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CAL,IFORNIA STATE UNIVERSITY, NORTHRIDGE

rrHE PSYCHOLOGICAL ASSESSMENT

OF THE HISPANIC SUBORDINATE BILINGUAL

A thesis submitted in partial satisfaction of the requirements for the degree of Master of Arts in

Psychology

by

Julie London

January, 198 4 v '

The Thesis of Julie London is approved:

l)arla Butler

Robert Dear

California State University, 'Nort..lrri.dge

ii (l •

Acknowledgments

Many people have been involved in the realization of this project. There are many individuals to thank and fondly remember. Foremost, my professor and Thesis Chair­ man, Dr. Leo Pirojnikoff, who introduced me to psycho­ logical assessment, making the study of the MMPI, both very challenging and stimulating. Dr. Pirojnikoff has been a wonderful mentor, encouraging me and believing in me, even when the product of this master's thesis was in its un­ differentiated stage.

Secondly, I would also like to thank my two other committee members, Drs. Karla Butler and Robert Dear. Dr.

Butler helped make my two years of graduate study as CSUN as supportive as possible; her confidence in my abilities provided me with invaluable support as I applied to my traineeship and Clinical Ph.D. program. Thanks for every­ thing Karla! I would also like to give Dr. Dear a special

"thank you" for graciously contributing of his time and statistical expertise on such short notice.

Drs. J.S. Fleming and Dr. Barbara Tabachnick also contributed a great deal to my thesis, helping me with computer statistical packages that would refuse to work or to be deciphered. Thank you, Jim and Barbara for making the computer rendezvous as painless as possible. Continued luck and success to both of you.

Developing my skills and appreciation of psycho­ logical research was enthusiastically passed on to me by

iii two very special individuals, Drs. Barbara Goldstein and

Michael Newcomb. Dr. Goldstein has been a source of inspiration ever since she was my T.A. for my first Psy­ chology course at UCLA, seven years ago. Dr. Goldstein has been a wonderful teacher, friends, and role model, always encouraging me, and telling me "You can do it!," and I finally have. Thanks, Barb. Dr. Michael Newcomb has also been a source of strength and inspiration over the past four years, helping me run that little "extra distance" both personally and professionally. Dr. Newcomb has been a special mentor, helper, and friend, sharing my enthusiasm, from multivariate statistics to bataca fights. Thanks for being there Barb and Michael.

Last, but certainly not least, I would like to thank my family for their encouragement and belief in me.

iv TABLE OF CONTENTS Page

Acknowledgments ...... iii

List of Tables ...... vi Abstract ......

CHAPTER I

Introduction •..•..•.. 1 Defining Bilinguality .•.•.. 2 Language and the Psychiatric Evaluation 8 Current Psychodiagnositic Trends with Minorities 14 Psychological Distress in the Hispanic Community .•...... 18 The Psychodiagnostic Process and Hispanics .... 23 Hypotheses 31 Objectives 31 Rationale 34

CHAPTER II

Subjects 37 Measures 37 Procedure 38

CHAPTER III

Results ...... 40 CHAPTER IV

Discussion 52

REFERENCES ...... 58 APPENDICES ...... 63

v LIST OF TABLES

Table Page

l Mean and Standard Deviation Scores for English vs. Spanish MMPI Protocols 41

2 MANOVA Table for a 2 x 2 Factorial Design with 6 Dependent Variables Each Having 2 Repeated Observations .•.••.....• 43

3 Cell and Marginal Means for a 2 x 2 Factorial Design .••....•..•.•.•...... • 45

3a Variable: Lie (L) Scale ..••...... 45 3b Variable: F Scale ...... 46 3c Variable: K Scale ...... 47 3d Variable: Depression (D) Scale ...•..... 48 3e Variable: Paranoia (P) Scale ....•.•.... 49 3f Variable: Schizophrenia (Sc) Scale ...•. 50

vi ABSTRACT

THE PSYCHOLOGICAL ASSESSMENT

OF THE HISPANIC SUBORDINATE BILINGUAL

by

Julie London

Master of Arts in Psychology

Twenty-six subjects, equally divided by sex, from

El Salvador, Central America, served as subjects for this study. The effects of language on thepsychological assess­ ment of the Hispanic subordinate bilingual individual, was investigated. It was hypothesized that the Hispanic sub­ bordinate bilingual would obtain significantly higher T score elevations on the English protocol of the MMPI, on scales L, F. K. D, Pa, and Sc. In addition, it was hypo­ thesized that higher T score elevations on the English MMPI would be observed in those individuals who were adminis­ tered the English protocol before the Spanish one.

The results of this investigation revealed that

Hispanic subordinate bilingual subjects scored signifi-

vii cantly higher on Pa when tested in English as opposed to

Spanish. The hypothesis which anticipated an order effect of language was not substantiated. Furthermore, no sig­ nificant differences across languages were seen on scales

L, F, K, D, and Sc. The author discusses trends in current psychodiagnostic practices with minority groups as well as strategies that will improve the psychiatric evaluation of the Hispanic patient.

viii CHAPTER I

Introduction

Within the last ten years, research concluding that minority groups in this country are often unfairly and incorrectly diagnosed has surfaced. In general it is now a commonly accepted fact that minorities are more often then not rated as more "pathological" than their Anglo counterparts. In many psychiatric and community mental health facilities, the initial evaluation of a new client begins with the administration of psychodiagnostic tests.

A client's performance on such psychological batteries is extremely important since such initial evaluations are often used to determine whether treatment will be offered, and if so, what type (Padilla, 1975). Thus, the issue that members of minority groups are being improperly diagnosed is of great importance, for improper diagnosis can vastly contribute to the current difficulties encountered in the utilization of mental health services by minorities in the

United States.

Patients whose mother tongue is not English comprise a significant proportion of the psychiatric population.

The English speaking clinician must frequently evaluate and treat such patients who lack full command of English, and as such, true communication is often hampered by a realis­ tic language barrier. The effect of such a language barrier has been investigated by Marcos (1973, 1976) in order to begin understanding the effect such a barrier has 2 ~':i •

on psychiatric interviews. In investigating the effect of

language on the psychiatric evaluations of 10 hospitalized

schizophrenics whose native language was Spanish, Marcos

(1973, 1976) demonstrated that these patients manifested a greater level of psychopathology when interviewed in

English. Thus, unlike other minorities, the Hispanic

population must face an additional obstacle in psycho­

diagnosis because of nonfluency in English. Hence, given

the different levels of psychopathology reported for

Hispanics and other minorities, it is imperative that the

clinician seek out psychodiagnostic methods that will

reflect the "true" condition of the patient as closely as

possible (Marcos, 1973).

In exploring the psychodiagnostic difficulties the

Hispanic patient encounters, the following investigation

will examine the dimensions of the Hispanic's bilingual/

bicultural world in the United States. Similarly, the

current trends in psychological assessment of the mental

health of minority groups and the problems of psychiatric nosology that interact with the sociocultural issues of the

Hispanic community will be reviewed. In general, the

forthcoming study will attempt to outline the various

linguistic and social barriers the Hispanic patient en­ counters when interfacing with the mental health system in

the country.

Defining Bilinguality

The precise meaning of the term "bilingualism" varies 3

throughout the literature (Hughes, 1981). Weinreich

(1953), for example, defines bilingualism as "the practice of alternatively using two languages." Although Wein­ reich's definition implies a degree of fluency in both languages, as well as the ability to switch from one language to another with little difficulty, it should be kept in mind that not all bilingual individuals can switch languages with such ease. This is because there are various categories of bilinguality, all which represent a wide range or degree of language fluency.

When describing the effect of language on the psycho­ diagnosis of Hispanic individuals, it is important to understand the different categories of bilinguals. More specifically, there has been a bilingual typology estab­ lished by the psycholinguistic researchers, Ervin and

Osgood (1954). There are three basic types of bilinguais according to Ervin and Osgood: "subordinate," "compound," and "coordinate." The subordinate bilingual shows a differential competence in his two languages, with his first language remaining most clearly dominant. In con­ trast, the coordinate and/or compound bilingual is equally proficient in both languages. In differentiating the coordinate from the compound bilingual, the social setting for language acquisition differs, with coordinates learning each language in different settings and compound bilinguals learning the languages in the same social setting.

