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NEEDS AND ATTITUDES OF RELATIVES AND CONSUMERS
OF MENTAL HEALTH SERVICES IN MUTUAL HELP
GROUPS IN PUERTO RICO

By

Milagrltos Gonzalez

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OFARTS

Department of Psychology

1988

ABSTRACT

NEEDS AND ATI‘ITUDES OF RELATIVES AND CONSUMERS
OF MENTAL HEALTH SERVICES IN MUTUAL HELP
GROUPS IN PUERTO RICO

By
Milagritos Gonzalez

Mental health disorders are considered one of the biggest health
problems in Puerto Rico. Many changes to the mental health system have
been suggested and several have been implemented to control the situation.
One of them is the promotion and development of mutual help groups for
consumers of mental health services and relatives. However. the needs of
the consumers have not been assessed and used as a basis for the design and
implementation of mental health services--especially the needs of the mutual
help groups' members.

The purpose of the present study is to assess the needs of consumers of
mental health services and relatives participating in mutual help groups in
Puerto Rico. Also, the members' attitudes about the family. sex roles. locus
of control, and religiosity were assessed to have a better understanding of
the group members‘ needs. General information about the group was
collected from coordinators, and information on group participation and
structure. and the members expectations of the group were collected .

Members of 10 mutual help groups afﬁliated with the mental health
system in Puerto Rico participated in the study. Forty-two interviews were

conducted after a pilot-test of a structured interview. Interviews lasted
approximately 45 minutes. Descriptive statistics and correlational methods
were used for the data analysis.

The ﬁndings indicated that the consumers' needs included areas of:
economic matters, employment. education. housing. social relationships.
health issues. and recreational activities. The relatives indicated the need
for economic support. training. physical health. trust in the mental health
services. a club house for the relatives. good family relationships and the
mental health of the consumer. Most of the needs of the subjects concerned
their societal environment. The mutual help groups could have greater
impact in that environment. Suggestions for new directions of the mutual
help groups are discussed. Results concerning relationships between needs
and. attitudes. group participation and group dependence were not
significant. The respondents showed traditional family beliefs and sex roles.

and religiosity.

ACKNOWLEDGMENTS

Many people told me that working on a master‘s thesis was going to be an
unforgettable learning experience. What they did not tell me was that part of
that experience was going to be summarized in this page.

This work reminded me, once again, that there would always be someone
to support my effort and guide me throughout new routes. I especially
appreciate all the people who were supportive during the development of
this study. and who trusted me throughout the process. Among them were
my advisor, Dr. William Davidson, and the members of my committee, Dr.
Esther Fergus and Dr. Robert Caldwell. I also appreciate the support and
encouragement of the Auxiliary Secretary of Mental Health in Puerto Rico.
Dr. Efrén Ramirez, the Director of Research, Dr. Glorisa Canino. and the
coordinators and members of the mutual help groups who made this study a
reality.

I would also like to acknowledge the efforts of my interviewers. my sister,
Lourdes. and my friend. Diana, for the long hours of work they put into this
project.

Finally. I wish to express my gratitude to the students in the Ecological
Psychology program. the staff at the Community Lodge Dissernintation
Project, and in a very special way. to my friends Waded, Ana Maria. professor
Olga Hernandez, my parents, and my older sister. for their love and trust in

me which kept me working and made me smile during times of uncertainty.

TABLE OF CONTENTS

CHAPTER 1
Introduction
Needs and Mental Health in Puerto Rico
Needs of Consumers of Mental Health Services
in Puerto Rico
Needs of Relatives of Consumers of Mental Health
Services
Summary
Attitudes
Attitudes and Beliefs About the Family
Role of the Puerto Rican Family
Sex Roles
Man's Role
Woman's Role
Locus of Control
Religiosity
Catholicism
Espiritismo
Summary and Hypotheses

CHAPTER 2
Method
Sampling Procedure

Groups Involved in the Study

Relatives and Consumers Involved in the Study
Demographic Characteristics

Interviewing Procedures
Interviewer Training
Interviews

Interview Format
Interview With the Members of Mutual Help Groups

CHAPTER 3
Results

Assessment of Needs
Situational Variables
Needs of Consumers
Needs of Relatives
Members Expectations of the Groups
Summary of Needs

116

Subjects' Participation in the Groups
Group Structure

Evaluation of Hypothesis
Hypothesis 1
Hypothesis 2
Hypothesis 3
Hypothesis 4
Hypothesis 5
Hypothesis 6
Hypothesis 7
Summary

CHAPTER 4
Discussion

Attitudes
Hypothesis
Needs of Consumers and Relatives
Needs of Consumers
Needs of Relatives
Needs in which the Members Wanted to be Helped
by the Groups
Mutual Help Groups in Puerto Rico
Structure of the Groups
Members' Participation in the Groups
New Directions for Mutual Help Groups
Limitations
Conclusion

REFERENCES
APPENDICES

OWWPPW?’

Keywords in Literature Search
Letter of Approval

Consent Forms

Tables

Statement of Equivalency
Instrument

Coordinators' Questionnaire

 

120
122
124
125
126
127
128
130
130
131
133

135
137
141
144
145
149
150

152
153
154
156
164
166

9°

N955”?

«090

LIST OF TABLES

. Demographic characteristics of consumers of mental health

services in 1985

Demographic characteristics of families in Alvarez's study
Participants in the study according to the groups and centers
of origin

Ages of the subjects

Items about subject's participation in the group

Items about structure of the group

Items used for personal satisfaction. importance. and
expectations about the group

Item-total correlations for traditional family beliefs

. Item-total correlations for traditional women's role
10.
1 1 .
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.

Item-total correlations for traditional men‘s role
Item-total correlations for external locus of control
Item-total correlations inscale of religiosity
Number of recipients of each source of income
Monthly income of relatives and consumers

Needs of the consumers

Consumers' ratings of importance of the needs
Consumers' satisfaction with each need

Needs of Relatives

Relatives' ratings of importance of the needs
Relatives' ratings of satisfaction

Items with which they want to be helped

Items most frequently rated as important by consumers
and relatives

iv

28
77

80
87
88
89

91
92
93
95
97
103
104
106
108
110
111
112
114
115
118

23.
24.

25.
26.
27.
28.
29.
30.

Sources of less satisfaction for consumers and relatives
Mean and standard deviations on traditional family
beliefs scale

Items combined in coordinator‘s control of the group
Mean score on traditional women's beliefs used in ANOVA
Analysis of variance

Reasons to remain involved with the mental health center
Group activities suggested by the members

Examples of group activities to solve the member’s needs

D-l Medical history

D-2 Educational levels of the respondents
D-3 Employment status

D-4 Relatives living in the group

D-5 Responsibilities in the group

D-6 Tabulation of leadership roles

D-7 Coordinator responsibilities

 

119
125

128
129
129
131
132
159
190
192
193
193
194
196
197

LIST OF FIGURES

1. Needs of the consumers in Woodbury's ecological model 146
2. Needs of the relatives in Woodbury's ecological model 151

vi

CHAPTER I
INTRODUCTION

In a recent interview the Puerto Rican Secretary of Mental
Health, Efrén Ramirez, stated that mental illness is one of the
biggest health problems of the island ("Médico Revela,”1986). He
elaborated on the magnitude of the problem with some statistics.
Currently. approximately 574.000 persons have been identified as
suffering from emotional or psychological disorders ("Médico
Revela." 1986). Other estimates have been reported in journals and
reports.

An epidemiological study conducted in 1984 and published in
1987 estimated that from 450.000 to 500,000 people met lifetime
criteria for one or more disorders in Puerto Rico (Canino et al..
1987). A tabulated report of population in need versus population
receiving services in 1986-87 indicated that 621,724 persons
needed mental health services in Puerto Rico. This needy group is
described as being composed of 336.189 adults. 219,927 children
and 65.807 elderly (Secretaria Auxiliar de Salud Mental. 1987). The

report also revealed that only 81,715 of the 621,724 persons in

2

need. received services from the Secretary of Mental Health during
that time period. Even when there are discrepancies on the
estimates. the numbers are always too high and alarming considering
that the Department of Health reported that the population of the
island in 1985 was of 3,282,500 inhabitants (Department of
Health.1985).

Mental illness cuts across all age groups and social classes. It is
interesting to note that the Auxiliary Secretary of Mental Health
stated that 15% of all the children in Puerto Rico have either
moderate or severe mental health problems ("Médico Revela." 1986).
Also. Morales et a1. (1985) reported that 20% of the population of
children and adolescents may need mental health services.

Ramirez (1985) noted that the hospitals in Puerto Rico are
serving a large population of adolescents and young adults whose
medical histories reveal: "deviant behavior," inadequate relations
with their families. school, and their jobs. and "bizarre" patterns of
social behavior. Morales et al. (1985) stated that the most common
population suffering mental health disorders are among young adults

from 20 to 40 years old.

 

 

3

Even more impressive is the testimony of a psychology professor,
Julio Ribera. to the Senate in Puerto Rico on April 7, 1987.
According to the newspaper account ("Large number of isle youths
said mentally 111." 1987). Ribera stated that the incidence of mental
disorders among teenagers and children is increasing and could
reach epidemic proportions. and that the island's mental health care
system is not prepared to handle such a situation. The professor
estimated that between 125,000 and 150,000 children and
adolescents suffer severe mental illness. and also reported that less
than 10.000 receive treatment. These estimates are lower than the
ones mentioned previously (Secretaria Auxiliar de Salud Mental.
1987).

A tabulated report of the prevalence of mental disorders and
their treatment in Puerto Rico from November 1986 provided a
description of other demographic characteristics of the people
suffering mental health disorders in Puerto Rico during 1985
(Oilcina de Investigaciones. November. 1986). In their
representative sample of adults; the percentage of females was 47.7 ,
and the percentage of males was 52.3. The following table

summarizes the tabulation of age. education. and marital status of the

consumers of mental health services. according to the report

(Oficina de Investigaciones. November. 1986).

 

 

Table 1
" .°'.. -.-_ ‘11 o 0!. !!’l' o ”‘12.!‘2 1“” ‘
19.1.9852

Ages Education ‘ Marital status
17—24 19% 0- 1 1 56.7% Never married 34.2%
25-34 22.2% 12 20.2% Married 50.4%
35-44 25.2% 13+ 23.1% Previously married 15.4%

45-54 19.2%
55-64 13.7%

 

Noggrlnformation in this table came from the tabulated report of the
prevalence of mental disorders and of their treatment in Puerto Rico.
The number of cases studied was 322.

The mental health situation in Puerto Rico seems worse when in
his presentation to the House of Representatives. Fernando
Passalacqua --Director of the Psychiatric Hospital in Ponce--
explained that in the period since 1976 until 1986. none of the
psychiatric hospitals administered by the government obtained the
accreditation of the Federal Commission for the Accreditation of
Hospitals (”Manicomios no han pasado revalida." 1986). As a

consequence of the precarious status of the mental health services in

5

the island. during 1985 the Federal Court established new
regulations to improve the services offered to mental clients at the
psychiatric hospital in Rio Piedras. and recommended a global
reform of the system (Ramirez. 1985). The Office of the Auxiliary
Secretary of Mental Health is beginning with a reform that focuses
on: (a) the dissemination of the therapeutic community philosophy.
(b) the design of alternatives for deinstitutionalization. and (c) the
improvement of the services available for institutionalized clients.
Other changes to the system during the last years can be
summarized as follows:

1. Creation of three centers of psychosocial rehabilitation
(Bayamon. Cayey. and Trujillo Alto) in 1978 (Morales et al.. 1985).
These centers initially received clients from the penitentiary and
from the main psychiatric hospital. identiﬁed as having potential for
rehabilitation. In 1982 the Secretary of Mental Health reported that
32% of the clients in centers for psychosocial rehabilitation had
successfully returned to the community life. ("Logran Rehabilitar a
124 Pacientes de Salud Mental.” 1982). The article said that 124 of
the 392 clients were rehabilitated.

2. Establishment of a Community Support Program in 1982.

 

known as "Programa de Apoyo Comunitario" (PAC) . The goals of the
program were: (a) to promote the development of a support system
in the community. responding to the needs of adults with severe and
chronic mental health problems: and (b) to promote the
improvement of the services that already exist or may be developed
for the chronic clients in Puerto Rico. ("Sistema Apoyo Comunitario
de Puerto Rico. Departamento de Salud". 1986).

Edivia Rios (1985) summarized the most signiﬁcant activities of
the first two years of the Community Support program as: (a) the
organization of two annual conferences to promote the concept of
community suppport: (b) the organization of training sessions to
generate mutual help groups. develop skills on relatives of the
consumers. and provide to the staff the knowledge and skills for the
psychosocial rehabilitation process: (c) the creation of a committee
of community support coordination; (d) the distribution of small
donations to five mutual help groups and volunteers; (e) the
participation of two clients. a family member. and three staff
members of the Oﬂlce of Auxiliary Secretary of Mental Health of

Puerto Rico in the Annual Conference of Community Support in the

 

7

United States; (f) the development of mutual help groups; (g) the
cooperation of the communication media with the efforts to build
community support systems. and (h) the publication of a monthly
newsletter. To this list of achievements can be added the
organization of the Third Conference of the Community Support
Program in 1985 in Puerto Rico and the work of the Office of
Community Support as advocate in the presentation of the proposal
for the Independent Housing Service. The proposal was approved
and the Independent Housing Project began in San German. Puerto
Rico in 1985.

Probably the key in the development of the Community Support
System in Puerto Rico can be considered to be the activities and the
formation of the mutual help groups. These groups are the ones that
involve clients in the process of reintegration into the community,
and also involve the participation of relatives as advocates for the
clients. They are seen as having the potential to fulfill many needs of
the relatives and c0nsumers of mental health services.

The changes to the Puerto Rican mental health system can be
observed in light of recommendations about important things to

consider when doing effective reforms in services. A monograph of

8

the Center for Social Research and Development (1974) states that
the assessment of human needs has preceded actions which have
produced solutions to problems of human needs. Baumheir and
Heller (1975) stated that although any form of research can serve as
a base for program development. probably no form of research, with
the exception of evaluation. is more closely and practically associated
with programs and services than the needs assessments. Delgado
(1982) emphasized that the services must be based upon a "solid"
understanding of the needs and the needs in turn. inﬂuence service
goals. objectives. methods of intervention. and evaluation of results.
This was not the case in Puerto Rico. Neither the change in focus of
the mental health system. nor the implementation of any of the
programs previously mentioned was preceded by a needs assessment
of the mental clients and/or the family members.

The Office of the Community Support Program. in Puerto Rico
lobbied for a needs assessment of the adult population receiving
mental health services. which is currently being conducted. The
instrument that is being used collects demographic characteristics.
information about services that the clients use. and information

useful for the generation of a profile of the client. The information

is being ﬁlled out in questionnaires by the case managers and/ or the
staff member who better knows each client. The data from this
needs assessment has not been analyzed yet (L6pez. personal
communication. March 26. 1987).

There are some disadvantages in the assessment that is being
conducted. According to Nidia Rios (personal communication. May
1. 1987). the needs of the mental clients in the mutual help groups
probably were not assessed in the study. Only hospitalized clients
were included. and the mental clients in mutual help groups are in
the community. most of them living with their families. Another
disadvantage of the needs assessment that is in progress is that the
procedure consists of staff members ﬁlling out a questionnaire about
each of the clients that he/she is supervising. Neuber. (1980) stated
that staff members may have a limited perspective regarding the
clients' needs.

The needs of the families of the consumers of mental health
services have never been studied in Puerto Rico. The present study
conducted a needs assessment of consumers of mental health

services and of their relatives in mutual help groups in Puerto Rico.

 

10

In order to be able to get the information about the needs of the
mental clients from themselves and to have access to consumers
and relatives. the subjects for the study were the members of the
mutual help groups in Puerto Rico. These groups were chosen
because they do not have a predeﬁned structure and direction. Thus.
they may be willing to use the information to grow in a way that may
help the members to fulfill their needs.

At this point it is relevant to discuss some of Silverman's main
points in her description of mutual help groups in general
(Silverman. 1980). One of these points is the difference between
self-help and mutual help groups even when sometimes both terms
are used interchangably. According to the author. mutual help always
starts with self-help defined as a person recognizing the existence of
a problem and searching for a solution. The main distinction is that
self-help can be a personal search which need not involve a group.
Also. self-care or self-help programs are mostly oﬁ’ered by
professionals. On the other side. mutual help is considered a sharing
experience between people who have a history of the same problem.
The author also mentioned other types of groups that sometimes are

erroneously considered mutual help groups. This is the case of some

11

voluntary associations. where the members are responsible for
raising money, promoting association goals. and perpetuating the
organization. Another type of group that she mentioned is the one
"coordinated" by a professional and sponsored by an agency as part of
the range of services it offers to the clients. Silverman stated that
this is the ideal format for the agency that wishes to maintain control
over groups operating under its auspices. but recognizes the value of
the mutual help experience to people undergoing critical changes in
their lives. The author goes even further specifying that these
groups technically are not mutual help groups and that the ways the
coordinator executes his/her role determine if it is a mutual help
experience or a traditional therapy group. Finally. the author
explained the characteristics of formal mutual help groups. which
can be summarized as follows: (a) an organizational structure
developed. with ofﬁcers. a governing body. and procedures for
continuity of the organization: (b) members determine all policy and
control all resources; (c) limit membership to people who have the
particular problem or problems with which the group is concerned;
and (d) evolve a specific assistance program which has evolved from

the experiences of the members.

 

12

As part of this study. general information about the mutual help
groups in Puerto Rico was collected concerning the groups'
structure. the members' participation in the groups. the things liked
more. and things liked the least. and the type of activities of the
groups.

Another aspect of the study comes from the recommendations of
Humm-Delgado and Delgado (1983) and De La Candela and Zavala
(1982). Both articles stated the relevance of the study of "culture-
speciﬁc needs" in the design of treatment services for culturally
diﬁerent groups. The efforts to identify possible sources of culture
specific needs came up with some characteristics that have been
attributed to the Hispanics. and considered in some ways related
with mental health and mental health services. Teichner. Cadden.
and Berry (1981). describing the historical. cultural. and
psychological aspects in the Puerto Rican patients stated the
importance of understanding the role of the family. the religiosity.
and the changes in the traditional sex roles for the treatment of
Puerto Rican mental clients. Bach-y-Rita (1982) mentioned another
characteristic attributed to the Hispanics, -- the ”issue of control"--

which involves the idea that the person has little or no control over

 

13

his or her life. In order to follow the recommendation of Humm-
Delgado and Delgado (1983) and De La Candela and Zavala (1982).
this needs assessment also was considered as a ﬁrst step for the
identiﬁcation of culture-speciﬁc needs. This was decided because
attitudes about the family and sex roles. the locus of control. and the
religiosity. as well as their relationship with some of the needs of
consumers and relatives in mutual help groups. could be assessed as
part of the study.

In recent years the increase in the number of Hispanics in the
United States. combined with their unique cultural and linguistic
barriers. has made the services to Hispanics a high priority and a
topic of research across the United States. Padilla (1979) indicated
that this type of research represents an extremely important step in
directing efficient planning for Hispanics. A better understanding of
the attitudes and needs of the consumers of mental health services
and their families, will provide information for future studies
focusing on identiﬁcation of culture speciﬁc needs of Hispanics in
their own countries and/ or those living in the United States.

In general the questions that this research intend to answer are:

14

1. What are the needs of the consumers of mental health services
participating in mutual help groups in Puerto Rico?

2. What are the needs of the relatives of consumers of mental
health services in the mutual help groups in Puerto Rico?

3. Which of their needs do they want to fulﬁll through the group?

4. What are the attitudes of the consumers and relatives in mutual
help groups toward the family and sex roles?

5. Is there a relationship between the attitudes toward the family
and sex roles and the needs of consumers of mental health services
and relatives?

6. Is there a relationship between the attitudes about the sex
roles and the status in the groups of the consumers and relatives?

7. What is the locus of control of consumers and relatives in the
mutual help groups?

8. Is there a relationship between the locus of control of the
consumers and relatives. and their preference of independence from
the mental health system?

9. Is religiosity a characteristic of the consumers and relatives in

mutual help groups?

 

15

10. Is the religiosity of the consumers and relatives related to
interest in group participation in religious activities?

1 1 . Do the consumers and relatives have control over their
groups?

12. Are believers in "espiritismo" participating in the mutual help
groups?

The next sections of this chapter include a literature review of
the needs of relatives and consumers of mental health services in
Puerto Rico and of the attitudes toward the family and sex roles, the
locus of control. and religiosity.

The literature review spans the period from 1958 to 1986. The
sources reviewed were: (a) a literature review on family attitudes
toward the mental clients. prepared in 1986 by the author of this
proposal: (b) a Comprehensive Literature Search prepared by the
University of Puerto Rico in October. 1986 in the Dialog System.
reviewing Social Scisearch (1972 -1986) and Psychinfo (1967-
1986): (c) the Inventory of Marriage and Family Literature. (1970-
1986); (d) the card catalog at Michigan State University; (e)
information supplied by the Secretary of Mental Health in Puerto

Rico in December. 1986 and July. 1987; (f) information supplied by

16

the Ofﬁce of the Community Support Program and the mutual help
group in Mayagﬁez. Puerto Rico in March. 1987: (g) the list of theses
prepared in the Department of Psychology at the University of Puerto
Rico until 1980; (h) the list of all theses from the School of Social
Work of the University of Puerto Rico; and (i) the newspapers EL
W and W (1981- 1987). The keywords used for the
literature research are shown in Appendix A.
Needs and Mental Health in Puerto Rico
Michael Woodbury (1977) deﬁned mental health within an

ecological framework model. According to Woodbury. the model
deﬁnes the person's ecology as the sum total of the four
environments: his/her physical environment. his/ her physical
internal environment. his/her psychological environment. and
his/her societal environment. The "Cornisién de Salud Mental de
Puerto Rico" deﬁned mental health as quality of life to be evaluated
through the impact of those four aspects of the person's ecology
(Comisién de Salud Mental de Puerto Rico. no date).

Evaluating the ecological model. Woodbury explained that
interactions between the environments forms the person's system.

and that each part of the system is related to needs that should be

17

satisﬁed in order for the person to be healthy (Woodbury. 1977).
The needs from each environment are summarized as follows:

1. From external environment. the needs are air. space. water.
food. balanced diet. shelter. communication facilities. linkages with
sources of energy. protection from noxious chemical and physical
agents. and proper waste disposal.

2. From the physical internal environment. the need is of
physical health and it produces needs of preventive measures. and of
good secondary and tertiary prevention systems.

3. From the individual's societal environment. the author stated
that there are needs of: a mothering person, a family system
integrated into a community. and a support system. Also. needs to
learn and behave according to the culture of the society; economic
needs in the form of money and employment: and need of an
explanatory system. such as religion and science.

4. From the psychological environment. the person requires a
satisfactory quantity and quality of mothering. parenting. education.
and participation in the institutions and activities of his/her socio-

cultural system.

18

Woodbury's article also discussed situations aﬁ'ecting each of the
different four environments in Puerto Rico until 1977. Among the
conditions and points that he stated are: (a) better nutrition and
population explosion: (b) political association with USA creating
rapid socioeconomic changes and conﬂicts at the cultural and
communication-language level; (c) cultural. spiritual values. and
standards of ethical principles cracking under the impact of rapid
change and development: (d) immigrants returning from New York
as cultural and languistic strangers; and (e) crowding.

Recently the results of a study conducted by the "Comisién de
Asuntos del Consumidor" revealed that one third of the Puerto Ricans
lived in extreme poverty ("En la miseria un tercio de la poblacién."
March. 1988). The article stated that currently 372.373 Puerto
Rican families have an income of $500.00 monthly or less. The
report also stated that the economic situation of people in medium
and higher socioeonornic levels have been adversely affected because
during 1986. 1.543 cases of bankrupcy were discussed in court. One
of the explanations of the situation given in the report was that the
population of Puerto Rico has increased 43.5% during the last 35

years, leading to a current large number of elderly and children.

19

The author stated that those elements and many others created a
poor quality of life. which was responsible for the high number of
mental disorders in 1977. He also advocates that. when the
individual becomes a psychiatric case. the community should work
with the subjects' unfulﬁlled needs from the four environments--
his/ her ecological system--to favor the most rapid and complete
return to mental health and community life.

Evidence conﬁrming how the system affects the individual's
health in Puerto Rico and a recent analysis of the conditions
discussed by Woodward--other than the economic situation and
crowding-were not found. However. he suggests an interesting
framework to understand needs of consumers of mental health
services in Puerto Rico. The following two sections describe what
has been suggested as the needs of consumers of mental health
services and their relatives in Puerto Rico.

--- . . _. 1‘ . lug r w gay-u; .

The needs of the consumers of mental health services in Puerto
Rico have not been assessed. A study was conducted by the Office of
Community Support but the data have not been analyzed (G. Lopez.

personal communication. March 26. 1987). However. some needs

20

can be summarized from studies done for the School of Social Work
and the School of Public Administration at the University of Puerto
Rico. Also recent proposals for the mental health system in Puerto
Rico provide information about needs that will be summarized in this
section.

A study for the School of Social Work in Puerto Rico asked 45
social workers involved with mental health services. what were the
main problems of the consumers of mental health services
concerning four aspects: the physical environment. the economic
situation. the psychological situation. and the social environment
(Alvarado de Rivera. E. et al.. 1983). The problem of housing was
indentiﬁed by 63.63% of the social workers as the main problem
concerning the physical environment. Many of the social workers
(43. 18%) considered that the client's main economic problem was
his/ her dependency on public and private agencies as sources of
income. Depression was reported as the main psychological
problem by 59.09%. There was much agreement among the social
workers on the main problem in the clients' social environment;

84.09% considered that it was the clients' family relationships.

 

21

Every time that changes are proposed or a new program is
implemented into the mental health system in Puerto Rico.
inferences about the needs of the mental clients are discussed.

The proposal for the dissemination of the therapeutic community
philosophy. argues: (a) that it was the better treatment for
schizophrenics. and (b) that the mental health system is serving a big
population of youngsters and young adults. who will beneﬁt from the
program (Ramirez. 1985). In the proposal. Ramirez described the
population of youngsters and young adults as subjects whose medical
histories reveal "deviant behavior“ and inadequate relationships in
the family. in school, and in their jobs. These patients cannot deal
effectively with everyday living situations and tend to present
symptoms of mental dysfunction in times of transition like the onset
of puberty. entrance to college. and maternity. The proposal
summarized the needs of both groups as: " the need to learn new
patterns of interpersonal relationships.”

