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American Journal of Orthopsychiatry, 71(2), April 2001
© 2001 American Orthopsychiatric Association, Inc.
Theory & Review
When Immigration Is Trauma:
Guidelines for the Individual and Family Clinician
RoseMarie Perez Foster, Ph.D.
This paper considers two pertinent strands in the contemporary immigrant mental health
literature: 1) the distinction made between stressors that are endemic to most immigrant
experiences vs. those migration stressors that precipitate trauma per se; and 2) clinical
guidelines that continue to refine the assessment of immigrants' presenting mental health
problems, given the provision of services in institutions that are foreign to both the
language and idioms of distress of the populations being served. Case vignettes highlight
the research findings and practice recommendations.
E
migrations of human groups have taken other country either because of war or scarcity of
place since the dawn of time, and they are food. Another 70 million have relocated around the
recorded in ancient texts. Seeking safety, world outside their native countries, primarily in
shelter, food, farmable lands, and human freedom, search of work. A large number of these immi-
people have sought to escape hunger, incarcera- grants are known to be at significant risk for poor
tion, torture, and oppression of the spirit. However, living conditions, economic exploitation, and racist
the two decades immediately preceding this mil- or prejudicial treatment from their host locations.
lennium have witnessed the largest migratory pat- Many countries have come to serve as a safe
terns ever recorded in history. Civil wars in Africa haven in the diaspora for many of these people.
uprooted centuries-old tribal communities. The fall The United States has traditionally assumed such a
of the Soviet Union unearthed genocidal aggres- role; however, the tremendous influx of immi-
sions in Western Europe. And struggling econo- grants to this country in the last decade has forced
mies in the Latin American world failed to enhance the American social service and mental health sys-
the lives of a large underclass. Natural and human- tems to generate new services, new sensitivities,
made disasters also moved people to seek safety, as and new interventions for large groups of people
droughts in Haiti, floods in Guatemala and Mex- who are recognizably needy, but unrecognizably
ico, and nuclear accidents in the former Soviet foreign. As a result, clinicians and researchers are
Union caused the relocation of several million now pressed to understand how best to serve the
refugees in the last 20 years, either to areas within nation's new immigrants—and have been led to in-
their own countries or outside of their borders. vestigate questions such as: How compromised are
According to the United Nations High Commis- people who have been forced to leave behind all
sion of Refugees (1993), there are upward of 20 they know? Does the trauma of war and disaster
million people in the world today who are desig- permanently impair the human psyche? Do people
nated refugees. These are people who fled to an- ever recover from psychological and physical tor-
Tin's paper was invited by tlie Editor. The author is at the Glass Center for Mental Health and Practice Research, Shirley M.
Ehrenkranz School of Social Work, New York University.
153154 When Immigration Is Trauma
ture? And the pragmatic question at the center of livers food on a bicycle, while his family of six
this paper: How do clinicians intervene so that awaits him in a rented room; and a physician from
people ultimately adjust to new host environments, Guatemala drives a cab in New York. Lack of flu-
and move on with productive lives? ency in the host language is frustrating, shameful,
This paper will consider some of the pertinent and sometimes terrifying for newcomers (Perez
knowledge that has been generated to answer these Foster, 1996a, 1998a), for whom a subway ride or
questions, and will seek to distill specific clinical a trip to the emergency room with a sick child can
guidelines for assessing the complex subjective turn into a grueling nightmare.
experiences of immigrant patients, who may pre- While immigrants who relocate as a family fare
sent for services alone or in the context of their better than those who migrate alone (Kinzie,
family group. Relkin, Lee, & Hirsch, 1986; Mollica, Wyshak, &
Lavelle, 1987), family units are faced with the
IMMIGRANT STRESS AND TRAUMA daunting task of frequent redefinitions of gender
First and Second Generations of Investigation roles (Comas-Diaz & Greene, 1994; Gil & Vazquez,
Moved by the needs of increasing numbers of 1996); host country mores and values that are com-
immigrant newcomers for social and mental health pletely dystonic with ethnic traditions; and chil-
services, investigative agendas designed by both dren who quickly seek to conform to their new
public and private institutions in the United States community and new peers (Harkness & Super,
focused initially on describing the important bio- 1996; McGoldrick, Pearce, & Giordano, 1982;
psychosocial features relevant to these varied im- McNicol, 1993). Elderly people who relocate with
migrant groups. Basically following a needs-as- their extended families tend to do more poorly
sessment approach, this research attempted to de- than their younger relatives, feeling isolated and
lineate the uniqueness of new immigrants' mental overwhelmed by the acculturation tasks that need
health and social-environmental needs, investing to be tackled. Immigrant women often encounter a
in those groups that have comprised the largest dual-edged phenomenon: more willing than men
numbers of emigres to this country since World to accept menial and low-paying jobs, they more
War II. These have been populations from Mexico, quickly become wage earners and are thereby in-
Puerto Rico, and other Latin American countries troduced to new configurations of traditional gen-
and, more recently, immigrants from China, der roles, especially in North American countries.
Southeast Asia, Africa, the former USSR, and However, those with male partners are often con-
Eastern Europe. This needs-assessment research fronted by unemployed and despondent men who
comprises what I would call the first generation of feel threatened by the power shifts in the dyadic
immigrant mental health investigation. relationship and family system. Indeed, for some
This literature reports a myriad of complex emo- recent immigrant groups, these conditions have
tional and physical tasks that must be accom- been associated with an increase in domestic vio-
plished by people who leave their homelands. The lence and substance use (Comas-Diaz & Greene,
immigrants' loss of family, community, and physi- 1994; Straussner, 2000).
cal environment are themes that reverberate The migration process is unquestionably linked
through both clinical and creative literatures, alike. to major adjustment stressors. The impact of these
The loss of familiar social networks is especially stressors on mental health are variable and com-
hard on families and women, who often find them- plex. As has been described in excellent reviews of
selves isolated, forced to deal on their own with the literature in these areas (Desjarlais et al, 1995;
the multiple demands of life in a foreign environ- Lone, 1998), anxiety, depression, posttraumatic stress
ment (Boylan 1991; Desjarlais, Eisenberg, Good, disorder (PTSD), substance abuse, and higher
& Kleinman, 1995). A downturn in socioeconomic prevalence of serious psychiatric disorders have all
status is the unfortunate norm for most immigrants been associated with multiple immigrant popula-
across the social and educational spectrum (Cana- tions both in and outside of the United States.
