A Correlational Investigation

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A CORRELATIONAL INVESTIGATION OF THE RELATIONSHIP BETWEEN
PSYCHOLOGICAL DISTRESS, LIFE SATISFACTION, AND HEALTH CARE
UTILIZATION AMONG ELDERLY MALE INMATES
by
Kristine Louise Burling
A thesis submitted in partial fulfillment of the

requirements for the Doctor of Philosophy degree in
Education (Rehabilitation Psychology)
in the Graduate College of The University of Iowa
December 1999
Thesis supervisors: Associate Professor Vilia Tarvydas

Assistant Professor Karen Cocco
UMI Number 9957253
UMI*
UMI Microform9957253
Copyright 2000 by Bell & Howell Information and Learning Company.
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Iowa City, Iowa
CERTIFICATE OF APPROVAL
PH.D. THESIS
This is to certify that the Ph.D. thesis of
Kristine Louise Burling
has been approved by the Examining Committee for

the thesis requirement for the Doctor of Philosophy
degree in Education (Rehabilitation Psychology) at the
December 1999 graduation.
Thesis committee:
Thesis supervisors
Thesis supervisor
Member
ember
To my Sweetheart, DA
ii
ACKNOWLEDGMENTS
I would like to express my gratitude to my friends and family who loved
me and respected my process; my colleagues and mentors who believed in me
and continued to nudge me forward; and to the study participants who risked
telling me their stories.
hi
TABLE OF CONTENTS
Page
LIST OF TABLES........................................................ vii
CHAPTER
I. INTRODUCTION................................................ 1
Statement of the Problem................................................................................. 2

Psychological Distress................................................................................. 3
Life Satisfaction.............................................................................................5
Inmate Adaptation.........................................................................................6
Health Care Utilization................................................................................. 8
Conceptual Framework.................................................................................... 8
Research Questions........................................................................................10
Limitations........................................................................................................10
Summary..........................................................................................................13
II. LITERATURE REVIEW ................................................................................. 14
Elderly Male Inmates.......................................................................................15

Growing Numbers .............................................................................. 17
Psychological Distress and Elders.................................................................18
Psychological Distress and Elderly Inmates..................................................24
Studies Supporting the Presence of Psychological Distress...................24
Studies Reporting an Absence of Psychological Distress....................... 31
Life Satisfaction and Elders................................... 33
Life Satisfaction and Inmates.........................................................................36
Life Satisfaction and Elderly Inmates............................................................ 38
Health Care Utilization and Elders................................................................. 39
Health Care Utilization and Elderly Inmates..................................................41
Conceptual Framework.................................................................................. 42
Life Space ...................................................................................... 42
The Nature of Reality................................................................................. 42
Insider and Outside Perspectives............................................................. 43
Differentiation......................................................................... 44
Regression.................................................................................................. 45
Unique Contributions of the Present Study...................................................48
iv
III. METHODOLOGY.......................................................................................... 49
Introduction........................................................................................................49
Ethical Considerations..................................................................................... 51
Standard Considerations............................................................................. 51
Special Considerations................................................................. 53
Institutional Review...........................................................................................55
Participants........................................................................................................56
Materials.............................................................................................. 58
Informational Questionnaire.............................................................. 58
Mini-Mental Status Exam................. 58
Geriatric Depression Scale..........................................................................59
Brief Symptom Inventory.............................................................................61
Life Satisfaction Scale................................................................................. 63
Health Care Utilization Index...................................................................... 65
Procedures........................................................................................................67
Statistical Analysis........................................................................................... 69
IV. RESULTS........................................................................................................71
Summary of Analytic Procedures................................................................... 71

Preliminary Analyses .............................................................................72
Selection Summary..................................................................................... 73
Research Questions and Analysis.................................................................. 74
Research Question One.............................................................................. 74
Research Question Two..............................................................................77
Research Question Three...........................................................................78
Research Question Four.............................................................................79
Research Question Five..............................................................................79
Qualitative Interview Responses.................................................................... 80
Self-Rated Health........................................................................................ 80
Infirmary U se................................................................................................81
Prison Housing.............................................................................................82
Involvement in Activities..............................................................................83
Range of Support........................................................................................ 86
Concerns and Problems..............................................................................88
Future Plans................................................................................................. 89
V. SUMMARY.....................................................................................................105
Purpose and Research Questions................................................................ 105

Literature Review............................................................................................107
Methodology....................................................................................................108
Results.............................................................................................................109
Discussion and Implications.......................................................................... 111
Future Research Considerations...................................................................115
APPENDIX A. INFORMATIONAL QUESTIONNAIRE........................................117
APPENDIX B. MINI-MENTAL STATUS EXAM............... 122
APPENDIX C. GERIATRIC DEPRESSION SCALE............................................ 124
APPENDIX D. BRIEF SYMPTOM INVENTORY SCALE................................... 127
APPENDIX E. LIFE SATISFACTION SCALE...................................................... 130
APPENDIX F. INFORMATION SUMMARY......................................................... 133
APPENDIX G. CONSENT FORM......................................................................... 136
APPENDIX H. SUMMARY DESCRIPTION OF VARIABLES.............................139
REFERENCES............................................. 142
vi
LIST OF TABLES
Table Page
1. Mini-Mental Status Exam: Summary of Results......................... 91
2. Geriatric Depression Scale: Summary of Results.......................................... 91
3. Brief Symptom Inventory Scale: Summary of Results................................... 92
4. Life Satisfaction Scale: Summary of Results.................................................. 93
5. Cost of Health Care Provided to Study Participants...................................... 94
6. In-House Health Encounters: 1/1/98 to 6/30/99..................... 95
7. In-House Prescription Medications: /1/98 to 6/30/99................. 95
8. Demographic Characteristics of Study Participants....................................... 96
9. Arrest and Incarceration History...................................................................... 99
10. Multiple Regression Results of Life Satisfaction Measures as Criterion

Variables and Psychological Distress as Predictor Variables......................100
11. Correlation Analysis of Health Care Utilization and Psychological

Distress: 1/1/98 to 6/30/99..............................................................................101
12. Correlation Analysis of Health Care Utilization and Life Satisfaction:

1/1/98 to 6/30/99..............................................................................................101
13. Multiple Regression Results using Health Utilization as Criterion Variable

and Life Satisfaction and Psychological Distress as Predictor Variables ..102
14. Self-Rating of Physical Health Condition ......................................................103
15. Infirmary Use.................................................................................................... 104
16. Summary Description of Variables................................................................. 140
1
CHAPTER I
INTRODUCTION
Geriatric inmates represent approximately 3 percent of the 1.5 million
Americans currently incarcerated in the United States (United States Department
of Justice, 1999). As the age structure of the United States shifts with the
graying of the Baby Boomers, the elderly inmate population is expected to grow
disproportionately to other age cohorts. Chronic illness and deteriorating health
in this population result in an enormous cost of medical care. The annual cost
estimate for maintaining a geriatric state inmate is $69,000, as compared to
$22,000 for a younger inmate (Donziger, 1996).
In an effort to impact rising health care costs among their community
dwelling peers, research has focused on unraveling the correlates of health care
utilization in the elderly. Psychological distress is one of the correlates that has
been investigated. Findings have been inconclusive and/or contradictory. Some
researchers have suggested that no relationship exists between psychological
distress and use of health care resources among the elderly (Berkanovic &
Hurwicz, 1989; Coulton & Frost, 1982; Prendergast, Creel & Chavez, 1983;
Wolinsky et al., 1983). Other researchers have indicated that there is a
relationship between psychological distress and health care utilization among the
elder population (Arling, 1985; Levkoff, Cleary, & Wetle, 1987). The discrepancy
in findings may be accounted for by methodological differences between studies,
i.e., differences in study populations, variability in definition and measurement of
psychological distress, and perceptual differences in health status and the
decision to seek care. The relationship between psychological distress and
health care utilization among community elders, therefore, remains unclear. No
studies have examined the relationship between psychological distress and
health care utilization among incarcerated elders.
Life satisfaction, or psychological well-being, is a second correlate to
health care utilization that has been studied among the elderly. Life satisfaction
has been ambiguously defined in the literature and has been alternatively
referred to as life satisfaction, morale, contentment, happiness, and quality of
life. In the current study, it is defined as the inmate’s subjective assessment, at
the time of interview, of the degree to which he feels psychologically satisfied
with various aspects of his life. No study has investigated the relationship of life
satisfaction and health care utilization among incarcerated elders.
Statement of the Problem
This study examines the relationships between psychological distress, life
satisfaction, and health care utilization in a population of incarcerated elderly
males. Previously documented findings, escalating health care costs, and the
increasing numbers of elderly inmates, are compelling reasons to explore and
understand the underlying dynamics related to health care utilization in this
sample of elders. Specifically, Clair, Karp, and Yoels (1993) estimated that the
cost of full-time institutionalized long-term care for an individual can costas
much as $38,000 per year. Generally these costs become the financial burden
of the patient, their family, their insurance program, and Medicare. In the case of
state-incarcerated elderly inmates, the problem belongs to the state and its
taxpayers. The purposes of this study are twofold. First, demographic
description of an elderly male inmate population currently housed in a state
prison facility in the western United States will be provided. Second, the
relationships between psychological distress, life satisfaction, and health care
utilization among these men will be examined.
This study entails examination of several broad, and, frequently poorly
defined constructs. In the next portion of this chapter, conceptual illustrations of
these constructs will be provided. Accordingly, definitions of the following
constructs are included: psychological distress, life satisfaction, inmate
adaptation, health care utilization, elderly, and field theory.
Psychological Distress
A large body of literature has confirmed that persons of varying ages who
experience symptoms of psychological distress are also high users of health
care resources (Gortmaker & Gore, 1982; Johnson, Weissman, & Klerman,
1991; Jones & Vischi, 1979; Manning & Wells, 1992; Mechanic, Cleary, &
Greenley, 1982; Mumford, Schlesinger, Glass, Patrick, & Cuerdon, 1984; Simon,
Ormel, VonKorff, & Barlow, 1995; Tessler, Mechanic, & Dimond, 1976). While
the dynamics of this comorbidity are complex and not completely understood,
some of the following consequences are associated with this comorbidity: (a)
Psychological distress may exacerbate pre-existing physical symptoms, (b)
psychological distress may prompt a physical health problem, (c) psychological
distress may complicate recovery from a physical illness, or (d) a health care
provider may misdiagnose and mistreat psychological distress concomitant to
physical health problems.
As previously mentioned, the relationship between psychological distress
and health care utilization among elders is unclear. This may be due, in part, to
under-recognition of mental health concerns among the elderly. Community
dwelling elders have been identified as a population that experiences a high rate
of under-recognized and untreated psychological distress (Blazer, 1990;
Friedhoff, 1994; Kalayam & Shamoian, 1993; Katon & Sullivan, 1990). There
are two likely consequences of untreated psychological distress in the elderly: (a)
decreased life satisfaction, prolonged personal suffering, loss of happiness, and
possible suicide (Blazer, Bachar, & Manton, 1986; Conwell, 1994; Koenig &
Blazer, 1992); and (b) increased use of health care services (Allison et al., 1995;
Arling, 1985; Broadhead, Blazer, George, &Tse, 1990; Friedhoff, 1994; Hibbard
& Pope, 1986; Levkoff et al., 1987; Schneider, 1985). Specifically, psychological
distress has been associated with more frequent office visits (Waxman, Camer,
& Blum, 1983), extended recovery time (Mossey, Knott, & Craik, 1990), more
prescription medications (Rigdon et al., 1997), more hospital days (Allison et al.,
1995; Levitan & Komfeld, 1981), and increased mortality (Gurland, 1992;
Koenig, Shelp, Goli, Cohen, & Blazer, 1989; Murphy, 1983). Additionally, eiders
are more likely than any other age group to suffer from multiple physical health
problems (Kramer, 1983), thereby necessitating greater use of health care
services. In this study, psychological distress will be used in reference to the
level of an individual’s negative psychological status. It is an indication of
discomfort, pain, suffering, and illness. It connotes psychopathology. It
suggests changes in physical, psychological, or social functioning that are not
part of the person’s normal way of being. In the case of elders, psychological
distress is not a part of the normal aging process.
Life Satisfaction
Many life satisfaction studies have assessed levels or states of health,
functioning, or well-being rather than including information on the values or
preferences of the respondents (Baltes, 1994). Objective measures of life
satisfaction may include longevity, functional independence, and mental health.
A different approach was encouraged by King and Stewart (1994). They
suggested asking subjects to evaluate or rate their satisfaction within a particular
domain (i.e., meaning of life, goals, and mood). In the current study, for
instance, they would recommend asking the inmate directly what his satisfaction
level was with the social contacts he had, rather than asking how many and what
kind of social contacts. This approach represents an evaluative response
dimension which more accurately describes the individual’s life satisfaction. In
the case of an inmate, he may be satisfied with a relatively low level of
functioning because he places a low value on a particular domain (e.g.,
finances). In contrast he may tolerate a relatively high distress symptom count
because he has adapted to the problem. He may have numerous symptoms of
distress, but consider his life much improved over his previous residence under a
viaduct. He may have lost his autonomy, self-determination, and freedom of
action, but he does have “three hots and a cot.”
Life satisfaction is a subjective assessment. It is the inmate's
assessment, at the time of interview, of the degree to which he feels
psychologically satisfied with various aspects of his life. It is synonymous with
his evaluation of the quality of his life or his well-being. Specifically, in this study
his life satisfaction is measured across eight domains of his life. The domains
include mood, finances, health, goals, meaning, self-concept, social contacts,
and daily activities. The inmate obtains a separate score for each domain, as
well as a final total score on the Life Satisfaction Scale.
Inmate Adaptation
An additional construct, highly relevant to understanding life satisfaction,
is inmate adjustment. Adaptation or adjustment has been linked to life
satisfaction and is defined as the ability to maintain a sense of well-being in the
face of adversity (Pearlin, Lieberman, Menaghan, & Mullan, 1981). The
consequences of prison confinement have been researched for decades. Initial
studies, in the 1950s, suggested that inmates would eventually deteriorate,
physically and psychologically, as a consequence of confinement- Two
contemporary reviews of the research on inmate adjustment (Bonta & Gendreau,
1990; Bukstel & Kilmann, 1980) dispute this deterioration model. Little evidence
has been found to support it. Instead, researchers have repeatedly found that
inmates have demonstrated no sign of physiological or mental decline (Ostfeld,
Kasl, D’Atri, & Fitzgerald, 1987; Zamble & Porporino, 1988).
Subsequent to the deterioration model, several other frameworks have
evolved to explain inmate adjustment. Paulus and Dzindolet (1993) proposed a
two-component model of prisoner adaptation to confinement. They suggested
that inmates became more familiar with the prison and prison routine and
thereby experienced decreased stress and illness symptoms. However, these
same prisoners became more negative in their evaluation of prison conditions,
because of conflict with staff and other inmates, disillusionment with
programming, and the deprivation experienced during confinement.
Wright (1991) proposed a third approach for understanding inmate
adjustment. He proposed an interactionist approach to understanding the
consequences of prison life. Based on this perspective, he encouraged
assessment of the individual, institutional conditions, and their interaction in
order to understand inmate functioning.
Overall, there are several existing models to understand inmate
adaptation. However, none of the existing empirical research has concerned
itself with the situation of the elderly.
Health Care Utilization
Knowledge about health care utilization in the elderly inmate population is
nil. This is partially due to the lack of significant numbers of elderly inmates to
date. However, reports that the health of inmates on admission to prison has
declined (Marquart, Merianos, Hebert, & Carroll, 1997), combined with the sheer
numbers of inmates soon to reach their later years, make investigation of the
utilization of health care services critical.
In this study, health care utilization refers to the use of services and
materials for the purpose of health care diagnosis and treatment. These
services and materials include medical appointments/exams, prescription
medications, lab tests, procedures, and hospitalization outside the prison facility.
Elderly in this study refers to those individuals who are 55 years of age
and older. This chronological age was chosen because it allows fora
reasonable sample size for the study and is often the youngest age used to
delineate an elderly sample in studies of senescence. Some research studies of
the elderly have included persons as young as age 45; however, most place the
age range from at least 50 and older. The Federal Bureau of Investigation uses
the age of 50 as indicating elderly years in the reporting of crime statistics.
Conceptual Framework
Kurt Lewin’s field theory (1951) offers a useful framework to understand
inmates’ experiences from their perspectives. Field theory suggests that the
person, his/her behavior, and his/her environment (or field) are reciprocally
related. That is, the environment is experienced, organized, and interpreted by
the person in a subjective manner. Behavior is goal-directed, but it is the
individual’s interpretation of the environment that must be considered in order to
understand motivation and action. The individual’s subjective interpretation
creates his/her reality. The person responds accordingly. Behavior, therefore, is
a function of the person and the environment.
Lewin’s conceptual approach to the subjective nature of reality is
foundational in this study. Applying field theory to the elderly inmate population,
it is the meaning of the inmate’s environment at the time of his interview, and the
dynamic psychological forces that he experiences in his environment, that
determine his reality and his response to it. From a Lewinian perspective,
relationships between psychological distress, life satisfaction, and use of medical
resources cannot be understood without consideration of the inmate’s internal
psychological world and his interpretation of the environment.
This project is specifically concerned with the participants’ interpretations
and the meanings they assign to their environment, their personal realities, and
its influence on their behavioral choices. Through interview and the use of
assessment tools, the inmates are given the opportunity to identify their priorities,
their concerns, their plans, and the significance of same. They determine what,
for them, is to be considered success or failure, satisfaction or distress.
Research Questions
This study will address the following questions:
1. What are the demographic characteristics (age, ethnicity, marital
status, educational history, work history, religion, crime history, type of
current crime and current sentence), the levels of psychological distress,
and the levels of life satisfaction among elderly male inmates?
2. Is there a relationship between psychological distress and life
satisfaction in elderly male inmates? Is this relationship influenced by
age, marital status, educational history, religion, crime history, current
crime and/or sentence?
3. Does a relationship exist between psychological distress and health
care utilization among elderly male inmates?
4. Does a relationship exist between life satisfaction and health care
utilization among elderly male inmates?
5. What are the relative contributions of psychological distress and life
satisfaction in determining health care utilization?
Limitations
There were several limitations imposed on this study that were specific to
the research site. Because of the forensic nature of the population and
environment, security concerns affect this study. For example, without notice the
facility could be placed on “alert” locking the inmates down for an indefinite
period of time, interrupting interviews and limiting access to participants.
11
Furthermore, because of security risks, outside persons could have their
clearance (ability to move about the institution) restricted at any time. High
security inmates were accessible for interview only when correctional officers
were available for escort and/or supervision. Finally, prison restrictions
interfered with the ability to attain ideal or consistent interview conditions.
The choice of screening instruments was limited due to the incompatibility
of item content and the inmate’s current living circumstances. For example,
questions about personal mobility/transportation were incongruent with the
inmate’s daily experience.
Several confounding variables threaten the internal validity of this study.
Specifically, there was variability in assigned housing units. Inmates resided in
either of two state facilities and their particular housing assignment varied due to
their /functional ability, their therapeutic programming, their proximity to the
infirmary, their security status, or random assignment and available beds. For
example, few of the older inmates were housed in a multi-tiered unit requiring
both stair climbing and stable equilibrium. Approximately 17% of the sample
were housed together in two residential units in order to facilitate their sex
offender programming. Several elderly inmates were housed together in a cell
block that allowed for handicap accessibility and others were located closer to
the infirmary for quicker access in a health crisis. Two inmates were housed in
the maximum security unit of the prison; one was there because of in-house
12
behavioral management problems, and the other was awaiting execution. The
remaining inmates were housed randomly throughout the two facilities.
Threats to external validity focus on the generalizability of the study
results. There are three primary concerns regarding generalizability of the
findings. First, inmates within the state of Utah may possess unique
characteristics that are specific to that geographical location. For example,
nearly 50% of the participants described themselves as members of the Mormon
church. Their lifestyle choices, prior to incarceration, may have been influenced
by this religion’s discouragement of the use of tobacco and alcohol. Therefore,
their health histories may have been influenced, making this study sample
unrepresentative of other state inmate populations. Second, the state of Utah
practices indeterminate sentencing. Indeterminate sentencing means that the
Board of Pardons has executive authority to determine how much of a sentence
the inmate will actually serve. For example, if the sentence ordered was 1 to 15
years, the Board of Pardons may decide to incarcerate the inmate anywhere
from 1 year up to 15 years. The influence of indeterminate sentencing on
inmates is unclear. Finally, study findings are generalizable only to state inmates
incarcerated in a medium-maximum security facility. Comparisons do not include
inmates in city or county jails, or federal prisoners in the federal penitentiaries.
Social desirability response sets may have biased study results. Inmates
could have either assumed a victim stance in their responses (“Poor me") or they
13
could have attempted to present a macho, invincible (“I can handle anything”)
image.
Finally, small sample size is a limitation of this study. Sample size was
limited by the number of male inmates who met inclusion criteria for the study, as
well as the number of inmates who declined to participate.
Summary
Existing literature suggests that there is a positive relationship in the
general population between psychological distress and health care utilization,
and an inverse relationship between life satisfaction and health care utilization.
There are no parallel data examining these factors in the elderly who are state
incarcerated. It is important to understand these relationships in this population
because there are growing numbers of elderly inmates with subsequent
enormous costs to taxpayers. Findings may also be useful in the development of
effective treatment planning for impaired inmates as well as prevention
programs.
14
CHAPTER II
LITERATURE REVIEW
The purpose of this chapter is twofold: (a) to place the present study in the
context of the contemporary literature; and (b) to identify the unique contributions
that this study offers to the current state of knowledge regarding elderly inmates.
A computer-assisted multidisciplinary review of the literature was done from
available data bases, including Psychological Abstracts, Dissertations Abstracts
Index, Medline, and Index of Legal Periodicals.
There are five primary components to the literature review, and they will
appear in the following order. The first component that will be presented is a
review of background information regarding elderly inmates. This section will
underscore the issues and concerns leading to the importance of studying this
population. The second, third, and fourth components of the literature review will
address the constructs of psychological distress among elders, life satisfaction
among elders, and health care utilization among elders in the general population,
respectively. Each of these sections will begin with a broader view of the
literature, tunneling to a more narrow focus on the constructs as applied to
elderly inmates. Finally, the last section discusses relevant concepts of Lewin’s
field theory, expanding on the conceptual framework presented in Chapter I.
15
No literature is currently available on how psychological distress, life
satisfaction, and health care utilization interface in an elderiy inmate population.
Research findings on the prevalence of psychological distress in this population
are inconclusive and contradictory, with researchers supporting the probability of
psychological distress among these inmates (Aday, 1994; Goetting, 1984;
Koenig, Johnson, Bellard, Denker, & Fenlon, 1995). Other authorities suggest
that this population is not vulnerable to psychological distress (Mabli, Holley,
Patrick, & Walls, 1979; Teller & Howell, 1981; Wiegand & Burger, 1979). Life
satisfaction has been minimally investigated in this population (Aday,1994;
McCarthy, 1983). Health care utilization among elderly inmates has not been
examined (Marquart et al., 1997). It is the interface that makes this study a
unique contribution to the current body of knowledge.
Elderly Male Inmates
Definition of the parameters of the term “elderly” in the literature on
inmates has fluctuated. Keller and Vedder (1968) cited an early study
(Schroeder, 1935) that used the age of 25 at which an inmate was considered
elderiy or aged. Apparently as life expectancy increased, so has the age cut-off.
For example, Wood and Waite (1941) and Moberg (1953) used the ages of 40
and 45, respectively, to demarcate their population.
By the 1980s, the age defining elderly had progressed to 50 or 55. The
Federal Bureau of Investigation currently uses the age of 50 as indicating elderly
years in the reporting of crime statistics. For most of the last two decades, the
16
term “elderly inmate” has referred to an incarcerated individual older than 50 or
55 years of age. The present study used 55 years of age and older as the
determining age parameter.
The literature on elders as perpetrators and inmates appears to have
proliferated in the early eighties. Prior to this, elders were more likely to be
viewed as victims of crime rather than the perpetrators of same (Hucker & Ben
Aron, 1984; Petrie, Lawson, & Hollender, 1982). The population of elderiy
offenders was seen as too small in numbers to be significant. Those elders that
did commit violent crimes were more likely to be diagnosed with organic brain
syndrome (Rodstein, 1975).
Initial investigations were primarily sociologically and legally oriented.
Studies addressed the various criminal activities of elders (Feinberg, 1984;
Meyers, 1984; Shichor & Kobrin, 1978; Wilbanks & Murphy, 1984); arrest
records (Shichor, 1984); sentencing practices (Feinberg & McGriff, 1989; Turner
& Champion, 1989); alternatives to incarceration (Watson, 1989); disciplinary
experiences and behavioral management (McShane & Williams, 1990); crimes of
elders in other countries (Bergman & Amir, 1973); facility/program needs of the
elderly (Goetting, 1984; Newman & Newman, 1984; Vito & Wilson, 1985); and
overcrowding concerns in correctional facilities (Smith,1982).
More recently, studies of elderly inmates have involved questions
concerning the similarity of their behavior and needs to other elderiy populations
(i.e., in residential care facilities, hospitalized inpatients, and community
17
outpatients). This interest has shifted for a number of reasons: (a)
Advancements in the sophistication of assessment tools and methods have
altered the focus and rigor of investigations: (b) multidisciplinary contributions
from the fields of gerontology, geriatric psychiatry, psychology, and forensics
have altered the paradigm of aging; (c) the empowerment of elders and the
subsequent possibility of litigation regarding the denial of their rights has served
as impetus for correctional administrators to better understand elderiy inmate
needs; and (d) increasing numbers of older offenders and pandemic
overcrowding in correctional facilities demand the examination of all aspects of
inmate populations and management concerns.
Growing Numbers
Although the number of elderly inmates has not grown at the rate that was
predicted in the 1980s (Chaneles & Burnett, 1989), the number of aging
offenders has grown. The aging of the Baby Boomer cohorts and the “graying of
America” account for a portion of this growth. National population projections
suggest that the number of persons ages 65 to 74 will increase 35 percent by the
year 2010, and persons over the age 74 will increase by 70 percent (Mem'll &
Hunt, 1990). The prison population will reflect these societal trends. Between
1988 and 1992, for example, the number of inmates age 55 and over increased
by 50 percent (Aday, 1994). Currently at 12 percent of the national inmate
population, inmates overage 55 are expected to account for as much as 16
percent by the year 2005. According to the Justice Department Bureau of
18
Statistics (1998), the age group of inmates just under age 55 is the largest
growing cohort of inmates.
Heightened awareness and identification of the crime of child molestation
and its perpetrators is another reason for the growth of the elderly offender
population. School educational programs, mandatory reporting laws, and
prevention and protection advocacy programs have impacted the community and
increased the number of adjudicated pedophiles. Studies report that between
one third and one half of the incarcerated elders have been convicted of sexual
crimes, most of them having victimized children. Increasing numbers of arrests
and adjudication of elders would suggest a heightened awareness of their
potential as criminals. Finally, minimum mandatory sentencing, “three strike"
laws, determinate sentencing (i.e., no chance of early parole), and the
correctional emphasis on containment versus rehabilitation have contributed to
the growing number of elderly inmates.
Because of their increasing numbers, the maintenance of elderly inmates
presents unique and costly demands on the correctional system. Health
concerns associated with aging and the collateral changing age structure of the
population will place new and heavy demands for services and create economic
problems.
Psychological Distress and Elders
As previously described, the construct of psychological distress is used in
this study as a description of the individual’s negative psychological status. As
19
such, it is an indicator of discomfort, negative affect, pain, suffering, and illness.
It suggests changes in physical, psychological, or social functioning that are not
part of the individual’s normal way of being and not part of the normal aging
process. Psychological distress connotes psychopathology. It is not a
diagnosis, but serves as an umbrella term under which symptoms of several
specific psychological disorders may be recognized (i.e., depression, anxiety,
obsessive-compulsive disorder, and phobias). A symptom count approach is
used in this study rather than a dichotomous diagnostic decision. This approach
has proven more useful for identification of the subsyndromal depression often
experienced in the elderly (George, 1990).
The body of knowledge encompassing elderly psychological distress is
relatively new. Efforts and funding directed towards understanding the mental
health care needs of elders have increased dramatically. In 1975, the National
Institute of Mental Health Conference on Research in Mental Health and Aging
(National Institute of Mental Health, 1975) established an agenda in support of
epidemiologic research on those mental disorders that were most common
among the elderly. More recently, two national projects (the 1991 Consensus
Development Conference on the Diagnosis and Treatment of Depression in Late
Life, and the 1995 White House Mini-Conference on Emerging Issues in Mental
Health and Aging) have generated a number of resolutions to advance the
understanding and treatment of psychological distress among elders (Gatz,
1995). These national efforts have been paralleled by growing numbers of
20
gerontological training centers and service agencies (Cohen, 1989). Research
literature on the mental health concerns of the elderly has proliferated as well.
Dementia is one specific common psychiatric disorder that afflicts the
elderly (LaRue, 1992). It is a syndrome characterized by memory and cognitive
impairment (Schneider, 1985), and the NIH has proposed the division of
dementia into three categories: reversible, arrestable, and progressive.
Pseudodementia (reversible dementia syndrome) occurs in approximately 10%
of patients with a concurrent diagnosis of major depression (Alexopoulos, 1992).
Blazer (1990) estimated that the percentage of elders who are affected by some
form of progressive dementia is 7.5%. As age increases, the rate of incidence
increases.
Another psychiatric disorder often experienced by elders is depression
(LaRue, 1992). Depression is a syndrome that may include physiological
symptoms (e.g., fatigue, loss of appetite), affective symptoms (e.g., sadness,
worthlessness), and/or cognitive symptoms (e.g., difficulty concentrating). The
NIH Consensus Development Conference Statement (1991) provided a profile of
the typical depressed elderly person: She is more likely to be a single woman of
lower socioeconomic status, to have experienced stressful life events, to lack a
supportive social network, and to have a coexisting physical condition.
Prevalence estimates of clinical depression among aging Americans vary.
Burns, Larson, and Goldstrom (1988) estimated prevalence rates at 5% .
21
Parmelee, Lawton, and Katz (1989) estimated prevalence rates at greater than
42%.
Subsyndromal depression, also known as subclinical depression, differs
from depressive disorders in terms of the severity and duration of symptoms and
by the effect of these symptoms on functioning. Research on subsyndromal
depression suggests that it is associated with high use of medical services and
with perceptions of poor quality of life (Broadhead et al., 1990; Snaith, 1987).
Elders (men in particular) are less likely to meet full diagnostic criteria and more
likely to experience depressive symptomatology (Blazer, 1990; Freidhoff, 1994).
Subsyndromal depression and the mistaken belief that these symptoms are a
natural part of aging have contributed to a high rate of under-recognized and
untreated psychological distress among community-dwelling elders (Blazer,
1990; Friedhoff, 1994; Kalayam et al., 1993). Cohen-Cole and Stoudemire
(1987) reported the following conclusion regarding subsyndromal depressive
symptomatology:
There is increasing evidence of a high prevalence of such symptoms

