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The Effect of Client Ethnicity on Clinical Interpretation of the MMPI-2

Cara A. Knaster and Joseph A. Micucci
Assessment 2013 20: 43 originally published online 1 November 2012
DOI: 10.1177/1073191112465333
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465333AssessmentKnaster and Micucci
The Author(s) 2013

ASM20110.1177/1073191112

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The Effect of Client Ethnicity on

Clinical Interpretation of the MMPI-2

Assessment
20(1) 4347
The Author(s) 2013
Reprints and permission:
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DOI: 10.1177/1073191112465333
http://asm.sagepub.com

Cara A. Knaster1 and Joseph A. Micucci1

Abstract
Client ethnicity has been shown to affect clinicians diagnostic impressions. However, it is not known whether interpretation
of the Minnesota Multiphasic Personality Inventory2 (MMPI-2) clinical scales is affected by ethnic bias. In this study, clinicians
(82 males, 60 females) provided severity ratings for six symptoms based on three MMPI-2 profiles (representing the 27/72,
49/94, and 68/86 code-types) with the ethnicity of the client randomly assigned as either African American or Caucasian.
To determine whether symptom severity ratings based on MMPI-2 profiles were affected by ethnicity, a 3 (code-type) 2
(ethnicity) MANOVA was performed. Neither the main effect for ethnicity nor the ethnicity code-type interaction was
significant. These results indicated that the symptom severity ratings based on the MMPI-2 clinical scales were not affected
by the clients identification as African American or Caucasian. Future studies are needed to explore the interpretation of
profiles from clients representing other ethnic groups and for female clients.
Keywords
ethnicity, MMPI-2, clinical judgment, diagnosis, assessment

Research has shown that clinical judgment can be influenced by a clients cultural membership, socioeconomic
status, and ethnicity. Some studies have reported that clinicians are more likely to diagnose mental disorders in ethnic
minority clients than in Caucasian clients. Neighbors et al.
(1999) found that African American and Hispanic inpatients
were more likely to be diagnosed with schizophrenia compared with Caucasians. Luepnitz, Randolph, and Gutsch
(1982) reported that clinicians were more likely to diagnose
alcoholism in low socioeconomic status African American
clients compared with middle socioeconomic status Caucasian clients. Lewis, Croft-Jeffreys, and David (1990) found
that British psychologists were more likely to diagnose case
vignettes depicting Caucasian patients with schizophrenia,
whereas vignettes depicting an Afro-Caribbean client were
diagnosed with a substance-induced psychosis.
Other studies suggest that Caucasians are more likely to
be given diagnoses of mental disorders, whereas ethnic
minority clients are more likely to be given diagnoses of
behavioral disorders. Pottick, Kirk, Hsieh, and Tian (2007)
found that clinicians attributed antisocial behavior to delinquency in African American and Hispanic juveniles whereas
similar behavior was attributed to a mental health disorder
in Caucasian juveniles. Cohen et al. (1990) reported that
Caucasian children were more likely to be placed in an
inpatient psychiatric facility whereas African American
children were more likely to be placed in a juvenile corrections facility.

Although these studies suggest the presence of ethnic

bias in diagnosis of African American and Caucasian clients,
other studies have failed to find evidence for such bias in
diagnostic assessments or ratings of symptom severity based
on case histories or videotaped vignettes (Garb, 1998). It is
also not known if similar biases are present in the interpretation of objective personality tests, such as the Minnesota
Multiphasic Personality Inventory (MMPI/MMPI-2).
The purpose of this study was to examine whether a clients ethnicity influences clinicians interpretations of
MMPI-2 clinical scale profiles. This study focused on two
ethnic groups: Caucasians and African Americans. The aim
of the study was to determine to what extent clinicians ratings of symptom severity were influenced by the ethnicity
of the client.

