Thesis for the MAS in Humanitarian Action

Academic Year 2009/2010

Culturally competent humanitarian actors:

Addressing psychosocial wellbeing in refugees:

The case of Hmong children in the United States

Presented by : Nicole Weber

Jury Members:

Director of Thesis: Dr. Fidel Font

President of the Jury: Dr. Louis Loutan

Expert: Ms. Myrna Lachernal

Contact: nicoleweber12@gmail.com

June 2010

Abstract

Promoting psychosocial wellbeing in resettled child refugees presents many opportunities

and challenges for humanitarian actors. While psychosocial wellbeing has been identified as a

humanitarian concern to be addressed in populations, especially after prolonged emergencies there

are questions on how to provide the best evidence based approach. This paper will examine the

issue of psychosocial wellbeing and humanitarian action through the case study of the ethnic

group Hmong child refugee population in the United States. The different psychosocial

programming models are discussed along with the role of traditional medicine. Furthermore, the

importance of cultural competence, accountability, and evaluation in psychosocial programming is

stressed.

La promotion du bien-être psychosocial des enfants réfugiés réinstallés dans des pays d’accueil

présente de nombreuses opportunités d’actions et de défis pour les acteurs de l’humanitaire. Alors

que la question du bien-être psychosocial a été identifiée comme une préoccupation humanitaire

qui doit être prise en charge par les populations, surtout après une crise humanitaire prolongée, il

existe des interrogations sur la meilleure approche à mettre en place. Ce travail va examiner le

thème du bien-être psychosocial de l’individu et de l’action humanitaire à travers l’étude d’un cas

pratique ; les enfants réfugiés du groupe ethnique Hmong aux États-Unis. Il passera en revue les

différents modèles de programmes psychosociaux ainsi que le rôle de la médicine traditionnelle.

Enfin, cette analyse insistera sur l’importance de la compétence culturelle et de la responsabilité

ainsi que sur l’évaluation dans l’élaboration de programmes psychosociaux.

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Acknowledgements

I would like to acknowledge the support and expertise offered by my thesis director, Mr.

Fidel Font and by the jury members. I thank the teaching and administrative staff of the Geneva

Center for Education and Research in Humanitarian Action (CERAH) for the knowledge and

expertise they shared with me throughout the academic year. Thanks to my sister for bringing me

library books from Wisconsin and to my parents for their continued support as I study.

Furthermore, thank you to the Rotary Foundation for the incredible opportunity to spend the year

studying in Switzerland as a Rotary Ambassadorial Scholar.

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Table of Contents

Abstract 2

Acknowledgements 3

Chapter One: Introduction 5

Methodology 9

Humanitarian Action and Psychosocial Health 9

Cultural Competency and Humanitarian Actors 9

Chapter Two: Hmong History in Brief 10

Life in Hmong Refugee Camps: Example of the Wat Tham Krabok Camp 11

General Living Conditions 11

Psychosocial Health Situation in the Camp 12

Hmong in the United States 13

Hmong Resettlement into the United States 13

Hmong in Wisconsin 15

Chapter Three: Refugee Background in the United States 17

Chapter Four: Psychosocial Wellbeing in Refugees 20

Chapter Five: Psychosocial Wellbeing Planning Models 24

Clinical Treatment Model: 24

Ecological, Environmental, and Empowerment Models 26

Hmong and Psychosocial Health 28

Chapter Six: Traditional Hmong Health Services 31

Chapter Seven: Culturally Competent Psychosocial Services 32

Providing Culturally Competent Psychosocial Services in a Western Environment 33

Response to Psychosocial Health Needs: Case of Hmong Refugees in Wisconsin 33

Chapter Eight: Challenges to Psychosocial Health Services 35

Chapter Nine: Accountability and Evaluation 36

Chapter Ten: Conclusions 37

Bibliography 38

Appendix I: Map of Wat Tham Krabok Camp and Further Details. 45

Appendix II: Refugee Population in Wisconsin 46

Appendix III: Excerpt from the Sphere Minimum Standards in Health 47

Appendix IV: Excerpt: Child Development Theories 50

Appendix V: Cultural Competence Continuum 52

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Chapter One: Introduction

“Before the earth began, a man and a woman, who were brother and sister, lived in the

sky…Then the man and the woman had other children… Teng Chu, the older, held up the sky; and

Lolo Chu, the younger, who caused lightning and rain. Their last child was an egg. The man and

the woman waited three years for the egg to hatch, but nothing happened. So they broke open the

egg to see what was inside. Many, many people came from the egg, and they spread out over the

earth…The man who lived in the sky looked at all of his children and said, “We have made many

people to live on the earth; we have children who make music and dance and children who support

the sky and bring lightning and rain. We have done enough.” Then the man and his sister died

and went to earth to be human…Later, Lolo Chu’s wife had children and they were also eggs. They

waited nine years, but the eggs did not hatch. Lolo Chu sent a message to earth to ask his father

what to do. Mon Yalu returned to heaven and looked at the eggs. “Before I was born on earth, he

said, “your mother gave birth to eggs, and there were people inside. These eggs do not have

people inside, they are filled with evil spirits that will make people sick and die. To save the people

of earth, you should burn these eggs.”

Lolo Chu said, ”These eggs are my children; they are like my heart; I will keep them…one

year later, the eggs hatched. The evil spirits came out of the eggs and chased Lolo Chu and his

wife all over heaven, trying to eat them. His wife could not escape and she was eaten, but Lolo

Chu flew away to earth and was saved. “ I cannot have this,” said Lolo Chu; “I will make a hole

in the sky so the spirits will go to earth and leave me alone.” Lolo Chu cut a hole in the sky, the

evil spirits went to earth and people got sick and died for the first time. To help the people, Gao Tse

went to earth and taught them ua neeb1

( shamanism), so they could heal sickness2. (Numrich et al,

2002)

Defining and treating health conditions is a result of the cultural context in which the event

takes place. Kleinman et al differentiate between the concepts of ”disease” and “illness” by

stating that –illness is the way in which an individual interprets his or her experience with the use

of cultural categories and the influence of social relations whereas American health care providers,

1 A Shaman is an individual who is viewed as a healer who has received a supernatural power and can enter a trance to

negotiate between the two worlds (Vang, 1998). 2 From How Sickness Came To Earth, from Living Tapestries: Folk Tales from the Hmong (Author: C. Numrich)

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by focusing on disease rather than illness, concentrate only on the sick individual, and not on the

individual as part of a much wider social setting. Western medicine has evolved so that doctors

diagnose and treat disease; patients suffer illnesses (2006). Kleinmann also stresses the importance

of psychosocial and cultural dimensions that give illness content and meaning (Fadiman, 1997).

Humanitarian actors, working with diverse populations, and often in a cultural context different

from their own, need to have a set of skills in order to address the needs of their beneficiaries. One

of these skills is the ability to understand the cultural beliefs surrounding, in this case, health, in

order to better provide an intervention that is both evidence based and in line with the beliefs of

the target population.

This paper focuses on the long term perspective of mental health services as those provided

to refugee3

children in the resettlement4

country. This paper will focus on the case study of the

Hmong resettlement of school aged children (between the ages of five and eighteen) in

Wisconsin5, United States between 2004 and 2006. It will not include Hmong children born on

United States soil. The question posed by my paper is do the psychosocial programs serving

Hmong refugee children in Wisconsin provide culturally competent services that include the

integration of traditional medicine?

As children are in development6

stages, they are a particularly vulnerable population to

mental health distress. A traumatic incidence early on in life can have a lifelong impact if proper

psychosocial support is not provided. Studying refugee children in the United States as a target

population is particularly interesting to me as there are two psychosocial stress factors occurring:

recovering from the psychosocial health distress that is a result of the reason why the children are

refugees, and secondly the psychosocial stress of adapting to a new environment.

This paper will begin with a brief history of the Hmong population and their refugee camp

life before resettling into the United States. The paper will then focus on defining psychosocial

3 a person who is unable or unwilling to return to his or her country of nationality because of persecution or a well-

founded fear of persecution on account of race, religion, nationality, membership in a particular social group, or

political opinion ( section 101(a)(42) of the United States Immigration and Nationality Act)

4 The process of relocating a refugee from the country of first asylum to another country. Worldwide refugee

resettlement figures are very low; fewer than one percent of refugees will ever be considered and accepted for

resettlement. (US Dept. of State)

5 See Appendix II for a map outlining the distribution of refugees in the state of Wisconsin.

6 Please see Appendix IV for a brief outline on theories related to child development

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wellbeing and it will cover which identified characteristics the Hmong exhibit as psychosocial

capacities and as risk factors, their traditional medical approaches, and how these can be utilized by

humanitarian and health actors in compliance with programming models in order to provide

culturally competent care. Finally, the paper will finish with a brief discussion of accountability and

evaluation of psychosocial programming

Methodology

The methodology utilized included a review of the literature regarding past psychosocial

programming that has targeted refugees arriving in the United States, the consultation of

evidence based scientific journals, books, and the utilization of the information provided by the

World Health Organization Mental Health, Evidence, and Research (MER) system.