The most compelling evidence for differential domin- 4

ance and the differences between types of bilinguals comes from research into the adventiously acquired language disorders, especially the categories of organically based disturbances collectively called aphasia (Diebold, 1969).

In 1934, Stengel and Zelmanowicz (cited in Diebold, 1969) noted that subordinate bilingual patients had greater deficits in their second language after becoming aphasic.

Diebold (1969) explains that the well documented occurrence of differential language impairment is a function of the motor-productive and sensory receptive habits associated with primary language acquisition (given continued usage of that language), which tend to confer a greater resistance to language pathology after an aphasia inducing trauma.

Such resistance, however, is not available to the subor­ dinately bilingual individual's secondary language, since the neurolinguistical structures are not as firmly in­ grained in a language that is clearly less dominant.

It is important to note that research with bilingual aphasics has also shed light on the specific differences between compound and coordinate bilinguals. Lambert and

Filenbaum (1959), for example, found while re-examining case histories of proficient bilinguals who were aphasic, that compound and coordinate bilinguals, despite their manifest fluency in both languages, were differentially impaired by aphasia. Lambert and Filenbaum (1959) noted that compound bilinguals, those who had simultaneously acquired both languages in childhood, tended to suffer 5

equal damage to both languages. Coordinate bilinguals,

individuals who had learned each language in demonstrably

different social settings, were found to be differentially

impaired by aphasia. In analyzing which of the coordinate

bilingual's two languages was most affected, Diebold (1969)

explains that a number of variables will determine which

language will be most affected. Variables such as latent

psycholinguistic dominance, frequency of language usage,

and the affective values attached to one or the other

language must be examined to make this clinical prediction.

There is general agreement that the process of latter

secondary language acquisition is qualitatively distinct

from primary language acquisition, regardless of whether

the latter involves one or two languages (Diebold, 1969;

Burling, 1982). The subordinate bilingual is often asso­

ciated with formal second-language instruction, in which

typically the incipient bilingual first develops a set of

"translation equivalences" between his native and the tar­

get second language (Diebold, 1969). In analyzing the

speech of the subordinate bilingual, the deviations and the

"conflicts" between phonological and grammatical rules

suggest an imperfect mastery of the secondary language.

Diebold (1969) noted that the interference documented in

the bilingual's secondary language was symptomatic of the dominance by the linguistic habits of the person's primary

language. In general, there is a basic "carry over" of

linguistic habits when the subordinately bilingual attempts 6

to speak in his secondary language. Such linguistic

interference is in great contrast to the language of the compound and coordinate bilingual, whose linguistic per­ formance is not affected by phonetic and syntactical interference. It should be noted that foreign accents and other grammatical mistakes seen in secondary language usage are examples of linguistic interference (Diebold, 1969).

The sociolinguistic features of bilingualism seem to be very important in nature. For example, a compound bilingual is an individual who acquired both languages in a

"fused" social context. This social context, where the speech community offered the person equal and simultaneous exposure to two languages, ultimately resulted in minimal differentiation of the social functions of both languages.

Diebold (1969) asserts that the compound bilingual com­ munity is relatively rare cross-societally, and when it does exist, it is not stable for long periods of time.

Typically, the sociolinguistic structure of the coordinate bilingual community is one in which one of the languages is sociologically dominant, where social functions of each language is maximally differentiated, such as Spanish at home and English at school. For the most part, then, coordinate and subordinate bilinguals are the norm rather than the exception.

The subordinate bilingual unlike the coordinate bi­ lingual, however, does not have linguistic systems that lead to maximal separation of cognitive processes and other 7

language mediated behavior (Diebold, 1969). The difficulty

the subordinate bilingual has in optimally separating his

linguistic systems has implications for the communication

style of many individuals who have an imperfect mastery of

their secondary language. More specifically, the Hispanic

patient who is significantly more dominant in Spanish will

have great difficulty consistently expressing himself in

English on demand.

With 1980 census estimates at 14.6 million, Hispanics

constitute the fastest growing ethnic group in the United

States. Vazquez (1982) cited that for at least 80% of

these Hispanic Americans, Spanish is the mother tongue.

Hence, it is not surprising that researchers in the field of mental health have needed to begin focusing on the

impact bilingualism and biculturality has had on Hispanic

individuals. Yet, for many decades, scores of Hispanic communities who have interfaced with the mental health system in the United States did not have the effect of their bilingualism taken into consideration in their psychiatric evaluations. Karno (1971) was concerned with the small amount of consideration given to the problem of language in clinical settings, especially in light of the importance that is typically attached to communication disorders in theories about schizophrenia and other family related psychiatric disturbances.

The interview is the main tool used to obtain in­ formation on the patient for purposes of psychiatric 8 p •

diagnosis. Assessment of various mental processes such as

orientation, thought disorders, delusions, odd ideas,

feelings, and judgment are all highly verbal in nature

(Price & Cuellar, 1981). Thus, the information bilingual

patients provide and the clinical picture they present is

very likely to be associated with the language in which the

psychiatric interview is conducted. There are significant

language related factors that influence the assessment of

bilingual patients. Some of these factors are lexical, morphological, syntactical, and phonological interferences

from one language to another, as well as structural and

idiomatic interferences from one language to antoher

(Olmedo, 1981). Hence, language is a multifaceted ability, one that can have far reaching implications for the obser­ vation of, and intervention with, human beings.

Language and the Psychiatric Evaluation

While investigating the effects of language on 10 subordinately bilingual Hispanic schizophrenics in New York

City, Marcos, et al. (1973, 1976) employed a standard psychiatric interview, the Brief Psychiatric Rating Scale

(BPRS) to examine the effect of language on the rating of psychopathology. Through the use of the BPRS, Marcos, et al. (1973, 1976) demonstrated the effect that linguistic incompetency, as manifested by gross speech disturbances, can have on psychiatric patients who are interviewed in

English. Marcos, et al., in studying subordinate bilin­ guals, (1973, 1976) noted that the fluidity of the 9

patient's thought process can become obstructed, often

causing the English speaking clinician to assess a psy­

chiatric disturbance tht is greater in severity. Thus, the

clinical picture of the subordinate bilingual is often misleading because the patient's speech seems at times

incoherent, showing a greater amount of concrete thinking,

and a general impoverishment of thought processes and

affect. In general then, because subordinate bilingual

patients tend to frequently misunderstand the questions

asked by their clinicians, and because they often provide

very brief responses to questions, with speech that seems

highly disorganized, it is conceivable that the clinician

interprets the above language effects as indicative of greater pathology.

In their analysis of 10 Hispanic schizophrenic patients, Marcos, et al. (1973, 1976) explained that when a patient attempts to speak a language other than his primary

language, he creates problems for both himself and his

therapist. The patient, in his attempt to communicate in a

less familiar language, adds a further burden to his

already impaired thought processes. In generalj then, the

subordinately bilingual's incompletely acquired second

language serves as a cognitive and psychological stressor, which futher compounds the level of manifest psycho­ pathology. Marcos, et al. (1973, 1976) found that the

cognitive organization and integration of his ptients was

affected in their use of English, but not of Spanish. This 10

finding substantiated that neurolinguistic habits asso­

ciated with primary language acquisition confer greater

resistance to change and/or stress. Similarly, Marcos, et

al (1973, 1976) observed that when his patients spoke in

English, they were more guarded and uncooperative in their

interactions with the investigators, thereby appearing less

communicative, and both more formal and emotionally with­

drawn.

In further investigating the dimensions of stress

that the nondominant language can have on the expression of

psychopathology, Grand, Marcos, Freedman, and Barraso

(1977) focused on the kinesic attributes of the 10 Hispanic

schizophrenics studied earlier. The findings of this

investigation suggested that kinesic behavior is related to

both cognitive processing dysfunction and the form of

language encoding in this sample of patients. Grand, et

al. (1977) also concluded, that in contrast to the Spanish

language interview, a greater number of hand movements,

which was found to be meaningfully related to stress, was

found during the patients' English interviews. The above

finding is further substantiated by Meara (1978) who demonstrated through linguistic analyses of the speech of

foreign language learners, that the speech of nonnatives is

structurally similar to the speech of schizophrenics. The similarities are found in terms of the type-token ratios,

predictability, use of contextual redundancy, and word

associations. Thus, Hispanic subordinate bilingual pa- 11

tients are at higher risk than average for being mis­ diagnosed as schizophrenic.