Use of the MMPI/MMPI-2

With African Americans
The original version of the MMPI was standardized on an
ethnically homogenous sample of Caucasian residents of
Minnesota and included no members of ethnic minority
1

Chestnut Hill College, Philadelphia, PA, USA

Corresponding Author:
Joseph A. Micucci, Department of Professional Psychology, Chestnut Hill
College, 9601 Germantown Ave, Philadelphia, PA 19118, USA
Email: micucci@chc.edu

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44

Assessment 20(1)

groups (Dahlstrom, Welsh, & Dahlstrom, 1972). Despite the

homogeneous standardization sample, the MMPI was nevertheless used in the assessment of ethnic minority individuals. Gynther (1972) reviewed research that compared
African Americans and Caucasians on the MMPI and concluded that African Americans scored higher than Caucasians
on scales F, 7, and 8. Penk, Woodward, Robinowitz, and
Hess (1978) found that Caucasian heroin users obtained
higher scores on MMPI scales 2, 3, 4, 5, 7, 8, and 0 and
lower scores on scales L and K when compared with African
American heroin users. However, Greene (1987) observed
that most of the T-score differences among ethnic groups
were less than 5 points, a magnitude too small to be considered clinically significant. Thus, although there were differences among ethnic groups on the MMPI, these differences
were unlikely to be large enough to have a significant
impact on the interpretation of the instrument.
The revised version of the MMPI (MMPI-2) was normed
on a sample that was larger and more diverse than the original standardization sample (Butcher, Dahlstrom, Graham,
Tellegen, & Kaemmer, 1989). Nevertheless, some researchers continued to report differences between African
Americans and Caucasians on the test. Timbrook and
Graham (1994) found that African American men obtained
higher mean scores on scale 8 compared with Caucasian
men and that African American women obtained higher
mean scores on scales 4, 5, and 9 compared with Caucasian
women. However, none of these differences exceeded 5
T-score points and thus did not achieve Greenes (1987)
standard for clinical significance. Timbrook and Graham
also reported that the MMPI-2 scales were equally accurate
at predicting partner ratings for Caucasian and African
American men and women.
McNulty, Graham, Ben-Porath, and Stein (1997) found
that African American men scored higher than Caucasian
men on the L scale by more than 5 T-score points. African
American women scored higher than Caucasian women
on scale 9, but this difference was not considered clinically significant as it was less than 5 T-score points.
Moreover, the differences in MMPI-2 scores between
African Americans and Caucasians were consistent with
the differences observed on rating scales completed by the
participants therapists. McNulty et al. concluded that
MMPI-2 differences between African Americans and
Caucasians were not due to an ethnic bias in the MMPI-2,
but rather were indicative of valid personality differences,
at least insofar as they are described by therapists. Arbisi,
Ben-Porath, and McNulty (2002) reported that African
American men scored higher on scales F, 4, 6, 8, and 9
than Caucasian men. African American women scored
higher on scales 6 and 9. However, these differences did
not exceed 5 T-score points, and so were not clinically
significant according to the standard advocated by Greene
(1987).

Although these findings suggest that there are few consistent differences between Caucasian and African American
populations on the MMPI-2, it is not clear whether or how
interpretations of the MMPI-2 might be influenced by client
ethnicity. Because a clients ethnicity affects a clinicians
appraisal of diagnosis and prognosis, it might also affect the
interpretation of self-report psychological test results. This
study explored whether a clients assigned ethnicity influences clinicians interpretations of MMPI-2 clinical scale
profiles. The research question was the following:
Research Question 1: Will African American and Caucasian clients who have the exact same MMPI-2
clinical scale profile receive different ratings of
symptom severity?

Method
This study used a quantitative, quasi-experimental design
to investigate the possible impact of client ethnicity on
interpretation of the MMPI-2. Data were collected through
the Internet. The institutional review board waived documentation of consent, as this study did not ask for any
identifiable information from the participants.

Participants
There were two criteria for participating in the study:
(a) participants must be involved in the field of clinical
psychology as a practicing or retired clinician, a current
graduate student, or a course instructor; and (b) participants
must have completed an assessment course or continuing
education workshop that included training in interpreting
the MMPI-2, or must be teaching the MMPI-2 in a graduate
program. To ensure the necessary familiarity with the
MMPI-2, each participant was required to answer four out
of five questions correctly on an online proficiency exam
on the MMPI-2.
Prospective participants were recruited through a random sample of the online membership directories of the
American Psychological Association (APA) and the Society
of Personality Assessment (SPA). The APA online membership directory was sorted to include members who had
listed assessment as an area of interest. A random number
generator was used to sample the APA and SPA directories
separately without replacement. Four rounds of emails were
sent including 50 emails to APA and 25 to SPA members. A
total of 168 prospective participants logged onto the study
website. Of these, 10 opted not to participate. A total of 16
prospective participants were eliminated for failing to meet
the inclusion criteria or not passing the proficiency exam.
The final sample consisted of 142 raters (82 male, 60
female). The sample was homogeneous in terms of rater
ethnicity (126 Caucasian, 1 Asian, 3 Hispanic, 1 African

