The Effects of Religion/Spirituality in Mien Americans

THE EFFECTS OF RELIGION/SPIRITUALITY IN MIEN AMERICANS

AND THEIR PERCEPTION OF MENTAL HEALTH

A Project

Presented to the faculty of the Division of Social Work

California State University, Sacramento

Submitted in partial satisfaction of the requirements for the degree of

MASTER OF SOCIAL WORK

Nai Saelee

SPRING 2020

Nai Saelee

THE EFFECTS OF RELIGION/ SPIRITUALITY IN MIEN AMERICANS

AND THEIR PERCEPTION OF MENTAL HEALTH

A Project

Nai Saelee

Approved by:

______, Committee Chair Maria Dinis, Ph.D.

______Date

iii

Student: Nai Saelee

I certify that this student has met the requirements for format contained in the University

format manual, and this project is suitable for electronic submission to the library and

credit is to be awarded for the project.

______, Graduate Program Director______Tyler M. Argüello, Ph.D. Date

Division of Social Work

Abstract

THE EFFECTS OF RELIGION/ SPIRITUALITY IN MIEN AMERICANS

AND THEIR PERCEPTION OF MENTAL HEALTH

Nai Saelee

This clinical study explored through research, how Mien American’s religion/spirituality effect their perception of mental health in Sacramento. This study utilized a quantitative survey design that allowed participants to respond to questionnaire items in a Likert scale format. A total of 58 (n=58) participants were selected via nonprobability snowball sampling and asked to respond to multiple survey questions regarding their demographics,

mien background, religious/spiritual affiliations, mental health perception/utilization, and

perception of religion/spirituality relating to mental health. Data analysis showed

associations between Mien American’s identify their mien background and how Mien

Americans identify their religion/spirituality beliefs. Data analysis also showed association with religion/spirituality of Mien Americans and their mental health perceptions. Although the results are not generalizable beyond the sample population, there was a significant association between religious and spirituality trends of the Mien participants and their perception on mental health service providers. Implications for social work is discussed.

______, Committee Chair Maria Dinis, Ph.D.

______Date v

ACKNOWLEDGEMENTS

I would like to express my sincere gratitude to a few individuals and organizations for supporting me throughout my Master study. First, and foremost, I would like to thank Dr. Dinis for providing me with her patience, insightful comments, knowledge, expertise, and guidance throughout the process of completing this project.

This project would not have been completed without her genuine support. I am truly thankful and appreciate all her support and assistance.

I would also like to thank the committed faculty in the Social Work Department at

Sacramento State for their wisdom and dedicated support. In addition, thank you to

Turning Point Community Program colleagues, friends, and mentors in supporting me through this journey in finishing this program.

Furthermore, I would like to thank my friends, fiancé, and families for their unconditional love in supporting me with the confidence and persistence to complete this project. Thank you to my brother A Saelee and friend Estela Cortez for answering the multiple questions I had and the long nights where you both provided me support in completing this project. Also, thank you to my sister Cheng Saelee and fiancé San

Saechao, for both of your endless support, always cheering me up, and being by my side throughout this journey.

Last of all, I would like to acknowledge my father, who passed away right before

I entered this program. Although he is gone, he remains in my heart and provides me continuous strength and motivation to be the best version of myself.

TABLE OF CONTENTS Page

Acknowledgements ...... vi

List of Tables ...... x

List of Figures ...... xi

Chapter

1. INTRODUCTION ...... 1

Background of the Problem ...... 2

Statement of the Research Problem ...... 4

Purpose of the Study ...... 5

Research Question ...... 6

Theoretical Framework ...... 6

Definition of Terms...... 13

Assumptions ...... 15

Justification ...... 15

Delimitations ...... 16

Summary ...... 16

2. REVIEW OF THE LITERATURE ...... 18

Historical Background ...... 18

Understanding Mien people ...... 20

Mental health in the United States ...... 22

Cultural Competency and Cultural Humility in Mien Health ...... 27 vii

Barriers for Mien People in America ...... 30

Mien Religions and Spirituality ...... 32

Religion/Spirituality and its Impact on Mental Health ...... 38

Gaps in the Literature...... 47

Summary ...... 51

3. METHODOLOGY ...... 53

Research Question ...... 53

Research Design...... 53

Variables ...... 55

Study Population ...... 56

Sample Population ...... 56

Instrumentation ...... 57

Data Collection Procedures ...... 58

Data Analysis ...... 60

Protection of Human Subjects ...... 60

Summary ...... 61

4. DATA ANALYSIS ...... 62

Demographics of Study Participants Population ...... 62

Survey Participants’ Mien Background ...... 72

Religious/Spiritual Affiliations ...... 76

Results for Mental Health Perceptions in Relation to

Religion/Spirituality ...... 80 viii

Findings of Mien Americans Perceptions on Religion/Spirituality and

Mental Health...... 84

Summary ...... 98

5. CONCLUSION...... 99

Summary ...... 99

Discussion ...... 102

Implications for Social Work Policy and Practice ...... 104

Recommendations ...... 107

Limitations ...... 108

Conclusion ...... 109

Appendix A. Letter of Informed Consent ...... 110

Appendix B. Research Instrument ...... 111

Appendix C. Recruitment Materials ...... 118

Appendix D. Human Subjects Committee Approval Letters...... 121

References ...... 123

LIST OF TABLES

Tables Page

1. Summary of Study Participant Demographics ...... 64

2. Summary of Survey Questions for Mien Background ...... 75

3. Religious and Spirituality Involvement and Affiliations ...... 79

4. Participant’s Religion/Spirituality and Perception of Mental Health ...... 82

4. Participant’s Religion/Spirituality and Perception of

Mental Health (Continued) ...... 83

5. Crosstabulation for Age and Educational Background ...... 86

6. Participants’ Age and Generational Group ...... 87

7. Country of Origin and Marital Status ...... 88

8. I hold strongly to my Mien culture and heritage vs. It is important for me to

continue following my parents’ religious/spiritual beliefs...... 90

9. Crosstabulation Between Participants’ Who Consider Themselves

Religious and Participants Who Consider Themselves Spiritual...... 91

10. Religion vs. Problems of Life ...... 92

11. Spirituality vs. Problems of Life ...... 93

12. Country of Origin vs. Perceptions of Mental Health Service Providers ...... 95

13. Recommend Mental Health Services vs. Perception of Providers ...... 96

14. Perceptions of Mental Health Providers ...... 97

LIST OF FIGURES Figures Page

1. Age of Participant ...... 65

2. Marital Status of Participants ...... 67

3. Participant’s Country of Origin ...... 69

4. Participant’s Age and Arrival to America ...... 71

5. Participant’s Language Preference and English as a Second Language ...... 73

6. Religious Affiliations Current & Growing Up ...... 77

7. Participants’ Thoughts on Life After Death ...... 81

8. Participants’ Understanding Mental Health vs. Mental Wellness ...... 81

Chapter 1

INTRODUCTION

Mien American’s perceptions of mental health differs from those of other ethnic and racial groups. Mien (a.k.a. Iu-Mienh), or “Yao” are known as Southeast Asian refugees who migrated to America after the fall of Saigon. Research shows that Asian

Americans are amongst one of the lowest racial, ethnic and cultural groups to receive mental health services. According to Substance Abuse and Mental Health Service

Administration’s (SAMHSA) National Mental Health Services Survey (N-MHSS) from

2018, Asian Americans were at 1% of utilization for inpatient, outpatient, and residential settings for mental health (National Mental Health Services Survey, 2019). Research shows that there is a prevalence in Asian Americans who have mental health challenges; but due to systems errors in epistemology data, they are not being accurately accounted for (Sue, Yan Cheng, Saad, & Chu, 2012). Depending on the historical backgrounds, social conditions, and experiences of oppression, every race, ethnicity, and cultural groups' perception of mental health can be different.

Amongst the Asian American population who are underutilizing mental health services are the Mien Americans. Like other racial and ethnic groups, Mien Americans have different perception of mental health than people who are Caucasian, African

America, Hispanic/Latino or even other Asian American subgroups. This researcher is interested in exploring perceptions of mental health by looking at Mien American’s religious and spiritual beliefs. The hope is to gain a better understanding of how much

religion and spirituality plays a part in Mien Americans’ lives now, and if it has an effect

on their perception of mental health and mental health services.

Background of the Problem

As stated, mental health utilization in Asian American, including Mien American is low, and a way to eliminate the gaps and disparities for this population is to understand their perceptions of mental health. There are little to no research regarding Mien

American’s perceptions on mental health; therefore, existing data used in this research are from Asian Americans or data from other subgroups of Asian such as Southeast

Asians. Past research of Asian Americans highlights different aspects of mental health usage amongst Asian Americans. These include things such as improving epidemiological data, increasing research on specific Asian American subgroups (like the

Mien Americans) and specific prevalence’s in mental health disorders amongst Asian

American groups (Sue et al., 2012).

According to SAMSHA’s, (2019) 2018 (N-MHSS), the 116,041 clients who reported their race in inpatient mental health care settings consisted of 1 % (or 1,160.41)

Asian Americans (SAMSHA). In residential mental health settings, Asian Americans also consisted of 1% (or 546.59 clients) out of the 54,659 clients that reported their race. In

the outpatient setting for mental health treatment services, Asian Americans consisted of

1% (or 33,888.23 clients) out of the 3,388,823 client that reported their races

(SAMSHA). Chu and Sue (2011) found that 8.6% of the Asian American population

compared to 17.9% of the general population will seeks mental health services. Although

these statistics show that Asian Americans are not utilizing mental health care services,

studies show that it does not mean there is no prevalence in mental health disorders (Chu

& Sue).

Studies from the National Survey on Drug Use and Health (NSDUH) (2008)

indicates that Chinese American scored within the same range as Caucasians on mental

health indicators for mood disorders. Chinese Americans scored somewhat lower for

anxiety, and Asian Americans scored lower for substance use (Chu & Sue, 2011). Sue

and Chu found one study that shows 62% of the sample Asian Americans participants as

having a 12-month prevalence of Posttraumatic Stress Disorder (PTSD) and major depressive disorders in Asian population and 51% for refugee population (Chu & Sue).

Southeast Asians continue to need more epidemiological studies to have adequate samples. The Mien American populations also need special attention due to high prevalence in PTSD from experiencing torture and combat during Vietnam War (Sue et al., 2012). Even though the prevalence and need for mental health services are there, Chu and Sue argue that Asians prefer to use informal solutions to seeking mental health.

Asian Americans have cultural ideas about illness and mental health (such as preferring to use a medicine healer), and the heightened concepts of stigma and shame (Chu & Sue).

In order to increase utilization amongst Asian Americans, specifically Mien

American’s, it is crucial to understand their needs and perception of mental health. In understanding Mien American’s needs, it is important to look at how their religion and spirituality can influence the epidemiological studies that is being collected. It is important to look at the prevalence of mental disorders related to each subgroup, their historical experiences/ historical traumas, along with religious and spiritual beliefs. This

examination provides some light about Mien American’s perception of mental health

(Sue et al., 2012). One of the solutions that researchers suggested to decrease mental

health disparities are to learn about the different expressions of symptoms and adjusting

assessments to meet the needs of the cultural group. Sue et al. also suggested to identify

modifying factors (such as: stigma, shame, and emotion inhibition), understand how they

can affect the level of comfortability and how much Asian Americans are willing to

disclose (Sue et al.). A third solution is to find systematic errors that contributes to the

misconception that Asian Americans have a low prevalence on mental health needs (Sue

et al.). Finally, Sue and her team of researchers suggested for clinicians to look at

innovated ideas and strategies to decrease biases and conceptions of mental health from a non-Westerner’s view (Sue et al.).

Statement of the Research Problem

Social workers are the key to providing mental health services to Mien

Americans. By using cultural competency and cultural humility, researchers can begin to understand the perceptions and needs of Mien people on mental health. Cultural competence, as described by National Association for Social Worker (NASW; 2020), is the process of how individuals interact respectfully with their systems regardless of their cultural background, language, religion, spiritual tradition, immigration status, and other factors. In addition, NASW (2012) describes cultural humility as the attitude and practice of working with clients in the micro, mezzo, and macro levels on restructuring the power imbalances by learning, communicating, offering help/support, and making professional practice/setting. By having more contributions on research about Mien American’s

perceptions on mental health, research on Mien American’s perceptions of mental health

providers and clinicians may provide a support in decreasing disparities for this

population. By using cultural factors such as, Mien American’s religious and spiritual

background, providers can apply cultural competence and cultural humility in

understanding their perceptions of mental health.

Unfortunately, there is a lack of literature on Mien Americans and their

perceptions on mental health, it is necessary to find information on other Asian

Americans and studies on Southeast Asian subgroups to gain a better understanding of

existing research data. It is important to note that due to the lack of literature and

knowledge of the differences between Asian American subgroups, it further leads to

misconceptions about Mien Americans and their views of mental health. According to

Sindhu, there is a lack of literature about Asian Americans, especially Mien Americans,

who are a small ethnic group amongst the other 40 different subgroups of Asians

Americans (Hsu, Davies, & Hansen, 2004). This researcher is interested in better

understanding in Mien American’s religion/spirituality and their perceptions of mental

health.

Purpose of the Study

The primary purpose of this research is to understand how Mien American’s religion/spirituality backgrounds affect their mental health perception. By analyzing Mien

American’s perception of mental health as it relates to religion/spirituality, it helps to

provide more literature on Mien American’s beliefs and what they value. This research

will also support mental health providers, by increasing understandings about this

6 population. This study will provide information on Mien American’s religious/spiritual background and whether it influences their perception of mental health.

The secondary purpose of this study is to better understand the mental health needs of Mien Americans, by looking at their perceptions of mental health. In order to decrease disparities, we need to understand their perceptions of mental health. By studying Mien American’s perceptions, the research can provide information on how knowledgeable Mien Americans are about mental health, how to disperse information about mental health that is most appealing to them, and overall to increase mental health utilization. Researching about the religious and spiritual background of Mien Americans and their perceptions of mental health will add to the literature about Mien people in

America and help bridge the gap between mental health providers and Mien American mental health consumers.

Research Question

The research question is: How Mien American’s religion/spirituality effect their perception of mental health.

Theoretical Framework

This project will be guided by Humanistic-Existential Theory. This theory will be narrated in this section and applied to how religion/spirituality might affect mental health perceptions.

Humanistic-Existential Theory, is a blend of humanistic approach and existential approach, focuses on the search for meaning in human existence (Hoffman, 2010).

Abraham Maslow’s provides the foundation to Humanistic-Existential theory by looking

beyond behaviorism and psychodynamic approaches (Hoffman). Hoffman states that

Maslow gave birth to help further understanding that humans have further potential than

originally thought. Humanistic psychology was introduced in the 1950s and 1960s and is

considered the third theoretical force of psychology that focuses on lovingness,

spontaneity, creativity, meaningfulness, freedom, and dignity (Robbins, Chatterjee, &

Canda, 2012). Robin et al., (2012) argues that Existential theory derived from time of

war, social crisis (including industrialization) and spiritual crisis (such as fascism and

Nazism) prompted psychologists, like Frankl and Kaufman, to closely examine the

meaning of crises and making meaningful sense from said or such crises. By looking at

the history and context of how Human- Existential theory came into being will show why this theory is most appropriate to apply to Mien American’s religion/spirituality effects on their perceptions of mental health.

Abraham Maslow’s ideas are seen is seen as the basis for this Humanistic-

Existential theory because he introduces the “Pyramidal Depiction of Maslow’s

Hierarchy of needs,” which promotes self-actualization and self-transcendence (Robbins et al., 2012). Maslow’s Hierarchy of needs have a pyramid with six needs, from the bottom of the pyramid are survival needs and leading to self-transcendence at the top of the pyramid. The bottom of the pyramid is physiological needs, the moving upward is safety needs, third is needs of belongingness and love needs, fourth is esteem needs, fifth and second highest is self-actualization needs (altruistic love, beauty, creativity, and justice), and the highest need is self-transcendence needs (peak experience and unitive consciousness). Robbins et al., states that the bottom needs are priority establishments for

8 an individual to move to the next hierarchal level. Although the lower needs are placed on the bottom of the pyramid, it does not mean that they are not as important or essential.

But because without the priority needs from the bottom, being met, it is harder to focus attention on creativity and other higher needs (Robbins et al.). Maslow emphasis that food and shelter are just as crucial to human beings as the sense of belongingness and need for love (Robbins et al.). By utilizing the hierarchy of needs, humans start to see beyond material needs of this world and begin to look at personal dignity, worth, lovingly accepting others, and self-love (Robbins et al.). Once Maslow’s contribution to psychology is understood, we can look at Humanistic and Existential theory as separate schools of psychology.

Behaviorism (social learning and exchange theory) and Freudianism’s

(psychodynamic theory) are psychology school of thoughts that came before Humanistic psychology. Humanistic approach view Behaviorism as looking only to genetics, biology and systems of a person, but not capture the whole human perspective (Drew, 2018).

Psychoanalysis view of human nature to a Humanistic approach are negative and pessimistic views of human nature (Drew). The need to go beyond behaviorism and psychodynamic approaches gave rise to humanistic approaches (Hoffman, 2010). The

Humanistic approach focuses on human potential and Existential theory states that it is important to also understand the important to recognize potentials as well as limitations of human. The view and approaches to humanistic approach and existential theory are complementary to one another because both theories are similar in what is being focused

(Hoffman).