among the elderly that do not meet criteria for major depressive disorder
or dysthymia but that nonetheless are clinically significant and for which
treatment, not now generally offered, may be warranted. Such depressive
symptomatology is associated with increased risk of subsequent major
depression, medical morbidity, increased use of health services, longer
hospital stays, slower or less complete recovery from an illness or injury,
and functional disability, (p. 144)
While a great deal of information has been accumulated regarding the
elderly population and mental health concerns, methodological differences have
made study comparisons and generalization of findings difficult. A description of
22
the problematic variables in the research on mental health and the elderly
follows.
Methods of data collection have varied. Some studies have collected data
via structured interviews conducted by psychiatrists, psychologists, graduate
students, and/or trained interviewers. Some studies have used self-report data,
some have been dependent on observer ratings from family members and/or
health care providers, and others have been conducted primarily by archival
review. Paykell and Norton (1986) presented an excellent review of the
variabilities of outcome depending on method of data collection. They noted that
variables such as interviewer/observer characteristics, bias, interviewee desire to
please, and incomplete or inaccurate records may all play a role in distorting the
data.
Psychometric assessment instruments that have been used in studies of
the elderly have not always been validated on older age groups or may be
inappropriate because of item content. Bromley (1990), in an excellent review of
the assessment issues relevant to working with this population, described the
lack of age-appropriate normative data that may reduce the reliability and validity
of assessment procedures. He specifically discussed this problem in relation to
both the Beck Depression Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh,
1961) and the Hamilton Rating Scale for Depression (Hamilton, 1960). While
highly reliable and valid with younger populations, older individuals (particularly
medical patients) may respond to the somatic content of the scales and be
23
misinterpreted as endorsing depressive symptoms. Bromley (1990) described
the Geriatric Depression Scale (Yesavage et al., 1983), used in the present
study, as a relatively new test for depression with improved design features
(dichotomous response categories) for use in elderly populations.
Study populations of elders have differed in their immediate environments.
For example, studies have examined community-dwelling elders (Yesavage et
al., 1983), nursing home residents (McGivney, Mulvihill, & Taylor, 1994), primary
care patients (Evans & Katona, 1993), medically ill inpatients
(Ackerman, & Fulop, 1989; Koenig, Meador, Cohen, & Blazer,1988; Lyons,
Strain, Hammer, Ackerman, & Fulop; 1989), both cognitively impaired and intact
outpatients (Burke, Nitcher, Roccaforte, & Wengel, 1992), and affectively
disordered outpatients (Herrmann et al.,1996). Influenced by environment, the
mental health experience of people from these varied groups may not be
compared easily. Lewin would argue that while age may be a shared variable
among these groups, the environmental context is critical in understanding the
individual experience.
As mentioned previously, case identification and prevalence estimates
have been influenced by the choice of diagnostic criteria. In order to be counted,
some studies have required participants to meet full diagnostic criteria for a
psychological disorder. Others have favored a symptom continuum approach,
focusing on the number of symptoms experienced by the individual during a
given period of time (George, 1993).
24
Psychological Distress and Elderly Inmates
Given their environment, offender status, lack of autonomy, numerous
losses, limited social support, and uncertainty regarding their future, it would
seem likely that elderiy inmates would experience high levels of distress. Add to
these concerns the complications of their deteriorating health and the picture is
grim. The picture is also controversial.
A number of researchers in the fields of criminology, gerontology, and
psychology have suggested that the incarcerated elder population is at risk of
suffering from depression (Adams & Vedder, 1961; Aday, 1994; Bergman &
Amir, 1973; Gillespie & Galliher, 1972; Goetting, 1984; McCarthy, 1983;
Rodstein, 1975;). Similarly, a number of researchers have suggested that this
population is not at risk (Mabli et al., 1979; Reed & Glamser, 1979; Teller &
Howell, 1981; Wiegand & Burger, 1979; Wolfgang, 1964). The following is an
examination of these conflicting studies that constitute this literature on the
experience of psychological distress by elderiy inmates.
Studies Supporting the Presence of
Gillespie and Galliher (1972) reported greater prevalence of depression
and anomie among elderly inmates (60+ years old), as compared to younger
(20-29 years old) and middle aged (30-59 years old) inmates. These authors
interviewed inmates regarding the pace o f their aging in prison. Subjects were
chosen from prison records, although those inmates hospitalized at the time or
25
assigned to work farms were excluded from participating. Therefore, the sample
was not random and possibly not representative of the population.
During half-hour interviews, inmates were asked if they thought that they
had aged faster or slower in prison than they would have on the streets. The
younger group claimed that the prison “matured them”; the middle-aged inmates
believed that the prison “preserved” them; and the elder group stated that prison
life had made them age faster than was normal. Gillespie and Galliher (1972)
interpreted this to mean that this older group of men lacked hope for prospects of
a better future. These researchers described the study participants as “confined”
and stated that “life was passing them by.” They elaborated: “He has no future
in any meaningful sense of the term, but instead sees himself either spending
the rest of his life in prison or returning to the streets too old either to do the
things he used to do or to start a new life” (p. 473).
It may be suggested that it is an unreasonable leap to go from the inmate
stating that he believed he had aged faster, to assuming that this meant the
following: “With the future holding little promise, except perhaps that of death,
the older person experiences the full force of present difficulties. The result is
disillusionment, despair, and apathy” (p. 481). From their work, as described by
Gillespie and Galliher (1972), it is impossible to know what “aging faster” meant
to the men.
Lewin would advocate for the importance of asking the men, individually,
for their interpretation of the present and what they anticipated in their future.
26
Following Lewin’s line of thought, the current study queried the inmates
regarding their perspective on the problems in their world, their health status,
and their plans for the future. Findings from this study will be contrasted to the
conclusions of Gillespie and Galliher.
Gillespie and Galliher (1972) concluded that inmates' susceptibility to the
anomic features of prison life increases with age. No empirical evidence was
provided. They made no mention of alternative variables that may have
influenced susceptibility to depression. Additional possibilities may have
included length of incarceration, amount of outside support, and involvement in
prison activities.
Finally, they suggested that social integration be assessed by the number
of inmates that the individual can identify by first name, or whether they ever
gave and received advice from other inmates. There are two problems with this
approach. Remembering numbers of names does not reveal the quality or
satisfaction with the contact that the inmate may feel with others. Indeed,
remembering names may be a function of his memory and not an indicator of
social integration. Additionally, exchanging advice between inmates is not part
of the convict code of conduct and is more likely to be received with an
admonishment to “Do your own time”.
An article by Bergman and Amir (1973) appeared in the literature on
elderly inmates. Critiqued by contemporary standards of research, this study
has some problems. The authors interviewed 24 experts whom they felt would
have experience with the elder offender and could shed light on this unknown
population. This study was actually about the immigrant population who had
come to Israel after 1948 as older persons. O f the 24 professionals chosen to
be interviewed, only 3 had actual experience with the population in question.
Despite this limited contact, the study group was credited with being able to
identify a number of factors that were characteristic of the population. The
authors attributed negative and violent criminal behavior to the Oriental category
of people. They likened the crimes of elders to resemble those of females’
criminality “. . .tending to be petty, conniving and passive in type” (p. 152).
Finally they reported that those criminals committing sexual offenses were the
“sexually maladjusted.. the homosexuals and the compulsive exhibitionists or
pedophiliacs” (p. 152).
Their evidence in support of the case for inmate vulnerability to
depression was as follows: “W e were told that aged inmates are very frightened
and depressed and tend to be demanding and dependent” (p. 156). These
authors concluded by describing the aged defendant in court. “He tends to ask
for mercy, to appear defenseless and weak, to lie, and to deny the offense
despite the evidence against him. He will usually blame others. Reality
distortion is very common. Some show remorse, although often it is insincere”
(p. 156). It could be argued that this statement is an accurate description of a
large portion of defendants, regardless of age.
28
Rodstein (1975) did not critique the methodology of the Bergman and
Amir article, instead referring to it as “excellent” (p. 639). There are two
significant distinctions in his article from the previous work: (a) He defined elderiy
prisoners as greater than 45 years of age; and (b) he suggested a possible
reason for the criminal behavior of the elderly, i.e., chronic brain syndrome and
the loss of inhibitions.
Goetting (1983) provided an overview of selected research on elderly
prison inmates in the United States. She reported that generally the
contemporary research provided mixed and inconclusive results regarding
social-psychological effects of the prison environment. She concluded that the
elderly have special needs, part of which are psychological; and that prison
administrators must recognize the need for addressing the well-being of the
elderly.
Using an empirical approach, Vega and Silverman (1988) researched the
stress and anger exhibited by elder inmates. Comparing a group of elders (ages
63-80) to a group of younger inmates (ages 20-54) on the State-Trait Personality
Inventory and the Anger Expression Scale, they found no significant differences
in responses between groups. When comparing these two groups of inmates to
normals (non-incarcerated), there were significant differences. The authors
suggested that the elderly inmates’ emotional reactions to imprisonment were
similar to those of younger inmates, in that they created a facade of positive
adjustment. In other words, although the elderiy inmates gave an impression of
29
a non-stressful life and a positive prison adjustment on interview, they actually
used denial and avoidance to keep their high stress levels in abeyance. This
empirical study was more methodologically sound than previous studies and
encouraged further investigation of the psychological well-being o f the
incarcerated elder.
In 1994, Aday undertook a study of elderly inmates, who had been
incarcerated for the first time as older men. This qualitative case study approach
involved 2-hr interviews with 25 volunteers. Aday reported background and
demographic information. The mean age of these subjects was 68 years. Areas
of research interest included the inmates’ personal adjustment to prison life, their
family and peer relationships, their declining health and thoughts about death,
and the role of religion in their lives. Although no psychological assessment was
done, Aday reported that the inmates endorsed indicators of depression and
psychological stress. These indicators included discussion of suicidal ideation,
hypersomnia, tearfulness, feelings of hopelessness and worthlessness,
psychomotor agitation, and difficulty concentrating. It appeared that after talking
to 25 men, it was Aday’s subjective impression that they were depressed.
The most sophisticated research to date on the likelihood that elderly
inmates are vulnerable to depression is a 1995 study done by Koenig, Johnson,
Bellard, Denker, and Fenlon. While most studies of elderly inmates have been
done at state prisons, this group of researchers investigated the experience of
elderly federal prisoners. Their sample was larger than previous studies and
30
consisted of 95 inmates who were age 50 or older. They hypothesized that there
would be a high rate of psychiatric disorder among the sample. They confirmed
this by conducting two independent psychiatric evaluations. Using DSM-III-R
diagnostic criteria for major depression, dysthymia, anxiety, obsessive-
complusive, and posttraumatic stress disorders, they identified 54 percent of the
inmates in the study as meeting criteria for a psychiatric disorder.
There are two problems with this study. Koenig et al. (1995) reported that
the prevalence of psychiatric disorders was higher among younger inmates in
the study, comparing 54-year-old to 57-year-old inmate groups. Is there a
legitimate difference in age between these two groups to suggest that the
difference between these ages is clinically significant? Also, because of the
subsyndromal experience of psychological distress among older persons, the
use of DSM lll-R criteria may have resulted in an identified higher prevalence of
disorder among younger persons.
A second concern lies in the generalizability of the findings. Koenig et al.
(1995) reported that 57% of the sample had been sentenced for drug charges
and had a lifetime history of alcohol or drug abuse. This history is an unusually
high percentage within the elder inmate population, who are more likely to be
sentenced for distribution, rather than use of drugs themselves. Another
problematic characteristic of this sample was that the inmates apparently resided
in two different environments: 25% of the sample was described as being
31
housed in a minimum security camp; the other 75% resided in a low to high
security risk compound. No between-group comparison data were given.
Studies Reporting an Absence of
Contrary to studies that found a high prevalence of psychological distress,
Reed and Glamser (1979) found little distress among elderly inmates. After
extensive interviews of 8 hr with only 19 inmates, 15 inmates reported feeling
younger compared to people on the outside their own age. The researchers
attributed this to eating well, resting often, and having ready/free access to
medical care, as well as not being exposed to heavy industry, hard labor, or
heavy drinking. Reed and Glamser found inmates to be “tough customers” (p.
360), discounting the effects of environmental influence and programmatic
differences between them (e.g., some of the inmates in their study spent their
time fishing in the prison pond).
Two methodological concerns render their conclusions problematic. Reed
and Glamser (1979) grouped inmates from 42 to 77 years of age in a single
category of “older prisoners.” In contrast, Gillespie and Galliher (1972)
delineated two categories within this age range and found markedly different
perspectives on aging depending on group membership. An additional limitation
on generalizability of this study was that Reed and Glamser selected their
subjects from those elders living segregated from the main population and
residing in a separate annex to the state penitentiary. Clearly this difference may
32
have influenced the inmates’ perspective on aging and self-image. To their
credit, Reed and Glamser acknowledged that psychological testing would be
necessary in order to verify their subjective impressions.
In 1981, Teller and Howell compared younger inmates (aged 17 to 49) to
older inmates (aged 51 to 75), and first and multiply incarcerated inmates with
one another. This was the first study to delineate two different types of older
inmates: first incarcerated and multiply incarcerated. Teller and Howell
determined that the elder first-incarcerated inmates were more likely to have
committed their crimes in a spontaneous manner and less likely to identify with a
criminal way of life. Of the 90 older subjects, 37% were first time offenders. The
multiply incarcerated elders were similar to the younger inmates, as far as
identifying themselves as criminals, committing property crimes instead of crimes
against people, and having greater difficulty adjusting to prison life. They noted
that “the first incarcerated older inmates were found to have more often engaged
in crimes of violence, were less involved in a criminal way of life, and were the
best adjusted of all the groups” (p. 553).
Teller and Howell (1981) gathered their data by record review and
assessment via the Bipolar Personality Inventory (BPI). There are two
methodological concerns with this study. Archival review depends on accurate
records, over which the researchers have no control. It happens that the Teller
and Howell study was done at the same prison facility that was used in the
present study. A record review for this study uncovered multiple inconsistencies
33
in the records regarding the criminal histories of inmates. It is unclear by their
discussion whether Teller and Howell cross-referenced records or read the
records in detail in order to collect their data.
The psychological information on the inmates for the Teller and Howell
(1981) study came from the administration of the BPI. As measured by the BPI,
Teller and Howell reported that the elder inmates were less likely to be
depressed than the younger inmates. It is unclear how these results might
compare with an instrument more commonly used, such as the Beck Depression
Inventory. The BPI was an instrument designed by Howell and his associates in
1971 (Howell, Payne, & Roe, 1971), and a search for further information on this
instrument and its use yielded nothing. It is unclear whether this instrument has
been normed on older populations, what the conditions were under which it was
administered, or what the validity and reliability data are.
Life Satisfaction and Elders
As longevity has been extended for Americans, and the Baby Boomers
begin to age, interest in the quality of life of older Americans has experienced a
growth surge. Generally the concept of life satisfaction and elders has been
associated with maintaining good health and functional independence as people
age. Americans are no longer simply concerned with how long they can expect
to live, but rather want to know how many of those years will be quality years.
The definition of life satisfaction has been amorphous. It has variously
included terms such as quality of life, contentment, morale, adjustment,
34
adaptation, happiness, competence, and successful aging, it has been
measured with multiple choice scales, open-ended questions, and single
question queries. Regardless of the measure or definition used, correlates of
lower life satisfaction for elders have been consistently identified as poor health,
low income, and lack of social interaction (Larson,1978).
Early attempts at assessing life satisfaction among elders were focused
on objective criteria, i.e., social productivity, biological health, and longevity.
More recently the focus has been multidimensional, with subjective evaluation by
the individual becoming an important component of the assessment of life
satisfaction (Baltes, 1994).
Fundamental to the construct of life satisfaction among elders is the
concept and challenge of successful aging. Successful or positive aging is
defined as the process of adapting to the interactions of aging, changing health
status, self, family, and society (Ory, Cox, Gift, & Abels, 1994). For example,
decreased mobility, the onset of a chronic illness, and limited social contact may
challenge the individual in their quest for continued quality of life. The process of
successful aging would assist the individual in finding new ways to adapt to
these challenges.
Maintaining a sense of personal control is a correlate of successful aging
(Baltes & Baltes, 1986). Personal control is the idea that one can take charge
over whatever may be happening in their life. Typically, for the elderly control is
associated with loss (Lachman, Ziff, & Spiro, 1994). “Sense of control and
35
quality of life are intimately interrelated. Sense of control is a pivotal contributor
to a wide variety of behaviors and to both mental and physical well-being”
(Abeles, 1991, p. 297).
Wallace and Bergeman (1997) examined the relationship between life
satisfaction and the sense of maintaining control over one’s environment. They
assessed the concept of goodness of fit, or match, between the individual’s
desire for control and his perception of his control. They found a positive
correlation between a mismatch (i.e., incongruence between desire for control
and perception for control) and symptoms of depression. In other words, if an
elderly individual desired control and perceived himself to have control,
depression was less likely. However, if there was a mismatch in either direction
(i.e., desire for more control and perception of little control, or desire for little
control and perception of having more control), symptoms of depression were
more likely to be evidenced. These findings (Wallace & Bergeman, 1997)
suggest that as elders experience a loss of control, it will affect them
idiosyncratically. Response will depend on their desire for control and their
motivation to gain it. Applying these findings to the current study sample, one
might discover that some inmates would find it distressing to live by prison rules
and regulations, eliminating free choice; some of their colleagues, on the other
hand, would find the absence of daily choices to be a relief.
36
Life Satisfaction and Inmates
The literature regarding life satisfaction among the inmate population has
come from an objective viewpoint and has largely been focused on the
psychosocial correlates of successful adjustment or adaptation to the prison
environment (i.e., number of disciplinaries, number of complaints, number of
requests for health services). No studies have included the subjective evaluation
of life satisfaction of the inmates themselves. None of the inmate adaptation
studies that have been completed have focused on elderly inmates.
Early studies on the correlates of prisoner adjustment supported the
deprivation model of prisoner adjustment, first proposed by Clemmer (1958).
This theory posited that inmates deteriorated psychologically while incarcerated;
that they adapted to their environment in ways that made it difficult to survive
lawfully on the outside; and that inmates became hostile to authority and
eventually resisted it. The opposing model for prisoner adjustment was the
importation model, which proposed that inmates brought to prison a set of norms
and cultural attributes that determined their behavior while incarcerated.
Reviews of the literature (Bonta & Gendreau, 1990; Bukstel & Kilmann,
1980) on the psychological effects of incarceration have concluded that the issue
is more complex than either of the previous explanatory models could address.
Apparently some inmates deteriorated in prison, some inmates did not
demonstrate a change in their psychological functioning, and some inmates
improved while incarcerated.
37
This more complex view of prisoner adaptation has been supported by
others (Toch, 1977; Wright, 1991,1993). Research findings of both Toch and
Wright have indicated that individual experiences and needs were more likely to
have predicted successful adaptation than were institutional design or level of
surveillance. Correlates predicting a poor or negative sense of inmate well being
have been identified as fewer visits from the outside, less participation in
activities, having been victimized while in prison (Woolredge, 1999), and loss of
a marital partner while in prison (Rokach & Koledin, 1997).
Zamble and Porporino (1988,1990) have confirmed that psychological
functioning remained stable during periods of incarceration, that inmates did not
change their attitudes to identify more with criminals, and that socialization in
prison happened much the same as it had on the outside. They likened the
behavioral lack of change as a “behavioral deep freeze” in which the men were
able to suspend their outside behaviors until they were released from prison and
could once again resume their previous mode of operation.
Zamble (1992) reported on a longitudinal follow-up study on 25 inmates
(the mean age was 37.5 years) who had participated in a similar study 5 years
previously. Findings indicated that the men became better adapted, over time,
to prison routine. Scores on instruments assessing depression and anxiety
dropped, inmates were seen less often in the infirmary for stress-related
problems, and the number of disciplinary infractions decreased.
38
Life Satisfaction and Elderiy Inmates
The correlates of poorer life satisfaction, i.e., poor health, low income, and
lack of social interaction, are likely to be present in the lives of elderly inmates.
However, empirical studies that have addressed the issue of life satisfaction
among elderiy inmates are sparse.
Goetting (1983) cited an unpublished study done by Wooden and Parker
(1980), claiming that the elder inmate's outlook remained positive. However, no
empirical testing was done, and their sample size was only 12 inmates.
McCarthy (1983) presented empirical data regarding life satisfaction of
elderly inmates that suggested a more negative stance. She questioned 248
elderly inmates about issues of health status, diet, and satisfaction with life. She
reported that 24.2 percent described life as dull, 25.4 percent identified their life
satisfaction as poor, and 34.7 percent reported they were not happy.
Approximately half of her sample reported that they worried very or fairly often.
Over half of the inmates endorsed the statement that they were lonelier than
when they were 10 years younger. It is unknown how these results would
compare to younger inmates or a group of community elders.
No psychometric assessment was done in the McCarthy (1983) study
regarding psychological distress. She concluded with a cautionary word of
warning to prison administrators regarding the seriousness of depression among
elders and, in particular, the high suicide rate among elderly men.
39
Gallagher (1990) researched older (45 years of age and older) inmates in
comparison to younger inmates (31 years of age and younger) at three prison
sites in Canada. She did not use the term life satisfaction in her study; she did,
however, assess physical, emotional, and social health, variables often identified
in life satisfaction studies. Findings indicated that the older men were doing well
on all three variables, with few differences between them and the younger
inmate group.
There are three problems with the Gallagher (1990) study. The study
sample was small (45 men in each group); the older inmate group included a
wide age range (45 to 85 years of age); and, most significantly from a Lewinian
point of view, the description of the prison environment was in sharp contrast to
the current state of affairs in most American prisons. The inmate populations at
each site were small, with the largest totaling 230 inmates. Inmates had
opportunities to participate in a variety of school or trade courses, as well as
multiple job opportunities. Gallagher concluded: “The clusters of living units,
well-equipped gymnasium, and library reflect a standard in prison design envied
by visitors from around the world” (p. 253).
Health Care Utilization and Elders
Comorbidity of physical illness and psychological disorder is significantly
more common among the elderly (Lebowitz & Niederehe, 1992). For example,
elders have a threefold increase in risk of depression if they also have a disability
or chronic physical illness (Blazer, Burchett, Service & George, 1991; Cohen,
40
1980; Gurland, Wilder & Berkman, 1988). Recent Medicare projections (Rainer,
1996) indicated that when retirees seek psychological treatment, their physical
health care costs dropped by 15 to 20 percent.
Community-dwelling psychologically distressed elders are more likely to
attribute their somatic symptoms to medical illnesses than their mental health
status (Alexopoulos, 1992; Allen & Blazer, 1991; Murrell, Himmelfarb, & Wright,
1983). Numerous researchers have documented the relationship between use
of health care services and psychologically distressed elders (Allison et al., 1995;
Arling, 1985; Broadhead e ta l., 1990; Friedhoff, 1994; Hibbard & Pope, 1986;
Levitan & Komfeld, 1981; Levkoffetal., 1987; Mumford etal., 1984;
Schneider,1985).
Bums and Taub (1990) reported that current cohorts of older persons are
as likely to seek assistance from primary care providers (2.4%) as mental health
professionals/programs (2.5%). Although requests for psychological help have
become more acceptable as the population has become more educated (Gatz &
Smyer, 1992), this view is less likely to be the case among current older cohorts
of Americans. They are more vulnerable to myths and stereotypes indicating
that mental health problems are indicative of deficiencies or personal failure.
Even persons considering suicide often consult a family physician about their
physical health rather than discuss their mental health concerns (Conweli, 1994;
Rabins, 1992).
41
Health Care Utilization and Elderly Inmates
Prison health care utilization reports of services for the incarcerated
population of all ages suggest that inmates use prison medical services at
greater rates than the non-institutionalized population (Suls, Gaes, & Philo,
1991). Prison health care utilization studies have not examined the specific
usage patterns of the elderly inmate (Marquart et al., 1997). Therefore, health
care utilization patterns, costs, and correlates among incarcerated elders are
unknown.
Several researchers have reported on the generally poor health status
and multiple health concerns of elderly inmates, but none have addressed the
health care utilization of these men. Aday (1994) reported that elderly inmates in
his study had an average of three chronic illnesses, but reported nothing about
their health-seeking behaviors. Koenig et al. (1995) reported that older inmates
in his study (mean of 57 years old) that met criteria for a psychiatric disorder had
poorer physical health.
McCarthy (1983) reported that 46 percent of 248 older inmates reported
having chronic health problems. She emphasized the need for special
gerontological training for staff, regular and comprehensive checkups, special
diets, exercise programs, and vitamin availability. Again, nothing was reported
about inmate health-seeking behaviors, although over half of the inmates
believed that their health needs were not being adequately met.
42
Conceptual Framework
To provide a thorough understanding of the conceptual framework of this
study, the following section will describe a number of constructs from Lewin’s
approach to the study of human behavior, as well as addressing their relevance
to the current study. Topics will be presented in the following order (a) Lewin’s
concept of life space, (b) his subjective nature of reality, (c) his emphasis on the
importance of understanding both the insider and outsider perspective of the
environment, and (d) his analysis of the processes of differentiation and
regression.
Life Space
Lewin’s field theory emphasized that the environment, or field, of the
individual must be characterized as a whole and constituted the individual’s “life
space”. Lewin and his colleagues defined life space as consisting of the
psychological characteristics of a person at a given time and his psychological
environment at the same time. Lewin's focus was on the present. It was,
therefore, time sensitive and implied the possibility of the forces of change over
time. The current study investigated the life space of its participants at the time
of interview.
The Nature of Reality
Lewin’s conceptual approach to the subjective nature of reality is
foundational in this study. Reality is developed as the individual experiences his
world. He experiences it, forms cognitive connections about it, and behaves
43
accordingly. Applying this concept to the elderly inmate population, it is the
meaning of the inmate’s environment at the time of his interview, and the
psychological forces that he experiences in his environment, that determine his
reality and his response to it. Relationships between psychological distress, life
satisfaction, and use of medical resources cannot be understood without
consideration of the inmate's internal psychological world and his interpretation
of the environment.
Insider and Outsider Perspectives
Another important concept of Lewin is the distinction that he made
between the “insider” and “outsider" perspectives of the environment. The
insider is the inmate, who intimately experiences and interacts with the
environment. It is his interpretation of reality that helps to define the problem.
While the common sense of an outsider may suggest that the restrictions of
incarceration would result in distress and decreased life satisfaction, it is the
insider’s frame of reference that is relevant. For the inmate, incarceration is only
a description of his physical boundaries and not his internal response to it.
incarceration does not necessarily mean psychological trauma, social isolation,
or emotional devastation.
The prison environment provides an ideal location to witness the
importance of the insider’s perspective in understanding human behavior.