In returning to Marcos, et al. 's (1973, 1976) con­ clusions on the effect of a nondominat second language on a psychiatric interview, it should be pointed out that significant differences in ratings of psychopathology were also found in individuals who appeared competent in Eng­ lish, more specifically, the coordinate bilingual. Glatt

(1969) discovered a significant statistical difference on the F scale of the MMPI in the English and Spanish proto­ cols of "proficient" or doordinate bilinguals. The sub­ jects of this investigation scored higher on the F scale in

Spanish than in English. It should be noted, however, that

Glatt's coordinate bilinguals were slightly more English dominant (as demonstrated by the subjects sociolinguistic background and their scores on sematic diffeential tests).

Since the subjects in question had higher T score eleva­ tions on Scale F on the Spanish protocol, it can be seen that the language of lesser fluency can serve as a cogni­ tive and emotional stressor.

In contrast to researchers postulating a higher level of psychopathology in subordinately bilingual patients who are interviewed in English, Del Castillo (1979) described the clinical episodes of five Puerto Rican patients who were awaiting trial for criminal offenses. Del Castillo

(1979) found his Spanish speaking patients to appear overtly psychotic in their primary language, but almost 12

normal in some cases, when interviewed in their nondominat language, English. Del Castillo (1979) explains his findings in the context of the unconscious mind, stating that the effort in communicating in another tongue produces an unconscious vigilance over the emotions. Unlike the psychiatric patients of Marcos, et al. (1973, 1976), Del

Castillo 1 s sample had a greater investment in consciously producing psychotic symptomatology, for they wanted to avoid trial. Fabrega (1968) like Del Castillo (1979), also found a higher level of psychopathology when Hispanic patients spoke Spanish as compared to English. Fabrega

(1968), on the other hand, attributes the same finding to the fact that many Hispanics are not hospitalized early in the course of illness. Thus, the patient is not provided with an initial evaluation until his mental disorder is in an advanced stage.

Price and Cuellar (1981) investigated the effect of interview language on the expression of psychopathology and the relationship of this effect to the variables of verbal fluency, acculturation, and self-disclosure. These inves­ tigators employed 32 Mexican-American patients institution­ alized in the Bilingual/Bicultural Unit of the San Antonio

State Hospital. These patients like those of Marcos, et al. (1973, 1976) were evaluated using the BPRS in separate

English and Spanish language interviews. Price and Cuellar

(1981) found, like Del Castillo (1979) and Fabrega (1968) before, that their sample of Hispanic patients expressed 13

significant symptomatology indicative of psychopathology during the Spanish interviews. In addition, Price and

Cuellar (1981) observed that verbal fluency and self­ disclosure were significant multiple predictors of the difference in expressed psychopathoogy in the interviews of each language type. In employing alternative statistical analyses, these investigators demonstrated that both verbal fluency and acculturation could also predict the observed difference in psychopathology across languages. Price and

Cuellar (1981) added that, while the variable of self­ disclosure did not solely contribute to the differences in psychopathology in the English and Spanish interviews, their patients did tend to more readily self-disclose during the Spanish interview, a finding also corroborated by Marcos, et al. (1973, 1976).

A related study, which also addresses the impact of interview language on psychopathology, was conducted by

Gonzalez in 1977. This investigator examined the rela­ tionship between language and the cultural background of mental health professionals and the assessment of psycho­ pathology in patients of Mexican-American descent. Three groups of clinicians, monolingual Anglo Americans, bilin­ gual Anglo Americans, and bilingual Mexican-Americans served as the raters for the English and Spanish evalu­ ations (interviews) of 10 bilingual Mexican-American schizophrenic patients. The results showed no significant difference in the rating of psychopathology across the 14

English and Spanish interviews. While Gonzalez on the other hand (1977), noted that his patient sample expressed more discomfort and hostility in Spanish, raters irrespec­ tive of their cultural background did not detect signifi­ cant differences in the expression of psychopathology across languages.

Current Psychodiagnostic Trends with Minorities

In examining and integrating the different factors that contribute to the difficulties experienced by Hispanic subordinate bilinguals, when interfacing with the mental health system, additional information on current cross cultural differences on personality assessment can be of value. In substantiating the earlier premise that minor­ ities are evaluated as more "pathological," David, et al.

(1973) found both race and educationally related differ­ ences on the MMPI scores of hospitalized Black and Cauca­ sian schizophrenics. Similarly, in examining the differ­ ential diagnoses in equal numbers of Black and Caucasian patients on first and second admissions to a psychiatric facility, Watkins (1975) found that Black patients received a significantly higher proportion of schizophrenic diag­ noses. Unlike Davis, et al. (1973), Watkins (1975) demon­ strated that such differences in diagnoses were not always a function of socioeconomic variables, for in his sample of patients, such discrepant evaluations remained across all educational levels. Hollingshead and Redlich (1958) on the other hand, maintain that there is a relationship between 15

poverty and mental illness. Baldwin, Floyd, and McSeveney

(1975) investigated the relationship between status indi­

cators and psychiatric diagnosis. Their analyses revealed

that patients with low socioeconomic class were more often

diagnosed as psychotic as opposed to normal or neurotic.

In general, these researchers concluded that race appeared

to be the most powerful predictor of the psychiatric

diagnosis a given patient would be likely to receive.

In investigating MMPI differences between Anglo­

American and Mexican-American college students, Reilley

(1970) found that Mexican-American students scored higher

than Anglo-American students on the Lie (L) scale. In

addition, male Mexican-Americans scored higher on the

psychasthenia (Pt), Schizophrenia (Sc), and Social Intro­

version (Si) scales than did male Anglo-American or female

Mexican-American students. Plemmons (1976) in comparing

MMPI scores of Anglo-American with Mexican-American psy­

chiatric patients in Central California, found that with

standard K-corrected T scores, the Lie (L) and K validity

scales of Mexican-American patients wre higher than for

Anglo-American patients. Similarly, with K-corrected T

scores, no significant differences were seen on the clinical

scales. Yet, when K-corrected T scores were not employed, differences between Anglo-Americans and Mexican-Americans were observed, with the Psychopathic Deviate (Pd), Psy­ chasthenia (Pt), and Mania (Ma) scales appearing lower for

the Mexican-American group. Plemmons (1976) concluded that 16

the K-correction factors elminate significant differences between both cultural groups on the clinical scales of the

MMPI.

In their cross-cultural study on personality dif­ ferences, Penk, Rabinowitz, Roberts, Dolan, and Atkins

(1981) examined the MMPI profiles of male heroin addicts in

Texas. MMPI scores from Hispanic, Black, and Caucasian addicts, revealed that Hispanics had the highest T score elevations on the Lie (L) scale, and the lowest T score elevations in the Masculinity/Femininity (Mf) and Psycho­ pathic Deviate ( Pd) scales. ·while researching the dimen­ sions of the personality structure of Anglo-American and

Mexican-American adult offenders, Holland (1979) observed

MMPI differences between both ethnic groups, noting the lower Masculinity/Femininity (Mf) that seemed to charac­ terize the male Mexican-American offender.

McCreary and Padilla (1977) analyzed MMPI profiles generated by Black, Mexican-&~erican, and Anglo-American male misdemeanor offenders, who had been referred to a forensic psychiatry program in order to help evaluate their readiness to stand trial. These investigators noted that in comparison to Anglo-Americans, Mexican-American had significantly higher T score evaluatuions on the Lie (L),

K, and Hysteria (Hs) scales. In researching the MMPI profiles of male and female psychiatric patients from

Anglo-American and Mexican-American cultural backgrounds,

Hibbs, Kobos, and Gonzalez (1979) found that in comparison 1 7

to Anglo-American patients, Mexican-American males had

significantly higher T score elevations on the Lie (L) and

K scales, while female Mexican-American patients had

greater elevations on the Hysteria (Hs) and Paranoia (Pa)

scales. Lastly, McGill (1980) evaluated the MMPI profiles of Mexican-American, Caucasian, and Black welfare re­

cipients, and he, like other investigators, noted sig­ nificantly higher T score elevations on scales L and K.

