 months, or 3.8 years).12 At the time of our review, the
ADX housed the majority (about 70 percent) of its inmates in general population,
while the remaining 142 inmates, who require closer control and increased levels of
security, are housed in the ADX’s Control Unit or its Special Security Unit.13 All
inmates in the ADX are in single-occupant cells and can receive programming
through a closed-circuit television system.

10 By 2012, the SMU program had expanded to 5 institutions with a population of over
1,700 inmates. However, as of June 2016, the BOP maintained its SMU program within two institutions,
USP Lewisburg (1,166) and USP Allenwood (124), both in Pennsylvania, which together house
1,290 inmates. According to the former Deputy Assistant Director for the Correctional Programs Division,
the BOP condensed the SMU program to two institutions because the need for the program had
diminished. He cited fewer inmate assaults, staff assaults, and protective custody cases throughout the
BOP. In October 2016, Psychology Services Branch officials told us that USP Allenwood’s SMU has since
closed and, currently, USP Lewisburg is the only remaining institution that maintains the SMU program.

In August 2016, as a result of recommendations made in the Department’s January 2016
restrictive housing report, the BOP issued a revised SMU policy that, among other things, reduced the
intended time frame for inmates’ completion of the program to 9–13 months. See DOJ, Use of
Restrictive Housing. See Appendix 2 of this report for more information on the revised SMU policy.
11

12 This was the most recent data the BOP had at the time that a Center of Naval Analysis and
Solutions (CNA) analysis was done, which we discuss further below. CNA, Federal Bureau of Prisons:
Special Housing Review and Assessment (December 2014), 58.

The ADX’s Control Unit provides housing for inmates who are unable to function in a less
restrictive environment without posing a threat to others. This unit typically houses inmates who have
assaulted or killed staff or other inmates or who have escaped or attempted escape from other
institutions. The ADX’s Special Security Unit houses inmates who are subject to Special Administrative
Measures, which are restrictions on communications that the U.S. Attorney General imposes, typically
for reasons related to national security.
13

3

Mental Illness among BOP Inmates
Reports citing statistics on the prevalence of mental illness, both within the
BOP’s inmate population and nationally, vary based on sources of data and mental
health information, the definition of mental illness used, and the research
methodology employed. For example, the BOP’s fiscal year (FY) 2016 Performance
Budget Congressional Submission cited an internal BOP study that suggested that
approximately 19 percent of federal inmates had a history of mental illness.14 In
comparison, a 2006 Bureau of Justice Statistics report concluded that 45 percent of
federal inmates had symptoms or a recent history of mental illness.15
According to the BOP, inmates with diagnosed mental illness, including
inmates with serious mental illness, may be housed in each of the RHUs described
above “due to safety and/or security needs for any length of time.”16 BOP policy
defines a mental disorder (illness) as:
A syndrome characterized by clinical significant disturbance in an
individual’s cognition, emotional regulation, or behavior that reflects a
dysfunction in the psychological, biological, or developmental
processes underlying mental functioning. Mental disorders are usually
associated with significant distress or disability in social, occupational,
or other important activities.17
In determining whether an inmate should be classified as having serious
mental illness, BOP policy states that mental health staff will consider the inmate’s
diagnosed mental illness or illnesses, the severity and duration of the symptoms,
the degree of functional impairment associated with the illness or illnesses, and the
14 This study was limited to 2,855 inmates who were new court commitments to the BOP’s
custody, spoke either English or Spanish fluently, could read at a fourth grade level, and were
physically and mentally able to complete self-reporting instruments. Philip R. Magaletta et al.,
“Estimating the Mental Illness Component of Service Need in Corrections, Results from the Mental
Health Prevalence Project,” Criminal Justice and Behavior 36, no. 3 (March 2009).
15 DOJ Office of Justice Programs, Bureau of Justice Statistics, Mental Health Problems of Prison and
Jail Inmates, Special Report (revised December 14, 2006), https://www.bjs.gov/content/pub/pdf/mhppji.pdf
(accessed June 27, 2017). This report was based on data collected from structured clinical interviews of
federal inmates during 2004. It was limited to inmates’ self-reported symptoms or recent history of mental
illness that must have occurred during the 12 months prior to the interview. It did not exclude symptoms
due to medical illness, bereavement, or substance abuse.

By contrast, this report also stated that about 11 percent of persons age 18 or older in the
U.S. general population displayed symptoms of mental disorder, while in 2015 the National Institute of
Mental Health estimated that 17.9 percent of all adults in the United States had experienced mental
illness within the previous year. See National Institute of Mental Health, “Any Mental Illness (AMI)
among U.S. Adults,” https://www.nimh.nih.gov/health/statistics/prevalence/any-mental-illness-amiamong-us-adults.shtml (accessed June 27, 2017).
16 BOP Program Statement 5310.16, 15. The BOP’s definition of mental illness is derived
from the American Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders,
5th ed. (Arlington, Va.: American Psychiatric Association, 2013) (DSM-5), which is a classification and
diagnostic tool used throughout the field of psychology.
17

BOP Program Statement 5310.16, 1.

4

inmate’s treatment history and current treatment needs. BOP policy lists specific
diagnoses that are generally classified as serious mental illnesses, as well as
specific diagnoses that may be classified as serious mental illnesses.18
According to BOP policy, when inmates with serious mental illness are placed
in restrictive housing, they should continue to receive mental health care
commensurate with their treatment needs.19 The BOP limits the placement of
inmates with serious mental illness in the SMUs and the ADX to those inmates who
present extraordinary security needs that cannot be managed elsewhere. Below,
we discuss how the BOP categorizes inmates’ mental health, as well as its policies
to address inmates with mental illness in RHUs.
BOP Mental Health Care Levels
The BOP classifies inmates into four Mental Health Care Levels (MHCL), which
are determined by the resources and services an inmate needs as opposed to the
inmate’s diagnosed mental illness. The BOP policy classifies inmate MHCLs as follows:


MHCL 1: The inmate shows no significant level of functional impairment
associated with a mental illness and demonstrates no need for regular
mental health intervention. Or, if a history of mental illness is present, the
inmate has consistently demonstrated appropriate help-seeking behavior in
response to any reemergence of symptoms.



MHCL 2: The inmate requires routine outpatient mental health care on an
ongoing basis and/or brief, crisis-oriented mental health care of significant
intensity, e.g., placement on suicide watch or behavioral observation status.



MHCL 3: The inmate requires enhanced outpatient care (i.e., weekly mental
health intervention) or residential mental health care (i.e., placement in a
residential Psychology Treatment Program).



MHCL 4: The inmate may require inpatient psychiatric care and acute care
in a psychiatric hospital if the inmate is gravely disabled and cannot function
within the general population at an institution having the mission and
resources to house MHCL 3 inmates.

According to BOP Psychology Services Branch officials, MHCLs are based on
resource utilization and, as such, the BOP tries to assess what type of resources an
18 BOP policy lists Schizophrenia Spectrum and other Psychotic Disorders, Bipolar and related
disorders, and Major Depressive Disorders as diagnoses that are generally classified as serious mental
illnesses. The policy lists Anxiety Disorders, Obsessive-Compulsive and related disorders, Trauma and
Stressor-Related Disorders, Intellectual Disabilities and Autism Spectrum Disorders, Major
Neurocognitive Disorders, and Personality Disorders as diagnoses that are often classified as serious
mental illnesses, especially if the condition is sufficiently severe, persistent, and disabling. See BOP
Program Statement 5310.16, 1–2.
19 BOP policy specifies that if an inmate with a serious mental illness must be placed in
restrictive housing, he/she will continue to receive mental health care commensurate with his/her
treatment needs. See BOP Program Statement 5310.16, 15, 19.

5

inmate needs to function effectively.20 Inmates at both MHCL 3 and MHCL 4 are
considered to have serious mental illness. However, inmates at all MHCLs may
have a serious mental illness. For example, an inmate with a history of psychosis
could be designated at MHCL 1 or 2 despite having a serious mental illness, as long
as he or she faithfully takes medication and does not need further staff intervention
to function effectively. MHCLs do not necessarily correspond to specific diagnoses,
although this is a factor that the BOP takes into consideration. Rather, MHCLs
correspond to treatment requirements and how often inmates need intervention.
The BOP directs its clinicians to assess inmates who are asking for services and
inmates who could benefit from services. For example, the BOP would typically
classify an inmate with Schizophrenia at MHCL 2, 3, or 4, even if the inmate does
not require reoccurring mental health interventions for a prolonged period of time,
because such services may be required in the future.
Recent MHCL Trends
BOP data indicates that a smaller percentage of inmates are being treated for
mental illness than the percentage that the BOP’s Mental Health Prevalence Project
reported as having mental health needs. Specifically, BOP data showed that as of
2015 only 3 percent of the BOP’s total sentenced inmate population was designated
at MHCL 2, 3, or 4, thus requiring recurring treatment, as opposed to nearly
4.3 percent in 2010.21 From the end of FY 2010 through May 2015, the number of
inmates designated at MHCL 2, 3, or 4 decreased by over 30 percent, from
6,853 inmates to 4,768 inmates, while the number of inmates designated at MHCL 1
increased slightly (2 percent). Most notably, the number of inmates designated at
MHCL 4 decreased by almost 60 percent. Table 1 below shows the total number of
inmates across all institutions, by MHCL, from FY 2010 through May 2015.22

20 Similar to how MHCLs delineate the mental health needs of inmates, the BOP also
designates institutional care levels to delineate the varying levels of medical and mental health care
that can be provided to inmates at its institutions. For example, an MHCL 4 inmate should be housed
only at a Care Level 4 institution because only Care Level 4 institutions have the resources needed to
address that inmate’s intensive mental health needs.
21 Later in this report, we discuss what BOP officials estimated as the percentage of the BOP’s
inmate population with mental illness.
22 In response to a working draft of this report, the BOP cited disparities following an MHCL
analysis of its inmate population at the end of FY 2010. While the BOP found the same ratio of its
inmate population who required recurring treatment in FY 2010 (4.3 percent) and May 2015
(3.0 percent), the BOP did not include 17,269 inmates in its FY 2010 numbers that we included in
Table 1 (below). According to the BOP, it did not include these inmates in its analysis because the MHCL
system was formally adopted in December 2009 and many inmates at the end of FY 2010 did not have a
MHCL yet assigned to them. However, the raw data the BOP provided to us for the end of FY 2010
showed that, with few exceptions, all inmates had MHCLs assigned to them. We based our analysis on
this data.

6

Table 1
Inmate MHCLs, FY 2010 – May 2015

147,907

150,884

Percent Change
(+/-)
2.01%

5,701

3,971

-30.35%

MHCL 3

578

551

-4.67%

MHCL 4

574

246

-57.14%

Inmates Designated at
All MHCLs
MHCL 1
MHCL 2

FY 2010

May 2015

Total
154,760
155,652
0.57%
Note: This table does not include inmates who had undergone an initial mental health records review,
were given a tentative MHCL designation by the BOP’s Designation and Sentence Computation Center,
but had yet to be examined, in person, by a mental health clinician.
Source: OIG analysis of BOP data

Over this same period, the BOP decreased its use of restrictive housing for
inmates in general by nearly 20 percent and for inmates designated at MHCL 2, 3,
or 4 by slightly more. Specifically:


The number of inmates housed in SHUs decreased 22.3 percent, with a
corresponding decrease of 26.3 percent in the number of MHCL 2, 3, or 4
inmates housed in SHUs.



The number of inmates placed in the SMU program increased 11.3 percent,
from 1,157 to 1,288. However, the number of MHCL 2, 3, or 4 inmates
placed in the SMU program decreased 13.9 percent overall (from 36 to 31).23



The number of inmates at the ADX decreased 7.6 percent (from 447 to 413)
and the number of MHCL 2, 3, or 4 inmates at the ADX increased by nearly
40 percent (from 33 to 46).

BOP policy currently prohibits the placement of MHCL 4 inmates in the SMUs or the
ADX. Similarly, under the BOP’s 2014 policy, most MHCL 3 inmates are diverted
from SMU or ADX placement, except when extraordinary security needs prevent
them from being housed anywhere else. Later in this report, we discuss further the
30 percent reduction in the number of inmates who receive regular mental health
treatment, including those in RHUs.
BOP Policies Impacting Inmates in RHUs, including those with Mental
Illness
In 2014, the BOP adopted a new national mental health care policy that
detailed enhanced standards of care for all inmates with mental illness. The BOP
supplements this policy with its longstanding Psychology Services Manual, which,
among other things, specifies national mental health screening requirements for all

We note that the number of MHCL 2, 3, or 4 inmates in the SMU increased by 294 percent
(from 36 to 142) from 2010 to 2012 and has since decreased by 78 percent (from 142 to 31).
23

7

inmates.24 To govern the operation of RHUs, the BOP maintains national policies
for institutions’ use of both SHUs and SMUs. Meanwhile, the ADX has local policies
and guidelines establishing an institution’s daily operating procedures, including
supplementing BOP policy regarding the care and treatment of ADX inmates with
mental illness. We discuss the policies below and provide additional detail in
Appendix 2.
National Mental Health Care Program
The BOP’s Psychology Services Branch, located within the Reentry Services
Division, and its Health Services Division develop policy and oversee the overall
psychology, psychiatry, and medical services provided at institutions. Within
institutions, psychology, psychiatry, and medical staff provide mental health services
to inmates with mental illness. Psychologists have the primary responsibility for
diagnosing inmates’ mental illness, treating inmates with diagnosed mental illness,
and monitoring the mental health of inmates, including all inmates housed in RHUs.25
Psychologists share these responsibilities with Psychiatrists, particularly for inmates
diagnosed with serious mental illness, for whom Psychiatrists may prescribe
psychotropic medications.26 General practitioners may also diagnose inmates’ mental
illness and prescribe psychotropic medications.27
Mental Health Care Policy
In May 2014, the BOP issued a national policy requiring that all inmates
receive mental health care commensurate with their needs, even while they are in
restrictive housing. The policy seeks to ensure that inmates with mental illness are
identified and receive treatment to assist their progress toward recovery and to
reduce or eliminate the frequency and severity of symptoms and associated
negative outcomes of mental illness, such as placement in restrictive housing.
According to the policy, any BOP staff member who observes unusual behavior that
may indicate mental illness must report such observations to the institution’s Chief
Psychologist or Mental Health Treatment Coordinator. The policy also redefines
MHCLs, as we described above, and incorporates additional diagnostic, impairment,

24

For more information about the Psychology Services Manual, see Appendix 2.

25 Psychologists are not medical doctors, but they attend graduate school and earn a
doctorate degree in psychology. They are trained to apply psychological assessments, testing for
mental health diagnoses, and various types of treatment; but they generally are not licensed to
prescribe medications without additional, specialized training.

Research refers to psychotropic medication as “any drug capable of affecting the mind,
emotions, and behavior” of an individual. See MedicineNet.com, “Medical Definition of Psychotropic
drug,” http://www.medicinenet.com/script/main/art.asp?articlekey=30807 (accessed June 27, 2017).
26

27 Both General Practitioners and Psychiatrists attend medical school and become medical
doctors who are licensed to diagnose mental illness and prescribe medications, including psychotropic
medications. Psychiatrists generally receive more extensive and specialized mental health training
than do General Practitioners.

8

and intervention-based criteria for inmates designated at MHCL 2, 3, or 4.28
Additionally, the policy increases the frequency of psychosocial interventions that
institution Psychologists are required to provide to inmates with mental illness,
mandating that such interventions occur at least monthly for MHCL 2 inmates and
at least weekly for MHCL 3 and 4 inmates. The policy requires that these
interventions be consistent with the goals of the inmate’s treatment and be
conducted out of cell, face to face, and in a private setting to the extent possible
based on security and safety considerations.29 Further, the policy establishes a
Care Coordination and Reentry (CCARE) team, which is a multidisciplinary team
that meets no less than once a month to share information on the treatment needs
of inmates with mental illness.30
Finally, the policy requires that all MHCL 2, 3, or 4 inmates have an
individualized mental health treatment plan, which Psychology Services staffs are
supposed to develop in collaboration with the inmate. Each plan identifies the
inmate’s individual and/or group programming needs and describes the inmate’s
mental health conditions and goals and the interventions planned to help the
inmate reach them. The policy requires plans to be reviewed and updated every
12 months for MHCL 2 inmates, every 6 months for MHCL 3 inmates, and every
90 days for MHCL 4 inmates.
The policy requires Psychology Services staff to conduct an Extended
Restrictive Housing Placement Review for each inmate housed in an RHU for an
extended period of time to determine whether he or she has mental issues that
preclude placement in this setting. The policy requires that Psychology Services
staff conduct these reviews when an inmate is housed in the SHU continuously for
6 months, in the ADX for 12 months, or in the SMU for 18 months.31

28 Prior to May 2014, MHCL 1 inmates “required clinical intervention no more frequently than
every 3 to 6 months.” Under the 2014 policy, MHCL 1 inmates are not required to be evaluated other
than during their initial mental health screening but inmates have the option to pursue mental health
services on an as-needed basis.

According to the BOP, psychosocial interventions are treatment interventions between mental
health staff and inmates and can include different types of psychotherapy, psycho education, self-help
and support groups, as well as skills training aimed at providing treatment, education, and support to
inmates with mental illness. According to BOP policy, the mental health staff’s psychosocial
interventions and individualized treatment plans must rely on evidence-based clinical practices that have
been demonstrated to reduce the symptoms of mental illness. See BOP Program Statement 5310.16.
29

According to BOP policy, a CCARE team meets to identify potential issues for inmates with
mental illness, such as an inmate who presents mental health symptoms that are unreported or have
gone unidentified or who demonstrates escalating patterns of destructive or dangerous behavior. Per
policy, the CCARE team must include, at a minimum, the Mental Health Treatment Coordinator
(CCARE team co-leader), psychiatric services provider (CCARE team co-leader), treating Psychologist,
institution Social Worker (if applicable), and Pharmacist. See BOP Program Statement 5310.16.
30

31

BOP Program Statement 5310.16, 16.

9

Restrictive Housing Units
As discussed earlier, to ensure safe and orderly environments for inmates
and staff, the BOP utilizes various forms of RHUs to confine some inmates,
including inmates with mental illness. The BOP has established policies to govern
how inmates are confined in each of the three primary types of RHU.
Special Housing Units
According to the BOP’s SHU policy, inmates may be placed in the SHU for
disciplinary segregation or administrative detention, but the SHU policy does not
specifically address conditions of confinement for inmates with mental illness.32 All
inmates placed in the SHU on administrative detention status receive a segregation
review within 3 workdays of placement. All inmates placed in the SHU, regardless
of the reason for their placement, receive a formal review within 7 calendar days of
placement, with subsequent reviews every 7 continuous days thereafter. In
addition, the SHU policy states that after every 30 calendar days of continuous
placement, each SHU inmate receives a mental health examination, including a
personal interview, and emergency mental health care must always be available.33
Special Management Units
The BOP’s mental health policy excludes the placement of inmates with
serious mental illness in the SMU unless there are extraordinary security concerns
that prevent their placement elsewhere.34 According to the BOP’s SMU policy, the
BOP designates an inmate to a SMU when greater management of the inmate’s
interaction is necessary to ensure the safety, security, or orderly operation of BOP
institutions, or for the protection of the public.35 Conditions of confinement are
more restrictive for SMU inmates than for general population inmates, though the
conditions become less restrictive as the inmate progresses through the phases of
the SMU program. Each inmate is evaluated by mental health staff every 30 days,
and emergency mental health care must always be available at the institution or
from the community.

32 Administrative detention status removes the inmate from the general population when
necessary to ensure the safety, security, and orderly operation of correctional facilities or to protect
the public. Administrative detention status applies only to SHU inmates, is non-punitive, and can
occur for a variety of reasons. See BOP Program Statement 5270.10, Special Housing Units
(August 1, 2011), 2.
33

See BOP Program Statement 5270.10, 5–6.

34

See BOP Program Statement 5310.16, 19.

35 National policy for the operation of the SMU is found in BOP Program Statement 5217.01.
As stated earlier, in August 2016 the BOP issued a revised SMU policy. See Appendix 2 for more
information.

10

Administrative Maximum Security Facility
The BOP’s mental health policy also excludes inmates with serious mental
illness from ADX placement unless there are extraordinary security concerns that
cannot be met elsewhere.36 Seriously mentally ill inmates who are to remain at the
ADX must have an individualized mental health treatment plan and be provided
with at least 10, and as many as 20, hours of out-of-cell time per week, consistent
with their treatment plan.37 In July 2015, the ADX issued local policy for the care
and treatment of its inmates with mental illness. The policy establishes that all
ADX inmates will receive psychotropic medications as clinically indicated and
requires that inmates receiving psychotropic medications be seen by a Psychiatrist,
Physician, or Psychiatric Nurse every 90 days, or more often if clinically indicated,
for at least the first year of ADX placement. When in-person psychiatry services
are not available, private tele-psychiatry is to be provided. In addition to private
group counseling and treatment, ADX inmates ordinarily have access to in-cell
therapeutic and recreation activities, including access to Psychology Services
programming through closed-circuit television.
For all types of restrictive housing, staff members are required to make
themselves available to RHU inmates for brief conversations and to demonstrate
their concern and availability to help. Qualified health practitioners and one or
more responsible officers the Warden designates (ordinarily the Institution Duty
Officer) are required to visit each inmate daily, including on weekends and holidays.
After every 30 calendar days of continuous placement in an RHU, each inmate,
including those with mental illness, is required to be examined by mental health
staff. The examination must include a personal interview to evaluate the inmate’s
adjustment to his or her surroundings and to determine whether the inmate poses
any threat to himself or herself, staff, or other inmates.38
Prior Reports on the BOP’s Use of Restrictive Housing and Inmates with
Mental Illness
As part of our review, we examined the following reports published by other
agencies related to restrictive housing and mental illness:
The Government Accountability Office’s Review of BOP Segregated Housing
In May 2013, the U.S. Government Accountability Office (GAO) issued a
report on the BOP’s segregated housing unit practices. The GAO found that from
FY 2008 through February 2013, the population of SHUs, SMUs, and the ADX had
increased 17 percent compared to just 6 percent growth in the BOP’s total inmate

36

See BOP Program Statement 5310.16, 19.

U.S. Penitentiary, Administrative Maximum, Institution Supplement FLM 5310.16A,
Treatment and Care of Inmates with Mental Illness (July 22, 2015).
37

38

BOP Program Statement 5270.10, 11–12.

11

population during the same period.39 The GAO also found that the BOP’s
monitoring of its segregated housing units varied greatly by type of unit, with some
institutions’ documentation related to conditions of confinement and inmate
placement being incomplete and with oversight of ADX-specific conditions of
confinement notably lacking. Further, the GAO determined that the BOP had not
evaluated the effects of long-term segregation on inmates’ mental health, despite
BOP policy acknowledging the risks. The GAO recommended that the BOP develop
ADX-specific monitoring requirements and that any BOP study to assess segregated
housing units also assess the extent that segregated housing contributes to
institutional safety and the impact of long-term segregation on inmates in SHUs,
SMUs, and the ADX.
The Center of Naval Analysis and Solutions’ Review of BOP SHUs
In 2013, the BOP funded an independent assessment of its operation of
restrictive housing following a June 2012 Senate Judiciary Committee hearing on
solitary confinement.40 During the hearing, the former BOP Director stated that
SHUs and the SMU are forms of solitary confinement but that the BOP had no
internal studies or policies to evaluate the effects of solitary confinement. Following
the hearing (and the release of the GAO’s May 2013 report discussed above), the
BOP contracted with the Center of Naval Analysis and Solutions (CNA), which issued
a report with 9 findings and 11 recommendations specifically related to the
diagnosis, care, and treatment of inmates with mental illness in the BOP’s RHUs.41
Most notably, the CNA disagreed with the BOP’s mental health diagnoses of inmates
in nearly two-thirds of the cases it reviewed and concluded that the treatment the
BOP provided was insufficient or inappropriate in over half of the cases it reviewed.
The CNA also found inmates in RHUs whose mental conditions should have
precluded them from assignment to these units; that most RHUs had no mental
health programming, including out-of-cell programming for inmates; that almost all
institutions reported a shortage of staff to provide mental health treatment; and
that a number of inmates in RHUs had symptoms of serious mental illness that BOP
GAO, Bureau of Prisons: Improvements Needed in Bureau of Prisons’ Monitoring and
Evaluation of Impact of Segregated Housing, GAO-13-429 (May 2013). The GAO also issued Bureau
of Prisons: Timelier Reviews, Plan for Evaluations and Updated Policies Could Improve Inmate Mental
Health Services Oversight, GAO-13-1 (July 2013). Although not specifically related to restrictive
housing, the GAO found that the BOP had not evaluated the effectiveness of most mental health
treatment programs, that the most common deficiencies cited in Psychology Services program reviews
were related to care provided in residential treatment programs, and that delays in completing BOP
internal program reviews were most often due to institution staffing issues. The GAO recommended
that the BOP update Program Statements 5310.13, Institutional Management of Mentally Ill Inmates
(March 31, 1995), and 5310.12, Psychology Services Manual (March 7, 1995).
39

40 U.S. Senate, Hearing before the Subcommittee on Constitution, Civil Rights and Human
Rights of the Committee on the Judiciary, “Reassessing Solitary Confinement: The Human Rights,
Fiscal, and Public Safety Consequences,” June 19, 2012.
41 CNA, Federal Bureau of Prisons: Special Housing Unit Review and Assessment (December
2014). The CNA report was issued just prior to the start of the OIG’s review. Our review did not seek
to support or refute the CNA’s findings.

12

psychology staff had failed to detect. The BOP concurred with some of the CNA’s
key findings, but also expressed concern with some recommendations and key
points the BOP believed the CNA report had omitted.
The Department of Justice’s Report and Recommendations concerning the Use of
Restrictive Housing
In January 2016, the Department issued a report on the use of restrictive
housing within the U.S. criminal justice system.42 The Department’s report included
“Guiding Principles” to serve “as best practices for correctional facilities within the
American criminal justice system” to implement if resources allow. The report
defined the term restrictive housing as “any type of detention that includes removal
from the general inmate population, whether voluntary or involuntary; placement in
a locked room or cell, whether alone or with another inmate; and inability to leave
the room or cell for the vast majority of the day, typically 22 hours or more.” The
Department recommended that the BOP expand its ability to divert inmates with
serious mental illness to mental health treatment programs, by increasing the
capacity of existing secure mental health units, and provided the BOP with an
estimated cost of this expansion. The Department also recommended that the BOP
expand its ability to divert “protective custody” inmates to less restrictive forms of
housing by building “Reintegration Housing Units” at multiple BOP institutions. The
Department further recommended that the BOP cut the duration of the SMU
program by half, direct Wardens to develop plans for expanding out-of-cell time for
inmates in restrictive housing, and finalize upgrades in data collection software to
improve tracking of inmates in restrictive housing.
A Department official provided the OIG with the Department’s “180-day
Status Report” on steps the BOP had taken in response to the Department’s
recommendations.43 According to the Department, the BOP implemented new
training for staff; ended the placement of juveniles and pregnant women in
restrictive housing; and limited the length of investigations and maximum penalties
for disciplinary violations, as well as the length of stay in SMUs. The BOP also
created new “protective custody” units, increased transparency by releasing
monthly data on restrictive housing, expanded a mental health pilot program, and
enhanced officer-to-inmate communication. Finally, the BOP revised its SHU and
SMU policies to address a number of the Department’s recommendations. We did
not assess the steps that the BOP took in response to the Department’s
recommendations as part of this review. However, throughout this report we
provide additional information on steps the BOP has taken as they relate to findings
resulting from our review.

42

DOJ, Use of Restrictive Housing.

43 DOJ, “Report and Recommendations concerning the Use of Restrictive Housing: 180-day
Status Report” (September 2016). The status report also discusses steps taken in response to
recommendations directed to the U.S. Marshals Service and the Office of Justice Programs, as well as
reforms at the state and local law enforcement levels.

13

Scope and Methodology of the OIG Review
We examined BOP program statements, policies, and other guidance related
to the screening, treatment, and monitoring of inmates with mental illness and
those related to the SHUs, the SMUs, and the ADX. Our fieldwork occurred from
April 2015 through October 2016 and consisted of document review, case file
reviews, data analysis, interviews, site visits, and observations. We analyzed BOP
population data, mental health data, and restrictive housing data from FY 2010
through May 30, 2015. We also analyzed how the BOP collects and analyzes
mental health and RHU data at BOP-managed institutions. We interviewed officials
with the Office of the Deputy Attorney General, the Civil Rights Division, BOP
officials in the Central Office, institution staff, and representatives from eight state
departments of corrections about reforms and policies related to the treatment of
inmates with mental illness. We also interviewed inmates with a history of mental
illness. See Appendix 1 for more information about the OIG’s methodology.
In this report, we discuss our concerns related to the confinement of inmates
with mental illness in RHUs, including single-cell confinement or conditions that
could be considered “solitary confinement,” as well as the screening, treatment,
and monitoring of inmates with mental illness, including but not limited to those in
restrictive housing.44 We also discuss steps that the BOP has taken to address
concerns with inmates in RHUs, including inmates with mental illness, and
additional steps the BOP might take to build on them.

