This thesis/project/dissertation has been reviewed for 508 compliance.

To request enhancements,

please email [email protected]. A COMPARATIVE ANALYSIS OF SHAMANISM AND CHRISTIANITY’S

PERSPECTIVE OF MENTAL HEALTH IN THE HMONG COMMUNITY

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

by

Lee Thao

Yeng Yang

SPRING 2016

A COMPARATIVE ANALYSIS OF SHAMANISM AND CHRISTIANITY’S

PERSPECTIVE OF MENTAL HEALTH IN THE HMONG COMMUNITY

A Project

by

Lee Thao

Yeng Yang

Approved by:

______, Committee Chair Maria Dinis, Ph.D., MSW

______Date

ii

Students: Lee Thao Yeng Yang

I certify that these students have met the requirements for format contained in the

University format manual, and that this project is suitable for shelving in the Library and

credit is to be awarded for the project.

______, Graduate Program Director______Dr. S. Torres, Jr. Date

Division of Social Work

iii

Abstract

of

A COMPARATIVE ANALYSIS OF SHAMANISM AND CHRISTIANITY’S

PERSPECTIVE OF MENTAL HEALTH IN THE HMONG COMMUNITY

by

Lee Thao

Yeng Yang

The study is a comparative analysis of Shamanism and Christianity beliefs of how it affects the perception of mental health in the Hmong community. The design of the study is a descriptive quantitative cross-sectional survey that uses the Likert Scale to measure the participants’ attitudes and beliefs toward mental illnesses and mental health services.

A convenience sample of Hmong people was selected at the Hmong New Year festivities.

There were 110 surveys completed. The chi-square tests were used to determine the relationship between perceptions of mental health and type of religion. There were no statistical significance differences found between perceptions of mental health and types of religions. Both types of religions have similar responses to perceptions of mental illness. Implications for social work practice are discussed.

, Committee Chair Maria Dinis, Ph.D., MSW

______Date

iv

TABLE OF CONTENTS Page List of Tables ...... viii

List of Figures ...... ix

Chapter

1. INTRODUCTION ...... 1

Statement of Collaboration ...... 1

Background of Problem ...... 2

Statement of Research Problem ...... 4

Purpose of Study ...... 5

Research Question ...... 6

Theoretical Framework ...... 6

Social Construction Theory ...... 6

Application of Social Construction ...... 7

Ecological System Theory ...... 8

Application of Ecological System Perspective ...... 9

Definition of Terms...... 10

Assumptions ...... 11

Justification ...... 11

Delimitations ...... 12

Summary ...... 13

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2. REVIEW OF LITERATURE ...... 14

Historical Background of the Hmong People, Religion, and Mental Health .. 14

Hmong People ...... 14

Religion ...... 16

Animism/Shamanism ...... 18

Christianity ...... 24

Mental Health...... 25

Western Treatment Approaches for Mental Illness ...... 28

Hmong Treatment Approaches for Mental Health ...... 30

Gaps in the Literature...... 33

Summary ...... 34

3. METHODOLOGY ...... 35

Research Question ...... 35

Research Design...... 35

Variables ...... 38

Study Population ...... 39

Sample Population ...... 39

Instrumentation ...... 40

Hmong New Year Events Data Gathering and Procedures ...... 41

Data Analysis ...... 42

Protection of Human Subjects ...... 42

Summary ...... 43 vi

4. DATA ANALYSIS ...... 44

Demographics ...... 44

Influences of Religions ...... 48

How does Shamanism and Christianity Affect the Perception of Mental

Illnesses in the Hmong Community? ...... 50

Perspective of Mental Illness ...... 50

How Does Shamanism and Christianity Affect the Perception of Mental

Health Services in the Hmong Community? ...... 55

Perspective of Mental Health Services ...... 55

Other Factors Influencing Perspective of Mental Illness and Services ...... 60

Summary ...... 67

5. CONCLUSION ...... 68

Summary ...... 68

Discussion ...... 70

Implications for Social Work Practice and Policy ...... 72

Recommendations ...... 74

Limitations ...... 75

Conclusion ...... 76

Appendix A. Participation Confirmation / Letter of Informed Consent ...... 77

Appendix B. Questionnaire ...... 78

Appendix C. Human Subject Approval Letter ...... 80

References ...... 81 vii

LIST OF TABLES Tables Page

1. Table 1 Influences of Religions...…………………………...….…………....49

2. Table 2 Mental Illness is Normal..…………………………….……………..51

3. Table 3 Mental Illness is Embarrassing…….…………….………………….52

4. Table 4 Mental Illnesses Affects Everyone…………………………….……53

5. Table 5 Mental Illness Can Be Treated By Mental Health Professionals…...54

6. Table 6 Mental Health Services Are Effective ……………………………...56

7. Table 7 Everyone Should Use Mental Health Services……………………...57

8. Table 8 Seeking Mental Health Services is Embarrassing…………………..58

9. Table 9 Everyone Should Refer Mental Health Services……………………59

10. Table 10 Gender & Refer to Mental Health Services ……………………….61

11. Table 11 Age & Refer to Mental Health Services…………………………...62

12. Table 12 Education & Refer to Mental Health Services……………………..63

13. Table 13 Gender & Mental Illness is Normal…………………………….….64

14. Table 14 Age & Mental Illness is Normal……………………………….…..65

15. Table 15 Education &Mental Illness is Normal……………………………..66

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LIST OF FIGURES Figures Page

1. Figure 1 Religion………………………………………………………….....45

2. Figure 2 Gender……………………………….……………………………..46

3. Figure 3 Age………………………………………………………………....47

4. Figure 4 Education……………………………….………………………….48

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Chapter 1

INTRODUCTION

In this chapter, it includes a state of collaboration, introduces the problems, and purpose of this study. The problem is that there is a high rate of mental illnesses within the Hmong community, but people are not seeking professional mental health services

(Lee, 2013). There have been many studies that show the barriers to treatment such as cultural or religious beliefs, language barriers, and stigma (Collier, Munger, &Moua,

2012; Fung & Wong, 2007; Gensheimer, 2006). However, the purpose of this research is to explore if there is a perspective difference between the two religions within the Hmong community. This information will provide mental health professionals increase their cultural competence within the Hmong community.

Chapter one will also explore the theoretical framework that researchers used to understand the problem such as social construction theory and ecological-system theory.

All the operational and conceptual definitions of the critical terms will be defined. The researchers’ assumptions as well as their justification of how this research will benefit the profession of social workers are discussed later in this chapter. Furthermore, the premises of the research will be clarified, and researchers will explain disclaimers to clarify any misconceptions readers may have of the study and a summary will be provided.

Statement of Collaboration

This project was written through the collaboration of both researchers. Lee Thao and Yeng Yang worked together on all chapters of this thesis. Sections were split up evenly when possible and divided according to personal interest and expertise. Each

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researcher conducted an even amount of surveys individually at the Hmong New Year.

Both researchers collaborated in inserting the data in SPSS and analyzed the information

together.

Background of Problem

In a given year, approximately one in five adults experiences mental illness

(National Alliance on Mental Illness (NAMI, 2016). In the United States, about tens of

millions of people are affected by mental health disorders and only half those people

affected receive treatment (National Institute of Mental Health, 2016). From recent data

from the National Latino and Asian American Study (NLAAS) in a 12-month period,

only 3.1% of Asian Americans use mental health services compared to 8.8% of the

general population (Spencer, Chen, Gee, Fabian,& Takeuchi, 2010). Among the racial

groups, Asian Americans used mental health services at about one-third the rate of

Caucasian Americans (NAMI, 2016). Why is this population not seeking services?

Asian Americans are one of the fastest-growing and most understudied racial groups in the United States (Spencer, Chen, Gee, Fabian,& Takeuchi, 2010). Mental illness is a rising health problem that Asian Americans face today in California,

especially the Hmong refugee families. From a study by Lee and Chang (2012), many

Hmong refugees experiences mental illness because of their involvement in the Vietnam

War and acculturation stresses. There are many studies of the types of mental illnesses that the Hmong community experiences, but there is no prevalence data of mental health

service usage found among the Hmong population in the United States.

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In the Hmong community, the word mental illness does not exist in the Hmong

literacy; therefore, it is difficult for the Hmong people to describe their mental health

problems (Collier, Munger, &Moua, 2012). In one study, Hmong mental health providers

expressed the difficulties of explaining what mental health is to the Hmong community

(Gensheimer, 2006). Mental illnesses are view as an illness caused by an evil soul or

spirit. Traditional Hmong culture and beliefs is Shamanism. Shamanism is a belief of

animism and ancestor worship (Gerdner, 2012).Animism is the belief in “a personalized

supernatural agent such as a soul, ghost or god” that may have caused mental health

problems (Fung & Wong, 2007, p. 217).

According to recent research, there is high mental health illness rate and low treatment seeking rate (Tatman, 2004). Studies conducted by Danner, Robinson, Striepe, and Rhodes (2007) and Fu, Burgess, Van Ryn, Hatsukami, Solomon, and Joseph (2007) discovered that many of their participants were not aware of Western treatments, which may also be the reason for the low rate of mental health utilization among the Hmong people specifically the older adults. Fu et al. found that not being aware or not understanding pharmacotherapy resulted in negative views toward thistreatment.

Nonetheless, after knowledge of this medication was known, the participants were willing to usepharmacotherapy for their addiction. Due to the awareness and knowledge of Western treatments, Hmong clients from both the studies conducted by Danner et al. and Fu et al. viewed counseling and medication as possibly being beneficial to their illness.

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Statement of Research Problem

The Hmong people are viewed as one religion and being treated accordingly to their traditional religion and culture. However, people do not know that many Hmong people have converted to Christians and developed a new culture around the religion. It is important for social workers to be aware that not all Hmong people share the same religion. Social workers need to be culturally competent towards the Hmong community because everyone has different beliefs and values. Culture sets a guideline for appropriate

behaviors, styles of thinking, ways to express emotions and it also shapes people’s beliefs

about illness and health (Reznik, Cooper, MacDonald, Benador, &Lemire, 2001).The

culture of each individual is different thus; people should not be group together because

they share the same ethnicity. Therefore, the Hmong people may respond differently to

appropriate treatment plans because of their cultural beliefs of illnesses.

There is also a lack of research conducted on the religion Christianity in the

Hmong community. Most studies conducted in the Hmong community are related to

Shamanism (Johnson, 2002; Pinzon-Perez, 2006; Reznik, Cooper, MacDonald, Benador,

&Lemire, 2001). In the Hmong community, all individuals do not practice Shamanism.

There are varieties of different belief systems/ practices that are exercise within this population. These practices include Christianity, Catholicism, Buddhism, or

Protestantism. Living in the United States, some of the Hmong people have converted to

Christian (Culhane-Pera, Vawter, Xiong, Babbitt,& Solberg, 2003). Therefore, this study is going to focus not only on Shamanism, but also Christianity.

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There is also a lack of research of mental illnesses in the Hmong community since

Westermeyer’s seminal study in the early 1980s (Vang, 2014). Most of the studies found are mainly focused on medical illnesses and not mental illness (Johnson, 2002; Pinzon-

Perez, 2006; Reznik, Cooper, MacDonald, Benador, &Lemire, 2001). Due to limited medical health literacy, as stated above, mental illness is a rising in the Hmong community and not all Hmong people know what to do to treat this problem. There is so little information about mental illnesses that there is no word in the Hmong literacy that describes these illnesses; as a result, it also lacks the knowledge of mental health disorders (Collier, Munger, &Moua, 2012). Therefore, the researchers want to further study mental illnesses and religious practices of Shamanism and Christianity in the

Hmong community.