Thus, members of the Hispanic community have typically higher T score elevations on some of the validity and clinical scales of the MMPI.

A related study by Dolgin (1981) addressed the dif­ ferences in psychological symptomatology in hospitalized

Hispanic and Anglo-American psychiatric patients in a

Colorado State Hospital. Dolgin (1981) utilized the files of former patients in order to obtain a list of approxi­ mately 60 problem variables that had been encountered by the psychiatric staff. Having determined that Hispanic patients had a significantly greater amount of problematic symptomatology than did their Anglo-American patient counterparts, the investigators performed a stepwise discriminant analysis of the original 60 "problem" vari­ ables with each ethnic group. Hispanic patients in this study were observed to have had higher rates of psychosis, depression, low self-esteem, loneliness, alcoholism, difficulties in communicating with spouse, resistance to treatment, and refusal of medications. Anglo-American 18

patients fared higher than Hispanics only with respect to delusional thought processes.

Stoker, Zurcher, and Fox (1968) compared the psy­ chiatric diagnoses of 25 Mexican-American women with those

25 Anglo-American women. These investigators controlled for socioeconomic, marital, and educational variables, yet,

Stoker, et al. (1968) observed significant differences in the defense systems these women used, as well as in the structure and symptamatology of their diagnoses. After analyzing the respective psychiatric records, Stoker et al. found that in general, Mexican-American females were bothered by affective disturbances, as manifested by symptomatology such as eating disorders, depressive somatic complaints, and suicide attempts. Anglo-American females, on the other hand, were seen to be most affected by anxiety syndromes, most often manifested by obsessive compulsive thoughts, anxiety/panic attacks, and bouts of suspiciousness. In analyzing the frequency of somatic complaints between ethnic groups, Mexican-American women tended to report four times as many somatic symptoms than did Anglo-American women. In general, then, differences in personality structures as operationalized by objective measuring instruments, have been consistently found across ethnic groups.

Psychological Distress in the Hispanic Community

In order to gain a comprehensive view of the factors that influence the psychological assessment of the Hispanic 19

individual, it is important to review the other stressors

that together with language, will impact on the type of

psychopathology diagnosed. Karno (1982) studied the pre­

liminary 1980 census data, which reveals that more than

2,000,000 of Los Angeles County's population of 7,000,000

people are of Hispanic origin. Karno (1982) reflected on

the high rates of unemployment, substandard and crowded

housing, active gang violence, high drug addiction, alco­

holism, and communicable diseases, which affect the mental

health of many Hispanics residing in Los Angeles County.

Santisteban and Szapocznik (1982) assert that Hispanic

families face special problems of adjustment due to their exposure and subsequent reaction to the acculturation process. Acculturation is defined by these investigators as a linear function of the amount of time a person has been exposed to the host culture. Santisteban and Szapocz­ nik (1982) also point out that the rate of the accultur­ ation process is dependent on the age and sex of the

individual. Similarly, they state that Hispanic families manifest their negative reaction to acculturation by the high incidence in the communication problems than can erupt between parents and children. In addition, certain anti­ social and behavioral problems seen in minority children and adolescents are often a by-product of the difficulty in acculturating.

In their research on acculturation and biculturalism,

Santisteban and Szapocznik (1982) propose a bicultural 20

involvement model of adjustment. According to this model,

individuals living in bicultural contexts tend to become maladjusted when they remain or become monocultural. It is frequently observed that individuals from minority groups cope with demands of the acculturation process by a) underacculturating; that is, failing to leaarn how, or not wanting to interact with the host culture; or b) coping by

"overacculturating" in the form of rejecting the primary culture. Such splitting is deemed as counter-adaptive because the disequilibrium produced by the defensive reaction makes the individual inflexible in coping with the realistic demands placed in a bicultural world.

Santisteban and Szapocznik (1982) applied their model of bicultural involvement by studying the relation­ ship between adjustment and biculturalism in Cuban-American junior high school students. These investigators analyzed teacher ratings of adjustment of the students involved in the study. Their findings clearly indicated that higher scores of adjustment were seen for those students who were equally bicultural. Thus, biculturalism appeared to predict the level of adjustment for Cuban American adoles­ cents. In elaborating on the operation of their model of bicultural involvement, Santisteban and Szapocznik (1982) state that the acculturation process occurs along two dimensions. The first dimension can be understood as the process of accommodating to the host culture, while the second dimension involves the complicated task of main- 21

taining an equilibrium between relinquishing and/or re­

taining the culture of origin.

Santisteban and Szapocznik's (1982) model is further

substantiated by Torres-Matrullo's (1976) investigation of

the relationship between mental health and sex role prefer­

ences in universal age Puerto Rican women. In her study,

Torres-Matrullo (1982) observed greater psychological

adjustment in those females who were nontraditional in

their sex role attitudes. In comparing the university

women with both housewives and female mental patients, the

nontraditional female students fared higher on all dimen­

sions of psychological adjustment examined. Torres­

Matrullo (1982) also found that Puerto Rican women who had

been diagnosed asd depressive and/or neurotic (and who were

currently under psychiatric care), had significantly more

traditional sex role expectations than the students or

housewives who had been evaluated as well adjusted. This

investigator also demonstrated that women who were non­

acculturated were shown to have elevations in their levels

of hostility, isolation, agresivity, as well as lower

levels of self-esteem and personal adequacy. Thus, in

delineating the important implications of her study,

Torres-Matrullo (1982) concluded that Puerto Rican women

who adhered to very traditional values, like other non­

acculturated women, were much less emotionally adjusted

than less traditional or nontraditional Puerto Rican women. 22

Tharp and Lennhoff (1968) support Torres-Matrullo's

(1982) findings above, through their comparison of accul­ turated versus nonacculturated Mexican women. Tharp and

Lennhoff found that nonacculturated Mexican women perceived themselves as poorer mothers and housekeepers than did acculturated Mexican women. In addition, nonacculturated women had lower self-esteem and fewer expectations for family cohesion and enjoyment, than did the acculturated women in Tharp and Lennhoff's (1982) sample. Thus, there are consistently clear differences in the mental health of

Hispanic individuals who remain unacculturated versus those who can acculturate.

In exploring the multitude of stressors that members of the Hispanic community experience, Dolgin (1981) states that the difference in patterns of behavior between His­ panic and Anglo-American patients is a function of the conflicts that emerge when the Hispanic individual attempts to adjust to a culture that is often not complementary to his own. Dolgin (1981) expressed that when an individual's set of values are in conflict, it is not uncommon to find significant increases in lowered self-esteem, depression, alcoholism, and even psychosis. Such emotional problems are often compounded when the Hispanic patient feels rejected by mental health professionals, who speak a different language, have a culturally disimilar background, and who are more often than not, insensitive to the pa-_ tient's cultural values. 23

The Psychodiagnostic Process and Hispanics

In continuing with the present review on psycho­ diagnosis it would be useful to examine some of the diffi­

culties inherent in psychiatric classification. The

psychiatric interview is highly susceptible to "response

bias." This form of bias occurs when subjects know that

they are being observed~ in this situation, the subject often does not behave as he usually would. Instead,

subjects or patients will perform in the way they perceive

is expected of them, or they will behave in the manner that will yield them the highest returns.

Often co-existing with response bias is "experimanter

bias." With this form of bias, the researcher or clinician

unknowingly (usually) influences the data or the patient's

behavior. Typically, while both forms of biases cannot be eliminated, they can be controlled. Such control is of great importance with cross cultural psychodiagnosis. In examining experimenter bias cross culturally,

Gross, Herbert, Knatterud, and Donner (1969) found that diagnostic errors increase and patient disposition becomes less specific as the sociocultural distance between the clinician and patient increases. Documentation on experi­ menter bias was further corroborated by the study by

Bloombaum, Yamamoto, and James (1968). these investigators were interested in assessing the prevalence of culturally stereotypic attitudes in psychotherapists. In predicting whether Blacks, Mexican-Americans, Jews, or Japanese- 24

Americans would be most likely represented by a cultural

stereotype, Bloombaum, et al. (1968) found that of all

ethnic groups, Mexican-Americans were the most likely to

be culturally stereotyped.

