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Twice imprisoned : loss of hearing, loss of power in federal prisoners in British Columbia 1995

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TWICE IMPRISONED: LOSS OF HEARING, LOSS OF POWER IN FEDERAL PRISONERS IN BRITISH COLUMBIA By Marilyn Dahl B.Sc.N., The University of British Columbia, 1979 M.A., Simon Fraser University, 1988 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE STUDIES Interdisciplinary Graduate Studies We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA April, 1995 Marilyn Dahl © Marilyn Olive Dahl, 1995 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. (Signature) / , - Department of Interdisciplinary Graduate Studies The University of British Columbia Vancouver, Canada Date ^ / t ^ A ^ / ? ? & DE-6 (2/88) ABSTRACT Problems experienced by individuals in institutions tend to be hidden from the public gaze. This is so for inmates of prisons where regulations and bureaucratic structure conceal the daily life situation of prisoners from public view. Anonymity and concealment are enhanced by the widespread misperception of prisoners as an homogenous group. As a result, problems of vulnerable groups, such as people with disabilities, can be ignored. One such group is prisoners with impaired hearing. This descriptive study utilized a multidisciplinary approach to investigate the problems experienced by prisoners within the context of social control. Drawing from selected literature in health, sociology and criminology, the theoretical framework merges the labelling perspective [interactionism] with macro-level theories of social control. The study provides, for the first time, an examination of the percentage, degree and social import of hearing loss in federal prisoners in the Pacific Region of the Correctional Service of Canada. Through the use of survey, audiometric measurement, and interview techniques, an examination was undertaken of the presence and implications of partial hearing loss in inmates of federal penitentiaries in British Columbia. Interview subjects were identified through hearing testing of volunteers in eight federal penitentiaries. Data were gathered through interviews with ii prisoners with impaired hearing, a comparison group of prisoners with normal hearing, and a selection of custodians. Of 114 prisoners screened, 69% had some degree of impaired hearing, often previously unidentified. Custodians, 86% of the time, labelled behaviours characteristic of the hard of hearing as deviant, and often aggressive, behaviours. Prisoner accounts revealed that failure to test hearing at time of incarceration has harmful effects on performance in programmes and encounters with the justice system. A social activist approach is recommended, to address structural inequalities among prisoners and barriers for prisoners in general. This work indicates that lower-class, lower-status persons may be more susceptible to negative labelling. Prisoners with partial hearing loss, due to the often invisible nature of their condition, are particularly vulnerable to negative labelling. Study recommendations include: 1] Routine hearing screening of all prisoners at time of incarceration. 2] Education of custodians to understand behaviours and communication needs of persons with impaired hearing. 3] A partnership effort between correctional services, the disabled consumer group, and professionals, to improve the situation of prisoners who are hard of hearing. ii TABLE OF CONTENTS ABSTRACT ii TABLE OF CONTENTS iv LIST OF TABLES \% LIST OF FIGURES X ACKNOWLEDGEMENTS xi CHAPTER ONE MAKING VISIBLE: HEARING IMPAIRMENT AND SOCIAL CONTROL 1 Introduction 1 Approach to the study 4 Social perspectives on the management of deviance 7 The biomedical perspective on the management of deviance 12 Summary of conceptual foundation 14 Hearing impairment: Significance of partial hearing loss in adults 16 The problem of partial hearing loss in prisons 18 Purpose of the study 20 Research questions 21 Outline of thesis 22 CHAPTER TWO HEARING IMPAIRMENT AND DEVIANCE: A REVIEW OF THE LITERATURE . 24 Introduction 24 Prevalence of hearing impairment 24 Definition and categories of hearing loss 25 Characteristics of hearing impairment 28 The hard of hearing and late deafened as a social group 31 Studies of hearing impairment 32 Hearing impairment as social deviance 40 Hearing impairment as medical deviance 45 Social and medical perspectives on deviance 49 a. Social perception, labeling and deviant behaviour 49 b. Social control and oppression 54 iv Critiques of the biomedical perspective on deviance 62 Perspectives on the experience of institutionalization 64 Summary of the literature review 66 CHAPTER THREE ASSESSING HEARING IMPAIRMENT IN PRISONERS: METHODOLOGY . . . . 68 Introduction: The study hypotheses 68 Study design 69 Methodology 71 a. Establishing the presence of impaired hearing 73 b. Establishing the meaning of context-bound behaviour . . . . 73 c. Research instruments 74 d. Funding for the study 75 e. Preparation and pre-testing of research instruments 76 f. Determination of study population 79 g. Self-definition of hearing impairment 83 h. Hearing screening 84 i. Hearing assessment 85 j . Identification of perceptions of hard of hearing behaviour.. 86 k. Interviews with custodians 87 I. Interviews with prisoners 90 m. Interviews with a comparison group of prisoners 90 n. Design for data analysis 91 o. Documentary examinations 92 Limitations of the study 92 Response rate 102 Additional comments on methodology 104 Summary 109 CHAPTER FOUR THE EXPERIENCE OF IMPAIRED HEARING IN PRISONS: PRISONER AND CUSTODIAN REPORTS 111 Introduction 111 Demographic characteristics of the study population 112 Labeling and prison relationships 116 Self-report of hearing problem 118 Substance use 123 Factors predisposing to hearing impairment 125 Summary: A composite prisoner profile 127 Prevalence of hearing impairment 127 v Audiological assessment of hearing impairment 128 Identification of hearing impairment in federal prisons 131 Custodial awareness of hard of hearing behavioural attributes 133 a. Excerpts from interviews with custodians 134 b. Prisoner concerns about custodial unawareness of hard of hearing behaviour 142 Custodians' perceptions of characteristic behaviours 143 a. Prisoner perceptions of mislabeling by custodians 147 The experience of prisoners with impaired hearing 152 a. Excerpts from interviews with prisoners 154 Comparison between perceptions of prisoners and custodians . . . 161 Comparison group of prisoners with normal hearing 162 Unexpected findings 164 Summary 167 CHAPTER FIVE PRISONERS WITH IMPAIRED HEARING: COMPLEXITIES AND CONTROL . 168 Introduction 168 Percentage of prisoners with impaired hearing 169 Identifying hearing impairment in prisoners 172 Lack of awareness of hard of hearing behavioural attributes 176 Mislabeling of prisoners with impaired hearing 184 Comparative interpretations of hard of hearing behaviours 188 Conclusion 190 CHAPTER SIX REASONABLE ACCOMMODATION FOR PRISONERS WITH IMPAIRED HEARING: CONCLUSION AND RECOMMENDATIONS 198 Introduction 198 Summary of study 199 Implications 204 Recommendations 205 Suggestions for future studies 211 Conclusions 214 GLOSSARY 216 BIBLIOGRAPHY 223 APPENDIX A Questionnaire and covering letter 245 VI APPENDIX B Form for hearing screening 250 APPENDIX C-1 Form for hearing testing, audiogram 251 APPENDIX C-2 Form for hearing testing, middle ear 252 APPENDIX D Interviews with prisoners who are hard of hearing 253 APPENDIX E Interviews with inmate comparison group who passed hearing test 254 APPENDIX F Interviews with custodians 255 APPENDIX G Initial invitation to prisoners to participate in the study, and consent form 257 APPENDIX H Information letter to staff and invitation to participate in the study 259 APPENDIX I Information letter to inmate committees and the native brotherhood 261 APPENDIX J -1 Information letter to inmates, about consumer interest in study 262 APPENDIX J - 2 Information letter to staff, about consumer interest in the study 263 APPENDIX K Prisoner consent form for documentary review 264 APPENDIX L SUPPLEMENTARY TABLES 265 Table L-1. Responses to Questionnaire: Characteristics of Self-Reported Hearing Problems. n=189 265 Table L-2. Cerumen. n=87 273 Table L-3. Tympanometry. n=87 273 Table L-4. Acoustic reflex. n=87 273 vii Table L-5. Custodians' perception of troublesome behaviour by inmates. Custodians' own words, categorized 274 Table L-6. Naming of behavioural characteristics by classification of officials. n=1365 275 Table L-7. Interview with inmate comparison group who passed hearing test. n=39 283 Table L-8. Comparison between custodial and inmate perception of behavioural characteristics 286 VIII LIST OF TABLES Table 1. Yantes' categories of hearing loss 25 Table 2. Models of physician/patient interaction 51 Table 3. Characteristic behaviours of adults with impaired hearing 78 Table 4. Typical prisoner population, institutions of the Pacific Region of the Correctional Services of Canada 80 Table 5. Prisoner volunteers for study 81 Table 6. Study sample. n=189 82 Table 7. Specific labels given to prisoners with impaired hearing, categorized. n=195 117 Table 8. Self-description of hearing problem. n=110 121 Table 9. Subjects' stated beliefs about cause of hearing impairment. n=110 122 Table 10. Prisoners' experience with identification of impaired hearing. n=42 133 Table 11. Custodian identification of hard of hearing behaviour in prisoners 146 Table 12. Areas of hindrance resulting from hearing impairment. n=42 . . . 153 Table 13. Interview results, normal hearing prisoners; a summary. n=39. . 163 IX LIST OF FIGURES Figure 1. Study design 70 Figure 2. Prison population [n=1808] and study population [n=189] by security levels. July, 1992 113 Figure 3. Reason for incarceration. n=189 115 Figure 4. Self-attribution of cause for offense. n=189 115 Figure 5. Type of hearing problem by self report. n=110 119 Figure 6. Hearing loss in family. n=72 120 Figure 7. Frequency of narcotic use. n=96 124 Figure 8. Factors predisposing to hearing impairment. n=501 126 Figure 9. Hearing test results. Screened n=144. Tested n=92 128 Figure 10. Extent of hearing loss. n=184 ears 130 Figure 11. Custodian identification of troublesome prisoner behaviours n=94 144 Figure 12. Custodian naming of behavioural characteristics. n=1365 146 x ACKNOWLEDGEMENTS Thank you to the members of my thesis committee, who provided support, guidance, and an insistence on excellence. The committee included Dr. Godwin Eni and Dr. Charles Laszlo, who served as Chairpersons at different stages, Dr. Janet Jamieson, all of University of British Columbia, and Dr. Brian Burtch of Simon Fraser University. Each provided a unique perspective and expertise which was much appreciated. The contributions of the university examiners, Dr. Robert Ratner and Dr. Carol Jillings, and the external examiners, Dr. Raymond Hetu of University of Montreal and Dr. Neata Kay Israelite of York University are respectfully and gratefully acknowledged. Grateful thanks to those individuals and agencies who facilitated the study. Suzanne Thorn, audiologist from Vancouver General Hospital conducted the hearing assessments. Margaret Roberts, audiologist, of the Hearing Conservation Department, Workers' Compensation Board of British Columbia loaned equipment for immittance testing, and provided professional advice and information. Laura Wang, Vancouver Audiology Clinic, arranged the loan of an audiometric screening device. John Neudorf, 'The Ear Man," entrusted me with the rental of his audiometric van. Sharon Hickey of The Correctional Service of Canada, Pacific Region, ensured and coordinated access to the prisons. Additional thanks go to the Canadian Hard of Hearing Association for encouragement to undertake the study. Elks Lodge #1 of Vancouver and the Canadian Federation of University Women deserve special acknowledgement and thanks for partially funding the study. Very special thanks to the prisoners and staff of the penitentiaries who were generous with their time and experience and accommodating of the study needs. A warm note of recognition and appreciation is extended to those ex-offenders in the Pilot Study, who told me their stories, to encourage and support the study. Dr. Perry Leslie and Dr. Sally Thorne, of the University of British Columbia read the thesis in its final phase, with a fresh perspective, and provided valuable criticism for which I am most grateful. Acknowledged also is the contribution of my personal enthusiasm and enjoyment in undertaking a pioneering study, for the discovery of information, and the process of producing a thesis. That enthusiasm owes its sustenance to the constancy and loving support of family and friends, who are most heartily thanked. xi CHAPTER ONE MAKING VISIBLE: HEARING IMPAIRMENT AND SOCIAL CONTROL "We will not realize our dream of increased and improved communication access by depending upon technological developments or the passage of new laws and regulation - necessary as these may be, they are insufficient. The essential ingredient is attitude, the attitude of society toward hearing loss. By our example, we can help society, including those individuals with unacknowledged hearing losses, to understand that a hearing loss, while not exactly a desirable condition, is simply a fact of life, and not a mark of shame to be hidden and denied. Only then can the condition be dealt with rationally and effectively. And only then will we realize communication access, in its most comprehensive connotation" [Ross 1993a:31]. Introduction With the concept of the gaze of power, Foucault [1980] provided social science with an original posture concerning the manner in which power is to be conceptualized. Use of the gaze of power involves the making visible of a person or population. This gaze is a technique of power, that is, it utilizes technical or scientific skills, through which the object of the gaze becomes known to the observer. The result is a systematized knowledge, coded and standardized, which is utilized by the observer as a resource to develop both knowledge and control over those so observed. Foucault stressed the negative implications of the knowledge/power interface. He suggested that medicine, along with penology and law, psychiatry, education and social work, used their domain of expertise as a way of disciplining the bodies of those who were the subjects of these experts [Foucault 1976, 1979, 1980, 1984, Fox 1994]. 1 The gaze, however, can have positive aspects when it involves making visible and bringing to public scrutiny the negative fate of those who are invisible, vulnerable and ignored. For example, since the implementation of the World Programme of Action Concerning Disabled Persons [United Nations 1983] people with disabilities, through group action, have been increasingly empowered to turn the gaze of the public on conditions which disempower them, and create barriers to their equal participation in society [Derksen 1980, Dluhy 1981]. They describe the problems which they experience as socially constructed problems, in both public and institutional settings. One such institutional setting is the prison, where people with disabilities have special problems. In this context, discussion has centred mainly on those whose disability is visible. For example, Baum [1984] and Motiuk [1994] refer mainly to prisoners with mobility handicaps. Hardin [1993] focussed on those with identified mental illness. Vlug [1992] addressed the problem of the profoundly deaf. This study draws attention to the plight of prisoners with an invisible disability, specifically, prisoners who are hard of hearing; i.e. have a partial hearing loss. Hearing loss is generally regarded as a form of deviation from the norm, yet only recently have researchers begun to investigate the relationship between the behaviours which result from being hard of hearing and the perceptions and labels which others report of such behaviours. This situation holds true for prisoners. The presence of hearing loss in prisoners has been investigated to some extent in the United States. Studies between 1970-1983 [ASHA 1973, Belenchia and Crowe 1983, 2 Blom 1967, Bountress 1979, Hamre 1973, Marsh 1983] indicate that about 40% of prison inmates suffer some kind of hearing disorder [Glossary], compared with only 7% in the general population. This latter number represents all ages, including the elderly wherein incidence rate increases markedly with age, whereas the prisoner population surveyed had an average age of 25. No similar studies have been reported in Canada. Since there appears to be such a high percentage of hearing disorders in the prisoner population, and since such disorders have often been previously undiagnosed, some researchers suspect that hearing disorders may contribute to criminal behaviour [Belenchia and Crowe 1983]. No single factor will explain criminal activity, but it may be a contributing factor. It has been shown that the behaviours associated with a hearing impairment deviate from behavioural norms in society in important ways [Ashley 1973, 1985, Jones, Kyle and Wood 1980, Levine 1960, Oyer 1974, 1985]. Intrinsic to deviance labelling is the issue of assigning labels to behaviours that are deemed not to be consistent with "normal" behaviour. It has also been shown that where a person is diagnosed as having a hearing impairment, the treatment is often focussed towards improving the hearing ability, to the neglect of the emotional, psychological, and social consequences of impaired communication [Health and Welfare Canada 1988]. In other words, the effect of impaired hearing on a person's behaviour may lead to the assigning of a label of deviance by persons in positions of authority. For example, a command by a prison guard may not be heard by a prisoner, who would 3 consequently be labelled as "resistive" or "uncooperative." The guard's misperception of the meaning of behaviour could be more likely to occur where the prisoner has a partial hearing loss and has been generally perceived as "normal" in everyday living. It is the category of partial hearing loss that may be difficult to identify and lead to mislabelling, in society at large and in institutional settings in particular. This study examines the issues associated with social control and partial hearing loss in the eight federal prisons in British Columbia. In particular, it examines the relationship between perceptions of prisoner behaviour by custodians, and the labels which result, as well as related implications. Approach to the study More than a quarter century ago, C. Wright Mills [1959:3-24] identified the relationship between "personal troubles" and "social issues." Mills noted that the troubles an individual experiences occur within the context of broader social problems, and are almost always interconnected with social structures. Thus, the lack of interest by officials who gave permission for this study on hearing impairment in prisoners, but would not fund it because it did not fit their priority objectives [a correctional policy decision], fitted in well with the neglect of the social implications of hearing impairment in current research and health policy development. For example, although hearing impairment is one of the most prevalent and chronic 4 disabilities in Canada [Statistics Canada 1992] in the 1987-1988 funding year, only 0.3 percent of Medical Research Council grants went to hearing-related research [Eni 1992]. Green and Kreuter [1991] note the cause-effect reciprocal relationship between health and social conditions. They highlight the importance of involving people in a community or organization in defining perceptions of individual experience and need. They suggest that participation by those concerned or affected by formation of policy will result in a heightened awareness of the need for health promotion. Thus, health policy and associated program development can be better formulated with the participation of the persons involved in the various aspects of the issue, including clients and policy makers. It follows that hearing impairment among prisoners should be investigated within the framework of macrolevel theories of social control, as well as within the context of individual experience. The theoretical framework, therefore, merges the interactional aspects of the labelling perspective with a more political macro-perspective of social control. As an exploratory study, the thesis identifies ways in which there is a fit between problems occurring at the interpersonal level, and the mechanisms of social control in correctional structures. At issue is the neglect of identification of impaired hearing in prisoners. This neglect appears to be coupled with an apparent 5 indifference, by some authorities, to the significance of not being able to hear adequately in interactions within the correctional system, whether at the interpersonal level of daily living, within programs, or before judicial bodies. At issue also is the potential for custodial misperception and mislabelling of the behaviour of a prisoner who has not heard well, in particular when the hearing loss had not been identified. Thus there is a need to identify prisoners who have impaired hearing, including those who were unaware of that fact, and to explore their individual experience. There is a need to identify the perceptions which custodians hold of behaviours particular to the hard of hearing condition, in the context of their work experience. Identification of these elements then can lead to analysis, in the light of current theory, of why this neglect exists, and how social structures, health and correctional policies contribute to the problem. The issues relate to the domains of health, sociology and criminology, each of which has a unique perspective. Because all of these domains are important to the problem, an interdisciplinary approach was selected for the study. Different patterns emerge from different ways of looking at things. Thus, the strength associated with interdisciplinary research is the synthesis of thought leading to the emergence of a fresh perspective on the issue. In this study, the result is a social activist approach [Harries-Jones, 1991], that is, research findings are analyzed and conclusions considered within the context of empowerment [advocacy] usage for a 6 client or class of clients such as a disability group. The study, therefore, identifies the presence and sociological implications of partial hearing loss in prisoners, and produces recommendations for policy change in correctional institutions. Prisoner experiences were examined through self-report survey, audiological assessments, and individual interviews. Interviews with custodians explored the meaning of prisoner behaviours, from an official perspective. Interviews with prisoners with normal hearing provided an additional perspective on the experience of prisoners with impaired hearing, and documentary review contributed to validation of the data. Social perspectives on the management of deviance All societies generally exercise some form of social control in reaction to a label of deviance [Becker 1973, Gomme 1993, Little 1989 ]. Such controls take the form of, and flow from, negative formal or informal responses to deviant behaviour. For example, informal responses may include gossip, derogatory comment, and social ostracism, and may relate to behaviour as diverse as divorce and drunkenness. Official responses may include warnings and punishments [Gomme 1993] for actions as varied as a traffic infraction, theft, assault, or violations of rules of behaviour in an institution. Social control may function in a preventive manner. For example, rules of conduct, both formal and informal, for institutionalized individuals and staff are 7 intended to establish order or to prevent confusion or chaos. Institutional rules that prisoners line up for meals, rise and retire at certain times, and obey security regulations, function both as preventive measures by decreasing the likelihood for adverse incidents to happen, and as negative responses to rule-breaking behaviour. Often couched in lofty terms such as "discipline" and "punishment," these rules are embedded within a wider context of power [Foucault 1979,1980]. Thus, the broadcast of rules or orders via a public address system in a prison [a preventive restraint] is likely to result in a rule violation by a person who has impaired hearing and who may not hear all of the announced rules, thereby risking a punitive response. It is the social perception of behaviour which induces deviance definition and social control actions. Social perception refers to the factors affecting the way we see others [Hastorf, Schneider and Polefka 1970]. Perception is a reflexive, integrated whole, involving the perceiver, the act of perceiving and the content of what is perceived. For example, we look at an individual, and observe and code appearance and behaviour [body language, speech, reactions to environment]. Additionally, the observable characteristics of the individual lead us to infer various traits such as friendliness, trustworthiness, vigour, hostility. This, however, does not imply that our assumptions of others are correct. Our perception of others, our coding of their behaviour, is based upon our own life experience and the ways in which we attach meaning to what we perceive [Manning 1989]. That meaning may imply the notion of deviance. 8 Deviant behaviour refers to behaviour which has been so labelled. It is generally viewed as differing from accepted behaviours which are considered to be norms within a particular social setting, and which breach those social norms [Becker 1964, 1973]. Behaviour is defined as deviant because some individual, group, or society takes offense and reacts negatively [Gomme 1993]. The societal response to deviance has usually been by some manner of social control, although the control chosen will relate to whether the deviant act is criminal or non-criminal. For example, people who are perceived to have broken the law may be arrested by the police, charged, tried in the courts, and if found guilty are incarcerated or otherwise punished. At its extreme, this process disqualifies convicted persons from active social participation and renders them comparatively powerless. In order to return to society they must conform to standards of accepted social behaviour. Ideally, corrective strategies are instituted to produce this conformity. Theoretically, the corrective approach is expected to lead to continued compliance with social rules of behaviour [Ignatieff 1978]. The concept of deviance has broader social applications than lawbreaking. Thus, persons who do not break laws, but who violate social codes of appropriate behaviour, may also be considered deviant [Gomme 1993]. Examples include the behaviours of persons who are mentally ill, or persons with disabilities. Thus, someone who does not actively participate in a group conversation because of a hearing problem may be labelled "asocial," "withdrawn" or "stupid." In addition to 9 behaviour, certain attributes may also be labelled as deviations from the norm. For example, disability and disfigurement elicit a reaction of perceived deviance as noted by Durkheim [1938], Thomas [1982], and West [1985]. It is the action of the group, or the "collective conscience" of people which defines deviance in a given society [Durkheim 1938]. In general, the ascription of a deviant label on individuals or groups often results from the actions of those in power or authority groups [Little 1989]. Thus, a feeling of powerlessness is a common attribute of deviance. Powerlessness often refers to an individual's [or groups's] perception of self in not having the cognitive competence, psychological skills, or resources needed to successfully influence his or her environment [Schlesinger 1987:4]. Those who feel powerless tend to attribute power to others. Those who experience powerlessness most sharply are often poor, uneducated, young [or very old], women, ethnic minorities, and institutionalized persons, for example in hospitals or prisons. Ogbu's [1978] "caste" concept [minorities] and Goffman's [1963] stigma concept of those who possess a discrediting attribute are examples of groups or individuals who feel powerless in the face of others with power. Much of human striving is concerned, directly or peripherally with the concept of power versus powerlessness. Other attributes which are often a part of the experience of deviance are feelings of domination and oppression by systems of social control. Domination may be defined as institutional conditions which restrict or prevent people from having a 10 part in determining their own actions or the conditions in which those actions take place [Young 1990]. Thome [1993] reports numerous anecdotes by chronically ill people, of feeling oppressed and humiliated in interactions with a health care system which exercised considerable control over their care. Similarly, inmates of prisons must adhere to the rules and regulations governing their behaviour [Culhane 1991, Gosselin 1982]. A companion to domination is the feeling of oppression, which refers to the effect of excessive hindrances in social structures and relations which affect those who must utilize such services [Young 1990]. Correctional policies which enforce sentences, regulate prisoner behaviour and maintain order may be much more oppressive to prisoners with disabilities than the average prisoner. This is especially so because provisions are seldom made for the special needs of prisoners with disabilities [Motiuk 1994]. Individuals or groups who feel powerless and oppressed are not without means of recourse. Increasingly this recourse has been group action, exemplified by the new social group movements. Such resistance takes various forms of extra- parliamentary methods of protest, withdrawal, and refusal [Habermas 1984, Schweitzer 1989]. Examples of resistance/protest group actions include ecological and peace movements, homosexual activism, and the disabled and prisoners' rights groups. A current example of individual informal protest is the "underground economy" in which many Canadians avoid paying taxes, an act described by the current Minister of Finance as "withdrawal of the consent to be governed" [Martin 11 1993:20]. The concern of these social group movements is with the "dynamics" of social justice relations and processes between system and lifeworld [Habermas 1984]. As a result, themes of "empowerment" and "partnership efforts" are emerging in approaches to policy and care. For example, in the domain of social policy and health policy the new conceptual approach is of a cooperative reform process between client, service provider and care-giver [Cull 1993]. In the community, this participatory reform process is facilitated by opportunities for participation in public forums and committees, and use of the media. In closed institutions such as prisons, a specialized approach may be needed, in that prisoners with disabilities may be at a special disadvantage for medical and social reasons [Briscoe 1994]. The participatory reform process attempts to reduce the dominant role of the physician, and the biomedical model, in establishing health policy. The biomedical model is also influential in the arena of criminal deviance and justice, and has special significance for the hard of hearing prisoner. The biomedical perspective on the management of deviance The biomedical perspective on health and illness focusses on specific disease entities, each with a specific biologic process [Mischler et al. 1981]. Kleinman [1980] notes that the biomedical science paradigm does not take into account the meaning of illness within the patient's cultural and social experience. This is a salient 12 problem for those with acquired hearing loss, for whom the impairment is, from the beginning, a social problem [Babcock and Patten 1993, Jones et al. 1987, Thomas 1984]. In Western culture, the medical profession defines illness, prescribes treatment and is, therefore, a mechanism for social control. Physicians hold power and function as gatekeepers to health services [Mischler 1981]. They control and judge entry into the sick role, which is considered deviance from the normal [Parsons 1951]. The sick person, rendered powerless, is not punished but diagnosed, treated and restored as much as possible to normal health and functions in society. In either case, those who do not respond by a return to conforming social behaviour [become well again] are transferred to the "chronic" or disabled role [Mischler 1981, Parsons 1951, West 1985] which is also subject to systems of social control. The biomedical model not only connects to the model for deviance management, but also extends into the field of justice and criminal deviance [Foucault 1980]. For example, the management of deviance is in large measure placed in the hands of medical and social professionals and specialists, who increasingly share social control decisions with the courts [Little 1989]. A major trend in crime policy is based on the concept of deviance as sickness, with the move from punishment to treatment, or punishment plus treatment such as medications and surgery [Allen 1985, Barnett 1985, Murphy 1985]. Foucault [1979, 1980] notes that social control, 13 both in medicine and criminology, has become more subtle, professionalised and oriented to surveillance of deviant behaviour. Judgements made from impressions of perceived behaviour are thus of major significance to those whose behaviour may be misinterpreted, such as prisoners with hearing difficulties. Summary of conceptual foundation Humans form social perceptions through consciousness and awareness, and selectively give meaning to actions and events in their environment. Such perceptions are influenced by tradition, laws, class, social status and culture. Put another way, we construct social reality, our lifeworld, based largely upon the way in which we experience, code, and attach meaning to the behaviour of others, as appropriate or deviant. Perception is both an individual and a group experience, and it is a collective social perception which defines deviance. Deviance labelling and the sanctions which follow are often the prerogative of those with whom power resides [Becker 1964, Gomme 1993, Little 1989], and who perceive themselves as having the resources to influence society. Individuals and groups who perceive themselves as powerless are especially vulnerable to deviance labelling and the social control measures which follow. Becker [1964:18] writes that 'Those groups whose special positions give them weapons and power are best able to enforce their rules." Dominant groups make and 14 enforce rules. A perception of powerlessness and deviance is often accompanied by the experience of oppression from dominant figures or groups. Oppression can be considered as structural [Young 1990], embedded in the taken-for-granted practices of everyday life. Oppressive practices are therefore not easily eliminated unless power structures are changed and stereotyped ways of perceiving, defining, and controlling others are altered. Prisoners are by definition a group who have been perceived and defined as deviant by society, and subjected to negative social control measures [Little 1989]. They are a largely powerless group within a dominant and oppressive system regulated by bureaucratic measures [Foucault 1979, Ignatieff 1978]. Prisoners who have partial hearing loss are rendered even more powerless because they are largely unidentified and therefore invisible and isolated within the system. Isolated action or resistance by a powerless individual tends to lack the effectiveness of group efforts. Actions of the newer social group movements demonstrate effective methods of resistance to dominant and oppressive social structures and mechanisms [Habermas 1984, Scott 1990]. Such groups have organized efforts and techniques to effect changes to health and social policy development. As a result, old themes of social control must be reworked, within a framework which includes clients, community and professionals working together in policy and program development. 15 Therefore, the theoretical elements which are applied in this study explore the interpenetration of micro- and macro-levels of social structure as applicable to a vulnerable, neglected disability group in prisons, inmates with a partial hearing loss. Hearing impairment: Significance of partial hearing loss in adults Hearing impairment, generally considered to involve various degrees of loss of hearing, is a condition that afflicts about 7% of the Canadian population [Statistics Canada 1992]. It is the most prevalent chronic disability among adult populations [Health and Welfare Canada 1988]. The importance of hearing impairment, in particular acquired hearing impairment, in the life of Canadian adults has recently been examined by Health and Welfare Canada [1988]. It is projected that the median age of the Canadian population will be increasing from 29.5 years in 1981 to 40.5 years in 2021 [Roadburg 1985]. This means that about 50% of Canada's population will be 40 years and above in about three decades. The frequency of hearing loss increases with aging; therefore, it can be expected that in future there will be a much larger proportion of the population with impaired hearing. The same trend is evident in the correctional population, where offenders over 50 years of age constitute the fastest growing age group in federal prisons [Grant and Lefebvre 1994]. 16 Some degree of hearing loss is regarded as a universal and natural consequence of progressively getting old. However, for all ages groups, whether young, middle-aged or old, there may be important psychological and social consequences leading to significant alterations in communication methods, perceptions and lifestyle, regardless of the course of the hearing impairment itself. About 5% of the Canadian population, approximately 1,287,325 people, are housed in institutions [Statistics Canada 1986]. Such institutions include care facilities for the aged, facilities for the mentally retarded and psychiatrically ill, and correctional facilities. Conceivably, the institutionalized population, including prisoners, will include not only persons who have officially been diagnosed as suffering from impaired hearing, but also those who have yet to be identified. Until now, no study has been undertaken to determine the number of unidentified persons with hearing impairment in institutions. The available literature shows that quite often, "hearing impairment tends to be associated with elevated rates of depression, anxiety, paranoia, general insecurity, and altered self-concepts" [Health and Welfare Canada 1988:3]. According to Valenstein [1981], such an impairment is often associated with increasing social isolation and a sense of disappointment or despair. Hearing impaired individuals may shun company or become depressed [Ulatowska et al. 1985]. 17 Although a specialized body of knowledge exists about the psychological, social and demographic characteristics of the profoundly deaf, there have until recently been comparatively few studies of the psychosocial implications of the hard of hearing condition. There are indications that partial loss of hearing has profound and pervasive social implications, for individuals who are hard of hearing and for their significant others, as well as colleagues and custodians of agencies with whom the individual interacts [Harvey 1985, 1987, Hetu and Getty 1987, Hetu, Getty and Waridel 1994, Jones et al. 1987, Wax 1984]. It is likely that people with impaired hearing who are incarcerated are vulnerable to the combined isolating and depressing effects of both the hearing deficit and institutionalization. One implication of these observations and findings is the social cost, for the individual with impaired hearing, in the institutional setting. It can be concluded that the individual who has a hearing impairment is vulnerable to mislabelling as isolative, uncooperative, withdrawn, antisocial, confused or unintelligent. It is likely that such labels may be applied by other prisoners and custodians, including those who make decisions on health care, discipline, and programs. The problem of partial hearing loss in prisons Persons with partial hearing loss tend to be unidentified by officials, and occasionally even by themselves, within institutions [Health and Welfare Canada 18 1989]. In common with other incarcerated groups they are vulnerable to a "mindless" or unthinking structural oppression [Young 1990]. This lack of identification is built into the mechanisms of institutional structures: hearing impairment is not commonly identified on admission unless a severe degree of loss is present, or it has been diagnosed and treated prior to admission. A hearing loss may also develop and progress gradually and go undetected in an institutional setting [Health and Welfare Canada 1989]. Given that many people who are hard of hearing tend to hide their hearing loss, and that there is a potential for misperception of the meaning of such behaviour, such individuals are susceptible to negative reactions from others. Prisoners are a particularly vulnerable group, because any behaviour which violates standing rules can lead to the implementation of further oppressive measures to punish or change undesirable behaviour [Culhane 1985, Foucauit 1979, Ignatieff 1978, Murphy 1985]. It has been demonstrated that the basis of social control may be located in the assumption of deviance management of the inherently powerless by a dominant group and in particular in the social perceptions developed over time which guide behaviour. Prisoners are rendered quite powerless by virtue of their imprisonment while custodians are a dominant group by virtue of the power given them to regulate, discipline, and control the actions of those placed in their custody. This study argues 19 that custodial management of inmate behaviour flows largely from perception and interpretation of prisoner behaviour as acceptable or unacceptable. Similarly, medical diagnosis of behaviour stems from physicians' perception of conditions within the context of their medical knowledge and awareness. Jones et al. [1987] note the frequent lack of awareness by the physician of undiagnosed partial hearing loss in patients. This included refusal to refer the patient for investigation of the complaint of a hearing problem. Given the gatekeeping character of the biomedical model, and its power to bestow or withhold a diagnosis [Friedson 1970], it follows that prisoners with unidentified hearing impairment would be particularly vulnerable to physician refusal to refer the inmate for investigation of impaired hearing. Purpose of the study The purpose of the study is to examine the process of social control as it affects an invisible disability in a bounded population. The study seeks, first, to estimate the number of prisoners with partial hearing loss in federal prisons in British Columbia; second, to study custodial labelling of hard of hearing behaviour; and third to identify problem elements of these prisoners' experience. 20 Research questions Of central concern in this study are the following research questions: 1. What is the percentage of impaired hearing among prisoners of federal prisons, compared to the general population? 2. What are the methods for identifying hearing impairment among federal prison populations, and are they adequate? 3. Are custodians aware of attributes associated with impaired hearing? What are their perceptions of behaviours evidenced by prisoners who have impaired hearing? 4. What labels do custodians attach to behaviours of prisoners who have impaired hearing? 5. How do prisoners with impaired hearing describe their behaviour associated with hearing difficulties, and how does this compare with the way these behaviours are interpreted by custodians? 21 Outline of thesis This chapter provides the interactionist and social control perspectives which shape the approach to the study. Within this theoretical framework, the psycho- social significance of the hard of hearing condition in institutionalized offenders is identified. In Chapter Two a review is presented of theory and knowledge relating to the social and emotional implications of being hard of hearing. The hard of hearing condition is discussed, within the context of social perception and meanings attached to deviant behaviour. This approach shows that the behavioural attributes associated with being hard of hearing are readily open to misinterpretation, particularly when manifested by the powerless and vulnerable, such as prisoners. In Chapter Three the rationale for the qualitative approach utilized in this study is discussed, including how the study population was determined as well as study procedure and limitations. Discussion also includes some of the special problems associated with the conduct of research in correctional institutions. Chapter Four includes the presentation, analysis and discussion of findings of the self-report questionnaire of the study population and from the audiological screenings and assessments. Where applicable, findings are compared with other data sources. Results are detailed from interviews with prisoners, a 22 comparison group, and custodians. A cross-tabulation and comparison of hard of hearing inmates' experience and custodial observations are provided. In Chapter Five, the study is summarized, conclusions are drawn and implications discussed. A clear connection is made between the power of custodians as a dominant group to ignore the needs of a vulnerable group of prisoners, largely through entrenched perceptions of deviant behaviour and social control methods. In Chapter Six, the implications for reasonable accommodation and human rights issues are discussed, in comparison to the mission statement, core values, and policy objectives of the Correctional Service of Canada [Correctional Service of Canada 1990]. Recommendations are suggested, paralleling specific objectives of the correctional service, for practical applications to this population and further policy and research. 23 CHAPTER TWO HEARING IMPAIRMENT AND DEVIANCE: A REVIEW OF THE LITERATURE "You know, one of the things that really 'kills' a lot of us who have grown up with a hearing loss is the fact that we were denied the simple and very important relationships of teens. We did not have the boyfriend/girlfriend experiences that most kids have. The making of friends that became short-lived 'love' affairs and such. Like times when kids meet a new person on Monday at 9 am, have decided to go steady by noon, are madly in love by Tuesday and break up Wednesday afternoon. This is important for people to learn how to get friends and to lose them, and how to deal with losses of things you have to value, and how to get over it. Most of us have not done that if we were hard of hearing all along. I did a little survey of those hard of hearing since childhood [in our group] and not one of us went steady in high school, not one went to the senior prom, or had any really meaningful relationships till later in life. Now many of us are having trouble with this. They either cannot face making friends or they will grab the first person who looks at them, and they cannot face letting go even if they know they want to" [Anonymous 1991]. Introduction In this chapter a review is provided of available literature which identifies the complexities of the psychosocial condition of partial hearing loss. A connection will be made between hearing impairment, deviance management, and its relationship to institutional structures of medical and social control. Prevalence of hearing impairment It has been estimated that the incidence of hearing disorders in the overall world population is between 6% and 10% [Pichora-Fuller et al. 1984]. A recent report by Health and Welfare Canada [1986] indicates that 4% of Canadians report having a hearing disorder, of which more than half are between the ages of 16 and 64 years of age. However, the prevalence of the phenomenon among working adults, who represent 67% of the Canadian population, has been estimated at 3.4% or 24 approximately 550,000 persons [Pichora-Fuller et al. 1984]. This situation led the 1988 Federal Task Force on Acquired Hearing Impairment to recommend complete otolaryngological [ear and throat] examination for every person with hearing loss [Health and Welfare Canada 1988]. Definition and categories of hearing loss Hearing loss is best viewed along a continuum, including all degrees of hearing loss, from slight to profound [Schein 1982]. Impaired hearing may refer to minor difficulties or to a complete inability to use hearing for communication purposes. Various studies specify different decibels of loss for categorization of degree of loss. This study utilizes Yantes' [1985] measurement categories of loss as follows: Table 1. Yantes' categories of hearing loss averaged at 500,1000 and 2000 Hz Decibels of loss <10-15 16-25 26-40 41-55 56-70 71-90 90> Category normal slight mild medium moderately severe severe profound 25 Different terms are employed in various studies, to define people with hearing impairment. "Impaired hearing" is a generic term, covering all limitations of hearing - both the ability to hear and to understand speech. The Health and Activity Limitation Survey [Statistics Canada 1992 C-3] utilizes the term "impaired hearing" in this generic way, and avoids the term "hearing loss" because "loss" incorporates the ability to detect sounds, but not the ability to distinguish between them. Obviously, the ability to distinguish between sounds is crucial to hearing and understanding. A medical definition is utilized by Health and Welfare Canada [1988] which defines hearing impairment [or loss] as a pathologic disorder which can be measured objectively, using standardized methods and can be described in both qualitative and quantitative terms. It is the actual limitation of physical ability to hear. A social definition refers to the individual's hearing impairment under his or her normal listening [living] condition [Moores 1987] and relates to a functional definition of degree of hearing impairment, rather than to an audiometric definition. The functional definition of "deaf is a profoundly hearing impaired individual whose primary mode of communication may be manual communication [sign language]. The functional definition of "hard of hearing" is a hearing impaired individual whose primary mode of communication is speech, and who utilizes residual 26 hearing capacity, that is, any remaining degree of hearing, likely to be assisted by the use of hearing aids and/or other assistive listening devices [Moores 1987]. The audiometric definition of "deaf is an individual with profound hearing loss as measured on the audiometer [90dB HL bilaterally, usually]. The audiometric definition of "hard of hearing" is an individual with hearing impairment as measured on the audiometer. The term "partial hearing loss" in this study indicates a degree of measurable loss, from mild to severe, and is applied to the hard of hearing. The term "deafness" is used to indicate the state of being deaf; "prelingual deafness" refers to being deaf before the mastery of oral language. "Adventitious deafness" refers to deafness acquired as an adult [Thomas 1984]. Although it is not pertinent to this study, mention may also be made of consumer group preferences for terminology. Currently persons who are profoundly, prelingually deaf prefer to capitalize "deaf as "Deaf [Gallaudet Today 1993-94, Slutsky 1994] to signify their identity as part of a cultural group which communicates via American Sign Language. The adventitiously deafened may refer to themselves as"late-deafened" or "adult-deafened" to convey that they do not view themselves as a part of the Deaf sub-culture and communicate expressively by speech and receptively by a combination of other visual modalities such as print, speechreading and/or manual gestures [Shuster 1994]. The International Federation of Hard of Hearing People and its member consumer organizations prefer to be termed "hard of 27 hearing" people [Laszlo 1985]. All of these terms are closely tied in with the insistence on a group identity which indicates not only a hearing difficulty but also the preferred communication modality. Characteristics of hearing impairment The terms "mild," "medium," "severe" or "profound" as used in the study do not indicate the practical effect, on a daily basis, of the hearing loss itself. A "mild" loss does not mean that the person has only a minor problem of hearing. Actual performance assessment, and the actual experience of the hard of hearing individual, are the final judge of hearing acuity on a daily basis, in the various environments one experiences [Martin 1991, McAlister 1994]. It is not only the invisible nature of hearing impairment which contributes to misperceptions by others. The apparent selectivity of a hard of hearing individual to hear sometimes and not others, to hear some people and not others results in suspicions that the problem has, for example, a social or interpersonal basis rather than a hearing difficulty. This phenomenon is termed "auditory frequency selectivity" [Moore and Roy 1986, Glossary] and refers to the ability of the auditory system to process signals received concurrently. Put simply, the individual with normal hearing has the capability to "screen out" unwanted sounds and thus hear and understand in the presence of background noise, or similar competing environmental sounds. 