Researching psychosocial health needs following protracted humanitarian action situations includes

researching in the fields of sociology, psychology, anthropology, medicine, and political science. As

psychologist Renos K Papadopoulos states ”the phenomenon of refugeedom intersects a wide

variety of dimensions and is by no means exclusively of a psychological nature; it involves issues of

political (internal party politics as well as foreign policy), ethical, ethnic, religious, financial,

sociological, ecological nature, to name but a few. Consequently, a single approach to refugees

cannot possibly be sufficient to address its multifaceted complexity” (Papadopoulos, 2001).

Humanitarian Action and Psychosocial Health

The World Health Organization 2003 report on Mental Health in Emergencies outlines

eight general principles that humanitarian actors need to consider in their program planning and

evaluation to include sensitivity to mental health needs which include “preparation before the

emergency assessment, collaboration, integration into primary healthcare, access to services for

all, training and supervision, long term perspective and monitoring indicators” (WHO, 2003

Mental Health in Emergencies). As the WHO report states ―fundings for mental health programs

are highest during or immediately after acute emergencies, but such programs are much more

effective when implemented over a protracted time during the years following the emergency. It

is necessary to increase donor awareness on this issue‖ (WHO, 2003). Not only do donors need

to increase their awareness of mental health issues, but additionally, humanitarian actors need to

increase awareness as mental health programming is a recently recognized field.

Even though mental health issues are prevalent in the general population and even more so

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in situations of urgency and post emergencies, humanitarian actors did not provide psychological

support services until the 1990s during the war in the former Yugoslavia (Ahearn, 2000). The basis

for programming evolved from the premises that mental health is a human right and that the

resolution of the source of suffering could not occur without a focus on strengthening the societal

ties (Abramowitz & Kleinman, 2008).

Identified problems with past psychosocial humanitarian interventions include providing

services that were poorly coordinated, workers with insufficient training who implemented

projects that lacked minimum standards and coordination7, and organizations providing programs

without using a culturally and contextually appropriate framework (Abramowitz & Kleinman,

2008). There needs to be an emphasis on the efficiency and effectiveness of current mental health

interventions in humanitarian action situations along with a greater sensitization to cultural needs.

Mental health goes hand in hand with humanitarian action as mental health is a critical

component of an individual's overall wellbeing and is a critical component of the World Health

Organization's definition of health8. This mental health component is often overlooked in crisis

situations when physical needs (medical care, access to water, food, etc) are often prioritized, with

limited resources and time allocated to mental health interventions. But the prevalence of mental

health diseases, as demonstrated by the Global Burden of Disease Study, which presents

depression as the fourth leading morbidity burden in 1990 and with predictions to move to the

second leading disease burden in 2020, shows the relevance of mental health disorders and justifies

funding these pertinent interventions

When examining the ten leading causes of disability worldwide, we find that five are

psychiatric conditions (Mollica, 2004). Although some mental health diseases have organic or

physiological causes, a large percentage are caused by social and economic factors, which are

extremely prevalent in post-conflict situations (Global Health Watch, 2008, pg. 49).

7 For example, the World Health Organization identified that more than 100 organizations were working in mental

health and psychosocial support in Bosnia without adequate coordination (Abramowitz et al, 2008). 8 The WHO defines health as being a complete physical, mental, and social wellbeing.

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Cultural Competency and Humanitarian Actors

In the book, The Spirit Catches You and You Fall Down: A Hmong Child, Her American

Doctors, and the collision of Two Cultures, author Anne Fadiman describes the conflict between the

approach of Western practitioners and traditional Hmong healing along with the importance of being

culturally competent by a quote by Arthur Kleinman9

He states that “as powerful an influence as the

culture of the Hmong patient and her family is on this case, the culture of biomedicine is equally

powerful. If you can’t see that your own culture has its own set of interests, emotions, and biases, how

can you expect to deal successfully with someone else’s culture” (Fadiman, 1997).

The United States Office of Minority Health (OMH)10

defines cultural and linguistic

competence as “a set of congruent behaviors, attitudes, and policies that come together in a

system, agency, or among professionals that enables effective work in cross-cultural situations”

(Office of Minority Health, 2005).

Furthermore, in relation to humanitarian actors, the Inter-Agency Standing

Committee11(IASC) Guidelines on Mental Health and Emergencies lists the third core principle as

“Do No Harm” in which the importance of ―developing cultural sensitivity and competence in the

areas in which they [humanitarian actors] intervene/work‖ and the guidelines go on to state the

importance of having ―basic information about cultural attitudes, practices and systems of social

organization, as well as both effective and detrimental traditional practices, rituals and coping

strategies‖ (IASC, 2007).

Including cultural competency helps ease the tension between refugees and service providers,

which arises due to power differentials between the two groups as the “awareness of one’s own

cultural heritage, and of other cultures’ history, sociopolitical influences, normative values,

family/community structures, and diagnostic categories and assessment procedures, are critical to

providing culturally sensitive assessment and treatment” (National Child Trauma Center, 2003).

9 Medical anthropologist and professor in the Department of Anthropology, Harvard University.

10 Established in 1986 to improve and protect the health of racial and ethnic minorities to fight health disparities.

11 Established in 1992 in response to General Assembly Resolution 45/182, which called for strengthened coordination of

humanitarian assistance.

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Chapter Two: Hmong History in Brief

The Hmong are thought to be originally from what is present day Iraq and Syria. With time,

they migrated from the Middle East to areas including Turkestan, Russia, Siberia, Mongolia,

Manchuria, Hunan, Tibet, India, Burma, Tonkin, and China. In China, the Hmong (Miao) were

forced southwards and their land and homes were taken by the Han Chinese government. (Vang,

1998). At the beginning of the nineteenth century, about 500,000 Hmong migrated to Indochina

(Laos, Vietnam, and later Thailand) from China in order to escape persecutions, epidemics, rising

taxes and decreased agricultural yields. Even during modern times, they continue to be nomadic by

migrating back and forth across national borders (Powell, 1997, p.162)

In Indonesia, Hmong continued to practice agriculture, including opium as a cash crop.

Most were illiterate, living in autonomous villages in organized extended family clans (Powell,

1997 p 164-166).

In 1954, the Geneva Agreements divided Vietnam into North and South Vietnam. The

United States, concerned about the spread of communism, began military support to the Royal Lao

Governmental Forces. Bound by the 1954 Geneva Accord, the United States could not send troops

when the civil war broke out in Laos in 1958, so instead the Central Intelligence Agency (CIA)

trained a secret guerilla army composed of about 35,000 Hmong soldiers, known as the Hmong

Armée Clandestine. The official United States involvement began in August 1964 following the

shelling of an American destroyer by North Vietnamese troops with fighting continuing until the

ceasefire agreement and the withdrawal of United States troops in 1973. Civil war began again

between South and North Vietnam with Cambodia, Laos, and South Vietnam becoming Communist

in 1975 (Fong, 2004).

Estimates of Hmong casualties range from ten percent to fifty percent, including many

civilians killed by land mines, bombs, postwar massacres, hunger, and disease. By 1970, more than

one third of Hmong were Internally Displaced Persons (IDPs). Due to the Hmong involvement

with the defeated United States army, they fell under persecution with the Communist government.

On May 13, 14, and 15, 1975, 3000 Hmong servicemen and their families were evacuated to

Thailand by the United States government. This still left many Hmong behind who then fell

victims to atrocities that resulted in a mass exodus of Hmong walking to Thailand and into the

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jungle in Laos. Refugee camps began in Thailand for the 35,000 Hmong who arrived while there

was an estimated 15,000 Hmong who died en route. The Hmong have never had legal refugee

status in Thailand as this country is not a state party to the 1951 Geneva Convention relating to the

Status of Refugees and the additional protocol of 1967. The Hmong in Laos continue to be

persecuted until present day, as demonstrated by the Thailand government who has recently

deported to Laos, Hmong refugees who were recognized by the United Nations High Commission

for Refugees (UNHCR). This led to concerns due to their protection needs (UN High Commission

for Refugees, 2009). This continued persecution does not allow security for the Hmong population

and therefore the repatriation of many Hmong refugees is not a possibility, leaving resettlement

into a third country as the only option.

Life in Hmong Refugee Camps: Example of the Wat Tham Krabok Camp

Following the exodus of Hmong from Laos into Thailand, several refugee camps were

founded including the Ban Vinai, Nong Khai, Ban Nam Yao, and the Chieng camps. Since this

paper focuses on refugees resettled from the Wat Tham Krabok, the research focuses only on the

conditions at this camp.

General Living Conditions

As is the case with many refugee camp situations, living conditions in the Wat Tham Krabok

Camp, from where the latest group of Hmong refugees resettled in the United States originated, have

been harsh (see Appedix 1). In the 1990s, the Thailand government began closing Hmong refugee

camps (Grigoleit, G. 2007). These refugees were therefore concerned over being repatriated and

henceforth they were given sanctuary by the late Abbott, Phra Chamroon in the early 1990s in the

Wat Tham Krabok temple, which is known for its drug rehabilitation centre. The Hmong at the Wat

Tham Krabok Camp have never had legal refugee status and therefore, once outside of the

compound, their rights were not guaranteed. There had been many incidences in which they had been

exploited including high costs for health care and lack of access to work and education (Grigoleit, G.

