Curr Psychol DOI 10.1007/s12144-016-9500-9
Psychological Distress among Latina/o College Students: the Roles of Self-Concealment and Psychological Inflexibility Hadrian Mendoza 1 & Bradley L. Goodnight 1 & Nicole E. Caporino 1 & Akihiko Masuda 1
# Springer Science+Business Media New York 2016
Abstract There is a dire need to understand behavioral health outcomes in U.S. Latina/o individuals. Following the psychological flexibility model of behavior change, the present crosssectional study investigated the role of self-concealment in a range of distress variables in a U.S. Latina/o college sample. Participants (N = 83, 76 % female, range = 17–50 years old) completed self-report measures online. Results revealed a direct effect of self-concealment on depression and large indirect effects of self-concealment on general distress, somatization, and anxiety through psychological inflexibility. These findings suggest that maladaptive cognitive and emotion regulation processes in general, and psychological inflexibility in particular, contribute to distress in the present Latina/o sample. Future research should examine whether psychological inflexibility and self-concealment predict onset, recurrence, and/or maintenance of psychological distress among Latina/o individuals over time. Keywords Self-concealment . Psychological inflexibility . Psychological distress . Latina/o Recent epidemiological findings in Latina/o individuals in the U.S. reveal that the lifetime prevalence estimates of mental disorder were 28.1 % for men and 30.2 % for women (Alegría et al. 2007). U.S.-born Latina/o individuals report higher rates of major mental disorders than Latina/o immigrants (Alegría et al. 2008). Latina/o college populations, on average, experience greater psychological distress compared
* Akihiko Masuda
[email protected] 1
Department of Psychology, Georgia State University, Atlanta, GA 30303, USA
to European American and African American counterparts (Kearney et al. 2005). Additionally, results from the multicenter epidemiologic Hispanic Community Health Study/ Study of Latinos indicate that 40 % of Latina/o adults report moderate to high levels of anxiety and depression (Camacho et al. 2015). Data from this study also reveal that increased time spent in the U.S. is associated with a higher risk of poor mental health among Latinas/os (Perreira et al. 2015). Despite these significant concerns, research on the behavioral health of Latina/o individuals in the U.S. remains limited (Alegría et al. 2007; Grant et al. 2004). Advancing our understanding of the U.S. Latina/o mental health requires examining the psychosocial factors that are associated with a range of distress outcomes (i.e., general psychological distress, somatization, depression, and anxiety). One such factor is self-concealment (Larson and Chastain 1990; Larson et al. 2015). Informed by the psychological flexibility model of behavior change (Hayes et al. 2006, 2011b), the present cross-sectional study investigated (1) whether selfconcealment is positively associated with a range of distress variables in a sample of Latina/o college students, and (2) whether the effects of self-concealment on these distress variables was due at least partially to the effect of selfconcealment on psychological inflexibility.
