A QUALITATIVE STUDY ON TRUAl'v!A AFfECTING ASIAN AMERICANS IN THE BAY AREA
A University Thesis Presented to the Faculty
of
California State University, East Bay
In Partial Fuliillment
Of the Requirements for the Degree
Master of Social Work
By
Pollie Bith-Nlelander
June2016 A QUALITATIVE STUDY ON TRUAMA AFFECTING ASIAN AMERICANS IN THE BAY AREA
By Pollie Bith-Melander ~
Approved: Date:
! / It' / /t Dr. Sarah Taylor o,~r Abstract
This qualitative study describes trauma affecting the Asian and Pacific Isl API population, suggesting that psychological issues should be treated as a part of larger interventions because such issues are often compounded by many factors and challenges . • • • iii -~< ______ Acknowledgements I would like to thank Dr. Sarah Taylor for all her support to ensure that I was progressing in all phases ofthis research project. Her comments and suggestions have made this project possible. I would like to thank two external advisors, Drs. Rose Wong and Lynn T. O'Leary, for their advice and suggestions. My long-time friend, editor and co-conspirator, Sharon May, for all her contributions in editing and fixing this thesis. 1 would also like to thank my son, Viking, for giving me the motivation to move forward and my spouse, Ronny, for his unconditional support and love . • • • iv Table of Contents Abstract iii Acknowledgements IV List ofTables Table 1: Group Observation 1 65 Table 2: Group Observation 2 65 Table 3: Group Observation 3 66 Table 4: Client Data 2016 80 Table 5: Common Diagnoses among Mainland Southeast Asians 81 Table 6: Under 18 Years Old 83 Chapter 1: Profile of Asian Americans Introduction and Background 1 History of Asian Migration to the United States 4 Cambodian Americans 9 The People of Laos 18 Lao Mien 19 T-lmong 20 Vietnamese 22 Demographics and Other Indicators 27 Mental Health Problems and Treatment 29 Conclusion 31 Chapter 2: Theoretical Approaches 32 Trauma and Other Related Experiences 32 Trauma and Its Conceptual Framework Transgenerational & Complex Trauma (Compkx Post-Traumatic Stress disorder) 34 Cultural Trauma 36 Evolutionary Perspective 39 Freeze, Flight, Fight, and Fright 41 Chapter 3: Research Methods 45 Research Questions 45 Methods 46 Research Procedures 48 Research Rationale 49 Data Analysis 51 Involvement of Other Organizations 52 Reflexivity in Qualitative Research 52 ••• v .. Participants 53 Recruitment Plan 53 Potential Risks/Benefits 54 Risk Reduction 54 Confidentiality 55 Consent Issues 52 Limitations 56 Research Purpose 56 Chapter 4: findings 58 Profile of Agency and Its Clients 58 Group Observation Findings 65 Participant Data Tables 65 Descriptive Statistics 66 Group Observations Overview 66 General Findings 69 Migration Experience 69 Western Modality, Treatments, and Side-Effects 71 Symptoms and Experiences Related to War 72 Daily Challenges and Barriers 76 Healing Through Art 77 Secondary Data Findings 79 Client Demographic Data and Diagnoses 79 General Findings 80 Rates ofPTSD and Diagnosis Complications 84 Trauma Manifestation and Perceived Psychological Control 85 Trauma, Stigma and Daily Challenges 88 Challenges of Western Modalities vs. Eastern Philosophies 89 Conclusion 92 References 94 ••• vi 1 Chapter 1: Profile of Asian Americans Introduction and Background Asian Americans are the fastest growing group in the United States and make up approximately 6% of the U.S. population. Out of this percentage, 67% are foreign-born and 75% speak a language other than English at home (U.S. Office of Surgeon General, 2001). One of the complex reasons why Asian Americans are generally ignored or overlooked by the U.S. government in terms of allocation of public funding is that Asian Americans seem to fall within the pretense of the “Model Minority” myth, the misrepresentation that they all live successful lives in the U.S. as compared to other minority groups. Asian Americans are in a precarious position as an immigrant/refugee group in America. Some Asian Americans fall under minority status, which allows them to take advantage of certain social benefits (e.g., Filipino and other Pacific Islanders), while others (i.e., Southeast Asian Groups) do not have minority status despite their poor socioeconomic standings. The reasons for minority status are political. The recent arrivals from Asia and Southeast Asia are excluded because they are simply new arrivals to the U.S. Among those included are mainland Southeast Asian refugees who arrived after the U.S. pulled its military forces out from Southeast Asia in 1975. This group received public assistance for a finite period of time due to refugee status. At the same time, they did not have minority status, which would have allowed them to access benefits from 2 foundations and corporations whose primary purpose is to provide scholarships to minority students. Another reason is that Asian Americans are perceived by other Americans as living the American dream. This image is in contradiction to the reality that many Asian Americans represent the two extremes in both health outcomes and socioeconomic status. What distinguishes Asian Americans from other ethnic minority groups, however, is their health-seeking behaviors, particularly in regard to mental health services. Various studies (Loya et al., 2010; Lin & Cheung, 1999; Li & Browne, 2000) have shown that Asian Americans are the least likely group of people to access mental health services. Only about 8.6% of Asian Americans sought mental health services compared to about 18% of the general population (Spencer et al., 2010). They have experienced and continue to experience various emotional and behavioral problems. The Centers for Disease Control and Prevention (CDC) ranked suicide as the tenth leading cause of death among Asian Americans and Pacific Islanders (CDC, 2016). This thesis focuses on Southeast Asians as they share a similar background and history that is distinct from groups from other regions of Asia, such as East Asia, South Asia, and Insular Southeast Asia. Therefore, particular attention will be given to people from Southeast Asia in this analysis. The majority of Southeast Asians arrived in the U.S. in the late 1970s after the Vietnam War. Cambodian Americans represent one of the three groups of people from mainland Southeast Asia; the other two groups are from Laos and Vietnam. In particular, Southeast Asians suffered serious trauma before they migrated; Cambodians in particular experienced atrocities that took place during the Pol Pot regime between 1975 and 1978. 3 Cambodian Americans, after thirty years of being resettled in the U.S., are still dealing with the past experience of trauma from torture and witnessing execution of loved ones during the Pot Pol regime, and this trauma continues to affect the younger generations. Trauma lingers on even after many decades. Southeast Asian refugees are still struggling to adapt, adjust, and make a new life in the United States because memories of the Vietnam War still haunt them. The Southeast Asian refugees who were seen as helping the U.S. in the war in Vietnam faced severe consequences at the end of the Vietnam War. Tribal groups, including Mien and Hmong, for example, were forced out of Laos and were perceived as traitors by the Laotian government. Similarly, Vietnamese pro-American individuals were not treated as friendly when the U.S. pulled out its forces. Those who were fortunate were able to leave the country at the same time as the Americans in 1975 (Seo, 1994). The Cambodians suffered most severely because of the consequences of the U.S. involvement in the war through a clever maneuvering of the U.S. policy and support, which allowed a xenophobic brutal ruler to take control of the country in a time of chaos and mismanagement (Chandler, 1996). The first large wave of Southeast Asian refugees started coming to the United States in 1975, after the end of the Vietnam War. Between 1975 and 1978, 178,000 refugees arrived from Cambodia, Vietnam and Laos (Seo, 1994). More than a million Southeast Asians now live in the U.S. (U.S. Census, 2010). Southeast Asians are only 13% of the total Asian American population in California, but they account for 87% of Asian Americans receiving public assistance (Seo, 1994). Their trials, tribulations, and challenges will be discussed sections below in order to gain a deeper understand of why this particular group of Asians is still struggling emotionally and psychologically. 4 History of Asian Migration to the United States The first groups of Asians to arrive in the United States came mainly for economic opportunities and as spouses for those workers. After the Vietnam War, however, the profile of Asians in America changed drastically from those who sought economic opportunities to those who were forced out of their homelands because of their involvement with the U.S. government’s wars in their native countries. East Asians and Insular Southeast Asians, namely Filipinos, settled early in the U.S. Filipino immigration to the United States began after the U.S. acquired the Philippines in 1898 as a result of the Spanish-American War (Meixsel, 2002a). The country became independent in 1946 (Meixsel, 2002a). A large number of immigrants went to work in Hawaii on sugar plantations before arriving on the U.S. mainland. Today, Filipino Americans are the second-largest group among Asian Americans. They represent one of the early arrivals of Asians in the United States. In many ways, they have paved the way for other immigrants and have made possible better opportunities and living conditions (Meixsel, 2002b). The earliest groups of Asians to settle in the U.S. were from Japan and China. The Japanese arrived in the United States in the 1880s. The first arrivals of Asians to the U.S. came to work in the sugar plantation industries. They came to the U.S. to seek economic opportunities and arrived gradually, beginning in the early 19th century. By May 17, 1868, 153 Japanese migrants had arrived in Hawaii specifically for employment in the sugar plantations (Takaki, 2008). Between 1886 and 1911, more than 400,000 men and women left Japan for the U.S. Over 28,000 Japanese migrated to Hawaii during that time 5 (Takaki, 2008). World War II drastically changed perceptions of Japanese in America. The attack on Pearl Harbor in 1941 set a tragic history in motion in which the U.S. government systematically segregated Japanese Americans from the other Americans (Hatamiya, 1993; Takaki, 2008). Approximately 1,500 people were detained as enemy aliens in Hawaii and 100,000 on the mainland during World War II (Hatamiya, 1993; Takaki, 2008). They were sent to internment camps on short notice and with limited belongings. In 1943, military-aged males were given the opportunity to join the Military Intelligence Service or a special segregated Japanese-American unit of the U.S. Army, the 442nd Regimental Combat Team (Crost, 1994). These men were determined to prove their loyalty to the U.S. government. However, the families of the soldiers remained in internment camps. In December 1944, the Supreme Court ruled that it was unconstitutional to detain U.S. citizens and internees were allowed to leave the camps the following month (Takaki, 2008). Some people returned home while others chose to relocate after the war. In 1980, Congress created the Commission on Wartime Relocation and Internment of Civilians to investigate the treatment of Japanese Americans during World War II in the internment camps (Takaki, 2008). It took an additional five years before Congress passed the Civil Liberties Act (Wei, 1993; Kim, 1986). Rep. Robert Matsui and Rep. Norman Mineta, who later served as secretary of transportation and secretary of commerce, co-sponsored the legislation in the House (Hatamiya, 1993). Mineta and Matsui, the sons of Japanese immigrant parents themselves, were interned with their families as children (Hatamiya, 1993). In the Senate, the effort was led by Sens. Spark Matsunaga and Daniel Inouye, both of whom were wounded in World War II while 6 fighting in the segregated 442nd Regimental Combat Team (Crost, 1994). It took both of their efforts to gain the acknowledgement of the mistreatment of Japanese who were U.S. Americans and who were loyal citizens of this nation. Similar to Japanese Americans, Korean immigrants came to Hawaii to work on sugar plantations. Approximately 7,000 Koreans were recruited and brought to Hawaii as plantation laborers between 1903 and 1905 (Chang & Patterson, 2003). They were brought in to meet the labor demand on the Hawaiian plantations after a series of laws barring Chinese labor immigration were enacted. Before the door was completely closed in 1924, due to the National Origins Act, an additional 1,100 Korean were brought to Hawaii as "picture brides” (Patterson, 1988). The Chinese were among the first Asians to immigrate to the United States with the attraction of the California gold rush. Today, the Chinese are the largest group among Asian Americans. Early immigrants from China were largely male laborers, and immigration was curtailed by anti-Chinese laws beginning in the late 1880s (National Archives, 1989). After China became an ally during World War II, the Exclusion Act (National Archives, 1989) was replaced by the Magnuson Act in 1943 (Low, 2008). The Magnuson Act made it possible for Chinese Americans to become naturalized citizens, but with an annual quota of 105 immigrants who were to be granted citizenship. The Immigration Act of 1965 repealed the quota system and allowed for family reunification (Low, 2008). Since the 1960s, Chinese have immigrated in large numbers to take advantage of the immigration policy’s emphasis on family reunification (Low, 2008). At the end of the 20th century, about 2.3 million Chinese Americans were living in various 7 states in the U.S. (Low, 2008). Recent immigrants over the past four decade include large numbers of educated professionals. While this thesis generally examines Asian and Pacific Islanders (APIs), particular attention will be given to a group of mainland Southeast Asians, namely Cambodian, Vietnamese and both lowland and highland Laotians, because of their unique historical experiences with the Vietnam War and socio-political-economic ties to the U.S. government. This history of U.S. involvement in Southeast Asia began in the 1950s, at about the same time the French pulled out of the region. The first mass influx of refugees came to the U.S. in the mid-1970s, following the U.S. military withdrawal from the region. By the late 1980s, large numbers of Southeast Asians--specifically Cambodians, Laotians, Mien, Hmong and Vietnamese--migrated and resettled in various parts of the United States. This was as a result of the continued conflicts in the region and the United States’ involvement in mainland Southeast Asia. There is a historical context to this mass influx of Southeast Asian refugees that took place in the mid-1970s and 1980s. In 1969, the U.S. began bombing sites in Cambodia and Laos in an effort to disrupt North Vietnamese supply routes during the Vietnam War. This bombing had the unintentional result of increasing support among the mainland Southeast Asians (Cambodians, Laotians, Mien, and Hmong), but in particular among the Cambodian people for a group of communist insurgents, nicknamed the Khmer Rouge, who were seeking to overthrow the Cambodian monarchy (Chandler, 1996). At the same time, the United States began a campaign to recruit Laotian highland people, specifically the Hmong, via the Central Intelligence Agency to fight the war that was taking place in Vietnam (Shawcross, 1981). 8 The monarch who reigned in Cambodia during this time was overthrown by his National Assembly and General Lon Nol, supported by the U.S. government, gained control of the Cambodian government. Although the Vietnam War impacted the entire mainland of Southeast Asia, the situation in Cambodia was compounded by internal turmoil. Cambodia became a testing ground for a regime whose goals were to practice ethnic cleansing and create a classless society. The Khmer Rouge insurgency erupted into a full-scale civil war in 1970, with the United States providing massive aid to the Cambodian government. The exiled Cambodian prince sided with the Khmer Rouge in an attempt to take back the country (Kiernan, 1996). This, combined with continued U.S. bombing of the Cambodian countryside and widespread corruption in the Cambodian government and military, gave further appeal to the Khmer Rouge (Chandler,1996). In 1975, the Khmer Rouge took control of the Cambodian capital, forcing U.S. personnel to flee the country. From 1975 until 1978, the Khmer Rouge, who were intensely nationalistic and xenophobic, ruled Cambodia with brutal force. They implemented a plan that called for the end of foreign influence, the complete eradication of the former political culture, the collectivization of the economic structure, and the destruction and reshaping of all social institutions. It is estimated that out of a population of 8 million, 1.7 million to 2.2 million people died from execution, starvation or over-work (Kiernan, 1996). Particular groups were targeted as threats to the government and were singled out for execution: former government employees, soldiers, students, intellectuals, religious leaders, merchants, doctors, Chinese, Muslim Chams, Vietnamese, and the families of these people. Cambodian society was swiftly and radically changed. All people were forced to live in 9 labor communes where children and parents were separated, education and Buddhism were abolished, and all traditional elements of social life were banned. They worked long hours with few if any days off and received starvation rations. The result was that disease, malnutrition, and undernutrition were epidemic. Haing Ngor (1987), a Cambodian physician who survived the Khmer Rouge regime by hiding his identity as a doctor, writes, “The hard work, the food shortages, the unsanitary conditions and the near-absence of medicine combined to cause illness on a scale I had never seen before in all my medical training” (Ngor, 1987). Cholera, malaria, pneumonia, tuberculosis, and dysentery were common. In 1978, the Vietnamese, responding to the constant border violations and attacks by Cambodia, invaded and defeated the Khmer Rouge government. This resulted in nearly 100,000 people fleeing to the Thai border. By 1979, an additional 500,000 Cambodians had fled to refugee camps in Thailand (U.S. Committee for Refugees, 1987). Numerous countries including the United States, Canada, France, and Australia responded by resettling these refugees. In the United States, the refugees gaining earliest resettlement tended to be younger, formally educated men and women. However, by the end of the resettlement effort, the majority of refugees were from rural, peasant backgrounds. Cambodian Americans The term Cambodian is used to encompass all migrants from Cambodia and their offspring. Although the term connotes a cohesive and identifiable ethnic group and culture, diversity exists in the social, economic, and religious background of Cambodian 10 Americans. The ethnic groups of Cambodia include Khmer, Chinese, Muslim Chams, Vietnamese, many tribal groups, and Indians. However, Cambodian’s Khmer represent the largest (85 to 90% of the population) dominant cultural group in Cambodia and of those who resettled in the U.S. Traditional Cambodian society is characterized by a large rural peasantry, a small elite class, and intermediate class (Kiernan et al., 1982; Ebihara, 1971). The peasants were and are largely engaged in wet rice cultivation, fishing, crafts, or unskilled manual labor. The elite class was comprised of members of the royal family (Cambodia was a monarchy for most of its history), high ranking government officials, Buddhist religious leaders, and wealthy professionals (Chandler, 2011). The