2007).

When the abbot died in 1999, the treatment of the Hmong in the Wat Tham Krabok camp

changed drastically without his influential support. Beginning in 1997, the Thai governmental

officials began to be concerned about the growing size of the camp, which numbered close to

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35,000 to 40,000 Hmong. In 2003 a Thailand Task Force entered with the goals of preventing any

drug smuggling. The area was fenced off, with curfews, and Hmong were prevented from free

movement and the amount of those who could be employed outside the camp was reduced.

Psychosocial Health Situation in the Camp

Since the Wat Tham Krabok camp was not considered an official refugee camp, there is a

lack of concrete data regarding the demographics and more specifically the health situations in the

camp. A 2004 Delegation from the Hmong Resettlement Task Force found that there were currently

no psychosocial health services being offered to residents in the Wat Tham Krabok Camp and that

assessment interviews demonstrated that there was a need. Regarding the population focus of this

paper, elementary students were found to be anxious and to have worries regarding denies to

resettlement, integration into a new school system, and concerns over food security (Hmong

resettlement, 2004). Over 50% of the camp population were children with over half of them having

no access to formal education (IOM, 2004).

The Hopkins Symptoms Checklist12

(Hmong HSCL-25) conducted by the Hmong California

Resettlement Task Force found that in the 54 adolescents (aged 10 to 17) surveyed, fifteen percent

reported mild to moderate symptoms of mental health needs and eighty-five percent of adolescents

reported little to no symptoms. There was a reported concern though that as the resettlement

process began, there would be increased psychosocial health needs as many families would be

separated since over half the residents at the Wat Tham Krabok Camp had not been registered by the

Thai government and therefore were not eligible for resettlement (Hmong Resettlement Task Force,

2004).

In 2004, there was just one undersupplied medical clinic providing patient care and many of

the Hmong at the camp stated they did not use the services due to mistrust over corruption and fraud.

Most attended Thai clinics or traditional healers outside of the camp (HHS, 2010). This also needs to

be taken into account by humanitarian and health actors in the third country party (in this case, the

United States), as the previous healthcare experiences that the Hmong have and the negative

12

The HSCL-25 was originally designed in the 1950s, it measures symptoms for anxiety and depression and it has been

translated into Hmong. Mouanoutoua, V. et al found that the Hmong test provided a sensitivity of 100%, a specificity of

78% and an overall accuracy of 89%, therefore rendering it an appropriate screening tool for the Hmong population

(1999).

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connotation they associate with health clinics affect how they manage their health needs.

Hmong in the United States

The 2000 United States Census numbered Hmong at 170,049 or .06 percent of the United

States population. The first Hmong resettlement occurred in 1976 with the first major wave of about

50,000 between 1979-1980 and the second wave taking place during 1987-1989 with approximately

28,000 refugees entering the United States. Although several other countries have accepted Hmong

refugees, including France, Canada, Australia, Argentina, French Guiana, and others, the majority of

them have been resettled in the United States due to past military ties (Fadimann, 1997).

Hmong Resettlement into the United States

The Wisconsin Bureau of Migrant, Refugee, and Labor Services document the seven steps

that the Wat Tham Krabok Camp refugees faced when applying for resettlement into the United

States. They were first provided with information, underwent registration with the UNHCR and had

the IOM Drug Test (for those over age 14), then had the U.S. Embassy Refugee Unit Interview in

order to prepare case file and the U.S. Department of Homeland Security interview for United States

admission. This was then followed by a IOM physical examination, an IOM one week cultural

orientation, and IOM transport to the United States. Only those who were registered by the Thailand

government were eligible to be considered for resettlement. This posed a problem for some Hmong

as due to mistrust of the Thai government and due to rumors that this registration would force them

back to Laos or be force them to move to a military camp, caused many Hmong to not register and

therefore rendered them ineligible (Grigoleit, 2006).

In order to facilitate assimilation and to “avoid burdening any one community with more

than its fair share of refuges” (Fadiman, 1997, p.185), the United States Immigration and

Naturalization Services (INS) created a scatter placement plan in which Hmong clans were broken

up. Most were settled into urban areas to provide access to employment and to receive social

services. Unfortunately, most Hmong lacked typical job skills upon arrival with many of them being

former soldiers and farmers with low literacy and educational levels (Fong, 2004). Furthermore, the

forced break-up of the clans caused many Hmong to migrate to different zones of the United States

to form again their clans.

In 2000, The Hmong Veteran’s Naturalization Act of 2000 (114 Stat. 316) facilitated

applying for naturalization for Hmong veterans by providing an exemption from the English

language requirement and special consideration for civics testing for certain refugees from Laos.

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The law limited the number of beneficiaries to 45,000 (U.S., 2004).

The 2000 United States Census outlines several demographic characteristics of the

Hmong population which included larger than average household size, higher rates of poverty

with a lower median family income, higher rates of individuals without a high school diploma,

housing tenure (ownership) and a lack of command of the English language. The table below

outlines these characteristics between the total population in the United States and the Hmong

population.

Table 1: Selected Demographic Characteristics of the Hmong population in the U.S.A

Characteristic Total Pop. Hmong Pop.

English spoken ―less than very well‖ 8.1% 58.6%

Poverty 12.4% 37.8%

Household size 2.59 6.14

Education: Less than High School graduate 19.6% 59.6%

Median Family Income $50,046 $32,384

Housing Tenure: Unit Owned 66.2% 38.7

Source: U.S. Census Bureau, Census 2000 special tabulation

These socioeconomic characteristics help us understand more about the Hmong population

and also some of the risk factors that can harm psychosocial well-being. As research by Dr. Hudson

demonstrates by the large scale longitudinal study of individuals, socioeconomic characteristics

such as economic displacement, unemployment, and housing dislocation are three major

contributing factors to mental health disease (Hudson, 2005).

There are several additional factors that also have been identified as risk factors for harming

psychosocial wellbeing including being dependent on welfare assistance, level of expectations

before arrival to the United States, and continuous county migrations in search of clan members and

in search of a life similar to that beforehand (Cha, 2003).

Gensheimer states that before accessing Western mental health services; Hmong often

pursue help for problems through their family and clan system, and through the use of traditional

healing methods, including tshuaj ntsuab (herbs), treatment by kws tshuaj (medicine doctor) or kws

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khawv koob (ritual healers), the tus txiv neeb, (shaman), or through a soul calling ceremony (hu plig)

(2006). Some evolving therapeutic practices of Hmong demonstrate the conversion to Christianity

as some now use prayer for serious illnesses. These traditional forms of Hmong

medicine will be further covered in Chapter Five.

Hmong in Wisconsin

Between June and December 2004, twenty one percent of the total Hmong resettled from

the Wat Tham Krabok arrived to Wisconsin totaling 1,941 new Hmong refugees (Grigoleit, 2006).

In 2001, 70% of Hmong school aged children were identified as having Limited English

Proficiency (University of Wisconsin-Extension, 2003). They joined the already present Hmong

population of 33,781 (U.S. Census, 2000). As demonstrated by the graphic below, the Hmong

population is composed in percentage by a much larger younger population than the total

Wisconsin population, with 57.1 percent of the Hmong population in Wisconsin being under age

18 (University of Extension –Wisconsin, 2003). According to the 2006 American Community

Survey, Wisconsin remains the third most Hmong populous state with 38,949 Hmong (USDA,

2007).

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Figure 1: Age-Sex Pyramid of the Hmong Population in Wisconsin (University of WI, 2000)

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Chapter Three: Refugee Background in the United States

In 2009, the United States was the leading industrialized country for being a recipient of

asylum requests with receiving thirteen percent of all applications (UNHCR, 2010). The

Displaced Persons Act of 1942 was the first United States legislation that addressed the issues of

refugees primarily for Eastern Europeans. Legislation that followed included the Refugee Relief

Act of 1953, the Fair Share Refugee Act of 1960, and the Indochinese Refugee Act of 1977.

The Refugee Act of 1980 gave the direction for the Section 101 (a) (42) of the United

States Immigration and Nationality Act (INA), which defines refugees and asylum seekers. A

refugee is defined in United States law as a “person who is unable or unwilling to return to his or

her country of nationality because of persecution or a well-founded fear of persecution on account

of race, religion, nationality, membership in a particular social group, or political opinion”. This

follows the international definition of refugee as contained in the 1951 United Nations

Convention relating to the Status of Refugees and its 1967 Protocol (Jefferys, K., 2008). In order

to quality for refugee status, an individual must meet the additional criteria of being of

special humanitarian concern13

to the United States and not be firmly resettled in any foreign

country. The refugee admission ceiling is determined by the President of the United States,

following consultations with the Executive Branch and Congress (Office of Refugee

Resettlement, 2010).