Purpose of Study

The purpose of this study is to examine Shamanism and Christianity beliefs of how it affects the perception of mental illnesses and mental health services in the Hmong community. The objective of the research is to understand the different perspectives between the two main religions in the Hmong community and their beliefs towards mental health. There is a disproportionate usage of mental health services in the Hmong community (Tatman, 2004), and there are some studies that explained the reasons such as cultural barriers, language barriers, and stigma (Collier, Munger, &Moua, 2012;

Gensheimer, 2006; Tatman, 2004). However, there is very little research done on the specific religion in the Hmong community and how religion affects mental health perspectives.

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Research Question

The research questions for this study are: (1) How does Shamanism and

Christianity affect the perception of mental illnesses in the Hmong community?; and (2)

How does Shamanism and Christianity affect the perception of mental health services in the Hmong community?

Theoretical Framework

Theories are important to help set a frame of reference. Since the researchers are studying the perspective from a group of community, Social Construction Theory is used to analyze how the Hmong culture and religion are used to construct their perspective of mental illness and mental health services in the United States. Ecological System Theory is also used to understand that the community, as individuals, is influenced by their ecological surrounding.

Social Construction Theory

The Social Constructivist Theory is traced back to the German philosopher

Edmund Husserl, John Dewey, and early theorists in the symbolic interaction tradition

Charles Horton Cooley, W.I. Thomas, and George Herbert Mead (Hutchison, 2013).

Social Constructionists are part of the postmodern movement. This perspective is use as an alternative way of understanding human interactions through the lens of person in the environment (Greene, 2008). Some of the basic assumptions of Social Constructivist are that individuals socially construct meanings and that it is built throughout daily interactions, dynamics, and life experiences (Greene, 2008). People create their own reality as they live it day by day. It is a belief that language, knowledge, and

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understanding is created and not discovered (Greene, 2008). Social Constructionists explain that “language is the central to our existence and how we come to know ourselves and our world: ‘We are born in language and we are also born into a set of beliefs about the nature of things’” (Greene, 2008, p. 242). Through language, each person weaves a

unique narrative about his/her life story (Greene, 2008). A person constructs his/her own

existence that provides an understanding of his/her life as the way he/she will live in the

present and future. Social Constructionists believe that there is no universal truth and that

it all depends on how an individual interprets it (Greene, 2008). As an individual learns

the core meanings of his/her own life, he/she will construct, reconstruct, and deconstruct

his/her own life. Communication and language are the sources of power through the

views of a Constructivist (Greene, 2008).

Application of Social Construction

Social Construction Theory is used mainly to understand human interactions

within the environment that they reside in. This theory will be use in this research to

understand the Hmong community’s perspective of mental illness and mental health. To

understand the Hmong community’s perspective, the researchers would view through the

Social Constructionist lens to understand their beliefs and values of the illness. The

researchers would consider viewing from the Hmong people’s religious beliefs and

practices of Shamanism and Christianity because each group views mental illness and

mental health differently. One group may view mental illness as a spiritual cause and the

other may view it as a natural cause. As the researchers explore the community’s

religious beliefs and practices through human interactions, they will gain a better

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understanding of the meanings of illnesses within the physical, cultural, and interpersonal environment of the Hmong community (Greene, 2008).

In the mental health field, the Hmong community is one of the populations that are underserved regarding their mental illnesses. Why do the Hmong community not seek

for services? There are many reasons why this community does not use the Western

mental health services. With the Social Constructivist view point, people will be able to

understand the why question and understand the different alternative treatment plan that

are used in the community to treat mental illnesses. The religious practices of the Hmong

people may have an influence on the community’s perspective of who to seek to for

treatment. Within the Hmong community, most individuals seek mental health services

through their religious leaders. The social construction theory will help readers have a

better understanding of why religious leaders are important figures when it comes to

treating mental health illnesses.

Ecological System Theory

Ecological System Theory was first introduced by UrieBronfenbrenner in late

1970s (Neal & Neal, 2013). This theory is used to understand the individual in different context. There are five levels of environmental context of the ecological model: microsystem, mesosystem, exosystem, macrosystem, and chronosystem (Bronfenbrenner,

1994). The microsystem is the setting in which the individual has a direct contact and influence such as home and school. The mesosystem is the interaction between two

different setting in which the individual is involved, such as the decisions made by parent

teacher conference. The exosystem involves two or more settings in which one setting,

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the individual does not have a direct role. For example, a child does not have role at a parent’s workplace, but it affects the child indirectly if anything happens at the workplace because the parent brings it home. Macrosystem is the cultural environment and ideologies such as the laws and policies that affects all the other systems. Chronosystem

was later added to the ecological model. It is the changes that happened over time that

had an influence on any of the system. For example, changes in socioeconomic status,

divorce, or moving to a new place (Bronfenbrenner, 1994).

Application of Ecological System Perspective

Although the Ecological System Theory is mainly used to understand the human

development, the researchers are using this theory to understand how the religion

influences the person’s collective perspective of mental health. The participants who are

identified as Christian or Shaman are directly practicing it, either by praying or

participating in rituals; therefore, religion in this context is in the mesosystem. This

model has been used to explain life situation of people such as substance abuse, life

choices, and academic outcome (Neal & Neal, 2013). Hence, it is reasonable to consider

the ecological system perspective to analyze the attitude towards mental health services

and people with mental illnesses.

The researchers believe that religion plays a big role in an individual’s life and

that it impacts his/her attitudes towards a problem or environment that he/she resides in.

In the ecological view of the individual, there may be a strong positive relationship

between the individual and religion that influences a person’s behavior towards a

particular setting/ environment in the exosystem. There may be a negative influence of

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the use of mental health services that impact the Hmong community’s relationship;

therefore it affects the community’s behavior of seeking for services. If there were a

positive relationship built between the agencies and the community, more individuals

would seek for mental health treatments. The ecological theory will help readers to

understand the positive and negative relationships within religion and mental health

agencies that influence people’s behavior towards mental illnesses and mental health

services.

Definition of Terms

There are some terminologies that are important to understand and know how

these are used throughout this study.

Religion: A belief in a higher being and a cultural system (Merriam-Webster, 2015). In

this research, religion is also used interchangeably with spirituality.

Shamanism: Traditional belief of animism and ancestor worship (Gerdner, 2012).

Christianity: The belief in God and the teaching of Jesus (Farlex, 2016).

Perspective: An attitude or belief toward something; a point of view (Oxford University

Press, 2016).

Mental health services: Any one of a group of government, professional, or lay

organizations operating at a community, state, national, or international level to aid in the

prevention and treatment of mental disorders (Farlex, 2016).

Mental illnesses: A condition that impacts a person’s thinking, feeling, or mood and may affect the ability to relate to others and function on a daily basis (National Alliance on

Mental Illness, 2016).

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Assumptions

In this study, the following are assumptions. (1) There is a difference between the two religions in the Hmong community and these differences can provide social workers different treatment plans to help the Hmong community cope with mental illness. (2)

Religion plays a role in how the Hmong community view mental illnesses and how they seek out for treatment. (3) The Hmong people seek for mental health treatment from their religious leaders. (4) As the Hmong people assimilate to the Western culture, they adopt more of the western views of mental health and illnesses. (5) Mental health professionals do not have enough education of the Hmong culture to work with religious leaders to provide alternative treatment plans for the Hmong community.

Justification

By 2025, more than two thirds of California’s population will be members of minority groups (Reznik, Cooper, MacDonald, Benador, &Lemire, 2001). Social workers will need to increase their professional knowledge and skills to provide services that will benefit the minority groups. Cultural competency has become an important issue in education and practice because of the growing minority population. According to the

NASW’s Code of Ethic, competence is one of the values that social workers should practice to enhance their professional expertise (National Association of Social Workers,

2016). As a social worker, it is important to build his/her knowledge of the different cultures that he/she will serve. Social workers should keep in mind that the culture of an individual is an integrated system of unconsciously learned behavioral patterns that are

12 characteristic of a group of people (Reznik, Cooper, MacDonald, Benador, &Lemire,

2001).

The objective of the research is to help future and present social workers to better understand the different perspectives between the two main religions in the Hmong community and their beliefs toward mental health. There is a large Hmong population in the Sacramento area; thus, social workers in Sacramento have a high chance of working with this community. Social workers should be culturally competent of the different religions in the Hmong community and not just assume that all Hmong share the same religion. By understanding the different religious practices in the Hmong community, the social workers will be able to build a better relationship and rapport with these clients.

This will enhance the value of importance of human relationships, according to the

NASW’s Code of Ethics (NASW, 2016). Once this rapport is built up, the social worker will be able to promote, restore, enhance, and maintain the well-being of an individual to create a treatment plan that the client will participate in treating his/her mental illnesses.

Delimitations

The study uses quantitative data, and does not include more in-depth qualitative methods to explore the research question further, or flexibility for more meaningful responses. The data collected is limited to that of Hmong individuals who are age 18 and older, speaks and understand English, and who attended the Hmong New Years in the

Central Valley of California. The survey instrument was created by the researchers, which would need additional testing of reliability and validity. Authenticity of self- reported survey answers is also not guaranteed, and must be taken at face value.

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Summary

This chapter included an introduction and background information about the research problem, a statement of the problem, the purpose of the study, the research question being examined, and the theoretical framework that is applicable to the research question. The chapter also is consisted of the justification of the research and a description of the delimitations of the study.

Chapter 2 will provide readers with a literature review of background information of the history of the Hmong people, religion, Shamanism, Christianity, and mental health.

It will also explore the Western treatment and the Hmong community’s approaches for mental illnesses. Chapter 3 will discuss the research methodology and chapter 4 will provide information that was gathered from administered research survey. Chapter 5 will discuss the final conclusion that was drawn from the study and will introduce future research studies that could be conducted.

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Chapter 2

REVIEW OF LITERATURE

In this chapter, the first section is a discussion of the history of Hmong people with sub-sections on their journey to the United States, their history of religion,

Shamanism, Hmong Christianity, and mental health, respectively. The second section is the Western treatment approaches for mental illnesses. The third section is the Hmong community approach according to their beliefs system. In the fourth section, the researchers will also discuss the gaps in the academic literature in regards to the Hmong community and how their religious practices influence their mental health perspectives and treatment. In addition, a summary of the literature will conclude the chapter.

Historical Background of the Hmong People, Religion, and Mental Health

In this section, there will be a discussion of the Hmong people, their religion, traditions and mental health. It is important to know the history of the Hmong people to understand their beliefs and how it has evolved. The Hmong traditional belief and their journey to becoming a Christian show their resiliency that influences their perspectives of mental health. These literatures of Hmong history as well as their culture and religion are critical to understand how each religious group’s perspectives are formed, influenced, and changed in their life today.

Hmong People

The fastest growing Asian population in the United States with a population of

260,076 is the Hmong Americans (Hmong National Development Inc., 2011). According to ancient Chinese texts in 2300 B.C. E., the Hmong lived in the northern central Asia

15 where now Mongolia resides (Culhane-Pera, Vawter, Xiong, Babbitt,& Solberg, 2003).

In the 1800s, they migrated to south Tibet, China, and then to Southeast Asia towards

Laos, Thailand, Vietnam, and other countries (Culhane-Pera et al., 2003). Currently, the

Hmong are identified as a group of Southeast Asian ethnic group from the mountain of

Laos (Lee, 2013). Although the Hmong lived in Laos, they lived separated from the native Lao people and reside in the outer tropical lands.

The Hmong people were recruited by the United States CIA to help the

Americans during the Vietnam War (Goodkind, 2006; Lee, 2013). After the war, Hmong were resettled in the United States as refugees from the persecution of Lao government

(Goodkind, 2006). In 2005, the newest waves of approximately 13,000 Hmong refugees were accepted to the United States (Gerner, Xiong, & Yang, 2006). According to the U.S.