Pokorney and Overall (1970) elaborated on the phenomenon of "experimenter bias" by stating that mental health professionals project nosological biases by often providing their patients with diagnoses that are particu­

larly common to the clinician's culture. In addition,

Pokorney and Overall (1970) suggested that particular diagnoses are often made to satisfy administrative and/or therapeutic needs. For example, these researchers asserted that when the clinician feels his patient should be insti­ tutionalized, he will often make a diagnosis denoting psy­ chosis. Similarly, if the clinician decides his patient needs ECT, he will provide such ab individual with diag­ nosis of depression.

Karno (1966) pointed out that differences in diagnosis and labeling are often accompanied by an "insensitivity" to the relevance of culture in clinical settings. Karno

(1966) affirms his concern with the psychiatric establish­ ment after noting in the case records of Mexican-American psychiatric patients that in only 4 in 28 records examined, was there any reference to the impact that the patient's ethnicity had on his psychiatric disturbance. Cuellar

(1982) hypothesized that if Hispanics were diagnosed in the same manner their Anglo-American counterparts were, Hispan- 25

ics would be rendered an inferior service inadvertently to

the extent that the whole patient would not be considered.

The failure to consider the whole patient, including his or

her cultural background, would weigh heavily in both

confusing the diagnosis and misdirecting the treatment.

Experimenter bias can also be revealed in terms of

the questions a clinician may or may not ask. Cuellar

(1982) noted for example, that some clinicians who are used

to seeing patients whose auditory hallucinations consist of

solely hearing voices, may fail to ask if the patient is

having auditory hallucinations that contain noises other

than voices.

Diagnosing mental disorders across cultural groups

appears to compound the problems of diagnostic reliability

and validity. Torrey (1973) points out that whenever

therapists from one culture diagnose and prescribe treat­ ment for patients in another culture, there is an inherent

probability of professional misjudgment. The problems

associated with making an accurate diagnosis in Hispanic

populations can at times cover the entire spectrum of

reliability and validity concerns in psychiatric nosology.

Basically, sociocultural factors or dynamics have been

implicated in terms of how mental illness is defined,

experienced, manifested, diagnosed and treated. Kleinman

(1978) statged that social and cultural influences on the

clinical picture have an important effect on diagnosis.

Katz (1969), for example, in his study comparing the 26

diagnostic practices between British and American psy­ chiatrists, noted that the definitions of psychiatric symptoms can vary in even groups of psychiatrists who are culturally very similar. More specifically, in diagnosing patients that had been videotaped, Katz (1969) noted, for example, that when u.s. psychiatrists denoted flatness of affect, they typically diagnosed such a patient as having schizophrenia, whereas British psychiatrists diagnosed the same patient as having a neurotic personality disorder.

Psychiatric diagnoses have also been known to vary within the United States, with the East Coast psychiatrists more frequently diagnosing schizophrenia than did mid-Western or

West coast psychiatrists. In general, however, Kendell,

Cooper, and Gourlay (1971) have noted that affective symptoms are most sensitive to cross cultural misinterpre­ tations. In their 1972 study Cooper, Kendell, and Gurland (1972) found that even when u.s. and British psychiatrists made their diagnoses according to the International Code of

Diseases, New York clinicians diagnosed schizophrenia far more frequently than did London psychiatrists.

Despite differences in psychiatric nosological practices, the 1973 International Pilot Study of Schizo­ phrenia (IPSS), sponsored by the World Health Organization, demonstrated that it was possible to conduct valid and reliable international studies on schizophrenia. The IPSS, after comparing schizophrenic syndromes around the world found that there was a high concordance among such symptoms 27

as lack of insight, predelusional signs, ideas of refer­ ence, preflexity, flatness of affect, and auditory hallu­ cinations. The IPSS findings demonstrate that when psychi­ atric screening and diagnostic instruments are properly translated, reliable and equivalent results can be obtained across different cultural groups (Cuellar, 1982).

Various cross-cultural studies have shown that if different definitions are used, clinicians can hardly be expected to arrive at comparable diagnoses (Shepherd,

Brooke, Cooper, & Lin, 1968). Variations in observations of symptoms and signs, and inferences drawn from observa­ tions also contribute to diagnostic disagreement (Shepherd, e t al • , 1 9 6 8 ) •

Wing, Nixon, Cranach, and Strauss (1980, cited in

Cuellar, 1982) have thoughtfully outlined seven stages of the psychodiagnostic process that have entry points which can influence the invalidation of a Hispanic individual's psychiatric evaluation. Such stages will be examined in the present discussion to highlight where the psycho­ diagnostic process can go wrong. The first stage revolves around identifying symptomatology and matching it up in the diagnostic and Statistical Manual of the American Psy­ chiatric Association (DSM-III). Ordinarily, clinicians do not have too much difficulty following this stage with

Anglo-American clients; however, this is not so, in the case of the Hispanic patient because Hispanics often categorize symptoms differently than Anglo-Americans do. 28

For example, it would be difficult to categorize susto

(fright), embrujado(a) (hexed or bewitched), for DSM-III does not outline symptoms with such broad terms. Hence, because Hispanics operationalize their symptoms differ­ ently, often the English speaking diagnostician must make assumptions about the exactness of the symptoms, thus leaving his diagnosis susceptible to invalidity and un­ reliability. In addition, as Cuellar (1982) points out, such terms as those above are often used by individuals who do not have a mental disorder. In examining the symptoms above, the clinician has no way of really classifying the symptom; he cannot determine if embrujado is an unusual perceptual experience, an affective disturbance, or some form of prodromal symptom (Cuellar, 1982).

The second stage as defined by Wing, et al. (1980, cited in Cuellar, 1982) is defined to the forthcoming investigation, in that this stage the language barrier encountered by Hispanic patients becomes exceptionally prominent. This stage is officially the psychiatric interview, where highly verbal phenomena such as thought processes are evaluated. Even with the aid of an inter­ preter, it would be highly difficult to assess loose associations, tangential thinking, and poverty of speech, all of which are important in concluding whether a major psychiatric disturbance is present.

The third stage is where the clinician needs to make a differential diagnosis for his patient. Differ- 29

ential diagnoses are difficult to make even without the language barrier, for there is often an overlap of symptoms between psychiatric disorders, thus limiting the relia­ bility and validity of the assessment even more.

The fourth stage begins when the clinician needs to gather information from the patient's significant others. The reliability and validity of someone's testi­ mony is always difficult to ascertain with certainty. Yet as was the case in the first stage, what does a relative mean when he describes his loved one as "nerviosa." Should the clinician assume it is anxiety, a hysterical reaction or what (Cuellar, 1982)? Cuellar voiced particular concern about this point in psychodiagnostic process because the diagnostic picture can become even more clouded, ultimately causing a diagnosis that may be harmful.

The fifth stage in the diagnostic process is rele­ vant to the forthcoming study, in that it is at this stage in psychodiagnosis where psychological test findings enter the diagnostic process. For example, how reliable would one's MMPI profile be if given via an interpreter? Thus, more artifacts enter, simply because the patient may not be sufficiently fluent in English. Intelligence testing becomes of particular concern because a low IQ may reflect cognitive retardation, perhaps as a secondary effect of psychosis, yet with a Hispanic individual who has a lan­ guage barrier, a low IQ may be used to label the person not only as "crazy" but of subnormal intelligence as well, 30

especially if the clinician is not sensitive to language and cultural issues of the Hispanic patient.

The sixth stage of the psychodiagnostic process involves integrating the previous stages and assessing whether the patient reports any change in his symptoms.

The seventh stage involves the gathering of etio­ logical factors. Usually, the English speaking clinician can gather the information with relative ease; yet, once again, the process becomes difficult because it would involve obtaining a psychiatric history of some sort from the relatives of the patient, who may or may not be suffi­ ciently fluent in English.