The number of admitted refugees has decreased over the past twenty years. At the United

States Senate Subcommittee on Immigration in February 2002, Senator Edward M. Kennedy

remarks in his opening statement that “the decline in admissions cannot be attributed entirely to

the war on terrorism. Well before the terrorist attacks, and in fact over the last decade, actual

refugee admission numbers have been far below the level approved by the Administration in

consultation with Congress”. In the 1980s around 200,000 refugees were resettled into the United

States and in 2009 only 74,602 were accepted (United States Congress, 2002). ArthurDewey14

,

responded by stating that refugee admissions were already on the decline before September 11,

13

As was the case with the Hmong population they had supported the United States military efforts during the

Vietnam war. 14

Assistant Secretary of State for the Bureau of Population, Refugees, and Migration,

18

200115 due to costs that were exceeding public and private funding. Leonard S. Glickman

16

commented that the U.S. Refugee Program had become less accessible prior to September, 11,

2001 due to increased bureaucratic processes with using only primarily UNHCR registered

refugees and a decreased acceptance of refugees through the family reunification resettlement

process (United States Congress, 2002).

The below figure demonstrates the fluctuations that there are in admitted refugees in the

United States according to the years with a gradual increase of refugee admissions in the 2006 to

present day period (Martin, 2010).

Figure 2: Source: U.S. Department of State, Bureau of Population, Refugees, and

Migration (PRM) Worldwide Refugee Admissions Processing System (WRAPS).

Key players in refugee resettlement include the United Nations High Commission for

Refugees (UNHCR), the International Organization of Migration (IOM), the Department of

15

Date of Al-Qaeda terrorist attack on the United States World Trade Center‘s Twin Towers and the Pentagon 16

Chair, Refugee Council USA and President and CEO, Hebrew Immigrant Aid Society

19

State, the Department of Homeland Security, the Office for Refugee Resettlement (HHS), and the

Centers for Disease Control (CDC), along with Voluntary Resettlement Agencies (VOLAGs),

Mutual Assistance Associations (MAAs), state refugee coordinators, and state and local

governments. The United States priority admissions are outlined in the Refugee Act of 1980. The

annual report to Congress includes a situation overview, admissions priorities, and the budget.

Priorities in ranking are individual cases, groups, and individual family reunification cases.

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Chapter Four: Psychosocial Wellbeing in Refugees

There are many stressors that are identified in the refugee child population. Refugee

children are at a high risk for rape and exploitation while in the refugee camp situation. Some

suffer separation of the family or loss of family members, which can particularly be a stressor

when they are the head of the household and the child must then fulfill this role (Boyden, de

Berry, Feeny, & Hart, 2002).

Once a child refugee is resettled into a third party country, psychosocial stressors persist.

Often, children assimilate and learn the language more rapidly than their parents and therefore are

often relied on to translate documents, and facilitate transactions that are normally only adult

affairs‖. This power in the terms of the language can create a situation of role reversal and loss of

identity (Zhou, 2001). Child refugees who integrate into the educational system in the United

States must also face cultural barriers and adapt to a system that often differs from their home

country or their holding country.

According to the National Center for Child Traumatic Stress, a child refugee is normally

considered to go through three phrases with distinct characteristics during their experience as

demonstrated in the below table and graphic (2003).

Table Two: Stages of a Refugee Experience and Associated Psychosocial Challenges

Stage Psychosocial Stressors and Challenges

Pre-Flight Separation of children from parents and family, exposure to insecurity, violence,

and hunger, disruption of educational system and social services

Flight17

Separation from parents and caregivers, uncertainty about the future, reliance on

others for provision of basic needs, interruption of education and fulfillment of

basic needs

Resettlement Adjustment to a new environment, language, educational system, social

networks, disruption of values and cultural beliefs

17

Includes time spent in refugee camps, which is important to note especially in prolonged refugee camp situations,

such as the Hmong in Thailand who have lived in the camps, some for more than 30 years.

21

Figure 3: The Experience of a Refugee (Papadopoulo, 2001)

For many child refugees who are born in refugee camps, only the transition and post-

arrival phrases can impact their psychosocial well being. In the case of the Hmong, due to the

prolonged existence of the refugee camps (beginning in 1976), it is critical to consider the

situation of the camp life in Thailand and the pre-departure and departure

phases are not as relevant . Defining Psychosocial Well being―The word ―psychosocial‖ captures the interrelation

between psychology (individual thinking, emotions, feelings and behaviour) and the social

world or environment in which we evolve (culture, traditions, spirituality, interpersonal

relationships in the family or community, and life tasks, such as school or work)‖ (IASC

Handbook for the Protection of IDPs).

Figure 4: Psychosocial wellbeing: the capacity to deploy resources from three core domains:

(Psychosocial Working Group, 2003)

22

The distinction between mental health and psychosocial wellbeing is essential to mention.

The World Health Organization defines mental health as “a state of well-being in which the

individual realizes his or her own abilities, can cope with the normal stresses of life, can work

productively and fruitfully and is able to make a contribution to his or her community,” whereas

psychosocial incorporates a broader spectrum into mental health by placing an importance on the

environment.

The Sphere Minimum Standards for Health Services18

(2004) identifies the Control of

Non-communicable Diseases Standard Three: Mental and Social Aspects of Health as that

“people have access to social and mental health services to reduce mental health morbidity,

disability, and social problems”. The Sphere Handbook goes on to say the importance

psychosocial interventions followed protracted emergencies (such as would be the case of the

Hmong after living for years in the precarious refugee camp environment) of Community-based

psychological interventions: interventions should be based on an assessment of existing services

and an understanding of the socio-cultural context. They should include use of functional, cultural

coping mechanisms of individuals and communities to help them regain control over their living

circumstances. Collaboration with community leaders and indigenous healers is recommended

when feasible. Community based self-help groups should be encouraged‖ (Sphere Handbook,

2004).

Morris et al, critiques the Sphere Standards and their applicability to the child population

by stating that no child focused literature review has been completed of any Sphere Standard and

that “recommendations for mental health and psychosocial interventions in guidance documents

are based on expert opinion rather than research” (2007). The article goes on to argue that most

suggested interventions come from the clinical Western model which concentrates on individuals

or subgroups displaying signs of distress or symptoms and use methods that are primarily

intra-psychic in nature, such as cognitive restructuring and emotional processing of the

traumatic event instead of considering the social and cultural consequences of exposure to

catastrophic events or appreciate children‘s resilience or indigenous ways of coping (2007).

This demonstrates that although psychosocial wellbeing support programs are generally

acknowledged as being necessary for children following traumatic events (natural catastrophes,

armed conflict, etc), there is considerable debate on the manner in which these services should be

23

provided in order to be culturally competent. There are two principle groups of theories: the

Clinical Treatment Models and the Ecological, Environmental, and Empowerment Models.

18

See Appendix III for an excerpt from the Sphere Minimum Standards for Health Services

24

Chapter Five: Psychosocial Wellbeing Planning Models

Clinical Treatment Model:

The Clinical Treatment Model focuses on the conceptualization of suffering through the

idiom of psychopathology, and particularly post-traumatic stress disorder. This has been

supported by an increasing body of evidence establishing elevated rates of symptom reportage

associated with potential PTSD diagnosis in war-affected populations. The American Psychiatric

Association's definition of Post Traumatic Stress Syndrome as defined in the DSM-IV as follows:

(b) “depressive reactions (thought to relate to life events); (c) somatic symptoms (not always

related to physical injury); and (d) the existential dilemma (a collection of profound attitudinal

changes which may endure for many years and interfere with close relationships”.

Criticisms of the PTSD Model: Further Victimizing the Victim?

Anthropologist Allan Young19 argues that the PTSD model is a result of historical and

political constructions due to a political struggle by psychiatrists to provide services to Vietnam

veterans (1997) and that its applicability should be held in question. Summerfield20 argues also

that “PTSD was as much a socio-political as a medical response to the problems of a particular

group at a particular point in time, yet the mental health held rapidly accorded it the status of

scientific truth, supposedly representing a universal and essentially context-independent entity.

This was to say, then, that from the beginning of history, people exposed to shocking experiences

had been liable to a psychiatric condition which only in 1980 had been fully discovered and

named” (1999).

Young goes on to state that using the clinical model places the victim into a passive role

and the attending expert into the authority role and undermines the capacities of the refugee, above

all in interventions targeting children. Children are portrayed as passive victims only, and

not as active survivors when interventions focus on the Western constructions of childhood which

rely on factors, assumed to be universal, including innocence, vulnerability and dependence and on

Western understanding of what is desirable and pathological in child health, welfare and

development (1999). Ma further argues that the application of the PTSD model signifies that the

19

McGill University anthropologist and professor in Social Studies in Medicine 20

Honorary senior lecturer at London‘s Institute of Psychiatry and a teaching associate at the Refugee

Studies Centre at the University of Oxford

25

trauma is already in the past, whereas Hmong refugees, “have difficulty putting the trauma, so to

speak, behind them since they remain in the thick of a disorienting labyrinth, with its linguistic and

cultural puzzles, their own heavy dependency on welfare and other social programs, homesickness

and a gnawing sense of impotence, dissolution of traditional lifestyle and values, American racism

and discrimination, and gradual Americanization of the younger generations” (Ma, 2005). This idea

is reinforced by the work of Pfatt. An additional example is given by Pfaff (1995) who summarizes

the new challenges faced by the Hmong refugees in their relocation to the United States:

Packing horrible memories of war and flight, they left behind squalid refugee

camps to begin lives in a highly industrialized, technologically driven consumer

society. They faced significant linguistic, educational, economic, cultural and

racial barriers, which created confusing, embarrassing, and even frightening

situations in their daily lives. Most had never lived in a house with plumbing or

electricity and had little familiarity with common household appliances.

