PCN 509 Grand Canyon University Counseling the Culturally Diverse Discussion

provide short answers to the statements below. Refer to the “Cultural Considerations Resource” for help in completing

Discuss the cultural issues and trends that specifically apply to each of the following regional population groups of the United States

>The Hmong in California

>Cuban Americans in Florida

PCN-509 Cultural Considerations Resources
Hmong Americans in the 2013 American Community Survey (2014)
Hmong Studies Journal (census data)
“Mental Health of Hmong Americans: A Metasynthesis of Academic Journal Article Findings,” by Lee,
from the Hmong Studies Journal (2013).
Cuban Americans
Hispanics of Cuban Origin in the United States, 2011
Hispanic Americans
Pew Hispanic Center: The 10 Largest Hispanic Origin Groups: Characteristics, Rankings, Top Countries
“Mental Health at the U.S.-Mexico Border: A BRFSS Glimpse,” by Olson et al., from Hispanic Health
Care International (2007).
Other Cultural Considerations Resources
“Stereotypes of U. S. Immigrants from Four Global Regions Stereotypes of U. S. Immigrants from Four
Global Regions,” by Timberlake and Williams, from Social Science Quarterly (Wiley-Blackwell) (2012).
© 2015. Grand Canyon University. All Rights Reserved.
Mental Health of Hmong Americans: A Metasynthesis of Academic Journal Article Findings by Song E. Lee, Hmong Studies Journal
14(2013): 1-31.
Mental Health of Hmong Americans:
A Metasynthesis of Academic Journal Article Findings
Song E. Lee
California State University, Fresno
Hmong Studies Journal
Volume 14, 31 Pages
The mental health of Hmong Americans has been studied since their arrival in the United States.
The purpose of this metasynthesis is to utilize a qualitative approach to analyze academic journal
article studies that assess mental health issues in Hmong Americans. Forty-eight published
articles from 1983 to 2012 were chosen for analysis. Each of the selected articles focused on
Hmong participants and contained findings relevant to the psychological well-being of Hmong
Americans. Results of this study revealed several common themes: trends in research,
depression, anxiety, adjustment issues, family issues, substance abuse, other mental health
concerns, factors linked to mental health, help seeking behavior and perceptions, effectiveness of
mental health treatments, strengths and resiliency, and supportive factors.
Keywords: adjustment, anxiety, depression, family issues, Hmong, mental health,
metasynthesis, resiliency, treatment effectiveness.
Mental Health of Hmong Americans:
A Metasynthesis of Academic Journal Article Findings
Hmong Americans are one of the fastest growing Asian groups in the United States, with
a population of 260,076 (Hmong National Development Inc., 2011). The Hmong are refugees
who fled Laos in the 1970s after the United States withdrew from the Secret War in Laos. Their
aid to the U.S. during the Secret War made them targets of the communist party. The Laotian
and Vietnamese communists attempted to eradicate the Hmong, resulting in the death of an
estimated half of the Hmong population (Meredith & Row, 1986). Many of those who survived
suffered from shot gun wounds, witnessed the death of their loved ones, and/or were in constant
fear for their safety before their arrival at refugee camps and in the U.S. (Hamilton-Merritt,
Past traumatic experiences and current adjustment issues have impacted the mental health
of Hmong Americans (Culhane-Pera, Vawter, Xiong, Babbitt, & Solberg, 2003; Lee & Chang,
2012a, 2012b). Although Lee and Chang’s (2012b) review of the literature found that incidence
rates of mental disorders in the Hmong population were understudied, previous studies found
that prevalence rates of mental health disorders are higher in Hmong Americans than among the
general U.S. population and other Southeast Asian refugees (Lee & Chang, 2012a; Vega &
Rumbaut, 1991; Westermeyer, 1988). Summarizing the findings of various research studies and
estimates by the U.S. National Institutes of Mental Health (NIMH), Lee and Chang (2012b)
estimated that the current mental health incidence status for Hmong Americans is close to 33.5%.
Depression, anxiety, and posttraumatic stress disorder seem to be most prevalent (Nicholson,
1997). Additionally, experiences and situations while living in the U.S. are stronger predictors
of mental health than pre-emigration issues (Nicholson, 1997; Westermeyer, 1988b). Some of
the problematic post-immigration issues that Hmong Americans encounter include family
conflicts, intergenerational gaps, a culture clash (Rick & Forward, 1992; Su, Lee, & Vang, 2005;
Ying & Han, 2008); changes in cultural practices (Helsel & Mochel, 2002); health concerns due
to new diets and environments (Franzen & Smith, 2009); barriers in medical care (Hoang &
Erikson, 1985); barriers in education, poverty (Hmong National Development, Inc. & Hmong
Cultural and Resource Center, 2004); various mental health issues (Lee & Chang, 2012a, 2012b);
sudden unexpected nocturnal death syndrome [SUND] (Adler, 1991, 1994, 1995, 2007; Young et
al., 2012), and suicide and domestic violence (Lee & Chang, 2012a, 2012b).