Self-Concealment Various psychosocial factors are considered key predictors of psychological distress in samples of Latina/o college students and young adults in the U.S. These factors include the perceptions of low expectations, stereotypes, clashes between mainstream culture and family culture, and financial barriers (Cavazos et al. 2010; Gloria and Castellanos 2012; Lui 2015). In addition to these risk factors, self-concealment, a
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generalized psychological vulnerability, is likely to be associated with a range of distress variables in this group (Larson and Chastain 1990; Larson et al. 2015; Masuda et al. 2016b; Mendoza et al. 2015). Self-concealment is often defined as Ba predisposition to actively conceal from others personal information that one perceives as distressing or negative^ (Larson and Chastain 1990, p. 440). Psychological processes captured by the construct of self-concealment have been discussed extensively throughout the history of psychology (Kelly 1998, 2002; Kelly and Achter 1995; Larson et al. 2015). A recent comprehensive review shows that self-concealment is associated with a variety of negative psychological outcomes in college samples (Larson et al. 2015), including general distress (CepedaBenito and Short 1998; Masuda et al. 2011a), depression (Cramer et al. 2005), anxiety (Edmonds et al. 2014a, b), and somatic symptoms (Leleux-Labarge et al. 2015). Selfconcealment predicts the aforementioned distress variables above and beyond self-disclosure (Larson and Chastain 1990; Larson et al. 2015), suggesting that intentional efforts to conceal personal, distressing information is not merely the opposite of self-disclosure (Uysal et al. 2010) or redundant with secret keeping (Kelly and Yip 2006; Maas et al. 2012). To date, no published studies have directly examined the relationship between self-concealment and distress variables among Latina/o individuals. However, one-cross sectional study with a Latina/o college sample shows that selfconcealment is positively associated with perceived stigmatization for seeking professional psychological help (Mendoza et al. 2015), a variable found to relate to greater psychological distress among Latina/o adults (Cheng et al. 2013). Concealing personal information is not necessarily maladaptive, and many cultures seem to support some of the behavioral patterns captured by the construct of self-concealment. For example, many Latina/o individuals value marianismo and machismo. Marianismo reflects beliefs that women should endure suffering with dignity and self-sacrifice, and machismo emphasizes a set of values that men should be strong enough to protect their families alone (Abdullah and Brown 2011; Andrés-Hyman et al. 2006). Extant literature suggests that these cultural factors encourage Latina/o adults to cope with their personal problems independently, perhaps to avoid the disruption of social harmony (Interian et al. 2007) or shame (Bermúdez et al. 2010). Chang (2015) also found that even Latina/o college students who expressed willingness to disclose personal problems to others generally preferred self-reliance. According to Chang (2015), Latina/o college students preferred selfreliance in order to avoid burdening others, bringing shame to their families, or inviting criticism of themselves. These culturally informed practices are considered adaptive and healthy in many Latina/o psychosocial contexts (AndrésHyman et al. 2006).
Psychological Inflexibility Regarding the intersection of culture and mental health, Hayes and colleagues (Hayes et al. 2011a; Hayes and Toarmino 1995; Masuda 2014) state that keeping personal struggles to oneself is adaptive in many sociocultural contexts; however, they also state that relying on this strategy alone for regulating one’s personal distress can be extremely detrimental to one’s wellbeing. This conceptual implication is based on the psychological flexibility model of behavior change (see Hayes et al. 2012a, 2006; Kashdan and Rottenberg 2010), which was first introduced to the field of behavioral health as a transdiagnostic model of psychopathology (Hayes et al. 2006, 1996). The psychological flexibility model of behavior change is most well known as the guiding theory of acceptance and commitment therapy (ACT; Hayes et al. 2006; Hayes et al. 2012b). According to Hayes and colleagues (Hayes et al. 2011b), psychological inflexibility is at the core of various forms of psychopathology. Psychological inflexibility can be conceptualized a global behavioral pattern of effortful avoidance in attempt to down-regulate unwanted emotional experiences, combined with the rigid adherence to literal content of thoughts (e.g., worries). A large body of evidence shows that psychological inflexibility is associated with a range of psychopathology symptoms (Hayes et al. 2006, 2011b; Kashdan et al. 2006; Kashdan and Rottenberg 2010), including general psychological distress (Masuda et al. 2011a), somatization (Tull et al. 2004), depression (Curtiss and Klemanski 2014), and anxiety (Kashdan et al. 2006). Similar to self-concealment (Larson et al. 2015), psychological inflexibility is related to a range of maladaptive emotion and behavior regulation processes, including suppression, rumination, and avoidance (Bond et al. 2011; Rawal et al. 2010). Although empirical evidence remains limited, several conceptual papers suggest the applicability of the psychological flexibility model to U.S. Latina/o mental health (Masuda et al. 2016a; Pasillas and Masuda 2014). Masuda and colleagues (Masuda et al. 2011a, b, 2016b) speculate that self-concealment becomes maladaptive when it serves as major regulation strategy for avoiding, suppressing, and down-regulating unwanted internalizing events. In other words, it may be that self-concealment becomes detrimental not necessarily because it involves personal secrets or the act of concealing them, but because it functions as a maladaptive emotion that paradoxically amplifies unwanted distress (Larson et al. 2015). Consistent with this line of reasoning, previous crosssectional studies show a positive association between selfconcealment and psychological inflexibility (Masuda et al. 2011a, b). Furthermore, psychological inflexibility mediates the positive associations between self-concealment and distress variables (see Larson et al. 2015 for review). The
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mediating role of psychological inflexibility is supported in samples of ethnically diverse college students (Masuda et al. 2011a) as well as sexual minority students (Leleux-Labarge et al. 2015). When the features of psychological inflexibility are controlled, self-concealment is no longer related to distress variables, or the associations are weakened (Leleux-Labarge et al. 2015; Masuda et al. 2011a).