dian Task Force, 1988). This is often a bitter sur- Currently, through both our clinical experience
prise for those who harbored hopes of fresh hori- with diverse groups and our slowly growing so-
zons in a country of new opportunities. Thus, a phistication in assessing multicultural samples via
former school teacher from Bosnia distributes better-validated methodological instruments and
leaflets for McDonald's; a Chinese mechanic de- designs, a more multifaceted understanding of theRoseMarie Perez Foster 155
immigrant trauma experience is evolving. In what Foster, 1998a), recent immigrants often avoid or
I call the second generation of immigrant mental obfuscate the pressing circumstances that moved
health research, clinician/researchers have begun them to seek safer haven. In just the half-century
to 1) refine the phenomenology of what we actu- since World War II, the United States has received,
ally term "immigrant trauma"; and 2) establish among many other groups, Jews who were tor-
guidelines for the assessment of immigrant mental tured in the Holocaust camps, Cambodians whose
health problems, as people present for intervention families and villages were destroyed in front of
in host-country institutions that are foreign to both their eyes, Chileans whose children permanently
their language and their unique cultural idioms of disappeared, and Russians who escaped homes
distress. These domains will be discussed sepa- contaminated by the Chernobyl nuclear accident.
rately in the material that follows. Both the clinical and quantitative mental health lit-
erature show robust evidence that these experi-
Stages of Immigrant Trauma ences prior to and during migration are directly as-
As noted above, the formidable immigrant men- sociated with psychological sequelae that will be
tal health literature that has emerged in the last experienced for years to come, as these immigrants
decade attests to the complex psychosocial stres- make their adjustments to a new life and culture
sors that appear to be endemic to the immigrant (Chung & Kagawa-Singer, 1993; Havenaar, Ru-
experience. However, the most recent reports in miansteva, & Ven Den Bout, 1994; Havenaar et
this area have begun to identify specific stressors al., 1995; Mollica, Mclnnes, Pham et al., 1998;
and their cumulative effect as precipitants of the Sack, Clark, Kinney, & Belestos, 1995).
symptoms of distress—i.e., PTSD and clinical lev- Trauma during transit. Intimately related to
els of anxiety and depression—associated with im- both the impetus for and contextual circumstances
migrant trauma. Desjarlais et al (1995) concluded of the migration decision are modes of exodus
that it is not migration alone but, rather, traumatic from the native country that can either extend the
or derailing events before, during, or after disloca- noxious experiences of premigration events or, by
tion that lead to psychological distress of clinical themselves, constitute formidable assaults on the
proportions. body and psyche. We are now hearing, for exam-
This new literature identifies four migration ple, especially from the southwestern United
stages at which there is significant potential for States, narratives of women who are crossing the
traumatogenic experiences that may lead to serious borders from Central to North America unaccom-
psychological distress: 1) premigration trauma, panied by partners or families. Engaging "coy-
i.e., events experienced just prior to migration that otes" (illegal travel brokers) for passage, some
were a chief determinant of the relocation; 2) trau- have been subjected to months-long sexual as-
matic events experienced during transit to the new saults and forced labor, as forms of "added pay-
country; 3) continuing traumatogenic experiences ment," before reaching their destinations (Martin,
during the process of asylum-seeking and resettle- 1999). Hundreds of Haitians and Cubans have
ment; and 4) substandard living conditions in the been lost crossing the Caribbean Sea to the United
host country due to unemployment, inadequate States every year, and those who survive (like
supports, and minority persecution. Elian Gonzalez) may witness the drowning of
Premigration trauma. Those who work in insti- loved ones or the terror of being adrift at sea be-
tutional settings know of the contained anxiety that fore being rescued (Bragg, 1999). Historically,
is so frequently a part of the recent immigrant's and at present, we have seen large groups of forced
presentation when soliciting mental health or so- or voluntary immigrants transported between con-
cial services for the first time. Preoccupied with tinents, and confined to small, squalid quarters for
the obstacles of a new language they can barely months at a time. Currently, these are the rural
speak, fearing clinicians/institutions as representa- workers from China whose indentured servitude
tives of the group in power, shamefully experienc- begins in the hulls of ships crossing the Pacific
ing themselves as the beleaguered "other," and ("Chinese found in Georgia...", 1999; United Press
sometimes hiding their illegal alien status (Chavez, International, 1999); in the seventeenth and eigh-
1992; Chavez, Cornelius, & Jones, 1985; Malgady, teenth century United States, they were West
Rogler, & Constantino, 1987; Marcos & Alpert, Africans whose forced migration on slave ships
1976; Marcos, Urcuyo, & Kesselman, 1973a; Perez opened a tradition of bondage and cumulative156 When Immigration Is Trauma trauma that merits discussion well beyond the States (Nicholson, 1997) have reported employment scope of this paper. Studies of many groups over issues, inadequate living conditions, and the need the past decade have linked trauma during the mi- to rebuild social networks as key factors in gratory process itself to clinical levels of psycho- refugees' psychological distress. Emigrating in the logical distress, with symptom severity being asso- hope of finding work and a new life in an adopted ciated with the level of risk and anxiety involved land, only to find themselves confronting isolation in the escape experience (Cernovsky, 1997; Ur- and exploitative living conditions, leaves immi- sano, McCaughey, & Fullerton, 1995). grants at significant risk. These postmigration con- Asylum/temporary resettlement. Host countries ditions painfully compound the distress experi- are not always the most hospitable environments enced by many who have already suffered perse- for newcomers, especially if they are themselves cution in their homelands, followed by the myriad economically hard-pressed and receive immigrants risks of difficult transit and relocation. in large numbers, in wartime, or as a result of some environmental or geopolitical crisis. Thus, resi- The Pivotal Influence of Premigration Trauma dence in temporary resettlement areas can be a Clinicians exposed to immigrant populations, harrowing experience, with overcrowding, fear, particularly those in institutional or agency set- and lack of provisions exacerbating the existing tings, are generally cognizant of the four stages of stressors of forced migration. Currently, the most migration outlined above, especially the final salient examples of these conditions are zones that phase, involving issues of adjustment to a strange house residents of the former Yugoslavia; Ugan- host country. However, the second generation of dan refugee camps for the south Sudanese (Paar- immigrant mental health investigations presses for dekooper, de Jong, & Hermanns, 1999)', and areas of clinicians to become equally adept at dealing with the Ivory Coast and Sierra Leone that received migration abuses and traumatogenic events experi- Liberian refugees (Jarbo, 2000). Reports from enced just prior to resettlement (Westermeyer & these three asylum areas indicate a common atmo- Williams, 1998). sphere of