THE NEPALI CASTE SYSTEM AND CULTURALLY COMPETENT MENTAL HEALTH TREATMENT: EXPLORING STRATIFICATION, STRESS, AND INTEGRATION. A Dissertation Presented to The Graduate Faculty at The University of Akron In Partial Fulfillment Of the Requirements for the Degree Doctor of Philosophy Scott Swiatek May 2021 THE NEPALI CASTE SYSTEM AND CULTURALLY COMPETENT MENTAL HEALTH TREATMENT: EXPLORING STRATIFICATION, STRESS, AND INTEGRATION. Scott Swiatek Dissertation Approved: Accepted: ___________________________ _____________________________ Advisor Department Chair Dr. Juan Xi Dr. Rebecca Erickson ___________________________ ______________________________ Committee Member Dean of the College Dr. Clare Stacey Dr. Mitchell S. Mckinney ___________________________ _____________________________ Committee Member Dean of the Graduate School Dr. Manacy Pai Dr. Marnie Saunders ___________________________ _____________________________ Committee Member Date Dr. Kathy Feltey ___________________________ Committee Member Dr. Marnie Watson ii ABSTRACT During the late 1990s, the Northern Bhutanese enacted policies marginalizing Bhutanese of Nepali Descent. Thousands of Bhutanese refugees were forcibly displaced to Nepal and established refugee camps where they lived for decades. While in the camps, refugees encountered traumatic life events, including torture, imprisonment, and sexual violence. Starting in 2008 and continuing for years. Bhutanese/Nepali refugees were resettled in the Akron area and encounter a new set of acculturation stressors related to finding employment, learning English, and reestablishing a new set of social networks. Older adults may cling to the Nepali caste system to cope with the unique stressors during the integration process. For over 100 years, people of Nepali descent subscribed to Muluki Ain, which codified discrimination against lower castes and mandated every individual be assigned a caste. Further, members of the ethnic and religious minority were often placed in the lower castes. Although discriminatory policies have been repealed, many Bhutanese of Nepali descent still subscribe to the caste system. This dissertation demonstrates that the caste system relates to health. On the one hand, the caste system operates as a fundamental cause, which may worsen physical and mental illness for lower castes. On the other hand, not everyone in the higher castes may experience their social position's benefits. Findings suggest that older women and persons with disabilities may encounter additional barriers to care. These findings demonstrate that Bhutanese/Nepali refugees would benefit from culturally competent programming sensitive to community member caste and religion. The community would also benefit iii from expanding social services related to learning English, finding employment, and community gardening. However, the federal government needs to ensure that local programs receive adequate funding and repeal restrictions on refugee admission. iv TABLE OF CONTENTS Page LIST OF FIGURES ........................................................................................................... xi LIST OF TABLES ............................................................................................................ xii CHAPTER I. INTRODUCTION ........................................................................................................... 1 METHODS ...................................................................................................................... 6 Neighborhood Setting .................................................................................................. 6 Pilot Project ................................................................................................................. 8 Project Overview ....................................................................................................... 10 Sampling Strategies ................................................................................................... 11 Coding Procedures ..................................................................................................... 12 Community Member Demographics ......................................................................... 13 Provider Characteristics ............................................................................................. 14 OVERVIEW OF CHAPTERS ...................................................................................... 15 II. HISTORY AND CULTURE ....................................................................................... 17 Bhutanese Culture and Ethnic Relationships ............................................................. 19 History of the Bhutanese Ethnic Cleansing ............................................................... 21 Life in the Camps ...................................................................................................... 29 v The Resettlement Process .......................................................................................... 35 The Nepali Caste System ........................................................................................... 39 III. CASTE AS A FUNDAMENTAL CAUSE ............................................................... 44 LITERATURE REVIEW .............................................................................................. 46 Traumatic Experiences in Bhutan .............................................................................. 46 Acculturation Stress and the Stress Process Model ................................................... 49 The Caste System ...................................................................................................... 50 Caste as a Fundamental Cause ................................................................................... 52 Cultural Health Capital .............................................................................................. 54 Caste Resources and Coping ..................................................................................... 55 Mental Health Consequences .................................................................................... 57 Theoretical Framework .............................................................................................. 59 METHODS .................................................................................................................... 61 Sampling Methods and Coding Procedures............................................................... 63 Community Member Characteristics ......................................................................... 63 Provider Characteristics ............................................................................................. 64 PROVIDER RESULTS ................................................................................................. 65 COMMUNITY MEMBER RESULTS ......................................................................... 70 TIKA AND PRAKESH: SEEKING TREATMENT IN NEPAL ................................. 71 SARAH: ACCULTURATION STRESSORS .............................................................. 75 vi BHIM: CULTURAL HEALTH CAPITAL .................................................................. 79 DISCUSSION ............................................................................................................... 82 Conclusion ................................................................................................................. 85 IV. THE CASTE SYSTEM: BARRIERS TO INTEGRATION AND CARE ................. 87 LITERATURE REVIEW .............................................................................................. 89 Assimilation, Integration, and Enclaves .................................................................... 89 Theoretical Framework .............................................................................................. 91 Economics and Barriers to Integration and Healthcare ............................................. 93 Social Networks as a Barrier to Integration and Healthcare ..................................... 96 Language and Culture as a Barrier to Integration and Healthcare ............................ 97 METHODS .................................................................................................................. 100 Sampling Strategy and Coding Procedures ............................................................. 100 Community Member Characteristics ....................................................................... 102 Provider characteristics ............................................................................................ 102 COMMUNITY MEMBER RESULTS ....................................................................... 103 Stigma as Barrier to Integration and Healthcare ..................................................... 103 Social Networks and Social Isolation as Barrier to Integration and Healthcare ..... 105 Employment as Barrier to Integration and Healthcare ............................................ 111 Language and Culture as Barrier to Integration and Healthcare ............................. 114 vii PROFESSIONAL/PROVIDER RESULTS ................................................................ 118 Caste and Barriers to Treatment .............................................................................. 118 DISCUSSION ............................................................................................................. 120 Conclusion ..............................................................................................................