intermediate class comprised the business owners, teachers, lower ranking government and military officials, doctors, and other urban “white-collar” workers. These classes may also be defined as urban and rural with the elite and intermediate classes mostly residing in Phnom Penh, the capital of the country. The majority of the rural people are peasants with little formal education. Cambodian Americans differ in class make up in one fundamental way. Cambodian Americans do not view class or monarchy as an important factor in their relationships with others in the community. Cambodian Americans come from both rural and urban backgrounds, but most are formerly rural villagers (Chandler, 1991). This means that many adults and elderly Cambodian Americans have little formal education and most likely do not know how to read or write in their native language. Many of the elderly Cambodian Americans also have never learned to speak, read or write in English. Younger Cambodians have been able to take advantage of educational opportunities in the United States, although there is 11 great variation in their English speaking, writing, and reading skills. The youngest generation is being reared in the United States. Its members face the problems common to every generation of immigrants straddling both the new culture of the United States and the old culture of their parents (Chandler, 2011). Cambodian Americans are divided along the line of individuals who receive public assistance and the educated/working professionals who do not. By extension, the working professionals also are home owners and are more acculturated than those who depend on government assistance (Chandler, 2011). The working professionals can fully function and participate in the mainstream society if they choose to. One difference between Cambodians and Cambodian Americans lies in belief systems. The majority of Cambodians in their country are Theravada Buddhists. However, Cambodian Americans are disparate when it comes to worshipping; some belong to the Church of Latter Day Saints, and Baptist and Catholic churches. Another difference between Cambodians and Cambodian Americans is the elite/royal group that exists in Cambodia but not in the U.S. The Cambodian American community for the most part does not identify with the current monarchy in the country, but some return to pay respects to their ancestors and reconnect with family members who are still living in the country. Khmer culture is an amalgamation of indigenous folk traditions, Indian, and French influences (Zadrozny, 1955). More than 85% of Cambodians practice Theravada Buddhism and the rest worship other belief systems, including Christianity and Islam. The folk religion centers on ancestral spirits who are either dangerous or benevolent. Dangerous spirits or ghosts are perceived to have supernatural power to cause harm on 12 living beings whereas benevolent spirits help maintain order in the natural world, including for all beings residing in it. In other words, some spirits are benevolent, while others are malevolent. This belief extends to the conception of health, disease, and mental illness. Western medical practices were introduced in Cambodia around 1860; however, indigenous practitioners or traditional healers were still sought first for treatment (Ebihara, 1971). Western doctors were seen only when the illness was perceived to be incurable by a traditional healer. There were indigenous practitioners who dealt with sorcery and exorcised the evil spirits from the patient. Buddhist monks sometimes would practice both Western and traditional medicine. Some of the causes of illness were typically attributable to supernatural beings and others to natural causes such as humoral imbalances. Some of mental illnesses are considered to be caused by supernatural beings. Spirits, for example, cause illnesses by entering the body through the patient's food. Healers who practice black magic can prevent or cause harm to people. Illnesses from humoral imbalance come from Ayurvedic medicine in India and Southeast Asia with its use of the five basic elements of wind, water, earth and fire to regulate bodily functions. According to the Ayurvedic system of medicine, illness occurs when there is an upset of homeostatic condition of the humors (Sargent & Marcucci, 1984). Some of the treatments that help resolve this imbalance of homeostatic condition include ritual ceremonies to deal with the nefarious spirits, paying homage to the benevolent spirits, performing moxibustion, and using herbal medicines (Sargent & Marcucci, 1984). The Cambodians are at very high mental health risk and suffer from post- 13 traumatic stress syndrome and depression that is exacerbated by many other stressors such as the struggle to acculturate in a foreign country, and social and economic barriers, including financial stress (Sargent & Marcucci, 1984). The majority of Cambodians in the United States have a close connection to the genocide under Pol Pot and the Khmer Rouge. There is a dose-effect relationship of trauma to symptoms of depression and post- traumatic stress disorder (PTSD) among Cambodian survivors of mass violence. Research studies have examined the Cambodian cultural concept of mental illness, specifically in regard to depression and PTSD (Handelman & Yeo, 1996). The cultural concept of mental illness, namely sadness or obsessive thinking or thinking too much, is one of the concepts that offers insight into the cultural meaning and understanding of mental illness. The concept of “thinking too much” has important implications. It suggests more than a headache and delves into the roots of the cause of mental illness--in this case, something that is continuous and impairs one’s ability to function. In other words, mental illness can be caused as a result of experiencing a traumatic event in life. Research into this concept provides a frame of reference for how Cambodians construct meanings in their traumatic experiences through an expression of a particular emotion--in this case, being sad or thinking too much to the point where these feelings dictate all aspects of live. A study examined this specific aspect of mental illness among Cambodian Americans who went through the Pol Pot Regime and found that sadness from obsessive thinking about the loss of family members or traumatic events in the killing fields were the root of the most common illnesses among 76 Cambodian elders in San Jose, California (Handelman & Yeo, 1996). This condition (pruit chiit/ kiit chraen) produces severe headaches and can be interpreted as suffering depression or reliving an experience 14 from the Pot Pot Regime. In the latter case, an individual might complain of the ailments, including recurring nightmares, racing thoughts, fear of noise, and insomnia. Similarly, in a study of emotional distress and violence among Cambodians in Long Beach, California, and Lowell, Massachusetts, respondents experienced headaches from "thinking too much" about the horrors of Pol Pot regime. Pruit chiit literally means “to worry the heart.” However, it can also be interpreted as having extreme worry about something that causes the heart rate to increase. Similarly, kiit chroen refers to “too much thinking.” Family violence may be the outcome of thinking too much, and a woman's solution to thinking too much might be to express her feelings in a manner that might offend someone, such as the head of the household in her family. Some Cambodian Americans self-medicate to deal with some of the symptoms of this condition, including using alcohol and prescription drugs, especially sleeping pills. Cambodian Americans have experienced ongoing trauma, during the post-migration period or resettlement in America. Those from Vietnam, Laos, and Cambodia have endured extreme violence during pre-migration. Cambodian Americans in particular have experienced violence from a regime that killed more than a third of its population in a span of three years (Chandler, 2011). My generation (1.5) and the next generation of Cambodians who were born in the United States will have to endure the legacy of a violent regime whose trauma is passing on from one generation to the next. My experience was similar to those of my mother and other older Cambodians who survived the atrocities of 1975 to 1978, but even my children and their children may have to endure some of the consequences of these experiences. They may experience symptoms of PTSD and the anxiety spectrum without 15 ever having to experience it firsthand. Another cultural condition that is difficult to explain and seems to be unique to Cambodians who have lived through the atrocities is the loss of eyesight. One study found that Cambodians who had functional visual loss may have conversion hysteria from wartime experiences (Drinnan & Marmor, 1991). This explanation for the emotional causes of physical illnesses points to the Cambodian cultural conception of health and illness. It requires a holistic approach for the reasons behind the medical problems. Disease is a medical construct that often cannot be used to explain a culturally specific phenomenon. The authors of the study concluded that it had to be a horrendous trauma to have caused such blindness to happen to a person (Drinnan & Marmor, 1991). One plausible explanation is that the shock from seeing someone hurt or killed caused one to ignore the present object from being seen. A traumatic population can become impaired easily. A reminder of a traumatic incident in the past, for example, can tip the emotional balance from being a fully functional being to completely impaired. What triggers such distress only time will tell. We now know that trauma can pass on from one generation to the next. There is no question that some of us (Cambodians and others who have experienced violence in their lifetime) will have some psychological issues. In addition to dealing with high level of emotional and psychological distress, Cambodians also have high rates of hypertension, diabetes, heart disease, stroke and seizures that are accompanied by many other somatic complaints such as headaches, stomach aches, dizziness and fatigue (Baughan et al., 1990). As Cambodians are learning to accept Western culture, the choices of choosing foods, either Western or traditional, and changes in food preparation style will ultimately 16 change their behaviors, which in turn can affect their health negatively or positively. For example, those who prefer to consume traditional food containing mostly vegetables, fish, and very little starch, would certainly reduce their chances of having complications with chronic conditions. Another health condition that is worth giving attention to is one of the cultural practices of betel nut chewing. Some older Cambodian women chew betel leaves and betel nut--a stimulant and narcotic substance that is quite addictive--with tobacco and red limestone paste. Chewing betel nut or betel leaves puts one at possible risk for oral squamous cell cancer that is prevalent throughout Southeast Asia (Reichart et al., 1996). Generally, betel chewing is seen in older women and is not as common among older men. In some ways, it is a rite of passage that allows a woman to age gracefully by moving on from one state of life to the next, moving into a state of seniority. Cambodians -view age as having wisdom. Cambodians do not necessarily view betel chewing as a health issue or an addiction. Similarly, Cambodian Americans often do not associate liver disease with Hepatitus B virus, only with heavy alcohol use (Jackson et al., 1997). The concept of illness is directly related to symptoms and there is also the basic understanding of mind and body connections that impact the overall health and wellbeing. In other words, illness is said to only exists when there are apparent symptoms. A deep understanding of Cambodian conception of health and illness may offer insight into how Cambodians view mental illness. All these conditions as discussed so far are intertwined in that both the mind and body work together to create harmony or cause disturbance in the body. Perhaps this is why about 10% to 15% of Southeast Asian refugees are carriers of Hepatitis B virus (Jackson et al., 1997). Cambodian Americans 17 still carry similar views despite their influence from the mainstream Western community. Although it has been three decades since the first Cambodian arrivals to the U.S., the Cambodian American community seems to be stuck in time and place. Some Cambodian Americans choose to only socialize in this vacuum and do not venture out to make friends with Americans, for example. Today, there are approximately 300,000 Cambodians residing in the United States. The majority live in California, Massachusetts, Washington, Texas, and Pennsylvania (U.S. Census, 2010). More males than females were killed during the civil war and during the Khmer Rouge regime in Cambodia (Chandler, 2011). The majority of Cambodians entering the United States have very little formal education. According to the 2010 census data, 24% had some high education or graduated from high school and 29% had some college education or graduated from college (ASC, 2011). Compared to these figures in the 1980s and 1990s, 42% had graduated from high school and 8% had received at least 4 years of college education (U.S. General Accounting Office, 1990). Cambodian Americans now are able to return home and visit their family members who were left behind. As they are acculturating into the mainstream community, they are also facing other challenges. Some of these challenges include Western views and treatments of mental illness, navigation through public systems (transportation and public assistance), language difficulty and lack of culturally sensitive services. The People of Laos Laos, Mien, and Hmong are different ethnic groups who lived in Laos. Iu-Mien (Mien) and Hmong are the tribal groups of people who lived in the highlands of Laos 18 with their origins in China. Mien and Hmong have their own ethnic languages and dialects, but the majority of them learn how to speak Laotian because of their frequent contact with their lowland neighbors, the Laotians. The Laotians are the lowland people. The Iu-Mien, including Hmong hill tribes, lived up in the mountains of Laos and found themselves displaced after the Secret War between 1963 and 1975 when they were recruited to help the U.S. fight the war in Vietnam (Moore-Howard, 1987). When the U.S. pulled out of Southeast Asia, the Iu-Mien people found themselves without a country. They were perceived as having helped the enemy fight their own government. Laos, which is often recognized as the home of the Iu-Mien, in reality is only a temporary place. The Iu-Mien occupied the land for a little more than a hundred years before the eruption of the Secret War in 1963 (Shawcross, 1981). The Iu-Mien people have undergone many transitions since they were forced out of China. They claimed their history of movement for economic and agricultural needs prior to the war in Vietnam, but after the Secret War, their struggle or movement was motivated purely by the terms of life or death. The Secret War, a United States Central Intelligence Agency (CIA) covert operation that utilized thousands of Hmong and Iu-Mien against the Pathet Lao Communists, led to a mass migration of both highland and lowland people from Laos (Shawcross, 1981). The Secret War was finally officially acknowledged by the U.S. government twenty years later, but it was not acknowledged at the time of the war’s official close in 1975. Today, there is international recognition of what happened to the Iu-Mien communities. Their involvement with the war in Vietnam did give reasons to a government that barely acknowledged their existence to force them out of their 19 homeland. The history of the Iu-Mien is one that is filled of turbulence. The Iu-Mien culture and identity has always relied on movement, migration, and resettlement as a tool and a valuable resource in times of conflict. Their origins date back to China. The Iu-Mien were displaced from China, Laos, and Thailand, but their experiences in the United States are unique because they have migrated for the first time from the mountains to the flatlands (Moore-Howard, 1987). Their lives were disrupted by the Secret War and acculturation has not been an easy task for the majority of them. However, some found solace in farming and have resettled in rural parts of the U.S. in an attempt to mimic their lives back home with old ways of sustaining oneself through subsistence. Perhaps this is an attempt to preserve cultural practices and identity. Lao Mien The majority of Laotians are Buddhists. However, most of the people who are considered Laotians in the U.S. are from Lao Mien background. Similar to the Hmong people, traditional Lao Mien believe that the spirit world can control the living and have influence over the natural world. These spirits have the power to help with the health and well-being of humans. The supernatural world consists of ancestral spirits, spirits of animals, and plants. They can protect, cause harm and afflict pain. The Mien have been strongly influenced by the Chinese Taoists as well as by the healing practices of Lao-tsu and his priests. An individual's spirit status in the spiritual world depends on whether a person can accumulate enough merits during his or her lifetime. Mien people believe that 20 good health depends on the status of the 12 souls that make up a person's life force (“hwen”) (Miles, 1973). These 12 souls correspond to the 12 parts of the body (e.g., eyes, ears, mouth and nose, neck, arms, chest and upper back, abdomen and lower back, legs, left side of the head, right side of the head, feet and hands). Illness is said to be caused by malevolent ancestors who express their negative feelings by creating a loss of “hwen” or 12 souls. Illness occurs as a result of this loss of souls in the body. Mien people consider illness as having two major causes: hereditary or supernatural. An illness that has a hereditary cause can only be cured by a "dia"—that is, a doctor versed in both traditional and Western medicine. A dia is someone who is trained to understand and treat using both traditional and Western methods. On the other hand, illnesses caused by supernatural causes require "tsiang" ceremonies for treatment. Only Taoist grand master priests or other priests and spirit mediums can treat such illnesses. Since mental illnesses believed to be caused by supernatural forces require a priest with unique and special skills, Western intervention may not be perceived as the correct course of action. In the U.S., Mien still practice this tradition. For example, Mien living in Richmond, California, have integrated traditional healing beliefs and practices with the use of Western health services (Gilman et al., 1992). Hmong The Hmong tribes had lived in the mountainous areas of China and then Laos for centuries before the outbreak of the Vietnam War. Hmong men were recruited to fight for the U.S. and became an important part of the battle against North Vietnam. Many of them lost their lives as a result. When Laos and Vietnam fell to the communists, the Hmong 21 found themselves in a precarious position. They were forced out of their land by the Lao government. Many of them tried to escape, but some were captured, imprisoned and sent to “reeducation” camps. The road to resettlement was not an easy one for many Hmong families. Prior to their involvement with the Vietnam War, the Hmong lived in a relatively isolated and very self-sufficient lifestyle based primarily on agriculture in rural mountainous areas. Their abrupt transition to U.S. urban culture was often traumatic. Families were traditionally very large, and some had been polygamous and clan-based; therefore resettlement meant that some