Navigating the dynamics of trust,rapport and power while conducting social health research with people in prison

Gaining trust and building rapport

Effective and successful rapport building is essential to obtaining quality data (Ostrander, 1995), particularly within the prison setting. Creating a sense of trust can provide for genuine dialogue (Liebling, 1999). As an outsider (i.e., an academic who works independently of, and is not affiliated with, correctional services), it is impossible to enjoy the benefits of being an ‘insider’, such as pre-established trust and rapport, which can be beneficial in qualitative research (Labaree, 2002). This was evidenced in the recruitment of participants at different study sites, whereby my key contact on the inside had different histories within the respective prisons where they worked. At one site, my key contact had worked in that correctional centre for over five years and was well known among people in that prison (and, hence, potential participants). In an instance where a participant with a pre-arranged interview was not available, she was able to recruit on-the-spot, presumably because of her trusted status among people in prison. This was in contrast to another study site where my contact had been working for only a few months. This contact had not yet established relationships or connections with people in prison, thus people appeared less inclined to agree to be interviewed by someone unknown; they hadn’t yet determined whether the newly employed staff member was trustworthy, let alone the outsider (me) seeking to connect with them.

It was important to seek expert guidance about the utility of the interview guides and their application within the prison setting before commencing research. To achieve this, I consulted with a formerly incarcerated person who had served five years in custody and was living with HCV at the time of his imprisonment. Together, we reviewed the interview guide and he made several recommendations informed by his lived experiences. One recommendation he made was the ordering of themes; we revised the schedule so that I would ask more confronting questions later in the interview (rather than opening with questions which may be perceived as invasive by those who are incarcerated). This consultation allowed me to learn about prison culture and strategies for making participants feel at ease about what they choose to disclose; including notifying participants of my mandatory reporting responsibilities prior to audio recording.

There are multiple barriers in developing trust and rapport with people in prison, including a research participant’s desire to present a certain ‘image’ of themselves (Tourangeau et al., 2000), and, specific to the prison setting, the ‘inmate code’ whereby people who are incarcerated do not disclose to prison officers or others in positions of authority (Wellford, 1967). Beyond a reluctance to speak to others, disclosing to a researcher could be perceived as potentially compromising a person in prison’s status within the prison setting. Other barriers include real or perceived risks of discussing drug use (a punishable offence within prison) with a researcher, or an outsider.

As my role was not ‘to help’ participants, but rather to ask guided exploratory questions and listen to responses, I was not confined to more traditional clinical power imbalances. However, vulnerability remained inherent due to the ‘inmate code’ and my asking questions within a power structure (i.e. prison) (Fook, 2016) in which participant answers could have consequences. Thus, establishing trust was critical. In the prison setting, trust is not only shaped through person-to-person interactions, but also the observed person-to-person interactions with others. Merely being seen to be conversing with an officer, irrespective of the content of the conversation, can have consequences for a person in prison, as can be seen in the following participant response (Lafferty et al., 2016b: 33).

But I mean … you know, you can never really build up a trust with them [officers]. You know, past a certain extent. Because if guys see you talking to them, they're like, “what's he doing?” You know? (Participant)

Prison officers and the prison culture can also influence trust of an outside researcher. However, as the field note below indicates, officers can influence the researcher’s sense of trust within the prison environment and evoke a protective response to ensuring participant confidentiality.

As I broke for lunch, I packed up my forms and audio-recorder into my prison-issue see-through bag. The officer asked if the audio-recorder had the “crims’” information on it. I confirmed that the device did. I asked if it would be safe for me to leave everything while I went to the cafeteria and he assured me it would be fine. But, as I was about to pass through security on my way out, I had a sense of unease about leaving the confidential recordings out of my possession and in access of the officers’. I found myself having a trust issue in prison – I was distrustful of staff and I felt I had a responsibility to the participants to ensure I protected their confidentiality. I asked to be escorted back to the office so I could collect the recording device. (Field notes, 2014)

As the interviewer, I worked to ensure safety of participants, but also my own personal safety. There was one instance in which I felt a participant was intent on making me uncomfortable, upon which I closed the interview early.