Inmates experience similar physical parameters of their environment. In a
prison, these parameters remain relatively constant. Various housing units may
44
differ in their location within the prison, the particular design of the unit (i.e., one
floor or two floors, solid doors or bars), or the number of men assigned to the
unit. However, all o f the inmates experience identical outside parameters of their
environment. Their field is bounded by the door on their cell, the electronic doors
blocking the hallways leading to their residential units, and eventually the razor-
wired walls of the prison. Not only is the physical environment well regulated,
but movement within or access to the environment is held constant by the
facility’s routine and the security officers managing it.
Despite very similar stimuli, inmates interpret their environment in highly
individualistic manners. Their incarceration experiences are unique to them.
Their individual realities are dependent on their insider perspectives. To gain an
understanding of the relationships of the variables of interest in the current study
(psychological distress, life satisfaction, and health care utilization), the insider
perspectives of the inmate was critical.
Differentiation
According to Lewin, the development of a person is the development of
the way that he experiences his life space. It is a process of increasing
differentiation. A child teams to master a greater range of behaviors, emotions,
relationships to space and distance, and interrelationships with others as he
develops and grows. This is his process of differentiation. The child’s reality is
developed as he experiences his world. He makes psychological connections to
45
stimuli (cognitive structuring), that in turn create his reality, that in turn motivate
his behavior.
In much this same way, an inmate develops his reality through a process
of increased differentiation as he begins to experience his life space. He begins
to identify/differentiate the life space as he moves through it, e.g., here is my cell,
here is where I eat, these are the rules of movement, and this is the time
schedule. He leams, and with his acquisition of knowledge, he experiences
cognitive structuring of his life space. It is this cognitive structuring, or
differentiation process, that determines his reality and his behavior.
Psychological connections are made with various environmental stimuli, meaning
is established, and the inmate’s behavior is the outcome. This continuing
process of differentiation is the keystone of development.
Regression
Regression is the antithesis to development. It is the process of
undifferentiation. It may represent a return to a previous developmental state
which the individual has already outgrown. The regressing individual may
become more concrete in his thinking and stereotyped in his behavior.
Regression may occur in the case of elderly inmates as an adaptive response to
their subjective reality and the meaning of their limited life space. Regression
may also serve as a partial explanation of the coping abilities of these men and
the absence of severe psychopathology within the sample.
46
Lewin outlines three aspects of regression that are particularly relevant to
this study. First of all, the life space of the individual becomes more limited or
smaller in scope. There may be an accompanying decrease in the range of
behavioral variety; a decrease in language skills and variety of word usage; a
decrease in the range of emotional variety; a decrease in the number and
complexity of needs, interests, and goals; and a decrease in the number of and
variety of social contacts. These changes in behaviors are accurately descriptive
of the study sample, as relayed by study participants.
Increased interdependence with the environment is another example of
regression. Generally as the child develops, the distance between his
psychological person and psychological environment increases. He becomes
more differentiated within his life space and is less helpless against the direct
influence of the immediate environment. The prison inmate experiences the
opposite. Lines on the floor and on the walls indicate “out of bounds” areas
where they must not trespass; “movement” times are announced by loud
speaker and are the only opportunities to move from one area of the prison to
another; and “official count” occurs several times every 24-hr period, restricting
the location of the inmate to his cell. The inmate regresses to a higher level of
environmental interdependence overtime.
Lewin’s second aspect of regression is that there is a reduction in the
dimension of reality-irreality. This phenomenon could be represented by a shift
from sanity to insanity. On a (ess dramatic note, it may represent an individual’s
47
inability to be realistic. Examples among elderly inmates include making future
plans or fantasies of the future on the outside when serving a life sentence,
proposing to go out and start a new business which will make him rich in a short
time, and denying his sadness as he cries through the interview.
Decreased time perspective is the third aspect of Lewin’s theory of
regression relevant to this study. Time perspective includes the totality of the
individual’s views of his psychological future and his psychological past existing
at a given time. As the individual develops, his time perspective expands, and
more and more distant past and future events affect present behavior. As the
individual regresses, his time perspective diminishes to the more immediate past
and future. Statements such as, “I’m doing my time one day at a time,” or when
asked about future plans, responding, “I don’t have an y .. .Just get out of prison,”
reflect this type of regression.
Lewin does make a distinction between the regression of the behavior of
an individual (situational regression) and the regression of the individual himself
(established regression). An inmate may become situationally regressed as long
as the circumstances of his incarceration continue. Once released, if he is
unable to return to his former level of functioning, the regression is considered to
be established. The longer the person is exposed to the stressful environment,
the greater the likelihood that the person himself will regress. He becomes
unable to function at a more mature level given the stressful environment
(established) and may be unable to return to a more mature level of functioning.
48
The longer the exposure to the stressor, the greater the likelihood of permanent
regression. An inmate serving a life term may experience permanent regression.
An inmate serving a shorter sentence may be temporarily regressed.
Unique Contributions of the Present Study
The literature is contradictory regarding the prevalence of psychological
distress in the population of incarcerated elders. There has been limited
investigation into the concept of life satisfaction in this population. Health care
utilization research among elderly inmates remains nil. It is the interface of these
three constructs, psychological distress, life satisfaction, and health care
utilization, among elderly inmates which this study presents as a unique
contribution to the current body of knowledge.
49
CHAPTER III
METHODOLOGY
Introduction
The purpose of this study was to investigate the relationships between
psychological distress, life satisfaction, and health care utilization among elderly
male inmates. Findings of the current study could be useful in treatment planning
and increased medical resource cost savings.
The purpose of this methodology chapter is to describe the (a) ethical
considerations relevant to working with this population, (b) participants in the
study, (c) methods of data collection, (d) instrumentation that was used to screen
the inmates, (e) procedures that were followed, and (f) the statistical analyses
that were used to analyze the data.
This study is correlational in design. Data were collected at the two state
prison facilities in Utah. Participation in this study was voluntary. Participants
were selected from the general population of male inmates age 55 and older.
Clinical interviews, self-report questionnaires, and archival records (both medical
and prison records) were included in these data. Participants were interviewed
individually and screened for levels of psychological distress and life satisfaction.
Information on health care utilization was collected from several sources,
50
including prison medical charts, electronic records, accounting files, University of
Utah Hospital records, and Gunnison Valley Hospital records. The health care
utilization data was retrospective, covering an 18-month period of time. The data
collection was either done by the investigator or directly supervised by her.
Several University Hospital employees collected University Hospital data as
hospital records were restricted. Data were collected over a 12-month period of
time.
The purpose of this study was to address the research questions that
were posed in Chapter I. They are as follows:
51
Ethical Considerations
Ethical guidelines accord prison samples the status of vulnerable
populations. Therefore, in addition to the standard ethical considerations given
to research participants, additional considerations were necessary. This section
outlines standard ethical matters that are a part of all responsible research, the
ethical matters that are specific to this inmate population, and the process that
was followed for review of this study protocol.
Standard Considerations
Every attempt was made to convey due respect to the participants and
appreciation for their help. They were addressed appropriately (“Mr. X as
opposed to “Inmate number XXXX”), given the full attention of the researcher
during the interview, and thanked at the close of the data collection.
Participant privacy, or controlling the access of others to information about
themselves, was protected by conducting the interviews in as quiet and private a
location as possible. As previously described, this interview was generally
conducted in a private room with a glass window or wall for observation by
officers. The interviews could not be overheard by prison staff. Participants
were aware, both by consent form, and verbal reminder, that no
acknowledgment of who did or did not participate was made to prison staff,
custody officers, or fellow inmates; and that confidentiality was assured by
52
attaching code numbers (not names or prison numbers) to all respondent data.
There was only one master coding list. Only the researcher had access to this
list. It was stored off prison premises in a locked cabinet.
Confidentiality, or controlled access to data, was protected by having one
person collect most of the data. Much o f the data was self-report, making family
member or staff observations unnecessary. In the case of University employees
assisting with data collection from University records, it was obviously necessary
to share a list of study participants. The list was exchanged in person and
confidentiality was stressed to these individuals.
All respondent study materials were stored outside of the prison walls in a
locked cabinet. Only aggregate data was used in the analysis and final report.
At no time did the Department of Corrections (DOC) have access to raw data or
identifying documents of any kind. No participant information was entered into
medical charts, electronic records, or prison files.
Risks to the participants were judged to be minimal. Inmates were not
asked questions where disclosure would place them at risk of legal action, i.e.,
questions about illicit drug use or crimes for which they had not been caught. No
deception or concealment was involved in this study. Debriefing was not done
following each interview due to the residential proximity and confinement of the
participants. Information about the study could have biased subsequent
participant responses. A summary letter was sent to respondents who requested
a follow-up report.
53
Special Considerations
There are two categories of special considerations which were relevant to
this study. The first of these was the age range of the participants. The second
consideration, and far more serious, was the incarcerated status of the inmates.
Vulnerable research populations are those that are considered to be
either subject to coercion and/or unable to make decisions. Examples include
minors, people with mental retardation, and fetuses. Some researchers (Lawton,
1980) have argued that elders are also a vulnerable population simply by virtue
of their age. Others (Ostfeld, 1980) have suggested this perspective to be
presumptive and discriminatory. It is, as well, misleading. Some elders are
institutionalized, senile, and unable to make decisions. Many are capable,
active, and leaders in their communities.
Melton and Stanley (1996) presented an alternative framework by which
to judge the vulnerability of elders. They suggested two considerations: (a) do
they have a disorder that would affect their decision-making ability; and (b) does
their residential status place them in a dependent position? It would appear that
these criteria are appropriate for younger persons as well. This author would
suggest that simply raising the first question of the vulnerability of elders is
discriminatory.
The second special consideration, the incarcerated status of the
participants, does identify them as a vulnerable population. Voluntary consent
means the agreement to participate without threat or coercion; to exercise
54
autonomy and free choice. Inmates are in a fully dependent position for their
care. They would probably not experience overt attempts to threaten or coerce
them to participate or not. However, their position as inmates invites subtle,
unspoken, and implied threat. The very purpose of incarceration is to limit
freedom and control behavior. Can voluntary consent really be obtained within
this institutional context? As Sieber (1992) pointed out, “. . . voluntariness may
become blurred in a captive population” (p. 32).
Grisso (1996) described an additional threat to obtaining voluntary
consent from participants. Because o f their past experience with prison
authorities, inmates could bring certain expectancies to the research situation
regarding their interaction with authority figures. These expectancies may
generalize to the researcher, who may be perceived as more of a prison official
than a researcher from an external entity. Therefore several efforts were made
as preventive measures. Specifically, inmates were told on three different
occasions (by letter, during the consent process, and during the debriefing
process) that (a) the research was not part of a prison program; (b) the
information collected during the study would not be shared with the prison
administration; and (c) whether or not they chose to participate, there would be
no influence on their release date, or any other decision made by the Board of
Pardons or DOC.
Additionally, Grisso (1996) suggested that every attempt be made to
distance the researcher and the research process from the institution and its
55
process. For this reason, all of the correspondence sent to the inmates went
through the external mail service. The researcher, while dressing professionally
for the interviews, did not wear prison staff dress code colors or uniform.
Institutional Review
Prior to any direct contact with the participants in this study the research
plan, protocol, and materials were reviewed and approved by four independent
review committees. These gatekeepers determined the appropriateness and
readiness of the study, and they were responsible for assuring the protection of
the participants. All of the steps in this process required written approval by the
specific sanctioning committee. The first of these was done by the dissertation
co-chairs, in concert with committee members. Following their written approval,
the project was forwarded to the universities and the correctional system.
Both the University of Iowa and the University of Utah Institutional Review
Boards (IRB) had to approve this study. The University of Iowa required this
step in order to support the research of one of its doctoral candidates. The
University of Utah IRB approval was required by the State of Utah Department of
Corrections in order to assure the protection of its wards (inmates).
The State of Utah DOC requires an internal approval by the DOC Bureau
of Research, as well as signatures from several prison officials, for both internal
research (conducted by staff) and external research (conducted by outside
persons). The Director of the Bureau, Dr. Chris Mitchell, was supportive in the
56
planning and implementation of this project, and was instrumental in this
process.
Participants
This study took place within the state prison facilities of the Utah DOC,
which houses approximately 5500 prisoners at its two state correctional facilities,
as well as several hundred inmates at county jails (U.S. Justice Department,
1999). Three percent of these offenders were 55 years of age and older; ninety-
four percent of these older inmates were male (Beck & Mumola, 1999).
Participants for the study were recruited from both of the state prison
facilities. The largest one, in Salt Lake City, houses approximately 4500 male
prisoners, as well as 250 female inmates. These residents are both medium and
maximum security offenders. Comprehensive infirmary services (including
dental and ophthalmology services), as well as a mental health staff of 60,
provide both inpatient and outpatient care. The second prison facility is located in
Gunnison, in the southern part of the state. It houses an additional 1000 inmates
(all male) and provides a full range of services, albeit on a smaller scale.
The sampling strategy of this study was to invite every eligible male
inmate housed within the state facilities of the DOC to participate. This process
did not include inmates housed in city and county jails. Females were not
included due to their limited numbers (i.e., two). A list of 229 potential inmates
was secured from the DOC, Department of Research. Fifty-eight men were
eliminated because of their county jail residency; 24 did not meet the 1-year
57
residency requirement or were too soon to be released; 10 were transferred to a
pre-release or less secure facility; 7 inmates were listed as “escapees”; 6 men
were eliminated because of their status as interstate custody inmates (they were
soon to be transferred); 1 was eliminated by prison administrators due to being
considered a security risk; and 1 inmate was eliminated due to having had
previous contact with the investigator. Participants were recruited voluntarily
from the remaining 122 elders within the general inmate population.
Exclusionary criteria included the following:
1. Being younger than 55 years of age as of October 15,1998.
2. Period of incarceration less than I year on the instant offense, i.e., the
offense resulting in this particular incarceration.
3. Inability to comprehend spoken English. (All materials were read to
the participant so the ability to read English was unnecessary.)
4. Anticipated release date within 6 months of the interview.
5. Identification as a security or behavioral management risk by the
prison administration.
6. Evidence of acute psychotic symptoms.
All of the eligible volunteers were contacted and invited to participate in
the study. Based on participation rates in previous research on elderly inmates
(Aday, 1994; Koenig et al., 1995) it was anticipated that approximately 100 of
these inmates would volunteer their time for this study. The final sample size
was 90.
Materials
The following questionnaires were used in this study. Included are
sample items and psychometric properties of the instruments.
Informational Questionnaire
The Informational Questionnaire (IQ) was the questionnaire designed to
elicit demographic information from the study participants (see Appendix A).
This information included age, marital status, religion, work history, educational
history, time served, time until release, and number of incarcerations. Questions
regarding the inmate’s use of medical sen/ices within the prison, his satisfaction
with same, his current health status in terms of chronic illnesses, his perceived
health status, questions regarding his support systems, his concerns, and his
future plans were also included.
Mini-Mental Status Exam
The Mini-Mental Status Exam (MMSE; Folstein, Folstein, McHugh, 1975;
Spencer & Folstein, 1985) was used to assess the cognitive capacity of the
inmate (see Appendix B). The MMSE is a 30-item assessment tool whose
purpose is to differentiate between cognitively impaired and unimpaired subjects
in a fairly quick manner. It was developed as a shorter alternative to the lengthier
batteries previously used to assess mental status. It provides a quick
assessment of orientation to date and place, attention, delayed recall, and
receptive and expressive language functions. A score of 20 or less indicates
cognitive impairment and further evaluation is generally recommended.
59
Test-retestdata (Folstein etal., 1975) indicated high reliability. A single
examiner, at a 24 hour retest, obtained a correlation coefficient of 0.89; multiple
examiners resulted in a coefficient of 0.83. Retest reliability data at 28 days was
0.98.
Folstein et al. (1975) determined concurrent validity by correlating MMSE
scores with Wechsler Adult Intelligence Scale, Verbal and Performance scores.
The association between the MMSE and Verbal IQ was 0.78; the association
between the MMSE and Performance IQ was 0.67.
The MMSE can be administered in approximately 10 minutes.
Standardized instructions for the administration of the MMSE were used.
Geriatric Depression Scale
The Geriatric Depression Scale (GDS; Brink, Yeasavage, & Lum, 1982;
Yeasavage et al., 1983) is a 30-item self-report instrument designed to be a
screening for depressive symptoms in the elderly (see Appendix C). It uses a
yes/no format. The GDS takes approximately 10 minutes to administer. Scoring
is as follows: 0-10 indicates a normal response, 11-20 indicates mild depressive
symptomatology, and 21-30 indicates severe depressive symptomatology.
Contrary to the Beck Depression Scale (Beck et al., 1961), none of the questions
address somatic concerns. As suggested by Hyerand Blount (1984) this may
decrease the number of false positives in a population with multiple chronic
health problems. The GDS contains items dealing with perceived locus of
control and is therefore recommended for use in elderly populations where the
60
individuals are confined. Such settings generally include hospitals or long-term
care facilities.
The GDS has been validated with a variety of elderly populations. These
include outpatients from an affective disorder clinic (Herrmann et al., 1996),
primary care outpatients (Evans & Katona, 1993), cognitively impaired and intact
psychogeriatric outpatients (Burke etal., 1992), medically ill inpatients (Koenig,
Meador, Cohen, & Blazer, 1988; Lyons et al., 1989; Rapp, Walsh, Parisi, &
Wallace, 1988), nursing home residents (McGivney et al., 1994), and community
dwelling elders (Mitchell, Mathews, & Yeasavage, 1993; Yeasavage et al., 1983).
In a study of 806 institutionalized persons, Parmalee, Katz, and Lawton (1989)
confirmed the high internal consistency of the GDS (Cronbach’s alpha .94).
Split-half reliability was .94. Retest reliability after one week was .85 (Koenig et
al., 1988). Yeasavage and colleagues (1983) reported a correlation of .83 with
the Hamilton Rating Scale of Depression (Hamilton, 1960) and a correlation of
.84 with the Self-rating Depression Scale (Zung, 1965). Hyer and Blount (1984)
reported a correlation of .73 with the Beck Depression Inventory. Schneider,
Eaton, Zemansky, and Pollock (1992) reported a correlation of .91 with the Beck
Depression Inventory. A cut-off of 11 points on the GDS yields 84% sensitivity
and 95% specificity.
Toner, Guriand and Teresi (1988) found that 35% of their sample could
not complete the self-rated GDS for three reasons. Visual acuity accounted for
28% of the problems, illiteracy accounted for 9%, and lack of motivation
61
accounted for 34% of those who could not complete it. For these reasons,
several studies have suggested reading the instrument to the subject (Idler,
1993; LaRue, 1992). This was the method employed in this study.
Brief Symptom Inventory
The Brief Symptom Inventory (BSI; Derogatis, 1975) was used to assess
the predictor variable of psychological distress (see Appendix D). The BSI is a
53 item self report instrument designed to measure current psychological
symptom status. It is the abbreviated form of the Symptom Checklist-90 (SCL-
90; Derogatis, 1977) and was designed for situations which allowed limited time
for assessment, as was the case in this study. It is intended for use with both
patient and non-patient populations, making it appropriate for this study.
There are nine symptom dimensions on the BSI and three global indices.
The symptom dimensions include somatization, obsessive-compulsive,
interpersonal sensitivity, depression, anxiety, hostility, paranoid ideation, phobic
anxiety, and psychoticism.
The three global indices of distress are as follows:
1. The Global Severity Index (GSI) is the best summary measure of
distress and combines information on both numbers of symptoms and intensity
of individual psychological distress. The GSI was the summary measure of
psychological distress used in the multiple regression analysis.
62
2. The Positive Symptom Distress Index (PSDI) indicates whether the
symptoms endorsed and the distress level reported are equal to the average.
The PSDI provided useful descriptive data on the population.
3. The Positive Symptom Total (PST) is an indicator of the number of
symptoms endorsed by the responder, regardless of distress level.
Each item on the BSI is rated on a 5-point scale of distress ranging from 0
(not at all) to 4 (extremely). Responders are asked to indicate how much a
particular problem (e.g., “Nervousness or shakiness”; “Feeling afraid in open
spaces”) has bothered them during the past 2 weeks. A score of 63 or greater
on any two of the nine symptom dimensions, or a score of 63 or greater on the
GSI indicates a positive case. This instrument has been normed on four
populations. The most similar norm group to this study’s participants, both in
age and clinical status, are the non-patient normals. The mean age of this group
(the non-patient normals) was 46.0 with a standard deviation of 14.7.
Test-retest reliability coefficients for a two week time period range
between .68 for Somatization and .91 for Phobic Anxiety. The GSI has a test-
retest coefficient of .90.
Convergent validity between the BSI and Minnesota Multiphasic
Personality Inventory (MMPI) was demonstrated by Derogatis, Rickels, and Rock
(1976) with a sample of 209 subjects. Correlational coefficients were greater
than .30 for the nine symptom dimensions of the BSI and the clinical scales of
the MMPI. Construct validity on the BSI was assessed using a principal
63
components factor analysis which had been done previously on the parent
instrument, the SCL-90. Nine interpretable factors were derived from a normal
varimax rotation which accounted for 44% of the variance in the matrix
(Derogatis & Spencer, 1982).
Modifications for administration of the BSI followed the directions in the
manual for narrative administration (Derogatis & Spencer, 1982). A card was
given to the inmate with the numbered descriptors on it in large print (i.e.,
0=“Not at all”, 1=“a little bit", 2=”moderately”, 3="quite a bit”, and 4="extremely").
This card served as a cueing device and the inmate indicated his response by
saying the appropriate number or words. Administration time is approximately
ten minutes.
Life Satisfaction Scale
The Life Satisfaction in the Elderly Scale (LSES; Conte & Salamon, 1982),
recently renormed and renamed the Life Satisfaction Scale (LSS; Salamon &
Conte, 1998) was used to assess the predictor variable of life satisfaction. The
LSS is a 40-item instrument that was designed to reliably measure life
satisfaction across a variety of domains. The eight domains included in the LSS
are daily activities (taking pleasure in daily activities), meaning (regarding life as
meaningful), goals (goodness of fit between desired and achieved goals), mood
(positive mood tone), self-concept (positive self-concept), health (perceived
health), finances (financial security), and social contacts (perceived satisfaction
with the number and quality of the social contacts which are characteristic of the
64
respondent’s usual routine). Each of the domains include five questions which
score one point a piece, or 25 points for each domain. Administration time is
approximately 25 minutes (see Appendix E).
Conte and Salamon (1982) offer reliability and validity data for three
sample populations, totaling 700 persons. The first population consisted of 408
community dwelling elders, 55 years of age to 90 years of age. The second
population consisted of 241 subjects who were affiliated with health care
providers (i.e., in-patient and ambulatory services or home-visiting nurse
services). The third sample, consisting of 50 subjects, 65 years of age to 89
years of age, resided in a housing complex for older adults. Internal consistency
as measured by Cronbach’s alpha was .93 for the entire test. Cronbach’s alpha
was computed for each of the domains and ranged from .60 (Goals) to .79
(Health). Test-retest at 1 month was .90 for the total scale and above .88 for all
subscales. Test-retest at 6 months was .67 for the total score.
A principal components analysis indicated that eight factors accounted for
more than 60% of the total variance. A confirmatory analysis was done using an
eight factor solution. Two factors were completely congruent with the variables
related to the Health and Finances subscales of the LSS. The other six factors
produced a number of significant loadings. A cluster analysis indicated that in all
of the subscales except self-concept, four of the five questions cluster together.
65
Concurrent validity was tested with the use of a psychosocial interview
and physical assessment, as well as administration of a health background
questionnaire. Subscale correlations with this data were between .44 and .66.
Health Care Utilization Index
Data on the variable of health care utilization were obtained through
archival review of the inmate’s medical chart, prison accounting, and electronic
record. This data covered an 18-month period of time.
In addition to frequencies of health care utilization, a Health Care
Utilization Index (HCUI) was calculated for each participant, using actual charges
from the respective cost centers. The HCUI is a composite figure (in dollars) of
all of the charges, based on obtainable figures, for one inmate for this 18-month
period of time. Therefore, the HCUI is an indicator for the cost of medical care
per inmate, from January 1,1998, until June 30,1999. Frequency and
descriptive data used to derive the HCUI included:
Outpatient Use— Prison
1. Infirmary appointments (number and cost of appointments with
physicians, physician assistants, and registered nurses)
2. Prescription medications (number and cost of prescriptions and refills)
3. Lab tests, X-rays, EKG (number of and costs where obtainable)
Inpatient Use— University Hospital and Gunnison Valiev Hospital
1. Hospital facility and service charges (costs)
2. Physician charges (costs)
66
Greenberg, Stiglin, Finkelstein, and Bemdt(1993) described two
approaches to determining the annual cost of an illness. The prevalence
approach uses the accumulated costs attributable to all individuals suffering from
the physical or mental health condition in question for a period of one year. The
incidence approach uses the costs of the present value of the expected lifetime
for persons who have newly acquired the illness in question. The incidence
approach involves only new sufferers and data is collected over a longer period
of time.
This study used the prevalence approach to estimate a dollar amount
representative of the medical resources used during the 18-month period of
study. This approach is used because of time limitations; interest in establishing
cost of care of inmates who already suffer from chronic illnesses; as well as the
difficulty in establishing value of expected lifetime of inmates, many of whom are
not gainfully employed. Direct charges of care (e.g., for office visits, prescription
medications, lab procedures) were calculated for each participant in the study.
The resulting dollar amount, or HCUI, was a composite of the charges for an 18-
month period of time to provide health care for each particular inmate.
Procedures
A list of all male inmates age 55 and over was obtained from the Bureau
of Research within the Utah DOC. This list was reviewed by prison
administrative staff and officers for removal of ineligible inmate names (inmates
who presented security risks). Only one inmate was eliminated in this manner.
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The remaining potential volunteers received a letter via the postal service
(see Appendix F). The letter was not sent through the prison mail system
because of the association that inmates may have made between the study and
the prison system. Because of concerns about their vulnerability and fears of
reprisal, it was important that they understood that although the DOC was
supportive of the study, it was not a DOC study. The informational letter
explained the purpose of the research project, described the procedure and time
commitment involved, and informed the inmates that they would be contacted in
person to inquire about their willingness to participate.
The second contact was approximately 2 weeks later. This was a face-to-
face encounter with the researcher. These meetings took place near the officer
station at the entrance to the inmate’s housing unit. They were conducted as
privately as possible.
The men were asked if they had received the letter of introduction, if they
had questions about the study, and whether they would be interested in
participating. If they wished to be interviewed it was either done at that time, or