family members were separated from their loved ones. Because their language had been primarily oral rather than written, the transition to a culture based on written words made acculturation even more difficult. The Veterans’ Naturalization Act of 2000 granted the Hmong permission to resettle in the U.S. (United States Government Publishing Office, 2000). Specifically, this act eased naturalization requirements for former spouses of deceased Hmong veterans who had supported U.S. military during the Southeast Asian conflict, granting them refugee status so that they could resettle in the U.S. (U.S. Government Publishing Office, 2000). The Hmong are a very traditional people without a written language prior to coming to the United States. The Hmong formed nomadic clans who wandered in the remote and sparsely populated mountains of Laos, used shamans, and were animistic in their folk healing beliefs. The Hmong, when they resettled in Laos from China, brought with them their own traditional beliefs and practices, especially in regards to health and mental illness. To some extent, this belief also extends to the causes and treatment of 22 illness. As with the Mien, many mental illnesses are attributed to supernatural forces, such as ghosts or ancestral spirits. However, the Hmong also use Chinese medicine and some adhere to Protestant Christian beliefs, but still maintain their beliefs in supernatural causes of illness such as spirit illness and soul loss (Fadiman, 1997). Temporary soul loss or soul separation is considered a factor in the majority of illnesses (Geddes, 1976). Whether it be physical or mental illness, the Hmong believe in both natural and supernatural causes. Souls, for example, can be separated by accident or by a frightening event, or may be taken by an angered or offended spirit, therefore causing a person to be sick. A shaman is an important leader and healer who is the only person who can communicate directly with the supernatural beings. Sudden Unexpected Nocturnal Death Syndrome among healthy Hmong refugees has been attributed to nightmare or attack by evil spirit that threatens to press the life out of its terrified victim (Adler, 1995). Supernatural danger extends to giving compliments to young children or seniors. Hmong may not make direct compliments or show great admiration for loved ones since this may attract the attention of evil spirits and arouse their envy. As a result of this envy, the evil spirits may take away the loved ones or cause an illness, including psychological problems. Vietnamese Over 130,000 Vietnamese left Vietnam in 1975 in the final days of the war, half of whom were evacuated by the U.S. military. These Vietnamese were mostly military, government officials, and U.S. employees who were considered at high risk for 23 imprisonment (UNHCR, 1981; UNHCR, 1989). Starting in 1977, large waves of Vietnamese refugees left Vietnam to escape the communist revolutionary government (Wain, 1981). In late 1978, Malaysia started preventing Vietnamese boat people from landing, or if they landed they were pushed back out to sea (UNHCR, 1989). Refugee drownings and other terrible stories of pirate attacks created an international outcry that affected the United Nation’s refugee policy for the next decade. By the end of 1978, about 62,000 boat people were in refugee camps across nine countries in Southeast and East Asia (UNHCR, 1989). In July 1979, the United Nations established a multilateral program to help Southeast Asian refugees and displaced persons around the world (Wain, 1981). Starting in July of 1979, Vietnam cracked down on illegal departures, which reduced the numbers of fleeing of boat people from 54,941 to 9,734 two months later (UNHCR, 1981). The U.S. Refugee Act of 1980 (i.e., the Immigration and Nationality Act, section 207) dealt with the ongoing problems of Vietnamese boat people and other Southeast Asians in need of resettlement (Wain, 1981). More than 80,000 mixed children of American fathers and Vietnamese mothers, as well as accompanying family members, were admitted to the U.S. through the Amerasian Homecoming Act of 1987 (Wain, 1981). By late 1980s, most of the resettlement countries resettled top priority applicants. The U.S. resettled some 4,600 former U.S. government employees and another 165,000 former reeducation camp detainees and their immediate family members (Wain, 1981). After the Southeast Asian refugees of the 1970s became naturalized citizens, many petitioned for immigration of their eligible family members, including many older parents, to come to the U.S. 24 Most of the Vietnamese who left Vietnam in the late 1980s came to the U.S. under approved immigrant petitions for admittance to this country (UNCHR, 1981). In June of 1989, the United Nations sponsored a conference to establish agreements among 70 countries, known as the Comprehensive Plan of Action for Indochinese Refugees to deal with the 100,000 Vietnamese boat people in camps throughout Southeast Asia and Hong Kong (UNHCR, 1995). In 1989, 70,000 Vietnamese boat people left Vietnam. This international policy reduced the number of disorderly refugee flights from Southeast Asia (UNHCR, 1995). When the Comprehensive Plan of Action for Indochinese Refugees ended in June 1996, the Vietnamese in refugee camps throughout Southeast Asia were either approved for resettlement or given incentives to return voluntarily to Vietnam (Robinson, 2004). By 1999, about 1.75 million Vietnamese had left Vietnam and been resettled all over the world (Robinson, 2004). Traditional Vietnamese believe in one or a combination of three models of health (Tung, 1980). First, the Am-Duong model, based largely on Chinese traditional medicine, is founded on the premise that illnesses are caused by imbalances in the body, commonly referred to as yin (am) and yang (duong) (Chhem, 2001). Physiological imbalances can be caused by high emotional states and environmental changes such as sudden climatic or seasonal changes that block the circulation of vital energy (chi) or blood in the body. Acupuncture is used to treat such disturbances in order to clear obstructions. A second physical or physiological model attributes mental and brain-related illnesses to disruptions of the nervous system. This system has important implications, suggesting that perhaps certain mental conditions have valid physical or physiological rather than supernatural causes. This interpretation seems in closest alignment with the 25 Western view of mental illness. For instance, neuroses are said to be caused by a weakness of the nerves (than kinh suy nhuoc) and psychoses are construed as turmoil of the nerves (than kinh thac loan). A final category of disease is attributed to supernatural causes. In this model, “tien” or supernatural deities have the power to protect. “Tien” is a supernatural deity. Ancestral spirits can do good or bad things to people by causing infection. Bad spirits are ancestors who have not been properly venerated by their descendants with ancestor worship ceremonies and offerings. The Vietnamese have spirit mediums and sorcerers who deal with these spirits. Buddhist priests and lay monks can also provide amulets and medicines for physical ailments and exorcism for spiritual ailments (Hickey, 1964). The life expectancy for Vietnamese living in the U.S. has increased in recent years. In 1979 to1989, Merli (1998) found that the life expectancy at birth was 61.4 years for males and 63.2 for females. Hoyert and Kung (1997) reported that in 1992 life expectancy in seven high Asian and Pacific Islander groups was 78.8 at birth, an 18.8 additional years above the previous norm of 61.4 years. In other words, Vietnamese who live in a developed country tend to live longer than those who lived in Vietnam. The authors caution that these estimates were based on small sample sizes, and so the results may not be reliable. Cancer is the leading cause of death for Vietnamese of both genders in the United States (Hoyert & Kung, 1997; Shinagawa et al., 1999). High smoking rates and exposure to passive smoking among Southeast Asian families have contributed to high cancer rates. Gender specific health issues have also emerged in this group. For example, the SEER data report (Miller et al., 1996) showed an increase in cancer rates for Vietnamese 26 males in nasopharynx, liver, and stomach cancers. Women showed increased cancer deaths from cervical, stomach and thyroid regions. Vietnamese women have the highest incidence of cervical cancer in the U.S. It appears that much of this can be attributed to the lack of Pap screening, but other factors such as high stress levels may also contribute to the Vietnamese women’s higher incidence of this cancer. The second leading cause of mortality for both Vietnamese men and women in the seven U.S. states was diseases of the heart, followed by cerebrovascular diseases (Hoyert & Kung, 1997). Among Vietnamese hypertensives over 40 years of age, essential hypertension was associated with significant increases in body mass index (BMI). However, this figure was far lower than the defined threshold of Occidental obesity. Insulin resistance was found despite very slight or no excess weight among Vietnamese hypertensives (Van Minh et al., 1997). This study suggests that thresholds established in Caucasian populations may be an inexact predictor for the Vietnamese. Related to the risk of cardiac and hypertension problems may also be the high rates of smoking (35%- 42%) among Vietnamese men. Other leading causes of mortality for Vietnamese men included accidents and adverse effects, homicide and legal interventions; for women causes of mortality included accidents and adverse effects, and pneumonia and influenza (Hoyert & Kung, 1997). A small community study of Vietnamese immigrants in Boston found that 32% of Vietnamese Americans smoked (54% males, 9% females); 24% used alcohol; 17% were depressed on the Vietnamese Depression Scale, with those older than 40 having more depression. In addition, ova parasites were found in 51% (63% of them required treatment); 70% tested positive on the TB test (39% required treatment); 83% had been exposed to hepatitis B and 14% were chronic hepatitis B carriers (Nelson, Bui 27 & Samet, 1997). Other environmental issues need to be addressed that may also impact mental health. Environmental exposures and developmental timing (i.e., exposures in utero, infancy, childhood, adolescence, young, middle and elderly adulthood) need to be examined to determine the level of toxicity and carcinogenic substances. Toxic exposure influences the health of Southeast Asian elderly for example, in high dioxin levels found in adipose tissue and exposure to Agent Orange in South Vietnamese (Verger, et al., 1994). As Southeast Asians acculturate and adapt to the American way of life, they also face the health consequences of those in the developed world. When diet changes, diseases that are found in the developed world (for example, those associated with longevity and high caloric food) also impacts them. This includes risk of stroke, diabetes and hypertension. Demographics and Other Indicators The population of Asians in the U.S was estimated at 18.2 million in 2011 (U.S. Census Bureau, 2013 Facts & Figures). The three largest Asian groups in 2011 were Chinese (4 million), Filipinos (3.4 million), and Asian Indians (3.2 million) (U.S. Census Bureau, 2013). The other large Asian groups were Vietnamese (1.9 million), Koreans (1.7 million), and Japanese (1.3 million) (U.S. Census Bureau, 2013). The U.S. Bureau’s projection estimated that there will be more than 40.6 million or 9.2% Asians living in the United States by 2050 (U.S. Census Bureau, 2013). States with the largest Asian populations are California (5.8 million) and New York (1.7 million (U.S. Census Bureau, 2013)). Self-described Asians in the U.S. are those from regions of Insular Southeast 28 Asia, Mainland Southeast, East Asia, and Southeast Asia. Most recent arrivals from Asia come from Bhutan, Burma, Vietnam, Sri Lanka, Nepal, India, and China. Approximately, 1,068 of these individuals reside in Alameda County, California (Raphael & Stoll, 2013). Overall, more than 4.8 million Asians live in California. Alameda county in particular was home to about 390,524 Asians in 2010, which made up 25% of the county’s total population (U.S. Census, 2010). In addition, Native Hawaiian/Pacific Islander made up another 0.8% (U.S. Census, 2010). According to the American Community Survey of 2006, Southeast Asians in California had a mental disability rate of 10%, while African Americans had a rate of 9% and Latinos had a rate of 4% in adults aged 65 years or older. About 20% of Asians had no mental health coverage at all; however, Vietnamese and Chinese had mental health coverage rates of 34% and 28%, respectively (Ponce et al., 2009). The Southeast Asian Americans who represent the low end of both socioeconomic status and health outcomes are those from Cambodia, Laos, Vietnam, and Burma. For example, there are 5,246 Cambodian Americans, 369 Hmong, 4,194 Laotians, and 34,823 Vietnamese living in Alameda County, according to the (Ponce et al., 2009). Southeast Asians have the lowest income per capita and are the least likely to have mental health insurance coverage compared to other Asians and minority groups (Ponce et al., 2009). The per capita income among selected Asian groups is generally lower compared to other minority groups in California. In 2006, Cambodian Americans’ per capita income was $13,624, while Hmong were at $8,470, Laotians at $13,914, and Vietnamese at $22,507, according to the American Community Survey in 2006 (ACS, 2006). In the 29 same year, the per capita income of Hispanics was $14,692 and of African Americans was $19,602 (ACS, 2006), which was higher than Hmong, Cambodian, and Laotians. Mental Health Problems and Treatment Asian Americans seem to respond best to mental health professionals who have similar backgrounds to themselves than to Western mental health professionals who do not share their cultural, ethnic or linguistic backgrounds. Asians are not a homogenous group, and because they have diverse historical backgrounds, providing mental health services is often complicated by the fact that there is not a single model that fits all. The Asian population in the U.S. has more than 43 ethnic groups speaking over 100 languages and dialects (U.S. Office of Surgeon General, 2001). Therefore, it is difficult to identify and collectively respond to patterns of mental illness or to develop prevention interventions that can meet collective psychiatric and psychological needs. In addition, Asian Americans have a long tradition of maintaining one’s reputation, which can affect mental health treatment. The concept of saving face can make it difficult to acknowledge the mental illness of family members and the likelihood of seeking mental health services. In order to understand the Asian American community’s response to mental health problems, it is important to examine the interconnectedness of health-seeking behaviors with cultural values as well as migration experiences and post-migration resettlement situations in America. Stigma is a major barrier for Asian Americans seeking treatment, compounded by the drive to succeed and the idea that failure is not an option. The fact that such a low number of Asian Americans actually seek mental health services compared to the general 30 U.S. population may in part be due to the idea of shame and stigma that runs deep in Asian American cultural values, beliefs, and practices. This value or belief tends to hinder one’s ability to seek mental health services. In other words, Asian Americans would rather avoid seeking help in order not to deal with stigma or shame. The experience of Asian Americans in America is similar to that other ethnic minorities in that they have been subject to poor treatment, discrimination, and racism. There has been anti-Asian racism since the first Asians arrived in America, and laws passed to deny basic rights, from marriage to property ownership to citizenship. By the 1900s, for example, the Alien Land Acts and Chinese Exclusion Act were passed to exclude land ownership and bar Chinese from entering the U.S. Migration experience provides useful data in examining the root causes of psychological/emotional problems in a population. The refugee/immigrant experience has been described as having four distinct phrases: has been pre-migration, migration, encampment, and post-migration (Abueg & Chun, 1996). Each of these periods is associated with different stressors. We are better able to understand how Asian Americans cope with their new realities in the U.S. by examining these different stressors. Language barriers, culturally sensitive mental services, and difficulty of accessing public services generally are compounded by other issues (e.g., psychological or psychiatric problems, Western treatments, lack of family support systems, and financial shortfalls) can push someone over the limit. 31 Conclusion Recent groups arriving to the U.S. from Southeast Asia and elsewhere on the Asian continent have suffered the psychological and emotional effects of recent wars in their homelands and often struggle to assimilate into mainstream America. Many have undergone torture, psychological and physical trauma, separation, and loss of family members. More than half of Southeast Asians have serious, often chronic, physical disorders caused or exacerbated by a mental health disturbance. Some of these conditions apparently were caused by pre-immigration trauma, including torture (O’Hare & Tran, 1996). Some of them have shown or manifested significant levels of PTSD, general anxiety, and depressive symptoms. Some Asian Americans continue to struggle to accept the Western modality of mental illness, and to understand what services are available to them, how to access these services, and recognize the symptoms associated with severe mental illnesses such as PTSD, schizophrenia, and bipolar disorder. Because of this lack of understanding, stigma/shame has persisted and continues to play a major role in the ability to decide to seek help. The next chapter will examine theoretical approaches with a focus on evolutionary perspective and transgenerational trauma in order to gain a deeper understanding of the API with mental illness. 