Automobiles, telephones, televisions, and computers - icons of modern American

life - had remained on the periphery of their experience. With a world view which

valued, first and foremost, the welfare of the family and group, Hmong refugees

attempted to cultivate the land of the "rugged individual" (p. 65).

Another criticism of the clinical model is that labeling individuals as PTSD cases turns a

normal reaction to a stressor into pathology, and that is does not take into account language and

ethno culture differences on how events are signified, communicated, and processed (Friedman,

M. & Jaranson, J., 1994).

However, M. Friedman, & J. Jaranson, go on to state that while PTSD has been criticized

for its applicability to the refugee populations, they believe that this approach can be beneficial

when it is modified for the ethno-cultural appropriateness and it is complemented by traditional

healing methods (1994).

26

Ecological, Environmental, and Empowerment Models

In contrast to the biophysical clinical treatment models, other psychosocial approaches that

have been utilized include those that are focused on the ecological, environmental, an

empowerment approaches. Instead of focusing on the individual as a victim with a disease or

pathology, these strategies focus more on the capacities of the individual and their environment

and how they can be used to cope with the psychosocial stressors. Three theories that I will discuss

include the Community Mobilization Strategy, the Ecological Approach, the Strengths Based

Approach, and the Explanatory Model.

The Community Mobilization Strategy is the conceptualization of activity more in

relation to community resources and the re-establishment of pre-existing coping strategies.

(Psychosocial Working Group, 2003) Professionals working with Hmong populations using this

model should consider the approaches that the Hmong used to deal with psychosocial stressors

even before arriving to the United States.

The Ecological Approach considers the refugee’s current environment and life situation

and also the environment and life situation prior to emigration when assessing and intervening. It

places an emphasis on understanding people and their environment and the nature of their

transactions. The important concepts of the ecological approach include transactions, good fit

between people and their environments and adaptation which are defined in the below table.

Table Three: Concepts of the Ecological Approach

Transactions Continuous reciprocal exchanges integral to relationships in which people and

environments influence, shape, and sometimes change each other

Good Fit Humans strive throughout life for the best fit between

their needs, rights, capacities, and aspirations and the qualities of their

environment. If the fit is not good, they may change themselves or their

environment, which is known as adaptation

Adaptation An active process of self-change or environmental change or both.

An example for the Ecological Approach is the consideration of the psychosocial wellbeing

of those in the surrounding environment of the Hmong youth. An example would be the wellbeing

27

of the parents and family. The National Center for Child Trauma Stress states that

―within families, fathers’ long-term unemployment (more than six months)

in the first year of settlement, mother’s emotional well-being, and family negativity are

associated with increases in refugee children’s symptomatology‖ (2003).

Another approach that humanitarian actors can utilize in approaching the promotion of

psychosocial wellbeing is the Strengths Based Approach. In this approach, the focus is on the

capacities, talents, competencies, possibilities, visions, values, and hopes of the population instead

of on their risk factors and weaknesses. (Fong, 2004, p. 136) In the case of the Hmong, identified

strengths include resilience cultural values, rich cultural tradition, Hmong temperament, and

spirituality centered. These traits are defined and detailed in the below table.

Table Four: Identified Hmong Strengths According to the Strengths Based Approach Model

Resilience: The ability to transcend adversities of war and

relocation

Cultural Values Family and clan centered resulting in social

supports and safety nets in times of crisis and

need

Rich Cultural Tradition Passing of beliefs, values, and practices from one

generation to the next orally, using stories and

narratives and more recently written works

Hmong Temperament Independent, insular, anti-authoritarian,

suspicious, stubborn, proud, choleric, energetic,

vehement, loquacious, humorous, hospitable,

generous

Spirituality Centered Practice of ancestral worship and animism21

,

Balance and Harmony with the earth and the

surrounding world

Furthermore, there is the Explanatory Model (Fadiman, 1997). Kleinmann recommends

asking eight questions before beginning programming and adapting that program to the answers

21

Practice of offering animals for protection and for soul exchanging (Vang, 1998)

28

given. The questions are as follows:

1. What do you call the sickness?

2. What do you think caused the problem?

3. Why do you think it started when it did?

4. What do you think the sickness does? How does it work?

5. How severe is the sickness? Will it have a short or long course?

6. What kind of treatment do you think the patient should receive? What are the most

important results you hope to receive from this treatment?

7. What are the chief problems the sickness has caused?

8. What do you fear the most about the sickness?

Asking these questions to the child and the child‘s family when providing psychosocial care

allows the beneficiary to be involved in their own care and allows the individual to address his or her

needs and desires.

Hmong and Psychosocial Health

Widely published research linking the refugee experience to a fragile state of mental health

first occurred after World War II and demonstrated the connection between the severity of the

trauma experienced and the psychiatric breakdown (Tribe, 2002). Further extensive research was

conducted following the retreat of the American military from the Vietnam conflict.

There are several different factors upon resettlement into a third party country that influence

a refugee’s state of psychosocial health. Factors identified by Fong, 2004 are found at the macro,

meso, and micro-level, as demonstrated in Table Four. There are also concerns that Hmong have

identified, which include the formation of young gangs, economic self-sufficiency, intergenerational

and intercultural conflicts. All of these concerns relate back to psychosocial wellbeing and can be

addressed by appropriate programming.

29

Table Five: Identified Factors Influencing Hmong Psychosocial Wellbeing

Macro-level Meso-level Micro-level

Meso-level Micro-level

Poverty Role Reversal Head of Household Role

Discrimination/Racism Husband-Wife Tensions Loss of Authority

Immigration Laws Grandparent relations Conflicts due to illiteracy

Languages Questions of Abandonment/Loyalty

Early Maturation due to necessity to

interpret for Parents

Perhaps one strong example of the stress caused by adjustment to life in the United States

can be demonstrated by the quote from Hmong mother Kia Vue from the book by Lillian

Faderman, I Begin My Life All Over: The Hmong and the American Experience. Kia Vue states that

“coming here [the United States], I have become helpless. Everything I do I just depend on

my children. Whatever I need, I just have to wait and wait until they do it for me…I am like my

four year old girl—and she even writes her name better than I could write my name” (175).

Vue goes on to say that she feels like a ”helpless mother” and that the “American society has

not been good for all of us. Our children are joining gangs and getting in trouble, like stealing cars or

killing someone. For me, I am very frustrated that these children do not see what their parents have

done to get them here. I don’t think that joining gangs and things like that is a nice way to thank us

parents” (175).

This role reversal and helplessness felt by parents is a critical factor in influencing the

psychosocial wellbeing and the behavior of their children. Faderman states that in pre-arrival, the

Hmong family had a clear hierarchy with the children at the bottom, whereas upon arrival, this

hierarchy has been completely broken (Faderman, 1998, p.164). The consequences of this

breakdown are outlined by Walker-Moffat who related the involvement of Hmong into gangs as

result of seeing their elders as irrelevant role models. The recent rise in juvenile delinquency among

Hmong adolescents suggests that the sense of security provided by the Hmong clan system no longer

meets the demands of survival in American streets and schools, and that some youths are turning to

their peers instead of their elders and extended family for security (Walker- Moffat, 1998, p.98)

30

Table Six: Concerns among Hmong Population of Psychosocial Risks and Results

Identified Concern Description

Youth Gangs Increasing Delinquency rates, socioeconomic contributing factors,

children lost and caught between two worlds (Fong, 2004)

Economic Self

Sufficiency

Hmong believe that a person’s worth is not measured by how much

money he or she has, but by the size of the family and wisdom

possessed

Intergenerational and

Intercultural Conflicts

Issues due to changed family dynamics and include parental

authority, modes of teaching and punishment, views on American

cultural, role reversal, gender-specific roles and expectations (Lo,

2001)

Research has demonstrated the prevalence of psychosocial needs among the Hmong

population and that this need is prolonged. A large community sample of Southeast Asian refugees,

including Hmong, in the United States found that the refugee camp experiences were significant

predictors of psychological distress even five years or more after migration (United States Public

Health Surgeon, 2001). Another study of Southeast Asians found that 70 percent of participants had

met the diagnostic criterion for Post Traumatic Stress Disorder with the Hmong from Laos and

Cambodia having the highest prevalence.

Another study in Minnesota that examined the mental health of 404 Southeast Asian

refugees (including Hmong, Laotian, Cambodian, and Vietnamese) found that 73 % had major

depression, 14 % had post-traumatic stress disorder, and 6 % had anxiety and somatoform

disorders (Kroll et al., 1989).

31

Chapter Six: Traditional Hmong Health Services

Hmong Shamans have practiced traditionally for more than 4000 years in China and

200 years in Laos (Vang, S., 1998). In his work, Vang states that becoming a Shaman is not a

personal choice, but rather is considered as the person who has received a higher power from

above with an obligation. The duties of the Shaman are to cure and to be a negotiator between

the two worlds (Vang, 1998). Shamanist, or “ua neeb” in Hmong, forms a part of animism

and spiritualism in the Hmong culture.

