U.S. Department of Justice 

Office of the Inspector General 

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 

1 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. 

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. 

2 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. 

ii 
 

 

 

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. 

3 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. 

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. 

5 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). 

6 BOP Program Statement 5310.16, Treatment and Care of Inmates with Mental Illness 

(May 1, 2014), 16. 

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. 

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

provides guidance and procedures for operation of the SMU. 

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. 

11 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. 

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. 

13 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. 

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
 

Inmates Designated at 

All MHCLs FY 2010 May 2015 Percent Change 

(+/-) 

MHCL 1 147,907 150,884 2.01% 

MHCL 2 5,701 3,971 -30.35% 

MHCL 3 578 551 -4.67% 

MHCL 4 574 246 -57.14% 

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 

23 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). 

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. 

26 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). 

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. 

29 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. 

30 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. 

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. 

37 U.S. Penitentiary, Administrative Maximum, Institution Supplement FLM 5310.16A, 

Treatment and Care of Inmates with Mental Illness (July 22, 2015). 

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 

39 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). 

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. 

44 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. 

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 

46 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). 

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). 

48 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. 

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. 

51 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). 

52 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. 

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. 

54 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. 

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 

59 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. 

60 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_5-

31-13.pdf (accessed June 27, 2017). 

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.) 

62 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_2-

24-14.pdf (accessed June 27, 2017). 

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. 

63 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. 

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. 

66 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. 

67 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. 

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 

68 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). 

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. 

74 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. 

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. 

81 We found that each state department of corrections has a different definition of serious 

mental illness and a different inmate mental health classification system. 

82 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. 

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. 

84 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. 

85 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. 

86 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. 

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 

OIG Analysis 

ADX Inmates with 

Mental Illness 

Total No. of ADX Inmates 415 59 

Average No. of Days at the ADX 1,376 1,906 

Median No. of Days at the ADX 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. 

88 Center of Naval Analysis and Solutions (CNA), Federal Bureau of Prisons: Special Housing 

Review and Assessment (December 2014). 

89 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. 

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 

51

81

24

68

39

0 20 40 60 80 100

0 ‐ 18 months

18 ‐ 24 months

24 ‐ 30 months

30 ‐ 48 months

48 ‐ 78 months

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.) 

93 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. 

94 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. 

31
 
 

 

 

 

 

 

 

 

Table 3 

Average Lengths of Stay for Inmates in the SMU 

BOP Statistics 

All SMU Inmates 

OIG Analysis 

SMU Inmates with 

Mental Illness 

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. 

97 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. 

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. 

98 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. 

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. 

100 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). 

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 

6,329

916

251

1,651

331

146

0 1,000 2,000 3,000 4,000 5,000 6,000 7,000

 SHU 

SMU 

ADX 

Inmates with a History of Mental Illness Inmates 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. 

102 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. 

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. 

107 American Psychiatric Association, Diagnostic and Statistical Manual for Mental Disorders, 

5th ed. (Arlington, Va.: American Psychiatric Association, 2013). 

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. 

115 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. 

38
 
 

 

       

Figure 3 

Number of MHCL 2–4 Inmates, September 2010 – May 2015
 

7,000

6,000

5,000
 

3,971
 

4,000
 

3,000

2,000

1,000 578 551

5,701

6,170

5,821 5,898

5,252

531 561

574

423

320 299

463

283 302 246 0

FY 2010 FY 2011 FY 2012 FY 2013 April 26, 2014 May 30, 2015

MHCL 2 MHCL 3 MHCL 4

Source: OIG analysis of BOP data 

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 

116 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. 

117 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. 

39
 
 

 

 

         

       

         

       

     

     

Table 4 

MHCL Changes for Sample RHU Inmates, October 2009 – August 29, 2015
 

BOP Policies 

No. of Inmates 

with Increased 

MHCL 

No. of Inmates 

with Decreased 

MHCL 

No. of Inmates 

with the Same 

MHCL 

Former Mental Health 

Treatment Policies 

(October 2009 – April 30, 2014) 

178 85 425 

New Mental Health Treatment 

Policy 

(May 1, 2014 – August 2015)

 45 110 533 

Percent Change (+/-) -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 

0

20

40

60

80

100

120

140

160

180

200

Former Mental Health Treatment Policies

(October 2009 – April 30, 2014)

New Mental Health Treatment Policy

(May 1, 2014 – August 2015)

No. of Inmates with

Increased MHCL

No. of Inmates with

Decreased MHCL

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 

118 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. 