anxiety, fear of loss, or the threat of repa- Often, a substantial barrier to these inquiries is triation. High risk for psychiatric disorders has an unstated collusion between immigrant client been noted in all these reports. (Sinnerbrink, Si- and clinician to avoid the details of traumatic mi- Loue, Field, Steel, & Manicavasgar, 1997). gration experiences. There is the conscious shame The process of seeking permanent, legal asylum of the immigrant in recounting the horrors of sub- in a host country carries its own set of acute stres- jugation and vulnerability to a clinician who is sors, as applicants can be held in detention centers both an ethnic stranger and a powerful representa- for months, even years, before being formally pro- tive of the mainstream culture. There is also the cessed (Postero, 1992). Examples of this in the less conscious urge to suppress recollection of ex- United States include undocumented emigres from tremely distressing and ego-disruptive experi- Haiti, Cuba, and Southeast Asia, who have left ences. These concerns of the client often reinforce their countries and traveled under formidable risk. the clinician's own anxious resistances and the At this stage of the immigration process, individu- wish to keep the horrors of the client's experiences als are in a state of limbo; conditions of quasi- at bay and outside of the therapeutic work (Davies imprisonment often fuel existing symptoms of iso- & Frawley, 1994; Bremner & Marmar, 1998; Perez lation and anxiety. The acute symptoms of PTSD Foster, 1998b). may be interpreted by correctional guards as "un- At a less clinically interactive and more phe- cooperative behavior." Many detainees at an im- nomenological level, there is also a call for clini- migration center in the Northeast, to which I pro- cians to become more refined in their distinctions vided consultation, had been imprisoned and between the functional impact of current resettle- abused in their own countries. For many of them, ment stressors and traumatic experiences occur- the atmosphere and treatment at the center aroused ring proximally to the migration. Examining the disturbing memories of their earlier trauma, and antecedents of posttraumatic stress symptoms in served as a contextual cue for awakening of fairly recent immigrants to Australia, Steel and trauma symptoms. colleagues (1999) found that trauma exposure just Settlement in the host country. Studies in both prior to migration accounted for 20% of the vari- Canada (Canadian Task Force, 1988) and the United ance in psychiatric symptoms, while current post-
RoseMarie Perez Foster 157
migration stressors contributed to 14% of the tion trauma exposure remained predictive of psy-
symptomatic distress. Hinton et al. (1997) simi- chological distress five years or more after migra-
larly discerned the differential influences of pre- tion. Similar long-term findings have been re-
and postmigration stressors in predicting depres- ported for Cambodians living in the United States
sion among Vietnamese immigrants. (Carlson & Rosser-Hogan, 1991; Socket al, 1995).
The present author is conducting an epidemiologi-
The Dose-Response Concept cal investigation of the effects of the Chernobyl
The most recent studies of traumatized immi- nuclear disaster on survivors who now reside in
grant populations have provided a devastating pic- the United States. Reports from both the Ukraine
ture of the violence that can be perpetrated on and Belarussia have noted the presence of psycho-
people by factions in power—and the chaos that logical sequelae in survivors up to seven years af-
individuals and families withstand when migration ter the event (Havenaar et al., 1994, 1995; Viina-
is determined by threats to their livelihood and makiet al., 1995). My own interest is in the poten-
daily safety. This work has also elucidated the psy- tial interaction and compounding effects of these
chological impact of trauma, and the factors that environmentally induced traumatic sequelae with
can move people toward extreme levels of distress postmigration acculturation stressors (Perez Fos-
and decompensation. In particular, recent investi- ter, 1999, 2000).
gations of Southeast Asian refugee groups that sur-
vived the violence of the Pol Pot regime in Cam- Migration Trauma as a Compounding Factor
bodia, and the political civil wars recently waged Clinical reports from a range of ethnic groups
in Vietnam and Laos, have yielded key findings on that have migrated to new countries typically un-
the relationship between the severity of experi- derscore the cumulative impact of multiple migra-
enced premigration stress and the intensity of its tion-related stressors on mental health (Desjarlais,
subsequent impact on relocated populations. 1995). Indeed, the concept of compounding stres-
Mollica, Poole, and Tor (1998), in their compre- sors is now an important frame through which as-
hensive work with Cambodian refugees, have be- pects .of human development are conceptualized,
gun to establish "dose-response" relationships be- especially with regard to socioeconomically vul-
tween cumulative trauma experiences and symp- nerable populations (Anthony & Cohler, 1987;
tom severity of depression and PTSD. A recent re- Garbarino, 1992). Thus, more recent quantitative
port of Vietnamese ex-political detainees newly assessments of the compounding effects of migra-
arrived in the United States specifically described tion stressors on mental health come as no surprise
this dose-effect relationship between torture expe- to front-line clinicians, who are well aware that
riences and psychiatric symptoms (Mollica, Mcln- premigration exposure to life threats, beatings,
nes, Pham et al., 1998). Similarly, the severity of rape, murder, imprisonment, torture, and disap-
PTSD symptoms in Bosnians emigres subjected to pearance of family are only further exacerbated by
"ethnic cleansing" was found to be correlated with the severe stress that can be induced in the new
the number and types of traumatic experiences suf- host country through such conditions as potential
fered throughout the violent ouster from their repatriation, poverty, unemployment, loss of fam-
homeland and ensuing transit toward a final safe ily, prejudice, and barriers to obtaining social and
haven (Weine, Becker, McGlashan, & Laub, 1995). clinical services (SiLoue, Sinnerbrink, Field, &
These relatively recent investigations of the Manicavasagar, 1997; Sinnerbrink et al., 1997).
traumatogenic factors that influence the lives of Using path analysis, Nicholson (1997) examined
people who migrate to host countries and seek the direct and indirect effects of a number of pre-
mental health services seem to follow broad phe- migration and postmigration factors on the mental
nomenological paths that are similar to the combat, health status of 447 Southeast Asian refugees. The
environmental, and sexual/physical trauma litera- most reliable predictors of current mental health
tures with which we are more familiar (Bremner & were the premigration factor of experienced trau-
Marmar, 1998). Thus, the premigration trauma lit- ma and the postmigration factors of current life
erature likewise illuminates, for example, the long- stress and perceived physical health. Current life
term effects of such experiences on daily life. stress was measured by the degree of discomfort
Chung and Kagawa-Singer (1993) found that, these immigrants associated with acculturative
among several Southeast Asian groups, premigra- tasks in the new country, e.g., finding employ-158 When Immigration Is Trauma
ment, learning a new language, building social net- so often enacted within the family system at multi-
works. Various other reports corroborate the com- ple levels of expression and interaction between
pounding stress of acculturative tasks on people children and their caretakers.