In his presentation to the Senate. Julio Ribera ("Large number of
isle youth said mentally ill". 1987) noted that about 30% of the young
people suffering from mental disorders are members of very low

income families. Eduardo Diaz reported in the MM:

22

W (December. 1985) that the population

of young adults with severe mental disorders abuses drugs and
alcohol.

Lugardo Gonzalez (1985) and Michael A. Woodbury (1977)
stated the importance of employment in aspects like self-esteem and
the person status in the community. They also discussed that the
unemployment problem strongly affects the chronic mental clients
in Puerto Rico. making them become less functional and more
isolated from the community. Benjamin Flores stated that there is a
vicious circle between incapacity and nonproductivity in Puerto Rico
(Flores. 1981). He elaborated on the idea that. in many cases of
incapacity. the signs and symptoms are escape mechanisms that the
organism uses to protect himself/ herself from problematic
situations that produce high stress and affect the human well-being.

In 1985. the Graduate School of Public Administration in Puerto
Rico published a report with recommendations for the Program of
Community Support to the Mental Health Patient. created in 1985
(Morales et al.. 1985). As part of their research. they used the
results of interviews with the clients. to derive a proﬁle of the

population of chronic clients and a list of their needs. They

23

described the clients as (a) members of large families. (b) low or
medium low socioeconomic level. (c) unemployed. (CI) 20-40 years
old. and (e) mainly single men. The list of problems presented by
Morales et al. included: (a) economic problems. (b) housing. (c)
unemployment. (d) difﬁcult access to the services. (e) stigmatization.
(f) recreation and use of spare time. and (g) education and training.
They also made the recommendation to the Community Support
Program to direct its efforts to the population of youngsters and
young adults with mental disorders. There are some problems with
the methodology they used because the interviews were non-
structured and the topics that the interviewer provided did not
guarantee that the clients were describing their individual
situations. The methodology of the study consisted of 69 interviews
in a sample of clients. providers. and relatives of clients. The
interviewers provided four topics: (a) deﬁnition of who is considered
mentally ill in Puerto Rico. (b) causes and related variables. (c) public
policy. and ((1) treatment.

Morales et al.. (1985) commented that. from their non-
structured interviews. they inferred two main concerns of the

clients: (1) to ﬁnd adequate help, and (2) to be able to maintain

24

stable relationships with their families.
“a, f 161.. v: f 0,11‘ f w !'1_!.x'

Goldman. (1982) stated that the United States policy of
deinstitutionalization of mental clients creates a potential for family
burden. Hatﬁeld (1984) had gone further. suggesting that the
success of the deinstitutionalization program might depend upon the
families' capacities to sustain a large portion of the burden.

Kint (1973) collected the responses from 228 relatives of
schizophrenics. and of 61 patients or former patients in the United
States. The study asked what families worried about. Kint found
that the main preoccupations of the relatives. were: (a) the
subjective symptoms of the patients. including altered sense
perceptions. altered emotion. and altered thinking: (b) the patient's
idea that people were talking about him or her; (c) the suicidal
attempts; (d) the damage to property caused by the patient. and (e)
physical injury to people. In another study. Kint (1977) reported the
results of a survey of 143 middle class family respondents to a
questionnaire survey in the Washington. DC area. identifying the

problems of the relatives of mental clients. The main problems

25

that they stated were: (a) worry about the patient. (b) to ﬁnd
eﬁ'ective treatment. (c) disruption of family life, ((1) employment for
the family. (e) social life of the patient. (f) ﬁnancial problems. (g)
patients' inability to take care of himself] herself. (h) patient living
arrangements. (1) being tied down to care for the patient. (1) feelings
of guilt. (k) fear of the patient. (1) getting a diagnosis for the client.
(m) problems with stigma. and (n) getting the patient out of the
hospital.

Hatﬁeld (1978) conducted a survey to 89 members of a self-help
group in which 57% of the families had a disabled relative living at
home. Many families in the study said that they lived in a state of
tension. Other families explained that their other children suffered
too much hardship and sometimes neglect. The families commented
that the siblings typically could not understand the patient's
irrational and bizarre behavior. blamed him/her for misbehaving. and
resented their parents for what they considered failure to exercise.
proper control over him/her. Hatﬁeld's study also reported that the
marriages suffered as a result of the problem because of the loss of
time and energy for leisure activities and interpersonal relationships

produced when there is a mentally ill person in the house.

26

A study of Puerto Rican families in the San Juan metropolitan
area found. among other things. that. in families where only the
husband was schizophrenic. the other members of the nuclear family
were drawn closer together and to the wife's family (Rogler. 1968).
However the study also found that in families where either the wife
or both spouses had schizophrenia. there was fragmentation and
disorganization within the nuclear family and more severe effects
within the nuclear families' effective social environment. The author
suggested as an explanation of this situation the fact that when the
husband was the mentally ill. the wife made a greater effort at
organization in the house.

In 1983. Hatﬁeld interviewed 138 family caregivers using mental
health services. asking them their needs and goals in therapy. The
participants in this study were Americans from the United States.
members of self-help groups located in nine different states. and
afﬁliated with the National Alliance for the Mentally 111. As part of
the methodolog. a list of 21 possible needs or goals for therapy was
read to the participants to indicate those that corresponded to their
purposes in seeking service. The items ranked in the top ﬁve

positions «according to their frequencies» were. (a) relief from the

 

27

anxiety. (b) need to learn how to motivate the patients. (c) how to set
appropriate expectations. ((1) where to ﬁnd help in crisis. and (e)
how to understand the nature of mental illness better.

The origin of the mutual help group has been described by some
authors as a response to problems and needs of the families. Some
demographic characteristics that can be expected can be
summarized from a thesis of the School of Social Work.

Fred Alvarez (1980) provides information about characteristics of
the client's families. Families of all the clients ages 20 to 40.
married. and receiving services in the Mental Health Center in San
Patricio during 1980. were included in the study. The husband or
wife of the mental client was interviewed. Forty-ﬁve interviews were
completed. Sixty-two percent of the sample were men and 38%
women. A high percent age of the subjects were within the range of
31 to 45 years old (65%). Table 2 summarized other characteristics

described by Alvarez in his study.

28

 

 

Table 2
"11015.01 121‘: '1 0 41111 VI‘Z' 1 0
Demographics
Education 1 1 i
1-6 grade 27% Catholic 69%
7-8 grade 13% Protestant 20%
9-12 grade 51% Testigo Jehova 2%
University 9% None 9%
Incoleem MaritaLsiatus
$300 or less 42% Married 89%
$301-600 47% Living together 1 1%
$601900 7%

$901- 1200 2%

 

Maria Santiago. quoted in the W
Wm (May. 1985). stated that
formation of the groups in Puerto Rico was the result of the desire of
the family members to participate actively in the decisions and
evaluation of the services for the clients. In the Newsletter of
December 1985. Gerardo L6pez explained the development of the

mutual help groups in the United States:
1. It was the result of the deinstitutionalization process. because

many chronic clients returned to the community which was not

ready to receive them.

29

2. The decisions about the treatment for the client were made
without the input of the relatives.

3. The professionals used to assume that the relatives were the
cause of the mental illness of the client.

4. The mental illness represented a situation in the home for
which the family was not prepared.

5. The families had some problems or needs that were not
receiving attention.

L6pez (1985) stated that these groups were formed in Puerto

Rico to respond to the same problems. He stated that the formation
of the groups began in 1982 with training. and a year later 14
groups were formed. Some groups were formed by family members.
others by clients. and many of them by both. More recent
information indicated that there were 13 mutual help groups in the
island (Rios. N. personal communication. May 1. 1987). Rios also
explained that ﬁve of them were groups comprised mostly of family
members; two consisted mainly of consumers and the rest were
formed by both. The only group with restrictions about the type of

members «consumers only-- is the Association of Consumers.

30

which was created recently. That group is only for mental clients or
ex-mental clients. Each group has one coordinator assigned who is a
social worker. a technician. or a psychologist at the mental health
center.
Summary

The evidence suggests that the needs of the consumers of mental
health services have not been assessed --especially the needs of the
consumers participating in mutual help groups. However. from the
literature discussed. a list of possible needs can be prepared. It will
include: economic needs (Morales et al.. 1985;'Ribera. 1987): need
of new patterns of interpersonal relationships (Ramirez. 1985);
access to services. employment. housing. support. recreation.
education. training. use of spare time (Morales et al.. 1985): active
participation of family members in the treatment of the clients
(Santiago. 1985): the clients' integration into the community and
into their family. and their trust in the professionals (Morales et al..
1985). Other needs of the families include education. suggestions
about how to cope with the consumer. economic needs. integration
into the community. access to the services. and trust in the

professionals.

Attitudes

The following sections present what has been considered as the
Puerto Ricans' traditional attitudes and beliefs about the family. sex
roles. locus of control. and religiosity.
WW

It has been stated before that there is not a deﬁnition of the
Puerto Rican family as an institution and as a differentiated
psychosocial reality (Torres-Zayas.1981). This situation produced
changes in public policy. public education philosophy. criterion for
court decisions. and other aspects of the social life. Torres-Zayas
(1981) also stated that social institutions and/ or the government had
being sharing some responsibilities that used to belong to the family.
and that this situation limited and reduced the responsibilities of the
family. However. at the same time. changes in public policy bring
back to the families some duties or creates new ones.

Traditionally. the Hispanic family has been considered a close-
knit. extended network (Escobar & Randolph. 1982). and the most
important social unit for the individual (Murillo. 1976) with the

extended family ties. family allegiance. and closeness to relatives

31

32

being the most very important sources of psychological support
(Fabregas . 1969).

Latin American societies also had been considered patriarchal
societies. where the woman submitted to the will of the husband or
father (De Roca.1963). Some other behavioral characteristics of this
type of structure are that the woman never goes out of the house
without permission of the husband or father. that she never receives
any man at home if the husband is not there. and that she stays at
home instead of going out to work. At the same time. a more
prestigious role is attributed to the women in her role of mother.
and the siblings are more attached to her than to the father--
especially the sons-- (De Roca. 1963).

More recently. Santana. Rogler. Harrel. and Ortiz (1982) stated
that some modiﬁcation of traditional male dominance has occurred
in Latin America due to urbanization and industrialization. but that
the historical and religious norms still support male dominance in
the family. In the same article. the authors classified the Latin
American societies as modiﬁed traditional societies. where the
woman has control and is responsible for some decisions in the

house. Tumin and Feldman (1958) found and described a tendency

33

in that direction among Puerto Rican families in 1958. They found a
clear difference in the authority patterns of families in a low
socioeconomic level and families with university education. Their
study reﬂected that those with university education were positively
more democratic in their family relationships and let the siblings
and wife participate in the decisions.

Unfortunately, many difﬁculties are found in a search for a
description of the Puerto Rican family. One of the problems is that
many studies of the Puerto Rican family were done with families in
New York and were based on the intergenerational conﬂicts.
Buitrago (1967) stated that the diﬁ'erences due to region. social
class. urbanization. education. and religion had been neglected in
family studies when they talk about "the Puerto Rican family" in
general. Another disadvantage is the lack of longitudinal studies.
because static studies of the Puerto Rican family cannot consider the
development of different patterns of interaction. roles. and authority
within the life cycle and history of the family. It has been stated also
that the Puerto Rican family had been studied mostly as part of the

analysis of a problematic situation or as "the problematic situation"

34

and that those approaches do not allow the discovery and
understanding of the different elements and aspects of the structure
of the family (Buitrago. 1967). Although maybe the most confusing
aspect in studies about the Puerto Rican family has been the fact that
sometimes they used the Latin American society or the United
States society as a basis for comparison. Among these type of studies
are the works of. Becerra. Kamo and Escobar (1982). Fernandez-
Marina. Maldonado-Sierra. and Trent. (1958). Maldonado-Sierra.
Trent. and Fernandez-Marina (1960). Mizio (1974). Rendom (1974).
and 'IYent (1965). who have studied the Puerto Rican as a Hispanic
family and sometimes compared Puerto Rican beliefs and attitudes
with those of the Mexican family.

There is still conﬂict between authors about which society
Puerto Rico resembles more. the United States or the Latin
American societies. It is interesting to note that authors in 1958
stated that Puerto Rico had shared many traditional Spanish colonial
values. but unlike other Latin American countries. has had a greater
"mainland American” inﬂuence with social. political. and economic
changes that were expected to be producing changes in the family

values toward the values of the United States (Fernandez-Marina.

35

Maldonado-Sierra. 8: Trent. 1958). A different point of view was
found in a more recent article. Santana. Rogler. Hurrell. and Ortiz.
(1982) stated that even as a commonwealth of the United States. the
level of economic development and cultural norms does resemble
more closely those of Latin American nations than those of the
United States. Another recent analysis stated that a variety of
cultural traits are ascribed to the Puerto Rican society because it is
thought of as basically Hispanic and Latin American. but that the
migration waves to the United States. coupled with the factors of
return migration and the colonial status of the island have produced
a strong americanizing inﬂuence on traditional cultural norms (Bird
81 Canino. 1982).

The following section presents a discussion of the attributes of
the Puerto Rican family found in the literature with special attention
on the ﬁndings about Puerto Rican beliefs about the family.
WW

One of the classic references about Puerto Rican families
(Fernandez-Marina. Maldonado-Sierra. 8: 'h'ent. 1958) studied what
were called the three basic themes in Mexican and Puerto Rican

family's beliefs. According to them. the central themes in the

36

Mexican family were: (a) the mother is the affectionate ﬁgure to
such an extent that the male's love and devotion to his mother may
interfere with the expected degree of love and devotion to his wife;
(b) great emphasis placed upon the children learning submission
and strong obedience to the will and dictates of the father and other
authority ﬁgures; and (c) a gender-based. dichotomous set of cultural
expectations. Fernandez-Marina and his colleagues' goal (1958) was
to evaluate the extent to which the values of the Puerto Rican
families varied from those of Latin American families. They used a
set of statements to study: (a) family affectional patterns. (b) family
authority patterns. and (c) differential evaluation of the status of the
sexes. However. major ﬂaws were found in the study. The
researchers used undergraduate university students. who may not be
a representative sample of people with traditional beliefs. The
control and experimental groups were formed without reliable
measures of the differences among them. The authors concluded
that their data supported the view that at the time of the study. the
reins of family authority were in the hands of the father. They also

stated that closer examination of their data showed discrepancies

37

between the male cultural ideal and acceptance of this ideal by the
females subjects. Neither reliability nor validity was reported. with
the exception of face validity.

Nine years after that study (Fernandez-Marina. Maldonado-
Sierra. 8: Trent. 1958). Trent (1965) examined the effect of the
economic development in Puerto Rico upon the identity of the
Puerto Ricans. He elaborated on the idea that drastic economic
changes in Puerto Rico have produced dramatic changes in the
Puerto Rican society and that the values clashed because the
Hispanic values were diametrically opposed to the United States
values. As a result of the conflict. he hypothesized that Puerto Rican
youngsters were in an identity crisis. The ﬁndings of the study made
him conclude. among other things. that there was not an absolute
differentiation in Puerto Rican family values with those of other
Hispanics. but that the change taking place was moving toward the
United States values. However. this study presents some
weaknesses. One is that it compares the changes due to economic
development with the results of Fernandez-Marina. Maldonado-
Sierra. and Trent (1958) which implies the limitations of using

secondary data analysis. besides the fact that the study in 1958 did

38

not report reliability and validity. Also the methodology had some
disadvantages. The researchers inferred the role of the family and
the conﬂict in the family from what they called "identity conﬂict" in
the Puerto Rican young people. The identity conﬂict was measured
by the researchers with the administration of a list of adjectives
among which the young people chose some to describe the ideal
woman and man. and the typical woman and man. The authors
correlated the differences in the adjectives used in both descriptions
with "neuroticism" and did not give details about how they measured
that construct.

Teichner. Cadden. and Berry (1981) presented a description of
the Puerto Rican family based on the literature (citing Fernandez-
Marina. et a1. 1958; and Trent. 1965) and on their own case studies.
They agreed that the Puerto Rican family includes an authoritarian.
dominant and frequently patriarchal father. and a submissive and
self—sacriﬁcing wife. They also gave details about the idealization of
the mother. who is expected to remain in the home. rather than to
seek a career; about the emphasis placed on virginity. and about the
idea that there is a double standard for the behavior of daughters and

80118.

39

Another trait that have been used to describe the Puerto Rican
family is the "respeto" [respect]. Rendom (1974) has written about
this trait "respeto" and deﬁned it as a strong feeling of affection in
interpersonal relationships and as a means to control hostility.

Mizio (1974) stated that the Puerto Rican family is different than
the United States family model. He stated that the Puerto Rican
family is an extended one. consisting of the nuclear family and
intimate relationships with kin. including those related by blood.
marriage or custom. "compadres" (companion parents). "padrinos"
(godparents). and "hijos de crianza" (children of upbringing).

Mellado (1973) studied the rural family in Puerto Rico using
participant observation and concluded that the extended rural family
is being replaced by the nuclear family. composed of father. mother.
and children. He stated that it is still patriarchal; that the family
bonds are still strong «especially between mother and son«. and
that the mother is an intermediary when conﬂicts arise between the
father and the children. He also found that emphasis is given to
education and religious indoctrination«mainly
Catholic. Roberto Ramos (1985) explained in his dissertation that

the urban families have undergone dramatic changes as a result of

40

Puerto Rico‘s social transformation. He discussed improvements in
the status of women; more and better participation of mother and
children in family affairs. and reduction in family size. Bird and
Canino (1978) summarized the salient cultural norms by which
Puerto Rican family structure is deﬁned saying that it included an
authoritarian pattern of parent-child interactions. a tendency
towards overprotection of children. a male-dominant family
structure. the inﬂuence of "machismo" on family interactions.
ingrained religious and parareligious beliefs and their relationship to
magical thinking. a double standard relative to the expression of
overt aggression and its net yield of passive-aggressiveness as a
cultural trait. the proclivity towards nonverbal communicative styles.
and respect for the members of the extended family in the dynamics
and interactions of the nuclear family. Glorisa Canino (1982) stated
that even though variations may exist in adherence to traditional
values. many Hispanics share a similar pattern of family structure.

As can be seen. there is no evidence in the literature specifying
the current Puerto Rican family's beliefs but it is clear that the family

plays a very important role throughout all the life of the Puerto

41

Ricans and that some of the characteristics that have been found
resemble the ones used to describe Latin American families.
However. the author of this study suggests that the Puerto Rican
family should be studied within its own ecological context. Even
when some of the attributes may be similar to the ones of the United
States or Mexican families. the particular way in which those
characteristics are displayed and/ or combined with other values and
cultural traits should provide a better picture of the Puerto Rican
family.

Due to the lack of complete information about this matter and to
the important role of the family. it also is suggested that until a
thorough description of the Puerto Rican family becomes available.
those people responsible for creation. implementation. and
management of service and / or social programs should try to
generate information about those aspects of the family of their clients
that will help them to design better services. This is relevant in
many ways to this assessment of the needs of members of mutual
help groups. The beliefs of the consumers and relatives participating
in mutual help groups also were assessed during the study because

they should help to understand the needs of the members and may

42

be useful in the design of new services and development of the
groups. It will be reasonable to think that if the consumers and
relatives adhere to traditional family beliefs. the needs of support
from the family. and good family relationships will highly affect the
person's well-being. The rest of this section discusses some ways
in which knowledge about beliefs about the family had been applied
to other mental health issues.

Maldonado-Sierra and Trent (1960) describe a "culturally
relevant" group psychotherapy program for chronic schizophrenic
Puerto Rican males based on assumptions about the Puerto Rican
family structure. In that paper and in Maldonado-Sierra. Trent. and
Fernandez-Marina, (1960). the authors described how they
translated these observations into action. First, they formed three
groups of eight patients. Each group spent several weeks together in
a variety of activities. A few days before the group sessions were
initiated. the author introduced to the group an older male therapist
who represented the father ﬁgure. The authors stated that the
therapist resembled the father ﬁgure because he maintained dignity.
remained aloof. and restricted social interaction to brief

interchanges. Another therapist introduced was an older female.

43

who fulﬁlled the mother ﬁgure expectations by distributing food and
chatting informally with the patients.

There are no comparative studies of the effectiveness of this
type of group psychotherapy. and the mutual help groups are not
therapeutic groups. However. it is a clear example of how
"traditional" beliefs do not necessarily need to be seen as harmful and
how the identiﬁcation of these ideas can be used in the design of
treatments and services. It is expected that mental clients and
family members holding traditional family beliefs will give more
importance to the need of positive and stable relationships with the
family. Therefore. if the need of positive relationships is reported
and the groups want to do anything about it. they should discuss and
understand what are the members' beliefs and expectations about the
family. This understanding will help them to reach the goal because
it will be easier then to change it into plans of action in agreement
with the members' beliefs about the family.

W

The possible existence of a sexual double standard on child-

rearing practices (Fernandez-Marina. Maldonado-Sierra. 8r Trent.

1958) and the explanation of male-female roles as clearly deﬁned

44

through the family structure (Nieves 8r Valle. 1982). makes it critical
to study the sexual roles as variables that may inﬂuence the activities
and needs of Puerto Rican mental clients and their families. Glorisa
Canino (1982) stated that there is a clear differentiation of sex roles.
characterized by the machismo and a virginity cult. She also said
that variations in adherence to these traditional values are observed
within a given Hispanic group and among different Hispanic groups.
in accordance with social class and educational levels. This also is
noted by Edward Christensen (1979) who stated that sex roles in
Puerto Rico are different from either the typical Latin culture or the
dominant Anglo-American culture of the United States.

Nieves and Valle (1982) stated that Puerto Rican sex roles are
rigid, and limit the communication and understanding between
males and females. They discussed distinctive factors affecting
Puerto Rican males and females. For the males they are: (a) child
rearing practices including more freedom for the male. (b)
machismo. and (c) lack of completion of high school. For the
females the factors are: (a) from very early in life restrictions.

speciﬁcally in dress. conduct. freedom. language usage. and

45

associations: (b) less aggressive behavior permitted. (c) channeling
aggresive tendencies into educational and socially acceptable
achievements. and (d) more security about being self-critical. The
roles that may be learned as the result of these and other rearing
practices are described in the following sections.
Me
One of the most typical cultural patterns attributed to the

Hispanics is the "machismo". This term had been used in the
United States to describe an attitude that Mexican men adopt vis-a-
vis women (Bach-y-Rita. 1982). The author also stated that it is
more accurate to interpret the concept as the way a man thinks and
feels about himself and his relationship with his environment. and
about general sex roles. This set of ideas includes beliefs about man's
strength. man's ability to restrain his feelings. stoic capacity to
tolerate pain and adversity. his relationship with other men. and
cultural patterns of social behavior (Bach-y-Rita, 1982). Stevens
(1973) identiﬁed the "macho" ideals as: courage. fearlessness. pride.
honor. charisma. and the ability to be a leader of other men.
Another author (Mejia.1975) preferred to split the notion of

"machismo" in two sets of traits; one group concerning the

46

individual's sexual behavior, and another how he stands in the
society. The ﬁrst set of traits includes sexual power. ”donjuanismo".
"parranderismo". ostentation of masculinity. virginity cult. sexual
repression of the female. and fertility. The other set of traits
includes and stereotype of male superiority. restraint of feelings.
generational gaps. independence. aggressiveness. drive for power.
physical strength, and courage.

Panitz and his colleagues (1983) stated that other notions of
the "machismo" are that a man should work and provide for his
family, be a "good" role model for his children. protect the family's
interest. and keep his feelings to himself. The article (Panitz et al..
1983) also explained that the man. by fulﬁlling his part of the
"bargain". is entitled to respect and obedience from his family and
has the right to have a mistress and to spend time and money
drinking with his male friends. The existence of this way of thinking
should not be considered as ethnically determined because. although
many articles present it as a characteristic of the Hispanics. there is
also another argument. Scott (1973) talked about ”machismo” and

male dominance as a phenomenon of social class. not culture. and

47

found data from low income Anglo groups revealing the same type of
male dominance.

There have been some attempts to declare that the Puerto Ricans
adhere to the ideas of the "machismo". In 1965 Trent used an
adjective checklist and asked Puerto Rican males and females to
describe the Puerto Rican man and woman. He used this method to
identify what he called an "identity crisis" in Puerto Rican students.
(Critiques of this research have been presented in the previous
section). However. it is interesting to note that they found that the
adjectives that were chosen more for the description of the typical
man (by both females and males) were: jealous. dominating. strong,
drinker. distrustful. authoritarian. and egoistic. When the women
were asked to describe the ideal Puerto Rican man. they used the
words: orderly. active. useful. noble. religious. sincere. and
respectable. and when males chose the description of the ideal
Puerto Rican man they chose adjectives such as: leader. just.
democratic. and industrious. The prevalence of the "machismo"
among Puerto Ricans should be studied because this trait may not be

typical or may have different manifestations that may or may not

48

interfere in many areas of the Puerto Ricans' lives.
Wale

George Bach-y—Rita (1982) talked about an implicit contract
within the Hispanic culture that makes the daughters and sons be
obedient to their father all their lives. and explained that it is
especially critical for women. He added that when they get married.
they are supposed to become obedient to their husbands. Although.
Bach-y-Rita was studying Mexicans and doing some generalizations
to all the Hispanics. evidence is unclear as whether these ideas are
dominant in Puerto Rico. Richard Trent (1965) found that when
Puerto Rican women were asked to describe the ideal Puerto Rican
woman. 60% of them included obedience. TYent did not say to
whom the women in the study thought that they should be obedient.
It would be interesting to have recent data about this attitude.

Other studies about the Puerto Rican woman's role have
identiﬁed traits of submission and obedience (Fernandez-Marina.
Maldonado-Sierra. 8: Trent. 1958: Maldonado-Sierra. Fernandez-
Marina. 81 Rent. 1960). Women have been described as sensitive.
weak. self-sacriﬁced. and mostly as housewives (Fernandez-Marina.

Maldonado-Sierra. & Trent. 1958; Maldonado-Sierra. Fernandez-

49

Marina. 8r Trent. 1960: Gonzalez. 1978).