The obstacles that the Hmong face in the U.S. may also be exacerbated by adjustment
stress, limited English language acquisition, having large family household sizes, and living in
poverty. Researchers and the U.S. census have shown that Hmong families have larger
household sizes and lower income than other ethnic groups (McNall, Dunnigan, & Mortimer,
1994; Reeves & Bennett, 2004). They also have had a lower level of educational attainment and
English language acquisition compared to overall U.S. population (Hmong National
Development, Inc. & Hmong Cultural Resource Center, 2004).
Purpose of the Study
Even though the first waves of Hmong refugees came to the U.S. in the 1970s, there have
been a limited number of academic journal articles focusing on Hmong samples and their mental
health status. The Hmong have not been prominent on many research agendas, reflecting Vega
and Rumbaut’s (1991) observation that “minority mental health has been seriously understudied
because there have been few minority researchers, and people of color often have not been
represented in the clinical patient populations used to develop the epidemiologic data base over
decades of research” (p. 356). Furthermore, numerous studies have not disaggregated data
pertaining to the Hmong, making the prevalence rates of mental health illnesses unclear (Lee &
Chang, 2012b).
The goal of this study is to focus on trends within academic journal research on the
Hmong in terms of mental health issues, and to provide an overview of the findings. Academic
journal articles are targeted in this review because they may be more easily accessible to
researchers and practitioners. In various research studies, academic journals are used more often
than books and other materials (Brown, 1999; Niu & Hemminger, 2012; Tenopir, King, & Bush,
2004). Even though literature on Hmong Americans and their health issues are growing, mental
health related studies in academic journals remain limited.
When examining the selected journal articles presented in this study, the author will
disaggregate the findings in each study so that issues unique to the Hmong can be analyzed. The
three general research questions that served to guide the researcher were the following:
1. What are the trends in the current research on Hmong Americans and mental health
2. What are current findings on Hmong American’s mental health?
3. Are counseling treatments effective with Hmong clients?
A metasynthesis approach will be used in this study. Metasynthesis involves the analysis
of findings of several studies, using qualitative methods to further our understanding of certain
issues (Bondas & Hall, 2007; Sandelowski, 2006; Sandelowski & Barroso, 2003). Validity lies
in the “inclusion criteria and sample description, procedures for data handling, data analysis and
interpretation” (Bondas & Hall, 2007, p.102). In this metasynthesis, the constant comparison
analysis method (Glaser & Strauss, 1967) will be performed to code findings of the selected
studies. The constant comparison analysis method consists of coding and recoding the findings
until major themes are formulated to capture the data. The themes serve as descriptors of similar
Before retrieving research articles, the author met with three research assistants to clarify
the definition of mental health and the search process. For the purpose of this study, mental
health will be regarded as “psychological well-being and resilience” (Vega & Rumbaut, 1991, p.
355). It is important to note that there is no uniformity in the definition of mental health among
researchers and practitioners. This challenge of defining mental health may cause difficulty in
measurement, research, etiology, and practice (Vega & Rumbaut). Articles retrieved in this
study focused generally on the Hmong Americans, and more specifically, on the issues related to
Axis I (mental health clinical syndromes), Axis II (developmental and personality disorders), and
Axis IV (psychosocial stressors) of the Diagnostic and Statistical Manual of Mental Disorders
(American Psychiatric Association, 2000). The main keywords used were Hmong, Southeast
Asian mental health, Asian mental health, stress, acculturation, health, and counseling Asians.
The databases used were PsycINFO, Academic Search Premier, Education Research Complete,
Sociological Abstracts, Humanities and Social Science Index Retrospective [Wilson], JSTOR,
Science Direct [Elsevier], and Google Scholar. These databases were most relevant to
psychology, as identified by the database search engine of Madden Henry Library at California
State University, Fresno. The Anthropology Plus [OCLC], CINAHL Plus, and ERIC databases
were also utilized. The author also reviewed a bibliography list on the mental health issues of
Hmong (Pfeifer, n.d.), all of the titles of Hmong Studies Journal articles available at the time of
this study (volumes 1 to 13), and references in various articles, especially those used in Lee and
Chang’s (2011) review of the Hmong’s mental health status.
Over 100 articles were retrieved from the databases and references. The author then
reviewed the retrieved articles and selected 48 qualitative or quantitative studies that included
findings specific to the Hmong and their mental health issues. Literature reviews and aggregated
findings were excluded.
Findings were then compiled in a data sheet and themes were generated using the
constant comparison method. Then a reviewer, a faculty colleague with expertise in research,
reviewed the themes to ensure that they adequately represented the findings. Modification of the
themes and its contents ceased once the researcher and faculty colleague agreed 100% on the
themes and its contents.
The most common themes that emerged were trends in research, depression, anxiety,
adjustment issues, family issues, substance abuse, other mental health concerns, factors linked to
mental health, help seeking behavior and perceptions of treatment, effectiveness of mental health
treatments, strengths and resiliency, and supportive factors. Each of the following sections will
summarize the major findings associated with each theme.