32 Chapter 2: Theoretical Approaches This research focuses on trauma and related experiences of the Asian and Pacific Islander (API) population in order to gain a deeper understanding of the current challenges and barriers facing this community. The chapter starts with a discussion of trauma and related experiences, then a thorough examination of theories of trauma as well as other theoretical perspectives. The chapter concludes with key concepts related to symptoms and outcomes of traumatic events that help provide a frame of reference and offer the reasons and perspectives on how APIs cope with mental illness. Trauma and Other Related Experiences Research has shown that both direct and historical trauma has a long lasting impact on the mental health and well-being of a population. Trauma is an event or process that overwhelms the individual, family or community, and hinders the ability to cope in mind, body, soul, and spirit (Atkinson, 2002). Trauma and its impact can be passed between generations (Schwerdtfeger & Goff, 2007). Some of the most noticeable experiences in America that have created long-term trauma include slavery and the internment of the Japanese during World War II. These experiences have had a profound impact not only on those who experienced these events but also on their children. Asian Americans who arrived in the 19th century to work on railroad projects and sugar plantations were subjected to poor working conditions, discrimination, and poverty. Later Japanese Americans were confined to internment camps during World War II, singled out as traitors by the U.S. government and suffered discrimination thereafter. Similarly, 33 Southeast Asian refugees who lived through the trauma of the Vietnam War continue to struggle to acculturate in the American society. Many of them have not recovered from their pre-migration and migration experiences, especially from the Vietnam War and communist regimes. The effects of conflict and violence on the mental health of a population have important implications for overall well-being as well as livelihood. Collective trauma, direct or indirect, can impede the success and survivability of a population even decades later and for generations thereafter. Trauma and Its Conceptual Framework Trauma is defined as a deeply disturbing or distressing experience, which can include a physical injury. Trauma can affect the social fabric of a nation or culture. The criterion for trauma in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is precise. It involves either direct exposure to an event or witnessing it in person. Cultural trauma, however, is more complex; it is deeply rooted at the collective level in cases such as war, natural disaster, and genocide. Trans-generational or historical trauma is defined as the subjective experiencing and remembering of events in the mind of an individual or in the life a community that is passed from adults to children in cyclic processes as ‘collective emotional and psychological injury’ (Atkinson et al., 2013; Stamm et al., 2004). Atkinson et al. (2013) stated that trauma can pass down from adults to their children, concluding that the link between childhood trauma and adult offending was a result of unresolved cultural identity and diminished sense of self-worth (Atkinson et al., 2013). Coping and adaptation patterns can be passed down from one generation to the 34 next. Multi-generation/historical trauma erodes what constitutes a culture through the prohibition of the use of language that is in tune with the cultural beliefs and values, spiritual/healing practices, and access to public spaces (Stamm et al., 2003). It causes a dramatic loss of identity and meaning (Salzman & Halloran, 2015). Cultural identity and cultural conceptions of reality evolve, in part, to provide protection against the most basic of all human fears. In other words, people are susceptible to anxiety and related symptoms if they have little faith or lose their cultural worldview (Salzman & Halloran, 2004). Cultural identity and the cultural conceptions of reality anchor a person’s sense of self and self-worth. Cultural trauma seems to inhibit both of these values and is innately important to the survivability and functionality of a population. Transgenerational and Complex Trauma (Complex Post-Traumatic Stress Disorder) Transgenerational trauma and complex trauma, also known as complex post- traumatic stress disorder (C-PTSD), have not been well understood until recently. The general definition of transgenerational trauma is trauma that is passed down from the one generation of trauma survivors to the next, and so on down through the generations of the survivors’ offspring. The latter transmission tends to manifest in complex post-traumatic stress disorder. The most obvious evidence in literature on the intergenerational effects of parents’ traumas concerns those individuals who survived the holocaust (Ying & Han, 2006). Symptoms associated with witnessing or experiencing traumatic events include volatility of emotions, hyperarousal, pervasive fear, and anxiety (Reuben, 2015). It is an adaptive response intended to keep a person away from similar dangerous situations in 35 the future (Bryant, 2010). Complex post-traumatic disorder (C-PTSD), or complex trauma, manifests as a set of symptoms resulting from repeated and prolonged stress of a social or interpersonal nature. Individuals who suffer complex trauma can present with marked emotion dysregulation deficits (Bryant, 2010). Academic literature provides obvious and uncontested evidence of how trauma impacts a community from one generation to the next, and how the additional violence experienced after resettlement in America can adversely affect a community (Yee, 1997; Young-Eisendrath, 1998; Palinkas & Pickwell, 1995; Mouanoutoua & Brown, 1995). Traumatic experience is not homogenous even within a specific region. Asian Americans comprise many diverse groups of people and their countries of origin are spread across the world from the Middle East to Insular Southeast Asia. Because of this diversity, the unique experiences of individuals cannot be fully described; however, there are some unique patterns that have emerge from specific regions, including from mainland Southeast Asia, East Asia, and South Asia. The early arrival experiences of people coming from Japan, the Philippines, and China to work in the United States included discrimination and segregation. More recently, treatment of the Japanese during World War II included forced relocation and confinement to internment camps. Encampment stressors include prolonged detainment in unsafe, over-crowded, poorly sanitized refugee or temporary camps (Abueg & Chun, 1998). In addition, the pre-migration stressors of Southeast Asians were often extreme. Southeast Asians were subjected to ongoing civil war and government-sponsored intimidation and threats to life and livelihood when communists gained power in their homelands. Stressors associated with extensive and sustained warfare include the death of 36 family and friends, brutalization, and loss of property and personal belongings (Abueg & Chun, 1998). Once Southeast Asians decided to leave their native countries, the challenges that they faced included separation from loved ones and fleeing one’s home country under life-threatening conditions (Abueg & Chun, 1998). This population continued to face ongoing trauma at various stages of the migration. They never felt safe at any of stage of their journey. It was also common for Southeast Asian refugees and immigrants to be assaulted and/or raped by border guards while entering neighboring countries to seek asylum (Casella, 1989; Wain, 1981). The end of the Vietnam War in the mid-1970s brought multiple waves of refugees from Cambodia, Laos, and Vietnam to the United States. Approximately, 1.2 million Cambodians, Vietnamese, Laotians, Mien, and Hmong migrated to the U.S. between 1975 and the 1990s (California Digital Library, 2015). The first wave of refugees in 1975 consisted mostly of those on the losing sides on the conflict, fleeing from the Southeast Asian communist regimes. Latter waves of refugees from the 1980s and 1990s consisted of those fleeing as a result of political, religious, and ethnic persecution. About 125,000 Vietnamese resettled in the United States in the first wave in 1975. Starting in 1978, another wave of Vietnamese began to flee their country. These were the "boat people," who were poorer and less educated than the Vietnamese who came in the first wave. These refugee families arrived in the U.S. suffering from post-traumatic stress disorder (PTSD) and with limited education and limited English language proficiency. Many of them were vulnerable to poverty, crime, and violence after resettlement in the U.S. Among the Southeast Asians, the Cambodians, Mien, and Hmong endured severe pre-migration traumas. The Khmer Rouge led a bloody campaign of genocide to establish 37 a Marxist agrarian society and rid the country of any Western influence. In their three- year reign, from 1975 to 1978, a third of the population was killed due to disease, mass execution, starvation and poverty. People were forcibly separated from family members put to work in segregated hard labor camps. The Khmer Rouge targeted professionals and working classes with severe punishment, including beatings, starvation, and torture, and death. I was one of their victims who lived through that regime. The Mien and Hmong were recruited by the CIA in Laos to help fight the war in Vietnam. Their cultures, are rooted in tribal agrarian and preliterate societies located in the mountain regions of Laos and other Southeast Asian countries. After the U.S. pulled out, they were tortured and ostracized by their own governments for assisting the Americans. The Burmese also endured many years of brutality by the military regime. Prior to the 1950s, Koreans migrated to Hawaii to work in the sugar plantations, especially when restrictions of Chinese immigrants were put in place (Low, 2008). Koreans in recent years seem to have a unique contemporary migration experience, having only two options to come to America: sponsorship by a family member or by attending school in the U.S. After completing university, Koreans may choose to stay; however, during this period of ambiguity they are most vulnerable to abuse. If they choose to stay after completing a degree, they must apply for a green card and hope for the best. Some choose to take this route and put themselves in a limbo while the U.S. government decides their fate. It is not uncommon for Koreans to wait from five to ten years to learn their residential status. In the meantime, their student visas expire and they must go underground or return home to Korea. It is during this waiting period that they are vulnerable to exploitation. They worked all hours with low pay, limited benefits (if 38 any), and subjected to harsh living conditions. The cycles of violence and trauma continue with recent deportations of refugees from the U.S. to their native countries, back to the very situations and governments that persecuted them in the first place. Many of the refugees being deported were children or infants when they fled Asia, and speak English rather than the language of their native country. For example, Over the past twenty years, more than 13,000 Cambodian, Vietnamese, and Laotian Americans have been served deportation orders, according to the Southeast Asia Resource Action Center (SARAC, 2015). Over 500 individuals have been deported from the U.S. to Cambodia alone since 2002 when the two countries signed a repatriation agreement (Calma, 2015). As refugees are sent back to countries from which they fled, this U.S. immigration policy is essentially re-traumatizing these individuals. All of the groups of Asian Americans mentioned here have experienced some degree of trauma in their lives, whether during the pre-migration, migration or post- migration period. These experiences of trauma continue to affect their livelihood and well-being. Cultural Trauma Cultural trauma refers to an experience that causes a dramatic loss of identity and meaning in the social fabric of a community; it generally affects groups of people who have already achieved some degree of cohesion (Salzman & Halloran, 2015). The Chinese Cultural Revolution is an example of cultural trauma. Some Chinese Americans are still mourning the loss of identity and cultural values caused by the mass campaign of 39 the Cultural Revolution to rid China of traditional values. Many Southeast Asian refugees also continue to live an environment of persistent poverty, drugs, and crimes, that creates another form of cultural trauma. Japanese, Filipinos, and other Asians are still living with the past trauma of the internment camps and discrimination experiences by the previous generations. Evolutionary Perspective Evolutionary perspective perhaps may offer a unifying and coherent conceptual framework within which etiologies and symptoms of mental illness that can be understood. Evolutionary perspective is a functional approach that helps us gain a deeper understanding of how we as human beings react to traumatic events. Trauma impacts us in most fundamental ways. It transforms the individual at both biological and psychological levels. The general biological processes underlying the stress response are said to be universal; however, the specific dynamics are a function of the unique sociocultural environment and psychological makeup of the individual (Ohman & Mineka, 2001; Wittchen et al., 2009). Fear is the key emotion in PTSD. Fear’s evolved function is to serve as a motivating survival trait through defensive behaviors (Marks & Tobena, 1990; Nesse, 1990). Cantor (2005) suggests that fear may be a defensive option taken to the extreme, part of the functional adaptation of humans to dangerous environments. Cantor describes evolved mammalian defensive mechanisms, including what he terms six key defenses: avoidance, attentive immobility, tonic immobility, withdrawal, aggressive defense, and appeasement. He describes how these six defenses would have been selected for early on in human evolution, as males and females were 40 vulnerable to human and non-human predators (Cantor, 2005). For example, several other writers have suggested continuities between tonic immobility (as seen in “playing possum”) and the dissociation that sometimes accompanies trauma (Cantor, 2005). Cantor, however, differentiates between two types of immobility which may be essential for defense: attentive immobility, which makes us stop and use all of our senses to identify a threat, and tonic immobility, which goes further in the face of an overwhelmingly dangerous threat (Cantor, 2005). Some of us freeze (or become immobile) when confronting dangers. Thus Cantor suggests that dissociation, which is commonly understood as pathological, may have been a defensive option taken to the extreme, and part of a functional adaptation to dangerous environments (Cantor, 2005). Recent contributions to evolutionary theory on numerous psychopathologies offer insight into human past experiences with dangers. The anxiety spectrum, for example, is rooted in the way the human species responds to dangers. Evolutionary study is about looking backward to understand the traits that have survived through many generations by serving an evolutionary purpose. This is not to suggest that all traits that are still present still provide advantages to the species. However, certain characteristics or traits, such as phobias, might have roots in the way we as humans once survived or recognized danger. As some authors have suggested, “evolution is not forward looking and could not anticipate a future where being stared at by a large group of nonsmiling, non-kin specifics was more likely than not to be followed by negative consequences” (Bracha & Maser, 2008). However, evolutionary theory offers sound scientific explanation of why certain human behaviors are present and what happens when too much of such behaviors are displaced. In words, it becomes problematic when there are too much of these behaviors. 41 All biological phenomena, including human basic emotions, are considered to have evolutionary advantages. Nesse (1990) provides two separate kinds of explanations in order to understand human responses to emotions. The first type involves a proximate explanation of the structure, regulation, and ontogeny of the glow organ (Nesse, 1990). The evolutionary explanation accounts “for the function of the character, its evolutionary history” and why any emotion exists (Nesse, 1990). The benefits of having emotions stems from broad categories of functions. These functions lie in the areas of motivation, communication, and cognition (Nesse, 1990). Emotions are defined as specialized modes of operation that are shaped by natural selection in order to adjust the physiological, psychological, and behavioral parameters of a species in ways that “increase its capacity and tendency to respond adaptively to the threats and opportunities characteristic of specific kind of situations” (Nesse, 1990). It is general knowledge that certain kinds of situations arouse certain types of emotions and that natural selection shaped the various emotions (Nesse, 1990). Some of the basic responses such as fear, panic and agoraphobia and moods (such as sadness and happiness) have evolved to serve specific functions for organisms, and especially in human beings (Ohman & Minka, 2001). The Anxiety spectrum, from anxiety to PTSD, can best be explained using this perspective because these traits are found not only in our species but also in the animal kingdom. Freeze, Flight, Fight, and Fright The concept of freeze, flight, fight, and fright can be explained using an evolutionary framework. Our response to danger has its roots in human evolution as part of the defense strategy. This lies at the core of involuntary functions in the human brain. 42 We are wired to record potential risks in order to protect ourselves from danger. Various research studies have focused on the concept of tonic immobility (TI) in species, including humans, as related to evolution in an attempt to gain a deeper understanding of our responses and reactions to danger. Evolutionary framework helps explain the various ways we confront danger. Some of us run when we feel afraid, some of us freeze when we face danger, and some of us fight when we perceive that we are at risk of being hurt or killed. There is extensive scholarly literature on TI that attempts to explain why such a response is necessary and how it evolved in all species over time. Tonic immobility is described as a basic defence strategy that every species has built in its involuntary response in the brain. It has been proposed that TI may allow a species an opportunity to perceive and find a way out (Galliano et al., 1993). In the case of TI, a species is said to respond in a non-reactive and immobile manner because it perceives that escape is not an option. There is no way out of the situation and thus a species assumes its best course of action is inaction. Data seems to suggest that TI may be a relatively frequent phenomenon in victims of rape and sexual abuse, but its occurrence has not been systematically explored in other types of trauma (Galliano et al., 1993). Research conducted on a selection of individuals who had experienced various types of trauma, from sexual to violent, specifically examined TI. This retrospective study used a sample of 100 university students in order to understand whether tonic immobility varies with the type and nature and of the trauma experienced (Bados et al., 2008). Participants were asked to define the levels of severity and types of trauma experienced (Bados et al., 2008). The Tonic Immobility Scale was used to measure immobility and trauma was assessed using the modified Traumatic Events Questionnaire. 