scheduled within the week. AH attempts were made to accommodate their
schedules by not interfering with such activities as work, school, church
activities, or visiting hours. If they did not wish to participate, they were given the
opportunity to comment on their reasons for not participating if they wished to
comment. Some of the reasons given for not participating were that they were
not interested, they would gain nothing from participating, they had concerns
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about the confidentiality of the study, and one man stated that he was afraid that
his participation would jeopardize his release date.
Seventy-three of the participants were interviewed in a private room in
either the infirmary or near their housing unit. Standard operating procedure in
the smaller prison facility was to chain the inmate to the wall or floor if he was
being interviewed. Therefore, interview conditions for 15 inmates included being
chained to the wall or floor. For security reasons, two additional inmates were
interviewed behind a plexiglass partition. All of the interviews were done within
sight of an officer, but could not be overheard, either because the distance was
too great or there were plexiglass walls between the officers and the interviewer
and interviewee.
First, the researcher administered the questionnaire and screened the
volunteer for cognitive impairment by administering the MMSE. Following the
administration of the MMSE, the remainder of the standardized instruments were
administered, in the same order, for all participants, regardless of their cognitive
status so that all inmates received the same treatment. The administration of the
instruments took approximately 45 minutes. However, because of the extensive
unsolicited disclosures on the part of the men, interviews ranged from 1 to 3
hours, with most averaging 2 hours.
Following the conclusion of the interview process, the participant was
again asked if he had any questions about the study or his participation in it. He
was given a copy of the consent form (Appendix G) and reminded that there was
69
a name of a staff person on it whom he could contact if he wanted to talk about
the study, or his responses to it, at a later date. If he wished to have a letter sent
to him at the conclusion of the study to describe study findings, he was prompted
to indicate so on the consent form. All 90 subjects requested this information.
He was thanked for his help and he returned to his housing unit according to
officer instructions. Data from the interviews were removed from the prison
premises immediately following the interview and stored in a private locked
office.
The record retrieval process for the collection of the medical resource
utilization data followed the interview process. Again, the same researcher
collected this data, with the assistance of both prison and hospital employees.
Statistical Analysis
Descriptive statistics were used to provide a profile of the respondents’
characteristics (Research Question One). The descriptive data analysis included
several indices of central tendency, as well as indices of within- and between
group variability. Information on sample demographics, levels of psychological
distress, ratings of life satisfaction, ratings of health status, use of infirmary
services and satisfaction, and amount and satisfaction with support services
were included.
Stepwise multiple regression analysis was used to examine the
relationships between the variables of psychological distress as measured by the
GDS total score and the global indices of the BSI, and life satisfaction as
70
measured by the LSS subscales and total score. Covariates included racial
identification, current marital status, education, months incarcerated on this
offense, length of sentence, and prison site (Research Question Two).
Correlation analysis was used to examine the relationships between
psychological distress, as measured by the total score on the GDS and the
subscales and global indices of the BSI, and health care utilization as measured
by the number of in-house visits to providers, the number of prescription
medication orders and refills, and the dollar cost of both in-house health care
services and off grounds health care services for an 18-month period of time
(Research Question Three). Correlational analysis was also used to examine
the relationships between life satisfaction, as measured by the subscales and
total score on the LSS, and health care utilization as measured by the number of
in-house visits to providers, the number of prescription medication orders and
refills, and the dollar cost of both in-house health care services and off-grounds
health care services for an 18-month period of time (Research Question Four).
Step-wise multiple regression analyses were used to determine the
relative contributions of psychological distress and life satisfaction to the use of
health care resources. Covariates included racial identification, current marital
status, education, months incarcerated on the current offense, length of
sentence, and prison site (Research Question Five).
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CHAPTER IV
RESULTS
The first part of this chapter presents the descriptive data that provide the
demographic profile of the study participants. Additionally, data are presented
for the separate prison facilities, where appropriate, as well as total numbers and
percentages. The second section of this chapter presents each of the research
questions with a description of the respective analyses and findings.
Summary of Analytic Procedures
Between-group comparisons (Draper and Gunnison facility groups) for
continuous variables (interval scale) were performed using a separate variance
Student’s t Test, or a two-sample t test for independent samples with unequal
variances. This test was used because it does not assume equal variance and it
is more robust with skewed distributions than the Student’s t Test (Rosner,
1995).
Comparison of two groups for unordered categorical variables (nominal
scale) were performed using a Fisher’s Exact Test for variables with two
categories and A Fisher-Freeman-Halton Test for variables with three or more
categories. The Fisher-Freeman-Halton Test is the Fisher’s Exact Test
generalized to greater than 2 x 2 contingency tables (Conover, 1980).
72
Comparison of two groups for ordered categorical variables (ordinal scale) were
performed using a Wilcoxon-Mann-Whitney Test. This label is used instead of
the WilcoxonTest and the Mann-Whitney Test, as they are essentially the same
and give identical P values (Siegel & Castellan, 1988).
Correlational procedures, chosen by level of measurement, were
performed to analyze the relationships between psychological distress and
health care utilization, and life satisfaction and health care utilization. Stepwise
multiple regression models were used to analyze the relationship between
psychological distress and life satisfaction and to determine the relative
contributions of each of these variables to health care utilization.
No statistically significant differences between Draper inmates and
Gunnison inmates were found on most of the demographic variables, with the
exception of self-rated health and amount of support perceived from staff.
Because of the absence of significant differences between the groups the data
for the two sites have been treated as one group.
Preliminary Analyses
Preliminary analyses included examination of all self report measures and
health care utilization data in this sample of prison inmates. Measures of central
tendency and variability were calculated for the subscales and total scores of the
MMSE, GDS, BSI, and LSS, and for the number of health care provider visits,
prescriptions ordered and refilled, and the costs of both in-house and off grounds
73
health care. These results are summarized in Tables 1 through 7 (end of
Chapter IV, pp. 91-95).
Selection Summary
There were 229 eligible inmates on the original list of potential subjects.
The final study sample was composed of 90 volunteers. Seventy-five inmates
(83.3%) in the study sample were housed at the Draper facility; 15 men (16.7%)
were housed in Gunnison. Eighty-eight of the 90 men who participated in the
study were able to complete the interview; 2 individuals did not finish the
interview due to illness. One of these 2 men was recovering from a respiratory
condition and felt too weak to complete the psychological screening instruments.
He was invited to complete the interview at a later date, but, again, was too weak
to do so. The second man who was unable to complete the interview
complained of fatigue. He continued to feel ill and died 6 weeks later.
There were 139 inmates who did not participate in this study for a variety
of reasons. Exclusionary criteria eliminated 107 inmates (46.72%). Fifty-eight
men were eliminated because of their county jail residency; 24 men did not meet
the 1-year residency requirement or were close to being released; 10 men were
transferred to a pre-release or less secure facility; 7 inmates were listed as
"escapees”; 6 men were eliminated because of their status as interstate custody
inmates (they were soon to be transferred); 1 man was eliminated by prison
administrators because he was considered to be a security risk; and 1 inmate
was eliminated because he had previous contact with the investigator.
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Of the remaining 122 men, 32 of them (26.23%) declined to participate.
Approximately half of those who declined to take part in the study offered their
reasons for declining. Several of the non-participants stated that they had
questions about the reporting aspect of the study and felt that the introductory
letter was “ambiguous” or “vague.” Other non-participants commented that they
were uncomfortable with the study; had no reason to participate; and did not take
part in “that sort of stuff.” One of the inmates who declined stated that he would
like to have taken part in the study, but felt that his release date would be
jeopardized if he did so. Another man stated that his case was being appealed
and that his attorney had advised him to speak to no one.
Research Questions and Analysis
Each research question will be addressed individually, starting with a
summary of the relevant demographic data. In addition, given the rich nature of
the inmates' verbal reports that cannot be captured on self-report measures, a
brief summary of the categories that were most frequently identified by the
inmates is provided.
Research Question One
What are the demographic characteristics (age, ethnicity, marital status,
educational history, work history, religion, crime history, type of current crime and
current sentence), the levels of psychological distress, and the levels of life
satisfaction among elderly male inmates?
75
Demographic Summary
The final sample consisted of 90 male inmates whose age ranged
between 55-80 (M=61.6) years. The ethnic composition of this sample included:
81% Caucasian, 3% Hispanic, 1% African American, and 1% Native American
males. Thirteen percent of the total sample indicated that they had a mixed
ethnic background and did not identify with predominantly one group. The most
frequent combination of interethnic identity included Native American and
Caucasian. At the time of the interview, 33% of the total study sample were
married, 47% divorced, 10% had never married, and 8% were widowed. For 9%
of the sample, marital status had changed since their incarceration and 2% were
unsure of their marital status. Table 8 summarizes the demographic
characteristics of study participants (end of Chapter IV, p. 96).
Education
Seventy-four percent of the men in this sample earned a high school
degree or its equivalent, 14% attended a vocational training, and 47% of the men
attended college for at least one year. O f those who attended college, 30%
earned up to 3 years of college credit, 9% graduated from college, and 8% had
pursued some graduate training.
Occupational History
Vocationally, most inmates had been involved in multiple occupations.
Vocational choices ranged from blue collar to professional, and few of the
inmates anticipated returning to their previous line of work. Twelve percent of
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the inmates claimed indigency, meaning that they had no money in their prison
account, no income, and no job. Indigent inmates received various staples from
the DOC and were not charged a co-pay fee for their medical care. Eighty-eight
percent of the men had some means o f an income.
Religious Preferences
The majority of the inmates endorsed a religious preference with only 14%
declining to identify with a particular religion. Additionally, 47% indicated that
they were involved in religious activities while in prison.
Drug Use History
Thirty-four percent of the men stated they had never used tobacco; 42%
had smoked up to two packs of cigarettes a day; 23% had smoked more than
two packs a day. The highest number of years spent smoking was 65 (M=24.5).
Thirty-nine percent of the inmates identified alcohol as having been a problem for
them; the range of years spent drinking alcohol was 0-63 (M=20.5).
Psychiatric History
Forty-one percent of the inmates acknowledged having previously been
treated for a mental health problem. Twenty-two percent of the men stated they
were currently receiving treatment for a mental health problem; 45% of those
receiving treatment were satisfied with the treatment.
Arrest and Incarceration History
The range in age at first arrest was 16-72 years; 21% of these men had
been arrested for the first time after the age of 50; the highest lifetime number of
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arrests was 55. Fifty-seven percent o f the inmates were serving their first term in
prison; 16% were serving their second sentence; and the highest lifetime number
of incarcerations was 12, (M -2.2). The range in lifetime number of years
incarcerated was 1-35. The time served on the current offense ranged from 12-
293 (M=78) months. Ninety-two percent of the inmates had committed crimes
against persons; 69% of these were sexual crimes victimizing children. Forty-
three percent of the men victimized family members; an additional 11%
victimized both family members and friends. Fourteen percent of the men used
weapons during the current offense. These findings are summarized in Table 9
(end of Chapter IV, p.99).
Research Question Two
Is there a relationship between psychological distress and life satisfaction
among elderly male inmates? Is this relationship influenced by age, ethnicity,
marital status, educational history, work history, religion, crime history, current
Using the eight subscales and LSS total score as the dependent
variables, and the GDS total score and the BSI global indices scores as
independent variables, stepwise multiple regression analysis indicated that a
large percentage of the variability in life satisfaction could be accounted for by
measures of psychological distress. Racial identification, current marital status,
education, months incarcerated on this offense, sentence, and prison site were
used as covariates. Table 10 summarizes these findings (p.100).
Research Question Three
Does a relationship exist between psychological distress and health care
Correlational analyses were performed in order to explore the relationship
between health care utilization and psychological distress as stated in question
three. Eighty-four respondents were included in the analysis. Health care
utilization was measured by number of provider encounters in-house, number of
prescription medications, number of refills, cost of in-house care, cost of care off
grounds, and HCUI for the period of time between January 1, 1998 and June 30,
1999. Psychological distress was measured by the GDS total, the BSI global
indices and subscales of Depression, Anxiety, and Somatization.
The results of these analyses by number of provider encounters and
distress measures indicated that there were no significant relationships, with the
exception of the BSI Positive Symptom Total (r=+.26, £>=0.018), and the BSI
Somatic subscale (r=+.48, £><0.001). Similarly, significant correlations were
noted between the number of prescriptions ordered during this period of time
and the BSI Somatic subscale (r=+.48, £><0.001); and the number of prescription
refills ordered and the BSI Somatic subscale (r=+.39, £><0.001). Total cost of in-
house health care for this period of time correlated with two global indices of the
BSI: the Global Severity Index (r=+.21, |>=0.050 and the Positive Symptom
Distress Index (r=+.23, £><0.03) correlated significantly. Finally, the HCUI and
these same measures of psychological distress demonstrated similarly
79
significantly correlations. The BSI Somatic subscale was significant (r=+.27,
£=0.012). These findings are summarized in Table 11 (p. 101).
Research Question Four
Does a relationship exist between life satisfaction and health care
Life satisfaction was measured by the LSS subscales of Health, Mood,
Meaning, Self- concept, and Total Score. The results of these analyses by
number of provider encounters and life satisfaction measures indicated that there
were no significant relationships, with the exception of the LSS Health subscale
(r=-.61, £<0.001). Similarly, significant correlations were noted between the
number of prescriptions ordered during this time period and the
LSS Health subscale (r=-.58, £<0.001); and the number of prescription refills
ordered and the LSS Health subscale (r=-.54, £<0.001). Total cost of in-house
health care for this period of time correlated significantly with the LSS Health
subscale (i=-.41, £<0.001). Finally, the HCUI and these same measures of life
satisfaction demonstrated similarly significant correlations. The LSS Health
subscale was significant (r=~ 26, £=0.017). These findings are summarized in
Table 12 (p. 101).
Research Question Five
What are the relative contributions of psychological distress and life
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Using the eight subscales and LSS total score, the GDS total score, and
the BSI global indices scores as independent variables,and the number of in
house encounters with health care providers, the number of prescription
medications ordered and refilled, and the cost of in-house and off grounds health
care as the dependent variables, stepwise multiple regression analysis were
performed. Table 13 summarizes these findings (p. 102).
At this juncture in the reporting of the results of the study, the qualitative
interview responses of the participants will be reviewed. These disclosures help
to elucidate the inmate’s experience of confinement and to broaden our
understanding of the human dimension and vulnerabilities of these individuals.
Qualitative Interview Responses
Self-Rated Health
The men were asked to rate their current health condition as excellent,
good, fair, or poor. There appeared to be a difference between the Draper and
Gunnison inmates on this variable, with the Gunnison inmates identifying
themselves as healthier. However, as previously mentioned, the sample from
Gunnison is too small to consider this difference clinically significant. Table 14
summarizes this data (p. 104).
Inmates were asked to identify, from a list, which health problems they
had experienced in the past or were having a problem with at the time of the
interview. They identified an average of eight health problems, with an average
of 2.6 problems for which they were currently receiving treatment. Those health
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conditions listed most often were cardiac/circulatory disease, respiratory
problems, gastrointestinal problems, and various cancers.
Infirmary Use
In 1994, the Utah DOC implemented a co-pay policy for medical services.
Inmates are required to pay $4.00 for each visit and $.50 for each prescription
that is filled. Payment is subtracted from their personal inmate account. In the
case of indigent inmates, there is no charge.
The men were asked to indicate how many times in a month or in a year
that they believed that they used the infirmary services. Their responses ranged
from 0 to 175 times per year, (M=10). Their actual number of visits to the
infirmary in the year 1998 were retrieved from prison records. Ninety-three
percent of the men underestimated their use of the infirmary, (M=16 visits).
Additionally, the men were asked to identify reasons that would keep them from
using the infirmary. These findings are summarized in Table 15 (p. 104).
Fears about not receiving appropriate health care at the prison were
numerous; reasons for their fear were extensive and graphic. The men told
detailed accounts of their frustrations in getting their health care needs
addressed: “I was without my medication for 2 months on one occasion. This
happens two or three times a year”; “I had a stroke and they kept me in the
infirmary for six weeks. I had no treatment at all”; “I was passing kidney stones
and asked for something for the pain. I was told that I couldn’t have been in that
much pain”; “I would like to participate in my own health care, but we are never
82
told any of our test results”; “I bled rectally for 9 weeks. They wouldn’t do
anything about it. Finally I was admitted to the University for severe anemia”;
“Twelve requests and 18 days after my fall, they finally did an x-ray. I had
injured 3 vertebrae”; “A guy from my housing unit broke his ankle. They wouldn’t
x-ray it. They kept telling him to take aspirin for the pain. Six weeks later his
ankle blew up with gangrene and they had to amputate his foot”; “I have
witnessed four or five deaths while I've been here. I saw a guy from my housing
unit die over here. They checked him out for an hour and then sent him back.
He lay down and asked for help. The officers were going to write him up for
causing trouble. Next morning he was dead."
Prison Housing
There has been concern expressed in the literature regarding whether to
house elderly inmates in segregated residential units or integrated units with
inmates of all ages (Aday, 1994). The advantages for segregation include
minimizing inmate vulnerability to victimization by younger inmates and providing
facility accommodations for specific elder needs. The advantage for integration
centers on using the elderly element of the prison population as a means of
moderating the energy level of the younger inmates.
In both facilities, older inmates were housed throughout the prison.
However, in the Gunnison facility, 60% of that group of participants were housed
together. The reason for this congregation of elderly men was unclear. In
Draper, there were three housing units that accounted for almost 60% of the
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residences of stud/ participants. Assignment rules to these three housing units
were not consistently employed. Generally speaking, one of these units was
located closer to the infirmary for those men who may need fast access to care;
one of these units was designed as a sex offender treatment unit and housed 10
of the elders in this study; and the third unit had no particular designation.
All of the participants were asked if they preferred living with similarly
aged individuals or mixed ages. Over half stated that they preferred living with
elders. Their comments regarding this choice centered on the difficulties in living
with “young punks” who (a) are trying to establish themselves in the prison
pecking order; (b) have no regard for human life (i.e., “they would just as soon
stick you”); (c) do not share or understand the history of the older men or what
they talk about; and, (d) are too loud and disrespectful of the elders’ special
needs (i.e., heating, cooling, mobility problems). Participants who preferred
living with mixed ages (34%) of inmates gave several reasons for their choice.
They stated that they wanted to be around young ideas and young people; they
did not consider themselves to be elderly; and they thought it would be
depressing to be around old men. Six percent of the men stated that they had
no preference regarding the ages of their cell mates; 6% had no comment in
response to the question.
Involvement in Activities
Responses to the question “What activities or programs do you participate
in at the prison?” were varied and included (listed in descending order by
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frequency): therapy, church, jobs, school, exercise, and no activity/nothing at all.
Individuals also mentioned reading, crocheting, writing letters, running
businesses, visitation from family and friends, phone calls, playing cards, and
watching television.
Following are further details of the most frequent activities that were
identified.
Therapy
Therapeutic programs included Sex Offender Treatment, Substance
Abuse Treatment, and classes entitled Thinking Errors, Anger Management, and
Life Skills. Delivery of therapy was qualitatively different between the two sites
and may help to explain some of the reported differences between the Gunnison
and Draper inmates perception of staff responsiveness. Gunnison inmates were
more likely to have received individual therapy, as well as group participation,
than were Draper inmates. Draper inmates were more likely to have received
instruction by way of psycho-educational classes, frequently taught by college
students.
Church Activities
Forty-two inmates (47%) acknowledged church activities as being one of
the programs or activities that they participated in at the prison. Being active in
their religious community included activities such as attending services, reading
the Bible or other religious materials, participating in religious classes, working
on geneological projects which were connected to the church, meeting with
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volunteer families from the religious community who visited them regularly (i.e.,
Family Home Evening), and singing in the church choir.
Em ploym ent
A number of inmates acknowledged having a job assignment at the
prison, although many claimed that there were not enough jobs available.
Wages ranged from $.40 an hour for janitorial positions, to minimum wage
positions in the prison computer center and furniture shop.
Education
Educational endeavors included literacy programs, GED coursework, and
university classes. Sixty percent of the men in Gunnison were enrolled in school
in Gunnison; 20% of the men in Draper attended classes.
Physical Activity
A small percentage of the men (11%) were active in self-initiated exercise
programs. A few of these individuals had competed professionally in body
building and maintained their work-out regime while incarcerated. However,
access to exercise equipment and areas were extremely limited; no specific time
was allotted for the elderly men to use the facilities; and many alluded to the
necessity and hassle of competing with younger men to do so. While walking in
the yard was available to everyone as an exercise option, the men in some
housing units were forced to stay outside for 1 hour at a time if they went out,
and for many this was a problem.
Range of Support
Support From Outside the Prison
Participants reported a range of support from outside of the prison.
Specifically, the men were asked to indicate how many visits, letters, and phone
calls they received monthly. Forty-seven percent of the inmates indicated that
the amount of support that they received from outside of the prison was
adequate, i.e., they were satisfied with it. An equal number of inmates indicated
that they would have preferred to receive more support than they had been
receiving. None of the men indicated that they preferred less support, although
the following sentiments regarding visits and outside contact were mentioned by
a number of participants. “It’s hard to hear about the outside. If there are
problems there is nothing I can do about it anyway”; “It’s too hard to watch them
leave.. .1 would rather they did not come”; and finally, “I don’t want them to see
me here like this. I don’t let them visit.” Friends and relatives were discouraged
from visiting for other reasons, as well. Inmates were concerned about how their
loved ones were treated by prison security staff as they were processed through
security gates and escorted to visitation rooms. Many of the men had family that
lived too far away to make the drive worth the 2-hour visit allowed. Several men
stated that their wives were not well enough to make the trip. Finally, the
inmates acknowledged that they found it too difficult to keep connected to both
worlds (inside and outside). Over half of the men indicated that they did not
have visitors. Several of them stated that the interview for this study was the first
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direct contact with someone from the outside that they had had for a number of
years.
The average number o f phone calls per month was six. However, one
third of the men reported no regular phone calls each month. Another third of
the men were in contact by phone up to four times per month. The remainder of
the participants made between 5 and 60 phone calls per month. Those inmates
who made greater use of the phone were generally operating businesses or
managing legal work from inside of the prison.
The number of letters received per month ranged from 0 (21 inmates) to
120. Four inmates represented the higher end of this range, receiving between
two and four letters per day. Many of the men complained that they did not
receive all of the mail that was sent to them, nor did all of their mail go out as
they had sent it.
Support From Inside the Prison
Seventy-eight percent of the inmates reported that they had confided in or
felt that they could confide in their fellow inmates. There appeared to be a sense
of community among these elders. For example, they described watching out for
one another’s health, taking care of each other after illness or surgery, and
ensuring that someone in their community who was particularly vulnerable would
not be harassed. Many of the older men spoke reminiscently of the criminal
code of conduct that they had experienced in years past in prison. This past was
characterized with statements about the importance of “doing your own time,”
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providing for a sense of inmate solidarity by “gang memberships being left at the
door,” and maintaining a sense of right and wrong. One man summarized it
thusly: ‘These young guys have no sense of morals or family. They would just
as soon stick you. Life means nothing to them.” There was a difference
between the two prison sites in the amount of support that the inmates perceived
from staff. In Gunnison, 80% of the men felt supported; in Draper, 48% of the
men felt staff support.
As regards satisfaction ratings with the amount of support they felt they
had from prison staff and each other, 49% of the inmates reported they were
satisfied with what they currently had, 14% reported that they would like more
support, and 2% reported that they would like less.
Concerns and Problems
Recent Concerns Outside the Prison
The participants were asked if there had been any particular recent event
outside of the prison that was of concern to them. Most frequently men spoke of
family members who were ill, were in trouble, or had died. They commented,
often about funerals that they had not been able to attend. One inmate, who had
served 10 years, stated that the first thing that he would do when he got out was
go to the cemetery; he had lost 15 close family members since coming into
prison. The men expressed concern over what had become of their possessions
on the outside. A few men spoke of world affairs, politics, recent geological
disasters, and local news stories.
89
Problems Inside the Prison
Half of the participants responded to the question asking “What is your
greatest problem inside the prison?" Their responses included their concerns
about mobility, privacy, safety, being listened to, unexpected transfers,
witnessing homosexual sex acts, getting into trouble, having to kill or hurt
someone, family members coming in to prison (being incarcerated), boredom,
earthquake vulnerability, deteriorating health, losing their sight, and dying.
Future Plans
Responses to the question W hat are your plans for the future?” were
varied. While many of them stated that their immediate plan was to get out of
prison, 66% of the men expressed uncertainty about their release date; 4%
stated that their future plan was to die in prison.
The most frequent type of response included comments about returning to
their families, renewing family relationships, or starting a new relationship.
Examples of these comments are: “I need about 50 years with my woman. She
has waited for 20 years”; “I just want to spend time with my grandchildren"; “If my
family will have me back, that is all I want’; “I am going to find me a young wife”.
The second most frequent type of response to the question about future
plans included comments about finding work or a way to make a living. Few
anticipated returning to their previous work. They gave several reasons for this:
(a) They would be too old and unable to do what they had done before; (b) they
had retired prior to their incarceration; (c) they could no longer work with children
90
because of their status as sex offenders; and (d) their professional licensing had
been revoked because of their incarceration. One individual was quite clear
about his intention to reoffend: “I will go out and burglarize. I have several
ideas. It is all I know that will support me at this point in my life.”
Other responses to the question about future plans included traveling,
going to school, working on improving their health (having delayed surgical
procedures, getting new teeth, consulting with specialists), recreating, getting (or
staying) involved in church work, doing volunteer work, and continuing (or
starting) therapy. All of the participants were able to identify at least one future
oriented idea or plan; many also stated, conditionally, that “it depends.”
91
Table 1. Mini-Mental Status Exam: Summary of Results
Draper Gunnison Total