Humanistic psychology derived from Maslow’s belief that humans have the potential to approach the highest regard of human nature. According to John Rowan,

Humanistic psychology is identified in four themes: 1) positive outlook on human nature,

2) having a whole person approach, 3) emphasis on change/development and 4) abundance of motivation (Hoffman, 2010). Maslow’s view on human nature, supports the development of Humanistic view of human nature as, being essentially good, and is seen as a reflection of human behaviors. The whole person view of Humanistic psychology provides a broad understanding of human beings in terms of physical, intellectual, emotional, social, and spiritual dynamic. The whole person view helps individuals with their problems with the different dimensions and is more long-term versus a quick short- term fix of medication with behaviorism, where they are only focused on that one behavior (Hoffman). Hoffman argues that Humanistic approach understands that there are dimensions in the human experiences and aims to support with all of them. The

Humanistic approach’s view of change/development emphasizes the importance in maturing and being success in different key phases of life. Just like Maslow’s idea, abundance motivation theme refers to the emphasis on motivating attributes of human nature because Humanistic approach will continuously encourage human nature to maximize human achievements (through dignity, creativity, and quality of relationships) rather than its deficits like other schools of psychology.

The five principles of Existential psychology align and complements with

Humanistic psychology’s themes. According to Hoffman, (2010) the five principles of

Existential Psychology are: 1) freedom and responsibility, 2) death and human limitation,

3) isolation and connectedness, 4) emotions, and 5) meaning versus meaningless. Victor

Frankl describes freedom as the ability to receive psychological freedom even when he was physically enslaved in the Holocaust (Hoffman). Although freedom can be liberating, it can also be overwhelming due to having the responsibility to make life meaningful (Hoffman). According to Erich Fromm, this responsibility becomes overwhelming and individuals submit their freedom to authoritarian power figures, destructive behaviors (and rationalizing it to love or duty) and automaton conformity

(conforming to the values of culture and institutions) (Hoffman). Fromm argues that each human has the responsibility to make a meaningful life and be held accountable for their actions; and based on that responsibility, each human being will either receive punishment or reward (Hoffman).

The second principle of Existential theory is on death and human limitation. Most may view this principle as pessimistic; however, it should be a view of a fuller life

(Hoffman, 2010). By accepting death as an ominous end, death will be less feared, and individuals will be able to love more deliberately (Hoffman). The third principle is the paradox on isolation and connectedness by Yalom in 1980s. The first type is interpersonal isolation where people stay in isolation by avoiding all relationships

(Hoffman). The second, intrapersonal isolation, is when people are in relationships that lack depth and isolates their own desires and feelings. The third isolation, identified by

Yalom, is the reflection that all humans dies alone. The Existential theory supports in having individuals, through communication, exist with themselves (intrapersonal), others

(interpersonally), and existentially (Hoffman). Hoffman also states that by doing so one

can develop an authentic sense of self and connectedness.

The fourth principle for Existential theory is emotion. Emotion in Existential

context is to emphasize that the goal is not to eliminate pain and discomfort, unlike other

approaches, but the goal is to have a satisfying and meaningful life. With this approach,

psychologists will listen to an individual’s emotions, understand their emotions, and

eventually make meaning out of it. The fifth and last principle is meaning versus

meaninglessness. By looking at the previous principles, we can see that the main goals

are to find meaning, as humans are meaning-creating and meaning-seeking beings. The

important thing is to find and reinforce these principles and find the key to freedom,

transcending deaths, building authentic relationships, and honestly living

experiences/emotions. The Humanistic and Existential theories are both similar and

complement each other.

Human-Existential theory goes beyond prior forces of psychology and utilizes

Maslow’s Hierarchy as the basis to find meaning to life. It is essential to the Humanistic

and existential theory that material belonging such as money, power, and sex are limited

in meaning in existence and the pursuit of money, power, and sex can even bring a person

pain, harm, and violence. With the views of Humanistic-Existential approach, people will look towards long term fulfillment in in their lives.

Application of Humanistic-Existentialism. Humanistic-Existentialism is now applied to the following research question in this study: “How Mien American’s religion/spirituality effect their perception of mental health?”

By using Maslow’s belief of Hierarchy of needs, Humanistic-Existential views are accepting of everyone’s search for meaning in life (Robbins et al., 2012). By utilizing the five principles of Humanistic principals, Mien Americans utilize religion/spirituality to find meaning to their lives (Hoffman, 2010). By Mien Americans applying religions and spirituality, they are looking for more than just food, shelter and security as they are looking for self-transcendence, which is a complete fulfillment of the self as a communion to be one with everything and believing in something some call God

(Robbins et al.). Although Mien American religions do not all believe in a God, they have a sense of communion where it is sacred and promotes communality while being a part of a sacred being or reality.

The Existentialistic theory applies to the Mien American’s religion/spirituality and their mental health. Freedom and responsibility in the Existential theory can be applied to Mien American’s freedom to choose between the different religions and spirituality in which they choose to participate (Hoffman, 2010). Mien Americans hold the responsibility to choose the religion/spirituality that gives them the most meaning in life. Based on that responsibility, they have the right to practice and hold values that are aligned with the religious/spiritual that will give them self-transcendence needs

(Hoffman). For instance, Buddhism relies on karmic beliefs that is tied to having freedom to act but also being accountable to those decisions you make as it will come back to you (Iu-Mien Buddha Light Temple, 2018). The death and human limitations are tied to the religions, as there is a strong tie to ancestral worship in Taoist religion, where

Mien Americans are constantly confronted with the deceased (Albert, 2016).

In addition to applying the principles of Existentialism, isolation/connectedness

and emotions relates to perceptions of mental health. Perceptions of mental health are tied to the intrapersonal and interpersonal relationship. Intrapersonal relationship is how they view themselves and interpersonal relationship are the relationships they have with their family, friends, and religion/spiritual background. By connecting to the true meaning of their intrapersonal and interpersonal relationships, Mien Americans can present themselves existentially (by truly being themselves), in this world. By using Buddhist practices, Mien Americans can confront their emotions, and through understanding their mental health/thoughts they gain insight to make meaningful life choices. By utilizing religion/spirituality in the context of Human Existential theory, one can better understand the views of Mien American’s perception of mental health.

Definition of Terms

The following terms are used throughout this study. Brief definitions with

references are used for each term.

Acculturation: Refers to the changing of one culture by incorporation of elements of

another culture (Robbins et al., 2012).

Assimilation: The process where minorities would give up their original culture and heritage to adapt to dominant (American) values and culture (Robbins et al., 2012).

Animism: Attribution of conscious life to objects in and phenomena of nature or to inanimate objects; a belief in the existence of spirits separable from bodies (Merriam-

Webster.com Dictionary, 2020).

Buddhism: A religion of eastern and central Asia growing out of the teaching of

Siddhārtha Gautama that suffering is inherent in life and that one can be liberated from it by cultivating wisdom, virtue, and concentration (Merriam-Webster.com Dictionary,

2020).

Intersectionality: The theory that the overlap of various social identities, as race, gender,

sexuality, and class, contributes to the specific type of systemic oppression and

discrimination experienced by an individual (often used attributively) (Merriam-

Webster.com Dictionary, 2020).

Kuan Yin: The Bodhisattva or goddess of compassion and mercy that emerged from East

Asian Buddhist and Chinese Taoists (Religion Facts, 2019).

Taoism (Daoism): A religion developed from Lao-Tzu (in the 6th century

B.C.). Taoist philosophy, folk and Buddhist religion are concerned with obtaining long life and good fortune often by magical means and teaches conformity to the Tao (Dao) by unassertive action and simplicity (Merriam-Webster.com Dictionary, 2020).

Iu-Mien: The Iu Mien people are a Southeast Asian subset of the Yao people, a minority group originally from China. Displaced by the Vietnam War, many settled in the United

States from the late 1970s to the mid-1990s (Wikipedia, 2020).

Immigrant: A person who comes to a country to take up permanent residence (Merriam-

Webster.com Dictionary, 2020).

Refugee: A person who flees to a foreign country or power to escape danger or

persecution (Merriam-Webster.com Dictionary, 2020).

Religion: Refers to a specific system of beliefs and organized practice of worship, ritual,

or belonging to a sect of individual (Eliason, Samide, Williams, & Lepore, 2010).

Spirituality: Includes one’s capacity for creativity, growth, and development of a value

system (Eliason, Samide, Williams, & Lepore, 2010).

Assumptions

The research presented in this survey has the following assumptions: 1) It is an

assumption that religion/spirituality or lack thereof plays essential part of someone’s

world views whether if they are aware of it or not. 2) That all participants are all Mien

(either mixed/part, half, or full), over 18-years of age, and reside in Sacramento. 3) That the participants are honest and thoroughly answering the survey questions to the best of their ability. 4) That the survey questions are written in English only; and this can affect who participates and how the participants answer the responses.

Justification

The objective of this study is to look at Mien American’s perception of mental health and how religion/spirituality plays a role. It is important for the field of social work field to better understand their consumer’s perspective of mental health. The study will look at whether religion and spirituality will be an important factor in the way they view mental health. The study will also look at general perceptions of mental health as it is related to the Mien American population to better understand the perceptions of Mien

Americans.

By looking at Mien American’s religious/spiritual beliefs and how it effects their perception of mental health, it is aligned with the core values from National Association

for Social Workers core value of providing “Dignity and worth of the Person” (NASW,

2020). With these core values, it is in the ethical duties of social workers to be mindful of cultural and ethnic differences amongst the people they are servicing and promote self-

determination despite their cultural differences (NASW). By acting as a liaison between

the minority groups and the consumers with different cultural, religious, and spiritual

backgrounds, it is beneficial to understand their perspective. In order to effectively

appropriately resolve conflicts between from the minority groups (such as Mien

Americans) and the dominant groups in society, it is important to understand both

perspectives (NASW).

Delimitations

This research study is purely quantitative and due to the survey research

methodology. The non-probability small sample size cannot be generalized to the

population. This research study only surveyed people in the Sacramento area and the

results should not be used with other populations in other areas of the world. The

structure of the survey is primarily a Likert Scale and limits the participants answers to

the options provided on the survey itself. Due to the nature of quantitative research

methodology, one can only infer possible associations between variables. Causation

cannot be determined with this study.

Summary

This chapter introduces the research, background of the problem, statement of the

problem, purpose of the study, theoretical framework, definition of terms, assumptions,

justification, and delimitation. Chapter two provides an extensive literature review with

Mien people’s history, religion/spirituality, and mental health needs/barriers based on similar ethnic subgroups. In addition, this chapter also provides importance of cultural competency/cultural humility, religion/spirituality, religion/spirituality as it relates to mental health, and literature gaps. Chapter three presents the research methodology and contains the research design, variables, subjects, instrumentation, data gathering procedures, and information of protection of human subjects. Next, Chapter four has a presentation of the data and analysis of results. Chapter five, the final chapter, includes the conclusion, discussion of results, limitations, and implications from the study.

Chapter 2

REVIEW OF THE LITERATURE

This chapter will include literature on themes related to Mien American’s religion/spirituality and how it effects their perception of mental health. This chapter will first examine historical background of Mien people. The second part of this chapter will

further examine literature to better understand Mien people. The third part of this chapter

will discuss mental health in United States. The fourth part of this chapter will review the

importance of understanding cultural competency and cultural humility in order to

improve mental health services. The fifth part of this chapter will explain barriers for

Mien People while living in America. The sixth part of this chapter will present

prominent religious/spiritual practices for Mien People. The seventh part of this chapter

will discuss the literature found on religion and spirituality and its impact on mental

health. Lastly, the gaps in the literature and chapter summary are presented.

Historical Background

Mien people are also known as Iu-Mien, Mienh, or Yao (New World

Encyclopedia, 2013). Mien people are the dominant subgroup of the Yao people (New

World Encyclopedia.). Yao is among the most recognized terminology for Mien people

when talking about historical context but is not preferred amongst Mien themselves, as

the term Yao means barbarians. Yao is a term used by People’s Republic of China to refer

to ethnic minorities (New World Encyclopedia). Mien people consists of majority of the

Yao ethnic minority groups (New World Encyclopedia). For the purpose of the research

in historical context, Mien people will be considered Yao as they are referred in the

literature. It is will not be until the 1950s to 1960s that researchers started to call Mien people Iu-Mien or Mien.

Other Researchers found that Mien people’s historical background is obscure and complex, so they are often categorized by time periods and geographic locations (Alberts,

2017). The earliest reference of Yao people was during the Shang Dynasty between 1600 to 1046 B.C., where their ancestors were thought to have started their kingdom on the lower lands of Yangtze River (New World Encyclopedia, 2013). From then on, Mien people were believed to have separated from the other ethnic groups during Sui Dynasty

(in 581-618 C.E.) and became their own ethnic group during Tang Dynasty (in 618-907

C.E) (New World Encyclopedia). This new branch of Yao people was believed to move and resided in Hunan, northern Guangdong, and Guangxi (New World Encyclopedia).

The Tang Dynasty allowed Yao people to search for new land to live on without needing to pay for taxes, but it was later revoked (New World Encyclopedia). The world also began to see Yao people as descendants of King Pan Hu (Alberts; New World

Encyclopedia).

It was not until the Song Dynasty, (in 1960-1279), when Yao people were recognized as their own ethnicity; and this is also when Daoism started to emerge within the Yao culture (Alberts, 2017; New World Encyclopedia, 2013). During the Yuan

Dynasty (1279-1368), Daoism became a dominant religion among the Yao people

(Alberts, 2017). Due to oppression and their inability to practice Daoist rituals, it led them to migrate towards Thailand, Laos, and other Southeast Asian regions from

Guangxi Province, starting in the 1860s (Alberts). During the Qing Dynasty (1644-1912),

20 officials documented Yao people’s religion while they attempted to convert them to

Confucianism (New World Encyclopedia). From the 1860s to 1880s, Mien people’s initial migration went to northern Vietnam, to Yunnan, later to Laos, then to Thailand by the 1900s (Jonsson, 2015).

Mien people were believed to have been living in the mountains of Southeast

Asian until their involvement in the Indochina War and Vietnam War (Jonsson, 2015).

Their involvement with the CIA in the Vietnam War eventually led Mien people to

America (Jonsson). Mien American today still throw rice in the direction of where their family members are deployed, during war (to bless them) (Jonsson). Among the Asian

American population, Mien and other Southeast Asian Refugees (SEAR) are prone to have mental health challenges but are reluctant to seek mental health services (Abe-Kim, et al., 2007). During the 1960s and 1970s, Mien were enlisted by the United States

Central Intelligence Agency (CIA) to be trained and equipped as fighters in the Vietnam

War (Jonsson). After the fall of Saigon, Mien people were exiled from their homelands of

Laos and lived in refugee camps, such as Nam Yao in Nan Province, Thailand (Jonsson).

After living several years in the refugee camps, Mien families were invited to start new lives in the foreign country called America (Jonsson). Mien American came to America along with approximately 3 million other refugees from the Refugee ACT of 1980.

Understanding the Mien People

In addition to learning about Mien American’s historical background, this section will also provide information on the history of their language, life after war, and cultural customs/ traditions.

Mien Language

Mien language is closely related to modern Mandarin Chinese following five

dialect tones: middle, low, rising, falling, and rising-falling (Cardeinte, 2006). The elder

Mien folks are fluent in Chinese and these were usually the spirit priests that were able to

chant in semi-Taoist sacred scripts. Thai and American Mien teenagers have adopted the

language of their locale. According to Cardeinte, teenagers do not show appreciation for

their Mien dialect. Mien language has been adopted in Thai language and romanization of

Mien language was believed to occur in the 1990s (Jonsson, 2015). Sue et al. (2012)

suggested that immigrant population of Asian Americans, including Mien, have more

challenges due to language. Still, teenagers and other U.S. born Asian Americans have

also have low rates of mental health utilization compared to other U.S. populations

(Cardeinte).

Life after the war

The marginalized Mien community also faces poverty. Due to being uninsured

and underinsured, they do not have financial resources for medical or mental health

services (Chu & Sue, 2011). Because of psychological stressors from the war, studies

indicate that individual’s frequent exposure to death are more likely to commit violent

crimes (Ngo et al., 2007). By reviewing cross-sectional studies, it is important to view underlining causes of being labeled as “more likely to commit violent crimes” as a discriminatory myth. Kim (2012) states that SEAR including Mien have four mental health domains as: emotional distress, psychotic symptoms, anti-social behaviors, and community living.

Cultural Custom/Traditions

Mien people were farmers in their homeland and their skills were transferred to

America as evidenced by the continuation way of life when they moved to central valley

California (Sowerwine, 2015). Mien people primarily lived in the “hills” or “mountains” of Vietnam, Thailand, Laos, Burma, and China (Gilman et al., 1992). Mien people originally lived in mountainous rural setting, had little to no educational background

(Kim, 2008). Their livelihood back in their home were consisted of having slash and burn agriculture and also relied on fishing for food (Cardeinte, 2006). There were a lot of adjustments to livelihood once Mien Americans moved to the U.S. (Kim).

Mental health in the United States

This section will examine the mental health in Asian Americans by looking at statistics and misperception of their mental health needs.