who have been traumatized prior to migration
(Hinton et ai, 1997; Loue, 1998). Additionally, Case Illustration: Magaly
those who are alone in a new country and sepa- Those of us who are both clinicians and re-
rated from family are more likely than those who searchers move between the world of individual,
are accompanied to suffer the psychological se- subjective experience and the quest to understand
quelae of premigration trauma (Hinton et al, whether these experiences occur in the context of
1997; Kinzie et al., 1986; Mollica et ai, 1987). particular circumstances at probabilities greater
Clearly, the sense of isolation and absence of fa- than chance. For professionals focused on immi-
milial support serves as yet another strike against grant mental health issues, the sheer numbers of
the already stressed newcomer. immigrants who increasingly request clinical ser-
vices propels the search for reliable descriptions of
The Maternal Buffer phenomena that can inform and guide clinical
A consistent theme in the immigrant mental practice with those whose cultural worlds may
health literature has to do with the role of maternal markedly differ from that of the clinician.
anxiety, and the mother's own psychological reac- While the research reviewed above suggests
tion to premigration stressors as a predictor of the guidelines for our clinical work, these data attain
mental state of the child. Children recently studied real meaning only when associated with real lives:
in the refugee camps of Croatia showed signifi- Magaly, a 30-year-old Latin American woman, was referred to
cantly more signs of distress if their mothers had me by her internist after she had been in the United States for
difficulty coping with displacement (Ajdukovic & four years. She lived alone, had few friends, and was employed
Ajdukovic, 1993). The mental health of politically as a bookkeeper. She presented for help with depression, sig-
nificant weight loss, and insomnia, about which her physician
displaced Guatemalan Mayan children was also
was concerned. She said that she had been treated once before
strongly correlated with the physical and mental for her "down moods" with medication.'She had no significant
health of their mothers (Miller, 1996). Afghan intimate relationships. Her command of English was good; she
refugee adolescents likewise showed levels of psy- had learned the language on the job and in evening classes at
chological distress that were related to their par- a local high school, after her arrival in the United States. She
lived as a boarder with an elderly American couple in a non-
ents' reactive states (Mghir, Freed, Raskin, & Ka- Hispanic neighborhood. She was attractively groomed in con-
ton, 1995). These phenomena are probably embed- temporary clothing that connoted a New York City stylishness.
ded in basic aspects of the parent-child interaction, While depressed, she seemed to project an air of social asser-
wherein parents, despite the context of crisis, are tion in her surroundings. The following is Magaly's story, in
able to maintain a semblance of both the physical her words:
"In my country, my family was comfortable. My mother
and emotional holding environment that is nodal to was a school teacher and my father was an accountant who
the child's psychic stability. worked for the Department of Highways. I had two older
In addition, recent investigations of childhood brothers. They died. My brothers were funny and a little on the
anxiety within normative, non-trauma-laden'con- wild side when they were young. But they were good
texts, have begun to quantify aspects of parental boys—they just had big mouths, and when they got together
with their school friends they would get into all sorts of talk
behavior and interaction that are significantly re- about how our country should be, how people were treated un-
lated to child affective states (Beebe, Lachmann, & fairly, and how things should change.
Jqffe, 1997; Cobham, Dadds, & Spence, 1998). "Our neighborhood was quiet and pretty. People used to say
These quantitative assessments of concurrent anxi- that it was like that because military types lived around there
and no one would dare cause a ruckus or leave anything in a
eties between mother and child are described at a
mess [in] their yard. Across the street...lived a family whose
more trenchant, intersubjective level of experience two children were my best friends. The father was quiet when-
in various clinical and qualitative accounts of fam- ever I saw him and didn't say much, but I never liked him. As
ilies in the process of recovery from or treatment I grew older and became a teenager I felt uncomfortable about
for premigration abuses (Ferrada-Noli, Ashberg, the way he looked at me. One day, I saw him at the movies
when I was with my boyfriend. On another day, he invited me
Ormstak, Lundin, & Sundbom, 1998; Sluzki, 1990).
to have a coffee with him—which I found strange and de-
These accounts underscore the powerful transmis- clined. I told my parents about this; they said to always treat
sions of anxiety that are experienced by families Don J with respect. Next thing I heard was that he had sepa-
who live in terrorist states, where the unspoken is rated from his wife and family and moved away. My motherRoseMarie Perez Foster 159
started to get sick around that time with cancer—I remember rorist activities sanctioned by the government of
because, for my first dance, it was my aunt who dressed me her country, she has managed some semblance of
and my mother was saying how nice I looked, from her bed.
acculturation and stability in a host country. Her
"When I came home from school one day...in my last year,
I saw...aunts' and uncles' cars in the driveway...and heard painful current life is an example of an immigrant
crying as I walked in. My two brothers had not come home newcomer whose cumulative migration assaults
from their night jobs and there was a rumor that they may have have left her compromised by posttraumatic stress
been arrested for questioning. My family spent.. .three horrible and a serious clinical depression, accompanied by
days going from precincts to hospitals, putting the word out
about their disappearance. We finally located them in a pre-
vegetative features. Her avoidance of social inter-
cinct...out of the city—a place where few people go but all- action with her own Latin American community is
know is...dangerous....My brothers and their group of friends aimed at circumventing the contextual arousal of
had been taken in for "interrogation" about the nature of their increasingly persistent flashbacks to the man/men
regular gatherings and the possibility that they belonged to an who held her captive. All young Hispanic men re-
insurgent group that harbored antigovernment ideas.