Census Bureau (2010), there are 92,224 Hmong people living in California and about

27,000 reside in Sacramento. Hmong diaspora are numbers about five million Hmong in

China and almost one million in other countries (Culhane-Pera, Vawter, Xiong,

Babbitt,& Solberg, 2003).

During the Hmong resettlement after the Vietnam War in 1975 to 1980, the

United States passed the Scattering Policy law, which separated families (Tatman, 2004).

Under this policy, the United States Immigration and Naturalization Services only allowed eight family members to immigrate together at a time (Cha, 2003). This caused difficulty because Hmong families are typically large consisting of three to four generations living in one household. Furthermore, the Hmong people were scattered all over the United States for the purpose of faster assimilation (Cha, 2003). However, this

16 scattering procedure harmed the Hmong community more than it was expected. In addition to the post-traumatic stress disorder that they experienced through the war, they also faced depression due to isolation and family separation (Tatman, 2004). This contributed to the high rate of mental illness in the Hmong community during this period of acculturation (Tatman, 2004).

The Hmong community “remains one of the most structured social groupings in the world,” (Owens, 2007, Community Structure, para. 1) in a hierarchy of clans to sub- clans to extended families, to the head of household. They are a collectivistic culture where families, and clans are viewed as most important because it is a survival mechanism that provides social and economical support (Owens, 2007; Tatman, 2004).

The Hmong people are also a patriarchal culture where the male are dominant and makes most of the decisions. These decisions include where to live, who to seek help from, what kind of medical treatments the family receives, and the family religion. The Hmong community and family structure is important to know to understand the impact it has on family decisions and religious conversion as it will be discussed further in the chapter.

Religion

The word religion has two root meanings from the Indo-European language: relegere and religare (Turner, 2006). Relegere means, “to bring together” which indicates the social gathering and development of membership within the religious group. Religare means to “bind together.” There is no clear stated or decided definition of religion.

Scholars who studied religion have not agreed upon a definition that can encompass all beliefs around the world (Turner, 2006). However, religion has been observed to have a

17 strong tendency to unite people. In Hmong community, one of the reasons families converted to Christians is because they want to be united with families or the support of the Christian community (Culhane-Pera, Vawter, Xiong, Babbitt,& Solberg, 2003).

Religion and spirituality does not necessarily means the same. Some use “religion to refer to an organized system of beliefs and rituals associated with an institutional structure, and spirituality to refer to a personal quest or connection to the divine that can occur either within or outside formal religion” (Blanch, 2007, p. 252). However, this paper will use religion and spirituality interchangeably to study the influences of beliefs.

Around ninety percent of people around the world believe in some spiritual or religious practices (Koenig, 2010). In the United States, Christianity is still the dominant religion. According to the Pew Research Center (2016), 70.6% of the 35,000 people who were surveyed across the United States identified under a branch of Christianity such as

Evangelical Protestant, Historically Black Protestant, Mormon, or other. Non-Christian faith such as Jewish and Muslim makes up 5.9% of the sample, and other faith such as

Atheist and Agnostic is 1.5% (Pew Research Center, 2016).

Religion is used to help people makes sense of the world and the challenges they faced in life (Koenig, 2010). People commonly use religion to cope with physical and mental illnesses (Pearce & Koenig, 2013). Therefore, religion plays an important role in influencing people’s perspective in mental health. This research looks at how significant religion influence the Hmong community in their perspective in mental illnesses and treatments.

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Animism/Shamanism

The Hmong and Han Chinese have many cultural and linguistic similarities.

These similarities include social structure, beliefs in the importance of ancestors and metaphysical concepts of the yin/ yang balance (Culhane-Pera, Vawter, Xiong, Babbitt,&

Solberg, 2003). Traditional Hmong society is patrilineal, patrilocal, and patriarchal

(Culhane-Pera, Vawter, Xiong, Babbitt,& Solberg, 2003). Since Hmong society is patrilineal, animist rituals and beliefs are passed down from fathers to sons. If people are curious of an individual’s family background, they can trace that individual’s family lineage through his father’s social and spiritual circumstances. Keep in mind that women do not practice animist rituals; it is forbidden in the traditional Hmong community.

Traditional Hmong culture and beliefs is Shamanism. Shamanism is an integral component of the Hmong people’s traditional beliefs of animism and ancestor worship

(Gerdner, 2012). Animism is the belief in “a personalized supernatural agent such as a soul, ghost or god” (Fung & Wong, 2007, p. 217). It is a belief that shaman practices were introduced to the Hmong community by the first shaman named Shi Yee, who is the founder of Hmong shaman and has healing power to cure all illnesses (Pinzon-Perez,

Moua, & Perez, 2004). According to Hmong legends, it is believed that Shi Yee lived in the “Land of the Dark (YeebCeeb), the world of the dead, supernatural, invisible, and impalpable” (Culhane-Pera, Vawter, Xiong, Babbitt,& Solberg, 2003, p. 31) and was sent down to Earth to help cure illnesses. But on his trip down, he refused to continue his journey and decided to toss away his spiritual instruments to Earth/ the “Land of

Light(YajCeeb), the world of living, palpable, and visible” (Culhane-Pera et al., 2003, p.

19

31).This was the start of the spread of shaman spiritual powers within the Hmong community.

The path to become a shaman is that it has to be passed down from a generational lineage(Pinzon-Perez, Moua, & Perez, 2004). A generational lineage means that the spiritual helpers are passed down from someone who used to be a shaman in the individual’s family. People are not randomly chosen to become a shaman. A shaman can be either male or female, but the individual has to be chosen by the spirits in order to receive and the healing powers (Helsel, Mochel, & Bauer, 2004). A shaman’s goal is to restore equilibrium within the person’s body. The yin and yang of an individual’s body have to remain balance for one to become healthy. Once a person inherited the offspring to become a shaman, he/she has to be trained by a master shaman for two to three years or more to fully master the spiritual healing power (Helsel, Mochel, & Bauer, 2004).

The spiritual instruments that shamans use to help guide them in their journey in the spirit world includes “KuamNeeb” (two halves of buffalo horn), “NruagNeeb” (a small metal gong), “QwsNtruag” (gong stick), “TxabNeeb” (rattle), “TswbNeeb” (finger bells), “PhuamNeeb” (veil), “NtajNeeb” (sword), and “RoojNeeb” (shaman bench)

(Pinzon-Perez, Moua, & Perez, 2004). The shaman will gather and put on these instruments before the actual chanting and transition of the ceremony begins. These special instruments will help fight evil spirits that are blocking the path to diagnose the individual in the nether world.

The Hmong people believe that it is important to worship their ancestors for protection and good health. It is a belief that a human body must remain balance to be

20

healthy. If the body is not equalized, the individual will become sick and can eventually

die if unable to solve the cause of illness. Traditional Hmong people believe that the

causes of illnesses are natural, supernatural, social, and personal etiologies (Culhane-

Pera, Vawter, Xiong, Babbitt,& Solberg, 2003; Helsel, Mochel, & Bauer, 2004).

Natural causes of illness are when the elements in natural and body are

imbalanced (Culhane-Pera, Vawter, Xiong, Babbitt,& Solberg, 2003). Hmong people

believe that weather change can cause illness. For instance, cold, rainy, windy weather

can cause colds. The misuse of food temperature can result in being ill. Women have to

be especially careful when they are menstruating and in her postpartum month. They are

required to drink hot/ warm water to prevent premenstrual and menstrual cramping and

bad or irregular periods and can also become infertile (Culhane-Pera et al., 2003).

Postpartum women have to wear clothing to cover their body and hats to cover their

forehead to prevent arthritis and headaches during their old age (Culhane-Pera et al.,

2003). The Hmong community is aware of the germs theory (kab mob) and inherited

disorders (muajcajceg mob li) (Culhane-Pera, Vawter, Xiong, Babbitt,& Solberg, 2003).

They will avoid and isolate themselves from those who are sick within the community.

Supernatural cause of illness are known to be caused by souls, shamanic-helping

spirits, spirits or ghosts, and sorcery (Culhane-Pera, Vawter, Xiong, Babbitt,& Solberg,

2003). In the traditional Hmong community, the most common illness is soul loss

(poobplig). This is when a person’s soul wanders or is scared out of the body and may not be able to find its way back to the body. If the soul does not return to the body, the individual will become sick and can eventually end up dying. Children’s soul as less well

21 integrated than adults (Culhane-Pera, Vawter, Xiong, Babbitt,& Solberg, 2003). Their souls are more likely to go missing if they get straddled, scared, and fall. During funerals, adults have to pay close attention to children. If a child falls, a ceremony must be performed to call the soul back before the deceased’s soul bring along the child’s soul with him/her. Other soul illnesses can be because the child does not like his/her name, its clan, parents, or is unhappy about its previous life.

Shamanic helping spirits (dab neeb) is another supernatural cause of an illness

(Culhane-Pera, Vawter, Xiong, Babbitt,& Solberg, 2003). When the spirits chooses a person to become a shaman, he/she becomes sick. A ceremony would be performed to reveal that he/she was chosen to become a shaman. If the individual accepts the shaman duties, he/she will physically recover. After ceremonies, if the shaman does not thank the helping spirits, they can make the shaman become ill. When a shaman dies, his/her shamanic helping-spirits will be passed to one of his/her children to become the next shaman.

There are many types of spirits that cause illnesses. These spirits include ancestral spirits, household spirits, evil/ wild spirits, and unsettled ghost (Culhane-Pera, Vawter,

Xiong, Babbitt,& Solberg, 2003). Worshiping ancestral and household spirits are important because they protect the family that lives within the household. If a person performs a ceremony and did not provide food or money for them, they will make you or your family becomes ill. Wild and evil spirits may take a person’s spirit while in the jungle, forest, or river and this can cause illness or death. Sorcery is another supernatural cause of illness. If a person hate or wants to get revenge on an individual, he/she will

22

seek for black magic (tsopobzeb tom), “casting stones to bite” to make the person sick

(Culhane-Pera, Vawter, Xiong, Babbitt,& Solberg, 2003).

Social causes of illness involve human-human or human-spirit interactions

(Culhane-Pera, Vawter, Xiong, Babbitt,& Solberg, 2003). It is believed that when a person mocks a sick or disabled, he/she or his/her children will be cursed with the same illness. The Hmong community also believes that words are powerful sources (Culhane-

Pera et al., 2003). When people curses one another and one of them is at fault, those harsh words will bring misfortune or illness to the individual or his/her family. This also applies to human and spirit interactions.

The last causes of illness are personal behaviors. The way in which a person lives his/her life affects his/her health. Using drugs and drinking alcohol are choices that people make that affect their health in the future. After a woman goes into labor, she has to follow strict restrictions in everything that she does like eating, sex, and physical activities during her postpartum month (Culhane-Pera, Vawter, Xiong, Babbitt,&

Solberg, 2003). If she does not follow these restrictions and later suffers from illnesses, people will know that she failed to follow her postpartum proscriptions (Culhane-Pera et al., 2003). In the traditional Hmong community, everything that a person does, eat, say, and act can bring to a cause of illness.

When the Hmong immigrated to the U.S., they still held on to their traditional beliefs and practices. As the rituals are practiced in the U.S., the traditional Hmong people face challenges that they are not aware of because of the lack of law knowledge in the United States. Some of the challenges to practice animism are that some neighbors

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many not like the noises that accompanies the rituals, fire laws the impede burning spirit

money or animal bones, and public health laws that prohibits killing animals inside city

limits (Culhane-Pera, Vawter, Xiong, Babbitt,& Solberg, 2003). Without knowing these

laws, some shamans were arrested for their practices.