Statistics on Mental Health

Despite the major progress that grassroot organizations like National Alliance of

Mental Illness in changing the lives of individuals, their families, and communities throughout the nation, there are still a lot of stigma surrounding mental illness. According to Substance Abuse and Mental Health Service Administration’s 2017 Annual report,

Asians show the lowest level of mental health utilization at twelve percent. In addition to

Asians being the lowest category of race that utilizes mental health services, Asian

Americans were also lumped with American Indians or Alaska Natives, Native Hawaiian, other pacific Islanders and other minorities. To further illustrate the lack of mental health utilization within the Asian population, the 2016 National Survey for drug use and health

indicates that the Asian population has lower rates of utilization than the national average

level. According to Chu and Sue (2011), lower rates of usage does not indicate lower

needs for mental health services, such as members of the Southeast Asians where there is

a high risk for Posttraumatic Stress disorder and high suicide rates among elders (Chu &

Sue).

Additional statistics from United States Department of Health and Human

Services Office of Minority Health (2019) states that suicide was the leading cause of

death in Asian Americans ages 15-24 in the year of 2017. In addition, U.S. Department of

Health and Human Services Office of Minority Health also states that Asian American high school female students are twenty percent chance more likely to attempt suicide than non-Hispanic whites’ females in 2017.

Misperceptions of Asian Americans

Misconceptions of Asian Americans contributes to the significant unmet mental

health needs in the United States (Cheng, Chang, O’Brien, Budgazad, & Tsai, 2017).

Epidemiological studies indicate that there is a low prevalence in Asian American mental

health needs (Cheng et al.). Low prevalence indicates to the general population that

Asian Americans low needs mental health services (Cheng et al.). Cheng et al. states that

this provides the public the idea that prevalence is not an issue among Asian Americans

and further adds to the disparities they face. Cheng at al. mentioned that the

methodological oversight and sampling contributes to the ethnocentric biases in the

studies. When implementing surveys, it is important to take into considerations of

cultural aspects, such as cultural idioms of distress/illness. According to Cheng et al.

different cultures conceptualize and perceives illnesses, especially mental illnesses,

differently from other racial or ethnic groups. The model minority stereotype is another

factor that contributes mental health disparities in America (Cheng et al., 2017). Asian

Americans are perceived as the model minority stereotype in society (Cheng et al.).

Model minority stereotype, according to Cheng et al. is the belief that minority groups can become successful with individual effort, strong values, and hard work (Cheng et al.).

This further perpetuates the idea that academic success and social mobility are easily accessible (Cheng et al.). This gives the false claim that if an individual is not successful it is due to their own shortcomings rather than a systemic one Cheng et al.). This indicates the misperception that Asian Americans do not struggle with social, economic, or political stresses (Cheng et al.).

Cheng et al. (2017) completed a study on model minority stereotypes in the

Northeastern region of the United States. Cheng et al.’s study was comprised of 425 final

sample size of undergraduate students, of which 97% of participants had no missing data.

Majority of the participants consisted of 71% female and the mean ages of participants

were 19.54 with standard deviation (SD) =2.92 (Cheng et al.). The percentages of race

and ethnicity on participants identifies were 71% white, 13% African Americans, 6%

Latino, and 5% Asian American/Pacific Islander and multiracial groups (Cheng et al.).

This study measure examined: (1) attitudes towards Asian American scale, (2) colorblind

racial attitude, (3) perceived mental health functioning (4) memory recall (memory

sensitivity is the hit rate minus the false alarm rate). The 18 and over participants were

randomly assigned to one of four conditions (1) a clinical vignette f a white college

student suffering from adjustment disorder, (2) the same clinical vignette as an Asian

American college student, (3) newspaper article story of whites and white clinical

vignette, and (4) the same newspaper article and clinical vignette of an Asian

American(Cheng et al.).

The attitudes towards Asian Americans scale consisted of 28-likert scale questions that ranged from 1 for disagree strongly to 6 for agree strongly (Cheng et al.,

2012). The higher the results of the score indicated higher positive or negative attitude towards Asian Americans (Cheng et al.). The colorblind racial attitude had 20 items to measure racial attitudes/ lack of awareness of finial of racism that ranged in a Likert-type scale that ranged from 1 as not at all appropriate or clear to five that is very appropriate or clear (Cheng et al.). Higher scores for colorblind racial attitudes indicated higher levels of unawareness (Cheng et al.). In addition to Colorblind racial attitudes there is a 6 items subscale to measure attitudes about out-group members that ranged from 4 as strongly agree to 1 as strongly disagree (Cheng et al.). Higher scores for subscales indicated higher positive attitudes towards members who are in the out-group (Cheng et al.). The fourth measure for perceived mental health functioning had Likert scale from 1 as strongly agree to 5 as strongly disagree to measure the participants’ perceptions of target mental health function from the vignette (Cheng et al.).

The first multivariant analysis looked at four conditions: 1) Asian American clinical vignette, 2) Asian American newspaper articles and Asian American clinical vignette, 3) white clinical vignette, 4) white newspaper article and white clinical vignette

(Cheng et al. 2017). The second analysis examined if perceptions of Asia American

26 mental health functioning was influenced by positive/model minority stereotype that was primed Cheng et al.). The study was primed by using a newspaper online with positive stereotypes for whites and model minority, references were changed to fit the stereotypes of each group, and to maintain validity the consistency of the prime was not disclosed

(Cheng et al.). The study indicated that perceived mental health functioning measures were significantly was correlated with colorblindness measures (Cheng et al.). Secondly, the model minority stereotype significantly contributed to hierarchical multiple regression (colorblindness, out-group orientation, attitudes towards Asian Americans)

(Cheng et al.).

The model minority also illustrates Asian American as a homogenous group

(Cheng et al., 2017). There are over 30 ethnic subgroups and over three hundred languages within the diverse Asian population. By understanding the different subgroups, it helps to better to understand the different needs of each subgroup (Cheng et al.). For instance, Asian American college students are at higher risk of having depression and suicide that other races (Cheng et.al.). By looking at the model minority stereotype, it is crucial to understand that mental health professionals are as prone to same biases as everyone else and this can lead to misdiagnosing or under diagnosing this population

(Cheng et al.). Asian Americans can be viewed by professionals as not having a severe enough mental health need and which would not require interventions (Cheng et al.). This can be fatal because it further contributes to Asian American’s already delaying mental health treatment since they already prefer to utilize informal care first (Sue et al., 2012).

In addition to these stereotypes of model minority, it further leads to the judgement and

27 attitudes of Asian Americans (Cheng et al.). It is important to understand these attitudes as it is linked to having clinical judgment biases (Cheng et al.).

According to Chu and Sue (2011), other barriers or reasons for Asian Americans to not utilize mental health services include stigma. Like any race in America, stigma is one of the main factors why people do not utilize many mental health services. Stigma is defined as the shame and guilt in having to admit that help is needed. With the added layer of shame, many Asian Americans tend to avoid social services altogether to avoid losing face (Chu & Sue). Restriction on access to mental health services, especially for

Southeast Asian, is a barrier in receiving help. Asian Americans prefer informal help from friends and family or self-help strategies before seeking alternatives like mental health services (Chu & Sue).One-third of Asians also drop out of mental health services during the intake and assessment period, which can be due to Asians having a stronger

Asian values and mistrust of Western views/culture (Chu & Sue).

Cultural Competency and Cultural Humility in Mental Health

Asian Americans are one of the fastest growing ethnic groups in the U.S. (Kim &

Keefe, 2010). Due to Mien Americans in Southeast Asia’s involvement in guerrilla warfare, Mien people are at risk of mental health concerns (Sue et al., 2012). In order to address these concerns, it is important to look at cultural factors, as suggested by NASW

Ethical standards, to use cultural competency and cultural humility. It is important to look at Mien people’s culture, traditions, and finally, religion/spirituality to understand their way of life and world view. This section will discuss about the importance of cultural competency and cultural humility in social work practice.

Cultural Competency and Cultural Humility

National Association of Social Workers (NASW) and the Diagnostic and

Statistical Manual (DSM) of Mental Disorders 5th edition (2012) are two of the

fundamental resources that mental health practitioners use as a framework when working

with clients. Cultural competency is valued in both resources. The NASW views religion

and spirituality as aspects crucial in understanding and improving one’s mental health. As

models for social work practice, the DSM-5 and NASW Code of Ethics/ Standards emphasize the necessity of cultural competence and cultural humility in social work practice.

According to NASW (2019), cultural competence is the process of how individuals and their systems interact respectfully and effectively to people of all cultures, languages, races, ethnic background, religions, spiritual traditions, immigration status, and other factors. The aim of cultural competence is to recognize, as well as affirm, the dignity and values of individuals, families and communities (NASW). By practicing cultural competency, social workers can learn to apply the knowledge and training to become more effective in helping clients (NASW). But the NASW professionals also state that it is not just a mastery of a practice, but rather a lifelong process for social workers. Cultural humility is a terminology to better explain the ongoing process of betterment while working with individuals, families and communities.

Cultural humility is the attitude and practice of working with clients in the micro, mezzo, and macro levels on restructuring the power imbalances when learning, communicating, offering help, and making professional practice/setting (NASW).

In order to understand why cultural competency and cultural humility is important, it is crucial to look at why culture is important. Culture is the integrated pattern of behaviors that includes, but not limited to thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious or social groups

(NASW, 2019). Culture considerations is also vital when clinicians diagnose a client.

According to the DSM-5 (2013), culture is transmitted and continuously revised within the family and other systems. Although behaviors differ from the social cultural norms,

DSM-5 requires by clinicians to take cultural relevance into consideration (DSM).

Cultural formulation (CF) are cultural identities and information that can be used to change an individual’s diagnosis, clinical assessment, and treatment plan (Dinh, Groleau,

Kirmayer, Rodrigues, & Bibeau, 2012). The study with Dinh et. al. illustrates the wealth of information by adding in a cultural broker, to provide cultural background, and adding a humanistic view of clients.

Cultural competency and cultural humilities require social workers to look at cultures as an important part of working with a client (NASW, 2019). Within cultures, it is important to look at the intersectionality approach of culture and cultural traditions

(NASW). Intersectionality theory derived from the feminist perspective as the manifestation of different diverse components of an individual’s, race, class, age, sexual orientation, gender and religious/spirituality (NASW). Amongst all the different intersectionalities, religion and spirituality are on that is essential when working with mental health clients.

Barriers for Mien People in America

This section will examine Mien American’s barriers while living in America and the themes include acculturation/assimilation, discrimination/ poverty, and mental health needs.

Acculturation/Assimilation

Acculturation was essential to Mien Americans in order to thrive in the new country

(Kim, 2008). When Mien people are being compared to other Southeast Asian groups, they were believed to have a greater risk of assimilating due to the differences in lifestyle form being in their homeland (Kim). Despite popular beliefs, studies show that Mien Americans had a relatively less difficult time in adjusting to life in America (Kim). The studies show that Mien refugee immigrants were able to acculturate by adapting and learning the host country’s mainstream language, values, norms, beliefs, and more (Szaflarki & Bauldry,

2019). Through Jonsson’s story the level of assimilation or acculturation can be illustrated by the experience upon the first years of a Mien person being in America, they made an agreement to collect money from the Mien community in hopes of saving money to go back to their motherland once the communists were defeated. However, by the end of three to five years, Mien Americans decided to stop the process of money collecting because they agreed to settled in the United States. Despite the level of success in acculturation amongst the Mien people in America, Szaflarki and Bauldry (2019) suggest negative outcomes such as substance use and poor dietary habits.

Discrimination and Poverty

When Mien people became refugee immigrants in America starting from 1975, the Mien people had no or very minimal experience in understanding English (Ying,

2007). In addition to Mien people in the new land where they did not know the language, they were discriminated as welfare recipients and faced different types of discriminations

(Ying). The marginalized Mien community members also faced poverty and due to either being uninsured or underinsured, does not have financial resources for medical or mental health services (Chu and Sue, 2011). Although all Mien people experienced discrimination, the refugee immigrants’ parents faced different discriminations from their children (Ying). Mien American parents faced threats from neighbors, financial stress, and unable to access resources (Ying). It was suggested by Ying that Mien children were faced with discrimination at school and even turned to gangs to find comfort.

The Racial discrimination that they experienced include residential segregation, access to education, jobs, healthcare services and mental health services. Mien people and other refugee subgroups experienced perceived discrimination from the Chinese,

Korean, and Japanese population for dampening model minority status (Leong and Lau,

2001). Individual discrimination can be characterized by their physiological responses such as their increase in heart rate, elevated blood pressure, and other mental to physical health to Mien individuals (Szaflarki & Bauldry, 2019). Unlike Chinese, Koreans, and

Japanese Americans, with the status of being, the “model minorities,” the Mien community were regarded as refugees (Leong and Lau). Not only are they distinguished

as different from Asian communities, but also to the mainstream society (Leong and

Lau.).

Mental Health Needs

Mien Americans, along with other Asian American who immigrated to the United

States, are prone to have significant mental health problems related to their refugee

experiences from the Vietnam War and are believed to have high rates of anxiety,

depression, PTSD and suicide. Mien refugees also experience unique experiences during

pre and post migration; stressors, war torture, terrorism, other disasters, famine, and

living in the refugee camps (Szaflarki & Bauldry, 2019). Despite the prevalence of

mental health disorders that is reported by Szaflarki and Bauldry, it is surprising to see

the utilization rates of Asian Americans to be so low. It is important for practitioners to

look for other symptoms that suggest mental health concerns such as: somatic symptoms,

fatigue, sleep disorder, paranoia, and suicidal thoughts (Szaflarki & Bauldry).

Mien Religions and Spirituality

Mien people utilized religion/ spirituality as a way to understand what is going on

in the world (Jonsson, 2015). In order to understand Mien people and their world view it

is essential to include their religion/spiritual beliefs, and the five dominant religions in

Mien culture (Animism, Daoism or Taosim, Buddhism, Kuan Yin, and Christianity), and

a summary of Mien religions and spirituality. According to Jonsson (2015), Mien

people’s religion ranges from different ancestor worships such as Daoism, Buddhism

(Bienh Hungh), Kuan Yin and Christianity. Mien people’s fundamental belief and

principles have a combination of Animism and Taoist religion that worshipped “Zu zong

mienv” (their ancestors) (Jonsson).

Cultural Practices and Superstitious Beliefs

Other examples of religious/spiritual belief practices in Mien people are the

practice of palm reading or also known as horoscope (astrological) readings that are

known to Western countries (Cardeinte, 2006). By utilizing the Chinese calendar, Mien

people use the “mangc maeng sou,’ astrological book, which literally translates to the fortune book. The combination tools of the priest blessings and the astrological book is used to determine things such as buying a car, house, and even marriage. By using the astrological book, the shaman or community leader will determine if when is a good time to purchase or participate in ceremony (Cardeinte). Another important belief or ritual of

Mien people is that of when a woman is pregnant. Mien people believe that throughout duration of the women’s pregnancy, the baby’s spirit/soul will be in a different part of the house, e.g., the stove, the door, bedroom, and so forth (Saechao, 2010).

Animism

It is important to understand that Mien people have an animistic view of life.

Animism is the world view of which humans assign agency and personhood to human

and non-human beings (Arhem & Sprenger, 2016). Animism according to Whitley,

(2012) is discourse of relationships cultivated in animal rituals (Arhem & Sprenger,

2016). Cardeinte, (2006) believe that it is the co-exist living way of life is normal to see

shaman or spirit priest perform blessing ceremonies called “sai mienv.” During these

blessings Mien people participate in sacrificing of animals such as chickens, pigs, and

cows. Due to the significance of ancestors, Mien people worship them by having a spirit

alter at their homes (Cardeinte). Several rituals and traditions are done to honor the

deceased members of the family to promise them a happy life in the spirit world and to

the new generations (Cardeinte). The belief of honoring the deceased is due to their belief

of reincarnation and hope for a better future in their next lives (Cardeinte). In addition to

the animism view of life, Mien People also believe in Taoism or Daoism.

Daoism (Taoism)

The Daoist view that the Dao is Limitless, Absolute, Finite and is the Great

Ultimate (Stanford Encyclopedia of Philosophy, 2016). Daoist is the teachings of being together in unity or oneness as the transcendent unity both beyond multiplicity (Stanford

Encyclopedia of Philosophy). The main stages of this belief are ontological and cosmogonic (Stanford Encyclopedia of Philosophy). The cosmogonic focuses on the pre-

celestial or “before the heaven” and post celestial after heaven (Stanford Encyclopedia of

Philosophy). Research found that Mien or Yao people in Southern China has been

practicing to Daoist deities such as the Thunder God (Alberts, 2016). Albert, states that

Daoist priests promoting Daoism and acted like imperial courts and missionaries of that

time

Buddhism

Another religion that Mien people participate in is the Mahayana Buddhism. The

Buddhist teachings help individuals and sentients beings to end suffering through the

human body to reach the highest form of happiness (Iu-Mien Buddha Temple, 2018).

This doctrine promotes human kindness, respect for others, and to promote peaceful lives

35 for all (Iu-Mien Buddha Light Temple). Mien Buddhists also believed in karma and reincarnation (Iu-Mien Buddha Light Temple). In order to reach the Ultimate Bliss and attain Supreme Enlightenment, one must live their lives in alignment with Buddhist beliefs (Iu-Mien Buddha Light Temple).