A different point of view was discussed by Christensen (1979)
who stated that females in Puerto Rico tend to have their roles more
clearly marked than does the male. He explained that the Puerto
Rican woman tends to adapt more readily. is more striving. more
oriented toward achievement. and more likely to have learned to
accomplish things through peaceful. typically educational endeavors.
Among the facts that the author used to support his assertions are
that there are always more women than men on the University of
Puerto Rico main campus. and the increasing participation of the
woman in the government and in traditionally male- dominated
professions. He made an interesting comparison of what he
considered symbols of feminine power and inﬂuence, among Puerto
Rico and the United States and found that the last one seems to be
in a more traditional and less "free" situation than the one attributed
to it. However. the author also stated that the Puerto Rican women
often pays for the child-rearing patterns and for the social
expectations that encourages her to be "superior". through increased
levels of stress. Even when educational attainment is a desirable

goal. for personal and social satisfaction. it can conﬂict with both

50

family roles and vocational aspirations and responsibilities
(Christensen. 1979).

Gonzalez (1978) studied the relationship between sex roles and
mental health among island Puerto Rican women. She concluded
that university females were more adjusted psychologically than both
housewives and female mental patients. Conversely. she stated that
Puerto Rican women who had been diagnosed as neurotic or
depressive and were receiving treatment. had signiﬁcantly more
traditional sex role expectations than the healthy housewives and
students. Gonzalez's interpretation of these results was that they
reﬂected a consequence of the rapid industrialization and
modernization experienced by the Puerto Rican society in the past
decades. A disadvantage of this study is that it did not present how
the "adjustment" of the university females was measured. and the
researchers measured traditional beliefs in the women with
disorders. after the women were diagnosed. Canino (1982) stated
that an alternative explanation of Gonzalez's (1978) ﬁndings is that it
may not be the adherence to traditional values per se that
precipitates psychological disorders. but the conﬂict experienced by

traditional women who lived in a society and family context where

51

less traditional values are reinforced. Stevens (1973) stated that
women received more compensation for adhering to the traditional
role. They are considered in the culture as morally superior to men,
stronger emotionally and spiritually. and as having semi-divine status
ascribed to the motherhood role.

Soto and Shaver (1982). based on clinical experiences with
the Puerto Rican women living in the United States and on a
literature review, proposed a causal model which relates
acculturation. traditionalism in sex roles. assertiveness. and
symptoms of physical and mental illness. They used a sample of 278
Puerto Rican women living in New York. A questionnaire was used to
measure the history of migration. academic achievement.
traditionalism. assertiveness. symptoms. religious beliefs. and
practices. and family history. But they did not report enough details
about their measurement instrument. The study presented a
negative correlation between sex-role traditionalism and

assertiveness, and assertiveness was negatively correlated with

symptoms.

52

A clariﬁcation of what the consumers of mental health services
consider as the woman's role in Puerto Rico will provide a
framework for the design of services and /or interventions.
Especially if Canino's (1982) alternative explanation of Gonzalez's
(1978) is true. disorders may arise when the traditional woman is
forced into a situation where her values are threatened or not
reinforced. Implications of sex role attitudes are discussed in the
following paragraphs.

George Bach-y—Rita (1982) talking about patients that are
"machistas". reported that they may deny illness. feelings and pain:
they tend to remain silent during therapy. and consider crying in
front of the therapists as a sign of weakness and giving power to the
therapist that should be avoided. He also suggested that the patient
will be less willing to change lifelong patterns and will attempt to
conform to what he believes is appropriate stoicism.

It is expected that groups where many members adhere to the
traditional sex roles will have more males than females in positions
of power. It is also expected that these attitudes about the sex roles
will be related with higher need of employment in males than

females.

53

From clinical experience with Hispanic women Torres-Matrullo
(1977). found women in groups with males are not advisable because
self-disclosure regarding more intimate matters is curtailed. She
referred especially to the discussion of sexual problems. It will be
useful to identify the attitudes of the consumers and relatives in
mutual help groups. because the restriction of topics may be an issue
in the groups' meetings. if they need support or help concerning
sexual matters. or the discussion of problems concerning sex role
stereotypes.

Glorisa Canino (1982) presented an example illustrative of how
the woman's role needs to be considered. She described a typical
woman as usually depressed. manifesting somatic complaints.
seldom coming out of house. with many children and a "macho"
husband. The woman will complain her husband never helps her
with either children or household chores. and that the children do
not help or obey her. If the woman sees a therapist. he or she will
probably assume that the woman is the victim of an oppressive family
system or an oppressive male. As a consequence the therapist may
tend to encourage independent coping skills in the woman. and

doing this could unbalance the family system and create a crisis

54

(Canino. 1982). The author suggested that the advice and counseling
given to the woman should be congruent with her role values and the
expectations of the family members.

Canino (1982). stated that to assume that cultural traits are
causing the dysfunctionality is a mistake that should be avoided. She
suggested that there must be some advantages within the traditional
female role in order for the role to continue to be maintained by men
and women. One of the explanations she proposed for the higher
incidence of psychopathology found among traditional Hispanic
women is that the dysfunction may occur more often when the
woman is in a societal and family context where the traditional role
is not valued.

Another implication that should be kept in mind is that it had
been found that females are preferred as counselors more often than
males «90% of female students and 43 % of the male students
preferred female counselors« (Christensen. 1979). Tying into this
situation the fact that 86% of the school counselors in Puerto Rico
were females in 1979 (in the United States it was 53% males and

47% women). The predominance of females indicates indicates the

55

female is perceived as more helpful and nurturing (Christensen.
1979).

The implications of this for mutual help groups are clear because
the groups will be receiving training and education on different
topics. and it may be useful to strengthen the role of the females as
helpers. There also is a risk in recommending behaviors and coping
strategies to the members that may not match their attitudes. Also
the attitudes about the sex roles will be reﬂected in activities and
organization of the work in the group.

W

The Hispanic has been regarded as displaying a pattern of
attitudes that is called "the issue of control" (Bach-y-Rita. 1982). He
described the concept as the idea of the Spanish-speaking
(generalizing to all Hispanics) person of rural. poor. or uneducated
background. who feels that he or she is in the hands of God. chance.
or some greater force. This idea. according to Bach-y-Rita. (1982) ‘
gave them little control in reality over his or her life. The idea of the
"issue of control" can be related to the theory of attributions of
Weiner and his colleagues (1971). This theory stated that when

people make attributions of situations of failure or achievement they

56

consider four possible causes: ability, effort. nature. or diﬁlculty of
the task. and luck. Weiner and his colleagues (1971) presented
these elements in two dimensions: stability and locus of control.
There is empirical evidence of the difference in attributions in these
two dimensions. Rotter (1966) found that differences among
external (luck) and internal (ability) attributions are responsible for
variations in the expectations and goals of the subjects. In the
stability dimension. Frank (1935) found that if the situation is
attributed to stable factors (ability or nature of the task) the
expectations and goals are more in agreement with the reality than
when they used attributions to luck or effort.

The causal attributions have been found to produce important
consequences in terms of self- esteem (Brockner. 1983).
persistence and expectations (Kernis. 1982). moral sanctions
(Schmitt. 1964). and evaluations in situations of achievement
(Surber. 1981).

Pedro Ruiz (1982) stated the deﬁnition of the therapeutic goals
with the Hispanic clients as one of the most difﬁcult problems
confronting a mental health specialist trained within Anglo culture.

The author elaborated explaining that the classic Anglo oriented

57

psychiatric training programs focus on the goal of gaining
"independence". and that on many occasions. Hispanic clients
(recently arrived migrants) placed little value 0n obtaining
"independence" and becoming responsible for their destiny. Alba
Nydia Rivera (1982) studied the collective perception. self-
perception. and assertiveness of groups of students and workers.
She found that students scored lower in assertiveness than the
workers. and that both groups had different views of the Puerto
Ricans. Students attributed to the Puerto Ricans traits of docility and
meekness. while the workers attributed more the traits of courage
and aggressiveness. Reinaldo Ortiz (1974) analyzed traits that had
been used in the literature (novels. poems. etc.). and in sociological
and psychological studies in descriptions of the Puerto Ricans.
Some of those traits were: conformity. resignation. inferiority

complex. respect for the parents. and "machismo. There is no
empirical evidence conﬁrming that the Puerto Ricans display those
traits. but if docility. meekness. conformity. and resignation (Rivera.
1982; Ortiz. 1974) came to be displayed . it would be reasonable to
ﬁnd a predominantly external locus control among the Puerto Ricans.

Also. according to the religious ideas on the island. the "issue of

58

control" and external attributions may be found. In that case a
relationship may exist between preference of independence from the
mental health system of consumers of mental health services and
their relatives.
seam

The Hispanics have been considered very religious people.
Bach-y-Rita (1982) stated that hundreds of years of Spanish rule
successfully ensconced Catholicism as the major religious presence.
The author argued that for the Mexicans. Catholicism serves to form
a system of symbols and beliefs. which establish long-lasting mores,
moods. and motivations.

As part of the data of a recent study. Bird and Canino (1982)
found that 90% of 459 Puerto Rican families interviewed reported
belonging to some organized religion. Seventy-six percent were
Roman Catholics. They did not discuss any affiliation to other
religious groups. Lubchansky and his colleagues (1970). Harwood
(1977) and Comas-Diaz (1981) have reported a high prevalence of
folk-religions. particularly spiritism in Puerto Ricans in the United

States and in the island. Canino (1986) reported that within a

59

sample of 287 patients diagnosed with DSM-III. 3.9% said that they
use only spiritualists and clergymen. and 21.4% reported that they
use both spiritualist and professional help for their 'emotional
problems".

There are no studies about Puerto Rican religiosity in general. but
some implications of the Catholicism and "espiritismo" (spiritism)
can be discussed.

Camelxism

There are not too many studies about Puerto Rican Catholicism
and mental health. However. the similarity of the Catholicism in
Mexico and in Puerto Rico (the structure of the church and the
beliefs are the same) makes possible the consideration of studies
with Catholicism and Mexicans. Bach-y-Rita (1982) suggested that
understanding Mexican-American religious thought is the key to the
framework for understanding the self. the environment. and the
personal relationships in Hispanic populations. The author explained
that Mexican Catholicism makes the people face reality with the
idea that they are born to suffer and that suffering is an integral part
of life. Suffering then, is exposed instead of hidden. and to endure it

for a good cause is admired. Together with suffering. service is

60

highly regarded as a Christian virtue. Bach-y-Rita concluded that
there is a joy attached to suffering and serving that may be alien to
many Americans.

Correa et a1. (1961) evaluated the attitudes toward mental illness
of relatives and neighbors of mental clients in Puerto Rico. One of
their hypotheses was that there would be a positive correlation
between attendance at religious services and positive attitudes
toward the mental clients. However. it is interesting to point out
that people who classiﬁed their attendance as "occasional" had the
most positive attitudes . followed by people who classiﬁed
themselves as "nominal catholics". and in third place by the group
that reported constant attendance to religious services.

Bach-y-Rita (1982) said that a basic Catholic premise is that God
put us on earth. governs our lives. and ultimately takes us from the
world. The author explained that illness is often viewed in a
religious context and God is frequently invoked as the cause of the
illness and suffering as well as the source of the cure. In his article
Bach-y-Rita argued that the presence of religious ideas and beliefs is
often a great help in therapy and that religious practices can be

utilized in the course of behavior therapy. Elaborating on these two

61

arguments. he stated that. sometimes in dealing with Mexican
clients in the United States. the single most useful facet of the
treatment was bringing a Spanish-speaking priest. Also. he
discussed the use of the rosary or prayer as a relaxation technique.
and stated that church activities oriented toward community service
continue to ﬁll the role of social support groups.

The idea that God is the cause and the source of cure may be an
important coping resource that can produce negative eﬁ'ects on the
clients if it is eliminated. If the consumers and family members in
and out of the mutual help groups are going to be receiving training
and education on health issues. it will be necessary to consider that
the religious ideas of the clients should be respected. even in the
topics that are chosen or recommended for the discussion in the
group. Also the fact that the church's activities may ﬁll an important ‘
role of social support. suggests that one of the needs of the mental
clients and their family members may be to participate in religious
activities. It is expected that mental clients and family members
with high religiosity will use external locus of control and manifest a

higher need to participate in religious activities. Finally. information

62

about religiosity of the members in mutual help groups will provide a
clearer picture of the possibilities of success of the modality of
mutual help which appeals to religion «known as GROW groups« in
Puerto Rico. These GROW groups have been broadly studied and
many elements of their success have been identiﬁed (Luke. 1987;
Roberts. 1987; Salem. Siedman & Rappaport.1987; Toro. 1987).
Distinctive elements of these highly structured. independent. and
religious groups (Catholicism) are discussed in McFadden (1987).

" 111 l "

Although the "espiritismo" is not considered a religion per se. it
involves ideas that make this group a special spiritual group. Ralph
(1977) stated that animism and beliefs in spirits have existed in
every known culture. and that these traditional beliefs are still active
in conjunction with other religious. philosophic. and scientiﬁc views
of the world. The "espiritista" [spiritist] doctrine is complex and
includes many modalities that are not the focus of this section.
However. a summary of some of the main concepts is presented due
to the impact these folk beliefs have on the mental health system.

Ralph (1977) stated that according to the "espiritista" doctrine.

Spirits are intelligent beings who reach perfection through many

63

reincarnations. These spirits can be good or evil. and can affect the
living. One can communicate with them and their activities can be
modiﬁed through the help of a medium-~a person with powers of
divination and the ability to contact the spirits. Lilliam Comas-Diaz
(1981) described the "espiritismo" (spiritism) system of beliefs. She
explained that it consists of an invisible world populated by spirits
who surround the visible world. These spirits can penetrate the
visible world and attach themselves to human beings. Some spirits
are presently incarnated (as human beings) and some are not. The
spirits are subjected to the law of "evolucion espiritual" (spiritual
evolution) which states that all spirits were created ignorant by
nature but with the mission to move or grow toward purity.
According to the author. the spiritism stated that in order to
progress from one level to another. the incarnated spirits must
undergo "pruebas" (trials). It is through the "medium". (espiritista)
that individuals know about their "pruebas". The "resguardos"
(protectors) are things that represent spirits acting collectively to
help the person to cope with causes of problems.

In the "espiritismo" , the person is not labeled as sick and is not

blamed for his or her misfortunes. The person is seen as suffering

64

from a "causa". A "causa" can be another person's envy of you that can
cause misfortune for your family. or "dario" which is harm inﬂicted
by a jealous individual (Comas-Diaz. 1981). The author also makes an
interesting point when she notes that the believers in "espiritismo"
reject the psychotherapists and their treatments because that means
that they are "crazy". and it carries a stigma that is maintained by the
psychotherapists. The believers in the "'espiritismo" assume that the
professionals usually do not understand or even blame the clients for
their misfortunes and provide inadequate treatment and poor
prognosis (Comas-Diaz. 1981). Rogler and Hollingshead (1960)
argued that in the "espiritismo" [spiritism] there is no stigma
attached to the mentally ill. Instead. the "medium" may explain to
the person. his/her relatives. and friends that the symptoms mean
that the person has "facultades" [psychic abilities]. and this will give
them prestige and become a supportive and positive view of the
situation.

Gaviria and Winthrop (1979). in a sample of Puerto Rican
psychiatric clients and nonclients in Connecticut. found that 90% of
their subjects believed that the "espiritismo". with the causes of

"envy" and "dano" is responsible for the mental illness of the people.

65

Rogler and Hollingshead (1960) studied what happened after
mental illness symptoms were displayed by low socioeconomic level
people in San Juan. Puerto Rico. They found that the people
frequently contacted spiritists and / or "mediums". The authors also
indicated that "espiritismo" also is practiced by people in other
socioeconomic levels. The ones in higher levels made efforts to
differentiate their "espiritismo" from that of the people in low
socioeconomic level by giving scientiﬁc and experimental attributes
to their beliefs (Rogler & Hollingshead. 1960).

If the "espiritismo" is as extensive among the Puerto Rican
mental clients as has been suggested. it will be possible to ﬁnd
believers in the "espiritismo" among the members of the mutual
help groups. If that is the case. their ideas may interfere with the
selection of topics for lectures and with the activities that are
planned by the groups. However. the ideas of the "espiritismo" about
the mental illness can make it difﬁcult to ﬁnd its believers in
situations like the mutual help groups which are voluntary and
afﬁliated with the mental health system.

This study will answer whether the "espiritistas" participate in

66

mutual help groups and if they do. if they will prefer more
ndependence from the mental health system than the members of
uthers religious groups.
W

In 1982 the ofﬁce of the Auxiliary Department of Mental Health
leveloped a Community Support Program in which clients
iarticipate through mutual-help groups. Speciﬁc goals and services
or the groups have not been established. because the groups are
:onsidered to be independent from the Community Support
’rogram. but coordinated by it. This situation will make the groups
my open to suggestions about objectives and goals that they may
rave. The Community Support Program and the mutual help groups
will beneﬁt from the identiﬁcation of a framework about needs and
Lttitudes of the members of the mutual help groups. useful in the
lesign of service alternatives. The mutual help groups in Puerto Rico
re formed by consumers of mental health services and/ or relatives
nd community members (mostly adults). However. the population
hat needs or will need the mental health services the most has been
escribed as typically composed of youngsters and young adults. The

ges of the members of the mutual help groups have not been

67

collected (N. Rios. personal communication. May 1. 1987). The
description of the members and other characteristics will be useful
in the development and improvement of services for the groups.

The purpose of the literature review was: (a) to discuss what has
been considered as the needs of the consumers of mental health
services and their relatives in Puerto Rico: (5) to present attitudes
that may be found in the Puerto Rican consumers and relatives about
the family. the sex roles. locus of control. and religiosity; (c) to
discuss possible implications and relationships of those attitudes
with the needs of mental clients and family members and in the
activities and structure of the groups. and (d) to use the information
about the needs of the consumers and the needs of the relatives as
evidence of the importance of the assessment of the needs of boths
groups-~especially of those participating in mutual help groups.

The needs of the consumers in Puerto Rico have been
considered to be: economic needs (Morales et al.. 1985: Ribera.
1987);, need of new patterns of interpersonal relationships (Ramirez.
1985): access to services. employment. housing. support. recreation.
education. training. use of spare time (Morales et al.. 1985): active

participation of family members in the treatment of the consumers

68

(Santiago. 1985); the consumers' integration into the community and
into their family. and their trust in the professionals (Morales et al..
1985). However. the needs of the consumers and the family
members in mutual help groups have not been assessed.

The Puerto Rican family could be seen. according to the
literature. as an extended one. composed by an authoritarian,
dominant and patriarchal father and a self-sacriﬁcing wife. However.
there is evidence that suggests that the attitudes about the family
may have changed. Many studies with Mexicans and other Hispanics
discuss relationships between the attitudes about the family and its
structure. and the mental health of the Hispanics. However. due to
the fact that the literature does not provide an actual description of
the Puerto Rican family. and of the important role attributed to the
Puerto Rican family in the life of the individual; it is suggested that
institutions providing services try to get a better insight into their
consumers' beliefs about the family. This study will do that with the
participants of mutual help groups.

The Hispanic women's role have been described in terms of

obedience to males. cult of virginity. and the goal of being a

69

housewife. However. there is contradictory data about this pattern of
attitudes as characteristic of the people of Puerto Rico. A
relationship between the role of the Hispanic women and mental
health issues had been suggested by many authors. Glorisa Canino
(1982) suggested that there must be some advantages within the
traditional female role in order for the role to continue to be
maintained by men and women. She also suggested that the advice
and counseling given to the women should be congruent with her
role values and the expectations of her family members. The
identiﬁcation of the attitudes about the sex roles held by consumers
and relatives in mutual help groups will be useful in the decision
about topics. lectures. and services for the groups. It will also help
to understand the distribution of work and type of activities that the
mutual help groups wants. The same will happen with the attitudes
about the man's role, which had been deﬁned in terms of the ideals
of the "machismo".

According to the religious ideas on the island. the "issue of
control" and external locus of control may be found as a
characteristic of the Puerto Ricans. If that is true. it can be found

among the consumers and family members in mutual help groups. It

70

may make the consumers and family members with external locus of
control prefer to remain dependent from the mental health system.

There is evidence that many Puerto Ricans are affiliated with
religious groups. Special mention was made of the Roman Catholic
church and the "espiritismo". because many studies have been done
about them with groups of Hispanics. If the mutual help groups are
receiving training and education on health issues. it will be necessary
to consider the religious ideas of the consumers and use them for
their beneﬁt. Also. the fact that the church activities can be.
considered a very important source of social support suggests that. if
the consumers are found to score high in religiosity. further studies
should explore if it is possible to make the religious groups the
strongest sources of social support for the consumers in the
community . Another alternative will be to implement GROW groups
or to include aspects of that modality of mutual help into the current
mutual help groups in Puerto Rico.

According to the "espiritista" doctrine. spirits are intelligent
beings who reach perfection through trials and reincarnations. The
"espiritismo" rejects notions of mental illness and the use of a

psychotherapist or other mental health professionals. Evidence

71

suggests that although the "espiritistas" (spiritist) reject the idea of
mental illness. they have been identiﬁed as receiving mental health
services. This situation means that "espiritistas" may be found in the
mutual help groups. It will be important to know if they participate
in these groups which are not considered therapeutic groups and are
voluntary. It is expected that they will prefer to be more
independent from the mental health system.

The purpose of the study was: (a) the assessment of the needs
of the consumers and relatives in mutual help groups mutual help
groups; (b) the measurement of the attitudes about the family and sex
roles. locus of control. and religiosity of the consumers and relatives
in mutual help groups. and (c) the evaluation of some hypotheses
about the relationship among the attitudes and needs of the mental
clients and family members.

The hypotheses were:

H1. There will be a positive relationship between the
traditional family beliefs of consumers and relatives in mutual help
groups and the need of stable and positive relationships with the
family.

H2. There will be more members in positions of power in

72

groups where the members adhere to the traditional sex roles.

H3. There will be a positive relationship among the external
locus of control of the consumers and relatives in mutual help groups
and their preference of dependence on the mental health system.

H4. Male consumers and relatives. who hold traditional sex
roles will express higher need of employment than the females
holding traditional sex roles beliefs.

H5. There will be a positive relationship between religiosity and
external locus of control of the consumers and relatives in mutual
help groups.

H6. Group members who believe in the "espiritismo" will prefer
to have the groups more independent from the mental health center.
than non-believers in "espiritismo".

H7. There will be a positive correlation between religiosity and
the interest in group particpation in religious activities.

Also information about the structure of the groups and. the
members' participation in the groups was considered during the
study as well as general information about the groups helpful to

understand the role of the groups in fulﬁlling needs of the members.

CHAPTER 2
METHOD
W

The primary focus of the study was to identify the needs of
consumers of mental health services in mutual help groups (also
known as Community Support Groups and Self-Help Groups) in
Puerto Rico. These groups are the most direct link between
consumers and mental health centers following discharge.

Approval to proceed with the study was obtained from the
Ofﬁce of Research afﬁliated with the Office of the Auxiliary Secretary
of Mental Health. A copy of the letter of approval is displayed in
Appendix B. Through personal communications (E. Rios. April 28.
1987; N. Rios. May 1. 1987) the author gathered the following
information about the mutual help groups:

1 . Approximately 1 80 family members. and from 70 to 80
consumers of mental health services participate in 13 mutual help
groups.

2. Five groups include only family members. two groups mainly

consumers. and the other six include both.

73

74

3. Ten of the mutual help groups are aﬁiliated with the Mental
Health Centers. No others are afﬁliated with psychosocial
rehabilitation centers. and the remaing one is affiliated with the
psychiatric hospital in Ponce.

4. The number of members in the groups varies from 8 to 25.

Based on this information, the groups were classiﬁed as groups
of consumers. of relatives. or both. From each of these categories.
one group was randomly chosen. Since the ﬁrst three groups
together did not produce 40 members (potential subjects) another
group was randomly chosen. The process of selecting active groups
continued until six groups were contacted. At that point it also was
clear that the original categorization of groups was inaccurate.
Groups that were thought to be comprised of relatives were
functioning as groups of consumers and relatives. The same was true
of groups of consumers. Also. a group was found in one of the
centers that was not included in the original list. It was necessary
to contact all 14 groups from which 10 were successfully contacted
and agreed to participate in the study. Forty-two members were
interviewed. A list of the groups that participated in the study. and

the information about the respondents is included in the section

75

titled "Final Sample." Groups in Aguadilla. Carolina. Humacao. and
Trujillo Alto did not participate in the study. N0 of them were not
going to have meetings during the period of data collection. and
were unable to call an extra meeting. In the other two cases. it was
impossible to talk to the coordinator and/or obtain information about
the group members.

When the groups had been identiﬁed. the coordinator was
contacted by phone. The purpose of the study was explained to the
coordinator at that time. The coordinator was asked about the
number of members in the group. the name and address of the
president. and the date of the next meeting. The president of the
group was then contacted by phone and provided the same
explanation. The president's consent to visit the next meeting of the
group and to invite the members to get involved in the study was
requested.

It was originally planned to visit each group twice «using the ﬁrst
group meeting to meet the members and make appointments for
interviews. However. it was necessary to use other alternatives. With
the exception of one group. all had only monthly meetings. By the

time that it was possible to speak to the coordinator. the groups had

76

only the July meeting on schedule. Just one group agreed to call an
additional meeting for the data collection. In the case where the
group was going to have two meetings during the period from June
15 to August 15. the group was visited twice and in the ﬁrst meeting
the explanation and presentation proceeded as planned.

Usually. the president and the coordinator agreed to call the
members and explained that the interviewer would visit the next
meeting if they were interested in knowing more about the study and
in having the option to participate.

In the meeting: (a) the interviewer was introduced by the
coordinator and/or the president. (b) the consent form was
explained and read (see Appendix C). and (c) the members had the
option to participate and be interviewed the same day or to choose
another date. All of the groups in this situation chose to be
interviewed the same day.

WW!
Ten groups participated in the study. These groups are affiliated
with the Mental Health Centers. the Psychosocial Rehabilitation

Centers. Psychiatric Hospitals. and the Office of the Auxiliary

77

Secretary of Mental Health. The groups that participated in the
study. and the number of members who agreed to participate are

displayed in Table 3.

 

 

Table 3.