One participant made me feel uncomfortable... It also felt as though he was attempting to be manipulative in the process of making me feel uneasy. This seemed to be the case through his language at the start – it felt, not contrived, but decisive in cajoling a response from me. It felt very targeted. He maintained strong eye contact and, when I asked about trust, he honed his eye contact while discussing eye contact as being an important indicator for him of whether he could trust someone. … I finished the interview early. I explained that he had answered all my questions and thanked him for his participation. I did not ask the demographic questions [typically asked at the end of the interview] as I felt I needed to close the interview. (Field notes, 2014)

It is important to not undervalue the personal connection of a handshake and treating everyone as human beings worthy of respect and dignity. Interactions between people who are incarcerated and prison officers is generally inhibited, often at best encompassing a superficial politeness occurring for the sake of civility (Crewe, 2011). Research engagement, however, is an opportunity to connect with the outside world – to render a moment in which questions about the person are genuine and considered. Upon shaking a potential participant’s hand, I would introduce myself by my first name and ask their name. These small exchanges proved beneficial in building rapport and obtaining quality data throughout my research. When asked why he had participated, one participant indicated:

Yous a breath of fresh air. (Participant, 2015)

I found it was important to double check with potential participants that they understood why they had been ‘called up’ (usually participants were requested by an officer to attend the location where the interviews were being conducted) to participate. Potential participants may forget they had agreed to participate or there may have been a breakdown in communication or recruitment processes. This lack of communication and follow-up early in the researcher–participant interaction can have implications on the quality and depth of the interview. In an instance where I, as the researcher, failed to check in with a participant about their knowledge of attending the interview, I was not able to gain rapport throughout the interview; the opportunity to build rapport and gain trust had been missed. This became apparent after concluding the interview and turning off the recorder.

The first interview today, he seemed to have a lot of trust issues when he was speaking with me. I felt that he didn’t feel comfortable discussing anything as he wasn’t very forthcoming with responses. Once I turned off the recording device, he then asked me several questions about how I had known that he had hep C, and I explained that it had been my understanding that the [key contact] had discussed the project with him, and he’d given preliminary permission to be involved. I apologised for that not being communicated appropriately. He asked about his confidentiality with the recording and what I do with the information. I reinforced that I will be blocking out anything that identifies him, such as his family background. I told him I may write up a report, and that I might use a quote that he’s said, but anything that might identify him would not be included in that. He seemed much more relieved about that knowledge and was very thankful for me sharing that with him. He left on a happier note. (Field notes, 2014)

Whilst conducting interviews within a HCV treatment as prevention trial, I conducted interviews with people prior to, and following HCV treatment scale up. These interviews were unlinked, meaning that I did not seek to re-interview participants, but rather broader sampling from within the trial at the prisons where the study was implemented. Employing trust and rapport building strategies during the pre-treatment interviews, participants spoke candidly about their injecting drug use whilst incarcerated and considerations of HCV risks during these occurrences (see: Lafferty et al., 2018). However, when I commenced the post-treatment interviews, I observed greater apprehension from participants in disclosing their current drug use and HCV risk concerns, as noted in the following:

Something that confronted me as an interviewer was an inability to have open and frank discussions with participants who were currently using about their perceived risks of reinfection and injecting drug use during and following hepatitis C treatment. There were no participants on day one (n=4) who reported current injecting drug use. This was corroborated with the study nurse after the interviews. There were 1-2 participants on day two (n=3) who reported current use. The first participant of day two I did not feel it was conducive to ask him when the last time he injected was, as he was hesitant to engage in the interview and spoke very quietly during some of his responses. The second participant on day two (a person who was currently using), talked about knowing of other people enrolled in the SToP-C study who were actively using and sharing equipment while undergoing HCV treatment. He felt this was inappropriate and a waste of ‘time and money’. I explained to him that the people leading the study had no expectation that people stopped or changed their usual injecting behaviours on account of treatment, as we know drug use does occur in prison and we know there are very limited means for people to protect against HCV transmission – ie., there are no needle syringe programs available to people in prison. I interviewed two people on day three. The first person identified as someone who currently injected drugs. When we talked about risk of reinfection, or the question regarding what people in prison thought the policy should be for people who become reinfected, he indicated he had heard that people were only eligible for one treatment course. Again, I tried to communicate that injecting drug use during treatment was anticipated by the people leading the study. Interviewing these participants who were potentially at greater or more prominent risk of reinfection felt as if participants were a bit censored in their responses, as though I weren’t able to create a sense of trust which made it easier for them to talk more openly. This was challenging for me as I had never encountered subtle barriers during interviews with people in prison so regularly. This felt different. Upon reflection, it seems that SToP-C participants are concerned how about they will be perceived by the study team if they become reinfected.