43 The study results found that 70% of the sample had experienced some kind of trauma; no significant differences in tonic immobility were noted between different types of trauma (e.g., physical abuse, assault or aggression, and serious accident) (Bados et al., 2008). The study did find that the mean tonic immobility score was significantly higher in the group with trauma that was directly physical/psychological or related to sexual abuse than in the group that indirectly experienced trauma from receiving news of the mutilation, serious injury, or violent or sudden death of a loved one (Bados et al., 2008). The tentative conclusion is that tonic immobility may not only be typical of sexual traumas but also of other kinds of directly experienced trauma (Bados et al., 2008). The fight or flight response is a physiological response that is triggered when a species feels fear. Fear is a normal emotional response in species to a perceived threat or danger. Fear is also closely associated with anxiety in some ways (Bracha et al., 2004). The fight or flight response is best explained in evolutionary terms; however, it is solely based on a functional approach. This reaction evolved to enable species to react with appropriate actions to either run away or fight. Within the evolutionary framework, the emotion of fear protected us from dangers, predators and other threats, and thus served to help the species survive. Fear serves as a form of protection against predators/dangers; therefore, fear is adaptive, functional, and necessary (Lerner & Keltner, 2001). There is also another important aspect of fear that has to do with decision-making processes as well as survival. When an emotion is triggered, it impacts how we make decisions in certain situations (Lerner & Keltner, 2001). One research study examined risk-taking in order to understand how we react and make decisions when confronted with emotions such as fear in human beings (Lerner & Keltner, 2001). The study found that individuals 44 with certain personalities react to fear in more negative ways, and that those who experience a more extreme emotion of fear tend to perceive risk at a higher level or more severe (Lerner & Keltner, 2001). They also found that participants who were fearful consistently made judgments and choices that were relatively negative and pessimistic, and those individuals tended to amplify their perception of risk in a given situation (Lerner & Keltner, 2001). This is in contrast to participants who were happy or angry; both those groups were more likely to disregard risk by making relatively optimistic judgments and choices (Lerner & Keltner, 2001). In addition, individuals who had personality characteristics dominated by the emotion of fear, tend to avoid taking risks that are generally perceived by others as relatively nonthreatening (Sylvers & LaPrairie, 2011). 45 Chapter 3: Research Methods Research Questions The research questions of interest in this study are: 1) What are some of the challenges related to the following variables: PTSD, depression, physical & mental health, coping mechanisms, and daily functioning of those who experience pre- and post- migration trauma? 2) Are there differences in depressive and other psychological symptoms and self-reported health between people who have direct experience with trauma and those who have only indirect experience with trauma? 3) What are the protective factors against responses/reactions to trauma and what coping skills do APIs commonly utilize when they experience depression or other psychological problems as a result of experiencing trauma? Research has shown that both direct and historical trauma has long-term lasting impacts on the mental health and well-being of a population. Trauma is an event or process that overwhelms the individual, family or community, and hinders one’s ability to cope in mind, body, soul, and spirit (Atkinson, 2002). Trauma and its impact can be passed between generations (Schwerdtfeger & Goff, 2007). Many Asian Americans have experienced traumatic events in their lives during their pre-migration and migration experiences in the Vietnam War, under communist regimes and even after resettling in America. The effects of conflict and violence on the mental health of a population have important implications for overall well-being as well as livelihood. Collective trauma, as direct or indirect experience, can impede the success and survivability of a population overall even decades after the event and in many generations thereafter. 46 Based on previous research, I hypothesized that trauma can impact many generations—that is, the children of those who experienced trauma may exhibit symptoms of trauma events experienced by their parents or previous generations that they themselves did not directly experience. In addition, I hypothesized that the success and survivability of API individuals to live productive and meaningful lives would be negatively correlated to the individual’s responses to traumatic events and the psychological consequences thereafter. Methods This study utilized field and observational data from 28 participants, aged 30-60 years old, as well as qualitative secondary data from 15 staff members consisting of notes on 1029 clients. Both types of data were collected at a non-profit agency located in Oakland, California. Field observations were made of support groups specific to a single ethnic group with a focus on social support and community networks; two groups were observed, one consisting of Cambodian clients and one consisting of Chinese clients. Out of the 28 observed clients, 17 were male and 11 were female. These support groups were organized primarily for therapeutic purposes. In other words, they were intended to help clients address some of the challenges that they were facing. The typical agenda of a session consisted of check-in, discussion of a topic chosen by the group (e.g., symptoms of trauma), discussion of coping mechanisms, and check-out. The support group sessions ended with group announcements of upcoming events and activities geared toward support resources or volunteer opportunities. Each session lasted for two hours. The third 47 group was a rehabilitation and recovery group focused on the arts; this group lasted three hours. During the session participants worked on art or other scape-book types of projects. The members of this particular group did not interact with one another but rather worked on their individual projects. Some of the group discussion focused on symptoms of mental illness. Other topics ranged from side-effects of psychotropic medication, house assistance, depressive/psychological symptoms from wars and violence in neighborhood, medical appointments, isolation, loneliness, social support systems, loss and grief. As an observer, I was not involved in the discussion and was asked to sit in the back of the room to solely observe the groups. The participants came from various programs within the agency. Their common condition is that they were slated on mental health care levels of 1 to 3. Rehabilitation and recovery group consisted of those who were considered severe mentally ill (SMI) as opposed to the Cambodian support groups mainly of moderately mentally ill. The PI wrote notes while observing the groups in a notebook. No general identifiers were utilized other than gender and age estimates, such as male in his 30s or female in her 60s, and specific identifying details have been removed. This project also utilized data collected from 15 staff about 1029 clients on trauma and mental health services. The data came from a non-profit agency that was assessing the internal priority needs in serving Asian Americans. This data was collected in 2015 by the agency’s staff with the help of the principal investigator (PI) in the development of interview guides. Actual data collection was done by the agency’s staff, who took notes and decoded the interviews. The PI was offered access to this raw data by 48 the agency’s executive director, Mr. Philip Sun. The purpose of this data collection was to assess the nature of services and extent of services provided to the agency’s clients and what other priorities the agency needed to focus for its immediate future planning. Secondary data came from staff who carried caseloads of clients from diverse backgrounds. The data from notes had no personal identifiers; they focused on treatment plans, progress or lack thereof after an intervention, and barriers and challenges expressed by clients. No names of staff were recorded in notes. Notes were handwritten or typed and in raw data form without analysis. Research Procedures The research procedures for this study were approved by the Institutional Review Board (IRB) of California State University, East Bay. Participants were observed in a familiar group setting rather than conducting qualitative interviews. The purpose of the field observations was to understand the challenges and barriers and factors contributing to resilience in the face of depression and other psychological stressors. Participants were not asked particular questions; rather, they volunteered to talk about difficulties in their lives and current living situations. I was told by the facilitators that I was not allowed to approach participants, but that I could take notes and react in silence by nodding my head or smiling occasionally if participants displayed a sign of my presence (e.g., staring at me or smiling at me). Finally, I was told that I could observe participants as they entered and left the room and could respond to any questions they asked me. I did not interact with them directly. I did, however, smile at them occasionally during the entire session. 49 I was not allowed to access specific demographic data. In fact, only limited demographic information was collected because of the sensitive nature of the support groups and personal discussions that took place about their barriers and challenges relating to their psychological conditions, including hallucinations, side-effects of medications, and abuse history. Therefore, out of sensitivity to the culture and history of this population, I did not ask for additional demographic data from participants. It has been documented that one of the challenges of researching the API community is the reluctance of the community to be subjects of scientific research and have one’s private information exposed, especially information regarding income, substance use, and one’s psychological issues. Research Rationale Ingrained in the Asian and Pacific Islander (API) community is the concept of saving face at the expense of getting better. Because of this belief, the less intrusive the research, the more likely and richer the data and findings that will emerge. Research in this most vulnerable API population that has undergone high degrees of violent trauma requires a degree of sensitivity and discretion so as not to intrude or interrupt therapeutic treatments. Therefore, I believe the research methods chosen through observations of groups in their natural settings was key to learning the important issues of this population and the true nature of what its members are experiencing on a daily basis. The observational research method was chosen for this study as the best approach to address the questions of trauma in APIs because of the extremely sensitive nature of the subject and the high risk for triggers. Some of the API population, especially those 50 recent immigrants and refugees who have just left a war torn country, still have vivid memories of the experiences. They may be likely to be triggered by past events if an intrusive approach such as direct questioning were to be used. Fear of authority figures, especially for those who have undergone torture or interrogation under regimes such as the Khmer Rouge, also means that certain direct interviewing methods by an outsider might not result in the most useful data. The observational research method is the best for this study because it allowed the participants to express their feelings openly in a safe environment and in a manner that was appropriate and on their own terms. Finally, observations were made in a treatment setting because seeing clients getting better in an appropriate setting provided invaluable information into the healing process that might not have been seen or captured in a more traditional study using a strict question-and-answer research approach. One of the challenges of researching the API community is the reluctance of subjects to engage in scientific research and a fear of having one’s private information exposed, especially information regarding income, substance use, and one’s psychological issues. The purpose of the observational method was to understand the challenges and barriers and factors contributing to resilience in the face of depression and other psychological stressors that are considered private in this community. Similarly, the gathering and analysis of the secondary data gathered by staff members enabled insight into various trauma issues and the challenges of using Western modalities to treat this population without intruding on the actual treatment of clients. 51 Data Analysis The data was qualitative in nature and limited to notes made during observations, including the recording of quotes from participants. Due to the small sample size, no statistical analysis program was used. In addition, the data for 1029 clients was in the form of written or typed notes from 15 staff members with direct quotes and without specific parameters, which would make it difficult to run a computer analysis. Instead, the data was analyzed by the PI. Because of the sample size of the groups I observed, I was able to listen and carefully to take extensive notes. From there, I was able to organize the findings into specific themes. I noticed immediately through the trained eye of an anthropologist who has often observed and taken notes in participants’ natural settings, several common themes, and a portrait of a community that has coalesced through time in order to present a clear picture of who they are and how they cope with their new realities. From the analysis of the notes, I derived the patterns, themes, and major points as well as conclusions. The observational research results addressed the following themes: 1) Migration Experience; 2) Western Modality, Treatments, and Side-Effects; 3) Symptoms and Experiences Related to War; 4) Daily Challenges and Barriers; and 5) Healing through Art. In addition, the secondary data analysis revealed findings related to the following trauma and treatment issues in the API population: 1) Rates of PTSD and Diagnosis Complications; 2) Trauma Manifestation and Perceived Psychological Control; 3) 52 Trauma, Stigma and Daily Challenges; and 4) Challenges of Western Modalities vs. Eastern Philosophies. Involvement of Other Organizations The principal investigator/researcher observed three sessions of support groups at a non-profit agency located in Oakland with her primary contact, Catherine Powell and Lynn T. O’Leary. One of these clinicians conducted the support groups. Collaboration and approval for use of the data for research was established. Reflexivity in Qualitative Research As an anthropologist and now a social worker, I often wonder about how the findings will be used in academia and other place or the usefulness of reflexivity in qualitative research. Over the course of twenty years of conducting research and experience in the field, I have learned the importance of a researcher’s knowledge of the culture, community settings, historical context, and environment of a study. Such insight into the lives of participants can greatly contribute to the richness of research findings. The concept of ‘reflexivity’ as discussed by D’Cruz et al. (2007), validates the importance of studying others and recognizes how our own lens as a researcher influences or informs the research findings. D’Cruz et al. (2007) state that reflexivity has become more important in social work literature as it relates to social work education. This seems to be the case with my own experience as an anthropologist, researcher, and now a social worker who conducts research studies in a social services agency’s setting. 53 The PI is an anthropologist (Ph.D.) by training and has provided culturally sensitive types of services to the agency for the past 10 years, from conducting needs assessments to language skills as well as volunteering to conduct trainings on the importance of using data. This was how the PI gained access to this non-profit agency and its clients. Participants The participants ranged in age from 40 to 60 years old, both men and women. Most of these participants have been clients of the agency for the past 15 years. They belong to another support group in the agency run by the same clinician who facilitated the trauma group that the PI was invited to observe and to collect data from. Field observations were made of support groups specific to a single ethnic group with a focus on social support and community networks; two groups were observed, one consisting of Cambodian clients and one consisting of Chinese clients. Out of the 28 observed clients, 17 were male and 11 were female. Recruitment Plan This research study has an institutional review board (IRB) approval and the PI informed the clinician of her availability to observe the group. The PI told the clinician that she could observe the group at the convenience of the participants and the clinician. Any issues of serious mental illness would be addressed by the PI and the clinician. None of the participants had serious mental illness or symptoms that were expressed during observations. None of the participants in this group was impaired in anyway. They 54 needed help with translation; however, the clinician spoke Cambodian and conducted the sessions in the Cambodian language. The researcher also speaks Cambodian. The researcher wrote notes from the group discussion in English. Potential Risks/Benefits There was no direct benefit to the participants for this study. There was no payment to the participants for this study. The PI received thesis credit when she enrolled in the thesis course as partial fulfillment for her Master’s Degree in Social Work. There was a risk of loss of privacy for participants. However, no names or identities were used in any published reports of the research. Only the PI had access to the research data. All members were asked to agree to keep what they shared in the group confidential. At the beginning of every session, the group was reminded of the agreement to maintain confidentiality. Pre-existing support and confidentiality agreements were already in place for each group, but the agreement of maintain confidentiality was also reiterated at the start of each of the three group meetings. Risk Reduction To reduce the risk of loss of privacy, there were no specific identifiers recorded for the data collected for this study. No names of participants were recorded. Only gender and approximate ages were used, such as male in his 30s, followed by the date of observation. The facilitator was a well-trained clinician who was also bicultural and familiar with the culture as well as fluent in the language spoken by the 55 participants. The PI was also bicultural and familiar with the culture as well as fluent in the language spoken by the participants. There was a risk of discomfort or anxiety due to the nature of questions asked in the group and interactions with other members; however, the participants were free to answer only those questions he/she chose to answer, and could stop participation at any time during the session. No negative reactions (discomfort with the presence of principal investigator) was reported after the observations were completed. There was a minimal risk that participants might experience some psychological distress as a result of openly discussing their life experiences. However, no one has reported any such reaction since observations were completed. Confidentiality The research data is kept in a secure location and only the PI has access to the data. At the conclusion of the study, all identifying information was removed from the data and the data is kept in a locked cabinet in the PI’s office. The notebook is kept with the PI at all times. No specific information is written on the notebook or inside the notebook. The notebook is labeled, “2016 Oakland, California.” The notebook is kept in a locked cabinet at the PI’s house. Consent Issues 1. Process The consent was written in English and was translated and read out loud by the clinician prior to the session. I was not aware of any participant refusing my presence and 56 I did follow up with the facilitator if this was the case. The same procedure was used each time the PI attended a group. 