28 Loss of hearing, even in the early stages [mild hearing loss], is characterized by loss of frequency selectivity. Therefore, the hard of hearing person will hear well in a quiet situation and do poorly in group conversations, or with background noise. Hearing impairment is an extremely complex issue, because of its physiology and because it interferes with our primary method of communicating, namely that of hearing and responding to the spoken word [Harvey 1985, Oyer 1974]. There are also many cultural and practical factors related to assessing degree of hearing disability [Jones et al. 1987, Levine 1960, Thomas 1984]. The most important are (1) time of onset of the impairment, (2) degree and nature of physiological damage, and (3) the individual's ability to cope [Jones et al. 1987, Levine 1960, Thomas 1984]. For example, approximately 20% of profoundly deaf persons are prelingually deaf [Schein 1974], view themselves as a cultural sub-group organized around the language of sign, rather than as "disabled", and admit to "disability" only within the context of claiming social benefits. The remaining 80%, who are post- lingually [adventitiously] deafened, and the much larger group of the hard of hearing, experience their acquired hearing loss as disabling within the context of their enforced separation from the normal social communication which has been a part of their cultural experience in larger society. The time of onset and degree of impairment, if congenital or early in childhood, affects the acquisition and development of language, academic, emotional 29 and social skills [Health and Welfare Canada 1984]. Adult onset hearing impairment affects interactive verbal communication and invariably has a pervasive negative effect on all aspects of the individual's life [Ashley 1973,1985, Gabizon 1993, Rutman 1989]. Changes to relationships occur in social, educational and work situations [Combs 1989, Harvey 1987, Hetu, Lalonde and Getty 1987, Hetu, Riverin, Lalande, Getty and St-Cyr 1988, Hetu, Getty and Waridel 1994, Suss 1993]. Others may react unfavourably to the person with hearing loss, through misinterpretation of changed behaviour and communication patterns. Self-concept and self-esteem are affected, as the person perceives him or herself in a different, often diminished way [Combs 1989, Goffman 1967, 1969, Harvey 1985]. Theberge describes the behaviour of an individual with acquired hearing loss as follows: "The employee who loses his hearing suddenly, or gradually, ... can rarely expect any improvement in his condition. Dismissal is then a monster at his heels, poisoning his workdays. He avoids the telephone and his boss, in the latter case so that his inability to understand all verbal directives will remain hidden" [Theberge 1991:11]. There are many whose hearing impairment has never been identified because of the lesser level of loss present. Some may have been "mislabelled" by professionals, for example, physicians, educators, and officials with the authority to 30 label [Brynelsen 1991]. Police officers, judges, and prison custodians are in authority positions to label or mislabel individuals. The consequent labels may be that of nonconformists, deviants and so on, possibly resulting in incarceration [ASHA 1973, Belenchia and Crowe 1983]. It is the interactional and behavioural aspects of conduct which most influence how a person is perceived, interpreted, and defined [Goffman 1959, 1961, 1963, 1967, 1969; Goode 1978, Sarbin 1983]. The hard of hearing and late deafened as a social group Persons with partial hearing loss or adventitious deafness comprise a group which is separated from the majority of non-hearing impaired persons by virtue of the behavioural effects of disruption to their receptive communication ability. By definition, they form an identifiable 'deviant' group, with specific characteristics [Israelite 1993, Jones 1987:18, Thomas 1984]. Their difficulty relates to receptive communication, not expressive communication. These people still speak normally, and look normal; it is difficult for others to grasp that they cannot also hear normally. Typically, individuals with impaired hearing cite (1) common negative psychological effects of their impairment, and (2) negative reactive social behaviours from others. Common negative psychological effects cited include isolation, fear and anxiety, depression, and diminished self-esteem [Ashley 1973, 1985, Gabizon 1993; Hetu, Getty and Waridel 1994, Martinsen 1993]. Negative reactive social behaviours 31 from others include rejection [being left alone], frustration, irritation, and embarrassment [Bruce 1993, Hetu, Lalonde and Getty 1987, Israelite 1993, Smith 1992]. Hard of hearing people also express relief and support from identifying and interacting with others with the same condition [Glass 1993, Israelite 1993, Jones et al. 1987]. Studies of hearing impairment: Examination of the literature reveals that published research on the psychological and psychosocial effects of partial hearing loss, and particularly of acquired hearing loss is a relatively recent phenomenon, increasing since the late 1980's. A problem plaguing earlier studies was the tendency of researchers to group together in studies those with profound prelingual deafness and the hard of hearing and late-deafened, and approach the subjects as an homogenous group of the "hearing impaired." But prelingually deaf individuals suffer a sensory deficit and have developmental problems, whereas those who experience a postlingual loss [the hard of hearing and adventitiously deafened] suffer a sensory deprivation and their problem is traumatic [Thomas 1984]. Most studies of the hard of hearing tend to be technically-based. Examples of such audiological measurement-oriented studies of the prisoner populations are American studies by Blom [1967], ASHA [1973], Mack [1973], and 32 Belenchia and Crowe [1983]. However, a Task Force appointed by the American Speech and Hearing Association in 1973 reported the results of a national survey of 200 state and federal corrections administrators. This study indicated that 77 % of those polled believed that the psychological and communication problems arising from hearing impairment can lead to criminal behaviour [ASHA 1973]. Crowe [1983] also surveyed penitentiary custodians on their perception of the role of hearing impairment in criminal deviant behaviour. He found that custodians believed that such hearing impairment, in some ways, contributed to criminal deviance. There is a growing body of published research on the adventitiously deafened. Rutman [1989] summarized this literature, stating that there had been few well-controlled empirical studies on the problems, functional limitations, and coping characteristics of those with adult-onset hearing impairment. Most of the research discussed by Rutman addressed the profound traumatic effects of complete or near- complete hearing loss which may be more intense than for those with a lesser degree of hearing loss. This group of literature included case studies, autobiographical accounts, and group studies. Common themes identified are the individual's perceptions and symptoms of depression and social isolation. Rutman also discussed denial as one of the "most common and potentially unhealthy" responses to acquired hearing loss. She noted that a progressive hearing loss may go undetected by everyone for years, with instances of 33 unusual or deviant behaviour, leading to labels such as "withdrawn", "senile," or "egocentric." One must question, however, whether "denial" always represents an unhealthy response. It may be that everyone, including the hard of hearing person, is unaware of the hearing loss because of its gradual onset and progression, and the ease with which related behaviours can be misinterpreted. It may be difficult for persons with the hearing loss to assess objectively what is happening to their hearing. Further, those particular individuals may not feel a need for information or social exchange to the extent that others do. Psychosocial concerns related to hearing impairment in job-related environments have been explored by Hetu,Getty, Lalande and others [Hetu, Lalonde and Getty 1987, Hetu et al. 1990, 1994a, 1994b]. Various controlled studies examined effects of impaired hearing on the individual with hearing loss, their family, and co- workers. In one study [Hetu et al. 1994b] two groups of workers with impaired hearing and their spouses were interviewed. One group had experienced a pilot rehabilitation program and disclosure of their hearing condition in a published article on job-related hearing impairment. Results showed that they had been stigmatized as deaf by co- workers. The second group, which had not experienced rehabilitation exhibited reluctance to admit to a hearing difficulty. Hetu et al. concluded that reasons for concealment stemmed from feelings of threat to identity in being perceived as less capable than formerly, fear of stigmatization, and fear of being socially marginalized. It is also suggested that ambivalence and uneasiness in talking about a hearing 34 problem is part of the adaptive process to acceptance and rehabilitation of the person with acquired hearing loss. Stevens [1990] undertook a pilot study to identify the psychological problems of middle-aged and elderly subjects with impaired hearing, and to determine if hearing aids reduce these problems. Subjects completed a standard "self-assessment of handicap inventory" for the hard of hearing. Findings showed that "social isolation" is the principal handicap identified. While hearing aids reduced the feeling of isolation, the adjustment problems associated with hearing aid use [increased auditory input, difficulty in discriminating signal from noise] identified the need for training in use and retraining in social skills. Thomas [1984] studied two small groups of hard of hearing persons, in relation to self-perceptions of handicap. The answer to whether hearing loss was perceived as a handicap was quantified with inventories of personality and psychological disorder. He found that hearing loss "did not contribute to any fundamental psychological change" [e.g. basic personality structure] in the individual. Thus, he recommended that if a hard of hearing person manifests what is perceived as bizarre behaviour, one should attribute such behaviour to the communication difficulty, and not to a presumed psychological abnormality. Thomas found that acquired hearing loss causes psychological disturbance to a varying level, and for varying duration, such as increased stress levels, anxiety, depression, sleep 35 disturbance, listlessness, and panic. Degree of disturbance also varied with the degree of impairment and personality characteristics of the individual. Problems encountered in family relationships were significant. The study findings led Thomas to conclude that many people may not be aware of the cumulative and insidious effect of very gradual hearing loss on their life quality. While such studies indicate feelings of helplessness and possibly powerlessness in individuals, no empirical approach was taken in Thomas' study to explore such concepts. Jones et al. [1987] included power and control as interactive factors in personal relationships, as items in their study of 123 people with acquired hearing loss. Qualitative interviews were conducted with a small subgroup drawn from the study subjects. They reported no conclusive results from this small sample, but speculated that denial of a hearing loss by the hard of hearing person may be a control measure, because once a diagnosis is accepted, the specialists who prescribe treatment modes take control. The condition is thus medicalized [O'Neill 1986]. Turbin [1993] noted his own feeling of helplessness in communication situations following his acquired hearing impairment. He used this insight as a starting point to apply "locus of control" theory to adults with impaired hearing. He reported on the construction and administration of tests [24-items in three scales] designed to measure "communication locus of control" in 100 hard of hearing adults. His results were inconclusive, possibly due to the test construction. He noted that relatively short 36 psychological tests cannot measure complex interactive dynamics between people. He concluded that old age related positively to adjustment variables, such as acceptance of loss and acceptance of self. Moreover, he speculated that "locus of control" is an effective way of looking at how people who are hard of hearing respond to communication problems: individuals with hearing problems can actively alter communication situations to meet their needs. In contrast to Turbin's [1993] finding about age and adjustment, Scott, Lindberg, Melin and Lyttkens [1994] found that younger subjects showed a significantly higher degree of success when dealing with task-solving of critical incidents. These researchers speculated that younger individuals adapt more easily to new conditions. This study tested control and dispositional style on 40 hearing- impaired subjects in a laboratory setting simulating three different communication situations. A life orientation test measured dispositional style, that is, the level of optimism in life situations. Guarnera and Williams [1987] found that internal locus of control correlated positively with dispositional optimism, as measured by the life orientation test. Subjects completed a hearing questionnaire which measured the ability to cope with different hearing situations. Four of the questions assessed locus of control. The study also examined auditory and non-auditory response patterns in challenging communication situations, including task-solving. The researchers found that degree of control, together with how relaxed and secure the subjects felt, is an important factor in successful coping behaviour. They concluded that more attention 37 should be given to the role of different communication patterns and psychological factors in developing effective rehabilitation programs for hard of hearing people. Soderlund [1994] investigated feelings of negative attitudes by coworkers for hard of hearing people in the workforce. An extensive qualitative survey was done of 588 hard of hearing people living and working in metropolitan Stockholm. The results showed that 43% of respondents reported "negative experiences" including social isolation, harassment, work barriers and belittling comments. Those respondents who were younger, or had a youth-onset loss, or concealed their hearing loss had more negative experiences than older adults who discussed their hearing impairment with coworkers. Unfortunately, no comparison survey was done of people with normal hearing to determine the percentage of normal hearing workers who had negative experiences. It would also have been helpful to determine the locus of control perception of the various respondents. Trychin [1994] summarizes the findings of seven years of work with hard of hearing people, their families, and their professional service-providers. He states that communication problems related to hearing loss are common but many of the communication partners do not know how to prevent or change this. A common misconception was that the impact of hearing loss on the person's life could be judged according to severity. In fact, he notes, mild hearing losses can be quite disabling, given other existing factors such as environmental noise or group communication 38 situations. Personal factors contributing to disabling effects could include not revealing the hearing problem, and not attempting to adjust environmental conditions. Examples of failure to adjust the environment would be not asking for a quiet seating location in a restaurant, or not requesting an amplified telephone in the workplace. Such helplessness or denial behaviours may contribute to the handicap experience. Stephens [1990] reported results of two public health surveys which consisted of self-completed questionnaires. In the Cardiff Health survey [1986], 14% of 4,266 individuals randomly sampled from the electoral system of Cardiff reported a hearing disability. In other studies of elderly persons seeking hearing aids for the first time, a distinct social class bias was found in the reporting of hearing difficulty. Professionals and white collar workers were more likely to report hearing problems than were the semi-skilled and unskilled. Stephens speculated that professionals and white collar workers may have more social interaction and depend more on hearing well in work situations. In other words, it appears that professionals and white collar workers may have a greater need for information exchange than do the unskilled labourers. 39 Hearing impairment as social deviance Hearing loss impairs communication and so strikes at the very root of personality and personal relationships, as well as interactive functioning. Noble and Hetu write that "From the viewpoint of affected persons, their families and close associates, the difficulties in interpersonal communication make it a problem of deviation from behavioural expectations - a moral problem" [Noble and Hetu 1994:117]. While the individual may accept the label, she or he has no real understanding of what the reality of the condition will be in one's daily life. Left alone to cope, the individual then labels one's self from categories such as separated, isolated, lonely, fearful, failing to cope, and different [Ashley 1985, Benderly 1980, Glass 1985, Levine 1960, Suss 1993]. As early as 1944, Hunt listed the intensity and variety of fears experienced: "... fear of failure, fear of ridicule, fear of people, fear of new situations, chance encounters, sudden noises, imagined sounds; fear of being slighted, avoided, made conspicuous; these are but a handful of fears that haunt the waking and even the sleeping hours of the sufferer from progressive deafness" [Hunt 1944:230-1]. The social reality for the hard of hearing person is placement into a tenuous category of belonging to neither the world of the hearing nor the world of the deaf. Instead one has a precarious hold on what has always been his or her place in normal society. Jones et al. [1987] discussed the denial syndrome. While some individuals "accept" the deviant label when so designated by the medical profession, others refuse to accept the label, or resist disclosure of the deviant condition to 40 others. For some the motivation may be a strategy to retain control in their life and avoid stress; for others it may be an ambivalence about identity location, and for others a struggle to maintain their "nondeviant social role." Turbin [1993] also discussed control motivation and strategies, as a way to influence both the behavioural reactions of others, and the social perception which others form of a person with impaired hearing. Thus, the person with an inner locus of control would be more likely to explain to another person how to speak so that they could be understood by the person with the hearing problem. Taking control of the communication situation would then save the other person embarrassment, and reduce the potential for stigmatization of the hard of hearing person. Hard of hearing individuals are often aware of the consequences of labelling. In a study of individuals with mild to significant levels of progressive hearing loss, between the ages of 16-65, Jones and her associates [1987] found that 70% of the subjects who had been through diagnosis and referral avoided disclosure of their hearing problem to others. Many delayed seeking a medical diagnosis, gave reasons of feeling that they could cope adequately anyway, and did not want to make their condition known. Jones et al. concluded that this is a strategy to retain control, and argued that disclosure is not necessary to successful rehabilitation [Ronayne and Wynne 1985:20]. They stated, "In fact, disclosure by a person almost certainly precipitates loss of control and a decrease in power for the labelled individual, and as a result is avoided by the individual. This avoidance of disclosure is completely different, we believe, from the psychological mechanisms of denial where there is no personal recognition of the problem" [Jones, Kyle and Wood 1987:57]. 41 Cox [1983:3] described the motivation to avoid a deviant label: "Personal pressure to deny the difficulty is considerable, as the feelings of normality which we take for granted are undermined and with that goes the loss of status we have come to expect as being treated as a normal healthy person." Various compensatory mechanisms to hearing loss were identified by Menninger [1924] in progressive hearing loss, and by Knapp [1948] with suddenly deafened soldiers. These compensatory mechanisms included: 1. Overcompensation [adopting an extrovert lifestyle]; 2. Talking a great deal to conceal inability to hear; 3. Denial [attempting to lead the same lifestyle as before, with no adjustments]; 4. Retreat from society; and 5. Somatic complaints. Wax [1984] described defense mechanisms in older adults including denial ["I don't have a hearing problem; you mumble"], repression [frequently losing or forgetting to put on the aid], rationalization ["having a hearing loss is really a blessing - no more noise"], in attempts to avoid the deviant label of "hard of hearing." Franks and Beckmann [1985] found that, for old people in residential care, one of the most common reasons for rejecting a hearing aid was fear of calling attention to a deficit perceived as unacceptable. In Stigma [1963], Goffman described this type of concealing behaviour as 'passing' - people with a stigmatizing condition try to conceal it and choose to try and pass as part of another more acceptable group - in this case, those with normal hearing. 42 All social groups have rules for behaviour. Persons within the social group, who keep the rules, are insiders; persons who break the rules become outsiders, having been perceived to break the rule and so were evicted from the group [Becker 1973]. Rules for social behaviour are largely tied up with communication methods. Social communication rules are, in the main, implicit rules, not overtly specified, but the majority of the population knows them as cultural expectations and norms and keeps them. Social communication rules are spatial [how physically near one gets to another], kinetic [what sort of body language is acceptable], auditory [how loudly and in what tone of voice one speaks] and linguistic [what is the appropriate terminology and language]. Goffman [1961,1967, 1969], in his research on social communication rules, stated that there are norms for the space to be maintained between individuals when speaking, when eye contact is or is not appropriate, touching, meanings of body gestures and movements and placements, rate and tone of speech, permissible repetition, and acceptable vocabulary. Violation of any social communication rule may render a person suspect, according to Goffman. Continued violations will surely lead to a definition of deviance and transition to the deviant, outsider status. Persons who are hard of hearing, by the very nature of their communicative impairment, continually violate social communication rules. Harvey [1987] specified these typical 'rule-breaking' behaviours. In order to attempt to hear, 43 hard of hearing persons will: move closer to the speaker, thus violating spatial norms; maintain close eye contact and focus intensely upon the speaker's face; may appear strained and tense while striving to understand the speaker; may speak more loudly or more softly than the norm; may request many repetitions; may fail to laugh at the punch line in a joke, or laugh inappropriately; may not respond appropriately in conversation. They may thus, in one group social interaction, violate many of the social communication rules and be moved to the outsider role. Persons with normal hearing, in response, will usually feel uneasy by violation of spatial norms and tend to draw back to reestablish acceptable distance from the other. They will react to the intense continuous eye contact of the hard of hearing person by looking away. This makes it even more difficult for persons who are hard of hearing, who need eye contact, to understand what is being said. Requests for repetitions and inappropriate responses will make them even more uneasy and they will seek to escape from this uncomfortable social situation. Both actors in the interaction will be aware of underlying tension and discomfort. The hard of hearing person will pick up the feeling conveyed by the other, and likely feel rejected, frustrated, and deviant. Moreover, the normally hearing person will be labelling the other as deviant, and possibly involving others in this defining process [Goffman, 1961, 1967, 1969, Klapp, 1969]. Levine [1960] described the contribution which persons who are hard of hearing may make to the social perceptions formed of them by others. Withdrawal from social interactions which have become an isolating and painful experience are 44 common. The individuals who are hard of hearing will be labelled as withdrawn, loners, confused or stupid. "None of the auditory turmoil he is experiencing shows in his behaviour; and since these experiences generally make for strain and tension in interpersonal relationships, the usual consensus is 'best to leave him alone'" [Levine 1960:65]. It is evident that a person with partial hearing loss is particularly vulnerable to deviance labelling based largely on social perceptions formed from interactive communication situations. The more powerless the status of the individual, the more susceptible to a negative label, and the less able to resist. Hearing impairment as medical deviance Hearing impairment has often been viewed as a medical phenomenon, and diagnosed or labelled as such. Therefore, the way in which hearing impairment is viewed as a medical deviance is important in the examination of the social consequences which such a label has for the person with the hearing impairment. It may be posited that "hard of hearing" represents a condition which is deviant from the medical model of disease. Unless it is sudden and severe or profound, hearing loss does not tend to be defined as illness. Nevertheless, it greatly alters the psychosocial experience of the individual and markedly affects interactions with ones social group [Elkins 1993, Glass and Elliot 1993, Hetu et al 1987, 1993, 45 Turbin 1993]. Hearing loss thus fits within the model of illness as conceptualized by Weinman [1980], yet it deviates from the popular conception of "illness" in our society. Studies of hard of hearing persons consistently identify the feeling of being between two worlds, that of the hearing and that of the deaf, with no certain identity [Babcock 1991, Israelite 1993, Turbin 1993]. For most, the stronger pull is toward the hearing world of which they have always formerly been a part, and where their basic values and interests lie [Harvey 1987, Jones et al. 1987, Ramsdell 1962]. It is the hard of hearing and adventitiously deafened who experience most intensely the struggle of transition from the normal to the deviant in society, and who are the focus of this study [Ashley 1973, 1985, Gabizon 1993, Smith 1992]. It has already been noted that the person who is hard of hearing occupies a somewhat ambivalent status in the context of the medical model and the illness role. In responding to a diagnosis of impaired hearing, the medical focus is physiological: fix the ear, correct the hearing; not to deal with the emotional and psychological implications of impaired communication and especially its effect upon interactive relationships [Harvey 1987, Ramsdell 1962]. The hearing problem is defined in terms of diagnosis and medical treatment delivery rather than as a management problem, the difficulty hearing is thus seen as a personal adjustment problem. Additionally, the average physician has little knowledge of the disabling or handicapping [see Glossary for definitions] effects of partial hearing loss and is 46 therefore not prepared to deal with the social consequences of the condition. Bloch [1992] notes that physicians have difficulty in dealing with the mixed social/economic/medical/legal dimension of disability determination, that is, the social dimensions of illness. He states: "Indeed, doctors can be committed to the belief that a particular condition, defined as a disability under applicable statutes and regulations, does not have, in fact, disabling effects" [Bloch 1992:xvi]. Jones et al. [1987] elaborate on the importance of the treatment and adjustment phase. Acquired hearing loss [for the hard of hearing and deafened adult] requires comparatively long-term adjustment, the length of which will vary with the individual situation and requires consideration of many factors such as premorbid personality, complexity of loss, and technological and social support systems. It is clear through this review of current literature that people who are hard of hearing tend to be aware of the high potential for negative social reaction to the behavioural attributes associated with their condition, and seem to be more likely to use withdrawal or avoidance measures in response. These may be strategies to resist the deviant label and consequent social control reactions. There are other, more positive kinds of adaptive responses to acquired hearing impairment which may stem from two sources, both of which are based on a recognition of the social significance of hearing impairment. Hetu, Jones and Getty [1993] advocate a transition from the disease model of hearing loss to a socially 47 constructed model. This approach takes into account the interaction between the person with the hearing impairment and the communication partner without impaired hearing. This is a professional approach utilizing communication therapy for hearing impaired adults [Erber 1988, Kaplan and Garretson 1987, Rezen 1993, Ross 1994] which includes training communication partners in the use of helpful strategies. Participation in such therapy indicates that the person who is hard of hearing has taken the initiative, often in conjunction with a partner, to obtain rehabilitative assistance in learning new coping skills. The second successful adaptive response is a pro-active approach in which the individual with a hearing problem becomes involved in a consumer self-help organization. Such organizations have traditionally focussed on mutual support and sharing of experience and information [ Bruce 1992, Fraser 1991, Laszlo 1991, Stone 1993]. Since the 1970's, many consumer groups of disabled individuals have adopted a sociopolitical stance and advocate for social change beneficial to their particular condition [Council of Provincial Organizations of the Handicapped 1986, Crichton, HusandTsang 1990, Dahl 1987,1988, 1993, 1994, Derksen 1971, Laszlo 1984, Olson 1994, Theberge 1991]. Israelite [1993] noted that the shared experience of the consumer group resulted in self-acceptance and assertiveness. This led to actions for the members to become more knowledgeable about their condition and related social problems, and resulted in advocacy for public acceptance and accommodation. The sense of deviance and stigma was reduced through the 48 perception of having acquired a group identity. Getty [1991 ] also noted the value of the group process in normalizing the difficulties of impaired hearing through shared experience. Social and medical perspectives on deviance a. Social perception, labelling and deviant behaviour Perspectives on deviance and social control responses have changed over time. These changes reflect the ideologies of predominant social institutions of a given era [Little 1989]. In this section current trends which influence the social perception of what constitutes deviance will be reviewed, as well as ways in which deviance is managed in our society, by authority groups. Hastorf et al. [1970] and Schneider et al. [1979] analyze the construction of reality as having three attributes of experience: structure, stability, and meaning. These attributes have an interactive component, which involves a process whereby we select and categorize our experience of the behaviour of others within the context of our own reality. Social perception is context-bound within the range of our own experience. "... perception is not a passive translation of physical energies into experience but is a process demanding active participation by the perceiver. He selects and categorizes, he interprets and infers to achieve a meaningful world in which he can act.... One of the 49 major variables which influence our behaviour vis a vis another person is the sort of impression we have formed of him and the dispositions we have attributed to him"[Hastorfetal 1970:17.] Neal [1983:39] notes that "the two most overriding concerns in the construction of social reality are meaning and action." This involves a group and an individual dynamic in which the individual is an active, primary contributor to reality construction. The cumulative experience of a group shapes the group's approach to reality construction, but "it is the individual's definition of the situation that shapes the immediate course of action he or she is likely to follow." For example, failure by a prisoner to obey an order will be generally perceived as rule-breaking by custodians. A guard who is sensitive to the fact that the prisoner may have a hearing problem and not have heard the order may interpret the behaviour differently and repeat the order more carefully, rather than instituting disciplinary measures ordinarily called for. In the context of the biomedical model, Friedson [1970], Fisher and Todd [1985], Becker [1973] and others have demonstrated that there is an interactive component in the negotiated process of establishing the reality of the deviance label [diagnosis]. Nonetheless, the physician invariably holds the dominant position. Shuhy [1985], Fisher [1985], and Cicourel [1985] have noted that miscommunication and consequent misperception in doctor/patient interactions occur in the areas of vocabulary; cross-cultural differences involving terminology; attitudes toward illness; social distance; and the structure of the discourse itself. As Hastorf [1970] observed, a person's perception of another is culture bound and context bound. 50 Waxier [1981] examined one case in the social construction of illness. "Learning to be a Leper" describes the socially negotiated labelling process of defining the behaviour of a leper, once the condition has been medically diagnosed. Social beliefs about a condition specify how the individual is to behave [be included or ostracized] but such beliefs are closely integrated with the medical specifications for treating the disease. Waxler's comparison of the way different societies manage a particular condition could be applied to hearing loss, blindness, mental illness or a number of other conditions. Frankl [1988] has reviewed the psychoanalytic/interactionist perspective of the doctor-patient relationship, in which three basic models of interaction are specified, with varying degrees of power relationships. These models are set out in Table 2. In all three models the physician holds power and authority to diagnose, prescribe, refer, admit, and discharge. Table 2. Models of physician/patient interaction. MODEL OF INTERACTION/ DEGREE OF POWER RELATIONSHIP activity/passivity guidance/cooperation mutual participation EXAMPLE SITUATION emergency situation [physician does things to the patient]. much of general practice [similar to interaction of parents with adolescent children]. chronic illness [patients know most about themselves in their condition]. Adult interaction. 51 Numerous theorists have commented on the influence of social class and power relationships in perceptual bias. Cicourel and Kitsuse [1969] showed that social class influences both the defining agents and adolescents in a high school, in their perception of expected social behaviour. Students from a lower social class were more negatively assessed than students of a higher social class. Appearances in dress, speech, presentation, and preset interpretive rules influenced perceptions and labelling. Diagnosis of behaviour will vary with the professional discipline of the labeller, and may also vary from that of parental reaction to the diagnosis. The social worker's diagnosis related to family-based economic problems, the teacher's to disciplinary problems, the psychologist's to the mental/behavioural state. In some instances, parents refused to accept the diagnosis, or offered their own interpretation of the problem. Piliavin and Scott [1969] focussed on how police officers as defining agents used preconceived notions and subjective bias to determine deviant behaviour in juveniles, including who is to be so defined. Stinchcombe [1969] described how the police employed cultural rules in typecasting and processing offenders. A particular action may be permitted in private places but may result in a charge of public nuisance. For example, one may be drunk and noisy within one's own home, but charged for exhibiting the same behaviour in a public restaurant. Chambliss and Liell [1969] focussed on the influence of appearances on perception and deviance identification by public agents. People who appear poor are more likely to be 52 perceived as criminals. Less respect is manifested in their treatment by police than is accorded to individuals of higher social status and income. Research studies have shown that stereotyping plays a part in influencing social perceptions of deviance. Stereotyping is defined as the expectations held of an individual, based upon the expectations held of an entire group of people, and which may or may not have a factual basis [Rubin 1973]. Scheff [1969] has shown that physicians enlist a diagnostic stereotype in assessing mental patients in order to influence the rehabilitation process. Hollingshead and Redlick [1969] examined the perceptual bias of those who are given the authority to be the defining agent, and noted that there is social class differentiation in both the diagnosis and the treatment of mental illness. Traditional theorists contend that persons are labelled deviant primarily as a consequence of the acts they commit. The individual so labelled can be treated and rehabilitated, and accordingly should benefit from the deviant label [Gove 1975, 1979, 1980, Smith 1977]. Gove maintained that in many instances, the social characteristics of an individual may play a limited role in the person being labelled deviant and consequently socialized into a deviant lifestyle. Although Gove and Smith do not mention this point, it is crucial that those who label can accurately recognize and diagnose the behaviour, and also understand the social and interactive meanings of that behaviour. The problem for the persons who are hard of hearing is that their 53 behavioural characteristics are extremely vulnerable to misidentification and mislabelling. The question is, therefore, - will the label be accurate and the appropriate rehabilitation measures be instituted? b. Social control and oppression Social control measures have varied with the predominant explanations of social deviance. When deviance was attributed to sin, social control measures tended to be punitive. For example, Newman [1978] has described the nature of trial by ordeal for persons accused of crimes. It was assumed that the accused, when subjected to painful or difficult tests, would be protected by God if innocent, and emerge unharmed, whereas the guilty individual would die a painful death. Examples of this approach included being made to walk on fire, or being thrown bound into the water to float or sink. The latter method was commonly used to determine if a woman was a witch. There was a period when persons with mental illness or mental retardation, disabilities or physical deformities were segregated as social outcasts. Their condition was viewed as the product of sin, but without any evident expectation for changed behaviour. The social control of criminal deviance, whatever the prevailing theory, thus tends to include elements of restraint, deterrence, and coercion to change behaviour. For example, the spiritual explanation of crime led to 54 the modern prison system [Erikson 1966]. The Philadelphia Quakers established a system of isolating criminals in cells with only the Bible to read and some manual labour to perform, thus providing an environment in which the criminal was to meditate, repent his sins and change his behaviour. Classical theorists view criminal deviance as a matter of individual choice [Void and Bernard 1986]. Retribution [or punishment] is seen as the just and impartial imposition, by society, of a "collective will" upon a violator of consensually created law [Fine 1980] based on the notion that individuals are free to change their behaviour in response to punishment and will choose in this regard while incarcerated [Pfohl 1985, Lynch and Groves 1989]. In contrast, critical theorists view crime as a social process. MacLean and Miiovanovic [1991] suggested that contemporary schools of criminological thought, which include left realism, postmodernism and feminism each attempt to move criminology "from a science of social control into a struggle for social justice." Thus, the neo-Marxism of left realism views the problem of crime as the victimization of the working class [MacLean 1991]. Feminism "struggles against the patriarchal control of women" [Currie 1991] and demands that gender be considered in relation to all issues. Postmodernism questions all claims to truth, knowledge, power and progress [Henry 1991] and the logic on which these claims are based. In so doing it rejects orthodox socialist thought and the state, champions fragmentation and diversity, and calls for local action rather than state solutions to social problems. 55 It could be noted, however, that many on the left, in their preoccupation with social process and structure, are unable to make the critical link between personal responsibility and social change. For example, there is a tendency to ignore or deny the role of genetics in shaping human behaviour and personality [Linden 1992, Taylor 1984]. Instead, the current socially acceptable theory is that human behaviour and crime are caused solely by environmental conditions and are thus socially structured. The current politically correct theory of genetic equality may therefore work to the detriment of those recidivist criminals whose behavioural difficulties are rooted in a biological condition such as schizophrenia, or other mental illness or neurological trauma. One may, therefore, call for a more multi-dimensional approach to the study of criminal behaviour. The work of Michel Foucault has formed the cornerstone of new thought in sociology and criminology, and in particular for the evolution of postmodernist thought. His concept of power and knowledge as forever entangled pervades his writings [1976, 1979, 1980, 1984], whether about the body in relation to power [Fox 1994], or the processes of deviance and social control. Foucault expressed deep concern with the repressive capacity of the state for self-perpetuating expansion from enclosed institutions into the community. He termed this the spread of the "carceral net" and noted one important implication as the tendency to remove the distinction between crime and abnormality [1979]. As a result, the departure from the norm, the 56 anomaly, the slightest irregularity in conduct had the potential for a new ascription of deviance, and subsequent punishment. The paradigm of deviance as sickness has influenced the treatment and rehabilitation approach. Foucault [1979] noted that rehabilitative and treatment modalities have become preludes to the punishment of the soul, rather than the body, and an attempt to "normalize" deviant offenders by enforcing corrective behaviours. Foucault, therefore, had raised the concern that social control measures in the hands of a professional elite holding a knowledge/power interface, have become more hidden from public view. Both McMahon [1992] and Foucault [1979] discussed the critical relationship between knowledge and power as they affect social control policies. McMahon noted: "..first, that the social formation of knowledge, and the exercise of power, intersect with and mutually reinforce one another; second, that knowledge is fundamentally ideological; and third, that one's frame of reference both defines and limits the story that can be told" [McMahon 1992:209]. McMahon noted that a particular contribution of Foucault's work has been the recognition of the interactive, reinforcing roles of knowledge and power within the penal system. 