Current Study Given the extant findings, it is likely that psychological inflexibility serves as a mediator of the association between selfconcealment and psychological distress among U.S. Latina/o college students. However, as emphasized elsewhere (Cheng and Sue 2014), it is crucial to conduct empirical studies to test the hypothesis within the target sample. Given previous findings (e.g., Leleux-Labarge et al. 2015; Masuda et al. 2011a), it was hypothesized that both self-concealment and psychological inflexibility would be positively associated with general psychological distress, somatization, depression, and anxiety. Additionally, we predicted that psychological inflexibility would at least partially mediate the associations between self-concealment and these distress variables.
Method Participants The sample consisted of n = 83 Latina/o undergraduate psychology students (76 % female; mean age = 19.83, SD = 2.72 years) at a public university in a metropolitan area of the southeastern U.S. A total of 1060 students with various racial/ethnic backgrounds completed an anonymous webbased survey, and data from the Latina/o subsample were used for the present analyses. All participants received optional course credit through being involved in the study and were informed that the purpose of the study was to examine various mental health-related attitudes and psychological wellness before providing informed consent. All men self-identified as Bheterosexual^, and approximately 97 % of women (n = 61) self-identified as Bheterosexual.^ One woman identified as Bbisexual,^ and one identified as Bhomosexual.^ Participants self-identified their Latina/o heritage as follows: approximately 34 % Mexican, 13 % Puerto Rican, 8 % Peruvian, 7 % Colombian, 7 % Salvadorian, 4 % Guatemalan, 4 % Venezuelan, 2 % Costa Rican, 2 % Dominican, 2 % Panamanian, 1 % Brazilian, 1 % Cuban, 1 % Nicaraguan, 1 % Spanish, 1 % Uruguayan, and 6 % mixed Latina/o (e.g., “Cuban and Venezuelan”). Three participants (3.6 %) declined to specify their heritage beyond BLatina/o.^ Approximately 47 % identified their families as Bworking class,^ 35 % as
Bmiddle class,^ 15 % as Bupper middle class,^ and 4 % as Bpoor.^ Measures The following self-report measures were used to assess selfconcealment, psychological inflexibility, and a range of distress variables. These measures were selected because they are the most widely used measures of the variables of interest; however, as is the case with many other self-report measures, psychometric information on the use of these scales with U.S. Latina/o college samples is limited. Self-Concealment The Self-Concealment Scale (SCS; Larson and Chastain 1990) is a 10-item, self-report measure of a person’s tendency to conceal personal information that he/she feels is distressing or negative (e.g., BThere are lots of things about me that I keep to myself^). Items are rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Responses to all 10 items are summed to produce a total score, with greater values indicating greater self-concealment. Test-retest reliability over 4 weeks and internal consistency has been reported, with estimates of .81 and .83, respectively (Larson and Chastain 1990). In a previous study with 129 U. S. Latina/o college students, Cronbach’s alpha for this scale was .86 (Mendoza et al. 2015). Cronbach’s alpha was .90 in the present sample. Psychological Inflexibility The Acceptance and Action Questionnaire-II (AAQ-II; Bond et al. 2011) measures experiential avoidance and the rigid dominance of psychological reaction over chosen values and contingencies in guiding actions. These phenomena collectively are called psychological inflexibility. Seven items are each rated on a 7-point Likerttype scale ranging from 1 (never true) to 7 (always true). Higher scores reflect higher levels of experiential avoidance; lower scores reflect greater acceptance and action. Items include, “My painful experiences and memories make it difficult for me to live a life that I would value” and “I’m afraid of my feelings.” Internal consistency estimates have ranged from .78 to .88 (Bond et al. 2011). No prior study investigated the psychometric properties of this scale in a U.S. Latina/o sample. However, the present study revealed Cronbach’s alpha of .93, suggesting excellent internal consistency of the scale in the present sample. Depressive, Anxious, and Somatic Symptoms The Brief Symptom Inventory 18 (BSI-18; Derogatis 2001) is a selfreport measure of major forms of psychological distress: depression (e.g., feeling hopeless, or unhappy), anxiety (e.g., feeling uneasy or tense), and somatization (e.g., feeling faintness or dizziness). A total of 18 items are rated on a 5-point Likert-type scale ranging from 0 (not at all) to 4 (extremely).