For the purposes of our analysis, we considered solitary confinement to be an inmate alone
in a cell for 22 hours or more per day with limited human contact.
44

14

RESULTS OF THE REVIEW
BOP Policies Do Not Adequately Address the Confinement of Inmates with
Mental Illness in RHUs, and the BOP Does Not Sufficiently Track or Monitor
Such Inmates
During the OIG team’s visits to BOP institutions, we found inmates who had
been housed in traditional Restrictive Housing Units (RHU), including Special
Housing Units (SHU), Special Management Units (SMU), and the U.S. Penitentiary
Administrative Maximum Security Facility (ADX), as well as in other conditions of
confinement that could be considered solitary confinement. However, the BOP does
not have explicit guidance and policy to define or address solitary confinement,
extended placement, or restrictive housing. While our review focused on traditional
RHUs, including the SHU, the SMU, and the ADX, we found that existing policies do
not account for the broad variation of RHUs throughout BOP institutions. In
addition, while the BOP recognizes that inmates’ mental health can deteriorate if
they are held in restrictive housing for long periods of time, BOP policy does not
limit the length of time inmates spend in restrictive housing. In contrast, we found
that state departments of corrections do limit the length of time inmates spend in
restrictive housing. We also found that the BOP does not track inmates’ single-cell
confinement or assess cumulative time in RHUs. The lack of specificity in BOP
policy for RHUs can potentially affect the mental health services provided to all
inmates, to include those in RHUs, which is particularly concerning for inmates with
mental illness.45
Though Policies Do Not Specifically Define “Solitary Confinement,” the BOP Houses
Inmates in Restrictive Conditions of Confinement that Could Be Considered Solitary
Confinement
Neither the BOP nor the Department has a definition for the term solitary
confinement. When the OIG asked the BOP for its definition of solitary
confinement, the BOP responded: “The Bureau does not recognize the term
solitary confinement. Therefore, the Bureau does not have a definition or a
reference to provide.” The former Correctional Programs Division Administrator
told us that “solitary confinement does not exist within the BOP.”
However, in testimony at a congressional hearing on solitary confinement,
the former BOP Director acknowledged its use in the BOP, stating, “we believe with
solitary confinement for the inmates who pose the most violence and disruption

45 In response to a working draft of this report, the BOP stated that the report cites only research
findings with negative outcomes for inmates in restrictive housing. The BOP also said the science in this
area is not settled and that credible research with different findings should also be included. The BOP
cited as an example a DOJ Office of Justice Programs, National Institute of Justice (NIJ) study on the
Colorado Department of Corrections, “One Year Longitudinal Study of the Psychological Effects of
Administrative Segregation,” https://www.ncjrs.gov/pdffiles1/nij/grants/232973.pdf (accessed June 27,
2017). We note that the NIJ’s study states that there may have been other negative consequences of
administrative segregation that the study did not evaluate.

15

within the facility that we utilize it as a deterrent to correct the behavior.”46 Even
the former Attorney General acknowledged in early 2016 that solitary confinement
does exist within the BOP, stating that she would require from the BOP an “acrossthe-board reduction of maximum penalties for punitive segregation to curb
excessive use of restrictive housing and solitary confinement as punishment.”47
The Department’s 2016 report on the use of restrictive housing used restrictive
housing as a “general corrections term” to describe various restrictive conditions of
confinement but did not use the term “solitary confinement.”48 Rather, it described
housing inmates in cells alone as “single-celled,” such as the case at the ADX.
However, we observed inmates, including inmates with mental illness, housed in
similar conditions within BOP institutions that we visited. Research indicates that
prolonged exposure to conditions of solitary confinement can result in psychological
and psychiatric conditions, such as irritability, anger, aggression, and rage.49
Inmates could also experience chronic insomnia, loss of control, panic attacks,
paranoia, and hypersensitivity to noise, light, and smells.50
At the ADX, we observed an RHU that held two inmates on “Range 13,” each
in his own cell, isolated from other inmates. The inmates did not engage in
recreation with each other or with other inmates and were confined to their cells for
over 22 hours a day. When we asked whether placement on Range 13 could be
considered a form of solitary confinement, a Psychologist at the ADX said, “you
have no contact, you don’t speak to anybody, and it’s a form of torture on some
level.… [Inmates] still talk to officers and stuff like that, but they don’t really get a
chance to see anybody…. They rec[reate] alone; we don’t even have to be back
there to rec them. So, yes, I would say that they are in fact in solitary
confinement.” Also, an RHU at U.S. Penitentiary (USP) Terre Haute, known as the
Special Confinement Unit, houses “death row” inmates in single-cell confinement for
an average of 23 hours a day. We interviewed two inmates in this unit who were
designated at Mental Health Care Level (MHCL) 2 at the time of our visit. One
inmate told us that, since his placement in this RHU 10 years ago, he has been out
Charles E. Samuels, Jr., Director, BOP, before the Subcommittee on Constitution, Civil
Rights, and Human Rights of the Committee on the Judiciary, U.S. Senate, concerning “Reassessing
Solitary Confinement: The Human Rights, Fiscal, and Public Safety Consequences” (June 19, 2012).
46

47 Loretta E. Lynch, U.S. Attorney General, Prepared Remarks (presented at the American
Correctional Association Winter Conference, New Orleans, Louisiana, January 26, 2016),
https://www.justice.gov/opa/speech/attorney-general-loretta-e-lynch-delivers-remarks-americancorrectional-association (accessed June 27, 2016).

The Department’s report defines restrictive housing as having three elements: (1) removal
from the general inmate population, whether voluntary or involuntary; (2) placement in a locked room
or cell, whether alone or with another inmate; and (3) the inability to leave the room or cell for the
vast majority of the day, typically 22 hours or more. See DOJ, Report and Recommendations
concerning the Use of Restrictive Housing (January 2016), 3.
48

49 Craig Haney, Professor of Psychology at the University of California, Santa Cruz, before the
Subcommittee on Constitution, Civil Rights, and Human Rights, Committee on the Judiciary, U.S.
Senate, concerning “Reassessing Solitary Confinement: The Human Rights, Fiscal, and Public Safety
Consequences” (June 19, 2012), 10–11.
50

Haney, “Reassessing Solitary Confinement.”

16

of his cell for only 3 hours a week, no more than 1 hour a day, and spends the
remaining 4 days alone in his cell, 24 hours a day.51 Another inmate, who has been
in this RHU since 2010, stated that, due to the nature of his crime, BOP policy
restricts him from recreating or participating in leisure activities with other
inmates.52 Due to these restrictions, he believes that his confinement constitutes
solitary confinement.53
Further, in five SHUs we observed single-celled inmates, many of whom had
a serious mental illness. One inmate, who Staff Psychologists told us was denied
placement at the ADX for mental health reasons, had been single-celled for about
4 years because staff believed he posed a serious threat to other inmates given his
violent history.54 While we did not observe inmates celled alone in Federal
Correctional Complex (FCC) Petersburg’s SHU, a Staff Psychologist told us that
single-celling inmates does occur in the institution’s SHU and that she did not
always know why some inmates were single-celled. She stated that single-celling
inmates can be an added risk (to an inmate’s mental health) and that, in the past,
she has annotated the SHU Application, a computer program, to request that
correctional staff refrain from single-celling specific inmates who had mental
illness.55
Although most inmates in the SMU have a cellmate, inmates, including
inmates with mental illness, may also be placed in single-cell confinement and in
conditions that may jeopardize their mental health. At USP Lewisburg, the only
remaining SMU institution, we observed infrastructure issues that were particularly
concerning in light of the fact that inmates may be placed in these conditions for
years. See the text box below regarding our observations and the concerning
conditions of confinement for inmates, including those with mental illness, at USP
Lewisburg.
There are three phases of restriction in the Special Confinement Unit, with Phases 1 and 3
representing the most restrictive levels and Phase 2 representing the least restrictive level. According
to BOP policy, inmates will remain at Phase 1 for at least 1 year and may be managed at this level for
an indefinite period of time. BOP policy also states that, in addition to recreation, inmates managed at
Phase 2 may also participate in out-of-cell leisure activities with up to two other approved inmates;
but this time is considered a privilege that is limited to the availability of the common area. We do not
know what phase(s) the BOP has used to manage this inmate since his arrival to this RHU. See BOP
Institution Supplement THX-5217.01K, Operation and Security of the Special Confinement Unit
(June 25, 2015).
51

This inmate was convicted with his co-defendant of murdering another inmate while in BOP
custody. BOP policy states that, “Phase 1 inmates will recreate alone” and that “inmates who have
committed murder or attempted to kill anyone while incarcerated will not normally be considered for
Phase II.” See BOP Institution Supplement THX-5217.01K.
52

53 The inmate also told us that he prefers this unit to the SHU at this institution. During our
fieldwork, BOP officials, staff, and other inmates told us that inmates sometimes prefer to be housed
in RHUs, including single-cell confinement, as opposed to placement in the general population.

Institution staff told us that the inmate had declined to go to the secure residential
treatment program, which at that time was pending activation. However, the institution’s mental
health staff told us that they did not believe that he was seriously mentally ill and thus he was suitable
for ADX placement.
54

55

We discuss the SHU Application later in this report.

17

SMU Conditions of Confinement
We found that the conditions of confinement, including the size and ventilation of cells, could
result in harm to SMU inmates with mental illness. For example, an unknown number of SMU cells
at USP Lewisburg in Pennsylvania do not meet the American Correctional Association’s (ACA)
minimum standards for restrictive housing cell sizes. ACA standards stipulate that all restrictive
housing cells provide a minimum of 80 square feet, of which 35 square feet is to be
unencumbered. According to the BOP, some SMU cells at USP Lewisburg are only 58.5 square feet
in size. When we asked BOP officials whether USP Lewisburg’s SMU cells met ACA standards, they
provided conflicting responses. Additionally, a senior official from the BOP’s Program Review
Division told us that the ACA standards for restrictive housing cell size are not mandatory.
We observed a lack of air conditioning at USP Lewisburg, which was the only one of the seven
institutions we visited that relied on ceiling fans instead of air conditioning to ventilate inmates’
cells and cellblocks. This is especially troubling since psychotropic medications can hinder the
body’s ability to sweat. These conditions can make inmates who take psychotropic medications
more prone to heat stroke and heat-related illnesses.
Sources: OIG observations; BOP Program Statement 5217.01, Special Management Units
(November 19, 2008), 6–7; ACA, Standards for Adult Correctional Institutions, 4th ed. (Lanham,
Md.: American Correctional Association 2003), 39; Human Rights Clinic, University of Texas
School of Law, Reckless Indifference: Extreme Heat in Texas Prisons (March 2015), 20

In addition, most inmates placed in RHUs, including those with mental
illness, have limited out-of-cell opportunities.56 For instance, inmates placed in the
SHUs do not have out-of-cell programming opportunities and inmates’ participation
in general population group therapy would be discontinued during their SHU
placement, according to Psychology Services Branch officials.57 These officials
indicated that the BOP is looking to provide inmates in restrictive housing with
group therapy opportunities but stated that not every institution has the resources
to do so. Also, while BOP policy requires that inmates have the opportunity to
exercise outside their individual quarters at least 5 hours per week, ordinarily on
different days in 1-hour periods, it also states that inmates, including those in
single-cell confinement, may have recreation privileges suspended.58 According to
policy, an institution’s Warden can deny exercise privileges for a week at a time if it
is determined that an inmate’s use of recreation threatens the safety, security, and
orderly operation of a correctional facility, or public safety. Further, the BOP does
not provide recreation on weekends to inmates in RHUs and, consequently, inmates
are confined to their cell for approximately 72 consecutive hours every weekend
without any out-of-cell opportunities. The BOP’s Correctional Programs Division
56 After the completion of our fieldwork, the BOP issued a revised SHU program statement in
November 2016. Although we did not evaluate this policy, we note throughout this report examples of
changes to the SHU policy as they relate to our findings during the course of our review. For example,
to enhance inmates’ out-of-cell time, the BOP’s revised SHU policy requires that staff at each
institution locally develop plans for increasing inmates’ recreation and that institutions with the
necessary resources should do so. See BOP Program Statement 5270.11, Special Housing Units
(November 23, 2016), 12.
57

We further discuss disruptions to inmate’s continuity of care later in this report.

58

BOP Program Statement 5270.10, Special Housing Units (August 1, 2011), 8–9.

18

(CPD) officials told us that the BOP does not have the correctional staffing
resources to offer recreation to inmates during the weekend. Psychology Services
Branch officials also recognized this resource limitation but acknowledged that
out-of-cell opportunities during the weekend would be beneficial for inmates,
including those with mental illness. We recognize the challenges in providing
inmates in RHUs with out-of-cell opportunities; however, confining inmates,
particularly those in single-cell confinement, in cells for prolonged periods of time
with limited human contact, could potentially harm their mental health.
We found a discrepancy between what we observed at BOP institutions and
what Department and BOP policies stated regarding single-cell confinement. The
former Acting Chief of Staff for the Office of the Deputy Attorney General told us
that the Department did not consider specific policies for double-celling or singlecelling inmates when developing its report. He added that the corrections and
advocacy communities define solitary confinement differently and that in reality
restrictive housing and solitary confinement are the same.59
While the Department’s report does not define solitary confinement, it does
reference Civil Rights Division investigations that, in some cases, define solitary
confinement more specifically. A May 2013 Civil Rights Division investigation of the
Pennsylvania State Institution at Cresson defined “isolation,” or “solitary
confinement,” as “the state of being confined to one’s cell for approximately
22 hours per day or more, alone or with other prisoners, that limits contact with
others.”60 In February 2014, the Civil Rights Division completed a system-wide
investigation of the Pennsylvania Department of Corrections (PDOC) after having
found that prisoners with serious mental illness and intellectual disabilities at
Cresson were routinely subjected to solitary confinement under conditions that
violated their constitutional rights and their rights under Title II of the Americans
with Disabilities Act of 1990.61 The February 2014 investigation referred to solitary
The Department’s report stated that the term solitary confinement is disfavored by
correctional officials because, in part, it conjures a specific and in some cases misleading image of the
practice. The Department also stated that not all segregation is truly “solitary” because many prisons,
including the BOP’s, often house two segregated inmates together in the same cell, a practice known
as “double-celling.” The Department adopted the terms restrictive housing and segregation to avoid
this confusion. See DOJ, Use of Restrictive Housing, 3.
59

Thomas E. Perez, Assistant Attorney General, DOJ Civil Rights Division, and David J. Hickton, U.S.
Attorney, Western District of Pennsylvania, letter to the Honorable Tom Corbett, Pennsylvania Governor’s
Office, May 31, 2013, https://www.justice.gov/sites/default/files/crt/legacy/2013/06/03/cresson_findings_531-13.pdf (accessed June 27, 2017).
60

61 For the purposes of the investigation, the Civil Rights Division used the state’s definition of
serious mental illness as “a substantial disorder of thought or mood that significantly impairs
judgment, behavior, or capacity to recognize reality or cope with the ordinary demands of life.”

In April 2016, the Civil Rights Division closed its investigation of the PDOC, noting the
significant improvements in the PDOC’s policies and practices regarding solitary confinement for those
prisoners with serious mental illness or intellectual disabilities. See Vanita Gupta, Principal Deputy
Assistant Attorney General, DOJ Civil Rights Division, and David J. Hickton, U.S. Attorney, Western
District of Pennsylvania, letter to the Honorable Tom Wolf, Pennsylvania Governor’s Office, April 14,
2016, https://www.justice.gov/crt/file/850886/download (accessed June 27, 2017).

19

confinement as “the state of being confined to one’s cell for approximately 23 hours
a day or more.”62
Since BOP and Department policies do not specifically recognize the term
solitary confinement, to help us evaluate actual conditions of confinement in BOP
institutions, we considered the Civil Rights Division’s definition, as well as the
United Nations’ “Mandela Rules.” According to a March 2016 report from the
National Institute of Justice, the United Nations passed the Mandela Rules in May
2015, which represented the first modification to the United Nations’ standards on
the treatment of prisoners in 60 years.63 The United Nations describes solitary
confinement in the Mandela Rules as “confinement of prisoners from 22 hours or
more a day without meaningful human contact.”64 (See the text box below.)

Jocelyn Samuels, Acting Assistant Attorney General, DOJ Civil Rights Division, and David J. Hickton,
U.S. Attorney, Western District of Pennsylvania, letter to the Honorable Tom Corbett, Pennsylvania Governor’s
Office, February 24, 2014, https://www.justice.gov/sites/default/files/crt/legacy/2014/02/25/pdoc_finding_224-14.pdf (accessed June 27, 2017).
62

A Civil Rights Division Deputy Chief and a Trial Attorney associated with both the Cresson and
PDOC investigations told us that they did not know why the definition of solitary confinement changed
between their May 2013 and February 2014 findings letters. They also told us that the Civil Rights
Division had not directly decided to change the hours from 22 to 23, but rather had done so in
collaboration with the BOP and other DOJ components. In the case of the Cresson and PDOC
investigations, and other investigations related to corrections, the Civil Rights Division works with the
BOP to ensure it does not conflict with BOP policies or practices and that factual distinctions are made
before the findings letters are released publicly. The Deputy Chief told us:
We couldn’t say anything in a blanket way that if you lock people up for 23 hours a
day, for months or even years, that that violates the Constitution. We couldn’t say
that, because BOP locks people up for 23 hours a day for months and years.… So,
therefore, we made factual distinctions [between the BOP and Cresson or PDOC],
because we had to.
According to an NIJ report, “Rule 43 of the Mandela Rules prohibits both indefinite solitary
confinement and prolonged solitary confinement (defined as lasting more than 15 days).” See NIJ,
Administrative Segregation in U.S. Prisons (March 2016), 1.
63

64

United Nations, Mandela Rules.

20

The Mandela Rules
The United Nations’ Standard Minimum Rules for the Treatment of Prisoners, Rule 44 states:
“For the purpose of these rules, solitary confinement shall refer to the confinement of prisoners for
22 hours or more a day without meaningful human contact. Prolonged solitary confinement shall
refer to solitary confinement for a time period in excess of 15 consecutive days.” Rule 45 states:
“The imposition of solitary confinement should be prohibited in the case of prisoners with mental or
physical disabilities when their conditions would be exacerbated by such measures.”
According to an official of the U.S. Department of State, the United States “whole-heartedly”
endorses all of the United Nations Rules and is proud to have participated in the collaborative
process that produced them.
Sources: United Nations, Standard Minimum Rules for the Treatment of Prisoners, September 29,
2015 (Mandela Rules); Sarah Sewall, Under Secretary for Civilian Security, Democracy, and Human
Rights, U.S. Department of State, Prepared Remarks (presented at a High Level Presentation of the
Nelson Mandela Rules — the Draft Revised Standard Minimum Rules on the Treatment of Prisoners,
October 2015)

While the Department’s definition of restrictive housing acknowledges the
placement of an inmate in a locked room or cell alone, it does not specify how
contacts between staff and inmates housed in such conditions are to take place.65
During our visits to BOP institutions throughout this review, we found that the BOP
houses inmates, including those with mental illness, for long periods of time
isolated from other inmates and with limited human contact — conditions of
confinement that could constitute solitary confinement according to the Civil Rights
Division’s definition, as well as the Mandela Rules.66 The Office of the Deputy
Attorney General’s former Acting Chief of Staff told us that it was clear that
restrictive housing usually involved someone being in isolation for 22 hours a day
without being able to leave and that focusing on the definition of the term solitary
confinement detracts from ensuring that inmates housed in restrictive housing for
long periods of time receive meaningful contact. BOP CPD officials told us that
meaningful contact was a “pretty broad term” and “hard to define.” Finally, officials
with the BOP’s Psychology Services Branch told us that the BOP has outlined for
staff what meaningful contacts should look like, through training and during
rounds; however, the BOP does not have policy to describe meaningful contact or
the monitoring of inmates in a cell alone.67
While we acknowledge that BOP policies require contacts between staff and
inmates, not all contacts are specified in BOP policies nor are they specific for
65

See DOJ, Use of Restrictive Housing, 14.

For the purposes of our analysis, we considered solitary confinement to be an inmate alone
in a cell for 22 hours or more a day with limited human contact.
66

Throughout our review, BOP staff and officials described several forms of contact for
inmates in SHUs, including rounds made by Correctional Officers every 30 minutes, a supervisor
seeing an inmate during every shift, a Captain seeing inmates every week, and regular visits from
inmates’ unit team, medical team, and a Chaplain. Also, inmates are fed three times a day and
Psychology Services visits each inmate every 30 days. Though communication is through a small
window, a Segregation Review Official sees an inmate every 7 days. After 30 days, an inmate will
have the opportunity to come out of his or her cell to speak to the Lieutenant.
67

21

inmates housed in a cell alone. By not acknowledging such conditions in policy and
establishing when they may be appropriate procedures for the management and
care of these inmates, including appropriate contacts for those with mental illness,
all inmates in such conditions are potentially subjected to long periods of time in
forms of confinement that could exacerbate existing mental illness or create the
onset of mental disorder.
The BOP Needs to Improve Its Tracking of Inmates Placed in Single-Cell
Confinement
In addition to finding that the BOP’s policies are inadequate to address
conditions amounting to solitary confinement, we found that the BOP is unaware of
how many of its inmates in RHUs (other than at the ADX or in secure residential
mental health treatment programs) are housed alone in a cell (single-cell
confinement) because the BOP does not track this information. The former Deputy
Assistant Director for the CPD told us that while institution staff review the
placement of inmates in the SHU on a weekly basis, there is no national database
that identifies inmates who are celled alone or tracks the duration of such
placement. He added that there are legitimate reasons why inmates may be singlecelled, such as for a contagious disease, disability, protective custody, medical
recovery, or because they are a danger to other inmates. Still, in light of mental
health concerns, Psychology Services Branch officials told us that they prefer
inmates to be double-celled in RHUs; but they acknowledged that some institution
staff are not receptive to this practice.
We recognize that some inmates with mental illness may be celled alone for
legitimate reasons, such as being too dangerous to house with others. However,
we question why the BOP does not separately track inmates who have been in
prolonged periods of single-cell confinement because, by most accounts, these
inmates are held in conditions of confinement that mirror conditions in the ADX,
which can have a detrimental effect on their mental health. Moreover, unlike the
ADX, most RHUs are not intended for long-term placement and thus lack the
staffing and infrastructure suitable for this type of prolonged confinement. Since
the BOP does not specifically track inmates placed in single-cell confinement, BOP
officials cannot easily identify inmates celled alone or ascertain the duration of such
placement and, consequently, cannot intervene when single-cell confinement may
not be necessary or may be unduly harmful to the inmate.
The BOP Does Not Have Adequate Policy to Address the Needs of Inmates with
Mental Illness in All RHUs
In addition to inadequate policies addressing single-cell confinement, we
found that the BOP’s SHU policy, issued in 2011, does not differentiate among the
various types of RHUs throughout BOP institutions. Also, neither it nor the mental
health policy issued in 2014 adequately addresses the mental health needs of
inmates housed in these RHUs. The BOP told the OIG that it defines restrictive
housing as “those situations when an inmate is placed in confinement, outside of
the general population for the safety, security, and orderly operation of our
correctional facilities.” The former CPD Deputy Assistant Director said that there
22

are RHUs at all BOP facilities
and that the SHU policy sets
the standard that all RHU
programs have to meet.68
During our site visits, we found
forms of restrictive housing in
which inmates with mental
illness experience conditions of
confinement contrary to the
BOP’s SHU and mental health
policies. (See the text box for
an example of an RHU at
Federal Medical Center (FMC)
Carswell in which the practices
appear to be contrary to BOP
policies.)
We also observed
another RHU at FMC Carswell,
the Administrative Unit, with its
own SHU that houses inmates,
including those with mental
illness, with histories of escape,
chronic behavioral problems,
repeated incidents of assaultive
or predatory behavior, or other
special management concerns.
As of June 2016, this unit
housed 17 total inmates,
including 6 inmates at MHCL 2
and 1 inmate at MHCL 3 (the
remaining 10 inmates were at
MHCL 1). Institution staff said
they do not consider this unit to
be an RHU but rather a “selfcontained, open unit.”69

Concerns regarding Inmates with Mental Illness in
M3
We found at FMC Carswell a unit, known as “M3,”
which has been used since at least 1999 to house the
most volatile and decompensating female inmates
(predominately MHCL 4 inmates), with the intent to
eventually return them to a less restrictive environment.
The Warden told us that inmates with serious mental
illness may be placed in this unit for administrative and
disciplinary segregation in lieu of traditional SHU
placement. We observed that the majority of inmates in
this RHU were single-celled, with no designated recreation
area. A Correctional Officer who has worked extensively
in this unit told us that he has seen a few inmates housed
in this unit for about a year. He also told us that when
the institution’s SHU is full, SHU inmates may also be
housed in this unit.
The BOP’s SHU policy states that inmates should
“receive the opportunity to exercise outside [their]
individual quarters at least five hours per week.” The
Chief Psychologist told us of the challenges, including
Correctional Officer staffing, which have hindered the
institution from having an outdoor recreation area for
inmates in this unit. While the unit has an indoor
recreation cell, the Chief Psychologist told us that it is
“important for the mental and physical well-being of a
person to get sun and fresh air and you cannot do that
indoors.” In addition, according to BOP’s new mental
health policy, all inmates in the SHU must receive an
extended placement review every 6 months. We found
that although the psychology staff conducts monthly SHU
reviews for the inmates in this unit, according to the Chief
Psychologist these inmates do not receive extended
placement reviews because the unit is not considered to
be a SHU. We discuss Extended Restrictive Housing
Placement Reviews later in this report.
Sources: OIG observation and analysis, interviews with
BOP staff

The BOP’s SHU Program Statement (5270.10) provides that alternative segregation
housing must be proposed by the Warden to the Regional Director, and ultimately approved by the
Assistant Director, CPD, before activation. These alternative housing units will be approved only as
SHU overflow for inmates in administrative detention or disciplinary segregation status. Operation of
such alternative segregation housing requires compliance with all BOP rules, policies, staffing, and
post orders for operating SHUs. See also BOP Program Statement 5310.16, Treatment and Care of
Inmates with Mental Illness (May 1, 2014).
68

69 The Unit Manager told us that all services, including recreation, education, mental health,
dentistry, unit team, psychology, and psychiatry, are provided within that unit. The Chief Psychologist
told us that in the rare instances when inmates are required to leave the unit, the entire institution is
placed on lockdown.

23

However, the unit’s local policy establishes, among other things, procedures for the
placement of inmates in the unit for “Administrative Detention” or “Disciplinary
Segregation.” Also, the Chief Psychologist told us that the unit “functions like the
ADX.”70 Specifically, the institution uses a five-level classification system to
manage inmates within the unit and those designated at the highest level are
confined to their cells for up to an average of 23 hours per day. The Chief
Psychologist told us that although inmates within the unit’s SHU receive more
frequent clinical contacts from mental health staff than what is required in the SHU
policy, none of the inmates in this unit receive SHU reviews, despite the fact that
the SHU policy states that all inmates in restrictive housing must be given a SHU
review every 30 calendar days to monitor their mental health.
CPD officials told us that the BOP does not maintain a centralized list or
otherwise track how many of these other forms of restrictive housing exist. With
the exception of SHUs, SMUs, and the ADX, the BOP does not know how many
inmates are housed in these units. For example, none of the inmates from FMC
Carswell’s Administrative Unit, including inmates with mental illness in this unit’s
SHU, were accounted for in FMC Carswell’s SHU population data that the BOP
provided to us. However, at time of our visit in August 2015, we observed inmates
with mental illness placed in this unit’s SHU, including one inmate designated at
MHCL 3 and two inmates designated at MHCL 2.
The OIG believes that not recognizing certain types of housing conditions as
restrictive housing may prevent inmates with mental illness from receiving
appropriate reviews, which has the potential to exacerbate the inmates’ mental
illnesses. The BOP should identify all forms of restrictive housing throughout its
institutions and ensure that all local policies reflect standards established in national
policies.71
The BOP Does Not Limit the Length of Time Inmates Spend in Restrictive Housing,
Including Single-Cell Confinement, Which May Affect Inmates’ Mental Health
During the scope of our review, in addition to not accounting for the various
types of RHU throughout BOP institutions, no BOP policy limited the length of time

70 In November 2016, the BOP issued a revision to its 1997 Management of Female Offenders
policy (see BOP Program Statement 5200.02, Female Offender Manual). We note that this new policy
acknowledges this unit and states that, “female offenders will receive mental health screening prior to
placement on this unit consistent with the procedures for male inmates referred to the Administrative
Maximum Penitentiary (ADX) described in the Program Statement Treatment and Care of Inmates with
Mental Illness.”
71 The Department’s “Report and Recommendations concerning the Use of Restrictive
Housing: 180-day Status Report” (September 2016) states that in May 2016 the BOP began posting
data on restrictive housing on its public website, “Statistics,” http://www.bop.gov/about/statistics
(accessed June 27, 2017). Our review of data posted to the BOP’s public website found that the BOP
provides data only on those inmates housed in SHUs, SMUs, and the ADX. The Department also
reported that the BOP was implementing new software to better track inmates as they progress
through restrictive housing and that testing on this software was expected to begin in the fall of 2016.