57 While Foucault [1980] took a negative view of this power/knowledge interaction, McMahon argued that the power/knowledge interface has not always been negative. She cited examples of positive results in improved living conditions and rehabilitative programs. Burtch [1992] noted that the strength of McMahon's argument is her call for a more balanced perspective in the application of power in the penal system. Garland [1990] disagreed with Foucault's premise that social control has become hidden from the public, suggesting instead that as a result of modem media, the viewing arena is now the individual living room. Garland also objected to Foucault's thoroughly negative evaluation of power in that it does not compare different sources of power and thus offer some alternate solutions, but instead attacks the entire concept of power. Garland moved the argument of how we treat offenders away from the power/knowledge paradigm to that of culture. He noted that the prison has long been a part of the community and that culture, reflected in current mores, sensibilities and perceptions determines what is acceptable and permissible punishment. Thus, not just intellectual systems, but thought and feeling, are involved in a socially constructed model of how we punish offenders. However, this determination of guilt and punishment rests, finally, in the hands of those who hold power. As well, the treatment of offenders, established by correctional policies, seeps back into and pervades the community. For example, euphemisms and other terms 58 developed to describe prisoners, such as "inmate," "offender," "degenerate," "feeble- minded," "psychopath" soon become a part of the common coin of language. Ignatieffs [1978] analysis noted the constraints of institutionalized structures of social power and the invisible pressures of the dominant class culture, in effecting punishment and reform measures. The more recent theoretical approaches of post-modernism, and in particular feminism [Harding 1986, Rosenau 1992, Smart 1990, Weedon 1987] raise significant questions about the status and power of knowledge. Sociological research has failed either to definitively explain criminal behaviour, or to solve the problem of crime. Postmodernism calls, not for more scientific activity and better theories, but for different questions and new paradigms [Smart 1990]. This has led to a focus not upon the power/knowledge paradigm, but upon group domination and oppression of powerless groups. It may be argued that the phenomenon of oppression is integral to social control. "Oppression," as used by the new social movemenst, may be defined as the disadvantage and injustice experienced as a result of the everyday practices of a well-meaning liberal society [Young 1990]. For example, this oppression includes systemic constraints on groups, and in this sense is structural and embedded in the system. As such it can also be "mindless" or unthinking oppression. The causes of such oppression lie in the typical experience of normal, everyday processes of social life, and the unquestioned norms, values, habits, symbols, assumptions, and rules, 59 on which those actions are based. Material forces such as class structures and economic interests are also a part of this embedded oppression. Members of the new social movements argue that we cannot eliminate structural oppression by bringing in new rulers, or by creating new laws, because oppression is systematically reproduced in the major institutions of economy, politics and culture. Rather, there must be fundamental changes to structures and a "new way of seeing things" [Smart 1989:1] which will result in changed perceptions, an insight into what constitutes systemic oppression, and what represents positive change in society for oppressed groups. Habermas [1984] considered the newer social group movement an historical evolutionary process, as well as a reaction to the inadequacies of more conventional approaches. He stated that such group movements tend to take either an offensive or defensive [resistance] stance. Scott [1990] considered it problematic to classify new social movements as either political or lifestyle oriented, because some of them are both. Resistance/lifestyle issues are often combined with pressure group activities. For example, contemporary environmentalist groups have forced changes in policies as diverse as baby seal killings, whale hunting, forestry practices. Pro-life [anti-abortion] and pro-choice [pro-abortion] movements struggle in opposition to one another. Contemporary social movements such as black liberation, feminists, and disability groups, embrace a political philosophy which is based on concepts of 60 domination and oppression [McMahon 1992]. Minority groups such as ethnic groups, prisoners' rights groups, and the disabled have adopted the rhetoric of the civil rights movement. They combine both resistance to domination and oppression, and a proactive attitude in order to remove culturally embedded barriers which affect them in society. Such groups may be considered special interest groups rather than social movements. This may be only a semantic difference, because they personify a gradual evolution in social attitudes and actions. Crichton, Hus and Tsang [1990] and Jongbloed and Crichton [1990] in discussing Canada's health care system noted the activities of organized pressure groups by persons with disabilities to promote their right, not only for self-help but to change government policy. In response to the United Nations [1983] declaration of the International Year of Disabled Persons, governments were forced to respond to policy issues. Since then, the disability movement has done much to change public attitudes about people with disabilities. Young [1990] noted that problems in society flow not from problems of the individual, but rather from problems of the group. The oppression that minority groups experience is not individual so much as group oppression. Oppression happens to social groups and is a result of structural conditions and contradictions that produce and perpetuate social problems. Bolaria [1991] provides a succinct analysis of this thought, noting also that not only has there been a shift from the medical model of deviance in analyzing social ills but also in social values and norms. He notes the need to begin to establish connections between personal troubles and 61 public issues. Thus, we may conclude that the personal problems identified in a powerless, deviant sub-group such as prisoners with impaired hearing may be indicative of a much larger social problem of social oppression and resistance. Critiques of the biomedical perspective on deviance Critics of the biomedical perspective on deviance express concern that the medical profession and other aligned social and health care professions have attained a high degree of control over the way in which deviance is defined and managed. In the advanced welfare capitalistic state, dominated by government bureaucracies, huge corporations, and highly skilled professionals, certain types of deviance are seen as sickness, requiring 'correction' in the form of disciplinary measures, treatment and rehabilitation [Little 1989]. Where crime is seen as the result of sickness or madness, the individual is absolved of responsibility. Social control of offenders is placed in the hands of specialists, with medical, psychiatric and social scientists, plus social workers, counsellors and probation officers, sharing in social control decisions with the courts. Treatment/rehabilitative measures instituted include surgery, drugs, mandatory therapies such as group behaviour modification, and aversion therapy. Thus, while social control measures have been increasingly defined in medical terms, the responsibility for health problems has been diffused to a wider sphere of disciplines [Ajzenstadt and Burtch 1990]. 62 Little [1989:341] noted "a subtle shift from a view of people personally responsible for their own behaviour and who are judged guilty or innocent by citizen peers to a view of people who are irresponsible and whose behaviour calls for evaluation by elite experts." Little expresses a further concern that "Medicalized deviant behaviour loses all potential for political meaning because sickness requires no motive." For example, civil rights activists are sometimes discredited by government as a "lunatic fringe" or "emotionally unstable." Another well known example is the psychiatric institutionalization of political dissidents in the former Soviet Union. Psychiatrists thus helped to control criticism of state policies. While crime and its punishment have been medicalized, there is also a tendency in society to define a wide range of deviant and problematic behaviours as illness [Kleinman 1980, Mechanic 1968]. Parsons [1951] saw social control/power as a health/illness process in which medicine creates illness as a social state. O'Neill [1986] used the phrase, "the medicalization of social control." Illich [1977] in Medical Nemesis attacked the sociopolitical trend of health care. This trend features the expansion of corporate, bureaucratic, centralized control over people's lives. Social policy is formed on the basis of the medical profession's perception of need and to support professional institutions, thus undermining the rights of individuals for autonomy and control over their lives. Waitzkin and Waterman [1974], Friedson [1970], Waitzkin [1984] and Mischler [1981] argue that certifying physicians tend to serve the interests and ideology of dominant groups in society, including their political 63 and economic interests. Much of the fate of the individual offender with a disability such as unidentified impaired hearing, therefore, rests on the "gatekeeping" power of the physician, the policies of an institution with regard to health procedures such as routine hearing screening, and the political and economic considerations which affect policy development. Perspectives on the experience of institutionalization Various studies have documented the experience of being institutionalized. Goffman's Asylums [1961] portrayed life in mental hospitals as a humiliating experience that stripped individuals of their identity and self-esteem and induced a variety of deviant adaptations that were reactions to institutionalization. Later studies [Linn 1968a, 1968b; Weinstein 1979, 1983] have not substantiated the profoundly negative conception of Goffman's findings. These studies found that some patients did not feel betrayed but considered the hospital to be a refuge, and felt helped by hospitalization. Some patients from disadvantaged backgrounds found the hospital experience less depriving than their customary life situation. While the experience of institutionalization may not be, for all individuals, as absolute as Goffman depicted, the description of being stripped of their usual identity, rendered powerless, and labelled according to a condition, remains a classic depiction of the process of institutionalization. In a more recent study, Thorne 64 [1993] stated that chronically ill patients reported feelings of powerlessness, helplessness and despair during their hospitalization experiences and encounters with the health care system. The institutionalization experience for a prisoner is distinct from other types of institutionalization such as hospitalization, in that prison incarceration is punishment. The prisoner has undergone public moral condemnation and bears that unique stigma. Prison is designed to "deprive of liberty...and inflict mental suffering in ways which satisfy a punitive public" [Garland 1990:166]. Foucault [1979] described the prison experience as corrective. Correctional service attempts to normalize the individual through assessing behaviour and measuring it against the rule. Surveillance and examination procedures are in effect to identify instances of non-conformity or departure from set standards. Infractions are recognized, recorded and dealt with. The prisoner is powerless to control this monitoring and recording. Foucault termed the prison the disciplinary mechanism which fashioned the delinquent [dangerous individual, needing supervision] from the offender [mere violator of laws, needing no supervision]. Gosselin argued that the penitentiary is a breeding ground for criminals and provides an apprenticeship in criminal techniques [Gosselin 1982]. He noted that, though most prisoners are not violent, the repression of the prison experience, coupled with isolation and lack of stimuli contributes to increased aggressivity and personality breakdown. Alienation is a part of the prison experience. Contact with the 65 outside world such as family, friends, and lawyers is limited and monitored. Mail is opened. Conversation during visits may be monitored. Visits are considered a privilege, not a right. Culhane [1991] described the constant humiliation, frequent beatings, refusal of urgent medical attention which characterize daily life in a prison. The dehumanizing experience of solitary confinement is a possibility. Culhane [1985:22] described solitary confinement as a "prison cell characterized by insanity, fear and violence." As well, the stigma of the "ex-con" awaits on release from prison. The incarcerated individual has become a part of the "criminal fraternity", a "social failure" [Garland 1990]. The prisoner must assimilate into the prison culture in order to survive [Cordilla 1983]. Prison incarceration provides additional difficulties which are unique to persons with disabilities. Prisons have been designed for custodial purposes, not for special needs of prisoners with disabilities [Stykes and Gee 1994]. Powerlessness, dependency, and alienation are thus amplified for the prisoner with a disability. Summary of the literature review The available literature on hearing impairment shows that powerlessness, helplessness, and dependency are typical acquired characteristics of those with adventitious hearing impairment. There is, however, a lack of research which examines the relationship between the hard of hearing condition and perceptions of deviant behaviour as it relates to the powerless such as criminal 66 offenders. The literature shows that social class differentiation and power differentiation are operative in the perception and construction of deviance. Authors from the 1960s focussed on the power invested in the rule enforcers who make subjective judgements of behaviour based upon their interpretation of such rules, rather than on the power of the rule makers. Theorists of the 1970s and 1980s provided a critical examination of the political aspects of power and control in a power-hierarchical model, and consider political dynamics as more important than interpersonal dynamics. This approach leads to the conclusion that individual and group problems are indicative of broader social problems. Both of these interactional and political perspectives are germane to an exploration of perceptions of powerlessness and deviance definition in the sub-group of prisoners with hearing impairment, within a prison population. Of particular relevance within this discussion are: self-perceptions of influence of hearing impairment on their state; perceptions of custodians; perceptions of other inmates; and ways in which the problems of this sub- group are indicative of broader social issues. The theoretical foundation established by this review of literature thus provided a basis for, and directed the shape of, the methodological approach taken to the study. In Chapter Three the methodology for the study will be described. 67 CHAPTER THREE ASSESSING HEARING IMPAIRMENT IN PRISONERS: METHODOLOGY "The theme that comes to mind when being asked about the effect of hearing loss concerns communication. I see situations where people are talking with one another and I may not be able to hear and follow the dialogue. Observing the process of communication, what I often saw was people were so self-conscious and eager for acceptance from others. I saw the flickering quality in people's eyes, how they were looking around for confirmation and information as to how others perceived them. They were preoccupied with their own image. They were simply not very present with each other, not really relating directly from one being to another. Thus, I saw the insecurity in many, possibly the same insecurity I could sometimes feel in myself and in my body when not fully participating in a group conversation. Again, I saw how vulnerable people are. Hence, a common thread in my perceptions and memories associated with hearing impairment is the human experience of vulnerability" [Gustavsson 1993:330]. Introduction In the preceding chapters, the literature review indicates that partial hearing loss in individuals is often difficult to identify. This may be due to individual actions of concealment or unawareness by the afflicted individual, or by others. It may also be due to policies and practices embedded in institutional systems, which overlook hearing as a variable in the person's health and social spectrum. By virtue of their powerless status, prisoners may be particularly vulnerable to neglect, or unacknowledgement, of hearing problems. Accordingly, this study investigates several questions: (a) What is the percentage of hearing impairment in prisoners of federal prisons in British Columbia compared to in the general population? (b) What are the existing methods for identifying hearing impairment in federal prisoners in British Columbia and are they adequate? 68 (c) Are custodians aware of the range of attributes associated with partial hearing loss ? How do custodians characterize the behaviours of prisoners who have impaired hearing? (d) What labels do custodians attach to behaviours of prisoners who are hard of hearing? (e) How do hard of hearing prisoners interpret their hearing-impairment- associated behaviours and how does this compare with custodial interpretation of these behaviours? This chapter reviews the theoretical considerations which shape the study design. As well, it explicates the methodology and implementation process of the study. This includes limitations and difficulties presented, how these factors were addressed, and where possible, overcome. Definitions of terms employed in the study are found in the Glossary. Study design The design of the study design follows the procedures identified in Figure 1. In essence, methodological considerations were developed after a review of literature and documentary examination, the identification of issues, and the development of appropriate research questions. 69 Figure 1. Study design Literature review >J_r T Problem Identification V Research questions Y Subject recruitment SurvevV Interviews with y  " A -prisoners with impaired hearing —\ Hearing / -comparison group/normal hearing ] screening -custodians  AJ Hearing V J Documentary Jt assessment? examinations Y Analysis • Findings and report - 70 Methodology This study is descriptive in nature. The study utilizes the techniques of survey and audiometric examination, interview and documentary examination in addressing study objectives. The goal in descriptive research is to adequately describe the phenomenon of interest as found in the population to be studied, therefore accuracy is important [Palys 1992]. Therefore, the emphasis in descriptive research is on minimizing bias, maximizing sample representativeness, and reliability and validity of measurement tools and strategies. Palys [1992] addressed the question of bias. Bias may occur in various areas. Questionnaires generate a large amount of data, but volunteer bias must be considered in relation to lower response rates and hence less sample representativeness. As well, literacy and vocabulary affect response rate and content, therefore clarity and unambiguity of questions is important in questionnaire construction. Interviews tend to have less problem with volunteer bias. Participation rates are higher than with questionnaires and the researcher is present to clarify any ambiguities. Literacy level of the respondent is not an issue since the researcher asks questions and records replies. The anonymity of questionnaires is sacrificed in the interview but it is suggested that the personal interaction of the face-to-face setting will generate a rapport between interviewer and subject, and reduce concerns about confidentiality. In establishing rapport, however, the interviewer must guard against 71 reactive bias in the subject. Reactive bias may relate to subject sensitivity to researcher behaviour, both verbal and non-verbal, which may be interpreted to suggest that the subject is giving "good" or "bad' responses to questions. To maximize sample representativeness, the study design called for the survey of the entire population of inmates of federal prisons in British Columbia. No sampling technique was to be used in the survey of the prisoners. Sampling was planned for interviews with custodians, with the selection method modified to meet the requirements of the prison staffing rosters, as discussed later in this chapter. Reliability and validity are issues in constructing assessment devices and methods. Reliability refers to the ability of the data-gathering device to obtain consistent results. Reliability of a data-gathering device such as questionnaire or interview format may be affirmed through pre-testing in a pilot study or through utilization of forms and scales from prior research. Where original scales and forms are developed, as for the interviews in this study, the issue of reliabiity must be further confirmed in subsequent study usage. Validity refers to the ability of the device to test what it is actually supposed to test. In this context, validity is demonstrated through the comparison of data with the operationalized definitions. External validity refers to generalizability of findings to other people, other settings and other times. Generalizability does not 72 depend on how representative the sample population is, but rather on the nature of the phenomenon studied, and its applicability to populations other than the sample. In a descriptive study, with a small sample population, care must be taken not to generalize beyond the study group. However, study findings can suggest the need for further studies and replication can improve the generalizability value of original findings. a. Establishing the presence of impaired hearing The presence of impaired hearing was established by means of audiological measurement and self-report questionnaire. This questionnaire collected information related to socio-demographic variables such as health and lifestyle factors, and age, sex and marital status [Treece and Treece 1977]. Complementary methods of research including documentary examination from individual health files and from public statistical sources served to cross-check the validity of the study data. b. Establishing the meaning of context-bound behaviour The individual interview was utilized as the main technique to determine the subject's social perception of observed behaviour. The interview followed a semi- standardized format in which the subject was asked a series of standard questions, followed by an opportunity to add comments, and expand on the topic as desired. 73 c. Research instruments This exploratory dissertation rests on several methodological approaches to the questions under investigation. Intrinsic to the approach was the development of research instruments. Research instruments employed in the study included a self-administered questionnaire for prisoners [Appendix A], etiologic test instruments for hearing screening [Appendix B] and for hearing assessments [Appendix C]. Instruments utilized for hearing testing included otoscope, audiometer, impedance bridge, industrial audiometric testing van with sound-proof booth, and sound meter [Glossary]. Instruments involved the self-administered questionnaire [Appendix A], semi-structured interviews for selected inmates with impaired hearing [Appendix D] and without hearing impairment [Appendix E], and interviews with custodians [Appendix F]. Documentary examinations were utilized to check data. Survey and interview tools were pre-tested by myself, as researcher. Hearing test instruments were subjected to pre-testing and standardized calibration by professional technicians who supplied the equipment [Melnick 1991]. 74 d. Funding for the study The search for funding revealed that social aspects of hearing-related research are considered to be low priority in many areas. This accorded with the low priority given to the social aspects of hearing-related research in the biomedical model of health, mentioned in Chapter One, and to the pioneering nature of the research. While the Correctional Service of Canada, Pacific Region, gave permission to undertake the study, they provided no funding on the grounds that the study was "not directly related to any of the eight Corporate Objectives currently driving all Correctional programming" [see Luck, 1991. See also Chapter 6]. However, assistance "in kind" from the Correctional Service of Canada, Pacific Region was provided through the initiative of the Project Manager, who photocopied the questionnaire and arranged its distribution through the correctional service mail system, to Health Unit contacts in the eight prisons. Other interested sources provided assistance through loans of equipment or donation of funds. Items loaned for the study were: a portable audiometer for hearing screening by the Audiology Department of Vancouver Health Department; an impedance bridge from the Hearing Conservation Department of Workers' Compensation Board; an otoscope from the Audiology Department of Vancouver General Hospital. Funds donated included an individual's donation to cover cost of rental of the sound meter. Awards from the Canadian Federation of 75 University Women and the Elks Lodge #1, Vancouver, were applied to the rental of an industrial audiometric van and the cost of employing an audiologist for hearing testing. e. Preparation and pre-testing of research instruments Instruments utilized for hearing screening and hearing assessments were acquired from professional sources who attested to the equipment's calibration and reliability. I was trained by a certified practising audiologist to carry out the initial hearing screening, and was pre-tested for reliability in screening procedures. The same certified practising audiologist was employed to conduct all hearing assessments and prepare accompanying reports. The audiologist was a part-time employee of Vancouver General Hospital [VGH] and had prior contact with prisoners [other than those involved in the study], as clients in the VGH audiology department. For late additions to the study during the hearing van phase, the same audiologist conducted the hearing screenings, in conjunction with further testing if needed. All interviews were conducted by the primary researcher. Survey questions were constructed, bearing in mind the goals of the study, the character of the study population, and Torabi's [1991] suggestions to improve response rates in mail survey questionnaires. Thus, simple clear instructions were provided for the completion of 21 questions in the first self-completion 76 questionnaire. A closed-end 'check-off format was utilized to reduce subject sensitivity in this area. Torabi notes that respondents feel more confident of anonymity with closed-end questions that require no identifiable handwriting. Closed- end questions were employed in a progressive format, moving from common demographic data, through details related to incarceration, and hearing-related data [Appendix A]. Questionnaires and envelopes were coded for confidentiality. Only the primary researcher had access to the coding list. A form was constructed for semi-structured interviews with custodians [Appendix F], based upon characteristics associated with hard of hearing behaviours, developed from literature by the researcher [see Table 3]. Completion of this form provides consistent, measurable indicators of perceptions of behaviour. Along with an interview which permits spontaneous exploration and expansion of personal opinion and experience, this form would provide more information and understanding of the social reality of the subject's experience. A form was also constructed for semi- structured interviews with prisoners who failed the hearing assessment [Appendix D], and for a comparison group of prisoners who passed the hearing screening [Appendix E]. 77 Table 3. Characteristic behaviours of adults with impaired hearing .Does not hear when spoken to from another room. .Does not hear/understand when spoken to from behind. .Frequently asks for statements to be repeated. [Says "eh?" and "what?" a lot]. .Frequently gives incorrect or inappropriate replies. [Often guesses, often wrong. More misunderstandings and arguments with others than the average person, over what was said]. .Watches closely the facial expression of the speaker. [More use of eyes, always watching]. .Strains forward to hear. Turns one ear towards the speaker. .Frowns or looks puzzled during conversation. [Startled looks, perplexed looks]. .Frequently nods head as though understanding the conversation but continues to nod inappropriately or otherwise reveal non-understanding of what was communicated e.g. does not get the punch line of a joke. .Understands at one time and not at another [giving rise to the impression that s/he hears only when s/he wants to]. .Complains about the way people talk nowadays. .Does not understand the speaker if any physical barriers intervene, for example a teller in a cage or a clerk behind a transparent barrier. .Reacts inappropriately in a situation through having misunderstood or missed significant sections of what was said. .Has difficulty hearing on the telephone. May hear better on telephone with one ear than the other. [Uses the telephone less than others do]. .Not aware of environmental sounds which are signalling others, such as music, birds, wind, oncoming train, fire alarm, telephone, doorbell. Turns television and radio up louder than is comfortable for other listeners. .Is quiet in social situations, does not participate actively in group conversations. This applies in classroom situations also. Jerks head around to locate speaker. .Impatient with interruptions [focuses on one speaker and is frustrated by interruptions by another speaker]. .Understands one speaker but not another, in the same situation. .Appears to be confused about the topic, or decisions taken or to be taken. .Indulges in inappropriate social behaviour within group conversation by for example, picking up a book or magazine to read, or otherwise separating self from the group. Tends to seek out one person to talk to in social situations. Tires more easily than others do in social situations, may fall asleep. .Rejects invitations to social events. .Avoids strangers. .Complains of head noises. .Has a very loud or very soft speaking voice. A person who is hard of hearing may, typically, manifest one or more of these behaviours. 78 The questionnaire was pilot-tested on a group of 10 ex-offenders recently released and living in Vancouver. The survey form for interviews with custodians was reviewed with one official of the Pacific Region, Correctional Services of Canada, and was modified through the removal of one question which the official noted would be inappropriate to ask. The semi-structured interview form for inmates was pre-tested on a hard of hearing ex-offender living in the community. As a pretest for reliability, I conducted hearing screening of three individuals, and the results compared favourably with the results obtained by the audiologist. The following description of the study procedure demonstrates how the study questions were addressed. f. Determination of study population The study population included prisoners of federal prisons in the province of British Columbia. There are nine institutions within the Pacific Region of the Correctional Services of Canada, eight of which are located in the Fraser Valley area and one on Vancouver Island [Table 4]. The population is predominantly male [one female at time of study]. Prisoners are incarcerated in nine federal prison facilities rated from minimum to maximum security. The population of the facilities ranges from 20 to 320 inmates. An example of fluctuations in population levels is shown in Table 4. As depicted in Table 4, the census for the federal prisons varies. 79 For example, the total population of federal prisons in British Columbia was 1808 on July 10, 1992, at time of distribution of the first letter of introduction to the study, with consent forms to participate [Appendix G]. It was estimated that about 100 prisoners would not receive the consent form and letter since "some will be in outside hospital, some will be in segregation, some will be in outside court, etc." [Hickey 1992]. The total number of request forms distributed to inmates of nine institutions was 1439, which means that 369 prisoners did not receive information about the study at that time. Table 4. Typical prisoner population, institutions of the Pacific Region of The Correctional Services of Canada. INSTITUTION Kent William Head Matsqui Mountain Mission Ferndale Elbow Lake Reg. Psych. Centre Sumas TOTAL CENSUS SECURITY LEVEL maximum medium medium medium medium minimum minimum tri-level minimum [day parole] POP. 1992 280 186 339 347 251 110 100 163 38 1808 POP. 1993 227 197 310 316 231 109 87 133 32 1642 POP. 1994 286 226 340 346 277 90 83 165 38 1959 80 Table 5. Prisoner volunteers for study INSTITUTION RPC William Head Matsqui Mountain Mission Ferndale Elbow Lake Kent Sumas TOTAL LETTERS DISTRIBUTED 125 133 249 289 232 110 90 188 23 1,439 SIGNED CONSENTS RETURNED 41 27 32 52 30 5 2 28 0 217 (15%of 1.439) One factor which influences prisoner population data is the movement of prisoners from one institution to another, either for treatment or program purposes. Therefore, subjects who completed questionnaire #1 in one institution and are coded in the study as a part of that institution's population, may later have been a part of the hearing screening and/or hearing assessment in another institution. Nevertheless, the prisoners remained as part of the study population. As well, new subjects were added as the study progressed. With the added visibility of the industrial audiometric van on the prison grounds, an increasing number of prisoners became aware of the study and asked to participate. This was particularly so in the medium and minimum security institutions, where prisoners move freely about within prison perimeters, and could 81 approach the van. In consideration of these facts, the report and analysis of findings will not provide detailed breakdowns of the study subjects by institutions, but will do so for the total study sample of prisoners. One smaller facility with under 40 prisoners, Sumas Correctional Centre, which houses day parolees, had no volunteers for the study, so findings are based on the other eight institutions. Table 6. Study sample. n=189 Volunteered Completed questionnaire Hearing screened Audiological assessment 240 189 = n [study sample] 144 [76% ofn] 92 [49% ofn] To encourage support and participation, information about the forthcoming study was supplied to all staff, to inmate committees, and to the Native Brotherhood. A memorandum informing of the study was sent from the Special Projects Manager of the Regional Research Committee of Correctional Services of Canada to all institutions which would be involved in the study. A letter of explanation from the researcher with a consent form was sent individually to all inmates [Appendix G], and a similar introductory letter was sent to senior prison custodians for distribution to all staff, prior to the study commencement [Appendix H]. Key prison custodians were provided with a description of the steps of the study, and approximate timetable. Chiefs of Health Care in each institution were kept informed 82 of each phase of the study by the Project Manager at first, and later directly from the researcher. Ethical considerations were addressed by conforming to the University of British Columbia's Screening Committee for Research Involving the use of Human Subjects. All subjects were free to refuse to answer any questions or to withdraw from the study at any time. Subjects were informed that confidentiality and anonymity would be maintained. g. Self-definition of hearing impairment All prisoners who returned a signed consent form received the first questionnaire. The objective of this questionnaire was to determine self perceptions of hearing status [Appendix 1]. The questionnaire was sent by the correctional service mail, in individually addressed and sealed envelopes, to the staff of the health care unit of each institution for distribution to prisoners. Completed questionnaires were returned by the same route to the researcher, unopened by custodians, via the Regional Headquarters of the Correctional Service of Canada. Subjects were encouraged to seek assistance with completion of the survey form, as needed. Two weeks later, individuals who had volunteered but not returned completed questionnaires, were sent a second letter and copy of the questionnaire. 83 h. Hearing screening The opportunity for audiometric screening was provided to all prisoners in federal prisons in the Pacific Region. Hearing screening by the researcher was undertaken for all of the subjects who returned completed questionnaire forms, and were available at the time of the researcher's scheduled visit to the institution [see Chapter Four]. Hearing screening utilizes pure tone audiometric testing, to determine if the subject's hearing is essentially normal or if more detailed testing is indicated [Martin 1991]. To ensure inter-test reliability, the screening took place in a private room in each institution. The room was identified as acoustically acceptable by the researcher through use of a sound meter. To ensure validity, the cut-off point for measurement was set at 20 dB HL which favours sensitivity over specificity [Konkle and Jacobson 1991, Northern and Downs 1984]. According to public health terminology, "sensitivity" refers to the accuracy of a screening test in correctly identifying the "positive" [abnormal] subjects. "Specificity" refers to the accuracy of the screening test in correctly identifying the "negative" [normal] subjects. Thus, pure-tone air conduction screening measured bilateral hearing sensitivity of each subject at frequencies of 1000 Hz, 2000 Hz, and 4000 Hz at a loudness level of 20 dB HL [Katz 1978, Belenchia and Crowe 1983]. Last explains: 84 "Screening tests sort out apparently well persons who probably have a disease from those who probably do not. A screening test is not intended to be diagnostic" [Last 1986:96]. Therefore, subjects who tested positive on hearing screening [i.e. those who were identified as "at risk" for hearing loss] became candidates for hearing assessment, to establish presence of impairment and determine degree of loss. i. Hearing assessments As noted above, hearing assessments followed the initial hearing screening process. Hearing assessments were carried out in an industrial audiometric van containing a sound booth, which was driven into each prison compound, in order to provide a secure, consistent and acceptable environment for testing [Roberts 1992]. All assessments were conducted by a certified and practising audiologist. Hearing assessments consist of a more detailed examination of hearing than does hearing screening, and can indicate degree of hearing loss and presence or absence of pathology in the middle or inner ear. Such assessments include pure tone air conduction thresholds for octave frequencies of 500-8000Hz; and immittance audiometry [middle ear testing] which includes tympanometry and screening for acoustic reflex thresholds and reflex decay at 105dB SPL [1000Hz] using a Madsen impedance audiometer ZS76-1. Otoscopic examinations were also done [Glossary]. 85 This range of assessment was deemed to be sufficient for the purposes of the study, that is, to identify presence of hearing loss [Martin 1991, Roberts 1992]. A complete audiological examination would include both pure tone testing and speech discrimination. The speech discrimination test measures the level at which selected words can be understood, and thus provides an estimate as to how well the individual might function outside of the testing booth. However, the estimate is only an "educated guess" because in normal situations, background noise can compromise the ability of the hard of hearing person to understand speech [Moore and Roy 1986]. Therefore, it was recognized that it would be necessary to conduct individual interviews, in order to explore the meaning of the hard of hearing experience for the individual prisoner. j . Identification of perceptions of hard of hearing behaviour The individual interview was the main technique employed to identify meaning attached to particular behaviour. The interview with hard of hearing prisoners averaged 25 minutes, accompanied by note-taking. Specifications were established for the variable "deviant behaviours" to include the type and number of behaviours associated in literature with being hard of hearing [Table 3] that are perceived as unacceptable, non-compliant, stubborn, or abnormal behaviours by custodians. This portion of the study largely utilized verbal 86 descriptions. The variable "labels" was defined as descriptions such as words, phrases, or sentences that are used by custodians to describe or categorize characteristics and attributes associated with being hard of hearing and manifested or experienced by those in particular institutions. Use of this approach resulted in cross-tabulation of attributes and corresponding labels used, as well as descriptions of interpretations. The variable "interactive relationships" was derived from the interpretations given by custodians of specific communicative behaviours and gestures from a list derived from the literature, and the result of the survey of prisoners with partial hearing loss. The interpretations were further tabulated according to one of two outcomes in relationships: positive or negative. For example, self-imposed isolation by an inmate may lead to a positive or negative relationship with a custodian, as would sustained eye contact, or a quiet, retiring disposition. The interviews with custodians focussed on their interpretation of probable relationship with inmates exhibiting certain behaviours that they consider "normal" or "abnormal" but which are associated specifically with hearing impairment. k. Interviews with custodians A selection of custodians was interviewed from each institution, including those in categories of correctional officers one, two and three [CO.1, CO.2, 87 CO.3], nurse, manager and supervisor, medical doctor, psychiatrist, psychologist, social worker, and teacher. As staff numbers vary with the size of institutions, and some personnel [e.g. social worker, psychiatrist, psychologist] serve more than one institution, this number varied from one site to another, but averaged six staff per institution, and totalled 41. Custodians were interviewed individually in a semi-structured interview format, to fit with the exploratory nature of the research. The duration of the interview averaged 25 minutes, and included notetaking. Opinions were elicited in regard to their perceptions of the meaning of specific behaviours which are associated with hearing impairment, within the context of their work experience, and their interpretation of the effects of such behaviours on relationships with subjects [Appendix F]. Through open and axial coding of data [Strauss and Corbin 1990] specific themes and categories began to emerge in the behavioural interpretations provided by custodians. Axial coding involves putting data back together in new ways, after open coding, by making connections between a category and sub-categories. [For examples, see Supplementary Table L-6 which involved reorganizing data according to custodial categories, and Supplementary Table L-8, which cross- referenced custodial interpretations with prisoner interpretations of behaviours]. As a result, labels were derived from the coding. Each interpreted relationship was 88 classified under the categories of "defiant, deficient, or defective" behaviours. "Defiant" types of behaviour included aggression, rule breaking, anti-authoritarianism, irresponsibility or lack of effort. "Deficient" types of behaviour included deficits in intelligence, education, or social skills. "Defective" types of behaviour included physical or personality defects or mental illness. The category of "Neutral" types was added, to include responses such as, "don't know," "normal" and "hard of hearing" or similar labels which indicated recognition of a possible hearing problem. Due to policies of the correctional institutions, it was not possible for the researcher to randomly select custodians for interviews from a list - the liaison person in each institution selected custodians for interviews, from custodians "on duty" at the time of the researcher's visit. However, while on-site in four out of seven medium to minimum security institutions it was possible for the researcher to approach some other custodians at random and ask them to participate in the study, when it would not interfere with the completion of their duties. With the exception of two Correctional Officers 1 in one medium security institution, all custodians readily cooperated in interviews. Both of these avenues of selection resulted in a random sample of subjects. Chapter Four expands on the results of interviews. 89 I. Interviews with prisoners Of the prisoners who failed the hearing assessment, 46% [n=42] were interviewed to determine the relationship between impaired hearing and behaviour in both pre-incarceration and incarceration situations. This group represented 29% of the total number screened [n=144]. The interview incorporated a semi-structured format which provided prisoners with the opportunity to express how they perceived their behaviours were interpreted by custodians and other inmates. Duration of the interview was 25 minutes, on average, accompanied by notetaking by the interviewer. In regard to hearing difficulties, no special strategies or assistive devices were utilized, or required, for the interviews. Interviews took place in an acoustically quiet room, on a one-to-one basis which facilitated both hearing and speechreading [lipreading]. Where there appeared to be a difficulty in comprehension on the part of the prisoner or the interviewer, pen and paper were employed. m. Interviews with a comparison group of prisoners A comparison group of prisoners who had passed the hearing screening, totalling 27% [n=39] of total screened [n=144] were interviewed using the same format and minus the questions specific to one's own hearing loss [Appendix E]. This interview averaged 15 minutes, accompanied by notetaking. The number of 90 prisoner participants in both interview groups was controlled by the number of prisoners available for such interviews. Availability was governed by the fact that they were in the institution when the researcher was present, and not busy in a program at that time. Interviews were also used to examine these normal hearing prisoners' perceptions of the relationship between impaired hearing, and incarceration. n. Design for data analysis The design for data analysis involved data reduction, including quantification, data display, conclusion drawing, and verification. These activities proceeded concurrently throughout the study. Thus, reduction of raw data through coding, cross-comparison, and graphic display led to the identification of specific themes. Strauss and Corbin [1990] note that the coding process is based on two analytic procedures, although their nature changes with each type of coding. These two procedures pertain to the making of comparisons and the asking of questions. Information obtained from questionnaires was compared with information from documentary examinations to identify differences between numbers of individuals previously identified officially as having hearing impairment, and those identified through audiometric assessment in this study. Analysis included cross-tabulation of survey, interview and documentary data including audiometric testing, for comparisons and cross-validation. Thus, both verbal and numerical designations were used to analyse and report results. 91 Liberal use of verbatim quotations from individual informants complements the survey findings. Each such reference illustrates an element which is characteristic of the shared experience of the subject and adds to "thick description" [Geertz 1973:5, Scheff 1986], with its promise of depth, quality, and richness in the research findings. o. Documentary examinations Documentary examination of inmate health files was used to obtain medical diagnoses and related behaviours, and note the incidence of hearing admission tests. All documentary examinations and data comparisons were conducted by the primary researcher. Review of the health file provided a check on demographic statistics received in Questionnaire # 1; and data specific to health status and assessments by medical personnel. Limitations of the study Certain limitations are inherent in an exploratory study of this type. The study was limited to the province of British Columbia, and the findings are not generalized beyond the population studied. Prisoners in B.C. may not necessarily have the same characteristics as prisoners in other provinces in Canada. For 92 example, proportions of various races may differ from one institution or province to another. The design of the study, taken over a length of time, suggested a need to select subjects who were incarcerated, and, therefore, more likely to be accessible during the time period of the study. Prisoners serving sentences of two years and more are incarcerated in federal prisons: minimum, medium or maximum security institutions. Inmates of provincial prisons receive sentences of less than two years; therefore, inmates of federal prisons were more likely to remain incarcerated over the length of the study. In consideration of logistics and resources, prisons in the Pacific Region of The Correctional Service of Canada were selected for the research. This study focussed on male offenders, given that males predominate in prison populations [Adelberg and Currie 1987]. It is recommended that a similar study should be undertaken with female prisoners to determine if the same findings hold true for females as for males. It was initially speculated that factors such as racial origin might influence the study. For example, there is a 50% incidence of hearing loss in Inuit and Indian [First Nations] children in northern Canada [MacDougall 1990]. This is believed to be partly genetic and partly environmental [e.g. high noise levels] in origin. Such hearing impairment is mainly a result of chronic otitis media [middle ear infections] and may resolve as the child grows older. It is not known how many of this cohort retain a hearing impairment into adult years, and it is possible that a 93 predominance of such inmates in one prison population might influence outcomes. Furthermore, hearing impairment during formative years may have had a negative effect on language and education acquisition. This will have a continuing negative effect on the individual even though the hearing has improved later and the person is, therefore, not identified as having a hearing loss. There were not a large enough number of native Indians [First Nations people] in the study to bias the results in this regard. Security precautions in federal prisons present many limitations and hurdles to be surmounted. Incidents relating to safety and security arise when opportunity presents. To avert incidents, adherence to structure and schedule is mandatory. Spontaneity is increasingly less desirable, the higher the security level. The following is an account of these restrictions and how they were addressed. Security clearance was received for the primary researcher and audiologist, as well as for the rental audiometric testing van. Routine security checks of personnel, equipment and van were conducted on each admission and departure from every institution. A prisoner's right to privacy is a factor to be considered in research. Although prisoners had signed a "consent to participate" form in order to participate in the study, confidentiality regulations required that prisoners sign an additional form to authorize the researcher access to their health files [Appendix K]. Two subjects 94 decided not to authorize access by the researcher to their health file. Privacy is an issue for research interviews. In all institutions except maximum security, inmates arrived unescorted at the health unit for the hearing screening. In two instances, in a medium security institution, a guard escorted the subject and remained in the room. In the main, inmates were given privacy with the researcher for the screening, assessment, and interviews. In maximum security the researcher was escorted by a Correctional Officer to each living unit. Here, the screening was conducted in a windowed room adjacent to the office. A guard remained in the room with the inmate in three instances out of eleven. During the hearing assessments, security precautions required the presence of a guard in the van, during the hearing tests, and while the test results were interpreted to the subject. During the interview visits, conducted under the same situation as the hearing screenings, the guard observed through a window from an adjoining office. A sign adjacent to the window stated that conversation could be monitored and recorded. It was not possible to estimate the effect of interview monitoring on the spontaneity of the prisoner's comments during the interview. The scope and logistics of the study placed additional requirements on staff, for scheduling, arranging space and escorting the researcher and equipment, and certain inmates, within the facility, notably in maximum security. No problems were encountered in this area, and cooperation was accorded. 