Helsel et al, states that Hmong newly arrived to the United States may seek out

shamans to connect to their culture and family in order to feel healthy and for a holistic

approach. The usage of communal shamanic activities can help alleviate the sadness of the

shared losses that the Hmong have experienced before, during, and after the refugee process

(2004).

Helsel et al goes on to state that “the ―restless spirits‖ of dead parents, spouses, and

children left behind in Laos were frequently identified by shamans as sources of illness; this

interpretation may be part of a cultural expression of the pain of their losses and their

ongoing uncertainty that coming to America was the best thing for them, their families and

their culture. Many Hmong Americans apparently share the sentiments expressed by one

who noted: ―Laos still remains deep inside me” (2004).‖

“Many Hmong believe that simply talking about an illness means that they are asking

the illness to occur. This belief is closely tied to the emphasis on sustaining harmonious

relationships with the spiritual world to maintain health and well being. It is believed that

many diseases are caused by dabs, or bad spirits which, when offended, can cause pain,

disease, or misfortune‖” (Reznik, Cooper, MacDonald, Benador, & Lemire, 2001).

32

Chapter Seven: Culturally Competent Psychosocial Services

The American Association of Medical Colleges has defined the goals of cultural

competency as “an awareness of self and one’s own value system; an understanding of the

concept of culture and its role as a factor in health and health care; a sensitivity to cultural

issues for each patient and an understanding and ability to use specific methods to deal

effectively with cultural issues in interacting with individual patients, their families, members

of the healthcare team and the wider community” (Reznik, Cooper, MacDonald, Benador, &

Lemire, 2001).

The Cultural Competence Continuum

The below graphic demonstrates the different stages in which practitioners find

themselves, ranging from the cultural destructiveness in which programming they provide

views culture as a problem and promotes activities which destroy the culture to cultural

proficiency in which programming holds diversity of cultures as a important factor that can

benefit programming22

Figure 5: The Cultural Competence Continuum (SAMSA)

22

See Appendix V for a description on the other stages of the Cultural Competence Continuum

33

Providing Culturally Competent Psychosocial Services in a Western Environment

The mental health approach in the United States tends to approach the situation

with an individualistic view of self. The values that are greatly valued include

independence, the ability to express one’s self and autonomy (Global Health Watch 2,

2008). Another feature in the Western model is the collection of symptoms that are then

used to diagnose the patient and therefore determine their treatment.

A Hmong public health specialist and cross cultural trainer; Bruce Thowpaou

Bliatout, states that the most important factor in providing care for the Hmong population is

to provide a conjoint treatment in which Western approaches are integrated into traditional

healing practices, especially to improve mental health. He also states that refugees need to be

given more opportunities to help themselves, that clans should be promoted to be reunified,

and to use bilingual and bicultural interpreters (Fadimann, 1997).

The importance of providing culturally competent mental health services to Hmong

was already recognized by the United States federal government and local health authorities

when in the mid-1980s, the Nationalities Service of Central California in Fresno received a

short term grant to provide an integrated mental health delivery service utilizing Hmong

healers and western mental health providers.‖ Shamans were hired and 250 patients were

treated (Fadiman, 1997). Unfortunately, due to lack of continued funding, this program was

not financially sustainable.

Response to Psychosocial Health Needs: Case of Hmong Refugees in Wisconsin

Between June 2004 and May 2006, the state of Wisconsin has received the last group

of Hmong refugee families that will be resettled into the United States from camps in

Thailand. This was the single largest influx of refugees that Wisconsin has received (Sanders,

2006).

The Hmong Resettlement Task Force Report to Wisconsin’s Governor Jim Doyle in

2005 identified mental health as a priority area stating that one priority was to “develop and

sustain linguistically and culturally competent mental health services, which shows the

recognition by the state of the importance of psychosocial programming” (Hmong

Resettlement, 2005).

The 2005 Hmong Resettlement Task Report to Wisconsin state Governor Jim Doyle

stated that the state government would offer up to seven mental health grants in order to aid

34

the new Hmong refugees. The purpose of the grants will be to develop and maintain the

infrastructure necessary for community-based, bilingual/bicultural mental health services to

provide a community Mental Health Education program, a culturally adapted Mental

Health Assessment Tool, additional financial support from Medical Assistance, insurance,

bi-lingual, bi-cultural case-management and treatment programs; and cultural competency

training for psychosocial health service providers.

The grant would also require establishment of an Advisory Committee for each

geographic region, which includes Hmong leadership, to monitor and report on the

progress of mental health infrastructure development to the State of Wisconsin.

35

Chapter Eight: Challenges to Psychosocial Health Services

The Interagency Standing Committee (IASC) on Task Force on Mental Health and

Psychosocial Support in Emergency Settings has identified several challenges for

humanitarian actors in addressing psychosocial wellbeing. These challenges include:

1. Lack of mental health structures in certain locations

2. Lack of trained medical interpreters

3. Lack of specialized personnel in governmental services or in the aid community

4. Lack of understanding of, and respect for cultural norms and practices, which can

cause harm if responses are inappropriate

5. Lack of donor awareness and lack of funding for mental health projects.

When providing psychosocial health services to Hmong child refugees, there are

several very pertinent challenges that have been identified. Fadiman clearly outlines the

challenges faced in regard to cultural and linguistic barriers (Fadiman, 1997). Health

professionals use many mental health conditions and much specialized vocabulary that have

no clear equivalence in Hmong language. Timm identifies several conflicts between

mainstream American values and Hmong values which include strong clan oriented society,

tradition of bringing personal decisions to clan elders for advice and a willingness to follow

the advice given, a tradition of arranged and early marriages, a belief in spirits and animistic

religious beliefs and ancestor worship (Timm, 1994). These conflicts present humanitarian

actors with a challenge: to treat a target population who has values differing from their own.

This challenge demonstrates the i evidence-based models which help to distance the

practitioner from projecting his or her own values onto the psychosocial programming.

Furthermore, there is the stigmatization attached to psychosocial issues and therefore

many children will have underlying psychological disorders, but they will manifest these

problems through psychosomatic reactions by complaining of vague chronic pains including

headaches, insomnia or hypersomnia, abdominal pain, anorexia, myalgia, and nausea which

can cause the practitioner and the child to lose time while searching for a medical reason for

the pain (National Center for Child Traumatic Stress, 2003).

36

Chapter Nine: Accountability and Evaluation

Along with the provision of humanitarian aid and health services to vulnerable

populations, there is always the question of efficiency and accountability. As editor Frederick

L. Ahearn, Jr. states in the introduction of the book Psychosocial Wellness of Refugees: Issues

in qualitative and quantitative research, ”most agree that researchers and practitioners alike,

need to defend the assumptions of their psychosocial programs and demonstrate the efficacy

and appropriateness of their interventions through a careful application of research that

definitions and program outcomes may be clarified, which in turn will fuel the discussion of

policy, planning and funding of psychosocial programs” ( Ahearn, 2000). Ahearn goes on to

state that although the need for psychosocial health services in refugee populations is now

being widely recognized, there is a lack of accountability and a lack of monitoring and

evaluation.

Although there has been an increase in the amount of financial and professional

support in mental health programming for the Hmong refugees in the United States, there has

been a lack of accountability and evaluation of these programs due to financial and time

constraints. This presents a challenge for practitioners to know whether or not the needs of

their population are being met and it also presents a challenge when asking for additional

funding.

37

Chapter Ten: Conclusions

Although the Hmong are facing a rapid population growth in the United States, they

remain among the most understudied racial/ethnic groups especially in the area of public

health (Johnson, 2002). For humanitarian actors to provide competent services, there needs

to be adequate research, evaluation, and accountability of programs to ensure that the needs

of the population are being met. In order to provide culturally competent services to a

population, the focus needs to be set on raditions rather than focusing on a strictly clinical

model; it is important to include the ecological and empowerment approaches.

Humanitarian actors work with populations in need who have undergone both acute

and prolonged stressful situations. One such population is composed of the 10.5 million

refugees worldwide of whom the UNHCR is concerned (UNHCR, 2009). With the number of

prolonged complex conflicts on the rise and with the increase of the frequency and intensity of

natural disasters, the humanitarian actors need to prepare for the increased number of refugees

in need of psychosocial programming. In the case of the Hmong population, the information

and models provided demonstrate what was already recognized in the Fresno program in the

mid 1980s. Providing an ecological, strengths-based approach that incorporates traditional

medical practices allows humanitarian actors to address the needs of the Hmong population in

a manner that is sensitive, effective, and in a manner to which they are receptive. Culturally

competent psychosocial well-being promotion is critical in order to provide resources for

Hmong children, improve the quality of life, and deal with the identified concerns including

for example youth gangs and intergenerational conflicts

38

Bibliography

Abramowitz, S. & Kleinman, A. (2008). Humanitarian intervention and cultural translation.

International Journal of Mental Health, Psychosocial Work and Counselling in Areas of

Armed Conflict. Volume 6, Number 3/4, Page 219 – 227

Aheam, F. (2000 ). Psychosocial wellness of refugees: Issues in qualitaive and quantitative

research. Oxford: Berghahn Books.