King Pan Hu is the reason for Mien American’s allegiance to Buddhist customs and religion (Alberts, 2016). Jonsson (2015) discussed in his research regarding the elaborate King Pan Light House temple that was used to signify veneration and revival of

King Pan for Mien Buddhists (Jonsson). The goal was to build a temple like the of the one in Hunan Province, China. it was believed that one or more Mien people in China,

Thailand, and California was visited in a dream or trance like to state by King Pan’s spirit instructing Mien people build a temple to resemble him (King Pan) to prevent the Mien culture from fading away(Jonsson). According to myth the Mien ancestors agreed to settle down and build a permanent place of worship (Jonsson). In addition to Mien people’s devotion to Buddhist beliefs, some Mien people also had a Kuan-Yin emphasis to the Buddhist religion (Jonsson).

Kuan-Yin

Kuam Shih Yin is known as Kuan-Yin or (Guan Shi Yin) which is the Bodhisattva or goddess of compassion and mercy which emerged from East Asian Buddhist and

Chinese Taoists religion (Religion Facts, 2019). The translation of Kuan Shih Yin meant,

“to observe the sound of the world” (Religion Facts). The history of earlier legends depicted Kuan Yin in both genders but more recently as someone who is female

(Religion Facts). Legends say that KuanYin had the option of going to heaven but due to

the cries she heard on earth she decided to stay until all sufferings ended on earth for all

salient (Religion Facts). In current day, Kuan-Yin is depicted as being evolved to having thousands of arms and thousand eyes in order to be omnipresent and being able to help anyone who may be suffering and in need (Nations Online, 2015). Although, Mien people have different religions and spirituality they all have similar values and beliefs.

Christianity on the other hand, challenges Mien beliefs such as things like ancestor worship and changing it to worship one god (Jonsson, 2015).

Christianity

Christianity as Jonsson suggest, is contrary to Mien beliefs and require the severing of relation and rituals of the Mien religious ethnicity (Jonsson, 2015). Overseas

Missionary Fellowship’s involvement introduced Christianity to Mien People during

1949 and made its way into northern Thailand by 1955 (Jonsson). Jonsson suggests that there is a great divide between the usage of traditional script and bible between Mien people. However, there are continued collaboration amongst the two religious’ groups. traditions and beliefs (Jonsson).

It is apparent that Mien people’s language, culture, traditions, religion/spirituality are different from Western cultures and views of the world (Jonsson, 2015). The differences in Western and traditional Mien culture, caused a lot of hardship and barriers for Mien people who resettled in America (Jonsson). Christianity is the belief that there is one god and that Jesus is the song of God (Swihart, & Martin, 2019). Christians believe that God is one all-powerful creator of the universe (Swihart, & Martin). God is also seen as a communicator of the commandments to Moses an believe in the sanctity of life

(Swihart, & Martin). Daily Practices included praying and when approaching death, they are encouraged to seek denominational beliefs (Swihart, & Martin). In addition, Swihart

& Martin mentioned that they believe in life after death such as heaven or hell.

Summary of Religion and Spirituality for Mien People

Through the war and strife experienced by Mien people from the Vietnam war, and living in refugee camps, Mien people’s conversion to Christianity (Jonsson, 2015).

Jonsson argues that Mien people converted to Christianity due to reasons like not being able to secure a chicken for sacrifice, having to find a spirit medium(shaman) and returning them home after the ceremony was too difficult. Other reasons for Mien people’s conversion to other religions also included stories about hearing other Gods like

King Pan Hu (Jonsson). The King Pan Light house temple is also seen as another benchmark to Mien people to build churches, other religious sanctions, and/or community centers for Mien people to attend once or more a week (Jonsson).

Due the lack of literature on Mien religions we can conclude from Jonsson’s research that mien religions are transnational (Jonsson, 2015). Due to the complex changes in Mien religion/spirituality is important to utilize cultural competency/cultural humility when working with Mien Americans. Main religions of Mien people are

Animism, Daoism, Buddhism, Kuan-Yin, and Christianity. It is fascinating to understand that regardless of the religion or spiritual belief that a Mien person has, it is transitionally represented. For instance, the Mien language is Romanized in the United States and Thai scripts as well in Thailand (Jonsson). The medium for spreading Mien religious beliefs and traditions are being transmitted through phones, internet, and more. Throughout these

38 involvements the interconnectedness of Miens from China, Thailand, Laos, United States continues to grow and change (Jonsson). Within the diverse components of the different intersectionalities of Mien people, religion and spirituality beliefs are important components of an individual’s mental health (Jonsson).

Religion/Spirituality and its Impact on Mental Health

This section will define and talk about the history of religious/spirituality involvement in mental health, define religion, define spirituality and its impact on mental health.

History of Religious and Spirituality as it Relates to Mental Health

The Priority of St. Mary of Bethlehem built in London in 1247, was believed to be the first mental health hospital in Europe (Koenig, 2012). According to Koenig,

Throughout the years of secular authorities, the hospital was infamous for inhuman treatments and was torn down in 1547. Following the death of a Quaker patient in an asylum in England, William Tuke changed interventions for the mentally ill to be changed to moral treatment (Koenig). In 1813 Quakers developed the first private institution called, “Friends Hospital,” and dedicated to only helping individuals with mental illness.

It was not until modern times when scholars like Jean Charcot and Freud in the mind 1880s that introduced neurotic and hysteria of religion and dissembled the connectedness of both (Koenig, 2012). DSM III-R also relates one-quarter of its mental health cases to religious and spiritual contexts and contributed to the division of religions/ spirituality and mental health (Koenig). According to Koenig, 56% of the participants

with depression and anxiety seldom inquire about religion and spirituality. Koenig

positively notes that despite the split between the two subjects (religion/spirituality and

mental health), there is rapid growth in the number of people studying this topic.

Religion

Religion as defined by Koenig (2012), is the involvement of beliefs, practices,

and rituals to the transcendent (such as God, Allaah, Braham, Buddha, Dao). Koenig

(2009) also states that religion is regarding the spirits like angels, or demons. Religions

usually have beliefs about life after death and have guidelines about on how one should

be in a social group (Koenig, 2009, 2012). Religion is usually practiced by an organized

overtime through a community but can also be done alone or in private and inquires

multiple dimensions (Koenig, 2009, 2012).

Spirituality

According to Koenig (2009), spirituality is defined as, more personal, free of rules

and does not have to relate to religion. Spirituality according to Koenig (2012), can be

also distinguishes as humanism, values morals, and mental health. Although this is the

understanding of spirituality, it is essential to look at the derivation of the term

spirituality. The word spiritual derived from the Latin root spiritualis which in turn,

derived from the Greek work pneumatikos (Koenig, 2009). In the context of the Romans a spiritual person refers to a spirit of God such as a clergy (Koenig, 2009). The use of the meaning spirituality is expanded to be inclusive to people who are religious and non- religious. A quote called, “Lily, Be Free,” by Talitha Day Fair illustrates the importance of religion and spirituality in one’s thoughts, feelings, and behavior:

Psychological and spiritual components are as important or more important for

you. Thoughts and feelings can change neurochemistry, just as chemistry can

change feeling and behavior (Goodreads, 2019).

Spirituality is being intimately connected to the supernatural, mystical and can extend beyond organized religions (Koenig, 2012). Spirituality and religion are the belief system and framework for individuals to find meaning, purpose, and resources to cope with times of adversity or illness (Cook, 2017). Due to the intimate nature of religion and spirituality, it makes sense that it plays a big part in mental health and psychiatry services

(Cook).

Religion, Spirituality, and Mental Health

This sub-section will discuss about the regulation/cultural competency when delivering services and the debates on religion, spirituality, and mental health. Religion and spirituality over the decades but there are yet to be a consensus.

Regulations and Cultural Competency.

Mien American and other Asian Americans are deprived of quality mental health services due to the deficiencies of cultural competencies. The Joint Commission (TJC) require healthcare professionals to practice the incorporation of maintaining patient rights, accommodations, religious and spiritual values (Swihart & Martin, 2019). This is similar to the discussion on the NASW Ethical Standards discussed earlier in this chapter.

Under cultural awareness and social diversity, social work professional should obtain education and seek to understand the nature of one’s religion (NASW, 2019). It is important for all systems of care to view individuals holistically to include wellness of

41 the body, mind, and spirit (Swihart & Martin, 2019). The incorporation of cultural competence and cultural humility in treatment opens the discussion for religion and spirituality allows for better collaboration between the clients and providers. There is no harm in understanding one’s cultural, religious, and spiritual beliefs, but the debates seem to have boundaries on how much religion and spirituality is incorporated into treatment plans and therapeutic settings.

Debates on incorporating religion/spirituality on mental health.

To better understand the debate, even the dialectical behavioral therapy, which is an evidenced-based therapy utilizes the concept of mindfulness and it was matched and linked to Buddhism. Due to the match in practice and teaching, it is being questioned on where using mindfulness is a cult or legitimate therapy (Poole, Cook, Higgo, 2019).

Poole et al. also suggests that it is important to understand the power dynamic between clients and providers. It is also important to maintain boundaries and consider the set of rules before considering the affects it can have on clients (Pool, et al.).

Another research brings up the distinctions between being religious and spiritual or just spiritual. Religion is the seen as a concern of institutions, hierarchies, dogma, tradition and rituals (King et al., 2013). Spirituality is defined as a distinct human experience having the ultimate importance and concern for meaning of purpose, life, truth, and values (King et al.). A study was done in England indicated the people who have spiritual understanding of life but have an absence of a religious framework are more vulnerable to mental health disorders. The research study of 7,403 participants in

England indicated that 35% of the participants were religious and spiritual, 19% were

42 spiritual but had no religious framework, and 46% were neither religious nor spiritual

(King et al., 2013). Consistent with the study done in England, Whitley (2012) also states that there are criticism of religiosity and how it affects and influence alcohol, substance use, patterns in sexual activities, sleep, and diet (due to fasting).

In addition, Whitley (2012) discusses the possibility of religious practices spilling over to other domains of life and cannot be separate or compartmentalized from other everyday activities. By incorporating religious/spirituality and all aspects of an individual’s life, including their family members and clergy men (as cultural brokers), it positively influences treatment to prevent pathologizing an individual when not necessary

(Whitley). Whitley also notes that mental health professionals have tend to ignore and pathologize the religious/spiritual dimension of life. By incorporating the two, it will start to mend this concern in a positive way (Whitley).

One positive aspect for incorporating religion and spirituality is that it can act as a protective actor, especially when being associated with better physical health (Whitley,

2012). Clients, such as Mien American and other minority groups, usually have a religious and spiritual component to their treatment, and it improves to their treatment.

Whitley notes that these religious and spiritual practices provide access to clients with material, emotional, moral and social support. Religious and spiritual affiliations for clients means support when in distress and when feeling vulnerable. Finally, by incorporating religious and spiritual needs, illustrates to client and their families the efforts in providers working toward cultural humility by showing to client that

practitioners are willing to learn about their culture in an empathetic, humble and

respectful way.

There are a lot of debates on religion and spirituality as it relates to psychotic

disorders due to religious beliefs. Koenig examined (2009) 16 studies and for participants with less psychosis/psychotic behaviors had a religious and/or spirituality belief. Studies on substance use also indicate less use of substances among 90% of individuals with a religious belief (Koenig). It is important to take into consideration that although severely mentally ill clients may have religious delusions, but other healthy normative believes help a great deal for individuals with isolation, fears, and loss of control (Koenig). The importance of Koenig’s research is for clinician to utilize religious and spiritual beliefs as a source of coping skills and to be able to identify when client’s views get distorted. It is important to limit the contribution of pathologizing clients through religions and spiritual beliefs (Koenig).

The need for healthcare professionals to include both religious and non-religious treatment interventions changes the meaning of spirituality today. Today, spirituality is a term used to promote one’s well-being, positive psychology, and encourage individuals to think about the meaning and purpose of life (Koenig, 2009). Koenig argues that the meaning of spirituality is correlated with good mental health, is methodologically flawed, and spirituality should be used synonymously with religion. Koenig’s article looks at the different studies that incorporated religious and spiritual practices in mental health settings. Using religious and spirituality practices is considered important when coping with mental health challenges. Systematic research indicates about 90% of Americans

44 turn to religion and spirituality when coping with stressful events such as September 11,

2001 (Koenig). The reason for this Koenig believes is because people turn to religious beliefs to provide meaning and purpose during difficult times. During difficult times such as September 11, religion and spiritual beliefs provide a sense of indirect control, link individuals to communities, and reduce isolation. Another important benefit to religious and spirituality beliefs is that it does not require any financial, social, physical or mental circumstances (Koenig, 2009).

Koenig (2012) conducted a study to systematically review findings between religion/spirituality and mental health. Koenig conducted a systematic research by reviewing scholarly articles on an online database, like PsychINFO and MEDLINE.

Second Koenig reached out to researchers in this field to alert them to contribute by providing known research on this topic from prior research or research they themselves conducted. Third Koenig utilized reference lists of the studies that were already located.

Out of the methods used, Koenig was able to locate 3,300 studies between the period of

1872 to 2010. Harold G. Koenig (HGK), examined the studies and ranked the qualities of the studies from 0 ( low quality) to 10 (high quality), by utilizing the eight criteria’s of: sampling method, number of religious measures, quality of measures, quality of mental health outcome measure, contamination between religious/spirituality measures and mental health outcomes, inclusion of control variables, and statistical method adapted from Cooper (using integrated research review method).

Cooper’s method emphasizes the definition of variables, validity, reliability of measures, sample from representative (sample size, sampling method, and response rate),

research methods, design conformity, level of statistical test appropriateness, and

interpretation of the results (Koenig). To further test the reliability, HGK compared 75 of

his rating to an outside researcher name Andrew Futterman (AF), Ph. D., professor of

psychology in College of the Holy Cross with the same rating criteria (Koenig). Andrew

Futterman was chosen as the outside examiner due to him being a scientist that was familiar with scoring and examining studies in religion/spirituality research (Koenig).

Overall, both HGK and AF agreed on 56 out of the 75 studies, which consisted of 75% of the studies being cross examined. This researcher included examples of Koenig’s most rigorous examples that are most relevant Mien American population’s positive emotions, meaning/purpose, anxiety, depression, suicide.

Koenig (2012) study indicated that only 256 out of 326 (79%) quantitative studies found significant positive relationship between religion/spirituality and well-being. On the other hand, meaning and purpose reported having better result with 42 out of 45

(93%) studies that indicated significant positive relationships between religion/spirituality

and meaning and purpose (Koenig). Koenig’s study also reported on 239 cross-sectional studies, 9 single-group studies, 19 prospective cohort studies, and 32 randomized clinical trials: a total of 299 studies. Nine out of nineteen studies (47%) reported lower level of anxiety over time, one study (5%) reported increase in anxiety while experiencing abortion, seven no association was reported, and two had missed or complex results

(Koenig).

Over 444 studies were implemented for depression since early 1960s (Koenig,

2012). From the 178 of the most rigorous studies, 119 (67%) reported inverse

46 relationship for the relationship with religion/spirituality and depression (Koenig). In the same study, 7% indicated a positive relationship between religion/spirituality and depression (Koenig). Depression cohort studies indicated that 39 of the 70 (56%) have lower levels of depression or faster remission of depression, 7 (10%) predicted worse future depression, and 7 (10%) reported mixed results (Koenig). Suicide correlations between individuals’ religious/spirituality beliefs and suicide attempt, completed suicide or attitudes that individuals have with suicide are consistently correlated with individuals’ experiencing depression, with low self-esteem, and without hope (Koenig). Of the 59 rigorous studies that examined relationships with religion/spirituality and suicide variables (depression, low self-esteem, and hope), 39 (80%) indicated less suicide, less suicide attempts, or negative attitudes toward suicide and 2 (4%) indicated positive relationships (Koenig).

According to Koenig (2012), about eighty percent of research on religion and spirituality consists of metal health to include psychological, social, and behavioral needs. The reasons for religion/spirituality’s existence is to improve positive emotions and neutralize negative emotions (Koenig). For instance, religion is a resource for individuals to cope with stress and to have that powerful cognition, with strong held beliefs, and overall an optimistic worldview (Koenig). Religion also positively influences people to be on good behavior and further re-enforces positive behavior (Koenig).

However; on the other hand, sometimes it is too hard to live up to the religious regulations/doctrines, individual can turn to drugs, crime, divorce, or other things that contribute to negative mental health outcomes (Koenig).

During hard times, it is important to remember that religion/spirituality

emphasizes love, caring, forgiveness, gratefulness, patience and more (Koenig). These

positive affirmations neutralize the negative outcome on a person’s life (Koenig).

Although, individuals can use religion for their own gains such as power, to promote

aggression, promote prejudice, and hate. It can also lead to the individual to become fearful, have anxiety, and guilt (Koenig). Although a person has the free will to do what they choose, it is important to understand that religion provides a greater well-being, improve stress as a coping skill, and better mental health (Koenig).

Gaps in the Literature

Although Mien Americans have been in America for over four decades, the amount of literature on Mien people remains limited. Due to the scarce amount of research done on this population, some of the resources came from student dissertations, thesis, and non-profit websites in order to get the most current information. Although there is growing evidence that Asian Americans, especially Mien Americans, are more likely to be at risk of having mental health challenges. There are not enough data or research studies to show efforts in providing culturally competent and cultural humility while working with this population. There are calls to action in order to eliminate the disparities for health and mental health services for Asian Americans such as the Mien population (Sue et al., 2012).