24

inmates can be assigned to an RHU.72 The BOP’s mental health policy states that
“inmates referred for extended placement in restrictive housing (i.e., SMU, ADX)
must be reviewed by Psychology Services staff to determine whether mental health
issues exist that preclude placement in this setting.”73 However, neither the BOP
nor the Department defines “extended placement.”74 Rather, the BOP policy
requires that an inmate receive an Extended Restrictive Housing Placement Review
after being continuously housed in the SHU for 6 months, in the ADX for
12 months, or in the SMU for 18 months.75 Moreover, these are only minimum
intervals, after which the staff must review the inmate’s placement. The policy
does not limit the amount of time an inmate can ultimately spend in an RHU.
The former CPD Deputy Assistant Director told us that there is no limit to the
amount of time an inmate can be placed on extended placement. He further stated
that the length of an inmate’s placement in restrictive housing depends on the
behavior of the inmate and that RHUs are used in an effort to change or regulate
negative behavior. According to BOP data, one MHCL 3 inmate was housed in the

72 The ACA manual defines restrictive housing as “a placement that requires an inmate to be
confined to a cell at least 22 hours per day.” ACA, Restrictive Housing Performance Based Standards,
4th ed. (American Correctional Association, August 2016), 3. In addition, the BOP issued a revised
SMU policy in August 2016 that, among other things, restricts all inmates’ length of time in the SMU to
24 consecutive months. However, it is important to note that this limit applies only to the SMU and
that no BOP policy prohibits inmates’ continued placement in other RHUs (SHUs, ADX, etc.) following
24 months of placement in the SMU. See BOP Program Statement 5217.02, Special Management
Units (August 9, 2016).
73 During the scope of our review, BOP policy did not preclude the placement of inmates with
serious mental illness in SHUs. While SHU inmates received Extended Restrictive Housing Placement
Reviews, BOP policy did not prevent their placement in SHUs. See BOP Program Statement 5310.16,
16, 20–21. We discuss Extended Restrictive Housing Placement Reviews later in Results of the
Review.

Since the completion of our fieldwork, the BOP issued a revised SHU policy that prohibits SHU
placement for inmates whom mental health staff have designated at MHCL 3 or 4, who have a
psychology alert in SENTRY (the BOP’s primary mission support database), or who have been
identified on the monthly SHU advisory (Hot List) unless the inmate presents an immediate or serious
danger to self, staff, or the orderly operation of a facility. In the event that an inmate who meets one
of these criteria is placed in the SHU, Psychology Services staff must be notified and must conduct a
mental health evaluation within 24 hours of the inmate’s placement. See BOP Program
Statement 5270.11, 15–16.
The ACA defines extended restrictive housing as “housing that separates the offender from
contact with general population while restricting an offender/inmate to his/her cell for at least
22 hours per day and for more than 30 days for the safe and secure operation of the facility.” ACA,
Restrictive Housing Performance Based Standards, 3.
74

The Department’s report briefly discusses Extended Restrictive Housing Placement Reviews,
replicating language from the BOP’s Program Statement 5310.16; but the Department does not define
extended placement. See DOJ, Use of Restrictive Housing, 51.
75 Institution Psychologists complete Extended Restrictive Housing Placement Reviews, which
include records reviews, behavioral observations, a clinical interview, and psychological testing if
clinically indicated. See BOP Program Statement 5310.16, 16.

25

SHU for 5 years (1,912 consecutive days).76 Another inmate with mental illness,
who previously had been designated MHCL 2, had spent over 6 years
(2,326 consecutive days) in the SMU and was still there at the time of our site
visit.77 Additionally, an MHCL 3 inmate had spent about 19 years
(6,874 consecutive days) at the ADX before being transferred to a secure
residential mental health treatment program in 2014.78 These cases show that
inmates, including those with mental illness, may in effect be placed in an RHU for
an unlimited amount of time.
Not only may inmates be placed in restrictive housing, including in single-cell
confinement, for what essentially could amount to an unlimited amount of time;
but, equally concerning, inmates may be placed in these conditions for long periods
of time and then be released directly into the community, as we discuss in the text
box below.79 Research shows that “time spent in solitary confinement contributes
to elevated rates of recidivism” and that many inmates released into the
community from RHUs “come out of these units damaged and functionally
disabled,” which can be a public safety concern.80

76 According to BOP data, in October 2011 the BOP diagnosed this inmate with Antisocial
Personality Disorder and Schizophrenia. The number of consecutive days in the SHU for this inmate
was valid as of October 2012, and he was an MHCL 3 inmate as of September 2012.
77 From as early as 2005, the BOP diagnosed this inmate with Oppositional Defiant Disorder,
Borderline Intellectual Functioning, Borderline Personality Disorder, Malingering, Antisocial Personality
Disorder, and Exhibitionism. The number of consecutive days in the SMU for this inmate was valid as
of September 2015, and he was an MHCL 1 inmate at that time. However, he had been designated at
MHCL 2 from December 2012 until January 2014.
78 The inmate’s diagnoses date to as early as 2006. The BOP has since diagnosed this inmate
with Borderline Personality Disorder, Antisocial Personality Disorder, Personality Disorder Not
Otherwise Specified, Major Depressive Disorder-Recurrent, and Anxiety Disorder Not Otherwise
Specified. At the time of his departure from the ADX, he was designated at MHCL 3 and transferred to
a secure residential treatment program. We discuss these programs later in this report.
79 In August 2016, the OIG released a report on the BOP’s Release Preparation Program,
which seeks to prepare inmates for the challenges they will face when they are released into the
community. DOJ OIG, Review of the Federal Bureau of Prisons’ Release Preparation Program,
Evaluation and Inspections Report 16-07 (August 2016). Also see DOJ OIG, Audit of the Federal
Bureau of Prisons’ Management of Inmate Placements in Residential Reentry Centers and Home
Confinement, Audit Report 17-01 (November 2016).

In November 2016, the BOP issued its revised SHU policy, which stated that, ordinarily,
inmates nearing the end of their term of incarceration will not be placed in SHU, except when their
presence in the general population threatens the safety, security, or the orderly operation of a BOP
institution, and that every effort will be made to prevent inmates’ direct release from the SHU into the
community. See BOP Program Statement 5270.11, 16.
80

Haney, “Reassessing Solitary Confinement,” 15.

26

Despite Concerns, the BOP Has Released Mentally Ill Inmates into
the Community Directly from RHUs
Based on a sample of 239 SMU inmates with mental illness, we found that 31 inmates
(13 percent) were released directly into the community from the SMU. We also found that, on
average, these 31 inmates had spent nearly 29 months in the SMU prior to their release. The
former CPD Deputy Assistant Director said it is “troubling” to release someone from that status into
the community.
Some institution staff told us that they are aware of inmates with mental illness who have
been released from their institution’s SHU directly into the community. One Psychologist stated
that within the previous 2 years she could recall an MHCL 3 inmate who was in the SHU for at least
6 months and was then released directly into the community. Both she and the institution’s Chief
Psychologist told us that releasing inmates from the SHU directly into the community has become
increasingly rare in recent years as the BOP has improved its efforts to prevent it.
We did not find that inmates at the ADX had been released directly into the community. The
Deputy Chief Psychologist over the ADX told us that this does not occur and that inmates will be
transferred to and released from other institutions. However, she also stated that until a couple of
years ago the BOP used to transfer ADX inmates with upcoming release dates to a U.S.
Penitentiary that would then place the inmates in its SHU until they were released into the
community. She stated that this practice was “no different than releasing from the ADX.”
Sources: OIG analysis

State Departments of Corrections Do Limit the Length of Time that Inmates Spend
in Long-term Restrictive Housing
The OIG found that, unlike the BOP, at least some state departments of
corrections do limit the length of time inmates are placed in restrictive housing. We
interviewed officials from eight state departments of corrections (Colorado, Maine,
Massachusetts, New York, Virginia, Mississippi, Washington, and Pennsylvania) to
better understand their initiatives to limit or prohibit the placement of inmates with
serious mental illness in restrictive housing.81 Corrections officials from three states
(Massachusetts, New York, and Mississippi) told us that their states have at least a
30-day limit on housing inmates with serious mental illness in RHUs.82 We also
found that three other states (Pennsylvania, Colorado, and Maine) no longer place
inmates with serious mental illness in RHUs at all. We found that states are
implementing alternatives to long-term segregation by placing inmates with serious
mental illness in residential treatment programs. We discuss these state programs,
as well as the BOP’s secure residential mental health treatment programs, later in
this report.

We found that each state department of corrections has a different definition of serious
mental illness and a different inmate mental health classification system.
81

In response to a working draft of this report, an official with Mississippi’s Department of
Corrections told us that, since the time of our fieldwork in 2015, Mississippi no longer limits the
placement of inmates with serious mental illness in restrictive housing.
82

27

The BOP Does Not Monitor Inmates’ Cumulative Time in All RHUs
Inmates’ Cumulative Time in the SHU May Be Extensive
As we discussed in the Introduction, studies have shown that the frequency,
duration, and conditions of confinement of restrictive housing, even for short
periods of time, can cause psychological harm and significant adverse effects on
inmates’ mental health. While the BOP tracks and monitors inmates’ time in SHUs,
we found that the BOP does not monitor inmates’ cumulative time in SHUs.
According to officials with the BOP’s Psychology Services Branch, assessing such
information could be clinically relevant for some inmates. As a result of the BOP’s
failure to track such information, the BOP cannot determine the number of inmates
who frequent the SHUs in multiple, shorter durations or may have longer overall
periods in such conditions of confinement.
BOP policy now requires that all inmates receive an Extended Restrictive
Housing Placement Review after 180 consecutive days in the SHU.83 To assist
institutions in meeting this requirement, the BOP developed a dashboard that each
month notifies institutions of inmates who have been in the SHU for at least
150 consecutive days and may be due for their review during the upcoming
month.84 However, Psychology Services Branch officials and staff told us that the
clock resets if an inmate has a 24-hour break in SHU housing placement.85
Consequently, an inmate theoretically could spend up to 363 days of the year in the
SHU, up to 179 days at any time and, per policy, not warrant an Extended
Restrictive Housing Placement Review. In addition, a Staff Psychologist said that
when an inmate leaves the SHU, his or her record in the SHU Application is
“completely erased.”86 This includes the Psychology Services staff’s mental health
notes for SHU correctional staff, which can be comprehensive for inmates with
serious mental illness. Collectively, these limitations may compromise the BOP’s
ability to monitor inmates who have been in SHUs for multiple, shorter durations
83

BOP Program Statement 5310.16, 20.

While BOP policy requires that all inmates receive an Extended Restrictive Housing
Placement Review after every 180 consecutive days in the SHU, the BOP staff must still check the
report to verify which inmates are due for review by the end of each month. For example, the
dashboard may identify inmates who have been in the SHU for 9 months but do not require their
second Extended Restrictive Housing Placement Review until they reach 1 year in the SHU.
84

BOP officials told us that while the dashboard is useful, it has limitations and that ultimately
it is the responsibility of institutions’ SHU staff to ensure that all inmates who require an Extended
Restrictive Housing Placement Review receive one, whether or not the dashboard identifies them. For
example, institution staff told us of an inmate who had been housed in the SHU for approximately
4 years as of August 2015. Based on our analysis of dashboard reports, at the end of FY 2014 this
inmate was reported as having been in the SHU for only 290 days.
85

As referenced above, the SHU Application is a computer program that the SHU staff uses to
manage, record, and track daily activities in the SHU. Although the SHU Application does not preserve
the notes mental health staff document for SHU correctional staff once the inmate’s placement in the
SHU concludes, clinical notes documented by mental health staff in the BOP’s mental health system
(the Bureau’s Electronic Medical Record System and Psychology Data System (BEMR-PDS)) are
preserved, regardless of the inmate’s housing assignment.
86

28

that add up to extensive periods of time and can limit the Psychology Services
staff’s ability to detect deteriorations in mental health that would make continued
SHU placement inappropriate.
Inmates with Mental Illness Are in the ADX Significantly Longer than their Peers
As with the cumulative time that inmates spend in the SHU, the BOP does
not monitor the cumulative time in the ADX for inmates, including inmates with
mental illness, who have been placed there on multiple occasions. Psychology
Services Branch officials told us that they would not normally be aware of an
inmate’s prior placement in the ADX unless the inmate had previously been
removed from the ADX for mental health reasons.87 Rather than assessing
cumulative time, the BOP monitors the number of consecutive days that inmates
are placed in the ADX. Based on the most recent data available, from November
2013, the BOP determined that inmates had been confined in the ADX for an
average of 1,376 consecutive days (about 45 months, or 3.8 years).88
We analyzed data for a judgmental sample of 82 ADX inmates with mental
illness to determine the average number of consecutive days they had spent at the
facility.89 We found that 59 inmates from our sample, as of November 23, 2013,
had spent an average of 1,906 consecutive days (about 63 months, or 5.25 years)
in the ADX. Our analysis showed that inmates with mental illness were housed at
the ADX for an average of more than 17 months longer than what the BOP reported
for all ADX inmates. (See Table 2.)
Table 2
BOP ADX Statistics vs. OIG ADX Analysis
BOP Statistics
ADX Inmates
Total No. of ADX Inmates
Average No. of Days at the ADX
Median No. of Days at the ADX

OIG Analysis
ADX Inmates with
Mental Illness

415

59

1,376

1,906

941

1,213

Note: The data in this table was valid as of November 23, 2013.
Sources: BOP Office of Research and Evaluation and OIG analysis of BOP data

87 CPD officials told us that they would be aware of an inmate’s previous placement in the
ADX but this would not be a consideration for them in deciding whether the inmate should be
re-admitted to the ADX.

Center of Naval Analysis and Solutions (CNA), Federal Bureau of Prisons: Special Housing
Review and Assessment (December 2014).
88

Our inmate sample includes all ADX inmates whom the BOP designated at MHCLs 2–4 from
the end of FY 2010 through May 30, 2015.
89

29

In total, we found that our entire sample of inmates with mental illness had
been placed in the ADX for an average of 2,109 consecutive days (about
69 months, or 5.8 years).90 Thus, our analysis indicates that inmates with mental
illness were housed at the ADX significantly longer than their peers.
Inmates with Mental Illness Are in the SMU Significantly Longer than the
Program’s Intended Duration
We also examined the length of time that inmates with mental illness spent
in the SMU. Similar to the ADX, the BOP monitors consecutive days for inmates
who are placed in the SMU, but not their cumulative time in such units. We also
found that, even focusing on consecutive days in the SMU, inmates with mental
illness spend, on average, about 5 to 11 months longer than the program’s
intended duration of 18 to 24 months.91 Between FY 2008 and FY 2015, inmates
with mental illness averaged about 896 consecutive days, or about 29 months, in
the SMU program and 50 percent of stays in a SMU by inmates with mental illness
were longer than 24 months.92 (See Figure 1 below.)

90

This data was valid as of December 2015.

91

BOP Program Statement 5217.01, Special Management Units (November 19, 2008), 1.

92 Our sample included all 239 SMU inmates whom the BOP had designated as MHCL 2–4 at
the end of FYs 2012, 2013, or 2014 or on May 30, 2015. “Stay” refers to the number of consecutive
days the inmate spent in the SMU. See Appendix 1 for more information.

Although the OIG was able to determine that inmates with mental illness were placed in the
SMU significantly longer than the program’s intended duration, the OIG could not conduct a similar
analysis for inmates with mental illness at the ADX because this RHU does not have an intended
duration of placement for its inmates.

30

Figure 1
Months that Inmates with Mental Illness Spent in the SMU
FY 2008 – FY 2015

48 ‐ 78 months

39

30 ‐ 48 months

68

24 ‐ 30 months

24

18 ‐ 24 months

81

0 ‐ 18 months

51
0

20

40

60

80

100

Note: The sample includes 239 inmates, and statistics are valid as of
September 3, 2015. Because some sample inmates participated in the SMU
program multiple times, this figure displays the lengths of 263 inmate stays in
the SMU. The longest length of stay was 2,326 days, or about 76.5 months,
by an inmate still in the SMU.
Source: OIG analysis of BOP data

From our sample of SMU inmates, we also found that inmates with mental
illness were housed in the SMU for almost 14 months longer than what the BOP
reported for all SMU inmates. Specifically, in November 2013, the BOP reported
that the average length of stay for all inmates in the SMU, including inmates with
mental illness, was 277 days, or about 9 months.93 However, we found that
151 SMU inmates with mental illness from our sample were still in the SMU at that
time and had spent, on average, 698 days, or about 23 months, in the SMU.94 (See
Table 3 below.)

The BOP’s data was valid as of November 23, 2013, and was reported as part of the CNA’s
2014 report on special housing.
93

These 151 inmates included all SMU inmates whom the BOP had designated as MHCL 2, 3,
or 4 at the end of FYs 2012, 2013, or 2014 or on May 30, 2015, and who were in the SMU as of
November 23, 2013. See Appendix 1 for more information.
94

31

Table 3
Average Lengths of Stay for Inmates in the SMU
OIG Analysis
SMU Inmates with
Mental Illness

BOP Statistics
All SMU Inmates
Total No. of SMU Inmates

1,675

151

Average No. of Days in SMU

277

698

Median No. of Days in SMU

211

628

Note: The data in this table was valid as of November 23, 2013.
Source: BOP Office of Research and Evaluation and OIG analysis of BOP data

Perhaps even more concerning is that the most recent analysis from our SMU
sample suggests that the length of time for inmates with mental illness who were
still in the SMU was increasing. As of September 2015, 65 of the inmates from our
SMU sample were still in the SMU and had been there for 935 consecutive days
(about 31 months).95 This is particularly troubling in light of other concerns we
address later in this report regarding the mental health treatment provided to SMU
inmates at USP Lewisburg, which now houses all SMU inmates.
Misleading Performance Metrics
We also found that misleading performance metrics in SMU program data
could suggest that inmates with mental illness complete the SMU program at higher
rates than they actually do. For example, CPD officials said that an inmate should
be designated as “SMU Complete” in the BOP’s program data only if the inmate has
progressed through all phases of the SMU program and has returned to the general
population. However, when we examined our sample of 239 inmates with mental
illness, we found that 138 inmates were identified as SMU Complete, but 15 of the
138 (11 percent) were actually transferred out of the program for mental health
reasons, not because they had completed the program.96

95 After the completion of our fieldwork, the BOP issued a revised SMU policy, which now
restricts all inmates’ length of time in the SMU to 24 consecutive months (see BOP Program Statement
5217.02). However, even with the BOP’s revised policy, inmates may still spend long periods of time
in restrictive housing, without limit, before coming to the SMU or after leaving the SMU. One SHU
Lieutenant we interviewed stated that, because of limited SMU capacity, approximately 30 inmates
were in the SHU for over a year before finally being transferred to the SMU. Additionally, he stated
that two of these inmates were still in the SHU awaiting transfer to the SMU at the time of our visit.

The Department’s “180-day Status Report” stated that the BOP had reduced the SMU program
to three phases that would take, on average, 9 to 13 months to complete. The report also stated that
the BOP had established an incentive program for high-performing inmates to advance through the
program on a faster timeline.
96 During our fieldwork, in September 2015 the BOP stated that, “we are unaware of the
existence of any data that would indicate the reason for removal from SMU, beyond the assignments
(Cont’d)

32

In addition, we found that BOP policy provides that an inmate can be
designated as a “SMU Failure” if the inmate continues to exhibit disruptive conduct
after spending 30 months in the SMU, 6 months beyond the program’s maximum
intended duration of 24 months.97 The Warden at USP Lewisburg told us that when
he arrived in June 2014 there were over 100 inmates designated as SMU Failures.
He said that was no longer the case because inmates were “programming” and
progressing through the SMU program’s phases. At the time of our site visit in July
2015, this institution had only five inmates designated as SMU Failures. However,
as discussed above, there were 65 inmates from our sample who were still in the
SMU as of September 2015 and had spent, on average, 935 days, or about
31 consecutive months, there. Despite this, none of our sample inmates were
designated as SMU Failures, including one inmate who had been in the SMU for
almost 77 consecutive months. This data suggests that, contrary to BOP policy, the
BOP may in effect rarely be designating inmates as SMU Failures, even though
many inmates appear to meet this criteria and remain in the SMU well beyond the
program’s maximum intended duration. In October 2016, a CPD official confirmed
that inmates who remained in the SMU 6 months longer than the program’s
maximum intended duration should be classified as a SMU Failure throughout the
remainder of their placement.
Finally, many inmates with mental illness were given new SMU entry dates
before ever leaving the program. We found that 53 of our sample of 239 SMU
inmates with mental illness started the program multiple times, and 5 inmates
restarted the program within 2 weeks of being designated as SMU Failures. While
some of these inmates completed the program, transferred to other institutions,
and were sent back to the SMU, more than half of the inmates who restarted the
program did so before they had exited the program. CPD officials told us that SMU
inmates may have received a new entry date when they transferred from different
SMU institutions. However, by giving new entry dates to SMU inmates who
restarted the program from the beginning, the BOP could artificially decrease the
documented length of stay for these inmates. Consistent with our findings
discussed earlier, this practice could prevent the BOP from accurately tracking
inmates as they progress through the SMU program, and inmates with mental
illness may linger in multiple iterations of the program much longer than what BOP
data indicates.

of Complete or Fail.” In response to a working draft of this report, the BOP stated that staff document
a unique code in SENTRY for inmates who were removed from the SMU for mental health reasons.
The BOP cited a February 2017 memorandum from the Assistant Director of CPD to the Chief
Executive Officers, which reflected the existence of an assignment code in SENTRY with a description
for “SMU Removal Mental Health.” While this code may exist today, the fact remains that none of the
15 inmates that we cited above should have been documented as having completed the SMU program.
See BOP Program Statement 5217.01, 11. In this revised SMU policy, the BOP has reduced
the intended duration of the SMU program to 9 to 13 months. In addition, the policy states that if an
inmate fails to complete the SMU program within 24 consecutive months, which is the maximum
amount of time for an inmate to be placed in the SMU, the inmate will be placed in SMU Failure status
and the BOP will identify an appropriate institution for the inmate.
97

33

Mental Health Staff Do Not Always Document Inmates’ Mental Disorders,
Leaving the BOP Unable to Accurately Determine the Number of Inmates
with Mental Illness and Ensure that It Is Providing Appropriate Care to
Them
We found that the BOP cannot accurately determine the number of its
inmates who have mental illness, including inmates in RHUs, because institution
staffs do not always document inmates’ mental disorders. This could prevent the
BOP from ensuring that it is caring for all of these inmates appropriately.
Based on our analysis of BOP FY 2014 data, 19,034 inmates, or
approximately 12 percent of the BOP’s total inmate population, had a history of
mental illness.98 However, this number appears too low to be accurate, according
to BOP officials and institution staff. In 2015, the BOP’s Chief Psychiatrist
estimated, based on discussions with institutions’ Psychology Services staffs, that
approximately 40 percent of inmates had a mental illness, excluding inmates with
only personality disorder diagnoses. A Deputy Chief Psychologist estimated that
50 percent of inmates at her institution (which housed 961 total inmates as of May
2015) may have Antisocial Personality Disorder, which, according to staff we spoke
with, is one of the most prevalent mental disorders among BOP inmates.
Nevertheless, we found that this disorder was documented for only about
3.3 percent (5,272) of the BOP’s total inmate population (157,872).99 Psychology
Services Branch officials told us that the BOP’s mental health policy requires mental
health staff to document mental disorders for inmates with an enduring pattern of
behavior and for Antisocial Personality Disorder, a pervasive pattern of antisocial
behavior may not necessarily be identified during an intake screening evaluation.100
However, we believe that the underrepresentation of this disorder could also
indicate that a significant number of inmate disorders are not formally documented
and may as a result go untreated.

We determined the prevalence of inmates with a history of mental illness by quantifying
those inmates who had at least one documented BOP diagnosis — either current, in remission, or
resolved — provided in the BOP’s data. This includes both psychotic disorders and personality
disorders but excludes chemical dependency (substance abuse). This does not include inmates who
had undergone an initial mental health records review, were given a tentative MHCL designation by
the BOP’s Designation and Sentence Computation Center, but had yet to be examined, in person, by a
mental health clinician. See Appendix 1 for more information.
98

As discussed in the Introduction, according to the BOP’s Mental Health Prevalence Project,
approximately 19 percent of federal inmates entering the BOP had a history of mental illness.
99

This includes both Antisocial Personality Disorder and Adult Antisocial Personality Disorder.

In response to a working draft of this report, the BOP stated that an Antisocial Personality
Disorder diagnosis would be given as a mental health diagnosis only if the inmate was functionally
impaired in prison as a result of the condition (e.g., self-harm, poor emotional regulation, distress).
100

According to BOP policy, “all current mental health illnesses should be diagnosed in a
Diagnostic and Care Level Formulation note in PDS, including personality disorders and intellectual
disabilities. The cumulative effect of the disorders on functioning is taken into account when assigning
a mental health care level.” See BOP Program Statement 5310.16, 9.

34

The BOP’s data indicates that approximately 22 percent of inmates in RHUs
had a history of mental illness at the end of FY 2014.101 Specifically, according to
our analysis of BOP data, 37 percent of ADX inmates, 27 percent of SMU inmates,
and 21 percent of SHU inmates had a history of mental illness.102 (See Figure 2.)
Figure 2
Inmates with a History of Mental Illness by RHU Type, FY 2014

146

ADX

251

331

SMU

916

1,651

SHU

6,329

0
■ Inmates

1,000

2,000

3,000

with a History of Mental Illness

4,000
■ Inmates

5,000

6,000

7,000

with No History of Mental Illness

Source: OIG analysis of BOP data

We believe that the BOP data used to determine the above numbers of
inmates with mental illness in these RHUs may well be underinclusive. For
example, in August 2015, during our site visit to the ADX, we observed a Care
Coordination and Reentry (CCARE) meeting. Prior to this meeting, the ADX staff
provided us with mental health documentation for 109 inmates whose cases the
staff reviewed during the meeting. Based on this documentation, we found that
101 Using the BOP’s unique inmate registration numbers, we cross-referenced SHU, SMU, and
ADX population data as of September 30, 2014, with BEMR-PDS data as of September 30, 2014. See
Appendix 1 for more information.