"The story at this point is not so clear in my mind, but what
mind her of the brothers she loved and lost so bru-
I know is that the man who lived across the street was con- tally.
tacted and asked if he could intercede in the release of my Magaly's valiant and extremely resilient effort
brothers. My father was desperate. My mother was sicker. to accommodate to her surroundings highlights a
Months passed and everyone knew that [my brothers] were be- mechanism that is beginning to emerge in the com-
ing mistreated at the precinct. We knew. ..they were not dead
because Don J would now stop by every week with some small
plex and multifaceted acculturation literature:
news. He was paying a lot of attention to me, asking me to take namely, a behavioral adaptation to the style, lan-
walks with him, to tell him how 1 missed my brothers. He made guage, social behavior, attire, and activities of the
me feel terrible. My father told me to do whatever he said. host country that does not necessarily correlate
"1 was 'given' to Don J in exchange for my brothers' re- with the affective and cognitive aspects of affilia-
lease. It was all done in a very quiet and, some would say,
social way. He took me out on dates to clubs and bought me
tion that denote genuine fuller acceptance and inte-
gifts. My father acknowledged that he was now my suitor. 1 gration in one's current milieu. This is a phenom-
was a virgin. When he touched me, I felt dead. He raped me enon well known to psychodynamic clinicians,
every day on our dates. Finally, 1 was brought to live with him whereby manifest behavior can be isolated or split
where 1 had little contact with my family. Sometimes, when off from meaningful connection. Thus, Magaly,
other men came to play cards all night, he would force me to
have sex with them.
while managing most impressively to cope with
"I think that I lost my mind during this time. I have no recol- her new life, remained bereft and emotionally fro-
lection of what 1 felt or was thinking. About three or four years zen by her earlier experiences.
later, the government of our country changed and Don J no
longer had his position, I think. Anyway he lost his money and CLINICAL ISSUES IN THE
had to move from the fancy place where he lived with me. In a ASSESSMENT OF IMMIGRANT PATIENTS
way, I began to see that he was'maybe letting me go. My Advances in clinical assessment that have emerged
mother died and my oldest brother was taken by police one day
and disappeared.
from the recent wave of immigrant mental health
"I found my way to New York. I came by myself with just research—the "second generation" investigations,
the name of a girl I had met in a nightclub when Don J used to which have been referred to above and reviewed in
take me to those places. I found her and she helped me find my greater detail elsewhere (Perez Foster, 1998a)—
job, but didn't want to be friends with me. I don't mix with the have moved the field toward both a further recog-
people from my country. They know what happened to me and
I feel ashamed in front of them; they talk about me. I keep to
nition of the ways in which culture and language
myself. My oldest brother committed suicide a few months af- shape the expression of psychological distress in
ter I came to this country. They say that he was out of his mind diverse populations and an acknowledgment of the
from the tortures...and knowing what happened to me. ethnocentric biases inherent in North American as-
"I have trouble sleeping and I have been feeling so de- sessment measures. They address issues that are
pressed that I can't go to work. They are trying not to fire me
but I can't get myself together. All the things that happened to
encountered daily by clinicians in the consulting
me are crowding my mind. I'm not even sure when my own room who attempt to use Western European crite-
mother died." ria to distinguish idiosyncratic pathology from
Magaly's experiences, beginning some four culture-specific behavior in new immigrants, and
years prior to her emigration, have left the indeli- by researchers who administer assessment instru-
ble marks of psychic trauma. Burdened with the ments that have not yet been standardized for the
death of her own mother and the horrible deaths of *Portions of this section on clinical assessment are drawn from
her brothers, due directly or indirectly to the ter- that earl ier work (Perez Foster, 1998a).160 When Immigration Is Trauma
ethnic group being studied. There is now a grow- pendent evidence of criteria-related validity with
ing body of literature that critiques the universal the separate ethnic groups has usually not been es-
application of Western perspectives on psycholog- tablished.
ical function and dysfunction (Bruner, 1986; Cir- Simply put, a translated instrument becomes a
illo & Wapner, 1986; Kirschner, 1990). new measure, one in need of its own validity, relia-
In the domain of psychological testing of ethnic bility testing, and standardization norms for the
groups, there are the pervasive problems of testing particular group it is meant to assess. Furthermore,
bias and the ethically questionable practice of us- the question of content validity in the factor con-
ing psychological instruments designed, standard- struction of U.S. test products stands as a scientific
ized, and validated from American majority per- and epistemological problem when these instru-
spectives (Malgadyetal., 1987). While the contro- ments are used with immigrant subjects. When ad-
versy in this area has focused mainly on intelli- ministering our instruments to other ethnic groups,
gence testing and its impact on African-American are we essentially testing for "American depres-
subjects, there is now an emerging concern about sion," "American intelligence," and "American
the instruments used to assess personality charac- psychosis"? Yanagida and Marsella (1978), Lutz
teristics and psychopathological functions, partic- (1988), Jenkins (1994), and others have noted
ularly as they are applied to people whose cultural variations in culturally constructed meanings of
and semantic systems may differ markedly from numerous affective states, demonstrating notice-
the U.S. norm. able differences in the factors that are mainstays of
Integrated within the administrative procedures, clinical diagnostic criteria for the Western affec-
factor construction, and parametric criteria of any tive disorders.
diagnostic instrument are ethnocentric assump- More recently, investigators have explored the
tions about what constitutes mental health and heuristic, clinical, and research value of using the
mental pathology. Thus, in diagnostic instruments PTSD concept with cross-cultural and, especially,
that assess psychopathology, test items are often immigrant refugee populations (Friedman &
keyed to reflect pathology on an empirical basis, Jaranson, 1994). Fawzi et al. (1997) and Carlson
constructed and standardized on Anglo-American and Rosser-Hogan (1994), in their work with Viet-
diagnostic samples (Guernaccia, Rivera, France, & namese and Cambodian refugees, respectively,
Neighbors, 1996). The works of Padilla and Ruiz found that the number of traumatic events experi-
(1973), Malgady et al. (1987), and Guernaccia (1992, enced by these groups was significantly related to
1993) on the assessment of psychopathology in the severity of their symptoms as assessed on vari-
Hispanic subcultures, for example, all point to the ous measures traditionally used in Western re-
disturbing frequency with which culturally syn- search and clinical settings. However, in a study
tonic behavior, affects, and belief systems are erro- that conforms more closely to previous reports of
neously diagnosed as pathological when assessed work with non-Western cultural populations (Sue
along the diagnostic criteria of Anglo-American & Sue, 1990), Peltzer (1998) noted that the diag-
functioning. Similar findings have been reported nostic assessment of clinical responses to trauma
for Asian-American samples (Sue & Sue, 1990). in various African subgroups should emphasize
In an effort to overcome what is erroneously be- somatic vs. psychic symptoms, as these are more
lieved to be simply a "language barrier" effect, and consistent with indigenous idioms of distress.