There is a growing need for more research on subgroups of Asian Americans to target Iu-Mien with refugee statuses (Sue et al., 2012). Researchers should also take into consideration the variations of subgroups within Asian Americans in order to decrease

systemic errors and get a more accurate picture of clinical problems within each subgroup

(Sue et al.).There should be more information on the underlying reasons for utilization,

and disclosure of or lack of disclosure of mental health services (Sue et al.).This research aims to examine religion and spirituality and how it plays a role in mental health utilization amongst Mien Americans.

Another area of concern is why do Asian Americans, along with Mien people, do

not seek professional mental health services until there is a crisis (Sue et. al, 2012).

Researching on bridging the gap between mental health providers and other informal

supports, such as clergy men and priests, can be a way to promote mental health services.

This study will also review how to better understand Mien American’s stance on mental

health as it relates to religion and spirituality.

Research studies show that there is a rise in suicide rates of Asian American

elderly population (Chu & Sue, 2011). There should be more efforts in understanding the

underlying causes and ways to support the elderly of the Southeast Asian American

population (Chu & Sue). The elderly population within the Southeast Asian Americans

have already experienced a lot of trauma from war, migrations and so forth, and will need

the support from what researchers can provide (Chu & Sue). There should be better

distinction made between Asian American subgroups, their intergenerational differences,

and hierarchy of Mien populations within themselves (Jonsson, 2012). In addition to

needing additional research on Mien people, it is important to distinguish the

heterogeneity and complexities within the Mien population as well.

The literature gaps are due to not having enough information to show prevalence in epidemiological studies accurately. This lack of information can essentially be a barrier to Asian Americans receiving mental health services (Cheng et al., 2017). Cheng et al. also states that their study is limited and that they need to have a more diverse group to better understand misperceptions about Asian Americans. For instance, their study was done only on college students from New England University with psychology majors. By implementing these sorts of stereotype studies researchers can get a better understanding of the overall stereotype from different groups and not just a specific group of people.

The research from Szaflarski and Bauldry (2019) indicated that there is a gap in literature on longitudinal study to better understand how discrimination can affect the immigrant population’s health. Szaflarski and Bauldry also mentioned that it is useful to understand both the documentation status and how immigrants arrived in the U.S. This factor is important in understanding if there are any differences between immigrant groups, who had different migration experiences (Szaflarski & Bauldry). The third literature gap includes the need to look between moderating mediations, meaning two factors (Szaflarski & Bauldry). In the case of Szaflarski and Bauldry, these factors would be looking at discrimination and psychosocial or social support. In the case of Mien

Americans, it would be good to look at discrimination and individuals with PTSD.

One study emphasized the need to understand demographic information, such as the participants’ culture, health literacy, insurance coverage, and immigrant status, as these all can influence their health behaviors (Kim et al, 2012). Asian American’s perception of providers’ gender, cultural, and linguistic sensitivity has been a great

indicator for Asian Americans to seek services and it would be helpful to have more

studies done on this (Kim et al.). Lastly, the same study indicates that it is crucial to have

healthcare experts who are knowledgeable about the Asian American culture and their

social conditions in order to truly mitigate the barriers of services and eliminate myths.

Clinical implications, as indicated by Koenig (2012), on religion and spirituality

is his rationale for implementing integration of spirituality into professional/clinical

practice. Koenig suggests that the field of religion/spirituality is growing within both

mental and physical health. He validates his claim by utilizing peer reviewed journals pointed out from multiple disciplines, such as social science, counseling, psychology, psychiatry, social work, public health, demography, economics, and religion (Koenig).

Koenig emphasizes the need for health professionals to provide whole person care by familiarizing themselves and becoming educated on research-based spirituality. In order to integrate whole person care, Koenig suggests providing consumers with sensitive and sensible care to support with addressing their body, mind, and spirit.

There are also limited research conducted on religion related to Mien people.

Although there is information on Taoism, Buddhism, Kuan Yin, and Christianity, there is not much information related to how these religions are incorporated within the Mien

Culture (Alberts, 2016; Iu-Mien Buddha Temple, 2018; Religion Facts, 2019; Jonsson,

2015). This research may provide some information on how these religions are incorporated into Mien People’s lives. Due to the ever-changing complexities of culture, it is important to continue to have a better picture of how Mien American’s culture, traditions, religion and spirituality has changed overtime. Another concern is the

51 ethnocentric view from researchers like Watters (Sue et al., 2012). There is a growing need to provide cultural competence and cultural humility to our clients and Watters’ view is going in the opposite direction (Sue et al.). This viewpoint does not align with the social work principles and values of promoting cultural awareness and diversity. By providing a wider point of view and inclusivity of other cultures, the principle of cultural humility is used.

This study will contribute to filling in the gaps of literature to Mien Americans by providing a better understanding of Mien people to the general population. This study will provide better understanding of Mien people and allow social work professionals to increase cultural competency and cultural humility when working with this population.

There is geographic heterogeneity to provide a better understanding of this specific sample group. This study fills in the gap for systemic errors from epidemiological studies because this study is on a specific group Mien Americans who are age 18 and over and reside in Sacramento. The cultural competency and humility of Mien Americans will help with having more Mien people seek help versus delaying help until symptoms become severe. This study will provide a better understanding of religious and spiritual beliefs of

Mien Americans and how it effects their perception of mental health.

Summary

In this chapter, the researcher discussed about the historical background of the

Mien people, the lack of mental health utilization amongst Asian Americans, the importance of cultural competency and cultural humility in mental health settings, Mien people and their religion and spirituality. And lastly, religion and spirituality were

52 described as it relates to mental health services. Gaps in the literature were presented. The next chapter will describe the methodology of this study.

Chapter 3

METHODOLOGY

In this chapter, the methods used for the study are presented. This chapter discusses the research question, research design, variables, study population, sample population, instrumentation, data gathering, data collection procedure, and statistical data analysis along with protection of human subjects.

Research Question

The research question is: How does Mien American’s religion/spirituality effect their perception of mental health?

Research Design

The researcher utilized a quantitative exploratory survey research design to answer the research question stated above. Quantitative research is measured using numerical values and quantitative research is measured by text, word, photographs, sound bites and more (Trochim, Donnelly, & Arora, 2016). In order to conduct a study,

Trochim et al., that is more rigorous and scientific, the quantitative design is more credible than qualitative research. Qualitative research is viewed as being more sophisticated, in-depth, and can also be easily converted into numerical forms (Trochim et al.). Despite the debates on both, the authors recognize the close relationship between the two: quantitative data can be used to understand or prove qualitative judgments and qualitative data can be used to understand and be manipulated into numerical data

(Trochim et al.).

The researcher chose this design due to the lack of available research and information on Iu-Mien, their religion/spirituality, their mental health utilization. The data collected supported in analyzing the relationships between the Mien American’s religion/spirituality and how it effects mental health utilization. Although, the research cannot be generalized beyond its sample population, it can easily be replicated into a larger sample size or even another target population

The quantitative method of research is good for this research as the survey included questions about participants’ demographics and history. This study also included pre-experimental and cross-sectional survey questions, which is considered a weakness because it only focuses at one point in time. Consistent with quantitative research, the remainder of the survey consisted of Likert scale questions and variables entered the SPSS program as ordinal values. Unfortunately, using the Likert scaling system has some drawbacks and limit the criterion and construct validity (Trochim et al.,

2016). By using the Likert scale system, the researcher used qualitative judgements in developing the survey. The surveys are self-reported, and there can be different interpretations of the seemingly straightforward questions (Trochim et al.).

The researcher used the Iu-Mien Community Services agency to recruit members of the older Mien generations to participate in the survey. Language is a barrier with this population as the survey was written in English and was not translated into the Mien language. The Iu-Mien did not have a written language until 1990s, so it would not be beneficial to translate the survey in Mien because the older Mien generations did not e

use written language. In order to combat this barrier, the research allows for flexibility in

how, when, and where it will be administered.

Although there are many weaknesses with this design, the purpose of this study is

to gain a better understanding of the effects of religion/spirituality of Mien Americans on

mental health utilization. The strengths of this research design are to use the Likert scale

system because it naturally yields quantitative measures (Trochim et al., 2016). With the

quantitative approach, this research provides both descriptive and inferential statistics.

The research can provide inferences and illustration of the relationships between the religion/spirituality of Mien Americans and mental health utilization. Lastly, the research can be an addition to the limited literature available on Mien Americans and to better understand their mental health services utilization.

Variables

To answer the research question, the independent variable is the religion/spirituality of Mien Americans and the dependent variable is mental health utilization. The independent variable is defined by the different types of religion/spirituality affiliations such as: Taoist, Buddhist, Christianity, or other. The independent variable will categorize the religion of participants that they grew up with, and, if married, if there was a change from their marriage. The dependent variable is mental health utilization and it is measured by the survey questions. In the survey questionnaire, included were the generic questions related to participants’ knowledge of mental health by providing answers and a fill in the blank option if none of the answers

fit. The dependent variable is also measured similarly to a Likert scale of options:

“strongly agree,” “agree,” “disagree,” “strongly disagree,” and “not sure/ I don’t know.”

Study Population

The study population for this research consisted of individuals who are Mien

Americans, 18 and older, and reside in Sacramento. The study population consisted of 58 participants who agreed to complete the survey and read the informed consent. This research questions included Mien Americans living in Sacramento of varying degrees of age, gender, level of educational background, and socio-economic backgrounds.

Sample Population

The nonprobability snowball sampling method was used. The sample size was 58

(n=58) sample participants. The purpose of using this method was to reach out to as

many different participants as possible and to gather a well-rounded sample of the target

population. The researcher recruited participants from Iu-Mien Community Services by

posting a flyer and continuing the snowball sampling to other agencies in the Sacramento

area that serve this population. In addition to posting the flyer for the survey, the

researcher also reached out to acquaintances, colleagues, school peers, and even social

media.

There are several advantages to the use of convenience snowball sampling

method in a study because it is easier to locate subgroups within the targeted population.

One drawback is that the individuals may not understand written language either in

English or in Mien; however, the survey used in this study allowed flexibility in how it is

taken, and it ensures that the informed consent is presented along with the survey

57 questions. The flexibility meant that individuals of the older generation that cannot read in Mien or in English could utilize a professional, spouse, friend, or even a family member to translate the survey. The main advantages to using nonprobability convenience and snowball sampling method was cost-effective, convenient, and a way to expedite the data gathering process. One disadvantage is that the researcher may have known some of the participants. However, the risk was minimized by the researcher providing flexibility in how the survey was taken and the researcher was also not in the room when participants completed the survey.

Instrumentation

This research study used a questionnaire method of survey that was created by the researcher (Appendix B). The questionnaire survey with 33 questions was available via

Qualtrics with a hyperlink through the recruiting process or a paper version provided by the researcher. The questionnaire consisted of five different sections regarding information on participant’s demographics, Mien background, religious/spiritual affiliations, mental health utilization, and information on religion/spirituality when using mental health services. This questionnaire survey research study did not include a pretest.

The demographics section provided options to circle or fill in the blank. Survey questions included questions on participants’ gender, age, marital status (if participant is married there will be an additional question asking if the religion changed after marriage), country of origin (if participant was not born in America what year was the arrival date?), educational background, and generational status in relation to America.

The Mien Background provided a combination of fill in the blanks, circling yes or no

58 questions, and Likert scale items. The survey questions asked about the participant’s preferred language, if English is a second language, and a series of questions related to their mien background, level of assimilation and the importance of religious/spiritual beliefs. The survey questions related to religious/spiritual affiliations provided options for participants to circle and answer or specify and answer if not listed. The sections on mental health utilization and religious/spirituality when using mental health services were

Likert scale of options: “strongly agree,” “agree,” “disagree,” “strongly disagree,” and

“not sure/ I don’t know.”

The study questionnaire not did have any specific reliability or validity tests conducted; however, it still included some face validity from the reviewing process of the

Division of Social Work faculty.

Data Collection Procedures

Due to the convenience sampling method, it is important to take note that complete confidentiality cannot be promised amongst participants. The researcher reached out to Iu-Mien Community Services agency and received approval to post a flyer at their office to reach participants. The researcher also sent out recruiting emails to acquaintances, colleagues, school peers, and social media in order to get the desired number of participants to satisfy the research. The purpose of the study is explained in the recruitment materials that can be viewed in Appendix “C.” The participants were provided flexibility in how they wanted to complete the survey. The participants could complete the survey questionnaires at home, school, community agency settings, or other community settings. The first page and screen of the survey contains the informed

59 consent explaining to participants the summary of the research, the intent of the study, confidentiality rights of participants, that the survey is voluntary, and participants can opt-out at any time. The researcher informed participants to print out a copy of the informed consent prior to continuing onto the survey questions.

The researcher gathered data hard copies from participants and used Qualtrics to complete the survey using an instrument provided to students by the university. The researcher gathered the data when participants completed the surveys and periodically checked to see the number of participants for the survey. The researcher kept the hard copy surveys locked up. To protect participant’s confidentiality from researcher, the researcher did not review the hard copy surveys until the desired amount of incoming surveys from both Qualtrics and hard copies reached 30-50 participants. This helped to provide some protection to the participants because the researcher then did not know which participants answered the survey. Once the desired number of participants was reached, the researcher entered the answers provided on the hard copies of the survey onto Qualtrics. Once the survey answers were entered Qualtrics, the researcher shredded the information on the California State University, Sacramento campus to ensure protection of confidentiality for participants. Once the survey information is securely disposed and entered onto Qualtrics, the researcher also began the data entry process onto

Statistical Package for Social Sciences (SPSS) program. The survey information remained secure in the California State University, Sacramento drive and kept safe on

Qualtrics as well.

Data Analysis

The survey data from Qualtrics were entered into the SPSS program to measure information on independent variable of religion and spirituality of Mien Americans and dependent variable of mental health utilizations. The SPSS program can provide both descriptive and inferential statistics to organize information gathered from the surveys.

Survey questions from 1-11 were assigned as nominal data. The remaining questions from question 12-32 are Likert scaling questions that were assigned numerical values.

Question number 33 is not reflected on the data analysis as it is used as a snowball sampling method to reach other participants. Questions that were not answered are skipped and entered into the SPSS program as missing. The researcher used frequency distribution, charts, and chi-squares tests to perform data analysis. The tests performed provided information on the effects of religion/spiritual backgrounds of Mien Americans

on their utilization of mental health services.

Protection of Human Subjects

Before the surveys were distributed to participants, a Human Subject application

was submitted and approved by the Division of Social Work Human Subjects Committee

to ensure the safety of human subjects. This research study was approved as “exempt” by

the Division of Social Work Human Subjects Committee, See Appendix “D.” The

protocol number for the approved study is 19-20-038.

The survey included an informed consent and the researcher requested for

participants to keep the keep a copy of the informed consent for their own records. By

continuing with the survey, participants could choose to stop the survey at any time if

questions become too personal. The demographics asked general questions of participants

and did not ask to provide any personal identifiable information. The researcher

emphasized and ensured the confidentiality of the responses from participants.

Anonymity was not possible to guarantee as the sample was created via a snowball

approach. However, the data received from participants was encrypted to protect their

identities. The informed consent also stated that the data would only be viewed by the

researcher and the project adviser.

Summary

This chapter was to discuss about the methods used in this quantitative explorative study. The chapter included the study the research question, research design, variables, study population, sample population, instrumentation, data collection, data analysis, and protection of human subjects. This chapter focused on data analysis plan and the next chapter will include the results from the findings and analysis of data collected.

Chapter 4

DATA ANALYSIS

This chapter will analyze the data gathered from the research study of how religion and spirituality of Mien Americans affect their perceptions of mental health. This study contains data on participant’s demographics, backgrounds, their religious/spiritual affiliations, perception of mental health, and additional questions related to their religion/spirituality in accordance with mental health perceptions. After examining the data sets of variables, the chapter will begin to analyze crosstabulations. This chapter will conclude with a summary statement. The purpose of this chapter is to answer the research study question: How Mien American’s religion/spirituality effect their perception of mental health. The study utilizes chi-squares tests to find statistically significant associations between the different variables in Mien Americans living in

Sacramento.

Demographics of Study Participant Population

There was a total of 67 (n=67) sample participants who started the survey, but the study will be comprised of 58 (n=58) Mien Americans who were at least 18 years of age and living in Sacramento. Of these sample participants, 9 (n=9) participants were excluded due to not answering enough of the survey questions and possibility of it affecting the survey sample. Of the 67 (n=67) participants, 58 were included: 1 (n=1) participant completed 62 % of the survey questions, 3 (n=3) participants completed 73% of the survey questions, and the remaining 54 (n=) participants completed 100% of the survey questions.

From the 58 (n=58) participants, Table 1 includes a summary of their

demographics information and the summarized demographics will be the information

used in the crosstabulations when running chi-square tests. From the 58 sample participants, 81% (n=47) identified themselves as female and 19% (n=11) participants as male (See Table 1). The age range of the participants ranged from 18-55 years of age.

The survey consisted of participants from four age groups: 20.7% (n=12) participants were between 18-25 years old; 53.4% (n=31) participants were between 26-35 years old;

19.0% (n=11) of the participants were between 36-45 years old; and 6.9% (n=4) of the participants were between 46-55years old (See Figure 1). For the purpose of analyzing this research, age groups will be combined in two major age groups: 74.1% (n=43) of the participants were between 18-35 years old and 25.9% (n=15) of the sample participants were between 36-55 years old (See Figure 1).