Trends in Research
The research literature was categorized into decades: 1980s, 1990s, and 2000s (see Table
1). As seen in Table 1, academic journal articles on the Hmong and their mental health issues
were published more frequently in the 1990s than other decades. Articles were published in 31
different academic journals. Journals with the most articles on the Hmong’s mental health issues
were Journal of Nervous and Mental Disease (N = 5), Hmong Studies Journal (N = 5), and
American Journal of Psychiatry (N = 3). Overall, only 7 of the 48 research projects (15%) were
led by Hmong researchers. The ethnicity of the authors was determined by the researcher of this
study’s personal knowledge and by using Google search.
The types of issues that were assessed varied in the 48 articles examined. Depression
was studied most, appearing in 46% of the articles (n = 22). Adjustment issues (n = 13) and
anxiety (n = 9) were second most studied. The concerns least studied were family issues (n = 3).
Table 1
Academic Journal Articles Pertaining to Hmong and Mental Health Reviewed_______________
Hmong Sample Size (N)
1980s (n=14) Tobin & Friedman (1983)
Westermeyer, Vang, & Neider (1983)
Westermeyer, Bouafuely, & Vang (1984)
Westermeyer, Vang, & Neider (1984)
Westermeyer, 1986
Westermeyer (1988)
Westermeyer (1988b)
Hirayama & Hirayama (1988)
Frances & Knoll (1989)
Kroll et al. (1989)
Westermeyer (1989)
Westermeyer, Bouafuely, et al. (1989)
Westermeyer, Neider, & Callies (1989)
Westermeyer, Lyfoung, et al. (1989)
1990s (n=19) Mollica et al. (1990)
Westermeyer, Callies, & Neider (1990)
Mouanoutoua et al. (1991)
Westermeyer et al. (1991)
Westermeyer (1993)
Chung & Lin (1994)
Hutchinson & McNall (1994)
McNall, Dunningan, & Mortimer (1994)
Mouanoutoua & Brown (1995)
Westermeyer, Schaberg, & Nugent (1995)
Chung & Bemak (1996)
DoungTran et al. 1996
Stewart & Jambunathan (1996)
Velasco (1996)
Jambunathan & Stewart (1997)
Westermeyer & Uecker (1997)
Yang (1997)
15 Observations*
Ying & Akutsu (1997)
Ying et al. (1997)
2000s (n=15) Foss, Chantal, & Hendrickson (2004)
Culhane-Pera et al. (2005)
Supple & Small (2006)
Danner et al. (2007)
Fu et al., (2007)
Lee (2007)
Xiong & Tuicomepee (2008)
Lee et al. (2009)
Constantine et al. (2010)
Lee & Green (2010)
Supple, McCoy, & Wang (2010)
Xiong & Huang (2011)
Bahrassa, Juan, & Lee (2012)
Bart et al. (2012)
Collier, Munger, & Moua (2012)
focus groups*
64 (4 focus groups &
28 interviews)
Note: n = sample size of articles in each decade.
* Sample size varies or unclear in the article.
Depression is a mental health diagnosis that is most prevalent in Hmong Americans. In a
sample of 225 Hmong patients, 80.4% of them were being seen for depression, compared to
11.8% for posttraumatic stress disorder, 3.5% for anxiety and somatoform disorders, 2.7% for
psychoactive substance use disorder, 2.0% for organic mental disorder, .8% for schizophrenia,
and .4% for personality disorder (Kroll, Habenicht, Mackenzie, & Yang, 1989). Only 11.8% of
those who came to the clinic had no psychiatric diagnosis.
Hmong Americans who tended to show more depressive symptoms or were more at risk
for depression were those who were on welfare (Westermeyer, Callies, & Neider, 1990) or were
no longer on welfare (Chung & Bemak, 1996); who were farmers pre-migration to the U.S.
(Westermeyer, 1988b); who had roles that were not continued in the U.S., such as religious
leaders/healers and soldiers (Hirayama & Hirayama, 1988; Mouanoutoua & Brown, 1995;
Westermeyer, 1988b; Westermeyer, Bouafuely, et al., 1984); who had more changes in leisure
activity in the U.S. upon arrival (Westermeyer, 1988b); who spoke no English or limited English
(Foss, Chantal, & Hendrickson, 2004; Mouanoutoua, Brown, Cappelletty, & Levine, 1991); who
were unsatisfied with employment (Hirayama & Hirayama, 1988) or unemployed (Mouanoutoua
& Brown, 1995); who were older (Mouanoutoua & Brown, 1995; Mouanoutoua et al., 1991);
who lacked social support (Mouanoutoua et al., 1991); who were women (Mouanoutoua and
Brown, 1995; Mouanoutoua et al., 1991); who had less education (Lee, Jung, Su, Tran, &
Bahrassa, 2009; Mouanoutoua et al., 1991); and who had conflict with parents (Lee et al., 2009).