Traditional shamanic practices have changed over time due to assimilating to the

Western culture and socially constructed their rituals to avoid breaking laws and prevent

future arrest. The changes that are made to adjust to the American society are that

animals be brought into houses in cages, cows that are used during funeral ceremonies to

be stood outside of funeral homes with strings connecting to corpse, and burning spirit

money be limited and must obtain fire permit (Culhane-Pera, Vawter, Xiong, Babbitt,&

Solberg, 2003). Animals used for ceremonies sometimes are killed ahead of time from

licensed slaughterhouse and placed behind the shaman bench during the ceremonies. The

Hmong community continues to adjust their rituals according the U.S. laws to remain

their practices.

Other challenges to animism are that fewer people are learning rituals because of adjusting to the American society. Younger people are more focus on their studies, going to work, and engaging in their electronics instead of watching the elders’ conduct/ practice ritual ceremonies. It is difficult for the younger generations to learn and practice the traditional ritual as it is expected from the American society to go to school and get a

job to pay bills. Also assimilating to the American culture, many younger people are

forgetting their native language and it is difficult to understand rituals if one does not

24 speak the language used during ceremonies. Another challenge is that more and more people are converting to Christianity rather than practicing Shamanism/animism.

Christianity

Christianity began in Judea, which is now Isreal, two thousand years ago (All

About Religion, 2016). During this time, the Roman Empire was powerful with social injustice and slavery (Murvar, 1975). The harsh governing of the Roman Empire impelled the poor people and slaves to believe and have hope in the teaching of

Christianity (Guesepi, n.d.). The emergence of the Christian religion was to address the

“needs of slaves, serfs, foreigners, outsiders, and disadvantaged lower classes of the

Roman Empire” (Murvar, 1975, p. 234).

Christianity was a religious revolution as it goes against the traditional belief of the Roman Society (Murvar, 1975). It was based on the teachings of Jesus of Nazareth, a

Jewish teacher who was believed to be the son of God (Guesepi, n.d.). He traveled the

Roman Empire to preach the words of God and performed miracles that spread hope to the poor and fear to the Jewish religious authorities (All About Religion, 2016; Guesepi, n.d.; Murvar, 1975). It was believed that Jesus died on the Roman cross and was resurrected three days after his death (All About Religion, 2016). Through the sacrifice of

Jesus, people who believe in him will be forgiven of their sins and be admitted to heaven after death. This notion attracts many followers and Christianity soon spread throughout the Middle East and gradually throughout the world through the work of missionaries.

There are some conflicting sources on when Christianity was first introduced to the Hmong people. Tapp (1989) assumed that Catholic might have been introduced to the

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Hmong before Protestant, which is a form of Christianity. As reported by Xiong(2010),

Dr. Timothy Vang stated that the first Hmong to be converted to Christian was in Laos in

1950. However, in the book, Healing by Heart, Hmong people were exposed to

Christianity in the 1800s in Southern China(Culhane-Pera, Vawter, Xiong, Babbitt,&

Solberg, 2003). The earliest recorded missionary work was in 1899 by Samuel Polland, a

British Methodist missionary in China (Tapp, 1989). In early 1900s, Missionaries went to

Laos and converted many Hmong villages (Culhane-Pera et al., 2003).

Conversion happened in masses because Hmong people have the tendency to follow their leaders and relatives. Once the clan leader decides to convert, the rest of the clan follows to stay together for support because a lot of the Hmong rituals require a number of family and community support to carry out the tradition (Culhane-Pera,

Vawter, Xiong, Babbitt,& Solberg, 2003). If a large number of people in the community started to convert, there will not be enough people to help carry on the traditional beliefs.

Hmong people continue to convert to Christianity in the United States because many of the resettlement sponsors were Christians. Other reasons Hmong families converted to

Christians were the scarcity of spiritual healers in the United States, law prohibited some

Hmong practices, and families want to gain support from Hmong Christian community, especially if they are distance from their blood relatives (Culhane-Pera et al., 2003).

Mental Health

In early history, many cultures view mental illness as a religious punishment or demonic possession and in ancient Egyptian, Indian, Greek, and Roman writings, it is categorized as a religious or personal problem (Unite For Sight, 2015). During the

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18thcentury in the U.S, negative attitudes towards mental illness lead to stigmatization

(Unite For Sight, 2015). The society socially constructed in labeling mentally ill individuals. These people were categorized as having “madness,” meaning they are people who significantly disturb the society and sometimes themselves (Gomory,

Cohen,&Kirk, 2013). When a person is labeled as having madness, he/she is isolated for treatment to cure the illness.

In the 1840s, the building of 32 state psychiatric hospitals were developed because of activist Dorothea Dix’s voice to find better living conditions for those who are mentally ill (Unite For Sight, 2015). The institutional inpatient care model was applied and considered the most effective in caring for those with mental illness (Unite For Sight,

2015). In the hospitals, professional staffs cared for the mentally ill. This increased access of mental health services, but the hospital was underfunded and understaffed to provide quality of care for all patients (Unite For Sight, 2015). Clifford W. Beers, former psychiatric patient, established the Mental Health America in 1909 as a community-based nonprofit program to help mentally ill people live healthier lives (Mental Health

America, n.d.). Deinstitutionalization and outpatient treatment focusing on community- oriented care raised during the mid 1950s (Unite For Sight, 2015).

The Community Mental Health Centers Act of 1963 was passed and closed state psychiatric hospitals in the United States (Unite For Sight, 2015). The numbers of mentally ill people deceased in state hospitals and were moved to community mental health homes. There were arguments that community based programs were better fit for most mentally ill people than state hospital and that it also cost less (Unite For Sight,

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2015). In 1946, Harry Truman passed the National Mental Health Act, which created the

National Institute of Mental Health and provided government funds for research in finding the causes and treatment for mental illness (National Institutes of Health, 2016).

Other acts such as, the Mental Retardation Facilities and Community Health Centers

Construction, were also passed to help improve and provide mental health services for mentally ill people (Unite For Sight, 2015). Theories have been developed to understand the causes of mental illnesses, but it has not scientifically validated the causes the illnesses (Gomory, Cohen,&Kirk, 2013). After many years of studying, the American

Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorder was created to categorize the illness that people experienced in the United States.

Mental illnesses in the Hmong community were never talked about or not known until their involvement in the Vietnam War with the U.S. The trauma from the war experiences is one of the key elements of mental illnesses in the Hmong community (Lee

& Chang, 2012). The Hmong people lived peacefully in the jungle and their lifestyle changed when assisted the U.S. Living in the jungle all their lives, growing and harvesting vegetables was the environment that many Hmong people came from and now living in the city, buying vegetables from the store, and adapting to the American culture is new and different. The Hmong community faces many challenges, as they know nothing about the American culture when immigrating to the U.S. As stated in the studies used in Lee and Chang’s article, “acculturation stress was the strongest factor of refugees’ mental health” (p. 59). Some mental illnesses that the Hmong community isexperiencing are described as depression, post-traumatic stress disorder (PTSD),

28 anxiety disorders, somatoform disorders, severe stress and acculturation difficulties

(Collier, Munger,&Moua, 2012; Vang, 2014).

Western Treatment Approaches for Mental Illness

According to social theory, community and culture influence the way people react to illness (Olafsdottir&Pescosolido, 2011). “Responses to illness are first constructed in the community by individuals experiencing symptoms as well as by those around them”

(Olafsdottir&Pescosolido,2011, p. 929). This means that people tend to self diagnose their symptoms and find treatments according to their diagnosis. Treatments will correspond to the person’s experience and his/her community’s knowledge and belief of the illness.

As it has been discussed in the history of mental health, the Western treatments have evolved as theories developed and more knowledge on mental illnesses has been acquired. According to the National Alliance on Mental Illness (NAMI) (2016),

A mental health condition isn’t the result of one event. Research suggests

multiple, interlinking causes. Genetics, environment and lifestyle combine to

influence whether someone develops a mental health condition. A stressful job or

home life makes some people more susceptible, as do traumatic life events like

being the victim of a crime. Biochemical processes and circuits as well as basic

brain structure may play a role too(para. 3).

The United States culture based mental health on pathological sciences and empirical research as described above. What are believed to be effective are therapy, social support, education, and medications (NAMI, 2016). Evidenced based treatment are

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considered to be more valuable and effective in the United States as it has been proven to

show progress. Some evidenced based mental health treatment used for chronic mental

illnesses such as Schizophrenia is antipsychotic medications, family education and

support, illness-specific counseling, assertive community treatment (ACT), and supported

employment (Lehman, Goldman, Dixon, & Churchill, 2004). Other treatments for mental

illnesses in general include case management, hospitalization, support group, self-help

plan, and peer support (Mental Health America, n.d.).

Drugs are used to control severe symptoms such as hallucinations and delusions,

while family education and support are important to prevent a person from relapse

(Lehman, Goldman, Dixon, & Churchill, 2004). Psychotherapy includes illness-specific

counseling such as Cognitive Behavioral Therapy, Exposure Therapy, and Dialectical

Behavior Therapy. Psychotherapy and medication are found to be most effective as it

provides coping skills and psychosocial treatment along with medication to balance

chemical in the brain (Lehman et al., 2004). Sometimes hospitalization is required for

severe cases, in which the patient will receive intensive care to increase their medication,

receive social support and case management, as well as psychotherapy (Mental Health

America, n.d.).

The American culture depends heavily on the Diagnostic and Statistical Manual

of Mental Disorder (DSM), which classified and assigned symptoms to mental disorders.

This manual holds the power to label people and determined how people are treated. The fifth edition was recently published in 2013, changing how some mental disorders are classified and viewed. These constant changes to the DSM show the inconsistency of

30 mental health diagnosis. The DSM changes followed the socio-cultural changes in

America as it tries to become more culturally accepting and include cultural concepts in its diagnoses. However, the DSM is still bias towards the American culture as it uses

American terms and expressions to describe and diagnose people. For example, the DSM has diagnosis like delusional disorder with symptoms like grandiose ideation. In the shamanistic culture, these same symptoms may be called a spiritual awakening, a healing process, or even spiritual possessions (Marohn&Somé, 2014).

Hmong Treatment Approaches for Mental Health

There are no definite Hmong treatment approaches for mental health. The traditional therapeutic practices that are used to treat illnesses include home therapies, medicine doctors with herbal medicines, ritual or magical healers, soul callers, and shaman (Culhane-Pera, Vawter,Xiong, Babbitt,& Solberg, 2003; Gensheimer, 2006).

In the Hmong community, home therapies that are used to treat certain illnesses include coining, cupping, divining, soul calling, ritual healing, and administering herbal medicines (Culhane-Pera, Vawter,Xiong, Babbitt,& Solberg, 2003). There are people in the community that knows about medicinal plants that helps treat illnesses. The roots, leaves, and branches are used as tea to resolve the symptoms that the individual is experiencing. Coining is used to rub on specific areas that the individual is experiencing symptoms and cupping is used to exert negative pressure on the skin (Culhane-Pera et al.,

2003). It is important to know what these methods can do to the skin because the aftermath of these methods can look like bruises and it may look like signs of abuse, but it is not. Massages of the abdomen, arms, legs, and fingers are also home remedies. After

31 the massages, needle poking will be conducted and the blood from the poke will be placed in a bowl of water to release the illnesses.

Medicine doctors (kwstshuaj) also provide treatment for illnesses (Culhane-Pera,

Vawter, Xiong, Babbitt,& Solberg, 2003). The doctor would examine the body, diagnose the illness/ condition, and provide herbs to treat the condition. The knowledge comes from older medicine doctors and helping spirits (dab tshuaj) (Culhane-Pera et al., 2003).