2. Special Consent Provisions None of the participants was cognitively impaired, but all needed translation. The clinician as well as the PI are fluent in the participants’ languages. The PI speaks Cambodian, so do the clients and group facilitators. Limitations This research is limited in time and scope. Observations were conducted during a one-month period and limited to three sessions. The structure of the focus groups was agreed upon one year earlier and was ongoing. Members had relationships, including social interactions, outside of the group sessions. Because of time limitation, I did not have the opportunity to observe group dynamics in a manner that typically occur in the early stage of group formation when bonding is being established. In addition, the hand- written or typed notes were not structured in research study design. Research Purpose The findings will be used to gain a deeper understanding of how mental illness affects the API population and will shed light on how we as human beings have evolved to respond to fear and trauma. The findings offer insight into our experiences of trauma, war, and violence and how symptoms pass down from one generation to the next. The findings from this research study offer insight and important information to help tailor services (i.e., develop individualized treatment plants) geared specifically to a 57 cultural group that may not express symptoms that are not typically known within the Western paradigm of mental illness. In the larger picture, this study offers some implications on the problems we face today with issues of mental illness and the availability and accessibility of guns and other weapons. We are living in a fast-paced world with our needs being met instantly, especially with information and news available at the click of a button. What we witness and watch on television and other media outlets can influence and impact us in many ways. Tragic world events (e.g., wars, natural disasters, and disease outbreaks), whether we directly experience them or watch through television, will impact us psychological and can impair our ability to function normally. We need to address these issues as a community if we are to respond more effectively. 58 Chapter 4: Findings This chapter examines trauma as it relates to mental health services provided to clients by a non-profit agency. Clients were observed in two types of groups: support and rehabilitation & recovery group. Participants or clients were from a non-profit agency. In addition to group observation, secondary data was also collected from staff. This material included notes on diagnosis, some treatment issues, challenges and barriers experienced by clients, as well as demographic data. There were no names attached to the notes. The notes were either hand-written or typed. This chapter is divided into three parts. The first part focuses on the history of the agency and the profile of its clients in order to provide historical context and an understanding of the challenges and barriers faced by the agency’s population. The second part addresses the findings from the group observations. Finally, the third part consists of a review and analysis of data gathered from staff notes. Profile of Agency and Its Clients This agency has been in existence for almost 40 years. It provides culturally and linguistically competent mental health services to the most vulnerable members of Asian communities in the East Bay Area of northern California. The clients are monolingual new immigrants of all ages who are affected by stressors of acculturation, low economic status, chronic mental illness, violence and/or developmental disabilities. The agency has provided services to adults and seniors since its early inception. Currently, there are various programs of different levels that serve adults (ages 25 years and older), Medi-Cal 59 recipients, seniors, and individuals with severe mental illness (SMI). The agency works with populations that are reluctant or resistant to seeking mental health services and their family members or care takers, so that they can get the support they need or connect with outpatient mental health services. One of the goals is to increase understanding of mental health disorders while reducing the effects of untreated mental illness in adults with SMI and their families. The agency also provides linkage to appropriate and ongoing mental health and treatment services. The agency is founded on a strengths-based, person-centered model that aims to build trust and respect in the community and with clients, family members, and caretakers to address immediate needs; it seeks to connect individuals to community resources in order for them to live productive and meaningful lives. The agency’s staff work with clients in a model that focuses on three different stages of change in their lives from pre-contemplative to contemplative, preparation to action, and finally to maintenance. Their staff believe that the need to meet clients where they are at is critical in helping them to make the decisions that are healthy for them so that they can modify their behaviors and their surroundings. They serve adults who may have a history of co- occurring substance use/abuse and mental illness as well as family members, caretakers, and/or support people of their priority populations who are often left grappling with trying to obtain help or finding appropriate resources themselves. The agency serves Alameda and Contra Costa counties with its priority groups of adults: Asian and Pacific Islander (API), African American, Latino, Native American and unknown adults, both male and female. It has built on community networks to achieve its goals. ACMHS services and programs have diversified as the East Bay Asian and Pacific 60 Islander population has continued to grow in the last 40 years (26% in Alameda County) and (~15% in Contra Costa County), according to the 2010 Census. The organization currently serves more than 2,000 clients annually and has more than 85 multilingual, full and part time staff, including lived experience staff. It provides and advocates for services in four service areas: 1) Adult Behavioral Health; 2) Children and Youth; 3) Prevention and Early Intervention; and 4) Vocational Support. The agency has a team of licensed psychiatrists, psychologists, clinical social workers, marriage and family therapists, and case managers as well as peer support specialists that provide services in more than 14 languages including Cantonese, Vietnamese, Cambodian, English, Japanese, Mien, Korean, Burmese, Mandarin, and Tagalog. Other languages spoken include Thai, Laotian, Karen (Burmese dialect), Toisanese and other Chinese dialects, Urdu and Hindi. In 2010 and 2012, the agency applied for and received both Alameda and Contra Costa mental health service funding to serve API underserved communities in expanding and coordinating outreach, prevention, and early intervention strategies. Two projects called Asian Pacific Islander Connections (APIC) and Building Connections served API groups, including Mien, Laotians, Burmese, Bhutanese, Tibetan, and Nepalese. Through these projects, the agency was and is able to plan and reach out extensively to API communities with wellness-focused activities, and to help those communities access and enroll in resources and services. The agency aims to enroll clients into the care system and to help them take advantage of coordinated prevention and early intervention services in order to avoid costly intensive treatment and hospitalization. 61 Through its contracts with the Alameda County, the agency serves 650 clients who have severe mental illnesses. Their clients are ethnically diverse, low-income families and refugees/immigrants with limited English proficiency who represent more than 10 distinct Asian languages and dialects. In the past 5 years, the agency’s target population has been API adults, seniors, and adolescents with early onset, mild to moderate mental health risk, co-occurring with disorders/substance abuse, and those with severely mental illness (SMI). Although the agency was founded to serve primarily the Asian and Pacific Islander immigrant and refugee communities, its current services have been expanded to diverse populations, especially in the area of adult and senior programs. The current caseload make-up is representative of this diversity with Asian and Pacific Islanders at 55%, African Americans at 35%, Latinos at 4%, Whites at 3%, and Others at 3%. Most of the agency’s staff were born in the U.S. or belong to the “1.5” generation. In other words, they also have extensive professional experience working in low-income and urban neighborhoods where many of their clients and families reside. In addition, some of the staff also live in those same communities. The agency plans to continue to diversify its staff by hiring more Spanish-speaking and African American mental health specialists within the next five years. It has always invested in clients, family members, care takers, and client communities since its earliest inception almost 40 years ago as part of its mission to increase, promote, and encourage clients to live self-sufficient lives. The agency has recruited, trained, and hired former clients, most of whom now actively engage in various services, including advising, brokering between the agency and their respective communities, and coordinating with government agencies. The agency 62 continues to plan to train and develop additional peer navigators and family coaches to provide culturally responsive support to participants in their respective underserved ethnic communities. Currently more than 10 clients serve as leaders on the Client Advisory Board and many others actively engage in various capacities within the agency, working as data analysts, family support specialists, and family coaches. Depending on previous skill levels, professional work experience and educational backgrounds, former and current clients who wish to take greater roles in managing their health and well-being are sent to various training programs to prepare for leadership positions in which they express interest. For example, some former clients were sent to three days of training in Whole Health Action Management (WHAM) with an additional two days or more of training as needed by the agency to become certified Peer Wellness Coaches. The agency’s staff have extensive experience in helping family members by recruiting and training them in how to help clients manage their symptoms and navigate public assistance, transportation, mental health care, and medical services. The agency involves former clients and family members as well as community and religious leaders who can help engage with clients in their homes, in clinical settings such as emergency rooms or hospitals, in jail, on the streets, with family, or in other places in the community. Through these extensive and collaborative networks of clients, family members, community leaders and the agency, the staff are able to identify and reach out to populations that do not necessarily want to engage in ongoing services or treatment. In ongoing efforts to improve services, a total of 47 clients participated in the agency’s forum to identify problems and needs, most recently in early 2016. Results from 63 these client participants were similar to those ones identified in national surveys with Asian American Pacific Islander (API) patients conducted by researchers (Le, 2016). As in the national surveys, clients identified as problems the lack of cross-cultural understanding and sensitivity of their symptoms and illness; lack of respectful and attentive providers and service; lack of linguistic and culturally competence outreach; lack of transportation, childcare and other support services; and no follow-ups on referrals. The results also showed some environmental risks, such as lack of access to public assistance, education, housing, employment, legal aid and resources, in addition to lack of knowledge as to how to navigate these services. These factors can prevent clients from accessing mental health services. Other risk factors include obesity, high blood pressure and cholesterol, and diabetes, which are common chronic health conditions for API clients with SMI. Most of them do not receive the early screenings that could prevent their health conditions from worsening. Specific to Southeast Asian clients are barriers and challenges rooted in past negative contact with authorities, such as government officials, the military, and other authorities. Language and cultural barriers are also significant issues. The staff work to eliminate any barriers that clients might have, including assisting clients with public transportation, childcare, other family support services including accessing medical and health clinics, and other support services such as Parks and Recreation programs, community college programs, public libraries, and creative arts programs. The agency also has multiple contracts with Contra Costa County to provide similar services. The agency’s Mental Health Services Act Prevention and Early Intervention Services are contracted with the Department of Behavioral Health Services 64 Division/Mental Health to build connections in underserved cultural communities by providing: 1) community outreach through home visits to senior housing sites, medication compliance education, community integration skills education, older adult care-giving skills, basic financial management, survival English communication skills, travel training, health and safety education, computer education, structured group activities, and health and mental health system navigation; and 2) early intervention programs implemented by teams of specialists that assist clients who exhibit early signs of mental illness. These specialists help clients to actively manage their own recovery process by integrating them into a recovery model framework. The agency promotes diversity and practices with cultural themes from around the world, including creating inviting environments with various rooms decorated and staffed by people from different cultures. The agency also designates safe spaces for participants who need privacy and discretion when they receive services. These recently renovated rooms are used for support groups, group activities, and for rehabilitation and recovery purposes. The agency has professional staff who are ready to immerse themselves in the community and engage members by reducing barriers and assisting in solving the problems and challenges clients face. A number of barriers are commonly seen among their clients that are related to the lack of English skills. These challenges include having difficulty navigating public transportation and larger healthcare, mental health, and other public systems. The agency emphasizes addressing needs through providing alternative support systems that allow for flexibility and are culturally attuned to specific ethnic groups. The agency’s models for wellness centers and various social, rehabilitation and recovery support groups are based on strengths and needs suggested by the clients 65 themselves. Some support groups involve client-led sessions that are culturally specific; other sessions are on first-come, first-served basis, and there are ongoing and drop-in groups. Group Observation Findings Participant Data Tables The data tables (Tables 1, 2 & 3) below come from the principal investigator of this research. They describe the participant make up for group observations made between February 2016 and April 2016. The principal investigator observed all three groups. Table 1: Group Observation 1 Gender Ethnicity Age Range Male: 4 All Cambodian 40-60 Years old Female: 5 Table 2: Group Observation 2 Gender Ethnicity Age Range Male: 7 All Cambodian 40-60 Years old Female: 2 66 Table 3: Group Observation 3 Gender Ethnicity Age Range Diagnosis Male: 6 All Chinese 30-60 Years old All diagnosed in Female: 4 the schizophrenia spectrum Descriptive Statistics No specific demographic data was available to run descriptive statistics. Age range was between 5 and 60 years old. In total, 28 clients were in 3 group observations (18 Cambodians and 10 Chinese) plus staff notes for 1029 clients. Out of the 28 observed clients, 17 were male and 11 were female. Group Observations Overview I observed 3 groups with a total of 28 participants, 17 males and 11 females. Group One: All the Cambodian women in the first group were very engaged and all volunteered to check-in and discussed all daily challenges. Three women discussed physical symptoms and one woman attributed her psychological condition to a diabetes. Four men in the first group said they did not feel medication support was necessary. One man in the first group said he had a mental disability and health problems to the war and violence he experiences daily in his neighborhood. Two of the participants said they were happy to be divorced. One said she would never remarry. Three of them had issues with authority. One men said his physical ailments are as a result of the Pol Pot regime. One 67 woman said she was married in a refugee camp and divorced in the U.S. She has four children, one of which attends university. She wants to move to another city, but she is afraid of not knowing how to get around town. One man said he is concerned about his housing situation and high rent. He said he cannot afford such a high cost and wants to get a job. He said he cannot work due to emotional problems. He attributed his psychological conditions to the Pol Pot regime and the Vietnam War. Group Two: In the second group, 7 females volunteered to check-in. They made jokes about their psychological conditions being the result of trauma in the Pol Pot regime. One man said he needed help with translation because he wanted to tell the psychiatrist to switch his medications. He said the medication that he was taking had serious side-effects. He wanted to cry all the time. He was anxious and couldn’t sleep; he hated everyone and had a short temper. Another man said he needed help with a Medi- Cal application form and making a doctor’s appointment. One woman wanted to stop coming to the support group because she wanted to take cosmetology classes. Another woman giggled and then said she was enrolling in a hair-cutting class for beginners. She said she did not want to take her medications anymore because they made her feel crazy. She said she couldn’t think or behave normally; she felt anxious all the time. One woman said she became violent and frustrated if she didn’t take her medications. She had violent thoughts toward people around her. She said she had nightmares almost every night; she had dreams of the Pol Pot regime. In her dreams, she saw people dying. She saw dead bodies everywhere. She was hungry. She cried. These nightmares were repeated every night, sometimes more vivid and more violent. She said she woke up feeling sad and sick in her stomach. She sweat profusely when she woke in the middle of a night. She felt 68 alone. She said her husband does not understand her and she could talk to him about it. She said he gets scared if she tells him about her dreams. One man said he forgot where he was going on a bus after he fell asleep. He said the bus driver had to call police and ask for assistance. Another woman echoed the same sentiment and said she too was lost after she woke up one time while she was on the bus. She was completely lost and had lost her orientation. She could not remember where she lived or whether she had a family. She said there was nothing in her head. Two women said they lost their consciousness after they took their medications. They forget how to do the most basic things like cooking or bathing. Another woman said she usually gets disorientated after she took her medications. She lost her sense of self and her sensitivity toward the feelings of others. She said she felt sad and she cried a lot. One woman said she was hungry all the time, especially after she took her medications. She said she was gaining a lot of weight and she was worried. One other woman said since she was diagnosed with psychosis, she has not been the same. She hears voices telling her to do bad things. She said she does