Barr, D. & Wanat, S. (2005). Listening to patients: Cultural and linguistic barriers to health

care access. Journal of Clinical Research and Methods. Vol 37: No.3

Cha, D. (2003). Hmong American concepts of health, healing, and conventional medicine.

London: Taylor & Francis Books.

Chan, S. (1994). Hmong Means Free. Philadephia: Temple University Press.

Council, J. & Loehrke, J. (2004) The Hmong migration. Gannett News Services. Retrieved 10

May 2010 from http://www.wisinfo.com/legacy/thailand/images/thailandmap.PDF

Duncan, J., & Amtson, L. (2004). Children in Crisis: Good practices in evaluating psychosocial

programming. Save the Children.

Extension, University of Wisconsin. (2003). Wisconsin's Hmong Population. Retrieved May

20,2010, from University of Wisconsin: Appleton:

http://www.apl.wisc.edu/publications/HmongChartbook.pdf

Faderman, L. (1998). I begin my life all over: The Hmong and the American immigrant

experience. Boston: Beacon Press

Fadiman A. (1997). The spirit catches you and you fall down: a Hmong child, her American

doctors, and the collision of two cultures. New York: Farrar, Straus, and Giroux.

39

Flick, U. (1998). The social construction of individual and public health: Contributions of

social representations theory to a social science of health. Social Science Information

37: 639-662

Fong, R. (2004). Culturally competent practice with immigrants and refugee children and

families. London: Guildford Press

Fox, R. (2005). Cultural competence and the culture of medicine. New England Journal of

Medicine. 353:13

Force, H. R. (2004). Wat Tham Krabok (WTK) summary report. Fresno.

Friedman, M. & Jaranson, J. (1994). The applicability of the Postraumatic Stress Disorder

concept to refugees. Admist peril and pain: The mental health and well being of the

world’s refugees. Washington D.C.: American Psychiatric Association

Gensheimer, L. (2006) Learning from the experiences of Hmong mental health providers.

Hmong Studies Journal. 7:1-31. Global Health Watch 2. (2008). London: Zed Books

Ltd. .

Goodkind J. & Hang, P. & Yang, M. (2004) Hmong refugees in the US: A community based

advocacy and learning intervention. In The Mental Health of Refugees: Ecological

Approaches to Healing and Adaptation. Miller, K. & Rasco, L. (eds).

Goodkind, J. (2006). Promoting Hmong refugees‘ well-being through mutual learning:

Valuing knowledge, culture, and experience. American Journal of Community

Psychology, Vol. 37, Nos. 1/2, March 2006

Green, J., & Labonte, R. (2008). Critical perspectives in public health . London: Routledge

Tayon and Francis Roup .

Grigoleit, G. (2006) Coming home? The integration of Hmong refugees from Wat Tham

Krabok Thailand into American society. Hmong Studies Journal,7:1-22.

Helsel, D., Mochel, M., & Bauer, R. (2004). Shamans in a Hmong American community.

Journal of Alternative and Complementary Medicine. Vol. 10. Num:6, p.p 933-938

40

Holtz, C. (2008). Global health care issues and policies. London: Jones and Bartlett Publishers.

Hudson, C. (2005). Socioeconomic status and mental illness: Tests of the social

causation and the selection hypotheses. American Journal of Orthopsychiatry. Vol. 75,

No. 1, 3–18

Inter-Agency Standing Committee. (IASC). (2007). IASC guidelines on mental health and

psychosocial support in emergency settings. Geneva: IASC.

Inter-Agency Standing Committee (IASC) (2008). Mental Health and Psychosocial Support:

Checklist for Field Use. Geneva: IASC.

Jefferys, K., & Martin, D. (2008). Refugees and Asylees:2007. Retrieved March 20, 2010, from

DHS Office of Immigration Statistics: http://www.dhs.gov/

xlibrary/assets/statistics/publications/ois_rfa_fr_2007.pdf

Johnson, S. (2002). ―Hmong health belief and experience in the Western health care system.‖

Journal of Transcultural Nursing, 12(2):126-132.

Kleinman, A., Eisenber, L.,& Good, B. (2006). Culture, illness, and care: Clinical lessons from

anthropologic and cross culture research. American Psychiatric Association.

Kroll, J., Habenicht, M., Mackenzie, T., Yang, M., Chan, S., Vang, T., Nguyen, T., Ly, M.,

Phommasouvanh, B., Nguyen, H., Vang, Y., Souvannasoth, L., & Cuagao, R. (1989).

Depression and post-traumatic stress disorder in Southeast Asian refugees. American

Journal of Psychiatry, 146, 1592–1597.

Lee, K., & Collins, J. (2005). Global change and public health. London: Open University Press.

Lee, S. (2007). The self-rated social well-being of Hmong college students in Northern

California. Hmong Studies Journal, 8: 1-19.

Ma, Sheng-Mei.(2005). Hmong refugee‘s death fugue. Hmong Studies Journal, 6: 1-36.

Martin, D. (2010). Refugees and Asylees: 2009. Annual Flow Report. United States

Department of Homeland Security. Office of Immigration Statistics. Retrieved 01 May,

2010 from http://www.dhs.gov/xlibrary/assets/statistics/publications/ois_rfa_fr_2009.pdf

41

Mollica, R., Cardozo Lopes, B., Osofsky, H., Raphael, B., Ager, A., & Salama, P. (2004).

Mental health in complex emergencies. Lancet , 2058-67.

Mouanoutoua, V., & Brown, L. (1995). ―Hopkins Symptom Checklist-25, Hmong version: A

screening instrument for psychological distress.‖ Journal of Personality Assessment: 64.

376-383.

Morris, J., van Ommeren, M., Belfer, M., Saxena, S., & Saracenol, B. (2007). Children and the

Sphere standard on mental and social aspects of health. Disasters,31(1): 71−90.

National Child Traumatic Stress Network Refugee Trauma Taskforce. (2003) Review of child

and adolescent refugee mental health. Boston: Massachusetts

Ngo, B., Bigelow, M., & Wahlstrom, K. (2007). The transition of Wat Tham Krabok Hmong

children to Saint Paul public schools: Perspectives of teachers, principals, and Hmong

parents. Hmong Studies Journal. Vol. 8. p.p. 1-35.

Numrich, C., & Yongyuan Wu, C. (2002). Hmong Shamanism and Hmong health care choices.

Health Communities Conference. Minneapolis: Minnesota. Retrieved 20 May 2010 from

http://www.crosshealth.com

Office of Minority Health. (2005). What is cultural competency? United States Department of

Health and Human Services. Retrieved 20 May 2010 from

http://minorityhealth.hhs.gov/ templates/browse.aspx?lvl=2&lvlID=11

Papadopoulos, R. (2001). Refugee families: Issues of systemic supervision. Journal of Family

Therapy : 23: 405-422

Perez, M., Gonzalez, A., Pinzon-Perez, H. (2006). Cultural competency in health care systems:

A case study. California Journal of Health Promotion. Vol 4: No.1. p.p. 102-108

Perrin, P. (1996). War and public health: Handbook on war and public health. Geneva:

International Red Cross Committee.

Pfaff, T. (1995). Hmong in America: Journey from a secret war. Eau Claire, WI: Chippewa

Valley Museum Press.

42

Pinzon-Perez, H., Moua, N., & Pérez, M.A. (2005) ―Understanding satisfaction with

Shamanic practices among the Hmong in rural California.‖ The International Electronic

Journal of Health Education. 8:18-23. Retrieved May 20, 2010 from

http://www.aahperd.org/aahe/publications/iejhe/loader.cfm?csModule=security/getfile&pageid=

38876

Psychosocial working group. (2003). Psychosocial intervention in complex emergencies.

Edinburg: United Kingdom. Retrieved January 20, 2010 from

http://www.forcedmigration.org/psychosocial/papers/Conceptual%20Framework.pdf

Reeves, T., & Bennett, C. (2000). We the people: Asians in the United States. Washington,

D.C. : United States Government Census .

Reznik, V., Cooper, T., MacDonald, D., Benador, N., & Lemire, J. (2001). Hais cuaj txub kaum

txub–To speak of all things: A Hmong cross-cultural case study. Journal of Immigrant

Health, 3(1), 23–30.

Roy, A. (2009). The practice of international health. Oxford: Oxford University Press . Sanders,

J. (2006). The new face of refugee resettlement in Wisconsin: What it means for

physicians and policy makers. Wisconsin Medical Journal , Vol 105. No. 3.

Secrist, J. (2006). Perceptions and Knowledge of Hmong High School Students Regarding

Mental Health. University of Wisconsin-Stout Research thesis. Retrieved 20 May 2010

from http://www.uwstout.edu/static/lib/thesis/2006/2006secristz.pdf

Sphere Project (2004). Sphere Handbook: Humanitarian Charter and Minimum Standards in

Disaster Response. Retrieved 12 June 2010 from http://www.unhcr.org/refworld

Strategy, U. C. (2004). Citizenship in the United States. Retrieved May 20, 2010, from United

States Citizenship and Immigration Services Office of Policy and Strategy :

http://www.uscis.gov/files/nativedocuments/Citizenship_2004.pdf

Stubbs, P. (2005). Transforming local and global discourses: Reassessing the ptsd movement in

Bosnia and Croatia. Forced migration and mental health. NewYork: Springer Science &

BusinessMedia (pp. 53-66).