'._ I1 0-.1 1 ' 0. . 001'1- 0 . ' ° 0 9 2-10. ‘1 ' -

origin

Groups Center N

1. Grupo de Apoyo Ponce PHa 2
Comunitario

2. Grupo Apoyo Mutuo Bayamén MHCb 4
San Patricio

3. Asociacion Organizadora Manati MHC 5

de Ciudadanos Utiles
4. Organizacién Puertorriquer’ia Office of the Auxiliar 4
de Consumidores de Servicios Secretary of Mental

de Salud Mental Health
5. Club Diurno en Accion Arecibo MHC l2
6. Organizacion Salud Mental Mayagiiez MHC 7
Oeste
7. Asociacién Pro Ayuda a Cayey PRCC 3
Residentes Centro Psicosocial
Cayey Inc.
8. Grupo de Apoyo Cayey MHC 1
Comunitario
9. Grupo de Ayuda Mutua Coamo MHC 2
10. Grupo de Salud Mental
Antiguo Hospital
Veteranos Puerto Nuevo 2

 

a PH refers to Psychiatric Hospital: b MHC refers to Mental Health
Center: C PRC refers to Psychosocial Rehabilitation Center

78

The coordinators of the groups ﬁlled out a short questionnaire
(see Appendix D) concerning general information about the mutual
help groups. Seven of the ten coordinators provided the necessary
information for the description of the groups. From their responses
the following information was summarized:

1. The groups have been together from two to seven years. with
a mean of three years.

2. Attendance at the meetings ranges from 5 to 30 members.
(M=14).

3. Six of the seven groups from which the coordinators provided
information had their meetings monthly. The seventh group, which
had his meetings weekly. is considered also the national directive of
the newly formed National Association of Consumers.

4. All the groups that submitted information (seven groups) had
presidents. four men and three women.

5. One group reported not having had any newcomers during the
previous four months. while. (a) one group had one. (b) two groups
had two. (c) one group had four. and (d) two groups had six.

6. All the groups reported that they had been meeting regularly

79

during the last six months.

Among the list of the main activities of the groups: (a) four
mentioned the organization of parties. or social activities. (b) three.
the recruitment of new members. and (c) two. the incorporation of
the groups with the State Department Ofﬁce. Other activities
mentioned by individual groups were: (a) attending the National
Assembly of Consumers of Mental Health Services. (b) managing a
small cafeteria. (c) having writting a proposal requesting funds for
workshops and seminars. (d) lobbying to get a Club House for the
consumers of mental health services. and (e) having meetings to
discuss problems with the services for the consumers.

l v n u r I v lv 11

Forty-two interviews were completed during the study. Twenty-
seven were with consumers of mental health services and eleven
with relatives. Four subjects were both relatives and consumers of
mental health services. No subjects did not complete the
interviews. and their data were not included. One of them reported
being tired. and the other was unable to understand many questions

and to answer what was being asked.

80

m hi i
Some characteristics of the respondents are described in the
following paragraphs. Others are included in the results section as
situational variables.
The ages of the consumers and relatives were recoded into
categories. All the members were over 21 years of age. The highest
percentage of people in both groups was in the range of 46 to 56

years old. The ages of the subjects are summarized in Table 4 .

 

 

 

Table 4.

Weds

Ages Frequencies %
Relatives (n=15)

36 to 46 1 7%

46 to 56 6 40%

56 to 66 5 33%

66 to 76 3 20%
Consumers (n=31)

21 to 36 7 23%

36 to 46 6 19%

46 to 56 1 1 36%

56 to 66 5 16%

66 to 76 2 6%

 

Data concerning the medical history of those who were

consumers of mental health services were collected from the

81

subjects who remembered that information. The self-reported
medical history information that was collected is summarized in the
following paragraphs and a tabulation is displayed in Table D-l in
Appendix D .

The 31 members who classiﬁed themselves as consumers had
received or were receiving mental health services at the time of the
study. Common services were. medicines (55%) and therapy (42%).
Other services mentioned with lower frequency were; ambulatory
services. psychiatry. vocational rehabilitation. and external clinic.

All the consumers reported that they had been hospitalized. but
some of them were unable to answer how many times. Among 12
respondents who answered that question. the number of
hospitalizations varied from 1 to 20. (IL/(=4). Nelve consumers were
able to indicate the year of their ﬁrst hospitalization. The time since
the ﬁrst hospitalization ranged from 2 to 27 years with (M=12) .
Ten of them recalled the year of their most recent discharge. The
range of years since the last discharge ﬂuctuated between 1 and 10
years ago. IM=4). Only nine consumers in the study indicated that
they recalled their last diagnosis. Six subjects indicated

schizophrenia. one manic-depressive disorder. and one neurosis.

82

None of the 31 subjects reported having used street drugs and/or
being in a drug rehabilitation program.
W

A structured interview was used as the method of data
collection. The interview form was ﬁrst written in English and a
translated into Spanish. It was reviewed before and after a pilot-test
by a faculty member from the University of Puerto Rico.

Five members of the mutual help group at the Mayagr‘iez
Community Mental Health Center were interviewed during a pilot-
test. As a result of the pilot-test. minor changes were made in the
wording of some items and the instructions of one section. At the
same time. the changes were done to the English version in order to
keep it as equivalent as possible. (See letter from O. Hernandez in
Appendix E). The English and Spanish versions of the interview are
in Appendix F.

Wining

The interviews were done by the author and two interviewers.

One of them (Interviewer 2) was recruited at the beginning of the

study and went through three training sessions. The ﬁrst session

83

lasted approximately four hours and was used to discuss: (a) the
topic of the study. (b) the purpose. (c) the method. ((1) the
environment. (e) issues of privacy and conﬁdentiality. and (1)
recommendations about how to handle hypothetical situations that
may come up in the interviews.

The next day. the interviewer went to the Community Mental
Health Center in Mayagr‘iez with the author and listened to four
consecutive interviews done as part of the pilot-test. A ﬁfth
interview was done the same day. but this time the trainee and the
author (interviewer) exchanged their roles. and the trainee
conducted the interview. The following morning. the author and the
trainee discussed the instrument. criticizing it according to the
notes that they both wrote during the pilot-test. During the meeting.
a revised version of the instrument including minor changes in
wording of some items and instructions. was written. A codebook
and the instruction manual for the interviews were written according
to the revised version.

The ﬁrst four interviews also were used to pilot the format of
the instrument. The percent of agreement between the author and

the trainee during the ﬁrst four interviews was 97.52%.

84

Another interviewer had to be recruited because the study was
extended one week more than expected. This new interviewer is
identiﬁed as Interviewer 3. Due to time constraints. she was trained
in only one session. lasting seven hours. The same topics discussed
in the ﬁrst training meeting were discussed. The instruction
manual. the codebook. and the interview form also were discussed.
At the end of the meeting. the trainee (Interviewer 3) interviewed
the author and received feedback about her performance.
hum

Interview sessions were scheduled with the members of each
group during the same day. All the interviews were done on an
individual basis. Every tenth interview until the thirtith interview
(10.20.30) was done by one interviewer in the presence of another
interviewer who also recorded all the responses. The percent of
agreement for these three interviews was 98%. The author went to
all the interview sessions.

All of the interviews were conducted at the place where each
group had its meetings. With the exception of one group. which had
a meeting in a community activities center. all the others had their

meetings at the psychosocial rehabilitation centers. community

85

mental health centers. and the Ofﬁce of the Auxiliary Secretary of
Mental Health.

The ﬁrst minutes before the interview were used to talk
informally with the respondent. Then a copy of a consent form was
read to the respondent at the same time that he/ she had a chance to
read it. The consent form is displayed in Appendix C. It reminded
the subjects of their rights of anonymity and conﬁdentiality. and
their option to withdraw at any point.

When the subject had decided if he/ she was willing to be
interviewed. and signed the consent form. the interviewer
proceeded with the interview following the instrument. A
description of the instrument is provided in the next section.

W

All the interviews were conducted in Spanish by female
interviewers. The interviews lasted from 45 to 90 minutes.

If the coordinator of the group was available. general information
about his/her group was collected the same day. In other situations.

the coordinators preferred to keep the form and mail it back.

NEW

The purpose of the interview was to collect information about:
(a) demographic characteristics of the relatives and consumers of
mental health services in the mutual help groups: (1)) the subjects'
status in the groups: (c) the structure of the group; (d) the subjects'
participation in the group; (e) the members' plans concerning the
mental health center and the group; (f) needs of the members: and
(g) their attitudes about family. sex roles. locus of control: and
religiosity.

The following subsections describe the content of each of the
different sections of the interview displayed in Appendix F.

W The instrument included questions
about: (a) age. (b) marital status. (c) education. ((1) occupation. (e)
sources of income. (f) monthly income. (g) type of dwelling. (h)
members of household. and (i) sex of the respondents. Horn those
who identiﬁed themselves as consumers of mental health services.
the number of hospitalizations concerning mental health problems.
the year of the ﬁrst hospitalization. the date of last discharge. and

the most recent mental health diagnosis. was collected.

WW3, This section gathered information

87

about the respondent as a member of the group. T‘wo open—ended
questions provided the opportunity to talk about what he/ she liked
or disliked about the group. The items about participation in the

group are listed in Table 5

 

 

 

Table 5.

mmmmmmmmmsmhm

Variables Letter of the item

Months afﬁliated with the group P-lO

Frequency of attendance P~10b

Responsibilities of the member to the group P-l 1

Relatives participating in the group P-12.P-12

Things enjoyed the most about the group P-13

Things liked the least about the group P-13b
mm This section focused on the groups'

formal and informal leadership. It asked the name of the person in
each of the leadership positions. and identiﬁed each person as a
consumer. a relative. or the coordinator of the group. An open-
ended question was included asking the responsibilities of the
coordinator. The variables used to describe the structure of the

groups are displayed in Table 6.

88

Table 6.
WWW

 

 

Variables Letters of the items
Person with most inﬂuence P- 14

Leader of the group P-15
Responsibilities of the coordinator P- 16

Members of the directive P-17 a.b.c.d

 

Needs. This was the main section of the interview and involved
four subsections. The ﬁrst part consisted of an open-ended question
about the subjects' needs or major concerns. This was followed by a
list of possible needs and their importance rated on a 1 to 4 Likert
scale. An index card with the four options was handed to the
respondent.

Two other sections involved this list of needs. One asked the
subject to indicate his/her satisfaction with each of the items. An
index card with the options corresponding to a 1 to 4 Likert scale
was used.

Finally. there was one section presenting the same items or
needs and asking if the respondents expected to fulﬁll the need
through their participation in the group. Table 7 displays the items

used for the sections about importance and satisfaction. and for the

8 9
identiﬁcation of the needs that they wanted to fulﬁll through the
group.
Table 7

m - ‘0 0 H11 011m” -.- ' -.1QL.1r .._o {m 1‘

man

 

Variables Letter of the item in sections
P-19.20.21

 

Employment

Housing

Participation in recreational activities
Access to mental health services

Support received from mental health services
Academic education

Informal education

Involvement of your family in your activities
Participation in Community matters
Opportunities to meet other people
Participation in religious activities
Relationship with your family

Opportunities to interact with youngsters
Opportunities to teach your experiences
Support from the neighbors

Religious beliefs

Physical health

"Emotional" mental health

Sense of usefulness

manuoag~wh-rmr~onocm

 

W This section included ten statements
extracted from the literature about traditional family beliefs. They

were read to the subject to get his [her level of agreement. All the

90

statements were presented in the positive or "traditional" direction
using a 1 to 5 Likert scale. The response options were given to the
respondent on an index card. The sentences Were divided into ﬁve
categories according to their content: (a) attitudes about the role of
the father. (b) attitudes concerning the role of the mother. (c) the
role of the siblings. (d) the composition of the family. and (e) the
importance of the family. The items are on page 1 1 of the
instrument displayed in Appendix F.

Two items were deleted from the scale (see items g and h in
Appendix F) because they were confusing to the subjects. Two more
items were dropped because of their low item-total correlations. Six
items with a coefficient Alpha of .83 were used to form the ﬁnal
scale. Those items and their item-total correlations are included in

Table 8.

91

 

 

Table 8.
- n f r i n l 1
Items Item-total correlations
a. The father should be the authority .51
ﬁgure in the house
b. To obey your father is more important .55
to love him
c. The mother should always be more loving .62
than the father
(1. The mother should obey the father's will .72
e. The siblings should always obey their father .67
f. Even though you are angry with your parents. .56

their will should be complied with because .of
"repeto" (respect)

 

Attitudesahoirtmmiionalmmles. This section included

14 statements about what has been presented in the literature as the
description of the traditional Hispanic man and woman. Section VI
of the instrument in Appendix F displays the items including seven
about the traditional women. and seven about the traditional men.
All the statements (14) were read about both. the men and the
women. and answered using a 1 to 5 Likert scale. The respondent
received the same index card mentioned in the previous section.
The question; "to what extent do you agree with the idea that the

woman should...(item)"was read before each item. It was read twice

92

for each item. The ﬁrst time "the woman" is mentioned as the
protagonist. the second time "the man" All the statements (14)
were read about both the men and the women.

Eleven items correlate with a reliability coefﬁcient (Alpha) of .50

for the traditional women's role. Those items and their item-total

correlations are listed in Table 9.

Table9
- l l rri lwmn'

 

Items Item—total correlations

 

The woman:

b. Should be religious .48
c. Should obey her husband and/ or father .48
(I. Should be sentimental .49
e. Should rear her siblings .47
f. Should iron. clean. wash and do the housechores .48
g. Should work out of home‘ .42
h. Should have strong character‘ .43
j. Should have a better job and earn more money .45
than her spouse‘
k. Should "venerate" (or give more importance .48
than to any other person) her mother.‘
I. Should impose discipline to her children.‘ .46
111. Should bear pain without complaining.‘ .47

 

‘ Means the item was recoded in this scale.

Another scale was prepared for the traditional men's role. This

time the scale included only four of the original fourteen items. The

93

reliability coefficient of this scale was .37 and the items included. as

well as their item-total correlations are displayed in Table 10.

 

 

Table 10
- i n i '
Items Item—total ‘
correlations
The man: ——
b. Should be religious‘ .37
n. Should go out with women other than his wife .01
1. Should have a better job than his wife .03
(I. Should be sentimental‘ .36

‘ Means that the item was recoded.

The low reliability of the items about the traditional men's role is
attributed to the format of the question. The subject was asked the

item about the man immediately after responding to the same item
concerning the women. This format encouraged the subjects to
answer the same way about the man or the woman. This situation
was perceived by the interviewers. Due to the inadequate format
and considering that (a) the item was always read ﬁrst about the
woman. and (b) that all the items considered as descriptive of either
the traditional man or the woman were antonymic to their

corresponding idea concerning the opposite sex. the set of items

94

about the traditional women role were chosen as a measure of the
traditional sex roles.

W The locus of control was measured with the
items of a subscale of Gurin. P.. Gurin. G.. Lao. Rosina. and Beattie
(1969). "Multidimensional IE Scale". Gurin et al.'s instrument is a
modiﬁed version of Rotter's IE scale (Rotter. 1966). The whole
instrument consists of 23 items from Rotter's scale. three items
from the Institute of Social Research Personal Efﬁcacy Scale. and 13
items written especially to tap beliefs about the operation of personal
and external forces in the race situation in the United States. The
scale yields four factors: (1) control ideology. (2) personal control.
(3) system modiﬁcation. and (4) race ideology (Gurin. et al..1969).

For the purpose of this study. only the subscale for personal
control was included. The subscale contained ﬁve items. all phrased
in the ﬁrst person. indicating subject's beliefs in his/her own
control. According to Gurin et al.. (1969) the personal control scale
is the closest to Rotter's (1966) conceptual deﬁnition of internal-
external locus of control. The ﬁve items of personal control are

included as section VII of the instrument in Appendix F. The

95

respondents were asked to choose from each pair. the statement
with which they agreed the most. One statement in each pair
concerned external locus of control and the other internal locus of
control. If the subject chose the statement about external locus of
control he/ she got a score of 2 in the item. If they chose the other
statement. they receive a 1 in the item about extemal locus of
control. One pair of items (number 4) was dropped because it was
not clearly understood by the subjects. From the other four pairs.
the four items about external locus of control were combined into a
scale. The reliability of the scale (Alpha) was .42. The items

included and their item-total correlations are presented in Table l 1.

 

 

Table 1 1

- l r f
Item Item-total correlation
1A. I have often found that what is going .217

to happen will happen.
2B. Sometimes I feel that I don't have enough .27

control over the direction my life is taking.
3B. It is not always wise to plan too far ahead .38

because many things turn out to be a matter of
good or bad fortune that you may have.

5A. Many times I feel that I have little inﬂuence .08
over things that happen to me.

96

W. The eighth section of the questionnaire included a
question about the religious afﬁliation of the subject. and 8 of the 21

items of Poppleton and Pilkington 's (1963) scale to measure
religious attitudes. The original scale was designed to measure
religious attitudes of British college students and was developed
with the method for the Thurstone scales (Poppleton & Pilkington.
1963).

Four items from the original scale were randomly chosen from
the items phrased in the positive direction (high religiosity
according to the original use of the instrument). Another four items
were randomly chosen from the set of items phrased in terms of low
or no religiosity. A l to 5 Likert scale was used to record the
agreement of the respondent with each item. The values of the
options for the high religiosity statements range from 1 equal to
strongly disagree to 5 equal to strongly agree.

After the pilot-test. two items were eliminated. Item number 8
was dropped from the scale because it was confusing. The third item
also was dropped because it correlated negatively with the scale. Six

items were used in the scale of religiosity. The internal consistency

97

of the scale was .59. The items included and their corresponding

item-total correlations are displayed in Table 12.

 

 

Table 12.

m- l i l f i i
Items Item—total correlation
1. To lead a good life it is necessary to have .29

some religious and /or spiritual belief.
2. I genuinely do not know whether or not God exists.‘ .37

4. The existence of disease and famine in the world .52
demonstrates that God does not exist.‘

5. International peace depends on the world wide .25
adoption of a common religion.

6. Life is meaningless without believing in God. .19

7. If you lead a good and decent life. it is not necessary .21
to go to any church.‘

 

‘ Means that the item was recoded.

aur-o. onin-n- - - .. .211 -1- 2111-2- .,
The last section of the interview included open-ended questions
about future plans concerning the group and the mental health
center. The questions were: (a) do you want or plan to stay involved
with the mental health center?. why or why not?; (b) how well do
you believe that you would be without the help of the mental health
center? why or why not?. and (c) in what activities of the community
would you like the mutual help group to get involved. and with what

associations or groups?

9 8
When the interview ended and the respondent left the ofﬁce .or
place of the interview. the interviewer had to complete the last page
of the questionnaire noting (a) the sex of the subject. (b) the date of
the interview. (c) the time when the interview ended. (d) the
interview number in the interview session. and (e) any unusual

comments and circumstances.

CHAPTER 3
RESULTS
W

This section describes (a) situational variables. and (b) needs of
relatives and consumers of mental health services in mutual help
groups in Puerto Rico.

u n V l

Em. All the subjects reported that they had some formal
education. Consumers and relatives reported similar levels. Thirty-
six percent of the consumers (n=1 1) and 26.7% of the relatives
(n24) did not go to high school. but completed different levels in
grade school. Thirty-ﬁve percent of the consumers (n=1 1) and 40%
of the relatives (n=6) went through 1031.111h and/or 12th grade.
Ten percent of the consumers (n=3) and 7% of the relatives (n=1)
studied one or two years of a Bachelor or associate degree. without
completing them. Nelve percent of the consumers completed
technical or associate degrees or studied 3 to 4 years of a bachelor
degree program without ﬁnishing it (n=4).while 7% of the relatives

(n=1) ﬁnished a technical or associate degree. One respondent in

99

100

each group ﬁnished a Bachelor degree. Two of the relatives had
Master. or PhD degree. and one of the consumers had a Masters
degree. A tabulation for each individual educational level is
displayed in Table D-2 in Appendix D .

3211mm Thirty-eight of the subjects indicated some
religious afﬁliation. Only four subjects indicated affiliation with any
religious group. Some of those affiliated to religious groups indicated
been affiliated to more than one group. Therefore the following
distribution of religious denominations was found: 22 Catholics. 13
Pentecostals. 2 Christians/no denomination. 2 Methodists. 2
Adventists. and 7 Spiritists.

W The largest percent of people in both groups
reported being married; 16 consumers and 12 relatives (51% and
80% respectively). Among the 31 consumers: (a) six (19%) were
single. (b) seven (23%) divorced; (d) one (3%) was a widow. and (e)
one (3%) was in a consensual union. In the group of 15 relatives. (a)
two (13%) were divorced, and one (7%) reported being a widow.

929112311931 Thirteen of the ﬁfteen consumers (87%) were not
working for proﬁt. However they do not consider themselves

unemployed. because they were: (a) housewifes (n: 10 . 67%). (b)

101

retired (n=2. 13%). and/or (c) involved in voluntary work (n=1,
7%). N0 (13%) reported being involved in other types of jobs (i.e..
salesman).

A similar situation was found among the consumers. In this
group 87% (n=27) reported being unemployed. not seeking a job.
being housewifes. retired. or involved in voluntary work. Also. one
subject reported being unemployed seeking a job. another (3%) was
employed in a sheltered workshop. and two (7%) reported that they
have other types of job (i.e. .artisan). A tabulation of the data for each
category is displayed in table D3 in Appendix D.

The fact that most of the members of the mutual-help groups
(consumers and relatives) are voluntarily unemployed has to be
related to the fact that the meetings of the groups in the study. are
held before noon and during weekdays. This restricted the
membership in the groups to people who do not have daytime jobs.

Wing. Most of the consumers and relatives reported
living in private houses: 21 consumers (68%) were living in houses.
and 13 relatives (87%). Three consumers (6%) were living in
apartments. Seven (23%) lived in government public housing

projects. One person (3%) lives in the Independent Housing Project

102

in San German. Within the group of relatives; (a) one respondent
(6.5%) lives in an apartment: and (b) one (6.5%) lives in a public
housing project of the government.

WM. Not many subjects were living alone
among the relatives or consumers. Only four consumers (13%) lived
alone. Among the others. twelve (39%) lived with only one person.
(c) four (13%) lived with two. ((1) four (13%) lived with three. (e)
two (6%) lived with four. (0 three (10%) lived with ﬁve persons. (g)
one (3%) lived with ten persons. and (h) one (3%) lived with 45
persons.

Among the relatives. only one person (6.6%) was living alone.
Seven (47%) members were living only with one person. Four
subjects lived with two. three. four or ﬁve respectively. and three
(20%) lived with six persons.

Most of the subjects lived with relatives. A higher number of
them lived with wifes or husbands (48% consumers and 80%
relatives). Forty percent of the relatives and 19% of the consumers
lived with sons and daughters. Table D4 in Appendix D displays the

tabulation of members of the family living with the respondents.

1 03
mm Two questions were used to identify if the subject's

family was nuclear or extended. If the subject responded that
his/her family involved more than nine members. and that it
includes members other than the nuclear family«parents and
siblings« the respondent's family was coded as an extended family.
Twenty-six subjects had extended families.

W. Each respondent was asked if he/she
received economic support from a list of possible sources of
income. The highest percentage of the respondents was receiving
social security income. The percentage of people who received

support from each source is tabulated in the following table.

 

 

Table 13
r n r f n

Respondents

Sources of Income Relatives Consumer
N % N %

Salary 2 13% 4 1 3%
Social Security 10 67% 13 42%
Food coupons 2 13% l 1 3 5%
Social services « 2 6%
Family support 2 13% 8 26%
Vocational rehab. 1 7% 1 3%
Unemployment checks « «
Alimony « «
Disabled insurance « 2 6%
Retirement beneﬁts « 4 1 3%
Other sources 5 33% 3 1 0%

 

104

The amount of money that each respondent was receiving

monthly from each source was added to get the approximate
monthly income of the subject. The monthly income of the
consumers ranges from 0 to $600. The monthly income of the
relatives ranges from 0 to $1,700. The following table summarizes

this information.

 

 

Table 14

WW

Subjects N %

Consumers
Nothing 2 7%
less than $100 5 16%
$101 to 250 1 3%
$251 to 399 10 32%
$400 to 549 8 26%
$550 to 700 4 13%
$735 1 3%

Relatives
Nothing 1 7%
$100 to 249 3 20%
$250 to 399 2 13%
$400 to 549 1 7%
$550 to 700 2 13%
$949 to 1.247 2 13%
$1,326 to 1.530 2 13%
$1.530 to 1.560 2 13%
$1,700 1 7%

 

1 05
Needs of Consumers

An open-ended question gave the consumers the
opportunity to express the things that they needed. Each
individual item mentioned by each subject was translated into
English. After this. all the responses went through content
analysis. A list of needs was generated including things as
speciﬁc as "a sewing machine". and abstract as "to be in God's
grace". Table 15 displays the list of needs and the frequencies
with which they were mentioned. The list of needs have been
divided according to general topics. The needs mentioned with
higher frequencies concerned the following topics: (a)
transportation. (b) economic help. (c) physical help. ((1) housing.
(e) a job. (i) medicine. and (g) good family relationships. Also
many of them reported that what they need the most was not to
be discriminated against in the community. which can be

interpreted as not to be stigmatized.

106

Table 15
h n m r

 

 

Needs N %
Economic matters ,

1. Economic support 5 16%

2. Transportation 4 1 3%

3. Savings 1 3%

4. Clothing 1 3%

6. A sewing machine 1 3%
Employment

1. A job 9 29%
Education

2. Tl’aining for the relatives 1 3%
Housing

1. Housing 5 1 6%
Social relationships

1. Friends 1 3%

2. A companion 2 39%

3. Good neighbors I 3%
Health issues

1. Going to the doctor 1 3%

2. Medicine 4 1 3%

3. Physical health 8 26%
Personal goals

1. Independence 1 3%

2. Not to be discriminated against 10 32%

3. TYust in the mental health services 2 6%

4. To live in God's grace 2 6%
Group goals

1. A club house for the consumers 1 3%
Family issues

1. Good family relationships 6 1 3%
Activities

1 . Pastime or recreational activities 1 3%

 

107

A list of potential needs was read to each subject. to collect

his/her rating of importance of the item. Many of the needs in the
list were also mentioned as responses to the open-ended question
by the subjects. Most of the respondents rated many of the items as
extremely and / or very important. The percentages of ratings of each
item as very and extremely important were added to identify the
items considered as most important with the highest frequencies.
The items rated most important are: (a) to be physical healthy. (b) to
feel support from the staff. (c) to have his/her family get involved in
his/her activities. ((1) to have opportunities to meet other people. (e)
to have positive family relationships. (f) to have religious beliefs. (g)
to have emotional health. (h) to feel that you are useful. and (i) to
have access to mental health services. Table 16 displays the mean

ratings of importance of the items.