People usually pay fee for the medicine that were given and proven effective. If the ill person gets better from the treatment that the medicine doctor provided and did not pay a fee, he/she can become sick again until the fee is paid. The healing spirits cause this illness because individual is disrespecting the healing spirits powers.

Ritual or magical healers help treat illnesses caused by sorcery/ black magic. This healer learns its craft from other healers who passed along their knowledge, healing power, and helping spirits (dab khawvkoob) (Culhane-Pera, Vawter, Xiong, Babbitt,&

Solberg, 2003). Incenses are used to call the spirits and the healer will communicate with them by chanting ancient Chinese and Laotian words (Culhane-Pera et al., 2003). The healer will guide their helping spirits toward the person’s ailment and cure the illness.

There are many types of healers that are an expert in “specific problems such as burns, broken bones, eye problems, startled children, childhood fevers with rashes, hemorrhage, headache, and recurrent spontaneous abortions” (Culhane-Pera et al., 2003, p. 43).

Soul Callers play an important role of calling a loss soul to come back to its body, especially if the loss soul wandered off or was frighten or a person fell during a funeral.

The procedure that is used to check if a soul was loss would be to break an egg into a

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bowl of water (Culhane-Pera, Vawter,Xiong, Babbitt,& Solberg, 2003). Soul Callers will

check the physical body for signs of pallor, sunken eyes, or dry lips, or patterns of blood

vessels behind the ear lobe (Culhane-Pera et al., 2003). The Soul Callers will perform a ceremony inside and in front of the individual’s home call the soul to come back. He/she will know when the soul is back depending on the responses of the patterns of the

“KuamNeeb” (two halves of buffalo horn) (Culhane-Pera et al., 2003). The chicken that was used during the ceremony will be the evidence to review if the soul was retrieved after cooking it. The soul caller can be a shaman or an individual who knows how to preform the soul calling ritual.

Shamans play a big role in diagnosing and treating illnesses. He/ she is connected to the spirit world and can cure illnesses that care cause by supernatural etiologies. When a person is ill, the ceremony “UaNeebSiab” will have to be performed by the shaman in order to diagnose the ill person(Pinzon-Perez, Moua, & Perez, 2004). The family will consult with the shaman of the symptoms that the patient is experiencing and the shaman will try to discover the diagnosis of the illness through his/her journey in the spirit world.

After the ceremony, the shaman will suggest the treatment “UaNeebKho” that needs to

take place in order to cure the illness(Pinzon-Perez et al., 2004).If the family does

complete the treatment that the shaman suggested in the time frame that it was set, the individual will recover from his/her illness.

Assimilating to the Western culture, Hmong Christian treatment approaches are praying and seeking help from church groups for mental health services. The use of traditional herbal medicines continues to be use by Christians (Culhane-Pera,

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Vawter,Xiong, Babbitt,& Solberg, 2003). There are times that when serious or chronic illnesses do not respond to prayers or Western treatments, some Christians will seek for traditional healing practices (Culhane-Pera et al., 2003).

Gaps in the Literature

There are a number of studies on the religious influence on mental health and its use in treatment (Hall, 2004). However, specific research comparing two religions within one culture is rare, as it has been commonly accepted that one ethnic group is associated with only one religion. When speaking of religion, most of the studies specifically mention Christianity and spirituality is used as a person’s relationship with God or a higher being. There are few studies that describe spirituality as relationship with inanimate things and the spirits of the deceased. Most studies were conducted through the western perspective and there were little reflection for Eastern religions in the studies.

Researchers have also noticed that studies show how religions and different cultural beliefs can be an asset to helping people cope with mental illness. As it is mentioned above, more people seek help from their religious leaders, before they go to professional mental health providers (Blanch, 2007). However, there are very few studies that show how religion can deter people from getting professional mental health services and treatments.

As stated above, in the Hmong community there is an uncertainty of definition for the word mental illness. Mental illness is viewed as a physical health condition (Pinzon-

Perez, 2006); therefore, there are very little literatures on mental health treatments in the

Hmong community that relates to psychological and social issues. This may be because

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mental health is a new concept in the Hmong community and there are no distinct

differences between physical and mental illnesses.

This study addresses a few of the literature gaps stated above. Researchers

explored two different religions, Shamanism and Christianity, within the one community.

The researchers believe that it is important to identify the different religions in the

community because it can help mental health professionals understand that there could be

different perspectives of mental health and mental illness in the same community. This

can also help professionals identify treatments that correspond to how religious group

cope with mental illnesses. Mental illness is a term that the Hmong community does not

have a word that translates; therefore this study can help the community be aware of the

term and the services that are available in their environment.

Summary

This chapter discussed the history of the Hmong people and their traditional

religions. It further described into the history of religion and the religion statistics in the

United States as well as the history of mental illnesses. The researchers also compared mental health treatments in the Western culture and the traditional Hmong culture.

Literature gaps were also analyzed in this chapter. In the next chapter, the methodology of the current study will be presented.

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Chapter 3

METHODOLOGY

Chapter 3 consists of the methodology information for this research study. The

researchers will explore the research questions and design. The study and sample

population will be discussed. The variables and instruments of the study will be

explained. The researchers will provide information of the data gathering and procedures

and the data analysis. The procedure of the protection of the human subjects will also be

explained. Lastly, there will be a summary of the chapter.

Research Question

The research questions for this study are: (1) How does Shamanism and

Christianity affects the perception of mental illnesses in the Hmong community? (2) How

does Shamanism and Christianity affect the perception of mental health services in the

Hmong community?

Research Design

The research design used for this study is a descriptive quantitative cross-

sectional survey research design. A “descriptive research provides characteristics of

individuals, groups, or situations that aims to discover new meanings, describe what

exists, determine the frequency in which something occurs and categorize information”

(Walker, 2005, p. 572). Descriptive designs are meant to collect information and not

infer any causal relationship (Dudley, 2010). This can be done using either qualitative or

quantitative methods. A descriptive method was used for this research because there have

been many studies done on religion and mental health (Hall, 2004; Koenig, 2010; Pearce

36

& Koenig, 2013). This research aimed to build on the foundation that religion has an impact on people’s mental well-being and further describe the nature of how mental health is being viewed by the different religious Hmong groups. Using quantitative method, the two religions are compared by using the frequency of attitudes towards mental health beliefs.

This research is also a cross sectional design because it collects data from one point of time only (Dudley, 2010). A cross sectional design is appropriate because this research is not looking for changes over time, and thus, a longitudinal design would have no purpose. However, this research is studying the present time that the participants are taking this survey and evaluating their present beliefs with their current perspective of mental health. This study is not meant to show causation; as such design will not allow it to determine cause and effect. Researchers are looking at relationships and making inferences according to these relationships.

Researchers used a self-reported questionnaire survey with a five point Likert

Scale that ranges from strongly disagree, disagree, neutral, agree, to strongly disagree.

This scale was used to measure the perspectives, attitudes and beliefs towards mental health between the two religious groups of Shamanism and Christianity. Demographic questions such as age, gender, religion, and education were also asked in the beginning of the survey.

According to Babbie (2016), the ordering of the questionnaire is important because the first question will affect how the participant answers the rest of the questions.

For this survey, demographics and the role of religion were strategically placed in the

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beginning of the survey to make participants aware of their religion because the rest of the survey is based on the influence of their religious belief. To ensure the reliability and validity of the survey, a pretest should be administer to ensure there is no or limited errors (Babbie, 2016). However, because of limited time and resources, there was no pretest performed.

One of the weaknesses of survey questionnaire is that participants must be literate to answer. For this research, many older participants were excluded because they were illiterate and lack English skills. Another weakness is that responses may be superficial

(Babbie, 2016). Since the answers were already given, people are forced to choose those

and it may not reflect their true feelings. One of the weaknesses of the Likert scale is that

“neutral” was given as an option. The neutral option gives people the choice to have no

opinion. This later leads to a problem because too many people choosing neutral leads to

insignificant results. Research have found that Asian Americans answers tend to be more

neutral or towards the midpoint, and avoiding the two endpoint of the answers (Wang,

Hempton, Dugan, &Komives, 2008). To amend for the mistake of having a neutral

option, researchers grouped neutral with the disagree area which may have skewed some

results.

There are many benefits to a survey research. It is a great method for measuring

attitudes and beliefs in a large population (Babbie, 2016) and it could be generalized

through a sample size. Surveys are popular because it is also fast and efficient way of

collecting data. It does not take a long time as participants can quickly choose the given

38

answers. Another important strength about the survey method is that it is confidential and

thus people may be willing to be more honest about their opinions.

Variables

The dependent variables of this research study were the perceptions of mental

illnesses and mental health services. In a research study, Bussing, Ostermann and

Matthuessen(2005) found that many people rely on religious beliefs to “relieve stress,

retain a sense of control, maintain hope and their sense of meaning and purpose in life”

(p. 2). This means that religion plays a role in how people view the world, and so it is expected that people with mental illnesses may be perceived differently, and thus the

treatment may also be diverse. This research studied the two different religions in the

Hmong community, and how they perceived clinical definition of mental illness and

clinical treatments.

The independent variable was religion, which is Shamanism and Christianity.

Shamanism and Christianity are used for this study because it is the two most prevalent

religions in the Hmong community (Lee, Matsuoka, Yee,& Nakasone, 2015). These

religions are self-identified by the participants. Seven participants identified as other

religion. Researchers did not include their data into the greater research. It is important to

note that although someone may identify as Christian or Shamanism, everyone will vary

in his/her practices, commitment, and interpretation. The independent variables such as

their religion are nominal and the dependent variables such as their attitudes, beliefs, and

perspective are measured in ordinal scale.

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Study Population

The Hmong New Year festivals were the most optimal and convenient location to conduct surveys because of the large amount of Hmong people from all over the country attending these events. In the California central valley, cities such as Fresno, Merced,

Stockton, and Sacramento together, there is an approximate of 72,989 Hmong people out of 92,224 Hmong people in California (U.S. Census Bureau, 2010). Sacramento and

Fresno New Years are the biggest festivals attracting over 40,000 attendees (Vang, 2015).

It is important to have the same amount of participants that belongs in the different religious groups so that the researchers will be able to collect a more precise data from the sample population regarding their perception of mental health and mental illnesses. Therefore, the researcherstargeted half of the Hmong population that are

Christians and the other half that are traditional believers of Shamanism.

Sample Population

A large sample means that there is a lower chance of random errors and higher validity (Emerson, 2015). A non-probability sampling method was used to gather a convenient sample of Hmong people. Participants were selected from the following cities: Sacramento, Merced, and Fresno.The participants were chosen through a convenience sample which targets the Hmong population from an age group of age 18 years old and older and only those who are able to read and understand English. Surveys were passed to random groups at the Hmong New Year events, and religious booths were specifically approached for convenient sampling. Convenience sampling is when the individuals who fit the criteria of the study are identifiable (Emerson, 2015), which in this

40

study are the Hmong individuals with English literacy skills.One hundred and three

surveys were collected, but only ninety-six surveys were completed for the analysis.

The strength of the sample is that there is a big pool of Hmong population to

choose during the Hmong New Year events in the different cities. The weakness of the

sample is that participants are limited to those who are able to read and understand

English, which excludes all the elderly and older generation Hmong who cannot read

English. The sample is also limited to those people who the researchers were comfortable

approaching to participate. Although researchers do not intend any biases, there are

possibilities that there may be some researcher biases in picking participants such as

avoiding participants that may look dangerous during the events.