The effect that symptom perception has on both the client and the clinician is another area that is parti­ cularly relevant to psychodiagnosis wioth Hispanics since it is not uncommon to see a symptomatological dichotomy between patient and clinician. More specifically, Ruiz

(1982) noted that some Hispanics tend to see certain symptoms as a gift or positive quality. For example, to the Anglo-American clinician hallucinatory experiences would represent psychopathology while to the Latino client the hallucination(s) may represent a spiritual "revelation" of sorts. Thus, in psychodiagnostic practices with Latino clients, especially those who are not as acculturated, it is important to specifically assess the meaning such sumptoms have for the patient. Ultimately, such sensi­ tivity may curtail initial therapeutic misalliances, which 31

often end up alienating the Latino client from utilizing

the mental health facilities in this country.

Hypotheses

H The scales L, F, K, D, Pa, and Sc will have greater 1 statistical and clinical elevations when Hispanic sub­ ordinate bilinguals are tested with the English rather than the Spanish MMPI form.

H The L, F, K, D, Pa, and Sc scales will be more dis­ 1 tressed when the English MMPI is the first form taken by

Hispanic subordinate bilinguals.

Objectives

The following study had several objectives in mind.

While various socioculture factors influence the psychi­ atric and psychological evaluations of the subordinately bilingual Hispanic, the principal objective of this exam­ ination was to assess the impact of language on the psy­ chological evaluation across English and Spanish. While research addressing the influence of language on psycho­ diagnosis has substantially increased over the past decade,

Vazquez (1982) asserts that this ~rea of investigation is presently in a state of confusion because many of the studies thus far are ladened with several methodological weaknesses. Thus, before the objectives in this study are outlined, it would be useful to examine the methodological problems that studies before this one had encountered.

It is difficult to arrive at any type of conclusion on the impact that a nondominant secondary language can 32

have on the measurement of psychopathology. Marcos et al.

(1973, 1976) for example, found higher ratings psycho­

patholgically when bilingual individuals were examined in

the English language. Price and Cuellar (1981) and Del

Castillo (1979) on the other hand, found greater indices of

emotional dysfunction when bilinguals were interviewed in

Spanish (the individual's dominant language). Gonzalez

(1977) adds greater confusion to the directionality of the

impact of language, by documenting that in his sample of

bilingual patients, no differences in emotional disturbance

could be observed between English and Spanish interviews.

In comparing Marcos' (1973, 1976) methodology with

Price and Cuellar's (1981) methodology, various differences

in the experimental procedures could have accounted for the

conflicting findings. In contrast to Marcos' Puerto Rican newly hospitalized schizophrenics, Price and Cuellar had chronically hospitalized Mexican-American schizophrenic patients. It is possible that the present sampling dif­ ferences affected the results, for Price and Cuellar's patients were more used to being handled by psychiatric personnel, thus influencing the higher levels of self­ disclosure seen in the Spanish interviews. The highly guarded and emotionally withdrawn behavior seen in Marcos' patients may have been due to the acutely ill status of his subjects.

Other procedural differences that may have influenced the findings are related to experimenter differences. 33

Marcos (1973, 1976) introduced ethnic bias into his study by having monolingual Anglo clinicians evaluate the English interviews and bicultural/bilingual clinicians evaluate the

Spanish interviews. Price and Cuellar (1981) controlled for such ethnic bias, yet introduced another form of experimenter bias by having the clinicians sit in the room with the subjects who were administered the Brief Psychi­ atric Rating Scale (BPRS). Marcos, et al. (1973, 1976) had the BPRS questions placed on audiotape for both interviews.

Lastly, while Marcos, et al. (1973, 1976) attempted to establish interrater reliability, Price and Cuellar (1981) did not.

The present investigation had as its objective the clarification of the directionality of language on the assessment of psychopathology in subordinate bilingual

Hispanic individuals. Measuring the manifest level of psychopathology using an objective psychological instrument like the Minnesota Multiphasic Personality Inventory (MMPI) is of interest because it may limit the methodological problems cited in the aforementioned studies. More spe­ cifically, the use of an objective measuring device like the MMPI would eliminate some of the confounding variables that had been introduced in earlier studies by the sub­ jective assessment instrument used. In addition, it would be of interest to see the actual level of pathology mea­ sured when information on nonverbal behavior and speech disturbances are not examined as was the case in Marcos', 34

et al. (1973, 1976) and Price and Cuellar's (1981) studies.

A more objective measure of the person's thought process can be obtained using the MMPI across language instead of the BPRS.

Rationale

Psychodiagnosis has a strong bearing on the delivery and utilization of mental health services. Since large problems currently exist in the utilization of· mental health services in the Hispanic community, it is important to investigate the obstacles that exist in the mental health services provided. Hispanic individuals are subject to increasingly high levels of stress typically because of economic and acculturative issues, as well as the stresses imposed because of problems in language fluency. Psycho­ diagnosis is one of the principal entries into the mental health system, and therefore it is important to explore this area. In turn, such an investigation may reveal where in the mental health system the underutilization of serv­ ices in the Hispanic community exists.

The effects of poor assessment on the Hispanic com­ munity have been documented. Olmedo (1981), for example, describes a famous lawsuit that took place in the early

1970s which resulted from Mexican-American children being placed in classes of the mentally retarded because of their retarded English fluency. In the "Diana vs. the Board of

Education" case (cited in Oilmedo, 1981), children were improperly placed in school because the Mexican-American 35

assessment procedures used for placement emphasized English language skills and failed to take into account the child­ ren's Spanish speaking abilities. When the court mandated that the children be tested in both languages, there was an average gain of 15 IQ points, and 7 of the 9 children no longer fell into the mentally retarded range. It is pos­ sible, then, that similar "malpractice" occurs at the psy­ chodiagnostic level. By employing bilingual psychological instruments that are objective, the rate of misdiagnosis could decrease, ultimately insuring that Hispanics receive treatment more concordant with their emotional needs. As accuracy in psychodiagnosis increases, the delivery and utilization of mental health services in the Hispanic community will increase as well.

Karno (1971) pointed out that in the corning years a large decrease in the number of medical students spe­ cializing in psychiatry will be observed because of the

Federal Government's de-emphasis on primary mental health care. This trend has implications for minority groups, since fewer minority mental health specialists will be available to serve their respective communities. Thus, it is of particular importance that methods be made available to the Anglo-American clinician to insure as much accuracy as possible in the psychodiagnosis of minorities. Hence, with respect to Hispanics who are not fluent in English, it will be of utmost importance that present and succeeding clinicians be sensitive to the language barriers introduced 36

between clinician and patient.

Samuda (1975) documented the availability of up to

100 psychometric tests that had been translated into

Spanish. These include translations such as the WISC,

WAIS, Stanford-Binet, Cattell's Culture Free Test, and the

MMPI, among others. While there is typically wide vari­ ability in the accuracy of such translations, there are a sizeable number of assessment batteries in Spanish that would be useful in evaluating Hispanic individuals who are not sufficiently proficient to be tested or interviewed in English. While u.s. assessment practices will usually be somewhat culture bound even after successful translation, various instruments such as the MMPI can be useful in measuring psychopathology in Hispanic individuals (Butcher,

1976). Thus, the rationale of the present study is based on the necessity of proper psychodiagnosis in individuals who cannot validly and reliably be evaluated in English.

By comparing the levels of psychopathology measured in

English with those measured in Spanish, the clinician may gain additional information which could minimize the possibility of misdiagnosis and subsequent inadequate treatment disposition. The present investigation, then, was a preliminary study for the purpose of ascertaining the effect of language on MMPI performance in Hispanic indi­ viduals. Such a study should help to promote the greater use of bilingual assessment batteries in clinical settings, since such bilingual materials are heavily underutilized. CHAPTER II

Methods

Subjects

A total of 45 subjects, equally divided by sex, were recruited to participate in this study. After accounting for subject attrition, the sample ended up consisting of 26 subjects, also equally divided by sex, who were immigrants from El Salvador. For a summary of the subjects' demographical information, refer to Appendix B.