better or thinks better after she takes her medications. Group Three: There was no conversation in this group, but one man was actively engaged in Chinese calligraphy. He did not look up at me when I entered the room, but the rest of the participants did look up. They did not show any reaction and soon they returned to work on their respective projects. Soft Chinese music played in the background. No one talked at all. 69 General Findings The general finding from the group observations are organized into the following categories: 1) Migration Experience; 2) Western Modality, Treatments, and Side-Effects; 3) Symptoms and Experiences Related to War; 4) Daily Challenges and Barriers; and 5) Healing through Art. Migration Experience The majority of clients had similar migration experiences of war trauma during the Pol Pot regime, violence in the refugee camps, and violence in their neighborhoods in the U.S. They all discussed their experiences of feeling fear of witnessing loved ones being hurt or tortured during the war and/or the pre-migration process. They talked about the difficulty of leaving their homes, personal belongings and other family members behind when they left their country. While in refugee camps, some were abused or physically assaulted by guards or trapped in cycles of violence instigated by different political groups. They are now also constantly faced with violence in their neighborhoods after resettlement in the U.S. These stories have been often discussed in the group. For example, when one participant wanted to share her story about her life before coming to the U.S., another participant, a male in his 30s, said, “We heard your story many times already.” The female participant responded with a giggle by stating, “I know I shared already.” She plunged ahead with her story. She said she was married in a Thai refugee camp and was later divorced. She gave details about her children; she was very pleased her youngest was attending university. She said her husband left her after they came to the U.S. to go 70 to Cambodia and remarry a younger woman. She said her journey to the U.S. was similar to other Cambodian refugees’ journeys. She said she started walking from her home village and stopped at many places in transition refugee camps in Thailand, then went to the Philippines, and settled in her final destination in the Midwest. Later she moved to the San Francisco Bay Area after she made contact with family members in Cambodia. She said one of her cousins told her about Cambodians and family members living in California. She added that California seems unless like a foreign land, but the Midwest did feel strange. She also stated that California weather resembled Cambodian weather and this was the deciding factor in her relocation. She would be better off, so she packed up the family and moved to California after one year braving the cold climate in the Midwest. Another participant, a female in her 40s, echoed similar experiences of migration. She was sent to refugee camp in Thailand at first, then to a camp in the Philippines. In the Thai refugee camp, she was asked by officials to choose what country in the West she preferred to resettle. She was given four options: Canada, Australia, Japan, or the United States. She said she did not care where she was relocated, but she learned that people spoke French in Canada. She chose the U.S. without any specific reason. She said she was happy to leave the refugee camp. The two participants spent a good portion of the time discussing their migration experiences. The rest of the members generally agreed and nodded their heads. 71 Western Modality, Treatments, and Side-Effects The majority of the clients struggled to grasp with what it means to live with psychological problems and treatments for those problems that are often not well understood. The clients came from a different belief system for treatment and care in which the mind-body connection is key to understanding symptoms and symptom management. At the same time, they perceive Western medicine as something similar to magic that cures symptoms, which is contradictory to the Western treatment of mental illness, which uses treatment to minimize symptoms (for example, by daily ingestion of medications) but does not offer a cure. Most participants spoke about struggling to cope with symptoms and medications. Some participants did not understand their diagnoses and why the medication seemed to cause more problems. The participants complained of insomnia, loss of appetite, nausea, jittery feelings, and fatigue from the medications they are taking. There also had questions about health care services and the limitations of that care. One female in her 40s said, “I think too much and it hurts my head.” She said she cried a lot and was feeling sad all day. She could not make herself feel better. She said if she were to be happy, she would be okay to go out and do things. Another participant, a female in her 50s, stated that she was forgetful. She gets lost using public transportation. On many occasions she fell asleep on a bus and the driver had to wake her up. When this happened, she said she could not remember where she lived or where she was going. She also said that she did not like to take her medications because they made her feel like she lost her sense of self; they made her feel numb, and as if she was having an out-of-body experience. She might need to change the 72 dosage to improve her arom (“consciousness”) or arom chhit (“heart’s consciousness”). This particular participant felt that the medication she was taking made her lose her sense of self and who she was (i.e., consciousness). She said she was unable to think clearly and felt as if a big cloud were hanging over her head. Similar, another participant, a female in her 30s, broke the silence and began talking. She said she did not like her medications because they made her sick. She wanted to stop taking them. She said she could not feel the left side of her body. She had insomnia. She said she felt disconnected from herself. Her mouth became dry from the medications. She said she felt panicked, anxious, and afraid of everything. She said whenever she took the prescriptions her heart rate increased and she lost her ability to think. Another participant, a female in her 40s, stated that she could not eat or sleep. She felt cold all the time. She wanted to know if her diabetes was giving her problems. She had been diagnosed with type II diabetes and wondered why she was always cold. She said she did not like taking the medications. She wanted to stop taking them. She was worried that she would get too much weight and get fat. She said she had problems with weight gain after she started taking the medications that her psychiatrist prescribed to her. Symptoms and Experiences Related to War The majority of the members in both Cambodian groups described their symptoms as something that was caused by the Pol Pot regime. They stated that they believed that had they not experienced atrocities, they would not be psychologically impaired. They expressed that the violence, the guns, and killings did something to their 73 brains. Some said they had felt numb since then when they witnessed someone being killed or hurt during the war. Others said they felt overly sensitive as a result of witnessing a loved one being hurt or killed. For example, one participant said she experienced increased anxiety when she thought about or tried to leave her home. Another one said she did not like leaving her house for fear of gun fire and other related violence in her neighborhood. Another participant, a female in her 40s, said her problem began after resettled in the U.S. She wanted to socialize with other people, but she did not want to leave the house when she felt sad and was crying. Her eyes would show she had been crying and she said she would be embarrassed to interact with other people in that state. She also stated that when she felt sad, she got angry. She attributed her psychological conditions to the war in Cambodia. When she got angry, she got violent. She would throw things, such as sticks, shoes or bags, at people. She was still trying to overcome her anxiety, fear, and panic attacks that occur whenever she witnesses a violent event or hears the voices of people fighting from the window of her home. She said she lives in a violent neighborhood. Her neighbors scream and yell at all times of day or night. Another participant, a female in her 50s, stated that the war in Cambodia had done things to her surviving family. She attributed her son’s psychiatric condition in her own psychological problems. Her only child tried to commit suicide by cutting himself. He was diagnosed with schizophrenia when he was very young. She said he never recovered from the war and experienced ringing in his head and heard voices. Everything frightened him, including the outside world. She said she felt hopeless and helpless, but she was hoping that the doctor could save him. She had him committed to a hospital and then he 74 was referred to a more permanent facility where doctors could monitor him more closely. The group offered sympathy and acknowledged how brave she was to have to go through seeing one’s son go through such an ordeal. They took turns stating, “Thank you for sharing your stories.” Another participant, also in her 50s, female, said she had been unhappy lately, but she had no reason. She too was affected by violent past experiences. She stated that she wanted to see her children, but they lived too far away in another city; she said she felt lonely now that she lived by herself. She said that her family believed she was never right after she left Cambodia. She witnessed some disturbing events that changed her life. Her violent experiences did not take place during the Pol Pot regime, but afterward in the refugee camps where she was abused and tortured by Thai soldiers. She had also been trapped in battles between Thai soldiers, guerrilla fighters, and Vietnamese soldiers numerous times when she and her family tried to leave Cambodia. After she stated this, the group’s mood then changed. No one talked after that. The facilitator allowed them time to contemplate in silence. It was at this moment that one participant, a male in his 60s, began laughing. He spent the next thirty minutes talking to himself. He appeared completely disengaged from the group. The same man who had disengaged from the group began talking intermittently. He too appeared to be affected by the war. He laughed first and then he cried. He said something inaudible. Then he cried out loud, “Shoot them! They are coming!” He had not engaged with the group, but it was obvious he had symptoms of PTSD. He also appeared manic. Soon he had another outburst. He was singing this time. The facilitator looked up at him and tried to engage him, but he did not seem to notice her. She called his name 75 several more times, but he ignored her completely. Soon the disengaged man had his third outburst. This time he was clearly audible. He said, “Bananas, gardening, and planting. Shoot them! Put up your gun!” He then giggled to himself. He did not look at any participant in the group. The facilitator tried to ask what he was laughing about, but he again ignored her completely. Then he had another outburst. This time he said, “Take out your guns! Why aren’t you shooting? He is the enemy!” It appeared that he was reliving past experiences or hallucinations were about atrocities during the war in Cambodia. After that, the facilitator tried to engage him again, but she failed. He became incoherent and began talking to himself again. At the end of the session, I asked the facilitator the reason for the participation of the disengaged man, because his symptoms seemed more severe than that of the others. She said that the group members wanted him with them. They had all migrated to the U.S. at about the same time and lived in the same neighborhood. They said he had been better before for a while, but had regressed recently. I also noticed that one of the participants, a male in his 50s, gently took the man’s hand and led him out of the room at the end of the session. There was a clear bond of understanding among the group. When they all walked out together while chatting loudly and lively, the quiet disengaged man was included among them. In another example a client attributed her difficulties to past war trauma. A female in her 40s said she gets sad easily and wants to cry. She said she thought too much about everything, the past and present. She talked about her experience in the Pol Pot regime and how she believed hard labor had impacted her ability to think clearly now that she was older. 76 The oldest male in the group in his 60s concurred with her, in yet another example. He said, “It’s obvious that the Pol Pot regime did things to the people’s heads, even now.” He said he was generally frightened of loud noises and the sounds of airplanes. He stated that he was diagnosed with PTSD after he lost his job and became depressed. He said if he knew how to speak English, his life would be better. He attributed his inability to learn to being in the Pol Pot regime and the experiences of war and fighting thereafter, and said felt constant fear of violence in his own neighborhood. Daily Challenges and Barriers The group members were concerned about some of the challenges they face daily. This included using public transportation, making doctor’s appointments, and filling out forms for government services. Several members in the group talked about their children and how lonely they felt now that they were grown up and living their own lives. Some of the discussion focused on loneliness and isolation and what to do with their free time; housing situations or the lack of affordable housing; and being divorced. When discussions of daily challenges came up, participants often began talking at the same time, along with side conversations. For example, one participant stated she wanted to move. She said she had a Section 8 voucher. An older male participant in his 60s stated that he would like to move out and find a three-bedroom apartment, so that all his children could move back home. He emphasized how he wanted to have a big family again. Another participant, a male in his 30s, said that public assistance income was not enough to support him. He needed to 77 work, but he could not seem to get himself to apply for a job for fear that he would have panic attacks at work and get fired. One participant, a female in her 50s, cried in the group. She said it was difficult to be in this country. She said she does not speak English and had a hard time getting around. She felt lonely and isolated. She wanted to move to another city to live close to her children, but she could not go. She said she would have a hard time looking for a new doctor there and getting around town. Healing through Art I observed one recovery and rehabilitation group focused on healing through art rather through speaking and group interaction. The healing through art group was meant to help participants gain independence and a sense of self-worth as they learned to cope and manage their own psychotic symptoms. The clients observed in this group were considered as having severe mental illness and were all diagnosed in the schizophrenia spectrum. None of them spoke English. This support group was meant to provide them with an outlet to heal and express themselves through art. More males than females attended this session. The facilitator spoke both Mandarin and Cantonese, but only interacted with members when asked to do so. Otherwise, everyone worked quietly on their own projects and did not interact with one another. This particular group focused on arts as a form of rehabilitation and recovery. All members worked on individual projects. All had been diagnosed within schizophrenia spectrum. This was the only criterion for participating in this art group. I was told by the facilitator that the group was aware of my presence and that they had permitted me to 78 observe. However, the facilitator said that I should not expect any interaction from group members. A few of the projects stood out immediately. One member, a male in his 50s, worked on a collage made of pictures of singers, movie stars, and famous politicians. The collage included some pictures of what appeared to be of his own family members. He worked diligently and rarely looked at others in the group. Four of the members painted pictures of flowers and cherry blossoms. They chose different colors. Another man, in his 60s, worked on Chinese calligraphy. He worked in a delicate manner with slow strokes and deliberate moves. He wrote on a huge piece of painting paper. The facilitator said quietly that this male participant also wrote poems. He remembered hundreds of poems, including old poems that had profound meanings. I was told by the facilitator that he was trying hard to manage his psychotic symptoms. For example, he recited these poems constantly to control the voice in his head. He did calligraphy at the group, at home, on the bus, in the streets, and at the playground. Wherever he went, he took a piece of paper with him. He rarely said much, according to the facilitator. The members worked quietly the entire session. This group lasted about three hours. No one seemed to notice the others in the room. Chinese instrumental music played in the background at a very low level. Apart from this, the room was generally quiet. They all worked in isolation and only looked up occasionally. 