Table 1

Summary of Study Participant Demographics

Demographic Categories Frequency Percentage Gender Female 47 81% Male 11 19% Age 18-35 years old 43 81% 36-55 years old 15 25.90% Marital Status Single 4 6.90% Married/ Other marital status 25 43.10% Country of origin America 27 46.60% Laos 8 14% Thailand 21 36.20% Vietnam 0 0.00% China 1 1.70% Other 1 1.70% Mien Identity Full 52 89.70% Half/Mixed race 6 10.30% Educational Background High school/ Diploma/ GED & lower 20 34.50% Certificates/Associate and higher education 38 65.50% Mien Generation First Generation (Refugee/Immigrants) 29 50.00% Second Generation (First American Born) 28 48.30% Missing System 1 1.70%

Figure 1. Age of Participants

The next set of demographics included the marital status of the 58 (n=58) sample participants. The sample participants included 56.9% (n=33) participants who identified as single; 36.2% (n=21) participants as married; 1.7% (n=1) participant as divorced; and

5.2% (n=3) participants as other (See Figure 2). When looking at the different variables using chi-square tests, the researcher will look at crosstabulations by using only two of the categories of either single or other marital status. 56.9% (n=33) participants were single and 43.1% (n=35) participants were either married, widowed, divorced, and identified as other for their marital status (See Table 1).

Figure 2. Marital Status of Participants

Other demographics included the participant’s country of origin. The study indicated that 46.6% (n=27) participants were born in America, 13.8 % (n=8) were born in Laos, 36.2% (n=21) were born in Thailand, 0% (n=0) were born in Vietnam, 1.7%

(n=1) were born in China, and 1.7% (n=1) participant indicated other (See Figure 3).

Figure 3 will show the pie chart for participant’s country of origin and Table 1 also illustrates the summary of country of origin. From examining the country of origin of participants, it shows that about 46.6% (n=27) participants reported that they were born in America and 53.4% (n=31) of the participants reported that they were not born outside of America.

Figure 3. Participants’ Country of Origin.

Of the 53.44% (n=31) participants, Figure 4 illustrates the participants age and what year of arrival to America for 23 (n=23) participants out of the 31 (n=31) participants who were born outside of America. Eight (n=8) participants either skipped or provided erroneous information that was not useful for the study. Figure 4 shows the age and year of arrival of the 23 (n=23) participants. By looking at the y axis the year of arrival ranges from 1978 to 1996. By looking at the x axis, the participants age ranges from 0.5 years old to 17 years of age. The mode or most popular year of arrival from the participant studied was 1980, where 5 (n=5) of the participants arrived in America.

Majority of the participants were between 0.5 years of age to 9 years of age indicating that majority of the sample participants have been in America for at least 10 years or longer.

Figure 4. Participants’ Age and Year of Arrival to America

As seen on Table 1, the next demographics on the survey examines the participants’ Mien identity, educational background, and generational group. The survey indicated that 89.7% (n=52) participants were full Mien (meaning both parents are Mien) and 10.3% (n=6) participants reported that they were either half/mixed race. Educational backgrounds of the participants indicated that 34.5% (n=20) of the survey participants received a high school diploma/GED/ and/or lower level of education, and 65.5% (n=38) participants received either a certificate and/or higher education (either associates, bachelors, masters and or doctoral degrees). It is important to take note that majority of the survey sample consisted of Mien participants who pursued higher education after high school, and this can influence how survey questions are answered. Generational identity survey questions indicate that 50% (n=29) participants were the immigrant/refugee immigrant group (first generation in America), 48.3% (n=28) of the participants were second generation Mien Americans (First generation born in America), and 1.7% (n=1) participant reported other on generational group (See Table 1).

Survey Participants’ Mien Background

In order to better understand the survey participants, the researcher examines the

Mien participant’s background and the participants’ preferred language and examine if

English was a second language. Over two-thirds (68.97%) (n=40) of participants prefers

English language, 13.79% (n=8) participants prefer using Mien language, and 17.24%

(n=10) participants have no language preference (See Figure 5). Figure 5 also demonstrates that 89.66% (n=52) participants indicated English as a second language and only 10.34% (n=6) participants said English was not their second language.

Figure 5. Participants’ Language Preference and English as a Second Language

In addition, learning about participants’ language, the survey included Likert scale type questions to further examine how participants’ view themselves in relation to their

Mien identity. Table 2 provides a Summary of the Likert scales as “agreed” or

“disagreed.” Participants who answered, “strongly agree” and “agree” were indicated as

“agreed” on Table 2. Likewise, participants who answered “disagree,” strongly disagree,” and “not sure/I don’t know” were indicated as “disagreed” on Table 2. Table 2 shows that at least 50% (n=28) participants hold strongly to their Mien culture and heritage, consider themselves assimilated to American culture, and believes it is important to follow religious/spiritual beliefs of their parents.

Table 2

Summary of Survey Questions for Mien Background

I hold strongly to my Valid Cumulative Mien culture and heritage Frequency Percent Percent Percentage Valid Agreed 46 79.3 79.3 79.3 Disagreed 12 20.7 20.7 100 Total 58 100 100 Total 58 100 100

I consider myself assimilated into the mainstream North Valid Cumulative American culture Frequency Percent Percent Percent Valid Agreed 49 84.5 84.5 84.5 Disagreed 9 15.5 15.5 100 Total 58 100 100 Total 58 100 100

It is important for me to continue following my parents’ Valid Cumulative religious/spiritual beliefs Frequency Percent Percent Percent Valid Agreed 32 55.2 55.2 55.2 Disagreed 26 44.8 44.8 100 Total 58 100 100 Total 58 100 100

Religious/Spiritual Affiliations

The survey questions also explored the participants’ religious/spiritual affiliations and the participants’ level of religious involvement. Figure 6 indicates that participants’ current religion and participants’ religions growing up. Participants answered that

53.45% (n=31) participants identify as Taoists (Shamanism), 5.17% 3 identify as

Buddhists, 32.76% (n=19) identify as Christians, 6.90% (n=4) as other religious affiliations, and 1.72% (n=1) participant did not report anything. Figure 6 also indicates that 74.14% (n=43) participants were Taoists (Shamanism), 6.90% (n=4) were Buddhists, and 18.97% (n=11) were Christians. There was an increase of 13.79% (n=8) participants who identified their current religion as Christianity. There was a 1.72% (n=1) participant reduction in current Buddhist religion from participants growing up to current participants. Taoist (Shamanism) had the most decrease in current participant’s participation than any other religion. Figure 6 showed that 20.68% (n=12) participants changed from Taoist (Shamanism)to a different religion. Participant answered that there was a 74.14% (n=43) while growing up that identified as a Taoist Shamanism) and is now reduced to 53.45% (n=31) of the participants who still identified as being a Taoist

(Shamanism). Lastly, Figure 6 shows that there is a rise or increase of participants who identified as being Christian.

Religion and Spirtuality

4 OTHER 0

19 CHRISTIANITY 11 Current 3 Growing up BUDDHIST 4

31 TAOIST (SHAMANISM) 43

0 10 20 30 40 50

Figure 6. Religious Affiliations Current & Growing Up

The research survey questions examined the participant’s religious and spiritual beliefs/practices, and participants’ religious/spiritual involvement/affiliations. The participants’ level of involvement is measured with a Likert scale but summarized into two categories, “religious” or “not religious” on Table 3. Table 3 show participants who answered “not religious/spiritual,” “ don’t know,” and “slightly religious/spiritual” were indicated as “not religious/spiritual” and participants who answered “moderately religious/spiritual” and “very religious/spiritual” were indicated as “religious “or

“spiritual.” With the given statements above, 65.5% (n=38) participants considered themselves “not religious” and 34.5% (n=20) participants considered themselves

“religious.” On the other hand, 46.6% (n=27) participants considered themselves “not spiritual” and 53.4% (n=31) participants as “spiritual.” Table 3 also showed that 74.1%

(n=43) participants feel that there is a difference between being religious and being spiritual and 25.9% (n=15) participants who does not believe or does not know if there is a difference between being religious and being spiritual.

Table 3

Religious and Spiritual Involvement and Affiliations

Do you consider yourself to Valid Cumulative be religious? Frequency Percent Percent Percent Valid Not Religious 38 65.5 65.5 65.5 Religious 20 34.5 34.5 100 Total 58 100 100 Total 58 100 100

Do you consider yourself to Valid Cumulative be spiritual? Frequency Percent Percent Percent Valid Not Spiritual 27 46.6 46.6 46.6 Spiritual 31 53.4 53.4 100 Total 58 100 100 Total 58 100 100

Do you feel there is a difference between religious Valid Cumulative and being spiritual? Frequency Percent Percent Percent Valid Yes 43 74.1 74.1 74.1 No 15 25.9 25.9 100 Total 58 100 100 Total 58 100 100

How often do you turn to your religion to help you deal with problems in your life? Valid Cumulative Valid Frequency Percent Percent Percent Never/Rarely/ Sometimes 43 74.1 74.1 74.1 Often/Always 15 25.9 25.9 100 Total 58 100 100 Total 58 100 100

In addition, Table 3 also indicates that 74.1% (n=43) participants reported that they “never”, “rarely”, or “sometimes” turn to religion to help deal with life problems and

25.9% (n=15) participants reported that they “often” or “always” turn to religion to help deal with life problems. Figure 7 shows the participants’ perspective of life after death and 24.1% (n=14) participants answered, “heaven and in hell,” 43.1% (n=25) participants answered “rebirth/reincarnation,” 8.6% (n=5) participants answered in “spiritual being,” and another 8.6% (n=5) participants answered “nothing/ I don’t believe in life after death,” and 15.5% (n=9) participants answered “don’t know/other”. The participants’ religious/spiritual affiliations have a huge impact of how they view life after death.

Results for Mental Health Perceptions in Relation to Religion/Spirituality

Next, Figure 8 examined the survey participants’ understanding of mental health and mental wellness. Figure 8 examined if participants understood the difference between mental health and mental wellness. Participants answered, “mental health/mental wellness as the same or different,” “involves good” “bad people,” “involves everyone,”

“all the above,” or “none of the above.” Results indicates that 56.90% (n=33) participants answered “all of the above” for mental health and 37.93% (n=22) participants answered

“all of the above” for mental wellness (See Figure 8).

The remaining survey questions will be summarized on Table 4 and Table 5 to examine how participants ‘religious/ spiritual background relates to perceptions of mental health. Table 4 & Table 5 shows that the participants who answered, “strongly agree” and

“agree” are indicated as “agreed” on Table 4. Participants’ who answered “disagree,”

“strongly agree,” and “not sure/ I don’t know” are indicated as disagreed.

Figure 7. Participants’ Thoughts on Life After Death

Figure 8. Participants’ Understanding Mental Health Vs. Mental Wellness

Table 4

Participant’s Religion/Spirituality and Perception of Mental Health

I believe I can identify if a family member and/-or close friend needs Valid Cumulative mental health services Frequency Percent Percent Percent Valid Agree 44 75.9 77.2 77.2 Disagree 13 22.4 22.8 100 Total 57 98.3 100 Missing System 1 1.7 Total 58 100

I would recommend mental health services to a family member and/or- Valid Cumulative close friend if needed Frequency Percent Percent Percent Valid Agree 50 86.2 87.7 87.7 Disagree 7 12.1 12.3 100 Total 57 98.3 100 Missing System 1 1.7 Total 58 100

I believe it is important for mental health service providers to understand Mien people's religious/ spiritual backgrounds when treating Valid Cumulative mental health Frequency Percent Percent Percent Valid Agree 44 75.9 77.2 77.2 Disagree 13 22.4 22.8 100 Total 57 98.3 100 Missing System 1 1.7 Total 58 100

I am aware that under the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental health providers are required to take into consideration one's cultural, religious, and spiritual background when working with Valid Cumulative individuals Frequency Percent Percent Percent Valid Agree 33 56.9 61.1 61.1 Disagree 21 36.2 38.9 100 Total 54 93.1 100 Missing System 4 6.9 Total 58 100

Participant’s Religion/Spirituality and Perception of Mental Health (Continued)

I would consider recommending mental health (MH) services for a family member/ close friend who is Mien if I knew that MH providers considers cultural, religious, and spiritual background when working with Valid Cumulative individuals Frequency Percent Percent Percent Valid Agree 47 81 87 87 Disagree 7 12.1 13 100 Total 54 93.1 100 Missing System 4 6.9 Total 58 100

I think mental health providers do a great job in trying to understand Mien people's Valid Cumulative religious/spiritual backgrounds Frequency Percent Percent Percent Valid Agree 7 12.1 13 13 Disagree 47 81 87 100 Total 54 93.1 100 Missing System 4 6.9 Total 58 100

My religious and spiritual background does Valid Cumulative not impact my mental health Frequency Percent Percent Percent Valid Agree 24 41.4 44.4 44.4 Disagree 30 51.7 55.6 100 Total 54 93.1 100 Missing System 4 6.9 Total 58 100

I think mental health is tied to my religious Valid Cumulative and spiritual background Frequency Percent Percent Percent Valid Agree 22 37.9 40.7 40.7 Disagree 32 55.2 59.3 100 Total 54 93.1 100 Missing System 4 6.9 Total 58 100

I think religious/spiritual background is tied Valid Cumulative to my mental health Frequency Percent Percent Percent Valid No 19 32.8 35.8 35.8 Yes 34 58.6 64.2 100 Total 53 91.4 100 Missing System 5 8.6 Total 58 100

Findings of Mien Americans Perceptions on Religion/Spirituality and Mental Health

By looking at the demographics of the participants, Table 5 will look at participant’s age and their educational background. As illustrated in Table 1, chi-square test of independence indicates that there are no association between the participants’ age and educational background. The results illustrate that the participant’s age is not a factor in their level of educational background.

Table 6 looks at the demographics of two age groups (18-35 years old and 36-55 years old) to first-generation Mien Americans and second-generation Mien Americans.

Table 6 illustrates that there is a weak negative association between the age and generational groups. Meaning the age of participants negatively correlates with whether they are first-generation or second-generation Mien Americans. This finding illustrates that as Mien Americans’ age rises, the amount of first-generation and second generations decrease. Exclusive to this participant group, it is safe to say that there are less people giving birth to other Mien Americans. The participants’ age has a strong negative effect on whether they are first-generation or second-generation and results are significantly significant (χ²=10.433, df=1, p=.001).

Table 7 illustrates that the chi-square test of independence indicates that there is an association between the participants’ country of origin (either America or another country) and participants’ marital status. Table 7 illustrates that the participants’ country of origin has an influence on their marital status. This is significant as the Table 7 shows that participants born in America are more likely to be single rather than married and participants born in a different country other than America are more likely be married

85 than be single. A participant’s country of origin has a moderate effect on their marital status and the results are statistically significant (χ² =10.433, df=1, p=.001).

Table 5

Crosstabulation for Age and Educational Background

Educational background?

High Certificates school and other diploma/ higher GED or education lower degrees Total Age 18-35 years Count 16 27 43 old Expected Count 14.8 28.2 43.0 % within Age 37.2% 62.8% 100.0% % within What is your 80.0% 71.1% 74.1% educational background?

% of Total 27.6% 46.6% 74.1% 36-55 years Count 4 11 15 old Expected Count 5.2 9.8 15.0 % within Age 26.7% 73.3% 100.0% % within What is your 20.0% 28.9% 25.9% educational background?

% of Total 6.9% 19.0% 25.9% Total Count 20 38 58 Expected Count 20.0 38.0 58.0 % within Age 34.5% 65.5% 100.0% % within What is your 100.0% 100.0% 100.0% educational background? % of Total 34.5% 65.5% 100.0%

Table 6 Participants’ Age and Generational Group

Which of the following groups do you most identify with? First Generation Second (Refugee/I Generation mmigrant (First born group) in America) Total Ages 18-35 years Count 16 26 42 old Expected Count 21.4 20.6 42.0 % within Age 38.1% 61.9% 100.0% % within Which of 55.2% 92.9% 73.7% the following groups do you most identify with? % of Total 28.1% 45.6% 73.7% 36-55 years Count 13 2 15 old Expected Count 7.6 7.4 15.0 % within Age 86.7% 13.3% 100.0% % within Which of 44.8% 7.1% 26.3% the following groups do you most identify with? % of Total 22.8% 3.5% 26.3% Total Count 29 28 57 Expected Count 29.0 28.0 57.0 % within Age 50.9% 49.1% 100.0% % within Which of 100.0% 100.0% 100.0% the following groups do you most identify with? % of Total 50.9% 49.1% 100.0%

Table 7 Country of Origin and Marital Status

Marital Status Married/Other Single Marital Status Total Country of America Count 21 6 27 Origin Expected Count 15.6 11.4 27.0 % within Country of 77.8% 22.2% 100.0% Origin % within Marital Status 63.6% 25.0% 47.4% % of Total 36.8% 10.5% 47.4% Another Count 12 18 30 Country Expected Count 17.4 12.6 30.0 % within Country of 40.0% 60.0% 100.0% Origin % within Marital Status 36.4% 75.0% 52.6% % of Total 21.1% 31.6% 52.6% Total Count 33 24 57 Expected Count 33.0 24.0 57.0 % within Country of 57.9% 42.1% 100.0% Origin % within Marital Status 100.0% 100.0% 100.0% % of Total 57.9% 42.1% 100.0%

Table 8 results show that there is an association between the relationship with participants who identified themselves as someone who holds strongly to their Mien

Culture and heritage has a moderate effect on whether it is importance for them to follow their parents’ religious/spiritual beliefs. Table 8 also illustrates that, 51.7% of the participants who hold strongly to their Mien culture and heritage also thinks that it is important to continue their parents’ religious/spiritual beliefs, and this indicates that the results are statistically significant. (χ² =9.07, df=1, p=.003).