Mouanoutoua et al. (1991) also found that even though both limited English and lack of
education accounted for depression, lack of education predicted more depression than limited or
no English speaking ability. Additionally, symptoms that were found to be correlated with
depression were loss of libido, irritability, body image, sense of failure, pessimism, sadness, and
helplessness (Mouanoutoua et al., 1991). Depression does seem to decrease over time due to
acculturation in early resettlement years (Westermeyer, Neider, & Callies, 1989). However,
Mouanoutoua et al. (1991) did not find length of stay in the U.S. to be correlated with
Findings of depressive symptoms or disorders were found in both small and large
samples of patients in treatment and non-patients (Westermeyer, Lyfoung, et al., 1989;
Westermeyer, Vang, & Neider, 1984). When comparing patients to non-patients, both of the
Hmong groups had depressive symptoms, with the patients having moderately severe depressive
symptoms and non-patients having mild depressive symptoms (Westermeyer, Vang, & et al.,
1984; Westermeyer, 1986). In later research, mental health patients had higher depression scores
than non-patients (Mouanoutoua & Brown, 1995; Mouanoutoua et al., 1991).
In other studies focusing on non-mental health patients, depression symptoms were also
present (e.g. Culhan-Pera et al., 2005; Danner et al., 2007; Foss et al., 2004; Hirayama &
Hirayama, 1988; Lee, 2007; Lee et al., 2009; Stewart & Jambunathan, 1996). Although some of
these studies had a small sample size, an overwhelming number of the participants had several
depressive symptoms or had enough symptoms for a depressive disorder diagnosis. For
example, Hirayama and Hirayama (1988) found that over half of their 25 participants (52%)
were measured to be at risk for depression.
Several articles compared the Hmong with other ethnicities in terms of depressive
symptoms or disorders. When compared to other Southeast Asian refugees, the Hmong were
most depressed (Chung & Bemak, 1996; Foss et al., 2004; Kroll et al., 1989; Ying et al., 1997),
most demoralized, and least happy (Ying & Akutsu, 1997). Specifically, Kroll et al. (1989)
reported that Hmong Americans have a higher prevalence rate of depression (80.4%) than
Cambodian (70.7%), Laotian (59.2%), and Vietnamese (54.1%). Additionally, Lee et al. (2009)
also found that Hmong American college students reported more neurotic tendencies, depressive
symptoms, and family conflict than other peers who are non-Hmong. On the other hand,
Hutchinson and McNall (1994) found no difference in depression among married Hmong high
school students and female high school students of other ethnic groups.
Anxiety was another mental health issue that was found to be prevalent in Hmong
Americans. Anxiety was associated with those who were on welfare (Westermeyer, Bouafuely,
& Vang, 1984; Westermeyer et al., 1990) or were no longer on welfare (Chung & Bemak, 1996),
men who were herbal healers or did not fish in Laos (Westermeyer, Bouafuely, et al., 1984),
having more people in the household, living nearest to another Hmong household (less than 1
mile apart), having health problems, having a nihilistic outlook (Westermeyer, Schaberg, &
Nugent, 1995), having neuroticism, being older, being less educated, being unemployed
(Mouanoutoua & Brown, 1995), and having family conflict (Lee et al., 2009). Less anxiety was
associated with optimistic outlooks in life. Anxiety was also found in postpartum Hmong female
subjects (Foss et al., 2004) and participants with Type-2 Diabetes Mellitus (Culhane-Pera et al.,
2005). Like depression, anxiety was observed to decrease in time during the first decade, postimmigration (Westermeyer, Neider, & Callies, 1989).
Adjustment Issues
This section will summarize findings pertaining to adjustment disorders and
acculturation, which is a type of adjustment process. Adjustment disorders are common in
Hmong Americans. In Westermeyer (1988), 31% of the participants (N = 97) had enough
symptoms to qualify for an adjustment disorder. Additionally, in Westermeyer et al. (1990),
most of the participants on welfare had chronic adjustment disorder. Even in smaller sample size
studies (N = 17), adjustment difficulties were detected in participants (Westermeyer et al., 1983;
Westermeyer, Vang et al., 1984).
In terms of acculturation, less acculturation seemed to be associated with paranoid
symptoms (Westermeyer, Neider, et al., 1989), having a higher risk for depression, relying
largely on their family and the Hmong community instead of the larger society (Hirayama &
Hirayama, 1988), and those on welfare (Westermeyer et al., 1990). Compared to other Southeast
Asian refugees, the Hmong reported more psychosocial dysfunctions and were more likely to
hold onto their cultural traditions (Ying & Akutsu, 1997; Ying et al., 1997). However, in another
later study, most of nthe 110 Hmong participants were able to “maintain their cultures and are
able to accept and adapt to the host’s culture” (Lee & Green 2010, p. 2).
Focus groups and interviews of Hmong participants identified the following to be related
to adjustment difficulties: intergenerational and cultural differences between older and young
Hmong Americans; the breaking down of the clan system in solving conflicts; and older adults
feeling helpless, less competent, and useless because of language and cultural barriers that they
experience in the U.S. (Collier, Munger, & Moua, 2012). Statistically, age upon entry to the
U.S., length in the U.S., educational level, and English language skills seemed to have huge
impact on adjustment (Lee & Green, 2010). Furthermore, length in the U.S. and age of
participants also impacted self-perceptions (Jambunathan & Steward, 1997; Yang, 1997).