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Cronbach’s alphas for the depression, anxiety, and somatization scales have ranged from .74 to .89 (Derogatis 2001). In a previous cross-sectional study with an ethnically diverse sample of college students (Masuda and Tully 2012), Cronbach’s alpha for these subscales ranged from .78 to .85. In the present sample, Cronbach’s alpha ranged from .84 to .85. General Distress The General Health Questionnaire-12 (GHQ-12; Goldberg et al. 1997) is a 12-item, self-report measure of current psychological distress (e.g., feeling incapable, strained, insecure, useless, and unable to enjoy day-to-day activities). The questionnaire uses a 4-point Likert-type scale ranging from 0 (not at all) to 3 (much more than usual). Higher scores reflect greater mental health difficulties. Internal consistency has been reported (Bond and Bunce 2003). In a previous cross-sectional study with an ethnically diverse sample of college students, Cronbach’s alpha was .87 (Masuda and Tully 2012). In the present study, Cronbach’s alpha was .86. Procedure All study procedures were approved by the Institutional Review Board. Participants were recruited from undergraduate psychology courses through a web-based research participant pool and provided informed consent. Participants anonymously completed a web-based survey of mental health-related attitudes and psychological health, which included the measures of interest as well as a demographic questionnaire.
Results Descriptive statistics and Pearson correlations among the study variables are presented in Table 1. Excluding demographic control variables (i.e., age and gender), all study variables were positively significantly correlated with one
another, with the exception of self-concealment and anxiety (r = .20, p = .07). Women had greater self-concealment, t(81) = −2.27, p = .03, and greater psychological inflexibility, t(81) = −2.30, p = .02, than men. There were no missing data among the sample of 83 Latina/o students. Hypothesis tests were carried out with path analysis in Mplus 6.1 using maximum likelihood (ML) estimation. Path analysis allows for simultaneous evaluation of multiple regression coefficients, eliminating the risk of type-I error rate inflation resulting from separate regression analyses. Path analysis was selected over standard structural equation modeling (SEM) because the sample size (n = 83) was not sufficient for the estimation of latent variables with multiple indicators. The path model consisted of scale scores for the four distress outcomes (general distress, depressive, anxious, and somatic symptoms) each regressed on the scale scores of the hypothesized predictor variables (psychological inflexibility and self-concealment, Fig. 1). Confidence intervals for indirect effects were estimated using bootstrapping with 10,000 samples. A visual inspection of the univariate relationships using scatter plots with Loess lines indicated linearity of relationships. The path model included age and gender as control variables. The path model was Bjust-identified,^ having an equal number of observations and parameter estimates. Model fit statistics therefore indicate trivially perfect model fit, χ2 (0, n = 83) = .00, p < 0, Root Mean Square Error of Approximation = 0, Comparative Fit Index = 1, Tucker Lewis Index = 1, Standardized Root Mean Square Residual = 0. In the final path model, neither age nor gender was significantly associated with any other variables, but were retained as control variables. Psychological inflexibility demonstrated a significant effect on all outcome measures, including general psychological distress, b = .30, SE = .10, p < .01, somatization, b = .17, SE = .07, p = .02, depression, b = .18, SE = .08, p = .03, and anxiety, b = .22, SE = .09, p = .02. Self-concealment had a significant effect on psychological inflexibility,
Table 1 Means, standard deviations, and zero-order relations between all variables
1
2
3
4
5
1. Self-Concealment (SCS) 2. Psychological Inflexibility (AAQ-II) 3. Distress (GHQ) 4. Somatization (BSI-18 Somatization) 5. Depression (BSI-18 Depression)
– 0.64** 0.37** 0.28* 0.48**
– 0.50** 0.41** 0.51**
– 0.37** 0.69**
– 0.74**
–
6. Anxiety (BSI-18 Anxiety) 7. Age M SD
0.20 −0.05 26.99 9.26
0.37** −0.12 19.58 9.47
0.56** −0.14 12.18 6.46
0.74** −0.09 3.81 4.22
0.76** −0.12 5.14 5.10
6
7
– −0.09 4.34 4.96
– 19.83 2.72
N = 83, *p < 0.05, **p < 0.01, SCS Self Concealment Scale, AAQ-II Acceptance and Action Questionnaire-II, GHQ General Distress Questionnaire, BSI-18 Brief Symptom Inventory-18 i