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 

before the new policy, mental at MHCLs 2–4 

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, 

serious mental illness; but, as of May 2015, the number of ADX inmates designated at 

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 

requirements for inmates who Psychology Technician for the ADX while also adding one 

may not clinically need that Deputy Chief Psychologist to help manage mental health 

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 

with whom we spoke the BOP’s new mental health residential treatment 

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 

increased staffing at the ADX may have contributed to the increase in the MHCLs of 

may have contributed to the inmates at the ADX. 

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). 

124 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. 

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 

127 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. 

128 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. 

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 MHCL Decreases 

Ratio of MHCL 

Increases to 

Decreases 

Former Mental Health 

Treatment Policies 

(October 2009 – April 30, 2014) 

16 16 1:1 

New Mental Health Treatment 

Policy 

(May 1, 2014 – August 2015) 

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 

130 DOJ OIG, Review of the Federal Bureau of Prisons’ Medical Staffing Challenges, Evaluation 

and Inspections Report 16-02 (March 2016). 

131 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. 

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. 

136 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. 

137 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. 

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. 

139 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. 

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. 

143 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. 

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 

149 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.

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

each phase.

 151 During our visit to USP Allenwood, Step Down was not yet fully activated. As of November 

2016, USP Allenwood’s program had 30 inmates. 

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. 

152 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. 

153 DOJ, FY 2016 Performance Budget Congressional Submission, 36. 

154 We did not evaluate the effectiveness of the Mental Health Step Down and STAGES 

Programs as part of this review. 

155 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. 

53
 
 

 

 

 

 

 

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 

156 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. 

157 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) 

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. 

158 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. 

159 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). 

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. 

161 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. 

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 

150 Consecutive Days 

1,862 1,871 2,072 1,197 780 -58.11 % 

Average No. of Days in 

a SHU 296 280 291 285 268 -9.46 % 

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 

165 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. 

166 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. 

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 

171 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. 

172 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. 

58
 
 

 

 

 

 

 

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. 

174 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. 

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. 

179 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) 

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). 

180 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. 

61
 
 

 

 

 

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. 

62
 
 

 

 

 

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 

63
 
 

 

 

 

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. 

64
 
 

 

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: 

65
 
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. 

66
 
 

 

 

 

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 

BOP Mental Health Illness 

Inmates MHCL 

1 2 3 

A 1 

B 2 

Bipolar I Disorder – 

Most Recent Episode 

Depressed 

C 4 Antisocial Personality 

Disorder 

Psychotic Disorder Not 

Otherwise Specified 

Personality Disorder Not 

Otherwise Specified 

D 2 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. 

67
 
 

 

 

 

 

 

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 

183 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. 

184 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. 

185 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. 

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. 

68
 
 

 

 

 

 

 

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. 

186 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. 

69
 
 

 

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 

71
 
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. 

72
 
 

 

 

 

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). 

74
 
 

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 

Inmate 

Designations 

Former Mental Health Treatment 

Policies 

(FY 2010 – April 30, 2014) 

New Mental Health Treatment 

Policy 

(May 1, 2014 – Present) 

MHCL 1 No required recurring mental health 

services after the intake screening 

No required recurring mental health 

services after the intake screening 

Treatment interventions at least 

once every 3 months after the 

intake screening 

Treatment interventions at least 

once per month after the intake 

screening 

MHCL 2 CCARE meetings not established 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 

MHCL 3 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) 

New Mental Health Treatment 

Policy 

(May 1, 2014 – Present) 

No detailed timeliness standards 

for treatment interventions 

Treatment interventions at least 

once per week after the intake 

screening 

MHCL 4 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 

194 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. 

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. 

79
 
 

 

 

 

 

 

 

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). 