Table 9 shows that there is an association between participants’ who consider themselves as religious and participants’ who consider themselves spiritual. Table 9 indicates that the participants’ who consider themselves religious has a moderate effect on whether they also consider themselves spiritual, and the results indicate statistical significance. (χ² =12.214.07, df=1, p=.00).

Table 10 shows that among the participants who responded as “not religious,”

26.7% responded “often/ always” on how often they turn to their religion to help with problems in life. Table 10 also indicates that 55% of the participants who consider themselves “religious” also responded that they “often/always,” turn to religion to help with problems. The results are statistically significant (χ² =13.517, df=1, p=.00).

Table 11 shows that among the participants who responded as “not spiritual,”

13.3% responded “often/ always” on how often they turn to their religion to help with problems in life. Table 11 also indicates that 86.7% of the participants who consider themselves “spiritual” also responded that they “often/always,” turn to religion to help with problems in life. The results are statistically significant (χ² =8.97, df=1, p=.003).

Table 8

I hold strongly to my Mien culture and heritage vs. It is important for me to continue following my parents’ religious/spiritual beliefs.

It is Important for me to continue following parents’ religious/spiritual belief.

Agree Disagree Total I hold strongly to my Agree Count 30 16 46 Mien culture and Expected Count 25.4 20.6 46.0 heritage. % within I hold 65.2% 34.8% 100.0% strongly to Mien culture/heritage % within Important 93.8% 61.5% 79.3% to following my parents’ religious/spirituality % of Total 51.7% 27.6% 79.3% Disagree Count 2 10 12 Expected Count 6.6 5.4 12.0 % within I hold 16.7% 83.3% 100.0% strongly to Mien culture/heritage % within Important 6.3% 38.5% 20.7% to following my parents’ religious/spirituality % of Total 3.4% 17.2% 20.7% Total Count 32 26 58 Expected Count 32.0 26.0 58.0 % within I hold 55.2% 44.8% 100.0% strongly to my Mien culture/heritage % within Important 100.0% 100.0% 100.0% to following my parents’ religious/spirituality % of Total 55.2% 44.8% 100.0%

Table 9

Crosstabulation Between Participants’ Who Consider Themselves Religious and

Participants Who Consider Themselves Spiritual.

Do you consider yourself to be spiritual? Not Spiritual Spiritual Total Do you consider Not Count 24 14 38 yourself to be Religious Expected Count 17.7 20.3 38.0 religious? % within Do you 63.2% 36.8% 100.0% consider yourself to be religious? % within Do you 88.9% 45.2% 65.5% consider yourself to be spiritual? % of Total 41.4% 24.1% 65.5% Religious Count 3 17 20 Expected Count 9.3 10.7 20.0 % within Do you 15.0% 85.0% 100.0% consider yourself to be religious? % within Do you 11.1% 54.8% 34.5% consider yourself to be spiritual? % of Total 5.2% 29.3% 34.5% Total Count 27 31 58 Expected Count 27.0 31.0 58.0 % within Do you 46.6% 53.4% 100.0% consider yourself to be religious? % within Do you 100.0% 100.0% 100.0% consider yourself to be spiritual? % of Total 46.6% 53.4% 100.0%

Table 10

Religion vs. Problems of Life

How often do you turn to your religion to help with problems in life?

Never/Rarely Often/ / Sometimes Always Total Do you consider Not Count 34 4 38 yourself to be Religious Expected Count 28.2 9.8 38.0 religious? % within Do you 89.5% 10.5% 100.0% consider yourself to be religious? % within How Often 79.1% 26.7% 65.5% do you Turn to Your religion to Help with Problems in Life? % of Total 58.6% 6.9% 65.5% Religious Count 9 11 20 Expected Count 14.8 5.2 20.0 % within Do you 45.0% 55.0% 100.0% consider yourself to be religious? % within How Often 20.9% 73.3% 34.5% do you Turn to Your religion to Help with Problems in Life? % of Total 15.5% 19.0% 34.5% Total Count 43 15 58 Expected Count 43.0 15.0 58.0 % within Do you 74.1% 25.9% 100.0% consider yourself to be religious? % within How Often 100.0% 100.0% 100.0% do you Turn to Your religion to Help with Problems in Life? % of Total 74.1% 25.9% 100.0%

Table 11

Spirituality vs. Problems of Life

How Often do you Turn to Your religion to Help with Problems in Life? Never/Rarel/ Often/ Sometimes Always Total Do you consider Not Count 25 2 27 yourself to be Spiritual Expected Count 20.0 7.0 27.0 spiritual? % within Do you 92.6% 7.4% 100.0% consider yourself to be spiritual? % within How Often 58.1% 13.3% 46.6% do you Turn to Your religion to Help with Problems in Life? % of Total 43.1% 3.4% 46.6% Spiritual Count 18 13 31 Expected Count 23.0 8.0 31.0 % within Do you 58.1% 41.9% 100.0% consider yourself to be spiritual? % within How Often 41.9% 86.7% 53.4% do you Turn to Your religion to Help with Problems in Life? % of Total 31.0% 22.4% 53.4% Total Count 43 15 58 Expected Count 43.0 15.0 58.0 % within Do you 74.1% 25.9% 100.0% consider yourself to be spiritual? % within How Often 100.0% 100.0% 100.0% do you Turn to Your religion to Help with Problems in Life? % of Total 74.1% 25.9% 100.0%

Table 12 shows that among Mien Americans who were born in America, 53.5% agreed to the statement, “I believe it is important for mental health service providers to understand Mien people’s religious/spiritual backgrounds when treating mental health.”

Table 12 also indicates that among the Mien Americans who stated that they were born in another county, 69.0% also agreed to the statement, “I believe it is important for mental health service providers to understand Mien people’s religious/spiritual backgrounds when treating mental health.” The results are not statistically significant.

Table 13 shows that among the participants that agreed with the statement, “I would consider recommending mental health services for a family member and/or close friend who is Mien if I knew that mental health providers consider cultural, religious, and spiritual background when working with individuals,” 87.2% disagreed with the statement “I think mental health providers do a great job in trying to understand Mien people’s religious/spiritual backgrounds.” The results are not statistically significant.

Table 14 shows that among the participants that agreed with the statement, “I believe it is important for mental health service providers to understand Mien people’s religious/spiritual backgrounds when treating mental health,” 85.4% disagreed with the statement “I think mental health providers do a great job in trying to understand Mien people’s religious/spiritual backgrounds.” The results are not statistically significant.

Table 12

Country of Origin vs. Perceptions of Mental Health Service Providers

I believe it is important for MH service providers to understand Mien people’s R/S backgrounds when treating MH.

Agree Disagree Total Country America Count 23 4 27 of Origin Expected Count 20.7 6.3 27.0 % within Country of Origin 85.2% 14.8% 100.0% % within I believe it is 53.5% 30.8% 48.2% important for MH service providers to understand Mien people’s R/S backgrounds when treating MH. % of Total 41.1% 7.1% 48.2% Another Count 20 9 29 Country Expected Count 22.3 6.7 29.0 % within Country of Origin 69.0% 31.0% 100.0% % within I believe it is 46.5% 69.2% 51.8% important for MH service providers to understand Mien people’s R/S backgrounds when treating MH. % of Total 35.7% 16.1% 51.8% Total Count 43 13 56 Expected Count 43.0 13.0 56.0 % within Country of Origin 76.8% 23.2% 100.0% % within I believe it is 100.0% 100.0% 100.0% important for MH service providers to understand Mien people’s R/S backgrounds when treating MH.

% of Total 76.8% 23.2% 100.0%

Table 13

Recommend Mental Health Services vs. Perception of Providers

I think mental health providers do a great job in trying to understand Mien people’s religious/spiritual backgrounds.

Agree Disagree Total I would consider Agree Count 6 41 47 recommending Expected Count 6.1 40.9 47.0 mental health % within I would 12.8% 87.2% 100.0% consider services for a family recommending mental member or close health services… friend who is Mien if I % within I think mental 85.7% 87.2% 87.0% health providers do a knew that mental great job… health providers % of Total 11.1% 75.9% 87.0% consider cultural, Disagree Count 1 6 7 religious, and spiritual Expected Count .9 6.1 7.0 background when % within I would 14.3% 85.7% 100.0% consider working with recommending mental individuals. health services… % within I think mental 14.3% 12.8% 13.0% health providers do a great job… % of Total 1.9% 11.1% 13.0% Total Count 7 47 54 Expected Count 7.0 47.0 54.0 % within I would 13.0% 87.0% 100.0% consider recommending mental health services… % within I think mental 100.0% 100.0% 100.0% health providers do a great job… % of Total 13.0% 87.0% 100.0%

Table 14 Perceptions of Mental Health Providers

I think mental health providers do a great job in trying to understand Mien people’s religious/spiritual backgrounds.

Agree Disagree Total I believe it is Agree Count 6 35 41 important for mental Expected Count 5.3 35.7 41.0 % within I believe it is 14.6% 85.4% 100.0% health service important for mental providers to health service providers to understand Mien understand… people’s % within I think 85.7% 74.5% 75.9% mental health religious/spiritual providers do a great backgrounds when job… % of Total 11.1% 64.8% 75.9% treating mental Disagree Count 1 12 13 health. Expected Count 1.7 11.3 13.0 % within I believe it is 7.7% 92.3% 100.0% important for mental health service providers to understand…. % within I think 14.3% 25.5% 24.1% mental health providers do a great job in trying to understand… % of Total 1.9% 22.2% 24.1% Total Count 7 47 54 Expected Count 7.0 47.0 54.0 % within I believe it is 13.0% 87.0% 100.0% important for mental health service providers to understand… % within I think 100.0% 100.0% 100.0% mental health providers do a great job… % of Total 13.0% 87.0% 100.0%

Summary

This chapter analyzed the relationship between different survey items that measured how Mien American’s religious and spiritual background effect their mental health perceptions. Demographic information was also presented about the Mien

American participants. Chi-square tests analysis were conducted to present the relationship between the independent and dependent variables. The next chapter will outline and conclude the study findings. The next chapter will also discuss about social work implications, explain the limitations of this study, and offer recommendations.

Chapter 5

CONCLUSION

Chapter five will presents the main findings this research explored, summarized, and concluded. This chapter will also include social work implications practiced at the micro, mezzo, and macro. In addition, recommendations for future students, social workers, researchers, and policy makers will be discussed. Lastly, the limitations of this study will also be provided.

Summary

The purpose of this study was to explore how Mien American’s religion/spirituality affect their perception on mental health. The researcher surveyed

Mien Americans over 18 years of age who lived in Sacramento to gain better insight into how this populations’ religion/spirituality background and their perceptions of mental health. Demographics were also collected by this population including gender, age, marital status, country of origin, Mien Identify (either full, half, or mixed), educational background, and generational status. Chapter four included five different sections of the survey that looked at (1) demographics, (2) mien background, (3) religious/spiritual affiliations, (4) mental health perception/utilization, and (5) perception of religion/ spirituality as it relates to mental health and vice versa. The data presented in chapter four analyzed the participants’ survey answers within the five different sections and analyzed their associations between the sections.

The frequency distribution of responses to several survey items provides trends to religious affiliations and their perceptions of mental health service providers. The results

100

of chi-square tests revealed associations between multiple characteristics of the

independent variables, such as age, generational identification, country of origin, and

marital status. Furthermore, the chi-square tests showed associations between multiple

characteristics of the dependent variables, such as how Mien American’s identify their

mien background and how Mien Americans identify their religion/spirituality beliefs as

associated with each other. There were associations between dependent variables such as

religion/spirituality of Mien Americans, and their mental health perceptions.

As illustrated in the tables on chapter four, there were significant associations between the age of the participants and first/second-generation Mien Americans. The negative weak association between the participants’ age and generational group suggests that as the first generation grows older there is a decrease in population from first/second generation. This is evidence of first-generation Mien Americans have outgrown their reproductive years. Chi-square tests did show a significant association between the participants’ country of origin and marital status. This association indicated that marriage was more valued in individuals who were born in another country. This is because marriage was more sought for in a different country or it can be that American born people are delaying marriage.

Also shown in chapter four, there are significant associations between how the

Mien American participants viewed themselves to how they perceive what is important to them. In one of the significant associations, where participants identify themselves as holding strongly to their Mien culture and heritage, it has big implications on whether it was important for them to follow their partner’s religious and spiritual beliefs. This

101 illustrated that 46, (79.3%) participants hold strongly to their Mien cultural and heritage, which are greatly influenced by their parents’ religious and spiritual beliefs. Similarly, participants who identified as religious also considered themselves spiritual. Mien people’s views of religion is compatible with their views of spirituality. On the other hand, this research also showed a strong association between people who say they are not religious, but also turn to religion for help with their life problems.

From the 38 participants who responded as “not religious,” 26.7% of those participants consequently “often/always” turn to religion to help with their problems.

This association illustrated that even when Mien participants identified as “not religious,” they still utilize religious practices during hard times in their lives. The study shows significant association between identity spirituality and whether or the respondent turns to religion to help with life problems. According to this study, 86.7% of participants who identified as “spiritual” also responded that they “often/always” turn to religion to help with problems. In addition, 13.3% of individuals who identified as “not spiritual” also identified that they “often/always” turn to religion to help with problems. This indicates that even though individuals do not hold strongly to religion or spirituality also turn to religion to help with problems. Lastly, this study provides frequency distribution showing a rise in trend for Mien Americans participants who identify as Christian and in Taoist

(shamanism) beliefs. Frequency distribution tables shows that 47 (81%) participants would consider recommending mental health services for Mien family members/close friends if they knew that mental health providers consider cultural, religious, and spiritual background, when working with individuals. However, 54 (93.1%) participants

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“disagree” to the statement, “I think mental health providers do a great job in trying to

understand Mien people’s religious/ spiritual background.” These frequency distributions

indicate that Mien people would likely seek services but does not feel that mental health providers are doing well in trying to understand cultural aspects (such as religion and spirituality) among Mien people.

Discussion

The data collected in this study revealed different attitudinal characteristics about how Mien American’s religion/spirituality effect their perceptions of mental health. The current research also showed associations between participants’ demographic backgrounds within each other and associations between religious identity and perceptions of mental health. Although this study has significant results within characteristics it does not answer the following research question: How does Mien

American’s religion/spirituality effect their perception of mental health?

There is no research found on how Mien American’s religious/spiritual effect their perception on mental health, perspectives of religion/spirituality on mental health, or perspectives on mental health relating to Asian Americans (Cheng et al., 2017; Koenig,

2012; Sue et al., 2012).The data collected from this study indicated a negative correlation between first-generation Mien Americans’ increase in age and decrease in Mien population. Similarly, the study also showed that participant’s marital status is related to their country of origin. Studies shown that Mein Americans Mien people primarily lived in the “hills” or “mountains” of Vietnam, Thailand, Laos, Burma, and China in agricultural slash and burn societies. Agricultural lands require Mien people to have a

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large family to support their lifestyles and is relevant to why Mien Americans population

differs from Mien population in Asia. Mien populations in Asia value large family

structures and as Mien Americans assimilate to American culture does not have the same

lifestyles. The data collected showed Mien Americans reporting that they hold strongly to their Mien culture/heritage and identifying that they think that it is important to continue parent’s religion is closely related to Animism (Jonsson, 2015). Mien people’s

fundamental belief and principles have a combination of Animism and Taoist religion

that worshipped their ancestors (Jonsson). The belief of worshipping their parents and

their elders are innate to them growing up.

The data collected on religious and spirituality are consistent with what other

researchers found. Research indicated concepts of religion are like spirituality and that

individuals turn to either one during times of struggles as indicated on the survey (Cook,

2017). As stated by Cook, spirituality and religion are the belief systems for people to

find meaning, purpose, and resources to cope with times of adversity or illness (Cook).

The difference of religion and spirituality is that religion usually comprise of a

community and spirituality can be more personal and freer of rules (Koenig, 2009, 2012).

It makes sense that individuals who either believe in God or another higher being would

turn to religion for support. Similarly, individuals who are spiritual would also turn to

religion for help with adversities.

The data collected in this study indicated that that conversion to Christianity is

growing within the Mien participants. The rising trend of Christianity is explained

through Jonsson’s research. Although Mien cultural/traditions and religious/spirituality

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are different from those of the West, Jonsson (2015) suggest that this rising trend is

caused by the hardships they faced that eventually lead them to convert to Christianity. In

addition, Jonsson argues that the conversion is also lead by Mien people’s lack of

resources and inability to secure a chicken for sacrifice or having limited transportation

for a spirit medium(shaman). This study also collected data on the frequency distribution

on the Mien Americans’ perception of mental health service providers showed that Mien

Americans “disagree” that mental health service providers do a great job in understanding

Mien people’s religious/ spiritual background. This is shown by the perception that the

Asian American population is one homogenous group, when there are over 30 ethnic

subgroups and over three hundred languages among Asian Americans (Cheng et al.,

2017). In addition, Asian Americans being perceived as the model minority, further

contributes to them delaying mental health services until it becomes severe. It is

important for researchers to support providers and Mien American populations in

bridging the gaps to ensure mental health needs are being met.