95 Seeking compliance from staff was viewed as a potential problem, in dealing with eight separate institutions, each with its own management structure and shift workers. To establish acceptance of the study and increase compliance, all contacts with the institutions, including materials, flowed through a central source, the Projects Manager at the Pacific Regional Office of The Correctional Service of Canada, to the wardens and the Health Units. There was evidence that copies of Questionnaire #1 were not distributed to all inmates, at least in one institution. This was confirmed by a correctional officer who stated that there was a very low level of awareness of the study among the inmates of his institution. However, there were also instances in which staff encouraged certain inmates to participate. A major difficulty for any study is that the more a researcher must depend on others for distribution, completion, or collection of research data, the less control the researcher has that these steps will be carried out, and the less the likelihood that the work will be completed. Once the hearing screening phase was completed, the researcher secured permission to liaise directly with Chiefs of Health Care in each institution, to arrange further scheduling. This resulted in quicker access and more convenient scheduling for van visits and interviews than had been the case for the hearing screenings. As well, the decision was made to accept new subjects who volunteered when they saw the van on site, if they would sign the consent form and complete the first questionnaire. 96 When designing the study, it was recognized that special strategies might be called for in seeking compliance from inmates. Therefore, information was sought from several sources [ex-offender, prison researcher, literature, The Correctional Service of Canada Regional Project Manager] about characteristics of inmates of federal prisons, in particular their attitudes to research, in order to identify strategies to promote compliance with the study. Some of these characteristics and the strategies identified for dealing with them were: (1) Resistance to research: Inmates of federal prisons have a poor record of volunteering as research subjects, or indeed of volunteering information to any type of survey. As noted by an ex-offender, prisoners tend to be very "macho," and it would damage their self esteem to admit to any type of disability [Anon. 1992]. Therefore it can be expected they will not want to have a hearing impairment detected, even more than would the average person. A teacher within The Correctional Service of Canada recently reported that the inmates hate research studies - they feel they are being put on display [Hickey 1992]. The strategy chosen was that the introductory letter emphasized that the results of the individual hearing screening would be kept "confidential," and the individual results would be given only to the subject. This may have reduced a perceived threat to self esteem. As well, a letter was added to the introductory letter, indicating support from a consumer group, the Canadian Hard of 97 Hearing Association, for this type of study, and noting the potential for results beneficial to the study population [Appendix I]. (ii) Motivation: Prisoners require motivating to participate in any program. The system "motivates" them to participate in education/vocation upgrading courses by paying them to attend, and decreasing some privileges if they do not. They are paid $4 per day to attend educational classes, the same amount they receive for their jobs inside the prison, but they could lose their $4 on the day they attended the research activity. Also, they have a full schedule of leisure and work activities and thus do not have a factor like boredom to drive them to participate in something extracurricular to their schedule [Hickey 1992]. The strategy selected was that the institutions were asked to not withhold their pay for the time subjects attend the research activity. As well, a letter was sent to the inmate committees and the Indian and Metis Brotherhood committee, to seek their support for the study, which could increase participation [Appendix J]. An additional monetary incentive was considered, which frequently increases the participation rate in research [Zusman and Dubly 1987]. Lacking the resources to offer monetary compensation, permission was requested to use a lottery approach. Blyth [1986] showed that use of a lottery as incentive significantly improved 98 response rate to surveys. The Correctional Service of Canada policy however does not permit any type of 'gambling' in its institutions, so permission to offer a monetary incentive was denied. (iii) Other priorities: Prison programs and schedules take priority over research. Attendance was voluntary and some prisoners made a decision not to attend, or were unable to attend due to some other restriction. Some of these restrictions included: work schedule, change in security status, move to another institution, out on parole, or released. Prisoners who changed their minds did not have to provide a reason. However, in one situation I concluded that the weather and time of day were a factor. At an institution where subjects had to climb the hillside from quarters to the screening room, attendance was complete for morning screenings but dropped after noon lunch, when the winter weather became colder and stormy. To improve the participation rate, permission was secured from staff to return the next morning. The subjects kept their appointments that day. At another institution, since most prisoners were away at work on the scheduled day, a return visit to the institution on a more convenient day [Saturday] was permitted. In all institutions, efforts were made by the researcher to organize visits around work and 99 treatment programs, including scheduling Saturday visits and using flexibility in rearranging appointment times. Additional factors identified in relation to prisoner compliance with the study were: (i) Seeking primary or secondary gain: It was considered that there might be self-selections in response. Subject responses in the study could be motivated by one's own agenda for participation, and thus seek to influence study results. Rintelman [1991], discusses problems of identifying non-organic or functional hearing loss [pseudohypacusis - see Glossary] in test subjects, and suggests methods for identification. It was determined that middle-ear testing [immittance testing] provides a check on pseudohypacusis, where there is discrepancy between a failed hearing screening, and evidence that middle-ear function is entirely normal and incompatible with the air conduction tests. If the audiologist is in doubt of the findings, the subject can be referred for further in- depth testing, such as an Auditory Brain Stem Response test [Martin: 1981]. For one subject, the discrepancy between the audiogram and middle ear testing was clear evidence of pseudohypacusis and in the opinion of the audiologist, no further testing was called for. 100 (ii) Denial of hearing loss: It is fairly common for individuals with hearing loss to resist disclosing their impairment [Jones 1989]. For this reason some prisoners with hearing impairment might have refused to participate in the study. Evidence of this arose from time to time, at different institutions, where staff or a prisoner reported that a prisoner had a definite difficulty in hearing but had refused to participate in the study. No followup on these reports was possible, for ethical reasons. Reliability of information as it relates to confidentiality is also an important factor to consider in research. The names of prisoners participating, and the lists of names for scheduling appointments, indicated to staff that these individuals possibly had hearing impairment. This did not seem to present a problem to those who participated but may have prevented others from taking part. Some prisoners commented on their completed returned survey forms that the survey could not be considered confidential, as their mail would be opened. In fact, Health Unit staff had agreed to not open the sealed envelopes, and in most cases, the envelopes were returned sealed to the researcher, with the prior agreement that any contraband enclosed would be reported by the researcher. No contraband was enclosed. Some prisoners refused to answer some questions and stated that the sensitive information would make them vulnerable to reprisals from the system, for example someone with a case to go before the courts noted that he could not comment on certain matters. 101 Prisoners are transferred from one institution to another according to program and treatment needs or security level requirements. This sometimes interfered with follow-up. Prisoners were moved with some frequency between institutions, or out into the community. In some instances it was possible to locate the subject and arrange the follow-up visit at another institution, in others it was not. The design of the study did not permit follow-up contact with those who were out on parole or released. These factors reduced the number of participants in the study [see Chapter Four for specific numbers involved]. Other factors affected the collection of data. Recognition must be given that in replying to questionnaires and interview questions, different meanings may be inferred from the phrasing, and therefore some inaccuracies in responses may occur. This factor was dealt with at least in part through the pilot study questionnaire, an interview with an ex-offender and having questions reviewed by the Special Projects Manager and members of the Research Committee. Response rate Traditionally, there is a rather low rate of return of questionnaires [Torabi 1991]. The following attempts were made to improve response rate: 102 a] Questionnaires were distributed to the participants by health care staff, rather than by direct mail; b] A follow-up letter was sent to those who did not return forms promptly; c] A method was set for return of the forms within the institution to Health Care; and d] Missing questionnaire responses were reviewed with the subject at the time of the initial hearing screening, or during the interview. Torabi [1991] also identified the importance of questionnaire length, so the form was limited to 21 closed-ended questions. Clear simple instructions were provided for completion [Appendix A]. Credibility was addressed by using the University of British Columbia letterhead stationery for the covering letter. Relevance was identified through use of a covering letter which identified the significance of unidentified hearing impairment in other prison studies [Appendix I]. One difficulty unique to this population arose in relation to demographic questions. The question of "average income prior to incarceration" was unacceptable and threatening to some of those who were incarcerated as a result of some type of theft. The questions of "employment prior to incarceration" and "reason for incarceration" were also objected to as sensitive areas. 103 Additional comments on methodology In addition to the methodological procedures described and the limitations outlined, there were other essential considerations to be taken into account, in preparing for the study implementation. These considerations were factors behind the setting described, and the approach to the situation utilized knowledge gained from prior experience, both professional and maturational in nature. Some discussion of these points may illuminate the methodological process involved. il Interacting with bureaucracy: Several factors influenced the approach taken. The Correctional Service of Canada is hierarchical in structure, as are other institutions which employ civil servants, whether federal or provincial. It is important to comply with requirements that one liaise only with the designated official. Permission to conduct the study came from the Regional Research Committee. However, several potential obstacles loomed. Each warden of the eight institutions approached had the power to permit or refuse admission to his or her individual institution. Further, I was aware of the power of staff at the "line" level [McNeil and Vance 1978, Yates 1993] to "sabotage" research, if they were so inclined. Similar evidence was produced from a term of nursing in a provincial psychiatric hospital, where ward nursing staff 104 confirmed my observation that if they did not approve of a directive coming down from an upper level of the hierarchy, they sabotaged the endeavour, reporting that "we tried it and it didn't work." It was therefore important to do some preliminary research to discover who, within the correctional system, could facilitate the study, and would be sympathetic to its goal. The strategy selected was to seek an in-person interview with the designated liaison on the premise that an empathetic reaction might ensue. This proved serendipitous and led to a rapport, since the liaison person was like myself, a nurse, pursuing graduate-level education, and sympathetic to research. She determined that she would direct the process by routing the study through Departments of Health Care, which reported to her, and that this route would result in acquiescence to the project by wardens. As well, no onus was placed on other staff such as guards, to facilitate the study, except as required to provide escort duty. ifl Attitude toward individuals within the institution: The public in general tends to hold negative views towards secure institutions such as penal and psychiatric facilities. This negative viewpoint is often grounded in fear and ignorance of the type of persons incarcerated. A general perception of the prisoner or patient as prone to violent and unpredictable behaviour seems to lie at the root of this fear. Additionally, staff are often [sometimes unfairly] characterized in negative terms as unfeeling, sadistic or otherwise incompetent. This negative perception is reinforced by the fact that staff in such institutions can never 105 defend themselves in the media. Professional ethics and institutional policies forbid it. Goffman's Asylums [1961] reinforced this negative perception. However, Goffman was later reported to have said that, had Asylums been written after his own experience of mental illness, he would have written somewhat differently [Gove 1980]. My prior experiences had led to the conclusion that, as within any institution, there would be a variety of personalities and competencies amongst the staff. Similarly, there would be a variety of fairly ordinary people amongst the prisoners. iii] Presentation of self to subjects: The conclusion drawn from the preceding comments is that it is advantageous to approach any such research situation with a Rogerian approach of "unconditional positive regard" [Rogers 1951] for the people one is about to encounter. Eliciting information from subjects, whether prisoners or officials, is best coupled with the existentialist attitude of May and Maslow [Ford and Urban 1963] of relating authentically to others. This technique is recognized as important in dealing with individuals who are alienated or isolated. The intent is to understand the subjective point of view of the individual being interviewed, and let the individual feel that he has been listened to and understood. It was also important to let custodians who participated know that there were no right or wrong answers, and no trick questions. The intent was simply to 106 understand what certain things meant to them, from their experience - something which I wanted to learn and understand. Strategies to reinforce a sense of "commonality" rather than distance from subjects included such simple, but planned steps as ensuring that the audiologist and I wore casual, non-provocative clothes, since most others encountered would be either in prison garb or custodial uniform. The fact of my hearing impairment was introduced in conversations. When appropriate, staff were told of my nursing credentials and experience in caring for violent, psychotic individuals, with the objective that they might have some reassurance about my ability to behave appropriately in the institutional setting. Each prisoner was greeted with a handshake and use of his full name, a thorough explanation of the test procedure to be done, provided immediately after the procedure with a careful explanation of test results, and thanked for his participation. While simply common courtesy, it was hoped that such interactions would encourage continued participation in succeeding phases of the study. As a "good will" gesture, all staff were offered the opportunity to have their hearing screened, when openings in the schedule would permit, and a number of staff did have their hearing screened [see Chapter Four, Unexpected findings]. It was hoped that such involvement would encourage cooperation and support for the study. 107 iv") Theoretical sensitivity: Strauss and Corbin [1990] identify theoretical sensitivity as an important personal quality in a researcher. The terms implies a perceptiveness to subtleties of meaning in the data. Sources of theoretical sensitivity include professional and personal experience, as well as familiarity with literature and other sources of information which sensitize one to the phenomenon under study. Thus, the experience of living with a profound, progressive hearing loss for almost all of my adult life has been an insightful and sensitizing experience. In addition, the recent 15 years have included study of the psycho-social-cultural effects of hearing loss at levels ranging from local to international. This has provided exposure to both the commonality, and the rich variation of experience which individuals relate. One learns to "expect the unexpected" and that nothing can be taken for granted in subject response. Strauss and Corbin [1990] illustrate the importance of this factor by calling for continual analytic interactions with the data throughout the process of data collection. A continued questioning of findings contributes to keeping a balance between what is expected and what is real, and contributes to theoretical sensitivity. Palys [1992] notes the possibility of reactive bias in the interview subject. That is, the subjects may react to cues [body language, nods] from the researcher which indicate that they are "doing well" as a participant and giving expected responses. Efforts were made to guard against this type of influence. It may 108 be speculated whether awareness of hearing impairment in the researcher predisposed the study subjects to be forthcoming about their experiences with hearing loss because they felt they would be understood. However, those who completed the first questionnaire did not know of this fact and provided written comments similar to comments from interview subjects. Summary This chapter has provided an outline of the methodology employed in the study. A combination of survey, including audiological measurements, interview and documentary examination was integrated in the study design. It was recognized that a voluminous amount of data could be expected from the type of data-gathering techniques planned, so systematic plans for coding and data reduction were developed at the outset. Taken as a whole, the primary data collection techniques employed in the study were interactive, that is, direct contact and direct response. Secondary data collection [non-interactive techniques] included documentary examination. Research with a prisoner population has special problems which flow from institutional policies, prison culture and prisoner rights issues. This chapter has delineated the various hindrances and limitations encountered, and the steps taken to successfully address these difficulties. 109 A strength of the strategies used was the opportunity to cross-check data from several sources. This methodological approach has proven particularly valuable in the process of producing this original research and its contribution to knowledge. A second strength of the study related to theoretical sensitivity. Theoretical sensitivity is the "ability to recognize what is important in data and to give it meaning" [Strauss and Corbin, 1990:46]. Theoretical sensitivity flows from professional and personal experience, as well as being well grounded in theory. Theoretical sensitivity also grows from continual interactions with the data throughout the research process. Thus, the researcher's prior experience with populations of secured institutions [hospitals, but not prisons], and with the field of hearing impairment, as well as theoretical grounding in the subject matter, contributed to theoretical sensitivity to the data. The next chapter will provide and discuss the findings flowing from implementation of the study process. 110 CHAPTER FOUR THE EXPERIENCE OF IMPAIRED HEARING IN PRISONS: PRISONER AND CUSTODIAN REPORTS "I have a severe bilateral congenital hearing loss. I went through the mainstream school and finished Grade 12 but I had a hard time of it due to my hearing impairment. I hated the educational experience. I never had hearing aids. Between the ages of 20 and 251 was in prison five times, once in the penitentiary for three years. Incidents of violence led to my incarceration. I was full of anger, and it had to do with my hearing impairment. People made fun of me, or rejected me, and I would have nothing to do with them. I had no hearing aids and was always going, 'eh7 'what?, straining to hear. So I got into fights. That's what it was like in prison. I wouldn't play poker and I wouldn't have sex, so they wanted nothing to do with me. The guards were not mean to me though. They sort of protected me, probably because of my hearing loss. And the only place I worked there was in the greenhouse, alone" [Anonymous 1992, ex-offender]. Introduction Perspectives on the social implications of living with impaired hearing have been introduced in the first two chapters. The literature has revealed that there are many complex factors resulting from the effects of partial loss of hearing on such individuals and those with whom they interact. One common fear noted for the hard of hearing individual is the consequences which may arise from not having heard properly. Such consequences pertain to having others misinterpret their communication-associated behaviours. This type of misinterpretation may relate to the behaviours associated with trying to hear, or of mishearing and responding inappropriately, or of behaviours associated with avoidance, concealment or denial of a hearing impairment. Of particular concern is the stigmatization, deviance labelling, and related social consequences which result when others have a poor understanding, 111 or no awareness, of the presence of impaired hearing. The potential for institututional structures of social and medical control to dominate and oppress individuals and groups through ways which may include a "mindless unawareness" was also discussed. These concepts were then considered in relation to vulnerable groups such as prisoners, and the study questions were specified. In Chapter Three, the methodology for investigation of the study questions was detailed. The research focused on identifying prisoners with impaired hearing, determining how their hearing- loss-related behaviour was interpreted by custodians, and what the consequences of such behavioural interpretations were for the individual prisoners. In this chapter, the study findings are reported. In the first section the study population is described, as identified by the demographic survey of Questionnaire #1. Subsequent sections provide the research findings organized in order of the study questions. That is, data are selected from questionnaire, audiometric assessment and interview responses and presented in relation to the study question under consideration. This strategy provides a cross-check of data and serves to strengthen findings. Demographic characteristics of the study population The following discussion provides a summary description of the study population, as presented by respondents to Questionnaire # 1 [Appendix A]. Complete responses to this questionnaire are provided in Appendix L, Supplementary Table L-1. Incorporated into the discussion are comments provided spontaneously 112 at the end of the questionnaire. Of these comments, 25% [n=47] were about hearing loss, 3% [n=5] were about the institution, and 1 % [n=2] were about guards and other staff. No comments were given by 71% [n=135] of the respondents. The number of prisoners in the study population represented approximately 13% of the total prison census. Of the 189 male participants who completed the mailed questionnaire in the study, 59% [n=111] were located in medium security institutions; 11% [n=20] in the maximum security institution; 16% n=[30] in minimum security; and 14% [n=28] in the psychiatric treatment facility, which has multiple security levels. When compared to the prison population as a whole, a slightly higher percentage of prisoners in minimum security and the tri-level facility returned completed questionnaires. Figure 2. Prison population [n=1808] and study population [n=189] by security levels. July, 1992 1000 900 800 700 § 600 | 500 | 400 300 200 100 0 280 20 30 med. min. Security level Security levels [?x] prison pop. §|§ study pop. 163 L I tri-level 113 Some hearing loss is a natural concomitant of aging, and such deterioration can be considered as not unusual after age 40. Seventy-one, or 38% were in the group aged 41 and over. Compared to the prison population, the study group had a slightly higher percentage of participants within the particular age groups of 41-50 and over. Somewhat more than half of the subjects [62% n=118] were in the under 40 age group, when hearing can be expected to be in the normal range. Ethnic distribution of the study population had somewhat more Caucasian and somewhat fewer North American aboriginals than that of the prison population as a whole. Racial origin of the subjects was 81% [n=152] Caucasian, 11% [n=23] North American Indian, Metis or Inuit, with other races divided almost equally in the remaining 7% [n=6]. In comparison, Correctional Services of Canada Pacific Region 1992 statistics reveal 77% Caucasian, and 13% North American Indian, Inuit and Metis. The majority of respondents [81 %, n=154] stated their occupation prior to incarceration had been in the category of unskilled or semi-skilled work; 13% [n=24] listed a skilled occupation. Fully one-third of respondents indicated they had some level of post-secondary education, with the majority indicating that this represented university course credits or vocational training received while in prison. Pay ranges stated did not correlate positively with education and skills training. High yearly income sometimes correlated with low level of education or skills training, and a career description such as "trader," which indicated income from drug trading or other illicit sources. Of the types of offenses leading to incarceration, crimes of 114 violence accounted for 54% [n=102]. This figure is not surprising because the federal penitentiaries house those with sentences over two years, for more serious offences. Figure 3. Reason for incarceration. n=189 Category of offense j | drug-related. n»18 H| property crime. n«49 [iTTI violence. n*102 j j no reply. n=20 , m i;«i ^^J^n=20,10% k • ^̂ $6&uu jfl I L n-102,54% ;:;K:;; Tjm ^ , Figure 4. Self-attribution of cause for offense. n=189 Attribution of cause another person. n=50 [jjj| society/drug. n=81 | f disability. n=5 • self. n=49 H I no reply. n=4 115 When asked to name the type of behaviour which led to their incarceration, 69% [n=131] stated it had something to do with another person, or with society; 26%[n=49] noted the cause as themselves, and their personal fault. Only 3% [n=5] believed that a disability contributed to their incarceration. The majority of respondents had been in their present penitentiary for under five years. However, a total of 55% [n=104] had been in the present and other institutions for anywhere from five to more than 20 years. Labeling and prison relationships The majority of respondents felt that they "got along well" with others in the prison. An average of 17% [n=31] stated they had a bad relationship with guards, other prisoners or everyone in general. Most of the respondents [86%, n=162] stated they were aware of labels or nicknames being given to prisoners in the prisons, and thought that labels influenced how other prisoners related to the persons so labeled. Somewhat more than half of the respondents [62%, n=100] thought labels influenced how guards related to the labeled person. Respondents also believed that some labels related to how prisoners with hearing difficulties are viewed by others. All of the labels named by the respondents were pejorative terms. When asked to list such labels relating to hearing problems, 155 labels were provided, with most of them [80%, n=124] the type of label which indicated the prisoner lacked normal intelligence. The remainder were in the category of "weird behaviour" [14%, n=21] 116 and obscenities [6%, n=10]. As discussed in the literature review, Chapter Two, it is a common fear of people with impaired hearing that they will be labelled in some way as lacking in intelligence. Another common fear is that others will become frustrated or irritated with them. These types of fears seem legitimized for the experience of the prisoner who is hard of hearing, as depicted by the labels reported in Table 7. Table 7. Specific labels given to prisoners with impaired hearing, categorized. n=195 LACKING INTELLIGENCE bonehead [1] cement ears [1] deaf [7] dense [1] dope [2] dumb-dumb [1] dummy [31] goof [6] idiot [3] meathead [1] no good [1] no mind [2] oldman[4] reject [1] silent minority [1] stupid [17] waterhead [5] bugs [3] deadhead [2] deafmute[2] doorknob [1] dumb fuck [3] dumbo [2] ears [3] hands [1] ignorant [1] melon head [1] no brain [2] off in space [1] one light [1] rock [1] slow[1] tin ear [1] witless [1] not enough marbles [1] WEIRD BEHAVIOUR bad news [1] crazy [2] creep [1] lennythe loon [1] passive Christian [1] wacko [1] weirdo [1] [others which applied to sex offenders and race, non-specific to hearing loss] OBSCENITIES asshole [2] cocksucker [1] deaf prick [1] fucken pinhead [1] fucken zombie [1] fuckup [1] rat [3] shit [1] shit for brains [2] In addition, one respondent provided a label suggestive of selective hearing: "hard of hearing - hears only when he wants." The accusation that he (or she) "could hear better if he (or she) wanted to," or "hears only when he(or she) wants to" is frequently reported by people who are hard of hearing. 117 Self-report of hearing problem In general, there are indications that the majority of people who seek a hearing evaluation already suspect they have a hearing loss [Jones et al. 1987, Martin et al. 1989]. Slightly more than half, that is, 58% [110] of subjects completing this questionnaire believed they had a hearing problem. Because not all of these respondents participated in the hearing screening, it was not possible to establish a comparison for this group. If a comparison is made with a census survey [Statistics Canada, 1992], 4 out of every 100 Canadians, or 4%, self-reported a hearing loss severe enough to interfere with activities of daily living. The Canadian Hard of Hearing Association [1993] has stated they believe this number to be lower than the actual number, because people tend to under-report hearing loss. Prison populations were not included in that survey. According to self-perception of hearing loss in this study population, the percentage of prisoners who reported a hearing loss is much higher than in the general population by a ratio of 12:1. If this number [110] is compared to the 1,439 who received the letter seeking volunteer participants, the percentage who self-reported a hearing loss is 8%, which is also higher than that of the general population. Of the 110 who stated they believed they had a hearing problem, 55% [n=60] said it had been identified before; 45% [n=50] said it had not. Of the 60 who had their hearing problem previously identified, 48% said they or a family member 118 had identified it. In comparison, Jones et al. [1987] state that 85% of the hard of hearing subjects in their study first raised the issue of their own hearing problem. Figure 5. Type of hearing problem by self report. n=' 41fl •inn on • sn j BU X 7 0 - . •J 6 0 - 8 50 — 9 E 40 — z 30 — 2 0 - 1 0 - n -(66- 29 I 'l I H.L.p -I"8"} - [7 110 Categories of awareness |F[TTT| hearing conversation ^ way ear feels fH| don't know | ringing in ear — ~l roblem Of the prisoners with identified hearing loss, 60% [n=66] claimed they knew they had a problem hearing and understanding people or television. As noted in the literature review, it is typical of people who are hard of hearing that the major concern related to impaired hearing pertains to interactive communication and to receiving information. This is depicted proportionally in Figure 5. Their actual words giving descriptive statements of their experience are found in Table 8. The situational indicators which they identify are ones commonly given by people who suspect a hearing problem. [Jones et al. 1989]. Out of 84 responses, 54% [n=45] were concerned with social communications situations-conversation with other people or hearing television programmes. This experience of disruption to social 119 communication, and associated feelings of social isolation have been identified by people who are hard of hearing as the most distressing effect they experience from their hearing impairment. Figure 6. Hearing loss in family.n=72 Hearing loss in family | 2 ormore. n=17 HI other. n=15 HI sibling. n=6 §1 parent. n=33 Subjects were asked about hearing loss in the family. It is often difficult to determine if the cause of a hearing loss is heredity [genetic]. Having close blood relatives with hearing loss is an indication of possible hereditary loss, even in individuals with adult-onset hearing loss [Phillips et al. 1994]. However, it could be expected that individuals with a hearing loss in their family would be more aware of related behavioural indicators and thus more likely to suspect their own hearing loss, and seek evaluation for it. Of all respondents, 38% [n=27] stated someone in their family had a hearing loss. 120 Table 8. Self-description of hearing problem. n=110 Problems with the ear and way it feels "Bilateral loss in the higher decibel range" "Comes and goes - sometimes can't hear anything for 30 seconds" "Concussion" "Deterioration over last 10-15 years [over 50 now]" "Ears very sensitive to high-pitched sound" [2] "Erratic popping of ears, sinus congestion and sore throat" "Need two hearing aids" "Partial [or total] hearing loss, one ear [9] "Partial hearing loss" [2] "Right ear feels tender, hears less well" [2] "Ringing in the ears" [8] "Sometimes I hear different, sometimes nothing" "Sometimes muted sound and feeling of pressure" "Told I had a hole in one eardrum" "Total loss of hearing left ear and speech impediment" "Wax buildup, as a result I speak too loud" Problems hearing people speak [socialization concerns! "Can't hear low sounds" [2] "Don't hear TV well, turn it up loud" [4] "Hard to hear in a roomful of people talking" "Have problems understanding people if there is the slightest distraction" "I don't understand a lot of people" [11] "I speak too loud - can't hear own voice well" "I say 'what' a lot, ask people to repeat a lot" [7] "I'm not sure if it's my hearing or just me-sometimes people talk directly to me and I don't hear what they have said-don't know if it's my hearing or just going into myself "Just don't hear as well as I should" "Just a little bit of not understanding conversations" "Misinterpret what people are saying, or just can't hear" [3] "Miss low tones [when people speak low]" "Misunderstand words" [3] "Not a problem but I think my hearing has deteriorated to some degree" "Often have to ask people to repeat" [2] "People have to talk loud to me" "People frequently must repeat sentence or call my name a lot" "Problem with pronunciation" "Problems hearing TV and other people" "Sometimes I feel that I have missed parts of a conversation" "Sometimes I can't get anything meaningful out of a remarks, even after repeating 5-6 times" "Sometimes I have a problem hearing some words" "Trouble hearing people behind me" Problems with noise "Can't hear in noisy situation [machine, ventilator fan]" "Can't hear high tones due to work with jet engines" "Noise makes me nervous" "Noise deafness, 2 aids help a little" 121 Table 9. Subjects stated beliefs about cause of hearing impairment. n=110 Loud noise "Industrial noise without ear protection" [12] "Loud engines & machinery" [12] "Loud music" [17] "Steady noise level in jail" Trauma "Assault injuries" [2] "Beaten by guards after the 1971 Kingston riot" "Blow to head twice with a 2 x 4" "Blow to head in childhood" "Diving accident" "Head injury" [4] "Hit on head with a rock. Left ear bled" "Motor vehicle accident" [2] "Physical and mental abuse" "Punctured left eardrum when trying to get rid of a fly, left ear" Medical "Biological or biochemical" "Ear, nose and throat infections" [2] "Ear nerve damage" "Genetic" "Inner ear problem" "Medical" "Meningitis" "Neurotransmission" "Perforation of eardrum" "Possible birth defect, hearing loss confirmed at age 2" "Steady ring, left ear" "Tiredness" "Wax" [2] Other "Being into many quiet places" "Blocking out of fear" "Bureaucracy" "Complex problems and feelings" "Don't know" [25]; 122 When asked to state the cause of their hearing problem, of the 110 replies, over half [52%, n=57] believed the cause to be noise. The situations most commonly specified by prisoners as causing their hearing impairment relate to industrial noise and loud music. The actual words they used to describe what they believed to be the cause of their hearing impairment are provided in Table 9. Only 10% of the 189 respondents stated their hearing had been tested since incarceration, with 7 having a hearing loss prior to admission, 3 tested at industrial work sites, and 10 evidencing significant behavioural indicators to warrant a hearing examination. Substance use Certain chemical substances can cause hearing impairment through damage to the inner ear or auditory nerve. These include substances as varied as certain antibiotics, some diuretics, nicotine, tobacco, heroin, cocaine [Health and Welfare Canada 1988]. Respondents were asked to specify their substance use prior to incarceration; 73% [n=138] of subjects stated they had used alcohol prior to admission. Of this 138, 50% [n=69] said they usually drank more than 12 bottles of beer a week. Seventy-eight percent of subjects [n=147] said they used drugs. Of these, 65% [n=96] used narcotics, and 61% [n=90] used tranquilizers or other prescription drugs. 123 Respondents were asked to state their narcotic usage prior to admisson. Figure 7 depicts the frequency of narcotic use by offenders. Of the 96 narcotic users, 42 [44%] used 2-3 times or more per day; 37 [39%] said they used from 1-3 times a week, and the remaining 17 [17%] said they used from 3-10 and more times per week. Some subjects indicated that their response related to present rate of consumption. One subject summed up his narcotic use as: "whatever comes in to [name of prison] off the street; some weeks - its either feast or famine." Figure 7. 50%^ w40% - = 30%- O) | 20% - 9 $ 1 0 % -Q. 0%- Frequency of narcotic use. n =96 44% (39% mm mm, — 1 7% - I Time categories rime categories of use 2-3>xday. n=42 % 1-3xwk. n-37 3-10>xwk. n=17 Of the 44 subjects who estimated their tranquilizer usage, average use varied, depending on drug availability, and whether or not it was a physician- prescribed drug. Of the 46 subjects who used other prescription drugs, two-thirds 124 said they used these drugs from 2-3 or more times a day. It was difficult for prisoners to categorize their drug use. Some take tranquilizers on physician's order; others use them when obtainable through the drug underground. As one prisoner remarked, "I found it difficult to fit my drug use into this format as I take such a variety of whatever I can get my hands on, whenever it is available." In this summary, marijuana is categorized with the narcotics. Though that classification can be debated, marijuana is a mood altering drug but not usually called a tranquilizer or a prescription drug [Davison and Neale 1978]. Factors predisposing to hearing impairment Major illness or injury can be a causative factor in hearing loss. This may sometimes pertain to the type of disease, for example, meningitis, or to medications prescribed for a condition [Health and Welfare Canada 1988]. A high incidence of illness and trauma was reported by the subjects, of whom 66% [n=125] indicated they had some major illness or injury during their lifespan. Respondents also named multiple categories of factors which predispose one to hearing impairment. Of 501 replies, 140 referred to a severe blow to the head; 170 to viral disease and/or earache; 130 to tinnitus, 101 to vertigo, and 39 to ear discharge. Tinnitus, vertigo and ear discharge are not in themselves causes of hearing impairment, but rather symptoms of the presence of some condition which may predispose to a hearing impairment. 125 Figure 8. Factors predisposing to hearing impairment. n=501 • • n Categories of factors viral disease H | severe blow to head tinnitus | dizziness ear discharge 100% 80% § 60% c § 40% o Q. 20% 0% Factors A total of 501 responses were received in the categorization of types of exposure to excessively loud noise. The most frequently cited noise exposure, by 74% [n=140] of 189 was from loud music, factory or construction noise, and secondly 63% [n=119] of 189 cited gunfire. Of 189 respondents, 20 [10%] said their hearing had been tested since admission. Of these, one had no hearing loss identified, but strongly believed that he had a hearing loss; 7 had a hearing loss identified prior to incarceration; 3 were Workers-Compensation-Board-screened at industrial work sites; and 9 had manifested significant behavioural indicators which warranted a test of hearing. Nine [5%] said they now wear a hearing aid. 126 Summary: A composite prisoner profile On reviewing these data, we have a composite picture of the average respondent to the questionnaire as someone in a medium security institution, under age 40, a white male who held a semi-skilled job with a pay range under $20,000 prior to incarceration. He has a secondary-level education and possibly some additional educational course while in prison. He may be single. He has been imprisoned for between 5-15 years, charged with an offense involving violence and he believes that his imprisonment has something to do with another person. He believes that he gets along with people in general and is aware of the detrimental effects of labelling on prisoners. He believes he has a hearing problem, which was first identified by himself and his family. One parent is hard of hearing. He thinks noise and drugs caused his hearing loss. He uses tobacco, narcotics, and prescription drugs. He has not had his hearing tested before or since incarceration, and complained of a hearing problem but was refused a hearing test by the prison physician. Prevalence of hearing impairment The first question asked what the percentage of impaired hearing is among prisoners in federal prisons in British Columbia compared to in the general population. The percentage of hearing impairment among prison populations was 127 arrived at by determining the numbers with hearing loss in the study sample, and comparing with that of the general population. The presence of impaired hearing in the study sample was determined through hearing screening and confirmed by audiological tests. Audiological assessment of hearing impairment Figure 9. Hearing test results. Screened n=144. Tested n=92. Of 144 subjects hearing screened, 69% [n=99] had some level of hearing loss. Of this group, 92 were tested and 95% [n=87] confirmed with a hearing loss. 128 The purpose of the various audiological tests used in this study was to establish the presence and degree of loss of hearing. Tests which pertain to "cerumen," "tympanometry," and "acoustic reflex" were part of this diagnostic procedure and are provided in Appendix L [Supplementary Tables L 2, 3, 4]. These tests also provide information as to the presence of pathologies in different parts of the auditory system. However, the focus of this study is not on various pathologies of the ears examined. Therefore, these data will not be elaborated on here, but will be reserved for secondary analysis in the future. Comments are in order, however, about the extent of hearing loss noted. Of 184 ears tested [92 subjects], 38% [n=71 ears] registered a hearing loss from medium to severe [Figure 10]. In general, individuals with medium to severe degrees of hearing loss manifest behavioural characteristics which are typical of people who are hard of hearing, and could be detected by those knowledgeable about hearing impairment. In this study it was found that in general, impaired hearing went unrecognized except where the individual had a profound loss, or wore a hearing aid to cope with a severe to profound loss. Of 184 ears tested [92 subjects] 31% [n=56 ears] had a mild hearing loss [Figure 10]. Individuals with a mild hearing loss do not tend to be readily identified by others, or by themselves, as having a hearing problem. However, as explained in Chapter 3, page 88, even a mild hearing loss can interfere with speech comprehension, for example, in noisy situations, or in group settings. 129 Figure 10. Extent of hearing loss n=184 ears DEGREE OF LOSS H non® H m i | d HI medium | moderately severe 1 | severe HI profound NUMBER WITH LOSS Although the focus of this study is the social perception and interpretation of behaviour associated with impaired hearing, a great deal of data were collected which will prove a rich resource for secondary analysis. One such example will be the opportunity to undertake a comparison of significant variables related to partial hearing loss, as recorded for those who passed the hearing screening [i.e. had normal hearing], and those who failed the audiological tests. 50 40 30 20 10 44 56 26 13 130 Identification of hearing impairment in federal prisons The second question asked if the existing method for identifying hearing impairment in inmates of federal prisons in British Columbia is adequate. Prisoner report and hearing tests revealed that the prison system failed, in most instances, to identify their hearing impairment. Hearing screening is not a part of the admitting health assessment, and documentary examination of health files of study subjects revealed no notations about hearing except where the prisoner had a hearing aid or a severe hearing loss. Health staff in two prison facilities stated they have a hearing screening device in the health unit, which is used only if there is significant behavioural indication of hearing impairment. Evidently, self-report of a hearing problem is not considered a behavioural indication of impaired hearing. Of the 42 prisoners with hearing loss who were interviewed, all believed there should be automatic screening of hearing as part of the admission health assessment. One stated, "I feel that all institutions could make hearing tests mandatory, to benefit both prisoners and CSC without appearing to infringe or force one's rights. It could be a very helpful exercise. Both at RPC Treatment Centres and other CSC institutions." Two stated they wore hearing aids on admission, which was noted on their health files. Forty said they were not checked for a hearing problem although 20 of these men said they had complained of not hearing well. Six who complained requested and received hearing testing and were fitted with hearing aids. 131 The remaining 14 said that the "doctor looked in the outer ear canal and said it looked fine to him," so were refused audiometric testing. As one put it, "I get screwed around with things that I might need from the doctor and they throw my request away sometimes. Like last time I put in for to see an ear specialist." Another stated: " I have problems hearing in the courses offered here. I asked to have my hearing tested but was refused." One prisoner referred to his childhood experience of missed diagnosis of hearing loss: "Family doctors should not be the ones to decide if a person has a hearing problem. The old watch test is too inefficient to tell if someone has a hearing problem." [An informal test for hearing was to hold a ticking watch near to the patient's ear]. The following vignette is indicative of the typically low priority given to hearing problems in the health care system, as discussed in earlier chapters. One prisoner stated: "I had a very scant health check on admission. Health checks depend on how busy or rushed the health staff are. I am healthy otherwise so my hearing problem was ignored." However, prisoners did not always pay attention to possible health-related problems. One stated, "I am pleased to hear someone wanting to take part [about this study] and their concern for our physical health. And I am also looking forward to having my hearing tested. It took me over 20 years to find out that I needed glasses. No [sic] what I mean?" 132 Table 10. Prisoners' experience with identification of impaired hearing. n=42 PRISONER EXPERIENCES WITH HEARING IMPAIRMENT n=42 Believed or knew had hearing impairment prior to test Wore hearing aid when incarcerated Complained to prison physician of hearing difficulty Stated physician denied prisoner had a hearing impairment Tested and fitted with hearing aid Did not know of hearing loss until tested in study Believed hearing impairment had adverse effect on incarceration # 34 02 20 14 06 07 29 % 81 05 48 33 14 17 69 Custodial awareness of hard of hearing behavioural attributes The third question asked if custodians are aware of the range of attributes associated with partial loss of hearing, and how custodians characterize the behaviour of prisoners who are hard of hearing. To explore this question, 41 custodians were interviewed, to determine their level of awareness of behavioural attributes associated with impaired hearing. As noted in Chapter Three, most custodians [n=29] were approached by the prison liaison for the study [usually a Health Unit person], and asked to participate in an interview. The selection process was usually informal. Custodians were selected from the duty roster on that particular day when the researcher was present in the institution. Others [n=12] were approached at random by the author while in the various prison compounds, and agreed to an interview when their time permitted. Only in maximum security were the 133 custodian subjects selected ahead of time and scheduled for strictly timed interviews, with no variation permitted. a. Excerpts from interviews with custodians Custodial unawareness of hearing problems was prevalent, as noted by the following typical comments excerpted from interviews. In this section, 'R-researcher; 'C'=custodian. See also Appendix L, Supplementary Table L-6 for a complete tabulation of custodial labels of specified behavioural characteristics. C1: "We have a lot of people here who neglect their health terribly. We have men whose vision is so bad that they need to hold a paper two inches from their eyes in order to see it. But they never complain about it, or ask for vision tests or glasses. I suppose it must be the same with hearing problems, though I have never thought about it. I know we do have a couple of people with hearing aids in this institution, though we do not have any in the education program." C2: "I know how to identify hard of hearing in the classroom. They have a short attention span, they never pay attention to what you are saying, and they don't look at you at all. They are very poor at looking at you and paying attention." R: [to C2] 'This is your experience, your perception of the meaning of this sort of behaviour in the classroom?" 