The BOP’s FY 2014 population data for the ADX included 936 total inmates, 46 of whom
were designated at MHCLs 2–4. However, during our site visit to the ADX, the staff provided us with
documentation that the ADX’s rated capacity is 490 inmates. Further, many of the inmates provided
in the BOP’s population data had minimum, low, and medium security levels, which is inconsistent
with inmates housed in the ADX. According to the BOP, this dataset included inmates housed in the
Minimum Security Camp (Camp) as well as ADX inmates because, at the time, the ADX was
responsible for the Camp and thus ADX staff counted its inmates. In March 2015, inmates in the
Camp were realigned in the BOP’s database to fall under FCC Florence’s medium security institution.
Therefore, we selected all 397 inmates with a high security level designation, which is consistent with
inmates at the ADX. See Appendix 1 for more information.
102

35

76 (70 percent) inmates had at least 1 mental health diagnosis. We also found that
71 (93 percent) of these 76 inmates were diagnosed with at least Antisocial
Personality Disorder.103 However, as of the date of this CCARE meeting, 99 of the
109 inmates (91 percent) were designated at MHCL 1 and the remaining
10 inmates (9 percent) were designated at MHCL 2.
According to BOP policy, all inmates designated at MHCLs 2–4 must have
been diagnosed with mental illness along with a Psychologist’s rationale for the
inmate’s diagnosis and assigned care level.104 However, based on our analysis of
the BOP’s FY 2014 data, 968 of 5,542 inmates (17 percent) designated at
MHCLs 2–4 across BOP institutions did not have any documented diagnoses of
mental illness. We also found that 74 of these 968 inmates (8 percent) were
housed in RHUs.105 The BOP’s Chief of Mental Health Services told us that she had
found a similar percentage of inmates who did not have a documented mental
health diagnosis. Based on her review of a sampling of inmate records in the
Bureau’s Electronic Medical Record System and Psychology Data System (BEMRPDS), she stated that BOP staff had not entered any mental health diagnoses in
BEMR-PDS for “a few” of the 968 inmates. She said that the incomplete dataset
was caused mostly by diagnoses that were not properly entered.106 In response to
a working draft of this report, the BOP stated that staff were not documenting
diagnoses in the appropriate location in BEMR-PDS. To reconcile this issue,
Psychology Services Branch officials told us that they had alerted institution staff
about inmates designated at MHCL 2–4 who did not have a documented diagnosis
in the system that was consistent with the Diagnostic and Statistical Manual for
Mental Disorders (DSM).107 In addition, these officials said that the BOP has since
made changes in BEMR-PDS to ensure that mental health staff consistently enter
DSM diagnoses.
Finally, we found that the BOP could improve its management and oversight
of inmates with mental illness if it differentiated inmates at MHCL 1 who have
mental illness and inmates who do not. According to BOP policy, inmates
designated at MHCL 1 are not required to have a mental health diagnosis.108
According to BOP data, over 90 percent of inmates are designated at MHCL 1,
103 We included Adult Antisocial Personality Disorder diagnoses into this raw count and
excluded chemical dependency (substance abuse).
104

See BOP Program Statement 5310.16, 9.

105 Of the 74 inmates, 1 inmate was in the ADX, 1 inmate was in the SMU program, and
72 inmates were in SHUs.
106 The Chief of Mental Health Services elaborated that while staff entered diagnoses in BEMRPDS, they either did not enter the appropriate diagnosis code or they manually entered diagnoses as
free text rather than selecting diagnoses from a drop-down menu. As a result, she indicated that
these inmates’ diagnoses were not included in the data provided to the OIG. It was beyond our scope
to further review them.

American Psychiatric Association, Diagnostic and Statistical Manual for Mental Disorders,
ed. (Arlington, Va.: American Psychiatric Association, 2013).
107

5th

108

BOP Program Statement 5310.16, 8.

36

including most inmates with documented mental illness. However, as we indicate
above, some inmates have undocumented mental illness and, as a result, the BOP
cannot differentiate between inmates designated at MHCL 1 who may have
undocumented mental health diagnoses and inmates who do not have any mental
health diagnoses. To reconcile this issue, the BOP could reassess its MHCL system
and use different classifications to differentiate between inmates who have some
form of mental illness from inmates who do not have mental illness.
Since the BOP Adopted Its New Mental Health Policy, BOP Data Shows a
30 Percent Reduction in the Number of Inmates Who Receive Regular
Mental Health Treatment
As noted in the Introduction, in May 2014 the BOP issued a new mental
health policy intended to enhance the treatment of inmates with mental illness,
including those in RHUs.109 During our review, we found that the BOP has not
provided sufficient resources, specifically with regard to the number of mental
health staff, to implement the new policy. With no corresponding increase to
mental health staff, we believe that mental health staff at institutions may have
reduced the number of inmates designated at MHCLs 2–4 to help alleviate the
increased work requirements associated with these care levels. Based on our
analysis of BOP data, from the end of FY 2010 through April 2014, the number of
inmates designated at MHCLs 2–4 remained relatively steady, decreasing by only
1 percent. However, as we describe in detail below, during the year after the new
policy was issued, the number of inmates designated at MHCLs 2–4 decreased
approximately 30 percent.110 In addition, we found that the BOP’s current mental
health staffing challenges could result in some inmates with mental illness,
including those in RHUs, not receiving the appropriate treatment for their mental
health needs. Finally, we found that mental health staffs disagree on the diagnoses
of inmates with mental illness, and even more so for inmates in some RHU
programs, which can affect the treatment and continuity of care of inmates with
mental illness in RHUs.
Insufficient Resources to Implement the New Policy May Have Affected How
Clinicians Determined the Mental Health Treatment Needs of Inmates
The BOP’s new mental health policy requires staff to provide more
comprehensive care and treatment for inmates with mental illness, including
inmates with mental illness in RHUs. We found that mental health clinicians may
have reduced, or been reluctant to increase, some inmates’ MHCLs because of a
lack of resources to implement the enhanced treatment standards. According to
109

BOP Program Statement 5310.16.

110 We requested that the BOP provide inmate population data for May 1, 2014. However,
due to technical issues, the BOP instead provided us with inmate population data for April 26, 2014.
We thus determined the BOP’s decline in inmates’ MHCLs from April 26, 2014, to May 30, 2015.

Additionally, while we indicate in the Introduction that the BOP reported a slightly smaller
decline (about 20 percent) for inmates designated at MHCLs 2–4 from FY 2010 through May 2015, the
BOP told us that it also had found a 30 percent reduction from April 2014 to May 2015.

37

the Senior Deputy Assistant Director of the Reentry Services Division (RSD), which
oversees the BOP’s mental health services, the BOP’s new policy “raised the bar”
for the mental health care that the BOP wanted to provide to its inmates. The Chief
of Mental Health Services told us that the BOP had expected to see an increase in
inmates designated at MHCLs 2–4 under the new policy, and that its objective in
developing the policy was to encourage staff to be “thoughtful and inclusive of the
need for treatment when they see it.” For example, the policy introduced the term
“serious mental illness,” which included personality disorders.111 The Chief of
Mental Health Services said that, prior to the new policy, mental health staff may
not have considered personality disorders to be serious mental illness.112 She
added that personality disorders are very serious throughout the BOP’s inmate
population, are more prevalent in restrictive housing, and may require more
frequent treatment than under the previous policy.113
In light of this information, we believe that the inclusion of personality
disorders in the criteria for serious mental illness certainly should have contributed
to an overall increase in inmates designated at MHCLs 2–4 after adoption of the
new policy in May 2014. According to BOP data, from the end of FY 2010 through
April 2014, the number of MHCL 2–4 inmates had remained relatively steady,
decreasing by only 1 percent.114 Yet, from the end of April 2014 through May 2015,
after the BOP issued its new mental health policy, the number of MHCL 2–4 inmates
decreased about 30 percent, including a decrease in the number of MHCL 2–4
inmates at USP Hazelton by approximately 81 percent (from 238 to 46 inmates).115
Figure 3 below shows the BOP’s total number of sentenced inmates designated at
MHCLs 2–4 across all BOP institutions from the end of FY 2010 through May 2015.

111 According to the BOP staff we interviewed, personality disorders are among the most
prevalent mental disorders throughout the BOP’s inmate population.
112 The Coordinator of a secure residential mental health treatment program told us that
some mental disorders, such as personality disorders, do not involve psychosis, which may cause
some staff to view these disorders as less severe forms of mental illness. We discuss secure
residential mental health treatment programs later in the report and in Appendix 3.
113 For example, as we discuss above, in August 2015 ADX staff provided us with mental
health documentation for 109 inmates whose cases the staff reviewed during a CCARE meeting.
Based on this documentation, we found that 76 (70 percent) inmates had at least 1 mental health
diagnosis and that 71 (93 percent) of those were diagnosed with at least Antisocial Personality
Disorder. In addition, a SMU Psychologist told us that approximately 90 percent of SMU inmates have
mental illness, if personality disorders are included, and that over 90 percent of SMU inmates exhibit
antisocial behavior.
114 We based the percentage on the number of MHCL 2–4 inmates (6,853 out of the BOP’s
total of 154,760 inmates) at the end of FY 2010, compared to the number of MHCL 2–4 inmates
(6,761 out of 159,284) as of April 26, 2014.

We based the percentage on the number of MHCL 2–4 inmates (6,761 out of 159,284 total
inmates) in April 2014, compared to the number of MHCL 2–4 inmates (4,768 out of 155,652) in May
2015. The median for our analysis is an MHCL reduction of approximately 28 percent.
115

38

Figure 3
Number of MHCL 2–4 Inmates, September 2010 – May 2015
7,000
6,000

6,170

5,898

5,821

5,701
5,252

5,000
3,971
4,000
3,000
2,000
1,000 578
574
0
FY 2010

320

299

FY 2011

Source: OIG analysis of BOP data

MHCL 2

-

FY 2013

MHCL 3

551
302

283

FY 2012

.......

561

531

463

423

April 26, 2014

246
May 30, 2015

.......MHCL 4

Based on a sample of 688 inmates in RHUs during the period of our review,
we found that after May 2014 — when the new policy was implemented — the
mental health staff was more likely to decrease and less likely to increase some
inmates’ MHCLs.116 We found that prior to implementation of the new policy, for
our sample of 688 RHU inmates, 178 inmates’ MHCL increased, compared to
85 inmates whose MHCL decreased. Since the new policy, 45 inmates’ MHCL
increased, compared to 110 inmates whose MHCL decreased. Table 4 and Figure 4
below show the changes in the MHCLs for our sample of inmates in RHUs.117

Our analysis is limited to a sample because it was not feasible to assess every inmate’s
MHCL history. We selected a sample of RHU inmates designated at all MHCLs and individually
assessed the history of changes in their MHCLs before and after the new policy was issued. Our
analysis does not account for every MHCL change that may have occurred between these times, but
notes the inmate’s MHCL change, when applicable, from FY 2010 through April 2014 and from late
April 2014 through August 2015. See Appendix 1 for more detailed information on our methodology.
116

Although the BOP established the MHCL system in December 2009, a few inmates in our
sample had MHCLs initiated as early as October 2009, which explains why the scope of Table 4 and
Figure 4 (below) predates when MHCLs were officially established.
117

39

Table 4
MHCL Changes for Sample RHU Inmates, October 2009 – August 29, 2015
BOP Policies

No. of Inmates
with Increased
MHCL

Former Mental Health
Treatment Policies
(October 2009 – April 30, 2014)
New Mental Health Treatment
Policy
(May 1, 2014 – August 2015)
Percent Change (+/-)

No. of Inmates
with Decreased
MHCL

No. of Inmates
with the Same
MHCL

178

85

425

45

110

533

-74.72%

29.41%

25.41%

Source: OIG analysis of BOP data

Figure 4
MHCL Changes for Sample RHU Inmates, October 2009 – August 29, 2015
200
180
160
140
120

-+- No. of Inmates with

-

100

Increased MHCL

80

No. of Inmates with
Decreased MHCL

60
40
20
0
Former Mental Health Treatment Policies
(October 2009 – April 30, 2014)

New Mental Health Treatment Policy
(May 1, 2014 – August 2015)

Source: OIG analysis of BOP data

We discussed our analyses with BOP institution officials and staff, as well as
Central Office officials.118 Based on these discussions, we believe that the
additional requirements established by the new policy, along with no increase in
mental health staffing, resulted in institution mental health staffs reducing the
In May 2015, we asked BOP officials in the Psychology Services Branch to comment on the
results of our data analyses showing a decrease in the number of BOP inmates designated at
MHCLs 2–4. Both the Senior Deputy Assistant Director and the Chief of Mental Health Services had
not anticipated our finding and were unaware of the reduction of inmates’ MHCLs BOP-wide. They
wanted to review the data to better understand this reduction before commenting. In October 2015,
we re-interviewed these officials for their opinions on our results.
118

40

number of MHCL 2–4 inmates, who are required to receive more frequent mental
health care. A BOP Chief Psychologist told us: “If I have [an MHCL] 2, I’ve got to
see them every month, they have a treatment plan, diagnostic formulation, I’ve got
to update them, I’ve got to go to a [CCARE] meeting, … that’s a lot of dominoes to
fall down. So what do you think human nature is? Well, I am going to lower my
threshold and have less [MHCL] 2’s.… I don’t want to lower my threshold but I
know that when staff are overwhelmed … there may have been sometime where
people are reducing care levels in order to survive.” In light of staffing challenges,
he suggested that the BOP could add another care level to the MHCL system that
would allow Psychologists to treat on a quarterly basis those inmates who do not
clinically need monthly treatment. Another Staff Psychologist told us that since the
new policy she has encountered more transferred inmates with reduced MHCLs with
which she disagreed. She believes that many institutions are pressed for staffing
and were making such efforts to meet the new policy’s standards.
Other institution mental health staff told us about staffing challenges
associated with meeting the requirements established in the new policy. Another
Chief Psychologist told us that the new policy has great intentions, but “there are
just not enough bodies to
carry out the policy.” A third
The Increased Mental Health Staff at the ADX May
Chief Psychologist told us that
Have Contributed to an Increased Number of Inmates
at MHCLs 2–4
before the new policy, mental
health staff had greater
We found that despite decreases in the ADX’s overall
latitude to concentrate
inmate population since FY 2010, the BOP has significantly
resources on inmates with
increased the ADX’s mental health staffing. We found that,
as of May 2015, the number of ADX inmates designated at
serious mental illness; but,
MHCLs 2–4 had increased by nearly 40 percent (from
under the new policy, those
33 inmates to 46 inmates). According to the Department,
resources are needed to meet
between 2012 and 2013, the BOP hired three additional fullthe minimum mental health
time Psychologists, one Psychiatric Nurse, and one
Psychology Technician for the ADX while also adding one
requirements for inmates who
Deputy Chief Psychologist to help manage mental health
may not clinically need that
services throughout FCC Florence, including the ADX. We
level of mental health
found that during this time, the BOP began to decrease the
treatment. While many
ADX’s inmate population, in part due to a number of
institution mental health staff
inmates with serious mental illness who were transferred to
the BOP’s new mental health residential treatment
with whom we spoke
programs. However, despite the BOP’s efforts to reduce the
described a lack of resources
number of inmates with mental illness at the ADX, the
to implement the new
number of MHCL 2–4 inmates increased. It appears to us
requirements, it appears that
that the increase in mental health staff to treat ADX inmates
may have contributed to the increase in the MHCLs of
increased staffing at the ADX
inmates at the ADX.
may have contributed to the
increase in inmate MHCLs at
Source: DOJ, Use of Restrictive Housing, and OIG
the ADX (see the text box).119
observation and analysis
119 A Deputy Chief Psychologist told us that recent litigation caused the BOP to increase its
mental health staffing resources for the ADX. An ADX Psychologist stated that BOP institutions have
different thresholds for assigning MHCLs. At the ADX, the staff has a lower threshold for raising an
inmate’s MHCL because of the scrutiny over the use of restrictive housing and the recent litigation.

41

When we asked about the sharp overall decrease in the number of inmates
designated at MHCLs 2–4 that our analyses showed BOP-wide, the BOP’s Chief of
Mental Health Services stated that over time it is difficult to determine whether
MHCLs have been “rising or falling” because, since the inception of MHCLs, the BOP
has changed its guidance on how to assign them.120 However, she added, “if
[MHCLs have] fallen since the new policy, that’s a concern.… If the resources aren’t
there and a psychologist has to make choices about the amount of service they can
provide … because they don’t have enough time to provide services to everyone on
their caseload, they may be [an MHCL] 2 instead of [an MHCL] 3. I am very
concerned about that.” Psychology Services Branch officials told us that they do
not believe the BOP has “adequate staffing to fully implement” the new policy.
While the BOP’s new policy was intended to enhance care for inmates with
mental illness, we believe that the new policy could have unintended consequences
that negatively affect some inmates’ treatment. During our review, BOP officials
and staff acknowledged the concerns revealed by our analysis of MHCL data after
the BOP issued its new policy, including the need to consider assigning additional
mental health staff to effectively implement the policy’s enhanced standards. We
believe that the BOP should regularly monitor trends in inmate MHCLs to further
assess how the new policy affects the treatment of inmates with mental illness,
particularly those in RHUs. Although Psychology Services Branch officials told us
that they monitor trends for MHCL 3 and MHCL 4 inmates, they do not monitor
MHCL fluctuations at the institution level for all MHCLs. We believe that by
monitoring MHCLs and their relation to RHU populations, the BOP Central Office
could identify institutions with unusual MHCL fluctuations and further investigate
institution or RHU-specific factors that may be influencing these changes.
Mental Health Staffing Does Not Support the Treatment Needs of Inmates with
Mental Illness, Including Those in RHUs
The BOP “recognizes that an inmate’s mental health may deteriorate during a
restrictive housing placement.”121 We found several concerns related to the BOP’s
mental health staffing that could result in some inmates with mental illness,
including those in RHUs, not receiving the appropriate treatment for their mental
health needs. A lack of or inappropriate level of resources could impact inmates’
treatment and contribute to a decline in some inmates’ mental health.
First, the numbers of Psychologists within BOP institutions are below the
BOP’s base staffing guidelines. According to the RSD Senior Deputy Assistant
120 The RSD Senior Deputy Assistant Director added that mental health staff could have been
influenced by program review guidelines that were issued before the new policy provided guidance
specific to MHCLs. The program review guidance combined treatment standards from the old policy
with standards detailed in the new policy, which had not yet been released. For example, under the
old policy, MHCL 2 inmates were to be seen at least quarterly; but, under the new policy, they are to
be seen monthly. If the staff was influenced by guidance in the old policy, this may have “fuzzied” its
understanding of the new policy’s guidance on MHCL definitions. However, during our interviews with
institution staff, we did not find any evidence to support this concern.
121

BOP Program Statement 5310.16, 16.

42

Director, staffing guidelines were “established in 2011 and are based on the mission
of the institution and the gender of the inmate.”122 The BOP’s FY 2016 budget
submission stated that a significant number of institutions are short Psychologists
to the point that they do not meet the baseline standard of a 1:500 Psychologist to
inmate ratio.123 We observed this shortfall in six of the seven institutions we
visited, which at the time of our visits were understaffed by at least one mental
health staff position. A Deputy Chief Psychologist told us that one of those
institutions with 1,200 inmates had only a single Staff Psychologist.124 Based on
data provided by the BOP during our fieldwork, we found that an FMC housing some
of the BOP’s most seriously mentally ill inmates had filled only 12 of its 21 full-time
mental health staff positions as of December 2015.
Likewise, we believe that the ratio of SMU Psychologists to inmates at USP
Lewisburg does not meet the BOP’s staffing guidelines. As noted above, the BOP
requires a staffing ratio of no fewer than 1 Psychologist per every 350 inmates for
high security institutions. We found that USP Lewisburg was operating with 1 Staff
Psychologist per every 582 SMU inmates.125 This ratio of Staff Psychologists to
inmates was more than four times worse than the 1:138 ratio at the ADX, which
may well impact treatment for USP Lewisburg SMU inmates with mental illness.126
Just as we noted above that increased mental health staffing at the ADX may
have led to increased recognition of higher MHCLs for inmates there, we believe that
limited SMU staffing may have led to a decrease in MHCL designations for SMU
122 According to Psychology Services Branch officials, as of 2011 the BOP’s institutions had
the following Psychologist to inmate ratios: Federal Medical Centers (1:100), female institutions
(1:250), Detention Centers (1:350), high security institutions (1:350), medium security institutions
(1:500), low security institutions (1:600), and camps (1:700).

In response to a working draft of this report, the BOP stated that Staff Psychologists are not
the only clinicians counted in these guidelines. For example, the Chief Psychologist, Resolve Program
Coordinator, Internship Program Coordinator, and other Psychologists in the institution contribute to
meeting the staffing guidelines. Some Psychologists are excluded based on their mission, e.g., Drug
Abuse Program Coordinators.
123 DOJ, FY 2016 Performance Budget Congressional Submission, 80,
https://edit.justice.gov/sites/default/files/jmd/pages/attachments/2015/02/02/27._federal_bureau_of
_prisons_bop_se.pdf (accessed June 27, 2017).

Based on BOP data, there were 1,548 inmates at this institution as of May 2015. Of these
inmates, 95 of were in the SHU, which means that they require more frequent mental health
assessments. Six of the 95 SHU inmates were at MHCL 2, which further increases their need for
mental health assessments.
124

125 Our estimate is based on staff and inmates at USP Lewisburg at the time of our site visit in
July 2015. BOP data provided to us showed that the institution housed 1,163 SMU inmates in May
2015. When we visited USP Lewisburg in July 2015, two SMU Staff Psychologists were working
primarily with SMU inmates. We were told that the institution had hired a third Staff Psychologist,
who had not yet started treating SMU inmates at the time of our visit.
126 We believe that the ADX is the most appropriate staffing comparison to USP Lewisburg’s
SMU because both institutions are MHCL 2 facilities that house disproportionately high concentrations
of disruptive inmates who are placed in restrictive housing for prolonged periods of time and have
been referred from other BOP institutions due to behavioral issues.

43

inmates and a possible reluctance to designate new inmates at higher MHCL levels.
Based on our sample of 239 SMU inmates with mental illness who had their MHCLs
changed at USP Lewisburg during our scope, we found that SMU staff made an equal
proportion of MHCL increases and decreases among our SMU inmate sample prior to
the BOP’s new mental health policy. However, after the new policy, no sample SMU
inmates at USP Lewisburg had increased MHCLs and the number of SMU inmates
with decreased MHCLs nearly doubled. While the numbers are not high, this
pronounced trend is consistent with our MHCL analysis for all SMU inmates, which
shows a 56 percent reduction (from 70 to 31 inmates) in the total number of
inmates who receive regular mental health treatment in the SMU since the BOP’s
new policy was issued.127 In fact, while approximately 11 percent of inmates at the
ADX were receiving regular mental health treatment as of May 2015, only about
2.5 percent of inmates in the SMU were.128 Collectively, these analyses are
concerning in terms of the impact of staffing on MHCL designations and, therefore,
on the treatment of inmates with mental health needs. Table 5 below shows the
MHCL changes by SMU staff at USP Lewisburg for our sample of SMU inmates with
mental illness.129

We based the percentage on the number of MHCL 2–4 inmates in April 2014 (70)
compared to the number of MHCL 2–4 inmates in May 2015 (31). However, during that time in
FY 2015, the SMU at USP Florence, which had confined 358 SMU inmates in April 2014, closed. In
October 2016, CPD officials told us that some SMU inmates were released from USP Florence’s SMU
into other institutions’ general populations while other inmates were transferred to the SMUs at USP
Lewisburg or USP Allenwood. As a result, it appears that the closure of USP Florence’s SMU may have
contributed to the overall reduction in the total number of SMU inmates who received regular mental
health treatment. Although BOP data shows an 11 percent reduction in the overall SMU population
during this time, it is important to note that USP Lewisburg’s SMU population increased nearly
40 percent (from 844 to 1,163) during this same period.
127

As of May 2015, we also found that approximately 7 percent of the BOP’s SHU population
received regular mental health treatment, which is also considerably higher than the rate at USP
Lewisburg’s SMU.
128

129 Based on our sample of SMU inmates with mental illness from October 2009 through
August 29, 2015, we also found that SMU staff at USP Allenwood had also increased (four) and
decreased a comparable number of inmates’ MHCLs (three) prior to the issuance of the May 2014
policy. However, after the new policy was issued, SMU staff did not increase any sample inmates’
MHCLs but did decrease the MHCLs of three sample inmates.

44

Table 5
MHCL Changes at USP Lewisburg for Our Sample of SMU Inmates with
Mental Illness, October 2009 – August 29, 2015
BOP Policies

MHCL Increases

Former Mental Health
Treatment Policies
(October 2009 – April 30, 2014)
New Mental Health Treatment
Policy
(May 1, 2014 – August 2015)

MHCL Decreases

Ratio of MHCL
Increases to
Decreases

16

16

1:1

0

27

0:27

Note: Although the BOP established the MHCL system in December 2009, a few inmates in our
sample had MHCLs initiated as early as October 2009, which explains why the scope of this table
predates the official establishment of MHCLs. Additionally, our analysis does not account for every
MHCL change that may have occurred during these time periods but notes the inmates’ MHCL
changes, when applicable, from October 2009 through April 2014 and from April 2014 through
August 2015. See Appendix 1 for more details.
Source: OIG analysis of BOP data

Second, we are also concerned about the BOP’s challenges in recruiting and
retaining Psychiatrists. We discussed this concern in detail in our March 2016
Review of the Federal Bureau of Prisons’ Medical Staffing Challenges.130 As of
October 2015, the BOP had filled only 28 of 49 (57 percent) of its authorized fulltime Psychiatrist positions nationwide. The former Assistant Director of the BOP’s
Health Services Division told us that the BOP does not have a staffing formula to
identify its Psychiatrist-to-inmate staffing ratio. The Senior Deputy Assistant
Director of the Health Services Division told us that Care Level 4 institutions (FMCs)
are given first priority for Psychiatrists, followed by Care Level 3 institutions.131
However, we found that as of FY 2015, one FMC had only one Psychiatrist position
filled out of seven positions authorized and one FCC, which includes an FMC, had
only two Psychiatrist positions filled out of eight positions authorized. Our March
2016 report talked about some of the challenges the BOP has faced in filling these
positions, which is a problem that the BOP should continue to address if inmates
are to receive the level of psychiatric care indicated by their MHCLs.
Third, as a result of a shortage of Psychiatrists, we found that General
Practitioners, without the specialized training normally provided to Psychiatrists, are
left to prescribe psychotropic medications to inmates in RHUs. Institution
Psychiatrists told us that while General Practitioners have basic training in
diagnosing and medicating basic disorders (e.g., depression), they may not be able
DOJ OIG, Review of the Federal Bureau of Prisons’ Medical Staffing Challenges, Evaluation
and Inspections Report 16-02 (March 2016).
130

Similar to how MHCLs delineate the mental health needs of inmates, the BOP also
designates institutional care levels to delineate the varying levels of medical and mental health care
that can be provided to inmates at its institutions. For example, an MHCL 4 inmate should be housed
only at a Care Level 4 institution because only Care Level 4 institutions have the resources needed to
address that inmate’s intensive mental health needs.
131

45

to manage more complex cases and therefore should consult with a Psychiatrist.132
One FMC Psychiatrist said that General Practitioners can diagnose and treat
depression, and likely have the knowledge and skills to assist with MHCL 1–2
inmates, but that more complex cases may be more difficult for a General
Practitioner to manage and treat.
Fourth, the BOP has expanded its use of tele-psychiatry, a form of “direct,
patient-to-provider, visual interaction” that occurs in a private setting; but we
found that not all institutions are supported by this service. A Chief Psychologist
told us that her institution was 25th on the BOP’s tele-psychiatry waitlist for about a
year before the institution filled its tele-psychiatry vacancy. Though the institution
is a Care Level 2 facility, the Chief Psychologist’s caseload has about eight or nine
MHCL 3 inmates who require more complex treatment and could benefit from this
service. Conversely, other staff expressed concerns about the treatment provided
through tele-psychiatry and it appears that one SMU institution we visited elected
to significantly limit tele-psychiatry services for its inmates.133 (See the text box.)
USP Lewisburg Has Significantly Limited Tele-Psychiatry
Services for SMU Inmates
While the SMU houses inmates with mental illness at MHCL 2, SMU officials told us that,
despite having the capability, the institution has rarely, if ever, offered tele-psychiatry services to
inmates since 2013 because the mental health needs of its inmates do not necessitate such
services. The Medical Officer at USP Lewisburg told us that tele-psychiatry is problematic because
tele-Psychiatrists often prescribe medications based on inmates’ self-reported conditions in
sessions that last only 15 to 20 minutes. He prefers to observe the inmate over extended periods
of time. He added that while the institution still has the capability for tele-psychiatry, staff treat
inmates themselves. The Medical Officer told us: “We haven’t stopped [tele-psychiatry]. It’s still
available. It’s just that since I’ve come on-board, it’s not utilized because I consider myself pretty
adept at treating all these conditions.” Five SMU inmates told us they were unable to participate in
tele-psychiatry at USP Lewisburg, despite having done so while in SMUs at other institutions. The
Health Services Division Senior Deputy Assistant Director told us that she would be “very
surprised” if an institution had the capability but did not offer tele-psychiatry and that USP
Lewisburg would be a “perfect spot” for tele-psychiatry.
Source: OIG interviews

Finally, inmates told us that they did not think they were receiving the
appropriate treatment and care to address their mental health needs. For example,
according to the May 2014 policy, individualized treatment plans should be based
on collaboration with the inmate and should describe “the inmate’s problems and
goals, and the interventions planned to assist with goal attainment.” Inmates we
interviewed indicated that they were generally unaware of their individualized
mental health treatment plan, which raises questions as to how collaborative these
treatment plans actually are, as well as how they influence the treatment and care
of inmates with mental illness in RHUs. Psychology Services Branch officials told us
132 The BOP’s Chief Psychiatrist told us that there is no issue with general practitioners
providing psychotropic medication since it’s a practice in the community.
133

We did not evaluate the effectiveness of tele-psychiatry as part of this review.