The subjects in this study were lower middle-class workers, mostly merchants and/or lower managerial employees. All subjects were differentially competent in English and

Spanish, with Spanish being the dominant language of the two. Screening criteria insured that subjects had lived in the United States for a minimum of 5 years and have had comparable experience in speaking and reading basic English via employment or "English as a Second Language" classes.

All subjects volunteered their time for this study; in return this investigator presented a lecture on the per­ sonality structure of bilinguals.

Measures

The Minnesota Multiphasic Personality Inventory (MMPI) was chosen as the instrument for this investigation, since it provides an objective and multidimensional assessment of psychopathology. Both the English and Spanish (trans­ lation) forms were employed to ascertain the effects of linguistic difficulty in English. It should be noted that

37 38

research by Glatt (1969) suggests that the Spanish version of the MMPI is both adequate and comparable in quality to the English standard form. The Spanish MMPI used is publised in Mexico City, and is known as the "Inventario

Multifacetico de la Personalidad": El Manual Moderno, S.A.,

1968. In contrast to Spanish translations from other

Spanish speaking countries, the MMPI used in Mexico has had a great deal of empirical research demonstrating its high clinical utility (Butcher, 1976).

Procedure

Each subject took the English and Spanish MMPI. The time interval between the two tests was seven days as suggested by the test-retest reliability coefficients obtained by Rosen (1953), Schoefield (1950), and Glatt

(1969). The distribution of testing materials was ran­ domized to prevent potential confounding variables that could arise if one test was taken consistently first.

Thus, half of the sample took the English MMPI first, while the other half took the Spanish MMPI first.

The MMPI's were administered in the standard way, with the purpose of the study being briefly communicated to the subjects (see Appendix A). As suggested by Glatt (1969), each subject was discouraged from trying to remember and duplicate the responses they may have made on the first test. English/Spanish dictionaries were available to aid the subjects in looking up words and/or idioms they did not comprehend. Glatt (1969) noted that dictionaries should be 39

allowed, for they are routinely available to patients who take the English MMPI in mental health settings.

All subjects were assured of their confidentiality on their MMPI 1 s. Two weeks after the subjects completed their second MMPI, a lecture was presented on personality and bilinguality in return for the subjects• participation. CHAPTER III

Results

A 2 x 2 between-within subjects multivariate analysis of variance was performed on. 6 of the 13 clinical and validity scales (without the usual K-corrections) of both the English and the Spanish translation of the MMPI. The

MMPI scales L, F, K, D, Pa, and Sc served as the 6 depen­ dent variables, while language (English and Spanish) and order of language (English first versus Spanish first) served as the two independent variables. Only 6 MMPI scales were analyzed because of the small sample size available.

The scales in question were chosen because the clinical scales, in particular, appear to contain the highest number of "critical items" found in the MMPI. The validity scales were selected for study because of their impact on the various clinical scales and because of the apparent sensitivity such scales have to cross-cultural differences.

SPSS MANOVA with the repeated measures option was used for the analyses. The mean scores and their respective standard deviations on the English version and the Spanish translation of the MMPI are presented in Table 1.

40 41

Table 1

Mean and Standard Deviation Scores

for English vs. Spanish i"~4PI Protocols

Scale Mean in f"lean in English SD Spanish SD

Lie (L) 79.6 26.5 86.9 28.0

F 76.1 14.6 73.1 18.0

K 51.5 5.37 50.1 6.39

D 56.5 8.93 57.8 12.5

Pa 55.3 9.54 50.1 11.7

Sc 50.4 16.8 52.4 16.2 With the use of Wilks' criterion, the combined depen­ dent variables were significantly affected by language,

=.641, with 2=.76. A greater T score elevation on the Pa scale was observed when subjects were tested with the

English MMPI form. The multivariate test for both the order and the interaction of language by order failed to reach statistical significance. The multivariate tests for significance are presented in Table 2. 43

Table 2

~~OVA Table for a 2 x 2 Factorial Design with 6 Dependent Variables Each Having 2 Repeated Observations

Exact S.N. Roy Exact s.s. Wilks Conversion Union Conversion Coll1IOC>n Effects Likelihocd to F Inter- to F Rejection due to: Ratio Statistic section Statistic Regions

Inter- action Language Order • 74704 1.07228 .25296 1.07228 F F .05,6,19 =2.57

Main Effect: Language .23724 10.18128** .76276 10.18128** F F.Ol,6,19 =3.81

Main Effect: Order .64141 1.77037 .35859 1.77037 44

To investigate the effects of each main effect and the

interaction on the individual MMPI scales, a univariate analysis was performed. The univariate analyses demon­ strated that the Paranoia (Pa) scale was significantly affected by language, F1 ,24= 14.76 which is greater than F.ol, 1,24= 7.82 with the English Pa scale being significantly higher than the Spanish Pa scale of the MMPI.

The cells and the marginal means for this 2 x 2 factorial design are presented in Tables 3a-3f. Table 3a Cell and Marginal Means for a 2 x 2 Factorial Design

variable: Lie (L) Scale

Language

Spanish English

T11=1053 T12=1091 Tl. =2144 First Y=95.72727 yl2=72.73333 Y1 .=82.46154 n1=ll n2=15 n2=26 Order -

T21=1208 T22=978 T2.=2186 Second y21=80.5333 y22=88.90909 Y2.=84.07692 l n2=15 n1=ll n=26

T.1=2261 T. 2=2069 Y. 1=86.96154 Y. 2=79.57692 n=26 n=26 46

Table 3b

Cell and Marginal Means for a 2 x 2 Factorial Design

Variable: F Scale

Language Spanish English

T11=789 T12=1137 T1 .=1926 First Yll=71. 72727 yl2=75.80000 Y1 .=73.763635

n1 =11 n 2=15 n=26 Order

T =1112 T =1148 21 22 T2•=2260 Second y21=74.13333 y22=76.54545 Y2.=75.33939 n=26 n=ll

T.1=1901 T.2=2285 Y. 1=73.11538 Y. 2=76.11538 n=26 n=26 47 .

Table 3c

Cell and Marginal Means for a 2 x 2 Factorial Design

Variable: K Scale

Language

Spanish English T =54o· 11 T12=791 Tl.=l331 First Yll=49.09091 yl2=52.73333 Y1 .=50.91212 n =11 n=l5 1 n=26

Order ·~ . ·-· ·... · ··- .

T21=764 T22=548 T2.=1312

Second y21=50.93333 y22=49.81818 Y2.=50.375755 n2=26 n1=ll

T.1=1304 T.2=1339 Y. 1=50.15385 y .2=51.50000 n=26 n=26 48 ~ '

Table 3d

Cell and Marginal Means for a 2 x 2 Factorial Design

Variable: Depression (D) Scale

Language

Spanish English

T11=656 T12 =827 T1 .=1483 First Yll=59.63636 yl2=55.1333 Yl.=57.384845

n1- -11 n=l5 n=26 Order

T21=848 T22=64l Tl.=l489 ' Second y21=56.53333 y22=58.27273 Yl.=57 .40303

: n2=15 n1=ll n=26

T.1=1504 T.2=1468 Y. 1=57.84615 Y. 2=56.46154 n=26 n=26 49

Table 3e

Cell and Marginal Means for a 2 x 2 Factorial Design

Variable: Paranoia ( Pa) Scale

Language

Spanish English u- ·- ... -- r T =SOS T =846 I T .=1351 11 12 1 1 First yll=45.90909 yl2=56.40000 Y1 .=Sl.l54545

n1=11 n2=15 n=26 Order

T21=799 T22=S93 T2.=1392 Second y21=53.26667 y22=53.90909 Y2.=S3.58788 n=26 ~=15 n1=11

T.1=1304 T.2=1439 Y. 1=SO.l5385 Y. 2=SS.34615 n=26 n=26 50

Table 3f Cell and Marginal Means for a 2 x 2 Factorial Design

Variable: Schizophrenia ( Sc) Scale

Language Spanish English

T11=559 T12=805 Tl.=l364 First yll=50.81818 yl2=53.66667 Y1.=52.242425 n1- -11 n2=15 n=26

Order ··------·------·

T21=803 T22=506 T2.=1364 Second y21=53.53333 y22=46.0000 Y2.=49.76665 n2=15 n1=11 n=26

T.1=1362 T. 2=1311 Y. 1=52.38462 Y. 2=50.42308 n=26 n=26 51

Language, then, will affect MMPI performance with

Hispanic subordinate bilinguals. More specifically,

Hispanics who are subordinately bilingual scored significantly higher in Pa on the MMPI when tested in

English than when tested in Spanish. CHAPTER IV

Discussion

Hispanic subordinate bilingual subjects in this study scored significantly higher in the Paranoia (Pa) scale of their English MMPI form. More specifically, the subjects of this investigation had a mean T score of 55.3 in English as compared to 51.1 in Spanish. The elevation observed in the Pa scale of the English MMPI may reflect the increase in distrust and interpersonal sensitivity the subjects

I experienced as they were tested in English. Such an increase in distrust and sensitivity may have resulted from the anxiety Hispanic subordinate bilinguals experienced when encountering questions they could not decipher lin- guistically.