134 C2: "Yes. And I know this is correct. My daughter is taking training to be a special education teacher in the classrooms, and she told me this." What is most significant in the above remarks is the failure to identify prisoners who are hard of hearing in the classroom situation. C1 has noticed none at all, although the researcher had, through testing, identified several prisoners with impaired hearing who were in the education programme. Further, C2's definitive declaration of behaviours which are typical of a student who is hard of hearing would apply to small children, but not to an adult. On the contrary, an adult prisoner would probably watch the speaker quite closely, and strain to hear. Prisoners themselves stated this was their typical hard of hearing behaviour in a group situation. General lack of knowledge and awareness about hearing loss was evidenced by the following type of comment by a health care professional: C3: "I know nothing about the hard of hearing or how to identify this in offenders. Never had this in training. Don't think there's too much of this around." The following interview with a professional illustrates the change of attitude from unawareness to interest when some knowledge is gained about hard of hearing behavioural characteristics and implications. R to C4: "Can you tell me more about the group therapies? For example, what type of person does best in therapies - what sort of personality or character?" 135 C4: "The more outgoing, aggressive type of person. The sort who will get angry. They tend to speak out their feelings more, and so be more responsive to the reactions they get from others. The quiet types, withdrawn, shy, not saying much - those don't tend to do as well. They not only don't speak out, they don't respond to others, so get little insight." R: [to C4] "So the more aggressive types tend to gain insight and benefit from the groups. What about the quieter non-participatory types? You say they do not tend to get insight? Do they not succeed, not 'pass' the group therapy then?" C4: "That is correct. They are assessed - not by me - by the team. The team does the assessments and submits their reports to me. The paranoid type of person won't be open at all. But the loner, withdrawn, can make progress - will eventually open up. If he does not open up, he fails the programme." R: [to C4] "What happens to those who fail the group therapies?" C4: "Well, the report is sent to the institution they came from and they are returned there. Based on the report, some other decisions are made as to their future." R: [to C4] "What if this quiet type of person was actually hard of hearing and no one knew it?" C4: "That is possible." R:[to C4] "How would you tell if someone was hard of hearing? What behaviour would you expect?" 136 C4: [shifts uneasily in his chair] "In my experience, the person usually tells. Now P.[a prisoner in the study] -1 sat in a meeting with him and the treatment team. I realized he was hard of hearing in the left ear. I was facing him and he heard me, but did not hear the staffer at all, who was sitting on his left." R: [to C4] "Did P. tell you he was hard of hearing?" C4: "No, he did not." R: [to C4] "Could I describe to you the typical behaviours of hard of hearing people in a group situation, which behaviours will be there, whether or not you or anyone else guesses that they have a hearing problem?" With his nod of assent, I described such withdrawn and quiet, non- participatory group behaviours as are characteristic of the hard of hearing. He became quite still and then began to ask questions about the study. His final question was: C4: "Will there be recommendations flowing from this study, and will we get them?" This dialogue was consistent with the typical unawareness of professionals in regard to behavioural attributes associated with being hard of hearing. In this instance the prisoner had a profound hearing loss in one ear, and told me he had confided in his primary nurse about it. The condition was noted by the professional here interviewed, but he was unable to suggest behaviours indicative of other levels of hearing loss. 137 Comments from other custodians provided their perceptions of prisoner behaviours. Excerpts from interviews follow. C5: "I feel that there are a lot of inmates here with hearing problems. I can tell, but others on the staff are not so aware of this. They just don't know enough about hearing problems here, or how to tell when someone is hard of hearing." R: [to C6] "What happens if someone does not respond the way he should, if you or someone gives an inmate directions to do something and he just seems to ignore it?" C6: "It depends a lot on the situation and the guy. There is a lot of their just pretending not to hear orders, or hearing some things and not others. It is very common in the institution. Selective hearing. So it depends on the situation and if the inmate is, oh, a troublemaker anyway - known for this sort of thing - a smartass type. Depends on the place too. He might lose time for not obeying an order. Get punished that way. Or maybe just get a talking to and warned that next time he will lose his privileges." Accusations of selective hearing ... "he hears only when he wants to"... are commonly reported by people who are hard of hearing. It appears that if the prisoner has been labelled for this sort of behaviour, actual testing of hearing would be beneficial, to determine if the label of "troublemaker" is valid. Three custodians had the highest scores in identifying the listed behaviours as indicative of a hearing problem. These individuals mentioned that they 138 either had a hearing loss themselves or had a close relative who manifested the behaviours listed. These three custodians are quoted below. C7: "I recognize most of these symptoms as I have a brother who was fitted with hearing aids approximately two years ago. He should have had them many years earlier. He was always asking people to repeat, often missing the gist of the conversation or the entire conversation. Since getting his hearing aids, he no longer has these problems. He compares it to entering a whole new world." C8: "Of your list of inmates to see here, I know that three of them are hard of hearing. They are in my therapy group. They are always straining to hear and asking for things to be repeated. This one [he points to a name on the list] is also in my group. He got a hearing aid last year, and it made a big difference in his participation. His social skills and socialization have improved a lot since he got the hearing aid. R: [to C8] "Have any of these three men asked for a hearing test, or hearing aid? Have they complained of not hearing well?" C8: "No, they have not said anything but I can tell. Through the years, I have observed some of these behaviours which are described here, in offenders. I generally ask if they want me to speak slower or louder. I have a fairly low voice in any event so I do not encounter many difficulties." 139 While he was correct in identifying these three, there were two more in his group who tested with a hearing loss, of whom he was not aware. He stated one of his parents is hard of hearing. This is an example of the fact that even a person who has some sensitivity to hearing impairment, and personal experience in living with someone with a hearing loss may fail to identify hearing impairment and its effects in others. He confirmed, in answer to a question, that since prisoners did not ask for hearing tests and hearing aids, nothing was done about their evident difficulty in hearing in the group. One professional noted that a young adult in his caseload had confided in him that he was deaf in one ear: C9:"l told the team that I questioned whether [name of prisoner] should continue in group therapy because of his difficulty in hearing made it counterproductive for him to sit there and not be able to participate." While sensitive to his client's plight, he was not aware of assistive listening devices or other strategies which could be employed to enable the prisoner to participate, nor had he sought out, or known where to seek, this information. Similarly, another professional raised the subject of his own hearing loss, after he identified most of the behavioural characteristics in the survey as indicative of impaired hearing. He was aware of background noise as very annoying and intrusive. He had the problem of turning television sound up too loud for others' comfort. Because of his suspected hearing impairment he was sensitive to its implications, for himself and for prisoners. He had no awareness of resources or group listening 140 devices which would benefit him or his clientele, nor was he aware of hearing impairment in the prisoners in his caseload. He did however indicate interest in obtaining more information in respect to helpful devices. The case of one prisoner in the study, who shall be designated as P1, portrays the helpful role which a sensitive professional can play in assessing a prisoner and recommending a rehabilitative program. P1 had spent his childhood and youth [a total of 17 years] in an institution for the mentally handicapped, and was then released into a group home in the community, where he shortly ran afoul of the law. He had been in and out of jails for several years, finally ending up in a medium security penitentiary. Here, an astute psychologist, after testing, decided that P1 was not retarded but had gross visual and hearing problems. After vision and hearing assessment, P1 was fitted with spectacles [very thick ones] and two hearing aids for severe hearing impairment. The psychological assessment expands on the problems which impaired vision had caused for P1 in the learning and social developmental process. But he has written nothing about the effect of unidentified hearing impairment upon his learning and social development. In other words, he was aware of the implications which impaired vision could have for the client, but not of the significance of impaired hearing. In general, with custodians the issue appeared to be mainly unawareness of the behavioural indicators of impaired hearing and its implication for 141 habilitation and rehabilitation. Even the minority who were aware of hard of hearing indicators, were unaware that resources were available to them [or the prisoners] to cope better with barriers to communication. In view of the extent of impaired hearing discovered in the study, this knowledge gap has serious implications. b. Prisoner concerns about custodial unawareness of hard of hearing behaviour The 42 prisoners interviewed had concerns about custodial lack of awareness of hard of hearing behaviours. One-third of the respondents urged more education of staff about the hard of hearing condition. More than two-thirds stated that unawareness of hearing impairment resulted in unwitting discrimination against prisoners with impaired hearing. As one prisoner said, "I have seen many inmates who do not respond appropriately because of hearing problems. Staff are not aware of signs to recognize the problem, myself being a prime example." Twenty-one percent [n=9] of prisoners stated there is a lack of awareness about special needs such as telephone and television devices for those with impaired hearing. One prisoner stated, "I hope your conclusions will include recommendations for special telephones and other equipment for hearing impaired in the prison system." A similar number noted the detrimental effect of excessive noise in the institutions;"... always the public address system blaring, noisy living 142 quarters." One provided a more optimistic note: "In prison when [I was] younger, often in maximum security because of my rebellious nature, it was very noisy. Slept on my good ear, deaf ear up, even through a riot." While a sense of humour or a philosophical attitude towards a hearing impairment can be a positive coping strategy, it may also have a negative effect if it is used as a "denial" mechanism to stand in the way of seeking help. Custodians' perceptions of characteristic behaviours The fourth question asked what labels custodians attach to behaviours of prisoners who are hard of hearing. This question was investigated by first determining what custodians perceived as problematic prisoner behaviours, in order to gain some understanding of how behaviour is coded and standardized by custodians [Foucault 1979]. This step also provided some insight into custodial sensibilities to prisoner behaviour. Custodians were asked, "What are the behaviours by inmates that give you the most trouble in talking to them?" Custodians provided 94 individual responses, which listed 46 different labels [Appendix L. Supplementary Table L-5]. A review of these responses indicated that they fell into three categories, which were coded, A:"defiant behaviour" - aggressive behaviour, rule-breaking and anti-authority, lack of responsibility or effort [passive aggression]; B: "deficit behaviour" - deficits in education, intelligence or social skills; and C: "defective behaviour" - personality deficits, mental illness, physical defects. These responses 143 are summarized in Figure 11. Sixty-nine percent of the responses [n=65] cited type A [defiant] behaviours as most troublesome; 13% [n=12] of the responses cited type B [deficit] behaviours as troublesome, and 18% [n=17] of the responses cited type C [defective] behaviours as troublesome in talking with prisoners. Since the majority of prisoners were admitted for crimes of violence, this finding of defiant behaviours as most troublesome does not seem surprising. Figure 11. Custodian identification of troublesome prisoner behaviours. n=94. ' Legend ^ f l | defiant ^ defective M defIclt 70% 60% 50% 40% 30% 20% 10% 0% 69% 18% 13% Custodians were then given a descriptive statement of 31 different behaviours and asked to state what that behaviour would mean to them, in the context of their work situation. The behaviours described were all characteristic of people who are hard of hearing [Appendix F]. A fourth category, "D", was established, to 144 include "neutral" and "don't know," "possibly hard of hearing" and similar types of response. Custodians were categorized under Health [nurse]; Correctional Officers 1, 2, 3 [C01, C02, C03]; Managers and Supervisors; Other [medical profession, teachers, social sciences]. When asked to describe the meaning of a behaviour, 88% of the time, health staff perceived the behaviour as meaning something negative [deviant]. A negative interpretation was selected by Correctional Officers 90% of the time; by managers and supervisors 81% of the time. Others [teachers, social science, medical profession] did so 81% of the time. The average was 86% negative interpretation of behaviours, by all personnel interviewed. Custodians identified some behaviours as typical of people who are hard of hearing. Behaviours which were most frequently identified as "possibly hard of hearing" are depicted in Table 11. Supplementary Table L-6 provides the actual labels by custodians, according to job classification. Orientation towards the selection of a label tended to relate to work roles. For example, a role which related to working with conditions such as "Attention Deficit Disorder" tended to produce much more interpretation of certain behaviours as indicative of that condition, and not of hearing impairment as a plausible reason for the behaviour. 145 Figure 12. Custodians naming of behavioural characteristics. n=1365 HEALTH COR.OFF. MAN&SUP. PROFS. Categories of custodians Table 11. Custodian identification of hard of hearing behaviours in prisoners BEHAVIOUR IDENTIFIED AS "POSSIBLY HARD OF HEARING" Turns television and radio up louder than the others want it Complains about the way people talk - accuses others of mumbling Always speaks in a loud voice Jerks his head around a lot to locate who is speaking Is always watching, staring, watches closely the facial expression of speaker Doesn't want to use the telephone n 24 20 15 10 10 08 % 44 40 33 22 22 16 The 42 prisoners interviewed had concerns about the consequences of misinterpretation of their hearing-related behaviour, in particular by those with power over them. When asked to express their views about being hard of hearing, the most 146 commonly shared concerns were feelings of isolation [57%] fears of being misjudged or mislabelled [55%]. Fully one-third of the respondents [33%] noted that "it's hard - others don't understand." As noted in the literature review in Chapter Two, these are feelings commonly expressed by people who are hard of hearing. However, prisoners may be much more vulnerable to negative effects from being mislabelled, and the sense of isolation may be intensified by incarceration. As one prisoner stated, "I believe my hearing loss has caused many problems. Understanding people is damn hard. I can hear but I don't always understand. For example, you say 'Oog' and I hear 'Bog' or 'Fog'." a. Prisoner perceptions of mislabelling by custodians The literature reveals that people who are hard of hearing feel aware of the potential for negative assessments by others, of their intellectual status, behaviour and capabilities, based on misapprehensions of their hearing-related reactions and actions [Bruce 1993, Hetu et al. 1990, Israelite 1993, Jones et al. 1987]. While this was important for social situations, it was vitally important in situations involving authority figures [Soderlund 1994, Theberge 1991]. Similarly, prisoners feel vulnerable to the impressions others will form of them, and to the consequences of being mislabelled, as illustrated by some of the following statements: 147 P2:" I think my hearing loss affects my current status, yes - I can't hear in groups. I am always straining to hear - this is tiring. I keep quiet about it because I fear rejection if I tell them. I can tell that others get irritated with repeating." P3: "I was blamed in class and in group for not paying attention and I accepted the blame for this. Now I realize it was because I could not hear - not my fault." P4: "I have problems hearing in the courses offered here. Can't take part in the discussion. Don't know what I have missed. I often feel misjudged." Being misjudged or mislabelled in class or group therapies has significant implications for prisoners, because their progress through the penal system relates to their behaviour, including how well they perform in group and class. Performance at work is evaluated also. Prisoners who had an unidentified hearing loss reported problems at work. P5: "My hearing loss has a big effect on my interaction with others. It causes me problems at work, too. I have my head down to see what I'm doing and never hear what was said to me by my boss." P6: "I work in a very noisy place. Hard to hear requests. I can't understand. Make mistakes. Others get annoyed at me. Happens all the time. Like, I'm working in the kitchen and it's very noisy there. Men at the counter call for toast and get mad because I don't bring it." 148 Common complaints made about people who are hard of hearing include, "He hears only when he wants to," or "He could hear better if he tried." Family members as well as authority figures, such as a teacher or employer have been documented as making such statements [Combs 1989, Elkins 1993, Smith 1993]. The lower the social status of the person with the impaired hearing, the more difficult it can be to convince the labeller of the invalidity of this label. Serious consequences can ensue. Some prisoners' statements provided variations on this. P7: "Guards are impatient with inmates. They expect to be understood, don't want to repeat"[emphasis in the original]. Complaints of not being able to hear in group and work situations were common. As a rule, the prisoners did not explain to the group or official why they were not understanding or participating. More than half [55% n=23] of the subjects expressed concerns of being misjudged or mislabelled. Being called "stupid," "uncooperative," "slow," or "dummy" was common. Three subjects stated they had not heard an order from a guard and were punished for disobeying a directive. P8: "I did not hear a guard. He did not believe me and claimed I had disobeyed an order. I got thrown in the hole. Lost good time." 149 One area of concern was the effect of hearing impairment in the courtroom and before the parole board. There was an evident potential for mislabelling and miscarriage of justice. Five stated they had not heard in the courtroom except in one-to-one situations with their lawyers. McAlister [1994] explains in detail the potential for misunderstandings by prisoners in the courtroom, and the difficulties they face in accessing their judicial rights. Most often, the prisoner with impaired hearing does not know that communication could be made accessible to him, and meekly acquiesces to a situation of not knowing what is being said. P9: [referring to the courtroom] "I kept asking my lawyer, 'what's he saying, what's going down?' and he kept shushing me, telling me to keep quiet." P10: [referring to appearance before parole board] "I missed hearing a lot; had a hard time. Finally I just sat back and gave up on it. I could feel irritation from them because I kept saying 'what, what?'." Body language may contribute to misperceptions of behaviours by those who do not hear well. This prisoner demonstrated throwing himself backward in his chair, shoulders and body sagging and head down, with a dejected look on his face, in effect, giving up. But this behaviour is also open to interpretation as "not caring," "not interested," or "withdrawing." For example, he stated, "I do the same with the guys here when we are sitting around [a minimum security situation where 150 more group socialization occurs than in medium and maximum security prisons] -1 can't hear, so I just sit back as though I don't care or I'm not interested. But I feel isolated. It's hard." Behaviour in social situations and groups is open to interpretation by both fellow prisoners and correctional officers who make judgements on socialization skills and aptitudes. Not all prisoner comments were negative. Some prisoners who had a hearing aid, and thus a medically validated and visible hearing impairment, stated their hearing problem received consideration in the planning of their programme. P11:"l wear two hearing aids so they know I have a hearing loss. Group therapies in this institution are being very helpful. I am gaining insight. Others in the group and the therapist are not really aware of the feelings related to hearing loss and we're just beginning to talk about this. Groups have helped me to understand my anger and frustration and its source in my hearing loss. I have just now begun to talk about how my feelings from hearing loss go way back and contributed to my crime." P12:"l wear two hearing aids and the teacher has fixed it up so I sit at the front of the class. I'm getting an education for the first time in my life." There was however no awareness of other assistive devices which could have facilitated hearing in class or group for these two inmates, or of available resources to consult for helpful strategies. 151 P13:"They put me to work in the greenhouse where I work alone and don't have to worry about hearing others. Can't wear my hearing aids there though because of the high humidity, but that does not matter because I am alone there." One tall, robust individual who suspected he had a hearing loss stated with a grin and a self-assured manner that no one gave him any difficulty about his hearing problem due to his size and strength. The experience of prisoners with impaired hearing The fifth question asks how hard of hearing prisoners interpret their hearing-impairment-related behaviours and how this compares with custodial interpretations of these behaviours. Almost one-half [46%, n=87] of the study sample [n=189] were identified as having a hearing loss. To investigate the fifth question, I interviewed 48% [n=42] of the 87 prisoners identified with hearing loss. A semi- structured format was used [Appendix D]. Responses of the interview subjects were later cross-referenced with those of custodians who provided labels to the 14 items desaiptive of hard of hearing behaviours [Supplementary Table L-6]. The data from cross-referencing are demonstrated in Supplementary Table L-8. Of the 42 hard of hearing prisoners interviewed, 81 % [n=34] believed or knew prior to testing, that they had some hearing impairment, as indicated by their 152 earlier responses to Questionnaire #1; 17% [n=7] did not know until the study was done. About two-thirds [69%, n=29] believed their period of incarceration had been adversely affected by their hearing impairment. When asked to identify areas in which they had experienced disadvantage due to a hearing problem, prisoners identified multiple categories, as illustrated in Table 12. Table 12. Areas of hindrance resulting from hearing impairment. n=42 AREA OF HINDRANCE EXPERIENCED phone, television, public address system groups and classes social contact with other prisoners health care staff guards and/or administrative staff excess noise levels in institution interpersonal relationships parole board employment everywhere in general n 38 31 29 18 17 13 10 10 09 03 % 90 74 69 43 41 31 24 24 21 07 Thirteen percent of other respondents who noted that social contact with other prisoners had not been hindered, stated, "No, there is not much social contact here anyway." While the nature of imprisonment greatly restricts social contact, this is a typical comment from a person who is hard of hearing, avoids social contact in order to conceal his hearing loss, and avoids facing that fact. 153 Ninety percent [n=38] of the prisoners who were hard of hearing felt hindered in use of the telephone and television and had difficulty with, or were completely unable to understand, communications via the public address system. All prisons in the study use a public address system to give directives to prisoners or call individuals for specific reasons. Some prisoners said they ask others what has been said. All said they had at some time experienced the result of a negative assessment by a custodian through having not responded appropriately to a communication via the public address system. It is significant that three-quarters of this group expressed concern over being hindered or held back in group and class situations. Educational and therapeutic situations represent their hope for improvement and advancement through the system, and prisoners with impaired hearing appear to be at a disadvantage in this area. Excerpts from interviews with prisoners Excerpts from prisoner interviews illustrate the experience of offenders who are hard of hearing, in regard to perceptions of self, and in relation to interactions with custodians. Feelings of isolation, rejection and withdrawal were common, coupled in some cases with compensating behaviour. Comments by P14 and P15 illustrate compensating behaviours typified by actions to give one power and make 154 oneself noticeable to peers, in place of feelings of frustration and isolation. They also all mentioned lowered self-esteem following the onset of impaired hearing. P14: [on effect of hearing loss related to other offenses]: "I felt rejected by others when I could not hear, or I misunderstood, or did not reply when spoken to - I did not know they were speaking to me. I withdrew. I felt isolated. I compensated for these feelings by doing things - aggressive things - this gave me some power." This prisoner stated his hearing loss occured while he was in high school, at an age when being similar to one's peers is very important. He felt unable to respond adequately to the situation and experienced loss of control over his place with peers. He was no longer noticed in a favourable way. Aggressive acts brought him notice and made him feel in control. The following individuals made similar observations. P15: " My hearing loss was first noted when I was in Junior High. I became isolated. Began to change my behaviour and got into trouble. I do relate my hearing loss to my criminal behaviour." P16: "My hearing loss started when I was 23. I withdrew. My self-esteem dropped." In commenting on the effect of impaired hearing on his current status: "I have a slowed response to conversation. I need time to think, to grasp what was 155 being said. By time I'm ready to reply, others have gone on to something else. I get left out." Lowered self-esteem is commonly reported by those with adventitious hearing loss. The need for a longer time to process receptive communications is a typical hard of hearing experience. Others tend to label them as "slow", "dense," or "confused". P17: "I greatly miss socializing - my hearing loss began after a car accident and has deteriorated since. It's frustrating. Just do my work and that's about it." This prisoner displayed the mild depression and withdrawal typically associated with adventitious hearing loss. P18: "Some people I just can't understand. They talk fast and mumble. I feel very frustrated." This is the classic complaint of people who are hard of hearing. It is notable that the above prisoners were concerned about the effect of hearing impairment on socialization, more than on information exchange. This is indicative of the socially isolating effects of both institutionalization and impaired hearing. Some also were concerned about the effect on interpersonal relationships and intimacy. The following comment is typical of the effect of hearing impairment on an existing relationship. P19: "My personal relationships are affected, with my girl friend. She has a high-pitched voice. Seems like she's mumbling." It is common for people who are hard 156 of hearing to describe their communication difficulty as resulting from the communication partner's speech pattern, i.e. "she mumbles." The hearing impairment may be the primary source of comprehension difficulty, but many hard of hearing people attest that another's manner of speaking often contributes to or exacerbates the problem [Erber 1988, Rezen 1993]. As well, some had difficulty in forming relationships due to a high frequency hearing loss, which was the most common type of loss in this study group. P20: "I have trouble forming relationships. The female voice is high-pitched. I can't hear it. It's all a mumble." A great difficulty for the hard of hearing person in this type of situation is not knowing how to guide the communication partner in strategies to facilitate improved communication [Trychin 1994, Turbin 1993]. For the person who is hard of hearing and is attempting to form a relationship, embarrassment and fear of rejection often prevents even telling the other person what the difficulty actually is, or even revealing that one cannot understand. The strategy of bluffing will result in being misinterpreted by the other, as will avoidance and withdrawal. Because most prisoners in the study reported taking such a wide range of drugs it was difficult to correlate drug usage and hearing loss. Jensema [1990] reports that heroin users in a jail study frequently reported ringing in the ears while using the drug. Some stated they could tell the quality of the heroin by the intensity 157 of the ringing. One prisoner in this study believed that for him, cocaine use resulted in tinnitus. P21: "My hearing loss started about ten years ago. It may have had a very little effect on my offense. My offense was cocaine use. I had withdrawn a bit from socialization due to hearing problems - trying cocaine maybe was a bit of a compensating act. The ringing in my ears started when I was using cocaine and it has never gone away. I have it all the time now." When hearing begins to deteriorate gradually, particularly with a high- frequency type of loss, the individual is often unaware of the progressive loss, and rationalizes instances of not hearing, or hearing incorrectly, such as the following: P22: "I can't hear my small daughter when she visits - she mumbles and hides her face." This prisoner had a moderately severe hearing loss, with a verbal history which suggests that it is possibly a loss of some standing. He was unaware of the hearing loss prior to the hearing screening. Such an individual, although unaware of impaired hearing, also begins to lipread [speechread] simply through watching the speaker's face and concentrating on what is said, and possibly, being alert to contextual clues in body language and intonation of speech. By this approach one gradually compensates, often without awareness [Combs 1989]. Someone knowledgeable in the field of hearing loss will note that such an individual closely 158 watches the speaker, and may get close in order to hear better. To the uninitiated person, this intense watching may be interpreted as a bold stare and produce discomfort. This characteristic trait was noticeable in the prisoner quoted above and in a number of the prisoners who came for testing. The following accounts illustrate how a missed diagnosis of impaired hearing in a child can result in life-long negative effects. P23:"Our family doctor missed diagnosing my hearing loss. As I grew up I did not relate to my peers, thus chose to isolate myself from them to avoid further hassles. This isolating of myself is a major factor in the development of my insecurities with people. I had fantasies of getting back [revenge] which I would later act out. School called me stubborn, anal-retentive. I was aggressive. I fought a lot." P24, a First Nations person, did not know he had a medium hearing loss until tested in this study. He stated he did poorly in school -"I failed a lot." He is having great difficulty in the prison system because he refused to cooperate with the programme set up for him. "I did not participate in the life skills class and basic education class because I failed in them before and they sent me back here to maximum security. I don't know why I failed them. Thought I was too dumb. Didn't know I had a hearing loss. I don't know what to do now, to get out of here, get back to medium security." 159 This individual spells at a Grade Three level and he believes he needs an education. He reported feeling very frustrated and helpless. He can hear only in one-to-one conversations. He has never told anyone of his hearing difficulties and it did not occur to him that he has a hearing impairment. He shed some tears during the interview. His history, both oral and documentary, is that he has had problems since childhood with social and educational matters. He recalls ear ache and infections. It appears that he may have had impaired hearing since childhood and, having never known anything different, has believed that it was the normal way to be. It is quite common for someone who has been hard of hearing since childhood, and not met other people who are hard of hearing, to be unaware of their own hearing impairment and accept others' valuation of his/her behaviour as "stubborn," "difficult" or "rebellious," and "poor learner" [Brynelsen 1991]. Possibly the most poignant and articulate statement, which encapsulates much of what was said by others, appeared as a comment in the first questionnaire. It was written by the following prisoner who has had a severe to profound hearing loss since age five: P25:"My hearing impairment continues to alienate me. It affects my self worth. It affects my ability to socialize with others. It's a hidden disability that I have to keep explaining to people and many times I've had to physically defend myself because I 160 don't hear people when they speak to me and they think I'm being aloof or arrogant when I don't answer them, so they want to fight me." Comparisons between perceptions of prisoner and custodians Some of the most common responses from prisoners included not knowing when others, especially guards, are speaking to them. Examples given were situations when the prisoner is not looking directly at the guard, such as the guard coming from behind; and when participating in any group. This behaviour was most commonly interpreted by custodians as wilful and hostile action. Getting close to hear, watching closely, staring or frowning, were also often interpreted as hostile acts. Not understanding, looking puzzled or startled, getting things wrong were interpreted frequently as evidence of stupidity. Behaviours related to non-participation in group situations tended to be labelled as indicative of an asocial personality. Complaints about others not speaking clearly, or so they can understand, or of head noises were largely interpreted as relating to mental problems. Head noises [tinnitus] are frequently reported by individuals with impaired hearing, in particular those with sensorineural hearing loss. In most instances, prisoners did not believe that mislabelling by custodians was deliberate. These data suggest that prisoners believe custodians discriminate against prisoners who are hard of hearing largely due to unawareness 161 of the behavioural attributes associated with the condition. However, prisoners stated a strong concern that hard of hearing behaviour was being misinterpreted, and consequently mislabelled and misjudged. Their vulnerability and feelings of helplessness to change this situation were expressed by comments such as "the guards don't know and I don't tell them," "I can't hear in classes but I don't tell,"" I sometimes feel invisible in a group." Comparison group of prisoners with normal hearing Thirty-nine prisoners who passed the hearing screening and were identified as having no hearing impairment were interviewed as to perceptions of hearing impairment in their fellow prisoners. [Appendix E]. The rationale for this interview group was to provide some information on how peers reacted to individuals with an invisible disability. The number interviewed represented 27% of the total population screened, and was roughly equivalent in number to the 42 prisoners with impaired hearing, who were interviewed. Detailed responses to the interview are provided in Appendix L, Supplementary Table L-7. A summary of pertinent findings is provided in the following Table 13. 162 Table 13. Interview results, prisoners with normal hearing; a summary. n=39. EXPERIENCES WITH IMPAIRED HEARING IN FELLOW PRISONERS Correctly identified a behaviour typical of a hearing problem Have concerns about hearing impairment Believe prison/custodians discriminate about hearing impairment due to unawareness Knew of fellow prisoners with impaired hearing Felt a negative effect from behaviour of person with hearing impairment n=39 34 26 26 05 04 % 87 67 67 13 10 In identifying behaviours characteristic of someone with a hearing problem this group of prisoners specified the same behaviours most commonly noticed by custodians, and by the public at large. Such behaviours include frequently asking for repeat of statements, "They say 'eh?' and 'what?' a lot"; misunderstanding statements; straining to hear; turning up the sound on the television. While 34, or 87%, of this group could identify the most common behavioural indicators of impaired hearing, only 5 of them could actually identify a fellow prisoner with a hearing loss, and in each instance, the hearing loss was profound. One individual named by all 5 prisoners, was completely deaf, did not speak, stayed by himself, and communicated only with pencil and paper. The second prisoner identified was deaf in one ear and wore a hearing aid in the other ear, to partly compensate for a severe hearing loss. This individual was also comfortable with, and articulate about, directing others to speak in his "good ear," and others responded positively to this direction. 163 P1 "There's only this one guy and I just go around to his hearing aid side when he asks me to." One noted that he stayed away from the deaf man in order not to be bothered. Another indicated he found the prisoner with impaired hearing irritating as he did not like to repeat things. Subjects also stated, as did the hard of hearing prisoners that "there's not much socializing going on around here anyway." Unexpected findings One unexpected finding of the study was the extent to which prisoners are bothered by noise in the institution. The issue of troublesome noise in the prison was first raised individually by Matsqui prisoners. A correctional officer at Matsqui confirmed that the institution is excessively noisy and drew a diagram of the prison layout to illustrate the flow of noise through the living quarters. Noise is now considered the number one cause of hearing loss in society, and a contributor to increased levels of stress [Health and Welfare Canada 1981]. I decided to add this line of inquiry to future interviews. Therefore, subjects were asked if they found their prison noisy. They were also asked how many institutions they had been in, and if so, was one more noisy than the others? All prisoners who had been at some time in Matsqui depicted Matsqui as very noisy [ see Table L-7(i)]. One stated "I had a lot of tension, strain in my neck while at Matsqui. Don't notice any of that feeling here." Another spoke of feeling very fearful and anxious while there. Several said there were more fights and dissension at Matsqui than at other prisons. "There's too much noise 164 in this institution for a hearing aid wearer. For example in the living quarters there's loud radios, TV's, chairs dragging." In comparison, prisoners at Mission stated they have a noise code to control noise levels in their living quarters. It would appear that the issue of noise levels in institutions warrants further investigation. Another unexpected finding was that of staff needs relative to hearing impairment. It became fairly common for staff to approach me for information about resources such as devices or self-help measures for a relative or friend who was hard of hearing. Additionally, staff at every institution were told that if there were empty intervals between prisoner appointments, we would be ready to screen their hearing, a procedure taking 3 minutes. No count was kept of the number of staff who participated, but an estimated 12 had their hearing screened. In one instance, a custodian has been told by his family physician, after a test with a tuning fork, that he had no hearing loss, and declined to refer him for further testing. However, his staff colleagues felt that he did have a problem hearing and encouraged him to approach us. When his hearing was screened in the van by the audiologist, he had a medium hearing loss and should seek a complete hearing assessment. This was a classic example of the power of the physician to withhold a diagnosis, and illustrated that what happens to prisoners with impaired hearing also happens in society at large. The consumer organization [Canadian Hard of Hearing Association 1992] reports that such incidents are fairly frequently reported by consumers - there are individuals who 165 seek resources for family or friend, and who report that family physicians are slow to diagnose hearing loss, or refer for audiological testing. Another interesting feature was that prisoner responses in both questionnaire and interviews did not reveal a negative attitude towards correctional officers. This appears to correlate with Yates' comments that "I wear one uniform and he wears another; I have an employee number and he has a correctional services number. But we're both locked behind the same bars. All human beings together. We are the line" [Yates 1993:10]. Another perspective on this may be that of a fear of reprisals arising from negative comments [Cordilla 1983, Culhane 1991, Gosselin 1982]. Only 7% [n=3] of prisoners actively complained in interviews about the way they were treated by guards. Of respondents to Questionnaire #1, 68% [n=129] stated that they got along well with guards. One prisoner raised the problem of being misunderstood and misjudged due to the difficulties he had with English as a second language. "I am big and I speak in a loud voice, which is natural in my native language, but here it gets me into trouble. People think I am aggressive. I have problems adapting to the tone of the spoken language so I lack the ability to hear properly and understand." While this does not relate to impaired hearing, it is a good illustration of the important role of social perception, and social discomfort with anyone who violates our standard expectations for social communication behaviours. 166 Summary This chapter has provided a demographic profile of the study sample, and in some instances compared it to other populations in society at large. It is apparent that there is a much higher percentage of hearing impairment in the study sample than in society at large. The present method for identifying hearing impairment in these prisons appears to be inadequate. Hearing is not screened on admission, nor is it recorded in the health files unless a profound loss is present, or the prisoner had hearing aids on admission. Prisoners report that complaints of a hearing difficulty are not routinely followed by a hearing screening. Staff confirm that hearing screening is not done unless the prisoner appears to have a severe problem in hearing. Custodians have demonstrated, in their own words, that they lack awareness of the range of behaviours associated with partial loss of hearing. The data show that they are five times more likely to characterize a behaviour as due to any reason other than a problem in hearing. A comparison of custodial and prisoner interpretation of behaviour shows that prisoners behave in ways typical for persons who are hard of hearing, but that custodians tend to interpret these same behaviours in negative and deviantizing ways. The majority of prisoners believed that such interpretation seems to flow mainly from unawareness of the range of behavioural indicators of impaired hearing. In the next chapter, these findings will be analyzed and their implications will be identified and discussed. 167 CHAPTER FIVE PRISONERS WITH IMPAIRED HEARING: COMPLEXITIES AND CONTROL "I was fitted with hearing aids for the first time while in the penitentiary, in a minimum security work camp, three months before I was released. I was really pleased at being able to hear, for the first time in my life, even though the other inmates teased me about the aids, made fun of me. After I got out, with my aids, I've never been back in prison again. Tried to turn my life around. Could get only short term, low paying jobs, unskilled labourer. Went through two marriages. Could never earn enough to hold the marriage together. Now I'm taking courses in the community designed for upgrading skills and employment opportunities for the hearing impaired" [Anonymous ex-offender 1992]. Introduction The experience of impaired hearing, and in particular, partial hearing loss, has been conceptualized in Chapters One and Two as a complex social phenomenon. Factors intrinsic to deviance definition, biomedical diagnosis, and social structures, all influence the experience of being hard of hearing, or deafened. For powerless individuals and groups, such as prisoners, the experience of impaired hearing is usually a negative one, emergent from factors of control, domination, and oppression embedded in institutional and social structures. In Chapter Three, the methodology for investigating hearing impairment in prisoners of federal prisons in British Columbia was detailed, including difficulties inherent in accessing a unique population in secured institutions. In this chapter, the research findings from Chapter Four are discussed in relation to social control and deviance theory, and located within a broader macro-political perspective on institutionalized social control and resistance. The politics of deviance and uses of power are considered. 168 The discussion in this chapter follows the order of the study questions. Discussion first focuses on the identification of prisoners with partial hearing loss in the sample population, drawing from results of survey, audiological measurements and self-report and compared with other research findings and theory. Second, existing methods in the prisons for identifying impaired hearing in prisoners are reviewed and analyzed. Here attention is drawn to technical aspects of health care service delivery as noted in the study, and to the apparent deficiencies in assessment of hearing status. Descriptive statistics, prisoner and custodian reports, documentary evidence and theory are triangulated to answer the second study question. The third and major area discussed is that of the powerful role played by social perception as it affects those who define and manage deviance. Such perceptions have significant negative implications for prisoners with impaired hearing, who experience the labelling, as indicated in individual interviews with inmates and custodians. The conclusions drawn, in conjunction with existing theory, provide answers to the third, fourth and fifth study questions. Percentage of prisoners with impaired hearing The first question asked what the percentage of partial hearing loss in prisoners of federal prisons in British Columbia is, compared to in the general population. 