(n = 72)a CD. —15) (N = 87)
Mean SD Mean SD Mean SD
Mini-Mental Status Exam 27.9 1.9 28.9 1.2 28.1 1.9

(MMSE)b
(Number of points earned out of
30 points)
a Number of inmates at each site.
b Higher points indicate greater cognitive capacity. Score of 20 points or less indicates
cognitive impairment and need for further evaluation.
Table 2. Geriatric Depression Scale: Summary of Results

(n = 72)a (n = 15) (N = 87)
Mean SD Mean SD Mean SD
Geriatric Depression Scale 8.5 6.4 6.7 6.2 8.2 6.4

(GDS)b
Depressive category n (%) n (%) n (%)
determined by score
Normal (0-10) 46 (63.9) 11 (73.3) 57 (65.5)

Mild (11-20) 22 (30.6) 3 (20.0) 25 (28.7)
Moderate-Severe (21-30) 4 ( 5.6) 1 ( 6.7) 5 ( 5.7)
a Number of inmates at each site.
bNumber of responses indicating depressive symptoms out of 30 total points.
92
Table 3. Brief Symptom Inventory Scale: Summary of Results
Draoer Gunnison Total Ranae

(n=72)a (n=15) (N=87)
Mean SD Mean SD Mean SD Min Max
Subscale
(Norm)b
Somatic (54) 60.3 13.0 58.9 14.1 60.1 13.2 42 80
Obsessive (54) 58.3 11.2 55.9 11.3 57.9 11.2 39 80

compulsive
Interpersonal (53) 57.9 10.1 58.3 10.5 58.0 10.1 44 80
sensitivity
Depression (54) 61.6 11.2 58.9 10.8 61.1 11.2 43 80
Anxiety (53) 58.0 12.8 52.9 12.9 57.1 12.9 41 80
Hostility (53) 52.5 10.3 51.6 10.5 52.3 10.3 40 76
Phobia (56) 55.8 9.8 52.6 7.1 55.3 9.5 47 76
Paranoia (52) 61.6 9.2 57.9 12.0 61.0 9.8 42 80
Psychoticism (55) 64.3 11.2 61.8 11.6 63.9 11.3 46 80
Global Indices
Global Severity Index 62.8 10.8 58.6 12.2 62.1 11.1 39 80
(G S If (53)
Positive Symptom 59.7 8.3 57.3 8.8 59.3 8.4 44 80
Distress Index (PSDI)
(54)
Positive Symptom Total 60.2 9.5 57.1 9.6 59.7 9.5 39 80
(PST) (52)
aNumber of inmates at each site.
b Normal population mean values of non-patient adults.
c Higher scores indicates more distress.
93
Table 4. Life Satisfaction Scale: Summary of Results
Draper Gunnison Total Range

(n = 72)a (n = 15) (N = 87)
Mean SD Mean SD Mean SD Min Max
Subscale
1. Daily Activities 16.4 3.7 18.1 3.3 16.7 3.6 7 25
2. Meaning 16.2 4.2 16.7 4.5 16.3 4.2 5 24

3. Goals 15.5 3.6 15.3 4.2 15.5 3.7 1 22
4. Mood 19.1 3.3 19.1 4.2 19.1 3.4 10 25
5. Self Concept 17.3 3.3 18.7 2.9 17.5 3.3 8 24
6. Health 15.4 4.9 16.3 4.7 15.6 4.8 5 25
7. Finances 16.3 5.1 15.3 4.9 16.1 5.0 5 25
8. Social Contact 17.8 3.7 19.6 3.9 18.1 3.7 7 25
Total Score* 134.0 21.9 139.1 24.3 134.9 22.2 77 184
Note: Higher score indicates more positive evaluation of life satisfaction.
3Number of inmates at each site.
bTotal score out o f 200 on all scales.
Table 5. Cost of Health Care Provided to Study Participants
Site Where Care 1998 1999 1998-99

Provided (12 months) (6 months) (18 months)
ln-Houseb n!=86 n=84 N=89
Mean 616C 473 995

Median 313 252 546
Range 7 -4 ,3 1 5 7 - 3,281 1 8 -7 ,0 2 5
Outside/Off Grounds'1 n=36 n=33 n=46
Mean 4,412 2,734 5,416

Median 735 762 1,489
Range 27 - 39,253 9-25,411 9 - 58,939
In-House/Off Grounds ri=45 n=45 n=89
Mean 4,360 2,635 3,797

Median 1,074 985 742
Range 21 -43,568 7 - 25,999 1 8 -6 1 ,8 0 7
a Number of inmates.
bHealth care provided within the prison.
c Number shown in dollars ($).
d Health care provided by all sites external to the prison.
95
Table 6. In-House Health Encounters: 1/1/98 to 6/30/99
Draper Gunnison Total cost

Number of Number of dollars ($)
encounters3 encounters
Mean 28.5 19.1 $ 342.30
Median 19.0 16.0 $ 203.00
Range 2 to 116 2 to 54
a Number of encounters by any provider.
Table 7. In-House Prescription Medications: 1/1/98 to 6/30/99
na Mean Median Range
Prescriptions Ordered 83 8.7 7.0 1 to 29
Prescriptions Refilled 82 14.5 10.0 1 to 48
Medication Cost ($) 84 $ 590.30 $ 189.00 0 to $6,401.90
aNumber of inmates.
96
Table 8. Demographic Characteristics of Study Participants
Characteristics rf. (%)