Curr Psychol Fig. 1 . Dimensions of depression regressed on psychological inflexibility and self-concealment (n = 83). Note. Coefficients are standardized; dashed lines indicate nonsignificant effects at alpha of .05; coefficients control for the effects of age and gender
.43
General Distress .08 .20
Psychological Inflexibility
.38 Somatization
.58
.01 .62
.71
.47
.33 SelfConcealment
Depression
.8
.27 .75 .42 Anxiety -.05
b = .36, SE = .09, p < .01, and a marginal effect on depression, b = .15, SE = .08, p = .05. Path results are presented in Fig. 1. Tests of indirect effects using bootstrapping with 10,000 samples indicated that self-concealment is associated with distress indirectly via psychological inflexibility, including general distress, b = .19, SE = .07, p < .01, 95 % CI [.07, .34], somatization, b = .11, SE = .05, p = .04, 95 % CI [.02, .23], depression, b = .11, SE = .06, p = .04, 95 % CI [.02, .24], and anxiety, b = .14, SE = .06, p = .02, 95 % CI [.03, .27]. The direct effect of self-concealment on all of the outcome variables except depression was non-significant.
Discussion There is an urgent need to better understand the behavioral health of U.S. Latina/o individuals. Following the psychological flexibility model of behavior change, the present crosssectional study examined whether self-concealment is associated with a range of distress variables in the sample of U.S. Latina/o college students. Furthermore, we investigated whether psychological inflexibility mediated the association between self-concealment and these distress variables. Consistent with previous research with general college samples (e.g., Masuda et al. 2011a), self-concealment was positively associated with general distress, depression, anxiety, and somatization in the present Latina/o sample. More specifically, psychological inflexibility mediated the effects of self-concealment on anxiety, somatization, and general distress, and partially mediated the relationship between selfconcealment and depression. These results suggest that selfconcealment is a useful concept for understanding a range of distress variables in U.S. Latina/o college students in part because it reflects maladaptive emotion regulation efforts,
captured by the construct of psychological inflexibility (Masuda et al. 2011b). Extant literature presents psychological inflexibility as a major pathological process underlying much of psychopathology (e.g., Hayes et al. 2006), possibly across diverse sociocultural groups of individuals (Masuda 2014). However, such a claim should be made based on empirical verification (Cheng and Sue 2014). The present study is the first to offer evidence of psychological inflexibility as a potential process underlying various distress variables in U.S. Latina/o university students. It is important to emphasize that the present findings do not suggest that Latina/o cultural practices are maladaptive. As noted elsewhere (Masuda et al. 2016a; Mendoza et al. 2015), we speculate that self-concealment, to an extent, reflects adaptive cultural practices, and yet reflects maladaptive efforts to down-regulate one’s own distressing internal experiences. Although it is beyond the scope of the present study to evaluate, our findings are consistent with the possibility that self-concealment establishes its association to a range of psychological distress in the present sample because part of it reflects maladaptive regulation efforts. This conceptual speculation is in line with the psychological flexibility model of behavior change. Self-concealment had a direct effect on symptoms of depression after accounting for the effects of psychological inflexibility. One possible explanation for the unique effect of self-concealment is that it is accounted for by correlates of depression and self-concealment that are not captured by the construct of psychological inflexibility. In other words, nonemotion regulation factors, such as diminished social support, may also contribute to the link between self-concealment and depression in the present sample (Cepeda-Benito and Short 1998; Kelly and Achter 1995). Friedlander et al. (2012)