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Knaster and Micucci

Table 1. T-Scores for MMPI-2 Validity and Clinical Scales for
Constructed Profiles
Profile L

Hs

Hy Pd Mf Pa Pt Sc Ma Si

27/72 56 45 58 46 72 48 58 45 55 69 53 50 59
49/94 58 55 50 46 50 48 69 45 55 59 53 72 59
68/86 58 55 50 46 50 48 69 45 55 59 53 72 59
Note. L = Lie; F = Infrequency; K = Correction; Hs = Hypochondriasis (Scale 1);
D = Depression (Scale 2); Hy = Hysteria (Scale 3); Pd = Psychopathic Deviate (Scale 4); Mf = Masculinity/Femininity (Scale 5); Pa = Paranoia (Scale 6);
Pt = Psychasthenia (Scale 7); Sc = Schizophrenia (Scale 8);
Ma = Mania (Scale 9); Si = Social Introversion (Scale 0).

American, 6 multiethnic, and 5 declined to disclose). Raters

ranged in age from 24 to 89 years (median = 55). The raters
included 118 doctoral-level licensed clinicians, 5 doctorallevel unlicensed clinicians, 13 doctoral students with a masters degree, 1 doctoral student without a masters degree, 3
masters-level licensed clinicians, and 2 masters-level unlicensed clinicians. In terms of clinical experience, 19 (9.9%)
had completed a minimum of one practicum, 4 (2.8%) had
completed an internship, 8 (5.6%) reported less than 5 years
of experience, 23 (16.2%) reported 5 to 14 years of experience, and 93 (65.5%) reported more than 15 years of experience. Regarding experience with the MMPI-2, 92 (64.8%)
had more than 10 years experience, 24 (16.9%) had 5 to 10
years, 18 (12.7%) had 2 to 4 years, and 8 (5.6%) had less
than 1 year of experience.

Instruments
MMPI-2 profiles. We constructed three profiles representing depression/anxiety (27/72), psychosis (68/86), and antisocial personality disorder (49/94) in an attempt to cover a
range of psychological disorders (Table 1). All clients were
described as male to control for gender as a potential confounding variable. Two versions of each profile were prepared, one attributed to an African American client and the
other to a Caucasian client. The two profiles were otherwise
identical. To control for clients age, the 27/72 profile
was attributed to a 23-year-old client, the 49/94 profile was
attributed to a 25-year-old client, and the 68/86 profile was
attributed to a 21-year-old client.
Symptom Severity Survey. Participants were asked to indicate the severity of six symptoms on a 6-point Likert-type
scale by interpreting the MMPI-2 profile in light of the
demographic information provided. The symptoms were
anxiety, psychotic features, suicidality, depressed mood,
substance abuse, and antisocial behavior. The participant
was asked to identify if the symptom was Not Present (1),
Very Mild (2), Mild (3), Moderate (4), Severe (5), or Very
Severe (6). Symptoms were identified by these terms only
and no descriptions of the anchor points were provided.