43

Summerfield, D. (1999). A critique of seven assumptions behind psychological trauma

programmes in war-affected areas. Social Science & Medicine: 48 . 1449±146

Summerfield, D. (1995). Addressing human response to war and atrocity: Major challenges in

research and practices and the limitations of Western psychiatric models. New York:

Plenum Press

Sveaass N. & Reichelt, S. (2001), Refugee families in therapy: From referrals to therapeutic

conversations. Journal of Family Therapy 23: 119-135.

Timm, J. (1994). Laotian Hmong students and American education: Meeting special needs and

challenges. Paper presented at the American Educational Research Meeting, New

Orleans.

Tribe, R. (2002). Mental health of refugees and asylum seekers. Advances in Psychiatric

Treatment .8: 240-247

UNHCR. (2009). Asylum levels and trends in industralized countries. Retrieved May 20, 2010,

from UNHCR: http://www.unhcr.org/4ba7341a9.html

UN High Commissioner for Refugees. (2009). Deportation of Lao Hmong must stop. Retrieved

20 May 2010 from http://www.unhcr.org/4b38d1049.html

United States. Congress. Senate. Committee on the Judiciary. Subcommittee on

Immigration(2002). Empty seats in a lifeboat : are there problems with the U.S. refugee

program? : hearing before the Subcommittee on Immigration of the Committee on the

Judiciary, United States Senate, One Hundred Seventh Congress, second session,

February 12, 2002. Washington : U.S. G.P.O., 2002:

United States Department of Health and Human Services. (2004). Background on potential

health issues for Hmong refugees from Wat Tham Krabok (pp. 1–21): Bridging Refugee

Youth and Children‘s Services Clearinghouse.

United States Public Health Surgeon (2001). Mental health: Culture, race, and ethnicity. A

supplement to mental health: A report of the Surgeon General. U.S. Public Health

44

Service. Retrieved May 20, 2010 from

http://www.surgeongeneral.gov/library/mentalhealth/cre/

United States Public Health Surgeon (1999). Mental health: A report of the Surgeon General.

Chapter 3: Children and mental health. U.S. Public Health Service. Retrieved May

20,2010 from http://www.surgeongeneral.gov/library/mentalhealth/pdfs/c3.pdf

Upham, A. (2008) Wisconsin Refugees. Wisconsin Department of Children and Families.

Retrieved March, 11, 2010 from http://dcf.wisconsin.gov/refugee

Van Ommeren, M., Saxena, S., & Saraceno, B. (2005). Mental and social health during and

after acute emergencies: emerging consensus? . Geneva: World Health Organization.

Vang, S. (1998) Hmong perceptions and behaviors regarding Shamanic practices and Western

medicine. University of Wisconsin-Stout. Retrieved May 20, 2010 from

http://www.uwstout.edu/static/lib/thesis/1998/1998vangs.pdf

Walker-Moffat, W. (1995). The other side of the Asian success story. San Francisco: Jossey-

Bass

Walker, M.T. (2006). The Social Construction of Mental Illness and its Implications for the

Recovery Model. International Journal of Psychosocial Rehabilitation. 10 (1), 71-87

Wisconsin Bureau of Migrant, R. a. (2004, April 28). Wat Tham Krabok processing

procedures. Retrieved May 20, 2010, from URSW: http://www.ursw.org/news.articles.cfmf

Yang, K. (2003). Hmong Americans: A review of felt needs, problems and community

development. Hmong Studies Journal. 4: 1-23

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Appendix I: Map of Wat Tham Krabok Camp and Further Details

Source: (Council, et al, 2004)

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Appendix II: Refugee Population in Wisconsin

Source: Upham, 2008

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Appendix III: Excerpt from the Sphere Minimum Standards in Health

Services

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Appendix IV: Excerpt: Child Development Theories

Development Viewed as a Series of Stages

Freud and the psychoanalyst Erik Erikson proposed a series of stages of development reflecting

the attainment of biological objectives. The stages are expressed in terms of functioning as an

individual and with others—within the family and the broader social environment (particularly in

Erikson‘s theories). Although criticized as unscientific and relevant primarily to the era and

culture in which they were conceived, these theories introduced the importance of thinking

developmentally, that is, of considering the ever-changing physical and psychological capacities

and tasks faced by people as they age. They emphasized the concept of ―maturation‖ and moving

through the stages of life, adapting to changing physical capacities and new psychological and

social challenges. And they described mental health problems associated with failure to achieve

milestones and objectives in their developmental schemes. These theories have guided generations

of psychodynamic therapists and child development experts. They are important to understand as

the underpinnings of many therapeutic approaches, such as interpersonal therapy, some of which

have been evaluated and found to be efficacious for some conditions. By and large, however, these

theories have rarely been tested empirically.

Intellectual Development

The Swiss psychologist Jean Piaget also developed a stage-constructed theory of children‘s

intellectual development. Piaget‘s theory, based on several decades‘ observations of children was

about how children gradually acquire the ability to understand the world around them through

active engagement with it. He was the first to recognize that infants take an active role in getting

to know their world and that children have a different understanding of the world than do adults.

The principal limitations of Piaget‘s theories are that they are descriptive rather than explanatory.

Furthermore, he neglected variability in development and temperament and did not consider

the crucial interplay between a child‘s intellectual development and his or her social experiences

Behavioral Development

Other approaches to understanding development are less focused on the stages of development.

Behavioral psychology focused on observation and measurement, explaining development in

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terms of responses to stimuli, such as rewards. Not only did the theories of the early pioneers

(e.g., Pavlov, Watson, and Skinner) generate a number of valuable treatments, but their focus on

precise description set the stage for current programs of research based on direct observation.

Social learning theory emphasized role models and their impact on children and adolescents as

they develop. Several important clinical tools came out of behaviorism (e.g., reinforcement and

behavior modification) and social learning theory (cognitive behavioral therapy). Both treatment

approaches are used effectively with children and adolescents‖ (United States Public Health

Surgeon, 1999)

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Appendix V: Cultural Competence Continuum

(Excerpt from the SAMHSA‘s report on Developing Cultural Competence in Disaster Mental Health Programs: Guiding Principles and Recommendations) The continuum includes six stages: cultural destructiveness, cultural incapacity, cultural

blindness, cultural pre-competence, cultural competence, and cultural proficiency.

Cultural Destructiveness The negative end of the continuum is characterized by cultural destructiveness. Organizations or

individuals in this stage view cultural differences as a problem and participate in activities that

purposely attempt to destroy a culture. Examples of destructive actions include denying people of

color access to their natural helpers or healers, removing children of color from their families on

the basis of race, and risking the well-being of minority individuals by involving them in social or

medical experiments without their knowledge or consent. Organizations and individuals at this

extreme operate on the assumption that one race is superior and that it should eradiate lesser

cultures.

Cultural Incapacity Organizations and individuals in the cultural incapacity stage lack the ability to help cultures from diverse communities. Although they do not intentionally seek to cause harm, they believe in the

superiority of their own racial or ethnic group and assume a paternalistic posture toward lesser

groups. They may act as agents of oppression by enforcing racist policies and maintaining

stereotypes. Employment practices of organizations in this stage of the continuum are

discriminatory.

Cultural Blindness

Cultural blindness is the midpoint of the continuum. Organizations and individuals at this stage

believe that color or culture makes no difference and that all people are the same. Individuals at

this stage may view themselves as unbiased and believe that they address cultural needs. In fact,

people who are culturally blind do not perceive, and therefore cannot benefit from, the valuable

differences among diverse groups. Services or programs created by organizations at this stage are

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virtually useless to address the needs of diverse groups.

Cultural Pre-competence

Culturally pre-competent organizations and individuals begin to move toward the positive end of

the continuum. They realize weaknesses in their attempts to serve various cultures and make some

efforts to improve the services offered to diverse populations. Pre-competent organizations hire

staff from the cultures they serve, involve people of different cultures on their boards of directors

or advisory committees, and provide at least rudimentary training in cultural differences.

However, organizations at this stage run the risk of becoming complacent, especially when

members believe that the accomplishment of one goal or activity fulfills the obligation to the

community. Tokenism is another danger. Organizations sometimes hire one or more workers

from a racial or ethnic group and feel that they have done all that is necessary.

Cultural Competence

Culturally competent organizations and individuals accept and respect differences, and they

participate in continuing self-assessment regarding culture. Such organizations continuously

expand their cultural knowledge and resources and adopt service models that better meet the

needs of minority populations. In addition, they strive to hire unbiased employees, and seek

advice and consultation from representatives of the cultures served. They also support their staff

members‘ comfort levels when working in cross-cultural situations and in understanding the

interplay between policy and practice.

Cultural Proficiency

Culturally proficient organizations hold diversity of culture in high esteem. They seek to add to the

knowledge base of culturally competent practice by conducting research, developing new

therapeutic approaches based on culture, and publishing and disseminating the results of

demonstration projects. Culturally proficient organizations hire staff members who are specialists

in culturally competent practice.