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proposed that the relationships of self-concealment to social disconnection and hopelessness explain its association with depression and suicidal behavior among university students. Future research should consider social support and other potential variables when examining the link between selfconcealment and depression in U.S. Latina/o college samples. Although it was not part of study hypotheses, our study revealed that female students demonstrated higher levels of psychological inflexibility and self-concealment compared to men. Interestingly, female students did not demonstrate higher levels of any of the distress variables compared to male participants. It may be that higher levels of self-concealment and psychological inflexibility among female participants may be related to traditional gender roles for women in Latina/o culture (Castillo et al. 2010). Castillo et al. (2010) examined 370 Latina/o female university students to elucidate their understanding of marianismo, which included maintaining silence to preserve social harmony, being subordinate to men, keeping the family unified, being “pure” (i.e., virtuous and chaste), and being the spiritual leader of the family. These perceived expectations may lead to greater self-concealment and psychological inflexibility in women, while endorsing the equivalent levels of psychological distress with men. The present results offer clinical implications. In addition to targeting the underlying process of psychological inflexibility (e.g., using ACT; Hayes et al. 2006; Masuda et al. 2016a), outreach and counseling programs directed toward distressed Latina/o students may benefit from the encouragement of reasonable self-disclosure and social support-seeking. In a study that sampled Latino male college students, problem-oriented self-reliance was the most commonly endorsed method for coping with distress but the use of emotion-focused coping techniques (e.g., seeking emotional support) was the strongest predictor of psychological wellbeing (Gloria et al. 2009). Latina female students appear to benefit from seeking support from their friends and family as well (Gloria et al. 2005). In addition to encouraging informal support-seeking, it may be beneficial for universities to provide opportunities for Latina/o students to address their negative experiences in non-judgmental, supportive groups (Consoli et al. 2014). This study has several limitations. First, the sample was limited to English-speaking Latina/o students from a single U.S. university; results may not generalize to U.S. Latina/o adults broadly, clinical populations, non-English speakers, or Latina/o individuals in other countries. Further, it was not possible to attend to the heterogeneity among Latino groups (Alegría et al. 2008, 2007) due to the small sample size. Future studies should attend to the unique challenges facing various Latino groups as well as the potential influences of generational status, acculturation, and specific cultural values. Acculturation and enculturation, for example, have been identified as key correlates of distress variables in U.S. Latina/o
adults and were not measured in the current study (Nuñez et al. 2015). Second, the cross-sectional design of this study is a major limitation. Data from multiple time points, such as those in longitudinal study, will be necessary to establish temporal precedence from self-concealment to psychological inflexibility to distress outcomes. Third, the psychometric properties of some study measures (e.g., SCS) have not been fully evaluated with Latina/o samples. Although the current data support their internal consistency, future research would benefit from further examination of their validity with specific cultural groups. Finally, this study relied on self-report measures; findings might be affected by common method variance. However, this likely would have deflated rather than inflated hypothesized relationships, as participants endorsing high self-concealment might be expected to underreport distress. Future studies should incorporate multi-informant assessment of distress to confirm the effect of self-concealment. Despite limitations, the present study is the first to examine psychological inflexibility, self-concealment, and psychological distress among Latina/o adults. Study results show a substantial mediational effect of psychological inflexibility on the relationships among self-concealment, general psychological distress, somatization, anxiety, and depression. Further investigation of psychological inflexibility as a process underlying the association between risk factors and negative psychological outcomes in this population is warranted.
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