Age
5 5 -5 9 44 (49)
6 0 -6 4 25 (28)
6 5 -6 9 11 (12)
7 0 -7 4 5 ( 6)
75 + 5 ( 6)
Mean 61.6
Ethnicity
Caucasian 73 (81.1)
Hispanic 3 ( 3.3)
African-American 1 ( 1-1)
Native American 1 ( 1-1)
Other 12 (13.3)
Marital Status
Incarceration Date
Married 38 (42.2)
Divorced 39 (43.3)
Single 6 ( 6.7)
Widowed 7 ( 7.8)
Interview Date
Married 30 (33.3)
Divorced 42 (46.7)
Single 9 (10.0)
Widowed 7 ( 7.8)
Unsure 2 ( 2.2)
EmDlovment Status
Employed 44 (48.9)
Not Employed 5 ( 5.6)
Unsure / No response 41 (45.6)
Education
High School Diploma or GED
Yes 67 (74.4)
No 23 (25.6)
College (1-3 years) 27 ( 30)
College Degree 8 ( 9)
Advanced Education 7 ( 8)
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Table 8— continued
Characteristics n (%)
Financial Status
Indigent 11 (12.2)
Not Indigent 79 (87.8)
Reliaion
Mormon 44 (48.9)
Catholic 10 (11.1)
Baptist 4 ( 4.4)
Protestant 2 ( 2.2)
Other 17 (18.9)
None 13 (14.4)
Activities in Prison
Therapy 66 (73.3)
Church 42 (46.6)
Jobs 30 (33.3)
School 24 (26.6)
Exercise 10 (11.1)
No activities 10 (11.1)
SuDDort
Outside Prison
Visits fDer month)
Zero visits 49 (54)
1 to 4 visits 28 (31)
5 or more visits 13 (15)
Telephone calls fDer month)
Zero calls 33 (37)
1 to 4 calls 32 (36)
5 to 12 calls 15 (17)
more than 12 calls 10 (10)
Letters fDer month)
Zero letters 21 (23)
1 to 4 letters 35 (39)
5 to 15 letters 24 (27)
more than 15 letters 10 (11)
Satisfaction with external suDDort
Would like more contactfsuDDort 42 (46.7)
Would like less contact/support - -
Satisfied with contact/support 42 (46.7)

Unknown 6 ( 6.7)
98
Table 8— continued
Characteristics H (%)
Support (cont)
Inside Prison
Fellow Inmates
Yes 70 (77.8)
No 20 (22.2)
Prison Staff
Yes 48 (53.3)
No 42 (46.7)
Satisfaction with internal suDDort
Would like more contactfsupport 13 (14.4)
Would like less contact/support 2 ( 2.2)
Satisfied with contact/support 44 (48.9)
Unknown 31 (34.4)
Drug Use Years'5 Ranae
Alcohol
Number of years of use 20.5 0 to 63
Problematic - Yes 35 (38.9)
No 55 (61.1)
Tobacco
Number of years of use 24.5 0 to 65
Mental Health
History of Treatment
Yes 37 (41.1)
No 53 (58.9)
Current Treatment
Yes 20 (22.2)
No 70 (77.8)
b Average number of years.
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Table 9. Arrest and Incarceration History
Characteristic o! (%)
Current Offense fN = 90V3
Sexual crime against a child 62 (68.9)
Homicide 11 (12.2)
Burglary 4 ( 4.4)
Sexual crime against an adult 3 ( 3.3)
Possession /distribution of illegal drugs 3 ( 3.3)
Assault 2 ( 2.2)
Forgery 2 ( 2.2)
Driving under the influence 1 ( 1.1)
Communication fraud 1 ( 1.1)
Conspiracy to kidnap a child 1 ( 1.1)
Sentence (N = 90)
Up to five years 11 (12.2)
More than five years 31 (34.4)
Up to life in prison 43 (47.8)
Life in prison 4 ( 4.4)
Death 1 ( 1.1)
Crime Victim (N = 90)
Family member 39 (43.3)
Non-family member 31 (34.4)
Both family member and non-family member 10 (11.1)
Unknown 3 ( 3.3)
Property crime 7 ( 7.8)
Lifetime total number o f incarcerations

(Mean - 2.2, range - 1 to 12)
1 51 (57.3)
2 14 (15.7)
3 9 (10.1)
4 6 ( 6.7)
5 1 ( 1.1)
6 6 ( 6.7)
9 1 ( 1.1)
12 1 ( 1.1)
3Total number of inmates included.
bNumber of inmates.
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Table 10. Multiple Regression Results of Life Satisfaction Measures as Criterion

Variables and Psychological Distress as Predictor Variables
Criterion Variable Predictor R2 beta £ value

Variable value
LSSa - Total Score GDSb 0.63 -0.59 <0.001
BSI-PST -0.27 0.002
LSS - Daily Activities GDS 0.42 -0.65 <0.001
LSS - Meaning GDS 0.46 -0.50 <0.001
BSI-PST -0.24 0.024
LSS - Goals GDS 0.27 -0.52 <0.001
LSS - Mood GDS 0.52 -0.72 <0.001
LSS - Self Concept GDS 0.33 -0.29 0.013
BSI-PST -0.34 0.005
LSS - Health BSI-PST 0.32 -0.51 <0.001
Months -0.31 0.003
Incarcerated
Sentence -0.24 0.023
LSS - Finances GDS 0.26 -0.51 <0.001

LSS - Social Contact GDS 0.26 -0.47 <0.001
Race -0.19 0.035
Education -0.28 0.002
Months -0.26 0.004
Incarcerated
a LSS- Life Satisfaction Scale - (subscale).
b GDS- Geriatric Depression Scale.
c BSI-PST- Brief Symptom Inventory - Positive Symptom Total Global Index.
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Table 11. Correlational Analysis of Health Care Utilization and Psychological

Distress: 1/1/98 to 6/30/99
Health Care Variable BSI Somatic BSI / GSIb BSI / P S T

Subscale3
Provider Encounters r = +.48, NSd r = +.26,
g<0.001 £=0.018
Number of Prescriptions r = +.48, NS NS
£<0.001
Number of Refills r = +.39, NS NS
£<0.001
Cost ($) - In-House £ = +.27, r = +.21, r = +.23,
£<0.011 £=0.05 £=0.03
Cost ($) - Off Grounds NS NS NS
Health Care Utilization r = +.27, NS NS

Index £=0.012
3 BSI = Brief Symptom Inventory: Somatic Subscale.
6 GSI = Global Severity Index.
c PST = Positive Symptom Total.
d NS = not significant.
Table 12. Correlational Analysis of Health Care Utilization and Life Satisfaction:
1/1/98 to 6/30/99
Health Care Variable LSS Health Subscale3
Provider Encounter r = -.61, p<0.001

Number of Prescriptions r = -.58, p<0.001
Number of Refills r = -.54, p<0.001
Cost ($) - In-House r = -.41, p<0.001
Health Care Utilization Index r = -.26, p=0.017
3 LSS = Life Satisfaction Scale: Health Subscale.
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Table 13. Multiple Regression Results using Health Utilization as Criterion

Variable and Life Satisfaction and Psychological Distress as Predictor
Variables
Criterion Variable Predictor Variable R2 beta ^ value

value
Provider Encounters LSS - Health3 0.37 -0.61 <0.001
Number of Prescriptions LSS - Health 0.40 -0.58 <0.001
LSS - Social Contact +0.24 0.008
Number of Refills LSS - Health 0.37 -0.52 <0.001
LSS - Social Contact +0.29 0.002
Cost ($) - In-House LSS - Health 0.17 -0.41 <0.001
Cost ($) - Off Grounds No variable ---- ---- ----
Health Care Utilization LSS - Health 0.07 -0.26 0.017

Index
..
3 LSS - Life Satisfaction Scale - (subscale).
103
Table 14. Self-Rating of Physical Health Condition

(na=75) (n=15) (N=90)
Self-Rating of Health
n (%) n (%) n (%)
Excellent 16 (21.3) 6 (40.0) 22 (24.4)

Good 21 (28.0) 6 (40.0) 27 (30.0)
Fair 19 (25.3) 1 ( 6.7) 20 (22.2)
Poor 18 (24.0) 2 (13.3) 20 (22.2)
No answer 1 ( 1.3) ■■■ 1 ( 1.1)
104
Table 15. Infirmary Use
Mean Number of Encounters/Year

Estimated Encounters 10.25
Actual Encounters 15.5
Number of Inmates
Reasons for not using the Infirmary Services
I am never sick. 13
It is too expensive. 25
I don't like the staff. 24
It doesn’t do any good. 41
I don't like the facility. 11
It takes too long to get an appointment. 50
It is too much of a hassle. 40
I am worried about what others might 1
think.
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CHAPTER V
SUMMARY
Purpose and Research Questions
This study investigated the relationships between psychological distress,
life satisfaction, and health care utilization in the lives of a sample of elderly male
inmates. Previous research has examined these constructs among the
community dwelling elderly and among the general inmate population. Among
the elderly there is evidence to suggest that psychological distress may be
under-recognized and undertreated; that a key factor in the assessment of
elderly life satisfaction is health status; and that comorbidity and the decision to
seek health care services among the elderly is a complex one.
Among the inmate population, research efforts have focused on the
adjustment process to prison life. Early theories of inmate adaptation suggesting
eventual psychological deterioration have not been confirmed; more recently
investigations favor an interactionist approach to the understanding of inmate
adaptation. That is, consideration of personal inmate characteristics,
environmental particulars, and the meaning and interaction between them must
be included in order to understand this adaptive process. No empirical research
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has focused on these constructs, psychological distress and life satisfaction,
among the elderly inmate population.
This growing elderly element of the inmate population is anticipated to
present huge demands on the correctional system. For one, the system is
already overtaxed. Second, elders as presented in the community dwelling
literature, have unique needs. If these needs are paralleled in the elderly prison
population, the correctional system is unprepared and without a template on how
to deal with the problems. Third, the number of aging Baby Boomers portends
greater stress on the correctional system in the coming years. The specific
intent of this project was (a) to describe the demographic characteristics of an
elderly male group of inmates, (b) to assess levels of psychological distress and
life satisfaction, (c) to analyze the cost of health care utilization for an 18-month
retrospective period of time, and (d) to examine the inter-relatedness of these
variables.
Lewin’s field theory offered a useful framework through which to view the
inmate’s experience and interpretation of it. In concert with Lewin’s field theory
paradigm, the inmates were asked for their evaluation of their environment,
themselves, and the interaction between these elements. Stressing the
importance of the insider’s perspective on the nature of reality, field theory’s
principle of reciprocity of the interaction between environment, person, and
behavior, provided a structure through which to examine the constructs of
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psychological distress, life satisfaction, and the inmate's decision to seek health
care.
Five research questions were investigated:
Literature Review
A literature review was conducted that examined the supporting literature
in several content areas as well as related populations. Content areas included:
elderly inmates, psychological distress, life satisfaction, inmate adaptation, and
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health care utilization. Studies were reviewed that targeted similar populations:
the elderly, the inmate population, and finally the geriatric inmate population.
Summarizing the existing literature, the following can be concluded: (a)
there have been an increasing number of elderly arrests, adjudication, and
incarcerations, as well as an increasing interest in the concerns of this
population; (b) literature regarding the psychological distress of elderly inmates is
inconclusive and contradictory; (c) similar to Lewin’s field theory, recent studies
on the adaptive capacity of younger inmates favor an interactionist perspective,
emphasizing the importance of a combination of personal characteristics,
environmental constraints, and the interaction of these to determine inmate
adjustment; (d) life satisfaction, as subjectively evaluated by the inmate, has not
been considered in the studies of adaptation or life satisfaction of these men;
and (d) information on the health care utilization of elderly inmates has not been
available.
Methodoloov
Ninety volunteers participated, representing 74% of the inmates who were
initially invited to take part in the study. Participants were housed in two prison
facilities in the state of Utah. These participants were interviewed, and assessed
for psychological distress as measured by the Brief Symptom Inventory and the
Geriatric Depression Scale. Participants were asked to evaluate their current life
satisfaction as measured by the Life Satisfaction Scale. Information regarding
109
criminal history and health care utilization data were retrieved by record review.
Data was collected over a period of approximately 12 months.
Results
The results of this study provide both a qualitative and quantitative body
of data through which the experience of this elderly inmate sample may be
elucidated. Eighty-eight men completed the entire interview and assessment
process. The men who chose to participate in this study appeared eager to talk
about themselves and their situations. Once assured of confidentiality, they
spoke freely of their concerns, personal losses, health problems, difficulties
navigating the legal and correctional systems, and fears of dying in prison.
Interviews averaged two hours in duration. For many of them, the interview was
the first direct contact that the inmate had with someone from the outside in
several years.
Derived from the Lewinian concept of action research, Sanford (1982)
proposed the idea that the interview is an intervention, “. . . a tool for helping
people think and talk about relevant aspects of their lives” (p. 899). Such
appeared to be the case in the preponderance of these interviews. Many of the
men expressed appreciation for the opportunity to speak of their situations, and
gratitude for being respectfully listened to. For example, when asked to write a
sentence for the MMSE, several wrote about their pleasure in taking part in the
study. Half of the inmates were tearful as they answered the interview
questions, and it was not unusual for an inmate to comment following the
110
interview, that he felt better after talking. Several inmates sent letters of
appreciation for the opportunity to participate through the prison mail system.
Some of the study participants considered themselves to be doing well.
They thought their quality of life had improved since coming to prison, giving
examples of having time to read and think; not having access to alcohol; not
having to face the stress of daily decisions, and not having to earn a living. They
commented that they had access to health care, regular meals, and more rest.
One man who was particularly satisfied with his situation said that his life had
improved, he had plenty of people to talk to, and his wife could not nag him
anymore.
On the other hand, many of the men expressed humiliation and horror.
They worried about their families; they grieved the loss of their personal dignity;
they feared for the welfare of their victims; they anticipated their health
worsening and were afraid of getting substandard health care; and they were
unsure of their future and reluctant to make plans. Doing time, one day at a
time, was a common mantra.
The preponderance of the inmates spoke of their difficulty in living with the
negative staff element in their environment. The inmates agreed that their
punishment was to be incarcerated, but adamantly objected to the humiliation
and subjugation they experienced by the staff. The inmates complained that the
hostility, derision, and disrespect that was delivered daily by members of both
the security and medical staff, made life unnecessarily painful. One participant
111
summarized it thusly: “They look at us like we’ re not human. We know what
we’ve done. We may be convicts but we are still human beings.” It is not
possible to know what influence this has had on the inmates' levels of
psychological distress and life satisfaction, but the environmental component of
disrespect and minimization was an obvious and powerful force, by virtue of the
numbers of participants that commented on it, and the number of incidents
witnessed by the researcher.
The profile of the average participant in this study is a man in his early
sixties, Caucasian, divorced, Mormon, high-school educated, with limited contact
from outside the prison (most likely an occasional letter). He probably considers
himself in good health, although he is likely being treated for at least two chronic
illnesses. He is serving a sentence for the sexual offense of a child (most likely a
family member), has had multiple victims, has been incarcerated about 6 years,
is unsure of his release, and may spend the rest of his life in prison. He is
currently involved in therapy and/or church activities. He is generally more
psychologically distressed than his community dwelling peers, and less satisfied
with his life. His assessment of his current situation can be summarized: “I get
by.”
Discussion and Implications
Descriptively this study sample appeared to be different than the samples
of two other studies that included elderly inmates. Two-thirds of these inmates
were serving time for having committed a sexual crime. This figure appears to
112
be unusually high. Teller and Howell (1981) reported that 5% of their sample
were serving time for sexual offenses. Koenig and his colleagues (1995)
reported that 57% of the men in their sample were serving time for drug charges,
mostly abuse; only 3% of the inmates in this study were committed on drug
charges, and these were primarily for distribution of substances. The mean age
of the men in the current study also tended to be older than either of these study
samples (Koenig et al., 1995; Teller & Howell, 1981).
Responses to the objective self-report assessment measures used in this
study provide another lens through which to understand these inmates.
Comparable to the higher prevalence rates of distress as reported by Parmelee
and her associates (1989), results on the GDS indicated that one third of this
sample were experiencing mild to severe symptoms of depression at the time of
the interview. Eighty-three percent of those inmates endorsing depressive
symptomatology obtained scores in the GDS mild category, evidencing the
experience of subsyndromal depression as described by Blazer (1993) and
Friedhoff (1994). Similarly, results on seven (78%) of the BSI subscales and all
three of the BSI global indices demonstrated that these men experienced greater
psychological distress than would be expected from a similar nonpatient sample
of elders. These results support the findings of Aday (1994), Gillespie and
Galliher (1972), and Koenig and his colleagues (1995).
Results on the LSS indicated that this group of elderly men evaluated
themselves as experiencing less life satisfaction than their community-dwelling
113
peers. However, contrary to the interpretation by Gillespie and Galliher (1972)
that signs of distress obliterated their hope for the future, all of the participants
were able to identify at least one future-oriented plan.
Health care utilization data suggested great variability between individual
inmate use. There was evidence that use of health care resources (infirmary
visits and prescription medications) correlated with indicators of somatic
symptom count and poorer health status. There were indications that the costs
of in-house care have risen between 1998 and 1999. Interpretation of off
grounds health care costs was hampered due to difficulties in obtaining accurate
and thorough records, although the range in costs did fall within the parameters
as indicated by Clair and colleagues (1993) and Donziger (1996). Although the
participants in this study were considerably older than the inmates in Gallagher’s
1990 study, their concerns regarding the health care services at the prison and
the negative attitudes of the medical staff were similar. The inmates’ decision to
seek health care was elucidated by their expression of concerns regarding
complicated accessibility to substandard in-house treatment delivered by rude
staff. These concerns were similar to those expressed in the Gallagher study
(1990) in Canadian correctional facilities.
The conclusion that can be drawn from these results is that, in this group
of elderly inmates, there is evidence of considerable psychological distress,
consistently lower assessment of life satisfaction, increased health care
114
expenses from January of 1998 through June of 1999, and the likelihood of at
least half of these men remaining incarcerated for the rest of their lives.
Wright's concept of spread (1960) is useful in explaining the possible
thought process and subsequent behavior of some of the staff. It also may
further understanding, regarding the inmates use of health care resources.
Wright defines spread as the power of single characteristics to evoke inferences
about a person or a trait that is known. In other words, because he is an inmate,
an inmate is a liar, stupid, mentally ill, fiscally irresponsible, a degenerate, a
sexual pervert, a monster, and lacking compassion. With this line of thinking,
one would assume that if an inmate was asking for help, he would be lying about
his symptoms, trying to get unnecessary attention, and attempting to acquire
drugs. Many of the participants explained their refusal to go to the infirmary for
help because of having been treated poorly in the past.
The processes of differentiation and regression, as described by Lewin
(1951), serve as a model by which to understand the process of study participant
adjustment. In order to elicit compliance and maintain control, correctional
philosophy does not value autonomy, independent thinking, and free choice.
These skills, acquired in what Lewin referred to as the differentiation process,
are not useful nor rewarded in successful adjustment to prison life. For example,
it would not be in the inmate’s best interest to exercise his reasoning skills when
an officer gives him a direct order; to share his knowledge and expertise about a
complex issue; or to make plans for the holidays. Regression to a less mature
115
state may be more adaptive. Regressive behaviors (e.g., decreases in the range
of emotional variety, language usage, expectations, and future orientation) were
observed. Similar to Zamble and Porporino’s description (1988) of inmate
“behavioral deep freeze,” settling down to do time was a survival process
described by one man: “When I first came in I was more upset and my answers
to these questions [asked in the study] would have been different. Now I don't
think about anything in here. I couldn’t handle it if I did. You just go numb and
do what you are told. My mind is always somewhere else.”
It will be some time before a full understanding of the dynamics between
psychological distress, life satisfaction, and health care utilization in this
population will be reached. Few resources have been allocated to assist inquiry.
Future research recommendations may include the use of larger sample sizes;
longitudinal studies to provide more than a snap-shot view of the circumstances
of these men; development of assessment tools, appropriate in content and easy
to administer, in correctional settings. Thorough recording and accessible record
retrieval would aid in the research process with this population. Additionally,
investigative consideration directed towards the training, beliefs, and behavior of
correctional staff is warranted.
Future Research Considerations
Future areas of research will need to address the concerns of the elderly
inmate as eventual parolees. What steps might be taken to assist them in that
phase of their adjustment process? What will be their experience of
116
psychological distress and life satisfaction, and what will be necessary in order to
provide for their health care needs upon release from prison?
Finally, the next cohort of elderly inmates are literally waiting in the wings.
The group of inmates ages 45 to 55 represents the largest number of inmates
currently incarcerated. Factors such as serving longer minimum mandatory
sentencing, correctional philosophy emphasizing containment rather than
rehabilitation, increased exposure and sophistication about mental health needs
and treatment, and reportedly entering prison in worse physical health than their
predecessors, make these men unique and represent both an ethical and
financial challenge to the correctional system of new proportions.
This study was an initial attempt to investigate the relationships between
psychological distress, life satisfaction, and health care utilization among the
current elderly inmate population in a state prison facility. The qualitative content
of the participants’ disclosures were extensive and rich. Quantitative findings
suggested that these men exhibited levels of psychological distress that were
greater than their community peers; and that their self-evaluation of life
satisfaction placed them far below their community peers. The relationship of
their health care utilization to these variables remains complex and unclear.
Future attempts to unravel these correlates are critical as this incarcerated
population grows in numbers and health care costs continue to rise.
APPENDIX A
INFORMATIONAL QUESTIONNAIRE
118
1. Code number
2. Housing unit Prefer elders?
3. Security level
4. Date of birth
5. Incarceration date
Anticipated release date
Number of times incarcerated
Approximate number of months incarcerated (total)
6. Financial status
(indigent or not)
7. Education
(completed eighth grade, high school, trade school, college, other)
8. Ethnicity/Race
(Black, Caucasian, Hispanic, Asian, other)
9. Life work
(skilled labor, unskilled labor, professional, farmer, business, other)
10. Marital status

(currently married, divorced, single/never married, widowed, unsure)
11. Religious activities/Spiritual involvement

(Mormon, Protestant, Catholic, Baptist, Pentacostal, other)
12. Social support from outside prison

number of visits per week/month
number of phone calls per week/month
letters received per month
12A. Question: How satisfied are you with the amount of contact/support you
have with people on the outside?
119
13. Social support from inside prison

number of fellow inmates
number of staff
13A. Question: How satisfied are you with the amount of

contact/support you have with people on the inside?
14. Physical health status
14A. Question: How would you describe your physical health condition?
(excellent, good, fair, poor)
14B. Question: How satisfied are you with your current physical health
condition?
14C. Question: Have you ever had any of the following health problems?
(Asthma, arthritis, chronic bronchitis, emphysema, kidney disease, bladder
disease, heart trouble, lung trouble, hardening of the arteries, stroke, high
blood pressure, stomach ulcers, cancer, diabetes, sinus trouble, rheumatic
fever, varicose veins, hemorrhoids, hay fever, gall bladder, liver trouble,
stomach problems, thyroid trouble or goiter, epilepsy, skin trouble, hernia,
prostate or urinary problems, tremors, paralysis, back problems, hearing or
vision difficulties, pain, other)
14D. Question: Are you currently being treated for this/these problems?
(Yes, no)
15. Infirmary services

15A. Question: How often do you use the infirmary?
( x per month, x per year)
15B. Question: What reasons keep you from going to the
infirmary?
(Too expensive, don’t like the staff, don’t feel listened
to, it doesn’t do any good, don’t like the facility, never
sick, takes too long to get an appointment, not worth the
hassle, worried about what others might think of me,
other)
16. Activities of daily living