79 Secondary Data Findings Client Demographic Data and Diagnoses Data presented in this section were drawn from staff notes and analyzed by the principal investigator in terms of client demographics and diagnoses. These notes came from the clinic, one of the agency’s three departments (Clinic, Developmental Disabilities, and Outreach/Advocacy). Therefore, the numbers below refer only to the clinic and are not indicative of the total number of clients served by the agency as a whole. Table 4: Client Data 2016 Total: 1029 clients served, ongoing Ethnicity – Top 5 ethnic groups served Chinese (471) Vietnamese (151) Cambodian (92) Korean (47) Non-White (51) Other ethnic groups African American Burmese Filipino Guamian 80 Indonesian Japanese Karen Laotian Latino Malaysian Mongolian Mien Other Asian Other Pacific Islander Shan Taiwanese White Yemeni The agency serves a diverse group of people as reflected in the Table 4 above. This diversity is also indicative of the agency staff. The agency has more than 85 staff who speak more than 14 languages and dialects. Regarding Southeast Asians, Vietnamese and Cambodians rank in the five top or largest groups of clients served. Mien and Laotian are not among the top five largest client groups; however, they do have similar pre-migration experiences as those clients who are from Vietnam and Cambodia, as both Mien and Laotians were involved in the Vietnam War. The similar background of those who experienced the Vietnam War is reflected in the similarity of symptoms and 81 diagnoses of those clients now (see Table 5, below). Table 5 shows common diagnoses among mainland Southeast Asians—namely Vietnamese, Cambodian, and Mien clients. Post-traumatic stress disorder (PTSD) is the most common mental condition being diagnosed among Cambodians. Similarly, Vietnamese and Mien clients also show a high prevalence of PTSD. Related to PTSD, anxiety disorder is also common among mainland Southeast Asian clients. As seen in Table 5, similar patterns emerge with regard to mental illness. PTSD and other related symptoms of trauma are more prevalent among Southeast Asians generally due to their involvement in the Vietnam War, atrocities from the fallout thereafter and trauma during migration process. Table 5: Common Diagnoses among Mainland Southeast Asians Vietnamese Depressive disorder Major depressive disorder, severe with psychotic features PTSD Dysthymic disorder Anxiety spectrum (anxiety disorder) Cambodian Major depressive disorder PTSD Panic disorder without acrophobia Anxiety spectrum Intermittent explosive disorder 82 Mien Major depressive disorder, recurrent severe with psychotic features Mood disorder The war in Vietnam did have a long and profound impact on those who experienced its violence as shown in Table 5. In addition to formal diagnoses, clients expressed extreme fear and anxiety about things and events that reminded them of war in their home countries. A loud noise from an airplane, an explosion, or gun fire could trigger and impair their ability to function. Compounding the war experiences, there are other psychiatric issues that typically occur in the general population that also impact this population, such as schizophrenia, other psychotic disorders, and depression. Table 6: Under 18 Years Old Youth Diagnosis: Ethnicity: Medium Age: 17.3 y/o PTSD African American Youngest: 5 y/o Anxiety disorder White Oldest: 18 y/o Major disorder Non-white Female: 15 Adjustment disorder with Nepalese Male: 17 mixed features Other Asian Oppositional defiant Chinese disorder Vietnamese Impulsive disorder Karen Attention-deficient 83 hyperactivity disorder Table 6 shows a sample of clients the agency serves under the age of 18 years old. The median age is 17.3 years old and youngest 5 years old. This particular data come from a small project. The data is representative of a population with issues and challenges seen in all clients ranging from very young to very old (elders in their 70s and 80s). General Findings After reviewing various notes on the agency’s clients, one major theme stood out with regard to Southeast Asians. The majority of the clients are suffering from anxiety spectrum (e.g., generalized anxiety disorder, social anxiety disorder, PTSD, panic disorder, acute stress disorder, and some other mixed features) as a result of their pre- migration, migration and post-migration trauma. Most of them live in violent neighborhoods in an urban city. Some clients experience great difficulty after enduring violence and harsh treatment in their native countries and/or while fleeing as refugees. After resettling in the U.S., they continue to feel fear in this foreign land. I have organized the general findings regarding aspects of trauma into the following categories: 1) Rates of PTSD and Diagnosis Complications; 2) Trauma Manifestation and Perceived Psychological Control; and 3) Trauma, Stigma and Daily Challenges. The final category discussed concerns the Challenges of Western Modalities vs. Eastern Philosophies. This final theme is fundamental. The Western-based modality of services, including the interpretation of mental illness and diagnosing using psychiatric 84 labeling, leads to labeling clients unnecessarily; clients do not understand the relevance of such labels and treatments. For example, some diagnoses are made in order to be able to bill Medi-Cal for treatment. This type of intervention has term limits that do not necessarily coincide with how clients feel in regards to symptoms and management of symptoms (medical support). Often times, they feel lost as far as treatment is concerned, especially in regard to symptom management and resources. Rates of PTSD and Diagnosis Complications The clients in this agency have a higher rate of PTSD than in the general population, perhaps due to their migration experiences of escaping some of the most brutal regimes in history. Clients from Burma and Cambodia, for example, appear to have a higher rate of C-PTSD and trauma-related conditions compared to those individuals who did not live through such brutal regimes. Most of the clients in the agency experience trauma repeatedly for months or years at a time during different phases of migration. The current PTSD diagnosis does not always capture the severe psychological harm that occurs with prolonged and repeated trauma. Some of clients at the agency have lived through concentration camps or have been prisoners of war. Some were tortured repeatedly while in captivity. Those who have experienced prolonged totalitarian control with organized violence either in a political, criminal or domestic context, exhibit psychological problems more severe, more complex, and more enduring than the current definition of PTSD found in the Diagnostic and Statistical Manual of Mental Disorders (DSM). 85 It seemed clients did not feel it was relevant if they knew of their diagnoses the name of their psychological conditions as described by the DSM series. Of fundamental concern is how these disorders are being translated into other languages and cultural contexts for these clients. A diagnosis—such as bipolar disorder, borderline personality disorder, obsessive-compulsive disorder, or schizoaffective disorder—is often lost in translation, both in the meaning of the words and in concept of the Western model of mental illness. The issue lies in the etic versus emic conceptions of illness. The etic conception stems from a Western modality whereas emic interpretation is innately indigenous. These two views of illness are often incongruent or contradict each other. The emergent themes in DSM’s diagnoses that are most relevant here are those associated with trauma and trauma-related experiences. Such attention given to transgenerational and complex trauma with its own spectrum in the DSM-5 could provide some relevant significance to understanding how trauma affects an individual and an individual’s responses and reactions to repeated violent events. Diagnoses that are rooted in these violent events such as post-traumatic stress disorder, generalized anxiety disorder, major depressive disorder with mixed features (i.e., anxiety or mood disorder), or adjustment disorder with mixed features (i.e., anxiety disorder or depressed mood) may offer us insight into our ability to survive in time of confronting with threats and our ability to cope with the consequences thereafter. Trauma Manifestation and Perceived Psychological Control Trauma impacts an individual for a very long time and can pass on from parents to children. Recent evidence suggests a psychological link of lived experiences to an 86 event that happened five or more decades earlier. Clinicians in this research study, for example, reported that it was not uncommon for Chinese clients who were diagnosed with schizophrenia to hallucinate with symptoms that appeared rooted in the Chinese Cultural Revolution. Some of the clients were born in the Bay Area and did not have direct knowledge about that period, but they described their lived experiences in vivid detail about Chairman Mao Zedong. The Cultural Revolution was a complex social upheaval that began as a struggle between Mao Zedong and other top party communist leaders. Generations of Chinese who lived through that period felt that their culture was stripped away by Chairman Mao and being replaced by a foreign concept, a non-cultural value that was based in communism. Similarly, some of the Cambodian clients still feel that they are being watched by communist leaders. In a support group that I observed, one older man in his 60s seemed to lose his ability to be present and engage with the other group members. When he blurted words out loud, some of those utterances were innately war-based. One particular example occurred when he yelled out loud, “Shooting each other! Call off fire!” Many Cambodians, Hmong, Mien, Vietnamese, and Burmese clients were tortured or lived in an environment in the refugee camps with the constant fear of being physically harmed by guards, soldiers, and other authority. This form of torture is a deliberate infliction of severe physical and mental pain and suffering. While some experienced torture under their own governments, others suffered abuse under the governments that ousted the communist regimes. Also, some clients suffered atrocities committed by people who their neighbors and friends living in their communities back home. This type of experience has created for clients a distrust of strangers and difficulty 87 in relating to others. Some clients have become paranoid and sensitive to sharing information even if the information seems nonthreatening. Cambodian clients refuse to talk in order to feel safe. This is a form of defense mechanism that they used to survive under an authoritarian regime and to protect themselves against people they did not know. Some of the more recent arrivals fear that they are unable to communicate with their host communities. Many also worry about family back home and about the difficulty of maintaining cultural and religious traditions. Many recent refugees are unemployed and lack the skills to gain employment. This is compounded by psychological and psychiatric problems related to war and violence. Clinicians reported examples of this in Bhutanese and Nepalese clients. Cambodian clients at the agency talked about violence in their pre-migration experiences as if the atrocities had just happened recently. In addition, the fears of being identified as an upper class Cambodian or working professional is still so intense that most of the people continue to use the language that was forced on them during the communist regime of the Khmer Rouge. For example, the multiplicity the words for “to eat” in the Cambodian language, which are based on age and class, was removed by the communist regime and replaced with a single word that stripped off class and age subtexts. To this day some Cambodians still use this specific word for eating instead of the other culturally appropriate terms known in the language system pre-dating the Khmer Rouge regime. While many Cambodians cannot express why bad things happened to them during the war, they can describe some of the violent experiences in vivid detail. Some 88 Cambodian clients at the agency, for example, still relive traumatic episodes from the past when triggered by a current event, which causes them paralysis and fear of being harmed again by some stranger or an authoritative figure (e.g., police, soldier, or guards). Some clients also expressed symptoms in physiological terms such as chronic headaches and body pain, sleeplessness, bad dreams, waking up with sweat and extreme anxiety, and loss of appetite. Trauma, Stigma and Daily Challenges Trauma plays a significant role in the lives of clients at the agency, but these difficulties are manifested in a manner that cannot be easily identified or understood. The agency’s clients often suffer in silence for fear or shame or because of a traumatic incident in their lives that caused them not to be able to open up about their psychological or psychiatric conditions. In addition, many clients face cultural and linguistic challenges. They experience difficulty navigating through a system that is foreign to them, whether using public transportation or applying for public assistance. Clients face daily challenges such as getting around town, struggling with English, trying to find employment, getting housing and being a part of their community with people who share their experiences. They also concerned with the lack of support systems, mistreatment from authorities, inability to fit into mainstream society, and violence in their neighborhoods. Those who have found work tend to work long hours with minimal pay and without benefits. If they accept cash, they receive no vacation, health insurance or retirement compensation. These challenges 89 sometimes exacerbate what other symptoms they may have and can push them over the limit. One other major issue with this population is their inability to express themselves in a manner that they view as dignified or without stigmatization. They do not know how to express their emotions and therefore tend to isolate themselves from people who could help them. The agency’s clients are a diverse group of people who share similar migration experiences, including their limited knowledge of Western diagnosis of psychological or psychiatric conditions. Some clients might have endured less psychological and emotional hardship before their resettlement in the U.S. Others might have been abused and mistreated and continue to cope with the challenges of living through trauma here in the U.S. Their children may also have potential difficulties because they may inherit their parents’ experiences of trauma. Challenges of Western Modalities vs. Eastern Philosophies Many the agency’s clients continue to face challenges after their resettlement in the U.S. Some of them are major issues that could drive them into extreme desperation. One of the clinicians who spoke both Mandarin and Cantonese and carried a caseload of mostly Chinese-speaking clients remarked in his written notes that the lack of family support is a major issue for the majority of his clients. For example, he noted that one of his clients expressed a sense of desperation over not having his brother, sisters, or parents nearby after he learned that his oldest daughter was diagnosed with Down Syndrome. This client was in his mid-fifties and struggling with depression himself. The clinician noted this client was struggling to understand the Western modality of a developmental 90 disability and what it meant in the context of trying to care for his daughter. The clinician also noted that the client expressed psychological distress after receiving the news about his daughter’s diagnosis. The client regressed and experienced symptoms that included low energy, lack of motivation, and sleeplessness. In addition to his own struggle with psychological problems, the clinician noted that the client does not speak English. He noted that the client was facing many other challenges, such as utilizing public transportation, accessing public social services, and understanding the Western modality of developmental disabilities. These issues were also compounded by cultural values and beliefs of shame/stigma relating to psychological problems, mental illnesses, and disability issues in general. The clinician noted that the client felt lost and in desperation. He had no support systems because all his family members lived in China. Other clinicians noted that a good portion of their clients faced daily challenges. Some could not read or write in any language. Others could not see that there was a future being in this country. At the same time, most clients were still dealing with past experiences from their native countries, especially those individuals who were tortured or beaten. They have brought these experiences with them and are unable to express them in a manner that can help them. When they regress, some of the symptoms expressed by these clients make it apparent that they have suffered the experiences of wars. They talk about their experiences as if the event recently happened. Some did not go through the event but talked as if they had. They said they felt generally not good because of their sick minds. Southeast Asian refugees have endured many challenges that now they are dealing with the emotional consequences. Common themes that emerged from this group 91 of Southeast Asians included the experience of violence in refugee camps and/or a prolonged stay in refugee camps, war/atrocities, starvation, persecution, diseases, and brutal regimes. Most did not feel the need to be open for fear that others might know of their psychological conditions. The agency’s clients are a diverse group of people comprising individuals from countries across the continent of Asia. They are from China, Burma, Cambodia, Vietnam, Laos, Burma, Afghanistan, Japan, and Korea as well as ethnic minority groups from Laos and Burma (e.g., Karin, Mien, and Hmong). More recent groups come from Nepal and Bhutan. All these clients have in common is their shared experiences of war and trauma back home. Some were stripped of their former cultural identities, as in the case of the Chinese Cultural Revolution. In the case of atrocities in Cambodia, a significant portion of the population died under the Khmer Rouge regime as a result of execution, torture, disease, and starvation. The prolonged brutality of military regime in Burma also caused a major displacement of a large population. Burma’s military dictatorship that sought to ethnically cleanse certain minority groups from that country caused major displacement and death among various ethnic minority groups; most Burmese refugees lived in multiple refugee camps and were abused either by other ethnic groups or, like many Cambodians, were abused by those who were in charge of the camps. All these clients share a common history of trauma either in their native countries, during the migration process and/or the post-migration after resettlement in the U.S. 92 Conclusion The data from the agency offers invaluable insight into the lives of those who suffer from mental illness. These clients often suffer in isolation and are struggling to understand the Western modality of mental illness. Treatment, medication, and the like may offer them short-term relief; however, in order to be effective, long-term plans need to include support systems that are culturally sensitive and linguistically appropriate. The data on the agency’s clients offer a partial picture into difficult lives, the experiences clients have had, and the ongoing trauma they face in their neighborhoods. Some symptoms they expressed might have evolutionary roots that offer us some explanations as to why and how we as human beings react and respond to fear and trauma the way we do. We have evolved in ways that can be beneficial and also in ways that can be harmful. This study is limited in scope and time. A thorough and long-term study that includes both qualitative and quantitative methodology would offer a more complete picture of this population. This study also has a geographical limitation. Each region has its own specific issues and challenges, whether it be in the API population or others. Similarly, socio-economic status and educational levels may also affect how an individual views psychological or psychiatric problems and challenges in his/her life. Finally, the ability to be able to maneuver in this larger system of care and services can make a difference in how one functions in a community. There are serious implications for researchers and mental health professionals when working or researching the API community. One implication is that the API population is no different from any other groups of people who have experienced high degrees of trauma, crime, violence, war, and poverty. Their expressions of these 93 experiences may differ, however. In other words, there is a tendency to be less confrontational and more avoidant in behavior when it comes to addressing mental illness. Instead of looking for help, the API population tends to avoid using mental health services. The second implication is that this is a culturally diverse group of people without a common language with which they all can communicate; there is no single language or culture. In addition to values related to stigma and shame, API group also tends to justify seeking mental health services by means of providing alternative explanations that involved physiological conditions rather than psychological or psychiatric symptoms. Finally, the API group appears to be less resistant to accessing mental health services from people who share similar cultural and ethnic backgrounds. 94 References Abueg, F.R. & Chun, K.M. (1996). Traumatization stress among Asian and Asian Americans. In A.J. Marsella, M.J. Friedman, E.T.,Gerrity, & R.M. Scurfield (Eds.), Ethnocultural aspects of posttraumatic stress disorder: Issues, research, and clinical application . 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