46

that clinicians have to document that they discussed the treatment plan with the
inmate; however, there is no documentation for the inmate to sign acknowledging
discussion of his/her treatment.
The May 2014 policy also requires that “all inmates with mental illness in
restrictive housing units (i.e., the SHU, SMU, and ADX) will receive, at a minimum,
face-to-face mental health contacts consistent with the type and frequency
indicated by their care level, to the extent feasible.” While our review of case files
for inmates at MHCLs 2–4 suggests that contacts occur as frequently as policy
requires, the policy also states, “Inmates are removed from their cells for private or
extended interviews with Psychology and Psychiatry Services staff as a standard
procedure.”134 During our review of inmate case files, we found inconsistent
documentation regarding whether inmates were removed from their cells for private
or extended interviews.135 Specifically, some staff documented the location of
private face-to-face interviews with inmates, whereas others did not. One inmate
also told us that psychology is “supposed to [make rounds], but whether they do or
not is a whole other question… there’s no consistency.”136
According to Psychology Services Branch officials, documenting whether
critical contacts occur inside an inmate’s cell or outside of a cell in a private setting
is a best practice but it is not required by policy.137 Whether the contact takes
place inside or outside an inmate’s cell, the officials further explained that the May
2014 policy requires that inmates be treated in a private setting. However, the
BOP’s inability to track the location in which clinical contacts occur prevents the
BOP from assessing the extent to which its policy goal to protect inmate privacy has
been achieved and limits its ability to correct practices that are inconsistent with
policy, which may limit the appropriate treatment and care afforded to inmates
according to MHCL.
Inmates also had concerns regarding their continuity of care. An inmate at
an FMC told us that before she was taken to the SHU she had been participating in
one-on-one counseling sessions with a Psychologist but that those sessions stopped
after she entered the SHU. While the May 2014 policy updated and refined
134 The May 2014 policy includes exceptions to private critical contacts and mental health
treatment in cases in which the inmate is behaving in an aggressive manner or when institutional
safety and security require an exception. BOP Program Statement 5310.16, 16.
135 The CNA’s review and assessment of BOP restrictive housing found that “very few of the
monthly mental health assessments occur in private settings on a face-to-face basis.” The CNA
recommended that BOP psychology and psychiatry staff completely reevaluate inmates’ mental health
records every 30 days and include a face-to-face interview in a private setting. In the BOP’s response
to the CNA, the BOP did not specifically address private interviews between Health Services staff and
inmates. However, in the CNA’s report, the CNA notes that the BOP’s 2014 mental health policy
addresses critical contacts in a private setting. CNA, Special Housing Review and Assessment.

The May 2014 policy also states, “During rounds, all staff will make themselves available
for brief conversations that demonstrate concern and their availability to provide assistance.” We
further discuss institution staff rounds below.
136

According to policy, all critical contacts, regardless of an inmate’s MHCL, will, to the extent
possible, be conducted in a private area. BOP Program Statement 5310.16, 15.
137

47

designation, transfer, and release procedures for inmates with mental illness, with
an emphasis on continuity of care both across institutions and in the community,
we found that it does not discuss the continuity of care for inmates with mental
illness in RHUs. According to Psychology Services Branch officials, if an inmate is in
group therapy while in general population, the inmate can no longer participate in
group sessions during his or her time in restrictive housing. Despite the BOP’s
efforts to offer group therapy opportunities for inmates in restrictive housing, we
found that inmates in restrictive housing may not receive continuous mental health
treatment. See below for more information regarding the BOP’s secure residential
mental health treatment programs.
Mental Health Staffs Disagree on the Diagnoses More Often for Inmates with Mental
Illness in RHUs, Which Can Affect the Treatment of Those Inmates
Based on our review, we found that ensuring appropriate mental health
treatment for inmates in RHUs is a challenge for the BOP. Specifically, we found
that differing clinical opinions among mental health staff, as well as staff not
working collaboratively to diagnose mental disorders, could impact continuity of
care. These issues raise concerns as to whether inmates with mental illness are
receiving appropriate care.
BOP policy states that all inmates must undergo an initial screening when
they arrive at their designated BOP institution. The screening is usually conducted
by BOP Psychologists and, based on our review of 59 case files from the RHUs that
we visited, with a few isolated exceptions, it is generally done in a timely fashion.138
BOP officials told us that during the screening the mental health staff should identify
an inmate’s mental health disorders and, based on their evaluation, assess whether
the inmate needs regular treatment to determine his or her MHCL.139 If the mental
health staff disagrees with an inmate’s previous diagnosis, BOP policy states that the
Mental Health Treatment Coordinator or treating Psychologist attempts to reconcile
differences; consults with other treatment providers, including the Health Services
staff; performs a clinical interview; and observes the inmate’s symptoms and
behaviors in making a determination.140 The Chief of Mental Health Services told us
that if a Psychologist makes a diagnosis that differs from the inmate’s previous
mental health diagnosis, that Psychologist must explain both the rationale for the
new diagnosis and why it is inconsistent with the previous diagnosis.
According to mental health staff we interviewed, BOP providers disagreed
with the prior diagnoses of approximately one out of five inmates. Of the
138 Program Statement 5310.12, Psychology Services Manual (PSM) (March 7, 1995). In
August 2016, the BOP rescinded Program Statement 5310.12 and issued a revised PSM. We did not
assess the August 2016 PSM as part of this review. See Appendix 2 for a summary of changes
between the March 1995 and August 2016 PSMs.

One Chief Psychologist also told us that she will continue to monitor an inmate for up to
12 months after their initial screening before potentially changing the inmate’s mental health
diagnosis and that the screening of inmates does not conclude with the initial screening process.
139

140

BOP Program Statement 5310.16, 9.

48

29 mental health staff we interviewed, 26 (90 percent) told us they have disagreed
with inmates’ previous diagnoses that were documented by other institution staff.141
While staff at every institution we visited reported diagnosis disagreements for
inmates with mental illness, staff at the ADX, SMU, and secure residential mental
health treatment program institutions reported higher rates of diagnosis
disagreements for their inmate populations, with an average reported disagreement
rate of 24 percent as opposed to 16 percent by staff from the remaining institutions
we visited.142 More frequent disagreements among the staffs for these inmate
populations could negatively affect the continuity of care for these inmates.
Our case file reviews also confirmed instances in which mental health staff
disagreed on the prior diagnoses of inmates placed in restrictive housing.143 In one
inmate’s case file, the Psychologist had noted that she did not agree that the
inmate met the criteria for Bipolar Disorder and reduced the inmate’s care level to
MHCL 1, thus discontinuing the inmate’s treatment. In another inmate’s case file,
psychology records indicated that the inmate had previously been diagnosed with
Psychotic Disorder (Not Otherwise Specified) and Borderline Intellectual
Functioning. A different Psychologist did not identify any “significant mental health
issues” during a subsequent mental health review and, consequently, reduced the
inmate’s care level to MHCL 1. Case file documentation for another inmate
revealed that although Health Services believed that the inmate should be
diagnosed with Schizophrenia (Paranoid Type), Psychology Services found “no
evidence” of that disorder at the time and did not adjust the inmate’s level of care.
However, less than 3 months later, the inmate was transferred to an FMC after
Psychology Services elevated the inmate to MHCL 4.144 We further discuss

141 We did not include mental health staff we interviewed who were not qualified to
independently diagnose inmates’ mental disorders.
142 From the 29 mental health staff we interviewed, we based our calculations on quantifiable
responses from 25 mental health staff. We believe that staff responses from ADX, SMU, and secure
residential treatment program institutions (which house many former ADX inmates) may have been
influenced by the disproportionately high concentrations of disruptive inmates managed under strict
controls for prolonged periods of time.

Although we reviewed inmate case files, we could not use these documents to determine a
reliable rate of conflicting diagnoses by mental health staff for several reasons. First, OIG staff are
not professionally trained to determine whether diagnoses are conflicting or complementary. Second,
there were institutional inconsistencies in the mental health documentation provided to us and
diagnostic disagreements may have been noted in documents we did not receive or request, such as
diagnostic reconciliations that may have occurred when the inmate was not in restrictive housing.
Third, case file documents indicate the current diagnoses for inmates but generally do not show
diagnoses that have been subsequently removed. Last, as we discuss in Appendix 1, we focused our
review on case files from January 2014, 4 months before the new mental health policy was issued,
until the most recent documentation available to us at the time of our site visit. Thus, we did not
review these inmates’ entire historical records of diagnosis and treatment while in BOP custody.
143

144 In response to a working draft of this report, the BOP stated that these are complex cases
and that diagnostic discrepancies are common. Additionally, the BOP stated that research on the
reliability of the DSM diagnoses finds relatively high rates of diagnostic discrepancies among
community treatment providers. Finally, the BOP stated that diagnoses change over time and that
(Cont’d)

49

differences in clinical opinions between Psychology Services and Health Services
later in this report.
Institution staff members offered a number of reasons that could account for
some of the disagreements in diagnosis. A Staff Psychologist said that an inmate’s
Psychology Services Intake Questionnaire, used to screen the inmate upon arrival
at a BOP institution, is not very thorough and can be difficult to confirm because
information is self-reported. She added that, generally, BOP clinicians tend to overdiagnose inmates because they are not “unpacking the core” of inmates’ mental
health issues. She stated that large mental health caseloads prevent staff from
screening inmates more comprehensively. A Psychology Services Branch official
told us that BOP staff are able to identify inmates “where their symptoms are pretty
prevalent” but acknowledged that the BOP does not have the resources to do an
in-depth mental health evaluation of each inmate entering the BOP. Another Staff
Psychologist told us that because mental health is fluid, even an accurate diagnosis
could become inaccurate at a later point in time, which we recognize as contributing
to clinical disagreements for inmates with mental illness.
We also found that differing clinical opinions between institutions’ Health
Services, including General Practitioners, Psychiatrists, and Psychology Services,
contribute to conflicting diagnoses for inmates with mental illness.145 Some
Psychologists told us that these disagreements may be attributed in part to
differences in each profession’s education and mental health training.146 One
Psychologist told us that because some Health Services staff may not have extensive
mental health training, certain words they hear from an inmate may lead them to
conclude that the inmate must have mental illness. Another Psychologist said that
Psychologists and Health Services staffs frequently disagree about complicated
mental health cases, particularly when inmates are reporting different symptoms to
different staff for personal gain (we discuss malingering later in this report).
In addition, we were told that Health Services and Psychology Services staffs
do not always work collaboratively to diagnose inmates’ mental disorders. A
Deputy Chief Psychologist said that she disagrees with Health Services’ mental
health diagnoses up to 60 percent of the time and that her institution’s Psychology
modifying a diagnosis is a requirement of good clinical care. Nevertheless, we believe that the level
and nature of the discrepancies we found are potentially significant for the BOP in ensuring that it
provides an appropriate level of care to inmates.
145 In the BOP, Psychologists are primarily responsible for diagnosing and treating the mental
disorders of inmates. However, Psychologists can share these responsibilities with General
Practitioners and Psychiatrists, particularly when an inmate needs medication.
146 Both General Practitioners and Psychiatrists go to medical school and become medical
doctors who are licensed to diagnose mental illness and prescribe medications, including psychotropic
medications. Psychiatrists generally receive more extensive and specialized mental health training
than do General Practitioners. Psychologists are not medical doctors. They go to graduate school and
earn a doctorate degree in psychology. They are trained to apply psychological assessments and
testing for mental health diagnoses, but they generally are not licensed to prescribe medications
without additional, specialized training.

50

Services and Health Services staffs were not working collaboratively. A Staff
Psychologist at this institution told us, “I don’t even know half the time who medical
[Health Services] is.” The Staff Psychologist added that Health Services was
extremely short staffed, which contributed to this problem. A Chief Psychologist at
another institution told us that her institution’s Psychology Services and Health
Services staffs had made no effort to reconcile discrepancies in BEMR-PDS for
inmates with conflicting mental health diagnoses.147 Because the two staffs may
disagree on inmates’ diagnoses, the treatment that Psychology Services provides
may not be complemented with medications that, generally, only a qualified Health
Services provider can prescribe. This may result in inmates receiving inadequate
care, particularly in RHUs where disagreements may be more prevalent.
While the BOP Has Taken Recent Steps to Mitigate Mental Health Concerns
for Inmates in RHUs, Additional Actions Can Be Taken
As discussed above, the BOP’s 2014 mental health policy, intended to enhance
mental health treatment for inmates, has nevertheless led to additional concerns that
inmates in RHUs may not be receiving adequate mental health care. Still, during our
review period, we found that the BOP has made efforts to mitigate mental health
concerns for inmates in RHUs. The BOP has begun diverting inmates with serious
mental illness from traditional RHUs into alternative programs such as secure
residential mental health treatment programs. The BOP also has reduced the use of
SHUs and the length of time that inmates are placed in them. While we believe these
are positive steps, we found a number of areas that the BOP needs to further improve,
such as by developing formal performance metrics to help measure the effectiveness
of secure residential mental health treatment programs, improving the mental health
training for RHU correctional staff, increasing the use of alternative sanctions to further
prevent inmates with serious mental illness from being placed in restrictive housing,
and developing guidance and training to discern and document malingering.
The BOP Has Started to Implement Secure Residential Mental Health Treatment
Programs as Alternatives to Traditional Restrictive Housing
In October 2013, the BOP began transferring a limited number of inmates
with serious mental illness from placement in RHUs, including SHUs, SMUs, and the
ADX, to secure residential mental health treatment programs. These programs
house inmates in a single-cell, modified therapeutic environment that requires all
participants to live on the same unit and engage in treatment together.148 Inmates
have out-of-cell time for recreation or individual and group programming. These
147 In 2014, the BOP merged the PDS, the system the Psychology Services staff uses, into the
BEMR, which the Health Services staff uses. We were told that the BOP merged these systems in part
to help facilitate a better working relationship between Psychology Services and Health Services. As a
result, both staffs have access to each other’s clinical notes and mental health diagnoses for BOP
inmates at their institution.
148 Secure residential mental health treatment programs are designed to reduce psychological
symptoms, improve functioning, facilitate institutional adjustment, reduce incidents of misconduct,
reduce the need for psychiatric hospitalization, and facilitate successful reentry into society. See DOJ,
FY 2016 Performance Budget Congressional Submission, 38.

51

programs are generally viewed as being better environments for the treatment of
inmates with mental illness than confinement in traditional RHUs. In August 2015,
the BOP had two such programs: Secure Mental Health Step Down (Step Down)
and Steps Toward Awareness, Growth, and Emotional Strength (STAGES).149
However, slow inmate progression through these programs and limited resources
such as staff and bed space create waitlists and prevent inmates with mental illness
from availing themselves of these alternative treatment opportunities.
We found that an inmate with serious mental illness may be on a waitlist for
a secure residential mental health treatment program because it could take years
for an actively enrolled inmate to complete the program. For example, Step Down
was activated in October 2013 at USP Atlanta and currently operates in two
facilities, including USP Allenwood, as a residential treatment program for inmates
with serious mental illness and a history of violence. As of October 2016, no
inmate had completed the program despite its target duration of 18 months.150 The
USP Atlanta staff told us that one of the biggest challenges with the program is
identifying the appropriate custodial setting for inmates after they complete it. The
BOP’s Chief of Mental Health Services said that the BOP wants to open a secure
open unit into which inmates from the high security mental health Step Down
program can transition. Unfortunately, the lack of staffing and resources make it
difficult for the BOP to expand this program.
Similarly, the Secure STAGES Program operates at one BOP institution for
male inmates with serious mental illnesses and a primary diagnosis of Borderline
Personality Disorder. As of October 2016, Psychology Services Branch officials told
us that there are currently 30–40 inmates on the waitlists for both Step Down and
Secure STAGES. The waitlists for these programs are a treatment concern because
inmates awaiting placement are not receiving the level of care they would receive if
they were enrolled in a mental health program. BOP officials told us that the BOP’s
Central Office manages these waitlists on a one-in, one-out basis.
BOP officials told us that the BOP would like to expand its use of residential
mental health treatment programs; but, as discussed above, limited numbers of
staff and beds — according to BOP, a total of 67 as of November 2016 for the
2 programs — impacts the scalability of these programs. For example, Step Down
at USP Atlanta has the capacity for 30 participants but, as of August 2015, had staff
available for only 21.151 Similarly, STAGES has the capacity for 18 participants but
BOP Program Statement 5330.11, Psychology Treatment Programs (March 16, 2009),
contains policy, procedures, and guidelines for BOP psychological treatment programs, including
mental health treatment programs such as Step Down units. The program statement does not discuss
secure residential mental health treatment programs. See Appendix 2 for more information on
psychological treatment programs established within Program Statement 5330.11. For more
information about the secure Step Down and STAGES Programs, see Appendix 3.
149

The program’s 18-month target completion time assumes perfect inmate progress through
each phase.
150

During our visit to USP Allenwood, Step Down was not yet fully activated. As of November
2016, USP Allenwood’s program had 30 inmates.
151

52

as of August 2015 had staff available for only 12. The RSD Senior Deputy Assistant
Director told us that the Psychology Services Branch considers a variety of factors
in the development of these programs, including the recruitment of enthusiastic,
highly skilled coordinators. These programs are staff intensive, which makes it
difficult for the BOP to staff them adequately. For example, at the time of our
fieldwork, the Step Down Program at USP Atlanta had a ratio of 4 staff to
21 inmates. USP Atlanta had a Psychologist vacancy and only 2 Psychologists for
the program’s 21 inmates.152 In addition, a Psychologist told us that inadequate
Correctional Officer staffing can affect the scheduling of inmate programming,
adding that it is especially problematic due to staffing changes and requirements for
many Correctional Officers to move inmates. Nevertheless, according to the BOP,
“these programs have demonstrated [their ability] to significantly reduce
misconduct among program participants.”153
Finally, the BOP does not have formal performance metrics for these
programs.154 Staff for the Mental Health Step Down Program told us that
measuring and tracking behavioral change is a challenge given that behavior is a
human, subjective measurement. BOP officials told us that potential performance
measures for the STAGES Program are fewer suicide risk assessments, fewer
disciplinary infractions, and a lower number of days of suicide watch. Despite the
inherent challenges, BOP officials told us that the BOP is developing a formal
evaluation of these programs.
The expansion of these treatment programs is contingent on funding for
mental health positions. When we requested the costs associated with these
programs, the BOP responded that it was “unable to break down the costs of the
various programs within the Psychology Services Department (we do not have the
capability to capture the cost to that level of detail).” However, the Department
has estimated that it would cost approximately $10 million to expand the
programs.155 According to the BOP’s Chief of Mental Health Services, this would
enable the BOP to expand these programs to all security levels and to at least one
female institution. We believe that, in order to make informed decisions regarding
the potential increased use and staffing for these alternative housing programs, the
BOP needs to develop and implement metrics to assess their performance and cost.

In response to a working draft of this report, the BOP stated that the Step Down Program
at USP Atlanta has a ratio of 5 mental health staff to 24 inmates. There is a Program Coordinator, two
Program Psychologists, and two Program Treatment Specialists.
152

153

DOJ, FY 2016 Performance Budget Congressional Submission, 36.

We did not evaluate the effectiveness of the Mental Health Step Down and STAGES
Programs as part of this review.
154

The Department’s January 2016 report on the use of restrictive housing “estimates that
the expansion of these programs would cost in its first year approximately $5.843 million for staff and
$4 million for building and facilities and modernization.” DOJ, Use of Restrictive Housing, 113.
155

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Residential Mental Health Treatment Programs in State Departments of
Corrections May Offer Insights to Help the BOP Improve Its Mental Health
Treatment Program
As part of our review of the BOP’s mental health treatment program, we
researched the programs of eight state correctional systems. We found that six of
the eight state systems have developed residential mental health treatment
programs as alternatives to housing mentally ill inmates in traditional RHUs.
Officials with Pennsylvania’s Department of Corrections told us that they have
Diversionary Treatment Units, which are secure units that provide expanded or
personalized mental health services to inmates with serious mental illness who
have committed disciplinary infractions. Inmates are allowed 20 hours of out-ofcell time per week, which can include recreation, group therapy, and private
consultations with a Psychologist. Officials from the Massachusetts Department of
Corrections told us that inmates with serious mental illness may be housed in a
Secure Treatment Unit, which allows inmates 15 hours per week of out-of-cell
clinical programming in addition to recreation. Four state officials told us that their
programs have out-of-cell group therapy for high security inmates for 10–20 hours
per week using “program security chairs or tables,” which allow inmates to be
safely restrained in a classroom setting.156 Officials with the Washington State
Department of Corrections told us that program security chairs were a “game
changer” for providing treatment and programming for inmates. In contrast to the
state systems that had security chairs, at BOP institutions we observed inmates
with serious mental illness participating in out-of-cell group therapy using individual
metal enclosures to separate them during group treatment.
The BOP Has Reduced Its Use of SHUs
As we discussed above, the frequency, duration, and conditions of
confinement of restrictive housing can have significant adverse effects on inmates’
mental health. We found that the BOP reduced the overall number of inmates,
including but not limited to inmates with mental illness, placed in the SHUs by
about 20 percent from FY 2010 to May 2015. The former CPD Deputy Assistant
Director told us that the BOP accomplished this reduction through three initiatives.
First, the BOP developed an investigative template that reduces the amount of time
inmates are held in a SHU pending completion of a protective custody
investigation.157 Second, the BOP developed a daily, automated SHU report to

The Department’s January 2016 report stated: “In 2016, the Bureau expects to publish a
final rule modifying 28 C.F.R. § 552.22(h) (4), thereby permitting the use of secure programming
chairs. Once the revised rule is published, the Bureau intends to purchase 610 of these chairs, which
would allow inmates to receive in-person educational and mental health programming in a less
restrictive manner than currently used. The Bureau estimates that the one-time purchase of security
chairs would cost approximately $1.7 million.” DOJ, Use of Restrictive Housing, 116.
156

To further reduce the placement of inmates in the SHU for non-punitive reasons, such as
protective custody, CPD officials told us that in February 2014 the BOP developed the Reintegration Housing
Unit at the Federal Correctional Institution (FCI) in Oakdale, Louisiana, which allows vulnerable inmates to be
(Cont’d)
157

54

assist BOP officials and institution Executive Staff, such as the Warden, in
monitoring SHU inmate totals by institution. Third, the BOP has been training
Disciplinary Hearing Officers (DHO) to consider administrative time served when
determining sanctions for inmates who have committed a prohibited act.158 The
former CPD Deputy Assistant Director also told us that the BOP is revising its
program statement on the Inmate Discipline Program and is considering whether to
significantly reduce the maximum sanction for the greatest severity offenses.159
We visited FCC Terre Haute, which emphasized diverting inmates, including
inmates with mental illness, from the SHU whenever possible.160 Institution officials
told us that if the Psychology Services staff identifies an inmate with a serious
mental illness and a history of self-harming behavior during prior SHU placements,
the staff may house the inmate in the general population while the discipline
hearing is pending.161 The institution’s DHO said that BOP policy does not restrict
him from imposing alternative sanctions if the Psychology Services staff expresses
concerns about SHU placement. Rather than placing an inmate in the SHU, the
DHO may impose a monetary fine, which he said had been a particularly effective
deterrent; confiscate the inmate’s property; or restrict the inmate to his cell. At the
placed into less restrictive settings through state placement and reintegration into the general population.
However, in January 2016, the Department reported that this program does not accept inmates who require
“substantial medical or mental health treatment.” DOJ, Use of Restrictive Housing, 24.
The Department’s January 2016 report, Use of Restrictive Housing, recommended that the
BOP revise its written policies for the Inmate Discipline Program to require that time spent in
administrative detention status pending investigation be credited toward any term of disciplinary
segregation status imposed for that violation. According to the Department’s “180-day Status
Report,” the BOP revised its internal document to require that all disciplinary investigations be
completed within 30 days, absent compelling circumstances.
158

The BOP stated that this effort was partly in response to the CNA report, which stated that
the BOP should “establish by policy that a sanction of restrictive housing time should be issued
retroactive to the date of the original admission, providing credit for time served.” See CNA, Federal
Bureau of Prisons: Special Housing Unit Review and Assessment (December 2014).
159

The Department’s January 2016 report, Use of Restrictive Housing, also recommended that
the BOP reduce its maximum sanction to 60 days for a first offense and 90 days for a subsequent
offense. The Department recommended that the BOP provide guidance that, ordinarily, DHOs should
impose concurrent sentences for disciplinary violations arising from the same episode and that the
BOP should prohibit SHU placement for all low level and first-time moderate level offenses. According
to the Department’s “180-day Status Report,” maximum penalties are codified in the Code of Federal
Regulations and any changes would require formal rulemaking. The Department is reviewing a draft
Notice of Proposed Rulemaking, which is expected to be issued for public comment in the near future.
160 According to the BOP’s revised SHU policy, the BOP now prohibits SHU placement for
inmates whom mental health staff have designated at MHCL 3 or 4, who have a psychology alert in
SENTRY (the BOP’s primary mission support database), or who have been identified on the monthly
SHU advisory (Hot List) unless the inmate presents an immediate or serious danger to self, staff, or
the orderly operation of a facility. In the event that an inmate who meets one of these criteria is
placed in the SHU, Psychology Services staff should be notified and should conduct a mental health
evaluation within 24 hours of placement. See BOP Program Statement 5270.11, Special Housing Units
(November 2016), 15–16.

During our site visit, the institution’s DHO told us that there were approximately 100 inmates
pending a disciplinary hearing who were currently placed in the SHU under administrative segregation status.
161

55

time of our visit, only five inmates were in the institution’s SHU for disciplinary
segregation, which the DHO attributed to his use of alternative sanctions.162 The
former CPD Deputy Assistant Director said that DHOs have always had the
discretion to deny inmate privileges in lieu of imposing SHU time. Based on our
observations and the DHO’s statements, we believe that the BOP should consider
policies that encourage the use of alternative sanctions when appropriate to further
prevent inmates with mental illness from placement in restrictive housing.
Also at FCC Terre Haute, the acting Complex Warden told us that during SHU
meetings, which are held to review inmates’ continued placement in the SHU, the
staff first discusses inmates based on length of time in the SHU rather than in
alphabetical order, which is intended and helps to prioritize discussions on whether
these inmates can be returned to the general population. The acting Complex
Warden also stated that, for transfer inmates who are routinely placed in SHU on
“Holdover Status,” staff will work to determine which inmates can be safely released
to the general population while pending transfer to their designated institution.
By contrast, we found that the BOP routinely places holdover inmates in
SHUs as a standard practice, despite the potential mental health concerns
attributed to placing inmates in restrictive housing. At FCC Petersburg, we
observed that holdover inmates were all housed in its SHU while awaiting
transfer.163 The Chief Psychologist at the time of our visit told us that holdover
inmates with mental illness can become particularly problematic for staff and that
her institution receives holdover inmates who have serious mental illness. She
estimated that they may be single-celled in the SHU for up to 3 weeks. Although
the staff physically places inmates with serious mental illness at the front of the
SHU so they can be monitored more closely, she acknowledged that SHU placement
can be detrimental to these inmates’ mental health and may also compromise the
SHU staff’s safety. She added that her institution receives holdover inmates who
are new to the BOP and, as a result, the Psychology Services staff has little
information about their mental health and generally does not provide intake
screenings for inmates in holdover status.164 We believe that the BOP can improve
162 At the time of our site visit, the USP Terre Haute SHU also housed its FCI SHU inmates
due to construction. This was also a factor that contributed to the DHO’s alternative sanctions
because the USP’s SHU was normally full with both medium and high security inmates.

We note that as of May 30, 2015, this institution had the most MHCL 3 inmates in its SHU
compared to all other BOP institutions. According to BOP policy, MHCL 3 represents inmates with
serious mental illness. At the time of our site visit, we also interviewed multiple inmates who had
serious mental illness and were currently in the SHU. However, as discussed earlier, because we
believe that the BOP’s new mental health care policy (BOP Program Statement 5310.16) may have
affected some inmates’ MHCL designations, it is difficult for us to compare and contrast BOP
institutions. We also recognize that FCI inmates placed in the USP’s SHU may have skewed the data.
163 At the time of our site visit, the SHU Lieutenant stated that there were approximately
35 holdover inmates housed in the institution’s SHU.
164 BOP policy states that, for individuals in holdover status, a preliminary screening by a
Physician’s Assistant is sufficient, unless a significant problem is identified. Inmates referred to
Psychology Services following their preliminary medical screening are supposed to be evaluated
promptly by a Psychologist. See BOP Program Statement 5310.12, ch. 4, p. 3.