169 According to the self-report data, 110 prisoners believed they had a hearing impairment. This represents 8% of the prison population approached for the study [n=1439]. In comparison, Health and Welfare Canada [1986] reported that 4% of Canadians self-reported a hearing impairment. If prisoners with impaired hearing were more inclined to participate in the study than prisoners with normal hearing, the resulting bias suggests that true percentage may be underestimated. Studies published from 1970-1983 [Chapter 1:1], report an average range of 30%-40% presence of hearing loss in young adult male prisoners. Jensema [1990] reports a 35% presence in a jail population, with a tendency to more hearing loss amongst the older prisoner age group. Grant and Lefebvre [1994] of the Research and Statistics Branch of The Correctional Service of Canada report that offenders over 50 years of age constitute the fastest growing group in the correctional offender population in Canada. Incidence of hearing loss correlates positively with aging [Statistics Canada 1992]. Therefore it can be expected that the incidence of hearing impairment will be on the increase in prison populations. It has also been noted that hearing loss is increasing among all age groups, due mainly to exposure to excessive noise in both work and leisure situations [Health and Welfare Canada 1988]. As well, prisoners in the study, both hearing and hearing-impaired, report a high incidence of events predisposing to impaired hearing, such as high exposure to excessive noise, high incidence of drug use, major head trauma and certain illnesses. These reported factors hold across all age groups in the study. 170 Given the high proportion of impaired hearing identified in this study sample, and when findings are considered in view of the literature reviewed, it is suggested that further investigation is warranted. Such investigation should identify others with hidden hearing impairment, and lead to the establishment of appropriate rehabilitation strategies to permit them to participate fully in treatment programmes. The results of hearing tests indicate that 46% [n=42] of those with impaired hearing had a loss from medium to profound. Such a degree of loss would result in inability to comprehend fully in any communication situation involving more than two people, in an acoustically quiet room. If the environment were noisy, comprehension would be reduced accordingly. For the 31% [n=28] with a mild degree of hearing loss, where environmental noise is present, comprehension would be piecemeal and reduced, whether in a one-to-one situation or in a group. As discussed in Chapter Three, page 88, a mild level of hearing loss, as measured by audiological assessment, does not represent actual degree of hearing acuity. Much depends upon the actual hearing environment, and the ability of the individual to comprehend in that situation. If there is interference with the opportunity for an individual with impaired hearing to hear and understand, he could not expect to achieve the learning objective of a class or group. The treatment goal and the potential to gain insight would be effectively denied the prisoner. It is important for prisoners to have maximum contact with families, friends, and lawyers. Visiting areas and common rooms, with their open spaces and 171 mixed sound reverberations can represent hostile listening environments for prisoners with any level of hearing impairment. This situation can serve to amplify existing alienation. The power/knowledge paradigm [Foucault 1979, McMahon 1992] has been reworked by post-modernists [Rosenau 1992, Smart 1990, Young 1990] to a perspective of [often unthinking] oppression of the powerless by dominant institutions or groups. Thus, because past corrections policy has not mandated hearing testing for prisoners, and the issue of hearing impairment has not been a priority, there is an apparent reluctance and indifference to consider its significance. Embedded attitudes, perceptions, and beliefs are not easily changed. For example, one British researcher wrote the author, "When I raised the question of these findings (Dahl, 1994) with our Chief Inspector of Prisons, whose two daughters are severely hearing-impaired, he said, that in his own experience, the prevalence of hearing-impaired prisoners appeared to be at par with that of the general population" [Rice 1994]. Rice also notes that they do not screen hearing of prisoners. Identifying hearing impairment in prisoners The second study question asked what the methods are for identifying hearing impairment in federal prisoners in British Columbia, and if these methods are adequate. This question was explored through self-report and interview data and 172 documentary examination. First, 58% [n=110] of the prisoners surveyed in Questionnaire # 1 believed they had a hearing impairment but stated it had not been identified. Only 10% [n=20] of all respondents had, at their own request, undergone a hearing test since incarceration. Seventeen percent [n=16] of prisoners who failed the hearing tests [n=87] were unaware of their own hearing loss until tested, and it may be inferred that there are other prisoners in the same circumstance in the prison population. Second, of the 42 prisoners with hearing loss who were interviewed, 48% [n=20] had complained to the doctor of a hearing problem. Of those who complained, 70% [n=14] did not receive audiological testing, stating that only the outer ear canal had been examined by the prison physician, who said that it "looked fine," and no treatment or hearing testing was warranted. Only six of the complainants received audiological evaluation and hearing aids. Their hearing loss was in the severe to profound range, where communication is grossly impeded and, therefore, very noticeable. Third, the review of individual health files revealed that, in separate admission health assessments by doctor and nurse, the areas pertaining to hearing assessment on the admitting documents had nothing recorded, unless the offender had a hearing aid and/or a profound hearing loss. Vision status was recorded. 173 In all of the health files reviewed, where prisoners had received physical and mental assessments through referrals to specialists, none of the specialists had recorded any test of hearing in the medical consultation file and had made no mention of the presence of a hearing impairment, unless the prisoner wore a hearing aid, or had a profound hearing loss. It is recognized that unawareness of a hearing impairment is quite possible because such assessments would be conducted in an acoustically quiet examining room or office, usually on a one-to-one basis with the physician examiner. Individuals with severe hearing impairment who are good speechreaders can manage to converse well under such conditions [Kaplan et al. 1987]. The point is that partial hearing loss can be missed unless the examiner is specifically looking for it and conducts an audiometric screening to identify it. As noted earlier in the study, neither the "watch test" nor the "tuning fork" test can be considered reliable to detect a hearing loss [Martin 1981:7-14]. This failure to look for, or be alert to, the possibility of partial hearing loss in prisoners, is a striking example of the gatekeeping power of the physician to withhold diagnosis through not screening the hearing of the prisoner, or asking the nurse to do so [Jones 1987, Little 1989]. Similarly, the nurse may exercise this type of gatekeeping power by denying a patient a requested appointment with the doctor, a request for referral to an audiologist, or not screening the hearing, in those institutions which have an audiometric screening device. 174 Gove [1975, 1979, 1980] argues for the beneficial result of medical labelling, where diagnosis results in effective treatment. A beneficial result, however, would be dependent on a correct diagnosis. Two prisoners in the study who reported receiving hearing aids post-incarceration stated their hearing impairment was taken into consideration in planning their treatment programme. For the prisoner with impaired hearing in this study who had not received a medical diagnosis, the labelling by custodians tended to be often an incorrect, negative and deviantizing one with consequent powerful negative effects. Power of any sort is more like a process than an object. It tends to operate as both cause and effect [Schur 1980]. The correctional system itself exercises this restrictive power by not mandating hearing screening as a part of the admission procedure. Withholding of the "hard of hearing" label is crucial at this point, and sets the stage for whatever type of labelling is to follow, from others with the authority to label. There is the power of the correctional officer as case manager to assess and label behaviour, which in turn controls the prisoner's programme. There is the power of the parole board members to assess and sit in judgement on eligibility for parole. In the deviantizing process, it is the perception that counts. Much responsibility, therefore, rests on official ignorance of the importance of undetected hearing impairment, relative to assessing behaviour, and to the treatment programme. "It is through social definitions, responses, and policies that particular behaviours, conditions, and individuals acquire their 'deviantness'" [Schur 1979]. Power differentials are very important in affecting what happens to specific individuals subject to stigma. 175 In summary, hearing testing and prisoner report, compared with theory and research, suggest that present methods for identifying hearing impairment in federal prisoners in British Columbia are inadequate. The absence of routine hearing screening on admission and a lack of awareness about the significance of any level of hearing impairment in the individual prisoner may be said to constitute inadequacy of methods for identifying impaired hearing in prisoners. Lack of awareness of hard of hearing behavioural attributes The third asked if custodians are aware of the range of attributes associated with partial hearing loss; and how they characterize hearing loss-related behaviours in prisoners. The literature reviewed in Chapter Two has established that the behaviour of a person who is hard of hearing is very easily misinterpreted because it often is at variance with established rules and norms of social communication situations. While misinterpretation is more likely to occur when the hearing impairment is unidentified, it may also happen even in situations where one knows well the hard of hearing person. McAlister describes the dilemma as follows: 'The hearing of the hard of hearing has unpredictable and off-putting ways and is often misinterpreted as arrogance. We might comment with pleasure on a distant train whistle or ship's horn and then sit oblivious to a nearby doorbell or whistling tea kettle. We might be disturbed by light footsteps from the other end of a house and then awaken loved ones by crinkling cellophane we can't hear. Even those most attached to us are thrown by such anomalies and the inability to judge what we can and can't hear. The hardest thing to get used to is not that we don't hear, but that sometimes we hear very well. Defective hearing is a constant 'Sometimes'"[McAlister 1994:179]. 176 This characteristic also leads to the misperception and accusation, commonly reported by hard of hearing people, that "he hears only when he wants to," and "she could hear better if she would try." Additionally, sometimes the hard of hearing person does not know that he or she is not hearing. This is a characteristic of sensorineural hearing loss [Glossary]. The individual continues to hear the sound of a voice, the intonation and pace of speech, and assumes she or he is hearing and comprehending. However, inner ear damage results in damage to discrimination, which means that certain speech sounds are no longer heard. This results in misinterpretation of what was said, and is also characterized by the hard of hearing individual saying, "I'm not deaf. I can hear you but I just can't understand you." Two other common societal myths are part of the lack of knowledge of hard of hearing attributes. One relates to "speechreading," the other to "hearing aids." One of the most frequent questions posed on meeting a hard of hearing person is, "you lip-read, don't you?" It is untrue that all communication difficulties will be overcome by lipreading. The term, "lipreading," or the act of discerning words from the movements of the mouth as words are spoken aloud [Kaplan, 1987], is a misnomer. The more correct term is "speechreading," which is the ability to understand a speaker's thoughts by watching movements of the face and body [Kaplan, 1987] and all other contextual clues such as situation and language. 177 Speechreading thus largely incorporates educated guessing, and depends not only on the reader's skills but also the speaker's skills. The speaker needs to maximize the speechreading environment, ensuring a slow clear rate of speech, with facial and voice expression, clear view of the mouth and face, at a distance of not more than four feet from the speechreader. Six feet is the maximum distance for effective speechreading. Additionally, lighting must be good, and on the speaker's face, rather than the reader's. Mustaches, beards, gum or anything else in the mouth, sunglasses, stiff lips and/or thin lips, foreign accent, failure to maintain eye contact, are all examples of factors which can sabotage speechreading. Some level of speechreading may be automatically and unconsciously acquired by individuals who are not aware of their own hearing impairment, but nearly all speechreaders will benefit from additional training [Jeffers and Bailey 1978, Mezei and Smith 1993]. The second societal myth is that a hearing aid will eliminate all communication difficulties. Hearing aids amplify sound but do little or nothing to assist with speech discrimination. A hearing aid does not correct hearing loss, it helps one to hear somewhat better, some of the time and so represents only a partial solution. Further, hearing aids amplify all sound, including intrusive environmental [background] noise, which a normal ear, hearing unaided, is accustomed to screen out. Some of the newer hearing aids have the capability to dampen background noise to an extent [Ross 1994]. However, environmental noise, even if it is not substantial, has the capacity to prevent speech comprehension. 178 Neither the hearing aid alone, nor speechreading alone is sufficient for speech comprehension by a person who is hard of hearing. Rather, the vast majority of people who are hard of hearing must use a combination of a hearing aid, and speechreading under good conditions to understand speech. The vast majority of people with normal hearing commonly subscribe to these two societal myths, that lip reading or hearing aids are solutions for hearing difficulties, and are susceptible to misjudging hard of hearing behavioural attributes. The prison environment of hard, bare echoic surfaces; requirements to speak through bars or windows of an office; to keep one's distance, are environmental factors which provide barriers for hard of hearing prisoners. Persons with beards or large mustaches, or lack of animation in facial expression and speech; or a disinclination to maintain eye contact, are cultural factors which hinder comprehension for prisoners with impaired hearing. These factors promote misidentification of hearing-loss-related behaviours. An assistant warden stated that in his experience, correctional officers are very careful in assessing behaviour before making judgements because they, as case managers, know the treatment programme for their caseload. They are aware of the need to assess the individual situation before making a judgement. He stated they would know of a prisoner's hearing problem by a self-report of not hearing; or by other inmates reporting frustration with them. Also, such inmates with impaired 179 hearing, the assistant warden stated, would be angry, frustrated people. These may indeed be a part of a hard of hearing prisoner's behaviour, but only the self-report of impaired hearing could be considered a valid indicator. Furthermore, the data show that this self-diagnosis in the majority of cases, is not accepted by custodians or acted upon unless the individual has a severe to profound hearing impairment. The evidence shows that very few of the characteristic attributes listed in the interview format with custodians were fairly consistently identified as behaviours of people who were hard of hearing. These behaviours were: "Turns television and radio up louder than others want it" [44%, n=24]; "Complains about the way people talk" [40%, n=20]; "Always speaks in a loud voice"[33%, n=15]. However, these same statistics reveal that the majority of custodians interviewed failed to perceive these behaviours as indicative of a hearing problem. The problem is that various typical hard of hearing behaviours are also indicative of other causes than hearing loss. Therefore it is important that hearing loss be identified, or ruled out as a cause of a problem behaviour. Furthermore, custodians indicated that they felt a lack of professional preparation in this area. In interviews with custodians, when the interview reached the stage that the custodian began asking questions of the researcher and seeking information about hearing impairment, the professional would invariably remark that they lacked information about hearing impairment. As one nurse stated,"Nurses do 180 not have enough information about hearing loss. Neither does the correctional system." Another custodian remarked, "we had nothing about this in our training." All hard of hearing prisoners interviewed stated that they believed discrimination against prisoners with impaired hearing existed because prisons [custodians and correctional services] are unaware of the presence of impaired hearing in prisoners. As noted earlier, partial hearing loss can be undetected, by the one experiencing the loss, and others [Jones et al. 1987, Thomas 1984]. Also notable in this context is the comment by the professional [Chapter Four, interviews with custodians] that in his experience, many prisoners do nothing about their eyesight problems, and by inference there might be the same neglect on their part of hearing problems. This latter comment might imply that prisoners, by virtue of their not complaining, contribute to their own deviance labelling. The prisoner, however, is in a powerless situation, already labelled as deviant, and susceptible to deviance amplification. "Stigma successfully lowers the individual's confidence and self-esteem, restricts his or her opportunities, sets the stage for engulfment in the stigmatized role, and generates the likelihood of further, and intensified stigmatization" [Schur 1980:13]. There is a powerful tendency towards deviance amplification through self-fulfilling, self-reinforcing, and self-propelling processes. The hard of hearing prisoner behaves in certain ways; that behaviour is misunderstood as having a different cultural meaning; and a negative label is attached to the individual. For example, I had opportunity to observe an interaction between a hard of hearing 181 prisoner and a nurse. This nurse had thin lips, a high-pitched, breathy voice, and always spoke rapidly. As an experienced speechreader, I found her pleasant, but quite difficult to speechread. Following an interview with me, the prisoner approached the nurse, carrying a copy of his audiogram from the study, with the audiologist's recommendations written at the bottom. The prisoner was known to be hard of hearing but was not wearing his hearing aids because of infection in both outer ears, probably due to an allergy to material in his two new ear moulds. He was requesting an appointment with the audiologist about this new problem. But it did not occur to him to explain to the nurse that he was not wearing his hearing aids. Because the nurse had previously supplied him with an ear ointment ordered by the prison physician, and he had been instructed to not insert his earmoulds, he may have thought that the nurse would be aware of his increased difficulty in hearing. I could see that they were angry and irritated with one another - he, standing in the corridor at the nursing station open window, speaking, holding out the paper and gesturing with it insistently; she inside the nursing station, speaking firmly, rapidly, negatively to him through the window. One could infer that he was not understanding her, nor was she empathetic to his comprehension problem. When I came into the office and they both saw me, they both replaced their angry looks with pleasant smiles. [She 182 may have been considering him "stubborn" and he may have been viewing her as rejecting, but I was the "outsider" not permitted to see any altercations]. When I explained his problem and his need, she agreed to make the appointment for him. Thus, through not understanding how he, himself, was contributing to the disagreement [not explaining that his inability to wear his hearing aids meant he could not understand her], the prisoner participated in the deviance amplification. Through her unawareness of how to speak helpfully so a hard of hearing person could speechread her, the nurse contributed to deviance amplification. She held the power to refuse his request and at the same time, attach a new label to his behaviour and enforce additional stigmatization and involve others in it, if the matter had not been clarified. The behaviour of the prisoner in the preceding anecdote characterizes the attribute of "learned helplessness" common to individuals with impaired hearing, in particular those who feel powerless and vulnerable, and have previously had negative experiences [Baker-Shenk 1985]. Statements by prisoners as recorded in Chapter Four contain numerous illustrations of helplessness behaviour. For example, withdrawing and acquiescing, in response to feelings of irritation from authority figures such as the parole board, or one's lawyer in court, when unable to hear in either situation. Harvey [1982] writes that, "Repeatedly being frustrated in attempts to assert one's rights [results in] learned helplessness." 183 The data indicate that the social characteristics of a hard of hearing prisoner can play a significant role in his being inappropriately labelled deviant because custodians with power to label are unfamiliar with the range of typical behavioural attributes of someone with partial hearing loss. Mislabelling of prisoners with impaired hearing The fourth question asked what labels custodians attach to hard of hearing behaviours in prisoners. The interview format with custodians [Appendix D] provided opportunity for their spontaneous provision of labels to characterize their perception of specified behaviours, attributable to someone who is hard of hearing. No cues or suggestions were offered, in order to avoid influencing perceptions of the meaning of the behaviours described. If anything, the study was biased in terms of suggesting that the listed behaviours were associated with difficulty hearing, as the study was commonly referred to in documents and dialogue within the Correctional Service as the "hard of hearing study." In fact, one professional [psychologist] declined to complete this portion of the interview because he would feel predisposed to identify the behaviours as having to do with hearing loss because "the study is about the hard of hearing." As noted in Chapter Four, custodians were first asked to state which prisoner behaviour they perceive and experience to be the most problematic in 184 interactions with inmates. When collating the responses, the most commonly listed behaviours were categorized as "defiant" behaviours - aggression, rule-breaking, anti- authority, lack of responsibility or effort [passive aggression]. Sixty-nine percent [n=28] of custodians identified this type of behaviour as giving most difficulty in talking to prisoners. Nineteen percent [n=8] of custodians responding identified "defects" as being most problematic - physical or personality defects or mental illness. Thirteen percent [n=5] identified deficits in education, intelligence and social skills as giving problems in interactive situations. Therefore, custodians appear to have a frame of reference relating predominantly to defiant inmate behaviours [violence, hostility, aggression] through which they view interactions with prisoners. When these identified behaviours are compared with custodial interpretations of behaviours specified in the interview [Appendix D], it is evident that there is a high potential for misinterpretation of behaviours associated with impaired hearing, leading to consequent mislabelling, because of the existing perception that prisoner behaviour may have a hostile context. In addition, a prisoner may have a diagnosis of, for example, "attention deficit disorder" to which specific behaviours are attributable. The same behaviours could be indicative of a hearing problem. But the hearing impairment remains unidentified because his hearing has not been audiologically screened, and custodians are not sensitized to the implications of hearing loss in prisoners. 185 The labels attached to the specified behaviours were both context- bound and culture-bound [Hastorf 1970]. It was apparent that stereotyping played a significant role in the defining of behaviours [Rubin 1973]. To illustrate, the example of "complains of noises in his head" were characterized as having a mental illness by 63% [n=32] of respondents. Only 14% [n=7] suggested this might relate to tinnitus or an inner ear problem. One respondent suggested it might indicate a hearing problem. "Leans toward you when you talk, gets close" was labelled by 63% [n=27] as hostile, rude and aggressive behaviour. Only 7% [n=3] suggested a person behaving in this way might possibly be hard of hearing. The tendency to stereotype as aggressive and hostile, or failing that, as deficient or defective in some way was paramount in all labelling of all behaviours tested. The social characteristics of individuals manifesting these behaviours appear to be major variables in how they are perceived and defined, most particularly when taken within this social and cultural context. Powerlessness, vulnerability and their criminal classification are all variables predisposing to this labelling stereotype. Control measures and security precautions predispose custodial perceptions of behaviour as potentially hostile. The findings indicate that there exists a high level of unawareness of the various behavioural indicators of hearing impairment amongst prison custodians. About 86% of the time, custodians interviewed in the study failed to identify behaviours as indicators of a possible hearing impairment, suggesting instead a negative interpretation of the behaviour. A review of Supplementary Table L7 186 [Appendix L] shows that correctional officers who work at the "line" level [Yates 1990] with prisoners were more likely to attach violence-related labels to behaviour. Health care staff were more likely to attach medical labels. Managers and supervisors were more likely to attach labels related to a "deficit" or "defect" in the prisoner. Professionals were more likely to say "I don't know." These data indicate that job description, and by extension, level of training and education, influences labelling. This may be defined as social class. Similarly, Cicourel and Kitsuse [1969] showed that social class influences both the definers and the defined in labelling. To summarize, on the average, approximately 86% of the time, staff chose a negative label to describe their perception of a behaviour, which also described a typical behaviour of a person who is hard of hearing. Put another way, the fourth question is answered by the finding that staff were five times more likely to perceive a certain behaviour as relating to a behaviour or personality problem of an inmate - as a deviant behaviour - than as a hearing problem, and to react accordingly in bestowing a label. These findings emphasize the powerful role of our ordinary cultural norms and expectations of behaviour, as exemplified by rules of social communication. Deviations from such rules are not well accepted. In particular, deviations which are characterized by individuals of a lower social status violating norms for bodily nearness, degree and intensity of eye contact, failure to respond 187 when spoken to by someone in control, and so on, result in negative perceptions and stigmatizing consequences. Comparative interpretations of hard of hearing behaviours The fifth question asked how prisoners with partial hearing loss interpret their hearing-impairment-related behaviours and how this compares with custodial interpretation of these behaviours. When custodian labelling of specific behaviour was cross-referenced with hard of hearing prisoner interpretation of behaviour, the differences in interpretation are quite clear, as displayed in Supplementary Table L8 [Appendix L]. Characteristic hard of hearing behaviours are repeatedly labelled by custodians as "hostile,""resistive," "selective hearing," "stupidity," "ignorance," "antisocial," "manipulative" traits. The same behaviours are explained by hard of hearing prisoners as the "need to be up close, in a one-to-one, face-to-face, position, in a low noise environment," to be able to hear and understand. The results show that prisoners with hearing impairment perceive themselves as not being well understood by custodians, and this is reflected in how selected behaviours are interpreted by custodians. The data show that custodians place very different interpretations than prisoners do on hearing-loss related prisoner behaviour. 188 For prisoners, there were adverse consequences to custodial misinterpretation of hearing-loss-related behaviours. Some of these were cited in Chapter Four. For example, a prisoner reported punishment because a guard would not believe he had not heard an order: "I was thrown in the hole, lost good time." Another was moved to a higher security level for failure to comply with the basic education program he had failed in the past. A prisoner was judged and documented as failing insight therapy group. Another prisoner detailed his poor performance before the parole board "I could feel they were irritated with me because I kept asking for repeats ... I just gave up and sat back." Prisoners may reject the label, but are powerless to change it. The implications are serious. Whatever the prevailing theory, the social control of deviance includes elements of restraint, deterrence, and coercion to change behaviour. Thus, the prisoner with unidentified hearing impairment is expected to change those behaviours which are labelled as defiant and uncooperative, but which in fact he cannot change because they are an unavoidable result of his inability to hear properly. He is expected to manifest changed behaviour through insight gained from participation in group programmes. It is difficult to impossible to gain insight and demonstrate progress when much of the dialogue may have been unheard. Prisoners who are hard of hearing, therefore, lack access to treatment programmes, to degrees which vary with the individual and with the circumstance. 189 Conclusion The findings indicate that there exists a high level of unawareness of the range of behavioural indicators of hearing impairment amongst prison custodians. About 86% of the time, custodians interviewed in the study failed to identify behavioural indicators as suggestive of impaired hearing, and offered instead a negative interpretation of the behaviour. The behaviours which are symptomatic of hearing impairment cannot be eliminated. They may be modified through provision of hearing aids and assistive listening devices, and through education of custodians to communicate in a more helpful manner. It is one of the principles of communication with the hard of hearing population that both persons in a communication situation must modify their communicative behaviours. It was noteworthy in the prisoner interviews that those few who had been previously hearing screened by a Workers Compensation Board sponsored technician at industrial work sites were conscious of the need to protect their hearing from noise inflicted damage. Furthermore, four young men, after the hearing screening in the prisons, reported during the interviews that as a result of our hearing tests, they had now become more aware of the need to protect their hearing. A hearing screening programme on admission to the institution could have a positive effect in hearing loss prevention, as well as reducing the inequities to rehabilitation which are presently experienced by prisoners with impaired hearing. 190 The situation is a complex one, because hard of hearing prisoners are generally not aware of one another, within the same institution. This unawareness of one another, the hidden nature of partial hearing loss, and the tendency to conceal the loss [which was expressed by 50% of those interviewed] results in a powerlessness to call for changes. Their problems are individual ones, occurring at the interpersonal level [Gomme 1993, Hastorf 1970, Thomas 1984]. Some of the prisoners have been unaware of their own hearing loss, some conceal their hearing problem, some have asked for audiological referral and been refused. One stated, with anger, that he was waiting for hearing aids, which were being withheld due to economic reasons. He received them during the course of the study, and health unit personnel explained to me that the question of which department was to pay for them had delayed their arrival. A fundamental question may be one of economics - whose budget will pay for the hearing aid and its ongoing maintenance? Another incident which reinforced this question involved a Chief of Health Care whose concern, on learning of a prisoner who would likely need two hearing aids, was that the Department's recently submitted budget had not included the cost of hearing aids for this individual, and how many more throughout the system were going to need them? The solution suggested was that I not tell this prisoner, or any other prisoners, the results of their hearing assessments, and let the head of Research for the Pacific Region of the Correctional Service of Canada decide what should be done with the study findings. 191 As Shur [1980:7] notes, "The social order is of course conditioned by the economic order to a high degree, and in its turn, reacts upon it." Economics is an important complexity in the implications and uses of power. It was not possible to comply with the request of this custodian because the ethical requirements of the study mandated that each prisoner would receive a copy of his audiogram, and an explanation. The prisoner would then decide whether or not to approach the Health Care Department for his institution, with his copy of his audiogram, to request followup. All prisoners who had a hearing loss requested that a copy of their audiogram be placed on their health file and that the health staff be informed of its meaning by the researcher. While the economic factor is an important one, another major factor is pervasive ignorance amongst custodial staff about the implications of impaired hearing. Both of these factors illustrate the powerful and oppressive effect of "mindless unawareness" [Young 1990] by a dominant group on the social control measures used with prisoners with impaired hearing, and not only with those in whom that hearing loss is so far unidentified. An additional factor must be taken into consideration, in particular as relates to guards. The prison is an alienating environment for both guards and prisoners who are in the constant adversarial roles of the keepers and the kept [Culhane 1991, Gosselin 1982]. Cormier [1975] alludes to the ongoing paranoid thinking and bitterness to which prison guards are regularly 192 exposed and the difficult task of maintaining normal decent functioning in a setting where they are hated and feared. Thus, the torment of imprisonment is shared by custodians and inmates. To cope with such stress, custodians may inure themselves to the plight of those in their keeping. Additionally, the "code of honour" among guards negates speaking out against one another, in instances of individual mistreatment of prisoners, whether by neglect or by act [Culhane 1991, Gosselin 1982, McNeil and Vance 1978]. Individual sensibilities can be and are subjugated to the culture of the prison and its institutionalized power structure. Overall, the study findings support the conclusion that the presence of hearing impairment in inmates of federal prisons in British Columbia is largely under-identified and overlooked. The major contributing factors to this situation appear to be the lack of awareness of the significance of partial hearing loss in prisoners by the various levels of caregivers, and in particular by those who set policy and procedures for the Correctional Service of Canada. Culhane [1991] and Gosselin [1982] document an "enormous lack of care" [Gosselin 1982:35] of the ecology of inmate health, as well as of direct medical care. Hearing impairment is both a health and a social issue. A primary flaw appears to be in the medical health failure to screen hearing on admission and to respond fully to individual complaints about hearing problems. A secondary system flaw lies in the absence of adequate education of caretakers in regard to behavioural indicators of 193 hearing impairment and its attendant implications for labelling and treatment/rehabilitation approaches. All of the hard of hearing prisoners interviewed had experienced problems resulting from their inability to hear and understand in situations of everyday life in the prison, and in programmes developed for their rehabilitation. Those programmes included work, educational, and therapeutic situations. Such programmes are designed to increase insight into problematic behaviour, to increase skills for future functioning in the community, or to occupy their time productively while in prison. In most instances, those programmes were to some degree inaccessible to the prisoner. The starting point for their hearing-related lack of accessibility appears to lie with the gatekeeping role of medical care, which does not mandate hearing screening in health admission examinations. Problem areas have been indicated in the present health delivery structure in federal prisons, which result in oppressive conditions for an ignored and largely invisible group of prisoners - those with impaired hearing. An examination of the process of labeling and deviance definition has revealed that, for the hard of hearing prisoner, social characteristics and social class are major factors in others' perception and definition of their behaviour. The preceding discussion has highlighted the individual experience. As Mills [1959], Bolaria [1991] and others have argued, problems of the individual are indicative of larger social problems. For prisoners with 194 disabilities the problem echoes that of disabled people at large, that is, barriers, both physical and attitudinal, to access to services and social participation. The issue is human rights and social justice. Steps have been taken to address accessibility needs of prisoners with disabilities. In 1981 the Treasury Board policy on "real property accessibility" was issued by the federal government. This policy requires that all federal government properties be accessible to people with disabilities. The Correctional Service of Canada has set March, 1995 as the target date to implement this accessibility policy in its institutions [Kobernick 1994]. However, this is a "minimum accessibility" policy and does not call for proactive measures in determining the extent to which access will be provided. There is considerable concern that prisoners with invisible disabilities, specifically the under-identified hard of hearing will continue to go unidentified and thus never have their special needs met. Kobernick [1994] notes that failure to place the inmate in a setting which provides access for their disability can put the Correctional Service of Canada in breach of its own guidelines and the Treasury Board Policy, as well as the Canadian Charter of Rights and Freedoms. She adds that very few inmates with disabilities have launched legal action on this point, thus far. Based on the findings in this study, it may be an indication of the lack of awareness of the individuals of the implications of their disability, or that there are means of access which could be made available to them. It may be a sense of helplessness to effect change. 195 Prisoners do not possess the power to organize any significant resistance to problems in their environment. Prisoners with impaired hearing face the disempowering effect of an isolating and invisible condition similar to solitary confinement in its effects on the person. Other disabling conditions may have similar disempowering effects. Therefore, grassroots organizations such as the disabled consumer group and other community agencies concerned with prisoners must build liaisons with professionals and those who set policy. Such liaisons could work to educate and establish systems and methods to ensure that prisoners with disabilities, whether they be hearing-related or otherwise, have their special needs met. Franca Carella [1992], Executive Director of the Vitanova Foundation, which involves the community in work to help ex-offenders remain drug-free, calls for "passion in advocacy and coalition-building." A goal of such effort would be to build more empowering social development models. Garland [1990] writes that a problem with Foucault's conception of knowledge and power is that he did not differentiate between various kinds of power, but attacks all "power" as negative. McMahon [1992] suggests ways in which power and knowledge can be used in a positive manner, such as furtherance of some successful rehabilitation programmes. An effective utilization of knowledge as power is the social activist approach which marries social science research with political advocacy. The critical criterion for social activist research is that it be advocacy with the clients, for their empowerment, not advocacy for the clients. Where advocacy is 196 by the researcher or "expert" for the client group, the danger is that the "experts"acquire control over the production and use of knowledge [Harries-Jones 1991]. This latter scenario has implications of the more negative power/knowledge interface which Foucault decries. The study has integrated theory which suggests that, while traditional institutionalized power structures tend to utilize knowledge and power mainly for the perpetuation of their existence and status, there are alternative ways of mobilizing power and utilizing knowledge. One such is the newer social group movement, with its drive to mobilize the community in proactive participation in themes of social justice [Eyerman and Jameson 1991, Scott 1990]. 197 CHAPTER SIX REASONABLE ACCOMMODATION FOR PRISONERS WITH IMPAIRED HEARING: CONCLUSION AND RECOMMENDATIONS "Human justice, like Luther's drunken peasant, when saved from falling on one side, topples over on the other" [Mazzini 1984]. "The problem of hearing loss in a prisoner is not additive but exponential. That is, it is not the challenges of hearing loss plus incarceration, but rather hearing loss times incarceration" [Jamieson 1994]. Introduction In the past decade, in conjunction with the Decade of the Disabled [1983], the government of Canada adopted, in all of its departments, a policy of reasonable accommodation for persons with disabilities [Status of Disabled Persons Secretariat, 1990]. Departmental adherence to this policy is reflected in objectives set by various departments, such as Transport, Treasury, and so on. The mission document of the Correctional Service of Canada [1990], sets out in several of its Strategic Objectives, its commitment to meeting the needs of individual offenders: Core Value 1:"We respect the dignity of individuals, the rights of all members of society, and the potential for human growth and development." Strategic Objective 2.1 'To ensure that the needs of individual offenders are identified at admission, and that special attention is given to addressing mental disorders." Strategic Objective 2.3:"To provide programs to assist offenders in meeting their individual needs, in order to enhance their potential for reintegration as law-abiding citizens." 198 Strategic Objective 2.4:"To ensure that offenders are productively occupied and have access to a variety of work and educational opportunities to meet their needs for growth and personal development." [Correctional Service of Canada 1990]. This study undertook to investigate the presence of individuals with impaired hearing in federal prisons in the Pacific Region of the Correctional Service of Canada, to determine how they were assessed for hearing difficulties, and how their needs were being met. In this chapter, the study and its findings are briefly summarized and conclusions are drawn. A comparison is made with Core Value One of the Mission Statement of the Correctional Service of Canada and three of its strategic objectives, numbers 2.1, 2.3, and 2.4, as set out at the start of this chapter. Finally, recommendations are made for actions flowing from the study findings, and suggestions for future studies are outlined. Summary of study This was a descriptive study, utilizing survey, audiological measurement and interview techniques to identify hard of hearing prisoners and discover elements of their prison experience. A comparison of hearing-loss-related variables was also undertaken, as a contribution to future research. A high percentage of partial hearing loss was identified in the study population. The majority of these individuals had, prior to the study, believed they had 199 a hearing problem, but nothing had been done about it. In some instances they had not sought a hearing examination, in the larger number of instances, they had requested help and been refused a referral to an audiologist for hearing tests. The theoretical grounding to the study, as presented in Chapters One and Two, confirms that partial hearing impairment in individuals is often difficult to identify. The prison situation reflects that of society at large. Individuals conceal or deny their hearing loss through fear of stigma. Such stigma may be manifested by rejection, the attachment of negative labels associated with deviance, and additionally in the prison milieu, the fear of further punishment, jeers or harassment. Prisoners confirmed the validity of this fear, by documenting the numerous labels they have heard or experienced, as attached to the prisoner with impaired hearing. Other individuals with impaired hearing, whether in society at large, or in prison, may be unaware of their partial hearing loss and succumb to, or collaborate in, negative assessments of their behaviour. Such interactions have been well documented in literature on hard of hearing children, youth, adults, and the elderly. The lowered self-esteem which accompanies a hearing impairment, whether or not the loss is identified, contributes to vulnerability to deviance labelling. Prisoners, by virtue of their deviant and powerless status, are doubly vulnerable to such labelling and, by extension, to neglect of an investigation of their condition. This theory was corroborated by the study findings. 200 Further investigation explored the study concepts, through interviews with hard of hearing prisoners, their custodians, and prisoners with normal hearing. Here the findings were robust, in support of the study hypotheses. In particular, in combination with documentary examination, the massive neglect of evaluation of hearing health status in the prisons became apparent. Clearly, methods for assessing hearing integrity in prisons are inadequate, and almost non-existent. Much of this neglect flows from unawareness, stemming from a lack of knowledge about the hard of hearing condition, as stipulated during interviews by custodians of all professions and vocations. This may also include a misunderstanding of the nature of hearing loss, as evidenced by misconceptions brought to light during the interviews. Some of the neglect may be said to flow from indifference, given the social tendency noted by Young [1990] for authority to support existing, embedded structural conditions. Hearing impairment is largely a social experience. For the prisoner with impaired hearing, their sentence in a communication-inaccessible environment may be equivalent to solitary confinement, a dehumanizing experience. Gosselin [1982] Culhane [1985, 1991] and others have detailed the demoralizing, oppressive and isolating effects of solitary confinement, and of imprisonment in general. However, for the prisoner with impaired hearing, 'The problem of hearing loss ... is not additive but exponential. That is, it is not the challenges of hearing loss plus incarceration, but rather hearing loss times incarceration" [Jamieson 1994]. 201 Prisoners noted that, while there is not much socialization in prison, they felt isolated due to their problem in hearing, both socially and in gaining information. Sources of inaccessible information included the public address system, correctional staff, programmes such as groups, classes, and work situations, and appearances before the parole board and in court. The telephone and television were inaccessible to a significant degree, and some had difficulties with interpersonal relationships with significant others. Because prisoners lacked knowledge about, and had no access to, assistive communication devices, they expressed helplessness and powerlessness to individually change or improve matters. It is a significant factor that hearing impairment isolates, and is an invisible condition. It is not unusual to hear a hard of hearing person say, "for the longest time, I thought I was the only one like me; the only hard of hearing person of my age. I knew no other hard of hearing people." In general, hard of hearing prisoners were not aware of one another within the prison. They lacked resources, knowledge and contacts, to seek to have their hearing-related needs met. Thus the problems of individual prisoners are symptomatic of the problems of a large group of prisoners. This lack of knowledge of resources is common in society. The difference is that the individual at large has freedom to actively seek out hearing assessment, technical assistance, and other hard of hearing people. The prisoner lacks this freedom and is prey to amplification of isolation, stigma and labelling. 