Lastly, respondents with higher levels of adaptability are also at lower risk for depression and
tend to use resources both inside and outside of the Hmong community (Hirayama & Hirayama,
In terms of young Hmong Americans, findings show that acculturation has few negative
impacts. Even though a cultural gap may seem more stressful for girls because of cultural
restrictions and parental expectations (Supple, McCoy, & Wang, 2010), there was no significant
difference between genders in acculturation conflicts with both of their parents (Bahrassa, Juan,
& Lee, 2012). In this study, cultural attributions only accounted for 22% to 30% of the conflict
with parents. Lastly, there was no significant difference related to acculturation in delinquent
and non-delinquent siblings (Xiong & Tuicomepee, 2008). Delinquent siblings, instead, differ
from their non-delinquent counterparts in antisocial attitudes (including self-control), organized
activities at home and in school, and in delinquent behaviors.
Family Issues
Findings relevant to family issues include relationships with parents, family conflicts,
cultural impacts, gender differences, and sibling differences. In Supple and Small’s (2006)
study, the lack of or limited support and warmth from parents, parents’ limited knowledge of
children’s whereabouts, and authoritative parenting styles did not put Hmong adolescents at risk
for substance abuse, low self-esteem, and low academic performance. Furthermore, when
parenting style was statistically controlled, Hmong young people had similar grade point average
(GPA) to that of European American adolescents and had higher self-esteem and less at-risk
behaviors than their European American peers. Additionally, Lee et al. (2009) found that
although conflicts with parents were moderately correlated with depression and significantly
related to anxiety, family conflict was related to completing the first year of college for Hmong
men. Family conflict also did not relate to sexual activity for Hmong college students and there
were no statistically significant association between GPA and family background variables, such
as income and parents’ education.
In a mental health needs assessment study, Collier et al. (2012) found several family
issues that their Hmong focus groups and interviewees emphasized. These included
intergenerational communication difficulties, marital discord, and domestic violence. Older
Hmong Americans reportedly had difficulty understanding young Hmong Americans in the U.S.
On the other hand, Hmong youth felt pressure to succeed and to maintain Hmong traditions that
were expected by Hmong elders. The participants also believed divorce rates and marital discord
had increased since the Hmong arrival to the U.S. They believe Hmong men marrying a second
wife from Laos contributed to the increase in marital discord. The focus group also mentioned
that domestic violence in families is often neither reported nor discussed and “only mentioned by
women, not men, in the context of informal discussion” (p. 79).
Substance Abuse
Like domestic violence, substance abuse often goes unaddressed in the families. In two
of the studies (Westermeyer, 1993; Westermeyer, Lyfoung, Westermeyer, & Neider, 1991),
young participants reportedly started abusing substances with relatives and peers. Opium and
tobacco seem to be two substances used by most participants in older studies by Westermeyer et
al. (1991) and Westermeyer (1993). Other types of substances abused found in Westermeyer’s
(1993) study included cannabis, alcohol, cocaine, and heroin. In another study (Constantine et
al., 2010), Hmong women started smoking at a younger age than Hmong men (14 years old
verses 21 years old). However, there was a significantly higher rate of tobacco use in Hmong
men. Additionally, Constantine et al. found that most of the participants were considered light
smokers (less than 15 cigarettes on any given day) and started smoking after immigrating to the
U.S. Even though the Hmong have a lower prevalence rate of smoking than other Southeast
Asian groups (Constantine et al., 2010), substance abuse is moderately correlated with sexual
activity in young Hmong adults (Lee et al., 2009). Also, in spite of this researcher’s findings that
conflict with parents did not correlate with lifetime drug use, family conflict was related to
greater alcohol use among Hmong female college students.
Other Mental Health Concerns
This section summarizes the findings of studies of mental health issues among Hmong
populations that do not fall into the previous themes. High rate of mental health disorders were
observed in several samples (Westermeyer, 1988; Westermeyer, Bouafuely, et al., 1984).
Westermeyer (1988) found that the Hmong had a psychiatric rate of 43%, double that of the rate
of the U.S. population. PTSD was also found in the samples of several researchers working with
Hmong informants (Danner et al., 2007; Mollica, Wyshak, Lavelle, & Truong, 1990).
Some other mental health issues that have been assessed in the Hmong participants were
paranoia, somatization, and hostility symptoms. In a longitudinal study, most of the participants
(92%) did not have paranoid symptoms (Westermeyer, 1989). Those few who did have paranoid
symptoms tended to have low self-esteem, poor self-confidence, and suffer from unemployment.