56

its handling of holdover inmates to further prevent inmates with mental illness from
being placed in restrictive housing when it may not be necessary.
The BOP Has Made Particular Progress in Reducing Lengthy SHU Placements
In addition to reducing overall SHU use by about 20 percent since FY 2010, we
found that the BOP has reduced by 58 percent the total number of inmates placed in
a SHU for at least 150 consecutive days and these inmates’ average number of days
housed in the SHU by almost 10 percent. Specifically, 1,862 inmates were housed in
SHUs for at least 150 consecutive days, with an average duration of 296 consecutive
days, at the end of FY 2010.165 By the end of FY 2014, the BOP had reduced this
population to 780 inmates housed in SHUs for at least 150 consecutive days, with an
average stay of 268 consecutive days. (See Table 6.)
Table 6
Inmates in a SHU for at Least 150 Consecutive Days
FY 2010 through FY 2014
FY 2010

FY 2011

FY 2012

FY 2013

FY 2014

% Change
FY 2010 –
FY 2014
(+/-)

No. of Inmates in a
SHU for at Least
1,862
1,871
2,072
1,197
780
-58.11 %
150 Consecutive Days
Average No. of Days in
296
280
291
285
268
-9.46 %
a SHU
Note: This table includes all inmates who were continuously placed in a SHU for at least 150 days as
reported by the BOP’s dashboard, which does not specifically identify inmates with mental illness.
Source: OIG analysis of BOP data

In addition to reducing the overall use of SHUs and the incidence of particularly
lengthy SHU stays, the BOP has implemented a number of other actions that are directly
targeted at helping monitor and mitigate mental health concerns for inmates in RHUs:


The Psychology Services staff must conduct a Psychology Services Review after every
30 days of continuous SHU placement for every inmate, regardless of MHCL.166

We requested that the BOP apply its SHU dashboard to previous fiscal years to assess
inmates who were in comparably prolonged periods of SHU confinement. As mentioned earlier, the
BOP developed this dashboard after the new mental health care policy to notify institutions’ staff of
inmates who may be due for their required Extended Restrictive Housing Placement Review. We were
told that inmates, as detailed in Table 6, from FY 2010 through FY 2013, did not receive these reviews
because former BOP policies did not require them.
165

Based on our case file reviews of inmates with mental illness in RHUs, we found that
Psychology Services Reviews were conducted within the timeliness standards detailed by policy. However,
contrary to policy, we found that the Psychology Services staff at the ADX did not always document the
threat the inmate posed to self, staff, and other inmates. Our case file reviews indicated that the BOP had
developed standardized default fields for SHU and SMU reviews to capture this information but ADX
reviews did not incorporate these standardized data fields, which we believe contributed to this issue.
166

57



The Psychology Services staff may also place inmates with mental illness on the
monthly advisory (Hot List) in the BOP’s SHU Application to alert correctional
staff of those who “could potentially cause a problem if placed in SHU.”167



If restrictive housing appears to affect an inmate’s mental health, the Mental Health
Treatment Coordinator is required to work with the CCARE team to “mitigate the
negative impact or identify an appropriately secure alternative placement.”168

The BOP distributes among various staff members the responsibility for
monitoring inmates in RHUs.169 The May 2014 mental health policy states that all
staff are required to make themselves available to RHU inmates for brief
conversations and demonstrate concern and availability to provide assistance.170
The former CPD Deputy Assistant Director said that Correctional Officers must make
RHU rounds every 30 minutes, a supervisor must visit with each RHU inmate during
every shift, and the Captain must visit with each RHU inmate every week.171
Finally, institution staff told us that the Executive Staff, including the institution’s
Warden, Associate Wardens, Captain, Chief Psychologist, and Health Services staff,
make weekly RHU rounds.172
The BOP Has Taken Steps to Address Mental Health Staffing Shortages
Despite staffing challenges, we found that the BOP has sought to increase
the mental health services it provides to inmates, including those in RHUs. BOP
officials told us about and we observed some steps that the BOP has taken, or is in
the process of taking, to meet inmate treatment requirements, including efforts to
increase pay for BOP Psychiatrists, hiring regional health service recruiters, as well
as program initiatives (detailed below) intended to improve psychology services
throughout the BOP. The BOP’s FY 2016 budget submission requested
167 While only the Psychology Services staff may edit the SHU Application’s Hot List, all SHU
staff members can see it and become aware of potential issues. Further, the SHU Application includes
some information from BEMR-PDS so that the correctional staff can see when the Psychology Services
staff last visited with an inmate. We found that the correctional staff with whom we spoke were aware
of the Hot List, and they told us that they are required to review it at least monthly. They also stated
that the Hot List may be distributed to them in an email and may be posted in the applicable RHU.
168

BOP Program Statement 5310.16.

169 The Department’s “180-day Status Report” stated that the BOP is developing a training
program called “Core Correctional Communications,” which is intended to enhance communications
between Correctional Officers and inmates. The BOP is conducting pilot training and plans to expand
the program to all of its institutions by the end of 2017.
170

BOP Program Statement 5310.16

We did not review BOP documentation to assess RHU rounds by the correctional staff.
However, Correctional Officers told us that they make irregular 30-minute rounds to monitor inmates.
171

Inmates told us that Executive Staff make rounds on a weekly basis. Executive Staff
rounds are recorded in a logbook that all staff members must sign as they enter the unit. The RHU
logbook records the staff member’s name, times of entry and exit, and the reason for the visit. We
could not use the logbook to verify whether or not the Executive Staff walked each RHU range and
made themselves available to each inmate on that range because these actions can be verified only
through observation. As a result, we did not review RHU logbooks.
172

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130 additional mental health positions, mostly Psychologists, to address staffing
concerns. However, the BOP did not receive its requested positions and Psychology
Services Branch officials told us that the BOP was not anticipating additional
funding in FY 2017.173 Additional steps taken or underway include:


SHU Pilot Program. According to BOP officials, the pilot program was
initiated at six high security institutions in which a Restrictive Housing
Psychologist will be designated to the SHU. The program was intended “to
increase the treatment of SHU inmates and evaluate an inmate’s need for
placement in SHU” with individualized interventions based on inmate needs.
As of October 2016, the BOP had filled five of six pilot program positions.



Psychology Internship Program. The Pre-Doctoral Psychology Internship
Program allows Pre-Doctoral students to complete their 1 year of internship
at a BOP institution. The program, which the BOP indicates predates and
was expanded prior to the May 2014 policy, includes student loan repayment
as an incentive for individuals interested in working for the BOP.174

Though we acknowledge these positive steps in attempting to address mental
health staffing shortages, we believe that the BOP needs to do more to ensure that
inmates with mental illness, including those in restrictive housing, receive care
consistent with its May 2014 policy.
The BOP Needs to Improve Mental Health Training for Its Correctional Staff
As stated above, various staff members, including correctional staff, monitor
inmates in RHUs. During our site visits, BOP Psychology Services staff told us that
they provide suicide prevention training to SHU staffs on a quarterly basis, in
addition to the annual refresher training on mental health that all staff receive.175
An ADX Correctional Officer told us that the annual refresher training covers erratic
behaviors, changes in behavior, and how to report and document these
observations. However, a SHU Lieutenant suggested that annual refresher training
could be improved by incorporating de-escalation techniques to help the
correctional staff learn how to calm inmates with mental illness who become
distressed. Further, while all correctional staff we interviewed said they had
received annual refresher training, several RHU correctional staff could not speak to
any specific information related to the training’s mental health content.

173

See DOJ, FY 2016 Performance Budget Congressional Submission.

We spoke to a Psychologist who started her career with the BOP as a Pre-Doctoral
Psychology Intern. She later became a Staff Psychologist, was promoted to Advanced Care Level
Psychologist, and is now an Internship Coordinator. Several Psychologists told us that the internship
program is a good recruitment tool for the BOP.
174

175 The BOP’s revised SHU policy mandates that correctional staff must complete quarterly
SHU trainings prior to each quarter, regardless of prior completions, and includes training content in
dealing with inmates who have mental illness. See Program Statement 5270.11, 17.

59

According to BOP policy, additional mental health specialty training will be
made available in select MHCL 2–4 and administrative institutions.176 During our
site visits, staff at two BOP secure residential mental health treatment program
institutions told us that they had received specialized mental health training to
better manage inmates with mental illness in restrictive housing.177 However, we
found that staff at other BOP institutions who work with inmates with serious
mental illness in RHUs had not received this specialized training. One Correctional
Officer who has worked extensively with MHCL 4 inmates in restrictive housing
stated that he has been provided with only RHU-specific suicide training in addition
to basic SHU training. A Chief Psychologist at a Care Level 3 complex told us that
he was unaware of the specialized mental health training referenced in BOP policy.
BOP policy states that “to support this specialized training, adequate Psychology
Services staffing must be in place” at these institutions. Despite the policy
providing for such training in select MHCL 2–4 and administrative institutions, the
BOP’s inadequate mental health staffing has affected the Psychology Services
Branch’s ability to provide specialized training to correctional staffs working in RHUs
who are responsible for monitoring the behavior of inmates, including many with
mental illness.178 Psychology Services Branch officials told us that due to the lack
of additional funding the BOP has not required that specialty training be provided to
any institution staff. As of October 2016, specialty training was offered at some
FMCs and MHCL 2 and 3 institutions.
The BOP Lacks Guidance and Training for Determining and Documenting When an
Inmate’s Symptoms May Not Be Genuine, Which May Affect Inmates in Restrictive
Housing
We found that the BOP does not have guidance or training for staff in
determining and documenting when an inmate’s symptoms may not be genuine, a
behavior commonly known as malingering.179 Because malingering is classified as a

176 BOP policy states that the “Mental Health Specialty Training will include 24 hours of
specialized mental health training, including suicide prevention, understanding mental illness, cultural
diversity and sensitivity, psychiatric medications, behavior management principles, confidentiality,
communication skills, de-escalation skills, and building collaborative relationships.” See BOP Program
Statement 5310.16, 22.
177 During our site visit to USP Atlanta’s secure residential mental health treatment program,
a staff member, who had worked in this RHU for nearly 2 years, told us that although additional,
specialized mental health training was provided to correctional staff initially assigned to this RHU, this
training had not been provided on a recurring basis. As a result, correctional staff who rotate into this
RHU did not receive the more extensive, specialized mental health training and, consequently, this
staff member did not believe they are adequately trained to work in this RHU.
178 According to the Department’s “180-day Status Report,” the BOP has begun training that
incorporates the “Guiding Principles,” established in the Department’s January 2016 report on
restrictive housing, into curricula for quarterly and annual training programs for staff assigned to SHUs
and to Wardens, Associate Wardens, Captains, Lieutenants, and new Correctional Officers.

Malingering is the intentional production of false or grossly exaggerated physical or
psychological problems and, usually, is the result of an individual’s external motivations. Malingering
is not considered a mental illness but should be suspected when there is a discrepancy between the
(Cont’d)
179

60

behavior and not a mental disorder, BOP policy does not require staff to document
malingering when they observe it.180 Consequently, staff use their own discretion to
document malingering and inmates with legitimate mental illness may continue to be
placed in RHUs for longer periods of time without receiving the treatment they need.
According to BOP data, at the end of FY 2014 there were 430 inmates, or
less than 1 percent of the BOP’s total inmate population, for whom staff chose to
document malingering. But such reporting is not required, as discussed above, and
feedback that the OIG received from BOP staff strongly suggests that it may not
accurately reflect the prevalence of malingering throughout the BOP. For example,
staff at USP Lewisburg told us that malingering is widespread in the SMU inmate
population. The text box provides an example of an inmate who staff believed was
malingering, who was taken off previously prescribed medications but was later
removed from the SMU because of mental health reasons.
Challenges for SMU Staff in Determining When an Inmate’s Symptoms
May Not Be Genuine
According to an inmate’s case file, he was diagnosed with three mental disorders when he
arrived at the SMU and was prescribed one antipsychotic medication and one medication to reduce
the side effects of antipsychotic treatment. The inmate previously had been diagnosed with five
mental disorders and prescribed a variety of medications during his incarceration at other BOP
institutions.
Nine months after arriving at the SMU, the inmate was removed from his medications after
the SMU Psychologist determined that his behavior was malingering rather than genuine
symptoms of mental disorder. The Psychologist’s notes state, “Despite the litany of diagnoses and
psychiatric medications [the inmate’s] contacts with psychology staff indicate a clear history of
malingering and feigning symptoms to change conditions of his confinement.” The inmate “has
not exhibited nor reported any mental health symptoms indicative of an acute mental health
disorder, although he has repeatedly engaged in disruptive behaviors as well as malingered
suicidality in an attempt to regain his medications.” Two months later, two of the inmate’s three
mental disorders were classified as no longer current. Nevertheless, 3 months after the inmate
was removed from his medications, and 1 year after the inmate entered the SMU program, the
inmate was transferred out of the SMU for mental health reasons.
Source: BOP inmate case file

According to the Administrator of the Psychology Services Branch, mental
health staff should be “conservative about attaching that label [malingering] to
anyone because once it’s in the record, it can really color other peoples’ judgment
about the inmate.” Institution staffs told us that they rely on their prior clinical
training, correctional experience, or even a “gut feeling” to determine whether an
inmate’s symptoms are real or the inmate may be malingering. One Clinical
individual’s claimed distress and the clinician’s objective findings, a lack of cooperation during
evaluations and in complying with prescribed treatment, or if the individual has been diagnosed with
Antisocial Personality Disorder. See Medscape.com, “Malingering Clinical Presentation,”
http://emedicine.medscape.com/article/293206-clinical (accessed June 7, 2017).
Therefore, we could not use BOP data to determine the prevalence of malingering
throughout the BOP or RHUs or to assess BOP or RHU trends of malingering.
180

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Director told us that it would be useful for the BOP to issue guidelines or training
that explains how to deal with malingering inmates because it is a “big problem in
the institutions” and many inmates are simply seeking medication. Yet, BOP
officials cautioned us about the risks of providing guidance to staff to assess
malingering. The Chief of Mental Health Services cautioned:
We want to make sure that our staff [doesn’t] find malingering when
it’s actually not there. If you’re working in a stressful environment
with difficult inmates, it can be easy to dismiss someone. You could
be at risk to dismiss someone as malingering so you can get them off
your caseload and not have to deal with them. So, I think what we
focus on is making accurate mental health diagnosis for true disorders
and recognizing that yes, someone can have a serious mental illness
and malinger.
BOP officials offered alternatives to guidance on malingering. A Senior
Deputy Assistant Director from the RSD said that the BOP could provide staff with
webinar trainings on using a psychology assessment tool known as the Structured
Interview of Reported Symptoms to better accurately assess inmates’ symptoms.181
While training to assess whether mental health symptoms are genuine could assist
mental health staff, we question whether, without careful guidance and
consideration, inmates with legitimate symptoms of mental illness will be dismissed
as malingerers by overworked RHU mental health staff.

181 The BOP also employs Forensic Psychologists, who are licensed and have more specialized
training in malingering because, as part of their job duties, they screen the mental health of
defendants in criminal cases who could have a strong incentive to malinger symptoms of mental
illness. However, most BOP Psychologists are not Forensic Psychologists. According to Psychology
Services Branch officials, up to 40 percent of BOP Psychologists are unlicensed.

In response to a working draft of this report, the BOP stated that in order to be hired as a BOP
Psychologist, an individual must have a doctoral degree in clinical or counseling psychology from an
accredited university, which fully qualifies him or her to diagnose mental disorders regardless of
licensing status. Nevertheless, we believe that many BOP mental health services staffs, both Health
Services and Psychology Services staffs, may benefit from receiving more specialized training in
screening inmates for genuine mental illness.

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CONCLUSION AND RECOMMENDATIONS
Conclusion
The BOP’s mission is to protect society by confining federal offenders in
correctional facilities that are safe, humane, cost-efficient, and secure, and to
provide reentry programming to ensure inmates’ successful return to the
community. While in the BOP’s custody, inmates at times may have to be placed in
Restrictive Housing Units (RHU) to ensure the safety and security of inmates and
staff. However, studies show that the frequency, duration, and conditions of
confinement of restrictive housing, even for short periods of time, can have a
significant impact on inmates’ mental health and can be particularly harmful for
inmates with mental illness. The BOP has taken some measures to improve the
treatment of inmates with mental illness in its institutions and to monitor all
inmates who are housed in RHUs. However, we believe that significant additional
steps are required to screen, treat, and monitor inmates with mental illness in
these restrictive environments, especially those in single-cell confinement. The lack
of policies to adequately address conditions of confinement that amount to solitary
confinement may result in inmates having limited human contact and out-of-cell
opportunities, which research suggests may negatively affect their mental health.
We have identified several areas of concern with regard to the frequency, duration,
and conditions of confinement for inmates with mental illness in RHUs.
First, BOP data shows, and we observed, inmates with mental illness housed
in traditional RHUs, such as Special Housing Units (SHU), Special Management
Units (SMU), and the U.S. Penitentiary Administrative Maximum Security Facility
(ADX), as well as other forms of restrictive housing, for long periods of time and in
conditions that could constitute solitary confinement. We also found that the BOP
cannot determine how many of its inmates are placed in single-cell confinement
because it does not track this information.
Moreover, although the BOP monitors all inmates’ consecutive days in RHUs,
it does not monitor inmates’ cumulative time in RHUs, including the SHUs that
house over 80 percent of BOP’s restrictive housing population. Also, inmates with
mental illness spend disproportionately longer periods of time in restrictive housing
than do their peers. The OIG’s analysis of BOP data shows that inmates with
mental illness at both the SMUs and the ADX spent about 14 to 17 months longer in
these RHUs than what the BOP reported for all inmates in these RHUs.
Additionally, we found that the BOP does not sufficiently track or monitor
inmates with mental illness, including those in RHUs. BOP mental health officials
estimated the percentage of inmates who have mental illness as significantly higher
than what BOP data indicates. We believe that the prevalence of mental illness
throughout the BOP is likely underreported because institution staffs do not always
document inmates’ mental health diagnoses. Also, because over 90 percent of BOP
inmates are designated at Mental Health Care Level 1 and are not required to have
a mental health diagnosis, the BOP cannot differentiate between inmates who may
have undocumented mental illness and inmates who simply do not have any mental
disorders. Consequently, the BOP cannot accurately determine the number of
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inmates, including those in RHUs, who have mental illness or ensure that it is
providing appropriate treatment to all inmates with mental illness.
Although the BOP issued a policy in 2014 intended to enhance mental health
treatment for inmates, including inmates in RHUs, it does not appear that the BOP
has provided sufficient staffing to implement the new policy effectively. To the
contrary, the OIG found that after the new policy was issued, BOP mental health
staff reduced the number of inmates required to receive regular mental health
treatment by approximately 30 percent. Based on our analysis of BOP data and
feedback from institution staffs, we are concerned that the number of inmates
required to receive regular treatment decreased substantially following the BOP’s
adoption of the 2014 policy and, as a result, the treatment for many inmates with
mental illness, including those in RHUs, may have been discontinued.
In addition, shortages of Psychologists and Psychiatrists throughout the BOP
may also affect the treatment provided to inmates with mental illness, including
those in RHUs. Staffing challenges can contribute to conflicting mental disorder
diagnoses, which can also affect the continuity of care for inmates.
We identified a number of issues with U.S. Penitentiary (USP) Lewisburg’s
SMU program in particular, which is concerning since this SMU is the BOP’s most
populated RHU and, as of June 2016, confined over 1,100 inmates. Among the
issues we identified, we found that since the BOP issued its new mental health
policy, SMU staff downgraded the level of care for a disproportionate number
(56 percent) of SMU inmates and, as a result, some inmates may not receive
necessary mental health care. In addition, inmates with mental illness are in the
SMU significantly longer than their peers and longer than the program’s intended
duration. Further, misleading SMU performance metrics may compromise the
BOP’s oversight of the program and inaccurately reflect the circumstances of
inmates who have been in the SMU. Moreover, USP Lewisburg’s aged
infrastructure, including its undersized cells with poor ventilation that do not meet
generally accepted standards, could adversely affect the conditions of confinement
for all SMU inmates and may be particularly harmful for inmates with mental illness
who can spend years in this SMU.
Finally, while the BOP has taken steps to remove inmates from placement in
traditional RHUs and to mitigate mental health concerns for inmates in RHUs, we
found a number of areas that continue to need improvement. The BOP needs to
develop meaningful performance metrics to help measure the effectiveness of its
secure residential mental health treatment programs. We found that some state
corrections systems have developed variations of residential mental health
treatment programs with potential efficiencies that we believe the BOP should
consider. Further, the BOP should improve the mental health training for RHU
correctional staff, explore the potential to increase the use of alternative sanctions
to further prevent inmates with mental illness from being placed in restrictive
housing, and provide additional guidance and training to mental health staff to
determine whether mental health symptoms are genuine and to document
malingering.

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Recommendations
To ensure that inmates, including those with mental illness, are placed in
restrictive housing under conditions of confinement that adhere to specific
standards that are applied consistently and sustain appropriate mental health care,
we recommend that the BOP:
1.

Establish in policy the circumstances that warrant the placement of inmates
in single-cell confinement while maintaining institutional and inmate safety
and security and ensuring appropriate, meaningful human contact and outof-cell opportunities to mitigate mental health concerns.

2.

Define and establish in policy extended placement in measureable terms.

To ensure that inmates receive appropriate mental health care and are
sufficiently tracked and monitored during their placement in restrictive housing, we
recommend that the BOP:
3.

Track all inmates in single-cell confinement and monitor, as appropriate, the
cumulative amount of time that inmates with mental illness spend in
restrictive housing, including single-cell confinement.

4.

Identify all forms of restrictive housing utilized throughout its institutions and
ensure that all local policies are updated to reflect standards for all inmates
in restrictive housing consistent with established nationwide policies.

5.

Evaluate and limit as appropriate the consecutive amount of time that
inmates with serious mental illness may spend in restrictive housing.

6.

Ensure that the Psychology Services staff documents inmates’ mental illness
diagnoses in the Bureau’s Electronic Medical Record System and Psychology
Data System.

7.

Reassess the Mental Health Care Level system to ensure that it fully captures
the mental health needs of inmates, including inmates in restrictive housing,
and that classifications distinguish between inmates who have some form of
mental illness and those who do not have any form of mental illness.

8.

Regularly monitor, by institution and type of Restrictive Housing Unit, trends
in inmates’ designated Mental Health Care Levels to further assess the
factors that affect the treatment of inmates with mental illness.

9.

Determine what additional steps can be taken to prioritize and incentivize the
hiring of mental health staff at institutions that have inmates with mental
illness in long-term restrictive housing.

To improve the BOP’s efforts to mitigate the placement of inmates with
mental illness in traditional RHUs and enhance the effectiveness of secure
residential mental health treatment programs, we recommend that the BOP:

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10.

Assess the scalability of secure residential mental health treatment programs
and develop alternatives to address their potential limitations.

11.

Develop and implement formal performance metrics sufficient to measure the
effectiveness of secure residential mental health treatment programs.

12.

Survey institutions and/or take other steps to identify alternative practices
that reduce the frequency and duration of the placement of inmates with
mental illness in restrictive housing, and implement such alternatives when
appropriate.

13.

Provide additional mental health training to correctional staff who are
responsible for monitoring the behavior of inmates in restrictive housing.

14.

Provide additional guidance and training to mental health staff on diagnosing
mental illness, including guidance on documenting malingering behavior by
inmates.

To address concerns regarding inmates with mental illness at USP
Lewisburg’s SMU, we recommend that the BOP:
15.

Conduct a comprehensive review of U.S. Penitentiary Lewisburg’s Special
Management Unit that addresses the staffing, treatment, conditions of
confinement, and performance metrics of the program.

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APPENDIX 1
METHODOLOGY OF THE OIG REVIEW
Standards
The OIG conducted this review in accordance with the Council of the
Inspectors General on Integrity and Efficiency’s Quality Standards for Inspection
and Evaluation (January 2012).
Data Analysis
Inmates with a History of Mental Illness
The OIG used BOP data from the end of FY 2014 to determine the number of
sentenced inmates whom the BOP had diagnosed with mental disorders. The BOP
provided us with inmate mental disorders that were documented in the Bureau’s
Electronic Medical Record System and Psychology Data System (BEMR-PDS) for every
BOP inmate within our scope.182 Each BOP inmate had one data row with corresponding
columns that were populated with as many mental disorders as applicable, since many
inmates had multiple mental health diagnoses. Table 7 is a condensed version of actual
mental illness data for a sample of four anonymous BOP inmates. Based on BOP data in
this table, Inmate A did not have any documented diagnoses while Inmate B had one,
Inmate C had three, and Inmate D had two.
Table 7
BOP Inmate Mental Illness Data
Mental Health Illness

BOP
Inmates

MHCL

A

1

B

2

Bipolar I Disorder –
Most Recent Episode
Depressed

C

4

D

2

1

2

3

Antisocial Personality
Disorder

Psychotic Disorder Not
Otherwise Specified

Personality Disorder Not
Otherwise Specified

Mood Disorder
Not Otherwise Specified

Psychotic Disorder Not
Otherwise Specified

Notes: MHCL = Mental Health Care Level. The BOP data also included the date the BOP diagnosed the
inmate with the mental disorder; the status of the diagnosis (current, remission, or resolved); and the date
the inmate’s status was documented in BEMR-PDS. We did not include these categories in this table.
Source: BOP data

Because we asked the BOP to provide all mental illness diagnoses in a
sequential order beginning in the “Mental Health Illness 1” data field, we were able
to use this data field to filter out all of the inmates who did not have any
documented diagnoses and determine the number of inmates with a documented
182

We excluded chemical dependency (substance abuse) diagnoses from our data request.

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history of mental illness (18,066 inmates). In doing so, as discussed in the report,
we found that there were 968 inmates who were designated at Mental Health Care
Levels (MHCL) 2–4 who did not have any corresponding diagnoses documented in
the data.183 Because these 968 inmates were designated at MHCLs 2–4, we knew
they had to have a history of mental illness. As a result, we added this inmate total
to the 18,066 inmates with a documented history of mental illness to determine
that at least 19,034 inmates, or approximately 12 percent of the BOP’s total inmate
population, had a history of mental illness.184
Inmates with a History of Mental Illness by Restrictive Housing Unit Type, FY 2014
We used BOP mental illness data from the end of FY 2014, as well as BOP
population snapshot data, to determine the number of sentenced inmates whom
the BOP had diagnosed with mental disorders and who were in Restrictive Housing
Units (RHU). In addition to the mental illness data discussed above, the BOP also
provided us with Special Housing Unit (SHU), Special Management Unit (SMU), and
U.S. Penitentiary Administrative Maximum Security Facility (ADX) population
snapshot data from the end of FY 2010 through FY 2014, as well as for May 30,
2015. The BOP’s mental illness dataset and its SHU, SMU, and ADX population
datasets included the inmates’ full name, gender, and unique BOP registration
number. Using the BOP’s inmate registration numbers, we matched all 397 ADX
inmates; all 1,248 SMU inmates; and 94 percent of all SHU inmates (8,166 out of
8,667) who were in these RHUs at the end of FY 2014 to BOP mental illness data
from the end of FY 2014. Using this methodology, we determined that 37 percent
of ADX inmates (146 out of 397); 27 percent of SMU inmates (331 out of 1,247);
and 21 percent of SHU inmates (1,651 out of 7,980) had a BOP-documented
history of mental illness.185

As we discussed above, the BOP’s Chief of Mental Health Services told us that these
inmates did not have diagnoses in the BOP data provided to us because BOP staff did not enter any
mental health diagnoses into BEMR-PDS; staff entered diagnoses into BEMR-PDS with different
diagnostic codes that were not provided to us; or staff manually entered diagnoses as free text rather
than selecting diagnoses from a drop-down menu, which resulted in the diagnoses not being captured
when the BOP extracted this information.
183

In this report, an inmate with a history of mental illness is defined as any inmate who has
at least one BOP diagnosis — either current, in remission, or resolved — documented in BOP data.
Also, as discussed in the report, we did not include inmates in our count who had undergone an initial
mental health records review, were given a tentative MHCL designation by the BOP’s Designation and
Sentence Computation Center, but had yet to be examined, in person, by a mental health clinician.
184

Because we were able to match only 94 percent of all SHU inmates (8,166 out of 8,667) at
the end of FY 2014, we cannot comment on the prevalence of documented mental illness among the
501 inmates whom we were unable to match. Additionally, while we successfully matched 8,166 SHU
inmates with BOP mental illness data, 186 of these inmates had yet to be examined, in person, by a
mental health clinician. Thus, we also excluded these inmates from our analysis.
185

Furthermore, while we successfully matched all 1,248 inmates at the SMU, we excluded
1 inmate from our analysis because this inmate had yet to be examined, in person, by a mental health
clinician. We therefore determined the prevalence of documented mental illness among 1,247 SMU
inmates.