make assessment scales designed in English suit- Adding further to the complexity of clinical as-
able for use by different ethnic populations, au- sessments of ethnically diverse people is the rec-
thors have sought to translate testing instruments ognition in the literature of what are broadly
into various other languages. An example of this, termed "culture-bound syndromes" (Guernaccia,
in the pressured and overcrowded agency systems 1993; LaBruzza & Mendez-Villarrubia, 1994).
of multiethnic urban centers, is the hasty and often These refer to coherent patterns of psychological
unsystematic translation of instruments for admin- distress manifested through affective, cognitive,
istration to recently arrived immigrant children and behavioral symptoms that are indigenous to
and adults. These translated instruments (if trans- certain cultural groups. Whereas they often over-
lated systematically) often demonstrate acceptable lap with DSM-IV categories, they seldom have a
correlations with their English counterparts when symptom-to-symptom relationship to DSM-IV di-
administered to bilingual subjects; however, inde- agnoses. In addition, Guernaccia (1992, 1993) hasRoseMarie Perez Foster 161
noted that culture-bound syndromes, unlike the who present for treatment.A key concern of the
criteria sets of DSM-IV diagnostic categories, do clinicians who work with immigrants is whether
not confine their definitions to psychological bilingual individuals can be adequately evaluated
symptoms; rather, they may also integrate the so- in their new, second language. While the tides of
cial, moral, or spiritual state of the person to iden-ethnic representation in the mental health profes-
tify a clinical state of distress. sions are very slowly changing to bring greater di-
versity into our ranks, the most common cross-
Clinical Assessment and Bilingualism cultural clinical situations are those of English-
There is by now a substantial multidisciplinary speaking clinicians evaluating patients who func-
literature (Amahti-Mehler, Argentieri, & Canestri, tion at varying levels of English proficiency.
1993; Perez Foster, 1998a) on the ways in which The small body of research that has focused on
bilingualism affects the expression of symptoms how the language of the interview affects the as-
and their subsequent assessment by clinicians. For sessment of severe psychopathology has yielded
example, there is evidence of differences in the contradictory results. In different studies, both the
neurocognitive organization of language in the native and second languages have been identified
bilingual speaker's mind, such that significant seg- as the idioms in which patients manifest the most
ments of languages learned after the initial devel- severe forms of cognitive pathology. Del Castillo
opmental language acquisition period appear to be (1970) and, later, Price and Cuellar (1981) found
stored in different areas of the cortex (Kim, Relkin, fewer psychotic symptoms in their hospitalized
Lee, &• Hirsch, 1997; Ojemann, 1991; Paradis, psychiatric patients when they were interviewed in
1977). Potential ramifications are suggested for English—their second language. Del Castillo con-
the functional access of experiential memory when jectured that this served as a buffer against further
stored in one language code, and retrieved through cognitive disorganization and helped maintain pa-
a different code (Marcos & Alpert, 1976; Perez tients in better contact with reality, a position es-
Foster, 1992, 1996a, 1998a). poused earlier by others (Buxbaum, 1949; Green-
Psychodynamically oriented clinicians have de- son, 1950; Thass-Thienemann, 1973). The second
scribed the anxiety-reducing value of narrating language, acquired later in life, was thought to be
traumatic or conflictual experiences in the lan- associated with higher-level ego functions. The
guage in which the events did not take place. In native language, on the other hand, recalled and
particular, it has been proposed that a second lan- aroused the regressive associations and primitive
guage can serve a defensive function, allowing a cognitive functions of the early infantile period. A
bilingual individual to isolate the affect associated case study reported by Laski and Taleporos (1977)
with trauma and narrate the charged material, similarly noted that the native language was the
stripped of its affective and potentially ego-disrup- consistent venue utilized by a bilingual patient for
tive charge (Marcos & Alpert, 1976; Greenson, the expression of hallucinatory symptoms.
1950; Perez Foster, 1992). This set of neatly corroborating findings was
However, as succinctly stated by Oquendo (1996), contradicted, however, by the work of Marcos and
"the evaluation of patients in a second language colleagues (1973a; 1973b), who found the exact
presents many pitfalls" (p. 616). This perspective opposite: in their controlled assessments, Spanish-
has been corroborated by a number clinical reports American psychiatric inpatients manifested more
of work with bilingual clients (Aragno & Schla- psychopathology when they were assessed in En-
chet 1996; Bradford & Munoz, 1993; Javier, 1996; glish. The researchers reasoned, interestingly, that
Perez Foster, 1996a). These pitfalls may be their patients, who were already experiencing sub-
viewed as occurring within two related spheres jective inner turmoil due to their condition, be-
that have an impact on symptom expression: 1) came further disorganized with the pressure and
language differences in cognitive organization and effort of being assessed in their second language.
2) second-language anxiety. While these contrasting findings leave us with
questions that remain to be answered by future re-
Language and Cognitive Organization search, they should alert clinicians that the diag-
In metropolitan urban centers, and throughout nostic assessment of any bilingual patient is no
North America, mental health service providers simple matter. Evaluation needs to proceed with
encounter a wide variety of immigrant patients caution and an acceptance of the need to do clini-162 When Immigration Is Trauma
cal assessments in both languages, so that results tion was done primarily on hospitalized schizo-
can be compared. This language-diagnosis conun- phrenics or symptomatically psychotic patients
drum is further deepened, though, by Gonzales's (Del Castillo, 1970; Gonzales, 1977; Laski & Tale-
(1977) finding of no significant differences in the poros, 1977; Marcos et al., 1973a, 1973b). Notwith-
expression of psychopathology when bilingual in- standing the need for research on diagnostic
patients were assessed in both of their languages. groups with milder degrees of cognitive pathol-
Further research in this area will need to inte- ogy, it should be noted that the studies of schizo-
grate consideration of various methodologic, clini- phrenic inpatients confounded both acute and
cal, and dynamic factors. From the standpoint of chronic schizophrenic types as well as paranoid
methodology in psycholinguistic research, profi- and nonparanoid dimensions. These are parame-
ciency in each language needs to be more carefully ters in the schizophrenia spectrum that are well es-
assessed, with a further distinction made between tablished as manifesting significant differentials in
those bilinguals who learned their two languages cognitive processes, and thus may have influenced
in the same versus distinct environmental or devel- assessed level of pathology in the bilingual studies
opmental contexts. This is a factor that has been (Herron, 1977; Magaro, 1980). Del Castillo's (1970)
heavily implicated in the psycholinguistic concept subjects were longer term hospitalized patients,
of language independence. A core clinical issue whereas those studied by Marcos and colleagues
needing attention is the deep relationship between (1973a, 1973b) were recently hospitalized schizo-
symbolic expression in language and cognitive or- phrenics in an acute state of psychotic decompen-
ganization. Are the observed differences in level sation. In addition, despite the markedly different
of cognitive organization simply a function of ver- pattern of cognitive symptom presentation in para-
bal expression, or are they manifest expressions of noid and nonparanoid types of schizophrenics,
thought disorder per se? none of the studies distinguished between these
The heuristic and clinical fascination for those types in their subject pools (Neufeld, 1977; Perez
of us interested in bilingual processes is whether Foster, 1981; Ross & Magaro, 1976). This was an-
the supposed (neuro)cognitive separations, as ob- other source of symptom variance in the mixed
served in those who have learned their languages subject pools studied for language differences.