Procedure
Prospective participants received an email that included
information about the study, criteria for inclusion, the webpage address of the study, an estimate of the time required
to participate (10-15 minutes), and a statement indicating
that a $1.00 donation per participant would be made to
either APA or SPA up to a maximum of $120.00. After providing informed consent by electronic signature, participants completed a demographic survey followed by the
5-item MMPI-2 proficiency test.
Participants then saw an MMPI-2 profile on the following screen along with the Symptom Severity Survey.
Participants were instructed to complete the Likert-type
scale by interpreting the MMPI-2 profile in light of the clients demographic information. Each participant viewed a
series of three profiles with identical directions for completing the Symptom Severity Scale. Random assignment controlled the order in which the profiles were presented as
well as the assigned ethnicity of each profile as determined
by the Internet survey software.
Each participant completed three Symptom Severity
Surveys. One Symptom Severity Survey was collected for
each MMPI-2 profile code type (27/72, 49/94, and 68/86).
Ethnicity was randomly assigned to each of these profiles.
For the 27/72 profile, there were complete ratings for 61
African American and 61 Caucasian clients. For the 49/94
profile, there were complete ratings for 67 African
Americans and 55 Caucasians. For the 68/86 profile, there
were complete ratings for 56 African Americans and 66
Caucasians. This distribution did not differ from equal
assignment to each of the six possible profile ethnicity
combinations, 2(5) = 2.00, p = .849.
Data were downloaded to a password-protected hard
drive and exported to SPSS for analysis after the survey had
been closed.

Results
Table 2 shows the means and standard deviations of the
Likert-type scale scores for each symptom given by raters
to the three profiles. A 3 (code-type) 2 (assigned ethnicity) MANOVA was used to analyze the data.
Boxs Test of Equality of Covariance Matrices was significant (Boxs M = 340.261, F[105, 200961] = 3.105, p <
.001). Therefore, Pillais Trace statistic was used. As anticipated, there was a significant main effect of the code-type
on the symptom ratings, Pillais Trace = 1.618, F(12, 712) =
251.15, p < .001, partial 2 = .809. There was not a significant main effect for assigned ethnicity on the symptom ratings, Pillais Trace = 0.12, F(6, 355) = .730, p = .626 partial
2 = .012. There was not a significant interaction effect
between the assigned ethnicity and code-type on the symptom ratings, Pillais Trace = .032,F(12, 712) = .955, p = .491

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Assessment 20(1)

Table 2. Means and Standard Deviations for Symptom Ratings

by Code Type and Assigned Ethnicity

Anxiety
AA
C
Psychotic Symptoms
AA
C
Suicidal Ideation
AA
C
Depressed Mood
AA
C
Substance Abuse
AA
C
Antisocial Behavior
AA
C

Code Type
27/72

Code Type
49/94

Code Type
68/86

3.97 (0.80)
3.84 (1.00)

2.03 (1.06)
2.02 (0.95)

2.91 (1.13)
2.71 (1.08)

1.18 (0.53)
1.41 (0.74)

1.42 (0.82)
1.45 (0.90)

3.96 (1.17)
4.03 (0.88)

2.93 (1.17)
2.89 (1.16)

1.40 (0.80)
1.49 (0.90)

1.95 (1.15)
1.83 (0.97)

4.36 (0.75)
4.21 (0.80)

1.34 (0.57)
1.44 (0.79)

1.63 (0.89)
1.65 (0.79)

1.79 (0.95)
1.93 (1.05)

3.01 (1.49)
3.02 (1.47)

1.89 (1.14)
1.79 (0.95)

1.62 (0.82)
1.66 (0.92)

3.84 (1.21)
4.22 (1.15)

1.93 (1.17)
1.76 (0.90)

Note. AA = African American; C = Caucasian. All participants submitted ratings on

all six symptoms. For the 27/72 code type, there were 61 AA and 61 C profiles
rated. For the 49/94 code type, there were 67 AA and 55 C profiles rated. For the
68/86 code type, there were 56 AA and 66 C profiles rated.

partial 2 = .016. The failure to find a statistically significant interaction effect between assigned ethnicity and codetype nor a main effect for assigned ethnicity denotes that
this study was unable to detect any effect of the assigned
ethnicity on clinicians interpretation of the MMPI-2 clinical scale profiles for these code-types as measured by the
symptom ratings.1