16A. Question: Please indicate the amount of help you need
for the following:
no help some help lots of help
eating
showering
120
dressing
going to the bathroom
(bowel and urine elimination)
climbing steps
getting in and out of bed/chair
16B. Question: Are you satisfied with your

level of functioning/physical abilities? (yes, no)
17. Medications
17A. Question: How many prescription medications are you
currently taking?
17B. Question: How many other medications (OTC) are you
currently taking?
18. Nicotine
18A. Question: Prior to coming to USP, did you smoke
cigarettes? (yes/no)
18B. Question: How much did you smoke when you were smoking
the most? (Number of packs per day)
18C. Question: How long did you smoke? (Number of months)
19. Alcohol
19A. Question: Before coming to USP, did you drink alcohol?
(yes/no)
19B. Question: What did you drink? (Liquor, beer, wine, other)
19C. Question: How much did you drink when you were drinking
the most? (Number of drinksfounces per day)
19D. Question: How long did you drink? (Number of months)
20. Mental health status

20A. Question: Have you ever been treated for a mental health
problem while outside of prison? (yes/no)
20B. Question: What was the problem?
20C. Question: Are you currently being treated for a mental
health problem? (yes/no)
20D. Question: What is the problem?
20E. Question: Are you satisfied with the treatment? (yes/no)
21. Question: Is your quality of life better now than before you came
to prison? (yes/no)
22. Question: Has anything happened recently on the outside that has
upset you or worried you?
23. Question: What activities/programs do you take part in at USP?
24. Question: What is your biggest worry or problem at USP?
25. Question: What are your plans for the future?
APPENDIX B
MINI-MENTAL STATUS EXAM
123
Maximum
Score Score
Orientation
5 ( ) What is the (year) (season) (date) (day) (month)?
5 ( ) Where are we: (state) (county) (town) (building)
(floor)?
Registration
3 ( ) Name 3 objects: 1 second to say each. Then ask
the inmate all 3 after you have said them. Give
1 point for each correct answer. Then repeat
them until he learns all 3. Count trials and
record.
Trials
Attention and Calculation
5 ( ) Serial 7’s. 1 point for each correct. Stop after 5
answers. Alternatively spell “world” backwards.
Recall
3 ( ) Ask for the 3 objects repeated above. Give
1 point for each correct.
Language
9 ( ) Name a pencil, and watch (2 pts)
Repeat the following “No ifs, and, or buts." (1 pt)
Follow a 3-stage command:
Take a paper in your right hand, fold it in
half, and put it on the floor” (3 pts)
Read and obey the following:
“Close your eyes.” (1 pt)
Write a sentence (1 pt)
Copy design (1 point)
Assess level of consciousness along a continuum: Total score:
Alert Drowsy Stupor Coma
Note: Taken from Folstein, M. F., Folstein, M. F., & McHugh, P. R. 1975. Mini
mental state: A practical method for grading the cognitive state of patients
for the clinician. Journal of Psychiatric Research. 12.189-196.
APPENDIX C
GERIATRIC DEPRESSION SCALE
1. Are you basically satisfied with your life? yes/no
2. Have you dropped many of your activities and interests? yes/no
3. Do you feel that your life is empty? yes/no
4. Do you often get bored? yes/no
5. Are you hopeful about the future? yes/no
6. Are you bothered by thoughts you can’t get out of your head? yes/no
7. Are you in good spirits most of the time? yes/no
8. Are you afraid that something bad is going to happen to you? yes/no
9. Do you feel happy most of the time? yes/no
10. Do you often feel helpless? yes/no
11. Do you often get restless and fidgety? yes/no
12. Do you prefer to stay at home rather than going out and doing yes/no
new things?
13. Do you frequently worry about the future? yes/no
14. Do you feel you have more problems with memory than most? yes/no
15. Do you think it is wonderful to be alive now? yes/no
16. Do you often feel downhearted and blue? yes/no
17. Do you feel pretty worthless the way you are now? yes/no
18. Do you worry a lot about the past? yes/no
19. Do you find life very exciting? yes/no
20. Is it hard for you to get started on new projects? yes/no
21. Do you feel full of energy? yes/no
22. Do you feel that your situation is hopeless? yes/no
126
23. Do you think that most people are better off than you are? yes/no
24. Do you frequently get upset over little things? yes/no
25. Do you frequently feel like crying? yes/no
26. Do you have trouble concentrating? yes/no
27. Do you enjoy getting up in the morning? yes/no
28. Do you prefer to avoid social gatherings? yes/no
29. Is it easy for you to make decisions? yes/no
30. Is your mind as clear as it used to be? yes/no
Note: Taken from Brink, T. L., Yesavage, J. A., Lum, O., Heersema, P., Adey,
M., & Rose, T. L. (1982). Screening tests for geriatric depression.
Clinical Gerontologist. 1( 1), 37-43.
Yesavage, J. A., Brink, T. L., Rose, T. L., Lum, O., Huang, V., Adey, M, & Leirer,
V. O. (1983). Development and validation of a geriatric depression
screening scale. Journal of Psychiatric Research. 17. 37-49.
APPENDIX D
BRIEF SYMPTOM INVENTORY SCALE
128
Subscale Item SvmDtom
Somatic 2 Faintness or dizziness

7 Pains in heart or chest
23 Nausea or upset stomach
29 Trouble getting your breath
30 Hot or cold spells
33 Numbness or tingling in parts of your body
37 Feeling weak in parts of your body
Obsessive-compulsive 5 Trouble remembering things

15 Feeling blocking in getting things done
26 Having to check and double-check what you
do
27 Difficulty making decisions
32 Your mind going blank
36 Trouble concentrating
Interpersonal sensitivity 20 Your feelings being easily hurt

21 Feeling that people are unfriendly or dislike
you
22 Feeling inferior to others
42 Feeling very self-conscious with others
Depression 9 Thoughts of ending your life

16 Feeling lonely
17 Feeling blue
18 Feeling no interest in things
35 Feeling hopeless about the future
50 Feelings of worthlessness
Anxiety 1 Nervousness or shakiness inside

12 Suddenly scared for no reason
19 Feeling fearful
38 Feeling tense or keyed up
45 Spells of terror or panic
49 Feeling so restless you couldn’t sit still
Hostility 6 Feeling easily annoyed or irritated

13 Temper outbursts that you could not control
40 Having urges to beat, injure, or harm
someone
129
41 Having urges to break or smash things

46 Getting into frequent arguments
Phobia 8Feeling afraid in open spaces or on the

streets
28 Feeling afraid to travel on buses, subways,
or trains
31 Having to avoid certain things, places, or
activities because they frighten you
43 Feeling uneasy in crowds, such as shopping
or at a movie
47 Feeling nervous when you are left alone
Paranoia 4Feeling others are to blame for most of your

troubles
10 Feeling that most people cannot be trusted
24 Feeling that you are watched or talked
about by others
48 Others not giving you proper credit for your
achievements
51 Feeling that people will take advantage or
you if you let them
Psychoticism 3 The idea that someone else can control

your thoughts
14 Feeling lonely even when you are with
people
34 The idea that you should be punished for
your sins
44 Never feeling close to another person
53 The idea that something is wrong with your
mind
Note: Taken from Derogatis, L. R., & Spencer, P. M. (1982). The Brief
Symptom Inventory: Administration, scoring and procedures manual— I.
Baltimore: Clinical Psychometric Research.
APPENDIX E
LIFE SATISFACTION SCALE
(Items by subscale)
Scale Items
Daily 01. My daily routine is____

Activities 10. I generally plan activities.
22. My schedule of activities is ____
24. Things I do every day give m e____
40. I am pleased with my daily activities
Meaning 02. I am most satisfied with my life situation

11. In general I feel____
31. My present situation is____
33. I regard my life a s ____
39. I am satisfied with the way things are
Goals 03. I think about what I would like to accomplish

14. In my life I have achieved____
21. In looking back, I feel that I have done of the
things I’ve wanted to do.
23. As I look back on my life, I am ___
36. I am happy with the way things turn out
Mood 04. I am in a bad mood.

25. My usual mood is ___
30. People say that I am ____
37. I consider myself to b e ____
38. I am with my outlook on life
Self-concept 13. Compared to any other time in my life I am now

15. How important are you to others?
26. My intelligence is____
27. My physical appearance is ___
32. When it comes to taking care of myself I ___
Health 05. Physically I am ___

06. I take medication
12. I feel pain
28. I am generally___
35. I visit my doctor
132
Finances 07. I have enough money to enjoy myself

17. My current income is
19. I worry about finances
20. My financial status is
34- People think that I am financially well off
Social 08. I try to spend time with people

Contacts 09. I have friends
16. Being with other people is pleasurab
18. I find the company of others to be
29. The time I spend with friends is
Note: Taken from Salamon, M. J.f & Conte, V. A. (1998). Manual for the Life
Satisfaction Scale (LSSV Hewlett, NY: Adult Developmental Center, Inc.
APPENDIX F
INFORMATION SUMMARY
134
July 12,1999
Dear Sir,
A research project is being done with the help of male inmates who are 55 years
of age and older. The purpose of the study is to better understand the health
needs of older inmates. The findings of this research may lead to improved
services within the prison system for older inmates.
Kris Burling, a graduate student in Rehabilitation Psychology at the University of

Iowa, is doing this research project as part of her school requirements. This is
not part of her job. She does not work for the prison, but she can be reached at
the following address:
Department of Corrections
P.O. Box 250
Draper, UT 84020
Kris will be contacting you and asking you to participate. It will take about one
hour of your time. You do not have to take part in the study. Nothing bad will
happen to you if you decide not to participate. The choice is yours. You have
the right to withdraw at any time once you have agreed to participate.
Your participation in the study simply involves answering a number of questions

and giving permission to the researcher to read and record information from your
prison records. Examples of the questions you will be asked are, “Do you ever
feel nervous? Do you have problems sleeping? Are you satisfied with the
amount of support you get from family and friends?”
Examples of the information that will be looked at in your records are, “How
many prescription medications have you used in the last year? Have you been
hospitalized in the past year?”
There are no physical or mental risks to you if you participate. All of the answers
that you give and all of the information that is collected will remain confidential. It
may not be possible to guarantee this confidentiality. For example, I am required
by law to tell an appropriate person if I hear and believe that you are in danger of
hurting yourself or someone else, or if there is reasonable suspicion that a child,
elder, or dependent adult has been abused.
A special coding will be used so that your name will not be connected with any of
the information that is collected. The report that is written at the end of the
project will talk only about older inmates as a group, not about anyone in
particular. The Department of Corrections has agreed to let this study be done.
135
However, none of the information that is collected will be shared with staff,
officers, or other inmates.
You will be given time to ask any questions you may have. Thank you for your
time. I will be contacting you within the next few weeks.
APPENDIX G
CONSENT FORM
137
Title: Inmate study
Researcher Kris Burling
Consent form
The purpose of this research is to study the mental health and physical health
needs of older male inmates. Approximately 100 inmates will be interviewed for
this study. The findings of this research may help to plan for the future health
care needs of older inmates. This study is being done as part of the
requirements for the researcher’s Ph.D. in Rehabilitation Psychology at the
University of Iowa.
If you decide to take part in the study, it will take about one hour of your time.
There will be no other costs to you but this hour of your time. You will be asked
a number of questions about your mental and physicaf health. You will also be
asked to give permission for the researcher to read and record some information
from your prison chart. The benefit of the study is that you may help us
understand the needs of elderly inmates better so that these needs can be met.
There are no risks to you, mentally or physically, by taking part in the study. It is
possible that a participant could become upset by answering some of the
questions. For instance, if your answer to the question, “Do you feel happy most
of the time?” is “No” then you may be reminded that you are not happy and you
may feel upset. Likewise, if your answer to the question, “How is your general
health?” is "Poor" you may be reminded that you have many health problems
and you may feel upset. You will not be asked any questions about the crime
that brought you to prison or your offense/legal history.
You do not have to participate. The choice is yours. Nothing bad will happen to
you if you choose not to be a part of this study. Taking part in the study will not
effect your parole in any way. If you decide to take part in the study, and later
change your mind, you can withdraw from the study. The researcher also has
the right to withdraw a participant at any time.
No one will know what your answers were. The information won’t be shared with
anyone from the prison. A code number will be used so that there is no way for
anyone to know who said what. There are a few reasons why confidentiality
cannot be guaranteed. For instance, I am required by law to tell an appropriate
person if I hear and believe that you are in danger of hurting yourself or
someone else, or if there is reasonable suspicion that a child, elder, or
dependent adult has been abused.
138
You will receive a copy of this consent form. If after the study, you want to talk to
someone about it, you can contact either of the people below.
Kris Burling Dr. Frank Rees

Principal Researcher Supervising Psychologist
Department of Corrections Department of Corrections
P.O. Box 250 P.O. Box 250
Draper, Utah 84020 Draper, Utah 84020
I agree to participate in this study and I understand that:
1. The time required for this study is about one hour.

2. My name will not be used or my identity disclosed.
3. All of my answers will be confidential.
4. I will be asked a number of questions about my health and
how I am feeling. My prison records will also be reviewed.
Nothing will be added/written in them.
5. My participation is voluntary. I don’t have to take part in the
study. Nothing bad will happen to me if I don’t participate.
I can also withdraw at any time without anything bad
happening to me. Taking part in the study will not effect my parole.
6. If I have questions I can ask them at the time of the interview or I can
ask them later by contacting Kris Burling or Dr. Frank Rees.
Signature of participant Date
Signature of witness Date
I want to receive a report on the findings of this study when it is over.
Yes No
APPENDIX H
SUMMARY DESCRIPTION OF VARIABLES
140
Table 16. Summary Description of Variables
Variables Measures Scoring Scaling

Individual Questionnaire Self Report, Categorical,
Characteristics Demographic Information, Continuous
Health Status,
Criminal History
Cognitive Function Mini-Mental Status Self Report; Continuous
Exam. fMMSEI: 30 point instrument;
Folstein, Folstein, & 5 categories;
McHugh, 1975. - Orientation
- Attention
- Calculation
- Recall
- Language
Psychological Geriatric Deoression Self Report; Categorical,
Distress Scale. (GDS1: Assess level of depression; Continuous
Brink, Yeasavage, 30 item instrument; Yes/No;
& Lum, 1982. Dichotomous scoring;
3 categories;
- Normal
- Mild
- Moderate-Severe
Brief SvmDtom Self Report; Continuous
Inventory. (BSD: Assess psychological
Derogatis, 1975. symptom status;
53 item instrument;
5 point Likert scale;
9 symptoms dimensions;
- somatization
- obsessive-compulsive
- interpersonal sensitivity
- depression
- anxiety
- hostility
- paranoid ideation
- phobic anxiety
- psychoticism
3 global indices;
- Global Severity Index
(GSI)
- Positive Symptom Distress
Index ( PSDI)
- Positive Symptom Total
(PSI)
141
Table 16—continued
Variables Measures Scoring Scaling

Life Satisfaction Life Satisfaction Self Report; Continuous
Scale, (LSS); Assess level of
Salamon & satisfaction across eight
Conte, domains:
1998. - Daily activities
- Goals
- Mood
- Meaning
- Self-concept
- Health
- Finances
- Social contacts
5-point Likert scale
Health Care Health Care Record retrieval; Continuous
Utilization Utilization Index Indicates cost of
(HCUI) medical care provided
per inmate;
from 1/1/98 through
6/30/99;
Dollars
142
REFERENCES
Abeles, R. (1991). Sense of control, quality of life, and frail older people. In J.
Blrren, D. Deutchman, J. Lubben, & J. Rowe (Eds.), The concept and
measurement of quality of life In the later years (dp . 297-314). New York:
Academic Press.
Adams, M. E., & Vedder, C. B. (1961). Age and crime: Medical and sociologic
characteristics of prisoners over 50. Geriatrics. 4 . 177-181.
Aday, R. (1994). Aging in prison: A case study of new elderly offenders.

International Journal of Offender Therapy and Comparative Criminology.
38(1),79-91.
Alexopoulos, G. S. (1992). Geriatric depression reaches maturity. International

Journal of Psychiatry. 7. 305-306.
Allen, A., & Blazer, D. (1991). Mood disorders. In J. Sadavoy, L. Lazarus, & L.
Jarvik. (Eds.), Comprehensive review of geriatric psychiatry fpp. 337-351)
Washington, DC: American Psychiatric Press.
Allison, T., Williams, D., Miller, T., Patten, C., Bailey, K., Squires, R., & Gau, G.
(1995). Medical and economic costs of psychologic distress in patients
with coronary artery disease. Mavo Clinic Proceedings. 70. 734-742.
Ariing, G. 1985. Interaction effects in a multivariate model of physician visits by

older persons. Medical Care. 23. 361 -371.
Baltes, M. (1994). Aging well and institutional living: A paradox? In R. Abeles,

H. Gift, & M. Ory (Eds.) Aging and quality of life (pp. 185-201). New York:
Springer Publishing.
Baltes, M., & Baltes, P. (1986). The psychology of control and aoino. Hillsdale,
NJ: Lawrence Erlbaum.
Beck, A. J., & Mumola, C. J. (1999). Prisoners in 1998. Bureau of Justice

Statistics, August 1999, NCJ175687.
143
Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An
inventory for measuring depression. Archives of Generai Psychiatry. 4(61
53-63.
Bergman, S., & Amir, M. (1973). Crime and delinquency among the aged in
Israel. Geriatrics. 2 8 .149-157.
Berkanovic, E., & Hurwicz, M. (1989). Psychological distress and the decision
to seek medical care among a Medicare population. Medical Care.
27(11), 1058 1070.
Blazer, D. G., Bachar, J. R., & Manton, K. G. (1986). Suicide in late life: Review
and commentary. Journal of American Geriatric Society. 34. 519-525.
Blazer, D. G., Burchett, B., Service, C., & George, L. (1991). The association of
age and depression among the elderly: An epidemiologic exploration.
Journal of Gerontology. 46: M210-M215.
Bonta, J., & Gendreau, P. (1990. Reexamining the cruel and unusual
punishment of prison life. Law and Human Behavior. 14. 347-372.
Brink, T. L., Yesavage, J. A., & Lum, O. 1982. Screening tests for geriatric
depression. Clinical Gerontology. 1. 37-43.
Broadhead, W. E., Blazer, D., George, L., &Tse, C. K. (1990). Depression,

disability days, and days lost from work in a prospective epidemiologic
survey. Journal of the American Medical Association. 264. 2524-2528.
Bromley, D. B. (1990). Behavioural gerontology: Central issues in the

psychology of aaina. New York: Wiley and Sons.
Bukstel, L., & Kilmann, P. (1980). Psychological effects of imprisonment on

confined individuals. Psychological Bulletin. 88. 469-493.
Burke, W. J., Nitcher, R. L., Roccaforte, W. H., & Wengel, S. P. 1992. A

prospective evaluation of the Geriatric Depression Scale in an outpatient
geriatric assessment center. Journal of the American Geriatric Society.
40. 1227-1230.
Burns, B. J., Larson, D. B., & Goldstrom, I. D. (1988). Mental disorder among
nursing home patients: Preliminary findings from the national nursing
home survey pretest. International Journal of Geriatric Psychiatry. 3. 27-
35.
144
Bums, B. J.t & Taub, C. (1990). Mental health services in general medical care
and in nursing homes. In B. Fogel, A. Furino, & G. Gottlieb, (Eds.),
Mental health policy for older Americans: Protecting minds at risk (pp. 63-
83). Washington, DC: American Psychiatric Press.
Chaneles, S., & Burnett, C. (1989). Older offenders: Current trends. New York:
Haworth Press.
Clair, J., Karp, D., & Yoels, W. (1993). Experiencing the life cvcle: A social
psychology of aging. Springfield, IL: Charles C. Thomas.
Clemmer, D. (1958). The prison community. New York: Holt. Rinehart, and
Winston.
Cohen, G. D. (1980). Prospects for mental health and aging. In J. E. Birren &
R. B. Sloane (Eds.), Handbook of mental health and aging (pp. 971-993).
Englewood Cliffs, NJ: Prentice-Hall.
Cohen, G. D. (1989). The movement toward subspecialty status for geriatric

psychiatry in the United States. International Psvchoqeriatic. I. 201-205.
Cohen-Cole, S., & Stoudemire, A. (1987). Major depression and physical

illness: Special considerations in diagnosis and biologic treatment.
Psychiatric Clinics of North America. 10. 1-17.
Conover, W. J. (1980). Practical nonoarametric statistics (2nd ed.). New York:

John Wiley & Sons.
Consensus Development Conference. (1991, November). Consensus statement

on diagnosis and treatment of depression in late life. Bethesda, MD:
National Institutes of Health.
Conte, V. A., & Salamon, M. J. (1982). An objective approach to the

measurement and use of life satisfaction with older persons.
Measurement and Evaluation in Guidance. 15(3). 194-200.
Conwell, Y. (1994). Suicide in elderly patients. In L. S. Schneider, C. F.

Reynolds, B. D. Lebowitz, & A. J. Friedhoff (Eds.) Diagnosis and
treatment of late life depression: Results of the NIH Consensus
Development Conference (pp. 397-418). Washington, DC: American
Psychiatric Press.
Coulton, C. & Frost, A. (1982). Use of social and health services by the elderly.
Journal of Health and Social Behavior. 23: 330.
145
Derogatis, L. R. (1975). Brief Symptom Inventory. Baltimore: Clinical

Psychometric Research.
Derogatis, L. R. (1977). The SCL-90 Manual I: Scoring, administration and

procedures for the SCL-90. Baltimore: Clinical Psychometric Research.
Derogatis, L. R., Rickels, K., & Rock, A. (1976). The SCL-90 and the MMPI: A
step in the validation of a new self-report scale. British Journal of
Psychiatry. 128. 280-289.
Derogatis, L. R.t & Spencer, P. M. (1982). The Brief Symptom Inventory:

Administration, scoring and procedures manual—I. Baltimore: Clinical
Psychometric Research.
Donziger, S. (1996). The real war on crime. New York: Harper Collins
Publishers.
Evans, S., & Katona, C. (1993). The epidemiology of depressive symptoms in

elderly primary care attenders. Dementia. 4. 327-333.
Feinberg, G. (1984). Profile of the elderly shoplifter. In E. Newman, D.

Newman, & M. Gerwirtz, (Eds.). Elderly criminals fpp. 35-50). Cambridge,
MA: Oelgeschlager, Gunn, & Ham.
Feinberg, G., & McGriff, M. D. (1989). Defendant’s advanced age as a

prepotent status in criminal case disposition and sanction. In S. Chaneles
& C. Burnett (Eds.), Older offenders: Current trends (pp. 87-124). New
York: Haworth Press.
Folstein, M. F., Folstein, M. F., & McHugh, P. R. (1975). Mini-mental state: A

practical method for grading the cognitive state of patients for the clinician.
Journal of Psychiatric Research. 12. 189-196.
Freidhoff, A. J. (1994). Consensus development conference statement:

Diagnosis and treatment of depression in late life. In L. S. Schneider, C.
F. Reynolds, B. D. Lebowitz, & A. J. Friedhoff (Eds.), Diagnosis and
treatment of late life depression: Results of the NIH Consensus
Development Conference (p p . 492-511 ). Washington, DC: American
Psychiatric Press.
Gallagher, E. M. (1990). Emotional, social, and physical health characteristics

of older men in prison. International Journal of Aainq and Human
Development. 31f4L 251-265.
146
Gatz, M. (1995). Emerging issues in mental health and aging. Washington, DC:
American Psychological Association.
Gatz, M., & Smyer, M. (1992). The mental health system and older adults in the
1990’s. American Psychologist. 47f6L 741-751.
George, L. (1993). Depressive disorders and symptoms in later life. In M.