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Mental Health Care Level Changes for Sample RHU Inmates
We selected a sample of 688 RHU inmates designated at MHCLs 1–4. This
sample included inmates selected from BOP population snapshot data:


all 239 SMU inmates who were designated at MHCLs 2–4 at the end of
FYs 2012, 2013, 2014, and on May 30, 2015;



57 ADX inmates who were designated at MHCLs 2–4 or had been at one point
during our scope;



182 SHU inmates from institutions we visited who were designated at MHCLs
2–4 from the end of FY 2010 through May 30, 2015, or had been at one
point during our scope;



36 ADX inmates who were designated at MHCL 1 from the end of FY 2010
through May 30, 2015, or had been at one point during our scope; and



174 SHU inmates designated at MHCL 1 from the end of FY 2010 through
May 30, 2015, or had been at one point during our scope.

In our sample, we included 210 BOP inmates who were designated at MHCL 1
during our scope and who may not have had mental illness. We evaluated whether
BOP inmates designated at MHCL 1 may have had their MHCL increased before or
after the issuance of the BOP’s new mental health policy on May 1, 2014. We
believed that if we focused only on inmates who were already designated at MHCLs
2–4, this may have prevented us from recognizing MHCL 1 inmates whose care
level may have increased. As mentioned in the report, over 90 percent of BOP
inmates, including the majority of inmates with mental illness, are designated at
MHCL 1.
Also, as stated in the report, this analysis does not account for every MHCL
change that may have occurred for our sample of RHU inmates between FY 2010
and August 29, 2015. Rather, we identified whether or not sample inmates’ MHCLs
increased or decreased at specific points of time during our scope. More
specifically, we assessed sample inmates’ initial MHCL assignment (which began in
FY 2010 for BOP inmates) and then assessed whether an inmate’s MHCL increased,
decreased, or remained the same as of April 30, 2014 (the day before the new
policy was issued). Likewise, we then again assessed sample inmates’ MHCLs as of
April 30, 2014, and then assessed whether an inmate’s MHCL had increased,
decreased, or remained the same as of August 29, 2015 (about 16 months after the
new policy was issued).186 Table 8 below shows BOP data for a sample inmate’s
MHCL change. Based on the BOP data in this table, we recorded that this inmate’s
MHCL had increased before the new policy was issued and had decreased after the
new policy was implemented.
For some of our 688 sample RHU inmates, we could not determine whether the change to
the inmate’s MHCL occurred in restrictive housing, such as those who were placed in institution SHUs,
or in the general population.
186

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Table 8
One Sample BOP Inmate’s MHCL Data
Inmate’s MHCL

Date Inmate’s MHCL
Was Assigned

Date Inmate’s MHCL
Stopped

1

July 7, 2010

April 21, 2011

2

April 21, 2011

October 21, 2014

1

October 21, 2014

August 29, 2015

Note: The inmate in this table was designated at MHCL 1 when the BOP
extracted this information on August 29, 2015.
Source: BOP data

Site Visits
From June 2015 through August 2015, we visited seven BOP institutions
designated at Care Levels 2, 3, and 4: U.S. Penitentiary (USP) Allenwood,
Pennsylvania; USP Atlanta, Georgia; Federal Medical Center Carswell, Fort Worth,
Texas; Federal Correctional Complex (FCC) Florence (ADX), Colorado; USP
Lewisburg, Pennsylvania; FCC Petersburg, Hopewell, Virginia; and FCC Terre Haute,
Indiana. We selected these seven BOP sites based on their special RHU programs
or the large number of inmates with mental illness in their RHUs, as determined by
the number of inmates designated at MHCLs 2–4.
Interviews
We interviewed senior officials from the BOP Central Office’s Correctional
Programs Division, Reentry Services Division, Health Services Division, and Office of
Research and Evaluation.
During site visits, we interviewed Executive Staff, including Wardens, Chief
Psychologists, Clinical Directors, and a Chief Psychiatrist. We also interviewed
mental health staff who worked or had worked in RHUs, including Staff
Psychologists, Staff Psychiatrists, General Practitioners, a Psychiatric Nurse, a
Physician’s Assistant, a Treatment Specialist, and a Recreation Therapist. In
addition, we interviewed other institution staff, including RHU Lieutenants and
Correctional Officers, as well as unit team officials and Disciplinary Hearing Officers.
At the seven institutions we visited, the OIG team had private interviews with
53 inmates with a history of mental illness. Most of the inmates we interviewed
were in restrictive housing at the time of our visit or had recently been released
from restrictive housing.
We also interviewed officials with the Office of the Deputy Attorney General
regarding the development of the Department’s January 2016 report on the use of
restrictive housing, the project lead and Psychiatrist from the Center of Naval
Analysis and Solutions team that conducted the review and assessment of the
BOP’s use of restrictive housing, as well as officials from the U.S. Government
Accountability Office (GAO) for more information related to the two FY 2013 GAO

70

reports issued on the BOP’s use of SHUs and the BOP’s oversight of its mental
health treatment programs. Additionally, we interviewed staff from the
Department’s Civil Rights Division for more information related to its May 2013
investigation of the Pennsylvania State Institution at Cresson and February 2014
investigation of the Pennsylvania Department of Corrections.
Finally, we interviewed senior officials from eight state departments of
corrections that we had selected for their publicized reforms or progressive policy
relating to the placement of inmates with mental illness in restrictive housing.
These eight states were Massachusetts, Washington, Pennsylvania, New York,
Virginia, Mississippi, Maine, and Colorado.
Inmate Case File Review
We analyzed the content of case files for 59 inmates with a history of mental
illness, most of whom we interviewed during our site visits. These case files
included, but were not limited to, psychology intake screening documents
(screening), clinical contacts (treatment), and restrictive housing psychology
reviews (monitoring). Due to the size of the inmate case files, we limited our
review from January 1, 2014 (4 months before the BOP issued the new mental
health policy) to the most recent documents available at the time of our site visits
(June 2015 through August 2015). We reviewed these documents to assess BOP
mental health staffs’ compliance with BOP policy, such as timeliness standards,
based on document dates, indications of in-cell or out-of-cell contacts with inmates,
or other important notes that are relevant to the BOP’s screening, treatment, and
monitoring of inmates with mental illness in RHUs.
Our analysis featured several important limitations. The primary limitation
was the sample of documents each institution provided. While some institutions,
particularly the ADX, provided us with thousands of inmate records, other
institutions provided us with substantially less psychology documentation, which
hindered the consistency of our analysis of the institutions. Therefore, any
conclusions drawn from case file reviews about the screening, treatment, and
monitoring of inmates with mental illness could be based only on documentation we
received from the institutions we visited. There were also inconsistencies in the
psychology forms, such as Psychology Services Reviews, used among the
institutions we visited and even within the institutions, which in some cases did not
capture all of the information that we had regularly been assessing. This further
hindered the consistency of our analysis of psychology documents.
Finally, we learned that the dates we used to assess timeliness standards
were entered by mental health staff and were not automated by BEMR-PDS (other
than the date and time the form was completed). As a result, the dates we used in
our report to assess timeliness standards, such as the date Psychology Services
staff conducted an intake screening or a Psychology Services Review, result from
staff inputs. Although there are legitimate reasons for this, such as staff not having
time to input information into BEMR-PDS for all the clinical contacts they conducted
during a single day, we recognize that mental health staff could potentially
backdate these documents to artificially meet BOP timeliness standards. We note

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that mental health staff told us that the BOP has greater transparency in BEMRPDS; can see when a document was created, edited, and completed; and thus may
be able to detect any backdating of documents. Because we did not have access to
BEMR-PDS, we were unable to determine whether backdating documents may have
occurred for inmates with mental illness in RHUs.

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APPENDIX 2

BOP POLICIES GOVERNING RESTRICTIVE HOUSING AND
MENTAL HEALTH SCREENING, TREATMENT, AND MONITORING
This appendix contains a brief description of the requirements established
through BOP policies for Restrictive Housing Units (RHU) and mental health care,
including the screening, treatment, and monitoring of inmates with mental illness.
We describe the BOP’s national policies for operating its Special Housing Units
(SHU) and its Special Management Units (SMU), as well as local policy for the care
and treatment of inmates with mental illness at the U.S. Penitentiary Administrative
Maximum Security Facility (ADX). We also describe the BOP’s new national policy
for the care and treatment of inmates with mental illness; national policy for
disciplining inmates, including those with mental illness; and national policies,
procedures, and operational guidelines for providing psychology services.
Restrictive Housing Units
Program Statement 5270.10, Special Housing Units (August 2011)
SHUs at BOP institutions confine inmates separately from the general
population, either alone or with a cellmate. In a SHU, inmates may be confined to
their cells for up to an average of 23 hours each day. Inmates may be placed in a
SHU as punishment for having committed a prohibited act (disciplinary segregation)
or for a non-punitive purpose (administrative detention).187 While SHUs are not
intended for the long-term housing of an inmate, BOP national policy establishes no
limit to the number of times an inmate may be placed in disciplinary segregation,
nor does it limit the time an inmate, with or without mental illness, may remain in
administrative detention. All inmates placed in administrative detention are to
receive a review by a Segregation Review Officer within 3 workdays of their
placement, and all inmates placed in the SHU are to receive a formal status review
within 7 continuous calendar days of their placement, with subsequent reviews
conducted at the same interval thereafter. This policy also states that after every
30 calendar days of continuous placement in the SHU, all inmates are to be
examined by mental health staff, including a personal interview. Emergency
mental health care must be available to inmates in the SHU.
Program Statement 5270.11, Special Housing Units (November 2016)
On November 23, 2016, the BOP issued a revised SHU program statement in
response to recommendations cited in the Department’s January 2016 report on the
use of restrictive housing. According to the revised policy, the BOP now prohibits
SHU placement for inmates whom mental health staff have designated at Mental
Health Care Level (MHCL) 3 or 4, have a psychology alert in SENTRY (the BOP’s
primary mission support database), or have been identified on the monthly SHU
187 Reasons to place an inmate in administrative detention include protective custody; a
pending security classification or reclassification; holdover during transfer to another destination; and
segregation of an inmate who poses a threat to life, property, self, other inmates, the public, or to the
security or orderly operation of the institution.

73

advisory (Hot List) unless the inmate presents an immediate or serious danger to
self, staff, or the orderly operation of a facility. In the event that an inmate who
meets one of these criteria is placed in the SHU, Psychology Services staff should
be notified and conduct a mental health evaluation within 24 hours of the inmate’s
placement. Further, in an effort to enhance inmates’ out-of-cell time, the revised
SHU policy requires that staff at each BOP institution locally develop plans for
increasing recreation and states that institutions with the necessary resources
should increase recreation opportunities for inmates. The revised SHU policy also
states that, ordinarily, inmates nearing the end of their term of incarceration will
not be placed in the SHU, except when their presence in the general population
threatens the safety, security, or the orderly operation of an institution, and that
every effort will be made to prevent inmates’ direct release from the SHU into the
community. Last, the SHU policy mandates that correctional staff must complete
quarterly SHU trainings prior to each quarter, regardless of prior completions, and
includes training content regarding inmates with mental illness.
Program Statement 5217.01, Special Management Units (November 2008)
The SMU Program was established in 2008 to provide close management of
and programming for inmates referred to the program from other institutions BOPwide; to ensure the safety, security, and orderly operation of BOP facilities; and to
protect the public. Referral to the SMU program is non-punitive and must be
approved by the BOP’s Central Office, which may happen when the inmate has:


participated in or had a leadership role in geographical group/gang-related
activity;



a history of serious and/or disruptive disciplinary infractions;



committed any 100-Level prohibited act after being classified as a member of
a disruptive group;



participated in, organized, or facilitated any group misconduct that adversely
affected the orderly operation of an institution; and/or



otherwise participated in or been associated with activity such that greater
management of interactions with other persons is necessary to ensure the
safety, security, or orderly operation of BOP institutions, or to protect the
public.188

188 The BOP staff may impose sanctions on inmates who commit prohibited acts, which are
categorized by the Greatest severity (100 Level), High severity (200 Level), Moderate severity
(300 Level), and Low severity (400 Level). See Program Statement 5270.09, Inmate Discipline
Program (July 8, 2011). The BOP classifies inmates as members of a disruptive group when they
belong to or are closely affiliated with, for example, prison gangs, which have a history of disrupting
operations and security. This also applies to inmates who may require separation from a specific
disruptive group. See BOP Program Statement 5180.05, Central Inmate Monitoring System
(December 31, 2007).

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By policy, SMUs consist of four program phases, with each phase differentiated by
its conditions of confinement, level of interaction with other inmates, delivery of
programming, and expected time frame for inmates’ progression to the next
level.189 Inmates are expected to complete a four-phase program within 18 to
24 months. The four phases of the SMU program are:


Phase 1: Expected completion time is 4 months, with an initial progress
review within 28 days and subsequently every 90 days. Inmates will
normally be restricted to their cells.



Phase 2: Expected completion time is 6–8 months, with a progress review
every 90 days. Inmates will normally be restricted to their cells, but out-ofcell activities/programming may be increased on a case-by-case behavioral
performance basis.



Phase 3: Expected completion time is 6–8 months, with a progress review
every 90 days. Inmates may be housed and participate in activities
together, as necessary to protect the safety, security, and good order of the
institution. There are also increased privileges for inmates who accomplish
unit goals and maintain appropriate conduct.



Phase 4: Expected completion time is 2–4 months, with a progress review
every 30 days. Inmates must be able to demonstrate their sustained ability
to coexist and interact appropriately with other individuals and groups in the
unit.190

Conditions of confinement for SMU inmates are much more restrictive than
those for general population inmates, but they become less restrictive as an inmate
progresses from phase to phase of the program. Minimum SMU standards for
conditions of confinement include placement in cells that should ordinarily house
only the number of inmates for which the cells were designed and opportunities for
exercise outside inmates’ individual cells for 5 hours each week, ordinarily in 1-hour
periods on different days. Additionally, each inmate in the SMU program is to be
evaluated by mental health staff every 30 days, with emergency mental health care
always made available either at the institution or from the community.
Program Statement 5217.02, Special Management Units (August 2016)
On August 9, 2016, as a result of recommendations in the Department’s
January 2016 report on the use of restrictive housing, the BOP issued a revised
program statement for the SMU program. The revised SMU policy reduces the
phases from four to three and the intended time frame for inmates’ completion of
189 Inmates assigned to the SMU are expected to complete the four-phase SMU program in
18 to 24 months, after which they may be designated to another appropriate facility. Inmates at SMU
Program Phases 2, 3, or 4 who fail to make satisfactory progress may be returned to any previous
phase. If an inmate continues to exhibit disruptive conduct after 6 additional months in the SMU, the
inmate may be referred for designation to another appropriate facility, consistent with the orderly
operation of BOP institutions.
190

BOP Program Statement 5217.01, Special Management Units (November 19, 2008).

75

the program from an average of 18–24 months to 9–13 months. According to the
BOP, the revised SMU policy also requires a greater review of an inmate’s mental
health records prior to placement in a SMU, as well as at each stage of the program
to ensure that mental health needs do not preclude him or her from completing the
program. Specifically, the revised SMU policy states that a copy of an inmate’s
referral to the SMU program will be sent to the Psychology Services Branch, which
will review the inmate’s mental health record to determine whether mental health
concerns preclude SMU program placement. An inmate in the SMU program may
be removed if it becomes clear that his or her mental health does not reasonably
allow him or her to complete the SMU program. The recommendation is forwarded
to the Administrator, Psychology Services Branch, Central Office. If the
recommendation is approved, the Psychology Administrator notifies the Warden.
Upon successful completion of the SMU program, inmates are placed in the general
population or designated to another appropriate facility.
U.S. Penitentiary, Administrative Maximum, Institution Supplement FLM 5310.16A,
Treatment and Care of Inmates with Mental Illness (July 2015)
This policy supplements BOP national policy and provides institution-specific
guidelines for the treatment and care of inmates with mental illness housed at the
ADX at Florence, Colorado.191 The ADX houses inmates who have a history of
violent, disruptive behavior, both before and after their incarceration, and/or were
escape prone in other correctional institutions. Ordinarily, inmates diagnosed with
a serious mental illness will be diverted or removed from the ADX. The placement
or continued housing of an inmate with serious mental illness at the ADX may occur
only if extraordinary security needs are identified that cannot be managed
elsewhere. If an inmate is identified as suffering from a serious mental illness while
housed at the ADX, and the Chief Psychologist or ADX psychiatric services provider
determines that the inmate does not need inpatient hospitalization, the Mental
Health Treatment Coordinator will convene a multidiscipline committee to
determine whether extraordinary security needs exist that prevent the inmate from
being managed elsewhere.192 Inmates who are newly identified as suffering from a
serious mental illness while at the ADX, but who do not have extraordinary security
needs, will be referred to an appropriate treatment program or other setting outside
the ADX. Inmates at MHCL 4 are not to be housed at the ADX.
Upon arrival, Health Services staff will conduct inmates’ initial intake
screenings and assessments and identify whether newly transferred inmates have a
current prescription for psychotropic medication. The Health Services intake
screening seeks to identify inmates’ mental health care problems and needs, which
include, but are not limited to psychosis, hallucinations, suicidality, history of self191 The local policy supplements BOP Program Statement 5310.16, Treatment and Care of
Inmates with Mental Illness (May 1, 2014).
192 The multidiscipline committee will ordinarily consist of the Warden, Associate Wardens,
Captain, Special Investigative Agent, Case Management Coordinator, Unit Manager, Psychology
Services, psychiatric services provider(s), Assistant Health Services Administrator/Supervisory Nurse,
Psychiatric Nurse, and Supervisory Attorney. The Warden makes the final determination regarding
extraordinary security needs.

76

injury, mood disorders, disturbance, sexual victimization, and psychotropic
medication use. In addition, a psychology intake evaluation of each inmate will
follow within 7 business days of the inmate’s arrival at the facility. At this intake
evaluation, a Psychologist conducts a clinical interview of the inmate in a private
setting and evaluates the accuracy of the inmate’s designated MHCL. Psychology
Services and Health Services staffs ensure that every inmate with a clinically
identified need for psychological treatment has access to mental health care. An
inmate’s housing status does not affect the level of care he receives. Inmates will
ordinarily have access to in-cell therapeutic activities, including psychology
programming, through closed-circuit television.
A Psychologist makes weekly rounds in each ADX housing unit to identify and
address mental health and behavioral concerns and conducts a psychological review
of each ADX inmate at 30-day intervals. For inmates designated at MHCL 2 or 3,
inmates who have been referred for mental health services, or inmates who
demonstrate changes in functioning, both the weekly and 30-day rounds will consist
of a face-to-face interaction with the inmate’s outer cell door opened and a
correctional staff member present, if required. If clinically indicated, the inmate will
be removed from the cell to be interviewed in a private interview space. Consistent
with BOP national policy, inmates also receive Extended Restrictive Housing
Placement Reviews when continuously housed in the ADX’s SHU for 6 months or
elsewhere at the ADX for 12 months, with update placement reviews conducted at
the same intervals thereafter.
All inmates are to have reasonable access to “Inmate Request to Staff
Member” forms to request mental health services, although such requests are to be
accepted in any format. When a request or referral for mental health services
relating to an ADX inmate is received at the Psychology Services Branch, the staff
evaluates the referral or request on the same day; classifies it as emergent, urgent,
or routine; and responds to it within 4 hours, 24 hours, or no more than
10 business days, respectively. Tele-psychiatry services are available to ADX
inmates as needed when in-person psychiatry services are unavailable. To ensure
continuity of tele-psychiatry care, tele-Psychiatrists will make intermittent onsite
visits to the ADX to see inmates in person. At a minimum, inmates receiving
psychiatric medications will be seen by a Psychiatrist, psychiatric midlevel provider,
or other qualified provider every 90 days, or more often as clinically indicated, for
at least the first year.
The ADX Care Coordination and Reentry (CCARE) team meets weekly to
review inmate cases and identify strategies to mitigate the potentially negative
effects of the correctional environment on inmates with mental illness. Each ADX
inmate’s case is reviewed at least monthly, and the CCARE team reviews and
updates inmates’ individual treatment plans at 6-month and annual intervals. The
CCARE team, along with the treating clinician, identifies any proposed changes to
inmates’ treatment plans, and the treating clinician discusses them with the inmate.
For inmates with mental illness who are scheduled for release within the following
12 months, staff members involved in their pre-release planning attend CCARE
team meetings. Inmates with mental illness who are pending release into the

77

community, to home detention, or to a Residential Reentry Center are provided
reentry services.
Mental Health Screening, Treatment, and Monitoring
BOP Program Statement 5310.16, Treatment and Care of Inmates with Mental
Illness (May 2014)
The BOP issued this national policy to ensure that inmates with mental illness
are identified and receive treatment to assist their progress toward recovery while
reducing or eliminating the frequency and severity of symptoms and associated
negative outcomes of mental illness, such as placement in restrictive housing. The
new policy redefines inmate MHCLs and incorporates diagnostic, impairment, and
intervention-based criteria that substantially increased the work expected of BOP
mental health care staff for inmates at MHCLs 2–4.
Prior to May 2014, Program Statement 5310.13, Institutional Management of
Mentally Ill Inmates (1995), and a BOP policy memorandum that defined the BOP’s
MHCLs (2009) prescribed the BOP’s policies and guidance for the care and
treatment of inmates with mental illness.193 Table 9 compares the BOP’s former
and revised mental health treatment standards.
Table 9
The BOP’s Mental Health Treatment Standards

MHCL 1

Former Mental Health Treatment
Policies
(FY 2010 – April 30, 2014)
No required recurring mental health
services after the intake screening
Treatment interventions at least
once every 3 months after the
intake screening

MHCL 2

CCARE meetings not established

Inmate
Designations

MHCL 3

New Mental Health Treatment
Policy
(May 1, 2014 – Present)
No required recurring mental health
services after the intake screening
Treatment interventions at least
once per month after the intake
screening
CCARE meetings at least once per
year

No required updates for individual
treatment plans

Individual treatment plans updated at
least once per year

Treatment interventions provided at
least once per month after the
intake screening

Treatment interventions provided at
least once per week after the
intake screening

CCARE meetings not established

CCARE meetings at least once
every 6 months

No required updates for individual
treatment plans

Individual treatment plans updated at
least once every 6 months

193 Former mental health treatment policies include Program Statement 5310.13, Institution
Management of Mentally Ill Inmates (March 31, 1995), and the Assistant Director of the Correctional
Programs Division, policy memorandum, December 16, 2009, which established the BOP’s MHCL
system.

78

Table 9 (Cont’d)
Inmate
Designations

Former Mental Health Treatment
Policies
(FY 2010 – April 30, 2014)
No detailed timeliness standards
for treatment interventions

MHCL 4

New Mental Health Treatment
Policy
(May 1, 2014 – Present)
Treatment interventions at least
once per week after the intake
screening

CCARE meetings not established

CCARE meetings on a case-by-case
basis

No required updates for individual
treatment plans

Individual treatment plans updated at
least once every 3 months

Source: OIG analysis of BOP policies

All inmates at MHCLs 2–4 are to have an individualized mental health
treatment plan, which identifies individual and/or group programming needs and
describes the inmate’s mental health problems and goals, as well as the
interventions planned to help the inmate meet those goals. These plans are to be
reviewed and updated at a frequency determined by the inmate’s MHCL.194
Inmates also receive psychosocial interventions with mental health staff,
normally Psychologists, at a frequency determined by their MHCL.195 However, any
BOP staff member who observes inmate behaviors that may indicate mental illness
is to report these observations to the Chief Psychologist or Mental Health Treatment
Coordinator at the institution, which may result in an unscheduled psychosocial
intervention with mental health staff. The Psychology Services staff conducts an
Extended Restrictive Housing Placement Review when an inmate is housed
continuously in the SHU for 6 months, in the ADX for 12 months, or in the SMU for
18 months, to determine whether the inmate has mental health issues that should
preclude placement in that setting.
Program Statement 5270.09, Inmate Discipline Program (July 2011)
The BOP’s inmate discipline program helps ensure the safety, security, and
orderly operation of correctional facilities and the protection of the public. It allows
BOP staff to impose disciplinary sanctions on inmates who commit prohibited acts,
and to do so in an impartial and consistent manner that is neither capricious nor
retaliatory. Prohibited acts are divided into four categories based on their
respective levels of severity: Greatest (100), High (200), Moderate (300), and Low
(400). Each category of prohibited acts includes a range of disciplinary sanctions
Individualized mental health treatment plans are to be reviewed and updated every
12 months for inmates at MHCL 2, every 6 months for inmates at MHCL 3, and every 90 days for
inmates at MHCL 4.
194

195 As described in BOP Program Statement 5310.16, psychosocial intervention consists of a
face-to-face mental health contact between an inmate and a Psychologist, in a manner that protects
the inmate’s privacy to the extent that it does not compromise the safety and security of staff. The
contact should be consistent with the goals of the inmate’s treatment plan.

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that may be imposed upon determination of the inmate’s guilt. The discipline
process starts when the staff becomes aware of an inmate’s involvement in a
prohibited act. A staff member completes an incident report describing the
inmate’s behavior and provides a copy to the inmate.196 The Warden or a delegated
authority appoints a BOP staff officer to investigate the incident. The investigating
officer provides an investigative report to the Unit Discipline Committee, which may
impose sanctions or refer the case to a Disciplinary Hearing Officer (DHO) to
conduct a hearing.197 The DHO may conduct a hearing on an incident report only if
it is referred by the Unit Discipline Committee.198 Disciplinary segregation is among
the sanctions that may be imposed — up to 12 months for a Greatest Level severity
prohibited act or up to 6 months for a High Level severity prohibited act. Loss of
recreation privileges (exercise periods) may not be imposed on inmates in the SHU.
An inmate may be removed from any program or group activity for a specified
period of time as a sanction. Finally, consecutive disciplinary sanctions may be
imposed on inmates found to have committed multiple prohibited acts.
If it appears at any stage of the discipline process that an inmate is mentally
ill, the inmate will be referred to a mental health professional to determine whether
the inmate is responsible for his or her conduct and whether he or she is
competent. When an inmate is found to be mentally incompetent, the incident
report will show as a finding that the inmate should not be disciplined for the
prohibited act because he/she was found not mentally competent. If evidence, to
include evidence presented by mental health staff, indicates that an inmate cannot
understand the nature of the disciplinary proceedings or cannot participate in his or
her own defense, disciplinary proceedings may be postponed until the inmate is
competent enough to understand the proceedings and assist in his/her defense.
Program Statement 5310.12, Psychology Services Manual (March 1995)
The BOP’s Psychology Services Manual (PSM) established policies,
procedures, and operational guidelines for psychology services within the BOP. The
PSM pre-dated the BOP’s new program statement for the care and treatment of
inmates with mental illness by 19 years. Consequently, the PSM did not reflect
current BOP policy and procedures to designate inmates by MHCL. Further, the
PSM’s definition of mental illness reflected the criteria of an earlier version of the
American Psychiatric Association’s Diagnostic and Statistical Manual for Mental
Disorders.199 The PSM implemented a stratified approach for providing mental
health services to inmates with mental illness. Severely disturbed individuals are
196

The incident report should note anything unusual about the inmate’s behavior.

197

All 100 and 200 Level severity charges must be referred to the DHO.

198 The DHO is an independent officer who conducts hearings and imposes sanctions for
incidents of misconduct referred by the Unit Discipline Committee. The DHO is an impartial decision
maker who was not a victim, witness, investigator, or otherwise significantly involved in the incident.
199 The PSM (Program Statement 5310.12) defines mental illness using criteria of the
American Psychiatric Association, Diagnostic and Statistical Manual for Mental Disorders, 4th ed.
(Arlington, Va.: American Psychiatric Association, 1994) (DSM-4). The current version, as of the
issuance of this report, is DSM-5, which was published in 2013 and reflects a different definition.