It was through these field notes and reflective practice that I was able to ascertain the issues which were likely inhibiting participants from being more open. I modified the interview guide to begin interviews with participants’ understanding of eligibility for re-treatment should they become reinfected (Lafferty et al., 2020). Following this restructuring of the interview guide, participant responses about drug use and risk factors became more candid, with participants’ voice levels mirroring my own, rather than hushed and self-censored. This created opportunity for me to educate participants about universal health coverage of HCV treatment, irrespective of treatment history (i.e. in Australia, people are eligible for re-treatment following reinfection). This reflective practice and modification to the interview guide enabled greater dialogue and fostered more honest discussions, enriching the data in the process.

Power

Social research can present power imbalances for the interviewee whereby the interviewer may be perceived as possessing the power. Interviews have been described as a research method to “obtain knowledge about a given topic” (Brinkmann, 2014: 1009). But what is so often overlooked is that this situates the interviewee in a position of power as they possess the knowledge the researcher is seeking. In this way, research participation empowers people in prison as being both credible and knowledgeable. I argue that people who are incarcerated should be consulted regarding future research studies which affect them. This would enable greater empowerment of participants prior to participation.

Fook (2016) describes the entanglement of power and empowerment, noting that some efforts meant to empower another occurs at the expense of another’s power. In this way, empowerment and disempowerment can be conceptualised as scales, forcibly balanced. However, in my approach, given that I did not have a clinical role but rather a listening role, I was able to neutralise power amid interviewer-interviewee dynamics. In efforts to create a more neutralised power balance during interviews, I present myself in the interview as the learner seeking to be educated by the participant. Within prisons, it has been my experience that self-awareness as an outsider should be at the forefront of exchanges and to never assume knowledge. On several occasions, participants explained circumstances or scenarios to me of their experience in prison and would then follow up with, “you know?”. My response was always, “I don’t know”. This has the effect of evidencing active listening, while acknowledging my knowledge limitations and affirming their positioning as the expert within our researcher–participant exchange. This self-recognition of limited understanding often encouraged and enabled participants to further elaborate and discuss their responses in greater detail.

Semi-structured interviews allows “room for the respondent’s more spontaneous descriptions and narratives” (Brinkmann, 2014: 1008), an interview style that enables more natural style conversation. In my experience, semi-structured interviews were pivotal in dismantling power imbalances of the researcher–interviewee with people in prison. The following quote presents a participant’s reflections of research participation (Lafferty et al., 2016a: 8).

It’s good to, to um, break that cycle that we normally live in. […] To be able to talk about, like your personal issues and that, you know? […] I don’t tell them [officers], I wouldn’t tell them about half of this… (Participant)

This quote is indicative of a person in prison’s desires to participate in research and to be heard. Christopher et al. (2017) conducted qualitative interviews with people in prison from six medical intervention studies, seeking their reasons for research participation. Distraction from boredom, that is, a change from routine has been reported as a motivator for participation (Christopher et al., 2017). However, the participant’s quote above further indicates that research participation, particularly qualitative, may afford opportunity for social interaction beyond the customary bounds within prison, thus research participation may indicate a break from both the social and physical environments of incarceration.

In the prison setting, positions of power and vulnerability are not confined to the researcher–interviewee, but to the broader environment including researcher-officer. Although officers were not physically present in the room during interviews, it was important to ensure participant confidentiality during and after the interview. One prison had a literal open-door policy in place at the time of interviews, whereby I was not allowed to close the door to the interview room. This presented clear impositions for ensuring participant confidentiality. In these instances, I would alert a participant to the presence of an officer immediately outside the door or re-direct the interview if I suspected the interview was being listened in on. Quina and colleagues (2007: 136) describe their experiences of conducting research in which they were sometimes “seated uncomfortably close to a CO [corrections officer] or one might walk by regularly”. The risks to the researcher in these circumstances could compromise the integrity of the research. If a participant discloses drug use to me during an interview, and then is penalised by officers shortly after, I could be perceived as having ‘snitched’. The quality of future data collection could be compromised if I were to be implicated as no longer trustworthy among people in prison.