83
 
 

 

 

 

 APPENDIX 3 

BOP RESIDENTIAL MENTAL HEALTH TREATMENT PROGRAMS 

Table 10

Mental Health Step Down Program 

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 

84
 
Table 11 

Steps Toward Awareness, Growth, and Emotional 

Strength (STAGES) Program 

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 

86
 

u.s. Department of Justice 

Federal Bureau or Prisons 

OfJin ' oflfl" Dirty /o r Washingt(lll, DC 20534 

J une 23, 2 01 7 

MEMORANDUM FOR NINA S . PELLETIER 

ASS I STANT INSPECTOR GENERAL 

OFF I CE OF INSPECTOR GENERAL 

EVALUATION AND INSPECTIONS DIVIS I ON 

FROM: Thomas R. Kane , Act ing Direct o r 

SUBJECT: Response to the Office of I nspect o r General ' s (OIG) 

FORMAL DRAFT Report : OIG Review of the 

Federa l Bureau of Prisons' Use of Restri c t i ve 

Housing f o r Inmates with Mental Illness, Assignment 

Number A- 2015-0 04 

The Burea u of Prisons (BO P) a ppreciates the oppo r t unity to r espond 

to the open recommenda tions from t he draft report entitled OIG Review 

of the Federal Bureau of Prisons' Use of Restrictive Housing for 

Inma tes with Me nt al Illness. 

Pleas e find the Bu r eau 's r esponse to the r ecommendations below : 

Recommendations 

Recommendation 1: Establish in policy the circumst ances that 

warrant the placement of inmates in single - ce ll confinement whi le 

maintaining inst i tutional and inmate sa fety and security and 

ensuring a ppropriate meaningful human contact and out- of- cell 

op portuni t ies. 

Response: The BOP agree s with thi s recommendation and will 

establish in policy factors to be considered when placing/retaining 

mental healt h inmates in single- cell confinemen t . 
Reconunendation 2 : Define and establish in policy extended placement 

in measureable terms . 

Response: The BOP agrees with this recomme ndation and will define 

and establish extended p lacement in measureable terms . 

Reconunendation 3: Track all inmates in single-cell confinement and 

monitor , as appropriate , the cumu lative amount of time that inmates 

with menta l i llness spend in restr i ctive housing , i ncluding 

single-cell confi nement . 

Response: The BOP agrees with this recommendation as it pertains 

to mental health inmates, and we will track and mon i tor inmates with 

mental health care levels 2 , 3, and 4. 

Reconunendation 4: Identify all fo rms of re strictive housing 

util ized throughou t its institut ions and ensure that all loca l 

policies are updated to reflect standards for all inmates in 

restri ctive h ousi ng consistent with established nation- wide 

policies . 

Response: Th e BOP agrees with this recomme ndation and will review 

all forms of restrictive housing , a nd ensure local , or national , 

policies are in place to direct their operation. 

Reconunendation 5: Evaluate and limit as appropriate the consecutive 

amount of time that inmates with serious mental illness may spend 

i n restrictive housing . 

Response: The BOP agrees with this recommendation and wi l l 

establish limits, as appropriate , on consec utive placements in 

restrictive housing as i t pertains to mental hea l th inmates . 

Reconunendation 6: Ensure that t he Psychology Services staff 

documents i nmates' mental ill ness diagnoses in the Bu reau ' s 

Electronic Med i cal Reco r d System and Psychology Data System. 

Response: The BOP agrees with this recommendation . The Psychology 

Servi ces Branch will ensure Psychology Services staff document 

inmates' mental illness diagnoses in the Bureau ' s Electronic Medical 

Record and Psychol ogy Data System. 

Reconunendation 7 : Reassess the Mental Health Care Leve l system to 

ensure that it fully captures the mental health needs of inmates , 

including i nmates i n restrictive housing , and that classifications 

2 

87
 
distinguish between inmates who have some f o rm of mental illness and 

thos e who do n ot have any form of mental illness. 

Response: The BOP agrees with this recomme ndation . The Psychology 

Services Branch wi ll reassess the Mental Hea lth Care Leve l system 

to ensur e that it fully capture s the menta l health needs of inmates , 

inc luding inmates i n restrictive housing , and t h at there is a method 

to distinguish between inmat es who have some form of mental i llness 

and those who do not have any fo rm of menta l ill ness. 