in different environmental contexts, are paralleled The role played by the clinician's bias, which
by differences in psychic and characterological emerges from culture-related differences in world-
functioning. The notion of a bilingual self has al- view, sense of self in the world, and so on, also
ready been proposed elsewhere on the basis of needs to be more clearly understood for its impact
neuro-organizational factors in dual language stor- on these language and diagnosis studies. The clini-
age, projective testing data on language differen- cian's cultural counter-transference (Perez Foster,
tials in personality characteristics, and psychode- 1998b; Rendon, 1996) has been recognized as an
velopmental factors (Perez Foster, I996a, 1996b, important influence in the assessment of ethnic
1998a). In addition, these language-related self- groups. Price and Cuellar (1981) reviewed the find-
organizations have been associated with distinct ings of Marcos and colleagues (1973a, 1973b) and
ego-defensive structures and coping mechanisms proposed that their raters' lack of bicultural sensi-
(Greenson, 1950; Marcos, Eisma, & Guitnon, 1977, bility accounted for findings that generally dif-
Perez Foster, 1992, 1994, 1996a, 1996b, 1996c).The fered from those of other research in the area.
intriguing question for clinicians who are in the Gonzales (1977), on the other hand, found the rat-
position of assessing bilingual clients is: Would er's cultural background to have no significant in-
formal evaluation of each language-related self- fluence on assessment of psychopathology. While
state render a separate mental status, or a different more careful explorations of the interaction be-
level or type of pathology? tween clinician and bilingual patient factors need
We clearly have a long road ahead in the explo- to be pursued, the bulk of the research suggests
ration of this area, with a need for well-designed that the language in which the assessment is done
methodologies (Vazquez, 1982) and controls for does have an impact on the manifest expression of
linguistic proficiency, language acquisitional con- psychopathology—although the direction of this
texts, and diagnostic refinement. On this latter effect appears to be variable.
point, it should be noted that the research reviewed The following case example is offered as an il-
here on the bilingualism-psychopathology interac- lustration of the desirability of performing separateRoseMarie Perez Foster 163
assessments in each language. It is also indicative Throughout, given Nina's language fluency, she had always
of the way in which events attendant to the migra- been evaluated and interviewed in English. Now, upon her pre-
sentation at the New York clinic, which is part of a large teach-
tion experience can function as acute precipitating
ing hospital, available bilingual clinicians astutely proceeded
stressors for those with latent or prodromal indica- to conduct her interview and mental status evaluation in both
tions of schizophrenia. English and her first language, Spanish. Strikingly, her English
narrative projected cognitive functioning that was fairly orga-
Case Illustration: Nina nized, cohesive, reality oriented, and devoid of autistic or id-
Nina, a 68-year-old single Central American woman who had iosyncratic intrusion. Spanish assessment, however, mani-
migrated to the United States at age 25 with her four adult sib- fested thinking processes which, while organized, were in-
lings, was equally proficient in Spanish and English. She and truded upon by repetitive themes of a fairly fixed delusional
her extended family, with whom she had always lived, had just nature. These themes did not emerge in her current English
relocated to the New York area from South Carolina, where narrative, nor were they recorded in her earlier records. This
she had been treated successfully for more than 25 years as an ideation consisted of some of the paranoid beliefs that were
outpatient with a diagnosis of chronic paranoid schizophrenia. prominent during her early psychotic episodes. In fact, she still
She presented at the geriatric psychiatric clinic of a New York harbored the belief that indigenous people from her country
hospital, referred by her former facility for psychiatric evalua- were looking to harm and kill her.
tion and an assessment of her psychopharmacologic regimen. To the best of Nina and her family's knowledge, she had
Psychosocial evaluation of the patient, an interview with never received any form of protracted psychotherapy where,
family, and review of psychiatric records that were brought in within the context of a long-term therapeutic relationship, al-
hand revealed a complex and interesting history. Nina and her beit in English, these beliefs and their associations might have
family's original migration to the United States was instigated emerged. It would appear that her brief monthly psychiatric
by political upheaval in their native Central American country. follow-ups and her circumscribed daily routine on the job al-
Living on a coffee plantation, the family was the focus of lowed Nina to maintain a level of stable cognitive functioning
politicized indigenous groups who raided farms as a way of in English that may have been symbolically and affectively
regaining lands they originally owned. After the violent mur- removed from the more primitive resonances and associations
der of her parents and firesettings on the property, Nina left the of her native language. Based on the psychodynamic bilin-
country with her siblings. At the time, she was a graduate of a gualism literature, it might be surmised that Spanish would be
teacher's high school in her country and a gifted linguist, flu- the language of her deepest fears, conflicts, and potential psy-
ent in Spanish, English, and Portuguese. In fact, her initial em- chic disintegration. Indeed, initial superficial exploration of
ployment in the United States was as a multilingual secretary Nina's fears in Spanish by the bilingual clinician suggested
and translator. that their very personalized meanings had their origins in the
Three years after her arrival, Nina suffered her first psy- patient's early developmental and adolescent history, were as-
chotic break. She was diagnosed with acute schizophrenia, sociated with the details of the family's traumatic premigration
paranoid type, and hospitalized for two years after being found experiences, and had never been fully explored in a therapeutic
roaming her neighborhood, disoriented, floridly delusional, situation.