202 The misidentification of hard of hearing behaviour and the resultant negative mislabelling have a detrimental effect on the prisoner's progress through the correctional system. The majority of custodians identified typical hard of hearing behaviours as various trouble-making behaviours. This stereotyping is to be expected since aggressive types of behaviour were identified as common in this milieu. Given the valid potential for misidentification of behaviour flowing from impaired hearing, it is doubly important that hearing status be evaluated on admission and appropriate rehabilitative strategies instituted for the prisoner's program. An unexpected finding was the common complaint of excessive noise in most of the institutions. Matsqui institution was singled out by all prisoners and a guard as unacceptably noisy. In general, prisons tend to have mainly hard, bare, sound-reflective surfaces, by virtue of their need to provide secure custodial care. They have not been designed to accommodate persons with disabilities. Hitch [1991 ] writes that the Supreme Court of Canada has interpreted the clause in the Canadian Charter of Rights and Freedoms as follows, "that a prohibition of discrimination is not simply an obligation not to discriminate [a negative obligation] but is also an obligation to take reasonable, positive steps to create equality [a positive obligation]" [Hitch 1991:33]. Numerous authors from within the Correctional Service of Canada [Centen and Sampson 1991, Chaudry 1994, Kobemick 1994, Stykes and Gee 1994] have discussed the need for architectural modifications to prisons, to accommodate prisoners and staff with disabilities. In all cases, their discussion focuses on the 203 changes needed to accommodate those with mobility disabilities - wheelchair access is most commonly recognized. Stykes and Gee [1994:38] note the hard of hearing person's need for a non-echoic environment in contrast to the blind person's need for a sound-reflective milieu. However, needs for hard of hearing prisoners include group listening devices, which should also be part of an architectural modification. As well, reasonable accommodation for prisoners who are hard of hearing or deaf includes other assistive communication devices and resources. Stykes and Gee [1994:38] note that "offender participation in everyday life is a primary correctional goal." The problem for prisoners with impaired hearing, as shown by this study, is that the vast majority appear to be unidentified and their needs ignored within the prison system. Full participation is denied them. The common theme running through this study is the mindless and unthinking structural oppression, by the institution, of a powerless group. The key word is "unawareness." Clearly, the hearing impaired prisoners' rights, as set out in the strategic objectives listed at the beginning of this chapter, are not being addressed at the present time. Implications There is a serious under-identification of hearing impairment in prisoners within the Correctional Service of Canada. The roots of such neglect of 204 identification of hearing status of prisoners lie within the predominant institutional structures of our day. The first such institutional structure is the biomedical model, which views hearing impairment as deviant from the "sickness" model and a matter of individual adjustment. This biomedical influence is reflected in correctional institution policy which does not require hearing screening of inmates on admission. Social control measures in prison attempt to normalize the individual and in the process, assess and discipline non-conforming behaviour. Custodial decisions on management of prisoner behaviour flow from conclusions formed in interactional and observational situations. Deviance definition flows from social perception of the individual and group with power. In this context, the prisoner with unidentified hearing impairment is particularly disadvantaged and discriminated against, however unknowing that discrimination may be. Clearly, the implications of the study are that prisoners with impaired hearing are not receiving reasonable accommodation. This is happening through lack of diagnosis on admission, and consequent lack of provision of hearing access in the daily life of the prison, the programmes, and parole board appearances. Recommendations Recommendations are provided in conjunction with Core Value 1 of the Mission Statement of the Correctional Service of Canada. 205 Strategic Objective 2.1 requires that the needs of the individual prisoner should be identified on admission. At present, for prisoners with impaired hearing, this identification of their hearing-related needs is not happening. Recommendation #1 is that hearing screening become a mandatory part of the admission health examination in all prisons, and that audiological referral occur where any evidence of hearing impairment is noted. As well, prisoners within the system who have not had their hearing tested should have hearing tests, and appropriate action taken subsequently. Strategic Objective 2.3 requires that programs be provided for prisoners to meet their individual needs and enhance their rehabilitative potential. In this study, where hearing loss was previously identified, the prisoner's needs were being addressed, to an extent. Needs not addressed were in regard to assistive devices of which custodians had no knowledge. The majority of prisoners with impaired hearing were either unidentified, had not asked for assistance, had been refused tests when requested, or were mislabelled. Thus, their programming needs were not being met. Their major problem in this context is likely to be that the programme is not hearing accessible to the prisoner who is hard of hearing. Recommendation #2 is that the extent of hearing impairment be assessed by an audiologist and that personnel knowledgeable in technical devices 206 for the hearing impaired be consulted to provide and install the needed assistive communication devices. Such resources should include professional and technical sources, and knowledgeable consumers who are hard of hearing. This may be a hearing aid as the basic device. As well, this may include an assistive listening system for group situations such as class or therapy groups, or computer notetaking for those with more severe hearing impairment; an accessible telephone or telecommunication device; and special earphones or/and a telecaption decoder for the television. Computer note-taking involves a typist entering the dialogue into the computer, for display on a video monitor [or other screen], for the benefit of someone who cannot hear well enough to follow the spoken word in a group situation. Similarly, rate-of-speech typing of the dialogue, referred to as "real-time captioning" or "print interpreting" may be provided through use of a court reporter's device and a visual display, in any group situation where a stenotypist and equipment are available. In this context, parole board hearings and other group situations could meet the right of the prisoner with a hearing impairment to have access to participation in the proceedings. Strategic Objective 2.4 ensures productive occupations and access to work and educational opportunities for prisoners. Here, again, where the hearing loss had not been identified or understood, prisoners did not have full access to programmes. Further, they were subject to negative and assessments where their hearing-related behaviour was misinterpreted. 207 Recommendation #3 parallels that of #2 - that work and educational opportunities be made accessible to the prisoner with a hearing impairment through the provision of necessary devices and strategies to make the environment accessible. This includes a recommendation that the architectural environment be made acoustically acceptable for a person with impaired hearing. Education of custodians to understand and identify hearing-loss-related behaviours, and to develop facilitative communication behaviours is important to ensure that custodians themselves are not a part of the barrier to the rehabilitative programme, for prisoners with impaired hearing. Habermas [1984] notes that where there is oppression, social groups arise and offer resistance. Such resistance may take the form of defense or a group may adopt a proactive offensive strategy. Boggs [1986] emphasizes that contemporary social movements are not marginal expressions of protest but are a part of the social fabric of our time, and work for social equality and the application of democratic principles. For example, the contemporary disabled consumer organizations take a proactive stance, and actively advocate for equal access to society. The political strategies they adopt represent the development of an informed use of power [Dahl 1987]. The role and right of disability groups to speak on behalf of their constituency is recognized by federal and provincial governments. This is exemplified in the National Strategy for the Integration of Persons With Disabilities, in action in Canada from 1991-1994, which included a consultation process with 208 disabled consumer groups in cooperation with various Federal Government Departments such as Treasury and Transport. A major result of the social group movement has been the acceptance by government bodies of the need to form partnership efforts in addressing and solving social problems. The concept involves consumer groups in joint efforts with government, corporate, and professional bodies. There is a recognition that the people who experience the problem should be involved in developing the solutions [Jongbloed and Crichton 1990]. The concept of community participation in the criminal justice system has been given increasing emphasis during the past two decades. McCormick and Visano [1992] suggest community participation has two faces - that of citizen advisory committees to correctional services, which represent community inaction; and that of "communities-in-action" such as self-help groups [victims, ex-offenders, substance abusers, special needs] who mobilize, advocate and articulate an agenda which challenges the existing social control power structure. They argue that where the power structure itself creates and controls community participation through selected representatives to citizen advisory committees the result is simply a reinforcement of and deference to existing correctional policies. For prison inmates, prisoners' rights groups and committees exist, as do support groups such as Alcoholics Anonymous, but at present, no groups act to improve the lot of the hard of hearing prisoner. This is to be expected because 209 prisoners who are hard of hearing have been invisible individuals within the system, and unaware of their colleagues within the prison. There has been a similar problem in society at large. It is only in the past decade that people who are hard of hearing have begun to form social activist groups such as the Canadian Hard of Hearing Association, and advocate for positive change for their constituency [Dahl 1987, 1988, 1993, Laszio 1984]. Much of the positive action taken by the government of Canada in regard to the rights and needs of persons with disabilities stems from the actions of disability groups that have resisted oppression from social attitudes and other barriers to full participation in society [Department of Secretary of State 1985, 1989, 1990, Department of Justice Canada 1993, Employment and Immigration Canada 1991, Mulroney 1991]. For example, the Canadian Disability Rights Council [CDRC] writes that its membership has requested that the CDRC "monitor the situation of the Charter and the Deaf in prison" [Shah 1993]. The current emphasis on the concept of "partnership efforts" between government bodies, professional associations and consumers [Cadieux 1990, Cull 1993] is embraced by various government departments, and promoted in various major research areas [Social Science and Humanities Research Council 1994]. Government frequently establishes a consultation process involving consumers to precede reforms. The Solicitor General of Canada, in a letter introducing a consultation package on Directions for Reform, related to Corrections and Conditional Release, wrote that the Canadian correctional system has established closer ties to 210 the community, which has resulted in "greater sensitivity to correctional issues and demands for greater accountability" [Cadieux 1990]. He also encouraged "every interested Canadian" to participate in this reform process, and stated that individual and community involvement "is vital to the development of a system that has public safety as its primary goal, is effective and humane in its treatment of offenders, and is worthy of public trust and support" [Cadieux 1990]. It follows that involvement by social groups and professional multidisciplinary institutions, in cooperation with the Canadian correctional system, is appropriate to address the needs of prisoners with impaired hearing. Therefore, Recommendation # 4 is that the consumer organization of hard of hearing Canadians [Canadian Hard of Hearing Association] and professional organizations concerned with hearing loss address the needs of hard of hearing prisoners and collaborate with the Correctional Service of Canada to improve the status of prisoners who are hard of hearing. As Green and Kreuter [1991 ] note, health policy and health programme development can be addressed successfully only in cooperation with consumers and others who shape social policy and programmes. Suggestions for future studies This study has provided a first level assessment of hearing status in inmates of federal prisons. For the first time, it explores variables associated with 211 social perception and deviance definition in a unique and hitherto ignored population - prisoners with partial hearing loss. The theme, presented by Mills in 1959 and echoed by Bolaria in 1991, that personal problems of powerless individuals are indicative of broader social issues, has resonated throughout this study. Thus, micro-theory of the labelling perspective is interconnected with macro-theory of the process of social control. The study was based on existing theory. It did not set out to prove or disprove such theory, but to extend knowledge in this area. The rich amount of secondary data collected in this study will form the basis for future analysis. One area of planned analysis will be a comparison of variables [social characteristics] between those who had failed and those who had passed the hearing screening. This was a small sample; further studies could extend this work by ongoing collection and analysis of data pertaining to these variables, and their social implications, from larger samples. No similar studies have been undertaken on female offender populations. Such studies should be done. The Canadian Centre for Justice Statistics [1992] released a Juristat on Female Young Offenders, aged 12 to 17. Their report indicates that females constitute close to one-fifth of the young offender population. In 1990, among adults charged by police, 17% were females. Based on their data, female participation in crime is increasing. By reason of their comparatively small 212 numbers however, females tend to be considered "too few to count"[Adelberg and Currie 1987]. Hearing impairment in First Nations prisoners should be investigated. Mention is made in the study of the high prevalence of otitis media in First Nations children, which may or may not result in impaired hearing in the adult. There is a suggestion that First Nations people are over-represented in the offender population and there could be an investigation of the implications of unidentified hearing loss in this group. In-depth qualitative studies should also be undertaken, possibly in one institution, with prisoners who are identified with hearing loss and have an appropriate, hearing accessible, rehabilitative programme implemented, to evaluate and determine the success of an adequate therapeutic programme for hard of hearing prisoners. There has been no attempt, in this study, to argue that impaired hearing, particularly unidentified or untreated hearing impairment, leads to criminal behaviour. However, study findings demonstrate that such hearing impairment is a variable in deviant, and criminal behaviour, which must be considered. This consideration applies both to preventive programmes and to rehabilitative programmes. As Linden [1992] notes, there are very many different determinants to criminal behaviour. 213 Biological factors interact with non-biological factors to determine behaviour and in turn social and cultural factors determine the interpretation given that behaviour. The ability to label that behaviour and enforce the social control measures which follow is the prerogative of those who hold power. The study has made visible the plight of prisoners with an invisible disability, and the repressive effect of biomedical and correctional policies and perspectives on their carceral experience. Conclusions This study has broken new ground in exploring the presence, degree and implications of partial hearing loss in prisoner populations. The study contributes to existing knowledge regarding factors which influence the labeling of deviance; the social factors and institutional arrangements that are problematic for people with disabilities such as partial hearing loss, in conflict with the justice system; and lays the foundation for understanding and developing improved diagnosis and services for the study population. The study provides, for the first time, an examination of the percentage, degree and social import of hearing loss in federal prisoners of the Pacific Region of The Correctional Service of Canada. It describes the structure and process that influence perceptions of custodians and their relations to prisoners with partial hearing impairment, and provides information necessary for improvements in screening procedures, and the provision of services for prisoners with impaired hearing in penitentiaries. 214 The plight of prisoners with impaired hearing is a significant one, with part of their difficulty emanating from the invisibility of their condition and its vulnerability to mislabelling. Their situation is made even more distressing because of the neglect of accurate diagnosis, treatment and rehabilitation procedures within the correctional system. Through this study, the situation of prisoners who are hard of hearing has been opened to public scrutiny. It now remains for those individuals and groups who are concerned about the lot of prisoners, or who care about conditions for people with impaired hearing, to actively intervene to ensure that the needs of prisoners with hearing problems are adequately addressed. Overall, the study demonstrates the need for a thorough epidemiological study of hearing loss amongst prisoners. "We shall not cease from exploration And the end of all our exploring Will be to arrive where we started And know the place for the first time" [Eliot 1971:59]. 215 GLOSSARY For the purposes of this study, the following terms are defined - Attributes are defined in this study in terms of specific behavioural characteristics identified in the literature that are associated with hearing impairment [Table3]. Audiogram is a graphic representation of audiometric findings showing hearing levels as a function of frequency [Martin 1991]. Auditory frequency selectivity is "the ability to resolve a complex sound into frequency components. This ability plays a role in many aspects of auditory perception including: the masking of one sound by another; the perception of pitch for pure tones and complex tones; the perception of timbre; the perception of the relative phase of components in complex sounds, and the perception of loudness" [Moore and Roy 1986:v]. Custodians refer to persons charged with various responsiblities relating to the health, welfare and daily living of prisoners in prison systems. Used interchangeably with the term "officials," custodian includes nurses, doctors, psychologists, 216 social workers, teachers, correctional officers, and wardens. Correctional officers are also referred to as "guards" in the study. Deviant behaviour refers in this study to the perceptions which custodians hold of inmate behaviour which in the view of custodians is defined as differing from the accepted behaviours which are considered to be norms within the prison culture. Deviant behaviour in this context is that behaviour which breaches those social norms expectations of prisoners towards one another, and the norms required by correctional regulations. Hearing screening consists of audiometric testing comprised of pure tone air conduction at 20dB HL for octave frequencies of 1000-4000 Hz, conducted in an acoustically quiet room in the prison setting, using a Maico portable audiometer, with the subject receiving acoustic signals via a headset, and responding via hand signals. Hearing assessment refers to hearing evaluations consisted of (1) audiometric testing of pure tone air conduction thresholds for octave frequencies of 500-8000Hz, with signals received via a headset; such testing conducted in a soundproof booth, with responses given via a handheld switch; (2) immitance testing included tympanometry and screening for acoustic reflex thresholds and reflex decay at 105dB SPL [1000Hz] using a Madsen impedance audiometer ZS76-1; and (3) otoscopic examinations. 217 Hearing disorder refers to any abnormality, anywhere in the auditory system which results in some degree of loss in any of the auditory functions, for example, loss of sensitivity, loss of discrimination, increased sensitivity to noise, etc. Hearing threshold is the level at which a stimulus, such as a pure tone, is barely perceptible [Martin 1991]. Hearing sensitivity is expressed as the number of decibels above or below the average normal-hearing threshold for different pure tones [Martin 1981]. Pure tone average is the average of the hearing levels at frequencies 500, 1000, and 2000 Hz for each ear, as obtained on a pure-tone hearing test [Martin 1991]. Impedance is the opposite to sound wave transmission. Comprised of frictional resistance, mass and stiffness, and influenced by frequency, the term is used in regard to measurements of middle ear function [Martin 1981:56]. Immittance testing is a term to describe measurements made of eardrum membrane impedance, compliance, or admittance of sound transmission [Martin 1981:183]. The following four definitions are of immitance tests which were measured by Acoustic Immittance Meter, by virtue of a probe placed in either ear. 218 il Tympanometry is a measurement which tests the mobility of the eardrum, as a function of varying amounts of positive and negative air pressure in the external ear canal, which immobilizes the system. Tympanograms give information regarding mobility of the middle ear mechanism. ii] Compliance or "static compliance" is a measurement made of the mobility [flexibility] of the eardrum membrane. It is the opposite of "impedance." That is, as the stiffness of a system increases, it is said to become less compliant. iiil Acoustic reflex is the contraction of one or both of the middle ear muscles in response to a loud sounds, which has the effect of stiffening the middle ear system and decreasing its compliance. Both acoustic reflex and reflex decay give information regarding probable pathology of different areas of the auditory system [Martin 1991]. ivl Reflex decay is a change in the dynamic impedance in the plane of the eardrum membrane as the stapedius muscle relaxes during constant acoustic stimulation [Martin 1991]. Otoscopic examinations consist of the examination of the outer ear canal and eardrum via a lighted speculum inserted in the ear canal. Note is taken of skin and membrane 219 integrity and absence of infection, and presence of cerumen [wax]. Presence of cerumen may interfere with accuracy of both pure tone air conduction testing, and of middle ear testing. Pseudohypacusis [non-organic hearing loss] is defined as the exaggerated elevation of auditory thresholds. Subjects may be malingering, exaggerating a hearing loss, have a psychogenic disorder, or the test may be inaccurate for other reasons. A number of tests can be performed when pseudohypacusis is suspected [Rintleman 1991:650-652, Martin 1985:343-361]. Identification methods in this study refer to the traditional or usual means (if any) that are currently being employed at prisons for admission hearing screening procedures, compared to methods used in this study. Interactive relationship refers to the communication and symbolic gestures between two individuals in a particular setting that lead to various outcomes such as positive or negative perceptions of structure, stability and meaning (Hastorf et al. 1970:11-17). Penal institution in this study refers to Canadian federal prisons housing criminal offenders who have been sentenced for prison terms by the justice system in the law courts. 220 Prison population refers to convicts or offenders resident in federal penal institutions as defined above. Prisoners is the preferred term used in this study, meaning persons deprived of their liberty, rather than the term "inmates" which signifies "institutionalized and powerless" [Culhane, 1991:20]. Sensorineural hearing loss refers to loss of hearing sensitivity produced by damage or alteration of the sensory mechanism of the inner ear [cochlea] or beyond. World Health Organization fW.H.0.1 definitions [United Nations 1983] In 1980, the World Health Organization set a distinction, in the context of the health experience, between impairment, disability and handicap. This distinction profoundly influences both the meaning which is communicated by disability, and the societal response evinced by both the able and those with disabilities. The W.H.O. definition states: "Impairment: Any loss or abnormality of psychological, physiological, or anatomical structure or function. 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Journal of Research and Development in Education. 1987. 20[4]:73-78. 244 APPENDIX A Questionnaire and covering letter MEMO FROM: Marilyn Dahl, Researcher TO: Participants in the hearing study DATE: July, 1992 Thank you for volunteering to take part in this study. I hope that the results will prove valuable to your welfare and that of others in future. Enclosed is your copy of your signed consent form. The questionnaire enclosed is the second step of this study. Please answer all of the questions as best you can. Then seal the completed form in the envelope provided and send it back to me via the health unit. This is a confidential questionnaire and I am the only person who will open and read it. I will look forward to meeting you for your hearing screening sometime in September. This will be arranged through the health care department for your institution. Thank you again for your cooperation. Sincerely, 245 APPENDIX A Characteristics of Self-Reported Hearing Problems My name is Marilyn Dahl. I am a doctoral candidate at UBC. As part of my studies I am examining how persons with hearing impairments function in penitentiaries. The purpose of this survey is to find out how many inmates believe they have a hearing problem. Completion of this questionnaire is voluntary. If you have difficulty in filling out this form, please ask for assistance. Thank you for your cooperation. CODE 1. In which institution are you located? 2. What is your age group? [check category] under 20 Q 20-25 Q 26-30 Q 31-35 Q 36-40 Q 41-45 D 46-50 D over 50Q 3. What is your sex? male 0 female Q 4. What is your ethnic origin - Caucasian Q East Indian Q North American Indian Q Inuit D Metis Q Black D Asian Q Other rj specify which 5. What was your occupation prior to admission to this institution? 6. Please check the approximate range of your pay in your last occupation. under $5,000/year Q $5,000-$10,000/year Q $10,000-$20,000/yearQ $20,000-$40,000/year Q $40,000-$60,000/year Q $60,000-$80,000/year Q over $80,000fyear Q 7. Why are you in prison? 8. What particular behaviour do you think helped in getting you into trouble? a] something to do with another person rj b] something to do with society [eg. alcohol, drugs, etc] Q c] something to do with disabiity [eg. loss of vision, loss of hearing, etc. Q d] other rj 9. How long have you been in this institution? under 1 year Q 1-5 years Q 5-10 years Q 10-15 years 0 15-20 years Q more than 20 years fl 246 10. How long have you been in this and other institutions? under 1 year 0 1-5 years Q 5-10 years Q 10-15 years 0 15-20 years Q more than 20 years Q 11. In your opinion do you think you had a "good" [get along well] or "bad" [don't get along] social relationship with: good bad a] fellow prisoners Q Q b] guards fl D c] everyone Q Q 12. Sometimes people are given labels, such as "nicknames", by friends, family or others. a] Are you aware of labels or nicknames being given to inmates in your prison? yesD noQ b] If so, do you think the labels influence how: i. you relate to them? yes 0 no fj ii. other inmates relate to them? yes Q no Q iii. prison guards relate to them? yes fl no 0 c] In your opinion, do you think some of these labels such as nicknames are related to : i. problems in hearing and understanding? yes [] no Q ii. how inmates with hearing/understanding difficulties are viewed by others? yes Q no fl d] Please list some of the labels, such as nicknames, that you are aware of and are used in particular for prisoners having hearing difficulties: 13. What level of education have you completed? no education Q primary education Q secondary education Q professional education Q other (please state) 14. Are you- married 0 divorced FJ separated [] widowed [] living common-law 0 other relationship 0 specify 15. (a) Do you think you have a hearing problem? yes D no D (b) If yes, please describe it 247 (c) Does anyone in your family have a hearing loss? yes rj (d) If so, who? noQ father fl uncle D other fJwho?_ mother Q aunt Q brother D son D (e) If you think you have a hearing problem, has it been identified before? yes fl no fl (f) If so, by whom? selfQ doctor Q family member Q prison guard Q social worker Q any other person 0 sister 0 daughter!] (g) If you feel you have a hearing impairment, what do you think is the cause? (h) Has your hearing been tested since your admission to this institution? yes D no Q 16. Before you were admitted to that institution, did you [please check one or more] (a) drink alcohol yes rj no rj If so, how much in a week? about 3 bottles of beer Q about 6 bottles of beer 0 about 12 bottles of beer Q more than 12 bottles beer D (b) use drugs yes 0 no Q If yes, which ones? 1. tobacco fl 2. narcotics Q 3. tranquilizers Q 4. other prescription drugs rj please name (c) How often did you use these Drug tobacco narcotic tranquil- izers other prescrip- tions once a week 2-3 times/wk drugs? [please check all appropriate columns] 3-10 times/wk more than 10 times/wk 2-3 times a day more than 3 times a day 17. Have you had any other major illnesses, diseases or injuries- (a) in the past 5 years? yes Q no Q 10 years? yes 0 no Q 20 years? yes Q no Q during childhood? yes Q no Q (b) if yes, what was it? [please name] 18. Have you ever had - (a) a severe blow to the head Q (b) viral diseases Q (c) earache Q (d) dizziness \\ (e) ringing in the ears Q (0 ear surgery Q (g) ear discharge (fluid) 0 19. Have you ever been exposed to excessively loud noise such as - (a) gun fire D (b) explosions Q (c) loud music Q (d) factory or construction noise 0 (e} other [] please specify 20. Do you now or have you ever worn a hearing aid? (a) wear a hearing aid now Q (b) used to wear a hearing aid Q (c) have never worn a hearing aid 0 21. Have you ever had a hearing test before? yes Q no Q If so, what were the results of the test? (a) no hearing impairment noted Q (b) told I had a hearing impairment Q (c) no treatment prescribed 0 (d) advised to get a hearing aid Q (e) other (please specify) What two other questions do you think we should have asked in this questionnaire? Are there any other comments you would like to add? Thank you for your cooperation in completing this survey. APPENDIX B Form for hearing screening HEARING SCREENING Institution Date CODE. OBSERVATION 1. Is there any structural deformity to the ear? yes 0 no D 2. If a structural deformity, what is it? HEARING SCREENING TEST: Pure tone air conduction screening at loudness level of 20dB HL administered bilaterally HEARING SCREENING RESULTS Put "Y" for positive response, or "X" for negative response. Put "P" for Pass or "F" for fail. Number of test [1] [2] right ear left ear right ear left ear 1,000 hz 2,000 3,000 4,000 pass/ fail [Anyone who fails to respond to any tone in either ear will be readministered the test a second time. Failure to respond during a second administration as well is considered a failure of the hearing screening]. Comments: 250 APPENDIX C-1 Form for hearing testing, audiogram AUDIOLOGY REPORT P A T I E N T ' S A D D R E S S PROBLEMS: 10 0 10 20 30 40 SO 60 70 80 90 100 no 120 • T C L E P H O N C N U u a C R - proviout audio: . •or In foct ion . mumpi •or surgory . trauma noiio FREQUENCY IN Hi 25 250 500 1000 2000 4000 8000 - 10 0 10 20 30 40 50 60 70 80 90 100 110 120 MASKING L E V E L BC | j 1 R r R L E X A M I N E R vertigo . . . „ „ . . imbalance tinnitus haaring aid «__ family h l t t o ' y LEGEND EAR AIR R L unmotkad O X masltad D BONE urvnatkod maikod D > C < \ I TAPE • LIVE VOICE • SRT DISCR1M. RIGHT dB % ot dB dB WN L dB WN L LEFT dB % ot dB dB WN R dB WN R APPENDIX C-2 Form for hearing testing, middle ear IMPEDANCE AUDIOMETRY LEFT PROBE EAR . / H j O MIDDLE EAR PRESSURE f norma I rongt - 60 to + 60 mm/HjOl RIGHT PROBE EAR mm/HjO Good_ Olh.t. Fair Poof. TYMPANIC MOBILITY Good. Othor Fair Poor. Z| Z , c.c. c.c. MIDDLE EAR COMPLIANCE (normol ronae 0.3 to 1.5 c.c.) Z l . z. c.c. Toynboo OtKtr Valtovo EUSTACHIAN TUBE Toynboo _ Olhor Voltovo STAPEDIUS REFLEX LEFT EAR STIMULATED PROBE IN RIGHT RIGHT EAR STIMULATED PROBE IN LEFT R.ll.x Dtcay Rtcruitmonl Pur« Ton« Thr.ihold LE Contra Threshold Th,«t°ho'ld RE ipi: * Threshold RE Contra Thrtshold Puro Tont Threshold Rocruirmant R.ll.» Dtcay at S00 Hi 1000 Ht 2000 Ht 4000 Hi COMUENTSI APPENDIX D INTERVIEWS WITH PRISONERS WHO ARE HARD OF HEARING I nstitution Date CODE 1. When was your hearing loss first noted? 2. What is the correlation, if any, between your hearing loss and a. offenses b. current status 3 Do you believe that your period of incarceration has been adversely affected by a hearing impairment yes \\ no 0 don't know rj If yes, to what degree: a. some Q b. a fair amount 0 c. a large amount Q d. excessively Q e. don't know Q 4. With whom, if at all, has your hearing impairment hindered you or held you back: a. social contact with other inmates b. employment c. guards and/or administrative staff d. health care staff e. parole f. no or not applicable f. other. Please specify 5. What are your views about hearing impairment? 6. Do prisons discriminate in any way against offenders who have hearing impairment? 7. Do you think there should be a mandatory screening of hearing as part of admission health assessment? 8. Were you checked for a hearing problem when you were admitted here? 9. Did you ever complain of not hearing well? 10. If so, what was the result? Are there any other comments you would like to make? Thank you for participating in this interview. 253 APPENDIX E INTERVIEW WITH INMATE COMPARISON GROUP WHO PASSED HEARING TEST Institution Date CODE Thank you for agreeing to take part in this interview. I am going to ask some questions related to your perceptions of other inmates you may know, or know of, who seem to have a hearing problem. 1. Do you know any inmates who you think or know have a hearing problem? yesQ no Q 2. If yes, can you tell me which behaviours they have which lead you to think they have a problem hearing? 3. If yes, can you tell me how these behaviours affect you? Please explain 4. If yes, can you tell me how it affects your relationship with these inmates? 5. Do you think that your relationship with these inmates with a hearing problem is different from your relationship with other inmates? Please explain. 6. How would you identify someone with a hearing problem? 7. What are your views about hearing impairment? 8. Do prisons discriminate in any way against offenders with hearing impairment? Are there any other comments you would like to make? Thank you for participating in this interview. 254 APPENDIX F INTERVIEW WITH CUSTODIANS Institution Date CODE Thank you for agreeing to participate in this interview. You are someone who has experience in working with inmates of penitentiaries. I would like to draw on your experience in order to understand more about the behaviour of prisoners and what those behaviours mean. Your perceptions of behaviours and your interpretations of what those behaviours mean will provide a useful perspective to me in completing this study. GENERAL INFORMATION 1] What is your position in this institution? 2] How long have you worked here? 3] How long have you worked for Correctional Services Canada? 4] What do your duties entail [in what way do you interact with prisoners? 5] What are the behaviours by prisoners that give you the most trouble in talking to them? [please list] 6] How do you describe the character of a prisoner with the following behaviours [e.g. refusing to carry out an order is 'stubborn'] (1) Won't answer unless you come right up to him, to speak to him to his face. (2) Often asks for things to be repeated. [Says "uh" and "what" a lot]. (3) Often gives a reply that is incorrect or inappropriate. (4) Has a lot of misunderstandings and arguments with others. (5) Is always watching, staring [watches closely the facial expression of the speaker]. (6) Leans toward you when you talk. Gets close (7) Often looks startled or puzzled. (8) Frowns a lot during conversation. (9) Nods head a lot during the conversation as though agreeing but later it shows up that he never understood what was said. (10) Hardly ever understands a joke. [Never seems to get the punchline]. (11) Acts like he hears only when he wants to. 255 (12) Responds to some officials, but there are some officials he never replies to. (13) Complains about the way people talk - accuses others of mumbling. (14) Complains that others are talking about him behind his back. (15) Doesn't follow directions given to the group. (16) Doesn't want to use the telephone. (17) Doesn't get in line with the others when the bell rings or siren goes. (18) Turns television and radio up louder than the others want it. (19) Does not participate actively in group conversations. This applies in classroom situations also. (20) Jerks his head around a lot to locate who is speaking. (21) Gets impatient with interruptions [focuses on one speaker and frustrated by interruptions by another speaker]. (22) Often seems confused about the topic, needs a lot of individual explanations to understand. (23) Doesnt behave appropriately in a group conversation e.g. picks up a book or magazine to read, or gets up and walks out. (24) Tends to separate himself from the group - will talk to one person only. (25) Doesnt follow directions - doesn't do what he is told to do. Seems mixed up about what he was told to do. (28) Refuses to participate in social events. (29) Complains of noises in his head. (30) Always speaks in a loud voice. (31) Always speaks in a soft, low voice. 7] a] Do you know if any of the prisoners you work with have a hearing disability? b] If so, how do you know? [Please describe] Are there any other comments you would like to make? Thank you for taking part in this interview. 256 APPENDIX G Initial invitation to prisoners to participate in the study, and consent form Marilyn Dahl or Dr. Godwin Eni Department of Health Care & Epidemiology, Faculty of Medicine University of British Columbia 5804 Fairview Avenue, Room 266 Vancouver, B.C. V6T 1W5 Tel: 822-2366 TO: All inmates of federal penitentiaries in the Pacific Region FROM: Marilyn Dahl, PhD Candidate, University of British Columbia RE: Partial Hearing Impairment and Deviant Behaviour: A Study of Federal Prisons in British Columbia DATE: June. 1992 I have obtained permission from The Correctional Service of Canada to undertake a study in your institution. The purpose of this study is to find out how many prisoners have a hearing loss, and how this hearing impairment affects their daily living. The study will include a questionnaire for all inmates who volunteer, to complete, [about 15 minutes], and a hearing screening for all of these same inmates [about 7 minutes]. Hearing assessments [about 10 minutes] and interviews [about 40 minutes] will be done with a selected group of inmates. For an inmate who participates in the entire study, about one and one half hours would be required, taken over different periods of time. Time off from work will be given, to participate. A selected group of staff will also be interviewed. This interview will take about 40 minutes. No one who participates in the study will be identified in any way - only the study findings and the manner of conducting the study will be reported. If you participate you will receive the results of your hearing test, your test result will not be given to anyone else. It is important to note that you have the right to refuse to participate in this study or to withdraw at any time, without any adverse effect on your standing within The Correctional Service of Canada. Participation is purely voluntary. If you have any enquiries about the study or interviews, please contact the study supervisor or myself at the address or telephone number at top of the page. Your signature on this form will be taken to mean that you have consented to participate in this study. If you wish to participate in the study, please sign the form below and mail back to me in the small envelope provided. I will provide you with a photocopy of the signed form and letter for your own records. Thank you for participating. 257 I understand that I will receive for my own records a copy of this consent form and the attached letter of explanation. I of [Print name or number] [Institution] wish to participate in the Partial Hearing Impairment Study at this institution. Signed: Date: "PLEASE RETURN WITHIN ONE WEEK 258 APPENDIX H Information letter to staff and invitation to participate in the study Marilyn Dahl or Dr. Godwin Eni Department of Health Care & Epidemiology, Faculty of Medicine University of British Columbia 5804 Fairview Avenue, Room 266 Vancouver, B.C. V6T 1W5 Tel: 822-2366 TO: Staff of federal penitentiaries in the Pacific Region FROM: Marilyn Dahl, PhD Candidate, University of British Columbia RE: Partial Hearing Impairment and Deviant Behaviour: A Study of Federal Prisons in British Columbia DATE: June 1992 I have obtained permission from The Correctional Service of Canada to undertake a study in your institution. The purpose of this study is to find out how many prisoners have a hearing loss, and how this hearing impairment affects their daily living. The study will include a self-administered questionnaire for all inmates who agree to participate, [about 15 minutes], and a hearing screening for these same inmates [about 7 minutes]. Hearing assessments [about 10 minutes] and interviews [about 40 minutes] will be done with a selected group of inmates. For an inmate who participates in the entire study, about one and one half hours would be required, taken over different periods of time. Time off from work will be given to participate. A selected group of prison staff will also be interviewed. This interview will take about 40 minutes. No one who participates in the study will be identified in any way - only the study findings and the manner of conducting the study will be reported. Each inmate who participates will receive the results of their hearing tests, individual results will not be given to anyone else. It is important to note that you have the right to refuse to participate in the study, or to withdraw at any time, without any adverse effect on your standing within The Correctional Service of Canada. Participation is purely voluntary. If you have any enquiries about the study or interviews, please contact the study supervisor or myself at the address or telephone number given at top of this page. Your signature on this form will be taken to mean that you have consented to participate in this study. If you wish to participate in the study, please sign the form below, and mail it in the small envelope provided; and retain this part of the page for your records. Thank you for participating. 259 TEAR OFF HERE AND RETURN THIS PART IN THE ENVELOPE PROVIDED I have retained for my own records a copy of this consent form and the attached letter of explanation. I of [Print name and position] [Institution] wish to participate in the Partial Hearing Impairment Study at this institution. Signed: Date: 260 APPENDIX I Information letter to inmate committees and the native brotherhood. TO: INMATE COMMITTEES AND THE NATIVE BROTHERHOOD, WITHIN THE PACIFIC REGION OF THE CORRECTIONAL SERVICE OF CANADA FROM: Marilyn Dahl, PHD candidate, University of British Columbia DATE: June 1992 During the past few years, a consumer advocacy group, the Canadian Hard of Hearing Association [CHHA] has been collecting information about problems in hearing and understanding, experienced by people in interactions with the criminal justice system. Many of the people who report say they have had difficulties in hearing and understanding what was going on, or being said to them, in some of the situations when they had to deal with criminal justice. This may arise from a hearing impairment. There are now some reports which indicate that a quite high number of inmates of correctional institutions have a degree of hearing impairment. This hearing loss is often hidden - not recognized by either the inmate or by others. The question then arises, how long has the offender had this hidden hearing loss? Has it made a difference to how he has behaved, and been treated by others? If so, what can be done about it? These questions have never before been addressed in Canada and we believe the findings can be quite important for the welfare of offenders. The issue of hearing impairment and its role in labelling behaviours as deviant has not been studied in Criminology. CHHA approached The Correctional Service of Canada, asking that this type of investigation be carried out. Both the Department of Graduate Studies at University of British Columbia, and The Correctional Service of Canada have approved the project, and Marilyn Dahl, PhD Candidate, has been authorized to carry out the study. The study will be confidential, and will not identify participants. Participation will be purely voluntary. I am seeking the support of the Inmate Committees and the Native Brotherhood to encourage inmates to volunteer to take part in the study. A letter will be sent out to all inmates of the Pacific Region of CSC. Please watch for it and respond promptly. If you have questions about the study, please contact me, or Dr. Eni, study supervisor, at the address at top of this page. Thank you, Marilyn Dahl Graduate student c. Dr. Godwin Eni, UBC Past President, CHHA c. Sharon Hickey, CSC 261 APPENDIXJ-1 Information letter to inmates, consumer interest in study TO: INMATES OF THE PACIFIC REGION, THE CORRECTIONAL SERVICE OF CANADA FROM: Marilyn Dahl, PHD Candidate, University of British Columbia DATE: June 1992 During the past few years, a consumer advocacy group, the Canadian Hard of Hearing Association [CHHA] has been collecting information about problems in hearing and understanding, experienced by people in interactions with the criminal justice system. Many of the people who report say they have had difficulties in hearing and understanding what was going on, or being said to them, in some of the situations when they had to deal with criminal justice. This may arise from a hearing impairment. There are now some reports which indicate that a quite high number of inmates of correctional institutions have a degree of hearing impairment. This hearing loss is often hidden - not recognized by either the inmate or by others. The question then arises, how long has the offender had this hidden hearing loss? Has it made a difference to how he has behaved, and been treated by others? If so, what can be done about it? These questions have never before been addressed in Canada and we believe the findings can be quite important for the welfare of the offender. The issue of hearing impairment and its role in labelling behaviours as deviant has not been studied in Criminology. CHHA approached The Correctional Service of Canada, asking that this type of investigation be carried out. Both the Department of Graduate Studies at University of British Columbia, and The Correctional Service of Canada have approved the study project, and Marilyn Dahl, PhD Candidate, has been authorized to carry out the study. The study will be confidential, and will not identify participants. Participation will be purely voluntary. The letter of introduction attached provides you with a consent form to be signed - please mail it to me, and I will make a copy for your personal records and return it to you. Please respond promptly in order to have a chance to participate. If you have questions about the study, please contact me, or Dr. Eni, study supervisor, at the address or telephone number at top of this page. Thank you, Marilyn Dahl Graduate student c. Dr. Godwin Eni, UBC Past President, CHHA c. Sharon Hickey, CSC 262 APPENDIX J - 2 Information letter to staff, about consumer interest in the study. TO: STAFF OF THE PACIFIC REGION, THE CORRECTIONAL SERVICE OF CANADA FROM: Marilyn Dahl, PHD Candidate, University of British Columbia DATE: June. 1992 During the past few years, a consumer advocacy group, the Canadian Hard of Hearing Association [CHHA] has been collecting information about problems in hearing and understanding, experienced by people in interactions with the criminal justice system. Many of the people who report say they have had difficulties in hearing and understanding what was going on, or being said to them, in some of the situations when they had to deal with criminal justice. This may arise from a hearing impairment. There are now some reports which indicate that a quite high number of inmates of correctional institutions have a degree of hearing impairment. This hearing loss is often hidden - not recognized by either the inmate or by others. The question then arises, how long has the offender had this hidden hearing loss? Has it made a difference to how he has behaved, and been treated by others? If so, what can be done about it? Some staff will be asked to participate in one interview part of the study, in order to provide their important perspective and experience. These questions have never before been addressed in Canada and we believe the findings can be quite important for the welfare of the offender. The issue of hearing impairment and its role in labelling behaviours as deviant has not been studied in Criminology. CHHA approached The Correctional Service of Canada, asking that this type of investigation be carried out. Both the Department of Graduate Studies at University of British Columbia, and The Correctional Service of Canada have approved the study project, and Marilyn Dahl, PhD Candidate has been authorized to carry out the study. The study will be confidential, and will not identify participants. Participation will be purely voluntary. I will look forward to having your cooperation in completing this study. Thank you in advance, Marilyn Dahl Graduate Student Past President, CHHA c. Dr. Godwin Eni, UBC c. Sharon Hickey, CSC 263 APPENDIX K Prisoner consent form for documentary review. I * Correctional ServkJ* Service correcllonnel Csnsds Canada PATIEHT AUTHORIZATION TO DISCLOSE CSC PERSOHAL" HEALTH CARE INFORMATION AUT0RISAT10H DU PATIEHT RELATIVE A LA DIVULGATION PERSONNEL CONTEHUS DAHS SON DOSSIER OE SAHTE (SCC) Personal Inlormstlon BmK Numb»r(»): NumifOd) d* banques de doruvtea personnels: CSC/SCO- PRP40 • , , , Health Cera P 4 ° Solna medleaux Inmate's nam*. Nom du detenu F.P.S. numbur Numdro S.E.D. Oulo of birth Date-do nulssance INSTITUTION k ETABLISSEM6NT T Addressee - Oastinalalr* TO A mmmmmmimmmm FROM' I, the undsrslgnad. authorixt'tha dictator* of personal health car* Information contained In my h'aallh car* record (Personal Information BankNumberfi) ) to the following person or agen- cy for the purpose Indicated below.' Je eoueslgn*. autorts* la divulgation dee renselgnemenla parsonnal quo renterm* mon dossier de aante (Num*ro(s) de banquet d* oor. nies personnel* ) a ta pertonne ou a rorgenls/r. susmantlonni, pour le* motif* enonces ci-dassous. PartonfAgency - PertonnofOrganltme Purpose - Motll* Nam* - Nom ^aJl/^^'dt Address - Adress* m<^ Nolle* to sit parlies concerned - Avis mx Intiress**1 CSC medical authorities thai not assume responsibility for the pro- tection of Information dlscloaed In consequence with the patient's In- structions. Authorized reclplants of such Information are requested to treat the Information aa confidential. It Is understood thst this authorization Is only valid for the purposo stalsd sbove and for a period not to exceed two months from the date of authorization. Lea aulorltea medicafee du SCC ne aont pas responeablee data pic tocllon dee renaelgnemanla personnels dlvulgues telon Us InaUw lions du patlont. La- personna ou I'orgsnlsme qui recoil c* rensolonements est prle* de respecter leur earacter* confident!