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: [email protected] 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.

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 Methodology Humanitarian Action and Psychosocial Health Cultural Competency and Humanitarian Actors

5 9 9 9

Chapter Two: Hmong History in Brief Life in Hmong Refugee Camps: Example of the Wat Tham Krabok Camp General Living Conditions Psychosocial Health Situation in the Camp Hmong in the United States Hmong Resettlement into the United States Hmong in Wisconsin

10 11 11 12 13 13 15

Chapter Three: Refugee Background in the United States

17

Chapter Four: Psychosocial Wellbeing in Refugees

20

Chapter Five: Psychosocial Wellbeing Planning Models Clinical Treatment Model: Ecological, Environmental, and Empowerment Models Hmong and Psychosocial Health

24 24 26 28

Chapter Six: Traditional Hmong Health Services

31

Chapter Seven: Culturally Competent Psychosocial Services Providing Culturally Competent Psychosocial Services in a Western Environment Response to Psychosocial Health Needs: Case of Hmong Refugees in Wisconsin

32 33 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

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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 wellfounded 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 7

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).

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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. 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. 10

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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 10

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 11

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. 13

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 14

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,

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200115 due to costs that were exceeding public and private funding. Leonard S. Glickman16 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 16

Date of Al-Qaeda terrorist attack on the United States World Trade Center‘s Twin Towers and the Pentagon Chair, Refugee Council USA and President and CEO, Hebrew Immigrant Aid Society

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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.

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Figure 3: The Experience of a Refugee (Papadopoulo, 2001) For many child refugees who are born in refugee camps, only the transition and postarrival 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) 21

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 22

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

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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 Honorary senior lecturer at London‘s Institute of Psychiatry and a teaching associate at the Refugee Studies Centre at the University of Oxford 20

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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).

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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 26

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)

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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.

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Table Five: Identified Factors Influencing Hmong Psychosocial Wellbeing Macro-level

Meso-level Meso-level

Micro-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)

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

Youth Gangs

Description

Increasing Delinquency rates, socioeconomic contributing factors, children lost and caught between two worlds (Fong, 2004)

Economic Self

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

Sufficiency

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

Intergenerational and

Issues due to changed family dynamics and include parental

Intercultural Conflicts

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).

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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).

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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

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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 33

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.

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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).

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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.

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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

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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).

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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 50

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 52

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.

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