 

 

Table 16
Weeds
lmportancea
Items 1 2 3 4
1. Be employed 10% 1 3% 27% 50%
2. Have housing 3% 10% 77%
3. Participate in recreational activities 7% 3% 29% 61%
4. Have access to mental health services 3% 23% 74%
5. Feel support from the staff 16% 84%
6. Receive academic education 13% 13% 30% 43%
7. Receive informal education 3% 7% 35% 55%
8. Family get involved in your activities 3% 3% 26% 68%
9. ‘ Participate actively in community 3% 16% 26% 55%
matters
10. Have opportunities to meet other 6% 23% 71%
people
1 1. Participate in religious activities 3% 23% 74%
12. Have a positive (good) and stable 6% 94%
relationship with your family
13. Have opportunity to interact (to be) 6% 6% 29% 59%
with youngsters
14. Have opportunity to teach others what7 % 10% 26% 58%
you know
15. Feel and receive support from your 3% 7% 32% 58%
neighbors
16. To have religious beliefs 3% 16% 81%
17. To be physically healthy 100%
18. To have "emotional" health 10% 90%
19. To feel that you are useful 10% 90%

 

a The options used were; 1=not important; 2=not too important:
3=fairly important; and 4=extremely important.

As was seen in the tables above. a high number of subjects

mentioned the needs of employment. physical health. and positive

109

family relationships. Those three needs were also rated among the
most important needs. Other items that were frequently considered
as extremely important are discussed in light of the subjects'
responses to situational variables and to the rating of satisfaction with

each need. within the discussion section.

A 1 to 4 Likert scale of satisfaction was used to assess the
subjects' satisfaction with each item in the list of needs. It is
important to keep in mind that if the subjects did not have the item
but felt satisﬁed not having it. he/ she was instructed to report
satisfaction. In the same way. if the subject had the item but felt that
it needed to be improved. he/she was expected to express
dissatisfaction. This information provided a view of which of these
things the subjects need or want to change. and at the same time
reﬂected how strong their satisfaction was. The percentage of
responses in the very dissatisﬁed and the dissatisﬁed categories for
each item were added to identify items with which the subjects were
most dissatisﬁed. The items rated as sources of dissatisfaction were
employment. academic education, family involvement. opportunity to
interact with youngsters. opportunity to teach others. physical

health. and emotional health. Table 17 displays the subjects ratings

110

of satisfaction with each item or need.

Table 17

WW

 

Satisfactiona

Items 1 2 3 4

1. Your employment 23% 30% 20% 27%

2. Your housing arrangement 1 6% 3% 32% 48%

3. Your participation in recreational 13% 13% 52% 23%
activities

4. Your access to mental health services 6% 10% 26% 58%

5. The support you receive from the 13% 26% 61%
mental health staff

6. Your academic education 6% 36% 32% 26%

7. Your informal education] "hobbies" 26% 42% 32%

8. The involvement of your family in 10% 22% 42% 26%
your activities

9. Your participation in community 10% 6% 52% 32%
matters

10. Your opportunities to meet other 3% 23% 39% 35%
people

1 1. Your participation in religious 3% 23% 29% 45%
activities

12. Your relationship with your family 1 0% 3% 35% 52%

13. The opportunities to interact with 7% 23% 35% 35%
youngsters

14. The support you receive from your 14% 10% 35% 4 1%
neighbors

15. Your opportunities to teach others 13% 20% 37% 30%
what you know

16. Your religious beliefs 3% 3% 29% 65%

17. Your physical health 26% 19% 19% 36%

18. Your emotional health 23% 29% 29% 19%

19. Your sense of how useful you are 3% 23% 32% 42%

 

a The options were coded as: 1=VD; 2=D 3: FS; and 4=VS.

1 1 1

W

The relatives reported fewer needs than the consumers in
response to the open-ended question. The needs mentioned by the
highest number of relatives were; physical health. and good family
relationships. Other needs mentioned were economic support.
training for the relatives. trust in the mental health services. and a
club house for consumers. The following table reports the

frequencies corresponding to each need.

Table 18
Writes.

 

Needs N %
1. Economic support 2 1 3%
2. Training for the relatives 1 7%
3. Physical health 4 27%
4. Trust in the mental health services 2 13%
5. A club house for the consumers 1 7%
6. Good family relationships 4 27%
7. The mental health of the consumer 2 13%

The relatives rated the importance of the needs in a list. using a

1 to 4 Likert scale. Table 19 presents those ratings. According to

that information. the relatives considered the most important

112

needs: the staff support. positive family relationships. opportunities

to teach others. religious beliefs, physical health. emotional health.

and feeling useful.

 

 

Table 19
l v ' n f
Importancea

Items 1 2 3 4

1. Be employed 20% 20% 13% 47 %

2. Have housing 13% 87%

3. Participate in recreational 7% 40% 53%
activities

4. Have access to mental health services7% 20% 13% 60%

5. Feel support from the staff 13% 87%

6. Receive academic education 27% 19% 27% 27%

7. Receive informal education 7% 13% 73% 7%

8. Family get involved in your activities 7% 40% 53%

9. Participate actively in community 7% 7% 40% 46%
matters

10. Have opportunities to meet others 7% 33% 60%

1 1. Participate in religious activities 7% 33% 60%

12. Have a positive (good) and stable 100%
relationship with your family

13. Have opportunity to interact 20% 14% 33% 33%
(to be) with youngsters

14. Have opportunity to teach others 47% 53%
what you know

15. Feel and receive support from your 7% 7% 33% 53%
neighbors

16. To have religious beliefs 27% 73%

1 7. To be physically healthy 100%

18. To have good"emotional" health 13% 87%

19. To feel that you are useful 100%

 

a The options were coded as: 1=N I;2=NTI;3=FI: and 4=EI.

113

The respondents also rated their satisfaction with each of the
Only a few subjects reported dissatisfaction with items (Table 20 ).

When the ratings of very dissatisﬁed and dissatisﬁed for each item
were combined. the items with which they reported more
dissatisfaction (although with moderate frequencies) were:
recreational activities. access to the services. family involvement.
participation in community matters. family relationships.
opportunities to interact with youngsters. opportunities to meet

others. and support from the neighbors.

114

Table 20

 

 

l v ' i
Satisfactiona
Items 1 2 3 4
1 Your employment 7% 40% 53%
2. Your housing 13% 34% 53%
3. Your participation in recreational 27% 60% 1 3%
4 Your access to mental health 27% 33% 40%
services
5. The support you receive from the 13% 27% 60%
mental health staff
6. Your academic education 13% 13% 27% 47 %
7. Your informal education 14% 7% 65% 1 4%
8 The involvement of your family 33% 27% 40%
in your activities
9. Your participation in community 27% 40% 33%
matters
10. Your opportunities to meet other 7% 20% 53% 20%
people
11. Your participation in religious 13% 47% 40%
activities
12. Your relationship with your family 27 % 1 3% 60%
13. The opportunities to interact with 27% 33% 40%
youngsters
14. The support you receive from your 7% 29% 35% 29%
neighbors
15. The opportunities to teach others 13% 47% 40%
what you know
16. Your religious beliefs 7% 33% 60%
17. Your physical health 7% 13% 47% 33%
18. Your "emotional" health. 13% 73% 13%
19. Your sense of how useful you are 2 1% 36% 43%

 

a The options were coded as; 1=VD: 2=D;3=FS; and 4=VS.

115

W

The list of needs also was used to ask the subjects about the areas
the group could help them in. The following table presents the
frequencies in which the subjects indicated that they would like to
be helped by the groups. The section of the interview that gathered

the information can be seen in the instrument in Appendix F.

 

 

Table 21
m with which e wan hel
Consumers Relatives
Items N N
I. Find employment 1 7 3
2. Find housing 1 0 3
3. Recreational activities 27 8
4. Receive mental health services 26 1 1
5. Obtain support from mental 27 l 1
health
6. Obtain academic education 19 4
7. Obtain informal education 29 12
8. Family involvement 22 8
9. Participate in community 28 1 0
activities

10. Opportunity to meet other people29 1 2
1 1. Participate in religious activities 25 9
12. Positive family relationships 27 10
13. Interaction with youngsters 28 8
14. Opportunity to teach others 26 10
15. Obtain support from neighbors 25 7
16. Have religious beliefs 2O 6
17. Be physically healthy 25 9
18. Have mental "emotional" health 27 9

19. Feel useful 29 g +_ 14

116

The data from the consumers indicated that they are mainly
interested in being helped by the group in the areas of recreational

activities. mental health services. support from the mental health
services staﬁ‘. informal education. community activities.
opportunities to meet other people. positive family relationships.
opportunities to interact with youngsters. mental health. and
feeling useful.

The relatives were mainly interested in being helped by the group
in feeling useful, receiving mental health services. obtaining support
from the mental health staff. obtaining informal education.
participating in community activities. meeting other people. having
positive family relationships. and teaching others what they know.
W

The previous section described situational variables of relatives
and consumers of mental health services in mutual help groups in
Puerto Rico. and their responses to questions about their needs. The
following paragraphs summarize this information.

All the subjects had some formal education. Their education
levels ranged from fourth grade to a PhD. Only one consumer and

one relative reported being unemployed and seeking a job. The rest

117

were mainly retired. involved in voluntary jobs. and/ or housewives.

When their income was assessed it was found that most of the
consumers and relatives were receiving social security checks. With
the exception of three subjects who indicated that they did not
receive any income; the monthly income ﬂuctuated between less
than $100 to $735 for the consumers. and between $100 to $1,700
for the relatives.

A high percentage of subjects in both groups were married ( 51%
of the consumers and 80% of the relatives). Only four consumers
and one relative indicated that they lived alone. Most of the subjects
lived with relatives (n=39). mainly wives and/ or husbands.

In response to a question about their needs. the consumers most
frequently mentioned needs of (a) transportation. (b) economic
support. (c) housing. (d) a job. (e) medicines; (1) good family
relationships. and (g) physical help. They also indicated frequently
that they did not want to be discriminated against.

The relatives mentioned needs of (a) economic support. (b)
training. (c) physical help. (d) trust in the mental health services. (e)

a club house for the consumers. and (f) good family relationships.

118

They also mentioned that they need the mental health of their
relative.

A list of needs was used to record the importance and
satisfaction of the subjects. Table 22 displays the needs that were
rated as important most frequently. by consumers and the ones rated

in that way by the relatives.

Table22
' 0‘0‘1'1'0. . 1m” -_- 0 01, 11' 40.

 

Items

 

Consumers
To be physically healthy
Have a positive (good) and stable relationship with your family
To have good "emotional" mental health
To feel useful
Feel support from the staff
To have religious beliefs
Have access to mental health services
Have opportunities to meet other people
Family get involved in your activities

99°39’92“???

Relatives
To be physically healthy
Have a positive (good) and stable relationship with your family
To feel that you are useful
To have good "emotional" mental health
Feel support from the staff
To have religious beliefs
Family get involved in your activities
Have opportunity to teach others what you know

‘90.“99‘99392“

 

119

From the subjects' ratings of satisfaction with each of the
items on section P-20 of the questionnaire. the ones to which they

expressed less satisfaction were identiﬁed and are summarized in

Table 23.

Table23
11‘. ‘ ._ f rfo 01'111V_r'_-.-'-_I_‘

 

Items
Consumers
Your employment
Your "emotional" (mental) health
Your physical health
Your academic education
Your opportunities to meet other people
The involvement of your family in your activities
The opportunities to teach others what you know

NPP‘PP’P!‘

 

Relatives
The support you receive form your neighbors
The involvement of your family in your activities
Your participation in recreational activities
Your access to mental health services
Your participation in community matters
Yours opportunities to meet other people
Your relationship with your family
Your opportunities to interact with youngsters
Your academic education

5098999599?

k

i

The results and some implications of the ﬁndings about needs

are explained in the next chapter.

120

52W

One section of the interview was used to assess the relative and
consumer's participation in the mutual help groups. A description of
that information is provided in the following subsections.

W. The number of months that
the relatives had been in the group varied from 3 to 60 months
(M=27). Twelve of the 15 relatives had been in the group for one
year or more.

In the group of consumers. the months in the groups varied
from less than 1 month to 96 months (121531). Wenty four of the
consumers had being in the group one year or longer.

W Twelve of the 15 relatives (80%)
indicated that they always attended the meetings. while the other
three (20%) indicated that they almost always attended the
meetings.

Among the consumers n=17 (55%) reported that they attended
always and n=14 (45%) indicated that they attended almost always.

W. In this section of the interview an
open-ended question was used to ask each subject his/her

responsibilities in the group. A tabulation of the frequency with

121

which each responsibility was mentioned is displayed in Table D-5 in

Appendix D .
W All the subjects were asked if they had

any relatives participating in the groups. Three consumers reported
that their wives were members of their groups. Four other
consumers reported that they had. the mother. a daughter. a son.
or a husband in the group.

In the group of relatives. only three respondents indicated the
presence of a member of their family in their respective groups. In
all cases. it was the wife.

W The consumers listed the
things that they liked best about the groups and include: the
meetings. the opportunity to help the community. the therapy. the
harmony. the good fellowship. the sharing of experiences. the
relationship with the staff, the learning experiences. activities. the
unity. the mutual help. the chances to speak. and sewing classes.
The ones mentioned with higher frequencies were. the good
fellowship. and the sharing of experiences. The things that the
relatives liked best were: the meetings. the opportunity to help the

community. the therapy. the harmony, the sharing of

122

experiences.the learning experiences. the unity. the mutual help.
the chances to speak. and the improvement in the communication
with the institution. None of these were mentioned by more than
two subjects among the relatives.

The things that the consumers liked least were. poor attendance
to the meetings and conﬂicts between the members. Other things
that they did not liked. but mentioned infrequently were. poor
punctuality. disorganized meetings. lack of economic support for the
group. arguments. lack of original ideas. not owning a place for the
meetings. discussion of political issues. discussion of religious ideas.
and lack of youngsters. The relatives liked least the poor attendance
to the meetings and also reported their dislike of the number of
members in the group. disorganized meetings. the coordinator«in
only 1 case«. the members' apathy. and lack of original ideas.
Winn:

The main objective in the assessment of structure of the groups
was to explore how much control the members perceived that they
had over their groups. This section of the interview asked (a) who
was the most inﬂuential member. (b) who was the group leader. and

(c) who were the members of the directive.

123

The percentage of positions in the directive occupied by the
coordinator. a consumer. or a relative. was computed from the
responses. This information cannot be used to compare number of
relatives in leadearship positions as reported by consumers. and/ or
the inverse situation. because there were groups including
consumers and relatives and groups including only one type of
members. However. it is possible to describe the leadership roles of
the coordinators because all the groups had at least one (See Table
D-6 in Appendix D).

The data from the relatives showed that in 40% of the cases.
roles in the directive were played by relatives. while in 23% were
performed by consumers. None of the relatives indicated that the
coordinator performed any role in the directive. However. it is
important to see that the data reﬂected that the person they
nominated most frequently as the most inﬂuential. was the
coordinator (27%). Also. 20% of the relatives mentioned the
coordinator as the leader of the groups. These two facts indicated
that even when the coordinator is not allowed to perform any official

role in the directive. he/she may have strong inﬂuence in some of

1 24
the groups.

The data from the consumers showed that in 52% of the cases
roles in the directive were performed by themselves. while 4% of
the roles were performed by relatives. and .75% by the coordinators.

The coordinator was included by the consumers in the categories of
most inﬂuential and group leader. but not with the highest
percentage. This time the coordinator got the same percentage of
responses as the consumer in the item about who is the most
inﬂuential. Both received 29% of the responses as most inﬂuential.

The consumers reported that 71% of the group leaders were
consumers. 10% relatives. and 6% coordinators.

The subjects also listed the responsibilities of the coordinators of
the groups. Most of the responsibilities listed involved the tasks
required for the group maintenence and making the decisions in the
group. Table D-7 in Appendix D displays the lists of responsibilities
of the coordinators.

WW5
The main purpose of the study was the description of needs. but
at the same time information about the attitudes. and the structure of

the goups was used to explored seven hypotheses.

1 25
W1.

This hypothesis stated that there was going be a positive
correlation between traditional family beliefs and the need of positive
relationships with the family.

The variables used in the analysis of the hypothesis were (a) the
need of good family relationships reported as a response to the
open-ended question about needs. and (b) the scores in the
traditional family beliefs scale. The mean scores and standard
deviations of two groups on the traditional family beliefs scale were
compared with the t-test. for separate variance. Table 24 displays

the means and standard deviations compared in the analysis.

 

 

Table 24
I'OOU 1'2. 1 Q 1119-. 9. 9-“: 011011 - 2.0.1.011: f 9'. f
scale
T Groups
Information Aa Bb
Number of subjects 6 36
Mean 18.3 20
Standard deviation 5.27 6.44

h

a The A group included the subjects who reported a need of good
family relationships.

b Group B involves those who did not expressed a need of good
family relationships.

126

The null hypothesis was that there was not a positive correlation

between the traditional family beliefs and the need of positive
relationships with the family.

A t-test was performed to determine whether or not the means
diﬁ'er so much that the samples were unlikely to be drawn from the
same population. The computation came up with a t value of -.69
with 8 degrees of freedom and a two-tail probability of .5. Therefore,
the null hypothesis was not rejected.

Correlations between trasditional family beliefs and the
respondents' ratings of importance and satisfaction with the family
relationships. and with the family involvement in their activities
were analyzed and showed to be non-signiﬁcant. A positive
correlation was found between ratings of satisfaction with family
involvement in the respondent's activities and satisfaction with the
family relationships.

Hypothesis 2

A positive relationship between traditional sex roles and the

number of males in position of power was stated as a hypothesis.
Position of power was deﬁned as being the leader. the most

inﬂuential in the group. or a member in the directive. The

127

proportion of positions of power ﬁlled by males was computed for
each group. The proportion of positions of power were correlated
with the mean scores of the groups on traditional women beliefs.
This could be done because that scale included items about
traditional beliefs about the man and the woman (see section about
traditional sex roles in the results section). The null hypothesis was
that there was not a positive correlation between traditional sex roles
and number of males in position of power.
The Pearson correlation coefﬁcient was .39 and was not

signiﬁcant at .05 or .01 probability levels.
W

This hypothesis stated that there was going to be a positive
relationship between external locus of control and groups
dependence on the mental health centers. The group's
dependence on the mental health centers was measured with the
creation of a new variable called "coordinator control of the group".
EVery subject received a score of l in the variable if he/ she
mentioned any of the items on table 26 in response to the open-

ended question about the coordinator responsibilities. If the subject

128

did not mentioned any of those things as part of the coordinator
responsibilities he/ she scored a 2. In this way. the group was split
into two groups according to coordinator control; the ﬁrst one

including 17 cases and the second group with 22.

Table25
m min n rintr 11 If

 

Coordinator responsibilities

 

Conducts the meetings

Makes the decisions

Runs the groups

Finds the place for the meetings
Finds materials needed

Finds transportation for the group
Ends the meeting

Checks the punctuality

PNP’P‘PP’P!‘

A T-test was performed to compare the mean scores on the

external locus of control scale of subjects in both groups. The
separate variance estimate lead to a T value of -1.39. with 35 degrees
of freedom and a two- tail probability of .173. Therefore. the null
hypothesis was not rejected.

Wu

The fourth hypothesis was that male members with traditional

129

sex roles were going to express a higher need of employment than
women.

The traditional women's beliefs scale was used as the measure of
traditional sex roles. The presence or absence of the need of a job in
the subjects responses to the open—ended question about needs was
used as the other variable.

Analysis of variance was used to test differences between the
means of the groups of scores for women and men. The following
table presents the mean score on traditional women's beliefs for each

cell in the ANOVA.

Table 26.
Mean score on traditional women's beliefs used in the ANOVA

 

Need of a job

 

Sex Yes No
Females 37.80 (n=5) 38.21 (n=19)
Males 38.25 (n=4) 40.21 (n=14)

 

The following table displays the analysis of variance.

130

Table 27
W.

 

Source Sum of squares Df Mean squares F Sig.F
A =Sex 28.09 1 28.10 1.06 .31
B =Need job 8.47 1 8.47 .32 .58
A/B 4.21 1 4.21 .16 .70
Explained 40.77 3 13.59 .51 .68
Residual 1007.07 38 26.50
Total 1047.83 41 25.56

A*

As the previous table showed. neither the sex nor the need of a

job reﬂected a relationship with the traditional sex roles of the men
or women.
1135129135115

This last hypothesis stated that there was going to be a positive
relationship between religiosity and external locus of control.

The scores in the external locus of control scale were correlated
with the scales on the religiosity scale. A Pearson correlation
coefﬁcient of -.08 was found for an N of 39 and a signiﬁcance level of
.62. Therefore. the null hypothesis could not be rejected.
W

It was expected that believers in the "espiritismo" would be

found within the mutual help groups. Seven of the 42 participants

131

reported that they believe in the "espiritismo" . A hypothesis was
stated saying that there was going to be a positive relationship
between believers in "espiritismo" and members desire for
independence from the mental health centers. All the subjects
(N=42) reported that they wanted to remain involved with the
mental health centers. which made it impossible to compare
spiritists and non-spiritist in their plans concerning the mental
health centers.

The reasons why they wanted to remain involved with the

mental health centers are listed in the following table.

 

 

Table 28
i v 1v wi I 1

Reasons Frequency
1. Friendship 4
2. To get medicines 3
3. Trust in the mental health center 12
4. Is part of the treatment 3
5. Have mentally ill relatives 6
6. Believe in the mutual-help 4
7. Is a learning experience 1
8. To help the center 2
9. To help other clients 5
10. As a pastime 1
1 l. Follow-up to a case in court 1
12. To help the community 2
13. To feel responsible 1
14. Afraid of a reversal of the illness 1

 

132

The reason to remain involved with the mental health center that
was mentioned most frequently was: (a) trust in the mental health

center. (b) have mentally ill relatives.and (c) to help other clients.
W

This hypothesis stated that there was going to be a positive
relationship between religiosity and interest in group participation in
religious activities.

It was originally planned to conduct a T-test comparing the mean
scores of religiosity of those who express interest in group
participation in religious activities and those who do not. The
interest in group participation in religious activities was collected as
one of the responses to the open-ended question asking the subjects
in what activities of the community they would like the group to be
involved. However. due to the small sample size only one member
suggested that the groups should be involved in religious activities.
This fact eliminated the possibility of analyzing this hypothesis.

The following table presents the list of activities in the

community in which the subjects wanted the groups to be involved.

133

 

 

Table 29
r vi i b h m
Activities Frequency
1. Spreading information about the group 8
2. Recruiting people 3
3. Religious activities 1
4. Find economic support for the center 2
5. Designing new ways to help clients 3
6. Spreading information about mental illness 5
7. Visiting schools 1
8. Recreational activities 4
9. Visiting mentally ill 4
10. Creating new groups 3
1 1. Activities with youngsters l
12. Development of manual skills 1
13. Vocational training 1
1

14. Voluntary services to the community

 

This information revealed that the members were to be

interested mainly in spreading information about the groups and
about mental illness.
Sumerian:

The study proposed the evaluation of seven hypothesis. Two of
them were: the relationship between believers in "espiritismo" and
mutual help groups' members desire of independence from the
mental health centers. and the relationship between religiosity and
interest in group participation in religious activities. These two

hypothesis were not analyzed due to lack of variance in the

134

responses to some of the variables. All the subjects reported that
they planned to remain involved with the mental health centers. and
only one member suggested that the groups should participate in
religious activities.

The T-test was used to examine the relationship between
traditional family beliefs and the need of positive relationships with
the family, and the relationship between external locus of control
and groups' dependence on the mental health centers. In none of
these cases were the results of the analysis signiﬁcant.

It was expected that males believing in traditional sex roles were
going to express higher need of employment than women. However.
the analysis of variance did not reﬂect a relationship between either
sex or need of employment and the traditional sex roles.

The relationship between traditional sex roles and number of
males in position of power. and the relationship between religiosity
and external locus of control were tested with the Pearson
correlation coefﬁcients. In both cases the correlation coefﬁcients

were not signiﬁcant.

CHAPTER 4
DISCUSSION

The purpose of the study was to assess the needs of consumers
and relatives of consumers of mental health services participating in
mutual help groups in Puerto Rico. As part of the study. the subjects'
attitudes about traditional family beliefs. sex roles. locus of control.
and religiosity were assessed. This was done to explore possible
relationships between the needs and the attitudes that could provide
information for future studies of culturally-based needs of Puerto
Rican consumers of mental health services. Forty-two members of
10 mutual help groups in Puerto Rico participated in the study. They
were all individually interviewed with close and open-ended
questions about the needs. the group. and their attitudes.

The demographic characteristics of the members of mutual help
groups included in this sample are summarized in the following
aspects.

1. The members of mutual help groups in this study were older
than the typical consumers of mental health services and their
relatives in Puerto Rico-~considered to be adolescents and young

adults (Alvarez. 1980; Morales et al.. 1985; Oﬁcina de

135

136

Investigaciones. November. 1986). Most of the subjects in this study
were adults over 36 years old.

2. Nenty-four females and 18 males formed the sample. Four
females were both relatives and consumers of mental health services
and so were included in both groups. Therefore. eight females and
seven males were relatives. and 20 females and 11 males formed the
group of consumers.

3. All the consumers and relatives in the study had formal
education. This was another difference between the subjects of this
study and previous descriptions of consumers and relatives (Alvarez.
1981; Oﬁcina de Investigaciones. November. 1986).

4. With the exception of three subjects who indicated that they
did not receive any income. the monthly income ﬂuctuated between
less than $100 to $753 for the consumers. and $100 to $1,700 for
the relatives. According to recent statistics. the income of most of
these subjects classiﬁed them within the poverty level«$500 or less
monthly ("En la miseria un tercio de la poblacién." 1988).

5. Only. one consumer and one relative reported being

unemployed and seeking a job. The rest were mainly retired.

137

involved in voluntary jobs. and/ or housewives.

6. A large percentage of subjects in both groups were married
(51% of the consumers and 80% of the relatives). Only four
consumers and one relative indicated that they lived alone. Most of
the subjects lived with relatives. mainly wives and / or husbands.

7. A large number of consumers and relatives reported living
in private houses (68% of the consumers and 87% of the relatives).
Among the rest of the other subjects. none mentioned a housing
problem. other than some of them do not like their neighborhoods
and / or neighbors.