I completed my first day of interviews at [this prison]. It went reasonably well but not quite as well as the interviews at [another prison]. There is a policy here that requires the door to remain open in the clinic rooms – this literal open door seemed to slightly shift the dynamics of the interviews as participants were in direct line of sight of the officers, other people in prison awaiting medical treatment, and within earshot of healthcare workers and other personnel in the clinic. (Field notes, 2 Dec 2014)

Power and the ethics of research

Byrne (2005: 226) describes the ‘multiple gateways’ which must be navigated to gain access to prisons, including formal and informal gatekeepers, security issues regarding accessing people in prison, and “existing suspicions of prison administrators, staff and inmates”. For civilian academics, “these obstacles are intensified” as they are not part of the corrections system (Byrne, 2005: 226). Despite the numerous hurdles within the ethics application process prior to gaining access to prisons (Patenaude, 2004; Quina et al., 2007; Fox et al., 2011), none of these hurdles currently positions people in prison with any decision-making power.

The mantra “Nothing about us without us” refers to the notion that policies should be written in consultation and collaboration with the population group/s being affected by the policy (Charlton, 2000), thereby empowering those who are most likely to be impacted. The mantra and sentiment have been adopted by communities which have experienced misrepresentation or feel to be over-researched with limited to no policy improvements. A consortium of HIV/AIDS and injecting drug user networks in Canada have developed a manifesto using the mantra, to articulate rights to participate in decision-making processes which directly impact them, being involved in research projects about them, and other tools of empowerment (Canadian HIV/AIDS Legal Network, 2008). The statement has been adopted by injecting drug user and other peer-based organisations in Australia (See for example: AIVL, n.d.).

In the context of prison research, participation of people in development of policies affecting them remains, broadly, an idea rather than a reality. People in prison are rarely offered the primary choice whether research involving them should occur, as research conducted in prisons must first be approved by human research ethics committees or institutional review boards – gatekeepers who have on occasion forced research studies to change methods from in-person interviewing to letter writing (Burtt, 2020). Amid current calls to empower research participants at all stages of the research process (Earle, 2014), people in prison continue to be overlooked in decision-making processes. Unfortunately, there are limited primary opportunities for people who are incarcerated to have input into whether they support or decline research studies at the proposal stage (but are empowered to decline participation during recruitment (Christopher et al., 2017)). By the time this opportunity is afforded to them, the research is already in progress. I argue that people with experience of imprisonment, either currently or formerly incarcerated (i.e. released), should be consulted and involved in deliberations regarding research studies to be conducted with prison populations. This would best be achieved with an identified position for a person with lived prison experience to sit on research ethics committees/institutional review boards regarding prison-based research. The inclusion of those with lived experience of the proposed study population would re-position the power of researcher–participant-correctional authority. By not fostering inclusive participation of what research can and should be conducted, current systems unattentively retain the status quo of disempowering the already disadvantaged. Whilst the notion of the ‘paradox of empowerment’ suggests that intentional efforts to empower others may produce unintended consequences (i.e. to disempower through acts to bestow power) (Fook, 2016; Eylon, 1998), it is likely that such concerns would be obsolete amid the inclusion of voices of affected communities at the gatekeeper’s bureaucratic table.

Participatory research which includes an academic and one or more collaborators who are incarcerated has been achieved in previous work (see Bosworth et al., 2005). One of the benefits of this style of research is ensuring authenticity. Participatory research across the prison walls empowers those in prison as possessing knowledge (Bosworth et al., 2005). Other academics have included formerly incarcerated people within research reference groups, whereby reference group members may have scope to contribute to the study design and/or study tools to ensure the research is implemented in ways which are meaningful to those in prison. Despite researchers’ efforts to engage, there can be ethics barriers regarding consultation prior to obtaining ethics approvals. The inclusion of people with prior prison experience would promote greater balances of power, potentially enhancing opportunities for trust between social health researchers and participants in the prison setting. In New South Wales (NSW), for example, the Aboriginal Health and Medical Research Council Human Research Council of NSW assures review and ethics approval of research projects specific to, or involvement of, Aboriginal participants within the state by a Human Research Ethics Committee inclusive of Aboriginal people. The ethics review process assesses whether culturally appropriate considerations have been included and considered in the project’s study design and proposed methods of analysis (Aboriginal Health & Medical Research Council, 2020). Inclusion of formerly incarcerated people in ethics panels may even assist with snowball sampling methods and creating credibility of the research (and researcher) at recruitment phase.

There are some limitations which warrant mention. First, participant response bias can occur in self-report scenarios, such as qualitative interviewing (Furnham, 1986). Whilst it is plausible that some participants may have skewed their responses in the belief that this would appease the researcher, the reflections highlighted within this article predominantly focus on the interactions between interviewer and participant – that is, the process of exchange rather than the content. Second, this researcher’s experience with conducting research in the prison setting is limited to one state in Australia. Thus, there may be limitations in transferability of this work to international settings.