and carrying a kitchen knife in her bag. She was terrified that When questioned closely about the context and content of
indigenous mountain people from her country were following her differential language usage, Nina divulged that at the end
her and wanted to kill her. Nina was treated with the standard of her workday, her going to her room to "read" was also her
clinical intervention for schizophrenia at the time: hydrother- special time to talk to herself, think about her concerns, and
apy, physical restraint, and electroconvulsive therapy. How- analyze the "progress" that her persecutors were making in
ever, in 1955, with the advent of antipsychotic medications, finding her. "I think to myself in Spanish," Nina said. The fam-
Nina was in one of the first cohorts of psychiatric patients in ily confirmed that her sometimes audible "muttering" was al-
the United States to be treated with phenothiazines. Her pri- ways in Spanish, not clearly comprehensible, and something
mary symptoms abated markedly, and she was able to return that was always gently reprimanded, "/Para!" ("Stop it!").
home to her family, who were supportive and extremely cre- This was followed by their engaging Nina in some English
ative in reintegrating her into active functioning. She was conversation. Inadvertently, the family had created its own op-
given a job in the family business and included in all family erant conditioning protocol: negatively reinforcing manifest
social life. Nina's own self-initiated social contacts were mini- psychotic Spanish verbal behavior, and positively rewarding
mal, however; she maintained an essentially schizoid posture, English verbalizations that were coherent and reality oriented.
and spent most of her free time reading in her room. While these conditions had, on the one hand, created functional
Nina was maintained, essentially stable, for 40 years by a and adaptive behavior in the English-speaking domain (in
combination of antipsychotic medication and daily function-
which the entire extended family mostly lived), they had also
ing in her work and family milieu. In her thirties, she experi-
reinforced a deep linguistic separation in Nina's psychic life.
enced some psychotic decompensation; however, these epi-
sodes were treated at their onset with pharmacologic readjust- We can only speculate, in the case of this 68-
ment. Monthly evaluation and follow-up of her mental status year-old woman, as to whether some earlier work-
over the years eventually moved Nina into the chronic schizo- ing through and reformulation of Spanish ideation
phrenic designation and, as has been noted for some across the
lifespan of this diagnostic group, there was an amelioration in the context of a psychodynamic engagement
over the years of her cognitive symptoms of schizophrenia with a therapist would have so shifted elements of
(Cohen 1990). her psychic structure and internalized object rela-164 When Immigration Is Trauma
tions as to have promoted some movement of the ethnic groups is that the language in which these
schizoid posture maintained throughout her rela- clients are attempting to express disturbing and
tional functioning. My own belief is that a more charged experiences is, in fact, the language of the
thorough bilingual assessment across the span of group in power—and thus, to some, the oppressor.
her psychiatric treatment could have exposed It should be kept in mind that both the clinician
Nina's active psychotic thinking in Spanish, and and the clinician's very language may symbolize
encouraged formulation of a more comprehensive the "other." When viewed in the context of dy-
treatment plan. Long-term dynamic treatment in namic transferential processes, this type of interac-
this case might have provided the milieu for some tion can evoke tension sufficient to inhibit a host
reconstruction of Nina's inner life and expression of expressive functions in the patient (Perez Fos-
of the terror and losses she experienced just prior ter, 1998a).
to her arrival in the United States. In fact, Nina, in Viewed from a relational perspective, English,
her Spanish mutterings, was the "narrator" for sib- the language of the psychological assessment, may
lings who never spoke of the premigration trauma. also be the language acquired from this "oppres-
Clinging together as a family of siblings, they es- sive other," the one who begrudgingly tolerates
sentially kept their parents and homeland alive. one's stay in his country. Consequently, in interac-
tions with this "other," one is cautious, inhibited,
Second-Language Anxiety and Symptom Expression unexpressive, passive, and possibly deferential.
Anxiety or pervasive discomfort can accompany The learning of a second language in contexts in
the bilingual patient's clinical presentation in a which one is repeatedly made to feel inferior, and
second language, especially when these patients is confronted with an intimidating other, begins to
are markedly more proficient in their native idiom. organize a particular self-configuration that can
The notion of self-expression in an acquired lan- subsequently be evoked by future English usage.
guage as being distant from immediate subjective
experience is frequently voiced by patients, and USE OF THE MENTAL STATUS EXAM
has been entertained from several perspectives by AND PSYCHOSOCIAL HISTORY
both clinicians and theorists. Distance from experi- Individuals presenting at a mental health facility
ential truth (Lacan, 1977; Rozensky & Gomez, 1983), in psychological distress are likely to be assessed
defensive intellectualization of emotion (Buxbaum, with procedures that include some form of mental
1949; Greenson, 1950; Marcos & Alpert, 1976; Perez status examination and the recording of a psy-
Foster, 1992), and linguistic inaccessibility (Jav- chosocial history. Aspects of both of these proce-
ier, 1989; Kolers, 1968) have all been cited as ex- dures will be considered here in light of the pitfalls
planations for this phenomenon. However, adding that have been noted in the assessment of bilingual
to this multilayered veil of dulled expression, as it immigrant patients.
were, is the further derailing function of the bilin-
gual immigrants' anxiety when speaking their non- Mental Status Examination
dominant tongue. Cognitive Sphere
The thought of appearing passive, inarticulate, The research that explores the influence of lan-
simple-minded, or unsophisticated in a second lan- guage on the projection of cognitive psychopathol-
guage, which one knows is not expressing the full ogy in the diagnostic interview has yielded confus-
complement of one's thoughts and feelings, is anx- ing results, to be sure, but stimulates compelling
iety-provoking to many, and depressing to others. questions regarding the role of language in both
Several investigators have noted that, when speak- the organization and symbolic representation of
ing in their nondominant language, bilinguals per- ideas. With the work of Gonzales (1977) standing
ceive themselves as less intelligent and self-confi- as an exception, the consensus of the literature re-
dent (Segalowitz, 1976). As Marcos et al. (1973b) viewed is that, for the bilingual patient, the lan-
wisely pointed out, the monolingual clinician must guage of the assessment has some impact on the
take care not to misinterpret the halting quality, manifest expression of cognitive pathology. Al-
sparse words, and emotional preoccupation of the though assessment in a second language has been
struggling bilingual as psychopathology. reported to elicit confused and regressed cognitive
A related issue in the English-language assess- pathology from some bilingual patients (Marcos et
ment of immigrants from poor and disenfranchised al., 1973a, 1973b), the majority of clinical and ex-You can also read