Implications for Social Work Policy and Practice

As mention by The Council on Social Work Education (CSWE), it is estimated that there are as many as 672,000 social workers providing services in different variety of practice settings within the U.S. workforce (Social Work Licensure Organization,2011)

National Association for Social Workers (NASW) and Diagnostic Statistical Manual fifth edition (DSM-V) are social work standards that promote the implementation of cultural competency and cultural humility (American Psychiatric Association, 2013; NASW,

2020;).As modeled, it is important to utilize cultural competency and cultural humility

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while providing services to those we are privileged to serve (NASW; American

Psychiatric Association. According to NASW it is important to utilize Code of Ethical/

Standards to emphasize cultural competency and cultural humility. Consistent with Code

of Ethics/ Standards, DSM-V proclaims the importance of cultural formulation while

clinically diagnosing, assessing, and making a treatment plan (American Psychiatric

Association). Preluding to cultural formulation, social workers should also apply person-

in-environment theory while providing micro, mezzo, or macro services to consumers

(Conrad-Amlicke, 2020). The goal while performing under the different level of services

is to restructure the power imbalances by learning, communicating, offering help/support,

and making professional practice/setting (NASW, 2012).

On the micro level, social workers are providing individual direct services to help

their clients problem solve (Conrad-Amlicke, 2020). Sacramento contains one of the

biggest communities of Mien Americans, with a population of approximately 12,000 to

14, 000 (Department of Human Assistance, Sacramento County, 2016). Due to the

growing population of Mien Americans in Sacramento county, it is important to be

familiarized with how to effectively work with individuals of this population. As

suggested by Koenig (2012), it is equally important for practitioners to be sensible and

sensitive to client’s religious/spiritual needs in order to provide whole person care and

address their body, mind, and spirit. While providing whole person care, social work

practitioners are also aligned with the Humanistic-Existential Theory by focuses on the

search for meaning in human existence and promotes self-actualization and self- transcendence (Hoffman, 2010; Robbins et al., 2012).

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On the mezzo level social workers, provides services similar to the micro-level provides clients support in reaching their treatment goal and bringing in the client’s systems, such as: families, friends, other community providers, and communities of faith and schools (Conrad-Amlicke, 2020). By doing so, social work practitioners can be practicing cultural competency and cultural humility when providing these direct services

(NASW, 2020). In the context of providing Mien Americans services in the mezzo level, it is critical to utilize interpreters who are competent in the culture and behavioral health in order to provide the most effective support. When working with schools and other mezzo system, it is important to advocate for client’s needs by considering their culture which includes their language, customs, and religion/spirituality.

On the macro level, social workers provide support between client systems from the mezzo level and the larger systems (Conrad-Amlicke, 2020). By looking at culture, social workers should thrive to integrated patterns of behaviors that includes, but not limited to thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious or social groups (NASW, 2019). Although social workers are said to abide by Code of Ethics/ Standards, there has yet to be any laws implemented in behavioral health like the Joint Commission of the Accreditation of Hospital

Organization (JCAHO) by the U.S. (Koenig, 2012). For health care providers to respect patient’s cultural and personal values, beliefs, and preferences (that includes religious and spiritual beliefs) (Koenig). It would be wonderful to have laws implemented to protect the sanctity of different individuals’ cultural beliefs, so that social workers can be more liable for their actions towards those they are serving.

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Recommendations

The purpose of this study was to explore how Mien American’s

religion/spirituality affect their perception of mental health. This section provides

recommendations for future students, social workers, researchers and policy makers:

• Social work students and social workers could be aware of transferences, counter- transferences, and practice self-reflection of their own views while implementing clinical interventions regularly.

• Future social work students and social workers could always take into consideration the cultural background of clients, their families, and members of other social work systems.

• Future social work and social workers could also utilize religious and spiritual sensibility and sensitivity when working with clients, their families, and members of another service provider.

• Social workers could research and explore the longitudinal studies of immigrants and refugee groups to learn how it can intergenerationally affect them, their children now and in the future.

• Social workers could implement more studies on how to integrate religion and spirituality into mainstream interventions.

• Social workers could continually conduct themselves professionally and encourage clients, to collaborate in their treatment, and make decisions that are aligned with their cultural, religious, and spiritual preferences.

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• Social workers could always allow clients and their families to make decisions based on their cultural, religious, and spiritual preferences by maintaining their dignity with self- worth.

• Social workers could continually analyze and improve existing regulations, to promote cultural competency, cultural humility, religious, and spiritual beliefs.

Limitations

This research is limited in several ways including having a rigorous, quantitative design, low internal/external validity and having limited scope in research instrument.

First, the quantitative design consists of mainly Likert scale questions with answers varying from (strongly agree, agree, disagree, and strongly disagree) and limits accurate attitudes about the participant’s views, thus lowering internal validity. Second, the sample sized consists of 58 participants out of the estimated 12,000 to 14,000 Mien people from

Sacramento; therefore, the results are not generalizable beyond this specific data population. Third, the research did not assess for specific measures on attitudes towards whether participants believe that religion/spirituality effects their perceptions on mental health. In addition, there were several demographics collected on participants were between several age group and it is difficult to make generalizable statements about a specific group. Future studies would benefit from using methodologies to explore how each of the prominent Mien American’s religious/spiritual background factors into their perception of mental health.

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Conclusion

The purpose of this research was to explore how Mien American’s

religious/spiritual background affect their perception of mental health. The study found

that there were association between several research variables and demographic

measures. The results also indicated participants’ trends and prominent religious/spiritual beliefs, along with their perceptions of mental health providers. Future researchers should further explore how each Mien American religion/spirituality affect their perceptions of mental health that leads to their behaviors in utilization of services. This chapter discussed and analyzed the findings from chapter four. Implication for the field of social work was presented in the micro, mezzo, and macro level along with recommendations for social work students, social workers, researchers, and policy makers. Lastly, the limitations of this study were also reviewed.

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APPENDIX A

Letter of Informed Consent

Informed Consent Form The Effects of Religion/Spiritual background of Mien American in their Use of Mental Health Services

My name is Nai Saelee, I am a graduate student in the Master of Social Work Program at California State University, Sacramento. I am conducting a study on how religion/spiritual backgrounds of Mien-Americans influence their use of mental health services. There are no direct benefits or incentives for participating in this survey, but the study may benefit the Mien population by better understanding the use of mental health services in our Mien community.

Your participation in this study is voluntary. If you choose to participate in this survey, it will last approximately 10-15 minutes and will consists of 33 questions. You have the right to skip any questions. There are some risks to participating in this study if there is a breach in confidentiality such as through a computer malfunction or data breach; however, these risks are not anticipated to be anything greater than what people encounter in their daily lives. The data will also be maintained in a safe, locked location, and on a CSU, Sacramento computer server. This data may be used for future research studies or distributed to another investigator for future research studies without any additional informed consent from you. The raw data gathered in this survey will be destroyed after May 20, 2020.

Your participation in this survey is greatly appreciated. If you have any questions about the research or about this research study please contact [email protected] or Maria Dinis at [email protected]. For questions related to your rights as a participant in this research study, please call the Office of Research, Innovation, and Economics Development, California, State University, Sacramento @ (916) 279-5674 , or email [email protected].

□ By checking the box, the you acknowledge and agree to continue with this survey. You also understand and acknowledge that you can withdraw consent for participation at any time without any penalty or loss of benefits that are entitled to you.

*Please print and keep a copy for your own records* Human Subject Protocol #19-20-038.

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Appendix B

Research Instrument

Survey on the Effects of Religion/Spirituality in Mien Americans and Mental Health Utilization

For the following set of questions, please circle or specify the most appropriate response.

Demographics

1. Gender: (Please circle or specify) ·Female ·Male ·Non-binary ·Other, please specify: ______

2. Age: (Please circle or specify) ·18 years old- 25 years old ·26 years old- 35 years old ·36 years old- 45 years old ·46 years old- 55 years old ·56 years old and older

3. Marital status: (Please circle or specify) ·Single ·Married ·Divorced ·Widow ·Other, please specify: ______

4. If married, did you adopt a new religion after marriage? YES/NO (Circle one)

5. What is your country of origin: (Please circle or specify) ·America ·Laos ·Thailand ·Vietnam ·China ·Other, please specify: ______

6. If you were not born in America, what was your age were you when you arrived in America? ______Year of arrival: ______

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7. Which one is more accurate about your Mien identity? (Please circle or specify) ·Full Mien (both parents are Mien) ·Half (At-least one parent is Full Mien) ·Mixed Race (At-least one parent is part Mien) ·Other, please explain: ______

8. What is your educational background? (Please circle or specify) · No educational background · Equivalent to middle school · Equivalent to some high school · High school/ Diploma/GED · Associates Degree · Bachelor’s Degree · Master’s Degree/continuing education · Doctoral Degree · Other, please specify: ______

9. Which of the following groups do you most identify with? (Please circle or specify) · First Generation in America (Refugee or immigrants from another country) · Second Generation in America (First born in America) · Third Generation in America (Parents were born in America) · None of the above

Mien Background

10. What is your preferred language? ______

11. Is English your second language? YES/NO (Circle one)

For the following set of statements, please indicate your level of agreement or disagreement with them.

12. I hold strongly to my Mien culture and heritage. (Please circle one) · Strongly Agree · Agree · Disagree · Strongly Disagree · Not sure/I don’t know

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13. I consider myself assimilated into the mainstream North American culture. (Please circle one) · Strongly Agree · Agree · Disagree · Strongly Disagree · Not sure/I don’t know

14. It is important for me to continue following my parents’ religious/spiritual beliefs. (Please circle one) · Strongly Agree · Agree · Disagree · Strongly Disagree · Not sure/I don’t know

Religious/Spiritual Affiliations

15. What religion/spiritual belief do you currently identify? (Please circle one) · Taoist (Shamanism) · Buddhist · Christianity · Other, please specify: ______

16. What was your religion/spiritual belief growing up? (Please circle one or specify) · Taoist (Shamanism) · Buddhist · Christianity · Other, please specify: ______

17. Do you consider yourself to be religious? (Please circle one or specify) · Not religious · Slightly religious · Moderately religious · Very religious · Don’t know

18. Do you consider yourself to be spiritual? (Please circle one or specify) · Not spiritual · Slightly spiritual · Moderately spiritual · Very spiritual · Don’t know

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19. Do you feel there is a difference between being religious and being spiritual? (Please circle one) · Yes · No · Somewhat · Don’t know

20. What are your thoughts about life after death? (Please circle one) · Heaven and/-or Hell · Rebirth/Reincarnation · Spiritual · Nothing/I don’t believe in life after death · Don’t know Other. Please Describe______

21. How often do you turn to your religion to help you deal with problems in your life? (Please circle one) · Never · Rarely · Sometimes · Often · Always

Mental Health Utilization

22. What is your understanding of mental health? (Circle all that apply) · Different from mental wellness · Same as mental health · Involves bad people · Involves good people · Involves Everyone · All the above · None of the above ·Other. Please Describe______

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23. What is your understanding of mental wellness? (Circle all that apply) · Different from mental health · Same as mental health · Involves bad people · Involves good people · Involves Everyone · All the above · None of the above · Other. Please Describe______

24. I believe I can identify if a family member and/-or a close friend needs mental health services. (Please circle one) ·Strongly Agree ·Agree ·Disagree ·Strongly Disagree ·Not sure/I don’t know

25. I would recommend mental health services to a family member and/-or close friend if needed. (Please circle one) ·Strongly Agree ·Agree ·Disagree ·Strongly Disagree ·Not sure/I don’t know

Religion/Spirituality when Mental Health Services

26. I believe it is important for mental health service providers to understand Mien people’s religious/spiritual backgrounds when treating mental health. (Please circle one) ·Strongly Agree ·Agree ·Disagree ·Strongly Disagree ·Not sure/I don’t know

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27. I am aware that under the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mental health providers are required to take into consideration one’s cultural, religious, and spiritual background when working with individuals. (Please circle one) ·Strongly Agree ·Agree ·Disagree ·Strongly Disagree ·Not sure/I don’t know

28. I would consider recommending mental health services for a family member or close friend who is Mien if I knew that mental health providers consider cultural, religious, and spiritual background when working with individuals. (Please circle one) ·Strongly Agree ·Agree ·Disagree ·Strongly Disagree ·Not sure/I don’t know

29. I think mental health providers do a great job in trying to understand Mien people’s religious/spiritual backgrounds. (Please circle one) ·Strongly Agree ·Agree ·Disagree ·Strongly Disagree ·Not sure/I don’t know

30. My religious and spiritual background does not impact my mental health (Please circle one) ·Strongly Agree ·Agree ·Disagree ·Strongly Disagree ·Not sure/I don’t know

31. I think mental health is tied to my religious and spiritual background. (Please circle one) ·Strongly Agree ·Agree ·Disagree ·Strongly Disagree ·Not sure/I don’t know

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32. I think religious/spiritual background is tied to my mental health. (Please circle one) · Strongly Agree ·Agree ·Disagree ·Strongly Disagree ·Not sure/I don’t know

33. If you know anyone that may be interested in participating in the study, please provider their information below:

Name Contact Number Email 1

2 3

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APPENDIX C

Recruitment Materials

Recruitment Letter for Agencies

Greetings Health and Human Services Agency,

My name is Nai Saelee, I am a graduate student in the Master of Social Work Program at California State University, Sacramento. I am conducting a study on how the religious/spiritual backgrounds of Mien Americans influence their use of mental health services. Your agency is identified as an agency that serves the Mien population. This letter is to confirm that your agency grants permission for me to post a flyer at your agency location for this research. Please fill in information below along with a signature and date to indicate that your organization allows me to post a flyer in your agency building for participants to partake in this research study.

Thank you in advance for your time and for your contribution and support to the Mien community.

Warm regards, Nai Saelee MSW Year II Graduate Student Agency Agency Name Address Name Title Contact Email Phone # (optional) Signature Today’s Date

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Recruitment Email Greetings,

I am reaching out to you because you were identified by staff/management at your organization, agency or by another health and human services provider as someone who may have frequent contact or interaction with students/clients/general population of the Mien American Community. I am a MSW II student in the Masters of Social Work Program at California State University, Sacramento, who is conducting a study on how religious/spiritual backgrounds of Mien Americans influence their use of mental health services. Please assist me in sending this survey that I have attached and/or link to any Mien Participant that you think may be interested in participating in this study. Thank you in advance for your assistance in making this research study possible.

Sincerely, Nai Saelee MSW Graduate Student CSU, Sacramento Recruitment Flyer (1 of 2)

Greetings Mien Community Members,

Hello, my name is Nai Saelee, I am a graduate student in the Master of Social Work Program at California State University, Sacramento. If you are a Mien American, who resides in Sacramento, and over 18 years of age, then it would be an honor to have you participate in a study to support our Mien community on how religious/spiritual backgrounds of Mien Americans influence their use of mental health services. Your survey responses will be kept private and confidential. The survey will only take about 10-15 minutes of your valuable time to complete. If you feel that any of the survey questions are too personal or makes you feel uncomfortable, please feel free to skip any questions. The goal of this study is to provide a better understanding of the use of mental health services in our Mien community.

Your participation is greatly appreciated. Please feel free to forward this survey to your Mien friends and families who reside in Sacramento and are over the age of 18.

Thank you in advance for your time and for your contribution and support to our Mien community.

Warm regards, Nai Saelee MSW Year II Graduate Student CSU, Sacramento

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Recruitment Flyer (2 of 2)

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APPENDIX D

Human Subjects Committee Approval Letters

CALIFORNIA STATE UNIVERSITY, SACRAMENTO DIVISION OF SOCIAL WORK

To: Nai Saelee Date: March 16, 2020

From: Research Review Committee

RE: HUMAN SUBJECTS APPLICATION

Your modification requests to your Human Subjects application for your proposed study, “The effects of religion/spirituality in Mien Americans and their perception of mental health.” is Approved as Exempt. Discuss your next steps with your thesis/project Advisor.

Your human subjects Protocol # is: 19-20-038. Please use this number in all official correspondence and written materials relative to your study. Your file will be shredded three years from this approval date. Approval carries with it that you will inform the Committee promptly should an adverse reaction occur, and that you will make no modification in the protocol without prior approval of the Committee.

The committee wishes you the best in your research.

Research Review Committee members Professors Maria Dinis, Kisun Nam, Francis Yuen, Jennifer Wolf, Arturo Baiocchi, Teiahsha Bankhead, Susanna Curry, Susan Nakaoka

Cc: Dinis

Revised Sept 2018 ka

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CALIFORNIA STATE UNIVERSITY, SACRAMENTO DIVISION OF SOCIAL WORK

To: Nai Saelee Date: December 20, 2019

From: Research Review Committee

RE: HUMAN SUBJECTS APPLICATION

Your Human Subjects application for your proposed study, “The effects of religion/spirituality in Mien Americans and Mental Health Utilization.” is Approved as Exempt. Discuss your next steps with your thesis/project Advisor.

The committee wishes you the best in your research.

Research Review Committee members Professors Maria Dinis, Kisun Nam, Francis Yuen, Jennifer Wolf, Arturo Baiocchi, Teiahsha Bankhead, Susanna Curry, Susan Nakaoka

Cc: Dinis

Revised Oct 2018 KA

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