Smyer & M. Gatz, (Eds.), Mental health and aaina (pp. 65-73). Beverly
Hills, CA: Sage.
Gillespie, M. W ., & Galliher, J. F. (1972.) Age, anomie, and the inmates’

definition of aging in prison: An exploratory study. In D. Kent, R.
Kastenbaum, & S. Sherwood (Eds.), Research, planning and action for
the elderly (pp. 465-483). New York: Behavioral Publications, Inc.
Goetting, A. (1983). The elderly in prison: Issues and perspectives. Journal of

Research in Crime and Delinouencv. 20. 291-309.
Goetting, A. (1984). Prison programs and facilities for elderly inmates. In E.

Newman, D. Newman, & M. Gerwirtz, (Eds.), Elderly criminals (pp. 169-
173). Cambridge, MA: Oelgeschlager, Gunn, & Hain.
Gortmaker, S., & Gore, S. (1982). Stress and the utilization of health services:
A time series and cross-sectional analysis. Journal of Health and Social
Behavior. 23. 25.
Greenberg, P. E., Stiglin, L. E., Finkelstein, S. N., & Bemdt, E. R. (1993). The
economic burden of depression in 1990. Journal of Clinical Psychiatry.
54. 405-418.
Grisso, T. (1996). Voluntary consent to research participation in the institutional

context. In B. Stanley, J. Sieber, & G. Melton (Eds.), Research ethics: A
psychological approach (pp. 203-224). Lincoln, NE: University of
Nebraska Press.
Gurland, B. J. (1992). The impact of depression on quality of life of the elderly.

Clinics in Geriatric Medicine. 8(2). 377-386.
Gurland, B. J., Wilder, D. & Berkman, C. (1988). Depression and disability in

the elderly: Reciprocal relations and changes with age. International
Journal of Geriatric Psychiatry. 3 . 163-79.
Hamilton, M. (1960). A rating scale for depression. Journal of Neurosurgical

147
Herrmann, N., Mittmann, N., Silver, I. L., Shulman, K. I., Busto, U. A., Shear, N.
H., & Naranjo, C. A. (1996). A validation study of the Geriatric
Depression Scale Short Form. International Journal of Geriatric
Hibbard, J. H., & Pope, C. R. (1986). Age differences in the use of medical care
in an HMO: An application of the behavioral model. Medical Care. 2 4 (1 Y
52-66.
Howell, R., Payne, I., & Roe, A. (1971). Bipolar Psychological Inventory. Provo,
UT: Psychological Associates.
Hucker, S. J., & Ben-Aron, M. H. (1984). Violent elderly offenders: A

comparative study. In W. Wilbanks & P. Kim, (Eds.), Elderly criminals (pp.
69-77). Lanham, MD: University Press of America.
Hyer, L., & Blount, J. (1984). Concurrent and discriminant validities of the
Geriatric Depression Scale with older psychiatric inpatients.
Psychological Reports. 54. 611-616.
Idler, E. (1993). Age differences in self-assessment of health: Age changes,

cohort differences, or survivorship. Journal of Gerontology. 48(6), S289-
S300.
Johnson, J., Weissman, M., & Kierman, G. (1991). Service utilization and social
morbidity associated with depressive symptoms in the community.
Journal of the American Medical Association. 267. 1478-1483.
Jones, K., & Vischi, T. (1979). Impact of alcohol, drug abuse and mental health
treatment on medical care utilization. Medical Care 17 (December
Supplement), 1.
Kalayam, B., & Shamoian, C. A. (1993). Evolution of research in geriatric

psychiatry. International Journal of Geriatric Psychiatry. 8. 3-12.
Katon, W., & Sullivan, M. (1990). Depression and chronic medical illness.
Journal of Clinical Psychiatry. 51(61. (Supplement), 3-11.
Keller, O. J., & Vedder, C. B. (1968). The crimes that old people commit.
Gerontologist. 8 (1), 43-50.
148
King, A., & Stewart, A. (1994). Conceptualizing and measuring quality of life in
older populations. In R. Abeles, H. Gift, & M. Ory (Eds.), Aoino and
quality of life (pp. 27-56). New York: Springer Publishing.
Koenig, H. G., & Blazer, D. G. (1992). Mood disorders and suicide. In J. E.

Birren, R. B. Sloan, & G . Cohen (Eds.), Handbook of mental health and
aging (pp. 379-407). San Diego, CA: Academic Press.
Koenig, H. G., Johnson, S., Bellard, J., Denker, M.r & Fenlon, R. (1995).
Depression and anxiety disorder among older male inmates at a federal
correctional facility. Psychiatric Services. 46f4L 399-401.
Koenig, H. G., Meador, K. G., Cohen, H. J., & Blazer, D. G. (1988). Self-rated
depression scales and screening for major depression in the older
hospitalized patient with medical illness. Journal of the American Geriatric
Society. 36f8 l 699-706.
Koenig, H. G., Shelp, F., Goli, V., Cohen, H., & Blazer, D. (1989). Survival and
health care utilization in elderly medical inpatients with major depression.
Journal of American Geriatric Society. 37(7). 599-606.
Kramer, M. (1983). The continuing challenge: The rising prevalence of mental

disorders, associated chronic diseases, and disabling condition.
American Journal of Social Psychiatry. 3 . 13-24.
Lachman, M., Ziff, M., & Spiro III, Avron. (1994). Maintaining a sense of control
in later life. In R. Abeles, H. Gift, & M. Ory (Eds.) Aoino and quality of life
(pp. 216-232). New York: Springer Publishing.
Larson, R. (1978). Thirty years of research on the subjective well-being of older

Americans. Journal of Gerontology. 33(1V 109-125.
LaRue, A. (1992). Aoino and neuropsychological assessment. New York:

Plenum Press.
Lawton, M. P. (1980). Environment and aainq. Monterey, CA: Brooks/Cole.
Lebowitz, B., & Niederehe, G. (1992). Concepts and issues in mental health
and aging. In J. E. Birren, R. B. Sloane, & G. D. Cohen (Eds.), Handbook
of mental health and aging ( d p . 3-25). New York: Academic Press.
Levitan, S., & Komfeld, D. (1981). Clinical and cost benefits of liaison
psychiatry. American Journal of Psychiatry. 138. 790-793.
149
Levkoff, S. E., Cleary, P. D., & Wetle, T. (1987). Differences in determinants of

physician use between aged and middle-aged persons. Medical Care.
25(12). 1148-1160.
Lewin, K. (1951). Field theory in social science: Selected theoretical papers.

New York: Harper.
Lyons, J. S., Strain, J. J., Hammer, J. S., Ackerman, A. D., & Fulop, G. (1989).
Reliability, validity and temporal stability of the Geriatric Depression Scale
in hospitalized elderly. International Journal of Psychiatric Medicine. 19.
203-209.
Malbi, J., Holley, S.D., Patrick, J., & Walls, J. (1979). Age and prison violence:
Increasing age heterogeneity as a violence-reducing strategy in prisons.
Criminal Justice and Behavior. 6. 175-186.
Manning, W. G., & Wells, K. B. (1992). The effects of psychological distress

and psychological well-being on use of medical services. Medical Care.
30(6), 541-553.
Marquart, J., Merianos, D., Hebert, J., & Carroll, L. (1997). Health condition and
prisoners: A review of research and emerging areas of inquiry. The
Prison Journal. 77(2). 184-208.
McCarthy, M. (1983). The health status of elderly inmates. Corrections Today.

45(1), 64-65, 74.
McGivney, S. A., Mulvihill, M., & Taylor, B. (1994). Validating the GDS
depression screen in the nursing home. Journal of the American
Geriatrics Society. 42. 490-492.
McShane, M. D., & Williams, F. P. (1990). Old and ornery: The disciplinary
experiences of elderly prisoners. International Journal of Offender
Therapy and Comparative Criminology. 34(3). 197-211.
Mechanic, D., Cleary, P. D., & Greenley, J. R. (1982). Distress syndromes,

illness behavior, access to care and medical utilization in a defined
population. Medical Care. 20(4). 361-372.
Melton, G., & Stanley, B. (1996). Research involving special populations. In B.

Stanley, J. Sieber, & G. Melton (Eds.), Research ethics: A psychological
approach (p p . 177-202). Lincoln, NE: University of Nebraska Press.
150
Merrill, J., & Hunt, M. E. (1990). Aging in place: A dilemma for retirement
housing administrators. Journal of Applied Gerontology. 9(11 60-76.
Meyers, A. R. (1984). Drinking, problem drinking, and alcohol-related crime

among older people. In E. Newman, D. Newman, & M. Gerwirtz, (Eds.),
Elderly criminalsfpp. 51-66). Cambridge, MA : Oelgeschlager, Gunn, &
Hain.
Mitchell, J., Mathews, H., & Yeasavage, J. (1993). A multidimensional

examination of depression among the elderly. Research on Aaina. 15(2).
198-219.
Moberg, D. (1953). Old age and crime. Journal of Criminal Law. 43. 776-779.
Mossey, J., Knott, K., & Craik, R. (1990). The effects of persistent depressive
symptoms on hip fracture recovery. Journal of Gerontology. 4 5 .163-168.
Mumford, E., Schlesinger, H., Glass, G., Patrick, C., & Cuerdon, T. (1984). A
new look at evidence about reduced cost of medical utilization following
mental health treatment. American Journal of Psychiatry. 141(101.1145-
1158.
Murphy, E. (1983). The prognosis of depression in old age. British Journal of

Psychiatry. 1 4 2 .111-119.
Murrell, S. A., Himmelfarb, S., & Wright, K. H. (1983). Prevalence of depression

and its correlates in older adults. American Journal of Epidemiology.
111(2), 173-185.
National Institute of Mental Health. (1975). Issues in mental health and aaina:
Proceedings of the conference on research in mental health and aaina. 1.
Washington, DC: US Government Printing Office.
Newman, E., Newman, D., & Gerwirtz, M. (Eds.). (1984). Elderly criminals.
Cambridge, MA: Oelgeschlager, Gunn, & Hain
Ory, M., Cox, D., Gift, H., & Abeles, R. (1994). Aging and quality of life:
Celebrating new discoveries. In R. Abeles, H. Gift, & M. Ory (Eds.), Aaina
and the quality of life (dp . 1-16). New York: Springer Publishing.
Ostfeld, A. (1980). Older research subjects: Not homogeneous, not especially

vulnerable. IRB: A Review of Human Subjects Research. 2. 7-8.
151
Ostfeld, A., Kasl, S., D’Atri, D., & Fitzgerald, E. (1987). Stress, overcrowding,
and blood pressure in prison. Hillsdale, NJ: Lawrence Erlbaum.
Parmelee, P. A., Katz, I. R., & Lawton, M. P. (1989). Depression among

institutionalized aged: Assessment and prevalence estimation. Journal of
Gerontology. 44(1), M22-29.
Parmelee, P. A., Lawton, M., & Katz, I. R. (1989). Psychometric properties of

the Geriatric Depression Scale among the institutionalized aged.
Psychological Assessment. 1. 331-338.
Paulus, P. B., & Dzindolet, M. T. (1993). Reaction of male and female inmates
to prison confinement: Further evidence for a two-component model.
Criminal Justice and Behavior. 20(2). 149-166.
Paykel, E., & Norton, K. (1986). Self-report and clinical interview in the
assessment of depression. In N. Sartories & T. Ban (Eds.), Assessment
o f depression (d p . 356-3661. New York: Springer-Verlag.
Pearlin, L., Lieberman, M., Menaghan, E., & Mullan, J. (1981). The stress
process. Journal of Health and Social Behavior. 22. 337-356.
Petrie, W. M., Lawson, E. D., & Hollender, M. H. (1982). Violence in geriatric

patients. Journal of the American Medical Association. 248T4V 443-444.
Rabins, P. (1992). Prevention of mental disorder in the elderly: Current

perspectives and future prospects. Journal of the American Geriatrics
Society. 40(71 727-33.
Rainer, J. (1996). The pragmatic relevance and methodological concerns of

psychotherapy outcome research related to cost effectiveness and cost-
offset in the emerging health care environment. Psychotherapy. 33(21.
216-224.
Rapp, S. R., Walsh, D. A., Parisi, S. A., & Wallace, C. E. (1988). Detecting
depression in elderly medical inpatients. Journal of Consulting and
Clinical Psychology. 56(41. 509-513.
Reed, M. B., & Glamser, F. D. (1979). Aging in a total institution: The case of
older prisoners. Gerontologist. 19(41. 354-360.
152
Rigdon, M .t Haas, L., Hausam, R., Wing, H., Anderson, N., & Hill, R. (1997).
Relationship between psychological distress and measures of health care
utilization. Department of Family and Preventive Medicine, Health
Research Center, University of Utah Hospital and Clinics, Salt Lake City,
UT. Unpublished manuscript.
Rodstein, M. (1975). Crime and the aged. Journal of the American Medical
Association. 234T6L 639.
Rokach, A., & Koledin, S. (1997). Loneliness in jail: A study of the loneliness of
incarcerated men. International Journal of Offender Therapy and
Comparative Criminology. 41(2). 168-179.
Rosner, R. (1995). Fundamentals of biostatistics (4th ed.’i Belmont, CA:

Wadsworth Publishing Company.
Salamon, M. & Conte, V. (1998). Manual for the life satisfaction scale. New
York: Adult Development Center.
Schneider, L. S. (1985). Efficacy of clinical treatment for mental disorders

among older persons. In M. Gatz, (Ed.), Emerging Issues in Mental
Health and Aaina ( p p . 19-49). Washington, DC: American Psychological
Association.
Schneider, L. S., Eaton, E. M., Zemansky, M. F., & Pollock, V. E. (1992). The
Geriatric Depression Scale and the Beck Depression Inventory as
screening instruments in an older adult outpatient population.
Psychological Assessment. 4(2). 190-192.
Schroeder, P. L. (1935). Criminal behavior in the later period of life. American

Journal of Psychiatry. 92. 918-924.
Shichor, D. (1984). The extent and nature of lawbreaking by the elderly: A

review of arrest statistics. In E. Newman, D. Newman, & M. Gerwirtz,
(Eds.), Elderly criminals (p p . 17-32). Cambridge, MA: Oelgeschlager,
Gunn, & Hain.
Shichor, D., & Kobrin, S. (1978). Note: Criminal behavior among the elderly.
Gerontologist. 18.(21. 213-218.
Sieber, J. (1992). Planning ethically responsible research: A guide for students

and internal review boards. Newberry Park, CA: Sage Publications.
Siegel, S., & Castellan, M. J. (1988). Nonparametric statistics for the behavioral
sciences (2nd ed.). New York: McGraw-Hill.
Simon, G., Ormel, J., VonKorff, M., & Barlow, W. (1995). Health care costs
associated with depressive and anxiety disorders in primary care.
American Journal of Psychiatry. 152. 352-357.
Smith, D. (1982). Crowding and confinement. In Pains of imprisonment (d p .

45-62). Beverly Hills, CA: Sage.
Snaith, R. (1987). The concept of mild depression. British Journal of

Psychiatry. 150(2). 387-393.
Spencer, M. P., & Folstein, M. F. (1985). The mini-mental state examination. In

P. A. Keller & L. G. Ritt (Eds.), Innovations in clinical practice: A source
book. 4 (p p . 305-310). Sarasota, FL: Professional Resource Exchange,
Inc.
Suls, J., Gaes, G., & Philo, V. (1991). Stress and illness behavior in prison:
Effects of life events, self-care attitudes, and race. Journal of Prison and
Jail Health. 10. 117-132.
Teller, F., & Howell, R. (1981). The older prisoner. Criminology. 18(41 549-
555.
Tessler, R., Mechanic, D., & Dimond, M. (1976). The effect of psychological
distress on physician utilization: A prospective study. Journal of Health
and Social Behavior. 17(4). 353-364.
Toch, H. (1977). Living in orison: The ecology of survival. New York: Free
Press.
Toner, J., Gurland, B., & Teresi, J. (1988). Comparison of self-administered and
rater-administered methods of assessing levels of severity of depression
in elderly patients. Journal of Gerontology: Psychological Sciences. 43.
136-140.
Turner, G. S., & Champion, D. J. (1989). The elderly offender and sentencing
leniency. In S. Chaneles & C. Burnett (Eds.), Older offenders: Current
trends (pp. 125-140). New York: Haworth Press.
United States Department of Justice, Bureau of Justice Statistics (1998).
United States Department of Justice, Bureau of Justice Statistics (1999).
154
Vega, M., & Silverman, M. (1988). Stress and the elderly convict. International
Journal of Offender Therapy and Comparative Criminology. 32(21. 153-
161.
Vito, G. F., & Wilson, D. G. (1985). Forgotten people: Elderly inmates. Federal
Probation. 49f 1Y 18-24.
Wallace, K. & Bergeman, C. (1997). Control and the elderly: “Goodness-of-fit”.

International Journal of Aoino and Human Development. 45(41 323-339.
Watson, J. M. (1989). Legal and social alternatives in treating older child sexual
offenders. In S. Chaneles & C. Burnett (Eds.), Older offenders: Current
trends (pp. 141-148). New York: Haworth Press
Waxman, H. M., Camer, E. A., & Blum, P. (1983). Depressive symptoms and
health service utilization among the community elderly. Journal of the
American Geriatrics Society. 31. 417-420.
Wiegand, N., & Burger, J. C. (1979, September-October). The elderly offender

and parole. Police. 14-15.
Wilbanks W., & Murphy, D. D. (1984). The elderly homicide offender. In E.

Newman, D. Newman, & M. Gerwirtz (Eds.), Elderly criminals ( d p . 79-92).
Cambridge, MA: Oelgeschlager, Gunn, & Hain.
Wolfgang, M. E. (1964, July). Age, adjustment, and the treatment process of

criminal behavior. Psychiatry Digest. 21-35.
Wolinsky, F., Coe, R., Miller, D., Prendergast, J., Creel, M., & Chavez, M.
(1983). Health services utilization among the noninstitutionalized elderly.
Journal of Health and Social Behavior. 24. 325.
Wood, A. E., & Waite, J. B. (1941). Crime and its treatment. New York:
American Book Company.
Wooden, W., & Parker, J. (1980). Aged men in a prison environment: Life
satisfaction and coping strategies. Paper presented at the annual
meeting of the National Gerontological Society, San Diego.
Wooldredge, J. D. (1999). Inmate experiences and psychological well-being.

Criminal Justice and Behavior. 26(2V 235-250.
155
Wright, B. (1960). Physical disabilitv-A psychological approach. New York:

Harper & Brothers.
Wright, K. (1991). A study of individual, environmental, and interactive effects in

explaining adjustment to prison. Justice Quarterly. 8 .217-241.
Wright, K. (1993). Prison environment and behavioral outcomes. Journal of

Offender Rehabilitation. 20. 93-113.
Yesavage, J. A., Brink, T. L., Rose, T. L., Lum, O., Huang, V., Adey, M., & Leirer,
V. O. (1983). Development and validation of a Geriatric Depression
Scale. Journal of Psychiatric Research. 17. 31-49.
Zamble, E. (1992). Behavior and adaptation in long-term prison inmates:

Descriptive longitudinal results. Criminal Justice and Behavior. 19. 409-
425.
Zamble, E., & Porporino, F. (1988). Copino behavior and adaptation in prison
inmates. New York: Springer-Verlag.
Zamble, E., & Porporino, F. (1990). Coping, imprisonment, and rehabilitation.

Criminal Justice and Behavior. 17(1). 53-70.
Zung, W. (1965). A self-rating scale. Archives of General Psychiatry. 12. 63.

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INFORMATION TO USERS

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Bell & Howell Information and Learning

PSYCHOLOGICAL DISTRESS, LIFE SATISFACTION, AND HEALTH CARE

UTILIZATION AMONG ELDERLY MALE INMATES

Kristine Louise Burling

A thesis submitted in partial fulfillment of the

Thesis supervisors: Associate Professor Vilia Tarvydas

Bell & Howell Information and Learning Company

This is to certify that the Ph.D. thesis of

Kristine Louise Burling

has been approved by the Examining Committee for

I would like to express my gratitude to my friends and family who loved

me and respected my process; my colleagues and mentors who believed in me

telling me their stories.

LIST OF TABLES........................................................ vii

Statement of the Problem................................................................................. 2

II. LITERATURE REVIEW ................................................................................. 14

Elderly Male Inmates.......................................................................................15

Summary of Analytic Procedures................................................................... 71

Purpose and Research Questions................................................................ 105

APPENDIX A. INFORMATIONAL QUESTIONNAIRE........................................117

APPENDIX B. MINI-MENTAL STATUS EXAM............... 122

APPENDIX C. GERIATRIC DEPRESSION SCALE............................................ 124

APPENDIX D. BRIEF SYMPTOM INVENTORY SCALE................................... 127

APPENDIX E. LIFE SATISFACTION SCALE...................................................... 130

APPENDIX F. INFORMATION SUMMARY......................................................... 133

APPENDIX G. CONSENT FORM......................................................................... 136

APPENDIX H. SUMMARY DESCRIPTION OF VARIABLES.............................139

1. Mini-Mental Status Exam: Summary of Results......................... 91

2. Geriatric Depression Scale: Summary of Results.......................................... 91

3. Brief Symptom Inventory Scale: Summary of Results................................... 92

4. Life Satisfaction Scale: Summary of Results.................................................. 93

5. Cost of Health Care Provided to Study Participants...................................... 94

6. In-House Health Encounters: 1/1/98 to 6/30/99..................... 95

7. In-House Prescription Medications: /1/98 to 6/30/99................. 95

8. Demographic Characteristics of Study Participants....................................... 96

9. Arrest and Incarceration History...................................................................... 99

10. Multiple Regression Results of Life Satisfaction Measures as Criterion

11. Correlation Analysis of Health Care Utilization and Psychological

12. Correlation Analysis of Health Care Utilization and Life Satisfaction:

13. Multiple Regression Results using Health Utilization as Criterion Variable

14. Self-Rating of Physical Health Condition ......................................................103

15. Infirmary Use.................................................................................................... 104

16. Summary Description of Variables................................................................. 140

Geriatric inmates represent approximately 3 percent of the 1.5 million

Americans currently incarcerated in the United States (United States Department

disproportionately to other age cohorts. Chronic illness and deteriorating health

estimate for maintaining a geriatric state inmate is $69,000, as compared to

$22,000 for a younger inmate (Donziger, 1996).

In an effort to impact rising health care costs among their community

been investigated. Findings have been inconclusive and/or contradictory. Some

researchers have suggested that no relationship exists between psychological

Wolinsky et al., 1983). Other researchers have indicated that there is a

in findings may be accounted for by methodological differences between studies,

i.e., differences in study populations, variability in definition and measurement of

psychological distress, and perceptual differences in health status and the

decision to seek care. The relationship between psychological distress and

health care utilization among community elders, therefore, remains unclear. No

studies have examined the relationship between psychological distress and

health care utilization among incarcerated elders.

Life satisfaction, or psychological well-being, is a second correlate to

referred to as life satisfaction, morale, contentment, happiness, and quality of