Hmong participants who had an education, were employed, owned a home, and affiliated with
the Christian religion showed the least paranoid symptoms. Somatization, on the other hand, was
associated with less education, being unemployed, pathology, poorer adaptation, higher selfconfidence and self-esteem, mental health symptoms and diagnosis, seeking medical care, and
self-reported health problems (Westermeyer, Bouafuely, Neider, Callies, 1989). Lastly, hostility
symptoms were associated with women and non-leaders, unskilled occupations before migration,
animist practices, health problems, and larger numbers of household members (Westermeyer &
Uecker, 1997).
Some positive findings were also reported. For example, early education during the first
1.5 years of their residence in the U.S. was associated with less hostility (Westermeyer &
Uecker, 1997). Additionally, Hutchinson and McNall (1994) found that married female Hmong
high school students did not differ from their single female peers of other ethnicities in terms of
personal well-being, self-derogation, self-esteem, or mastery of life situations.
Factors linked to Mental Health
Several stressors and factors were prevalent in Hmong clients with mental health
symptoms. In Westermeyer (1989), 97% of the 100 participants reportedly had minimal to
extreme stress. Stress among researched Hmong samples in the 1980s was related to car
malfunction, homesickness, medical services, and employment (Hirayama & Hirayama, 1988).
In a more recent study on Hmong American clients with depressive symptoms, some of the
common stressors were unemployment, lack of education, and inability to speak English (Danner
et al., 2007). Many of the clients believed that they are depressed because of role loss; physical
illness; experiencing the war in Laos; and situational stressors, such as separation from a spouse,
financial strain, and unemployment (Danner et al., 2007). For Hmong American adolescents (N
= 20), most reported the following as stressors: having many chores (53%), personal pressure to
obtain good grades (50%), worrying about where to live or find a job after high school
graduation (47%), studying for a test (40%), and high expectations from parents to do well in
school (35%) (DoungTran, Lee, & Khoi, 1996).
Stress management and psychological dysfunctions are associated with a sense of
coherence, defined as one’s confidence that the world is “comprehensible, manageable, and
meaningful” (Antonovsky & Sourani, 1998, p. 79). When compared to other Southeast Asians,
according to one study, the Hmong have the lowest sense of coherence (Ying et al., 1997). The
variable sense of coherence reportedly was the “sole predictor of happiness” for the Hmong
(Ying & Akutsu, 1997, p. 133). Indirect predictors were being less traditional, being a recent
arrival, English competency, and living in an ethnically dense area.
Other important correlation findings were also discovered. For example, “spending
more years in transit, living longer in the United States, having no formal education versus an
elementary school education, and being unemployed were significant direct predictors of higher
levels of demoralization” (Ying & Akutsu, 1997, p. 135). Indirect predictors of demoralization
were having a primary education and poor English skills. In another study (Westermeyer, 1988),
Axis I (mental health clinical conditions) was not associated with Axis III (medical conditions)
in the Hmong. In yet another, variables that were associated with delinquent behaviors in
adolescents and young adults were hostile styles of interaction, a low grade point average, and a
lack of monitoring from mothers (Xiong & Huang, 2011). When looking at gender differences,
Xiong and Huang found that “the male youth’s lack of school commitment was the only factor
that was significant in explaining their delinquent behavior” (p. 19).
Help Seeking Behavior and Perceptions of Treatment
Some studies provided findings relevant to help seeking behaviors and perceptions of
treatment for their mental health issues. Results in one study found that the Hmong are the least
likely to seek Western treatments as compared to other ethnic groups (Chung and Lin, 1994). It
was reported that only 59% of the 302 Hmong participants were willing to seek Western
treatment. In another study (Hirayama & Hirayama, 1988), only those who had higher
adaptability levels were more willing to seek assistance outside of the family and the Hmong
community. Hmong Americans who had low adaptability levels were twice as likely to use only
resources within their family and the Hmong community. In a third study (Westermeyer, 1988),
all of the subjects who had been discomforted by their symptoms did not seek Western treatment.
Furthermore, in Westermeyer’s (1988b) study, 86 out of 102 participants (84%) did not seek help
for their adjustment disorder.
Lack of knowledge about treatment may have impacted help seeking behaviors. Many
participants did not know much about Western treatments (Danner et al., 2007; Fu et al., 2007).
With awareness and knowledge, Hmong clients in both Danner et al. and Fu et al. felt hopeful
that Western treatments such as counseling and medication would be beneficial to them.
Effectiveness of Mental Health Treatment
A review of six articles discussing the effectiveness of mental health interventions found
results to be mixed. Westermeyer (1988b) compared patients in a treatment group with high
depression scores to non-patients in a control group who also had high depression scores. With
treatment of counseling and medication, individuals in the treatment group had a significantly
lower symptom report as compared to non-patients. One year after treatment, a post-test found
that the control group had a slightly increased level of depression, while the scores of the
treatment group were half of their former level. At a two year post-test, depression scores were
also lower for the treatment group than the control group, although the difference was not
statistically significant. In another study, the anxiety score and the overall score of the Hmong
Hopkins Symptom Checklist, which assessed both anxiety and depression, did improve
(Culhane-Pera et al., 2005). In a case study of a Hmong woman, treatment was only effective
with psychotropic medication (Frances & Knoll, 1989). In another older case study, some
survival stress symptoms were alleviated with the Hmong shaman ritual, “ua neeb” (Tobin &
Friedman, 1983).