Attitudes

Four scales were used to assess the atitudes of the subjects.
haditional family beliefs were assessed with a scale of six items in a
1 to 5 Likert format. and with a reliability coefﬁcient (Alpha) of .83.
The maximum and minimum possible scores were 30 and 5. The
mean and standard deviation of the sample were 20 and 6
respectively. The subjects scored high in traditional family beliefs.
This preliminary ﬁndings indicated that the members of the mutual
help groups agree with traditional family beliefs, which is important

because it had been stated previously that the beliefs about the family

138

should be studied within different groups in the Puerto Rican society.
This ﬁnding also supports another argument that can be used by
those trying to clarify if Puerto Ricans adhere to traditional Hispanic
beliefs (Bird & Canino. 1978; Canino. 1978; Mizio, 1974: Ramos.
1985; Rendom. 1974; Teichner. Cadden 81 Berry. 1981). More
exhaustive studies of the traditional family beliefs of members in
mutual help groups should involve a bigger sample. use scales about
the traditional family beliefs. collect demographic information and
observe and assess the subjects' families. It will provide information
to study their family beliefs and compare them with their family
structure. At the same time. it will provide information to study
family beliefs and structure according to demographic
characteristics. Some of these suggestions will be discussed in the
section on new directions for mutual help groups in Puerto Rico.
The subjects' attitudes concerning the traditional sex roles were
studied with a Likert scale including eleven items with a reliability
coefﬁcient (Alpha) of .50. The maximum and minimum possible
scores were 55 and 1 1. The mean score was 39 and the standard
deviation was ﬁve. According to these results. the members of

mutual help groups had traditional beliefs about the sex roles. There

139

was not a large variation among the scores. which may be due to the
fact that the subjects seem to have similar backgrounds and
demographic characteristics. Unfortunately. the sample size was not
big enough to allow the analysis of these beliefs according to
demographic characteristics. These attitudes of the members of
mutual help groups should be studied further. Suggestions on how
to apply these ﬁndings for the future of the mutual help groups are
discussed in following sections of this study. Studies with a bigger
sample should ask the subjects to describe themselves in term of
their role and to describe their ideals and stereotypes of the Puerto
Rican male and female. because this will provide information on the
behavioral component of their beliefs.

Another scale with a reliability coefﬁcient (Alpha) of .42 was
used to assess the subjects' locus of control. The items were
combined in terms of the subjects external locus of control. The
highest and lowest possible scores in the scale were 4 and 8 and the
responses ﬂuctuated between those values. The mean was 6 and the
standard deviation was 1. The method used to assess the attitudes

concerning the locus of control did not prove to be the most

140

efﬁcient. It is suggested that the locus of control of the members of
mutual help groups should be measured with the design of day-to-
day scenarios concerning different situations (e.g.. illness. family
relationships. employment. enviromental phenomenon. group
misunderstandings and others) to which the subjects could react
and explain making their attributions. It will be even more speciﬁc
than studies that have examined subjects attributions concerning
failure and success. stability. expectations. and spiritual ideas
(Rotter.1966; Frank. 1935: Weiner et al.. 1971). This will provide a
more accurate and applicable idea of the members' locus of control
than the method used in this study. because the situations will be
known to the subjects, their reactions will be collected. and
situations concerning group issues may be presented. This last point
can become an educational experience for them as well as part of a
problem-solving procedure to increase understanding among the
members and between the members and the mental health system.
The religiosity of the subjects was assessed in a scale with a
reliability coefﬁcient of .59. The mean score for the group was 24.
and the highest and lowest possible scores were 7 and 30. This

fact. and the data showing that 38 of the 42 subjects reported being

141

afﬁliated with a religious group, indicated that the members of
mutual help groups are predominantly religious. Another piece of
information which conﬁrms that is that many of the subjects
reported being afﬁliated with more than one religious group. This
was similar to Bird and Canino (1982) ﬁndings of predominantly
religious families among Puerto Rican families in their study. Bird
and Canino (1982) also found a high percentage of their sample to be
Catholic. a situation that also was found in the present study.

It should be kept in mind that. for the purpose of the study.
"predominantly religious" involves only afﬁliation with a religious
group and beliefs in the value and role of organized religion in
general. Therefore. it might be useful to study the level of
involvement of the subjects in their religious groups. According to
the information found. elements of the adoption of elements of the
GROW groups by the mutual help groups may be beneﬁtial. and
should not present major difficulties.

meters
The relationship between traditional family beliefs and the need
of positive relationships was analyzed with a T-test. The result of

the analysis was not signiﬁcant because subjects who reported a

142

need of positive family relationship have very similar scores in
traditional family beliefs to those of subjects who did not express a
need of positive famly relatinships. A t-test also was used to explore
the relationship between external locus of control and group's
dependence on the mental health centers. The results concerning
this hypothesis were not signiﬁcant.

The analysis of the relationship between traditional sex roles
and higher need of employment in men than in women did not show
signiﬁcant results either. Relationships between sex and need of
employment with traditional sex roles were not found. This may be
related with the education. social class. residential area. and other
characteristics of the members of the mutual help groups. A bigger
sample will be necessary in order to perform that type of analysis.
Other alternative explanations are: (a) weakness in the scale about
traditional sex roles. (b) the fact that many subjects. due to their age
and/or diagnosis considered themselves retired of work or
unemployable. and (c) the possibility that the women in the mutual
help groups may be as oriented toward achievements as sometimes
have been said in generalizations about the Puerto Rican woman

(Christensen. 1979).

143

The Pearson correlation coefficient was computed for
relationships between traditional sex roles and number of males in
positions of power. and religiosity and external locus of control.
Signiﬁcant correlation coefficients were not found in any of these
cases.

Statistical analysis was not performed concerning hypothesis
about the relationship between believers in "espiritismo" and
members' desire of independence from the mental health centers.
All the subjects reported that they want to remain involved with the
mental health centers«even seven of them who believed in
"espiritismo". This represented an inconsistency according to ideas
stated before. concerning the spiritists' rejection of mental health
systems and services (Comas-Diaz. 1981). Alternative explanations
for this are that the most active members of the group may have been
the ones volunteering for the study. and that the degree to which the
believers in the "espiritismo" were involved with spiritist groups was
not assessed. The hypothesis to test the relationship between
members' religiosity and their interest in group involvement in

religious activities was not analyzed. Only one subject indicated

144

interest in group involvement in religious activities.
WW

Previous literature suggested some needs of consumers of
mental health services. These needs were: economic needs (Morales
et al.. 1985; Ribera. 1987); need of new patterns of interpersonal
relationships (Ramirez. 1985): access to the services. employment.
housing. support. recreation. education. training. use of spare time
(Morales et al.. 1985): active participation of family members in the
treatment of the clients (Santiago. 1985); the clients integration into
the community and into their family. and their trust in the
professionals (Morales et al.. 1985).

The relatives were expected to report needs in the following
areas: education. suggestions on how to cope with the consumers.
economic needs. integration into the community. access to the
services. and trust in the professionals.

The present study used an open-ended question about needs.
and items about importance and satisfaction with different possible
needs. to gather information about the needs of consumers and
relatives in mutual help groups. The following sections discuss these

ﬁndings.

1 4 5
W

The needs that were collected in response to the open-ended
question can be summarized as needs concerning the following areas:
economic matters. employment. education. housing. social
relationships. health issues. personal goals. family issues, activities.
and group goals (see Table 15 ). Needs were found in all the areas
that the literature suggested that the consumers of mental health
services will indicate needs (Morales et al.. 1985: Ribera. 1987;
Ramirez. 1985; Santiago. 1985).

The needs included within each category can be seen in terms of
Woodbury's ecological model (Woodbury. 1977). Figure 1 shows how
the needs indicated by the consumers will be located in a
representation of Woodbury's ecological model. It is very promising
to ﬁnd out that most of the needs mentioned by consumers
concerned their societal environment. because it is in that

environment that the mutual help group could have greater impact.

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147

Also it is expected that changes in that environment will afect
issues in other environments. Speciﬁc objectives. and procedures
could be designed for and with the groups. addressing each of these
needs. The section on new directions for the mutual help groups
provides examples of this suggestion.

Among the needs indicated by the subjects the ones mentioned
with higher frequency by the consumers were: transportation.
economic support. housing. a job. medicine. good family
relationships. and physical health. It is reasonable to ﬁnd a need of
economic support because most of the subjects were in a poverty
level of income. The other two needs that can be considered as part
of economic needs are transportation and housing. However. the
need of housing was not seen as an urgency because many of the
subjects lived in private houses. and the others lived in apartments.
residential facilities. or public housing. When the consumers' ratings
of satisfaction with different items were inspected. the ones with
which they showed less satisfaction and/ or dissatisfaction were:
employment. academic education. involvement of the family in the
consumer's activities, opportunities to meet other people.

opportunities to teach. physical health. and emotional health.

148

When these sources of dissatisfaction were compared with
frequent responses to the open-ended questions. it was found that
employment. concerns related to the consumer's family. and physical
health were brought up frequently in both sections. This suggests
that. when they answered the open-ended question they could have
been remembering those things with which they felt dissatisﬁed.
Interestingly. some of these needs and sources were frequently rated
as the most important ones for the consumers. This was the case
with concerns about the consumer's family and physical health. It
is important to understand that physical health does not include
mental illness. and that the subjects referred to mental illness as an
emotional problem ("problema mental o problema emocional").
which is a very common way among the Puerto Ricans to deal with
the taboos and the stigma associated to mental illness. Other things
considered to be very important to the subjects were: to have access
to mental health centers. to feel support from the staff. to have
opportunities to meet other people. to have religious beliefs. to have

good emotional health. and to feel useful.

149

(Seeds Qf the Relatives

The relatives reported needs of economic support. training,
physical health. trust in the mental health services. a club house for
the consumers. good family relationships. and mental health of the
relatives. in the open-ended question. The needs of community
integration and access to the mental health services were the only
ones among those expected to be found. that were not mentioned by
them. However. both things were mentioned later as firings with
which they were dissatisfied.

Figure 2 shows how the needs of the relatives stand within the
ecological model proposed by Woodbury (1977). It is clearly seen
that they reported fewer needs than the consumers. and that most of
their needs concern areas of the societal environment. The mutual
help group could work with those things as part of its objectives and
goals. Examples of how this can be accomplished are discussed in
following sections.

The sources of possible needs with which the relatives reported
less satisfaction were: participation in recreational activities. access

to mental health services. academic education. involvement of the

1 50
family in his/her activities. participation in community matters.

opportunities to meet other people. the relationship with his/her
family. opportunities to interact with youngsters. and the support
from the neighbors. When these responses were compared with the
items that they frequently rated as very important and/ or important.
only two things with which they were dissatisﬁed were mentioned
frequently. These two were. that the family should get involved in
his/her activities and should have a positive (good) and stable
relationship with his/her family.

The role of the family should be studied further because both
relatives and consumers. mentioned issues concerning the family
frequently in their responses to all the sections about needs« open-
ended. importance. and satisfaction. The needs in which the
member wanted to be helped by the groups were identiﬁed in order
to know how much they thought that the groups can intervene in
their lives.

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The consumers indicated frequently that they were mainly
interested in being helped by the group in areas of: recreational

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152

services staff. informal education. community activities.
opportunities to meet other people. positive family relationships.
opportunities to interact with youngsters. mental health. and feeling
useful. The relatives were mainly interested in being helped by the
group in areas of: getting mental health services. feeling useful.
obtaining support from the mental health staff. obtaining informal
education. participating in community activities. meeting other
people, having positive family relationships. and teaching others
what they know. Both groups coincided in their indication that they
want the groups to help them in getting access to mental health
services. support from the mental health services staff. informal
education. participation in community activities. opportunities to
meet other people and getting positive family relationships. The
next section discusses information collected about the groups. that
among other things. will clarify if the members' responses to this
question reﬂected current activities and/or objectives of the groups.
I H l r in
The subjects in the study were members of the mutual help

groups affiliated with the mental health system in Puerto Rico. The

153

following sections discuss the structure of the groups and the
subjects' participation in the group and make suggestions for new
directions for the groups.
W

The assessment of structure of the groups focuses on
identiﬁcation of how much control the members perceived that they
had over their groups. The ﬁndings indicated showed that the
coordinator had strong inﬂuence in most of the groups. The
coordinator was often nominated as most inﬂuential and as the group
leader by both consumers and relatives. Even when the coordinator
is not allowed to occupy any position in the directive two consumers
mentioned the coordinator as treasurer or secretary of the group.
This inﬂuence and also dependence on the coordinators were also
perceived from the responsibilities that the members attributed to
the coordinators. which involves all the different tasks necessary for
group maintenance. but that could be performed by members.

According to Silverman (1987). groups with this type of
dependence on coordinators can not be considered technically as
mutual help groups. because some of the characteristics of formal

mutual help groups are not present. These are that the members

154

should determine all policy. and control all the resources; and that
membership should be limited to people who have the particular
problem with which the group is concerned.

The role of the coordinators should be redeﬁned and many of
these responsibilities taken by the members. One of the basic ideas
implied in mutual help is that members help each other through
knowledge acquired from experiences. The coordinators will be
seen as professionals and the subjects may not learn to trust and
evaluate each other's suggestions, because of reliance on the
professionals to provide them answers. and/ or evaluate the
correctness of what is been discussed or suggested by other
members. This situation will not allow a speciﬁc program of
assistance to evolve from the members' experiences. which is
another characteristic of mutual help groups (Silverman. 1987).
Members' Psr_ti_eipsjien in the Greens

None of the members interviewed had been in the group longer
than ﬁve years. and most of the groups are relatively new«mean of
three years old. With one exeption. the groups had monthly
meetings and the attendance seems to be an issue for many groups.

This was concluded from coordinator's reports and from the

155

subjects' lists of things they liked least. where they included the
poor attendance. It is suggested that the groups increase the
frequency of their meetings and the interaction among the members.
Most of the responsibilities that the subjects indicated that they
had in their groups were: be a member of the directive. spread
information about the group. donate something for the activities. and
request economic donations for the groups. The responsibility to
share experiences was mentioned only by one relative. This made
the groups similar to the voluntary associations discussed by
Silverman (1975). Data about the main activities of the groups
gathered from the coordinators conﬁrmed this idea. Neither the
value of the voluntary groups nor the value of the real mutual help
groups should be underestimated. However. the supportive and
learning experiences of mutual help groups could be more beneﬁcial
to deal with the needs of the members. than just voluntary groups.
Mutual help groups of consumers can be expected to be
succesful because the members frequently mentioned the sharing of
experiences among the things that they liked best. Other things that

they liked included many positive attributes of the internal

156

environment of the group. such as harmony and good fellowship.
The relatives indicated similar things about their groups.

Many of the consumers reported having relatives participating in
their groups. Among the subjects in groups of relatives. only three
subjects reported the presence of a relative in their same group--in
all cases a spouse. There is no evidence of how the mutual help
experience will be affected by having people who experience
different aspects of the problem. but it could be expected that the
groups could be more effective if they are different groups for
consumers and for relatives. The experiences may be shared and
understood more easily. The effect of the composition of the groups
will have to be studied according to the goals and objectives of the
group.

W

The purpose of this section is to present suggestions and
alternatives that the groups may be interested in pursuing. It was
shown previously that the mutual help groups in Puerto Rico did not
adhere to the general characteristics of the mutual help groups. If
the members want to get the beneﬁts of mutual help. some changes

in the groups are necessary. beginning with decreasing and/or

157

eliminating the groups' dependence on the mental health systems
and coordinators. A new relationship between the groups and the
mental health system could evolve in which the mental health system
provides only the technical assistance that the groups request. To
keep a less protective relationship with the mental health system
may be necessary because all the subjects in this study mentioned
that they planned to continue being related to the mental health
center.

The main resources that the groups receive from the mental
health system are: a place for the meetings. some economic support.
and a coordinator. This situation could be changed because:

1. The groups can ﬁnd places for their meetings through
churches. schools. and /or civic associations.

2. The groups do not need large amounts of money to function.
and may be able to get what they need through fund-raising activities
and donations from the industry.

3. The groups may still be eligible to present proposals to the
Auxiliary Secretary of Mental Health for more expensive projects to
beneﬁt consumers of mental health services or for relatives.

4. The technical assistance that the groups may need in terms of

158

training and advice could be sponsored by private companies. civic
organizations. the groups themselves. or the mental health system.

The National Association of Consumers which gathers
representatives of all the mutual help groups could become the
coordinator of the mutual help groups. This core group could set I
general goals with input from the groups. and help the groups to
translate those into speciﬁc objectives according to the needs of the
members.

Members of this core group as well as the group leaders could
be trained on how to guide the members to identify their needs. and
choose the group's priorities. After these stages. each group should
design a plan of action. Examples of these activities are discussed
concerning the needs recorded from the subjects of the study. Most
of the examples apply to both groups «either consumers or relatives.
Table 30 displays the needs concerning societal and external

environments and examples of activities of the groups can conduct.

Table 30

..g,_19‘0°09.V1,‘ o

159

ON 1‘ ‘ 1‘. r“!

 

Needs

1. minimalist:
-economic support
-housing
-savings
-food
-transportation

-employment

2. W
-family involvement

-positive family relationships

3. Eduction
-continue studying
~training for relatives

Activities 4

-Organize themselves into small
business getting the training that
will be necessary

-Approach potential employers of
individual members.

-Get training on how to manage
their money.

-Offer lectures and training on
family relationships to relatives
and consumers.

-Assign a role to the relatives of the
consumers in some activities of the

groups.

~Identify ways in which the
consumers can help their families.

-Help the members with potential
to ﬁnd economic support. to
pursue academic goals. and / or
receive further training.

-TYain the members in topics such
as: problem-solving. job search.
group dynamics. and social
involvement.

-Train the relatives in how to
manage different aspects of the
mental illness.

160

Table 30 (cont'd.)

4. W -Encourage the members to spend
«friends time together out of the meetings.
-a companion
-"good" neighbors ~1ncrease the frequency of the
meetings.

-Encourage the members to
identify ways in which they can
become active in their
neighborhoods. and improve the
relationship with their neighbors.

 

Recommendations concerning personal goals. group goals. and

health issues will have to be specific for each group or individual.

The groups will have to decide how are they going to help
themselves to reach their objectives and conduct their activities. If
the group wants to be trained in speciﬁc topics. it may be beneﬁcial
if the professional or consultant uses his/her role to guide the
group's members to a better understanding of their situation.and of
the need or problem with which they are concerned.

The following paragraphs discuss ways in which the groups
could use knowledge about their attitudes to work with some of their

needs.

161

If the group decides that the improvement of family relationships
and/ or family involvement will be a priority the members should
understand what their beliefs about the family and their families'
structures are before they make a plan of action. The members can
do this with help of a consultant who can develop a survey or guide
questions for a group discussion.

The data from the present study showed that needs concerning
the family were reported very often. and also that traditional family
beliefs existed among members of the mutual help groups. When a
particular group ﬁnds out the members' beliefs about the family.
their plan of action concerning family issues should consider the
characteristics of the family that the members want to encourage
and/or preserve. For example. in the case of the present study.
training could be designed based on the assumptions that traits such
as "respect" (respetol for the parents. obedience. and other factors
are going to affect the interaction among family members. One of the
ways to involve the members in a helping process concerning this
issue will be to: (a) teach each member how to understand where
his/her family stands. compared to his/her beliefs and expectations

about the family; (b) teach ways to generate ideas that they can use

162

to promote the characteristics that they want in their families: and
(c) teach them to evaluate the advantages and disadvantages of the
desired traits.

An understanding of the group's members beliefs about the sex
roles could be useful as part of the information necessary to identify
activities that may be attractive to the members. For example. if
members adhere to very traditional sex roles. and the group is
comprised of males and females; females may be mainly interested in
getting training in household tasks (e.g.. sewing classes) and males
may be mainly interested in activities such as going to sports games
with other males. This may have even greater effects in terms of the
directions that the group should take if most of the members of the
groups have similar beliefs and are of the same sex.

Another area that could help the members to decide how are
they going to deal with their needs is the identiﬁcation of their
attributions concerning the causes of what creates and/ or maintains
their needs. The understanding of their locus of control on
attributions concerning important situations in their lives gives
insight into their experiences and could be a learning process that

could improve their helping skills. It also will suggest the areas in

163

which the members will take more responsibility and if the groups
could work independently from the mental health centers.

As. it was not possible to test this relationship. further studies will
be necessary.

Finally. another aspect that each group should consider is the
religiosity of the members and their religious afﬁliation. Most of the
members in the sample were afﬁliated with religious groups. If a
group ﬁnds out a similar connection among its members. options
such as the adoption of GROW groups' structure should be seriously
considered. Also. individual members who want the mutual help
group to become involved with religious organizations could decide
to form new groups following the structure and guidelines of the
GROW organization.

The best way to use some of these suggestions will be to have a
core group that. with the advice of consultants and the participation
of group representatives and members of the mental health system,
designs a general plan for the future of the group. This core group
should have ways to monitor the groups' processes and may want to

evaluate the main areas of the plan after their implementation. A

164

parallel group will have the same role concerning the mutual help
groups of relatives.
lmi

This study had some limitations concerning the sample and the
method used to measure some of the attitudes. The impossibility of
getting an updated and reliable list of the membership of the groups
interferes with the estimation of the sample size. The sample size
was small. even though.10 out of the 14 groups were successfully
contacted and members of the groups agreed to participate in the
study.

Another limitation was that the investigator had to depend on
the coordinators and/or groups' presidents to: contact all the
members by telephone and assess their interest on receiving
information about the study: decide if the researcher can go to the
meeting. and/ or call all the members for an additional meeting. The
author cannot guarantee that each member was invited and received
the same invitation to receive information about the study.

It was not possible to have access to reliable information about the
medical history of the consumers. Many of the subjects did not

understand/ or know details about their mental disorder. and or their

165

current stage in the mental health process. Variables concerning the
medical history of the members are very important to describe the
members of the mutual help groups and understand their needs and
goals.

The format of the instrument to measure attitudes about the sex
roles was inadequate. As was suggested before. further studies on
the topic should ask the subjects to describe different areas of their
behavior concerning sex roles. and their ideals and stereotypes of
the Puerto Rican male and female.

The scale used to measure locus of control had a low reliability
coefﬁcient and the items proved to be too general and difficult to
answer. Future efforts to assess the subjects' locus of control might
involve presenting scenarios concerning different situations to
which they subjects could react making their causal attributions.

Future assessments should gather more details about
demographic characteristics--especially situational variables« and
obtain information to test the reliability of this information. The
assessment also will be more complete with the members'
explanations of the problem that causes the need. and if they rank

order their needs.

9.1mm

This study assessed the needs of the consumers of mental health
services and relatives of consumers participating in mutual help
groups in Puerto Rico. Also. the members' attitudes about the
traditional family beliefs. the sex roles. locus of control. and
religiosity were assessed. and the relationships of these variables
with needs and characteristics of the group were observed. The
following research questions were stated and evaluated during the
study:

1. What are the needs of the consumers of mental health
services in mutual help groups in Puerto Rico?

The consumers showed needs in areas of economic matters.
employment. education, housing. social relationships. health issues,
personal goals. group goals. family issues. and activities. The speciﬁc
needs that they mentioned more frequently were: transportation.
good family relationships. economic support. housing. a job.
medicine. and physical health. However. data about the type of
dwelling of the subjects suggests that they do not have a need of
housing. The level of income conﬁrms their need of economic

support. Issues concerning the consumers' families and their

166

167

physical health. proved to be very important and the subjects
frequently reported dissatisfaction with them.

2. What are the needs of the relatives of consumers of mental
health services in mutual help groups in Puerto Rico?

The relatives indicated needs of economic support. trainin§.
physical health. trust in the mental health services. a club house for
the consumers. good family relationships. and the mental health of
the consumer.

Things with which they reported less satisfaction were:
participation in recreational activities, access to mental health
services. academic education. involvement of the family.
participation in community matters. opportunities to meet other
people. the family relationship. opportunities to interact with
youngsters. and support from the neighbors. They mentioned
frequently that issues concerning family relationships were very
important for their well being.

3. Which of their needs do they want to fulﬁll through the
group?

The consumers frequently showed interest in being helped by the

168

group in areas of: recreational activities. access to mental health
services. support from the mental health services staff. informal
education. community activities, opportunities to interact with
youngsters. mental health. and feeling useful. The relatives showed
interest in being helped by the group in: getting access to mental
health services. feeling useful. obtaining support from the mental
health staff. obtaining informal education. participating in community
activities. meeting other people. having positive family relationships.
and teaching others from their experiences. Both groups coincided
in many of their expectations about the groups.

4. What are the attitudes of the consumers and relatives in
mutual help groups toward the family and sex roles?

The scale about traditional family beliefs indicated that the
subjects agreed with traditional family beliefs. The subjects' scores
on traditional sex roles also were high, but some criticisms of the
format of the section to assess traditional sex roles discussed
previously do not allow for further conclusions to be drawn about the
ﬁndings.

5. Is there a relationship between the attitudes toward the

family and sex roles and the needs of consumers of mental health

169

services and their realtives?

The data did not showed the hypothetized relationships between:
(a) traditional family beliefs and needs of positive relationships with
the family; and (b) traditional sex roles and higher need of
employment than women.

6. Is there a relationship between the attitudes about traditional
sex roles and the status in the groups of the consumers and
relatives?

The traditional sex roles and the number of males in positions «
roles« of power in the groups did not appear to be related.

7. What is the locus of control of the consumers and relatives in
the mutual health groups?

The scale used for this assessment had been criticized in
previous sections and did not provided conclussive results.

A hypothesis was evaluated about the relationship between
religiosity and external locus of control. The data did not show this
relationship.

8. Is there a relationship between the locus of control of
consumers and relatives and their dependence on the mental

health system?

170

No relationship existed between the subjects' locus of control
and their dependence on the mental health system. However. a
high dependence on the coordinators «staff from the mental health
centers« was indicated.

9. Is religiosity a characteristic of the consumers and relatives in
mutual help groups?

The high scores of the subjects in the religiosity scale and the
number of subjects who reported being afﬁliated with religious
groups. indicated that religiosity«deﬁned only in terms of afﬁliation
with religious groups. and beliefs in the value of organized religion--
was dominant among the members.

10. Is the religiosity of the members and relatives related to a
high need of participation in religious activities?

The data from the subjects showed religiosity but only one of
them manifested interest in group’s participation in religious
activities.

1 1 . Are there believers in "espiritismo" in the mutual help
groups?

Seven believers in "espiritismo" were found among the forty-two

171

members of the mutual help groups.

A hypothesis was stated about the relationship between group
member believers in the "espiritismo". and a preference in having
the groups more independent from the mental health center. This
one could not be tested because all the members wanted to remained
involved with the mental health center.