Instrumentation

A questionnaire instrument was developed to survey Hmong Christians and

Shamans about their perspectives on mental health (Appendix B). The questionnaire was not tested for validity and reliability.The survey questionnaire consisted of 4

demographic questions with multiple choices. The demographics asked for age, gender,

education level, and religion preferences. In addition, there were fifteen Likert-type scale

questions. The Likert Scale was named after RensisLikert who developed the scale in

1932. A Likert-type scale is a “fixed choice response format and are designed to measure

attitudes or opinions,” (McLeod, 2008, para. 3). The questionnaires responses range from

strongly agree, agree, neutral, disagree, and strongly disagree. This measurement allow

participants to choose how much they agree or disagree with the statement, which shows

their attitudes and beliefs towards the statement.

41

There are advantages and disadvantages to using Likert Scale. One of the advantages is that the answer is on a continuum, and so it is not either a yes or no question which gives more flexibility to participants (McLeod, 2008). Another advantage is that it is easier to analyze because of its quantitative format (McLeod, 2008). It is also a quick and effective way to survey because it can be administered through mail, email,

Internet, and in person (LaMarca, 2011). One of the disadvantages is that it could be bias due to social desirability. However, the anonymity nature of the survey may reduce the likelihood of any dishonest answers (McLeod, 2008).

The questions are designed to measure the Hmong individual’s perspective towards mental health, where they believe mental illness came from, how they handle mental health crisis, and their willingness to refer people to mental health professionals as well as some demographic questions (see Appendix B). After reading the question, participant circled one of the scale format of ordinal measures levels of agreement or disagreement. Researchers printed the surveys and distributed to the target population at

Hmong New Year events.

Hmong New Year EventsData Gathering and Procedures

Researchers approached groups of Hmong people who fit the criteria of the sampling population. Researchers explained their research study and discussed verbal informed consent of their rights to participate in the study. Researchers gave the survey to anyone interested in participating. After each participant was finished with the survey, it was returned to the researcher and was placed in an unsealed envelope. Whena participant agreed to participate in the research study, it was explained to the participants

42

that by returning the survey to researchers, they gave their implied consent to participate

in the research study. It was also explained to study participants that any information they

provided would remain confidential and only the researchers and advisor would have

access to the raw data. All completed surveys were collected by researchers and were

placed in an unsealed envelope. After each New Year event, the researchers sealed the

envelope and placed it in a locked cabinet at their home.

Data Analysis

The data was collected and inputted into the Statistical Package for the Social

Sciences (SPSS). All variables were coded and frequency distributions and cross-

tabulation were used to describe the relation between religion and perspective of mental

illnesses and services. Chi Square tests were performed to analyze the relationships

between the independent variables (religion and other demographic information) and

dependent variables (beliefs, attitudes, and perspective of mental health and mental health

services). A p value of <. 05 were used as the significant level. It is determined that a

relationship is significant when the error probability is less than 5 percent (Dudley,

2010).

Protection of Human Subjects

Before the data was collected, the researchers submitted the research study to the

California State University, Sacramento’s Human Subject Review Committee. The

Human Subject Review Committee approved the study and the researchers started to

collect their data. The research was approved as “exempt”. The protocol number was 15-

16-003. Participant’s confidentiality was protected because the survey asked for minimal

43 identifiable information that was stored in a locked cabinet. All responses were anonymous to the researchers. The participants voluntarily decided if they wanted to participate in the survey. If the participant chose to participate, then they would hand in their completed survey. This procedure implied their consent to be a participant in the study. The data were stored in a locked cabinet.

Summary

This chapter included discussion of the methodology of the research study. The research question and design were explored. The researchers provided information regarding their study and sample population as well as the instrument of a survey questionnaire used to gather data. The procedure of data collection and data analysis was discussed as well as the protections of human subject. In the next chapter, the data analysis of the research study is presented.

44

Chapter 4

DATA ANALYSIS

In this chapter, the researchers will examine all data that are collected from the research survey questionnaires. All demographics will be discussed and analyzed from

the frequency distributions. The analysis of the survey will explore how the different

religions influence the perspectives of mental illness and mental health services in the

Hmong community. Chi-square tests are used to identify the relationship between

religion and certain variables from the data collected. A summary will conclude the

findings of all significant relationships of the variables used in the testes.

Demographics

In this research, a total of 117 Hmong participants completed the survey

questionnaire during the Hmong New Years in the Central Valley of California, but only

110 surveys met the criteria. Seven of the research surveys were not used because the

participants did not identify their religion as Shamanism or Christianity. As shown in

Figure 1, 41 people identify their religion as Christianity and 69 as Shamanism. Figure 2

displays that there were slightly more male participants (59.1%) than females (40.9%).

Age distributions were disproportionately higher in the younger adults. As shown in

Figure 3, more than half (58.2%, n=64) of the participants were young adults ages 18 to

25 years old. Approximately 42% of the respondents were 26 years old or older. Figure 4

shows the education level of the participants with 46.6% have obtained only a high

school diploma (n=51), 17.6 % have a AA/AS degree, 25.6% have a BA/BS degree, 4.5

have a MA/MS degree, and 8.2% identified to have other types education.

45

Figure 1. Religion.

46

Figure 2. Gender.

47

Figure3. Age.

48

Figure 4. Education.

Influences of Religions

A chi-square was computed to analyze whether religion plays a big role in the

participant's life. The distribution in Table 1 shows that overall 72% of respondents agree

thatreligion plays a big role in their lives. When compared within religions, there were a

higher percentage of Christians (82.9%) who agreed that religion plays a big role in their

lives. The Shaman group who agreed were 66.7%. The chi square test was approaching significance (χ2=3.428, df=1, p=. 064).

49

Table 1

Influences of Religions

Religion

Christianity Shamanism Total

religion plays Agree Count 34 46 80

a role % within religion 42.5% 57.5% 100.0%

plays a role

% within Religion 82.9% 66.7% 72.7%

% of Total 30.9% 41.8% 72.7%

Disagree Count 7 23 30

% within religion 23.3% 76.7% 100.0%

plays a role

% within Religion 17.1% 33.3% 27.3%

% of Total 6.4% 20.9% 27.3%

Total Count 41 69 110

% within religion 37.3% 62.7% 100.0%

plays a role

% within Religion 100.0% 100.0% 100.0%

% of Total 37.3% 62.7% 100.0%

50

How Does Shamanism and Christianity Affect the Perception of Mental Illnesses in

the Hmong Community?

This section will explore the perception of Shamanism and Christianity on mental illnesses. Other demographics such as education, age, and gender will be analyzed to rule out its influences on their perspective.

Perspectives of Mental Illness

When the questionnaire stated, “mental illnesses are normal,” there were no significant differences in the answers across respondents from either religion. In Table 2, slightly more people agreed that mental illness is normal, Christianity (56.1%) and

Shamanism (55.1%).

When looking at “Mental illness is embarrassing” statement, almost all of the people from both religions (Christianity=95.1%, n=39; Shamanism=95.7%, n=66) disagreed with the statement (Table 3). However, the chi-square test was not significant and two cells have expected count less than five.

Table 4 shows that both Christianity (78.0%), and shamanism (76.8%) agreed that

“mental illnesses affect everyone.” However, there was no statistical significance.

Table 5 reveals 65.9% of Christianity and 56.5% of Shamanism participants agreed that mental illnesses can be treated by mental health professionals. However, the chi-square test did not show significance. The findings were not statistically significant, but provided the researchers a valuable insight towards the research question.

51

Table 2

Mental Illness is Normal

Religion

Christianity Shamanism Total

MI Agree Count 23 38 61

normal % within MI normal 37.7% 62.3% 100.0%

% within Religion 56.1% 55.1% 55.5%

% of Total 20.9% 34.5% 55.5%

Disagree Count 18 31 49

% within MI normal 36.7% 63.3% 100.0%

% within Religion 43.9% 44.9% 44.5%

% of Total 16.4% 28.2% 44.5%

Total Count 41 69 110

% within MI normal 37.3% 62.7% 100.0%

% within Religion 100.0% 100.0% 100.0%

% of Total 37.3% 62.7% 100.0%

52

Table 3

Mental Illness is Embarrassing

Religion

Christianity Shamanism Total

MI Agree Count 2 3 5

embarrassing % within MI 40.0% 60.0% 100.0%

embarrassing

% within Religion 4.9% 4.3% 4.5%

% of Total 1.8% 2.7% 4.5%

Disagree Count 39 66 105

% within MI 37.1% 62.9% 100.0%

embarrassing

% within Religion 95.1% 95.7% 95.5%

% of Total 35.5% 60.0% 95.5%

Total Count 41 69 110

% within MI 37.3% 62.7% 100.0%

embarrassing

% within Religion 100.0% 100.0% 100.0%

% of Total 37.3% 62.7% 100.0%

53

Table 4

Mental Illnesses Affects Everyone

MI affect everyone

Agree Disagree Total

Religion Christianity Count 32 9 41

% within Religion 78.0% 22.0% 100.0%

% within MI affect everyone 37.6% 36.0% 37.3%

% of Total 29.1% 8.2% 37.3%

Shamanism Count 53 16 69

% within Religion 76.8% 23.2% 100.0%

% within MI affect everyone 62.4% 64.0% 62.7%

% of Total 48.2% 14.5% 62.7%

Total Count 85 25 110

% within Religion 77.3% 22.7% 100.0%

% within MI affect everyone 100.0% 100.0% 100.0%

% of Total 77.3% 22.7% 100.0%

54

Table 5

Mental Illness Can Be Treated By Mental Health Professionals

MI treated by MH professionals

Agree Disagree Total

Religion Christianity Count 27 14 41

% within Religion 65.9% 34.1% 100.0%

% within MI treated 40.9% 31.8% 37.3%

by MH professionals

% of Total 24.5% 12.7% 37.3%

Shamanism Count 39 30 69

% within Religion 56.5% 43.5% 100.0%

% within MI treated 59.1% 68.2% 62.7%

by MH professionals

% of Total 35.5% 27.3% 62.7%

Total Count 66 44 110

% within Religion 60.0% 40.0% 100.0%

% within MI treated 100.0% 100.0% 100.0%

by MH professionals

% of Total 60.0% 40.0% 100.0%

55

How Does Shamanism and Christianity Affect the Perception of Mental Health

Services in the Hmong Community?

This section will explore the perception of mental health services such as its effectiveness and willingness to use the services. Other demographic factors will also be used to analyze its influences on the perspective.

Perspectives of Mental Health Services

Table 6 shows that more than half of both Christianity (56.1%, n=23) and

Shamanism (60.9%, n=42) agreed to the statement that “mental health services are effective.” However the chi-square is not significant.

The statement that “everyone should use mental health services” is also agreed by the majority of both religions in Table 7 (Christianity=82.9%, n=34; Shamanism=79.7%, n=55). A total of 19.1% disagree with the statement. The chi-square test did not show any significance.

When looking at the statement that “seeking mental health services is embarrassing,” Table 8 shows that majority of both religions disagree

(Christianity=95.1%;Shamanism=89.9%). However, the chi-square tests do not showany significance.

The belief that, “Everyone should refer mental health services to family and friends who are in need” is agreed by the majority by both religions as shown in table 9

(Christianity=80.5%, n=33; Shamanism=75.4%, n= 52). Overall, 77.3% of the total participants agree to this statement. The results of the chi-square test do not showsignificance.