Contrary to positive findings in some articles, treatment was also found to be ineffective
by several researchers. For example, one study concluded that after 6 months of treatment, most
of the depressive symptoms worsened, especially self-worth (Mollica et al. (1990). In other
studies, depression did not improve with support or counseling groups (Culhane-Pera et al.,
2005; Danner et al., 2007). Additionally, several treatments for delusions were ineffective in
some patients with psychotic depression (Westermeyer, Lyfoung, et al., 1989). Lastly, in
another study, an attempt to empower Hmong clients in seeking employment resulted in more
anxiety and depressive thoughts (Velasco, 1996).
Studies focusing on treatment of substance abuse with the Hmong tend to focus on using
pharmacotherapy (Bart, Wang, Hodges, Nolan, & Carlson, 2012; Fu et al., 2007). Hmong
Americans’ lack of knowledge of Western treatments for substance abuse seem to impact their
views and usage of treatment. In one of the studies (Fu et al., 2007), researchers found that if the
participants were not aware or did not understand pharmacotherapy, they had negative views
toward using medication to treat their addictions. However, with awareness and knowledge, the
participants reportedly were willing to use medication to control their tobacco usage. In fact, in
Bart et al.’s (2012) study, the Hmong had better retention rates than non-Hmong in a one year
period in a methadone treatment program. The Hmong participants also required lower doses of
methadone to stabilize their opium addiction.
Strengths and Resiliency
Despite the high prevalence of mental health illness and low treatment seeking rate,
Hmong have also shown personal strengths and resiliency. In Westermeyer (1988b), both
patients and non-patients “had numerous undesirable and uncontrollable changes…However, the
non-patients continued to exert some control over their lives via vocations, avocations, and
religious practice” (p. 69). Also, “despite extensive losses and life change among all subjects,
only 20% (i.e., 20 out of 102) of them became so seriously depressed as to require psychiatric
treatment” (p. 69). In Westermeyer’s (1988) study, it was found that although a large number of
the Hmong participants did well with treatment, half of the participants with adjustment disorder
adjusted without treatment by still being functional within their families and occupations.
Westermeyer, Vang, et al. (1984) also found that a few of the participants improved with
minimal treatment interventions. Westermeyer and his colleagues believe that acculturation and
time attributed to the improved symptoms.
Studies of young Hmong Americans also have observed that although they encountered
obstacles, they were not at risk for certain negative outcomes (Hutchinson & McNall, 1994; Lee
et al., 2009; Supple & Small, 2006). For example, less supportive, less warm, and authoritarian
parenting did not put the adolescents and teenagers at risk for low self-esteem, at-risk behaviors,
and poor academic performance (Supple & Small, 2006). Families’ low income and parents’
lack of education were also not correlated with academic performance of first year college
students (Lee et al., 2009).
Supportive Factors
Supportive factors that help the Hmong cope with stressors and mental illnesses were
related to their family and the Hmong community. In the early years of the Hmong resettlement,
factors that helped the Hmong cope with losses and adjustments were an accepting and
supportive sponsor and a stable residence (Westermeyer, 1988b). From later studies, support
came from relatives (Mouanoutoua et al., 1991), families (Jambunathan & Steward, 1997;
McNall et al., 1994; Supple et al., 2010), peer groups and the Hmong community (McNall et al.,
1994). Lastly, with supportive and loving parents, adolescents seem to have a strong sense of
ethnic identity (Supple et al., 2010).
The findings of this metasynthesis study indicate that the research literature on Hmong
mental health has focused on depression, adjustment, anxiety, and adult populations.
Additionally, alarmingly high prevalence rates of mental health disorders and symptoms were
reported. However, few of the articles in the review focused on other prominent issues in the
Hmong community, such as mental health issues experienced by younger school age children,
sudden unexpected nocturnal death syndrome, homicides or suicidal issues. Additionally,
studies involving ethnic Hmong researchers and research on family issues are lacking. Some of
the findings of this metasynthesis review are similar to Lee and Chang’s (2011, 2012)
assessment of the literature on the Hmong’s mental health incidence status. However, the results
of this study also include other major themes in research over time pertaining to the mental
health of Hmong Americans.
It is important to note that most of the studies reviewed in this metasynthesis have been
conducted on the 1st (refugee adults), 1.5 (refugees who came to the U.S. as children), and 2nd
(born in the U.S.) generation of Hmong Americans who were in poverty during the 1980s and
1990s. Additionally, there are no current statistics on the prevalence rate of mental health
disorders in Hmong Americans (Lee & Chang, 2012b). Furthermore, many of the examined
studies did not measure nor discuss the impact of poverty or other factors associated with
minority status that may have impacted mental health. Minority status and low social economic
status is known to impact health negatively (Choudhuri, Santiago-Rivera, & Garrett, 2012; Gallo
& Matthews, 2003; Sue & Sue, 2012). For example, Gallo and Matthews found that SES relates
to negative emotions and cognition. Additionally, health surveys of different age groups in three
different years all showed that those with higher income reported better health (Smith, 1999).