Most of the needs reported by consumers and relatives concern
their societal environment. Fortunately. this is an area in which the
groups could have greater impact. The study discussed examples of
ways that the groups could help the members fulﬁll their needs.

The structure and many practices of the groups in Puerto Rico
did not resemble the ones of mutual help groups per se. The
groups appeared to be similar to voluntary groups in many areas. It
is not suggested that the mutual help groups «voluntary groups like
they are in Puerto Rico-- could not incurr in more activities to help
the members. but real mutual help experiences could make the task
easier. Changes to the structure and goals of the groups to enrich
them as mutual help groups are recommended. The main one. was
the decrease or elimination of the group dependence on the mental

health system and/or coordinators. The creation of a new type of

172

supportive relationship with the mental health system and the
creation of two systems of groups «groups of consumers and groups
of relatives« is recommended. This would beneﬁt the groups as well
as the system.

Broad plans could be developed with groups who wish to include.
as part of their goals. the fulﬁllment of the member's needs. In that
case each group should identify the needs of its members. The
groups will need technical assistance in many of the stages«i.e. to
evaluate the main elements of their plans. get necessary training. and

evaluate the outcomes to identify the most adequate structures.

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APPENDICES

APPENDIX A
Keywords in Literature Search

185

Sources and Keywords used in the literature review

 

Sources

Keywords

 

literature Review on Family
Attitudes

Comprehensive computer

Searchd'Psychological
Abstrais

Canprehemive canputer
search cn Mental Health
Maris

Inventory of Marriage and Family
um:

1. Parental attitudes and
mental patients
2 Fanily manbers a'
pawn. and mural
illness attitudes toward
3. Parent attitude research
instrument

4. Motherochild relation

5. Parent-child relation
‘Outpatients and rehabilitation were
personally reviewed through the
Psychological Abstracts

1. Parental attitudes and
mental disorder
(schizophrenia Ipsychosis)
2. Paternal atituds and
mental patients

1. Mental Health services
and families

2. Families with
schizophrenia

3. Blank: gwps inthe
United States

186

SodalSciencslnda

CardmialogatMSU

IndoctotheUSA
Gowmmeni's Documents

Computer Search Prepared by the
University of Puerto Rico

Computer search in Social
SciSearch

Computer search in Psychinfo

Inventory of Marriage and Family
Literature

Card catalog at Michigan State
University

1. Nursing home patients
2. Attitudes toward mentally

ill

1. Attitudes
. Family attitudes
3. Mental patients

N

I. Attitudes/ Mental health

2. Stigma
3. Family‘s attitudes

1. Mental Health and Hispanics

. Mental Health and Hispanics
. Puerto Rico/Mental Health

. Puerto Rico

. Puerto Rican Americans

. Hispanics

. Cross cultural studies

moisten.-

1.Puerto Ricans

. Hispanics
3. Family

N

1.Puerto Rico/Mental Health
2. Puerto Rico Department of Health
3.Puerto Rico/culture

4.Religiosity
5.Hispanics

 

APPENDIX B
Letter of Approval

187

O. --— 0‘ . . .-.

 

ssuoo use: nsocmoo oe PUEﬂTO moo
DEPARTAMENTO DE SALUD
SECRETARIA AUXILIAR DE SALUD MENTAL
OFICINA DEL SECRETARIO AUXILIAR
BOX 61. G P 0
SAN JUAN. PUERTO RICO 00936

 

MEMO

MGR-DP .

     

 

Alina Vales.m.o. J \\ it! Q;
Comite de Investigacidan %A
W W, m
De: Glorisa Canino.Ph.D. mbbmw Mm

Directora Investigacidn 4431 ‘

Re: Propuesta de investigation Milagritos Gonzale:
Fecha: 10 de junio,1987.

Adjunto 1e mando copia de la propuesta =ometida por la Srta.
Milagritos Gonzalez y que llego a mis manos el 9 de junio del
1987. Lei cuidadosamente dicha propuesta y la considero
excelente. No tengo ningun comentario que hacer para mejuratla
pues considero que la Srta. Gonzalez hizo una labor de gran
excelencia. Recomiendo por lo tanto que se Ie concede la
aprobacion de inmediato, ya que ella vendra a Puerto Rico deeﬂe
Michigan State para comenzar su estudio. Tesis comn betas eon lee
que necesitamos en nuestro Sistema, pues nos ayudan a mejorar
nuestros servicios.

cc. Milagritos Gonzalez
Luis de Celis 7
Mayaguez. Puerto Rico. 00708

 

 

 

 

APPENDIX C
Consent Forms

188

HDJA DE CONSENTIHIENTO

Usted ha sido seleccionodo para participar en un estudio sobre las
necesidades de los consumidores de servicios de salud mental y de sus
familiares en Puerto Rico. En dicho estudio tamoien se medira’n las
actitudes hacia la familia, los roles sexuaies, el punto de control 9 la
religiosidad. El estudio es conducido por Hilagritos Gonzélez,
estudiante graduada en Hichigan State University, 9 ha sido aprobado
por Efren Ramirez, Secretario Auxiliar de Salud Mental g Glorisa
Canino, Directora de lnvestigacio’n en la Secretaria Auxiliar de Salud
mental en Puerto Rico. '

Por favor lea esta iniormacio’n atentamente y si esta de acuerdo con
participar en el estudio, firme al final del documento g entre’gueselo al
entrevistador.

1. Su participacio’n en el estudio consistira’ en responder de
forma ano’nima (no se podra’ identificar quie’n respondici cada entrevista)
una entrevista individual que puede durar entre 45 g 60 minutos.

2. Su participacio'n es completamente voluntaria g su decisio’n
de participar o no, no aiectara ningu’n servicio que usted recioa en el
centro de salud mental.

3. No se le preguntara’ nada que se considere quepueda hacerle
sentir mal o incomodarlo. De esto suceder, usted tiene derecho a no
responder las preguntas que no le interese responder g/o dar por
terminada la entrevista si en algu’n momenta decide no continuar en la
misma.

4. Si usted firma esta hoja y esta de acuerdo con que se le
llome el dia antes de su entrevista, su nomore g nﬁmero telefo’nico
sera’n necesarios. El recibir esta llamada teleio‘hica para recordarle la
hora, fecha y lugar de su entrevista no es un requisito de su
participacioin. De usted desear que se la llame, su nombre g m’imero
telefo’nico al igual que toda la informacid’n que usted provea se
considerara’ de caracter confidencial. Luego que los tele'fonos hogan
sido utilizados para el propo'sito antes expuesto, la lista donde se
encuentren estos nomores g tele’ionos sera’destruida.

.189

5. Solo los tres entrevistadores tendraﬁ acceso a la
inf orrnacién g e’sto serd'sélo para el estudio antes expuesto.

Si usted tiene alguna duda o pregunta sobre el estudio, por favor '
déjenos saberlo antes de que usted decida participar o no en el estudio.
Si usted acepta participar, por favor firme la siguiente oracio’n:

He leido la Hoja de Consentimiento para participar en el
estudio de las necesidades g actitudes de consumidoresde
salud mental y sus familiares en Puerto Rico. Entiendo que
mi participacidn es complelamanta voluntaria, que si lo
deseo puedo terminarla en cualouier momento sin ninguna
consecuencia para mi, y que mi idsntidad no sera’ rsvelada.

Firrnando este documento accedo a participar en el estudio
bajo las condiciones antes expuestas g a que la informacioh
que yo provea sea utilizada en la investigacion conducida por
Hilagn‘tos Gonzalez.

Firma _- fecna ’

 

APPENDIX D
Tables

190

 

 

Table D-l

b t n 1 m 1 1h r

Variables Frequencies %
1. Received mental 31 100%

health services
2. Types of services

Medicines 17 55%

Therapy 13 42%

Ambulatory services 2 6%

Psychiatrist 3 10%

Occupational therapy 1 3%

External clinic 1 3%
3. Having being hospitalized 31 100%
4. Number of hospitalizations

One or two 7 23%

Four or ﬁve 2 6%

Six 1 3%

Nine 1 3%

Twenty 1 3%
5. Years since first

hospitalization
No or three years 2 6%
Five years 1 3%

Eight years 1 3%

Table D- 1 (cont'd.)

Ten years
Twelve years
Seventeen or eighteen years
TWenty seven years
6. Years since last discharge
One year
'I\vo years
Three years
Five years
Six years
Eight years
Don't know
7. Diagnosis
Schizophrenic
Neurosis
Manic-depressive
Don't know
8. Drug rehabilitation program
No

191

Haiti-n

HHHHMMH

31

3%
13%
10%

3%

3%
7%
7%
3%
3%
3%
3%

1 9%
3%
7%

l 0%

100%

 

Table D-2

Eu nlvl f

192

 

 

Subjects

Levels Consumers Relatives

n % n %
1 to 6 grade 4 13% 1 7%
7 to 9 grade 7 23% 3 20%
10-12 grade 11 36% 6 40%
1-2 years Bachelor or 3 1 0% 1 7%

Ass. Degree

Tech. or Ass. degree 2 6% 1 7%
3 to 4 years Bachelor 2 6% -- --
Bachelor degree 1 3% 1 7%
Post-grad. Master degree 1 3% 1 7%
Post-grad. PhD -- -- 1 7%

 

193

 

 

 

 

Table D3
Wm
Subjects
$13125 Relatives genegmeze
Housewife 10 18
Retired 2 I
Voluntary work I 2
Unemployed seeking job 1
Unemployed not seeking job 16
Employment in shelter work 1
Other 2 2
Table D4
Relatives living with the mapendent,
_People inthe same house ﬁatives Consumers
340ther 1 7
Father -- 3
Wife/husband 12 15
Sons 7
Daugthers 5
Partner -- 1
Brother / sister -- 3
Friends -- 2
Other relatives -- 3

 

194

 

 

 

Table D-5
WWW
Responsibilities Frequency - Percent
Relatives (n=15)
1. Group representative 2 13%
2. President 3 20%
3. Request donations of money 1 7%
4. Advisor of the group 2 13%
5. Kitchen chores I 7%
6. Subsecretary 1 7%
7. Vice-president 1 7%
8. Bring something for the activities 2 13%
9. Secretary 2 13%
10. Spread information about the group 1 7%
11. Share experiences with others 1 7%
12. Conduct the meetings 1 7%
13. Photogapher l 7%
14. No responsabilities 2 13%
Consumers (n=31)
1. Attend to the meetings 2 6%
2. Group representative 5 1 6%
3. Work in cafeteria l 3%
4. President 4 13%
5. Ask for economic donations l 3%

195

Table D-5 (cont'd.)

6. Subsecretary

7. Treasurer
8. Advisor
9. Kitchen chores

10.
11.
12.
13.
14.
15.
16.
17.

Vice-president

Donate something for activities
Secretary

Coordinate activities

Share with others

Conduct the meetings

Call other members by phone
No responsibilities

«Hewmwnwewwn

6%
l 0%
3%
l 3%
6%
6%
3%
6%
1 0%
3%
3%
23%

196

 

 

 

Table D-6
ul h
Optionsa

Items A B C D E F

Relatives (n=15)
1. Most Inﬂuential 7% 7% 27% 12%
2. Group leader 4% 33% 2% 7%
3. President 27% 53% 13% 7%
4. Vice-president 20% 27% 47% 7%
5. Secretary 27% 40% 27% 7%
6. Treasurer 20% 40% 7% 33% 7%

Consumers (n=31)
1. Most inﬂuential 29% 10% 29% 10% 22%
2. Group leader 71% 10% 6% 6% 6%
3. President 61% 13% 23% 3%
4. Vice-president 45% 3% 42% 10%
5. Secretary 58% 39%

3%

6. Treasurer 45% 3% 45% 7%

 

a A: Consumer; B=Relative: C=Coordinator: D= nobody: E=Don't
know: F=Not available.

Table D-7

ri rr niili

197

 

ill

 

Conducts meetings

Makes the decisions

Gives advice

Runs the group

Informs the group of general
meetings

Presents problems

Calls on meetings

Supervises the meetings

Pmsents general topics

Substitute the president

Finds place for the meetings

Finds materials needed

Finds transportation

Suggests dates for meetings

Makes suggestions

Represents the group

Checks the punctuality

Ends the meeting

Social work

Signs the checks

Don't know

Subjects
Relattvee geaeumeze
1 5
-- 2
3 3
-- 6
1 2
3 --
3
1 3
-- 2
-- 1
2 2
-- 2
-- 2
1 --
-- 1
3 l
-- 1
-- l
-- l
-- 2
l 3

APPENDIX E
Statement of Equivalency

198

UNIVERSITY OF PUERTO RICO AT MAYAGUH
Gmmun «IARNIAmslzumal
mnwmmzp.a.

Danes or rat Dun

September 14, 1987

Dr. William Davidson
Chairperson

Ecological Psychology
Michigan State University
East Lansing, Michigan

Dear Dr. Davidson:

During the past summer 1 1HH1 the opportunity
of reviewing the Spanish translation of Hilapritos
Gonzalez questionnaire. Before and after she
suhnitted the questionnaire to her pilot study, she
asked ru> to check if: the Spanish translation was
equivalent to the english version. Minor changes
were necessary and I certify that the snanish
version is equivalent in content, style and meaning
to the english version.

If I can he of any further help in this matter
please feel free to communicate with me.

Sincerely,

012% N. Hernandez,

Associate Dean
College of arts and Sciences

 

ONH/mml

APPENDIX F
Instrument

199

_( l -2)
Needs and attitudes of consumers of mental health services and
their relatives

P lace of the interview Type of interview (4)
( 3) A. Consumer
B.Family member

 

My name is (5) and since I know that you agreed to
participate in this study, I will proceed to ask you the questions that
correspond to the interview. I remind you that you can terminate the
interview at any time if you so desire. We encourage you to provide
the most explicit and honest answers that you can, because the
information that is being collected is very important. Do you have any

questions or comments before we begin the interview?

 

 

 

l. Demographic Data
P- l. When is your birth date? _/_/_J
(compute age=___) (6-7)
P-2. What is your marl tal status? (8)

1. Single

2. Married

3. Divorced

4. Widow/widower
S. Consensual union
6. Separated

7. Doesnot know

‘3
u

.0

}°.°°N.OS":5.°‘NT‘

200

. What was the highest grade 01' education that YOU

completed ?

No school (9- 10)

i-6 grade

7-9 oracle

10-12 gram

1 -2 years of a Bachellor’s Degree or Associate Degree (not completed)
Technical or Associate Degree

3-4 years of a Bachellor's Degree program (not completed)

Bachelor Degree

Post-Grad Master's

Post-Grad PhD

10. Does not know
P-4. What is your present occupation or what do you do at the

present time? (i i-i2)
l.

‘OQNQ‘SJ‘PP‘N

Unemployed-seeking a job
Unemployed-not seeking a job
Housewife

Student

Retired

In training for a job

Employed in sheltered workshop
Working in transitory employment
Professional work

to. Voluntary work
it. Does not know

l2. Other

 

201

P-S. i am going to read a list of sources of income. Please indicate
if you do or do not receive each one. For each you do receive,

indicate how much money you receive monthly. (Read each item to the

 

 

 

 

respondent)
YES NO
a. Do you receive a Salary? l 2 (13)
How much?

b. Do you receive Social Security's checks?l 2 (14)
How much?

c. Do you receive Food coupons ? l 2 (is)
How much?

d. Do you receive Economic aid from the l 2 (16)

Social Services program?

How much?

e. Do you receive Family support? i 2 (17)
How much?

 

f. Do you receive economic support from i 2 (l8)
the Office of Vocational Rehabilitation?
How much?

 

, g. Do you receive Unemployment checks? l 2 (l9)
How much?

h. Do you receive Alimony ? l 2 (20)
How much?

.202

i. Do you receive Disabled insurance I
How much?

 

j. Do you receive Retirement benefits? I
How much?

 

k. Do you have other sources of income 1
not mentioned previously? please specify,

 

Monthly total
P-6. In what town or city do you live?

 

 

P-7. In what type of dwelling do you live?

1. House
2.Lanvm
3. Apartment
4. Public Housing Project
5. Drug Rehabilitation program

2 (21)

2 (22)

2 (23)

(24-27)

(28-29)

(30)

6. Group Home or Independent Housing Project (San German)

7. Don‘ t know

a. If you answered i ,2 ,3,4 or S , please specify with how

many people do you live?

 

(3)-32)

D. Answer YES or no Indicating if the following persons ”V9

with you?

YES No
I). Mother I 2
2). Father I 2
3). Wife/husband l 2
4). Sons 1 2
S). Daughters i 2

(33)
(34)
(3‘5)
(36)
(37)

203

6). “Partner " i 2 (38)
7). Brother/sister I 2 (39)
8). Friends I 2 (4o)
9). Other relatives I 2 (4i)
not previously mentioned

P-8. Have you received mental health services?
of which type?

 

Do you receive mental health services at the present time?_ ‘
of which type?
If the respondent has received or is receiving mental
health services, indicate
1. Yes 2. No (42)
If the respondent answered affirmatively to question A
8. Have you been hospitalized for mental health problems?
I. Yes 2. No (44)
If the answer to B was affirmative:
a. How many times have you been hospitalized for mental
or “emotional” problems? (45-46)
D. In what year was your first hospitalization?
(47-48)
If the respondent does not remember: Do youd recall if

 

it occurred during the last two years?

 

c. When was your last discharge from the hospital?
(month and year) (49—50)

 

d. What is your most recent diagnostic about your
mental health? (Si-52)

204

P-9. Have you been or are you at the present time under
treatment in a drug rehabilitation program? (53)
I.Yes 2.No
ll. Participation in the Group
P-lo. When did you begin participating In the mutual help
group? (write the number in months) (54-55)
D. How often do you attend to the meetings? (56)
1. Always 2. Almost always 3. Rarely 4. Never
P-I i. What have been your assigned tasks or responsabilities
in the group? (57—58)
P-i2. Is any member/s of your family participating in the

mutual help group? l.Yes 2.No (59)
If yes:
a. Which member/s of your family?__ (60-61)

 

P- i 3. What things do you like the most about the group?
(62-63)
D. What things do you like the least about the group?
(64-65)

 

 

III. Structure of the Group
P-l4. What person has the most Influence (importance or
control) In the decisions of the group?(write the name)
i. Consumer 2. Family member 3. Coordinator (66)

 

205

P-lS. Who is the leader of the group?
l.ConsumerZ. Family member 3. Coordinator ( 67)

 

P- I 6. What are the responsibilities of the coordinator?
(68-69)

 

 

P’ I 7. Who are the members or the directive?
a. Who is the President?
l.Consumer 2.Family member 3. Coordinator (70)

b. Whois the Vice-president?

 

 

i.Consumer 2.Family member 3.Coordinator (71)
c. Who is the Secretary?

 

l.Consumer 2.Family member 3. Coordinator (72)
(1. Who Is the Treasurer?

 

l.Consumer 2.Family member 3. Coordinator (73)
IV. Needs
P-IB. To begin with a new topic now I want to talk about
things that you may be needing.
a. Can you tell me what are the things that you need or
that are your major concern to feel good?

 

(74-75)

206

P-io. I am going to read things that some people may
consider necessary or Important in their lives. I want to know
how important are each of these things for you. The card that I
am giving you shows the four options that will help you to
answer to each item. You can answer either telling me the or
the number corresponding to the option. (Extremely
important=i,Falrly lmportant=2, Not too important=3, Not
important=4)

HOW IHPORTMIT IT IS THAT YOU: El F l NT Ni
8. Be employed 1 2 3 4 ( l)
b. Have housing 1 2 3 4 (2)
c. Participate in recreational activities 1 2 3 4 (3)
d. Have access to mental health services l 2 3 4 (4)
e. Feel support from the staff I 2 3 4 (5)
f. Receive academic education (take courses) i 2 3 4 (6)
g. Receive informal education (training in l 2 3 4 (7)
some hobby, chats ect.)
h. Family get involved in your activities 1 2 3 (8)
i. Participate actively on I 2 3 4 (9)
community matters
1. Have opportunities to meet other i 2 3 4 ( l0)
people
k. Participate in religious activities i 2 3 4 ( I l)
i. Have a positive ( mod) and stable i 2 3 4 ( i2)

relationship with your family
m. Have opportunitytointeract(tobe)with l 2 3 4 (l3)

young 990019

207

n. Have opportunity to teach others what you
know

0. Feel and receive support from your
neighbors

p. To have religious beliefs

q. To be physically healthy

r. To havegood "emotional" (mental )health

5. To feel that you are useful

I

I
I
I
I

2
2
2

2

04040401

4
4
4

4

()4)

(l5)

(i6)
(17)
(l8)
(19)

P-20. Now I am going to ask how satisfied are you with the

things previously mentioned. The alternatives among which you can

choose your answer are indicated in the card that I am giving you.
(Very satisfied-=1, Satisfied=2, Dissatisfied=3, Very dissatisfied=4)

HOW SATISFIED ARE YOU WITH:

a. Your employment

b. Your housing arragement

c. Your participation in recreational
activities

0. Your access to the mental health services

a. The support you receive from the mental
health staff
f. Your academic education
g Your informal education/“hobby“, chats
h. The involvement of your family in
your activities

i. Your participation in community matters

d. Your opportunities to meet other mple
K. Your participation in religious activities
I. Your relationship with your family

VS

NNNCD

N

NNNN

01010404

.3

A-b-A-h

(20)
(21)
(22)

(23)
(24)

(25)
(26)
(27)

(28)
(29)
(30)
(31)

208

m. The opportunities to interact with 1 2 3 4 (32)
youngsters
n. The opportunities to teach other what you i 2 3 4 (33)
know
0. The support you receive from your 1 2 3 4 (34)
neighbors
p. Your religious beliefs 1 2 3 4 (35)
q. Your physicall health 1 2 3 4 (36)
r. Your "emotional'(menta1 ) health 1 2 3 4 (37)
5. Your sense of how useful you are 1 2 3 4 (38)

P-21. In this section I will read the needs that we have been
talking about . I want you to tell me if you would like the Self-Help
group to provide or help you satisfy each need. You just have to
answer yes or no to each one of the sentences that i will read to you.

Yes No
11 Find employment I 2 (39)
b. Find housing 1 2 (40)
c. Participate in recreational i 2 (41)
activities
11 Receive mental health services 1 2 (42)
e. Obtain support from the mental health 1 2 (43)
staff
f. Obtain academic edumtion i 2 (44)
0. Obtain informal education (hobby,chats) i 2 (45)
h. Involvement of the family i 2 (46)
in your activities
1. Participate in community activities 1 2 ( 47)
1. Opportunities to meet other 1 2 (48)
pacple.

k. Participate in religious activities 1 2 (49)

209

l. Positive(good) and stable relationships 1

with the family
m. To interact with youngsters 1
n. Opportunity to teach others what you i
know

0. Obtain support from your neighbors i
p. Have religious beliefs 1
(1 8e physically healthy 1
r. Have ”emotional" (mental )health 1
5. Feel useful 1

N

NNNN

2

(50)

(Si)
('52)

(S3)
(54)
(SS)
(56)
(S7)

P-22. Do you have any suggestion or comment about the

mutual help group that you want to let me know?

 

 

V. Attitudes about the family

P-23. Now i am going to read statements of opinions that you
may have heard before about how the family should or should not be.
I want you to tell me to what extent do you agree or disagree with
each of the following opinions. You can choose among the options in
this card. (Strongly agree=l, Agree=2, Uncertain=3, Disagree=4,

Strongly disagree=5)
Father

a. The father should be the authority figure in
the house

b. To obey your father is more
important than to love him

I

I

SAAUDSD
234 5(59)

234 5(60)

210

Mother

0. Themothershouldalways bemoreloving l 2 3 4 5 (61)
thanthefather

d. Themothershouldobeythefather's will i 2 3 4 5 (62)

Siblings

e. The siblingsshouldalways l 2 3 4 5 (62)
obeytheirfather

f. Eventhwghywareangrywith l 2 3 4 5 (63)

your parents, their will should be
complied with because of ”respeto"( respect)

Family composition

g. "Allthe family" refersggJLto l 2 3 4 5 (65)
the parents and their children.
h. ”Allthe family" refers to parents 1 2 3 4 5 (66)

children, grandgfathers/grandmothers,
nephews, uncles, cousins, godfather, ect.

Importance of the family

i. ltisessential to be ingoodterms i 2 3 4 5 (67)
with the family to feel good
1. It is essential tobeloyal to l 2 3 4 5 (68)
the family to feel good
D. How many people compose your family? (69)

 

c. Who are they? (70-75)

21 1
VLSex Roles
P-24. For each of the following statements 1 want you to tell me
to what extent you consider that the statement represents
characteristics that the Puerto Rican woman and man should show.
You should use the same card of options that was given to you for
the preceeding question.
To what extent do you agree with the idea that:

the woman the man
5A A U 0 50 5A A U 0 $0

a. Should be of weak character 1 2 3 4 5 ' 1 2 3 4 5 (1-2)
b. Should be religious i 2 3 4 5 l 2 3 4 5 (3-4)
0. Should ooey ner nusoano /w1T8 or 1 z 3 4 5 l 2 :5 4 5 (5-6)

father/mother
d. Should besentimental l 2 3 4 5 2 3 4 5 (7-8)
8. Should rear his/her siblings l 2 3 4 S l 2 3 4 5 (9-10)
1. Should iron,c1aan,washanddo l 2 3 4 5 1 2 3 4 5(11-12)

house chores
g. Should work out of home i 2 3 4 S l 2 3 4 5 (13-14)
h. Should havestrong character 1 2 3 4 S l 2 3 4 5(15-16)
i. Shouldcryif suffering i 2 3 4 5 l 2 3 4 5(17-18)
1. Should havea betterjob andearn l 2 3 4 S i 2 3 4 5(19-20)

more money than his lher spouse
k. Should "venerate”(or give more i 2 3 4 5 i 2 3 4 5(21-22)

importance than to any other person)

to his/her mother
1. Should ”impose" discipline 1 2 3 4 S l 2 3 4 5 (23-24)

tohis/her chlItIren
m. Shouldbearpainwithout l 2 3 4 S l 2 3 4 5(25-26)

complaining

212

n. Shouldgooutwith persons 1 2 3 4 5 I 2 3 4 5 (27-28)
of the opposite sex, other than
wifeor husband

VII. Locus of control.

P-25. In this section I am going to read pairs of sentences. You have one
card with each pair or statements. From each pair of statements I expect
you to choose the one with which you agree more.