Discussion
This study found that the ethnicity (African American or
Caucasian) assigned to a client did not affect how experienced
clinicians interpreted his MMPI-2 clinical scale profile. Thus,
it appears that the raters were interpreting the MMPI-2 profiles in a manner consistent with the empirical literature
(Greene, 1987; Gynther, 1972; Timbrook & Graham, 1994),
which has found only small mean differences between
African Americans and Caucasians on MMPI-2 clinical and
validity scales. The finding that profile code-type yielded a
significant main effect confirms that clinicians were in fact
using the MMPI-2 data to arrive at their symptom ratings.
Previous literature has suggested that clinicians might
make biased judgments regarding diagnosis based on cultural membership, socioeconomic status, and ethnicity
(Cohen et al., 1990; Lewis et al., 1990; Luepnitz et al.,
1982; Neighbors et al., 1999; Pottick et al., 2007). Using
objective assessments such as the MMPI-2 can help

clinicians formulate less biased clinical judgments. Since

clinicians in this study interpreted MMPI-2 profiles from
Caucasian and African American clients similarly, the use
of objective assessment measures can potentially counteract the ethnic biases that affect clinical judgment and result
in more accurate assessment of their clients symptoms.
This study had several limitations. The size of the sample was adequate to detect a moderate to large effect size
attributed to client ethnicity, but it was not adequate to
detect a small effect size. The possibility remains that client
ethnicity might have had a small effect on clinician ratings.
However, it is important to note that a small effect size is
unlikely to have clinical significance. MMPI-2 scale differences less than 5 T-score points (1/2 standard deviation) are
not considered to have significant clinical implications
(Greene, 1987). Therefore, even if a small effect of client
ethnicity were to be present, it is unlikely to have a significant impact on profile interpretation.
The sample in this study was also largely homogeneous,
with less than 10% of the raters representing ethnic minority
groups. As it is possible that rater ethnicity might affect the
degree to which client ethnicity influences MMPI-2 interpretations, future studies should include a more diverse sample of clinicians. On the other hand, the recruitment method
(targeting members of APA and SPA) was not biased against
selecting participants of diverse ethnic backgrounds. The
skewed ethnic distribution of the sample might be a reflection of the skewed ethnic distribution in the profession rather
than an inherent weakness in the study design.
This study was limited to two assigned ethnicities
(African American and Caucasian), males, three code types,
and six symptoms. Future studies should include female clients, members of other ethnic groups, and other code types.
This study was limited to the MMPI-2 clinical scales and
cannot be generalized to other MMPI-2 scales, such as the
content scales, supplemental scales, and RC scales (Tellegen
et al., 2003). Future studies should investigate these scales
as well as the MMPI-2-RF (Ben-Porath & Tellegen, 2008).
Although the symptoms selected for the rating scale represent broad categories that are typically assessed in clinical
settings, it is possible that differences attributed to assigned
ethnicity might have been detected if other symptoms had
been included.
It was assumed that each participant paid attention to the
ethnicity assigned to each profile. The main effect of the
code-type variable supports that each rater used the MMPI-2
clinical scale data to evaluate symptom severity of the client; however, no check was instituted to monitor the raters
acknowledgment of the assigned ethnicity. Future studies
should include a method of ensuring that the rater was
attending to the provided demographic information. One
way to do so might be to ask participants to verify the ethnicity, age, or gender of the client whose MMPI-2 profile
they are rating.

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Knaster and Micucci

Despite these limitations, the results of this study suggested that raters interpretations are based on MMPI-2 clinical scale elevations and are not affected by the client being
identified as African American or Caucasian. Thus, this
study supports the continued use of the MMPI-2 clinical
scales with African American and Caucasian clients. Further
research is necessary to study other ethnic groups and to
explore whether there could be subtler ethnic biases at work
in interpretation of the MMPI-2 and other psychological
measures.
Acknowledgments
The authors wish to acknowledge the contributions of Katherine
Dahlsgaard and the late Stephen N. Berk to earlier versions of this
article.

Authors Note
This article is based on a doctoral dissertation completed by the
first author.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.

Funding
The authors received no financial support for the research, authorship, and/or publication of this article.

Note
1.

In response to a recommendation of a reviewer of this article,

results were analyzed separately for each code type. Results
were identical to those reported for the 3 2 MANOVA. For
the 27/72 code type, Pillais Trace = .053, F(6, 115) = 1.08,
p = .378. For the 49/94 code type, Pillais Trace = .045, F(6,
712) = 115, p = .492. For the 68/86 code type, Pillais Trace =
.029, F(6, 115) = .57, p = .754.

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