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Table 6

Mental Health Services Are Effective

MH services effective

Agree Disagree Total

Religion Christianity Count 23 18 41

% within Religion 56.1% 43.9% 100.0%

% within MH services effective 35.4% 40.0% 37.3%

% of Total 20.9% 16.4% 37.3%

Shamanism Count 42 27 69

% within Religion 60.9% 39.1% 100.0%

% within MH services effective 64.6% 60.0% 62.7%

% of Total 38.2% 24.5% 62.7%

Total Count 65 45 110

% within Religion 59.1% 40.9% 100.0%

% within MH services effective 100.0% 100.0% 100.0%

% of Total 59.1% 40.9% 100.0%

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Table 7

Everyone Should Use Mental Health Services

Everyone use MH services

Agree Disagree Total

Religion Christianity Count 34 7 41

% within Religion 82.9% 17.1% 100.0%

% within Everyone 38.2% 33.3% 37.3%

use MH services

% of Total 30.9% 6.4% 37.3%

Shamanism Count 55 14 69

% within Religion 79.7% 20.3% 100.0%

% within Everyone 61.8% 66.7% 62.7%

use MH services

% of Total 50.0% 12.7% 62.7%

Total Count 89 21 110

% within Religion 80.9% 19.1% 100.0%

% within Everyone 100.0% 100.0% 100.0%

use MH services

% of Total 80.9% 19.1% 100.0%

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Table 8

Seeking Mental Health Services is Embarrassing

MH services embarrassing

Agree Disagree Total

Religion Christianity Count 2 39 41

% within Religion 4.9% 95.1% 100.0%

% within MH services 22.2% 38.6% 37.3%

embarrassing

% of Total 1.8% 35.5% 37.3%

Shamanism Count 7 62 69

% within Religion 10.1% 89.9% 100.0%

% within MH services 77.8% 61.4% 62.7%

embarrassing

% of Total 6.4% 56.4% 62.7%

Total Count 9 101 110

% within Religion 8.2% 91.8% 100.0%

% within MH services 100.0% 100.0% 100.0%

embarrassing

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Table 9

Everyone Should Refer Mental Health Services

Refer MH services

Agree Disagree Total

Religion Christianity Count 33 8 41

% within Religion 80.5% 19.5% 100.0%

% within Refer MH services 38.8% 32.0% 37.3%

% of Total 30.0% 7.3% 37.3%

Shamanism Count 52 17 69

% within Religion 75.4% 24.6% 100.0%

% within Refer MH services 61.2% 68.0% 62.7%

% of Total 47.3% 15.5% 62.7%

Total Count 85 25 110

% within Religion 77.3% 22.7% 100.0%

% within Refer MH services 100.0% 100.0% 100.0%

% of Total 77.3% 22.7% 100.0%

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Other Factors Influencing Perspective of Mental Illness and Services

Other demographic factors such as age, gender, and education may influence the participants’ perspectives of mental illnesses and mental health services. To rule out these factors, researchers ran a cross tabulation analysis with these factors to see if there is a significant difference. When looking at gender and the willingness to refer to mental health services, there was no significant difference. Table 10 shows that gender does not influence attitudes or beliefs in referring people to mental health services as both gender agrees (Male=76.9%, Female= 77.8%). Age and education also has no influence in attitudes towards mental health services as it is shown in Table 11 (18-25= 75%; 26 and older =80.4%) and Table 12 (H.S= 76.5%, AA/AS and higher= 78%). None of these chi- square tests were significant.

Gender, age, and education were also analyzed to rule out their influences on the perspective towards mental illness. Table 13 shows that males (63.1%, n=41) agree slightly more than female (44.4%, n=20) that mental illnesses are normal. The chi-square shows that it is approaching significance (χ2= 3.737, df= 1,p= .053). However, in Table

14, when looking at age and agreeing that mental illnesses are normal, the following were the agreement for the various age group: (18-25 years old=53.1%, 26 years and older=

58.7%) and education (H.S.= 49%, A.S and higher=61%). Table 14 and Table 15 shows that there were no significant influences from these demographics.

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Table 10

Gender & Refer to Mental Health Services

Refer MH services

Agree Disagree Total

Gender Male Count 50 15 65

% within Gender 76.9% 23.1% 100.0%

% within Refer MH services 58.8% 60.0% 59.1%

% of Total 45.5% 13.6% 59.1%

Female Count 35 10 45

% within Gender 77.8% 22.2% 100.0%

% within Refer MH services 41.2% 40.0% 40.9%

% of Total 31.8% 9.1% 40.9%

Total Count 85 25 110

% within Gender 77.3% 22.7% 100.0%

% within Refer MH services 100.0% 100.0% 100.0%

% of Total 77.3% 22.7% 100.0%

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Table 11

Age & Refer to Mental Health Services

Refer MH services

Agree Disagree Total

Age 18-25 years old Count 48 16 64

group % within age group 75.0% 25.0% 100.0%

% within Refer MH services 56.5% 64.0% 58.2%

% of Total 43.6% 14.5% 58.2%

26 years old Count 37 9 46

and older % within age group 80.4% 19.6% 100.0%

% within Refer MH services 43.5% 36.0% 41.8%

% of Total 33.6% 8.2% 41.8%

Total Count 85 25 110

% within age group 77.3% 22.7% 100.0%

% within Refer MH services 100.0% 100.0% 100.0%

% of Total 77.3% 22.7% 100.0%

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Table 12

Education & Refer to Mental Health Services

Refer MH services

Agree Disagree Total

Education H.S. Diploma Count 39 12 51

groups % within Education groups 76.5% 23.5% 100.0%

% within Refer MH 45.9% 48.0% 46.4%

services

% of Total 35.5% 10.9% 46.4%

AS Degree Count 46 13 59

and Higher % within Education groups 78.0% 22.0% 100.0%

% within Refer MH 54.1% 52.0% 53.6%

services

% of Total 41.8% 11.8% 53.6%

Total Count 85 25 110

% within Education groups 77.3% 22.7% 100.0%

% within Refer MH 100.0% 100.0% 100.0%

services

% of Total 77.3% 22.7% 100.0%

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Table 13

Gender & Mental Illness is Normal

MI normal

Agree Disagree Total

Gender Male Count 41 24 65

% within Gender 63.1% 36.9% 100.0%

% within MI normal 67.2% 49.0% 59.1%

% of Total 37.3% 21.8% 59.1%

Female Count 20 25 45

% within Gender 44.4% 55.6% 100.0%

% within MI normal 32.8% 51.0% 40.9%

% of Total 18.2% 22.7% 40.9%

Total Count 61 49 110

% within Gender 55.5% 44.5% 100.0%

% within MI normal 100.0% 100.0% 100.0%

% of Total 55.5% 44.5% 100.0%

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Table 14

Age & Mental Illness is Normal

MI normal

Agree Disagree Total

Age 18-25 years old Count 34 30 64

group % within age group 53.1% 46.9% 100.0%

% within MI normal 55.7% 61.2% 58.2%

% of Total 30.9% 27.3% 58.2%

26 years old and older Count 27 19 46

% within age group 58.7% 41.3% 100.0%

% within MI normal 44.3% 38.8% 41.8%

% of Total 24.5% 17.3% 41.8%

Total Count 61 49 110

% within age group 55.5% 44.5% 100.0%

% within MI normal 100.0% 100.0% 100.0%

% of Total 55.5% 44.5% 100.0%

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Table 15

Education & Mental Illness is Normal

MI normal

Agree Disagree Total

Education H.S. Diploma Count 25 26 51

groups % within Education 49.0% 51.0% 100.0%

groups

% within MI normal 41.0% 53.1% 46.4%

% of Total 22.7% 23.6% 46.4%

AS Degree and Count 36 23 59

Higher % within Education 61.0% 39.0% 100.0%

groups

% within MI normal 59.0% 46.9% 53.6%

% of Total 32.7% 20.9% 53.6%

Total Count 61 49 110

% within Education 55.5% 44.5% 100.0%

groups

% within MI normal 100.0% 100.0% 100.0%

% of Total 55.5% 44.5% 100.0%

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Summary

The chapter of this research analyzed the participants’ perspective on mental illnesses and mental health services based on their religion. Researchers also analyzed the other demographics such as age, gender, and education to rule out their influences.

The statements that were analyzed are specifically chosen to help answer the research questions. The next chapter will discuss and conclude all the findings of the data.

Implications for social work practice and policy, research limitations, and recommendations will also be discussed.

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Chapter 5

CONCLUSION

This chapter summarizes and concludes the research findings and data that were gathered in this study. The demographics that were used to rule out influences will be discussed as well as religious influences on participants’ perspective of mental illness and mental health services. This chapter will also discuss the limitations of the study, implications of social work practice and policy, as well as recommendations for future research.

Summary

The purpose of this research is to explore the Hmong population’s perspective of mental illness and mental health services based on their religious practices. The researchers compared the perceptions of the two religions, Christianity and Shamanism, to explore their differences or similarities. The data shows that there were no significant differences between the religions. There were more similarities than differences. When looking at education, gender, and ages, there were also no significant differences. As seen on the tables in Chapter 4, the data shows an even distribution of answers between the two religions.

The data shows that the perspective of mental illnesses in the Hmong community is not influenced by religion. In the literature, Koenig (2010) stated that religion is used to understand the world; however, most of the participants have some higher education, so they may be exposed to the scientific explanation of mental illnesses, which may change their perspectives. The results show that the Hmong community is neutral about

69

mental illnesses as it is shown in Table 2, where half of the participants think mental

illness is normal and the other half think it is not. Most of the people think that mental

illnesses affect everyone, yet they also think mental illness is embarrassing. These results

indicated that there might be another driving force within the community as a whole that

influences their perspective in mental illness. This could be the stigma or the lack of

knowledge of mental illness in the community.

Researchers were also interested in analyzing the Hmong community’s

perspective towards mental health services. Although there were no statistical differences

between the religions, it is important and interesting to note that the majority of the

sample population (80.9%) agreed that everyone should use mental health services.

However, only slightly over half of both religions think that mental health services are

effective. Most people from both religions agreed that everyone should refer family and

friends to mental health services; however, they also agreed that seeking mental health

services is embarrassing. This shows the barriers to Hmong community seeking help

from professional mental health providers. Although they know that seeking services is

beneficial, they do not want to go through with the embarrassment of being labeled as

mentally ill or seeking mental health services.

Many of the studies show how the Hmong culture influences medical treatments

(Culhane-Pera, Vawter, Xiong, Babbitt,& Solberg, 2003); however, there is very little research on mental illness treatments. Although this research is did not focus on mental illness treatment, researchers discussed how religions could influence the Hmong community’s preferences of treatment based on their perspective of mental illness and

70 mental health services. This study shows that the Hmong community has the same perspective despite their religion.

Discussion

The data collected from the survey revealed that religion does play an important role for many of the participants’ lives. However, there are no significant differences between the two religion of how it affects the perspective of mental illness and mental health services in within the Hmong community. This study has no significant result in answering the research questions of (1) How does Shamanism and Christianity affects the perception of mental illnesses in the Hmong community? (2) How does Shamanism and

Christianity affect the perception of mental health services in the Hmong community?

Religion has been a well-studied research and it is well known to be a big influence in people’s lives as many makes decisions based on religion. Religion is also a useful coping tools used by therapists and it influences people’s perspective of life

(Koenig, 2010). However, there is little to no research studied in the Hmong community of how religion influences people’s perspective on mental illness and mental health services. When researching on the Hmong community, the research tends to be conducted on one particular religion Shamanism, but little done on Christianity. Christianity is a rising practice that many Hmong people are converting to every year. It is important that people are aware of the different religious practices in the Hmong community, especially medical and mental health professionals. By learning an individual’s religious belief, professionals will be able to incorporate the individual’s beliefs with the proper medical or mental health treatment.