Personal Control

I. A. I have often found that W (29)
happenyﬂl happen

8. Trusting to fate has never turned out as well for me as making a

mend take museum

2. A. What happens to me is of my gun responsability (30)

8. Sometimes I feel that Waugh
M over the direction my life is taking

3. A. When I make plans, I am almost certain (31)

that W

B. It is not always wise to plan too far ahead
because many things W
W that you may have.

4. A In my case,getting what I wanted had (32)

Inueoommmmmmm.
8. Many times we might just as well decide

WWW-

213

5. A. Many times I feel that I havelﬂﬂﬂﬂﬂm (33)
over things that happen to ma

8. It is imacssiblalocmmbslievetbatcbamor
luck Wits.
v111. Religiosity
P-26. Are you affiliated to a religious or spiritual group?
i.Yes 2.No (34)
b. Which ? (35-36) ‘

P-27. I will read eight statements which concern religious beliefs.

 

Please indicate the extent to which you agree or disagree with each of
them. You can choose among the Options in this card that I am giving you.

SA A U 0 SD
1. Toleadagoodlifeitisnecessary 1 2 3 4 5 (37)
to have some religious and/or spiritual belief
2. I genuinely do not know whether or not God exist 1 2 3 4 5 (38)

3. People without religious beliefs can i 2 3 4 S (39)
lead just as moral and useful lives

4. The existence of diease and famine l 2 3 4 5 (40)
in the world demonstrate that God does not exist.

5. International peace depends on the 1 2 3 4 S (41 )
world wide adoption of a common religion

6. Life Is meaningless without believing in God. i 2 3 4 5 (42)

7. Ifyouleadagoodanddeoent life, 1 2 3 4 5 (43)
it is not my to go to any church

8. Religious education is indispensable to l 2 3 4 S ( 44)

preserve the morality of our society

214

P-28. Before ending this interview I want to know about your future
plans concerning the mental health services.

a. Do you want or plan to stay involved with the mental health
center? (45) why or why not?

 

(46-47)
D. How well do you believe that you would be without the help of the

 

mental health center? (48) why or why not?
(49-50)
c. In what activities of the community would you like the self-help

 

group to get Involved?

 

(SI-52)

 

 

with what associations or groups?
(53-54)

 

Thank you very much for your cooperation, if you have any questions or
comments that you think that I should know about the interview, the
Self -Help groups or about yourself, please discuss them with me

now,before we end the interview.

 

 

 

 

215

This section should be filled out after the interview:
Date
Time the interview ended
Sex of the respondent I. F 2. M

Interview number in the interview session.—

Notes

Unusual circumstances or comments

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPENDIX G
Coordinators' Questionnaire

216

_(1-2)
Necesidades y Actitudes de los Consumidores de Servicios de Salud
Mental y de sus Familiares

 

Luger on la entrevista (3) Tipo as entrevista (4)
A. Consumicbr

B. Familiar
Mi nombre es (5) y conociendo que usted ha

 

aceptado participar en este estudio procederé a hacerle las preguntas que
componen 1a entrevista. Le recuerdo que usted puede dar por teminada la
entrevista en cualquier momento que asi lo desee. Le pedimos que dé las
contestaciones mas claras y honestas que usted pueda, ya que la

inf ormaciOn que se esta recopilando es muy importante.

oTiene usted alguna pregunta o comentario que hacer antes de comenzar
la entrevista?

 

 

 

1. Dates Demograficos
P-l. 8Cuai es su fecha de nacimiento? __/__/_/
(calcule la edad=_) (6-7)
P-2. email as su estado civil? (8)

. Soltero

Cam

. Divorciado

. Viudo/viuda

. UniOn consensual

. Separado/a
. No sabe

uomaup—

217

P-3. LCual es el grado de educaciOn mas alto que completO? (9- 10)

O

. No asistio a la escuela

1 -6 grado

7-9 grado

10- 12 redo

1-2 ahos ch bachillerato o grado wooiado (sin completar)
Grade asociado o técnico

3-4 alias de bachillerato (sin completar)
Bachillerato

Estudios Post-graham (I‘lwstria)
Estudios Post-graduados (Doctorado)

No sabe

P-4. LCual es su ocupacién o a que se dedica actualmente? (1 i- 12)

995’9‘9‘9'9'5’3"

.0

Desempleado-buscando trabajo

. Desempleado-No buscando trabajo

Ame de casa

. Estudiante

Retirado

En entrenamiento para un trabajo (empresa privada)
Empleado en taller protegido (goblerno)
Empleado en ampleo transitorio (goblerno)
Trabaio profasional

lo. Trabaio voluntario

ii. Nosaba

12. Otro

99519191391».—

 

218

P-S. Voy a Ieerle una lista de fuentes de ingreso. Por favor indique
si recibe o no cada una de ellas. Para cada fuente de ingreso que usted
reciba, indique la cantidad de dinero que usted recibe mensualmente.
(Lea cada oracién al entrevistado)

$1 No
a. 8Recibe usted un salario? 1 2 (13)
LCuanto recibe?
b. 8Recibe cheques de Seguro Social? 1 2 (14)
8Cuanto recibe?
c. oRecibe cupones de alimento? i 2 (15)
8Cuanto recibe?
d. LRecibe asistencia econOmica del l 2 (16)

 

 

programa de Servicios Sociales?
8Cuanto recibe?

 

 

 

e. 8Rec1be dinero de su familia? l 2 (17)
LCuanto recibe?

f. aRecibe ayuda econdmica de la 1 2 (18)
Oficina de RehabilitaciOn Vocacional?
LCuanto recibe?

9. (Recipe cheques de desempleo? l 2 (19)
LCuanto recibe?

h. LRecibe pensiOn alimenticia? 1 2 (20)

LCuanto recibe?

219

1. (Recipe compensacibn del seguro 1 2 (21)
por incapacidad?

 

 

LCuanto recibe?

1. (Recipe beneficios por retiro? 1 2 (22)
LCuanto recibe?

k. LTiene alguna otra fuente de l 2 (23)

ingreso no mencionada? (Especifique, por favor)

 

 

 

Total mensual (24—27)
P-6. LEn qué pueblo o ciudad vive? (28—29)
P-7. aEn que tipo de vivienda vive? (30)

. Case
. Hospedaie

1
2
3. Apartamento

4. Proyecto de vivienda publica (residencial publico)

S. Programa de Rehabilitacibn Adictos a Drogas

6. Case grupal o Proyecto de Yivienda lndependiente (San German)
7. No sabe

a. Si respondio, l, 2,3, 4 o 5, por favor especiflque con cuantas
personas usted v1ve (31-32)
b. Responda si 0 no indicando si las siguientes personas v1ven

con usted.
$1 No
1). mm I 2 (33)
2). Para 1 2 (34)
3). Espm/Esposo i 2 (35)
4). Hijos I 2 (36)
5). Hijas I 2 (37)

220

6). “Oompafiero/a“sexo opuesto 1 2 (38)
7). Hermanw/harmanas l 2 (39)
8). Amigos/amine l 2 (40)
9). Otrosfamiliaresnomencionados I 2 (4i)

P-B. A (He recibido usted servicios de salud mental?
__Lqué clase de servicios?
LReclbe usted actualmente servicios de salud mental?—

Lqué clase de servicios?

 

51 e1 entrevistado ha recibido o recibe servicios de
salud mental indique si 0 no.
1. SI 2. No (42)
Si respondio afirmativamente a la pregunta A:
8. (Ha sido usted hospitalizado por problemas de salud
mental?
1. Si 2. No (44)
Si contesto afirmativamente a la pregunta B:
a. LCuantas veces ha sido hospitalizado por

problemas mentales o “emocionales”? (45-46)

 

b. LEn que ano ocurrio su primera hospitalizacién?
(47-48)
SI la persona no recuerda; LTiene alguna idea 51

 

esto sucedio durante los altimos dos anos?
c. LCuando fue dado de alta por altima vez?
f (mes y ano) (49-50)

 

d. LCuaI es su diagnOstico mas reciente de salud
mental? (51-52)

221

P-9. 8Ha estado 0 se encuentra usted actualmente recibiendo
servicios de algun programa de rehabilitacién de adictos a drogas?
1. Si 2. No (53)
II. Participacibn en el Grupo
P- 10. LCuando comenzo a participar en el Grupo de
Ayuda Mutua?( escriba numero de meses) (54-55)
h. LCuan frecuentemente asiste usted a las reuniones?
1. Siempre 2. Casi siempre 3. Raras veces 4. Nunca (56)
P-l i. 8Cuales han sido las tareas o responsabilidades que le

 

 

han sido asignadas en el grupo?

 

(57-58)
P-12. 8Hay algUn familiar suyo participando en el grupo de

Ayuda Mutua? 1. Si 2. No (59)
SI contesto 51;
a. aoue miembro/s de su familia?

 

(60-61)

 

P- i 3. LCuales son las cosas que mas le gustan del grupo?

 

(62-63)
b. 8Cuales son las cosas que menos le gustan del grupo?

 

 

(64-65)

 

III. Estructura del Grupo
P- I 4. aoue persona tiene mas inf luencia (importancia 0
control) en las decisiones del grupo? (escriba el nombre)
i.Consumidor 2. Familiar 3. Coordinador (66)

 

222

P-lS. LOuién es el Iider del grupo?
l.Consumicbr 2. Familiar 3.Coordinad1r (67)

P-16. LCuales son las responsabilidades del coordinador?

 

(.68-69)
P-17. LOuiénes son los miembros de la Directive?

a. caulén es el presidente?

1. Consumicbr 2. Familiar 3.Coordinador (70)

 

b. LOuién es el vice-presidente?
I. Consumidor 2. Familiar 3. Coordinador (71)
C. BOuién 95 BI secretario?
l. Consumidor 2. Familiar 3.Coordinador (72)
d. aouién es el tesorero?
I. Consumidor 2. Familiar 3. Coordinador (73)

 

IV. Necesidades
P- I 8. Cambiando el tema, ahora quiero que hablemos de
cosas que usted puede estar necesitando.
a. aPodria mencionarme cuales son las cosas que son su
mayor preocupacién 0 las que usted mas necesita para sentirse bien?

 

 

(74-75)

223

P-i9. Voy a Ieerle una lista de cosas que algunas personas
pueden considerar necesarias o importantes en sus vidas. Me interese
saber cuan importantes son esas cosas para usted. La tar jeta que le
estoy entregando muestra las cuatro opciones con las cuales podra
responder a cada una de las cosas que le ire mencionando. Puede
responder diciéndome Ia opciOn 0 el numero que corresponde a la
alternativa.(Muy 1mportante=1, Bastante Importante=2, Poca
importancia=3, No es importante=4)
l.Cuan importante es que usted:

MI I PI NI
a. Tang: on empr 1 2 3 (1)
b. Tonga una vivienda I 2 3 (2)
c. Participe an actividades racreativas l 2 3 4 (3)
d Puede recibir servicios de salud mental 1 2 3 4 (4)
e. Sientaque tiene e1 apoyo del personal de 1 2 3 4 (5)
salud mental
f. Reciba aducacibn academica (closes) I 2 (6)

g. Reciba educaciMinformaHentrenamiento l 2 3 4 (7)
para algun hobby o charlas)

h. Que la familia participeensusactividades I 2 3 4 (8)

i. Participe activamenteenactividacbsmla l 2 3 4 (9)
comunimd

I. Tengaoportunidadesdeconocer otras i 2 3 4 (lo)
personas

k. Participeenactividades religiosas l 2 3 4 (ll)

224

1. Tenga una relacion positive (buena)y I 2 3 4 (12)
estable con su familia

m. Tenga oportunidadde compartir(estar) l 2 3 4 (13)

con idvenes

n. Termoportunidadmensal‘laraotros I 2 3 4 (14)
lo que usted sabe

o. Sienta y recibe apoyo de sus vecinos i 2 3 4 ( 15)

p. Tenm creencias religiosas 1 2 3 4 ( 16)

q Tenga salud fisica l 2 3 4 (17)

r. Tenga salud "emocional"( mental) 1 2 3 4 ( 18)

5. Se sienta util i 2 3 4 ( 19)

P-20. Ahora voy a preguntarle cuan satisf echo esta usted con cada
una de las cosas antes mencionadas. Las alternatives entre las cuales
puede escoger su respuesta se encuentran en la tar jeta que le estoy
entregando.(Muy satisfecho= I, Satisfecho=2, Insatisfecho=3, Muy
insatisfecho=4)
l.Cuan satisfecho esta usted can:

115 S I 1'11
8. Suempleo l 2 3 4 (20)
b. Suvivienda l 2 3 4 (21)
c. Su participasiOn en wtlvidmbs I 2 3 4 ( 22)
racreativas
11. Les oportunidadesderecibir servicioscb I 2 3 4 ( 23)
Salud Mental
e. Elapoyoquereoibemlos empleados 1 2 3 4 (24)
mSalud Mental
f. Sueducacion académica I 2 3 4 (25
g Sueducacibn lnformal/entrenamiento 1 2 3 4 ( 26)
an un “hobby" o charlas

h. to partlcipaciéndesufamiliaansus i 2 3 4 (27)
actividades

225

1. Su pvticipecion en ectividades de la
comunidad
I. Sus oportunidades para conocer otras
personas
k. Su participacibn en ectividuhs religiosas
1. La relacibn con su familia
in. Les oportunidades pare compartir con
idvenes
n. Le oportunidad de ensenar e otros
lo que usted sabe
0. E1 apoyo que recibe de sus vecinos
p. Sus craencies religiosas
q. Su salud fisica
r. Su selud "emocionel" (mental)
5. Su idea de cuen util as usted

I
I
I
I
I

NNNN

2

01010100

3

bA-h-bh

(28)
(29)

(30)
(31)
(32)

(33)

(34)
(35)
(36)
(37)
(38)

P-2 1. En esta seccion leeré las necesidades que hemos estado

mencionando. Deseo que me indique si le gustaria que el Grupo de Ayuda
Mutua le provea o ayude a conseguir cada cosa. SOIo tiene que responder

si 0 no a cada oraclén que yo lea.
LDesea que el grupo 1e ayude a:

a. Conseguir ampleo

b. Conseguir vivienda

c. Perticipar en ectividades racreativas

d Racibir servicios de salud mental

e. Obtener apoyo de las empleados de salud
mental

f. Obtener educacidn academice

g. Obtener educacién informal .entrenemiento
an un "hobby'y/o charlas

h. Envolver a su familia en sus ectividades

i. Participar en ectividades de la comunidad

I. Conocer a otras personas

 

No

NNNNN

(39)
(40)
(41)
(42)
(43)

( 44)
(45)

(46)
(47)
( 48)

 

 

226

k. Participer en ectividedes religiosas 1 2 (49)
l. Toner relaciones positives (buenas) y l 2 (50)
estebles con su familia
m. Compartir con ibvenes I 2 (51 )
n. Enseher a otras personas I 2 (52)
lo que usted sabe
o. Obtener apoyodesusvecinos 1 2 (53)
p. Toner creencies rel igioses I 2 (54)
g Tener selud fisica I 2 (55)
r. Toner salud "emocional”( mental) I 2 (56)
S. Sentlrse um I 2 (57)

P-22. LTiene algun comentario sobre el Grupo de Ayuda Mutua que
desee hacerme saber?

 

 

227

V. Actitudes sobre la familia

P-23. Ahora voy a leer opiniones que usted puede haber oido antes
sobre como debe o no ser la familia. Me interesa mucho saber hasta
d6nde usted esta de acuerdo 0 en desacuerdo con cada una de las
siguientes opiniones.Las alternativas que podra utilizar estan en esta
tar jeta que 1e estoy entregando.(Completamente de acuerdo-1,De
acuerdo=2, Indeciso=3, En desacuerdo=4 y Completamente en

desacuerdo=5)
Padre CA DA 1 ED CD
a. El padre debe ser Ia figure de autoridad en la case i 2 3 4 5 (59)
b. Es mes importante obedecer a1 padrequeamerlo I 2 3 4 5 (60)
Hadre
c. Le madredebesersiampre mascarii‘iosaquealpedrel 2 3 4 5 (61)
d. to medre debe obedecer la volunted del padre 1 2 3 4 5 (62)
H1 103
a. Los hijos siempre deben obedecer el padre 1 2 3 4 5 (63)
f. Aunqueseesteenoiedoconlos pedreshayque 1 2 4 5 (64)
hacer su volunted por respeto

Composicion familiar
g. Le frase'Tomle familie"serefiaresglgmegtg i 2 3 4 5 (65)
a los padresylos hijos
h. Le fresa 'Todale femilie"serefiereePedres. I 2 3 4 5 (66)
hiios wualos/ebueles, sobrinos, tics, primes, pairings

lmportancia de la Familia

i. Esesencialileverse bienconle familia pare I 2 3 4 5 (67)
sentirse Dion
1. Es esencialsersiempreleelele familia para 1 2 3 4 5 (68)

sentirse bian

228

b. LCuantas personas forman su familia? (69)

c. LOuiénes? (70-71)
VI. Roles sexuales

P-24. Para cada una de las siguientes oraciones, quiero que me

indique hasta dende considera usted que representan caracteristicas que
el hombre y la mu jer puertorriquena deben mostrar. Estaremos usando las
opciones de la tar Jeta que le entregue para la pregunta anterior.
l.Cuan de acuerdo esta usted con la idea de que...

la mu jer el hombre
CADAIEDCD CADAIEDCD
a.Debeser débildecerecter 1 2 3 4 5 I 2 3 4 5 (1-2)

b. Debeserreligioso/e 2 3 4 S i 2 3 4 5 (3-4)
c.0ebeobedecerasuesposo/a I 2 3 4 5 I 2 3 4 5 (5-6)

‘

opadre/madre
doebesersentimentel l 2 3 4 5 I 2 3 4 5 (7-8)
e.Debecrleresushijos i 2 3 4 5 1 2 3 4 5 (9-10)
f.Debap1encher.lever,limpier i 2 4 5 I 2 3 4 5(11-12)
yhecertereescblacesa
g.DebetrebaIerfueredeIecesa I 2 3 4 5 I 2 3 4 5 (13-14)
h.Debetenercarecterfuerte I 2 3 4 5 I 2 3 4 5 (IS-I6)
i.DebelIorarsiestesufriendo I 2 3 4 5 I 2 3 4 5 (17-18)
I. Debetenermejortrabajoy I 2 3 4 5 I 2 3 4 5 (I9-20)
marmosdineroquasuasposo/a
k. Debevenerer odarmes I 2 3 4 S I 2 3 4 5 (21-22)
importencieasumwraquee
ninguneotrepersona
I. Debe'imponer'disciplinee I 2 3 4 5 I 2 3 4 5 (23-24)
sushijos
m. Deberesistirelmlorsin I 2 3 4 5 I 2 3 4 5 (25-26)
protester

n.8elirconparsonesdelsaxo I 2 3 4 5 I 2 3 4 5 (27-28)

229
opuesto we no seen su esposo/e
VI I. Punto dc Control

P'25. En I8 siguiente seccién VOY a leer pares de oraclones. UStEd
tiene 0803 par de oraCIones en I85 tarjetas QUC le 93(0)! entregando. De

cada par de oraciones espero que usted escoja aquella con la que
este mas de acuerdo.

Control personal

I. A Avecesheencontredome Iommsucede. ( 29)
B. Confier en el destino nunce me he selido ten bien como
tomar unadecisiﬁny tomar Wain.

2. A. Loquemesucedeemiesmmem (30)

B. A veces v0 siento que ere la
direcciOn que mi vida esta tomando.

3. A. Cuendo yo hego planes. estoy casi seguro/a de que mm(. 31)
1W

8. No siempre es sabio plenaar con mocha anticipacién, porque
mucous cosas WWW one term

4. A. En miceso,obtener loqueyoqueriatuvomm ( 32)
W

B. Muches veces uno debe decidir que hacer solamente mm
W.

5. A Muchesvecesyosientoquetenmmjnﬂmmjasobre (33)
lescosasquemewceden.

8. Me resulte 111112951qu las oportunidades 0 Jam
1W.

230

VIII. Religiosidad
P-26. LPertenece a algun grupo religioso o espiritual?1. Si 2. No (34)
b. (A cual? (35-36)

P-27. Voy a Ieerle ocho oraciones relacionadas con ideas religiosas.
Por favor indiqueme hasta dOnde usted esta de acuerdo con cada una. Puede
utilizar las opciones escritas en la tar jeta que le estoy entregandoy que
usamos anteriormente.

CA DA I ED 00
1. Peretener une buene vidaesnmrio I 2 3 4 5 (37)
tenor ideas religiosas y/o espirituales
2. Yo reelmente nose 51 Dies existe l 2 3 4 5 (38)
3. Les personas que no tienen ideas religiosas 1 2 3 4 5 ( 39)
pueden llever vidas moreles y utiles
4. Le existenciem les enfermedadesyel l 2 3 4 5 (40)
hembre en el mundo prueban que Dios no
existe.
5. Elquehayapazenelmundodependede I 2 3 4 5 (4i)
que todos los paises pertenezcan a one
misme religibn
6. Sin creeren Dios. la vidanotiene I 2 3 4 S (42)
significado
7. Siunolleve unavida bueneydecenteno l 2 3 4 5 (43)
ea necesario ir a ningune iglesie o templo.
8. Le educacibn religioso es esenciel 1 2 3 4 5 ( 44)
(indispensablel) para que las personas se

comporten morelmente en la socieded en que vivimos.

231

P-28. Antes de terminar esta entrevista me interesa conocer sobre sus
planes futuros en relaciOn a los servicios de salud mental.

a. LDesea o planea usted continuar relacionado con el centro de
salud mental? (4s) apor que o por que
no? (.46-47)

D. 8Cuan bien cree usted que estaria sin la ayuda del centro de salud
mental? (48) Lpor que o por que no?
(49-50)

c. (in que actividades de la comunidad le gustaria que el grupo de
ayuda mutua estuvlese envuelto?

 

(SI-52)
econ que asociaciones o grupos?
(53-54)

 

Muchas gracias por su cooperaciOn, si tiene alguna pregunta o
comentario sobre la entrevista, los grupos de ayuda mutua o sobre usted
que considera que yo debo conocer, por favor indiquemelo ahora antes de
dar por terminada esta entrevista.

 

 

 

Muchas Gracias
Esta secciOn debe ser completada al finalizar la entrevista:
Fecha (55-56)
Hora en que termino

 

Sexo: I. F emenino 2. Masculino (57)

232

NOmero que corresponde a la entrevista (58)

 

Notes

Circumstancias no usuales y comentarios

 

 

 

 

 

 

 

 

 

 

 

 

APPENDIX G
Coordinators' Questionnaire

233

General Information about the SOIT‘I‘IOID Group

MY NAME IS MILAGRITOS WNZALEZ AND I AM WORKING ON A NEEDS ASSESSMENT OF THE
MENTAL CLIENTS AND FAMILY MEMBERS IN THE SELF-HELP GROUPS. THE STUDY HAS BEEN
APPROVED BY THE OFFICE OF THE AUXILIARY DEPARTMENT OF MENTAL HEALTH. IF YOU AGREE
I AM WING TO ASK YOU 10 SHORT QUESTIONS ABOUT GENERAL INFORMATION ABOUT THE GROUP
THAT IS VERY IMPORTANT FOR THE DEVELOPMENT OF THE STUDY. NOTHING THREATENING OR
WFIDENTIAL WILL BE ASKED TO YOU. HOWEVER IF YOU DO NOT WANT To ANSWER ANY OF THE
QUESTIONS YOU ARE WMPLETELY FREE To SKIP IT OR To FINISH THE INTERVIEW. THANKS
AGAIN FOR YOUR COOPERATION AND IF YOU AGREE TO PROVIDE ME SOME INFORMATION, I NEED
YOU To SIGN THE FOLLOWING STATEMENT BECAUSE THESE INFORMATION WILL BE USED AS
PART OF THE RESEARCH.

I. l UNDERSTAND THAT MY PARTICIPATION IN THE STUDY HAS BEEN EXPLAINED To ME AND I
WILL BE REQUESTED TO ANSWER IO QUESTIONS IN A SHORT INTERVIEW.

2. I UNDERSTAND THAT MY PARTICIPATION IS COMPLETELY VOLUNTARY.

3. I HAVE BEEN INFORMED THAT I HAVE THE RIGHT TO WITHDRAW FROM THE STUDY 0R REFUSE
TO ANSWER ANY ITEM WITHOUT ANY NEGATIVE CONSEQUENCE OR ANY mMPLAINT.

 

 

SIGNATURE DATE

00 YOU WANT To PRWEED WITH THE SHORT INTERVIEW NOW?
00 YOU HAVE ANY QUESTIONS?
ARE THE GROUP'S MEMBERS CONSUMERS RELATIVES OR BOTH?
1. WHAT IS THE NAME OF THE GROUP?
2. HOW LONG HAS THE GROUP BEEN FORMED?
3. WHAT IS THE BEST ESTIMATE THAT YOU CAN MAKE OF THE AVERAGE OF ATTENDANCE TO THE
MEETINGS DURING THE LAST SIX MONTHS?
4. HOW FREQUENTLY DOES THE GROUP MEET?

 

 

234

5. mm ARE THE MEETINGS? DAV—TIME
6. DOES THE GROUP HAVE A PRESIDENT AND/OR A DIRECTIVE?
7. CAN YOU GIVE ME THE PHONE NUMBER OF THE PRESIDENT or THE GROUP OR or A MEMBER
or THE GROUP?
6. HAS THERE BEING NEw PEOPLE JOINING THE GROUP DURING THE LAST FOUR MONTHS?—
HOW MANY?
9. HAS THE GROUP BEEN MEETING REGULARLY DURING THE LAST SIx MONTHS?
lO.CAN YOU PLEASE DESCRIBE THE ACTIVITIES THAT THE GROUP HAS BEEN

CONDUCTING?

 

 

 

 

 

 

 

 

 

IS THERE ANY QUESTION THAT YOU WILL LIKE TO ASK ME OR ANY COMMENT ABOUT THE
SELF -HELP GROUPS THAT YOU WANT TO MENTION BEFORE WE FINISH THIS INTERVIEW?

 

 

 

THANK YW VERY MUCH FOR YOUR TIME AND (OPERATION.

 

DAY OF THE INTERVIEW TIME
TELEPHONE NUMBER
NAME OF THE RESPONDENT
OTHER PEOPLE CONTACTED IN THE OFFICE
DURATION OF THE INTERVIEW
ADDITIONAL COMMITMENTS

 

 

 

 

 

I‘IIII'I'IIIII .oI'IIII’ IIIIIIIIIIII