Recommendation 8: Regularly monitor, by institution and type of 

Restrictive Housing Unit , trends in inmates' designated Mental 

Health Care Leve l s to furthe r asse ss the f actors that affect the 

treatment of inma t es with mental illness . 

Response: Th e BOP agrees wit h this recommendati o n. Th e Psychology 

Servi ces Branch will mon itor trends in i nmates' designated ment al 

hea lth care level s by institution and type of restrictive housing 

unit. This will be used to further assess the factors that affect 

the treatment of inma tes with ment al i llness . 

Recommendation 9: Determine what additional steps can be ta ken to 

prioriti ze a nd i n centivize the hiring of ment al h ealth staff at 

i nstitutio ns that have i nmates with mental illness in long- term 

restrictive housing . 

Response: The BOP agrees with this recommendat i on . The Psycho logy 

Services Branch a nd Hea lth Services Divi s i on will determi ne wh at 

additional steps ca n be taken t o prioritize and i n cent i vize the 

hiring of mental h ealth staff at i nstituti ons tha t have i nmates with 

mental illness i n long-term restrictive housing . 

Recommendation 10: Assess the scalability of secure residential 

mental hea lth treatment p r ograms and develop alternatives to address 

t h e ir potential limitat ions . 

Response: The BOP agrees with this recommendation . The Psycho l ogy 

Services Branch will assess the scalability of secure residential 

menta l health treatment programs and develop alternatives to address 

the ir potential limitations. 

Recommendation 11: Develop and impl ement f orma l performance 

metrics s u ffici ent t o measure the eff ectiveness of secure 

r esidential mental hea lth treatment programs . 

3 

88
 
Response: The BOP agrees with this recommendation . The Psychology 

Services Branch wil l develop and impl ement f orma l performance 

metrics sufficient to measure the effectiveness of secure 

residential ment a l hea l th treatment programs. 

Recommendation 12: Survey insti tutions and/or take other steps to 

identify alternative pract ices that reduce the frequency and 

duration of the placement o f inmates with mental ill ness in 

restrictive housing , and imp l ement such alternatives when 

appr opriate . 

Response: The BOP agrees with t h is recommendati o n . The Psychology 

Services Branch and Correctional Programs Di vision will survey 

insti tutions and/or take other steps to identify a l ternat ive 

practices t h at reduce the freque ncy and duration of the placement 

of i nma t es with menta l illness in restricti ve housing , and impl ement 

s uch a l ternat ives when appropri ate . 

Recommendation 13 : Provide addi tional menta l health training to 

correcti onal staff who are responsible for monitoring the behavi or 

of inma t es in restrictive housing . 

Response: The BOP agrees with this r ecommendation , though we not e 

it appears to be based on the op inions of a few staff, instead of 

any adverse event or i nc i dent caused by insufficient training . 

Corr ectiona l staff responsib l e f or monitoring the behavior of 

inmates in r estricti ve housing currentl y receive a subst antial 

amount of training , of which OIG may not be awa r e , but we will identify 

opportuni ties t o provide additional training , incl uding remedial 

tra i ning. 

Recommendation 14: Provide additional guidance and training to 

menta l hea l th staff on d i agnosing mental i l lness, including gui dance 

on documenting malingeri ng behav ior by inmates. 

Response: Th e BOP agrees with this recommendation . The Psychology 

Services Branch will provide additional guidance and trai ning to 

ment al hea lth staff on diagn osing mental illness, including guidance 

on document i ng malingering behavior by inmates . 

Recommendation 15: Conduct a comprehensive revi ew of u . S . 

Pe n itent iary Lewisburg' s Speci al Management Unit that addresses the 

staffing , treatment , conditions of confinement , and performance 

metri cs of the progr am. 

4 

89
 
90
 
 

 

 

 

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. 

91
 
 

 

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. 

92
 
 

 

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. 

94
 
 

 

 

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. 

95
 
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. 

96
 
 APPENDIX 5 

97 

   

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