* It est eniendu que eelle autorlsstlon n'esl vsJlde qu'sux tins menllor noes et pour un* period* ne devant pas depasser deux mola. PATIENT'S AUTHORIZATION - AUTORISATION DU PATIENT •wmmmmmmmmmmmmm PtH«nU i lgni iuf t - Sign »tiff • du paHant C*C/*CC « • • (A<«4.«J . Witne»» tignoiurn - S l p n a i t w du l»motn 264 APPENDIX L SUPPLEMENTARY TABLES SUPPLEMENTARY TABLE L-1 Table L-1 Responses to Questionnaire Characteristics of Self-Reported Hearing Problems n=189 --1 (1) Institution in which located Institution Kent Elbow Lake William Head Matsqui Ferndale Mission Reg. Psychiatric Mountain TOTAL n 20 17 19 17 13 24 28 51 189 % 11 09 10 09 07 13 14 27 100 --1 (2) Age group category Aae arouD under 20 20-25 26-30 31-35 36-40 41-45 46-50 over 50 n 02 17 38 32 29 28 20 23 189 % 01 09 20 17 15 15 11 12 100 L-1 (3). Gender Gender male female n 189 0 % 100 0 _-1 (4) Ethnic origin- Race Caucasian East Indian North American Indian Inuit Metis Black Asian Other n 152 04 12 1 10 04 04 2 189 % 81 02 06 01 05 02 02 01 100 ,-1 (5) Occupation prior to admission to this institution Occupation Semi-skilled Unskilled Skilled other or not stated n 82 72 24 11 189 % 43 38 13 06 100 --1 (6) Approximate range of pay in last occupation Pav ranqe Under $5,000/year $5,000-$10,000/year $10,000-$20,000/year $20,000-$40,000/year $40,000-$60,000/year $60,000-$80,000/year over $80,000/year not listed n 17 21 48 51 17 05 17 13 189 % 09 11 25 27 09 03 09 07 100 --1 (7) Reason for imprisonment Offense n drug-related 18 Theft/B&E 49 Violence[murder and/or assault] 55 Sexual offences 47 Not stated 20 189 % 10 26 29 25 10 100 L-1 (8). Particular behaviour believed to contribute to Behaviour Something to do with another person Something to do with society [eg. alcohol, drugs, etc] Something to do with disability [eg.loss of vision, hearing, etc.] Other:personal[greed, poorjudgement.etc] [sexual deviance,hate.anger] innocent Not stated getting into trouble n 50 81 05 49 04 189 % 26 43 03 26 02 100 L-1 (9) Length of time in this institution Time span under 1 year 1-5 years 5-10 years 10-15 years 15-20 years more than 20 years n 97 75 14 01 01 01 189 % 51 40 07.5 0.5 0.5 0.5 100.0 .-1 (10) Length of t ime in this and other institutions Time span under 1 year 1-5 years 5-10 years 10-15 years 15-20 years more than 20 not stated years n % 26 14 58 31 46 24 30 16 15 08 13 06.5 01 00.5 189 100.0 --1 (11) Belief in social relationship with others: "get along well ' Social relationship arouD aood n % fellow prisoners 151 80 guards 128 68 everyone 152 80 "donl get a bad n % 23 12 42 22 27 15 ong' no response n % 15 08 19 10 10 05 total n % =189 100 =189 100 =189 100 267 L-1 (12) a] Awareness of labels Awareness of labels or nicknames ves n % 162 86 being given to inmates no or no resDonse n 27 % 14 in your prison total n % =189 100 .-1 (12) b] Perception that the labels influence Perceived influence of labels you relate to them other inmates relate to them prison guards relate to them quality of re ves n % 103 64 139 86 100 62 ationships no or no response n % 59 36 23 14 62 38 total n % =162 100 =162 100 =162 100 L-1 (12) c] Perception of relationship of labels to hearing Perceived relationship of labels to hearina impairment problems in hearing & understanding how inmates with hearing /understanding difficulties are viewed by others ves n % 74 46 91 56 impairment no or no response n % 88 54 71 44 total n % =162 100 =162 100 --1 (12) d] Labels cited as being applied to prisoners having hearing difficulties Cateaories of labels lacking normal intelligence weird in behaviour obscenities n=155 124 21 10 155 % 80 14 06 100 L-1 (13) Level of education completed Level of education no education primary education secondary education professional education university education other [univ. credits, vocational & trades] n 07 34 85 27 24 12 189 % 04 18 45 14 13 06 100 268 --1 (14) Marital status Marital status married divorced separated widowed living common -law other relationship - single no response n 26 43 15 06 24 73 01 189 % 14 23 08 03 13 38.5 00.5 100.5 L-1 (15) a] Self-awareness of a hearing problem Awareness of hearina problem yes no or no response n 110 79 189 % 58 42 100 --1 (15) b] Self-description of hearing problem Cateaories of awareness loss in one ear problems understanding people &/or Tv wax in ear way others speak to me problem with way ear feels problem with certain tones & noise nnging in ears don't know or no response n=110 23 46 04 04 02 16 07 08 110 % 21 41 04 04 02 15 06 07 100 .-1 (15) c] Awareness of hearing loss in family Presence of hearina loss in family yes no, don't know, or no response n 72 117 189 % 38 62 100 L-1 (15) d] Family member identified with hearing loss Family members with hearina loss parent sibling other several eg.2 or more n=72 33 06 15 17 72 % 46 10 21 24 100 L-1 (15) e] Prior identification of own hearing problem Prior identification of hearina problem yes no n=110 60 50 110 % 55 45 100 L-1 (15) f] Individual who identified hearing problem Identifier of hearina problem self family member social worker doctor prison guard any other person n=60 17 12 00 21 02 08 60 % 28 20 00 35 03 13 100 L-1 (15)g] Self-belief of cause of hearing problem Self-perception of cause of hearina problem don't know noise-related injury-related medical [nerve damage, infections, wax] psychological biochemical genetic n=110 18 57 18 13 02 01 01 110 % 16 52 16 12 02 01 01 100 --1 (15) h] Hearing tested since admission to this institution Hearina test since this imprisonment n % yes 20 10 no 69 37 no response 100 53 189 100 .-1 (16) a] Alcohol use prior to imprisonment Prevalence of alcohol use yes no no response n 138 44 7 189 % 73 23 04 100 L-1 (16) b] Average weekly consumption Averaae consumption Der week about 3 bottles of beer about 6 bottles of beer about 12 bottles of beer more than 12 bottles beer of alcohol n=138 31 17 21 68 138 % 23 12 15 50 100 L-1 (16) c] use of drugs Prevalence of drua use yes no no response n 147 38 04 189 % 78 20 02 100 L-1 (16) d] prevalence of drug jse by substance Prevalence of drug use yes bv substance n=147 % tobacco 131 89 narcotics 96 65 tranquilizers 44 30 other prescription drugs 46 31 L-1 (16) e] Frequency of drug use by substance Drug tobacco n=131 narcotic n= 96 tranquilizers n=44 other prescriptions n=46 1X/week n % 3 2 19 21 11 25 5 11 2-3X/wk. n % 1 1 18 19 6 14 3 7 no or no response total n % n % 16 11 51 35 103 70 101 69 3-10X/wk. n % 4 4 8 8 10 22 3 7 =147 100 =147 100 =147 100 =147 100 10X/wk> n % 6 9 4 4 5 9 9 9 2-3X/day n % 4 4 10 10 7 16 12 26 3X/day> n % 110 84 32 43 6 14 19 40 L-1 (17) a] Incidence of major illnesses, diseases or Cateaories of major illness/iniurv mental, medical &/or surgical infectious diseases trauma/injuries neurological drug overdose don't know or no response n=124 63 25 52 03 05 04 injuries % 51 20 42 02 04 03 271 --1 (18) Incidence of factors which may contribute to impaired hearing Cateaories of hearina-imoairment related factors a severe blow to the head viral diseases earache dizziness ringing in the ears ear surgery ear discharge (fluid) n=591 140 50 120 101 130 11 39 % 74 26 63 53 69 06 21 --1 (19) Incidence of exposure to excessively loud noise Cateaories of exposure to loud noise n=59 % gunfire 119 63 explosions 75 40 loud music 139 74 factory or construction noise 139 74 other..engines & sirens 28 15 kids shouting in ears when I was a kid 01 01 .-1 (20) Incidence of hearing aid use Incidence of hearina aid use wear a hearing aid now used to wear a hearing aid have never worn a hearing aid n 09 05 175 189 % 05 03 92 100 L-1 (21) a] History of prior hearing test History of prior hearina test yes no n 89 100 189 % 47 53 100 --1 (21) b] Results of prior hearing test Cateaories of test results no hearing impairment noted told I had a hearing impairment no treatment prescribed advised to get a hearing aid other n=89 26 25 13 12 13 89 % 29 28 15 13 15 100 --1 (22) Spontaneous comments provided n=189 Categories of key types of comments n %_ Comments about self 47 25 Comments about institution 05 03 Comments about staff [guards, others] 02 01 No comments 135 71 189 100 SUPPLEMENTARY TABLE L-2 Table L-2. Cerumen. n=87 Cerumen N=174 L.E. n % 32 19% R.E. n % 31 18% No cerumen n % 111 64% Total ears n % 174 100% 'presence of cerumen rated as "small amount" In all except 2 ears. SUPPLEMENTARY TABLE L-3 Table L-3 Tympanometry. n=87 Type A Ad As B C Total LE. n % 64 74% 4 5 5 6 3 3 11 12 87 100% R.E. n % 66 76% 4 5 7 8 2 2 8 9 87 100% Total ears n % 130 75% 8 5 12 7 5 3 19 10 174 100% Type A = normal Type Ad = excessively mobile middle ear mechanism Type As = increased stiffness at middle ear mechanism Type B = suggesting obstructive middle ear pathology Type C = suggesting negative ear pressure in middle ear cavity. SUPPLEMENTARY TABLE L-4 Table L-4 Acoustic reflex. n=87 Acoustic reflex Present Absent Total LE. n % 58 67% 29 33 87 100% R.E. n % 58 67% 29 33 87 100% Total n % 116 67% 58 33 174 100% 273 SUPPLEMENTARY TABLE L-5 Table L-5. Custodian's perception of troublesome behaviour by inmates. Custodians own words, categorized. n=94 A. Deviant behaviours 1. Aggressive types of behaviour. • aggressive [verbal & body language] - anger • belligerent • violent -demanding [especially native Indians [1] -hostility -selective hearing 2. Rule-breaking and anti-authoritv - under the influence - go against rules - sarcasm - negative attitude toward program/institution/ officers [the uniform], authority - testing limits of individual officers • attention seeking with numerous health complaints • selective hearing [hearing but not listening to what is said] - don't listen to authority - distrust of Correctional Services Canada • lack of honesty, game-playing, conning • lack of trust • lack of respect 3. Lack of responsible or effort. • indifference • lack of motivation - irresponsible • feel persecuted or singled out • disinterest - denial B. Deficit" behaviours Tdeficits in education- intelligence or social skills] - lack of social skills - instant gratification - illiterate - low education - low intelligence • unhygienic • have not lived with rules and regulations before • inability to concentrate for more than a few minutes • slow to get insight C. "Defect" behaviours- defects in personality. or other] - self centered - handicapped - "not able to tell" - oversensitivity -fear - pre-determined mindset - narrow focus - non-assertive - irrational childlike behaviour when you attempt to reason with them • concrete thinking - egocentricity • arrogance • stubbornness 274 SUPPLEMENTARY TABLE L-6 Table L-6. Naming of behavioural characteristics by classification of officials. n=1365 number of officials: health - 7; correctional officers 1 & 2 -16; managers & supervisors -14; other [teachers, social workers, etc.] n= number of officials. Cor. O. 3 listed with Man. & Sup. How do you describe the character of a prisoner with the following behaviours [e.g. refusing to carry out an order is 'stubborn'] L-6-Q) Won't answer unless you come right up to him, to speak to him to his face. n=45 n=7 Health attention-seeker [2] testing authority [1] distracted [1] controlling [1 ] poss. HOH [2] n=19 Corr. 1 & 2 attention seeker [2] testing authority [1] negative attitude [3] resent authority [1 ] playing a role [2] reluctant [1 ] non-assertive [1 ] hostile [2] stubborn [2] uncooperative [1 ] confrontational [1 ] intimidating [1] don't know [1] n15 Man.&Sup. uncooperative [2] testing authority [3] selective hearing [2] hostile [2] resistive [1 ] shy[1] stubborn [1 ] poss. HOH [3] n 4 Other poss. HOH [1] angry [1] preoccupied [1 ] don't know [1] L-6-(2) Often asks for things to be repeated. [Says "uh" and "what" a lot]. n=51 n=8 Health playing ignorant [1] slow learner [1] indifferent [1] short attention span [1] may not comprehend [1 ] poss. HOH [3] n=21 Corr. 1 & 2 playing ignorant [10] non-assertive [1 ] testing one's patience [1 ] short attention span [2] may not comprehend [2] needs simpler direction [1 ] poss. HOH [3] don't know [1] n=18 Man.&Sup. playing ignorant [2] ESL [2] learning disability [4] slow learner [3] poss. HOH [5] may not comprehend [2] n=4 Other may not comprehend [1] poss. HOH [1] don't know [2] L-6-(3) Often gives a reply that is incorrect or inappropriate. n=43 n=7 Health arrogant [1 ] selective hearing [2] playing ignorant [1] confused [1] lack of cognition [1 ] purposely irritating [1] n=18 Corr. 1 &2 arrogant [4] selective hearing [1] uncooperative [1] testing limits [1 ] mentally deficient [2] thinking deficit [1] lack of cognition [2] playing ignorant [5] slow [1 ] n=14 Man.&Sup. sarcastic [2] playing ignorant [3] learning disability [1] lack of cognition [1 ] mentally deficient [2] doesn't understand [2] poss. HOH [3] n=4 Other poss HOH [1] doesn't know answer [1] does not understand [1] don't know [1 ] 275 L-6-(4) Has a lot of misunderstandings and arguments with others. n=54 n=8 Health attitude problem [1] combative [1] aggressive [1] hostile [1] controlling [1] argumentative [1 ] antisocial [1 ] socially inadequate [1 ] n=22 Corr. 0 .1 & 2 attitude problem [1 ] combative [3] aggressive [4] hostile [2] power struggle [3] short fuse [1 ] antisocial [1 ] socially inadequate [2] rigid thinking [1] anger [2] poss. HOH [1] unknown [1 ] n=18 Man./Sup. attitude problem [1 ] potential beh. prob. [3] aggression [3] antisocial [3] poor adjustment [2] substance abuse [1] socially inadequate [2] different cultural background [1] poss. HOH [2] n=6 Other attitude prob. [1 ] anger [1] distrust [1] inability to comprehend [1] fear[1] poss. HOH [1] L-6-(5) Is always watching, staring, watches closely the facial expression of the speaker. n=46 n=7 Health intimidation tactic [3] aggressive [1] poss. HOH [2] don't know [1] n=20 Corr. 1 & 2 intimidation tactic [5] testing limits [1 ] hostile [1] angry [1] suspicious [2] negative attitude [1] rude[1] looking for hidden meaning [3] poss. HOH [4] unknown [1 ] n15 Man.& Sup. intimidation tactic [1 ] testing limits [1 ] hostile [1] psychotic [1 ] suspicious [2] poss. med. prob. [1 ] ESL prob. [2] slow to understand [2] poss. HOH [3] n 5 Other defiant [1] preoccupied [1] poss. med. prob. [1 ] unknown [1 ] poss. HOH [1] L-6-(6) Leans toward you when you talk. Gets close. n=43 n=7 Health threatening [3] intimidating [3] interested [1] n=18 Corr. 0 .1 &2 threatening [1] intimidating [6] interested [1 ] negative attitude [1 ] aggressive [1] confrontative [2] angry [1J insecure [1 ] poss. cultural trait [1] hiding something [1 ] unknown [1 ] poss. HOH Ml n=14 Man./Sup. threatening [3] intimidating [5] aggressive [3] trying to understand [1 ] don't know [1 ] poss. HOH [1] n=4 Other unknown [3] poss. HOH [1] 276 L-6-(7) Often looks startled or puzzled. n=43 n=7 Health mentally slow [1] confused [2] mental prob/meds [2] poss. HOH [2] n=18 Corr. 0.1&2 mentally slow [4] confused [3] not with it/meds [2] playing ignorant [1 ] neg. attitude [1] angry [1] cognitive deficit [2] anxious [1 ] jumpy/tense [1] nervous [1] doesn't understand [1] n=14 Man./Sup. mentally slow [2] dislikes answer [3] jumpy/tense [1 ] poss. surprised [2] don't know [2] poss. HOH [1] mental problem-substance abuse [3] n=4 Other preoccupied [1] poss. HOH [1] don't know [2] L-6-(8) Frowns a lot during conversation. n=49 n=7 Health angry [2] depressed [1] difficulty understanding [1] poss. HOH [1] don't know [2] n=24 Corr. 0.1&2 angry [2] does not want to hear the truth [3] difficulty understanding [4] thinks he is an institutional lawyer [1] neg. attitude [2] not happy to be talked to [1 ] poss. disappointed [1] not interested in topic [2] disagrees [2] does not like info given [4] j o s s . HOH [2] n=14 Man./Sup. angry [4] does not like the info, given [2] difficulty understanding [3] slow learner [2] unhappy [2] poss. HOH [1] n=4 Other don't know [1 ] does not like the info, given [2] difficulty understanding [1 ] L-6-(9) Nods head a lot during the conversation as though agreeing but later it shows up that he never understood what was said. n=49 n=7 Health mentally retarded [2] confused [1] on medications [1] not paying attention [1] poss. HOH [1] n=24 Corr. 0.1&2 mentally retarded [4] confused [1] on medications [1] conveniently misunderstanding [6] poss. HOH [1] no intention of complying [1] comprehension or language prob. [4] slow [4] did not get the msg [2] n=14 Man./Sup. mentally retarded [3] slow [2] insecure [2] substance abuse [2] don't know [1 ] poss. HOH [1] comprehension or language prob. [3] n=4 Other mentally retarded [1 ] preoccupied [1 ] don't know [2] 277 L-6-(10) Hardly ever understands n=8 Health no sense of humour [3] language barrier [3] mentally deficient [1] dense [1] a joke. [Never seems to get the punchline]. n=45 n=17 Corr. 0.1&2 no sense of humour [8] slow [3] mentally deficient [1] thinking deficit [1 ] hard core con. [1 ] confused [1 ] poss. HOH [1] n=15 Man./Sup. no sense of humour [8] no common sense [1] mentally deficient [1 ] unsophisticated [1 ] substance abuse prob. [1 ] poss. HOH [3] n=5 Other no sense of humour [2] don't know [2] poss. HOH [1] L-6-01) Acts like he hears only when he wants to. n=51 n=7 Health uncooperative [3] selective hearing [3] smart ass [1] n=23 Corr. 0 .1 &2 uncooperative [4] selective hearing [2] smart ass [1 ] stubborn [1] pretending [3] disinterest [1 ] bad attitude [3] negative attitude - testing [3] does not care about CSC staff [1] poss. HOH [3] n=17 Man./Sup. uncooperative [4] selective hearing [5] angry [1] stubborn [1 ] single-minded [1 ] language prob. [1 ] poss. HOH [2] substance abuse prob. [1 ] who doesn't? [1 ] n=4 Other way to deal with info, he does not want to think about [1] disinterest [1 ] preoccupied [1] poss. HOH [1] L-6- (12) Responds to some officials, but there are some officials he never replies to. n=47 n=7 Health uncooperative [1] prejudice/ discrimination [2] resistive/hostile [1] testing those he thinks vulnerable [1] selective hostility [1] poss. HOH [1] n=21 Corr. 0 .1 &2 uncooperative [2] prejudice/ discrimination [8] resistive/hostile [1 ] testing those he thinks vulnerable [2] gets his own way with certain people [5] attitude prob. [2] may have a prob. with certain staff [1] respects authority he agrees with[1] n=14 Man./Sup. uncooperative [2] prejudice/ discrimination [2] selective hostility [1 ] testing those he thinks vulnerable [1 ] wnts to hear it from the organ grinder, not the monkey [1 ] attitude prob. [1] hears some voices better than others [1 ] poss. HOH [1] doesn't hear lower voices [1 ] gets his own way with certain people [31 n=4 Other poss. HOH [1] prejudice/ discrimination [1 ] selective hostility [1 ] don't know [1 ] L-6-(13) Complains about the way people talk -accuses others of mumbling. n=50 n=8 Health paranoid [3] hearing prob. [3] lang. barrier [2] n=22 Corr. 0 .1 &2 paranoid [3] hearing prob. [6] whiner [3] does not accept responsiblity for own problems [6] not paying attention [2] don't know [2] n=15 Man./Sup. paranoid [3] poss. hearing prob. [9] whiner [2] ignorant of others [1] some people are never happy [1 ] n=4 Other don't know [2] poss. hearing prob. [2] 278 L-6-(14) Complains that others are talking about him behind his back. n=46 n=7 Health paranoid [6] low self-esteem [1] n=20 Corr. 0.1&2 paranoid [16] insecure [3] don't know [1 ] n=15 Man./Sup. paranoid [11 ] psychological prob. [1] self-centered [1] poss. HOH [21 n=4 Other don't know [2] prison fear of others [1] poss. HOH [1] L-6-Q5) Doesn't follow directions given to the group. n=44 n=7 Health uncooperative [2] loner [1] defiant [2] challenging ben. [2] doesn't understand [1 ] n=18 Corr. 0 .1 &2 uncooperative [5] loner [1 ] trouble-maker [5] manipulative [1] needs individual instruction [1 ] anger [1] stubborn [2] not listening [1] poss. HOH [1] n=15 Man./Sup. uncooperative [5] loner [1] rigid thinker [1 ] stubborn [1 ] doesn't understand [1] not listening [2] don't know [2] poss. HOH [2] n=4 Other challenging beh. [2] don't know [2] L-6-(16) Doesn't want to use the telephone. n=51 n=9 Health poss. HOH [1] no one to call [1] reclusive [3] stubborn [3] don't know [1] n=24 Corr. 0 .1 &2 poss. HOH [2] no one to call [6] suspicious [4] does not communicate well [4] no social skills [2] speech prob. [1] don't know [5] n=14 Man./Sup. poss. HOH [4] no one to call [4] don't know [4] mental illness [2] n=4 Other poss. HOH [1] don't know [2] mental illness [1] L-6-(17) Doesn't get in line with the others when the bell rings or siren goes. n=42 n=7 Health uncooperative [4] dislikes authority [2] loner [1] n=17 Corr. 0.1&2 uncooperative [2] dislikes authority [4] antisocial [1] rebellious [1] defiance [1] testing the officer [2] confused [1] poss. HOH [2] don't know [2] didn't hear it 11] n=14 Man./Sup. uncooperative [4] dislikes authority [4] antisocial [2] poss. HOH [3] don't know [1 ] n=4 Other defiance [2] poss. HOH [1] don't know [1 ] 279 L-6-(18) Turns television and radio n=9 Health self serving [2] inconsiderate [2] controlling [1] poss. HOH [4] up louder than the others want it. n= n=25 Corr. 0.1&2 self-serving [4] inconsiderate [4] ignores rights of others [2] acting out [2] poss. HOH [11] thinks he owns the joint [1 ] don't know [1 ] 54 n=16 Man./Sup. self serving [3] inconsiderate [3] ignores rights of others [2] poss. HOH [8] n=4 Other wishes to be annoying [1] don't know [1] wishes to block out other noise [1] poss. HOH [1] L-6-(19) Does not participate actively in group conversations. This applies in classroom situations also, r n=8 Health loner [2] poor social skills [2] low intelligence [1] shy[1] withdrawn [1] doesn't know the subject [1] n=22 Corr. 0 .1 &2 loner [3] poor social skills [2] antisocial [1 ] shy [2] withdrawn [2] doesn't know the subject [1 ] passivity [3] thinks he is smarter [1 ] doesn't work well in groups [1] reclusive [2] poss. HOH [3] don't know [1] n=15 Man./Sup. loner [1 ] poor social skills [2] low intelligence [1 ] shy [2] withdrawn [2] hostile [1] low self-esteem [1 ] non-assertive [1] doesn't work well in groups [1 ] poss. HOH [3] i=50 n=5 Other fear [2] peer pecking order [1 ] low intelligence [1] don't know [1 ] L-6-(20) Jerks his head around a n=7 Health poss. HOH [2] tense, twitchy[1] mental illness [2] impatient [1] uncomfortable [1] lot to locate who is speaking. n=46 n=20 Corr. 0.1&2 poss. HOH [2] tense, twitchy [2] suspicious [7] anxious [2] not paying attention [1] don't know [5] HOH in one ear [11 n=14 Man./Sup. poss. HOH [4] tense, twitchy [2] suspicious [3] hostile [1] not paying attention [1] anxious [2] caught by surprise [1 ] n=5 Other poss. HOH [1] mental illness [1] medication [2] don't know [1 ] L-6-(21) Gets impatient with interruptions [focuses on one speaker and frustrated by interruptions by another speaker]. n=49 n=7 Health short attention span [2] limited concentration [2] irritated/nervous/tense [1] short tempered [drug abuse] [2] n=23 Corr. 0.1&2 short attention span [4] limited concentration [6] irritated/nervous/tense [1 ] short tempered [drug abuse] [2] low tolerance fuse [3] low threshold of boredom [1 ] anxious [1] self-centered [1] selfish [1] don't know [1] can't hear [2] n=15 Man./Sup. short attention span [4] limited concentration [2] irritated/nervous/tense [1] difficulty focussing attention [1] low tolerance fuse [2] low threshold of boredom [1 ] rude[1] selfish [1] can't hear [2] n=4 Other don't know [2] can't hear [1 ] unable to focus due to peripheral noise [1] 280 n=7 Health low IQ [4] doesn't understand [1] poss. HOH [2] n=17 Corr. 0 .1 &2 low IQ [5] slow [4] poss. HOH [1] confused [3] lack of concentration^ ] cognitive deficit [1] depressed [1 ] don't know [1] n=17 Man./Sup. low IQ [5] doesn't understand [1 ] poss. HOH [2] slow[1] didn't hear all of it [1] cognitive deficit [1 ] poor education [1 ] language prob. [2] learning prob. [3] n=4 Other low IQ [2] poor education [1 ] poss. HOH [1] L-6-(23) Doesn't behave appropriately in a group conversation e.g. picks up a book or magazine to read, or gets up and walks out. n=44 n=7 Health anti-social [3] social deficit [2] poor attention span [1] bored [1] n=17 Corr. 0 .1 &2 anti-social [3] social deficit [3] poor attention span [1 ] rude [2] repressing hostility [1 ] disinterest [1 ] depressed [1] selfish [1] needs to be centre of attention [1] don't know [2] poss. HOH [1] n=16 Man./Sup. anti-social [2] social deficit [2] poor attention span [1] bored [3] repressing hostility [1 ] can't hear [1 ] poss. HOH [2] n=4 Other disinterest [2] don't know [1 ] poss. HOH [1] L-6-(24) Tends to separate himself from the group - will talk to one person only. n=45 n=7 Health loner [2] socially inadequate [2] lacks interaction skills [1] shy 11] isolative[1] n=20 Corr. 0 .1 &2 loner [6] socially inadequate [4] anti-social [3] shy[1] insecure [1] suspicious [2] don't know [2] HOH [1L n=14 Man./Sup. loner [2] socially inadequate [4] lacks interaction skills [2] anti-social [1 ] insecure [1] doesn't function well in a group [3] H0H[1] n=4 Other mistrust [2] disinterested [1 ] don't know [1 ] 281 L-6-(25) Doesn't follow directions - doesn't do what he is told to do. Seems mixed up about what he was told to do. n=50 n=7 Health uncooperative [3] mentally slow [2] confused [1] headstrong [1] n=25 Corr. 0.1&2 uncooperative [3] mentally slow [3] confused [2] stubborn [1] resistant to authority[3] pretending [3] non-compliant [1] being annoying [1 ] cognitive deficit [2] nervous or planning something [1J cannot grasp situation[3] not fully informed [1 ] poss. HOH [1J n=14 Man./Sup. drug abuse [1 ] mentally slow [1 ] confused [3] not interested [1] resistant to authority [4] cannot grasp situation [1 ] poss. HOH [3] n=4 Other mental illness [1] poss. HOH [1] overwhelmed by environment [1 ] don't know [1 ] L-6-(26) Refuses to participate in social events. n=46 n=7 Health anti-social [3] loner [3] shy[1] n=20 Corr. 0 .1 &2 anti-social [6] loner [2] shy [3] poor social skills [2] low self-esteem [2] mental illness [2] poss. HOH [2] don't know [11 n=14 Man./Sup. anti-social [7] loner [2] dislikes crowds [1] poor social skills [4] n=5 Other peer pressure [2] disinterest [1] mental illness [1] don't know [1 ] L-6-(27) Complains of noises in his head. n=51 n=7 Health psychological prob. [2] psychosis [2] medical prob. [2] don't know [1 ] n=26 Corr. 0 .1 &2 psychological prob. [10] psychosis [2] medical prob. [2] inner ear medical prob. [4] whiner[1] tinnitus [1] nuts[1] schizophrenic [2] drug user [1] don't know [2] n=14 Man./Sup. psychological prob. [5] psychosis [3] medical prob. [2] inner ear medical prob. [1 ] schizophrenic [1 ] hearing prob. [1] don't know [1 ] n=4 Other psychological prob. [2] medical prob. [1] inner ear med. prob. [1] L-6-(28) Always speaks in a loud voice. n=45 n=7 Health aggressive [3] domineering [1 ] controlling [1] HOH [2] n=20 Corr. 0.1&2 aggressive [3] domineering [3] boisterous [3] belligerent [2] manipulative [1 ] HOH [6] don't know [2] n=14 Man./Sup. aggressive [4] ESL[1] HOH [6] wants you to respond in a loud voice [1] don't know [2] n=4 Other agressive [2] poss. HOH[1] don't know [1 ] 282 L-6-(29) Always speaks in a soft, low voice. n=42 n=7 Health low self-esteem [4] shy[1] timid [1] don1know[1] n=17 Corr. 0.1&2 low self-esteem [5] shy [5] timid [1] don't know [1] loner [1] withdrawn [1] insecure [2] HOH[1] n=14 Man./Sup. low self-esteem [4] shy [3] passive [1] insecure [2] withdrawn [3] H0H[1] n=4 Other passive [2] don't know [1 ] poss. HOH [1] SUPPLEMENTARY TABLE L-7 Table L-7 Interview with inmate comparison group who passed hearing test. n=39 L-7a. HEARING INMATE AWARENESS OF HEARING PROBLEM IN OTHER INMATES N=39 yes no Total n 5 34 39 % 13 87 100% L-7-b. HEARING INMATE ABILITY TO CORRECTLY IDENTIFY BEHAVIOUR ASSOCIATED WITH A HEARING PROBLEM N=39 P1 "One man wears a hearing aid. If he can't hear he asks people to come around to the side of the aid." P2 "One deaf man - can talk but can't hear; uses paper and pencil." P3 "Couple of guys in the groups seem to not hear. They bluff." P4 "Man who says 'eh?' and 'what? a lot." P5 "Guy who turns up the Tv and radio too loud." Total= 5 13% L-7-c. POSITIVE OR NEUTRAL + + Total 1 3% NEGATIVE - Total 4 10% PERSONAL RESPONSE OF HEARING INMATE TO HI BEHAVIOUR N=39 P1 "I go around and talk to his hearing aid side when he asks." P2 "I stay away from the deaf man." P3 "I get a little impatient with the few I'm aware of." P4 "It aggravates me." P5 " I get irritated by the turned up loud Tv and radio." P6- [341 no reply Total replies 5 = 13% 283 L7-d. POSITIVE OR NEUTRAL + + Total 2 5% NEGATIVE - Total 3 8% HEARING INMATE PERCEPTION OF EFFECT OF HI ON RELATIONSHIP WITH HI INMATES N=39 P1 "Doesn't really bother me. I just go around to his good side." P2 "I don't mix with the deaf man." P3 " I say, 'ah forget it!'- don't like repeating. P4 "Get irritated with them because of the extra noise of loud Tv and radio." P5 "No effect." P6-34 No reply Total replies 5 13% L-7-e. YES yes Total 1 3% NO OR NEUTRAL no no [3] Total 4 10% HEARING INMATE PERCEPTION OF DIFFERENCE IN RELATIONSHIP WITH HI INMATES, COMPARED TO WITH OTHER INMATES N=39 P1 "No - only this one guy and I just go around to his hearing aid side when he asks me to. P2 "Yes, the deaf man can't communicate. Goes around with that paper and pencil but stays by himself." P3,4, 5 "No, not much socializing going on anyway." P6-34 No reply Total replies 5 13% L-7-f. CORRECT 12 2 1 2 1 1 1 1 1 1 6 1 1 1 1 1 Total 34 87% INCORRECT OR NONE no 4 no reply 1 Total 5 13% HEARING INMATES ABILITY TO CORRECTLY SUGGEST A HEARING-PROBLEM-RELATED BEHAVIOUR "They ask you to repeat a lot" "Leaning forward to hear" "Cupping ear" "Maybe signing" "Said 'eh?' a lot" "They say 'what?" a lot" "They get things wrong" "Not hearing in groups - bluffing" "Watches lips" "If doesn't understand" "Keep turning up the T V "Stare to hear" If you need to shout at the person to be understood" "If they ask you to speak up" "If they ignore things said" "Maybe don't speak" "Don't know" No reply Total = 38 100?% 284 L-7-g. HAVE CONCERNS ABOUT HEARING IMPAIRMENT. 15 9 2 Total 26 67% NEGATIVE OR NEUTRAL 13 Total 13 33% HEARING INMATE VIEWS ABOUT HEARING IMPAIRMENT N = 39 They should test hearing on admission, as part of the health checkup Hearing conservation conscious now Have stopped using headsets for music, to protect hearing Never thought about it Total replies = 39 100% L-7-h. HAVE CONCERNS about H.I. 25 1 Total 26 67% NEGATIVE OR NEUTRAL 13 Total 13 33% HEARING INMATE PERCEPTION IF PRISONS DISCRIMINATE AGAINST INMATES WITH HEARING IMPAIRMENT Not consciously, but through unawareness The hearing problem is not visible so they don't understand what's happening Never thought about it Total replies = 39 100% L-7i. Additional comments by hearing inmate subjects n=39 "I knew I didn't have a hearing problem but wanted to help the study along. Think it needs to be done." "Wanted my hearing tested because I'm hypersensitive to noise - feel irritable, tense. Didn't know what was wrong with me. Don't want anything like ear plugs in my ears, though. Very noisy here." " I felt oppressed by the noise in [Matsqui] - had tension headaches, and neck tension. I don't notice any such tension symptoms here at [minimum security]." "I'm very bothered by the prison noise - television, radio, music, bare surfaces that sound bounces of." "I'm more careful about my hearing now. Will wear ear protection in shop after this." 285 SUPLEMENTARY TABLE L-8 Table L-8. Comparison between custodial and inmate perception of behavioural characteristics [Actual words of respondents used, for all replies]. L- 8(1) Won't answer unless you come right up to him, to speak to him to his face. Custodian label negative attitude toward authority attention-seeker uncooperative playing a role reluctant confrontational hostile intimidating selective hearing testing authority angry don't want others to overhear resents authority resistive controlling hard of hearing preoccupied shy stubborn non-assertive distracted don't know HOH inmate description -I can't hear others talking behind me. (10) -At work I'm looking down and can't tell what my boss is saying - don't know when he's talking to me (10) -I can only hear one-to-one, up close - the rest, I just don't understand it at all. (20) L-87-(2) Often asks for things to be repeated. [Says "uh" and "What" a lot]. Custodian label indifferent purposely plays ignorant [happens often] being obtuse testing one's patience short attention span learning disability may not comprehend slow learner poor knowledge of English language needs simpler direction possibly HOH non-assertive distracted don't know HOH inmate description -I need to ask for repeats a lot; others get irritated. I feel isolated (9) -Guards call me stupid, uncooperative (6) -I felt irritation from the parole board at my repeated "what7s" (1) -Guards are impatient with inmates. They expect to be heard, don't want to repeat (2) -Often I don't hear and so ask for repeats. (11) -I wear two hearing aids so they know I have a HL (1) -Group therapies in this institution are being very helpful -1 never understood the relationship between HL and my personal anger and frustration. I am gaining insight. Others in the group and the therapist are not really aware of feelings related to HL and we're just beginning to talk about this. (1) 286 L-87-(3) Often gives a reply that is incorrect or inappropriate. Custodian label arrogant sarcastic selective hearing playing ignorant game-player uncooperative purposely irritating testing limits learning disability does not understand lack of cognition thinking deficit mentally deficient doesn't know the answer slow confused possibly HOH HOH inmate description -Others beat up on me cause 1 can't hear and answer wrong.(1) -They call me stupid, slow, dummy, uncooperative. (6) L-87-(4) Has a lot of misunderstandings and arguments with others. Custodian label attitude problem anger combative power struggle may be the way to show whose opinion counts aggressive hostile distrust potential behaviour prob. short fuse controlling argumentative antisocial poor adjustment socially inadequate inability to comprehend different cultural background fear HOH rigid thinking substance abuse unknown HOH inmate description -I have misunderstandings [with other inmates] due to when I don't hear (3) -1 can't hear well at work and others get irritated. (9) 287 L-8-(5) Is always watching, staring [watches closely the facial expression of the speaker. Custodian label defiant testing limits intimidation tactic angry hostile negative attitude aggressive rude slow to understand ESL problem possibly HOH maybe medical prob. suspicious psychotic preoccupied looking for hidden meaning unknown HOH inmate description -With some staff, 1 can't hear them, get behaviour misinterpreted. (11) -I work in a very noisy place [kitchen] hard to hear requests, example someone asks for toast, I can't understand - make mistakes - others get annoyed with me. Happens all the time.(2) -I can only hear one-to-one, up close.(11) -I can't hear in the group - its a strain, always tiring, always trying to see who's talking. (12) L-8-(6) Leans toward you when you talk. Gets close Custodian label threatening intimidating negative attitude aggressive confrontative angry person possible cultural trait interested trying to understand possibly does not hear insecure hiding something not noticed HOH inmate description -I can't hear in group therapies but I don't tell. I need a lot of repeats... strain to hear....get tired....feel they make the wrong estimates [wrong judgements] about me. (22) 288 L-8-(7) Often looks startled or puzzled. Custodian label negative attitude angry "what - who me?' mentally slow cognitive deficit does not like the answer preoccupied anxious jumpy, tense scared nervous maybe surprised substance abuse or mental/ physical prob. poss. HOH don't know not "with it" [medication] confused does not understand HOH inmate description -Can't hear (understand) the public address system (15) -Can't hear orders given - misunderstand what is going on unless other inmates tell me (10) L-8-(8) Frowns a lot during conversation. Custodian label angry does not want to hear the truth thinks he is an institutional lawyer negative attitude not happy to be talked to difficulty understanding slow learner possibly HOH possibly disappointment does not like the information given don't know not interested in topic disagrees unhappy depressed HOH inmate description -I have problems hearing in the courses offered here. I can't take part in discussion; don't know what I have missed. I feel misjudged (9) -staff don't bother me about my hearing loss - they don't know. (13) 289 L-8-(9) Nods head a lot during the conversation as though agreeing but later it shows up that he never understood what was said Custodian label conveniently misunderstanding no intention of complying not paying attention mentally retarded did not get the message lacking education language or comprehension prob. slow insecure preoccupied donl know substance abuse on medications confused poss. HOH HOH inmate description -1 fear rejection if 1 admit to a hearing loss (1) -I feel isolated (24) -Sometimes I hear wrong but don't know that I have misheard (14) L-8-(10) Hardly ever understands a joke. [Never seems to get the punchline]. Custodian label hard core con unsophisticated thinking deficit language barrier mentally deficient slow no common sense dense so sense of humour confused substance abuse prob. poss. HOH don't know HOH inmate description -I can't get a joke; can't hear the punchline. People don't say it so I can hear it. (5) 290 L-8-(11) Acts like he hears only when he wants to. Custodian label uncooperative pretending smart ass disinterest bad attitude selective hearing [quite common in prisoners] does not care about CSC staff negative attitude - testing angry way to deal with information he does not want to think about language prob. preoccupied possibly HOH stubborn who doesn't? substance abuse prob. single-minded HOH inmate description -I was blamed in class and in group for not paying attention and I accepted the blame. Now I realize it was because I could not hear; not my fault (2). -There needs to be more education of staff about the hard of hearing (42) L.-8-Q2) Responds to some officials, but there are some officials he never replies to. Custodian label uncooperative prejudice/discrimination gets his own way with certain people resistive/hostile testing those he thinks vulnerable wants to hear it from the organ grinder, not the monkey selective hostility attitude prob.- negative may have a prob. with certain staff respects authority he agrees with doesn't hear lower voice levels hears some voices better than others possibly HOH HOH inmate description -Some I can't hear -get my behaviour misjudged (11) -I walked away from a guard -1 did not hear him; he did not believe this and I was punished (3) L-8-(13) Complains about the way people talk -accuses others of mumbling. Custodian label whiner does not accept responsibility for own problems language barrier ignorant of others paranoid some people are never happy not paying attention difficulty hearing don't know HOH inmate description -I couldn't hear the parole board - missed a lot (8) -My personal relationships are affected - with my girl friend - she has a high pitched voice; seems like shes mumbling (3) -Some people I just can't understand - they talk fast, mumble (18) -I can't hear my small daughter when she visits - she mumbles and hides her face (1) -I have trouble forming relationships - the female voice is high-pitched- I can't hear it; its all a mumble (10) 291 L-8-(14) Complains that others are talking about him behind his back. Custodian label prison fear of others paranoid psychological prob. possibly HOH self-centered insecure low self-esteem dont know HOH inmate description -If people are talking behind me, I can't tell what they're saying (23) -Sometimes I feel like I'm invisible; people talk to one another and ignore me. I just sit back and act like I don't want to talk anyway (1) -I couldn't hear in court -1 asked the lawyer - he told me to keep quiet (2) L-8-(15) Doesn't follow directions given to the group. Custodian label uncooperative trouble maker challenging behaviour anger manipulative defiant loner needs individual instruction doesn't understand rigid thinker stubborn not listening possibly HOH don't know HOH inmate description -I can't hear in group therapies but I don't tell. I strain to hear, get tired, keep quiet. I feel misjudged. (22) -I have a problem hearing in the courses offered here. I can't take part in discussions; don't know what I have missed. I feel wrong judgements are made about me. (9) L-8-(16) Doesn't want to use the telephone. Custodian label no social skills possibly HOH speech prob. no one to call don't know mental illness does not communicate well reclusive suspicious stubborn HOH inmate description -I have trouble hearing on the phone (18) -I can't use the phone at all (4) 292 L-8-(17) Doesn't get in line with the others when the bell rings or siren goes Custodian label uncooperative dislikes authority challenging rules rebellious defiance testing the officer anti-social loner confused did not hear it possibly HOH don't know HOH inmate description -I can't hear what's said on the public address system or such like - others have to tell me.(10) -I am bothered by excessive noise levels in this institution (10) -There's too much noise in this institution for a hearing aid wearer. For example in the living quarters - loud radios, TVs, chairs dragging (3) -There should be control of noise levels in this institution (5) L-8-(18) Turns television and radio up louder than the others want it. Custodian label self-serving [inconsiderate] wishes to be annoying ignores rights of others acting out thinks he owns the joint controlling possibly HOH wishes to block out other noise don't know HOH inmate description -They get cranky when I turn my TV up loud -I can't hear my TV because of all the noise in living areas from other TVs (5) -I can't hear TV at all -I turn my TV up loud enough for me to hear and others object (12) L-8-(19) Does not participate actively in group conversations. This applies in classroom situations also. Custodian label passivity thinks he is smarter hostile loner does not work well in groups poor social skills peer pecking order low intelligence antisocial does not know the subject shy low self-esteem fear withdrawn non-assertive reclusive possibly HOH don't know HOH inmate description -They promote programs and it is very important to hear in them. I can't. I am very concerned about this. (1) -There is a danger of being misinterpreted and misjudged throughout the system - a problem with the invisibility of hearing loss (1) -I can't hear in group therapies but I don't tell. I strain to hear, get tired, keep quiet. I feel misjudged. (22) -I have a problem hearing in the courses offered here. I can't take part in discussions; don't know what I have missed. I feel wrong judgements are made about me. (9) 293 L-8-(20) Jerks his head around a lot to locate who is speaking. Custodian label hostile possibly HOH HOH in one ear don't know suspicious mental illness medication anxious tense, twitchy caught by surprise not paying attention impatient uncomfortable HOH inmate description -People don't know 1 have trouble hearing. 1 feel they misjudge me.(21) -I have a one-sided hearing loss and its hard to locate where sound is coming from. I have to keep looking around (4) -I try to watch the speaker (7) -I have a one-sided hearing loss and no hearing aid; its a problem knowing where sound is coming from.(3) L-8-(21) Gets impatient with interruptions [focuses on one speaker and dfustrated by interruptions bvy another speaker]. Custodian label rude low tolerance fuse short attention span limited concentration low threshold of boredom selfish inability to focus due to peripheral noise irritated/nervous/tense anxious self-centered difficulty focussing his attention short tempered [drug abuse] cant hear don't know HOH inmate description -Couple of people talking at the same time, I don't know what's going on (22) -I can't hear when more than one person is talking (22) L-8-(22) Often seems confused about the topic, needs a lot of individual explanations to understand. Custodian label lowlQ poor education language prob. learning prob. slow lack of concentration cognitive deficit doesn't understand depressed confused didn't hear all of it possibly HOH don't know HOH inmate description -Others call me stupid, slow, dummy (10) -Couple of people talking at the same time, I don't know what's going on (22) -I can't hear when more than one person is talking (22) -I can't hear in group therapies but I don't tell. I strain to hear, get tired, keep quiet. I feel misjudged. (22) -I have a problem hearing in the courses offered here. I can't take part in discussions; don't know what I have missed. I feel wrong judgements are made about me. (9) 294 L-8-(23) Doesn't behave appropriately in a group conversation e.g. picks up a book or magazine to read, or gets up and walks out. Custodian label rude repressing hostility disinterest anti-social social deficit poor attention span depressed bored selfish needs to be centre of attention can't hear HOH don't know HOH inmate description -1 can only talk one-to-one with people. (22) -1 sometimes feel invisible in a group. Can't follow what's going on. (8) -Couple of people talking at the same time, 1 don't know what's going on (22) -1 can't hear when more than one person is talking (22) -1 can't hear in group therapies but 1 don't tell. 1 strain to hear, get tired, keep quiet. 1 feel misjudged. (22) -1 have a problem hearing in the courses offered here. 1 can't take part in discussions; don't know what 1 have missed. 1 feel wrong judgements are made about me. (9) L-8-(24) Tends to separate himself from the group - will talk to one person only. Custodian label disinterested loner lacks interaction skills socially inadequate anti-social doesn't function well in group shy insecure mistrust suspicious isolative HOH don't know HOH inmate description -1 talk only to the few 1 can hear, one-to-one (9) -1 feel isolated by not hearing (17) -I feel misjudged by others (19) -It's sad, but what can one do? (2) L-8-(25) Doesn't follow directions. Seems mixedup about what he was told to do. Custodian label uncooperative resistant to authority pretending not interested non-compliant stubborn being annoying mentally slow cognitive deficit cannot grasp situation confused overwhelmed by environment possibly HOH not fully informed headstrong drug abuse nervous or planning something mental illness doniknow HOH inmate description -It is hard, others don't understand about my not hearing (14) -I can't hear directions given to me at work if 1 have my head down working or boss comes up to me from behind (10) -there needs to be more education of staff about the HOH (42) -There needs to be more education of police and judicial system about the HOH 6) -I sometimes feel invisible in a group. Can't follow what's going on. (8) -Couple of people talking at the same time, I don't know what's going on (22) -I can't hear when more than one person is talking (22) -I can't hear in group therapies but I don't tell. I strain to hear, get tired, keep quiet. I feel misjudged. (22) -I have a problem hearing in the courses offered here. I can't take part in discussions; don't know what I have missed. I feel wrong judgements are made about me. (9) 295 L-8-(26) Refuses to participate in social events. Custodian label peer pressure disinterest anti-social poor social skills loner shy mental illness dislikes crowds low self-esteem HOH don't know HOH inmate description -My hearing loss bothers me in sports events - a one-sided loss affects my participation. (1) -I talk only to the few I can hear, one-to-one. (22) -I can't hear in a group. (22) -there isn't much social interaction here anyway. (13) it L-8-(27) Complains of noises in his head. Custodian label whiner don't know inner medical prob. psychological psychosis tinnitus nuts schizophrenic medical prob. drug user hearing prob. HOH inmate description -I have a lot of ringing noises in my ears - in my head (22) -I have ringing noises in my ears-in my head - seems to be from taking cocaine and heroin (3) L-8-(28) Always speaks in a loud voice. Custodian label aggressive domineering boisterous manipulative belligerent controlling ESL HOH don't know wants you to respond in a loud voice HOH inmate description -I talk very loudly and others think that I'm aggressive (2) -I talk very loudly but I think it has more to do with my native language not English than with my hearing loss. But others think I am very aggressive (1) 296 L-8-(29) Always speaks in a soft, low voice. Custodian label passive toner don't know HOH low self-esteem shy withdrawn timid insecure HOH inmate description -1 missed hearing a lot before the parole board, sat back and just gave up on it. 1 felt 1 irritated them (1) [has a soft voice] -It is sad, but what can one do? (2) [both had a soft voice] -I did not participate in the life skills class and basic education class because I failed in them before and they sent me back here to maximum security. I didn't know why I failed them - thought I was too dumb; didn't know I had a hearing loss. I don't know what to do now, to get out of here (1) [low, soft voice, tearful visage]. 297

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