Additionally, it is critical to be aware that coping styles and aspirations in life may be
different for current and future generations who have educated parents or have a different SES
than the Hmong Americans who were part of the samples of researchers over the past three
decades. Furthermore, most studies on young Hmong Americans have focused on students
enrolled in high school and college instead of drop outs or non-college students. Those Hmong
youths who remain in high school and college may have more aspirations and better coping
mechanisms than other youth. Therefore, findings of such studies need to be used with care and
should be considered most applicable to understanding the experiences of youth enrolled in
secondary and post-secondary institutions and Hmong Americans who are among the 1st, 1.5,
and 2nd generations in the U.S.
As a caveat, there are limitations to this metasynthesis study that need to be considered
when reviewing the results. Although a full review of all literary sources would require a more
comprehensive view into the topic under review, academic journal articles were primarily
reviewed for this study. Future metasynthesis studies need to review book articles, unpublished
theses and dissertations, and findings of local agencies or community groups in order to gain
more insight into the Hmong and their psychological health.
Another limitation is that even though careful and considered examination were part of
every process of this study, some academic journal articles may have been unintentionally
excluded from this review due to human error and the databases used. Lastly, some results in the
selected articles may not have been included in this study if they did not fit the common themes
presented, even though the utilization of the theme “other mental health concerns” by the
researcher was intended to include findings from a variety of additional studies.
Future Research and Practice
It is apparent from this review that there is a gap in the current journal article research
literature in terms of studies on the mental health status of Hmong children, effectiveness of
mental health services with the Hmong, and other critical issues in the Hmong community (e.g.
family issues and suicide). In addition to closing these gaps, future research also needs to
explore how stigmatization, culturally defined symptoms, language, and/or perceptions of the
Hmong may have impacted mental health incidence, treatment, and research results. For
example, the Hmong’s belief in souls and spirits may have impacted Westermeyer’s finding that
“Hmong subjects with more subjective (but not objective) paranoid symptoms retained more
traditional affiliations and behaviors” (p. 53). Cha (2003) also believes that the Hmong “express
symptoms in a somewhat idiosyncratic manner, often employing many linguistic idioms to
describe their health” (p. 144). Additionally, there is incongruence between the Hmong and
English language. Even with interpreters, a lack of training in mental health concepts and the
incongruence of the Hmong and English language can lead to inaccurate translations of
symptoms impacting diagnoses, intervention, and research.
The ineffective treatments and lack of help seeking behaviors found by researchers
inluded in this metasynthesis may be related to culturally irrelevant assessment tools and
culturally insensitive intervention strategies. Mental health interventions may need to expand to
include atypical assessment and techniques in order to effectively assist Hmong clients and
increase penetration and retention rates. For example, counseling professional may need to
include more culturally relevant approaches, such as discussions about families and relations
(Cha, 2003). For other ethnic counselors, establishing rapport and trust in counseling may
require providing case management to fulfill clients’ basic needs before attempting to alleviate
symptoms. Furthermore, effective resources that Hmong Americans utilize need to be included
in interventions (e.g. support from families and indigenous healing practices). For additional
information about counseling strategies that have been used in working with Hmong clients see
Bliatout (1986), Bliatout (2003), Cerhan (1990), Cha (2003), Culhane-Pera et al. (2003), and
Tatman (2004). Lastly, the author agrees with Lee and Chang (2012b) that more targeted
research and grassroots efforts from within the Hmong community are needed in order to provide
effective treatments and improve the mental health status of Hmong Americans.
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This research was supported in part by grants from the Provost Research Award at California
State University, Fresno. Student assistants of this study also received grants from the Provost
and Graduate Studies at Fresno State. The author would like to acknowledge Drs. Albert
Valencia, Kyle Weir, Henry Delcore, and Susan Tracz for their review of the manuscript and
gratitude to the students for their assistance.
Contact details:
Dr. Song Lee
Preferred contact address for surface mail:
5005 N. Maple Ave M/S ED3
Fresno, CA 93740
Telephone: 559-278-0349
Email address: malee@csufresno.edu
About the Author:
Dr. Song E. Lee is an Assistant Professor in Counselor Education at California State University,
Fresno. She’s been a professor at Fresno State since 2006. She received her MS degree in
Counseling, with a concentration in MFT, and, the Pupil Personnel Services Credential in School
Counseling from California State University, Fresno. Dr. Lee earned her Ph.D. in Counselor
Education from North Carolina State University. Before her employment at Fresno State, Dr. Lee
was working as a counselor, serving families, couples, and children. Currently she teaches
master level counseling courses and serves as program coordinator for the Department of
Counselor Education and Rehabilitation. Her publications and research focus are on multicultural
counseling and the Hmong.Among her other duties at Fresno State, she also serves as a coadvisor for HmSA and SEAT at Fresno State.

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