80

cared for at inpatient treatment facilities, and less disturbed inmates most often
receive ongoing care in less restrictive environments.
According to the PSM, psychology services at each BOP institution should be
sufficient to ensure that every inmate with a documented need and/or interest in
psychological treatment has access to a level of care comparable to that available in
the community and consistent with the overall mission of the institution. All
inmates are to have access to direct clinical services from Psychology Services
staffs. These include crisis intervention, brief counseling focused on a specific issue
or problem, individual and/or group psychotherapy, and psycho-educational group
programs. Though the provision of psychology services within an institution may
vary depending on its mission, security level, staff and inmate characteristics, and
availability of resources, the PSM placed the highest priority on the treatment of
mentally ill inmates, initial psychological screening evaluations of newly admitted
inmates, and detention/segregation unit visits and psychological reporting.
A Physician’s Assistant medically screens each inmate for signs of
psychological disturbance with 24 hours of arrival at a BOP facility. When
psychological disturbance is suspected, the Physician’s Assistant refers the inmate
to Psychology Services for prompt and appropriate evaluation. Psychological
Services staff conduct psychological screening of an inmate within the first 14 days
of arrival at the facility (30 days for transferred inmates). This screening includes
the inmate’s voluntary completion of a Psychology Services Inmate Questionnaire,
an interview by Psychology Services staff qualified to conduct a clinical interview,
and psychological testing if judged necessary by the Psychologist.200 When an
inmate’s responses to the Psychology Services Inmate Questionnaire indicate
suicidal thoughts or feelings or when an inmate requests psychological services, a
member of the Psychology Services staff will promptly meet with the inmate. For
an inmate in holdover status, a preliminary screening by a Physician’s Assistant is
sufficient, unless a significant problem is identified. An individual referred to
Psychology Services as a result of this preliminary medical screening should be
evaluated promptly by a Psychologist.
Each Chief Psychologist is responsible to assess the treatment needs of the
inmate population on an annual basis and to determine what methods of treatment
will best meet these needs. A treatment plan is to be formulated and executed for
each inmate diagnosed with significant mental disturbance. The PSM refers to the
Health Services Manual in recommending that each institution without a full-time
Psychiatrist employ a consultant to meet the needs of inmates requiring
medication. Psychotropic medication is not designed for, nor should it be used as,
a method of chemical restraint to control behaviors unrelated to mental illness.
The BOP recognizes that extended periods of confinement in the SHU may
have an adverse effect on the overall mental status of some individuals. Therefore,
200 As time and resources permit, the BOP may enhance the psychological screening through
behavioral observations, review of available historical information found in the Central File or through
SENTRY (the BOP’s primary mission support database), and psychological testing when deemed
appropriate by a Psychologist.

81

any inmate confined in the SHU for 30 consecutive days or longer will be
psychologically evaluated. At least one member of the Psychology Services staff
will visit the SHU on a weekly basis and document this visit in the SHU visitor’s log.
An inmate housed in the SHU for 30 days or longer will receive a psychological
assessment at 30-day intervals.
Program Statement 5310.17, Psychology Services Manual (August 2016)
In August 2016, the BOP rescinded its March 1995 PSM and issued a revised
PSM that establishes general procedures, guidelines, and priorities for psychological
services.201 The revised PSM includes a revised mission statement and psychology
services priorities, including an increased emphasis on reentry services. The
revised PSM also includes previously issued guidance regarding Transfer Intake
Screenings, strategies to assess and support the core clinical skills of correctional
Psychologists, and guidance for the operation of graduate student practicum
programs in psychology services. The revised PSM removes duplicative content
addressed in other psychology services program statements and updates guidance
regarding the creation and maintenance of professional clinical documentation.
Finally, the revised PSM references other psychology services program statements
that provide more detailed procedures and guidelines for specific program areas.
In addition, the revised PSM establishes enhanced psychological services
offered in restrictive housing settings. For example, restrictive housing
Psychologists are assigned to provide direct clinical services such as screenings,
evaluations, pre-treatment, and treatment services for inmates in restrictive
housing settings, including the ADX, SMU, or at the six institutions participating in
the SHU pilot program (discussed in the Results of the Review). A Psychologist also
reviews the psychological status of any inmate confined in a SHU, SMU, the ADX, or
any other similar housing for more than 30 consecutive calendar days using data
from multiple sources, including contact with the inmate, input from unit
Correctional Officers, and documentation contained in the Bureau’s Electronic
Medical Record System and Psychology Data System (BEMR-PDS). The results of
the psychological review are documented in BEMR-PDS using an appropriate note,
such as ADX Review, SHU Review, or SMU Contact. The revised PSM also describes
prevention, diversion, mitigation, intervention, transition, and oversight strategies
employed by the Psychology Services Branch to intervene with inmates in
restrictive housing settings.
Program Statement 5330.11, Psychology Treatment Programs (March 2009)
This program statement establishes policy, procedures, and guidelines for
psychology treatment programs and serves as a training device for new
Psychologists and treatment specialists, as well as a reference for more experienced
201 The U.S. Government Accountability Office (GAO) recommended that the BOP Director
develop and implement updated program statements to ensure that these statements reflect currently
accepted treatment practices and standards related to inmate mental health care. See GAO, Bureau
of Prisons: Timelier Reviews, Plan for Evaluations, and Updated Policies Could Improve Inmate Mental
Health Services Oversight, GAO-13-1 (July 2013).

82

Psychologists and treatment specialists. The program statement, also known as the
BOP’s Psychology Treatment Programs Manual, establishes guidelines for five
treatment programs: (1) drug abuse programs; (2) “Resolve” trauma programs for
women; (3) the Bureau Rehabilitation and Values Enhancement Program; (4) the
Challenge Program; and (5) mental health treatment programs, including the
Habilitation Program, Skills Program, Axis II Program, and Mental Health Treatment
Units (or Step-Down Units).

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APPENDIX 3
BOP RESIDENTIAL MENTAL HEALTH TREATMENT PROGRAMS

Mental Health Step Down Program

Table 10
The Mental Health Step Down Program is a residential treatment program
offering an intermediate level of care for male and female inmates with serious
mental illness. The program is designed specifically to serve inmates who do
not require impatient treatment but lack the skills to function in a general
population prison setting. The program uses an integrative model that includes
an emphasis on a modified therapeutic community cognitive behavioral
therapies and skills training. The goal of the Step Down Program is to provide
evidence-based treatment to chronically mentally ill inmates in order to
maximize their ability to function and minimize relapse and the need for
inpatient hospitalization.
Mental Health Step Down Programs operate as modified therapeutic
communities and utilize cognitive behavioral treatments, cognitive
rehabilitation, and skills training. Criminal thinking is addressed through the
identification of criminal thinking errors and engagement in pro-social
interactions with staff and peers. The programs work closely with Psychiatry
Services to ensure participants receive appropriate medication and have the
opportunity to build a positive relationship with the treating Psychiatrist.
Program content is designed to promote successful reentry into society at the
conclusion of an inmate’s term of incarceration, and program staff collaborates
with community partners to facilitate reentry.
Inmates with serious mental illnesses, who would benefit from intensive
residential treatment, are considered for the program. Male inmates with a
primary diagnosis of Borderline Personality Disorder are referred to the
STAGES Program (see below). Mental Health Step Down Program participants
must volunteer for the program and must not be acutely mentally ill (i.e., they
must not meet criteria for inpatient mental health treatment).
The Mental Health Step Down Program is conducted over 12–18 months.
Inmates may participate in the program at any point in their sentence. Formal
programming is facilitated half-days, 5 days a week with the remaining halfday dedicated to an institution work assignment or other programming, as
participants are able.
Notes: The Step Down Program is available at Federal Correctional Institution (FCI) Butner, North
Carolina (medium security); U.S. Penitentiary (USP) Atlanta, Georgia (high security); and USP
Allenwood, Pennsylvania (high security). BOP Psychology Services Branch officials told us that a
female Step Down Program had been available at FCI Danbury; however, since FCI Danbury is no
longer a female institution, the BOP no longer has a Step Down Program for females.
Source: BOP, A Directory of Bureau of Prisons’ National Programs, May 22, 2015

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Steps Toward Awareness, Growth, and Emotional
Strength (STAGES) Program

Table 11
The STAGES Program is a residential treatment program for male inmates with
serious mental illnesses and a primary diagnosis of Borderline Personality
Disorder. The program uses an integrative model that includes a modified
therapeutic community, cognitive behavioral therapies, and skills training. The
program is designed to increase the time between disruptive behaviors, foster
living within the general population or community setting, and increase prosocial skills.
The program curriculum is derived from Dialectical Behavior Therapy and takes
place in a modified therapeutic community. There is also an emphasis on basic
cognitive-behavioral skills consistent with other BOP treatment programs; for
example, criminal thinking is addressed through the identification of criminal
thinking errors and engagement in pro-social interactions with staff and peers.
Program content is designed to prepare inmates for transition to less secure
prison settings and promote successful reentry into society at the conclusion of
their term of incarceration. Program staff collaborate with community partners
to facilitate reentry.
Inmates referred to the STAGES Program have a primary diagnosis of
Borderline Personality Disorder and a history of unfavorable institutional
adjustment linked to this disorder. Examples of unfavorable institutional
adjustment include multiple incident reports, suicide watches, and/or extended
placement in restrictive housing. Inmates designated to the STAGES Program
must volunteer for treatment and be willing to actively engage in the treatment
process. Willingness to engage in the treatment is addressed through a brief
course of pre-treatment in which the inmate learns basic skills at the referring
institution.
The STAGES Program is conducted over 12–18 months. Inmates may
participate in the program at any time during their sentence. Formal
programming is facilitated half-days, 5 days a week, with the remaining halfday dedicated to an institution work assignment or other programming.

Notes: The STAGES Program is available at FCI Terre Haute, Indiana (medium security), and USP
Florence, Colorado (high security).
Source: BOP, A Directory of Bureau of Prisons’ National Programs

85

APPENDIX 4
THE BOP’S RESPONSE TO THE DRAFT REPORT
U.S. Department of Justice
Federal Bureau of Pri sons

\\'as/1111gto11. DC 2053-1

Office of till' Diret'/Or

June 23, 2017

MEMORANDUM FOR NINA S . PELLETIER
ASSISTANT INSPECTOR GENERAL
OFFICE OF INSPECTOR GENERAL
EVALUATION AND INSPECTIONS DIVISION

FROM:

Thomas R . Kane , Acting Director

SUBJECT :

Response to the Of fice of Inspector Genera l ' s (OIG)
FORMAL DRAFT Report:
OIG Review of the
Federal Bureau of Prisons ' Use of Restrictive
Housi ng for Inmat es with Mental Illness , Assignment
Number A- 2015-004

The Bureau o f Prisons (BOP) appreciates the opportunity to respond
to the open recommendations from the draft report entitled OIG Review
of the Fede r al Bureau of Prisons ' Use of Restrictive Housing for
Inmat es with Mental Illness.
Please find the Bureau ' s response to t he recommendations below:
Recommendations
Recommendation 1:
Establish in poli cy the circumstances t hat
warrant t he placement of inmates in single-cel l confinement whil e
maintaining insti tutional and inmate safety and security and
ensuring appropriate meaningful human contact and out - of - ce ll
opportunit i es.
Response:
The BOP agrees with this recommendation and wil l
establish in policy factors to be considered wh e n placing/retaining
mental heal t h inmates i n single-ce ll confinement .

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Recommendation 2 :
Define a nd es tablish in p o licy extended placement
in me as ureable terms.
Response : The BOP a grees wit h this recommendation and will define
and establish e xtended pla cement in measureable terms.
Recommendation 3:
Track all inmates i n single - ce ll confinement and
mon itor , as approp riate, the c umu lative amount of time t h at inmates
with menta l i ll ness spend i n restr icti ve housing , i nc ludi ng
single - ce ll confinement.
Response:
The BOP ag rees with th i s recommendation as it pert ains
to menta l heal th inmates , and we will tra ck a nd monitor inmates with
mental health care leve ls 2 , 3 , and 4 .
Recommendation 4:
Ident i fy all fo rms of restr ictive housing
util i z ed throughout its i nstitutions and ensure that all local
policies are updated to reflect standards for a ll i nmates in
r estrict ive hou sing consist ent with establi s hed nati o n-wide
policies.
Response : The BOP agree s with this recommendation and wi l l review
all forms of r estri ct ive housing , a nd ensure local , or national,
po l ic ie s a re in place to direct the ir ope r at ion .
Recommendation 5:
Eva luate and limit as a ppropriate the consecutive
amount of time that inmates with se ri ous me n t al il l n ess may spend
in r estr icti ve ho using .
Response:
The BOP agrees with this re commendat i on and will
establish limits , as approp riate , on c onsecutive placements in
restrictive housing as it p erta ins to men ta l health inmates .
Recommendation 6:
Ensure that the Psychology Servi ces staff
documen t s inmates ' me nt al illness diagnoses in the Bureau ' s
El ectronic Medical Record System and Psychology Data System .
Response:
The BO P a grees with this recommendation . The Psychology
Services Branch will ensure Psycho logy Services staff d ocument
i nmates' mental il l n ess d i agnoses in the Bureau ' s Electronic Medi ca l
Reco rd and Psycho l ogy Data System.
Recommendation 7 : Reass e ss the Mental Health Ca re Level system to
ensure that it fully captur es the mental health n eeds o f inmates ,
including inma tes in restrictive h o using , a nd t ha t classifications
2

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distinguish between inmates who have some form o f mental il lness and
those who do not have any form of mental illness .
Response:
The BOP agrees with this recommendation . The Psychology
Services Branch will reassess the Mental Health Care Level system
to ensure that it fully captures the mental health needs of inmates,
including inmates in restrictive housing, and that there is a method
to distinguish between inmates who have some form of mental i l lness
and those who do not have any form of mental il l ness.
Recommendation 8: Regularly monitor , by institution and type of
Restrictive Housing Unit, trends in inmates ' designated Mental
Health Care Levels to further assess the factors that affect the
treatment of inmates with mental illness.
Response:
The BOP agrees with this recommendation . The Psychology
Services Branch will monitor trends in inmates ' designated mental
health care levels by institution and type of restrictiv e housing
unit.
Thi s will be used to further assess the factors that affect
the treatment of inmates with mental i llness .
Recommendation 9:
Determine what additional steps can be taken to
prioritize and incentivize the hiring of mental health staff at
institutions that have inmates wi th mental illness in long-term
restrictive housing.
Response:
The BOP agrees with this rec ommendat ion.
The Psychology
Services Branch and Health Services Di v ision will determine what
additional steps can be taken t o prioritize and incentivize the
hiring of ment al heal th staff at institutions that have inmates with
mental illness in long - term restrictive housing.
Recommendation 10: Assess the sca l ability of secure residential
mental heal th treatment programs and develop altern a t ives to address
their potential limitations .
Response:
The BOP agrees with this recommendation . The Psychology
Services Branch will assess the scalability of secure residential
mental heal th treatment programs and develop alternativ es to address
their potential limitations.
Recommendation 11:
Develop and imp l ement forma l performance
metrics sufficient to measure the effect iveness of secure
residential mental health treatment programs.
3

88

Response : The BOP agrees with this recommendation.
The Psychology
Services Branch wil l develop and impl ement f ormal performance
metrics sufficient to measure the e f fectiveness of secure
resident i al mental health treatment programs .
Recommendation 12:
Survey ins titutions and/or take other s teps to
identify a l ternative practices tha t reduce the frequency and
duration of the placement of inma t es wi th mental il l ness in
res tri ctive housing , and implement such alternatives when
appropriate .
Response : The BOP agrees wi t h thi s recommendation.
The Psychology
Servi ces Branch and Correctional Programs Division wi ll survey
institutions and/or take ot her steps to identify a l ternative
practices that reduce the fr equency and duration o f t he p lacement
of i nma t es with menta l illness in res t rictive h ousing , and implement
such alternatives when appropriate .
Recommendation 13:
Provide additional mental health training to
cor rectional staff who are responsible for monitoring the behavi or
of inmates in restrict ive housing.
Response:
The BOP agrees wi th this recommendation, though we n ote
it appears to be based on t he opin i ons of a few staff , instead o f
any adverse event or incident caused by insufficient traini ng.
Cor re ctional staff responsible for monitoring the behavior of
inmates in restricti ve h ousing c urrently receive a substant i al
amount of training, of whi ch OIG may not be awa r e , but we will identify
opportuni ties t o provide additional trai ni ng, includi ng remedia l
tra i ning .
Recommendation 14:
Provide additional guidance and training to
menta l heal th staff on diagnosing mental il lness, including guidance
on documenting ma li ngering behavior by inma te s .
Response:
The BOP agrees with this recommendation . The Psych ology
Services Branch wi ll provide addition al guidance and training to
mental h ea l th staff on diagnosing mental illness, including gu i dance
on docume nting mal ingering behavior by inmates .
Recommendation 15:
Conduct a comprehensive review of U. S .
Penitent i a ry Lewisbu r g ' s Speci al Management Unit that addresses t h e
staffing , treatment , conditions of confinement, and performance
metrics of the prog ram.
4

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Response : Th e BOP agree s with this recommendation.
A
multi - discipline group from various geographic locations is being
assembled to conduct a comprehensive r ev i ew of U.S . Penitentiary
Lewisburg's Special Managemen t Unit that addresses the staffing,
treatment, condit i ons of confinement , and performance metrics of the
program.

If you have any quest i ons regarding t h i s response , p l ease cont act
Steve Mora , Assistant Director , Program Review Division , at
(202) 353-2302 .

5

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APPENDIX 5
OIG ANALYSIS OF THE BOP’S RESPONSE
The OIG provided a draft of this report to the Federal Bureau of Prisons
(BOP). The BOP’s response is included in Appendix 4. The BOP agreed with all of
the OIG’s recommendations. Below, we discuss the OIG’s analysis of the BOP’s
response and actions necessary to close the recommendations.
Recommendation 1: Establish in policy the circumstances that warrant the
placement of inmates in single-cell confinement while maintaining institutional and
inmate safety and security and ensuring appropriate, meaningful human contact
and out-of-cell opportunities to mitigate mental health concerns.
Status: Resolved.
BOP Response: The BOP agreed with this recommendation and will
establish in policy the factors to be considered when placing/retaining mental health
inmates in single-cell confinement.
OIG Analysis: The BOP’s actions are at least partially responsive to our
recommendation. By October 27, 2017, please clarify whether all inmates,
including those with mental illness, will be included in policy, and how it will
maintain institutional and inmate safety and security while ensuring appropriate,
meaningful human contact and out-of-cell opportunities to mitigate mental health
concerns, and provide a copy of the proposed policy language.
Recommendation 2: Define and establish in policy extended placement in
measureable terms.
Status: Resolved.
BOP Response: The BOP agreed with this recommendation and will define
and establish extended placement in measureable terms.
OIG Analysis: The BOP’s actions are responsive to our recommendation.
By October 27, 2017, please provide the BOP’s definition for extended placement in
measurable terms and describe how it will be established in policy.
Recommendation 3: Track all inmates in single-cell confinement and
monitor, as appropriate, the cumulative amount of time that inmates with mental
illness spend in restrictive housing, including single-cell confinement.
Status: Resolved.
BOP Response: The BOP agreed with this recommendation as it pertains
to mental health inmates and will track and monitor inmates with Mental Health
Care Levels (MHCL) 2, 3, and 4.

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OIG Analysis: The BOP’s actions are partially responsive to our
recommendation. By October 27, 2017, please clarify whether the BOP will track all
inmates in single-cell confinement or only those inmates who have previously
needed recurring treatment interventions with mental health staff, as reflected by
MHCLs 2, 3, and 4 or otherwise. Also, please describe how the BOP will track
inmates in single-cell confinement and monitor, as appropriate, the cumulative
amount of time that inmates with MHCLs 2, 3, and 4 spend in restrictive housing,
including single-cell confinement. Further, please detail how the BOP will use this
information in reviewing the placement of all inmates in Restrictive Housing Units
(RHUs), including whether this information will be used as an additional metric that
can trigger an Extended Restrictive Housing Placement Review.
Recommendation 4: Identify all forms of restrictive housing utilized
throughout its institutions and ensure that all local policies are updated to reflect
standards for all inmates in restrictive housing consistent with established
nationwide policies.
Status: Resolved.
BOP Response: The BOP agreed with this recommendation and will review
all forms of restrictive housing and ensure that local or national policies are in place
to direct their operation.
OIG Analysis: The BOP’s actions are responsive to our recommendation.
By October 27, 2017, please provide the OIG with a list of all forms of restrictive
housing, per institution, and describe how the BOP identified these RHUs. Also,
please describe how the BOP will ensure that local or national policies are in place
to direct the operation of all RHUs.
Recommendation 5: Evaluate and limit as appropriate the consecutive
amount of time that inmates with serious mental illness may spend in restrictive
housing.
Status: Resolved.
BOP Response: The BOP agreed with this recommendation and will
establish limits, as appropriate, on consecutive placements in restrictive housing as
it pertains to mental health inmates.
OIG Analysis: The BOP’s actions are responsive to our recommendation.
By October 27, 2017, please provide the OIG with proposed limits for the
placement of inmates with serious mental illness in RHUs and describe how these
limits will be implemented. Also, please describe the circumstances that would
allow the BOP to exceed these limits in the placement of inmates with serious
mental illness in RHUs and how these circumstances will be communicated to
institution staff.

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Recommendation 6: Ensure that the Psychology Services staff documents
inmates’ mental illness diagnoses in the Bureau’s Electronic Medical Record System
and Psychology Data System.
Status: Resolved.
BOP Response: The BOP agreed with this recommendation. The
Psychology Services Branch will ensure that Psychology Services staff document
inmates’ mental illness diagnoses in the Bureau’s Electronic Medical Record System
and Psychology Data System (BEMR-PDS).
OIG Analysis: The BOP’s actions are responsive to our recommendation.
By October 27, 2017, please describe how the BOP will ensure that Psychology
Services staff document inmates’ mental illness diagnoses in BEMR-PDS.
Recommendation 7: Reassess the Mental Health Care Level system to
ensure that it fully captures the mental health needs of inmates, including inmates
in restrictive housing, and that classifications distinguish between inmates who
have some form of mental illness and those who do not have any form of mental
illness.
Status: Resolved.
BOP Response: The BOP agreed with this recommendation. The
Psychology Services Branch will reassess the MHCL system to ensure that it fully
captures the mental health needs of inmates, including inmates in restrictive
housing, and that there is a method to distinguish between inmates who have some
form of mental illness and those who do not have any form of mental illness.
OIG Analysis: The BOP’s actions are responsive to our recommendation.
By October 27, 2017, please describe how the BOP will ensure that the MHCL
system fully captures the mental health needs of inmates and distinguishes inmates
who have some form of mental illness.
Recommendation 8: Regularly monitor, by institution and type of
Restrictive Housing Unit, trends in inmates’ designated Mental Health Care Levels to
further assess the factors that affect the treatment of inmates with mental illness.
Status: Resolved.
BOP Response: The BOP agreed with this recommendation. The
Psychology Services Branch will monitor trends in inmates’ designated MHCLs by
institution and type of RHU. This will be used to further assess the factors that
affect the treatment of inmates with mental illness.
OIG Analysis: The BOP’s actions are responsive to our recommendation.
By October 27, 2017, please describe how the BOP will monitor trends in inmates’

93

MHCLs by institution and type of RHU, and how this information will be used to
further assess the factors that affect the treatment of inmates with mental illness.
Recommendation 9: Determine what additional steps can be taken to
prioritize and incentivize the hiring of mental health staff at institutions that have
inmates with mental illness in long-term restrictive housing.
Status: Resolved.
BOP Response: The BOP agreed with this recommendation. The
Psychology Services Branch and Health Services Division will determine what
additional steps can be taken to prioritize and incentivize the hiring of mental
health staff at institutions that have inmates with mental illness in long-term
restrictive housing.
OIG Analysis: The BOP’s actions are responsive to our recommendation.
By October 27, 2017, please describe the additional steps that the BOP can take to
incentivize the hiring of mental health staff at institutions that have inmates with
mental illness in long-term restrictive housing, including the length of time that the
BOP considers as “long-term restrictive housing” for this purpose.
Recommendation 10: Assess the scalability of secure residential mental
health treatment programs and develop alternatives to address their potential
limitations.
Status: Resolved.
BOP Response: The BOP agreed with this recommendation. The
Psychology Services Branch will assess the scalability of secure residential mental
health treatment programs and develop alternatives to address their potential
limitations.
OIG Analysis: The BOP’s actions are responsive to our recommendation.
By October 27, 2017, please describe how the BOP assessed the scalability of these
programs, the outcomes of the assessment, and the BOP’s plan to address any
limitations that may exist.
Recommendation 11: Develop and implement formal performance metrics
sufficient to measure the effectiveness of secure residential mental health
treatment programs.
Status: Resolved.
BOP Response: The BOP agreed with this recommendation. The
Psychology Services Branch will develop and implement formal performance metrics
sufficient to measure the effectiveness of secure residential mental health
treatment programs.

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OIG Analysis: The BOP’s actions are responsive to our recommendation.
By October 27, 2017, please provide the OIG with formal performance metrics for
the secure residential mental health treatment programs. Also, please describe
how the performance metrics were implemented and how the BOP will apply these
performance metrics in evaluating the effectiveness of these programs.
Recommendation 12: Survey institutions and/or take other steps to
identify alternative practices that reduce the frequency and duration of the
placement of inmates with mental illness in restrictive housing, and implement such
alternatives when appropriate.
Status: Resolved.
BOP Response: The BOP agreed with this recommendation. The
Psychology Services Branch and Correctional Programs Division will survey
institutions and/or take other steps to identify alternative practices that reduce the
frequency and duration of the placement of inmates with mental illness in
restrictive housing, and implement such alternatives when appropriate.
OIG Analysis: The BOP’s actions are responsive to our recommendation.
By October 27, 2017, please provide the OIG with the results of the survey to
institutions and/or describe other steps BOP has taken to identify alternative
practices that reduce the frequency and duration of the placement of inmates with
mental illness in restrictive housing. Additionally, please describe how the BOP
plans to assess, communicate, and implement alternative practices that can be
replicated across its institutions.
Recommendation 13: Provide additional mental health training to
correctional staff who are responsible for monitoring the behavior of inmates in
restrictive housing.
Status: Resolved.
BOP Response: The BOP agreed with this recommendation, noting that it
appears to be based on the opinions of a few staff, instead of any adverse event or
incident caused by insufficient training. Correctional staff responsible for
monitoring the behavior of inmates in restrictive housing currently receive a
substantial amount of training. The BOP believes that the OIG may not be aware of
this training; but the BOP will identify opportunities to provide additional training,
including remedial training.
OIG Analysis: The BOP’s actions are responsive to our recommendation.
By October 27, 2017, please detail all of the BOP’s current training for correctional
staff responsible for monitoring the behavior of inmates in restrictive housing.
Please also describe additional training opportunities for correctional staff who are
responsible for monitoring such inmates, including remedial training, and provide
copies of training materials for these identified opportunities.

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Recommendation 14: Provide additional guidance and training to mental
health staff on diagnosing mental illness, including guidance on documenting
malingering behavior by inmates.
Status: Resolved.
BOP Response: The BOP agreed with this recommendation. The
Psychology Services Branch will provide additional guidance and training to mental
health staff on diagnosing mental illness, including guidance on documenting
malingering behavior by inmates.
OIG Analysis: The BOP’s actions are responsive to our recommendation.
By October 27, 2017, please provide copies of training materials and guidance for
mental health staff in diagnosing mental illness and documenting malingering.
Also, please describe how and when the guidance and training materials will be
delivered to mental health staff.
Recommendation 15: Conduct a comprehensive review of U.S.
Penitentiary Lewisburg’s Special Management Unit that addresses the staffing,
treatment, conditions of confinement, and performance metrics of the program.
Status: Resolved.
BOP Response: The BOP agreed with this recommendation. A multidiscipline group from various geographic locations is being assembled to
comprehensively review U.S. Penitentiary (USP) Lewisburg’s Special Management
Unit (SMU) and address the staffing, treatment, conditions of confinement, and
performance metrics of the program.
OIG Analysis: The BOP’s actions are responsive to our recommendation.
By October, 27, 2017, please provide the OIG with an update regarding the BOP’s
review of USP Lewisburg’s SMU, including a description of the review’s objectives,
scope, and methodology.

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The Department of Justice Office of the Inspector General
(DOJ OIG) is a statutorily created independent entity
whose mission is to detect and deter waste, fraud,
abuse, and misconduct in the Department of Justice, and
to promote economy and efficiency in the Department’s
operations. Information may be reported to the DOJ
OIG’s hotline at www.justice.gov/oig/hotline or
(800) 869-4499.

Office of the Inspector General
U.S. Department of Justice
www.justice.gov/oig