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As stated in the literature reviews, mental illness are not in the Hmong vocabulary and essentially, does not exist in their traditional culture or community (Culhane-Pera,

Vawter, Xiong, Babbitt,& Solberg, 2003). This non-existence of mental illness in the community may be a reason why stigma emanate and raise embarrassment. This study shows that mental illness and seeking mental health services are a huge embarrassment in the Hmong community. Mental health educators and social workers will need to do more outreach to the Hmong community to help them understand the concept and the prevalence of mental illnesses.

In the Hmong community, mental illness is categorized or seen as physical illness.

When a person is ill, he/she will seek for traditional therapeutic practices which includes home therapies, medicine doctors with herbal medicines, ritual or magical healers, soul callers, shamans (Culhane-Pera, Vawter, Xiong, Babbitt,& Solberg, 2003; Gensheimer,

2006), and church communities first before seeking help from other health professionals.

Mental illness was not visible until the Hmong post Vietnam War, when people started to experience war trauma (Lee & Chang, 2012). In studies conducted, the Hmong community reports depression, anxiety, and PTSD (Vang, 2014).

Majority of the participants believes that mental health services are effective and available, yet does not seek for treatment because of embarrassment. The fear of disgrace and embarrassment upon the family’s name is something that most Hmong families try to avoid. Therefore, a culturally sensitive approach should be provided for the best treatment and involvement of the Hmong community. As Lee and Chang (2012) and

Vang (2014) points out, cultural competency is an important factor to add into treatment

72 plans. About three-quarters of the participants agree that religion does play a big role in their lives; therefore, incorporating cultural beliefs and practices should be taken into consideration when providing proper treatment for the Hmong community.

Implications for Social Work Practice and Policy

The Hmong population is a fast growing population in the United States (Hmong

National Development, 2011), and so it is important to serve this population because

Hmong is one of the five main threshold languages in the Sacramento County that are

Medi-Cal beneficiaries (Department of Health Care Services, 2014). With the knowledge

that Hmong Americans are underserved in the mental health field and a majority of the

first generation Hmong Americans has experienced some form of trauma and/or mental

health condition such as PTSD and depression, it would behoove social workers to serve

this vulnerable population (Collier, Munger, &Moua, 2012; Vang, 2014). It is the

responsibility of social workers to educate not only Hmong Americans but also the

community as a whole of this need to provide, if wanted, equal access to mental health

services. Social workers need to be aware of ways to reach out to the Hmong Americans in addressing their mental health needs. To adequately ensure social justice, cultural

competency and education of the Hmong population of social workers are also essential.

The implications for micro social work are that social workers are more culturally

aware or sensitive to the Hmong population. Social workers cannot automatically assume

that their Hmong patient practices Shamanism. As more Hmong are converting to

Christians and other religions, their values and practices may change. Although this study

did not show a difference in perspective, the literature indicated that different methods

73 are used to cope with illnesses. Instead of soul calling and doing the traditional shaman practices, Hmong Christians are seeking help from their pastor and church community.

However, as indicated in the literature review, it is also important to note that many

Hmong people still use herbal medicine no matter their religious practice. In addition, some Hmong still practices both religions, and so it is important for social workers to be aware of the dual practices or the family’s level of conversion to Christianity.

Furthermore, this research implies that embarrassment is a big barrier to seeking mental health services. This probably means that mental illness still has a lot of stigma in the Hmong community. Therefore, implications for mezzo social work is to do more outreach to the Hmong community and educate them that mental illness is just like having physical injury or illness. Since mental illness is a fairly new concept in the

Hmong community, it is important for Hmong social workers and mental health providers to come together to agree upon the language used to describe mental illnesses in the Hmong community. It is important to build a universal Hmong vocabulary in the mental health field to articulate clearly when educating the community and diagnosing symptoms.

The implications for macro social work are that social workers need to advocate for mental health policy to prevent discrimination of mental illnesses in the workplace and in the community. Mental illness still holds a strong stigma, not just in the Hmong community, but also in the larger community as a whole. It is important that social workers are familiar with the Mental Health Service Act so that they can advocate for their clients and advocate for funding to use towards culturally appropriate treatments and

74 outreach to the Hmong community. The Mental Health Service Act can also be used to fund programs to involve religious leaders in mental health treatment plans.

Recommendations

The purpose of this study was to explore the perspectives of mental illness and mental health services among the different religious group of Shamanism and

Christianity in the Hmong community. The following section includes a recommendation list of future research and resolution to better improve the findings of this study.

• The researchers could have extended their sample population to other events or

gatherings in the Hmong community such as churches to have an equal amount of

participants in both religious groups. This can also help resolve the age group

distribution and have older individuals to participate in the research study.

• For future studies, researchers should not be limited to those who are English-

only speaking. The researchers should have translated the questionnaire into

Hmong so that they could have included non-English speaking participants.

• When creating questionnaire, it is important not to add in the neutral option

because people tend to circle this option more often. This also gives the

participants an option not to provide their opinions.

• In the questionnaire, it would be great to add how long the participants practice

their religion because it will provide the researchers more information if the

participants just recently converted to Christianity.

• Future research study suggestions include researchers looking at a collective

community instead of the religions in the community and study if mental health

75

stigma influences people’s perspective towards mental illness and/or seeking

mental health treatments.

• Future studies could explore methods of how to provide effective mental health

services for the Hmong community.

Limitations

In this study, the limitations includes the population, age, and English-speaking and understanding individuals. The sample population that the researchers recruited was not large enough. The researchers were not able to find an equal amount of participants that has a religious belief of Shamanism and Christianity. Majority of the participants practices Shamanism. If the researchers were able to extend their study to church meetings, there might have been an equal amount of participants in both groups. Age was also a limitation that the researchers face. In the study, over half of our participants were between the ages of 18-25 years old. The Hmong New Year event is a popular place for this age group; therefore it was difficult to find older Hmong people to participate in the research. Also, the researchers were bias towards some individuals that looked unapproachable when distributing survey at the events. Another limitation is finding participants that are English-speaking and understanding individuals. The researchers were not able to recruit older adults who did not speak or understand English. To better improve this research study in the future, researchers would need to think about how to engage more participants from different demographic backgrounds.

76

Conclusion

The primary purpose of this study was to explore if religion impacts the perspectives of mental illness and mental health services within the Hmong community.

The research data and findings from Chapter 4 were discussed. The literature review from

Chapter 2 was used to analyze the findings of the study. The implications of social work practice and policy were also reviewed. The research study limitations and recommendations also were presented for future research suggestions regarding mental illness and mental health services within the Hmong community. In conclusion, this research reveals that there are no significant differences of how the religions of

Shamanism and Christianity affect the perspectives of mental illness and mental health services; even though 72% of the participants agree religion plays an important role in their lives. It is important for professionals and social workers to be culturally competent of the different religious beliefs and practices of the people that they serve to provide the best quality of care and treatment approaches that meet their client's needs.

77

Appendix A

PARTICIPATION CONFIRMATION / LETTER OF INFORMED CONSENT

STUDY TITLE: A Comparative Analysis of Shamanism and Christianity’s Perspective of Mental Health in the Hmong Community

Our names are Lee Thao& Yeng Yang, and we are second year graduate student in the Division of Social Work program at California State University, Sacramento. We would like to invite you to participate in this research study because your perspective and opinion regarding mental health services and mental illnesses is important.

If you choose to participate in this study, please complete the following survey. The survey will take no more than 10- 15 minutes to complete. The knowledge gained from this study may benefit future mental health professionals in their practices. There are no known sociological and economic risks associated with your participation in this study. The questions in the survey ask about your perspectives, attitudes and beliefs of mental health services and mental illnesses. There is a minimal risk that the participants might feel embarrassed regarding their understanding of mental illnesses and mental health services. Because the surveys are paper surveys, other people may come in contact with the information you provide, which could compromise confidentiality. However, your identity to the researchers will remain anonymous as well as your survey answers will also be kept confidential at all times. Information collected will only be reported in aggregate form.

Among the measures taken to insure confidentiality is the encryption of all electronic data collected and/or entered into a database (data stored behind a secure firewall). Hard copied data will be maintained in a safe, locked location and any descriptive information collected will be destroyed by August 31 of 2016.

You are free to withdraw your consent, skip answering any questions, and/or discontinue your participation in this study at any time. By choosing to complete and turn in this survey, you have given us your implied consent and therefore agree to participate in this study.

We are highly appreciative of your time. Please feel free to contact Lee Thao at [email protected] or Yeng Yang at [email protected] if you have any questions. You may also contact Maria Dinis, Ph.D., MSW, the project advisor/chair, at (916) 278-7167, or [email protected]. For questions about your rights as a participant in this research study, please call the Office of Research Affairs, California State University, Sacramento, (916) 278-5674, or email [email protected].

I have read the descriptive information on the Research Participation cover letter. I understand that my participation is completely voluntary. My completion of the survey and handing it into the researchers implies that I am agreeing to participate in this study. I may keep this copy of the Research Participation cover letter for my records.

78

Appendix B

QUESTIONNAIRE

Direction: Read each question andcircle the answer that best describe your opinion.

There is no right or wrong answer. This survey is design to measure your perspective, attitude, and beliefs towards mental health services and mental illnesses.

Demographics:

Age: 18-25 26-33 34-41 42-49 50 and older

Gender: Male Female Other

Religion: Christian Shaman Other

Highest Education: H.S Diploma AA/AS BA/BS MA/MS PHD Other

Perspectives, attitudes, and beliefs

1. Religion plays a big role in my life.

Strongly agree Agree Neutral Disagree Strongly Disagree

2. Religious leaders are important decision makers when it comes to mental

illnesses.

Strongly agree Agree Neutral Disagree Strongly Disagree

3. Mental illnesses are caused by spirits/devils.

Strongly agree Agree Neutral Disagree Strongly Disagree

4. Mental illnesses are normal.

Strongly agree Agree Neutral Disagree Strongly Disagree

5. Mental illnesses are embarrassing.

Strongly agree Agree Neutral Disagree Strongly Disagree

79

6. Mental illnesses can be treated by God.

Strongly agree Agree Neutral Disagree Strongly Disagree

7. Mental illnesses can be treated by shamans.

Strongly agree Agree Neutral Disagree Strongly Disagree

8. Mental illnesses can be treated by mental health professionals.

Strongly agree Agree Neutral Disagree Strongly Disagree

9. Mental health services are effective.

Strongly agree Agree Neutral Disagree Strongly Disagree

10. Seeking mental health services is embarrassing.

Strongly agree Agree Neutral Disagree Strongly Disagree

11. Everyone should use mental health services if needed.

Strongly agree Agree Neutral Disagree Strongly Disagree

12. Everyone should refer mental health services to family and friends who are in

need.

Strongly agree Agree Neutral Disagree Strongly Disagree

13. I seek help from my religious leaders when I am ill.

Strongly agree Agree Neutral Disagree Strongly Disagree

14. Mental illnesses are a sign of becoming a shaman.

Strongly agree Agree Neutral Disagree Strongly Disagree

15. Mental illnesses can affect everyone.

Strongly agree Agree Neutral Disagree Strongly Disagree

80

Appendix C

HUMAN SUBJECT APPROVAL LETTER

CALIFORNIASTATE UNIVERSITY, SACRAMENTO DIVISION OF SOCIAL WORK

To: Lee Thao& Yeng Yang Date: September 15, 2015

From: Research Review Committee

RE: HUMAN SUBJECTS APPLICATION

Your Human Subjects application for your proposed study, “A Comparative Analysis of Shamanism and Christianity's Perspective of Mental Health in the Hmong Community”, is Approved as Exempt. Discuss your next steps with your thesis/project Advisor.

Your human subjects Protocol # is: 15-16-003. Please use this number in all official correspondence and written materials relative to your study. Your approval expires one year from this 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 Teiahsha Bankhead, Maria Dinis, Kisun Nam, Francis Yuen

81

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