Marcos (1973, 1976) corroborates the above finding in his study of the effects of language on psychiatric inter- views. Marcos (1973) noted higher levels of distrust when his schizophrenic patients were interviewed in English as opposed to Spanish. Marcos reasoned that the increase in distrust during the English interviews was possibly due to the patients feeling of cross-cultural antagonism. In explaining his theory of cross-cultural antagonism, he explained that the above feeling was potentially a product of patients' having mistaken linguistic distance for affective distance in their evaluators.

The hypothesis suggesting a significant difference in psychopathology when Hispanic subordinate bilinguals

52 53 were tested in English first, was not substantiated. The effects of language order were not documented, possibly because no specific time constraint was placed in com­ pleting each MMPI form. Subjects often took 4 to 5 hours in answering the English MMPI, as opposed to two hours for the Spanish form of the MMPI. Perhaps, then, the lack of time pressure the subjects felt from this investigator influenced the lack,of effect when subjects took the

English as opposed to the Spanish MMPI first. The absence of order effects could also be due to the sampling dif­ ference between this investigation and that of Marcos

(1973). Unlike Marcos' subjects, who were psychiatric patients, the subjects in this investigation had never interfaced with any mental health facility. Psychiatric patients are typically more vulnerable than the general population, and thus, perhaps, more easily affected by a stressor such as a relatively unfamiliar language.

The hypothesis which stated that significantly higher

T scores would be found on scales L, F, K, D, and Sc in

English was not substantiated. Again, the lack of time pressure could have minimized some of the differences that might have been found. In addition, it is possible that memory effects carried over to the second test. Subjects possibly remembered the answers they provided on the first

MMPI and were able to successfully apply the same answer on the second MMPI they took. In addition, as was discussed above, differences in sampling should not be overlooked. 54

It should be remembered that the subjects in this study were natives from El Salvador as opposed to Mexico

(actually, subjects from other investigations cited were

"Hispanic Americans"). Although the various Hispanic groups share many cultural and family values, generaliza­ tions concerning more than one Hispanic group are at best tenuous (Canino, 1982). There are wide, within group differences, among members of the Hispanic community.

Degree of acculturation, socioeconomic status, reason for migration, political ideology, and educational status are just a few of the variables that differentiate Hispanic groups from one another. Thus, it is possible that no differences in scales L, F, K, D, and Sc were obtained across language because the subjects were not Mexican­

American, and they had achieved a higher level of education than the subjects in aforementioned studies. The differ­ ence in respective educational status should not be ignored since, as Torres-Matrullo (1976) points out, educated individuals who are not acculturated are significantly higher in emotional adjustment than are noneducated un­ acculturated individuals. Thus, while the subjects had lived significantly fewer years in this country than

Hispanic-American individuals cited elsewhere, greater stability in MMPI scores across languages could be due to an inherently more stable personality (when compared with psychiatric patients or other low functioning individuals), and higher educational level, ultimately obscuring a 55

difference in T score elevations across language.

The present study is not without shortcomings. While

the sample size is significantly larger than those of

Marcos, et al. (1973, 1976), and Price and Cuellar (1981),

the sample size used by this investigator is still rela­

tively small to document an appropriate level of external

validity. Similarly, the within subjects aspect to the quasi-experiemental design used limits the internal valid­

ity of this study. Thus, a larger sample and an experi­ mental design, which would eliminate the repeated measures

component, would help document potentially greater differ­

ences in MMPI test performance or psychiatric interviews across the English and Spanish language.

While the Spanish translation of the MMPI has been deemed both comparable linguistically and clinically to the standard English version of the MMPI, the use of the MMPI as a psychological instrument for this Hispanic group as well as for others is limited. Such limitation was high­ lighted after researchers in Mexico, Pucheu and Rivera

(1971, cited in Butcher & Pancheri, 1976) found that the

American norms which were being used to evaluate psycho­ logical health (as operationalized by the MMPI profile) in

Mexican medical students generated an unacceptable number of false positives. Once Mexican norms were established for the Mexican population, researchers in Mexico found this psychological instrument to be highly valuable in detecting psychopathology and discriminating among clinical 56

types. Thus, establishing MMPI norms for different His- panic groups would aid in accurately employing the Spanish translation of the MMPI. With respect to the subjects of this investigation, it should also be noted that the validity and clinical scales of the Spanish translation may have been also affected by some idiomatic differences found within individuals who speak Spanish, but who are of different nationalities.

Another limitation of the present study was that the degree of acculturation was not assessed for the subjects employed. Acculturation, according to the work of Price and Cuellar (1981) appears to influence, with fluency of language, the evaluation of psychopathology. The varia- bility of acculturation levels among Hispanics was docu- mented by Olmedo, Martinez, and Martinez (1978). These investigations found that the variance in raw acculturation scores of Chicano adolescents was three times that of Anglo adolescents. Thus, it is conceivable that had the present / investigation obtained the acculturation level for the El

Salvadorean subjects, the unilateral effect of language on

MMPI performance across languages could have been more confidently established.

The T score elevation observed on the Pa scale of the

English MMPI form has implications for the Hispanic comrnun- ity. This is especially true for emotionally distrubed

Hispanics. It is conceivable that the difference in Pa scale elevations across languages would increase exponen- 57 tially in individuals more vulnerable to the stress of

language incompentency. Should the Pa scale rise to

clinically significant levels on the English MMPI because of language difficulty, the clinician may provide the

Hispanic patient with a diagnosis of psychosis. In turn,

the patient may receive potent neuroleptic medication

instead of psychotherapy for symptoms that may have been

ambiguous to begin with. The label of psychosis and the

subsequent treatment may unfavorably affect the Hispanic patient•s self-esteem, subsequent utilization of mental health services, and his reintegration into his community.

Future studies are greatly needed in the area of

language and psycholog~cal testing. The effect of language on additional MMPI scales needs to be considered. It is

also important to ascertain the effect of language on the psychological testing of different Hispanic populations,

since Hispanic groups often differ from one another along various dimensions. In addition, investigating the effect of "cultural sensitivity" training for clinicians on the psychodiagnosis of Hispanics would be helpful. References

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Introductory Statement

Dear Volunteer:

The purpose of the following study is to gain further _standardization on the questionnaires you are about to fill out. The present questionnaires have been both widely and successfully used in the United States and .in Europe, with individuals of many different ages. Unfortunately, how­ ever, employment of these valuable questionnaires in Latin America has been difficult because the initial test trials did not employ a sufficiently large number of bilingual individuals to certify its many merits. Thus, today, with your assistance, the possibility of a large and effective development of statistical standards for this questionnaire begins to become a reality.

Your cooperation will be needed both today and exactly seven days from today, since the standardization of this instrument is most effective, if given in two parts, with each section being administered with equal time intervals. Your answers to the questionnaires will be kept confidential, since your names will be deleted when your answers are coded for analysis. It should also be known that you are free to end your participation at any point in the study. Lastly, two weeks after the second question­ naire is completed, I will be returning in order to present a lecture (the topic will be announced next week).

Thank you for your participation,

Julie London, B.A.

63 64

Appendix B

Mean SD

Age 35 10.2

Years in u.s. 8 3.2 Education Level (years) 13 4.5

Years of English 5 2.6

Relatives Speaking English 2 .08

Income (in dollars) 10,000 2,000